The medical oncologists at my centre take turns each week being on what we call “triage”. When we triage, we take calls from other care providers about patients who have a cancer diagnosis, or presumed diagnosis, but who do not yet have a medical oncologist in charge of their cancer care. Some of the questions we answer are about the need for further investigations: What should be done next? Is a biopsy required? Is the information collected to date enough to make a referral to the cancer centre? Other questions are about fitness for treatment: Is this patient eligible for treatment? Is there treatment that might help this person? How much might it help? Increasingly often, these triage calls include a reprimand for not being able to see a patient in a timely fashion. The latter are the hardest calls.
Last week, the gastrointestinal medical oncology triage physician took a phone call from a specialist at a neighboring hospital about a patient who was diagnosed with a new stomach cancer. Our triage doctor then sent the entire gastrointestinal medical oncology team an email, requesting a consensus decision be reached on whether we should see the patient. That email and the discussion that ensued within our group had a big impact on me.
The patient was a man in his early forties who presented to the hospital feeling unwell. His hemoglobin, white blood cell count, and platelet count were terribly low. He was requiring transfusion support. Despite his low platelet count, which usually makes people more prone to bleeding, he had developed blood clots. This is a bad prognostic feature for any cancer.
A CT and PET were completed which showed widespread bone metastases. There was also lymphadenopathy throughout his body which is often indicative of lymphoma, a type of cancer originating in lymph nodes. A bone marrow biopsy refuted the expected lymphoma diagnosis; instead, metastatic adenocarcinoma with a morphology suggestive of an upper gastrointestinal malignancy was detected. A gastroscopy followed. The camera that went down his throat found a deep stomach ulcer. A biopsy of the ulcer matched the result from his bone marrow biopsy: incurable stomach cancer was diagnosed.
The call to our triage physician was placed to ask if anything could be done for this man. The referring doctor was requesting a medical oncology consult for palliative chemotherapy. But was that even possible?
For most gastrointestinal tumours, palliative chemotherapy is reserved for patients who are well. “Well” to a medical oncologist means a patient is able to do most normal activities greater than fifty percent of the time. It is rare to consider chemotherapy in someone who is unwell enough to require inpatient hospital support. The most important reason for this is that chemotherapy has side effects. Let’s pretend we have a patient who is at eighty or ninety percent of their typical functional capacity. Let’s also pretend we know if we give that person chemotherapy, we would be dropping their capacity by ten to twenty percent. With those numbers, we might still end up with someone who is seventy to eighty percent functional. Now imagine we had someone who is only functioning at twenty or thirty percent capacity, which would be a good estimate for someone admitted to hospital. The addition of chemotherapy could kill that person. As such, chemotherapy is generally a “no-go” for hospitalized gastrointestinal cancer patients.
Now, these types of calls are extraordinarily difficult at any point in time. Unfortunately, last week, we had even more complicated factors to consider:
- We have maximized our capacity to see new patients. The wait list to see a gastrointestinal medical oncologist is very long. Patients with incurable gut cancers are waiting upwards of six weeks to see us. Patients decompensate while waiting to see us. Occasionally a patient will die before, or shortly after, their appointment date. These are unfortunate but real facts.
- We are in the process of converting our electronic health record system to a new-to-us system called ConnectCare. To stay afloat during this transition period, we have had to decrease the number of patients we see. Therefore, we currently have even fewer than usual slots to see new patients. This has resulted in an even longer queue than the status quo. We will not catch up any time soon.
Knowing these factors, my triaging colleague had legitimate questions for our group:
- Would people try to treat this man if he understood the risks of doing so given his clinical picture?
- If we would treat him, he would need immediate treatment. Is this an appropriate decision given the fact that our current wait list has us booking newly referred incurable patients into the middle of December?
- Is it ethical to see this patient, who would need inpatient support to initiate chemotherapy and who’s chance of being helped by treatment was minimal at best, when we continue to have to tell physicians we cannot move other patient’s outpatient consult up due to our maximized capacity?
These questions caused an astounding number of emails. It was encouraging to see the level of engagement our group had to try to come up with the best possible decision when there is no “right” decision to be made. It was also frustratingly heart-sinking to know we had to make a choice. The choices we make have tradeoffs. Our resources are stretched and limited.
