New Year's Eve with Friends

The halls are quiet today. I can hear my footsteps tapping on the tile as I make my way around the wards. All but two of my patients have managed to rally enough to escape, thus avoiding one of the most stale and depressing celebrations ever offered in a hospital - New Year's Eve.

Nurses and doctors look upon this holiday as an unlucky turn of the wheel which assigns them to duty on the one night when song and laughter waltz together under the cold winter sky, and families gather around bright fires, keeping an eager eye on the ticking clock. Those who must work tonight will huddle briefly around a radio for the countdown, then return to the harsh lights of the emergency room, or wander down a darkened corridor to answer a patient's call. Perhaps they pause and reflect on what they are missing - thinking of their children, up late tonight spilling popcorn on the sofa, or of parties of long ago when a midnight kiss between friends left a hint of romance on the lips. New Year's Eve is a time for new friends to meet and old friends to remember, and most people trapped in a hospital shift are denied both pleasures.

For the oncologist, however, the last day of the year is full of friends. They greet me in the waiting room of my office or as they step up onto the examining table. They wait for me in the halls of the hospital, or call my name as I enter the cafeteria. We all like to talk about ourselves and on this night my friends press closer, anxious to share their story. Each one relates a unique history, and their first words are always the same:

"This was the last year I was alive."

These friends, you see, were my patients - now gone.

When an oncologist reaches out to one living with cancer he does not know whether his hand will be grasped vigorously or dropped. If the clasp occurs it usually forms a lasting bond, for as a friendship develops the voices of his patients find a place to rest within him and speak out, even after life has ended. Cancer leaves behind indelible impressions on all it touches. It makes patients immortal in the mind of the doctor, whether he acknowledges it or not.

I therefore can see my friends all around me on this wondrous night. As the new year dawns let me recall their struggle with respect and admiration; let me entreat for solace for their families; let me pray for courage to face the challenges that lie ahead.

Let an oncologist honor his friends, present and past, with a simple motto: "You are worth it."

The Angry Husband

"When I go I'm taking that doctor with me."

Thus spoke a retired police officer one afternoon to his surgeon, who probably considered this blunt statement as merely a catharsis of anger, not a serious threat. The surgeon certainly didn't see any need to ring the authorities or even call the intended victim - in fact it was not until the following week, when he happened to run into "that doctor" in the parking lot did he mention the gentleman's unique promise, sporting a rather sardonic smile as he talked. The poor designee promptly dropped his tranquil demeanor and began to pepper his friend with urgent questions regarding the officer's mental status. The doctor in question, now laden with twenty fresh pounds of nausea, began to eye the space around him like a young wildebeest in the lion's den.

The doctor in question was me.

As I remembered the case I realized my predicament had formed from an unfortunate merging of misunderstanding with misfortune. The officer's wife had been my patient and had fought a difficult cancer for weeks, achieving the most precious of goals - a complete remission. Despite her gruff disposition (a trait both spouses had mastered), the necessary treatments were agreed upon and delivered, and now the storm of cancer had abated. All was well again in the world. Peace reigned throughout the body.

The officer's dear wife, alas, was destined for only a brief armistice. Within a month she developed a change in her laboratory values - a subtle sign to me of possible turmoil within. I tried to keep up hope since she certainly felt well, but as summer approached I became more suspicious that her disease might still be alive. If this were true her life would be lost, for no further treatment could eliminate the invader if it survives the initial killing blow.

I approached this potential crisis with the optimism of the young doctor, yet with the trepidation felt when inexperience clashes with rancor, and basically did nothing that would upset the patient. My counseling was rudimentary and any words of comfort I gave did little to assuage the anger boiling within both patient and spouse, who were convinced that cure was a certainty. I counseled caution - to wait it out and see if the tests stabilized, or the patient developed symptoms of concern.

Then as all doctors who are not employed by either royalty or state leaders do, I left for my summer vacation. When I returned, my partner informed me that the patient indeed had relapsed and died a few days after...and that the family "took it hard".

