Prognosis: Poor

I sat, unaccountably, at the head of a table in the resident lounge, listening to our Heme/Onc fellow begin the debriefing. At the hospital, a debrief allows us to voice our emotions over a difficult case, an ongoing problem, or a new fear. I was a fourth year medical student, and felt a wave of appreciation when our fellow offered to lead. The week had been difficult; a new diagnosis, an end-of-life conversation and Little Boy A.

There is something exciting about being a fourth year. Feeling, finally, that you both know what’s expected of you and that you are able to meet that expectation. You have figured out whether your Assessments and Plans will be by System or Problem, you have UpToDate – an evidence-based point-of-care medical resource – on your phone and you can withstand most pimping sessions from your attending. Pimping, here, referring to the popular medical exercise whereby the attending poses a series of questions to the medical student for educational purposes. But to do all this as a student, you must divorce yourself from the tangle of emotions that comes from constantly brushing against the painful truth that medicine doesn’t fix everything. It doesn’t make the parents less anxious, or the teenagers less moody or a case like Little Boy A less challenging.

Little Boy A was a seven-year-old with early B-Cell Acute Lymphoblastic Lymphoma (ALL). Children with ALL, particularly early B-Cell ALL have a generally excellent prognosis; 98% achieve remission with appropriate therapy, and 90% are declared cured after 10 years of remission. Little Boy A presented following multiple relapses after having received partial treatments abroad and was currently undergoing re-induction therapy.

At the Debrief,  I had placed my hands on the table, flat to avoid clenching them in distress as we went around the table sharing how we were feeling that week. We had just come from an ethics meeting, actually concerning Little Boy A, had discussed questions of insurance, physician responsibility and what constituted emergency care in a case like this. I was silent, apprehension filling me as each person got to speak, knowing, terrifyingly, that this wasn’t something I could do in the calm, rational manner that my colleagues had adopted. I heard our fellow ask me if I wanted to share anything. My hand went up to my mouth, perhaps unconsciously trying to stem the well of emotion that threatened to pour forth. There was a moment when I knew I would not make it. The words burst forth in an anguished sob, “Why?” I was shaking, as I forced myself to continue speaking.

I was grateful to the residents, the other medical student, and our fellow for seeming to understand the content of my somewhat garbled speech: that we had failed him. I struggled to understand how the system made it so a boy with an excellent prognosis could die. The physician abroad who had met the family upon diagnosis had not been able to convince them of the necessity of continuing therapy. The parents, instead, succumbed to understandable fear and switched to alternative therapies, halting chemotherapy. How had such a thing happened?

In medicine, after an event, or “near-miss,” there is something called a “Root Cause Analysis.” We learned this in our first year, that the system is meant not to blame but assess, prevent, and fix. We learn about the Swiss cheese model of accident causation: how a system of defenses may have holes that allow hazards to slip through. Little Boy A was not a hazard, but I could see the many layers that should have shielded him, and I couldn’t understand how he had fallen through. Why?

It was easier to ask why, in the midst of state-of-the-art technology and multiple teams from Oncology to Chaplains. I knew it could not have been easy for a physician to deliver a cancer diagnosis. I knew it could not have been easy for parents to hear that their child was sick. I knew it could not have been easy to see their child suffer the effects of chemotherapy. I knew it could not have been easy to leave their country in the hopes of saving their child. I knew it could not have been easy to hear that what was once a manageable disease was now a debilitating malady. I knew, but Little Boy A did not know. He simply knew he was sick. He did not know why. He did not know of the complex events that had led him to our hospital, on our floor.

I am calmer now, a resident puts a hand over mine, and I feel the support of a team that nods as we vent on the result of a series of unaccountable events. We will rise soon and return to round on patients, to reassess the floor, to update plans, to care. I feel the recharge that the session has brought me; the catharsis that opening up has allowed. As a medical student, I’ve learned the complex nature of medicine: once felt to be magic, crafted into an art, aspiring to be a science, managed as a business, made imperfect. To practice it, meant always striving for that elusive perfection. It meant to always, always try to do better. I expect I will meet many other Little Boy A’s in my career. I hope I may do my best.