There are a dozen or so patients that I want a second chance at. I wonder if, knowing what I know now, would I manage things differently? Would the outcomes be different? Would some of the people still be here?
Having a profession that requires one to be responsible for the lives and deaths of other people takes a degree of bravery and self-confidence that I could never muster. I don't even own a dog because I'm afraid I would miss something and kill my dog by mistake.
That you would come back to these old cases and wonder "what if" strikes me as both very brave and a bit heartbreaking. Actually, I see it as another manifestation of your desire to alleviate suffering and to make the world a better place by interrogating yourself over decisions you can never revisit.
But I feel that in the case of the last patient, you might have saved yourself some unnecessary torment and confusion if you had looked at his case a different way. Death is the Big One. Ain't nothing like it. None of us can possibly predict how we're going to feel when we get the bad news, regardless of how certain we were five minutes before we receive the diagnosis.
The way people approach their own deaths is impossible to predict ahead of time, and it covers the gamut, as I don't have to tell you. (I'm not a medical professional, but I was a hospice volunteer for many years, so I was privileged to see the full range of responses.)
Anyway, in the case of the man who put himself through months of chemo and hospitalizations because he had changed his mind about how he wanted to die: I'm speculating that when Death came calling, this man was super-charged with covetous greed and love for his one and only life. His one and only life. That's all.
There's a Black spiritual that I'm reminded of: "Think I'll run on, see what the end is gonna be." He wanted to see, even his death, right up until the last breath.
On a meta level, I see a fine line between learning from the past and ruminating on it. The patients I've lost (a very finite number in my young career) weigh on me. I know who they were. I know what happened to them. But I don't keep any sort of record of patients I've seen, and in a way I think that's probably good for my mental health. They effect me, but more in an impressionistic way. I expect their cases will fade from my memory and the lessons learned will integrate into my broader corpus of knowledge, but maybe there are some things I'll never forget.
Dr. Cifu, I always enjoy reading your Friday reflections. Although not a physician myself, I learn a lot from them about medicine and life. But I'll just point out one minor typo, which could be corrected if you plan to publish your post elsewhere.
Under the heading "I should have admitted her", you refer to a former patient (now deceased) with cancer whom you treated as an outpatient:
"It is hard to imagine that the experience, for PF’s family if not for her, would have been less stressful had I brought her into the hospital a few times during her final months." I believe the word "less" is an error here, and should instead read "more".
I look forward to reading more of your reflections.
I perceive primary care to be the most approachable and noblest sphere within medicine. My sincerest thanks to you for your invaluable contributions towards improving quality of life and alleviating human suffering. There truly is no more rewarding pursuit. I firmly believe that if any positive outcomes arise from other professions or advanced technologies, such as AI and cutting-edge diagnostic tools, they all invariably aim to optimize primary care. They work in concert, enhancing its effectiveness and reach, further cementing its essential role in healthcare.
"My Back Pages", Byrds version. The Faces song, nope! Thank you. I have such empathy for thoughtful, compassionate physicians like yourself. Early 1990's after watching 69 y.o dad suffer and decline horribly after experimental chemo at Mass General for inoperable lung cancer, I vowed I would never agree to that. The blasé attitude of his esteemed oncologist did not help. Dad had history of smoking (despite quitting 25 years prior) and asbestos exposure and was willing to try anything. His miserable death occurred 2 months after diagnosis. I've often wondered: would he/we have managed things differently?
As an R.N. since '83 I've researched mammography intensively, my first at age 38 due to an aggressive PCP. After 7 mammos, one negative U/S after a digital mammo, and becoming aware of rampant overdiagnosis and overtreatment, I decided against the yearly terror of this surveillance. My new 30 y.o. PCP wrote me via My Chart a month after my last visit, the first in 3 years due to Covid (barely examined me, said "we have 3 minutes left" when I asked a question.) In My Chart he asked if he could "assist in scheduling a mammogram or do you elect against breast cancer screening?". I found his choice of language "elect against" off-putting yet I know he is working under a punitive corporate system. I don't envy the new crop of physicians and what they're up against. I also fear this documentation could be used against me by insurance companies.
Damned if you do, damned if you don't. I am tempted to find a new PCP who is 50+ and accepting new patients (hard to find these days).
Will I change my mind about screening and treatment with advancing age? Only time will tell. ;-)
Doc...don't mean to be rude but I didn't see any discussion mentioned about nutrition, gut health or strengthening your immune system. Where IS the prevention instead of ONLY treatment??
