In my third year of medical school, I was privileged to have a career-changing rural rotation in a small town of about 2,500 inhabitants. There, I experienced medicine the way I had always imagined it should be practiced. Patients, who were neighbors, friends and family of the staff, were treated with the utmost respect and kindness. I consistently observed that patients’ medical conditions and proposed treatments were explained in detail, and unnecessary testing and procedures were not routinely performed. I felt end-of-life issues were confronted head-on, rather than avoided.

One of the most powerful experiences of my medical career occurred in that town. In the clinic, I had seen a 7-year-old boy who was dying of a brain tumor. I knew his history but was not prepared to see a child in a coma when I entered the room. “What was I supposed to do for the child?” I desperately thought, “This is not something we are taught in medical school.”

Unfamiliar territory
I did the only thing my stunned brain could think to do. Turning to the parents, I asked how they were doing. “Pretty well,” they said, relatively cheerfully. I was taken aback. They seemed to be handling things so well. “How long has he been like this?” I asked. “Oh, we were told (by a traditional healer) that he is sleeping peacefully in a theta state, gathering his energies and trying to heal.”

I was shocked when I realized the parents were unaware how close their obviously beloved boy was to passing away. In a panic, my brain searched for ways to break the news to them. They needed to be made aware, but in the most gentle way possible. I had a vague idea how I would proceed if these were my patients, but didn’t feel it was appropriate for me to take over this task for somebody else’s long-term patient. Desperately, I fled the room with some lame excuse and a promise of, “I’ll be back.”

I notified the superb resident who was in charge of me about the situation. He too was unaware the boy was in a coma, since the child had been conscious at his last visit. I was asked to go back in and give the boy a palliative osteopathic treatment. The entire family had experienced osteopathic treatments before, and had made the appointment for their son for that purpose as well as to discuss the next step in his treatment. They knew their son’s course was likely fatal, but at that point were not ready to give up.

I went back in a much more somber mood and treated the child. The feeling of gently touching the fragile body was inexplicably powerful. The parents relaxed and held hands peacefully, the mom leaning on the father’s shoulder and briefly shutting her eyes. Finally, the resident joined us. He took one look at the child and asked the parents the same thing I had asked “How long has he been this way?” Again, the parents said he had been resting peacefully for 4 days without waking up and without food. “He is storing up his strength,” they reiterated. Surprisingly, the boy did not look like he was suffering from dehydration, but his respirations were shallow and he was hooked to a portable oxygen tank.

Breaking the news, making a bond
The resident gently broke the news to them. “Yes, he is quite peaceful. I’ve seen a lot of people get to this stage and I believe he is really at the edge of this world and the next. I may be wrong; I hope I am. Anything can happen. But from all of my experience with people in this situation, I think that he is quite close to leaving this world.” I watched as their eyes welled up with tears. After giving them a few minutes of silence to digest what he had said, the resident proceeded. “So, the question now that you have to decide is how you want things to go for him. If you want we can admit him to the hospital. We will hook him to an IV and keep him comfortable. Or, if you want, you can take him home and we can send hospice to stay with him. He will also be comfortable and if he is in any pain, we will be able to give him medications at home.”

The parents decided with hardly a discussion to take him home. As they left, they gave me a giant hug. “Thank you for treating him. I know that treatment helped him.” I had a hard time choking back my own tears. After only one 30-minute visit I felt a strong bond to this family.

About a week later, I was working late and it was a quiet evening at the hospital. The resident got a call from the family asking if the two of us wanted to come out to the house because they thought the time “was near”. We left after getting an attending to cover for us for a few hours.

Learning beyond the classroom
We drove out snowy country roads that would have left me lost for weeks and arrived at a small group of tiny homes with many cars parked out front. I entered, not sure what to expect. Inside the house was permeated with the smells of home-cooked food. At least 3 children were running around playing, energetically but not loudly. Half a dozen adults and a hospice worker were talking in quiet tones. This environment was full of life yet peaceful, a stark contrast to seeing terminal patients hooked up to machines while invasive tests are performed.

On the couch, an aunt held the child in her arms. He was taking rapid, shallow respirations. “Oh god,” I thought, “he’s going to die soon.” I didn’t know what to do. “Go treat him,” the resident told me, while he talked with the parents.  Again, I laid hands on the child, this time with some trepidation. I had never been in the room when another human being actually passed away. I was nervous. As the treatment slowed the boy’s breathing, I also calmed down. The resident joined us and helped with the treatment. After a while, I played some games with the other children and chatted with the family. Then it was time to go back. We had received a call that more patients were rolling into the emergency room.

About 20 minutes after we arrived back at the small rural hospital, we received a call saying that the boy had passed on. I felt strange inside. I didn’t know if I felt like I had missed a pivotal experience or if I was glad that I didn’t have to be there. I did know I was very glad we had gone at the family’s request. Much later, I was able to reflect on how much I had learned from that experience. To paraphrase my resident, it was a million-dollar experience, something medical school cannot teach you.

Priceless experiences
This was an experience that I know I could never have had in a large city. I slept less during that month than I ever have on any other rotation, but no matter how tired I felt, I always had a warm glow inside; a sensation of reward for the work we were doing. The experience with the boy was a part of what made me fall in love with rural medicine. But it was by no means the only amazing experience I had during that month. I would say at least 90% of my encounters with patients on that rotation felt significant.

I sometimes wonder if doctors and medical students in urban areas have the opportunity to experience such an encounter in a year. I haven’t seen it very often on my other rotations. And I wonder how can they keep doing medicine without feeling the awe of fulfillment that comes from truly helping? No amount of money can buy that experience.