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Becoming a PA

The business of oncology

Allen, Greg PA-C

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Journal of the American Academy of Physician Assistants: August 2017 - Volume 30 - Issue 8 - p 1-4
doi: 10.1097/01.JAA.0000521141.46162.e0
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“Mr. Smith is dying,” Dr. Yarhi said as I walked through the door of the office.

Dr. Yarhi was the hematology-oncology fellow at the VA and my supervisor. He wore wire-rimmed glasses and a long, tightly buttoned white coat that almost touched the ground. His accent required focused attentiveness to understand, but it was well worth the effort as he was an insightful teacher.

“How do we know?” I responded as I hung up my jacket.

“He is septic. His serum lactate is 4.8, and his creatinine and LFTs are elevated and rising. We discussed this with the patient and his family yesterday, and they have decided to stop all treatments.” He paused and looked into his computer screen as if trying to gather his thoughts.

“You should go see him.” He glanced up and caught my eye to make sure I understood what he was saying.

Mr. Smith was my patient, so it made sense that I would check on him. I had been following him since he was admitted 2 weeks ago for a pleural effusion. In fact, he was the first patient assigned to me during the rotation.

BY CHOICE

Two weeks earlier, I was excited to start my hematology and oncology rotation because it was my first elective. I was an older student who had come to PA school after a career in business. I have always wanted to work in oncology.

On day 2 of the rotation, I was on the hematology/oncology inpatient consult service with Dr. Martin, the attending oncologist. He handed me a fax for a new inpatient consult for Mr. Smith, recently diagnosed with small-cell lung cancer (SCLC).

I looked up SCLC in UpToDate, and the prognosis of 8 to 13 months instantly caught my eye. I started thinking. Has anyone told Mr. Smith this news? Am I expected to tell him? I asked Dr. Martin what I should do.

“Go tell him what you know,” he responded.

I asked hesitantly, “Has anyone told him that he has cancer?”

He paused, looked over his glasses, and stared into his computer as he said, “They should have told him they suspect that he has cancer, but I doubt anyone has actually told him that he has cancer because the pathology report just came in this morning.”

“Are you going to go with me?” I asked.

He looked at me quizzically and replied, “You can handle it. If he asks anything you don't know the answer to, let him know we will be meeting as a team this afternoon and then coming to meet with him.”

As I walked down the hall, he shouted, “By the way, SCLC isn't curable. We can only offer palliative chemo.”

The words stopped me dead in my tracks. I stood there contemplating my next move. Should I turn around and refuse to see Mr. Smith on my own? I had never told anyone they have a terminal illness.

My body seemed to move in slow motion, but my mind was racing. I reminded myself that I wanted this rotation. This was my elective, I was here by choice, and I had specifically asked to not be sheltered as a student. I decided to proceed, reflected on what I knew on SCLC, and walked to meet Mr. Smith.

He was 65 years old and a bear of a man: 6 ft 2 in and 260 lb. He looked like a Harley rider with a white handlebar mustache and long white hair tied back in a ponytail. He appeared tough on the exterior, but when he saw me, he quickly sat up on the edge of his bed. I saw fear in his eyes. He knew why I was there.

“Hi, I'm Greg. I'm the PA student working with hematology and oncology. So, what do you know about your condition?” I asked, hoping he was already aware of his diagnosis.

His voice was gruff and deep, and I was surprised at how well it fit his look. “Well, I know that I have fluid around my lungs and they are concerned that a cancer might be the reason the fluid is there.”

His eyes were glued to mine, as if he was trying to get a read on what I was about to say.

“Some of the fluid that was removed from around your lungs was sent to pathology for analysis yesterday. We received the results back this morning, and I am sorry to inform you that you have cancer.”

For the first time in our interaction, he looked away, as if deep in thought.

“We also know from the pathology report that you have a type of cancer called small-cell lung cancer. Because we found the cancer in the fluid around your lungs, we know that this is a metastatic cancer. Unfortunately, it is incurable.”

As I spoke the words, he started to sob. His head hung as he sat on the edge of his bed. I walked over to his side and rested my hand on his shoulder.

“I am so sorry.”

Through his tears he asked, “So how long do I have?”

I remembered the 8- to 13-month mortality statistics I had previously seen, but I also recalled Dr. Martin's advice that if I felt I could not answer the questions, I should inform the patient that we would be meeting as a full care team later this afternoon.

“We do have palliative chemotherapy options available. This will slow down the cancer in your body, which should allow you to have a better quality of life.”

