35. A Physician’s Terminal Diagnosis | Facing mortality and sharing wisdom

• Dr. Maurer was a 46 year old internal medicine hospitalist who was diagnosed with multicentric glioblastoma in February 2018. A neurosurgeon told him that without surgery, he had about a month to live.
• Following resection, he completed chemotherapy and radiation.

• At the time of the diagnosis or soon thereafter, say things that are gentle.
• As the diagnosing provider, you might say, “I’m sorry we’ve given you such bad news, but there are treatments for this.” As a friend, say, “I’m sorry, let’s go get a beer. I’m here for you if you need me.”
• Don’t say, “You can beat this,” especially if that’s not likely.
• Don’t say, “How are you? How do you feel?”

• Be proactive. “Hey, I’m picking you up and I’m halfway there already. We’re going to the movies.”
• Just show up.

• What you don’t need when you have terminal cancer is to hear about cancer. Don’t ask how the cancer is going. And don’t bring up the diagnosis in every future conversation.
• People with cancer don’t want to talk about cancer. And if they do, they’ll bring it up. Talk about other interesting events in your life.

• When he first saw the tumor on his MRI, his reaction was a gasp of absolute shock and disbelief. Once the dexamethasone kicked in, he felt rage and anger. It was difficult to focus and concentrate.
• As time went on, he developed an intense immobilizing sadness. He was heartbroken for his children, far more so than for himself.

“Every day is worth so much… It’s easy to lose sight of that when you think you have tens of thousands of days left. But remember your mortality and choose your big and small decisions accordingly.” -C. Maurer

• Christiaan chose to be 100% direct. The information he shared with his children was unsugarcoated and sometimes slightly brutal. He tried to keep humor in it whenever he could.
• He found himself trying to compress the next 10-12 years of parenthood into 1 year, imparting wisdom that normally wouldn’t be shared until just before a child moved out for college.

“Fight for what is right, even if it costs you a job, money, a relationship, or a bad grade. Fight for the underdog, and don’t give up.” -C. Maurer

• When you call to admit a patient, be clear as to why the patient can’t go home. Rather than say, “He has gout”, say “He can’t walk, lives alone, and there are no family members who can help out.” And truly make an effort to contact and elicit help from family.
• The pushback from hospitalists often comes from chronic “bogus” admissions.

“If you’re an E.R. doctor that’s getting lots of pushback from lots of different hospitalists, then the problem might actually be you.” -C. Maurer

• Christiaan argues that you can only be one kind of ED doctor, and that’s a great one. You can’t be mediocre.
• Great ED doctors generate a broad differential diagnosis and rule out the top 6 on the list to the best of their ability.
• Providers should be able to present a patient clearly in one sentence.

• Christian gets very frustrated when a patient presentation begins with, “I don’t really know what is going on.” Upon hearing this, his brain instantly shuts off, and he just wants to end the call and figure the patient out himself.

• Remember that the interventions we do on patients (arterial lines, IVs, Foley catheters, removing adhesive tape, etc) cause significant suffering. Don’t do these procedures unnecessarily and remove them as quickly as you can.

• Christiaan noticed that with severe or critical aortic stenosis, in addition to the murmur radiating to the carotids, it also could be heard over the left scapular spine (because bone transmits sound better).

• Work hard,
• Don’t be lazy.
• Remember who this is really all for — the patient, the patient, the patient..