Tuesday, February 24, 2009

Patient is a Virtue

The student lounge was filled with young men and women, each attired in crisp hip-length white coats that identified them as medical students. I had been invited by Dr Grosh to speak to the second-year class at UVA School of Medicine as part of a course he directs on the psychosocial aspects of cancer. I was happy to oblige.

As the students settle into the chairs and couches scattered about the room, I invite you to listen in to some excerpts of our conversation:

“It is great to be here today. If you ask me, I think Dr. Grosh is simply showing off his most successful cases. In fact I’m pretty sure he would not have asked me to participate if I had already succumbed to my cancer as planned six months ago. I am glad to be here today!

“Let me tell you a little about my medical career… I enjoyed a very busy practice with over 3,000 patients… increasingly frustrated by the economic realities of modern medical care that drove a wedge between the patient and his/her physician, sometimes developing a ‘fortress mentality’ in the office… I then launched a solo subscription practice that allowed me to focus on personalized, prevention-minded, proactive care that was mutually satisfying for both me and my patients…

“All this ended abruptly on January 23, 2008 with the startling news of disseminated malignant melanoma… I knew my prognosis was grim… underwent countless studies, punctuated by numerous emergency room visits while waiting to qualify for Interleukin-2 therapy… experienced rapid decline, shaking chills, night sweats, bone-wracking pain, weight loss, nausea, vomiting, and extreme weakness...

“The hardest task was sharing the news with my grandchildren… adjusting to life no longer defined by my profession… an altered body image… concerns regarding my wife’s future financial security…

“Throughout the diagnostic work-up and the demanding treatment protocol I gained a greater appreciation for the consequences of orders I had blithely written for patients in the past… a liver biopsy that resulted in excruciating pain following the procedure… a complete spinal MRI that demanded one to lie perfectly still on a cold hard table in a cramped noisy tube for 1½ hours… the toxic hospital food… the session with a nutritionist who persisted in inquiring about my dietary habits undeterred by my convulsive contributions to the emesis basin… the breezy hospital gowns… the frequent vital signs that ensured sleepless nights… the drug-induced diarrhea (and accompanying embarrassment of soiled bed linens)… the drug-induced constipation (and accompanying hemorrhoids)… [They heard all the gruesome details…]

“From this physician-turned-patient who still faces a life-threatening illness, let me leave you with three earnest recommendations:

1 – Cultivate a fortress mentality… but place the ramparts so that your patients and your family are safely within the fort. Boundaries are necessary but you must work diligently to place them so that you do not compromise your professional integrity nor sacrifice those you love the most. Gain the confidence needed to maintain a relationship with your terminal patients, even when you are no longer the treating physician. Regardless, recognize the unintended consequences of the orders you write and own them.

2 – Strike a balance between honesty and hope. I don’t believe ignorance is bliss, but brutal honesty without genuine caring and sensitivity can be abusive. On the other hand, hope propped up by false or vacuous claims is deceptive. Your goal is to help your patient live and to live each day to the fullest. In reality, none of us is guaranteed tomorrow.

3 – Don’t run from conversations about faith. When it comes to issues of mortality, your patient’s world view is absolutely critical in determining their response to a life-threatening illness. If you do not feel personally equipped to do so, ensure that a pastor, chaplain, or spiritual counselor is available to your patient.

“As a doctor who became a cancer patient, my faith has made all the difference. Although I would not have written this chapter in my life, I am extremely grateful for the lessons it has taught me. The experience has been transformative. Because of my faith in a loving and sovereign God, I have no fear of tomorrow but gladly celebrate each day. My hope for you is that, in the midst of your intense medical training and the unending reach for that next goal, you won’t neglect the rewards in store for you today.

“Thank you for your attention. I’ll be happy to answer any questions.”

I fielded a number of questions that day, but the one that is most memorable was asked by a young woman who said: “You seem to have weathered some difficult times with a very positive attitude and a bright outlook for tomorrow, but how do you handle the patient who clearly has no hope of survival, where death is imminent?”

“Great question. First of all, there were several times in my own experience when I thought death was indeed imminent. What buoyed me up in those times was a confidence that God was with me and that He had secured for me a future that transcends this brief earthly existence. I am convinced that if I did not have that hope, I would have been in deep despair.

“I recognize, of course, that not everyone shares this world view, so I simply invite them to consider it. Dr. Sigmund Freud, for example, embraced a different (naturalistic) world view. Resigned to the harsh reality of his world view, he described death as 'the terrors of eternal nothingness' and actually arranged for his own euthanasia when he determined that he could not face another day with cancer.

“I view my role as a physician to help patients live, even when (especially when) their days are few.”

I have learned that being (a) patient is a virtue!


PS – Want to rent a great movie that portrays a doctor who learns the virtues of being a patient? Check out the 1991 film starring William Hurt, The Doctor. A helpful discussion of the film aimed at medical personnel is found here.

Saturday, February 14, 2009

Uncharted Territory

Ask my family and you will discover that I love an adventure… often to their dismay. When hiking an unknown mountain path, I must explore what lies beyond the next bend, or discover what vista surely waits just over the next rise (sometimes leaving Linda to rest upon a rock). Whether sailing straight into a fog bank, canoeing through a mangrove maze, or schussing down a slope of virgin snow in cross-country skis, I love to go “where no man has gone before”.

I vividly remember one occasion in which my penchant for exploring uncharted territory could easily have ended in disaster. Wanting to share the thrill of adventure with my family, I loaded them into our new Jeep Wagoneer and set about on an off-road exploration of the Tennessee back country. Careening over the crest of a hill, and with lightning reflexes animated by my wife’s blood-curdling screams, I slammed on the brakes just feet from the edge of an 80-foot crevasse.

When the computer game called Myst was released in 1993, I was hooked. In this highly textured fantasy world, I was free to satisfy the need for exploration without risking life or limb or loved ones. The family was glad to make this venue of adventure a regular birthday gift.

Once more we are embarked on a real-life adventure into uncharted territory. Once riddled with cancer, by God’s grace I have navigated successfully through four gamma knife procedures to the brain, two cycles of systemic high-dose Interleukin-2, and three sessions of external beam radiation to the left hip. I have arrived in a place that few with stage IV melanoma have lived to experience. I am feeling great but there are challenges just ahead.

Our most recent visit to UVA on Wednesday, February 11, revealed a complex landscape: imaging studies suggest both significant improvement in systemic control of the cancer and possible persistence of tiny growths in the brain. All pertinent labs and my exam remain normal. Although my oncologist and neurosurgeon are exploring various options, there are no road maps to guide us through the next steps. There is no proven protocol for survivors like me.

I am reminded of another adventurer, spoken of in scripture. In Genesis 12:1, God tells Abraham to venture forth “to the land which I will show you”. Not knowing precisely what lay over the horizon, he set out, trusting God to guide him and supply his every need. He was not disappointed.

As we await the recommendations of my highly-competent physicians on this next leg of our journey, experience has taught us to fully trust in God as our guide. I’m looking forward to yet another adventure!


PS – On this Valentine’s Day, I am truly grateful for the one the Lord has given me as a faithful companion on this journey. As I awoke this morning, these were the thoughts I shared with Linda:

Waking to another day
Joy fills my heart anew…
The greater gift, I cannot say:
This breath I take, or you?

Happy Valentine’s Day!