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Medical Schools, Patient Care, Stanford Medicine Unplugged

What happens when you can’t communicate with your patient?

What happens when you can’t communicate with your patient?

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

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Over the past eight months, I’ve rotated at the Palo Alto VA, Santa Clara Kaiser, Stanford outpatient family medicine and pediatrics clinics, and most recently, at Santa Clara Valley. At the VA and Kaiser, all my patients spoke English. Occasionally, at Stanford’s outpatient sites, our patients spoke a language other than English; however, this never felt like a barrier to care because Stanford had phone interpreters available, as well as iPads on wheels that you could use to videoconference in an interpreter. These resources made it feel as though the interpreter was right there in the room with us. And indeed, they could not only hear the patient’s words but also see their expressions, adding an extra dimension to the interpreting services they generously provided.

Valley, however, felt like a different world. As a county hospital, Valley doesn’t often have the luxury of flashy resources. I spent this past month there, on my general surgery/trauma rotation. On morning rounds each day, we would check on each one of our patients, asking whether their pain was under control, if they were able to eat post-surgery, if they had walked around the ward to get back to their baseline activity level, and more. These rounds would take place as early as 6:15 a.m., and they were efficient, since operating room cases would begin at 7:30 a.m.

At various point in the month, our Valley team had patients who spoke only Spanish, only Korean, only Cantonese, and only Vietnamese. Sometimes, we got lucky, and a member of the nursing staff spoke one of these languages. But at other times, we worked through hand gestures and simple words to try and ascertain patient pain, symptoms, etc. Phone interpreters were an option, but the early timing and rapid pace of rounds made it cumbersome to call an interpreter. We usually circled back in the afternoon with a phone interpreter – and if we happened to have multiple traumas that came into the hospital that day, it would be later rather than earlier that we returned to the patient’s bedside. Putting myself in patients’ shoes, I imagine how frustrating it must have been for them, to feel both dependent on the medical team for care as well as helpless to communicate how they felt and what they wanted.

I began to think about how this problem could be fixed, and my thoughts took me back to my middle and high-school years. In middle school, I was required to take at least one foreign language. I chose Spanish and continued taking Spanish throughout high school (then promptly forgot everything when I went to college, making me rather useless on surgery rounds). Wouldn’t it be useful to have a similar language requirement in medical school? I don’t mean a comprehensive foreign language course. Instead, I think it would be meaningful to know key words and phrases – Do you have pain? Are you able to eat? Where does it hurt? – in, let’s say, the ten most common languages spoken in the particular geographic region a medical school is located in.

I know, I know, medical school curricula are already teeming with courses and requirements, and adding a language requirement feels like just one extra thing. But, if it makes a valuable difference in patient care, isn’t it a worthwhile addition? It’s certainly something to ponder. As for me, I just downloaded Duolingo on my iPad, so if you catch me awkwardly practicing my Spanish out loud in any one of my favorite Palo Alto cafés, you’ll know why!

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics. 

Photo courtesy of Bill Pugin, The Sign Language Company

Education, Stanford Medicine Unplugged, Surgery

Ten percent more: Skirting the line between life and death in surgery

Ten percent more: Skirting the line between life and death in surgery

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

surgeryI was in the middle of my surgery rotation and was scrubbed in on a gastrectomy. A gastrectomy is a procedure to remove a patient’s stomach; in this case because of a stomach cancer. It’s a major operation that requires the manipulation of delicate structures but it offers an excellent outcome for many patients.

My job during the gastrectomy was to be a retractor – a classic medical student role. Retraction is a simple mechanical job that involves pushing skin, muscle, and other tissue out of the way in order to help the surgeons visualize the field in which they are working. More specifically, the attending surgeon handed me a metal plate and told me to use it to push down hard on the intestines so that we could get a good view of the stomach and associated blood vessels in the area. I was positioned behind the resident, who would be the one taking advantage of that view.

I pushed down with my left hand as the attending and resident went about clipping vessels and clearing tissue. Suddenly, the field of view filled up with blood. Some bleeding is to be expected during any surgery, particularly one like this. But this was more than expected.

The attending immediately started calling out orders. He told the resident to find the source of bleeding so that we could ligate it or clip it off. He asked the anesthesiologist to get blood ready in case we needed a transfusion. And then he turned to me and said, “Akhilesh, I need you to push down 10 percent harder. If we lose the field of view here, we might not find it again.”

I pushed down harder, and the search for the source of bleeding continued. The attending told us not to panic (when the attending says “Don’t panic,” that’s how you know there’s a reason to panic). He turned his attention back to me.

“Akhi, I need 10 percent more pressure.” And then: “20 percent more.”

