Hospital (40 page)

O
n January 30, Lisa Keen, the social worker, brought a difficult case to biopsychosocial. She wanted information about a twenty-four-year-old woman, undocumented, unmarried, two children, Hispanic—we’ll call her Ms. Hernandez. Mendel Warshawsky, the third-year fellow and cancer survivor from South Africa, said he knew the background: An initial workup had shown a negative breast exam. This was not, as one might think, good news. The cancer had metastasized.

“The prognosis in the case is dismal,” said Warshawsky. The sun shining brightly through the cafeteria windows seemed at first to mock this grim forecast but on reflection seemed the perfect backdrop for the specter of unseasonable death. Why was it sixty degrees in January? The persistence of unnaturally warm weather was creepy, a portent of doom, heralding the end of seasons as we had known them for the past many centuries.

Warshawsky was still waiting to hear from Astrow about the oncology job and was angry about the delay. “Astrow doesn’t have the balls to make a hard decision,” he told me before the meeting. “I don’t know if he’s going to last here.”

Warshawsky tried to concentrate on this difficult case, which left open many questions that he summarized for the group seated around the cafeteria tables they pulled together for the session, since there was no conference room for the fellows. Should the patient receive chemotherapy, which would not cure her and almost certainly make her feel sick but could prolong her life long enough for her to get her affairs in order?

What did it mean to get her affairs in order? “We have an undocumented woman, limited English,” Keen summarized, challenge in her eyes, as usual. “Boyfriend of three months, the only one who knows she has cancer. She’s entitled to nothing, working as a cashier in a supermarket off the books.”

Alan Astrow sat with his hands clasped on the table, his head slightly bent. “Probably not a big chain,” he said. “She’d have to have papers.” He seemed distracted. He had told me his mother had checked in to Sloan-Ketteringwith chest pain and was angry with him for not interceding with her doctor.

“Probably an Indian store,” said Sushma Nakka in her lilting Indian accent, her makeup flawless and tasteful.

Keen said, “We’re going to have to send her to Coney Island. Who’s going to follow her?”

“Where’s the father?” Astrow asked.

Keen said drily. “Somewhere.”

Warshawsky finished his diagnosis. “She has metastasis to every part of her body.”

Keen shook her head. “She doesn’t have a clue.”

Warshawsky straightened the yarmulke on his hairless head. “Maybe we shouldn’t just talk about chemotherapy but that she should start thinking about taking care of her kids, about going home. If we start her on chemotherapy, she’ll be so involved with that, and then she’ll be so sick she won’t be able to do anything, and then she’ll die in the hospital. There isn’t that much we can do for it.”

Sheldon Berman, the psychiatrist with the shaggy gray hair, several years older than Astrow, chimed in. “We know we have a young woman here. Mendel brings up the context of how we interact with the patient. How do you implement your plan? We have a patient we assume is going to die in the next year. I’m reading between the lines—physicians will talk about treatment without talking about imminence of death.”

Jason Tache, another third-year fellow, always spoke as if making a conclusion. “You’re talking about prognosis,” he said.

Berman shook his head impatiently. “No, not prognosis,” he said. “We’re talking about a young woman, limited English, how do we help her?”

“Help” in this conference meant something different from in the interdisciplinary meeting.

Berman was an old friend of Novetsky’s; they had developed the group-therapy style of this biopsychosocial conference together. Like Keen, he had a sensibility shaped by the 1960s, rebelliousness worn down to an attitude of weary cynicism, righteous fervor mellowed but intact. This would be one of his last sessions. He had told Astrow he wanted to leave as soon as another psychiatrist could take his place as provocateur.

Berman repeated, “How do we help her? What do we do?”

Keen laughed shortly. “Run away?”

Tache sighed. “We are not prepared to give her the psychosocial treatment you are talking about because of the patient’s financial and social situation.”

He looked at Warshawsky. “Has it spread quickly, or did she ignore it because she didn’t have the money? We can’t give her long-term care—”

Astrow interrupted. “I thought she would be referred to Coney Island and a fellow will follow through.” The Maimonides fellows did rotations at Coney Island, a public hospital four and a half miles away.

“They don’t have social services,” said Tache.

Astrow nodded. “They don’t have a Nella.”

Nella Khenkin was the cancer center’s social worker, who usually came to the meetings, but not that day.

“They don’t have a non-Nella,” Tache replied. “There is no one to help with social aspects.”

