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In medicine, the sickest patients always seem to come on Friday afternoons. At the end of the week, I'm hoping to move quickly through my last few patients -- a small corneal abrasion, a routine follow-up, or a stable glaucoma exam. I'm prepared for pleasant conversation and some friendly banter about rival football teams playing Saturday morning. But I'm wary. I have been doing this long enough to know that the 4:30 to 5:30 p.m. "witching hour" approaches.
After practicing for a year, I have told six patients they have a brain tumor. Maybe that seems like it would be an appropriate job for a doctor, but I am an eye surgeon, an ophthalmologist. I was trained to maintain and improve vision; my surgeries are life-changing -- in a good way. Once my patients were blind, now they can see. I wasn't trained to deliver this kind of bad news.
Mark, a 36-year-old construction worker, is my last patient, referred for headaches and blurry vision. My technician approaches me to say that his imaging didn't look right and is there anything else we should do? His visual field shows that he has lost his side vision. There are a few diagnoses rattling around in my Friday-at-4:30 p.m. brain, but one stands out and is most likely: brain tumor.
I look down the hall and can see the patient in the exam room. He is scrolling on his phone, solidly in the "Before." In the Before, he's excited about the Saturday afternoon game. He still just has headaches. His vision is just a little blurry. He is still just at an eye doctor appointment.
I walk in and introduce myself. We realize we are on opposite sides of the football game tomorrow and chuckle about the odds. I let him tell me about his symptoms, even though it doesn't matter -- I already know what needs to be done. I examine him and then sit back in my chair. I look into his eyes and get ready -- this is the moment where everything changes. This is the moment where he becomes a patient. This is the moment he isn't just worried about the game tomorrow or if he'll need to take off work next week.
This is the moment where everything separates into the Before and the After.
We've all had our own Before and After, when we receive bad news, when a family member dies, or when life somehow irreversibly changes forever. Maybe things will improve in the After, but they are never really the same.
If it were me, I'd want to be shocked. Don't let me down easy -- just say, "Hey, I think you might have a brain tumor; you should probably get an MRI." But, I'm a doctor, so maybe my mind works differently.
Should I be just an eye doctor? "I'm not sure what is going on here, but it seems to be more than just the eyes."
Or should I go somewhere in the middle? "I am very concerned that there is something going on in your brain that is causing your vision to be blurry."
I figure the middle road is best, and he says he understands. He will go to the emergency room and get a picture taken of his brain. I remind him to pick up his phone charger on the way -- it will be a long night. He assures me he will still be cheering for his team. He thanks me, like I've done something good for him, when really all the hard work is yet to be done.
He leaves, walking steadily into the After.
, is a glaucoma and cataract surgeon.
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