I was getting tired.

“I know you’re getting tired bro, but give me 10 percent more.”

Finally, after a great deal of suctioning, searching, and approximately 130 percent more pressure, we found the source and stopped the bleeding. Everyone paused for a second to breathe a sigh of relief, and then it was back to the procedure.

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Education, Medicine and Society, Stanford Medicine Unplugged

The real reason why med students only talk about school

The real reason why med students only talk about school

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

SOM sceneOn a recent Friday, I went out with a handful of classmates for some food to celebrate the end of a particularly long and tiring week of school. Interestingly, although we had spent hours each day shuttling between lecture halls, the hospital, and clinical exam rooms, the conversation kept drifting back to one, very familiar topic: school. We talked about everything we had endured that week, compared notes on our different experiences, and looked ahead to our future plans. This isn’t a new phenomenon, by any means; in fact, almost all of our off-campus gatherings are intruded by talk of school, to the extent that it only stops when somebody finally says, “Can we not talk about school for a few minutes?”

So, why is it that med students seem to only be able to talk about school when they get together after class? Contrary to popular belief, it’s actually not because we’re so busy that we don’t have time to have a life outside of school. My classmates are athletes, musicians, entrepreneurs, husbands, and mothers – there is plenty to talk about in the world that’s not medicine! Similarly, I don’t think it’s because we’re such science nerds that we just love to talk about medicine and science all the time. Most of us need a break from that every once in a while.

What I’ve discovered over time is that we talk about school so much because the process of debriefing with our peers helps us to stay healthy as students. When we’re in class, patient sessions, or the hospital, we’re (rightfully) expected to maintain a certain professional demeanor; this can prevent us from expressing our emotions and understanding the experiences of our peers in the present. Looking around the table during an emotionally charged and difficult encounter with a patient struggling with mental illness, I see only faces of peers that appear calm and composed. Only by talking about it afterwards, in private, does it become clear that several of us are undergoing strong feelings – of sadness, nervousness, discomfort. It’s incredibly easy in med school to think that you’re the only person in the room feeling a certain way, until you find out later that every person in the room was feeling the same way.

What we’ve learned from these exercises is that nobody knows better than your immediate peers what you’re going through as a med student. Faculty and mentors have been through it themselves but are many years removed from the process and may have had very different experiences. Family and close friends know you better than anybody but often have difficulty relating to the more unique aspects of medical school. This means that there is no substitute to having peers that you can rely on.

Finally, I think it’s critical to highlight the point that being able to debrief openly and honestly couldn’t be more important in a profession like medicine, where the high stress makes rates of mental-health problems particularly high. Unfortunately, physicians seem to have a long tradition of sweeping emotional challenges and mental-health issues under the rug, in fear that they’ll be judged and ostracized by their patients and colleagues. We owe it to ourselves and our patients to try to change that culture, and I’m hopeful that our tendency to keep an open conversation with peers will help to keep all of us healthy.

Nathaniel Fleming is a second-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by Norbert von der Groeben

Education, Patient Care, Stanford Medicine Unplugged

As long as I have these hands

As long as I have these hands

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

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In neurology clinic, I was asked to see a young man with epilepsy — a seizure disorder — due to cerebral palsy from birth. It was one of my first clinical encounters of my first rotation of medical school, the tenuous transition from knowledge-absorber to translator and caretaker. I walked in to find a patient who was wheelchair-bound and largely non-verbal, and who interacted with the world by tracking gaze and moving his arms. He held a toy in one hand that he rotated constantly; the other lay limp on the side of the chair.

I read in the medical record that he attended a day program where he enjoyed watching other children play ball and liked giving high-fives. So instead of launching immediately into an interview of his parents for recent medical symptoms, I asked my patient for a high-five.

At first he didn’t respond, his body like stone. The father patted him on the chest several times, hard, signaling to his son to make the movement while asking him in Spanish to do so. I winced at the vigor of each tap. But soon the young man responded. He put out his hand towards mine, his eyes locked on me, and we high-fived, softly and repeatedly. When I move my hand higher, or to the side, he followed excitedly, and he did not want to stop high-fiving me until the visit ended. “He likes you,” the father said, his fiercely protective expression softening a bit.

When my portion of the interview was over, the supervising neurologist entered the room. After ensuring that the patient’s seizures were under good control, the doctor asked if the family wanted to consider an injection that would help reduce the young man’s oral secretions.

