Category: Submissions

By: Raafia Siddiqui

The surgeon asked me for the second time, “So are you here alone?”

“Yes,” I answered, a bit impatiently this time. I was a 20-year-old who felt I had better things to do than be at this appointment. My family doctor had noticed a lump on my throat and insisted I see a specialist for it. We were supposed to discuss the results of the biopsy today but instead of telling me what the results were, he placed his hand on my shoulder and let out a long sigh. That’s when I realized he was holding something back.

So I asked him, “What is it?”

His reply was very short and urgent, “There’s a lump – and we have to take it out.”

Immediately, I understood what he meant and began pressing him with questions, “Is it malignant? Has it metastasized? What type of cancer is it?” Although I felt I had to pry answers out of him, the specialist finally told me I had a thyroid tumour which he believed had begun to spread.

I remember walking out of that appointment very confused, with the most daunting question still on my mind, “How do I explain any of this to my parents?” To my parents, both of whom were in good health and had no previous history of cancer within the family, cancer was a foreign and terrifying disease. They were unable to digest my reassurances that thyroid cancer was relatively “safe” compared to other types of cancer. My parents were astounded that their young daughter was suffering from what they held to be a non-treatable and deathly disease. I sought out the support of my family doctor, with the hopes that she’d know how to calm their worries. At first, things were going alright.

“Don’t worry, if you have cancer, you want this kind! She’ll be fine! Thyroid tumours are very easy to treat!” reassured my doctor.

I didn’t understand why someone would tell a cancer patient or their family that their cancer is something to be happy about, but I thought, maybe that’s her way of putting my parents at ease. Things went downhill when my mother asked if she could get a second opinion, greatly upsetting my doctor. When my father asked if there were any options other than surgery or radiation, she said he’d have to find out himself. When I suggested I had heard some alternative therapies may be helpful, she scoffed at me and said I could try “magical lotions and potions” if I wanted to but she was certain they’d have no effect. My family doctor clearly did not like that we were questioning what she thought was best. What she didn’t realize was that we were simply worried and would have benefitted from professional reassurance.

A few months later I underwent a thyroidectomy, in which I had my whole thyroid gland removed. This gland makes thyroid hormones, which regulate your metabolism and affects your body in numerous ways, from your weight to bowel movements and heart rate. I also had one round of radioactive iodine therapy, in which I was given a radioactive drink and was kept isolated in a radio-proof room for a couple of nights until the radiation wore off. Throughout this time, I grew increasingly resentful towards my family doctor and specialist. I remember feeling a total loss of control over my health and agency over my decisions. Moreover, there was no one for me to discuss my worries with. I had to put on a tough face for my family so they wouldn’t worry and at the time, I had no access to support groups. Inevitably, I turned to online blogs filled with misinformation and horror stories regarding surgery and radiation. I remember going into radiation treatment thinking I would die of low sodium because I had read about it on an online blog. Of course, I did not die or suffer any long-term consequences from either procedure but I did come out feeling a strong sense of distrust towards the health system and physicians in particular.

After treatment, I was put on thyroid replacement therapy for life and was supposed to see an endocrinologist or hormone specialist regularly to make sure the dosage was right.  A year after my surgery, the endocrinologist retired without referring me to someone else. I didn’t think much of it as by that point my faith in our health-care system had waned. My health plummeted. At one point I was twenty pounds thinner and my hands would shake frequently. My heart would start racing and I would have nightly panic attacks. I remember feeling like I was going insane, yet wasn’t sure why or how to get help. It wasn’t until a walk-in doctor suggested I have my thyroid hormone levels checked did I realize that my issues may have been related to my thyroid medication dosage.

Sure enough, the symptoms I was experiencing were due to my thyroid hormone levels being way too high. Other problems I developed included changes to my blood sugar levels, my reproductive hormones and my stress hormone levels. Motivated to improve my health, I sought out a new endocrinologist who worked with me to find an appropriate dosage. With a better understanding of how varying dosage levels affected my health, my condition slowly improved over the next several months.

As I reflect on my experiences as a cancer patient, I remember feeling bitter, angry, and powerless. I think many of these feelings stemmed from poor communication with my health providers and the limited support of my family.

