On pulmonary outpatient clinic, part 2

Last night marked the last TGIF yoga class from the teacher who has been there since well before I started med school. It was a momentous occasion: I've attended this class every single Friday night that I've been in Albany over the past two years. Friends have changed, apartment has changed, schedule has changed, I've changed, and this yoga class has been there the whole time. It reminded me of when I finally moved away from Boston, I realized that the most consistent companions I'd had over the six years post-high school (besides my family) were not my friends or my co-workers but the kids I babysat for every week. These are background patterns I take for granted.

It was an unexpectedly sad and amazing week on pulmonary outpatient clinic. For the first time in my career as a med student, I was fascinated and impressed by the rare cases as opposed to the mundane: nocardia pneumonia with a healing abscess, acquired pulmonary alveolar proteinosis, two patients both alive and well five years after diagnoses of lung cancer with brain metastases. In the past I've felt that the rare cases, while "cool," don't reflect what we really need to learn to manage most patients, nor do they encourage empathy for the suffering person. I'll take this as one more instance in which I'm becoming culturally more similar to the rest of my profession.

Friday ended with a pair of sisters--fairly young, fit and healthy-looking women in their early sixties (one thing I've learned this week is that my "healthy-looking" sensor can be way off)--sitting before me in the exam room. One of them was just diagnosed with lung cancer in May and had the entire right lower lobe of her lung removed in June. She was now suffering from bloody pleural effusions and her sister was there with her to learn how to drain the fluid at home. What a mental shift that must have been for both of them: one previously healthy to sick and missing a huge piece of lung; the other now taking on a caretaking role. Both seemed to be taking it in stride: cheerful, matter-of-fact, not grossed-out, hopeful yet concerned about prognosis. I was so impressed.

So this week was tinged with endings, both of the new-beginnings kind and of the beginning-of-the-end kind. Let's be thankful for the former.

On pulmonary outpatient clinic, part 1

I've heard that respiratory failure is one of the more painful ways to die. In renal failure, once you're off dialysis, toxins build up in your blood and you slip into a coma, going gently into that good night. In respiratory failure, you are hungry for air: it's a set of diseases that causes anxiety.

Similarly, then, patients living with lung disease live actively with their disease. They sense it, feel it, accommodate it, fear it around the clock or spontaneously here and there. Cystic fibrosis, asthma, emphysema are debilitating conditions around which patients may define themselves. This morning I met a very healthy appearing young woman, dressed nicely for her office internship, ready to start her college semester next week. On exam she seemed totally fine: no cyanosis, no clubbing, perhaps some very brief end-inspiratory wheezes but no extraordinary breath sounds. You would not pick her out walking down the street. Yet she has cystic fibrosis, a very treatable form, and when I told her I'd once met an older lady with CF during a lecture, she said, "An older woman? That's good to hear!" Raised with CF, treated with a drug only made available in 2012, she lives with a sense of her own mortality. She is comfortable enough with her mortality to allude to it in a comment to me, while I look at her and see a healthy person, and deny to myself the possibility of serious illness.

All of this to speculate as to why I've found the physician-patient relationships over the past week (shadowing in pulmonary) so profound, even as compared to a previous weeks in cardiology and endocrinology. It could just be the particular physician, but it could also be that hypertension and even type 2 diabetes are relatively silent diseases (for diabetes that's a questionable statement that certainly depends on the patient and how much insulin affects their daily living, but those in denial are able to live in denial, it seems). Over the past few days we've had patients cry in the office; express joy and gratitude over improved asthma; dismay over worsening, untreatable emphysema. My attending lingers with his patients, dreamily reminiscing about his intern days, thoroughly explaining the mechanisms underlying symptoms or treatments. I think it keeps them coming back, improves their disease self-maintenance. How privileged to be a fly on the wall for conversations that have been years in the making.