“Won’t that give him a dry mouth?” asked the father. “I don’t want him to suffer. I don’t want his mouth to be dry.” There was so much history to his mistrust; when the doctors had previously offered a surgery to help improve his son’s ability to walk, the son had ended up in this wheelchair. The mother shook her head before the words even left the doctor’s mouth, her red lips pursed. She looked at me imploringly, as if I would understand.  “No, no, no,” she said, holding up her arms to me. “As long as I have these hands, I can clean his drool.” Then, to the doctor, “I don’t mind.”

The doctor inquired again, suggesting that the oral secretions might be minimized by this injection and that it wouldn’t be permanent. “As long as I have these hands,” the mother said again, and I could read the depths of her care by the way she held her hands in the air, emphatically, hands that had mothered a son for many more years than she could have ever anticipated, but hands that had done so patiently, willingly, with no hesitation. Her hands will wipe his drool, no matter how much drips out of the corner of his mouth. She does not mind.

Now that I have completed most of my medical school rotations, I find myself returning to the phrase as long as I have these hands.

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Education, Stanford Medicine Unplugged

Teaching in medical school: Establishing quality standards

Teaching in medical school: Establishing quality standards

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

doctors and students talkingHaving just had three weeks off for winter break, I’ve spent some time thinking about my medical school experience. And in reflecting on my first several months of rotations, I realized that my most salient memories are not based on complex medical issues or patient interactions (although I have had one or two memorable encounters). Instead, they’re largely shaped by the interns, residents, and attendings whom I’ve worked with.

This is perhaps not an interesting revelation. Of course the people who we work with influence our experience. However, the implications of this statement are often overlooked in medicine.

Standardization is a hallmark of American medical education. While every school has distinctive curricular features, all of them cover the same core content and require similar clerkships. We use standardized patients to learn clinical skills, use textbooks that teach the same pathophysiology of disease and use the same set of resources to study for Step 1 of the U.S. Medical Licensing Examination. Medical students have many shared experiences.

The goal of such standardization is to ensure that all students achieve a threshold level of knowledge and skill that will allow us to be competent doctors. But amidst all the efforts to standardize curricula, information and experiences are ultimately conveyed by teachers. And maintaining high teaching standards is often de-prioritized, especially on rotations.

Every resident and attending takes a different approach to students. Some encourage us to be active and take on as much responsibility as possible. Others prefer students to have a more passive role. One resident carved out time to walk me through interesting medical cases nearly every day. Another told me that she didn’t have time for my questions.

As a result, two medical students might have vastly different experiences even if they are on the same rotation at the same institution at the same time.

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Education, Stanford Medicine Unplugged

The limits of textbook knowledge

The limits of textbook knowledge

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

open-163975_1280We are in the midst of an epidemic. It now causes more than 40,000 deaths and about 2.5 million emergency room visits in the United States annually, nearly double the number in 2001. It is the leading cause of non-natural death in the U.S. – even greater than motor vehicle accidents. Do you know what it is?

If your mind naturally jumped to gun violence, you would certainly be forgiven, given the recent spate of horrific events and the large volume of media attention they’ve received. However, the actual answer is (unfortunately) much more insidious: accidental drug overdose, the new leading cause of injury death of Americans. To make matters worse, of the nearly 44,000 deaths attributed to drug overdose in 2013, a shocking 52 percent of these were caused by prescription drugs – in other words, drugs that are theoretically being monitored and controlled by our healthcare system.

To me, the prescription-drug overdose epidemic forces me to consider one of the major challenges of the pre-clinical years of medical school: the fact that the textbook knowledge that we’ve learned about numerous diseases over our first two years can only take us so far in the real world.

For example, we learned all about the measles virus this year; we can recite who is most at risk, how it is transmitted, all of the signs and symptoms that it causes and how it is vaccine-preventable. But do you know how many deaths it caused in the United States in 2013? Zero. (In fact, thanks to the success of the MMR vaccine, most physicians in the U.S. have never even seen a single case of measles in their careers.)

This is not to minimize the severity of measles or to say that we shouldn’t be learning about it in medical school. What it does suggest is that it is far easier for us, as pre-clinical medical students, to learn what we call “illness scripts” – textbook presentations of diseases or conditions, many of which we are unlikely to ever see in our lives – than it is to gain an understanding of the complex, messy personal interplay involved in taking care of patients in the real world.

The problem with the prescription-drug abuse epidemic is that it lies somewhere at an ill-defined intersection of medicine, public policy, law and community health.

Unlike measles, it is a complex problem with no straightforward solution. With measles, I’m as confident as a second-year medical student can be. But with the drug epidemic, I can readily admit that it goes well beyond the scope of my knowledge. But should it? As medical students, we’re going to be putting our names on those prescriptions soon enough – prescriptions that cause 44 deaths per day in this country. We hear often that there are some things that can only be learned from experience. Now that our “textbook” knowledge is expanding during our second year of school, sometimes it feels as though that real world experience just can’t come soon enough!

