Tuesday, April 27, 2010

Physician, be thyself

I'm doing one of those things where I sit down and start writing but don't really have a god sense of where this is going to end up going. One of those times when writing is its most therapeutic for the writer because it gives a chance to explore thoughts, feelings, that maybe the writer didn't even have a full knowledge of even being present, much less any understanding of what they mean. So, here goes.
What got me started on this thought process, or more, brought it to the forefront of my mind again, is one of the patients in the hospital.
This young man woke up those morning with two arms, two hands, two legs and two feet.
By this evening, or maybe even by now already, one of those legs and one of those feet are gone.
His leg has been amputated from a point above his knee in order to save the rest of his body from the cancer in that leg. An aggressive cancer. A cancer that still has a fairly disappointing rate of long term survivorship, even with the most advanced and best care.
For the past several weeks, this young man has endured chemotherapy to try and make the tumor as small as possible, as inactive as possible. One of the goals is to be able to stop the tumor's ability to generate its own blood supply - one of the cruel and clever things these beasts of cancer do is to release hormones that tell the host's body to make a rich supply of blood vessels and to make all those blood vessels become direct food lines to itself. Like a dictator country with no oil of its own forcing the inhabitants of its neighboring and oil rich country to build oil lines into the dictating country. The human body, as amazing as it is, responds vigorously to this hormone signal and does its job - it makes blood vessels, and this is one of the ways a tumor becomes parasitic, opportunistic. Before a surgeon goes into the area of the tumor, a goal is to make sure that this area pumping full of blood has been reduced to a trickle.
Another goal of the chemo is to try and ensure that any small, even microscopically small, metastases from the initial large tumor have been made as inactive as possible.  If a patient is giving up a limb, we hope it isn't so that in a few weeks a new tumor, in a part of the body not easily removed or operated on,  will enter a growth spurt. Scientists have speculated that another genius of the tumors is that the largest tumor often releases a hormone that acts on other tumor cells in different parts of the body to make them less active. It tries to inhibit its competition, so to speak. Sometimes when a dominant tumor is removed, and that hormone is no longer being made, the previously inactive tumors start to take off. Cancer is a strange, mystifying thing...
So anyway, this young man has gone through weeks of pre-operative chemotherapy, or as we like to say in fancy terms, adjunctive chemotherapy. Last night he had a hospital room full of friends and family members, gathering around him, supporting him, and I'm sure most of them, especially the adults, wishing that they could take his place tomorrow, wishing they could give up their leg, their adolescence and young adulthood so that this boy could go back to his old life, be free of cancer and the anxiety, fear, frustration, pain that it brings.
None of them can do that for him, though, so bright and early this morning he was taken to the operating room, where one of the nation's most skilled and incredible orthopedic surgeons will remove his leg, his cancer, do her part to give him more years of life and happiness.
I don't have an established relationship with this patient like I do with some of our other patients. I didn't have conversations with him about how he has been feeling going into surgery. I can't tell you he was scared, or hopeful, or acting brave, or any of the things I might be able to say if I knew him better. All I can say is the obvious, and that is: it isn't fair.
The other thing I can say is something many doctors have though to themselves when taking care of patients in dire circumstances: I don't know if I could do it.
This isn't just referring to whether or not we feel like we could handle having a bad disease or diagnosis. This isn't about saying we aren't sure if we could put on  a brave face, have a good attitude, be a "good patient."
What I mean when I say it is different.
I don't know if I could allow my leg to be removed.
I don't know if I could endure chemotherapy.
I don't know if I could spend days, weeks, months in the hospital going through treatments, trying to "get well."
I don't know if I could sit in a bed every day while nurses, doctors, physical therapists came into my room trying to help me get better, when inside my mind, my highly educated mind, I know that my chances of survival or at least a recovery with any quality of life, might be minuscule.
I don't know if I could take those chances.

And this makes me question so many things about myself.
Does it make me superficial to think that I wouldn't be happy living without a leg, or an arm?
To that end, is there a part of my body I would be willing to live without? And does it come with qualification? Like, I would be willing to live without my arm only if it meant I got to live at least 7 more years? 5 more years? 3 more years? What if it was only one more year? Is there a length of life I'd be willing to give up for that arm?
What about my vision? My hearing? What if I had to have a colostomy? What if I was paralyzed?

Does it make me selfish?
There are times when I have thought that I would rather die and leave Henry without me than to endure some of the treatments I have watched my patients endure. If I KNEW I would live, KNEW I would be able to be a god mother, a good wife, a happy person, then it might change my mind. The fact is, though, in medicine, like all of life, there are no guarantees - and I'm not much of a gambler when it comes to some of this stuff.

Does it make me a hypocrite?
I take care of people going through these treatments, encourage them, try to support them. Sometimes when I'm with them, in my mind I keep thinking,
"I would never put myself through this." And there I am, talking to them about their schedule for chemotherapy, procedures, injections, surgeries.

All of us have our own limitations that only we can fully know or try to understand, and of course none of this knowledge is complete until we actually land in the place.
If I was diagnosed with cancer tomorrow, my whole attitude might (would most likely) change in ways that sitting here today, in the sunshine with the warm spring breeze on my face and my sweet little boy sleeping upstairs, I could never predict.

So why even bother worrying about what my reaction might be?
I think it's something we all have to think about, no matter the specifics of our life. Not just doctors, nurses, health care workers. It's something all of us need to think about at some point (this will be another blog).
For those of us in this field, though, I think it is part of our responsibility to those we take care of to put ourselves not only in their shoes, but in their bed. And not with their family surrounding us, but with our families surrounding us, our friends their giving us support (or not giving us support as the case may be - think about it).
The old adage* is "Physician, heal thyself." To that I like to add, "Physician, know thyself." So, this introspection will go on for me, likely until the end of my life, helping me try and find my place in this world, in this profession, in the hearts of those who love me. Part of the experience of being human, isn't it?

*I could have sworn this was a quote from our old friend Billy Shakespeare, but my googling today couldn't help me locate the exact source. Can anyone help me out here?