Reflections in a Head Mirror

Sometimes one creates a dynamic impression by saying something, and sometimes one creates as significant an impression by remaining silent.
-Dalai Lama    


Once each year, she gets dressed up and goes to her annual follow-up clinic appointment. She has been cancer free for a long time, but she indicates that still enjoys these visits, especially the part when the surgeon tells her that everything looks great.  

“How are you doing?” he asks her. “You look beautiful, as always! A vision of loveliness … that’s what you are!”  

She smiles demurely and flutters her fingers at him, attempting to deflect the compliment just a little. She is 81, and she has been listening to his banter for a long time.  

“Have you noticed anything that worries you?”   She smiles again and shakes her head. Nothing new. She looks at him happily. She knows that “nothing new” is good news.  

He runs through the physical exam. No new masses or ulcers. The tongue is soft. The pharynx is well-healed and open. The neck has no enlarged lymph nodes and the scars are all stable. The stoma — the opening where her windpipe is sewn directly to the lower neck skin — is open and clean. No changes since the last visit. He jots down a few notes.  

“Tell me how you are doing,” he says. “Any trips? Has your family been up from the South for a visit?”  

She gestures and tries to coax out some words. As always, he can only pick up a fraction of what she is trying to say. “Did you bring your electrolarynx today?” She shrugs and smiles sheepishly. She never brings along her speech device; the batteries likely died years ago. She digs in her purse for a pencil stub and a small spiral notebook.  

She concentrates as she writes out her responses in large capital letters. Writing has been her only means of communicating since her voice box was removed. It has now been 24 years since she has spoken a word out loud to anyone. Over the intervening years, the hospital where the surgery was performed has closed. Many of her original caregivers are dead. Yet, here she is: silent and unchanged. 

What if she had presented today instead of two decades ago? He skims her old, faded records and shakes his head. He knows that, today, her treatment would likely not include surgery at all. A few years after her voice box had already been removed, a large, randomized clinical trial demonstrated that treatment with chemotherapy and radiation was just as likely to cure larynx cancer as was the type of surgery she had undergone. Her physicians, acting on the best information available at the time, had removed her voice box.

She continues to write him notes on the lined paper. Despite his offers, she has refused other opportunities for restoring voice (“No more surgery! I'm not interested!"). She writes about spending time with family. She tells the surgeon she looks forward to the yearly visits. He tells her that he looks forward to seeing her, as well.    

They finish their time together and she gestures toward her notebook where she has written in large block letters, “MERRY CHRISTMAS!”  

“Have a wonderful year,” he tells her. She shakes his hand, smiles, and gestures enthusiastically. Then she slips on her coat and moves down the hall, silently disappearing around the corner. 

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The following is feedback received for this blog:

She sounds like a wonderful lady. I bet her doctor and his staff look forward to seeing her too. I know I would. Timing is everything (much anyway). Yes, if medical therapy had been a little more advanced when she was diagnosised, etc. But she is happy (or seems so from you post). I sometimes have to remind myself and patients not to judge treatment from 20 years ago by today's standards. We knew what we knew, and we did the best we could. - rl bates http://rlbatesmd.blogspot.com/

“Life must be understood backwards; but ... it must be lived forward.”
-Soren Kierkegaard  

He bumps the door open with his right hip and enters the operating room, water still dripping from his elbows. Toweling off his arms, he visually surveys the patient, the equipment, and the instruments. He is helped into his gown and gloves, and, while he waits for the rest of the team to get ready, he checks the lab reports and the CT scans one more time. The sounds in the room — the hum, the beeps, the ventilator, the chatter — are all familiar and correct. The patient has been positioned and the skin has been prepped. Everyone appears relaxed and ready.

The surgeon pauses and glances at a stack of papers on the table next to the door — one of the residents has evidently taken copious notes from textbooks about the type of surgical procedure they are going to perform today, creating a list of steps from incision to closure. The surgeon sets down the notes and steps to the operating table. 

The sterile barriers are placed. The anesthesiologist adjusts the IV, re-checks the monitors, and clamps the drapes to poles. The nurse and the OR technologist pull the tables, stands, and trays into position. The cautery and suction are connected.  

The residents and a medical student join him around the operating table. As he marks out the proposed incision, he assumes the familiar stance he will hold for the next two hours. He places his hand on the patent’s neck and assesses the enlarged masses below the surface.  

"Here," he instructs the trainees. "Feel the tumors and how they sit below the muscles. Can you appreciate how they move in relationship with the other tissues?"

