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The Patients That Deserve the Most Act the Least Entitled

The following manuscript was submitted to the November 2017 Military Medicine theme issue.

“How are you doing this morning, Mr. Tracy? Sorry we’re running late. You’ve been waiting an hour.”

“Pretty good. How ‘bout you, doc? Thanks for seeing me so early.”

“Sure, no problem, it’s only 9 a.m.; it’s not early at all; it’s my pleasure. Where are you coming in from today?”

“Well, you know, had little bit of a ride this ‘morn — live about 150 miles east of here; got up ‘round 4 a.m.; had a good ride on my bike.”

“You ride a motorcycle?”

“You bet. An old Harley my pops and I built back in the 80s. Most faithful thing in my life.”

“That’s great. I raced motocross as a teenager. There’s something exhilarating about being on the bike. Such a high, but also so dangerous!”

“Yah, I never got into those dirt bikes — buddy of mine back in ’76 crashed and wound up a cripple. Scares the shit out of me!”

“Well, thanks so much for being on time. Sorry about the wait. Let’s check out this cancer here, and see what we’re going to do. How long has it been there?”

“Yeah, you know, it’s been there for a bit — maybe a year or so, and I don’t care too much about what I look like. I just thought that was some bump on my nose, but apparently one of my friends, a real good fella, told me my nose ain’t right, so I ended up at a local dermatologist. They cut some little piece out, and I guess you’re going to take out the rest.”

“Yes, you have fairly large squamous cell carcinoma that will require excision with some sort of reconstruction. I see that you were exposed to Agent Orange during the war?”

“Yeah, boy those were some crazy days, but yeah they would rain that stuff down on us just about as often as it would pour down there in ‘Nam!”

“Sorry about that. We’ll never know for sure if your cancer was caused by that, but it certainly didn’t help. Sun exposure is usually the culprit. Based on what I see today, the area of cancer looks fairly extensive, and unfortunately, I think we’ll have to resect about half of your nose, which will then require a sequence of reconstructions to make things look right. I’m going to ask you various other questions, and try and get you a slot in the anesthesia preoperative clinic today, so that we can operate in the next week or so.”

I call anesthesia, and they explain that they’re totally booked for the day, and they cannot see Mr. Tracy. I plead with them given his drive, but they’re unwavering. They compromise with an appointment later in the week. I go back into the room to tell Mr. Tracy he’ll have to come back, despite his long journey.

“Don’t worry, doc. You folks are the best. You’re all working so hard. They’ll get to me when they can.”

The patient doesn’t show for his anesthesia visit later that week. I call the patient to ask why he missed, “Well you know, doc. Sometimes I have a really bad night and can’t sleep. Ever since the war, they say I have that PTSD, but I don’t really know if that’s a thing. I’ve done the treatments and all, and met with the VA PTSD people. I just do my thing, and some days don’t work out.“

Eventually we find a date for anesthesia and surgery six weeks later. Surgery goes very well, and after frozen sections are clear of cancer, half his nose is gone along with some underlying cartilage — as predicted. We perform the initial reconstruction, which involves taking a flap of tissue from his forehead and swinging it down onto his nose, connected at the base near his glabella. While this is ambulatory surgery in most cases, Mr. Tracy has no one to drive him home, and the local VA hotel won’t accept patients after general anesthesia, so he’s admitted to the hospital. I visit him the following morning.

“How’re you feeling, Mr. Tracy. Did you sleep okay?”

“Didn’t really sleep, doc. I hate hospital beds. I’d have been better off on the floor, but it’s okay. The nurses have been great — such good service here. I’m really happy to see my nose looks great.”

Mr. Tracy has a massive wad of tissue arching from his eyebrows, obscuring his right eye and sutured to his nose.

“Sir, I hope you realize — as we’ve discussed — that this is just the first stage. In a few weeks, we’ll come back and place cartilage, and then eventually disconnect this flap from your forehead. You’re going to have something that actually looks like a nose!”

“I see. Well that’s even better news. I know you docs here do such a good job. We’re all so thankful for the care. It looks fine to me, but if you can make it better, I’ll trust in whatever you think is best.”

After two additional surgeries, Mr. Tracy is cancer-free and living with a functional and aesthetically pleasing nose. In his final follow up visit, he asks me, “Throughout all these surgeries, who was that other gentlemen always with you, you know the one with no hair like me.” He gives a big belly chuckle. I explain that he was the attending surgeon — my boss and mentor. As I’ve explained to him before, I tell him I’m still in my surgical training, and thank him for allowing me to participate in his care.

“Thank you, Mr. Tracy. Thank you for your service!”

“You’re a real Cracker Jack guy, doc,” he quipped. “Hope you stay with us.”

Months later, my VA rotation ends, and I return to Stanford University Hospital. I walk into clinic to see Ms. Atherton at 11 a.m. who is following up from her fouth round of revisions to her reconstructed breasts.

Knock, knock. “Ms. Atherton?”

“Oh no. Not one of you. Can I just see the real doctor?”

“I am a physician, ma’am. I’ve been one for five years. Do you mind if talk with you prior to the attending?”

“You know what I mean, sweetie. I just want to talk to the attending. I hate this result. This morning has been terrible. I waited 15 minutes for the valet to even take my car, and they refused to park a Tesla out front, so it wound up in the regular lot. Anyway, I showed up 20 minutes early to my appointment, and you still didn’t see me until my appointment time.”

“I’m sorry to hear about all those troubles, Ms. Atherton. I’ll go get the attending. I hope you have a great day.”

Clifford Sheckter, MD Clifford Sheckter, MD (2 Posts)

Fellow Physician Contributing Writer

Stanford University

Cliff was born and raised in California’s Eastern Sierra. His passions included motocross and ski racing in his hometown of Mammoth Lakes. He attended college at UCLA where he majored in anthropology and excavated pre-contact Guaymi burials on remote Panamanian shores. After graduating summa cum laude and Phi Beta Kappa from UCLA, he went to USC for medical school on an academic scholarship. His research focused on surgical education in designing perfused cadaver models, and cost-effective means of delivering burn care. He graduated AOA and valedictorian, and matched into Plastic and Reconstructive Surgery at Stanford. Cliff completed a postdoc fellowship at Stanford’s Clinical Excellence Research Center learning value-based care, studying health policy, and getting a foundation in health services research. His current investigations include cost-effective delivery systems for burn patients, understanding the effects of reimbursement variation on surgeon decision making, and improving resident physician performance through targeting variation. Cliff aspires to be a burn surgeon with the goal of improving outcomes following reconstructive surgery. He also aims to improve shared-decision making when undergoing reconstructive burn surgery. More than anything, Cliff loves spending time with his wife Cassandra, who is a patent litigator in Palo Alto. They are raising twin boys, Jake and Charlie, who have quickly become their raison-d'etre. The family of four loves traveling.