Being at a tertiary cancer center where women come from
distances for consults and reconsults, I see a lot of patients who end up not
being treated in Boston. Some become part of my clinic–women who check in every
two or three months, management shared with their local provider. I have
always said that the best cancer care is local, and so many of my colleagues
outside of Boston provide consistently wonderful care. However, times may be
changing as clinicians are dealing with increased patient volumes and less
ancillary support.
Such was the case with Gabby. I had known her for six years,
after she had been diagnosed with recurrent endometrial cancer. She had been
through multiple therapies, and each had had success, rendering her progression free for months that
had extended to years. Until now.
During her last few visits to Boston, we had watched with
alarm as her tumor markers rose despite changes in treatment, and then imaging
showed evolving metastatic disease in her liver and lungs. Although she
remained symptom free, the signs were ominous–that her cancer was now
refractory to treatment.
At her last visit, we decided on yet another chemotherapy.
It was in a class of agents she had not seen in over 12 months, and I had hopes
we could stabilize her disease. Following one cycle she had developed abdominal
pain in her right side and I worried it signaled progression in her liver. A
few days later, her best friend e-mailed me that Gabby looked terrible, that
her pain was increasing, and she could no longer eat. She told me Gabby had
gone in to initiate her second cycle, but that a computed tomography (CT) scan
was urgently ordered, and that she would meet with her doctor to decide what the
next steps should be.
Not being there locally, I waited to hear the results of the
scan. That afternoon, Gabby called me directly–although she had my phone
number, she never used it before, so I knew it had to be urgent. I called her
back.
“Dr. Dizon,I didn’t see a doctor, just Leslie, the new nurse
practitioner. She just started, so I really don’t know her. Anyway, she told me
my doctor wasn’t in the office, but that she had talked to the one who was in
clinic. She told me that doctor said to tell me that I should stop all
treatment and my cancer was much worse. She told me the doctor thinks I should
be in hospice.”
I was floored. This patient who had been a part of the
clinical practice locally for six years had literally had the worst news
delivered to her in quite possibly the worst imaginable way. No one sat down
with her to examine her before the scan, and someone who was new to the
practice relayed the news of the covering doctor, who never came down to see
her.
As she said it, she realized how awful it sounded, as did I.
We talked some more, but even as I hung up the phone, I was dismayed. We as
clinicians are finding ourselves in a precarious situation; we are asked to see
more patients, with each scheduled at 15- or 30-minute intervals, which never
reflects the reality of clinical oncology. Our patients are complicated, and
one of those 15-minute visits can consist of a very serious conversation–about
a new diagnosis, disease relapse, cancer progression, end of life–and such
situations can never be rushed. Still, our systems do not take these in to
account, and as a result, care can be compromised.
But even so, oncology requires compassion and humanism. We
cannot let our patients feel like they are just a number in our calculated
RVUs. They deserve our time, consideration, and empathy–even when we are covering.
“She wasn’t on my schedule.” This can never be acceptable.
Not in medicine, and certainly, not in oncology.
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