There Comes a Time

Written while returning from my Galapagos trip, posting now.

It’s happening—the moment that we all dread as we age, that point in time where we realize that we are becoming our parents.  When I was a child, my father was a busy man, completing his residency in plastic surgery, establishing a practice, climbing the academic ladder.  He didn’t have much spare time for us kids, but occasionally he would make an effort to take us on an outing—the circus perhaps, or the zoo.  On those outings, I remember one thing above all.  As we walked along beside and behind him, he would methodically point out every physical imperfection he could see on passersby—a bulbous nose here, a weak chin there, a jagged scar perched on an otherwise perfect cheek or a poorly repaired cleft lip.  The world of the unbeautiful was his oyster and he knew what to do to fix it.

On our recent trip to the Galapagos Islands, I found myself scanning faces and bodies in a similar fashion, but I am no Pygmalion out to transform the luckless Galatea’s of the world.  What my roving eyes were seeing under that equatorial sun were skin lesions aplenty—a benign nevus here, a senile keratosis there, but then, more importantly, an obvious basal cell carcinoma above the upper lip of one of my fellow explorers.  And then came my dilemma:  do I say something to the hapless traveler?  Can I convey in a casual sentence or two, “By the way Joe, you have a skin cancer on your face.  You should have that looked at when you get home, but don’t worry about it!  It isn’t a melanoma, the life threatening kind of skin cancer.”  What to me is a simple helpful hint might be to my companion a bomb dropped in the middle of that peaceful archipelago.  I took the easy way out.  I exercised my right to remain silent rather than risk ruining his vacation.

There was one incident, however, on a bumpy Zodiac ride from the good ship Endeavor to our first sandy beach landing for snorkeling.  Our naturalist guide Xavier had applied a coating of zinc oxide over his nose and cheeks so thick it looked like Comanche war paint.  Yet still, that greasepaint could not disguise an obvious bump arising from his right malar prominence.  He admitted to me that his doctor in Guayaquil wanted to “cut it off.”  Quickly I motioned for my father and together we performed the first National Geographic skin examination of the tour.  As the zinc oxide was wiped away, simultaneously we crowed, “It’s benign!!!”

A day later, Xavier admitted to me that he was so relieved he called his wife and children on the mainland to tell them the good news.  Have I mentioned that dermatology was a field I strongly considered while in medical school?   Reporting from afield…. Miranda.

Bad Tidings We Bring

Yesterday was one of those bad days at work.  With my resident, I had seen a patient in consultation a week ago, a very nice man with an evil cancer—metastatic malignant melanoma—who had been referred for post-operative radiation therapy.  We were waiting for another test to be done which would help us with our radiation treatment planning.  Unfortunately the test showed us that the cancer had already recurred, two months after his surgery, when he had barely healed.  This meant that we needed to take a different approach with the patient than we had originally discussed, and we needed to tell both the patient and the referring MD.  Since my resident had seen the patient last week, he offered to go and speak to the patient while I called the patient’s medical oncologist.  By the time I came into the exam room, the mood was somber and the wife was fighting back tears.  By habit, I asked the patient how he was feeling.  His reply was, “I feel like having a bourbon.”  In a moment of unguarded truthfulness, I blurted out “So do I!”.

This is the third time in three weeks that this has happened in my practice, where the disease turned out to be more advanced or extensive than was originally suspected.  But if I think back through the years, there have been countless times when I have been required to give patients bad news.  In medical school, you are taught to do physical exams, and make assessments and plans.  But as yet there is no strong evidence that a medical student can be taught to deliver bad news to patients in a good way.  The University of Oregon Health Sciences published a study in 1999  comparing the performances of students who had received some training in this area to those who had not.  Although there was a trend in favor of those who had received formal instruction, the difference in performance was not significant.  When the American Society of Clinical Oncologists surveyed its members on this issue, the majority listed “how to be honest with the patient yet not destroy hope” as the biggest concern.  Educators have since been working hard to come up with guidelines on how to be the bearer of bad tidings—one that I found on line comes in the form of an acronym called SPIKES, which stands for (S) Setting up the interview  (P) assessing the patient’s Perception  (I)  obtaining the patient’s Invitation  (K) giving the patient Knowledge and information  (E)  addressing the patient’s Emotions with Empathic responses  (S) Strategizing and Summarizing the information for the patients.   Oh, surely I will remember all that when it comes time to give bad news again.

Call me a renegade, but I don’t think that empathy can be taught to a 20 something year old medical student.  I think that it’s something that you’re either born with, or something that is learned very early in life.  In the midst of assessing MCAT scores, grades, volunteer work, research and all of the other criteria that go into choosing who gets into medical school and who does not, somehow there MUST be a way to assess whether a prospective student can truly empathize with and care for another human being.  The basic tools are a gift that the best doctors are born with.   And then, if a student is very lucky, he or she will have a mentor at some point who shows compassion and grace when delivering devastating news to a patient, someone to emulate.  I was lucky many times over in that regard and will be forever grateful.

