Minor surgery is surgery someone else is having.
-J. Carl Cook
In a couple of minutes, I will knock gently on the door of the examination room and meet the new patient and her husband.
The young woman visited a doctor in the community because she had found a mass in her thyroid gland. She and her husband had been shocked when a needle biopsy had suggested that the mass might be cancer. Now, a couple of days later, she sits behind the door knowing that her life will never be the same.
I can barely imagine what the patient and her husband are thinking right now. Perhaps they are wondering how this cancer will change their lives. Possibly, they are worried about what to tell their children. Maybe they are too scared and preoccupied to think about much of anything at all. Their minds are, no doubt, alternating between terror and a desire for everything to be back to the way it was last week.
Her medical records, though, tell me that her case is relatively straightforward.
Even before I meet her, I am quite certain that I will advise her to undergo the complete removal of the thyroid and an evaluation of the lymph nodes in preparation for radioactive iodine treatments. The surgical procedure is tailored for each individual but the overall plan remains the same. Happily, the long-term outlook is bright. The vast majority of young women with early stage thyroid cancer do extremely well and the patient behind the door should be no different.
I knock and enter. The woman and her husband freeze in mid-sentence as they look up at me; she relaxes only a bit as we greet each other. On her lap is a notepad with a series of handwritten, numbered questions. Her husband shakes my hand as he sets aside the stack of articles and Web pages.
Between now and when they leave, they will need to understand the cancer treatment. They will want to know what to expect over the next few weeks and what to expect in the future. Hopefully, they will grow to trust me when I promise that our team will do its best to help them.
First, however, I will have to address their anxiety.
I tell them, “I am going to jump to the end. Is that okay?”
They nod.
“I promise that I will come back and fill in all of the gaps, but I want you to know that there is every reason to believe that you are going to be just fine.” I mean it. “I will be proposing a surgery that will be the first step toward completely curing this cancer forever.”
They look at each other as I repeat, “Our goal is to cure this cancer completely!” They look visibly relieved.
Over the next few minutes, I will carefully examine her and prepare them both for the surgery. There will be arrangements for consultations, surgical and research consent forms, handouts, appointments, teaching, questions, and scheduling. There is a lot of material to cover and much to think about.
Whenever I can, though, I start these conversations by "jumping to the end.” This approach removes the suspense. The patient is better able to hear the rest of the discussion and participate in the decision-making. And, hopefully, nothing beats a renewed sense of hope to make a bad situation just a bit more bearable.
The following is feedback received for this blog:
Nipping things in the bud can often be painful, but ultimately less hurtful. Great post. Thanks.
- Jabulani
Lovely story. Do you also "jump to the end" when the outcome is less clear, or when it is grim? As a palliative care provider, I find that physician's reluctance to walk patients through the bigger picture results in piecemeal optimism and contributes enormously to difficult end of life experiences.
-Risa Denenberg
http://risaden.blogspot.com/
When my mother was diagnosed with lung cancer (of which she died 7 months later), the doctor jumped to the end immediately with me (my mother had dementia, as well, so I was the first person with whom he talked) and I was never so grateful. It was the first time, in many years, that a physician had done this with me, with us. I hope lots of physicians read this.
- Gail Hudson
That jumping to the end was indeed what we wanted to hear and so very, very comforting. We cling to it. We barely hear anything else but "You will be cured!" We go for a second opinion. The next physician doesn't jump to the end, nor reassure, no stilling qualms. He too has expertise and an entirely different treatment plan. If one doctor is reassuring and the other merely scientific, should this play into whom you trust with your life? When you're scared and ignorant, as we are in relation to cancer, it is so easy, so preferable, to go with the comforting story. It is too hard to take in the science and decide the better course. Yet the rational mind, not the fearful newly diagnosed cancer patient, knows this is an important decision between two treatment plans. This decision should not be based on the comforting bedside manner, but rather on the best statistical chance for a good outcome. This decision needs a rational analysis not a needy fear-based reaction. When we are so afraid the comfort overtakes the science.
- Jane Boylan