Upon hearing this I suddenly gained the most unwanted form of wisdom ever found within a medical career: the gift of 20-20 hindsight. I now realized all the warning signs my patient displayed and what I should have done about it but did not, out of fear of facing her ire. I choked in a crucial time because I was scared to have to wade once again into the muck that was her cancer, knowing full well that she was doomed.

I neglected my duty out of a little fear, and now had to live with a greater one.

Walking quickly to my car each day I learned to scan my surroundings, looking like a cheap actor in a self-defense instructional tape. As the weeks went by eventually I convinced myself that the threat was simply a venting, and forgot about the angry husband.

About one year later I ran into that same surgeon and was impelled to ask him if he had heard from the officer recently. His reply left me standing in stunned silence: "Oh, he died of gastric cancer a few months ago."

This ends the story of The Angry Husband. To this day I am uncertain as to what message is contained within it - but whether I am enlightened or not, like Moses before the burning bush I kneel in respect of this formidable opponent...this pestilence that strikes with random fury. May all oncologists prove themselves worthy when the day of reckoning comes.

Saying Goodbye

Have you ever wondered what is on an oncologist's mind when he visits a patient for the last time?

No matter how sympathetic he is, someone in my profession who constantly views the face of the dying must eventually become inured from heartbreak, or otherwise risk losing the ablility to carry on with his duty. I too have learned to fashion a mask of impassiveness, molded from years of exposure to patients lost, to be worn at the hour of greatest sorrow. I dare not walk into a hospital room without it for fear of embarassing myself with a maudlin display of emotion, which could be interpreted by the family as a sign of irresolution or frailty. It is better to play the role of the "professional" at all times.

Surely therefore I pride myself on my ability to stand far away from grief - all the better to not be harried by it as I attempt to continue on with my busy day.

Surely I can minister to the dying without fear of breaking down this facade of calm concern.

Yes, surely I can - but the price paid is horrendous.

My face may appear composed, but let me share with you the truth: trapped within it are the tears of a thousand deaths. No oncologist can call himself a true professional who does not weep for the loss of life wreaked by this curse.

I weep for my patient who lies helplessly in a room he didn't ask to live in.

I weep for the person who sits by the side of the bed, stunned by the awful transformation of a spouse, parent, or child.

I weep for pain of not being able to do anything further to save a life.

Sometimes my breath is taken away by the awesome power of this disease to spirit off a good soul - away from a life no longer whole.

At the final goodbye, if the patient is conscious I will speak to him or her, ensuring that pain is under control. What should be said to the family is said: thanks for all their loving care, reflections on the life of the patient and on the relief soon to come. It is an emotional meeting and I find myself pausing, waiting for the ability to continue with composure - loyal to the code of the unflappable doctor. It is a time for a hand on the shoulder or a handshake, or a hug.

Inside I feel as if a part of me was left behind in that room...as if cancer has exacted its price also on the doctor who dares to defy it. If this were true, the day would soon come when there were no more oncologists, for after scores of goodbyes we all would eventually drain away, sealed forever within the memories of those we served.

Fortunately oncologists draw our strength from an inexhaustible well, for day by day as we give of ourselves to our patients, from them are we replenished.

Season's Greetings from Sir William Osler

In the spirit of the times, I wish you all a

Merry Christmas

or

Happy Hanukkah

or

"Have a Good One" (official holiday greeting for the non-religious)

Sir William Osler (1849-1919), the father of modern medicine and called "the most influential physician in history", was not only a brilliant healer, scientist, writer and teacher, but a prodigious font of memorable quotations. I plan to share with you some of his best words of medical wisdom in a future post but for today please accept a preview of the baronet's keen and insightful tongue:

"Courage and cheerfulness will not only carry you over the rough places in life, but will enable you to bring comfort and help to the weak-hearted and will console you in the sad hours."

(hmm......sounds like a good motto for the blog site)

"Live neither in the past nor in the future, but let each day absorb all your interest, energy and enthusiasm. The best preparation for tomorrow is to live today superbly well."

