2019 Physician Writing Contest: The hope of living better

I met Mr. AR for the first time in September of my intern year. He was a 70-year-old gentleman admitted to the hospital with nausea, vomiting, and abdominal pain. CT scans revealed an obstructing mass in the head of his pancreas. The rest of the workup yielded a frightening diagnosis of pancreatic cancer, prompting his primary medical team to consult us-the surgical oncology service. Although another resident had already seen him the day before, the patient’s daughter had only just arrived today, having traveled over 300 miles to be with her father. Mr. AR knew only that he needed to have surgery, so his daughter asked the nurse to page the surgery team, asking for someone to explain the proposed procedure.

I felt my heart pounding as I listened to the nurse relaying the request. I was barely three months out from graduating medical school, but my senior residents were operating (and so was the attending physician), so there was no one but me to walk to the north wing of the hospital, frantically studying diagrams on my phone as I made my way over. I made silent promises to myself that it would be okay to say, “I don’t know,” because I truly didn’t know. How long would he have to stay postoperatively? When could he eat normal food? What activity could he do afterward? Would he be cured? Would he still need chemotherapy? These were questions I’d ask if I were the patient, and yet I had none of the answers.

Up until that day, I had decided that I hated surgical oncology. The patients were ill to begin with, having spent some time fighting a malignancy prior to presentation, then some of them would be weakened by neoadjuvant chemotherapy, sustaining neither nourishment nor exercise, and then we would throw them into the gauntlet of a major surgical resection. Much of a surgical intern’s time is spent on the inpatient floor following postoperative patients, and I felt a crushing gloom entering the ward every day looking in on how sickly the patients seemed to be. Watching them die was even worse. The promise of more time to live, however long, didn’t seem worth it, and I struggled to care about these patients when everything seemed so futile to me.

Despondent, I knocked gently and pushed the door open, peering in. Mr. AR and his daughter looked up from their conversation, smiling brightly and asking if I was the surgery person. I stumbled over my greeting, taken aback by the sunny atmosphere. They were so glad that someone had come. He looked nothing like my patients: no temporal wasting, no ribs showing through his side, no exhaustion in his eyes. I drew pictures of the anatomy that would be altered during the procedure in order to remove the cancer. I apologized where I had no answer and reassured them that the attending surgeon would be by to fill in the gaps.

I also found out that he and his daughter came from my hometown, and by the time we were done chatting about more than just his diagnosis, an hour of my afternoon had drifted by. They thanked me for the information that I could give, and as I left the room, I couldn’t hide my own smile at having shared a positive connection with another human being.

The next time I saw him, Mr. AR had undergone his surgery and relocated to our surgical postoperative floor. His recovery was not without complications. He endured a prolonged course of ileus, a string of electrolyte derangements, fluid collections requiring percutaneous drains, and an infection requiring antibiotics. Despite that, he greeted me cheerily every morning, even if I came to bother him at five or six o’clock. When I caught him pushing a rolling walker in the halls, he wanted to show off his dance moves, weak as he was. The optimistic attitude he and his daughter shared was contagious, and it motivated me to continue working hard to get him better after every setback. By the time he left the hospital, he looked more like the cancer patients I was used to seeing, frail and thin, but he didn’t stop smiling.

Months later, a stranger tapped me on the shoulder. I almost didn’t recognize him. He was a far cry from the last I’d seen him: normal clothing, filled out cheekbones, standing on his own. Apparently he was there following up with his oncologist and was doing very well on his adjuvant chemotherapy. He thanked me for the care he had received and expressed that I must continue doing so for others. I left that encounter with a renewed sense of purpose: the care I was providing no longer seemed futile.

Though progress was slow, I began to see how Mr. AR had changed me. As an intern, I had focused on the nitty-gritty details: the diagnosis, the pathophysiology, the workup, the treatment, the answers to difficult questions from the attending, the right orders to input into the computer. As a second-year resident, I found that the knowledge and workflow were now second nature, and I began to really see the patients for who they were. I saw new patients, anxious about their symptoms, fearful of the “c” word.

I saw survivors, racking up years free of cancer, eating well and living normal lives. I saw beyond the details of the treatments and began realizing the principles and patterns guiding the care of cancer patients. I assisted in surgeries big and small, where some patients were cured with a small excision and others like Mr. AR had to face the gauntlet. For these latter patients, I could now picture where they would be a few months following their surgery, strolling down to the hospital cafeteria for a snack after their infusion.

But they wouldn’t get there on their own. Motivated by their stories, I challenged myself to take ownership of their care, to read as much as I could, to be able to answer their questions where I couldn’t answer before. I presented patients I had seen at the multidisciplinary tumor board. I took notes on my clinic patients the night before so that I could spend more time with them in person and less with the computer. I stayed past shift changes to struggle through difficult cases with my attending. So imagine the surprise when third year rolled around, and I said with certainty, “I want to go into surgical oncology.”

Mr. AR is still alive today, and the lesson I learned from our shared experience is still with me as well. He showed me a different perspective of caring for cancer patients. Where I had once viewed it as a process of dying and merely delaying the inevitable, now I view it through his lens, as a process of living for the hope of living better, no matter what length of time we can give them. He had the strength to face every day with joy and positivity, and now I can do the same for my patients who don’t have that strength themselves. This is what has helped me become a better doctor.

Scarlett Hao, MD, is an Asian-American resident physician in general surgery at the East Carolina Brody School of Medicine. She received her medical degree from the University of Maryland School of Medicine and speaks multiple languages, including Spanish and Mandarin. She is happily married and enjoys board games, Marvel movies, and trying new restaurants. Her hope is to become an academic surgeon in the field of surgical oncology.