LETTING HURT THE PROPER AMOUNT

A few months ago, I found myself in the haste of a busy consult day. I had my outpatient clinic in the morning and I wasn't able to start seeing new consults until early afternoon. It's not the type of work that goes well when rushed.

One of the new patients I met was a man who had lost 30 pounds and had reached the point where he couldn't get solid food down without it coming back up. He finally came to the hospital when he started having trouble keeping water down, too.

By the time I met the patient, he had already had an endoscopy, and the gastroenterologist's description left few likely diagnoses other than cancer. I sat in a chair next to his bed and started out like I usually do, asking him to bring me up to speed on how the situation unfolded. When he was done describing what had happened, I asked him what he was most concerned about. Of course, he was well aware of the possibility that this was cancer. He said so, directly, and without much emotion.

We stepped through his whole medical history and physical exam. When I asked him his living situation, he said he had kids at home, and for the first time the tears welled up in his eyes and his words got caught in his throat. I nodded and kept quiet, because nothing I had to say could have met the significance of his pause.

Based on the guy's age, I guessed that his kids could have been anywhere between 10 and 25 years old. I didn't ask him because I was afraid it would compound his grief and fear. I speculated that his kids were probably too young to live on their own, but old enough that he wasn't worried about them staying by themselves or with someone close for a few days, because he agreed to stay in the hospital for the rest of his workup.

I told him our plan for getting him to the start of his treatment, and that he would meet the rest of the team over the next few days. As we talked, the reality of his situation settled in, and when I shook his hand goodbye for the night, his sadness was more evident than it had been when we started talking.

I stepped out of his room into the hall and my focus shifted to the calls I needed to make to the other consulting teams about him. I wanted his stay in the hospital to be as brief as we could make it.

One of the toughest parts of hematology-oncology fellowship for me has been the emotional weight of each patient's angst and physical suffering. At first, my tendency was to let it all in: the fear of a new cancer diagnosis, the anxiety of staging scans, the pain of bony metastases, the exhaustion of frequent doctor appointments, sleepless nights, and rows of pill bottles to keep straight and take on schedule. It has taken conscious effort to fine-tune this, because the boundary needs to be porous enough for compassion but not so permeable that it compromises objectivity. It's always been a priority of mine to stay attuned to patients' emotions, interpretations, and symptoms, and over the course of fellowship I think I've found a way to do it without shouldering quite so much of it myself.

As I walked down the long, polished hallway of our medicine ward away from the man's room, a corner of my brain alerted me to a new problem.

It didn't hurt enough.

Early in fellowship, it would have hurt more. I'd have pulled thoughts of my own kids to the front of my mind and speculated on how I would feel were it me in that bed and them waiting for me at home. I'd have reflected on the fear and confusion that would accompany telling my family that I had cancer, and about the trepidation of recovery from surgery and months of chemotherapy.

None of that happened this time. It wasn't a conscious choice, it was something I noticed after the fact. It might be a healthy adaptation on my part, but I'll need to keep an eye on it.

Because patients' lives deserve to be thought about.

Because this guy and his family are going to suffer a lot from this diagnosis.

Because often, the predominant manifestation of illness in a patient's life is some form of pain, and a doctor does well to remember that.

One of the greatest challenges I've faced through training is letting it hurt the proper amount. Earlier in fellowship, I probably let it hurt too much, and that's not best for the patient. But to let the needle move too far the other way is also a mistake, because it's a big part of the connection with the patient.

At this point in medical history, oncology has an unfortunate and frequent association with tragic circumstances. As oncologists, if we stand too close, we lose perspective and objectivity. But if we stand too far away, we risk losing touch.