(see why I admire him?) and finally:

"There is a form that springs from the heart, heard every day in the merry voice of childhood, the expression of a laughter-loving spirit that defies analysis by the philosopher....Bubbling spontaneously from the artless heart of a child or man, with egoism and full of feeling, laughter is the music of life."

Whether this time of year fills you with memories of joy or memories of loss, may this music find your ears and bring you peace.
-The Cheerful Oncologist

The True Meaning of Healing

The winter sun was hanging just above the treetops, bathing the exam room with honeyed light as I sat beside a patient with cancer who was about to receive discouraging news. After two successful rounds of chemotherapy new tumors had been discovered in his liver and lungs. In order to have any chance for further life I would need to find an alternative treatment, one that would now be considered successful if it merely halted the progression of his disease. The chance for cure was gone. I began to steer our discussion toward the truth he must face.

Sometimes a talk with a patient is like a game of cards, where each person plays with the goal of winning the other over to his point of view. I had just laid out my best hand and expected my patient to agree that my plan aimed for goals that were now limited but realistic.

His reply to me was unexpected: "I know I am going to be healed."

I had just been trumped, and temporarily lost the power of speech.

As I wondered how to respond I knew that refuting his statement would be discourteous. Although I felt that his disease was beyond any hope of eradication, to argue with him over the issue of the miraculous cure would imply that there is no place for faith in the care of a cancer patient. To deny the value of faith is wrong in my view - faith is a great source of comfort to the patient. It is a great source of peace - and of healing. This led me to consider the nature of healing itself. Even though my patient was referring to healing of the body, could there be other types of healing hidden within this ordeal? Could he actually be right - that he was destined to be healed, but not in the sense he thought?

We doctors tend to focus our efforts only on restoring the body - on disease removal, which we then are proud to call "healing". My patient may very well become the recipient of an inexplicable cure, but even one who beats the odds will someday reach the end of life and die, despite continued pleas for more healing. This limit is the destiny of all patients - and their doctors, too. Perhaps we all should therefore reflect on whether healing is confined only to the restoration of physical health - or does it transcend this boundary?

As I prepared my response to my patient I considered what I had overlooked:

I thought of the healing that comes when we believe our life has been blessed by the God who provides eternal life.

I thought of the healing that comes with the final relief of our pain and suffering, for as we die our disease dies also, never to torment us again.

I thought of the healing that comes when we accept our fate and are released from the anguish of demanding more time.

I thought, most importantly, of the healing that comes with an appreciation of the greatest gift a dying patient can ever receive - the love of his friends and family. Whether the life lived was one of acclaim or obscurity, rare it is to find one who dies forgotten.

Healing is more than just a purging of illness...it is peace of mind, which provides a greater benefit than the doctor's potions. Peace of mind is the elixir of renewal, which lifts the sun up over the horizon in the morning, showing the world that we are ready to meet the day's challenges. It is the healing that once applied, never dies.

When is No Treatment the Right Treatment?

Imagine yourself the son or daughter of a hard-working man who put in his years of labor and skill without complaining, a father who in his day could hoist you and your squealing brother up over his shoulders with ease, a husband who adored his wife but couldn't say so, a master griller in summertime, a buddy to his buddies, a die-hard fan...

...and a man who loved his cigarettes.

Imagine now sitting beside him in a dreary hospital room as he labors for breath and strength, crushed under the weight of that disease which silently grew within him, only to burst forth like a sudden flame from smoldering embers.

How would you react if the medical oncologist on the case recommended not treating your father's cancer? This seems incompatible with the healing art, which exists only to improve the life of one who suffers. What is behind such a decision?

I often see patients who have lost the ability to take care of the daily activities we all take for granted, such as dressing oneself, because of the beating cancer inflicts on the body. An even worse scenario is when cancer unites with a chronic illness such as emphysema, which can rapidly drain whatever meager reserve the patient has left. In order to reverse this decline the cancer must be stopped, which usually requires the use of chemotherapy. The risk of complications and death from chemotherapy in a weakened person is high. It is a risk that in many cases cannot be hazarded, and withholding treatment then will not only prevent toxicity but spare the patient from becoming a statistic loathed by all oncologists - a "treatment-related mortality".