You mention how “TP” had never undergone another mammogram after her 1st one. It comes across as if your implying that her lack of mammograms had something to do with her terminal breast cancer diagnosis. Dr. Vinay Prasad recently did a great episode where he discussed the fact that there is zero data showing mammograms have reduced the number of breast cancer deaths. Perhaps you did not intend for it to read this way.
Thanks for sharing all of these cases with us. As always, beautifully written. It highlights for me the actual cognitive work that goes into being a general internist- especially the position we often have to counsel a patient on major decisions about end of life care. After 20 years of general internal medicine and pediatrics practice, what I have come to realize is that, for many of my patients who state strong objections to aggressive end of life care when they are healthy, their decisions about amount of life sustaining treatment they wish to have change dramatically when actually confronted with a serious medical illness. I often cannot predict who will have a dramatic change in wishes. I have had a number of conversations with these patients who recall their prior statements about life not being "worth living" if they have to be in a nursing home or survive a stroke. Their health declines and their priorities change and, for one woman she said that as long as she can sit in her nursing home bed and have a chocolate mousse and look out the window, that is a good quality of life for her. I still ask healthy patients about end of life wishes but often focus more on who they want to name for their health care proxy and ensuring that person understands their values and would be able to institute substituted judgement in an appropriate way. When patients are actually facing a severe illness, this is when I find a goals of care conversation to be most helpful -when actually planning for the next six months of life with a realistic lens on what impact the medical prognosis will have on quality of life. I think it might boil down to the face that we, as humans, are unable to truly understand that we have many competing values. While a young, healthy person might think that they would rather die than accept help from someone else for toileting, when the choice becomes accepting that help and being alive to witness a grandchild's graduation versus not being alive, their decisions can change. What motivates us to be alive changes as we age and are faced with new limitations. Our priorities shift and we often rearrange the order of importance of our values given a change in circumstances.
I agree, Adam. I'd visit the past 10 times over the future. I'll say this, though. I take comfort in the fact that God is sovereign and allows all things to play out for a reason. All well-founded arguments on theodicy aside, I take solace that my decisions (whatever the outcomes) as a physician and the decisions of my patients have a place in God's ultimate decree of time and events. I have learned so much from my mistakes and my near-misses...much more than my successes. I think that's partly bc I, like you, will rake myself over the coals when a patient dies. We, as internists, need to do that...but we don't need to live in that headspace. I'm thankful for your entries...feel like I'm reading my own life as a primary internist spill out in text right before me. Cheers and thank you!
As usual Dr. Cifu I am totally captured by your recollections.
I spend a fair amount of time ruminating about the patients I've taken care of. I've played the, "woulda - coulda - shoulda games and given myself a migraine. I'm really good at what I do. I know there is a time when no matter what my treatment, suggestion, course of action is the outcome is going to be the outcome it's supposed to be. I'm ok with that. I trust there is a power much greater than mine who is actually steering the ship. I always do my best until there is nothing left to do. I sleep at night. I may sleep with tears, but I sleep.
Adam, I’m certain that you have a deep faith in something “greater” than you, and as a recovering Catholic I have had to redefine my greater power over the years. Suffice to say it’s pretty strong these days now that I’m not as smart as I was when younger (great song choices).
Two “what if” patients that come to mind include the first one lost on my watch, and the last one. Both were active in their addiction. The first was cussing family members and I was asked what to do. I stated that what I would do is not what I would suggest but offered no detail beyond the statement; all I did was encourage them to follow their principals and hearts. They did, the patient got angry and booted a hot shot and was likely gone before he hit the ground. I would have liked another week with that patient.
The second was a potential HIPAA violation that, now that the person is no longer on earth, I would have preferred to toss the dice; reporting the person to the proper folks, and the patient - perhaps would have been angry and maybe even litigious - but alive.
I am, however, a deep believer in God’s grace and also in God’s plan. The short and long of it is that as long as I’m doing my best. I know that God is the ultimate authority and that a person’s success or lack therein is really not because of anything I did or didn’t do.
The faith I’m grateful for today lets me sleep at night though, simply because I know I did and continue to do my best, as I know you know you do.
I would be honored to have you as my PCP for my old complex body - it’s very clear that you follow the rules of caring for patients. Starting with the first rule of care...which is to CARE! Thanks for a great essay.
It continues to amaze me reading these types of examples you often write about. I've been thinking a lot about death but you're dealing with it directly.
I love this and I am grateful for the wonderful posters here. It feels like a solidarity of physicians that adore their profession and care about their patients. I sincerely hope that as we slide into the future that more physicians join or return to that club.
This is a beautiful , compassionate view of previous patients . It tells me of your dedication and empathy for all your patients both then and now.
