My first end-of-life conversation [PODCAST]

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“Looking back on these words at the end of my rotation, I understand what I had felt, and I feel confident naming it: the futility of medicine. We can comfort and treat patients, but there’s nothing more we can do after a certain point. As a bright-eyed medical student who wrote on all her medical school applications that she wanted to save lives, it was and still is difficult for me to understand that.”

Shereen Jeyakumar is a medical student.

She shares her story and discusses her KevinMD article, “My first end-of-life conversation.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Shereen Jeyakumar. She is a medical student, and she wrote the KevinMD article “My first end-of-life conversation.” Shereen, welcome to the show.

Shereen Jeyakumar: I’m so happy to be on the show and talk to you here today. Thanks so much for having me.

Kevin Pho: So we’ll get into the article a little bit, but first off, can you share your story and your journey to where you are today?

Shereen Jeyakumar: Right, yeah. So I’m currently a third-year medical student at Florida Atlantic University. I was born and raised in Florida, so I’ve lived here my whole life. I did a seven-year BS/MD program to get to where I am today.

I’ve always been really passionate about writing and reading. I have a diary that I’ve written in every day since I was in high school, and I try to read a book at least once a month. So those are two really big passions of mine, and I feel like intersecting that passion with medicine has been really important to me. So I’m so grateful for the opportunity that I got to write for KevinMD and have an article there that shows the thoughts I had during my rotations.

Kevin Pho: Tell me some of the challenges that you faced studying medicine during COVID-19.

Shereen Jeyakumar: Right. So last year, when COVID started, I was at the end of M2, and I was studying for my Step 1 exam. During that time, I think my Step 1 appointment at Prometric probably got canceled around 10 times, so every single time I had to reform my study plan. I was in dedicated for that exam for almost five months, I think it ended up being, because our third-year schedule got pushed back from rotations starting in May until August. So it was just a lot of difficulty, and it kind of felt like I was isolated, studying every day.

But you know, we’re at the end of it. And I think being a third-year medical student and being in clinical rotations for the first time in a pandemic has also been a really enriching and interesting experience, which I’ll kind of get into with my article as well, and how that affected my experience.

Kevin Pho: So let’s talk about that article. It’s titled “My first end-of-life conversation.” For those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Shereen Jeyakumar: Right, yeah. So last October, I was on my internal medicine rotation, and I think that rotation was really important in my formation as a physician, because it was the first time I really felt ownership and responsibility with my patients. So I wrote their notes, I saw them each morning on my own, I presented them at rounds, and I started to get an idea of what a physician-patient relationship is really like. So when I had a patient who was clearly dying on my rotation, it was a situation where I found it difficult to deal with that kind of futility and to not know what more we could do for her in that situation.

The patient I had was only 54, and she had metastatic ovarian cancer. She had recurrent small bowel obstructions and extensive ascites and kept needing serial paracentesis just for palliative care. Our team worked around COVID rules to at least have her husband in the room. So there was one morning we went in for rounds, and we had to face the reality of the situation with her and her husband. That was a very difficult situation to be in, and it was hard to watch the way that her husband was trying to find more ways or more reasons to keep giving her treatment, clinging to lab values like the albumin or the white count.

Being in that situation was hard. It was the first time, I think, that I cried in a patient room, and my attending cried as well, and the patient cried, and it was a bonding experience that I hadn’t had up until that point. And I mean, we say all this medical terminology, but at the end of the day, sometimes it means so little in terms of what we can actually do for a patient. So being brought face-to-face with that kind of futility was difficult, I guess, as a medical student. You know, we write on all our med school apps, “I want to be there, I want to help people,” and then being faced with the futility of sometimes there’s not much more you can do is a really difficult situation.

So I wrote in that article that I still hadn’t come to terms with that futility and that I was still struggling. And a couple of months after I wrote that, I am still struggling with that. But I think what’s really important, as future physicians and as musicians, physicians, is that we write about things like that, and we internalize it, and we give it the importance that it deserves. And I think that helps a lot, that kind of self-reflection.

Kevin Pho: Did you have any training in terms of end-of-life care, end-of-life role-playing, in your preclinical years that prepared you for that moment?

