‘This is going to hurt’ — when doctors have to ready patients for pain and grief

As a medical student, I recently went through my ear, nose and throat rotation. During my clinical posting at the hospital, there was a particularly poignant consultation that left an impression on me.

We were down to the last patient scheduled for the clinic that day.

The man who entered the room was tall and lanky. He had deep-set eyes and his cheekbones anchored his face.

“My GP (general practitioner) referred me to see you,” he said, sliding a white envelope across the table.

The patient had presented with blood in his phlegm for the past few months, along with a sensation of blocked nose, blood-streaked mucus, and a lump in his neck. He also had significant weight loss.

“Any family history of head and neck cancer?” the doctor inquired.

“No. None at all,” he replied.

“I need to do a scope to check the back of your nose and throat,” said the doctor, who obtained the patient’s consent.

A flexible nasoendoscope was threaded through his nostrils and advanced down his nasopharynx, a region at the back of the nose connecting the nasal cavity with the mouth.

On the endoscope camera, his nasal passageway was clear and patent.

His turbinates (bony shelves that act to warm and humidify air) were normal in size, and his nasal mucosa (moist inner lining of the nose) was pink and healthy.

Then, we saw it: An ominous bulge at the back of the nasopharynx, crusted over and polypoidal in shape.

The doctor hovered the tip of the camera over the mass for a few seconds. She stepped on the footplate to capture snapshots of her endoscopic findings, repeating the process with the other nostril.

“I’m concerned the mass I found at the back of your nose might be causing the symptoms you’re experiencing,” she stated as she showed the patient the images she had taken.

“You see this? This is not normal,” she circled her cursor over the outgrowth. “Shall we take a biopsy of the mass for sampling this visit?”

The patient took some time to process what the doctor had just explained, the crease between his eyebrows deepening to convey the words he failed to articulate.

“I can’t say for sure what it is now. We need further testing to confirm the diagnosis,” she clarified, cognisant of what was on his mind.

In the procedure room, the patient lay reclined on the bed. “I’m afraid,” he whispered, turning onto his side as he gripped the railing with one hand.

“The pain will be minimal,” the doctor reassured him. “It’s a very brief procedure.”

“It’s not the pain…” he trailed off.

“I’m worried I might have cancer.”

The doctor neither denied nor validated this possibility.

“What do you work as?” she asked, changing the subject.

“I’m a bus captain,” the man replied. “I come from Malaysia.”

Then, his face fell again. “I have two children back at home, doctor. I can’t afford to have cancer.”

“How old are they?” she persisted, keeping the mood upbeat.

“They’re both in their teens. The older one is studying to be a coffee brewer.” He smiled wistfully, “I haven’t seen them in a while.”

The equipment was ready and the procedure was about to start.

“This might hurt a little,” the doctor warned as she inserted the rigid endoscope through the patient’s nostril, extending her forceps to reach for the mass. “I’ll tell you before I take the samples.”

As doctors, we often inform our patients of pain before we perform an invasive procedure.

“This is going to hurt,” we caution, directing the patient to take a deep breath. We then  puncture the skin with the needle to draw blood from a vein, or plunge the drill into the lower back deeper to aspirate for bone marrow.

There are other instances of distress and grief, however, that we do not ready our patients for.

This is going to hurt, the biopsy came back positive. This is going to hurt, the scans show the cancer has recurred again. This is going to hurt, we tried our best but your father didn’t make it.

Does foretelling the pain make it a little more bearable? Does bracing yourself for the fall take the load off the impact? Can you ever prepare yourself fully for your own mortality?

The doctor and I returned to the vacant clinic room after the procedure. We stared at the endoscopic images of the mass again after we sat down, the lesion silent and imposing.

“It looks like nasopharyngeal carcinoma,” the doctor said quietly. She took off her gloves.

There was frankly nothing else the mass could be in the nasal cavity.

Nasopharyngeal carcinoma (NPC) is the sixth most common type of cancer in Singapore, the most common of head and neck cancers.

Majority of NPCs are detected at a late stage when patients present with a lump in the neck due to lymph node enlargement. Other common presentations include blood-stained secretions, nose blockage, and loss of weight.

The burden of conveying a diagnosis to the patient is a heavy and strenuous one. No one wishes to be a harbinger of bad news; we would all wish for the truth to be otherwise.

In every clinical encounter, what does it mean to know? What does it mean to carry a diagnosis, on both the side of the provider — the doctor, the messenger of the news, and the patient, the bearer of the message?

For the doctor, oftentimes, the diagnosis is only as powerful as the means to counter the aberrancy.

We are limited in how much we can do for our patients by current treatment modalities. Most times in medicine we do not cure; many times we rely on the body to recover itself, or assist it in its process of doing so.

So goes the old adage of medicine we pledge during the White Coat Ceremony, a rite of passage where medical students are inducted into the fraternity: To cure sometimes, relieve often, and comfort always.

It is not always necessary to make the patient completely well again. Healing can take place in other forms too.

For the patient, the significance of a diagnosis is closely linked to its prognosis.

Figures — the probability of functional recovery, the number of months one has left to live, the scores of survival statistics, only take on a life when tagged to one.

Many at times, it is a matter of context and congruence.

The individual lies at the heart of all we do in medicine. What constitutes a patient’s life? What matters to him?

And how is he, after hearing what has been relayed, going to make sense of the information, carrying on his life in a way that accommodates the new present?

Nevertheless, having a diagnosis provides relief and comfort for many. It defines the disease and informs prognosis and progression, charting the way forward for both patient and physician.

Giving a name to an entity makes it known. The disease becomes less of an enigma and more personal.

What a strange thought, isn’t it? To own a disease, to recognise it as a part of you.

There will always be questions, and we are limited in our ability to answer all of them. To live through the questions themselves then, is perhaps what we have to do.

As the poet Rainer Maria Rilke once wrote to his young mentee: “Do not now seek the answers, which cannot be given to you because you would not be able to live them. And the point is, to live everything.”

 

ABOUT THE AUTHOR:

Faye Ng Yu Ci is a fourth-year student at Yong Loo Lin School of Medicine, National University of Singapore. The personal details of the patient cited in this piece have been changed to preserve anonymity.