Withholding treatment, however, means that the cancer will still grow. This paradox is just one example of how cancer harbors its own unique form of distress for the patient and family - and for the oncologist who is now hindered in the wielding of his therapeutic sword. This choice must be considered, though. I have seen many a patient start out on chemotherapy with the highest of expectations only to die the next week from immunosupression.

Which option is worse, then - letting the cancer progress and avoiding the risks of treatment, or taking a chance on chemotherapy and an early demise?

Oncologists live with this dilemma every day, and when we make a final decision it is not imperiously like Solomon in his temple, but in concert with the patient and loved ones. The task is not easy but is vincible if four straightforward questions are asked:

1. What does the patient want? (if he or she cannot answer the reason why is usually not encouraging - cf. comatose)

2. What are the chances that the treatment will reduce the cancer? (anything less than 20% is typically not worth the risk)

3. Is life prolonged on this treatment, compared to providing supportive care only? (an answer of "no" is a compelling argument against)

4. What is the risk of severe toxicity and death? (patients who are bedridden, or spend most of their waking hours at rest are at higher risk)

All it takes is one conference...or two...or three or more, and soon the right decision will be manifest. As an oncologist I can provide informed consent and (purportedly) sage counseling, both of which will hopefully lead to a choice that is acceptable to all. Throughout this process, whether the discussion goes smoothly or painfully, my obligation to the patient will be more likely to be fulfilled if I follow one of the Laws contained in that classic satire on medicine, Samuel Shem's novel The House of God:

"The patient is the one with the disease."

...and the doctor is merely his servant.

Doctors and Their Books

"Medicine is my lawful wedded wife, and literature my mistress. When one gets on my nerves I spend the night with the other...neither one loses anything by my duplicity."

Anton Chekhov, the Russian physician and celebrated writer, said this in 1888. He was referring to his dual careers in medicine and writing, a combination of loves that has always attracted me. This post, however, is not about the physician as author - that topic must wait for a separate puff of afflatus to fill the sails of my mind. Today my interest is in the physician as reader. As you know, it is hard to become a doctor without developing accomplished, if not magnificent skills in reading. After using these skills in years of study, the young doctor then enters practice and finds that the required reading material has only multiplied. So many charts, reports, journals, articles and textbooks lie heaped on his or her desk there doesn't seem to be enough hours in the day to cover it all - let alone read for what my grade school teacher used to call "pleasure". This is sad, because in my opinion pleasure reading is one of the keys to a fulfilled life.

I love to read. I have read for pleasure as long as I can remember. There was a time, though, when I did not use my leisure time for reading, because I had to choose between reading and sleeping. This interlude in a doctor's life is called the residency, when the hours worked in a week come perilously close to the total allotted in the calendar. This is a time of concentrated exhaustion, when a long trail of newly published books floats past the young doctor's life without fear of being netted. There is simply not enough time to seriously enjoy reading during the training years.

What happiness must arise then, when servitude finally comes to a close and the glory years of the doctor's life beckons...

...except now he or she must still wrestle with the daily schedule, unexpected emergencies, family obligations, personal matters, to name a few, in order to find a quiet hour to soak up a good book.

Still, doctors are well-read, even in today's hectic world. With this in mind, I would like my readers to share something about the books they have had a personal relationship with, so to speak. I want to know what doctors and other medical professionals feel about the books in their lives - are they enriching themselves as they deserve, or watching reruns of Spongebob Squarepants? Do they love books as a true bibliophile does, or are they just name-dropping when they brag that they read The DaVinci Code on the beach in Jamaica?

