I‘m sitting in the oncology pod, fruitlessly attempting to cram more medical minutae into my brain, which feels full to bursting. All of my downtime during fourth-year clinical rotations in veterinary school is spent studying. Well, that was true for the other years too, but…you know.
Vet school and post-graduate training are organized much like human medical school: students spend their first two and a half years in the classroom, learning from textbooks, lectures, and labs. Our next year-and-a-half is spent in clinical rotation, with hands-on learning where we actually practice medicine. After graduating from vet school, many veterinarians enter the workforce as general, or primary-care, practitioners. Other veterinarians go on to complete a one- or 2-year internship, which involves more intensive training with various specialists, gaining the equivalent of 3-5 years of general practice. Like some other veterinarians, I elected to enter general practice after my internship. Those veterinarians who choose to specialize (internal medicine, surgery, cardiology, radiology, etc.) undertake an additional three-year residency.
The Cornell University Hospital for Animals is a two-story building. The top floor is dedicated to research, while the sprawling first floor is split into self-contained clinics called "pods." Each pod is dedicated to its own specialty. Randomized groups of 3-8 vet students rotate through each specialty every 2-4 weeks, learning from residents and faculty by seeing actual cases.
While I'm nose-deep in my notes, a dermatology resident walks through the door, addressing the oncology resident mischievously.
“I believe we have a case that suits your expertise better than ours," she says to the oncology resident that's overseeing us. "Wanna come take a look?” Without another word, the two residents head off to the case. The rest of the fourth-year students and I automatically shuffle behind like ducklings.
The corridor that connects the oncology pod to the dermatology pod is plain; unadorned white tile is lined with reinforcing stainless steel strips at waist-height to absorb gurney impacts. Cornell crimson is the only accent color.
We all squeeze into the tiny white dermatology exam room and it’s immediately apparent that the stunning middle-aged Golden Retriever in front of us should have been scheduled with oncology, not dermatology. A lime-sized, bony tumor bulges from the right side of her upper jaw, markedly disrupting the elegance of her show-quality facial symmetry.
The oncology resident wrinkles her brow at the dermatology resident, whose facial expression silently replies, “I don’t get it either.” Some of the fourth years glance hesitantly at one another for hints; others direct their glances definitively at the wall, trying to stay under the radar. (In my experience, only the most insufferable fourth year students seek out the limelight during clinics.)
Standing beside the stainless steel exam table is the elderly male owner, stone-faced and bent slightly forward at the waist with his hand on his cocked hip. He's the personification of “cowboy.” Beside him is his wife, eyes wide with terror, wordlessly seeking answers from each of us in turn.
This is an atypical appointment, to say the least.
“I just made the goddamned appointment with whichever service had the first opening because that’s the only way I ever get my practice's patients seen by the Great Cornell University," he booms with sarcastic intensity. This owner is also a veterinarian. Huh. His declaration immediately puts the residents on the defensive; within moments, the encounter escalates into a full-blown argument about scheduling and professional courtesy. After several minutes and several more bruised egos, things cool down. Finally, the terse conversation turns to our patient, who wags her tail at the sudden shift in attention. Her diagnosis and treatment finally become the focus.
Dr. Owner noted the mass several months ago and, being a veterinarian, immediately knew that cancer was likely. He attempted several local and systemic treatments without fantastic success. After reviewing the case history, it is still unclear what resolution - if any - this situation requires.
The list of possible causes (which veterinarians call the "differential diagnosis list") guides all conversations and recommendations in clinical practice. In this case, that list is pretty short and readily apparent to everyone in the room, with the exception of Dr. Owner’s wife. In fact, Dr. Owner has exhausted nearly every avenue available to treat his dog’s oral cancer. At this stage, it’s a matter of time, the focus on maintaining a decent quality of life for the patient until the cancer wins. Dr. Owner knows this, yet he proceeds to outline his handling of the case in detail. He’s done a great job with it, I think to myself. What on earth is he looking for from us? Why is he paying to ask questions he knows the answers to?
What's Really Needed
I notice Dr. Owner sneaking sidelong glances at his wife while the resident regurgitates the inevitable replies. Watching those glances, I have a sudden moment of realization.
“Whether benign or malignant, this tumor will eventually cause your dog's quality of life to decline to an unsustainable level. Regardless of intervention - surgery, radiation, chemotherapy - this location and tumor behavior indicate that no therapy will, or would have, significantly altered the outcome.”
Gesturing towards his still-silent wife without looking at her, his face hard and features set, Dr. Owner demands, “Please tell her there was nothing I could have done different.”
There's a pause while the oncology resident considers how to proceed.
Dr. Owner’s shoulders drop, his rough stoicism vanishes. Tears abruptly well up and pour from his eyes. Hoarsely, meekly, he breaks the silence and beseeches his colleague, “Please tell me there was nothing I could’ve done different.”
I’ve never lost the feeling that I’m a fraud, that I’m fooling everyone into believing I’m a capable doctor. That the very next case will expose my incompetence, leaving me standing in a room full of people who know better than I do, terrified I did something wrong and made a patient suffer. There’s a deep, dark shame I feel when I get something wrong. It's a shame all doctors carry. The ones who become good doctors convert that fear and shame into healthy humility - slowly, and with much effort.
Six years into my career, I feel increasingly confident about the decisions I make as a doctor, and I’ve gotten more comfortable differentiating between what I do and don’t know. Most days, I feel comfortable that I practiced competently and appropriately.
Sometimes, after a hard day of struggling under the weight of the expectation to never be wrong, I wish I could just cry and ask someone to tell me there was nothing I could’ve done different.