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The Art of Medicine


Sweeney, Cameron Young MMS, PA-C

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Journal of the American Academy of Physician Assistants: March 2020 - Volume 33 - Issue 3 - p 58
doi: 10.1097/01.JAA.0000654024.78957.a8
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The magazine ad promoted financial planning, but the headline intrigued me. “What kind of legacy will you leave?

My interest was piqued not with regard to a bequest of money or property but in a broader sense: something transmitted by a predecessor or received from the past.

I reflected on a preceptor from a clinical rotation during PA school. Each family medicine provider worked late one evening per week to see established patients for scheduled follow-up visits; this extended access to medical care to the working-class residents of the rural town. The evening hours were not intended for walk-ins or new patients. With only a few minutes before the front door would be locked one Thursday, the waiting room was empty and we were winding down our workday.

A thirty-something woman in jeans and a faded Harley Davidson T-shirt burst in, pushing a thin, disheveled woman in a wheelchair. They didn't have an appointment, and the mother hadn't been seen at the practice in years. She looked ill. When front office staff suggested that they go to the ED or, if the problem was less urgent, make an appointment for the next day, the daughter raised her voice. “My mother is hurting, and we are here, and someone needs to helphernow.”

I was sent to take the history. I don't recall the details of the case. What I do remember is the emotional challenge of the encounter. The daughter was disagreeable, but the patient was utterly unreceptive. She was unwilling to answer history questions. She refused the physical examination. She complained that she didn't want to be evaluated and just wanted to go home. I remember my aggravation. “Okay, fine,” I thought. “You don't want to be treated, whatever.” I imagine my attitude became dismissive. But the PA displayed far more grace than I did. She smiled broadly and sat down with the patient as if there were nowhere she would rather be. “Tell me about your pain.” She smoothly defused the family's hostility. She narrowed her differential, ordered diagnostic tests, wrote a prescription, and scheduled a follow-up. As they moved to leave, the patient's daughter grabbed the PA's arm and whispered her thanks. It was among the most important lessons of my training.

Fast forward to my first day as a freshly certified PA starting in oncology. I shadowed a PA as she interviewed a newly diagnosed patient who had already decided not to pursue any treatment. “I'm ready to die,” Diana wept. But of course she wasn't. Her cancers were treatable, and the PA and the oncologist spent hours convincing her to proceed not only with surgery, but also with pre- and postoperative chemotherapy and radiation.

Over the next 18 months, I saw Diana regularly. She got a mild rash; she lost her hair. She developed diarrhea, constipation, oral candidiasis, neuropathy, and anemia, but her body actually tolerated therapy fairly well. Her anxiety was so significant, however, that she protested against treatment at every visit. We cajoled, coaxed, and persuaded her. Eventually, her hair grew back. Diana became a survivor. After she successfully completed therapy, she sent a thank you note to her healthcare team that cataloged what she most remembered of each of us. The oncologist's persistence, the surgeon's confidence, the radiation oncologist's handwritten notes. She noted the first PA's assurance that “we were in it together,” the nurse's encouragement that she was “doing great,” the receptionist's smiling welcome, and the guitar player in the chemo room who sang “Amazing Grace.” She detailed my “gift... to look into your eyes and hear what is not even said. Cameron always made me feel heard.”

A famous quote describes the effect we have on others. “They may forget what you said, but they will never forget how you made them feel.”

As I have progressed in caring for cancer patients, I have come to understand that treatments can be of limited efficacy. Opioids lessen but rarely eliminate cancer pain. Chemotherapy can provide months or years of remission, but cancer often returns. What we as providers can offer with lasting effect is presence and attention.

After a patient with metastatic cancer missed her appointment recently, I called to see what happened. Valeria's memory was failing, either from her brain metastases or the radiation to them. At her rescheduled visit the next day, she looked fragile and frightened. A friend I didn't recognize sat in the corner. As I hugged Valeria, the friend observed, “Your face just softened; you look visibly more relaxed.”

“She has been with me from the start.” Valeria's voice wavered. “I love her.”

The PAs before me demonstrated the lessons of attention. I know now that my legacy is also one of intention.

Copyright © 2020 American Academy of Physician Assistants