If you feel like commenting, please answer these three requests:

1. Name a book that you cherish and cannot wait to read again.

2. Name a book that you refused to finish, or simply could not bring yourself to complete.

3. Name a book on your shelf that you cannot wait to dive into.

If the responses are remarkable enough perhaps I'll even share my answers...until then remember what Sir Winston Churchill said on this topic:

"If you cannot read all your books, at any rate handle, or as it were, fondle them - peer into them, let them fall open where they will, read from the first sentence that arrests the eye, set them back on their shelves with your own hands, arrange them on your own plan so that if you do not know what is in them, you at least know where they are. Let them be your friends, let them at any rate be your acquaintances."

"Good Doctors Leave Good Tracks."

This saying was the mantra of the most influential teacher I ever had - the doctor who taught me how to persevere through the daily sturm und drang of caring for those living with cancer. His theory was that you can always tell when a good doctor has been involved in a patient's case by the type of "trail" he or she left behind after the work was done - a ship's wake, if you will, that represents the effect the doctor had on the patient's life, a trail that does not always guarantee a healthier patient but that shows the world the type of doctor who captained the mission. This imprint reveals the depth and worth of the doctor's effort. The converse of the apothegm therefore is just as true: "Lousy doctors leave behind lousy work."

With a little training anyone can become an expert in deciphering the tracks of a doctor. It seems to me more apropos to illustrate the marks of a praiseworthy one, rather than try to describe the flotsam left behind by a hack - after all, I wouldn't want to be accused of being cynical!

Well then, let's take a look at the trail a perfectly wonderful physician leaves behind at the end of the day. These are the clues you have hired a good one:

The Written Word. There is no easier way to separate good and bad doctors than by the dictated reports, handwritten orders and notes, and letters they produce - by the ream, I might add. Good doctors have legible handwriting, no matter how much of a hurry they are in. They take the time to document the important facts of a patient's illness and the information relayed to the patient. Counseling sessions are put into the written record - the risks, possible side effects and alternatives of a treatment are recorded. The medical record should be inscribed so that a new doctor could pick it up the next day and know immediately what the case is all about.

The Spoken Word. I have already commented on the importance of proper communication with patients in an earlier post, but let me add this: a good doctor speaks clearly and respectfully, avoids medical jargon and slang, shuns a prejudicial attitude, never assumes that one attempt at explanation will be sufficient, nurtures assurance and hope in a time of dread, and tries to share the joys of jocularity when appropriate. It's as easy as that!

Critical Thinking and Investigation. Good doctors never assume that the patient's symptoms are due to the same old run-of-the-mill maladies that they see day after day. They excel at what is called lateral thinking - thinking "outside the box" of routine illnesses. They question themselves - "Do I have the right diagnosis?" They order tests that seem to fit the patient's clinical presentation, not just to get a nice peek at every organ in the body. When they are stumped, they research the question - and keep searching the medical literature until they are satisfied that they have a handle on what the problem is. If not, they ask an expert. A good doctor gets smarter every year by his commitment to lifelong learning.

Following-Up. Lastly, it is tedious but vital that doctors review the results of all the tests they order, that they keep in contact with sick patients who might suddenly get worse, that they double-check their plan of attack for an illness (especially cancer), and stay knowledgeable with current medical news and new developments. As the great physician Sir William Osler said, "To study the phenomenon of disease without books is to sail an uncharted sea..."

Osler was a bedside healer by the way, not just a laboratory researcher and the second part of this quote is "...while to study books without patients is not to go to sea at all."

Every morning a doctor sets sail into the vast and deep blue of medicine, eyes on the horizon and on the sky, with the hope that the voyage will be untroubled and lead to a life saved, a burden eased, a soul comforted. By watching the foamy trail left behind, we who are in need of the doctor's mastery can determine whether he or she is the right skipper for the journey.

Nightmares of an Oncologist

You don't hear much about this in the media and therefore, dear reader, perhaps you have concluded that the mood of doctors is calm and secure, but let me reassure any doubters out there:

The practice of medicine still is intellectually and emotionally grueling.

