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Harrowing Diagnosis Brings out Best in Physician


For this doc, reacting to and treating a patients potentially life-threatening diagnosis brings out the best in her.

One of my colleagues and I were discussing a mutual patient recently diagnosed with cancer. My colleague relayed how she felt her heart sink as she palpated the mass that ended up being malignant. We discussed those moments when we felt the lump, or saw the scan, or read the result and felt nauseous, flushed, or numb. Even though we barter and trade in disease and death as surely as we do health and wellness, we are not protected from the visceral reaction to a terrible diagnosis.

Two cases (of many) immediately come to mind. The first was a young patient about three years old whose mom brought him in because his abdomen felt full. Palpating his right quadrant, I felt a large mass, the edges evident under my prodding fingers. I suspected either a Wilms tumor or a neuroblastoma. While I was able to quickly recover and manage a frantic mom while we arranged admission to a tertiary care facility, there was that initial moment of panic. Not panic because I didn't know what to do, but panic because I knew that whatever it was, it was bad. There is something so different about feeling, palpating, or seeing the diagnosis right in front of you instead of reading the diagnosis on a piece of paper or viewing a picture on the screen.

The second patient was an older gentleman who came in with headache and dizziness – two common complaints. As I performed the same neurologic exam I've done hundreds of times before, I observed something I've only seen rarely – dysdiadochokinesia – the inability to rapidly perform coordinated movements and a sure sign of cerebellar damage. In the moment I registered his deficit, my mind sped through the sequence of events before him – MRI, neurology appointment, oncology appointment, difficult decisions, hospice, and finally death.

These moments are horrible – to see and feel so clearly the presence of disease – and wonderful in the sense that it makes me full of wonder to realize that I still can and do react to the tragedy and sadness and dread that define these moments. It is also inherent in medicine that we move forward, much like a soldier going into battle. We know that the outlook is grim and that suffering lies ahead. However, instead of dissuading us from the journey, the very need we see compels us to push aside the sinking in our gut or the fear in our heart and venture forth to do the job that we've been called to do.

If I never feel another mass or see another clinical exam finding a heralding medical disaster, I would be thrilled. However, I am glad that when I do, as I most assuredly will, I will feel that very human response of horror or sadness or revulsion at the certainty ahead. And, I know that I will move forward on that journey with my patient because it is my calling and it is my privilege.  

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