sometimes, you have to be pleased with small accomplishments

(image courtesy of xkcd.com)

I spent the day today in gyn-onc clinic, feeling, for the most part, useless and in the way. As a medical student, there is so much we don't know or don't have the power to decide. We go in, we barely have time to say hi and get the chief complaint before the resident barges into the room (in the interest of time, of course). If we're aggressive, we can snatch in a few questions or an abbreviated exam before it's on to the next anxious patient. Wowee!!

It was sheer luck, then, that I had one patient today with whom I was able to spend a fair amount of time. The residents had actually presented her at Tumor Board this morning as an example of a non-compliant patient who was now experiencing a recurrence of her cancer, and the topic of discussion had been how to best treat a patient who is now at high risk for complications given her need for repeat radiation therapy (not to mention what would happen if she again didn't finish her treatment). This was the dreaded impression I had when I went in.

I don't think anyone would have fallen in love with her at first glance - the neurofibromatosis nodules were scattered unpleasantly over her face, she was poorly dressed, and her initial manner was aloof. But after just a few minutes of talking to her, it was clear that underneath the tough facade was a scared woman who was acutely aware that the doctors here thought her an ignorant psycho who didn't give a damn about her body. Her discomfort was warranted. Both the oncologist and the radiologist who came in to speak to her were stern, and the radiologist's explanation of the risks of additional radiation was shrouded nonsense. When she started to tear, he had only the grace to look uneasy.

Perhaps it is the case that all people, when faced with enough tragedy, become jaded. Moreover, I can understand their frustration - it isn't easy pouring your heart into somebody, and it is a rejection when they refuse to meet you halfway. So this post is less about the shortcomings of physicians than the obligations of medical students. Put simply, we are the naive, the ones who are meeting the patients with fresh eyes, the ones who have not yet been shat upon. As such, it is our responsibility to compensate for the distance of our superiors, to provide kindness even if it is, ultimately, unwarranted.

I only had to stay in the room a few extra minutes to explain to her the risks of her needed radiation therapy, and why it was so important - difficult as it is for her to drive 100 miles to our clinic - to keep all our appointments. It felt good to be able to explain why surgery wasn't an option for her, and it felt good to be the person who made sure she got to talk to social work and came up with a feasible plan for receiving her radiation. I may be useless 99.9999% of the time, but it's that little 0.0001% that makes you want to stay in medicine.

Today's episode also brings up an important topic in cancer care, which is its huge regional bias. Everyone serious about oncology trains at a major city, where the research is good and patients are abundant. But statistically speaking, most cancer patients live outside the borders of these major cities, in the rural and suburban areas where preventative programs are scarce and support networks are stretched. I spent a good amount of time talking to my colleague about this access barrier this afternoon, but neither of us can think of a good solution.

Telemedicine, which is getting some publicity in areas such as Emergency Medicine, has limite utility in oncology because, as my attending pointed out, you can't telemedicine PET scans, chemotherapy, and other tools that don't exist in the target area. Satellite clinics, another option, faces the difficulty of staying financially afloat in areas where patients are scarce, yet still take up a lot of healthcare dollars for their expensive and lengthy treatments and tests. So far, I know of no satellite oncology centers that can serve the indigent. Another solution, which has been used with some success in mammography, is to create mobile clinics that can travel to the patients themselves. Of course, they would have nowhere the resources that an academic center has, but it is feasible that they could at least provide chemotherapy and radiation treatments, as well as physician consultation. Personally, I like this solution although I don't know of any place that does it - most likely due to cost, as is everything in medicine. Finally, you could improve the transportation system itself, but I think this would have to be done by the federal government and the DOT because the grassroots transportation aid programs that exist can serve only a few areas. But better than none - my patient is going to try to find a driver from the Georgia Cancer Society.

I'll sum up this post with a quote from Anne McCaffrey, an American science fiction writer, which I think is wise and a good motto to go by: "Make no judgments where you have no compassion."