Monday, February 07, 2005

Deciding to be Undecided

Time for you and time for me,
And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

T. S. Eliot, The Love Song of J. Alfred Prufrock, 1919

I frowned as I stared at the jumble of golf clubs peeking out from my bag, pondering which weapon to use on what looked to be a spine-tingling second shot over a pond the size of Lake Michigan. As I made the necessary mental calculations involving distance, wind, and more importantly, my famous slice, I heard the voice of one of our foursome cry "C'mon and make up your mind!" Ignoring the rube, I let several more ticks of the clock pass before selecting a club. I then approached the ball like Pharoah lording over the prostrate Moses and with one swing launched a perfect parabola that peaked near the heavens but ended where only minnows and frogs are happy. I wondered if I had made up my mind too hastily.

While waiting for the laughter around me to die down I thought about the problem of indecision and how it applies to my own vocation. It should come as no surprise that the cancer specialist is asked to make tough decisions every day. He must weigh the benefits of treatment against its risks and then determine if this therapy is safe to give to his patient. There is the possibility that treatment may lead to severe side effects, or even death. It is no wonder then that medical oncologists are often found slumped in their office with chin on hand, as deep in concentration as any man dreamed of by Rodin. They are truly under enormous pressure, and not just because a nearby statue has toppled.

Could there be a species of oncologist, however, that lacks the nerve to press the launch button and send a volley toward some hostile tumor threatening dear old grandmother? As I addressed the fiendish ball (a new one, since his twin now slept with the fishes), I recalled a man sent to my office last week for a second opinion. He was recovering from a successful operation to remove an early stage rectal cancer, and had seen a medical oncologist for advice on whether or not to take several months of adjuvant chemotherapy and radiation therapy. Since this visit was to receive a second opinion, I asked him what conclusions were advanced during the first.

"Oh, he didn't really say anything," he replied. "He said I could take chemotherapy if I wanted to, but that it was up to me."

Had a paparazzo surreptitiously snapped my face at that moment he could have sold it for a pretty sum (if I was a star), for I gave the patient a look like a fellow who has just seen a parking attendant back his Ferrari into a hot dog stand. Delving deep into the manual on tact and diplomacy, I was able to politely ascertain that his erstwhile doctor had taken no stand on the situation on the table - that is, should this gentleman endure six months of mementos such as diarrhea in order to improve his already favorable prognosis? The answer to this dilemma was clear to me: the current data on his stage of rectal cancer were encouraging enough to obviate the need for any adjuvant therapy.

No church bells pealed, however, when I revealed my impression to the man since he still had to live with the small chance that the malignancy could return, but in general he was satisfied with our time together. All that was left to do was dissect the reasons why my rival had vacillated at the moment of decision. I began to formulate hypotheses as I stepped onto the green, my scorecard blackened with strokes and penalties. At last an easy decision awaited me - I yanked my putter out of the bag and prepared to send the traitorous sphere into the pit with one sweep of the pendulum.

Assuming cowardice is not the flaw when an oncologist fails to deliver an opinion, what then makes a highly trained specialist tongue-tied when a plan of action (or no action in this case) is desperately called for? I worried about certain defects known to appear in the physician if his career careens, such as passive-aggressiveness, or indifference. No oncologist could maintain his practice for long if he sank into this kind of wickedness, and I doubted that my competitor was actually deranged. Rather, I suspected he had floated up into the seductive cloud of indecisiveness that tempts all physicians. High above the laboring crowd, a doctor who asks his patients to choose their care can rest easy, knowing that if the outcome is unfavorable he cannot be blamed. He lives without fear of making a mistake, and therefore is technically immune from any retribution. Such an oncologist is agreeable at all times to all people, for he is but a messenger - an attendant lord in the royal court, his head safe from the chopping block. There are many ways to decribe a "no opinion" oncologist, and Eliot did it best:

Deferential, glad to be of use,
Politic, cautious, and meticulous;
Full of high sentence, but a bit obtuse;
At times, indeed, almost ridiculous--
Almost, at times, the Fool.

Decisions in cancer care are often agonizing for the oncologist, patient and family, but they must be rendered. In the kingdoms of old no great battle was ever won by a declaration from the Fool. A wise doctor will recognize this and summon up the courage to give his opinion and then stand by it - perhaps not with regal splendor, but with enough dignity to warrant a cheer from the brigade of warriors massing around him.


At 2:48 PM, Blogger BotanicalGirl said...

High above the laboring crowd, a doctor who asks his patients to choose their care can rest easy, knowing that if the outcome is unfavorable he cannot be blamed.While I have been lucky enough to not require the services of an oncologist, I can think of 3 separate occasions within the past year when a physician has left the ultimate decision up to me. Or worse, accepted my self-diagnosis without much further examining. (While allergies can indeed produce a sore throat, a strep culture would have saved me 3 days of agony.) I at least am I biologist: I can potentially make a good decision about what meds are best, but I'm not an MD. I go to the doctor to utilize their training and experience. I can self-diagnose on the internet.

At 2:46 PM, Anonymous Anonymous said...

I have been confronted with major treatment decisions several times over the past three years. I'm thankful my doctor recognizes ambiguity, quality of life and the difference between outcome statistics and my individual health and well being. If our perceived risk of "adverse effects" in life equaled our actual risk the freeway would be a lot less jammed. Whether or not to drive, however, is my decision alone. Do we overtreat some people with cancer in the US? Almost certainly. Do we have enough data to discern in advance exactly who will or will not benefit? Not yet.

At 7:24 AM, Anonymous Mollydog said...

The love song of J Alfred Prufrock is my favorite poem. What a fitting verse!

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