Friday morning 7:55 a.m., I climb the stairs to the 5th floor of the VA hospital to make rounds. As I exit the stairwell and turn right to walk to the team room, I wonder if the biopsy results for Mr. Moore have returned.

Mr. Moore probably has metastatic lung cancer. He is 56 years old (my age) and presented to the ER on Sunday with increasing dyspnea and fatigue. He had lost 20 pounds in the past month. He had a productive cough, with occasional blood streaked sputum (for 1 week). Until this illness, his only problem had been dyspnea on exertion – so he quit exerting.

Mr. Moore started smoking at age 16, smoking approximately 2 packs per day over the subsequent 40 years. He drinks 2 beers a day, and denies illegal drugs. He worked as a truck driver – but has not had the energy to work for the past 2 weeks. He is married (32 years) with 3 children and 2 grandchildren.

His chest X-ray shows are poorly defined large mass in the right upper lobe. His laboratory data show a mild anemia, and abnormal liver tests. A CT of the lung suggests lung cancer. A CT of the abdomen suggests liver metastases.

On Tuesday we had pulmonary perform a bronchoscopy – they thought they got a “good sample” of what looked like tumor tissue. Wednesday we explained the possibilities to the patient and his wife.

As I walked into the team room I had a smile on my face. Actually I almost always have a smile on my face. My life has been very good, I have success in my career, a loving wife and 2 wonderful children. I love making rounds, and I like the resident, 2 interns and 2 medical students. Medicine is a constant wonder. I learn something new every day and hopefully will teach something today.

After the usual pleasantries, we start “running the list”. I always start rounds in the team room, discussing all the patients behind closed doors. In this setting I feel free to “pimp” the students and interns without the risk of embarassing them in front of patients. Sometimes doctors resort to black humor. Behind closed doors I consider that a tension relief, in the halls or the patient’s room it would be inappropriate.

As we run the list, the interns and students give my the 24 hours update. What tests have returned; what the consultants said; how the patient feels and looks this morning. As we discuss the patients I ask questions. Some of the questions elicit their knowledge – probing for weaknesses, since I should focus my teaching on their weaknesses. Some of the questions examine their management strategies. I ask what their plans are now, and ask them to justify those plans.

When we get to Mr. Moore, the intern – Sara Blevins – reports that the biopsy results show squamous cell carcinoma of the lung. I ask her what we should do. We discuss treatment possibilities, and agree that (1) he is not a surgical candidate – tumor is too widespread; (2) chemotherapy does not work well for squamous cell cancer of the lung; (3) radiation therapy may give some palliation; (4) the patient needs advanced directives and palliation planning. I ask if the patient knows his diagnosis yet. She responds that she just received the biopsy result, therefore he does not yet know. I tell the team that I will take this opportunity to role model delivering bad news.

After we finish running the list, we leave the team room to make walking rounds. We stop and talk to each patient, examining those patients who need examination. Walking rounds allow us to talk with patients, making sure they understand the plans and determining their impressions of their condition.

We enter Mr. Moore’s room, he is alone in bed. On my way to his room my countenance changes to a more serious tone. As I enter the room, I look for a place to sit. Serious conversations require sitting down. Fortunately, he has a chair in the room, which I move close to his bedside. The housestaff and students stand back from the bed watching.

“How are you doing today”, I ask.

“Still coughing doc”

“Mr. Moore, I have some serious news to discuss. We have a result from the biopsy”

I pause – but he says nothing.

“What do you think it shows?”

“Cancer?”

I nod my head and say “Yes”.

(My father worked as a psychologist for many years. He once taught me that when breaking bad news, it helps to have the other person state the bad news. For example, when I have to tell a family member that someone has died, I state that I have bad news about the patient and elicit from them the concept of death rather than just saying “he died”.)

“What questions do you have?”

“Can the surgeons fix it?”

The conversation lasts for 5 to 10 minutes. I make physical contact during much of the discussion – checking his pulse – because he needs physical contact during the conversation. We discuss treatment options – what might help and what side effects might occur.

As we are finishing, I acknowledge that I probably have not answered all his questions. I state that Dr. Blevins will come back around later during the day to expand on this discussion. We tell him that we will provide a copy of The 5 Wishes for him to consider and fill out.

Mr. Moore will need several more discussion. We must help him make decisions that are consistent with his desires.

After we leave the room, we stop and have a discussion about my conversation. I ask the team to criticize my performance both positively and negatively. Then we move on to the next patient.

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Mr. Moore represents a composite of many patients for whom I have provide care. He is not an actual patient.

Related posts:

1. Reflections on 30 years of ward attending
2. 17 days at the VA – day 15
3. A conversation I do not avoid
4. 15 days at the VA – day 10
5. A near miss

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