Medical Economics is proud to unveil the third-place entry in our 2015 Physician Writing Contest.
I remember getting the phone call.
It was a Tuesday night in June, just like any ordinary Tuesday night. It was around 11:30 pm and I was in deep sleep, exhausted from the day’s work as an intern in an internal medicine residency.
When I heard the phone ring, I instinctively thought, “who could possibly be calling me at this hour on a Tuesday night?” thinking that it might be a colleague on night float who was worried about one of my patients. But it was my father, uncharacteristically calling late in the night. I felt a sense of dread in the pit of my stomach.
“Remember how your brother was having some trouble breathing?” he said. “I sent him for a chest x-ray to make sure that everything was okay. The radiologist called me today and said it doesn’t look good. There are hundreds of pulmonary nodules. We’re not sure what they are exactly, but they could be metastases.”
My father continued to talk through his thoughts about what the possible diagnosis could be, that it was too early to know anything for sure, that my brother was fine, that everything was fine. At this point in my medical training, I had been taught to prepare for the worst, to always rule out the diagnosis that could kill the patient. My mind raced through all of the possible explanations for pulmonary nodules in an otherwise healthy 27-year-old with no risk factors. Could it be infectious? Inflammatory? Differentials meant nothing when the diagnosis was so clear that it was staring you in the face. My heart felt burdened with anxiety and I felt a deep ache within my chest.
Over the next several weeks and after countless labs, imaging studies and tissue biopsies, we received a diagnosis: stage 4 alveolar soft part sarcoma of the right calf.
My brother was my best friend. Growing up in small Texas town as the only minority students in a secular schooling system, we grew closer through our struggles with identity and our shared cultural/racial dyssynchrony with our surroundings. Somehow, the “fitting in” part came easier to me. My brother was more docile and more reserved, but once you got to know him there were few times he wouldn’t offer his opinion about a topic.
Outside of school, we both learned to play tennis under the tutelage of our father. Tennis provided us with both an outlet for our frustrations during adolescence and with a ticket out of small-town, provincial life. We played in many national tournaments and traveled from Memphis to San Diego, missing major events in our respective teenage social lives but gaining the experience of what hard work could afford us in the long run.
When we graduated from high school we both went on to play collegiate tennis--he to Vassar, I to Yale. After college I went to medical school and though he stubbornly tried to avoid following in my footsteps, my brother ultimately decided to forgo his law school career to become a psychiatrist. He was accepted to the University of Texas at Galveston in June 2013, one week before he went in for his chest x-ray. These series of events, retrospectively, seemed so tragic to me in the coming months.
As his cancer spread, I witnessed firsthand the slow physical and mental decline of my brother’s body and the parallel closing of a chapter of his dreams and our dreams of our future together. My brother, my best friend, was actively dying in front of my eyes.
As physicians, we fight constantly for our patients’ lives, buying time or recognizing that time is limited and preparing for end-of-life care. As an internal medicine resident in inner-city Brooklyn, I have seen tragedy. A 41-year-old female dying of complications from end-stage alcoholic cirrhosis. Or the 60-year-old male who has never seen a doctor in his life and is suffering from a massive coronary event that leaves him with irreversible anoxic brain injury. I have seen tragedy.
But over the nine months that I witnessed my brother’s battle with sarcoma, I realized that nothing could prepare me for this tragedy. The feelings I had once witnessed from afar in the families of patients who had suffered such immediate and heart-wrenching loss is exactly what I was now experiencing. I was no longer a physician but a family member. I was no longer the stoic one delivering bad news, I was the one collapsing after receiving it.
The final time I went home to see my brother, he had been told by his oncologist days prior to my arrival that there were no treatments left and that hospice care was the best option for him. When he died, no ghost rose from his body. But it helped to realize that his departure from our lives and from humanity had no relation to the events that followed: the zipping up of his body into a bag, the funeral, the cremation.
Months after he died, I hesitantly returned to the medical wards. Around that time I met Steven, a young father of two in his early forties, seemingly healthy, who had recently been diagnosed with pancreatic cancer. He was in the hospital for a workup of episodes of blood in his stool and had been diagnosed with cancer at another institution. In the coming days that I spent with him, he asked about his prognosis and about what he should tell his family. I felt a sense of ease in talking to him that I’d never had with a patient.
We talked about life, about what it meant to know that time is limited. I told him about my brother and about how my perception of mortality had shifted so suddenly. He didn’t have anything profound to say or any answers to give me, but he told me to try to not define my life through the tragedy, but rather to take my experience and use it to better my skills as a physician and a healer. His words resonated with me and though we lost touch, I know that he continued to define his life by the quality and not the quantity.
As I move forward in my career, I am forever changed by my experience. I approach my patients now with more compassion and less judgment. I realize that a cancer diagnosis, like any diagnosis, affects not only organ systems but the way the patient perceives their narrative.
I am open to grief and to sharing my experience with my colleagues and my patients in hopes that they may realize that in a profession where death is a daily occurrence, discussing values, preferences and personal goals in the event of debilitation is still considered an ambitious load. I am dedicated to approaching my patients about end-of-life care (what it means and doesn’t mean) to ensure that their departure from their physical self is most aligned with their spiritual one.
Rashmee Patil, MD, is a third-year internal medicine resident at Lutheran Medical Center in New York. She lives in Brooklyn, New York.