Far be it from me to whine about a career that I enthusiastically volunteered for, but would it be fair to allow me to "share" with you some examples of why oncologists sometimes do not sleep restfully? It isn't just because so many of our patients succumb to their illness. It is the way in which such a life was lost - the slow, relentless deterioration of a once healthy being - that breeds fear, anger, distress, pity, and hopelessness in both the patient and the doctor. I suppose these emotions are not unique to my profession, but are they encountered on a daily basis in other specialties? Wouldn't such continuous exposure to sorrow turn any oncologist to ashes?

Well, maybe not - this stress hasn't broken me yet and doesn't appear to be crippling our profession, as cancer providers are more confident than ever in the many new treatments available.

Even so, there are certain traumatic events in the professional life of a medical oncologist that haunt slumber. They are the oncologist's nightmares. They have visited me in my past.

I await their inevitable return with patient frustration.

Rather than dilate upon this any further, let me illustrate, with a brief explanation of their effect, the four worst nightmares of my career:

Patient Suicide: Three times in my career have my patients violently taken their own life after being diagnosed with cancer and before receiving any treatment. One of the patients had an indolent lymphoma, which is associated with years of remaining life. Why, I asked myself did he do it, especially after I told him about his relatively good prognosis? My initial shock of each patient's death led me to blame myself - I felt that my counseling skills must be pitiful if this is the result of a visit with me.

Treatment-Related Death: I have sat by the side of a smiling patient receiving chemotherapy on a bright afternoon only to be standing helplessly next to her in the ICU at 3 A.M,. as she dies of septic shock. Oncologists cannot predict with exact precision which patients will survive treatment, so we must use our best judgment in choosing a course of care, sometimes treating those with a higher risk of complications. Whether a patient is lost due to infection, pulmonary embolus or renal failure the end result is the same - we have failed in our mission to kill the patient's cancer, and we feel worthless.

Hostility: There is nothing more traumatizing for me than to have to meet angry people and try to convince them that I am the one to entrust the care of their loved one. It is a miserable experience to deal with hostile patients or families, and feels like trying to hold a discussion in a burning building with a gun pointed at your heart. The reason why it upsets us so much is not their ire, which is easy enough to understand, but because we often get irritated at being treated in such a manner, and an angry doctor is a inferior healer.

Irreversible Decline: How would you like to take a job where you meet delightful and interesting characters - former World War II veterans, teachers, grandparents, retired musicians, book lovers, ministers - and get to watch them slowly, inexorably lose their appetite, energy, weight, strength, hair and ability to share their lives with their loved ones? I realize this is what every caregiver and family member must suffer when their beloved is afflicted with cancer. It is a tragedy beyond measurement. An oncologist, however, feels that he or she has the power to stop this misfortune - if only the right treatment was given at the right time, with the right amount of luck or heavenly blessing. So we offer treatment, and if it is ineffective, if death then begins its unrelenting assault, gradually transforming robust flesh into a gaunt visage, and all we can do is watch it happen...

That to me is the oncologist's worst nightmare.

Since I have not named this blog The Frightened Oncologist, you may ask "How do you reconcile these distressful aspects of practicing medicine with your chirpy title?"

Ha!

Ever heard of the term fortitude? "Strength of mind that enables a person to encounter danger or bear pain or adversity with courage."

That, my readers, is the secret - if you don't have fortitude, you won't last long in this profession. Fortitude is the power that allows an oncologist to extract himself from the wreckage of discouragement, find another bicycle, and begin again to pedal uphill toward the place where his responsiblity and his patients await.

Communicating With Patients

Medical oncologists spend a tremendous amount of time communicating vital information to patients and their families. In order to begin a treatment designed to attack cancer, much must be done to educate them about the goals of treatment, the limitations, the risks and side effects, and the logistics of the treatment schedule. This information must also be given in such a way that not only are patients enlightened about their therapy, but that all involved are satisfied that the oncologist is indeed:

A. competent - not ill-prepared

B. confident - not vacillating

C. compassionate - not callous

D. considerate - not inflexible

Since I have a keen interest in improving the care of cancer patients let me, T.C.O., provide some simple advice on how a doctor might fulfilll the basic requirements of effective patient communication.

