Reflections in a Head Mirror

Words are, of course, the most powerful drug used by mankind.
-Rudyard Kipling  


“But, Doctor, tell me! What do you think it is?”  

We have finished the operation, catalogued and sent all of the specimens, closed up the wounds, and bundled the patient off to the Recovery Room. It will be a couple of hours before the patient is fully alert. And it will be a couple of days before the reports are back from the laboratory.  

“You’ve seen other cases like this. You must have an opinion about what the pathologist will say.”  

Of course I do. But, I think to myself, I have guessed wrong. What good would it do to raise hopes inappropriately or, on the other hand, dash hopes needlessly? I have, on more than one occasion told a family that I was pretty certain that the specimen would show no cancer, only to find out  days later that I had been wrong. I want to avoid the sinking sensation that has accompanied that mistake.  

“I wish I could tell you, but I’m just not certain. We will just have to wait for the reports.”  

There is a time of limbo in Medicine that begins when the procedure is completed and ends when the patient learns the results. It occurs millions of times each year after everything from major surgeries to blood tests. Although it was not the point of her essay this week in The New York Times, Dr. Paula Chen touched on these moments as a friend's father waited for the results of a pancreatic biopsy.  

From a relative’s perspective (yes, I’ve been there), waiting for the doctor to call or stop by after a procedure is akin to listening for the footsteps of the principal coming down the hall after you have been sent to the office. The wait is long and tense.  

From the physician’s perspective, the time between the procedure and the report is a breather that allows a release of concentration from this patient because nothing more can be decided until the report is available. The physician can refocus on someone else during the interval. The wait can seem very short.  

Finally, the report hits your desk. Or you call the lab. Or you are paged by the pathologist. Or you work your way through several passwords and computer screens and find the results.    

At that moment, the physician has a piece of information that the pateint wants and needs to be shared. Sometimes the report will bring relief and joy; sometimes, just the opposite; sometimes, just a shrug.  

But share, we must — clearly and promptly — even when it is hard and even when we don't know exactly how. People are waiting.

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The following is feedback received for this blog: Just to say I really enjoy reading all your posts..am slowly reading all previous posts. - just me http://simpleawareness.blogspot.com

"We are healed of a suffering only by expressing it to the full."
-Proust  


Years ago, in the ENT Clinic at the County Hospital, I was seeing a new patient. He had been sent to us from another physician with a hastily scribbled consultation note that read “Please evaluate for hearing change.” The patient was nervous but cooperative. His eyes darted around the room, but his gaze never met mine.  

“Good afternoon, Mr. Evans! What can I do for you today?”  

“My hearing has changed. Something is wrong with it.” His voice was flat.  

We talked for a while about his ears. His answers were short. No exposure to loud noises, no drainage, no pain, no ringing, and no episodes of dizziness. He seemed able to hear me just fine as we talked.  

“Let me take a look,” I said. I examined his ears. They both looked fine. Very little wax was in the canals, certainly no obstruction. The ear drums looked fine and there was no fluid behind them. I got out my tuning forks and did some basic testing of his hearing. Everything seemed pretty normal.  

“Mr. Evans, when did you notice the hearing change?” I asked.  

“When they increased my medicine!" he responded. This could be important since some drugs can be very toxic to the hearing and balance mechanisms.  

“Which medicine?” I asked. “Who is prescribing it?”  

“It’s one of the pills from my psychiatrist, but I don’t know its name!” he responded. As we talked, he was getting more and more agitated.  

I couldn’t think of any of the standard psychiatric medications that affect the hearing. I paged through a book which listed common drugs and their side effects and came up empty. I was baffled.  

One more try. “Mr. Evans, tell me in what way your hearing has changed since the medication was increased. What exactly is different?” I asked.  

His eyes widened and his lip quivered. “I can’t hear the voices anymore!” He started crying uncontrollably. “I can’t hear them telling me what to do!”  

We sat there. This was suddenly well outside of my area of expertise. I did my best to calm him and waited for him to regain some of his composure. Before long, I was on the phone, talking to one of my friends in Psychiatry. I later heard that things turned out well.

