It was relatively simple then--standing there, helpless, by the hospital bed, I wanted nothing more than to be in a position to help, to find solutions to the problems, to make a difference. But now I find that, as a physician-in-training, the waters have become a little muddy when it comes to dealing with the health care of family members. Where I used to see things only from a patient's point of view, I now have the added perspective of the care provider...and the two do not always co-exist in harmony.

This is my grandmother

My grandmother turns 96 years old this year, and last winter, she underwent a partial colectomy for advanced stage colon cancer. "Your mother is a little bit stressed out," I remember my dad warning me over the phone one evening, shortly before I was to fly home for winter break. "We met the chief resident last night, and she was just awful."

Ever since we had received the diagnosis a month earlier, my daily phone calls home had evolved to survey not only my grandmother's condition, but the physical and mental health of both of my parents as well. With the colon resection surgery scheduled on the eve of my final exams, my flight home would be just in time to catch the tail end of my grandmother's weeklong postoperative hospitalization.

In the meantime, I found myself anxiously trying to glean what information I could from these brief conversations. This latest news was troubling: although my parents had raved about the surgeon who performed my grandmother's operation, the chief resident and her team would be the ones actually managing my grandmother's care for the duration of her stay in the hospital.

A rocky start certainly did not bode well for the future. What had this doctor done to incite such frustration and dislike on the part of my parents? "Well, said my dad, "everything was fine, until the nurse mentioned to her that she should't use 'the C-word' in front of Grandma, because we hadn't told Grandma about the diagnosis...and then she flipped out. She's been rude to us ever since."

Although my grandmother has lived in the United States for 18 years, she neither speaks nor understands any English, save a few words--"cancer" being one of them. In almost all aspects of her life, but especially when it comes to medical matters, my grandmother has been completely reliant on my mother, counting on her to do all the major decision making.

This has always been the way things have worked in our household, partially due to cultural influences, but also in large part due to my grandmother's personality as an individual. Indecisive and timid by nature, my grandmother feels much more comfortable deferring to my mother, whose Ph.D. in the biosciences and fluency in American culture combine with an unfaltering devotion and concern for my grandmother's well-being to make her an ideal proxy.

As such, my mother struggled mightily with the decision not to inform my grandmother of the true nature of her ailment, but eventually concluded that, again, given the cultural and individual factors at play, telling my grandmother that she had cancer would do more harm than good. Knowing my grandmother, I have always believed that this decision was the right one.

Perhaps a year or two ago, I would have immediately pegged the chief resident in my mind as being a terrible doctor. Yet now, being a medical student, I had a unique dual perspective that forced me to examine the issue from the physician's perspective as well. I recalled a chapter I had read in an ethics textbook for our Practice of Medicine course, which ran off a litany of reasons against deception and nondisclosure to the patient, including the statement, "Even among patients from cultures in which nondisclosure is traditional, many want to be told their diagnosis".

Respect for patient autonomy is so strongly ingrained in us as medical students, and, indeed, the concept of individuality and autonomy is so much a part of American culture in general, that I began to wonder, was it really unreasonable for the chief resident to have acted in the manner that she did, given that she was a product of American medical training? How would our family situation have appeared to someone of her background and belief system?

I again recalled a documentary film we had viewed in class that implied the dangers inherent in allowing family members to translate for non-English-speaking patients. How easy would it have been to assume that my parents had their own agenda and were doing my grandmother an injustice by withholding her diagnosis from her? Was it equally frustrating to health-care providers to feel as though they were unable to communicate with the patient directly, and that the dialogue as it existed through my mother's translation was being driven entirely by my mother's concerns and decisions as opposed to the patient's?

It would have been impossible for anyone outside the family to know that my grandmother abhors decision-making, or that her tendencies toward pessimism and constant worrying would likely have robbed her of the days of happiness she had remaining, had she known her diagnosis. Yet while I now had a better understanding of what prompted the chief resident's reaction, the fact remained that the interaction had been unpleasant, and my family had come away with misgivings and feelings of distrust.

Regardless of whether the doctor was ethically justified in questioning my parents' actions, the end result suggested a failure of the patient-doctor relationship. What, then, could have been done differently, on either side? How could this problem have been avoided without either party having to compromise their values and beliefs?

I believe that a simple awareness of her own attitude may have prevented the chief resident caring for my grandmother from becoming a terrible doctor in my parents' eyes. A disapproving look, a condescending tone; these are things, I've learned, that can mean more and leave a longer lasting impression than level of technical competence achieved.

Possessing the right demeanor is just as important to being a good physician as possessing the right medical knowledge. So perhaps the question is how do we teach these subtleties of bedside manner? Or can we at all? I wouldn't wish upon anyone the experience of being a seriously ill patient, or the family member of a seriously ill patient, but I will say that being on the other side of the doctor-patient relationship is probably one of the best ways of cultivating the open-mindedness and tolerance that is so needed in this profession.

Epilogue: Being at home is nothing if not relaxing, but without my daily menu of Arbor meetings and lab meetings, etc., there isn't a whole lot to report! So I'll just leave you with these pictures, instead:

I worship at the altar of home cooking

The agony! The pain! Where is a good mu opioid receptor agonist when you need one?

Mere seconds before my ancient iPod up and died...guess that means I'll have to get a Nano? Tragic. ;-)

Plugging away