It had been an uneventful Sunday morning, and I was writing my final note for the day, hopeful to make a stealth exit and perhaps join my family at church. But as I closed the chart and looked up, I saw Ruthie, my oncology fellow, approaching with a grim expression. “I just left the room of a young woman with locally advanced nasopharyngeal carcinoma who weighs 350 pounds, has a tracheostomy, cannot speak, and had an emergent biopsy done Thursday. The case was signed out on Friday, but the surgical team just called us for an emergent consult.”
James W. Lynch, MD
She had presented with stridor and respiratory failure and was taken to the operating room immediately to open her airway surgically. After reviewing the sparse records and pathology report, we entered the patient’s room, finding Gloria sitting in bed gripping the bedrails tightly. Even with the oxygen tent covering her tracheostomy, her oxygen saturations were barely aerobic. She stared straight ahead, never making eye contact while we introduced ourselves and asked if we could talk to her about her condition. She shook her head, and frankly, we could not tell whether she did not understand or was unwilling to talk. Nurses and aides sprinted in and out of the double room attending to the patient behind the curtain, which added to the uneasiness. As I examined her neck, massive nodes the size of lemons had coalesced into an immovable collar, rock hard and so constraining her oral function that she could barely swallow. When she did, small streams of saliva dribbled from the corners of her mouth.
HER PERSISTENT hypoxemia was in no small part a result of her obesity. She had signs of obesity hypoventilation syndrome, hitherto undiagnosed because, as far as we could tell, she had received little if any medical care until this hospitalization. Despite her obesity, she was also malnourished, no doubt a combination of her decreased ability to eat, years of an unhealthy diet, and perhaps undiagnosed metastatic cancer. “When did you first notice the lumps? Have your doctors explained what is wrong with you?” No matter what the question or how simply phrased, there was no recognition in her eyes, only fear and confusion.
We searched for family to help with communication, but they were gone, and attempts to reach them were fruitless. We also learned from the nurses that Gloria had dropped out of school because she was “slow,” as her family put it. I had always considered myself skilled at communicating with patients from any background, but I was striking out. The combination of fear, lack of education, and her simplicity made our attempts to share even basic information an utter failure. If anyone needed the best medical care, it was this young woman, but we had no way to discuss with her the disease and its treatment. Although she was likely beyond the reach of curative therapy, we could surely offer her palliative treatment. After we did our best to comfort and give some hope, we left the room dejectedly returning to the nurse’s station. We made brief eye contact and shook our heads as we tried to cobble together some sort of plan to help while feeling the immense weight of our failure. I then said aloud, “God help us.”
Compassion Hardens to Anger
MOST PHYSICIANS have a deep virtuous desire to help the sick when entering medical school. I like to say young students are naive idealists about the profession. However, when reality emerges and they encounter a broken world that includes illness, despair, poverty, ignorance, prejudice, and other social ills, that naive idealism begins to crumble. Furthermore, we work within a broken health system (no matter which system), see fractured family relationships, meet patients who can be their own worst enemies, and come to realize our own inadequacy as physicians and human beings. It then becomes easy to look for someone to blame, or worse, develop a kind of jaded cynicism. Left unchecked, cynicism undermines compassion and empathy, darkens the soul, and robs us of the joy of practicing medicine.
“Today had become about me, not about my patient, as my lack of compassion had deteriorated into a selfish desire to run away.”— James W. Lynch, MD
That Sunday, Ruthie and I felt both helpless and hopeless as we tried to chart a way forward. Radiation? Surgery? Chemotherapy? Hospice? Social services? Pain control? No matter how we tried to frame a plan, it did not feel right. I could feel my compassion hardening into something sinister, like anger.
Why hadn’t she come in sooner? How in the world could her family ignore all her medical issues? Did they think it was normal to have masses choking you to death? Why had the surgeons waited until Sunday morning of all times to call an emergent consult when the diagnosis was made 2 days ago? What was I supposed to do to fix her?
Defeated and more than a little irritated, we lost ourselves in the chart, trying to say something of value. I have typically found a certain comfort in the ritual of putting my thoughts and recommendations to pen and paper, but not that day. In fact, I felt the shroud of shame, shame I had earned, chastising me for wanting to blame the patient and her family for her illness. Today had become about me, not about my patient, as my lack of compassion had deteriorated into a selfish desire to run away.
