In the spring, I took over the cancer care of a patient from a colleague of mine who “retired”. I write retired in quotation marks because his departure was not a traditional retirement. He left because he was burned out. He was only a few years older than me. He probably had a good fifteen years of doctoring left in him at the time of his departure. It is a little frustrating to me when I hear people say he retired. What really happened was that we lost an otherwise good medical oncologist because the system we work in is broken and we do not have enough people, time, and resources. We also do not have enough appropriate mental health and wellness support for healthcare professionals. Our work effects our mental health. Sometimes we crack and have to say, “Enough is enough – this is not a healthy environment for me. I’m out.”
Now, I also think doctors often make our own burnout worse. Sometimes, the type-A, perfectionist personalities that exist in my profession are like dogs with the biggest, most delicious bones imaginable. It can be hard for some physicians to set appropriate boundaries. These boundaries might include work-life boundaries, but they can often be within-work boundaries. An inability to ensuring we stay in our own lanes is a problem in my specialty. It is very hard to just do our jobs and not try to take on the jobs of others. Examples of other jobs we are often juggling include attempts at being a family physician, a palliative care doctor, a nurse, or clerk, or a computer wizard. We want to help. We don’t want to have to say, “I can’t help you” to a patient. However, not being able to say no to patients, or no to the system within which we work, encourages us to take on more than what our scope of practice should entail and plays a huge roll in burnout.
I bring this us because it plays a role in the story that follows. I think it is a very good example of two sides of the same coin: a patient on one side, a doctor on the other, both trying to normalize being okay standing tall in our own convictions. It was a very good learning moment for me.
The initial consultation I had with this new-to-me patient was in March. It was then that I took over her cancer care. Since then, I have appropriately only seen her once. Our next meeting will hopefully be in a little less than six months. She only needs to see me every six months for a few more years. This is a good thing. She is on a typical surveillance program for someone who has had metastatic spots of colorectal cancer resected.
My new-to-me patient has a current diagnosis of resected stage four colorectal cancer. This means she was diagnosed with a colorectal cancer, at some point it spread to other organs, and these areas were able to be cut out. Stage four colorectal cancer is rather special. For some reason we do not yet understand, it is different than a lot of other stage four cancers. If a stage four colorectal cancer grows back in a distant spot and that area that can be cut out, it is still potentially curable. We almost always recommend surgery in these cases if a surgeon thinks it can be cut out. This is what happened in the case of my new-to-me patient.
This patient has a rather complex cancer history and had a long history with my “retired” colleague. She was originally diagnosed with localized colorectal cancer in 2012. She had surgery to cut her bowel cancer out at that time. She met my colleague shortly thereafter to discuss chemotherapy which was recommended to significantly improve her chance of cure. She consented to treatment and went on to receive six months of capecitabine chemotherapy. She then started on a surveillance program which we recommend for up to five years after her surgery. Typically, this surveillance includes a blood test called a CEA, CT scans, and colonoscopies.
In 2014, through her surveillance, a liver metastasis was discovered. It was consistent with colorectal cancer spread. It was cut out and she went on to receive six more months of curative-intent chemotherapy, this time with a regimen called FOLFOX. She was then placed on surveillance once more.
In 2017, two further recurrences were detected in her lung. Both were amenable to curative surgical resection. She had two separate surgeries to remove these spots. No chemotherapy was recommended at that time because she had already had the best of the best chemotherapy and despite its use, her cancer found a way to survive and grow. There was no point in repeating a treatment that didn’t do the job it was intended to do. Surveillance started over again.
Then, in late 2021, another cancer spot was found in her lung. Her thoracic surgeon believed this could safely be cut out. She underwent a third successful lung surgery. She is still in a situation where her cancer might be cured. Only time will tell. Her surveillance program restarted again.
This is where I came into the picture. If all goes well, and her cancer does not grow back for the next four years, I will have the pleasure of discharging her in late 2026. This would be the absolute best-case scenario for this patient. I hope I get to see this happen.
I thought the first meeting I had with this patient went well. She was about six months out from her last surgery at the time. She had just had a monitoring CT. She reported having a slower recovery time from her most recent surgery than she recalled having after previous surgeries. She was noticing more shortness of breath when going up stairs, not atypical of someone who had as much lung surgery as she. She was generally improving but improvements were slow. I tried to normalize all of this for her. Her experience was common among patients who had gone through all that she had.
We discussed her CT results. I told her there is no evidence of metastatic disease and that her CEA was not concerning. We then discussed the fact that her surveillance clock had started over again. I reminded her she will continue with CEA blood tests every 3 months and CTs every 6 months for a total of 5 years. She was aware she needed a colonoscopy which was already in the works. I explained I will see her post CTs. I told her I would check on her blood work in between CTs and if all was well, she would not hear from me. For my patients, no news is good news.