Knowing my resident, I am sure that he did a good job delivering that bad news to our patient yesterday.  But I still feel terrible about it, twenty four hours later.

Why I Don’t Go to Funerals

For Nick

Some things are just so damned hard to write about.  People often ask me, “Why do you have so many animals?”  The current count is 4 dogs, two horses and a cat.  I used to say, “Because it’s good for my children to learn responsibility.  Having a dog, whose life is so much shorter than our own, teaches them about love, and about death.  They get to PRACTICE parenthood, before it’s for real.”  The fact is, now my kids are grown.  My animals are for me.  They teach me about love, and acceptance, and courage, and stoicism and yes, about death.  But how can one ever prepare for the death of a child?  It shakes a person to the very core of his soul.  I don’t practice pediatric radiation oncology.  I am just not constitutionally suited for it.

So it was with remarkable dread two years ago, that I faced a consultation regarding the role of radiation therapy in a 25 year old man, who was the favorite nephew of one of my medical oncology colleagues.  This young man had been a student at college when he suddenly lost sight in one eye. Initially he was misdiagnosed as having had a retinal detachment.  Sadly, that was the result, and not the cause of the problem.  The real problem was that he had a malignant melanoma, a very aggressive skin cancer that sometimes arises from the back part of the eye.  By the time he was properly diagnosed, the disease had taken away all chance of preserving sight, and the eye was removed.  It was an extraordinarily difficult choice for a young man to make—his eye, or his life, but he chose life.  Or so he thought.

By the time I was asked to see him, about six months later, he had a different problem.  The cancer had spread to his spine, and he was in excruciating pain.  He had been on chemotherapy which had not halted the progression of the disease.  Although melanomas are not thought to be very responsive to radiation, it was felt to be the last resort to try to get the pain under control.  What I remember about that first meeting was his incredible demeanor,  his grace under pressure, his forebearance, and his calmness.  Here was a young man who already knew that he was going to die. If he was angry, I certainly couldn’t tell.   This young man had decided to fight.  And fight he did.

Fortunately, his spinal tumor responded to radiation and his pain abated.  Despite the brief respite, his disease progressed –in his liver, his lungs, his bones and his skin, inexorably, site after site.  His doctors tried experimental protocols, vaccines, immunotherapy, every conceivable treatment available.  And each successive treatment failed—one after another after another.

The last time I was asked to see him, it was for pain resulting from a massively enlarged liver, loaded with cancer.  My staff bent over backwards to make sure that he could be seen, planned and treated all in one session.  In a radiation therapy department, this requires the coordination of at least 7 or 8 people, from the secretary, to my nurse and me, to my physicists, and finally to my therapists on the linear accelerator.  Everyone wanted to help this boy.  Despite his discomfort, and the shortness of breath caused by the liver constricting his lung capacity, he apologized for inconveniencing so many people.  We treated him at the end of the day.  I was surprised in the end that we were able to treat him at all, since it was so difficult for him to lie down and to be still, despite the fact that he had lost the use of his legs a few weeks earlier and was confined to a wheelchair.  The plan was to give him a single palliative treatment of radiation then return him to hospice care.  But it was far too difficult for me to say goodbye.  Instead I said, “if you’re better next week, come back and we can give you another treatment.”  I did not say goodbye.  I never said goodbye.

That last treatment was Thursday October 27.  He died on Halloween, October 31, nearly a year ago.  His uncle, my colleague was kind enough to tell me that the last treatment helped him, even if only psychologically.  Until the day he died, he talked about coming back to see his friends in radiation therapy, and me.  He passed peacefully, surrounded by his friends and family.

Doctors are notoriously awful about dealing with death and dying.  The experts say it is because we do not like to admit defeat and we do not like to face our own mortality.  As a group, we detest funerals, and we do not typically go to funerals of our patients, particularly in the field of cancer medicine.  The day came that this young man’s memorial service was held, in a beautiful garden at a public park, on a lovely fall day.  There was not an open chair in the garden.  Every single physician who had cared for this boy was there, and every last one of us was crying.  Sometimes, we just cannot run away.

When I was sixteen years old, and in high school, my history class was shown 16mm footage of the liberation of the Nazi death camps by American soldiers at the end of World War II.  I saw the hollow eyes, and the starved bodies of the survivors, too numb to even react.  And bodies of the dead, piled beside the road.  I remember that grainy black and white footage like it was yesterday.  Because that was the day I began to question the existence of God.

I know that when people die, the survivors say, “He went to a better place.”  Or “This has served a higher purpose.”  But really, what do you say when a child dies a hideous death from cancer?  If there is a higher purpose, I would really truly like to have it explained to me.  My friends and acquaintances say to me frequently, “Isnt it SO hard to do what you do? “  Most of the time, it is not.  But sometimes it is.  This was the one that was the hardest of all.