Five years later, I am now training to be a medical doctor myself. I have thought a lot about how my experience as a cancer patient has shaped my perspective as a medical student. I often ask myself ,  “Will I be a doctor like the ones who treated me?” “How can I be a doctor the patient in me would want to see?” The “doctor knows best” approach of the physicians who treated me left me feeling as though our interactions were not about me but about their ego, their feelings, and their ideas about what was best for me and my body. As a medical student, I have observed physicians who include their patients as active decision-makers in their care, and not just as passive bystanders.

A women’s health specialist I worked with would say to every one of his patients, “I can’t tell you whether or not you should have a procedure or treatment. That is because I am not the one who will lose sleep at night over the decision. It is your body so you must decide. My job is to tell you what options are available to you.” His words were a relief; these were the words I had longed to hear from my own care providers.

If I had to go back and do things differently, I’d speak up and demand that my concerns be heard. I’d advocate better for myself since I now know that asking for a second or third opinion is my right as a patient. I would seek out reliable resources in the community that could help me with the treatment and transition process. As a care provider in training, I know that I can be an advocate for my patients by giving them the agency they deserve. I can and should treat pati

ents as an expert when it comes to their bodies and as co-creators of health care knowledge.  I will be careful not to be dismissive of their concerns, or insensitive towards their conditions and the impact it has on them. I will be the doctor that the patient in me wishes she had.

By: Carlos Chan (c2020)

At McMaster University, we prize the ability to engage in self-reflection and learn from our experiences so that we can become better physicians. We dedicate an entire morning to it every week in pre-clerkship (professional competencies), we have required writing assignments centered around the idea (our reflective physician portfolio), and it’s been touted as a tool to guard against burnout in medical practice. As someone who tends to live in his own head a lot of the time, I personally think that self-reflection is a great practice as well. But I got some very interesting and unorthodox advice from my preceptor during my first week of clerkship, which sort of turns that idea on its head.

This surgeon mentioned that he often sees that clerks get into their own heads too much and become neurotic about things that ultimately don’t really matter. In the grand scheme of things, it really shouldn’t matter if we slipped up on terminology in front of a patient, unintentionally slighted a colleague, or made any other mistakes that are easily repairable. But it often is difficult to keep our eyes on the big picture when we’re all tunneling towards the goal of matching to our preferred residency. Indeed, it is almost impossible not to go insane as predominantly type A personalities obsessing over every little detail and then retreating into our own heads when doing so. Despite all of that my preceptor’s point was that it does a disservice to the team you are a part of to retreat in this fashion. You have to remember that while you are there, you are present to care for your patients, to learn from the team and to assist them in the goal of creating the best possible outcome for the patient.

I found myself slipping into my own head one night on call when the surgical team had to tell a patient in the emergency room that he had metastatic colon cancer and that there was not much they could do for him from a curative point of view. In that moment, I found myself thinking how horrible I was feeling about the entire situation and how it felt rotten just to be there in that room, even though I wasn’t even the one breaking the news. I was only a spectator.  The patient didn’t even seem to see the rest of the team in the room, his eyes remained fixed on the senior resident talking him through the news.

However, beyond that I cannot remember all of the details. Maybe I was too tired or perhaps it was because I avoided looking at him due to my own discomfort about the entire situation. But my feelings regarding that event still linger, like formalin that stays in your nose long after you’ve left the anatomy lab. And I do remember one other thing, the only thing he said in response to the resident’s monologue detailing the news which he must have been dreading.

“Shit.” Repeatedly.

Truthfully, I don’t remember much else about that consult. The night was still young and there were other surgeries to participate in and many other consults to attend to. But as I reflected on that experience, I felt badly about the fact that I had made that entire experience about me in that room. I was predominantly centered on how bad I felt about the situation, and how much I wanted to leave. My preceptor’s advice about getting out of my own head lazily wandered back into my mind, and I realized that I had disengaged from that moment, and I was not centered on the needs of the patient. I realized in that moment I had done exactly the opposite of what he had said that I should do. As I thought more on that situation though I realize now that perhaps it would have been unreasonable for me to not focus on myself and what I was thinking in that moment since it was my first time witnessing such a situation and I’m not sure I would have been capable of attending to the needs of both the patient and myself . But now that I’ve had this patient encounter and worked through my feelings on the matter, I know that I will be better equipped to engage with this type of situation in the future.