A woman in her forties, wearing a wig arranged with pageboy smoothness, entered the conversation. “She’s going to have to think about child support,” said Beth Popp, the hospital’s pain-management specialist, who was Orthodox and often wore headbands that matched her clothing over her smooth wig. She was eating oatmeal out of a Styrofoam container. She had told me she’d lost a hundred pounds before having her fourth child and was careful.

“Giving her some suggestions about things she can do that are helpful is better than telling her she has terrible cancer and we’ll know how bad after the test results,” Popp said. “We should send off some warning shots, and it has to be done with social workers who speak her language.”

Tache shook his head. “She has no insurance,” he said. “When she leaves this place, she has nothing.”

Popp raised her voice. “But she’s here now!”

Berman stepped in. “Listen to Jason’s approach,” he said. “He’s saying she is up the creek without a paddle.”

Tache smiled. “I’m not saying she’s there, but she’s on the way,” he said. “I speak the language, and it’s common these people come here and have three, four children at home.”

Keen stared at Tache. “Her mother is here,” she said.

“Is she a responsible human being?” Tache asked. “You think she has two kids and someone has to tell her she has to take care of them? Why do I have to figure out what to do with her kids?”

Astrow spoke. “No one is asking you to solve her social problem.”

Exasperated, Tache replied, “That’s exactly what Lisa wants and Shelly, too,” referring to the social worker and the psychiatrist.

Berman shook his head. “I’m trying to emphasize we are a team,” he said. “When you become an attending, it’s not just taking the temperature.”

Astrow listened, his hands folded on the cafeteria table.

“I agree with you, Shelly,” he said. “Let me reframe the question, because Jason has thrown down the gauntlet. People often want us to solve their social problems. Jason is suggesting it’s a limited role.”

Tache shrugged. “I have a limited amount of time to expend my energy,” he said. “What’s the most useful way to do that? In our system I don’t see how to help.”

Sramila Aithul spoke next. She was a second-year fellow who spoke with calm authority, a personality trait that had been reinforced during her tenure as chief resident. “Sometimes if you just talk to a patient in a way that gives them ideas of how to handle the situation . . . ,” she said. “You may not tell them what to do, but just talking to them, showing some compassion—”

Tache interrupted. “With all due respect to Sramila, compassion is not going to raise her two kids.”

Keen said, “I don’t have a problem finding services for people. My problem is dealing with a twenty-four-year-old who is dying. Somebody with two kids; my daughter’s age. I was half serious about wanting to run away. I need help.”

Inna Sominsky, the second-year Russian fellow, said she had the same situation with another patient, a thirty-year-old with colon cancer, stage three. “Was told about her disease and prognosis by the surgeon, but she has never asked about the future,” she said. “She doesn’t ask any questions, and I am avoiding.”

Astrow synthesized. “When a patient doesn’t ask,” he mused. “Sounds like this young woman—Ms. Hernandez—is not going to ask Mendel, and he’s raised some good questions. Does she want to go back?”

Keen shook her head. “She doesn’t,” she said. “Her mother and sisters are here.”

Astrow said, “Her country doesn’t have the services?”

“It depends what kind of services,” said Berman. “Loving care, kindness . . . it may be better. For me the most significant thing is pain management and end-of-life care, which, God knows, we don’t do well. Let’s think of this as a team. We are totally impotent to be able to stop the disease. Death is going to occur. This has to be part of our thought. Everybody dies, including us. If our goal is to help this woman, let’s deal with the fact her kids are going to grow up without her, go to elementary school, to high school, get married, have children, and she’s going to miss all that. The most important thing for family members is to know that you are there. Have any of you sat by the bed of a family member when they died?”

The discussion drifted in that direction for a few minutes, and then Astrow interceded. “The woman is not actively dying,” he said. “We haven’t finished the diagnostic workup. What is Mendel supposed to do?”

Berman said, “I’m suggesting that part of what we do is to be a human being, to be there in the moment, knowing we can’t make it better other than to say, ‘I am here.’”

Astrow tried again. “In the spirituality series, a priest talked about getting out of the fixing mode,” he said. “Instead of worshipping Jesus, he said, you should follow Jesus into the vale of tears. But before we follow this patient down the vale of tears, we have to help Mendel with the medical diagnosis and what to tell the patient.”

There was more conversation, and then Keen said, “This has made me feel better. Being in the room and caring is the most important thing. We shouldn’t underestimate the power of hope.”

Tache muttered. “Just don’t overestimate it either.”

Astrow glanced at his watch. They were reaching the end of the ninety-minute session. “It is important to be aware of your feelings,” he said. “Not whether you like or don’t like the patient, but helping them figure out what’s best for them. Part of being a good doctor is self-awareness.”