The man we were being asked to see would not normally be well enough for treatment. We don’t expect chemotherapy to rescue this kind of patient from the cliff that cancer is pushing him over. Yet, there is generally a societal will to try. Rightly or wrongly, the expectation, even from medical professionals, is that all cancer patients should be seen by a cancer specialist and that most, if not all patients, would be offered treatment.
This man was very sick. He was much too sick to go home. He was too weak. He couldn’t take care of himself. He did not meet our usual fit-for-treatment bar. The best we might do for him was offer of a “Hail Mary”. This would entail:
- a transfer to a bed at our cancer centre,
- an extremely frank discussion, explaining that he is dying from his cancer, that nothing will change that, that we could attempt chemotherapy in the hopes that we might buy him a little bit of time, but it could equally cut his life short, and,
- if he consented, a chemotherapy trial as an inpatient.
Could it be done? Sure. Should it be done? Now, that is an entirely different and more difficult question.
Is this man’s cancer more important than someone who has been waiting to see us for six weeks? Does his young age play a role in how we decide? Should we accept the fact that with or without chemotherapy this man will die and focus our limited resources on someone else who we might be able to help more? Who might that be? What is more? How do we know? What if this man is the needle in the haystack and actually gets benefit from chemotherapy and ends up living many more months than predicted? What if trying chemotherapy lets him enjoy more time with his family and friends? Should we be the people to make that decision? What if we try chemotherapy but kill him in the process? How do we decide? How do we marry our decision to our unmanageable waitlist? The questions generated from this patient’s situation were painstaking. . . and they were endless.
In some ways, medical oncologists are gatekeepers through our triage process. Is this fair? Maybe, maybe not. But, if we do not protect our resources, who will? We cannot see patients who are inadequately worked-up, who don’t have an actual cancer diagnosis, or who don’t have treatment options. We often don’t have the ability to see patients who are too sick for us to be able to help or who would benefit most from palliative care instead of active cancer care. We simply cannot see every single patient with cancer. We just can’t. There aren’t enough of us. Sometimes, we can barely see the people we can meaningfully help.
Please know we feel the weight of this reality. When we finally get to the patients who have been waiting for weeks to see us, we see the frustration in their eyes. We see the heartbreak and exhaustion in their loved one’s eyes. I hope they see the frustration our eyes too. It’s there. We might have to hide it to protect our sanity but it’s there. Our frustration lives right there beside theirs, along with growing resentment and despair for the system we work in.
Author Notes:
When our emails were flying around last week, I knew I wanted to write about this. This kind of stuff eats away at my colleagues and me. It negatively impacts our wellness. It increases our burnout rate and decreases our job satisfaction levels. However, I was also scared to write a truthful, honest blog post about the struggles we face in triaging and seeing the patients referred to us. I’m not sure a public admission of our lack of ability to serve our patient population adequately or efficiently will sit well with the powers that be.
I asked several of my colleagues, “Do you think I could get fired for writing something like this?” How’s that for psychological safety in the workplace?!?! Unfortunately, it is difficult to not think of these things when we choose to speak up about these hard things. Calling attention to a continuously inadequately addressed problem in our healthcare system is daunting.
I saw a colleague of mine leave a new patient clinic room in frustrated tears a few days ago. The patient she had just finished seeing had waited five or six weeks to see one of us for consideration of palliative chemotherapy for his metastatic pancreas cancer. By the time this patient was seen that day, he was too sick for treatment. The patient and his family insisted that if he would have been seen five weeks ago, he would have been a treatment candidate. Perhaps chemotherapy could have extended his life. We will never know as we couldn’t see him then. We don’t have enough space or time or staff to see more patients. And so, patients wait.
My colleague came out of that room and said she was done. She was done trying to look patients in the eye without answers to their questions of why they waited so long to see us, why no one helped them in the meantime, and why they are now too sick to get treatment. There are no good enough answers for this man and his family.
Knowing patients die waiting to see us, having to look a patient in the eye to tell them there is nothing we can do, that things might have been different six weeks ago – these are parts of our job that wear us down. We lose bits of ourselves to this job. If something doesn’t change, we will lose more than just some of our bits. We will lose capable medical oncologists because we will all be burned out.
I am curious to know, reader, what would you have chosen to do about the man referred to us? How do you think we might be able to improve available cancer care resources while trying to maintain the wellness of our cancer care team?
