Sunday, August 9, 2015

Week 37: Cancer's many faces, Berlin's many masks and my many impressions

What an interesting week I had. I spent three days throughout the week shadowing the chief. 

After the morning meetings, I would go to the private ward with him and see the patients he was taking care of. At 10, we'd go over to the office building for consultations until about 1:30pm. 

It was interesting because I was able to experience patients in all the different stages of cancer that exist. Being in the room for the moment someone is told they have cancer is a weird feeling. Especially, if you know the person has cancer before they come into the room and you we waiting in anticipation for the doctor to tell them. Doctors have a difficult task of conveying the message appropriately. You need to use the right words, in the right order and on the level of the patients understanding so that they really come to understand what their diagnosis means. As soon as the patient hears the word cancer, everything after that is usually not being registered. It's also a tough task because not every cancer is the same. If patients haven't had contact to cancer patients, they usually assume the worst outcome. If they have had cases of cancer in their family or circle of friends, they only know that specific case. But cancer is so different and personal to each person. Breast cancer is treated completely different than colon cancer. The outcomes and prognoses are different. The journey through treatment is different. Even one type of cancer, breast cancer for instance, varies a lot between patients in respect to treatment, outcome and journey. Some are hormone or genetically sensitive to treatment, others aren't. It is important to give the patient a sense of were they stand. At the same time, statistics are statistics and don't really have a meaning for the individual. We can only say how long most patients live statistically, but in the case for a specific person, that really isn't relevant. Most patients want it to be though and ask about statistics. As a doctor, we walk a thin line between giving false hope and real hope. Even if we articulate an appropriate amount of hope, it is received and interpreted by patients differently so we have to see if that which we were trying to convey, was registered correctly. 

I few things I noticed over the week were:

A) Many patients try to attribute a certain life event to their cancer. "I fell a few weeks ago and hurt my shoulder, can that be the origin of my sarcoma?" (It can't.)

B) Patients that are married seem to handle it all better. (This was actually proven in a study.)

C) If the patient with cancer is the husband, the wife does most of the talking. "He's been taking these and these pills. He's been doing so and so with the treatment. His next appointment is then and then." Probably why point B stands.

D) A few couples would say "we" have this or that appointment coming up. "We've" handled the treatment this way. It really shows how much cancer doesn't just affect the person with it but also the loved ones going through it.

E) In general, patients with a worse prognosis seems to take everything a lot harder (understandable) but that isn't always the case and the attitude of the patient has a lot to do with their support system and their view of the rest of their life. Some are quite inspirational. 

F) Quite a few patients live with their cancer as though it is a chronic disease. I think that is still a fairly new concept for people. Medicine has gotten so good that even if we can't cure you completely of your cancer, we can, in some cases, push it back so far that your life expectancy is about the same as without cancer, it just involves taking a pill everyday. And as with any pill you take, you have the risk of side effects. 

Chief surprised us in the afternoon meeting with 3 scoops of ice cream for each person!

I think the chief really enjoyed having me around, explaining things to me and letting me do the ultra sounds before he did them to confirm my findings. I think he also appreciated that I know how to politely deal with people. I think there is just a certain way you have to act if you are working with the chief because the patients have certain expectations when they come to consultations with the chief and it can't hurt to be greeted and escorted to the room by a friendly student. (And I'm also friendly to all the other patients too so it isn't like I'm trying to be any different than usual which makes it easy for me.)

Back on the ward, I finally got to do a bone marrow aspiration! It didn't go as smoothly as I had hoped it would but no unexpected harm was done and we got the material we needed so all good in the end. I just wish for myself that it had gone better but it was my first time so I guess it went well. I didn't accidentally go through the other side and do a colon biopsy (which as funny as that may sound, was my greatest fear, even worse, puncture a big vessel.) 
A good idea of what I did.    Google Images.

I'd also like to tell you about a situation with a patient because I think it is a good example that just because medicine is capable with doing things, it mustn't always be done if discussed openly with the patient. 

The patient has cancer. He's gone through chemo and was taking pills as the last option of treatment. The pills statistically could make him live a couple of months longer. While taking the pills, he suffered from gastrointestinal side effects and they left him not enjoying food anymore. He just didn't feel good in general under the therapy with the pills. He decided to take a break from the pills knowing that would statistically lower his life expectancy. As we talked with him, his wife, daughter and two grandchildren were in the room. He looked as though he was a normal old man enjoying his time with his family but you wouldn't have been able to tell he has cancer. After openly discussing with him the statistical benefits weighed against the reality of how he felt taking them, we all agreed that it would be better to take a break from the pills for the time being. If need be, he could always start them again. In his situation, I would have done the exact same thing. He weighed being under treatment and feeling bad, not enjoying life with feeling good, being able to enjoy life and statistically maybe living a few months less. But isn't a life you enjoy living and your loved ones can enjoy with you worth more than being able to say you lived a few months longer but weren't able to enjoy that time? It is a highly personal decision a person has to make for themselves. I thought it was a nice conversation to have witnessed. The doctor didn't push the medicine because of statistics but rather treated the patient as a whole and not as a disease that needs to be cured.

