Tuesday, April 25, 2017

Being Human

When I was a resident, my colleagues chided me for wanting to be an oncologist. Back then (and it pains me to be old enough to use that phrase, by the way), oncology was thought of as a field of futility. We administered toxic drugs to sick patients, who far more often than not would die of the cancer or from our treatments. The disease was cruel, and to many, oncologists didn’t really help­; they only prolonged suffering. Of course, I never saw oncology in that light­—I came in to this field to help us do better. To me, being an oncologist would be a privilege­—to help people through such a difficult diagnosis, and to stay with them through whatever happened next. It was primary care at its most extreme.

To be an oncologist today is to be a part of a revolution in medicine. Precision therapies have afforded us the opportunity to cure, and short of that, to control, this disease­­—and for some, control can last for years. My own clinic is comprised of women with advanced cancer, with typically poor prognoses. Yet, they are survivors beyond even my expectations. Whether due to angiogenesis, immune checkpoint, or to PARP inhibitors to name a few, they survived. Indeed, in a few cases, women who looked like they were approaching death are enjoying their lives once more due to modern therapies: the Lazarus effect, we sometimes call it.

When you see enough of these remarkable women, it becomes tempting to believe it is not only the drugs—that it is you. You, the oncologist, are the reason they made it. Sure, the drugs are critical, but you, Dr. Oncologist, are the reason. Where there is the Lazarus effect, perhaps there is the resurgence of the God complex as well.

I’ll admit it. Sometimes, I feel essential to my patient’s response to treatment. But, every time I feel that, something else strikes me as well— reality. Such was the case with Lee. I had met her after she had experienced recurrence of her uterine cancer. She had a serous carcinoma, one of the more aggressive cancers of the endometrium. She had undergone surgery, chemotherapy, and radiation before she met me, and had gone only six months before developing lung metastases.

However, she was not the first patient to face this scenario. Others had similar diagnoses, and two of my patients had responded exceptionally well to a new treatment. I decided to try it here as well, hoping she would respond as well to this “brilliant” plan (to me, at least).

Yet unlike my other patients, she did not respond. She got progressively sicker as the cancer caused shortness of breath and fluid build-up around her lungs. Each time she saw me she looked weaker, and although we both felt comfortable enough for her to go home, she would require admission after two or three days at home.

After yet another admission she came to see me for an exam prior to the start of a new cycle of treatment. She was ashen, thin, and was now requiring supplemental oxygen. She complained of pain, of fatigue, and excessive yet not restful sleep. It was clear that treatment was not working.
“Lee, I am so sorry treatment isn’t working. I had hoped you would be better by now.”

“Oh doc,” she said, “I know you’re trying. I am just getting so tired. But I don’t want to disappoint you. So if you think we should proceed, then I’ll do it.”

As she spoke her daughter looked at her, and then at me. It was a pained look­—love mixed with deep concern, and more than a hint of fear. Although she said nothing, I felt I could hear her.

“Lee, I think treatment is a bad idea. This cancer is aggressive and the treatment is making you weaker. You’re dying, and I only want you to be comfortable so you can enjoy whatever time you have left.”

With that, her daughter breathed a sigh of relief and started crying. Lee looked at her and then spoke. “Thank you, doc. I think it’s time too. I know you held out hope this treatment would kick in, but in all honesty, it’s been the hardest of the regimens we’ve tried. I just needed your permission to stop.”

“Well, if that’s what you need, then let me give it you. It’s okay to stop,” I said.

We hugged then and I arranged for her to get hospice care at home. Two weeks later her daughter called to tell me that Lee had died. She thanked me for caring for her mom, and I thanked her for allowing me in to their lives.

I think about Lee a lot and about her cancer. It frustrates me that treatment didn’t work for her when it had for others. It saddens me that she suffered partly because I suggested she continue on with treatment, even when the signs were there early on that it was not working. Mostly though, it humbles me because even though we are learning more and more about how to treat cancer more precisely, I still cannot guarantee an outcome, no matter how much I want to. It serves to remind me that at its heart, medicine is the most human of endeavors and must be rooted in humanism. I am not God and ultimately, I should never act like I am.  

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