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The following is feedback received for this blog: Wrong place, but maybe right time/ right doctor. You got him to the right place. :) - rlbates http://rlbatesmd.blogspot.com/

“The best way out is always through.”
-Robert Frost    


“Mr. Williams, the mass we took out of your neck was cancer. The surgery went well and I feel that we were able to remove all of it.”  

The surgery had, indeed, gone perfectly and I was feeling optimistic about his prognosis. Although his mass had been only mildly suspicious for cancer, we had been careful and had made certain that there were no other involved lymph nodes and no obvious sources for the tumor. Things were on-track.  

“I’m going to die, aren’t I?”  

I was stunned. I had just given him good news. He had responded as though I had signed his death warrant.  

“Not at all! I expect you will do well! We will send you for a course of radiation therapy.”  

His eyes widened and then closed tightly. He looked discouraged. Very discouraged. I was baffled. What could I say?  

“Mr. Williams, tell me about people you know who have had cancer.” I thought I would get him to understand that there was hope. “Have any of your family members or friends been treated successfully for cancer?”  

“No! Everyone I know who has had cancer has died!”  

This was not going well. Then the story came out.  

“Thirty years ago, my wife had breast cancer. It was pretty advanced. She had that radical surgery but the cancer came right back. When they did radiation, her skin turned red and then fell off. Her whole chest looked like raw steak. She was miserable! I’m certain that the radiation killed her.”  

He stared a hole in the floor. We sat there silently.  

“Mr. Williams, I’m sorry.” No response. “Would you be willing to meet with the radiation oncologist to hear about  the possibility of treatment?”  

He did not look up. “Yes.”  

A few weeks later, he was undergoing radiation. What courage does one need to begin a course of treatment you are not certain will help and that you are convinced killed your spouse? I cannot pretend to understand.

“If one is forever cautious, can one remain a human being?”
-Alexander Solzhenitsyn    


I never leave my work behind completely. That is probably why I read the late Alexander Solzhenitsyn’s book, Cancer Ward while on vacation. (Thanks to Eileen who gave it to me!) Cancer Ward is a semi-autobiographical work about a group of men in a Soviet hospital undergoing surgery, radiation therapy, and hormone treatments in 1955. Solzhenitsyn uses “cancer” as a metaphor for the deteriorating Soviet system and its effect on the citizens. Still, much of what he describes of the physicians and patients holds true in every time and place.   

The book highlights the paternalism of both Medicine and the Soviet system. In the story, the patients’ clothes and shoes are taken from them as soon as they are admitted. Treatments are rendered without consent. Patients are not told how long they will remain in the hospital. Casual comments dropped by the staff are routinely misinterpreted. Even the compassionate doctors routinely hide diagnoses, prognoses, and test results from the patients. 

One patient, Oleg Filimonovich Kostoglotov, an exiled former political prisoner, is wily enough to befriend several of the physicians and staff members. By borrowing medical books (“Strictly forbidden to the patients!”) and slyly asking questions, he finally manages to understand his cancer and the potentially horrific effects of overtreatment. He cleverly talks his way out of the hospital before the treatments do more harm than good.  

Oleg benefited only when he had plenty of good information and was able to hold someone’s attention long enough to get all of his questions addressed. Clearly, the more Oleg learned from the physicians, the more the physicians tended to see him, not as a patient, but as an equal. What a concept!  

Solzhenitsyn is not alone in decrying paternalism in Medicine. As the literary critic Anatole Broyard wrote in the months before he died of cancer:

“Just as he orders blood tests and bone scans of my body, I’d like my doctor to scan me, to grope for my spirit as well as my prostate. While he inevitably feels superior to me because he is the doctor and I am the patient, I’d like him to know that I feel superior to him too, that he is my patient also and I have my diagnosis of him. There should be a place where our respective superiorities could meet and frolic together.”  

When Medicine works, it becomes a partnership — a relationship of equals — that requires time, effort, and trust. Just as Oleg learned, and as patients and physicians continue to learn, forging this partnership can be a difficult, yet very rewarding, process.