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The Last Word

By Hujefa Vora, MD – Chair, Publications Committee

This piece was originally published in the January/February 2022 issue of the Tarrant County Physician. You can read find the full magazine here.

The medical students were sent into hiding.  We chose not to risk their bodies to the unknown illness.  Instead, most of them sat alone at home in front of computer screens.  They attended lectures virtually.  Physical contact became taboo.  Learning turned into rote memorization of presented facts, with little opportunity for the hands-on training of our time.  

In our clinics, we went into hiding as well.  Our appointments became virtual.  We too hid behind these computer screens.  Physical contact became taboo.  To start a visit note, we would write that the patient had consented in an informed fashion to participate in a virtual visit, utilizing a platform with audio and visual capabilities.  Patients would take their own blood pressures using their automatic home monitors.  Often, they would not only create their own objective findings, but also their own interpretations of their subjective history.  When we no longer touch our patients, when we can no longer hold their hands, we become severed.  The patient-physician relationship is powered by the force of our connection to our patients.  

A story that needs to be told.  I had a patient who smoked incessantly.  He was referred to my office by his cardiologist, who explained his worsening shortness of breath by saying it is not his heart.  He came into my office for the first and last time in March of 2020 just prior to the lockdown.  We spoke of his three packs a day habit.  We talked about how for the last month, he was unable to walk across his living room without becoming short of breath and coughing until it felt like his heart would pop out of his chest.  Fearing the worst, I sent him out to get a chest x-ray.  Those fears were confirmed with the finding of a complete white out of the right lung.  A CT scan confirmed the presence of malignancy in the setting of emphysema.  We couldn’t get a biopsy right away because the lockdown happened.  Many of you will remember that elective surgeries were put on hold.  Biopsy of a mass which I was sure was cancer was not necessarily elective, but getting the procedure done became nearly impossible.  I had to present the case to our surgical review board at the hospital in a Zoom meeting.  They authorized my procedure and scheduled the next available interventional radiologist.  As the day of the biopsy approached, we were informed that the patient would not be admitted without a negative COVID PCR result.  In the early days of the pandemic, PCR results took sometimes one or two weeks.  We had 72 hours, and it took about that long to actually get the test done.  Upon finding that we were not going to get the biopsy done, I spoke to the patient and his family over the telemedicine platform my office had just installed.  If we admitted him to the hospital, we might be able to get things done more efficiently.  The patient’s daughter refused this option.  We will be surrounded by COVIDI can’t risk that.  The patient continued smoking his cigarette pensively, deliberately.  The patient was offered a pulmonary consult instead and possible bronchoscopy.  It took another three weeks to get the patient in front of the computer screen of the pulmonologist, and then another two weeks after that to get the bronchoscopy done.  Ten days later, a pathologist called me to let me know that the patient had waited too long to quit his smoking habit and now had squamous cell carcinoma of the lung.  This is the kind of news that needs to be conveyed in person, not something to be said over the phone.  The patient refused to break his lockdown, so that meant the phone was how this would happen.  Unfortunately, the patient’s daughter was unavailable, so we were unable to establish the video component of the virtual visit.  I told my patient he had cancer over the phone, unable to reach out and make any physical contact, not even something as simple as a handshake or a pat on the shoulder.  I couldn’t see his face to read his thoughts, get some signal of the inner turmoil he might be experiencing.  I did my best to follow his verbal cues.  We talked about the plan.  He wanted to know our next steps.  Well, it took another month to get the patient onto a Zoom call with an oncologist.  Another three weeks got us into the virtual room of a cardiothoracic surgeon.  The surgeon agreed that the patient would need surgery to remove the tumor and at the very least improve his quality of life by making it so he could breathe.  The patient was referred back to our original cardiologist for cardiac clearance prior to surgery.   In order to get his stress test, he was subjected to another PCR test for COVID-19.  This came back a little quicker than expected, negative as was expected.  The patient underwent his stress test and was negative for inducible ischemia.  He was cleared for surgery.  At his preoperative evaluation for his scheduled surgery, the patient was told he would need another COVID-19 test.  He refused, as he had the PCR just two weeks prior at his stress test, and he was tired of the runaround.  Unfortunately, this assertion of control, this blatant attempt by the patient to avert further procrastination, further delays of his surgery, backfired.  In the meanwhile, I had been following the patient’s progress for the past six months with monthly phone visits or Zoom calls.  And so, I tried to take control of the situation.  I spoke to the surgeon, questioning why it had been necessary to delay surgery for a cardiac clearance in a patient with known cancer.  We would not have delayed the procedure for CABG had this been necessary.  So we had lost more time.  I produced the records of three COVID testing results over the past few months.  I again met with the hospital’s surgical review board.  We worked out a plan of care.  I brokered a deal.  The patient would go for surgery as soon as the surgeon scheduled.  We had one last meeting before surgery.  It was now September.  The patient asked me if he would be recovered by November 4th, election day.  I told him that I was not sure.  He informed me that he would not schedule his surgery until after election day, because he needed to vote in the election.  The surgeon reluctantly agreed to schedule him for surgery on November 5th.  The oncologist interceded and demanded that another PET CT be done prior to scheduling the surgery.  Another PCR was ordered and refused.  Another deal was struck.  The patient’s PET CT showed progression of the disease – not a surprise.  On November 5th, the patient finally went for his surgery, 249 days after our opening salvo. Ten days in the ICU.  I didn’t see him because we were in the heart of COVID at this point.  You know this patient though.  He was too stubborn to let this cancer beat him, too tough and thick-skinned to allow even COVID to get through.  He survived all of this.  The oncologists offered him chemotherapy and radiation treatments, but he refused.  He went back home to his couch and his cigarettes.  Behind the scenes, I continued to coordinate his care with the surgeons, his oncologists, the cardiologist, and the pulmonologist.  To him though, I was just another voice over the phone, a talking head disrupting his existence.  Molasses.  Quicksand.  COVID testing.

Our patients went into hiding.  Their trust of the medical establishment is broken.  Our relationship with them, though we looked out for their best interests, is broken.  We have socially distanced ourselves into a corner.  It is time to come out of hiding.  It is not taboo to touch our patients’ lives.  It is what they expect.  With this new year, we must wake up.  We must remind our patients that we will always fight for them, whether we are fighting against cancer, against COVID, against politicians, against ignorance, against fear.  Never against them, but always with them.  My patient survived, thrived, but I have never seen him again.  This is the Last Word.

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