When the seemingly simple becomes complex

01.06.2016
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I admitted a patient who was being transferred to the hospital for further treatment of prostate cancer. When he arrived at the hospital, he was frail but trying to show that he had some energy. He and his wife sat up as I walked into the room, and after I introduced myself, one of the initial questions I asked was, “How’s it going?”

In medicine, the seemingly simple questions become the complex ones. “How’s it going?” It is a question that is frequently asked whenever we encounter friends and acquaintances. In a given day, we ask this question many times out of courtesy and we expect to hear short, affirmative answers, such as “Things are good,” or “It’s OK” as we continue to walk to where we need to go since we are pressed for time.

It is a question that could promote more discussion about another person’s life, particularly if events are less than optimal, but having that type of conversation takes time, and many times other responsibilities call for us. We usually assume that the other person may not have time to hear about what is really going on in our lives, so we provide succinct answers when we are asked this particular question. It seems like a simple question on the surface given the simple answers we frequently give, but there is a hidden complexity to this question that can emerge at certain moments if we pay close attention. Many times, these moments occur when we deal with sick patients, particularly those dealing with a terminal illness.

A few months ago, I admitted a patient who was being transferred to the hospital for further treatment of prostate cancer. Previous treatments did not slow the progression of the disease, and the hope was that we potentially had a new treatment that could help his disease.

When he arrived at the hospital, he was frail but trying to show that he had some energy. He and his wife sat up as I walked into the room, and after I introduced myself, one of the initial questions I asked was, “How’s it going?”

Having been used to hearing short answers, I expected the same thing from this patient. Instead, he talked about the journey that he went through dealing with this illness. He talked about the challenge of undergoing treatments for his prostate cancer and its accompanying symptoms, the emotions that he and his wife had when he heard about progression of his illness, and the hope he had about possible improvement after being transferred to another hospital. I had other clinical responsibilities to attend to, but I realized that taking the time to listen to him gave me an idea of how to care for him during this hospitalization and also helped me to empathize with his struggle with prostate cancer.

Before he answered this question the way he did, I saw the brief hesitation that we all have when we debate whether to share the challenging things going on in our lives, but he took the gamble in believing that a doctor would show interest. I knew at that point that expecting short answers to this question in this case would only do him a disservice while he was under my care and while he was dealing with his illness.

As his hospitalization progressed, he was seen by other specialists while images and tests were reviewed. During this time, I kept asking him standard questions to get a sense of how he was doing physically while he tried to maintain a positive attitude about everything. He admitted to feeling tired and having a decreased appetite, and he was concerned about the increasing swelling he saw in his legs as well as increased effort that was needed when he tried to breathe. But overall, he remained hopeful.

Eventually the cancer had metastasized, and no treatment options were available to slow the progression of the disease. The patient took the news in stride. Again I found myself asking, “how’s it going?” And again he answered. But the focus of the discussion was different. He did not talk much about how he felt physically, but instead he started talking more about how his family would handle the news. He was not focusing on himself anymore but chose to focus on others instead.

New assumptions of how he would answer my question were challenged again since the focus was different, and it provided a new challenge in terms of how to care for him since he was not bringing up his symptoms as much. He was becoming more fatigued and the leg swelling and shortness of breath was more pronounced, but he never brought it up in this conversation. All he thought about was the potential impact of this news on his family.

Near the end of his hospitalization, more family members showed up as they prepared themselves for the inevitable passing of their loved one. Informative and compassionate discussions with palliative care prompted a new outlook. When I went into the room, I saw a man who looked the weakest that he had been, barely having energy to even lift his head off of the bed. I sat next to him and asked him how it was going.

He was concerned about whether he would be comfortable and whether his symptoms would be controlled; he also talked about the challenge of preparing to leave his family and if they would be supported by the hospice team as he approached his final days. This turned out to be the longest conversation I had with him during the hospitalization, but I sensed a genuine gratitude from him for simply asking “How is it going?” My patient died the following day with family by his side.

This experience helped me to realize that a question that I ask daily, which seemed so simple at first, turned out to be the most complex.

It is an example of medicine turning a relatively simple thing on its head, and it is a reminder that in this field, simple answers become a rarity and complex answers become the norm. The good news is that both patients and doctors benefit from this complexity, should we choose to accept it.

Image copyright: David Goehring, flickr, CC BY

Article last time updated on 07.06.2016.

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Medicine, Cardiology
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