Nathaniel Fleming is a second-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo by PublicDomainPictures

Public Safety, Stanford Medicine Unplugged

Medical tips for holiday travel

Medical tips for holiday travel

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

plane in skyThe holiday travel season is in full swing, and millions of people are off visiting their loved ones. So a seminar I recently attended on in-flight emergencies was quite timely.

I had been looking forward to the seminar, which was led by emergency medicine faculty members, all week. During the holidays, I have to travel on several different flights to get home, and occasionally, a flight attendant has asked on the loudspeaker if there is a doctor on-board. I was excited to finally be in the know.

Much of the conversation during the first part of the seminar focused on a New England Journal of Medicine article on how physicians should handle in-flight emergencies. It noted that the most common reported medical event during a commercial flight is fainting; the most fatal is a heart attack. Interestingly, heart attacks make up only 0.3 percent of in-flight emergencies, but they cause 86 percent of in-flight deaths.

For the second part of the seminar, emergency medicine faculty told us anecdotes about times when they had been called on during a flight – some stories were haunting, others interesting tidbits – and walked through three different simulations. The law about medical professionals helping people during in-flight emergencies is vague regarding medical students. But I know this: If a doctor is called during one of my upcoming flights, I sure hope someone onboard is more qualified than I am.

In all, I gathered several practical tips that could be helpful to readers. If you are traveling and concerned about in-flight medical events, please consider this:

  • Print or clearly write a list of medications you are currently taking. Include how often you take them and at what dose. Keep this readily accessible on the flight.
  • Make sure to travel with these medications in your carry-on in case your checked luggage is lost.
  • If you are traveling with someone you can confide in, make sure they know if you have any current illnesses. If not, please add this information to your list of medications.
  • If you have an allergy to any medication, please write this on your list. Write what kind of reaction you have, whether it is a tightening in your throat or a rash.
  • If you or a loved one does experience a medical event, stay calm.

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Education, Stanford Medicine Unplugged

My struggles with the third-year of med school – and the words that helped me

My struggles with the third-year of med school - and the words that helped me

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

495524570_415c91b283_z“I remember how hard it was to be a third-year medical student,” one of my residents once said to me. “You have to appear constantly enthusiastic. You feel continuously judged and evaluated. And worst of all, you know, deep inside, that if you were to get a cold or something and not show up one day, not one bit of the daily workflow would change because as far as pivotal people on the team go, you aren’t one of them.”

And with those words, my resident smiled and let me go home early, while she and the other residents stayed to finish up last-minute tasks and sign out to the night team. I was too excited about getting out early to think much about what she said that day (golden rule of third year: if your resident sends you home early, don’t argue. Count your blessings, and go home). But more and more, her words have begun to resonate with me – they summarize so well what I’ve struggled with as a third-year med student.

On a day-to-day basis, third year is awesome. The patients I’ve met have been absolutely incredible, and I’ve been so grateful for the stories they share and their willingness to teach me about their medical conditions. When I first started third year, spending time with patients was more than fulfilling for me, and I felt lucky that, as the medical student on the team, I had more time than others to do that. But, after a couple months on the wards, I felt myself growing a little restless – I wanted to do more to contribute to patient care in a meaningful way.

The trouble is that, as a student, it’s often difficult to do more. For instance, on some rotations, my classmates and I were told that we didn’t need to write notes, because they couldn’t be used as official patient notes anyway. At first, I rejoiced – writing notes, while at first novel and exciting, quickly becomes a tedious chore. But then, I realized that not writing a note meant one less way I could contribute to the team. On other rotations, even when we did write notes, the Epic medical student note template would have red, bolded text at the top that said something like, “Medical student notes are for educational purposes only. No part of this note may be copied or used.” That made me feel even less worthwhile – why was I spending time writing this note if it was very obviously not usable?

Ironically, this lack of a defined medical student role is also one of the greatest blessings of third year because it relieves you of responsibility. There were many days on my medicine rotation where our team was swamped with admissions, but since I was already carrying three or four patients of my own, my team would let me go home early, while they stayed to work till late hours, often past midnight.

But that doesn’t make it easier to come to terms with the fact that as a medical student, finding meaningful ways to contribute to the team is sometimes challenging.

I mentioned my unease to one of my faculty mentors, who gave me a piece of advice I’ve tried hard to incorporate into third year: “Your job as a medical student is to make yourself two things: teachable and indispensable. Be an excited learner, call consults, follow up on studies for patients, offer to update discharge summaries, give presentations and teach the team. Make it so that if you’re not there, the team feels the weight of your absence.”

