A USF course teaches medical students how to deal with patients they can't save - and the knowledge that doctors can't fix everything.
By LISA GREENE
Published April 26, 2004
PLANT CITY - One day, medical student T.J. Slavin plans to be a Super Doctor, a pediatric geneticist who will unlock the secrets of children's deadliest ills and make them better.
He talks about his plans with ease, confident of their success.
But this spring afternoon, Slavin was on a different mission. He drove past a field of cows, past another of horses. He turned right at the ramshackle store and left after the little white church, on his way to see a lady who is 90 years old.
For all his ambition, Slavin wouldn't be able to fix her. She was dying.
"It kind of goes against all the hallmarks of medicine," he said. "You're not trying to make the patient better. You're trying to help them die."
Slavin wasn't sure what to expect. He had never talked with a dying person before.
But then, that was why he was there.
* * *
A week earlier, Slavin and seven other medical students gathered at LifePath Hospice and Palliative Care in Tampa.
The rest of the year, students learn about delivering babies, treating ear infections and stitching up wounds. They see emergency room crises and routine checkups.
This program is different. The University of South Florida requires that every third-year student spend time with the dying.
Students will learn more about the services hospice provides, from helping with meals and medicine to providing spiritual counseling and advice for family members. But hospice staffers hope they will learn larger lessons as well.
"We're trying to develop comfort in the next generation of physicians so they can talk about these issues," said Dr. Ronald Schonwetter, LifePath's chief medical officer and professor and director of geriatric medicine at USF. "Physicians can be very uncomfortable talking about death and dying with patients and their families. They fear the responses of patients, they fear their own emotional responses, they may feel they're a failure if the patient dies."
Hospice staffers say they believe the program, which began in the mid 1990s, is one of only a few at U.S. medical schools that require hospice visits, but neither a national medical school group nor a national hospice organization track such data.
The March group of students includes Ana Miranda, a former nurse, who thinks this rotation won't be any big deal. Unlike many other students, she's seen plenty of death and dying. There's Luis Alvarado, who thinks the whole idea is just a little weird.
There's a student who wants to be a surgeon, another who wants to be a psychiatrist, and some who just aren't sure yet.
They start by taking a test. The questions include what you might expect: Which pain medicine should you prescribe? What's the dose?
And then the ones you might not: Your dying patient just started to cry. What should you do?
Students hear from doctors, social workers and nurses about how hospice cares for patients who are in their last year of life. Hospice staffers try to focus on easing patients' pain and improving the quality of their last days, rather than seeking a cure.
Mark Spiegel, LifePath's spiritual care specialist, told students about the day he was at a dying patient's bedside when the phone rang. The man was so weak, Spiegel had to hold up the phone. It was the man's doctor: "Now, Tom, you hang in, you're going to get better."
The man died the next day. His doctor's words were hardly unique, Spiegel said. Studies have shown that many doctors never break the worst news. One such study said only 37 percent of doctors gave honest survival estimates to patients dying of cancer.
Spiegel asked students how they would answer patients' harder questions. What happens, he asked, when a patient asks you, "I don't smoke. I don't drink. What have I done to deserve this?"
Easy, Slavin shot back: "You don't smoke. You don't drink. What have you got to live for?"
Everybody laughed. And one student chimed in: "So, you're not going to be a hospice doctor, are you, T.J.?"
* * *
A week later, Slavin drove to Plant City to talk to Oral Rodgers, who has lung disease and other health problems. He imagined she would be pretty ill. Maybe on oxygen. Maybe coughing a lot.
But when Slavin arrived, everyone was all smiles. Rodgers' daughter, Billie, ushered him and social worker Denise Healy into the house. Rodgers didn't get up, but she shook hands and said how it was nice to meet him.
"You have a nice home here," he told her.
The living room was neat and clean. A china bulldog sat on the floor across from Rodgers' recliner. Next to her was an oxygen tank, but for now, she wasn't using it.
"Do you feel comfortable here?" Slavin asked her.
"Oh, gosh yes," she said.
"What do you like to do?"
"Go shopping."
Slavin laughed. "Now I know I'm surrounded by women."
He asked about visitors, about who helps her, how she feels. Rodgers' answers were cheery but short. He asked if she had signed a living will, and even though everyone thought she had, the copy they found wasn't signed. Rodgers signed a new one.