I realized as I was saying this that I was not directly answering his question. He seemed to accept my answer, though, and replied emphatically, “When do we start?”

“We will be meeting as a team today to discuss your case, and I will be sure to let them know you would like to proceed with chemo. When we return this afternoon we will discuss the next steps.”

He nodded his head, acknowledging his acceptance of my statements.

“Do you have any family in the area that could come and stay with you while you are in the hospital?”

“I have a couple of nieces close by. I have a son, but I haven't spoken to him in a while.”

At the mention of his son, he started choking up again. I imagined that there must be a deeper story that he wasn't willing to share with me, and I wasn't going to prod him. In that moment, I felt I had reached my limit on the amount of information I was comfortable sharing with him. Even though our time together was brief, I was exhausted and thought we both needed time to process what had just happened.

“If you don't have any more questions, I will plan on seeing you this afternoon.”

“Okay.”

I walked slowly back toward the office, replaying the conversation in my head. Had I said the right things? Should I have been more emotional? Had I shown enough compassion?

HEALING A BREACH

Mr. Smith's case became more complex in the days that followed. He did not start chemotherapy right away as he was still accumulating a lot of pleural fluid, which required the placement of a chest tube. Pulmonology wanted to perform a talc pleurodesis to prevent a recurrent pleural effusion once the chest tube had drained off most of the fluid. This delay in initiating chemotherapy became more of an issue as Mr. Smith was becoming more symptomatic with each passing day. I met with him daily, often stopping by twice just to see how he was feeling. And so I got to know Mr. Smith. Underneath the gruff exterior, he was a teddy bear of a man. He was kind, accepting, generous, and never complaining. During one of these daily meetings, I found out about his son. I'm glad I broached the subject. I was concerned that he was deteriorating and felt his son needed to come to the hospital if we wanted to see his dad again.

“You mentioned that you have a son you haven't spoken with in a while. Have you reached out to him?”

“I haven't called him yet. I haven't spoken to my son in almost 10 years. It's a long story. Besides, I don't think he would come anyways.”

“Do you mind if I speak freely?”

“Yeah, sure.”

“You are very sick. If I was your son, I would want to know. Irrespective of what may have happened in the past, I would still want to know that my dad has cancer and is in the hospital. I would want to know so I could decide if it was time to bury the hatchet.”

Nodding his head he appeared to be acknowledging my suggestion.

“Will you consider it?”

“Yeah, I will think about it.”

I changed the subject and explained that we were considering starting chemo with the chest tube still in. I told him the team had discussed his case and were concerned that delaying chemotherapy might give the cancer a chance to spread to his brain. I told him too that chemotherapy depletes the immune system and increases the risk of serious, even life-threatening infection.

“I realize this is a change from what we were talking about before, but we are more concerned about how your symptoms are progressing. What do you think about that plan?”

I asked the question more as a rhetorical one, as I knew that he wanted to start chemo and was concerned about the delay.

“I told you before that I want to start chemo. I will take the chance of infection. I've been looking on the Internet, and everything I'm reading says that small-cell is really aggressive and should be treated immediately.”

I jokingly cautioned him about doing too much Internet research. I assured him that the only reason we had not initiated treatment was the risk of infection. I told him we would be back in the morning with the full team to discuss starting chemo.

The following morning, Dr. Martin, Dr. Yarhi, and I made our way to Mr. Smith's room. As we entered, a man was standing in the corner. He looked like a younger version of Mr. Smith. Obviously, Harley riding ran in the family. Before anyone could speak, Mr. Smith said, “This is my son, John.”

Mr. Smith gave me a wry smile. I chuckled on the inside and was glad to see he had followed my suggestion.

Dr. Yarhi started the discussion by making sure Mr. Smith understood all aspects of the plan. “We are gravely concerned that if we delay treatment any longer, you may develop metastatic disease in areas that can cause severe, if not fatal, complications. Small-cell lung cancer is known to spread to the brain. Because you presented with metastatic disease, we feel that delaying the start of your chemo any longer is taking a huge risk of brain metastases.”

Mr. Smith nodded that he was in agreement.

“The obvious risk is infection caused by depletion of immune system cells. However, we will take all necessary precautions to prevent infection.” Dr. Yarhi said.

Mr. Smith continued nodding throughout the entire talk. “Let's do it,” he responded.