I’m sharing this because it has been useful for me at the start of clerkship. I’ve since told myself to get out of my own head repeatedly whenever I encounter something new and scary or when I make a minor mistake that really does not deserve a second thought. Although this advice has been useful, I still think that there is a role for reflective practice. However, as with most things in life, balance is the key. It does not pay to stay in your head forever burning a circular track in your own mind. Stay in your head to figure it out but don’t stay too long. Your team and your patients need you. Get out of your own head and engage.

The first delivery I ever saw was on YouTube. I was reclined on my bed—cup of tea in hand, and the familiar ‘ding’ of Facebook chats ringing from another Internet tab. I didn’t pay too much attention to the video, because I only meant to prime myself for the next day’s horizontal elective in Obstetrics & Gynecology. Many of my friends had already embarked on Labor & Delivery shifts, claiming the “magic” of delivery, explaining it was something that you simply must see to understand. I clicked back and forth to the YouTube tab throughout the video, making sure to catch the important parts—appearance of the head, clamping of the cord, delivery of the placenta. A few quick minutes later, I shut my laptop and went to bed, feeling a bit apprehensive about how I may react physically to the real thing in hospital (…maybe I should bring a paper bag).

Fresh in my scrubs the next morning, I eagerly awaited what the day had in store. My preceptor had one impending delivery: Nicole, a healthy woman pregnant with baby number 4, accompanied by her husband, and anticipating a quick and uncomplicated delivery. I was tasked with keeping tabs on mom and baby—I quickly learned how to read the printout of the fetal heart/uterine contraction monitor, and my preceptor patiently taught me about the basics of labor. To my delight, he took extra time to introduce me to “Fiona,” a plastic pelvic model used to demonstrate childbirth maneuvers, and “unnamed creepy black suitcase,” a large case full of rubber vaginas (yes, seriously) used to learn manual cervical examination.

After spending some time with my preceptor, Fiona, and the suitcase, I was surprised and excited to be given the opportunity to manually palpate Nicole’s cervix. It was a quick exam, and afterwards, I felt grateful to have earned the trust of both my preceptor and our patient—after all, it was a very invasive and sensitive exam. The afternoon continued with more teaching, observation, and exposure to new and interesting obstetrical cases. Eventually, during a brief break between patients, I found myself shooting the breeze with my preceptor and the team of nurses. It was casual conversation that ended with what felt like a bombshell: “Okay, Sarah, let’s go check in on Nicole. She’s almost ready, and you’ll be delivering the baby.”

I kept my cool, trying my best to exude professionalism, gratitude, and excitement. Internally, I looked and felt quite the opposite: my stomach churned anxiously as I mentally cycled through the delivery procedure that I had learned merely an hour before. Internal rotation, flexion, external rotation… was I missing something? Was flexion first? I didn’t have much time to think, because before I knew it, I was standing at the foot of Nicole’s bed, hands outstretched, eyes locked on the tiny human being who was making his first appearance into the world. My preceptor guided my hands as he talked through the birth, and in just a few minutes, Nicole’s son was calm, swaddled, and resting on her chest.

I could spend hundreds of words describing those few minutes: my sense of gratitude, the sharp awareness that I was the first human to touch Nicole’s son, the unexplainable reverence of witnessing the first moments of a new life. I felt an overwhelming and awe-inspiring sense of connection—I’m still not exactly sure to what, but I was completely present and aware of the moment’s intensity. Having the privilege of participating in this profound experience sparked a reflection on the intense trust that physicians receive from their patients. I realized that yesterday’s assessment of the ‘important parts’ of labor failed to take into account the patient’s whole story: the YouTube video didn’t capture dad’s teary smile and sense of relief, or Nicole’s admirable fortitude, or even the more ‘real’ components—smells, fluids, blood.

I want to be a physician who doesn’t forget about the whole story: the patient’s narrative. I’m coming to realize that these profound moments—a delivery, a death, a diagnosis—do not and cannot exist in a vacuum outside of real emotions and experiences. Physicians are somewhat akin to mechanics in that a job must be done, and they are under pressure to do it well: fix something, stitch something, put together pieces of a puzzle. Excellence in these skills contributes to the excellence of a physician, but I think that part of the ‘magic’ of medicine comes from the ability to remain mindful of what I’m doing, respect the immensely personal and intimate nature of the patient-physician relationship, and constantly reflect on my gratitude for the privilege of becoming part of this profession.

