Reflections in a Head Mirror

"[J]ust as despair can come to one another only from other human beings, hope, too, can be given to one only by other human beings.
-Elie Wiesel


When her doctor told her that there was “nothing anyone could do,” and that she should “go home and get her affairs in order,” her life had changed. At 43 with a young family and a lifetime ahead of her, she now faced her own death for the first time. Suddenly, a Phantom accompanied her constantly, and every remark and experience filtered through this new presence. When I met her two weeks later, she was already accepting her sentence as inevitable. She was expecting more devastating news.  

Without recognizing the presence of the Phantom, I entered the exam room. I knew only her original diagnosis and some of the details of her recently completed treatment. After a difficult course of therapy for an early stage oropharyngeal cancer, a follow-up CT scan had shown some residual lymph nodes. I reviewed the next steps … a biopsy, a neck dissection, and a review of the pathology. “We have a good chance of curing your cancer with this,” I told her. She had never allowed herself to consider the possibility of cancer cure before.  

Unexpected cancer control happens.

For years, I followed a young man whose enormous pharyngeal cancer had completely evaporated with radiation therapy. Later, I cared for a woman whose recurrent oral cavity cancer disappeared after three cycles of a second-line chemotherapy. You just never know.  

As the appointment ended, she wept and rushed out to call her daughter. Until then, there had been a Phantom in the room with us, but we had only become aware of its presence once it had fled. Hope had been restored.
 
___

A previous version of this essay appeared in the MCW Cancer Center News.

---

The following is feedback received for this blog: You just never know indeed. That's why I try to leave my patients with hope every time I see them. - David Loeb http://doctordavidsblog.blogspot.com/

“Why love if losing hurts so much? We love to know that we are not alone.” -CS Lewis  


I held the photograph of her gingerly and was surprised how clearly the image evoked a sense of peace. Such tranquility could only have sprung naturally from a depth of character; in her presence, everyone had felt warmth and a sense of stillness. As her cancer returned, each time more aggressively, she worried, not for herself, but for her husband and daughters. Her tears at recurrence were as much for them as for herself.  

Her eventual death was not a surprise. For the visitation, her family had assembled photos and keepsakes of their collective time together. I stopped in front of each of the images, gazing at the smiling woman who would later become my patient. Photographs with bent, fingered edges recorded moments in her life when she held children, celebrated holidays, vacationed, and stood proudly at graduations.  

Among all of the souvenirs, this one image had captured me. She sits in three-quarter profile on a screen porch surrounded by summer foliage. Her scars are not visible from this angle. It appears that she had been writing but has paused for a moment to read what she has just written, pen in hand and notebook on her knees. A coffee cup and a pair of binoculars rest on a table beside her while sunlight filters through the slats of the railings. The viewer is invited to listen to the birds, gaze at the lake through the trees, smell the pine forest and the stained clapboards of the old cabin, feel the familiar roughness of the wicker furniture, and then slip quietly away, attempting not to disturb her in her moment of solitude. The photograph captures the most peaceful place on the planet.   

As I looked at the image, her husband unwrapped the story that accompanied it. “That photo was taken at a cottage in Maine that we first visited on our honeymoon. We returned many times over the years. The cabin is on a hillside near the shoreline so you get the feeling that you are up in the tops of the trees as you sit on the porch; they even call it 'The Crow’s Nest.' She absolutely loved to sit there and read. One day, I went looking for her and there she was. Later, when I showed her the photo, she was surprised. She never even knew I that had been there. It was her favorite spot on Earth.”  

We stood and admired the image for a few moments, and then I set the photo back down carefully and took a step backwards. Two-and-a-half years later, she would be gone, but, for that one moment, she had been returned to the place that most embodied peace, both for her and for those whose lives she had graced.

“We know what we are, but know not what we may be.”
- Shakespeare  


Many years ago, I knew a resident whose only focus was himself. He studied alone, consistently begged off of or ignored teaching assignments, interacted poorly with faculty members, and received poor marks from those with whom he worked. Observing him examine patients was painful — he appeared to be completely unversed in basic social skills. When he finished training, memory of him quickly evaporated. It was as though he had never been part of our lives.  

What had he lacked? Many things, I suppose, but even he agreed that he lacked any sense of empathy.

Some empathy (“imaginative” or “cognitive” empathy) can be learned and it allows us to assume the roles of others to predict their thoughts and feelings. Other forms of empathy (“vicarious” or “gut reaction” empathy) represent the spontaneous visceral response to another’s emotions. Vicarious empathy cannot be learned but it can be lost.  

A recent article documents the disturbing association of medical education with decreases in vicarious empathy. Groups of medical students were tested yearly for four years for their emotional responses to fictional situations. Findings included:

• Students entered medical school with vicarious empathy scores similar to the general public.
• Vicarious empathy decreased over the four years of medical school, especially during the first and third years.
• Students who eventually chose to enter specialties that focus on patient continuity (family medicine, pediatrics, internal medicine, OB/Gyn, and psychiatry) scored better on the empathy scale than students who eventually chose other specialties.
• Separate research has found that idealism and empathy drop during internship.

The authors encourage medical schools to celebrate positive professional traits and focus on providing mentors who “can aid students in overcoming losses in empathy.” Not a simple task.  

Consider the process by which physicians are trained: How can students not be dramatically changed by what they experience? They are locked into competitive, cloistered, expensive, and demanding curricula, often far from friends and family. During the initial clinical years, students are expected to witness and rapidly process a steady onslaught of sickness, death, suffering, injustice, loss, uncertainty and pain. Teachers, who are themselves products of the system, may not have the skills or insight to help the students understand what is happening to the patients or to themselves.  

Not surprisingly, medical students are aware that the very process into which they have entered is capable of transforming naïve, altruistic, emotionally fragile college students into hardened, egocentric, cold physicians; I suspect that they all too often observe the disturbing results but do not discern the process.  As they progress through the system, they declare, “That won’t happen to me!” But, of course, it can. Albert Einstein defined "insanity" as “doing the same thing over and over and expecting different results.” Something has to change.  

Medical training is evolving. Work rules are in place and curricula are under constant evaluation. Our school’s Medical Humanities program brings interested students into contact with the works of poets, artists, healers, philosophers, theologians, and writers, attempting to spark new insights and to nurture coping skills. Will we create Empathy in those who possess none? Of course not. But, will we nurture Empathy in those students with the gift and the desire? Since this new cohort of physicians will be the ones caring for my generation as we approach the end of our lives, I, for one, am pinning my hopes on it.    

___
Ref: Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P, Is There Hardening of the Heart During Medical School? Academic Medicine (March) 2008; 83:244-249.

Dr. David’s Blog (created by a pediatric oncologist at Johns Hopkins) posted a very impressive pair of socks that the good doctor spotted on rounds a few days ago.

His post reminded me of a remarkable pair of slippers that I noticed several years ago on one of our patients. She was actually in the hospital undergoing surgical treatment for a large cancer of the floor of the mouth. And, no, neither the patient nor her slippers quit smoking.

---

The following is feedback received for this blog: hose slippers are awesome! And your timing... remarkable. Just today, the owner of the socks I posted gave me 2 pair as a gift! There must be something in the air today... - David Loeb http://doctordavidsblog.blogspot.com/