The Cheerful Oncologist's Tips:

1. If feasible, always sit down when counseling - it sends the message that you are not in a rush to get out of the room.

2. At the beginning of the visit, learn the identity of all who are in the patient's room - relatives, friends, ministers, etc. It is courteous, and you never know who might be in there with the patient. It could be someone important in providing care, such as the patient's power of attorney.

3. Don't speak too rapidly, or shovel out reams of facts about the patient's case. People under stress cannot process a lot of data. Take it slowly, with pauses at crucial points in the relaying of information - especially if it is bad news. We all need time to react and it is doubly hard when stricken with a serious illness.

4. Never, never use medical jargon without immediately translating it into common English. It amazes me that some doctors still assume the average lay person is bilingual!

5. Look the patient and family in the eye! You wouldn't want to give the impression that you're lying to them or that you have no faith in the treatment you are proposing.

6. Of course, leave time for questions. If you know of a vital question that hasn't been asked, ask it yourself and then answer it.

7. Give some encouragement, for cryin' out loud! We oncologists are in the profession of killing cancer, relieving suffering, and prolonging lives - if we believe that our treatments can meet these goals then why keep it a secret? Why not make an effort to lift everyone's spirits, so that we all start out with dreams of recuperation, if not healing, if not triumph?

8. At the end of the visit go around and shake everyone's hand. Again, it is polite and it sends the message that this patient's welfare is now your mission.

Successful communication with patients is not difficult when you, the doctor maintain two visions - first of patients and families leaving despair and fear behind as a result of your counseling, and second of you, the doctor sitting in the chair occupied by your patient. Yes, just sit for a minute in this chair and imagine yourself waiting...waiting for the door to open, waiting for the battle of your life, for your life, to start.

You sure would want a good communicator now, wouldn't you?

A Walk Down the Path of Pain

"Oh Doctor, come hold my hand a while as I travel down the path cancer has chosen for me."

I hear these words echoing in my brain, as if from the pale lips of cancer patients waiting quietly in the hall for me to finish my paper work, waiting to guide me into the world of suffering that for me is just a job, but for them a grim reality. They stand silently, like Virgil awaiting Dante, ready to lead me down into the abyss where their tormenter resides.

"You, who claim to be an expert on this disease that has ruined us - what do you know of pain, or of dejection? Show us where you have earned the right to carry our lives in your arms."

True, there are times when I feel ashamed to be lecturing or coaching my patients - attempting to relate to those in pain. Why should they listen to my advice when I have no idea how it feels to endure such agony?

Much has been written about how to diagnose and grade pain, about how to get patients to communicate their pain, and of prime importance, how to effectively relieve pain. We oncologists prescibe pain medicines of all kinds - pills, liquids, patches, intravenous medications. Some of us are better than others at monitoring the efficacy of our remedies, as adjustments must be frequently made to keep up with pain's galloping through the patient. Very few of us, however, have ever experienced the relentless pain associated with malignancy.

Does this make us lesser physicians?

"No," we argue, for all of our training has provided us with a keen sense of how to identify pain in a patient and how to attack pain, usually with narcotics. Pain management is now a respected speciality, replete with new treatments for the sufferer.

Yet still...would a little pain in the doctor's life make him a more sympathetic healer?

My reason for bringing this up is that last year I developed an inguinal hernia. This hurt enough to be annoying but did not cause enough pain to interfere with work, or even a family holiday at Disney World (although I can now speak with authority against riding the Space Mountain roller coaster with a such a condition). Like a good patient I saw a surgeon and had an open surgical repair, which left me with an eight centimeter incision. Like a bad patient, I decided to not take any pain medicines during my recovery. After all, I come from a long line of ignorant, stubborn patients who hate to take pills. Plus I'm an oncologist, and many of us loathe taking narcotics due to the disturbing side effects they create. I therefore treated my pain with a couple of ibuprofen and an ice-pack. I, the defiant one, scoffed at any discomfort. I, the tough oncologist, laughed in the face of pain.

