“You can just turn right back around, and go get the doctor.”
I was a new oncology PA, and I asked if I could take her history and then bring in her attending physician, according to our common practice at that time of shared visits. Maud refused. “Tell him I'm here. I don't see PAs.”
I left the examination room and told the oncologist that Maud would agree to be evaluated only by him. He and our nursing staff laughed. Maud had been the oncologist's patient for more than 20 years. During that span, she had been treated for four primary cancers and at least two instances of metastatic disease.
In her professional career Maud had worked her way up to a position of significant authority. I imagine that she had a no-nonsense attitude and did not suffer fools gladly even then. Now a strong-willed woman in her late 80s, Maud had a razor wit to match her sharp mind and caustic tongue. She lived independently, and the only assistance she would accept was that of a cane to steady her gait. She shuffled slowly in rubber-soled shoes, but her back was straight. Her clothes were neatly pressed with creases as sharp as a knife's edge. She wore blouses buttoned to the top button and bright lipstick. She was always accompanied by the same quiet friend. Over the next year, she was seen only by the physician.
One day Maud called to request an urgent appointment for some complaint. The physician was out of town, so she grudgingly accepted an appointment with me. I no longer remember what prompted her to call that day. What I do remember is how grateful she was to be seen. I remember how anxious she was that some symptom might signify another recurrence of her cancer. I remember listening patiently, holding her hand, and reassuring her that, for now, her cancer had not returned.
A few weeks later, Maud's name again appeared on my schedule, this time for a regular toxicity check, not an urgent visit. When I entered the examination room, I asked if she wanted to see the physician instead, but she told me that she requested the visit with me. She had no specific complaints, and she continued to do well.
Over the next year or so, her appointments alternated between the attending physician and, with increasing frequency, me. When her physician left our practice, I called Maud personally to let her know that I would assist with transitioning her care to another oncologist. She told me that she didn't need a doctor as long as she had me, but I assured her that in a complex specialty like oncology, a physician was the most appropriate leader of her healthcare team.
Months later, Maud's tumor marker began to rise, a sign worrisome for another recurrence. A scan revealed progressive disease in the liver. Her new oncologist made a change in therapy. Her cancer responded, but Maud tolerated this treatment poorly, and I saw her often for various symptoms. I began to worry that she would not see another birthday, but I kept this concern to myself, always offering her a broad smile and as much reassurance as I thought reasonable but not overly optimistic.
After Maud had a brief hospital admission for pneumonia that could have been community-acquired or an adverse reaction to her cancer treatment, her doctor and I wondered if therapy was doing our patient more harm than good. Maud was weak. She now arrived in a wheelchair, no longer able to walk from the car past the reception desk to our examination room. We discontinued treatment.
Maud gradually regained her lung function, but off therapy, her overall performance status worsened rapidly. Her once-robust appetite was reduced, and she began to lose weight. Her coral lipstick made a stark gash across her wan face. Her tumor marker and liver enzymes began to climb again. She always mustered a wisecrack for me, but she seemed increasingly diminished. Given her age and worsening condition, we discussed transitioning to comfort care, but Maud insisted on further treatment. We had one weapon left in our standard arsenal, but it often was poorly tolerated by patients much younger than Maud. She wanted to try.
We started a reduced dose of chemotherapy, and a few days later Maud asked to see me urgently. “I'm afraid the pill isn't working, and I'm going to croak.”
Remarkably Maud had none of the common adverse reactions associated with this treatment. Her hemoglobin was improving, and her liver function tests normalized. A few days later the fire was back in Maud's blue eyes, and her cheeks had regained more color. Family said she was nearly herself again. I hugged her, and as I stepped toward the door, she grabbed my hand. I faced her again. “I would not be here without you,” said the patient who once refused to see a PA.