Reflections in a Head Mirror

"Experience is simply the name we give our mistakes."
-Oscar Wilde


A long-term cancer survivor comes for a regularly scheduled follow-up clinic visit. These usually routine appointments focus on problem-solving. It is quickly apparent, however, that she is in significant pain and has lost weight.

"How long have you had this neck mass?" I asked.

"It appeared shortly after my last visit and has been growing ever since. It hurts."

My heart sinks. Her cancer has spread. We will order scans and probably schedule surgery. The outlook is not good. Why hadn't she called for an appointment when she first noticed the mass? She shrugs. "I'm not sure."

This scenario is all too common. Researchers at Ohio State University collected information on over 3,600 follow-up clinic encounters and found that a new or recurrent cancer was identified at 5 percent of the visits. Of these, the patients had already diagnosed themselves 79 percent of the time; the physicians rarely found non-symptomatic cancers. Oddly, the confirmation of the cancer occurred at a regularly scheduled visit 73 percent of the time; patients rarely called and scheduled an early encounter. (Agrawal A, Laryngoscope Feb 2004; 114:232)

Why don't patients with symptoms call immediately for an appointment? Maybe they don't believe that cancer can recur. Maybe the visits are too expensive or frightening. Maybe they don't want to deal with potential bad news and more treatment.

Somehow, we haven't found simple ways to encourage patients to return as soon as they are alerted by a symptom or sign. In my practice, a worried, symptomatic patient often apologizes for taking up my time after I tell them everything is fine. I, on the other hand, am delighted and relieved when the symptom has a non-cancer explanation. I reassure and congratulate them, schedule another visit, take a breath, and move down the hall to see the next patient.

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This essay previously appeared in the MCW Cancer Center News

“Be near me when my light is low ... And all the wheels of Being slow.”
- “In Memoriam” Alfred, Lord Tennyson    


A friend asked, “What is the difference between Cure and Healing?” As a cancer surgeon, I was perplexed and challenged by the question. I eventually responded with two clinical vignettes.  

The first story is of a talented Senior Executive Assistant for an important local businessman. Her years of smoking caught up with her and she developed a large tongue base and tonsil cancer. Her surgery and radiation therapy were completely successful and her cancer was controlled.  Nevertheless, she was overwhelmed by depression. She continued to smoke and drink, refused to go out in public, quit her job, and rejected her friends.  She agonized over her appearance and speech. She refused to return for follow-up visits or counseling. I eventually lost track of her.  

The other story is of an immunocompromised woman I first met several years ago. Her first cancer took a portion of her mandible and tongue. She did well for several years, but developed a series of increasingly dangerous additional primary cancers and recurrences. All through the experience, I saw her regularly, and we suffered together. When she finally died of her cancer last year, I agonized. Until, that is, I received a letter that she had prepared in her own hand prior to her death. “Please don’t feel that you failed me,” she wrote. That message of comfort and gratitude was emotionally wrenching, but nevertheless, welcome and still treasured.  

One person was cured but not healed. The other was healed but not cured. We aim for both Cure and Healing, but the difference, I believe, rests in the relationships.  

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Previously published in the MCW Cancer Center News

The Medical College of Wisconsin White Coat Ceremony is Friday, Aug. 15, 2008. I was honored to be invited to give a talk during the ceremony where the first-year medical students receive their white coats, symbols of their new profession.  

I appreciated all of the comments that I received, both through the blog and in the hallways. I incorporated as many of the thoughts as possible.  

My hope is that the students will learn to listen intently and intentionally to the stories that surround them. The ability to listen will clearly make them better physicians for their patients.  

In addition, building on the writing of Rachel Naomi Remen, listening might even protect the students from becoming cynical and isolated from their patients. I tried to make this point with a couple of stories, some of which have appeared in this blog in the past and in other essays of mine.  

Attached is the final draft of my talk. Thanks again for your input!

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The following is feedback received for this blog: Very nice. I really enjoyed reading your talk to the new students. - rlbates http://rlbatesmd.blogspot.com/ Our son David is an MCW M-1. Thus my wife Anna and I were fortunate enough to attend the MCW White Coat Ceremony on August 15 . Your talk was right on point as to the " big picture " in becoming an excellent clinician . Thanks for helping make the ceremony a very memorable part of a very important day. - Lew Kaplan

"None are so old as those who have outlived enthusiasm."
-Thoreau    


My mother, bless her over-90-year-old heart, received a pacemaker this week. The procedure went perfectly. She is fine and is recovering beautifully.    

While sitting at her bedside in the hospital, we read the brochure that she received along with her pacemaker. My mother and I reviewed the warnings she must keep in mind with her new device. For example:    

• My mother should not hold a cell phone closer than six inches to her new pacemaker.

• My mother should not stand closer than 12 inches to a slot machine.

These are good and reasonable suggestions. Although she rarely uses her cell phone, she does own one. The company suggests that she hold the phone on the ear opposite the device when she needs to make a call. We made a note of that. Since my mother never gambles, she doesn’t have to worry about slot machines. Again, the company appears to suggest that it is safe to play the slots but big winners should not hug the machines after hitting a jackpot. Now THAT restriction might make a difference to some of my patients.    

We continued reading. My mother was also warned against the following activities:

 

• My mother should stand no closer than 12 inches to a chain saw. 
• My mother should be no closer than 2 feet from an arc welder. 
• My mother should NEVER use either a stun gun or a jackhammer. 

 These are also very reasonable suggestions, but less likely to have a direct impact on her day-to-day existence. I questioned her closely and she repeatedly assured me that she had long ago given up her aspirations to become a lumberjack, welder, peace officer, or heavy construction worker. 

Despite her claims, I am not totally certain that I can trust her. If any of you spot my mother heading off to either a job site or the casino, please let me know immediately. With the enhanced energy she is expecting from her new pacemaker, you never know. 
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By the way, Mom gave me permission to share this story. -BHC  

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The following is feedback received for this blog: Happy to hear your mother is doing well. I have a brother-in-law who did have to give up using a chain saw for cutting wood which with the increased energy was frustrating for him. The trade-offs that life hands us! :) - rlbates http://rlbatesmd.blogspot.com/ very entertaining-I'll keep my eyes open for her!! Y N RN I think this is the funniest blog you've written yet! In our litigious society it seems the practice of good medicine can be, at times, a bit inane, or even absurd! Thanks for sharing this anecdote. I also enjoyed your speech to the new M1s. - Lisa Kodadek