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The Art of Medicine

Saying grace

Sweeney, Cameron Young MMS, PA-C

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Journal of the American Academy of Physician Assistants: November 2017 - Volume 30 - Issue 11 - p 58
doi: 10.1097/01.JAA.0000525912.20720.73
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“Isn't it hard to work in oncology?” It's the question I hear more than any other when I tell someone what I do for a living. I wonder if colleagues who work in gastroenterology and focus on feces, or friends in dermatology who examine pimples, rashes, and wounds, are quizzed as I am.

Oncology is a truly challenging specialty, with extensive guidelines to memorize for specific tumor types, a seemingly endless array of chemotherapy regimens and immunotherapeutic agents to master, and adverse reactions to anticipate and ameliorate. But the intellectual challenge oncology presents is not what makes it hard.

What's hard about oncology is trying to cover a patient's complaints in a 15-minute appointment that might be appropriate for a sore throat, hypertension check, or sprained ankle—but not for cancer. The body of a cancer patient meets multiple cruel insults. We pump people full of poison and try to balance the antineoplastic effect with the resulting toxicities. GI cancer patients waste away, unable to eat more than a few bites, if at all. Faces and bellies bloat from steroids or shrink from weeks of nausea, vomiting, and diarrhea. Neuropathy progresses from toes to knee and causes a high-steppage gait and risk of falls. Anemia leaves a formerly hearty fellow gasping at the end of the driveway unable to fetch his mail. We offer antibiotics and paper masks to a patient with an absolute neutrophil count of 0 on manual differential; then we cross our fingers that a simple infection doesn't kill him before his white count recovers.

What's really hard about oncology is the emotions, barely contained, that bubble and threaten to spill with the slightest provocation. Women fearful of losing hair to chemotherapy or breasts to the surgeon's knife worry that they will no longer be desirable after treatment. They often don't realize that breast reconstruction may give the appearance they desire but will permanently compromise their sensation. Men are embarrassed that prostate cancer treatment has left them with incontinence and erectile dysfunction. Patients with colon cancer are self-conscious about the odor that accompanies a colostomy bag. I can practically see the worry of recurrence tethered to these patients, like an anvil that dangles overhead in a Looney Tunes cartoon, ready to strike.

There is little harder about oncology than delivering a terminal diagnosis or news of progression or recurrence instead of hoped-for remission. What's hard is the grandparent and grandchild with the same rare, incurable tumor that does not typically run in families who present for treatment together. The recent retiree who bought an RV and looked forward to road tripping with his love, only to be diagnosed with metastatic cancer as an incidental finding. The grandmother who served as devoted caregiver to her adult children during their critical illnesses and ignored the lesion she found in her own body until her “pneumonia” failed to respond to antibiotics. The middle-aged father whose unresectable tumor stubbornly progressed through each chemotherapy regimen until we had no weapons remaining to stave it off. All the training and role-playing to “master difficult discussions” cannot adequately prepare you for the feeling in the pit of your stomach as you pause outside the door before one of these conversations or try to swallow when the patient or loved one wails, “Why??”

What makes working in oncology a little easier is being part of the team that cares for those approaching the fragile end of life's journey. These men and women have absorbed more than a lifetime's share of loss, and yet they give more, offer a kind ear, a gentle hand. They wheedle and cajole schedulers, insurance companies, and radiologists to get a scan approved and read, stat. They move heaven and earth to get palliative medications released to a terminal patient in need on a Friday at 5 p.m. before hospice arrives Monday morning. They scour the obituaries so that we can have some small closure for every patient we have come to know. They are good, kind, funny people, and they encourage me to find a balance in my life so the work doesn't consume me.

I am new at this practice, and my meager knowledge is unlikely to alter the trajectory of a patient's course significantly. When I looked one man in the eye and said, “I'm sorry this happened to you. I can't imagine what you have been through,” he responded, “I can tell you care, not every doctor does. Thank you.” An older woman doing well with respect to her past cancer but still struggling with the loss of her husband years ago sniffs, “Thank you for listening” as I hold her hand. I realize that what I can do is honor these people, preserve their dignity, be respectful, humane, and true. It is an honor to serve those at this life crossroads. And so, although not a religious person, I say my grace. I am thankful beyond measure.

Copyright © 2017 American Academy of Physician Assistants