Blog | Monday, May 15, 2017

Thanks for listening


When we walked into the room, you could sense the anger and frustration on the patient's face, as well as two other relatives in the room. We knew that the patient had had lung cancer for several months and had failed radiation and chemotherapy. He had labored breathing and looked miserable.

I went to his bed and asked if I could sit down on his bed. I took his wrist and began checking his pulse. Then I asked him to tell his story.

The 50-something patient had many pack years of cigarettes. He understood his diagnosis and wanted to pursue further treatment options. His breathing had worsened, partly due to metastases in his upper chest.

He greatly disliked his oncologist and the radiation oncologist. He felt that they had not explained everything to him, and that they did not provide radiation to the upper chest mass.

He had clear metastases on CXR.

When we examined him, he was tachypneic and he was visibly uncomfortable breathing, yet his oxygen saturation was in the 90s. His lung sounds were clear. His heart was regular and without murmurs or rubs.

We told him that we we might be able to eliminate the cancer, but that we would do everything possible to make him feel better. We told him that we would work to get a different oncologist.

After we left the room, the team huddled. His number one problem was a sense of breathlessness. Our excellent palliative care physicians had taught me that low dose morphine worked wonders for breathlessness. We decided that we would use low dose morphine while we sorted out his other problems. So we went back into the room and explained the “game plan”.

The next day our patient had transformed. The entire room (now about 5 family members) and the patient were smiling and happy to see us. The patient and his family told us how pleased they were that we listened to him and did something to help him feel better.

He stayed in the hospital 2 more days, now able to walk in the halls. We found a different oncologist who offered him a newer biological option. The patient and his family understand that it might not work, but they wanted to try it. We continued the low dose morphine which “worked magic” for our patient.

At our last meeting before discharge, they thanked us enthusiastically. We had just done our job. We listened to the patient. We worked to address his needs. We worked to make each day the best it could be. We made no promises about quantity, but we did our best to optimize quality. They thanked us for listening.

In some ways we were embarrassed. The resident had spent much time with the family and the patient. She had spent time listening and reassuring. This is our job. We listen to our patients and do our best to respond to their discomforts. We really did not do anything that special, but it appeared that way to our patient and his family.

When we debriefed the team later that morning, the students and interns commented on what they had learned. For this patient the learning was not about physiology, anatomy or pharmacology. For this patient the focus was listening and reacting appropriately.

We did a great deal for this patient, while actually doing very little. Patients appreciate our honest concern and attempts to help their symptoms. And that takes time – time well spent.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.