Sitting in on Tuesday morning outpatients clinic was proving challenging - I had to manage not to yawn when the consultant was looking in my direction, whilst trying to remember what I actually did last night.
'Examine Mrs Jones1 abdomen please,' said Mr Sarcastic Surgeon. Gently I began to examine and have a prod; her liver felt knobbly and hard. Cancer always feels like that. Probably the cancer that was causing the white areas on her chest X ray had spread to her liver.
'What can you feel?' asked Mr Sarcastic. Mrs Jones was looking at me, terrified - she's assumed it was cancer as well, that was why she'd left it for three months before telling her GP she was coughing up blood.
'Her liver feels a little enlarged,' I muttered, hoping that didn't sound too deadly, she looks even more scared 'but that could be just me. I meant it might be normal - I haven't felt that many livers.'
'You're a fourth year medical student!' barked Mr Sarcastic 'Where have you been if you haven't felt that many livers? - well have another feel if you're not sure.' He guides my hand to the hard knobbly liver edge. 'Does that feel normal to you?' Then he asked the dreaded question 'What do you think that is?'
There are two commonly used strategies by medical students in this situation. The right one is to pretend that you have no idea what could be wrong with a patient. The downside of this is that the surgeon will assume that you don't know what is a fairly obvious diagnosis and, possibly, fail you. The wrong way is to confidently say 'I would suspect that Mrs Jones has a carcinoma of the bronchus which has begun to spread to the liver. If this is confirmed by biopsy there is a strong possibility that there it will not be operable.' There is, of course, the slightly less honest way - using all the jargon you can muster.
'Could there be some mitotic lesions Mr Sarcastic?' He nods gruffly and asks Mrs Jones to get dressed again so that he can tell her that she might have cancer.
Most consultants would only ask the student if the patient knew the diagnosis, so there is no reason for us to get embarrassed. But there's always the odd surgeon who doesn't follow this. A quick survey of medical students in the pub show that many of us have been asked the possible cause of the lump when the patient hadn't yet been told that they'd got cancer.
They, the surgeons2 will say that the patient will generally have a suspicion that they have cancer and that having a medical student confirm that it is a possibility will do no harm whatsoever. Others will say that they will expect us to use a euphemism such as 'mitotic lesions' that the patient would not understand. And indeed most of us do. They might also say that discussing the condition after the patient has left is hiding the truth from the patient which should be a thing of the past.
Finding out you have cancer, I would imagine, is a moment that you will never forget; finding out from a medical student who has been asked by the consultant is probably one of the worst ways.