The trainees palpate the growths and nod. The surgeon remembers his own time as a resident. How he had loved learning all about this procedure! At the time, he, too, had carefully summarized and underlined all of the surgical descriptions he could find and had memorized step-by-step how-to lists. Later, he had carefully crafted his own description of the operation from start-to-finish, planning to use his notes as a set of imperatives to carry him safely through these intricate procedures when he was in practice on his own.  

Now, he takes his turn palpating the neck. In his mind, the neck skin below his fingers has become translucent and all of the muscles, arteries, veins, nerves, bones, viscera, and the lymph nodes come into focus. He imagines how the structures are intertwining with each other and with the invasive tumors. As he stares at the neck, he visualizes how the dissection will look when the tumors have been removed and all of the structures explored.  

At this point in his career, instead of working through the operation from beginning to end, he imagines the outcome first, realizing that there are hundreds of potential ways to achieve the final goal. Over the next two hours, he will attempt to discern the most efficient, safe, and effective route, all the while avoiding pitfalls, taking advantage of circumstances, and recalling prior experiences. He will dissect the diseased tissues, working from known to unknown, until the surgical field looks like the one he had visualized before the incision was made. The challenge remains thrilling and the anatomy remains elegant.    

He releases his focus on the neck and the sounds in the room again reach his ears. The team is poised.  

"Ready?" He has seen the final outcome. "Let's begin."

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The following is feedback received for this blog:

Very nice. - rl bates http://rlbatesmd.blogspot.com/ Dr. Campbell -- Your latest post is a real gem. I've been thinking about it ever since reading it. It has applications in so many things that we do. I coach a men's sports team. I'm a big believer in envisioning exercises. Yet, envisioning is nothing without the repetition that we do at practice to hardwire actions. And, I'm a parent and your post had me thinking about that as well. - Chris Beautifully written, Bruce. - Paul Levy www.runningahospital.blogspot.com This was truly a compelling read! - sterileeye http://sterileeye.com

“You must trust and believe in people or life becomes impossible. “
-Anton Chekhov    


“No, Doctor, I don’t have any questions. What do you recommend? I’ll do whatever you tell me to do.” She looked past me and smiled resignedly. Her adult daughter sat with pen hovering over a spiral-bound pad already overflowing with notes and questions. “When will you get started?”  

This was a difficult case with no clear-cut treatment plan. She had an extensive cancer of the jaw. In younger, healthier individuals, this stage of disease is often treated with a complicated surgery, an intricate reconstruction, and then a combination of radiation and chemotherapy. Yet, at 77, she was not robust. My gut told me that she was a poor candidate for either the long surgery or a prolonged treatment course.  

Recommending the standard treatment was, it seemed, out of the question — she would never get through it. On the other hand, recommending less intense treatment, although still very challenging, carried lower prospects of ultimate cancer control.  

I tried to get her to react to the options. No luck. “I’m not certain, Doctor. What do you think?”  

A recent journal article studied cancer-related decision-making and desire for prognostic information in older adults. A study of 73 recently diagnosed adults with colorectal cancer between 70 years old and 89 years old found that only 30 percent of women and 56 percent of men wanted information on their expected survival times. Over half of the patients adopted a "passive" role in treatment decisions; that is, they agreed with either “I prefer that my doctor make the final decision about treatment, but seriously consider my opinion,” or “I prefer to leave all decisions regarding treatment to my doctor.” A quarter of the patients adopted a "collaborative" decision-making posture and a quarter wanted to be "active" decision-makers. Physicians were not consistently able to predict their patients’ decision-making preferences.  

This high proportion of passive decision-makers differs between age groups and cancer sites. The paper’s authors point out that cohorts of younger patients and patients with breast cancer have much higher proportions of “collaborative” decision-makers. They remind us to be sensitive to potential differences in the decision-making preferences in our older patients.  

In the end, my patient opted for a compromise of a less extensive surgery and post-operative radiation therapy. Although it was, I felt, the best available option, it was a treatment plan that she never questioned. She just let it happen.


Ref: Eiken EB, et al., Desire for Information and Involvement in Treatment Decisions: Elderly Cancer Patients’ Preferences and Their Physicians’ Perceptions, Journal of Clinical Oncology 2007; 25:5275-5280

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The following is feedback received for this blog:

I know I like it when patient's "work" with me in making the choices. Yet it must be overwhelming at times from the patient's point of view. I have often tried to imagine what it would be like, how can we not when patient's ask us what we would do in their place. But I truly hope I never have to find out. - rl bates http://rlbatesmd.blogspot.com/

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