Of course, what my mentor told me is easier said than done. But it’s helped me increase my sense of self-worth as the medical student on the team – and if any of you readers are or will soon be third/fourth year medical students, maybe it’ll help you as well. No doubt, something else that’ll help me feel better is a little vacation to reset after six straight months of clerkships – so it’s off to winter break for me! Happy Holidays and early Happy New Year to all of you!

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics. 

Photo by Adrian Clark

Education, Patient Care, Stanford Medicine Unplugged

Harm versus pain, an important distinction for physicians

Harm versus pain, an important distinction for physicians

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category

13866052723_2020820f89_zAbove all, we medical students are told to do no harm. It’s a maxim that we follow religiously and is one of the pillars guiding the ethics of practicing medicine. But our professors don’t tell us what really constitutes harm because it’s not so easy to define.

The first time we touched a patient during a physical exam, we were timid with our hands and instruments, hyperaware of any twitches or jerks that could indicate pain. We made sure to attend to all the patient’s discomforts. Before we entered the room, we adjusted the collars of white coats to appear pleasing. We warmed our hands and dabbed the sweat off our palms. When we palpated his abdomen, we pressed ever so gently, barely making a crater in his stomach. Even when placing our stethoscopes on his chest, we would do so delicately because if we pressed too hard, it would leave a bruise — or so we feared. Reflexes often could not be evoked because we didn’t want to fracture his kneecap by tapping it too hard with our hammers.

When we practice medicine, we walk a tight rope between life and death that has no safety net.

It is easy to conflate the two, but pain is not synonymous with harm. And we must realize that important distinction to practice good medicine. After all, in order to prevent, treat, or even cure disease, we will invariably have to cause the patient some degree of pain, and the physical exam is no exception. We must press the abdomen with enough force to feel the edges of internal organs or shine a blinding light into the pupils. But these tasks cause only relative discomfort.

What about more invasive procedures?

Mammograms can be painful and emotionally draining. Colonoscopies are uncomfortable and awkward. Prostate exams and pap smears force the patient into an undignified and vulnerable position. Even the quickest blood draw can tap into incapacitating needle phobias. And chemotherapy, the epitome of doing good by causing suffering, intends to trade months of agony for potentially years of survival.

So do we give a free pass to those patients who don’t want to undergo these procedures and whom we don’t want to see suffer? The greatest fear of any practitioner is to accidentally hurt the patient, and naturally, we are tempted to the easy route of inaction to avoid this possibility. Ironically, this deep-seated fear that can make us competent and caring physicians can also inhibit us from doing our duty.

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Patient Care, Stanford Medicine Unplugged

Seeing ghosts in the form of patients

Seeing ghosts in the form of patients

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

hallway-867226_640On my medicine sub-internship, I took care of an elderly man who was a retired military surgeon. When he first came into the hospital, mentally altered from an underlying infection, he was irascible and unpleasant towards many staff members, swatting their hands away as they attempted to draw blood for lab tests.

As the infection came under control, the shell of rage fell away to a quiet dissatisfaction. The bed was hard and pressing on a sore on his sacrum, but it was painful to move and so he denied the frequent turning recommended by his nurses to ease the progression of the ulcer. He was often incontinent of urine and thus preferred to have a urinary catheter, though the discomfort it caused often made him pull it out. It would be easy, to the hurried clinician, to write this person off as a difficult patient, one whose complaints may drain the energy from an already exhausted doctor.

But this man was all too familiar to me.

A few months ago, I lost my grandfather, a renowned cancer surgeon in India, after a bout in the intensive care unit.  The lively and generous man who cared for his entire extended family became, during those brief weeks of suffering, sometimes moody and difficult to appease.  Altered by delirium and nagging pain, he expressed frustration towards the people who were trying to help him. He constantly fixated on the thought that he had a malignancy in his lungs, despite multiple negative tests.

But I know that beneath the fragile skin of illness was the magnanimous grandfather, the hawk-eyed surgeon, the unrelenting teacher. That person emerged in glimmers: a sudden conversation about advances in oncologic practice, moments of deep concern for the well-being of his family members, and the clarity with which he described that he would not want to end his life on a ventilator and that he had lived fully and proudly. The last moments with him made me viscerally aware of the eagerness with which family members waited for daily news of their loved ones’ progress, or the importance of tiny details of their care (the number of milliliters of fluid drained from his lungs by the pigtail catheter, or how many spoons of broth he had eaten overnight.)

After my patient’s infection cleared, the scans of his lungs revealed some spots.

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