Shereen Jeyakumar: Right, yeah. So interestingly, we do have a palliative care physician who counseled us through medical school, and I remember in M2 we had a simulation for an end-of-life conversation with a standardized patient. I still remember doing that, but it was so crazy to me, in my mind, how doing that is so different from actually talking to an end-of-life patient, because it’s just the reality, the crushing reality of that situation, and how much more emotional it can be in that moment.

I think that a lot of times we’re taught to stay less emotional and not cry or be so explicit in emotions, but I think sometimes that is the appropriate reaction to have with a patient. So it was really important to me to have that experience.

And I think it’s good to have, like when we had the simulation, they would give us ways to talk to patients, you know, phrases to use to make sure that the patient knows that this isn’t their fault, that we’re working with them through this. Trying to use phrases like that helped in that situation, but it still is very different actually doing it.

Kevin Pho: So as you were having these difficult conversations with the patient and the patient’s family, what are some of the things that you did to help you through it?

Shereen Jeyakumar: As I was saying, I have a diary that I keep every day, and so the day that this conversation happened, as soon as I got out of rounds, that was the first thing I did. I just sat down and wrote about it, and I think that’s something that helps me so much, just self-reflecting about what happened during the day.

And you know, sometimes it’s hard. Sometimes you have a long day on a rotation, and you get out and you don’t really want to think about what happened. But I think it’s really important to find that emotional resolve to still write about it if you don’t want to see a patient as just a set of labs or a list of vital signs. You want to make sure that you see them as a full human being with their own thoughts and values and passions. And that’s kind of how I cope with it. I feel like just writing, playing music, doing something to put the emotions that you feel into a sort of product, I guess.

Kevin Pho: OK, and tell me what the reaction was of your medical team during that rotation. What kind of support did you get from the attendings and the residents during that time?

Shereen Jeyakumar: Right, yeah. So I think after that conversation, we did have a little debrief outside of the patient room. I expressed to the attending that that was my first time having a conversation like that with a patient and their family, and the attending was really empathetic and spoke to me about what her first time was like having a conversation like that with a patient. We just spoke about it for a little bit, and she let me know that I could always come talk to her if I wanted to look through this.

Once I wrote this article, I sent it her way as well to let her know how that experience impacted me. And she gave me advice too about how she has never come to terms with this kind of futility in medicine either, but just the same thing: that internalizing it and trying to get through it in your own way is what’s most important.

Kevin Pho: We’re talking to Shereen Jeyakumar. She’s a medical student, and she wrote the KevinMD article “My first end-of-life conversation.” Shereen, obviously no amount of simulation can prepare you for a real-life difficult conversation. Now, what are some of the lessons that you’ve learned that you can share with the other medical students who may be listening to this?

Shereen Jeyakumar: I think really the most important thing is to be there in that moment, to be emotionally present, to allow yourself to feel things when you’re with that patient, because they’re feeling things as well, and it’s important to be open to that and not be closed off. That was one big thing I learned.

And then, like I said, the same way, when you’re finished with that conversation, just when you’re off rounds, go home and write about it. Make music about it, write a poem, just do something that expresses what you’re feeling so that you can deal with those emotions, because you don’t want to keep them bottled up and have that affect you in a way later on. And I think, you know, a lot of physicians go through emotional burnout. I think one way to stave that off is to keep yourself self-reflecting every day on what you’re going through.

Kevin Pho: Now, I’m sure that your other medical school colleagues also have their own difficult conversations with patients as well. What are some of the ways that you see they handle the emotional experiences of such encounters?

Shereen Jeyakumar: We have an ethics session about twice a semester, I believe, and so students will give case presentations at those. I think that’s a wonderful thing for our school to have, because I see how other students cope with that. And yeah, sometimes it’s through writing, sometimes it’s through speaking with their attending, sometimes it’s through spending more time with a patient, just, you know, going back to the patient room later in the day and just sitting with that patient and learning more about them and seeing them as a person. I think all those ways are really helpful.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Shereen Jeyakumar: I feel like medicine is so much more than just futility, and even though we have these experiences, we still can do so much to help patients. You know, I’m only a med student. I’m at the bottom of the totem pole at the moment in the hospital. But as I said before, I really believe continual self-reflection is key to retaining that empathy. You know, it might be hard, but just think about what happens with your patients every day, and feel the emotions that you’re supposed to feel, and don’t feel like you have to bottle them inside.

Kevin Pho: Shereen, best wishes in the rest of your medical education, and thanks again for being on the show.

Shereen Jeyakumar: Thank you so much.

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