I continued to stop by each day while Mr. Smith received chemo. He spent about 3 hours receiving the infusion and the rest of the day resting. He started experiencing adverse reactions on the second day. He never really complained—just noted that he didn't feel well. Every day that I visited, his son was there. John asked a few questions but otherwise didn't say much. After the third day of chemo, you could see that the treatments were difficult for Mr. Smith. He was vomiting and looked miserable. He ended chemo on a Wednesday, and by Friday I thought he had turned a corner. His blood counts were low, but he looked healthy. He was joking with me about his plans versus my plans for the weekend. I wished him and John a good weekend, and I reminded him that I would see him Monday morning. He smiled and said, “Have a good weekend!”

THE TSUNAMI

When I returned to the hospital on Monday morning, Dr. Yarhi told me that Mr. Smith was dying. I grabbed my white coat and walked to his room. I knocked softly on Mr. Smith's door and entered. His son, standing in the corner, acknowledged me with a simple head nod. I walked over to the side of the bed. Mr. Smith was heavily sedated, and his respirations were labored, shallow, and irregular. Skin pallor demonstrated the lack of perfusion in his body. I took his hand. It was cool to the touch.

I quietly stated, “It was a pleasure to have met you, Mr. Smith.”

I didn't know if he could hear me or not. It didn't matter. I was going to say what I felt. The first time I came to his room, I had been told, “tell him what you know.” I told him only what I knew. I never speculated, never guessed. If I didn't know, I told him so. I knew that I wanted to let him know how much he had affected me on my journey in medicine.

“Thank you for allowing me into your life. I am a better person for having had the experience.” I wasn't sure if I was imaging it, but at that moment I felt his hand move ever so slightly in mine. Looking up, I met his son's eyes and saw tears streaming down his face. I responded with the same nod he had given me when I arrived, and I turned and left the room.

“Doctor .... Doctor,” the man's voice called, louder and more forceful than before. “Doctor,” the man was almost shouting now, and I turned to see if he was calling out to me, as patients often mistake me for a doctor. The voice came from Mr. Smith's son.

“Yes, sir,” I replied, walking back toward the room.

We stepped back inside. He looked down, as if trying to find the words that he wanted to say. He looked completely broken.

“I wanted to say thank you,” he said, his speech interrupted by tears that were turning into sobs. “I don't know if I would have been here if you hadn't been involved in my dad's care. I don't know how I could have lived with myself if I had missed this.”

He extended his hand, I took it, and we looked deep into each other's hearts. I didn't respond verbally. I didn't need to. I walked back into the hallway. I felt a tsunami of emotion sweep over me as I moved quickly down the hall. I was almost running by the time I hit the front doors to the hospital. I ran down the sidewalk and found a bench away from people. I buried my face in my hands and let the tsunami of emotions consume me.

About an hour passed, and I eventually began to gather myself. I noticed how warm it was outside. The sun was out, and birds were singing. A grizzled veteran out for a morning walk sat down on the bench next to me.

“Awfully nice out today,” he noted. “Feels like spring has finally arrived.”

I nodded, acknowledging that I was listening to him. I didn't want to turn and look at him, as I was sure my eyes were bloodshot.

“Great day to be alive!” he added.

“It sure is,” I replied, struck by the irony of that statement given what I had just experienced. “Well, I'd better get back to work. Have a great day,” I said as I walked back into the hospital.

LOSING AND WINNING

As I entered the office, Dr. Yarhi was working at his computer. I sat down, and he stopped typing. He knew what had just happened to me. He turned his chair to face me.

“That is the business of oncology,” he said softly and very deliberately. His accent somehow seemed more pronounced.

“You are going to lose people. In fact, you lose a lot of people. But not everyone dies. There are a lot of patients who respond very favorably and go on to live a long time where they would otherwise die untreated. Also, there is always that person who comes in with metastatic cancer that no one gives a chance to. They make a miraculous recovery and you are able to tell them that they are cancer-free. You let those who die push you to make sure that you are offering the next patient the best possible care, paying attention to every detail in hopes that they have a great outcome. You bask in the moments when you experience the shared joy of telling a person their body is cancer-free.”

He turned back toward his computer. After a moment, I logged into the health record. Instinctively, I clicked on Mr. Smith, as I had done every day for the past couple of weeks. A box that I had not seen before popped up in the middle of the screen.

“Patient is deceased. Do you wish to continue?”

I took a deep breath and paused.

“Are you okay?” Dr. Yarhi asked, without turning away from his screen but sensing what had just happened.

“I am fine,” I mumbled, my emotions still too raw to share.

I clicked on the “no” button and the warning box disappeared, replaced by the next name on the consult list.

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