The Patient Knows Best

As medical students and future physicians, we are often used to being the ones with the answers. We have been programmed to be presented with a clinical case and immediately know the diagnosis and treatment. On my internal medicine rotation, I met Ms. E, a patient diagnosed with metastatic cervical cancer. One of the original questions my team and I had about her case was how she was able to develop advanced cervical cancer in a U.S. health care system that one may confidently say screens aggressively for it. On questioning Ms. E, she told us that she had received a screening for cervical cancer in which the results came back abnormal; however, she had declined to follow up. When it comes to cervical cancer screening in the United States, evidence shows that it is inefficient (1). The costs accompanying increased screening have not proven to aid in positive disease outcomes. Some women are aggressively screened, not screened entirely, or are lost to follow-up (1). Every year, the incidence of cervical cancer is around 12,000 cases, with 4,000 cases resulting in patient death (1). A recent article published in Annals of Internal Medicine (2) mentions that in the United States, the incidence of cervical cancer screening is lower because of the aggressive screening protocols. These screening programs started in 1950 when cervical cancer was the primary cause of death for women in the United States (2). In the United States, cases of cervical cancer can be seen among underrepresented groups, immigrants, and those who were lost to follow-up after abnormal screening results (1). Nonetheless, my team and I concluded that the "why" aspect did not matter at that moment, and we had to provide the best care we could for the patient.

Ms. E seemed to have given up on life when I first met her. She did not acknowledge me and kept her eyes on the wall when I entered the room. She had a thin, white hospital blanket wrapped tightly around her body so you could see only her head. Moreover, all of the shades were down in her room, giving an illusion of darkness on an otherwise bright morning.

Trying to change the otherwise somber atmosphere in the room, I said, "Hi, Ms. E! How is your morning?" I got no reply. I followed up with, "My team wanted me to help you get out of bed and start moving." She replied, "I am not moving." I would spend the next 30 minutes trying to convince Ms. E with my textbook medical school knowledge of the importance of getting her out of bed. Yet, every reply was either, "No," "I don't want to," or "Tomorrow."

Little did I know that each subsequent day would get worse. Each day I was tasked to go into her room to help her ambulate, and each day I was faced with the dilemma that either she would do it "tomorrow" or simply that she would not feel like it at all.

As the days went by, I could feel my frustrations building up. I felt saddened that the patient was aware of her prognosis but had a dismissive approach. I would see the medical team explain in detail all the intricacies of her health course, which she would understand. However, no explanation or clarification was enough to change her mind. In a field such as oncology, a provider can offer insight into the benefits of various kinds of treatment. Yet, it can differ from the patient's desires, experiences, and understanding (3).

One day, I boldly went into her room determined not to be swayed by promises of "tomorrow" and instead was adamant about getting her to walk. I walked into her room and told her, "You're walking!" She confidently said, "No, I am not." Being mindful not to provoke her too much, I tried a softer approach, letting her know that I knew that what she was going through was hard, but she should try to make every effort not to be consumed by it.

Thinking I was trying my best to be empathetic, her reply was, "You do not know what this feels like. Do you know what it feels like to know that you are dying? Would you like to switch places?" I stood still, speechless, at a loss for words because nothing in my medical school bedside curriculum could have prepared me for this moment.

That brief encounter taught me a profound lesson that resonates with me until this day. As health care professionals, we are programmed to be the fixers and always have the answers. Providers can often find themselves optimistic and miss the opportunity to consider their patients' desires (3). At that moment in the patient's room, I had to accept that I did not have the answer and did not know. When considering the role of physicians and terminal illnesses, end-of-life care must receive the same high-quality treatment as care intended to prolong the patient's life, and this balance is important (3). As frustrated as I was as I left her room, I couldn't help but think she was right. I did not know, and I had to deal with that. I chose to approach her case with compassion, regardless of whether it ended in life or death.

References

1. Kim JJ, Campos NG, Sy S, et al; New Mexico HPV Pap Registry Steering Committee. Inefficiencies and high-value improvements in U.S. cervical cancer screening practice. A cost-effectiveness analysis. Ann Intern Med. 2015;163:589-97. [PMID: 26414147] doi:10.7326/M15-0420
2. Reynolds EE, Weinstein A, Farid H, et al. When and how would you screen this patient for cervical cancer? Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med. 2022;175:267-275. [PMID: 35130045] doi:10.7326/M21-4372
3. Pizzo PA. The Doctor: for life and at the end of life. Ann Intern Med. 2015;162:228-9. [PMID: 25486216] doi:10.7326/M14-2399