Having a profession that requires one to be responsible for the lives and deaths of other people takes a degree of bravery and self-confidence that I could never muster. I don't even own a dog because I'm afraid I would miss something and kill my dog by mistake.
That you would come back to these old cases and wonder "what if" strikes me as both very brave and a bit heartbreaking. Actually, I see it as another manifestation of your desire to alleviate suffering and to make the world a better place by interrogating yourself over decisions you can never revisit.
But I feel that in the case of the last patient, you might have saved yourself some unnecessary torment and confusion if you had looked at his case a different way. Death is the Big One. Ain't nothing like it. None of us can possibly predict how we're going to feel when we get the bad news, regardless of how certain we were five minutes before we receive the diagnosis.
The way people approach their own deaths is impossible to predict ahead of time, and it covers the gamut, as I don't have to tell you. (I'm not a medical professional, but I was a hospice volunteer for many years, so I was privileged to see the full range of responses.)
Anyway, in the case of the man who put himself through months of chemo and hospitalizations because he had changed his mind about how he wanted to die: I'm speculating that when Death came calling, this man was super-charged with covetous greed and love for his one and only life. His one and only life. That's all.
There's a Black spiritual that I'm reminded of: "Think I'll run on, see what the end is gonna be." He wanted to see, even his death, right up until the last breath.
At least, that's what I think.
On a meta level, I see a fine line between learning from the past and ruminating on it. The patients I've lost (a very finite number in my young career) weigh on me. I know who they were. I know what happened to them. But I don't keep any sort of record of patients I've seen, and in a way I think that's probably good for my mental health. They effect me, but more in an impressionistic way. I expect their cases will fade from my memory and the lessons learned will integrate into my broader corpus of knowledge, but maybe there are some things I'll never forget.
Dr. Cifu, I always enjoy reading your Friday reflections. Although not a physician myself, I learn a lot from them about medicine and life. But I'll just point out one minor typo, which could be corrected if you plan to publish your post elsewhere.
Under the heading "I should have admitted her", you refer to a former patient (now deceased) with cancer whom you treated as an outpatient:
"It is hard to imagine that the experience, for PF’s family if not for her, would have been less stressful had I brought her into the hospital a few times during her final months." I believe the word "less" is an error here, and should instead read "more".
I look forward to reading more of your reflections.
I perceive primary care to be the most approachable and noblest sphere within medicine. My sincerest thanks to you for your invaluable contributions towards improving quality of life and alleviating human suffering. There truly is no more rewarding pursuit. I firmly believe that if any positive outcomes arise from other professions or advanced technologies, such as AI and cutting-edge diagnostic tools, they all invariably aim to optimize primary care. They work in concert, enhancing its effectiveness and reach, further cementing its essential role in healthcare.
"My Back Pages", Byrds version. The Faces song, nope! Thank you. I have such empathy for thoughtful, compassionate physicians like yourself. Early 1990's after watching 69 y.o dad suffer and decline horribly after experimental chemo at Mass General for inoperable lung cancer, I vowed I would never agree to that. The blasé attitude of his esteemed oncologist did not help. Dad had history of smoking (despite quitting 25 years prior) and asbestos exposure and was willing to try anything. His miserable death occurred 2 months after diagnosis. I've often wondered: would he/we have managed things differently?
As an R.N. since '83 I've researched mammography intensively, my first at age 38 due to an aggressive PCP. After 7 mammos, one negative U/S after a digital mammo, and becoming aware of rampant overdiagnosis and overtreatment, I decided against the yearly terror of this surveillance. My new 30 y.o. PCP wrote me via My Chart a month after my last visit, the first in 3 years due to Covid (barely examined me, said "we have 3 minutes left" when I asked a question.) In My Chart he asked if he could "assist in scheduling a mammogram or do you elect against breast cancer screening?". I found his choice of language "elect against" off-putting yet I know he is working under a punitive corporate system. I don't envy the new crop of physicians and what they're up against. I also fear this documentation could be used against me by insurance companies.
Damned if you do, damned if you don't. I am tempted to find a new PCP who is 50+ and accepting new patients (hard to find these days).
Will I change my mind about screening and treatment with advancing age? Only time will tell. ;-)
you are a gifted writer. Thank you for sharing these.
Doc...don't mean to be rude but I didn't see any discussion mentioned about nutrition, gut health or strengthening your immune system. Where IS the prevention instead of ONLY treatment??
You mention how “TP” had never undergone another mammogram after her 1st one. It comes across as if your implying that her lack of mammograms had something to do with her terminal breast cancer diagnosis. Dr. Vinay Prasad recently did a great episode where he discussed the fact that there is zero data showing mammograms have reduced the number of breast cancer deaths. Perhaps you did not intend for it to read this way.
