“You have a lot to learn,” he said sternly as the heat in his voice rose and his finger stood tremulously in front of my nose. “How old are you? I demand to know.”
This is what my home visit to an 82 year old hospice patient devolved to as I told him that he should no longer be driving. I reminded him of the several falls he had taken recently in parking lots and in stores. I reminded him of his recent fender bender. “Trust me,” I said. “If I had a 30 year old patient with your disease and medication profile, I’d say the same thing.”
”I don’t trust you. Now get out!”
I’m a 32 year old woman awaiting board certification in hospice and palliative medicine. I’m fellowship trained in the fields of hospice and palliative medicine, and at this point in time, I’ve spent most of my life in school or in training for this, my dream job. This is my first year as an attending physician. I spend my day visiting hospice patients in their homes; some are imminently dying, requiring family conferences on the fly to glean understanding from family members and to ensure my patients are getting maximal symptom management. Some of my patients are really of the palliative care sort, either referred to hospice too soon or not fully in line with the hospice mindset. These patients are just as challenging. My patients and their families generally share with me everything about their lives, past and present, as I’ve found that the concept of dying often allows people to open up about things they never dreamed they would. They tell me of failed relationships, beautiful family memories, run-ins with the law, things they regret, and things they are most proud of. What my patients and families generally don’t tell me is whether or not they trust me, the young-looking woman who is in charge of theirs or their loved one’s final phase.
I do often hear age-related comments about my appearance. The most popular of these (“You don’t look old enough to be a doctor!” and “Are you Doogie Howser?”) are often inserted in the middle of an in-depth and sensitive conversation about death and dying. It’s what is unsaid that makes me nervous.
Do families discount what I spent hours saying because of my appearance? My age? My relative lack of life experience? Do they dismiss whatever I may say over the ensuing two hours when they see “the very young doctor” walking through their door? When I touch on sensitive topics, like driving, are patients and families less inclined to hear my concerns for all who are on the road because of my age and inexperience as a physician?
Of course, all physicians must start out in their first attending job. In primary care, however, my job as a physician is based mostly on guidelines, with a good amount of evidentiary support for run-of-the-mill problems. I don’t need a lot of life experience to discuss these issues with patients and patients understand this. In palliative care, where issues are neither black nor white, it helps to back up recommendations with experience in medicine and in life.
As hospice and palliative medicine emerges as a critical medical specialty, and as fellowship training is (as of 2013) the only way to obtain certification in HPM, our physicians will be entering the field at a younger age and with less experience. Will this be a detriment to our field? To this point, a lot of our physicians have come to palliative care as a second or third career in medicine, lending their expertise in areas like neurology, emergency medicine, geriatrics, and surgery to patients at the end-of-life, and advancing our specialty in credibility and trustworthiness. Will this change with the new breed of 30 year olds responsible for continuing the charge?
I do have a lot to learn. I agree with my very angry patient. But I know a lot, and I know a lot about the good death and about symptom management leading up to the good death. I feel that I am a skilled communicator, thanks to my training, and good at building rapport quickly. I also have a lot to say, and a lot to bring to my chosen field. Considering and appreciating all of the things I can do, what I can’t do is change time. So from here, I’ll look forward to living more life and learning more every day.
Maybe from now on, I’ll find myself asking my hairstylist to leave the gray strands in.
Bethany Calkins, MD