Most of the benefits my patients receive from my work as a medical oncologist comes from the drugs I prescribe for their cancers. Some of these drugs can increase cure rates. Some of these drugs do not help cure a cancer but can prolong the life of the cancer patient whose cancer is not curable. I think it is important to state that it is the drugs that cure the cancer or prolong the life, not the doctor that does this. I do not get to choose whose cancer is cured or not. I do not get to decide who lives and who dies or when death will come for my patients. I would not want to have those powers.
Truth be told, anyone with a medical degree and oncology specialty training can prescribe cancer drugs. This is the science part of oncology. I love the science. That is for sure. But, if my job were only about the drugs I use, my interest would have likely lied with a different medical specialty. There are plenty of other areas of doctoring that use cool drugs or that perform even cooler procedures. Many of these other specialties provoke far less hard-to-deal-with emotions and produce much less physician burn-out.
So why did I choose medical oncology? Why did I want to have a job where I sit with people in some of their most scared moments and talk through prognosis, survival rates, and death?
For me, the answer is a complex one. I believe there is a much more interesting and meaningful part of my job than the science portion. It is the part that I thrive on, enjoy, even relish: the so called “art” part of medicine. I have the privilege of forming relationships with my patients. This is a big deal to me. I think the relationships my patients and I build are an essential part of their care. For some patients, I think these may be equally as important as the drugs we choose to use.
Every once and a while however, a relationship does not form or progress the way I know it should for my patient to have the best possible experience along the windy road their cancer journey takes them down. These rare occurrences make me feel terrible. They make me feel I have failed at my job. They impact my moods and my thought processes. They frustrate me. They make me hurt. I know this is also true for many of my colleagues.
Today I would like to share a failed relationship I had with a patient. Why? Because I believe it is important for people to know this can happen, that it can be awkward for both the doctor and the patient, and that it can have a negative impact on the wellbeing of both the patient and physician.
I met Sandra and her husband in January of 2020. Sandra is not her real name. Sandra was diagnosed with stage four pancreatic cancer in the fall of 2019 at the age of fifty-four.
For the better part of two and a half years prior to her diagnosis, Sandra was having pain and “unusual feelings” in her back and abdomen. In 2017 multiple investigations were undertaken including an ultrasound, a CT, and an MRI of her abdomen. None of these tests showed an abnormality in her pancreas or anywhere else for that matter. Her abdominal pain continued. She had more tests that did not find a reason for her pain. In the fall of 2019, for lack of knowing what else to do, another CT was ordered which finally found a lump in her pancreas. A biopsy of this mass confirmed she had pancreatic cancer.
At the time of Sandra’s diagnosis, her cancer was felt to be potentially curable because there did not appear to be any spread to other organs on her staging CT. She was taken to the operating room for an attempt at curative surgical resection. However, sometimes cancer spread with small spots in the belly cavity or liver cannot be seen until a surgeon is in the belly. Unfortunately, this was the case for Sandra. When her surgeon opened her abdomen, there were many small spots on her liver. An intraoperative biopsy of a liver spot confirmed cancer spread. Her curative surgery was aborted. There was no longer a chance of cure.
I met Sandra after she recovered from her surgery. She was continuing to struggle with back and abdominal discomfort. She had tried opioids to help with these pains but felt they constipated her, and she felt unwell on them. Instead, she was opting to use ibuprofen, cannabis oil, and cannabis vaping with some effect. Her pain was limiting her function. She was unable to do much of anything during the day. Sandra was known to have a longstanding history of anxiety. Her anxiety had significantly worsened with the realization she had pancreas cancer that would kill her. She told me at our first visit that her anxiety can paralyze her. She felt half-paralyzed already. She told me she did not want help with her pain or her anxiety, that she would figure it out on her own.
There were hints the relationship I was trying to form with Sandra was not going to go well:
#1) Sandra was angry at the medical profession. This included being angry at me, even though I had nothing to do with her until our first meeting. She was fifty-four, much too young to die, had spent the last two and a half years telling people there was something wrong with her and, in her opinion, was dismissed because nothing was found on traditional, but appropriately ordered, tests. Even though nothing wrong was done in this situation, it took a long time for her to get diagnosed. I would be angry about this too. I understood.