Thanks for sharing all of these cases with us. As always, beautifully written. It highlights for me the actual cognitive work that goes into being a general internist- especially the position we often have to counsel a patient on major decisions about end of life care. After 20 years of general internal medicine and pediatrics practice, what I have come to realize is that, for many of my patients who state strong objections to aggressive end of life care when they are healthy, their decisions about amount of life sustaining treatment they wish to have change dramatically when actually confronted with a serious medical illness. I often cannot predict who will have a dramatic change in wishes. I have had a number of conversations with these patients who recall their prior statements about life not being "worth living" if they have to be in a nursing home or survive a stroke. Their health declines and their priorities change and, for one woman she said that as long as she can sit in her nursing home bed and have a chocolate mousse and look out the window, that is a good quality of life for her. I still ask healthy patients about end of life wishes but often focus more on who they want to name for their health care proxy and ensuring that person understands their values and would be able to institute substituted judgement in an appropriate way. When patients are actually facing a severe illness, this is when I find a goals of care conversation to be most helpful -when actually planning for the next six months of life with a realistic lens on what impact the medical prognosis will have on quality of life. I think it might boil down to the face that we, as humans, are unable to truly understand that we have many competing values. While a young, healthy person might think that they would rather die than accept help from someone else for toileting, when the choice becomes accepting that help and being alive to witness a grandchild's graduation versus not being alive, their decisions can change. What motivates us to be alive changes as we age and are faced with new limitations. Our priorities shift and we often rearrange the order of importance of our values given a change in circumstances.
I agree, Adam. I'd visit the past 10 times over the future. I'll say this, though. I take comfort in the fact that God is sovereign and allows all things to play out for a reason. All well-founded arguments on theodicy aside, I take solace that my decisions (whatever the outcomes) as a physician and the decisions of my patients have a place in God's ultimate decree of time and events. I have learned so much from my mistakes and my near-misses...much more than my successes. I think that's partly bc I, like you, will rake myself over the coals when a patient dies. We, as internists, need to do that...but we don't need to live in that headspace. I'm thankful for your entries...feel like I'm reading my own life as a primary internist spill out in text right before me. Cheers and thank you!
As usual Dr. Cifu I am totally captured by your recollections.
I spend a fair amount of time ruminating about the patients I've taken care of. I've played the, "woulda - coulda - shoulda games and given myself a migraine. I'm really good at what I do. I know there is a time when no matter what my treatment, suggestion, course of action is the outcome is going to be the outcome it's supposed to be. I'm ok with that. I trust there is a power much greater than mine who is actually steering the ship. I always do my best until there is nothing left to do. I sleep at night. I may sleep with tears, but I sleep.
“I may sleep with tears, but I sleep.” 🙏
Adam, I’m certain that you have a deep faith in something “greater” than you, and as a recovering Catholic I have had to redefine my greater power over the years. Suffice to say it’s pretty strong these days now that I’m not as smart as I was when younger (great song choices).
Two “what if” patients that come to mind include the first one lost on my watch, and the last one. Both were active in their addiction. The first was cussing family members and I was asked what to do. I stated that what I would do is not what I would suggest but offered no detail beyond the statement; all I did was encourage them to follow their principals and hearts. They did, the patient got angry and booted a hot shot and was likely gone before he hit the ground. I would have liked another week with that patient.
The second was a potential HIPAA violation that, now that the person is no longer on earth, I would have preferred to toss the dice; reporting the person to the proper folks, and the patient - perhaps would have been angry and maybe even litigious - but alive.
I am, however, a deep believer in God’s grace and also in God’s plan. The short and long of it is that as long as I’m doing my best. I know that God is the ultimate authority and that a person’s success or lack therein is really not because of anything I did or didn’t do.
The faith I’m grateful for today lets me sleep at night though, simply because I know I did and continue to do my best, as I know you know you do.
I would be honored to have you as my PCP for my old complex body - it’s very clear that you follow the rules of caring for patients. Starting with the first rule of care...which is to CARE! Thanks for a great essay.
Thanks so much for the thoughtful read and comment. Definitely extends my thinking.
It continues to amaze me reading these types of examples you often write about. I've been thinking a lot about death but you're dealing with it directly.
I love this and I am grateful for the wonderful posters here. It feels like a solidarity of physicians that adore their profession and care about their patients. I sincerely hope that as we slide into the future that more physicians join or return to that club.
The hallmark of a committed professional: always asking "How could I have done better?" 👏
That is a really good line! (I might need to steal it in the future. 😉)