The Living Canvas

Last summer while driving through the farmlands of Missouri we plowed into a thunderstorm spawned from towers of clouds that lined the late afternoon horizon. We drove steadily on through the storm and soon the dark wall receded. I peered with anticipation through the wet sunshine and saw a giant arc of color off in the distance. "Look at the rainbow!" I called out. My children, always on the alert for an opportunity to confirm their suspicions about my childish behavior, ignored me. Not to be daunted, I increased the volume and resumed the science lecture. One could sense they were silently laughing.

"Over there on the right - can you see it?" I asked. Remnants of youthful innocence stored within them must have awakened, for they slowly turned to the window and scanned the sky. "We don't see anything," they replied. I tapped the windshield and said "There! Over there!", but they still were blinded. Finally they identified the radiant bands sweeping across distant clouds. I marveled at their obtuseness, but forgave them and motored on. As the rainbow vanished I considered how a keen sense of perception adds so much more to the enjoyment of life. How many other delights, such as the meadowlark's song, or the cotton-candy scent of honeysuckle, languish as we limp through another day? Consider the world I work in - cancer medicine. Would refined skills of observation make one a better physician?

I am not sure that success depends entirely upon a doctor's power of perception and insight, but I do know one thing - it makes his job a lot easier. A physician gains a special benefit by remaining vigilant, and that benefit is this:

The doctor who sees the clues contained within an illness also sees into the future, therefore, one who perceives the future can prepare for the tribulations it contains. The hints a patient reveals in the course of a visit can predict what direction his illness is turning. For example, last week I entered an exam room to see my patient sitting in a chair with a cane by his side. I smiled at him, because it was the first time since he had started treatment that he was not in a wheelchair. X-rays confirmed that his lung cancer was shrinking rapidly, and he made plans to travel this spring. While examining a different patient I noticed that her bulky abdominal mass was markedly smaller just one week after receiving treatment for chronic lymphocytic leukemia. This response, while welcomed by all, seemed unusually rapid to me. I checked her blood chemistries, and her potassium, uric acid and creatinine were all high - consistent with the complication called tumor lysis syndrome. By suspecting this problem I was able to prepare to relieve it.

Other clues foreshadow distress in the times ahead - I recall the patient who told me he had stopped balancing his checkbook because it was too difficult to complete the task; he was soon diagnosed with brain metastases.

A patient constantly exhibits signs of the state of his illness - signs that if read correctly, can be useful in planning future care. He is like a distant rainbow or a magnificent painting, an extraordinary composition to study if only noticed. A skillful doctor, like a master artist, develops a keen eye for the details arranged in the living canvas before him. He studies the patient as thoroughly as he would scrutinize the Mona Lisa, looking for clues as to what truths lie within such an awesome work of art. His work is tiring, but like a long walk through the Louvre, it is a source of endless satisfaction.