#2) Sandra did not trust doctors. Her two and a half years’ worth of pain without finding anything wrong with her and the fact that her potentially curative surgery needed to be aborted were massive stains on my doctor’s jacket. She essentially sentenced me to her mistrust of physicians, her skepticism, her lack of ability to accept any truths I would tell her from the moment we met. She knew this and so did I. I tried to have a conversation with her at our first visit about this, a conversation that would repeat itself at almost every visit with me, but to no avail. I knew I would be lucky if Sandra trusted anything that came out of my mouth.
#3) Sandra was suffering – physically and mentally but she couldn’t find a way to allow herself to get the help she needed. I see this sometimes. It is not uncommon or abnormal with cancer diagnoses. Sandra was closed off. It was as if she felt she was already dead. Perhaps she could not allow me to help her because she pre-judged me to not be trustworthy. Perhaps she was so overwhelmed there was no way she could even begin to feel there were options to deal with her physical and mental anguish. I will never know. I do know there was a massive wall standing between her and I. That wall allowed no possible way through to mutual understanding. I was not going to be able to help this woman if she was not willing to partner with me.
Sandra went on to receive four cycles of a first-line chemotherapy concoction. She did poorly and needed downward dose adjustments with each cycle. Sandra’s cancer grew on this treatment. We tried to get second-line chemotherapy into her, but her performance status did not allow for more than two doses.
Part way through her chemotherapy Sandra requested a change of providers. Sandra was angry with me, she didn’t trust me, and she was still suffering. There is a formal process at most hospitals that allows a patient to request a different doctor. At our centre, this involves a written request through our patient advocacy office, a review by our medical oncology departmental physician lead, and possible reassignment with a different physician that treats the appropriate type of cancer. A request to change doctors is not taken lightly and is sometimes denied. Reasons a different doctor would not be granted include, but are not limited to, race, religious affiliation, sexual orientation, sex of the physician, and scarcity of physician resources.
The last time Sandra was in our cancer centre, she was almost catatonic from her anxiety. Her husband was unable to cope with her care needs at home. She was admitted urgently to our tertiary palliative care unit for end-of-life care. She died a few days later. From what I was told, she did not speak during her last few days.
Sandra did not live long enough to be reassigned to a different physician. She and I never did sort out our differences. I could never break through the Sandra wall. This was a very difficult relationship for me to navigate. The relationship Sandra and I had was definitely broken.
Author notes:
Relationships are hard. They are beautiful but they are hard.
In my opinion, relationships are the epitome of the human experience. I have come to understand connection with another person, in a real and raw way, is the best part of my job. I have also learned, albeit more slowly, the relationships I have outside of my work are the best parts of my life. I do not think I knew this for some of my adult life. I should have, but I didn’t.
I love that each relationship I share with someone is different and interesting in its own way. Some are superficial and built that way on purpose; some are deeper by intention. Some are less special than others; some more fulfilling. One for me is much more impactful and essential than I could have ever imagined; this one surprised me in the best possible ways and continues to do so on daily basis.
I have had a handful of ineffective relationships over the years with patients. I have also lost a few significant relationships in my personal life over the last twenty years. The common thread with these difficult relationships is that I did not want to lose them. I tried to save them. That is probably the care giver in me. I wanted to help, to make things better, to fix things. I would have continued to try to build and/or rebuild them in collaboration and cooperation and by working on myself. But that is not how those stories ended. My heart was broken into many pieces from these losses at the time they occurred.
I have come to understand whether at home or in the workplace, some of the relationships I form are not meant to be, are not supposed to last. Even with the best of intentions and the humblest of efforts, I can fail to provide the services that satisfy a patient’s expectations, or for whatever reason, I cannot be who a friend or partner needs and wants me to be. And that is okay. I have learned, with plenty of help, there is shared responsibility for relationship breakdowns; it is not all on me. I have embraced that sometimes the happy ending comes with moving on and putting my heart pieces back together so that over time they fit in a more authentic and comfortable way.
I am grateful for the bright sides of broken relationships – the bitter-sweet realizations of self-compassion and self-love.
I am curious to know about a failed relationship from you reader. What was your part in the relationship breakdown? Could you have done better? What did you learn from an unplanned goodbye from a life partner or friend?