*Names have been changed for confidentiality purposes.

Jack* did not come into the shelter quietly. He blew in angry, yelling, slamming doors, and pointing fingers. His ongoing monologue was heard by everyone within 10 feet — sometimes it formed logical sentences, and sometimes it did not. From what I could gather, he was annoyed with a man named Ernest* – it wasn’t his fault, he would like everyone to shut the **** up, and he didn’t need any of this ****ing ****. To describe him medically, he seemed to be responding to internal stimuli, and his drooping red eyes, lack of coordinated movement and slurred speech pointed to some level of intoxication.

When asked by the staff if he wanted to come in to chat, he responded with an emphatic “no” and stormed off into the main lobby. Something was atypical about Jack’s presentation. Off to the left of the room, standing with her arms folded around herself, was his mother. Her eyes were heavy with the look of someone who had been through this with her son several times before. Yet, her eyebrows were knitted together with genuine concern over her son’s current condition. In order to try and de-escalate the situation, we took Jack’s distraught mother into the clinic room while a social worker went to talk to Jack one-on-one, and we let them know Jack was welcome to come and join the conversation at any time.

In the room, the staff I was with introduced us to Jack’s mother, and let her know that Jack was a client that was familiar to her, as he was a frequent visitor to the clinic building. The staff let her know that while we weren’t at particular liberty to disclose any information we had about Jack, she was welcome to share with us whatever she was comfortable with sharing, even if only for the therapeutic effect of talking about it. Jack’s mom proceeded to give us a full picture of how Jack’s life had played out up until the point where we had seen him today, yelling and angry in the shelter. She described a lifetime of mental health struggles, learning difficulties and neurocognitive concerns about Jack — a myriad of ways Jack’s brain had struggled throughout the years to help him take care of himself. On top of this, Jack had experienced several traumatic events throughout his lifetime that his mother said had caused him to spiral further away from a place where she felt she could help him. He had been abused by a family member at a very young age, and had started purposely hitting his head off of any surface he could find from the age of 18 months. From then on, his mother had watched as he struggled through school, struggled to cope with self harm, depression and social interactions, and then eventually struggle to cope with substance abuse.

All of these things had led him to where he was, in the shelter today, describing vivid hallucinations and bizarre thoughts, confused, and running out of options. He had been kicked out of his previous shelter for this behaviour. Jack’s mother  had seen him in plenty different states before, but never like this, she said. She was becoming increasingly worried about him, and didn’t know how to help him. If you were merely walking past Jack in his current state, you might have cast him as a classic young man living on the streets — seemingly intoxicated, aggressive, accusatory and destructive.

It is a rare opportunity to hear such a thorough life history, from birth to present moment, to give you a complete picture of how someone has ended up experiencing homelessness. It is a good reminder that everyone you meet is somebody’s baby.

The next thing we knew, Jack came knocking on the door of the clinic room. When we opened the door, a totally different Jack was standing there, social worker behind him. Jack looked meek and walked in quietly and then sat down next to his mom and held her hand. He apologized quietly and sat there on the examination table, head down, feet dangling off the edge of the table. Suddenly, it felt as if he had shrunk five sizes. After calming down with the social worker, he agreed to come chat. He admitted that the reason why he was so distraught today was that what he thought was weed last night had turned out to be peyote — something he only found out after consumption. He had been seeing and hearing all kinds of things ever since and seemed genuinely scared, ashamed, and unsure what to do. His eyes locked in on his mom like she was the only thing in his life not spinning wildly out of his control.

As a student observer in this situation, I became acutely aware that to anyone without the privileged view that I had at that moment, Jack was still that intoxicated, accusatory and destructive street youth — no evidence of anything otherwise.

He eventually agreed to stay at the shelter that night, and to come to the clinic the next morning to check in on how he was feeling. Agreeing to do that did not untangle Jack’s complicated situation, nor did it resolve any of the larger issues contributing to where he was that day. But for Jack — his mother held his hands and said, “Remember what we talked about about making one good decision a day? You just did that. And I’m so proud of you”.

In medicine, we are privileged to see people in significantly more detail than the rest of the world does. At the same time, we don’t always get the whole picture, and we often get to see people at their worst. My time on this elective, and this appointment in particular, taught me a lot about compassion, and the importance of always remembering that patients come into the office with a whole story behind them. We are just seeing today’s page.