He asked if she had any concerns about the end of her life, but it's not a conversation that Rodgers needed to have.
"Do you feel you're ready to go to heaven?" Slavin asked her, broaching a topic students are taught to ask about.
"When it comes, it comes," Rodgers told him. "I don't even think about it."
Slavin drove away mulling over his visit, thinking about what he did right and wrong. It was hard, because Rodgers didn't seem to have much she wanted to say.
Nor did he want to push her too much.
"It's hard to talk about death and dying," he said. "Especially because she looks good ... in the back of my mind, I didn't want to depress her."
He liked her though. She's a nice woman, with a nice family and a positive mind-set.
It was strange, to see the fuss over her signing a living will again. He hasn't had to deal with that. And he didn't like it - signing legal documents, as if you need permission to die.
"It's so impersonal," he complained. "You can't even die in this country. Everything has to be set up."
In the end, Slavin said, he has to accept there just wasn't much he could do.
"It's why doctors hate talking about it," he said. "Doctors always want to fix things. When you can't fix it - it gives you a feeling like medicine failed."
But not fixing doesn't have to mean failing, Slavin said. For him, talking about death is no longer taboo.
* * *
A week later, it was Alvarado's turn. He went for a second visit with his patient, William Friday, who lives on a quiet, shady street in Brandon with his wife, his daughter and son-in-law, and their children.
Friday, 74, was growing steadily weaker as his heart failed. It had been a bad week for him, and he was tired. But he greeted Alvarado and a social worker with a smile.
He told Alvarado all about his grandchildren, how 3-year-old Nicole still climbs into his lap, how Dalton, 10, will compete soon in a go-cart race.
"I'm just sorry I can't be there to see him," he said.
Nicole ran into Friday's room to say hello. She has lugged along the family cat, nearly her size, so she could show her off for Alvarado.
He admired the cat, and then turned to Friday with an earnest manner, asking questions to draw him out. Alvarado brought up a topic that they discussed last week - that, even though Friday feels loved and well-cared for, he worries he is a burden.
"I've never had somebody to wait on me," Friday told Alvarado. "I watched my mother wait on my father for 10 years. He had a stroke. He couldn't move. How could you feel, but a burden?
"Any of them would do anything I like them to do. I just feel that way myself."
They chatted more about Nicole, and Alvarado asked about whether Friday would want to be put on a ventilator. Friday said he was surprised he has lived longer in hospice than most of his friends. Then Friday began to drift, because his new pain pills make him sleepy, and Alvarado said his goodbyes.
He stopped in the family room to chat with Friday's wife, Elene. She was glad to have him there.
"It might help us," she said. "Maybe we can help them. Maybe him seeing my husband might help him to help other people."
Alvarado was sure it will.
"When you work in a hospital, you're focused on your medical care. Here, you talk about who they are, what they've been through. It reminds you of why you're doing medicine."
* * *
Another week, and the students gathered to talk over their experiences. A few found patients confronting worries - a drinking problem, estranged family members, medicine that dulled awareness along with pain. But many students were surprised by their patients' acceptance of their final days.
For Miranda, meeting her patient, an 82-year-old veteran with heart disease, was a revelation. Before, she said, she didn't even know that hospice cared for patients with diseases other than cancer. And all too often, she had seen doctors step out of a room, tell staffers to consult hospice, and move on.
Miranda's description of what she called a "let's wash our hands" attitude touched a nerve. Hospice workers chimed in, telling stories of patients referred to hospice without knowing why, patients whom doctors ignored once they were diagnosed.
This, Dr. Stephen Leedy told the students, is why they were here.
"We envision a day, five to 10 years from now, when you all are out there where those doctors are now," Leedy said. "And you're going to know better."
* * *
A few weeks later, the group was in the midst of its surgery rotation, and Miranda had just heard about a patient whose surgery to remove a cancer showed instead that it had spread too far to cure.
In the past, she said, students might walk by the rooms of such patients, because there was nothing more that they could do.
Now, she knows that there is. This time, she said, she will stop. She'll talk about hospice. She'll ask what she can do. She'll listen.
"I have to make sure he knows he's not alone," Miranda said. "We have to be with our patients to the end."