Similar situations happened during consultations. There was one situation though, were I as the patient, would have decided differently. The woman has cancer. Due to a certain factor she "luckily" has positive in her type of cancer, there is a pill that works highly specific and targets the caner cells which gives her a significant statistical advantage for survival over not taking them. The common side effects are also easily manageable. She decided she was done with medicine and was not going to go through with the therapy. This was rather baffling to me (especially with her medical professional background) and the chief was also not for her decision. Seeing that Germany is a free country and we can't force anyone to do anything (and our mentality isn't such that we would) the chief explained the benefits to her multiple times in the hopes that she might see the benefit and change her mind. After repeated attempts, he told her that his suggestion for treatment stands and that he wasn't going to change his recommendation but that he had to respect her decision even if he doesn't agree. I can live with situations like this when the patient is an adult and has understood the consequences. I have issues when these situations happen with children and their parents are the decision makers. Many things, if need be, can be done with a court order. Other situations, such as vaccinations, are a different thing. A big reason why pediatric medicine, although lovely on so many fabulous levels, will probably not be the area I work in. 

That was my rather interesting week in Hem/Onc. Two more weeks to go. The chief is on vacation the next two weeks and starting Monday we have an elective student in the department. I'll take over mentoring her a bit to see where she stands with drawing blood, placing lines and such.

Now a little travel report for those that are interested. :)

I spent the last weekend showing my friend from Miami a bit of Germany. We met up in Hamburg on Friday. Took the train to Berlin Saturday morning and both left Berlin Sunday evening. 

Christopher Street Day was going on in Hamburg. There were booths with drinks, food, tightly dressed men, rainbows and loud music all around. We took a stroll through all the festivities. The big department store Alsterhaus and the town hall both had pride flags displayed. I thought it was an incredibly cool symbol from the city to show support for the event. Germany in general is a very accepting country. Many might not associate that with Germany right away due to its history but we have acknowledged our past and dealt/are dealing with it. Nowadays, I feel it is one of the most accepting countries I've been in.

East Side Gallery shenanigans. Berlin

If you are in Hamburg, are starving and can't decide what you want to eat but just want a good variety of food immediately without having to look for a restaurant first, I suggest going to the LeBuffet on the 6th floor of the Alsterhaus. It has a buffet with a wide variety of food at a good price and a view on the water!

If you are in Berlin and want some really delicious Arabic food, you must go to Casalot (Claire-Waldoff-Strasse 5)....SO delicious and the presentation of the food is also outstanding. The service is very friendly and the place offers a lot of outdoor seating.

Pretty gelato flowers from Amorino
A restaurant I wouldn't suggest going to is DIE EINS (Wilhelmstraße 67A, 10117 Berlin). I hate to give a bad review but this place can easily be a tourist trap. It has a very nice location right on the river, around the corner from the Brandenburger Gate and a hop, skip and a jump away from parliament. My friend and I were just so starving that we sat down. Before even ordering I had a feeling the place relied highly on its location and could therefore care less about the food or its presentation. I ordered something of the breakfast menu (seeing our breakfast to that point had been a felafel, coffee and half a KIND bar). Granola with milk, quark (its German, think of thick yogurt) with berries and honey, fruit salad and fresh squeezed orange juice. That sounded really good to me and I could think of multiple ways of presenting that nicely. In reality, I was served a bowl of cornflakes with a few walnuts of top (how fancy), the quark was basically runny yogurt with jam in it, the fruit salad contained many broken grapes and in general was not that appealing. The fresh squeezed orange juice was 100ml....didn't feel like much more than a shot. It was just bad. I easily could have made a better meal at home for far less. My friends omelet and salad didn't look or taste half as appealing as the menu made it out to be. So if you aren't starving, avoid this place and go down a few streets for something nicer. 

Some fun in a store that encourages taking pictures: Store Berlin

Saturday evening, we stumbled upon the Monbijou Theater Strand Bar dance event. Every day of the week, they have a different DJ playing music and a dance floor set up right next to the river. You can get drinks and order Pizza and it is just such a lovely atmosphere in a lovely part of town. We sat down for a good long while and watched the couples glide across the dance floor. I seriously need to take my grandma up on her offer to pay for dance lessons to learn the standard dances and then I have to get my booty out on that dance floor someday! 

We did a Free Walking Tour of Berlin on Sunday. It takes about 2.5 hours and its great! While back packing through Europe, my travel buddy and I would often partake in them. The tour guides have always been fun and were really enthusiastic about it. They don't give you boring facts and move on, the stuff they talk about is interesting and explained well. A great part about it, and their business model, is that it is absolutely free and the tour guides work on a tips basis only. This makes it easier for students who might not be able to afford as much to decide what the tour was worth to them. If I had the extra funds, I'd probably be giving them double what I do because I always enjoy the walk so much. Great way to see the important things in the city if you have limited time. 

That is all for now my friends! Stay healthy!


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