Family Medicine Vital Signs

I teach Physician Assistant (PA) students the art of the medical interview and this morning had just finished teaching the lecture entitled, “Delivering Bad News.”  I walked the students through the S.P.I.K.E.S model, encouraging them to plan out the Setting, think about the patient Perception, get an Invitation from the patient to present information, impart Knowledge to the patient, explore Emotions and Empathize and then Summarize the news.  We discuss how this is a model for organizing the encounter, but not a rigid structure. I tell the students how it is a privilege to deliver bad news and that how we do this can shape a patient’s experience with this life-changing information.  I explain that one of the challenges of primary care is that we are often dealing with incomplete information, doing the best we can without knowing many of the answers.  I do think that the most important thing that I teach the students to do, though, is to be human. To see the person sitting in front of you. To be kind.

My last patient this Friday afternoon was new to me.  She was around 47 years old and had a cough and chest tightness for over a week that just wouldn’t go away.  And she wasn’t sick.  And she knew something was wrong.  She was a survivor of early adulthood non-Hodgkin’s lymphoma and was 30 years out from her treatment, including chest radiation.  Although she was calm and her exam and vital signs were reassuring, she felt like she couldn’t take in a deep breath.  She was alone today, she hadn’t told her wife yet that she was coming in afraid that she would worry. We both agreed that if she hadn’t previously had cancer, we would “watch and wait” but that today, in her case, an x-ray was warranted.

The films weren’t good.  Bilateral hilar lymph node enlargement.  Patchy perihilar opacities. Fibrotic changes? Scarring? I called the radiologist and he asked when she had developed lung cancer.  Apparently today, I mumbled.

Walking back into the room, I forgot about the model that I had taught so many times.  I just sat next to my patient, we looked at the x-ray together.  She was at one time shocked, but not surprised.  She was sad and had questions that I didn’t know the answers to.  I knew that she needed a CT and labs, that I couldn’t confirm anything today, but that she was sick.  Again.  We discussed telling her wife.  Her kids.  We discussed next steps and trying to stay present.  I gave her my home number and said I would call tomorrow and check in. She said she felt ok to go home.

I got into my car and cried.  I cried for her and her family. For the unfairness of disease and the fact that her treatment for one cancer can cause another.  And, because it’s human nature, I cried for myself.  Five years out from my own cancer treatment, I had figured that sometime in the future I could stop worrying about the headaches that lasted a little too long, the tiny lump or the cough that doesn’t make sense.  That sometime in the future you get to rest and not look for the recurrence or the new disease.

When I could breathe again, I drove home.  I went back to teach on Monday.  I told my students to be human, to see the person sitting in front of you.  Be Kind.

Joanne Rolls, MPAS, PA-C, is a Certified Physician Assistant and an Assistant Professor (Clinical) at the University of Utah School of Medicine, Division of Physician Assistant Studies. She is a Family Medicine PA who serves University of Utah students and patients as a PA educator and Family Medicine PA.