An Unusual Visitor
THAT SUNDAY MORNING, we had an unusual visitor to the nurse’s station—an elderly man, a bit gaunt and clearly out of place. He was sitting in a therapy chair, leaning over the tray wearing a light green faded hospital gown only partially tied. His gown had slipped down, allowing his right shoulder to peak out, and his head slumped forward in sleep. His sparse tufts of white hair were fighting one another for a place to lie down, but without success. He was wearing a support garment, a combination vest and harness to prevent him from doing a face plant in his food. His arms were lifeless on the tray, his hands a bit drawn, and his legs thankfully covered by the gown; a sheet helped preserve some sense of his dignity.
He had been moved into the hall to facilitate a clean-up project, but as a large clot of physicians and staff made their way down the hall with their cart and a patient came the other way from the elevator on a stretcher, our visitor was rolled to safety behind the protective wall of the nurses’ station. I had noticed him as Ruthie and I ventured toward Gloria, and like everyone else, ignored him like a piece of broken furniture one had to walk around on the way to doing the real work of seeing patients.
While muttering to myself and writing in the chart sorting through my guilt, I noticed him again out of the corner of my left eye. Turing my head, I for the first time truly saw him. Now far from being “out of it,” he was sitting upright, his eyes full of playfulness and on his face a sly grin as he scanned the nurses’ station deliberately sizing up all of the activity. Then without warning or prelude, in the midst of the chaos, this elderly, somewhat impaired man began slowly singing a beautiful old hymn. His voice was clear, full, and pitch perfect. He was smiling broadly and turned his head rhythmically from left to right, making eye contact with all who would dare return his gaze.
Initially there were a few audible snickers, but a growing flood of awe and wonder quickly washed them away. Nurses, electrocardiogram technicians, food service workers, nursing assistants, ward clerks, students, and physicians all stopped their work. By the end of the first stanza, all activity had ceased, and there was absolute silence save for his voice. Everyone had turned in his direction, and those in little cubby holes or the lounge came out to see the source of this angelic sound. He sang with the kind of selflessness, confidence, and kindness that simply melted all icy hardness and cynicism in one’s heart. The virtues of compassion and love surfaced again in my heart as I listened. Ruthie and I looked at one another with tears streaming, feeling renewal from the last place we would have expected.
THE MELODY of this old hymn flows lyrically like a combination of a love song and a lullaby. Its title and lyrics assert a simple faith that no matter how difficult one’s circumstances, “God Will Take Care of You.” I had sung this hymn as a young man and as a person of traditional Christian faith had always believed this, at least as a theologic proposition. But my faith took on a different quality and depth in the wake of this encounter. Perhaps it was seeing this man living out the words of the Psalm, “. . . even though I walk through the valley of the shadow of death, I will fear no evil, for Thou art with me.” Maybe this was an example of Marshall McLuhan’s famous aphorism, “The medium is the message.” If this man trusted God in the midst of his affliction, surely I could trust Him and be the physician I was called to be. Soon after he finished his song, many of us nodded our gratitude, our daily activities resumed, and the nursing staff returned him to his room. I never saw him again.
“With the passage of time, it has become clearer to me how much I learn about life from my patients and how easy it is to miss those lessons.”— James W. Lynch, MD
I wish I could say that this experience enabled me to suddenly be able to reach Gloria and communicate more fully, but that never happened. The absence of a connection with her still haunts me to this day. However, the man in the vest had awakened me from my self-pity and a bit of fog cleared. Ruthie and I then had the clarity of thought to realize Gloria needed the care of our intensivists, rather than emergent chemotherapy or radiotherapy. Focused now on her needs, rather than my fatigue and sense of failure, I had the presence of mind to facilitate her transfer to the intensive care unit. With appropriate treatment, she improved and went on to receive palliative chemotherapy and radiation under the care of a colleague.
More than 20 years have passed since that day. With the passage of time, it has become clearer to me how much I learn about life from my patients and how easy it is to miss those lessons. With a slight change in the circumstances and timing, I might have slipped out quickly to be with my family and perhaps even made it to our church service. Had I done so, I would have missed what turned out to be one of the most spiritually enriching experiences of my life. I never knew his name, but I will never forget the way the ailing man in the vest served as a channel of God’s grace, restoring joy and perspective to each of us who were there that Sunday morning. ■
At the time this article was published in the Journal of Clinical Oncology, Dr. Lynch was a medical oncologist at the University of Florida College of Medicine, Gainesville.