I, who care for people living in pain, journeyed a little down that path they are forced to march every day - just a little ways down the path...for a few days.

The pain was unbearable.

I couldn't find a comfortable position, couldn't concentrate, couldn't even watch Night of the Living Dead on DVD without heavy, aching pain squeezing my groin. Even now I can't adequately describe what it felt like. It was impressive though, and it made me think.

It made me think, even one year later, of pain and how it devastates a human life. Pain consumes a person's spirit and wraps itself around the waking mind like iron chains. It robs the sufferer of the ability to accomplish tasks, or even interact with loved ones. Pain is evil.

Having written this, I shall pledge to always remember what it was like to be in pain, as I pledge to remember what the good men and women in my care are going through on this day, and the many evenings to come.

The Nervous Patient

A cancer specialist requires a certain amount of calm and equanimity, what I call the proverbial reassuring manner, in order to provide effective care. The reason why is blatantly obvious. Our patients battle horrific diseases that often leave them weak and depressed. Many times they are faced with no hope for cure. Is it no surprise, then, that some of them become nervous? And if you, the patient, are aflame with anxiety, would you enjoy listening to a loudmouth, restless, high-strung oncologist who likes to quote discouraging statistics, and is adept at inappropriate smiling?

Of course not. This is why we cancer docs must teach ourselves to counsel with tranquility. It is not easy to learn at first - a young oncologist is lucky if he or she trains under a professor who has mastered the art of giving out bad news in a way as to not cause a family riot. With time and experience, though, most of the great oncologists develop the poise needed to deal with high-stress encounters with desperately ill people.

Still, though, there are some patients who are so tormented with worry that their emotions make the doctor a nervous wreck. I met one such nice gentleman this week.

My new patient, just diagnosed with metastatic lung cancer, was attempting to deal with the panic that comes when one in perfect health last week is now sitting on the edge of a hospital bed, listening to descriptions of his various organs bulging with tumors, all documented clearly by a CT scan. My patient's anxiety was not only apparent, it somersaulted all over the room. He peppered me with questions, starting out with "Are you sure this is cancer and not an infection?" Classic Kubler-Ross stuff, I thought to myself. As I discussed what I knew about his situation with him, sitting calmly beside him in a chair, I used my most reassuring if not downright serene manner. I explained the facts of his case, came up with a plan to help him, outlined the logistics of the next several day's worth of tests, and did my best to raise the flag of encouragement over his bedpost.

Except, it didn't work worth a hoot.

The more I tried to allay his fears, the more nervous he became. He sat rigidly in his chair, repeating questions that I had answered earlier. Clearly, I thought to myself, he is overwhelmed, and it is time to call it a day. Let the passing of a night hopefully bring solace to him, and pick up our conversation tomorrow.

Great idea, except now I began to feel anxious.

I felt that because I left him as nervous as when I entered the room that I had failed, maybe not in my primary mission, which was to dispense essential information about the cancer, but in my inability to inspire confidence or at least a modicum of hope. The more I flapped my gums, the more my words just sounded annoying.

With this in mind, I unleashed the secret weapon of the medical oncologist, the mysterious strategy we cancer docs keep hidden from public view, to be used only in the event of a dire emergency, such as this one:

I scheduled an office visit for the patient and his whole family.

If there's one thing I have learned about caring for the nervous patient it is that the best way to relieve distress is to form a bond of friendship with him or her. To form such a bond, continue to counsel the patient - it is as simple as that! By sending the indispensable message "I care", the doctor creates trust, trust that the patient knows his doctor will act in his best interest - will become his advocate, in good times and in bad. My feeling is, the more time spent supporting the patient, the more confidence the patient will have in your support. Thus is revealed one oncologist's answer to the problem of the agitated patient: keep talking - and keep listening.