I reminded her there was no chemotherapy that could currently improve her chance of cure. She was aware of this already from previous discussions with my colleague. As she was a new-to-me patient, I told her what I tell all my patients with a similar diagnosis just to make sure she had the opportunity to hear the words from my mouth: if her disease recurs and is amenable to surgical resection, that would be the first plan and that plan would still be a curative plan. If, however, she had a recurrence which was not amenable to surgical resection, her cancer would be deemed incurable. Incurable colorectal cancer has treatment, but the goals of treatment would shift to focusing on trying to control symptoms and extend survival but not cure. I stated in such a case, the average length of life would be between two and three years. She stated she understood. I told her that if she had any cancer related concerns or questions, she could contact me via telephone. As I typically do with all my patients, I explained her other medical problems should be dealt with through her primary care physician who would quarterback her health concerns. We set up a plan for another appointment in 6 months after her next CT.
There was a lot of hope for cure in this case. This type of visit is usually a happier type of visit compared to those visits I share with my incurable patients. I felt I had explained the way I practice and laid out appropriate expectations of the therapeutic relationship that this patient and I were embarking on. I moved on to my next patient and didn’t think much more of the encounter for the next six months.
A few weeks before the recent appointment I had with this patient, she called my office asking if she should follow through with a radiology test a different doctor had ordered for an issue unrelated to her cancer. As this was not a cancer related medical concern, I had my administrative assistant relay a message to her that I took and look and thought it was probably best to go ahead with that test but that it was not my decision to be made; she was directed to talk to the doctor who ordered the test.
When I saw this patient for the second time, I gave her good news. Her CT and CEA showed no suggestion of cancer recurrence. Things looked great. But things were not great. I knew something was not great by her apparent unease when I entered the room.
She let me know she was bothered by our first interaction six months prior. She started hesitantly saying, “I don’t mean to compare you to Dr. ______, but,” she did. I listened while she told me how at our initial visit, she heard me tell her that if her cancer came back, I would desert her and not do anything about her cancer. She told me my “retired” colleague would have never said such a thing. She said he always took care of everything for her, no matter if it was cancer related or not. She told me for the last six months she felt I was not being her advocate. She told me he would have called her back himself with the message I asked my administrative assistant to deliver to her. She told me she understands I am different than my retired colleague but that she was bothered by that. She wanted me to be more “hands on” like he was.
I didn’t know how to respond for several awkward seconds as I racked my brain trying to recall our first interaction. My recollection was that which I wrote above. It was an everyday kind of consult for me. I used the same words with this patient as I always do in surveillance situations. I knew I didn’t say I would desert her. Yet, there she was telling me that I had. What was happening?! She had hung on to all these feelings for the last six months. It was a lot for her to say; it was a lot for me to digest.
We spent the next five minutes reviewing the information I had given her six months earlier. I tried to relieve some of her concerns by repeating the fact that if her cancer returned and it could not be cut out, we could discuss palliative intent chemotherapy. But I also re-iterated that in such an instance, there would come a time that there would be no treatments left or that she would get too sick for treatment; when that occurred, she would be discharged from the cancer centre so that pain and symptom needs could be appropriately delivered in the community or via hospice. I revisited the fact that I focus on treatment for her cancer and that other care needs must be delivered by more appropriate members of her health care team. I think we resolved the concerns she had about me but I’m not entirely sure. Time will tell.
I’ve had a little time to reflect on this encounter. I applaud my new-to-me patient for having the guts to stand up for herself when she felt an injustice occurred in my clinic. She is allowed to feel the way that she feels. Equally, I am allowed to try to manage unrealistic expectations placed upon me by my patients and by the system. If I don’t, I could easily become another burnout casualty. I think it was a really great thing this patient felt comfortable expressing her concerns to me – to be able to have the conversation we did is a beautiful thing. Thank you for being brave, new-to-me patient. Thank you for standing tall in your own skin. I am proud to say I did too. I hope we will figure out a way to continue our therapeutic relationship.
Author Notes:
I had something stolen from me recently. The theft wasn’t a large one. The person who stole from me was trying to intimidate and bully me. He was unable to control a situation he wished he could control and so instead of getting to the root cause of the issue, he lied and cheated and took something that was not his. He was wrong to do this. He acted unethically. His actions were cowardly.
I could have just ignored his act of injustice. I could have walked away, turned the other cheek so to speak, and let it go. Perhaps I should have. What was stolen didn’t have a lot of value so to waste my time on it seemed, in a way, unnecessary. The problem is, every which way I look at the situation, it reeks of unfairness.
Instead of letting this person get away with their bad behaviour, I tried to hold him accountable. I don’t know if there will be any repercussions for this person’s wrongdoing, but that’s not the point. The point is that all too often, people who act with poor judgement and take advantage of others, are left to get away with their bad behaviour without challenge. I don’t think that’s right.
When I stood up for myself this week, my new-to-me patient came to mind. I felt the need to write about her. It takes courage to speak up, to stand tall. I am very thankful when I can do this for myself. We might not always get it right, but we should be proud of ourselves for being gutsy. I hope my patient is proud of herself.
I am curious, reader, if you have ever had an experience in your life where you have had to stand up for yourself in a way that helped you love yourself more? How did that experience change you?
