New and Nervous

Shweta Gupta, MD
Published: Monday, Oct 07, 2013
I was filled with excitement and enthusiasm as I looked forward to my first day as an attending physician in medical oncology. The training was finally over and the dream was finally realized. I was my own boss— that too with a fatter pay check. All I had to do was put my training to good use. How hard could that be!

My first new patient had a large mass hanging out of their liver with test results that revealed normal liver function, positive hepatitis B, normal alpha-fetoprotein, and a CT scan result that read “kindly correlate clinically.” As a result of a 3-year practice as a fellow, my instinct led me to my senior attending’s room, where I stopped at the threshold and realized that now I was an attending as well. “Should I go in and ask for help or try to sort it on my own?”

I began reading UpToDate and NCCN, but this time it was different. I was not supposed to read to impress my attending and follow his directions; I actually had to make a clinical decision on my own. For the first time, there was no second opinion. My decision was the final one—the one that may be good but also could be bad. And not to mention the note I’d sign could not be changed. (God, I wished so much for paper notes at this point.)

To add to the shakes, the primary team wanted my opinion on the patient’s possible diagnosis and need for an abdomen MRI quickly because they were planning discharge.

While I was thinking, a voice came from behind me.

“Doctor, shall we talk about the patients on the list?” Little did I realize that I had been sitting at the computer for over a half hour trying to ensure that I was not missing anything.

Now, there were over 20 patients on the inpatient list and my team of residents, students, and fellow gathered around waiting for me to discuss everything with them. Needless to say, I didn’t want to sound stupid in front of the team. So I decided to run through the old patient list first and then talk about this new patient.

Most patients on the list already had a plan in place and I was relieved that things were running at a good pace, until another dilemma arose. This time, I was faced with a young, 40-some-year-old patient with metastatic colon cancer and multiple large liver metastases. This patient had an excellent performance status but very deranged liver function with a bilirubin of over 15 with no ductal obstruction. He desired chemotherapy and the oncology team could not discuss this in detail with him until now. So, as the new attending on the team, it fell upon me to go and speak with him.

My fellow asked, “So what shall we do in this case?” It took me a moment to gather my wits to say, “Hmm let’s see…what do you think?” And I did emphasize the “YOU.”

There was a pause which offered me the chance to breathe for a few seconds. Finally, the team revealed they were not sure how to proceed. Since we were going to see patients after lunch, I dismissed them a little early and asked my fellow to read up and enlighten us on the chemotherapeutic options for colon cancer with severely deranged liver function.

For the first time in my life I thanked God that I had a stubby neck so that my racing pulse could not be seen by anyone. I rushed back to my room and began looking up information on the computer to enlighten myself. Lunch was forgotten, but at the end of the hour I somewhat had a plan for both of these patients. I would order a biopsy for the first patient and speak to the other patient about a dosereduced chemotherapy option, if he wanted it.

Rounds were going well and the discussion was more fruitful than I expected. My team had a good expression of tranquility about our progress and I felt that I would survive the day successfully. And as we expect a storm to follow a big quiet, just minutes before we called it a day, a call came from an ear, nose, and throat (ENT) resident in the operating room about a new consult.

This was a 30-some-year-old young man with a tongue mass and neck nodes, whose biopsy results revealed malignant melanoma. I take pride in the fact that during my training I saw a few cases of malignant melanoma and treated them, but this mucosal melanoma was a first.

The ENT resident was asking for chemotherapy options for him. I told them I needed to review the case before giving my opinion. The team looked at me for what looked like a nice essay they expected me to provide about mucosal melanomas. Instead, what followed was somewhat shabby by my standards but made my team light up with a smile…I asked them to go home since it was close to 5 o’clock and I explained that I would take this consult on my own.

The team happily departed and I was left once again thinking back to earlier that day...“How hard could this be!” I finally decided to conduct research again. However, I also decided to get a second opinion this time. I walked to my senior attending’s room. The door was open and I knocked gently, feeling a little embarrassed. She gave me a big smile and said “Finally…I was wondering when you would show up.”

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