It’s ten o’clock on a Thursday morning, and as I leave the exam room where I’ve been trying to convince a patient with bad side effects not to abandon her course of radiation, I glance at my watch. Shit, my review clinic is already running thirty minutes late.
Ivy, the cheery, indefatigable nurse charged with making sure the clinic runs smoothly, thrusts a file into my arms and shoos me towards another room. Over her shoulder, I glimpse the irritated glares of patients in the waiting room.
“Review clinic” is the weekly session where I see all the patients currently receiving radiotherapy under my care. Its purpose is to assess their progress, help with side effects, and offer support. It’s held in a windowless rabbit warren of rooms adjacent to the radiation bunkers, and its dark and oppressive atmosphere have earned it the moniker of “the pit.” Despite Ivy’s best efforts, it hardly ever runs on time, partly because patients often require extra time to discuss new concerns or anxieties, but mainly because “the pit” serves as convenient landing spot for any patient, not just my own, receiving radiotherapy with an unforeseen problem requiring urgent assessment. It’s basically the ER of the radiation department.
Already this morning I’ve dealt with a man with lung cancer who’s coughing up so much blood he’s become anemic. I had to arrange an emergency transfusion. I’ve also seen a woman with breast cancer with new chest pain and breathlessness. I was worried her symptoms might herald a heart attack, so I wanted her seen in the emergency department. It took ten minutes of my time on the phone to convince the harried emergency doctor to see her.
On top of these situations, I’ve been interrupted by one of my medical oncology colleagues, an imposing man who never takes no for an answer, demanding an urgent radiation consultation on a patient of his. The doctor staffing “the pit” is an easy mark for such requests.
“Sure, send her over,” I said, as Ivy rolled her eyes behind his back.
Ivy gives me a gentle shove into the next room. Martha and Eric, a frail-looking couple in their eighties, sit huddled together. Martha, a stooped, grey-haired woman, is the patient: she’s getting a course of palliative radiation treatments for a recurrence of uterine cancer. Her cancer has spread to her lungs and liver, and radiation is being given to her pelvic area to control pain and bleeding from a large tumour.
Eric, her husband, sits beside her. He’s a thin, bald, elderly man, wearing wire-rimmed glasses and chunky hearing aids.
“Finally,” Eric grunts.
The tone of irritability in his voice catches me by surprise. Because radiation therapy is usually given over several weeks, I become very attuned to the personalities of each of my patients and their partners. Up to now, Eric and Martha have struck me as a very stoic, affable couple who were taking her situation in their stride. Today though, they both look tired and defeated.
“How are things?” I ask.
“Terrible. I’m at the end of my rope.”
Eric pulls a sheet of paper from a folder. As he hands it to me, his hand trembles.
On the paper there’s a list in scrawled handwriting:
MARTHA – CONCERNS
- No energy
- Stuffed up
- No appetite, can’t eat
- Sore back and shoulders
- Losing weight
- Coughing a lot
- Trouble walking
- Not sleeping
- Difficult to get breath
- Gets tired easily
- Swollen wrists and ankles
- No bowel movements
Oh no. A list like this can brings the review clinic to a shuddering, screeching halt.
I know it’s common advice for patients to bring written lists of concerns to the doctor, in case an issue is forgotten or overlooked. The downside is lists like this one often cannot easily be dealt with in a short visit. A thorough assessment of all of Martha’s problems would take at least an hour, probably more, and with many other patients waiting, I just don’t have the time.
Yet I know for Eric and Martha, each one of these problems is important. I’m on a teeter-totter familiar to most doctors as I straddle a pivot between giving them adequate time and attention while being mindful of those who are waiting.
I also know in a person with advanced cancer like Martha, most of these issues have no clear answers. I could subject her to a battery of tests, but I bet few if any of them will show a reversible cause for her symptoms. Her lack of appetite and tiredness, for example, are common symptoms in many patients with advanced cancer. I’d like to offer easy fixes, but it’s just not possible.
Eric and Martha study my face. I scan the list once more. I remember a technique taught me by a professor years ago. Prioritize.
“Okay, I see you have a long list of problems. Which of these is the most distressing right now?”
“They’re all distressing!” snaps Eric.
Okay, I’ll pick one. In a patient with advanced cancer, soreness might be the first sign of bone metastases – spread of cancer to the bone. Bone pain is something we might be able to do something about with a shot of radiation.
“Let’s start with the soreness. Where exactly is it?”
Eric indicates a wide swath of Martha’s back extending from the base of her neck down to her waist.
“Does it seem to settle in one area?”
“It’s all over,” sighs Martha.
“Can I have a look?”
Eric pulls up Martha’s sweater and she leans forward. I watch as her vertebrae slide beneath the paper-thin layer of skin on her back. It’s so delicate I’m afraid of tearing it. I press gently on her spine and ribs. There’s no area of discrete tenderness. I doubt she has cancer in her bones.
“It’s probably just arthritic. Do you have some painkillers?”
Eric pulls a spreadsheet from the folder. It’s a lengthy list of medications organized by strength, dose, and frequency. She’s already on two different painkillers.
“Ah. Is she taking these?”
“I stopped them. They just made her goddamn constipated.”
“Okay, but they will help her pain. I’ll give you a prescription for a laxative to keep her bowels moving.”
“Another medication for me to manage!” Eric huffs.
“In a week or two the radiation will kick in and ease some of the pain. Then the painkillers can be reduced.”
“What about the cough? The lack of appetite? The swelling?”
“I’m not sure…”
There’s a gentle rap and the door opens slightly. Ivy’s smiling face appears in the gap. She and I have an understanding if I get bogged down with one patient, she will interrupt and try to rescue me.
“Everything okay?’ she says.
“No,” mutters Eric.
“We’ll be done in a few minutes,” I say.
“I thought you might need some help,” says Ivy.
She opens the door wider, revealing Charmaine, a middle-aged woman with an angelic smile and golden tresses cascading on her shoulders.
“This is Charmaine,” says Ivy, “our palliative care nurse.”
“Palliative care? We’re not ready for that,” growls Eric.
Eric’s is a typical reflex reaction to the word “palliative.” People often confuse palliative care with terminal care. Palliative care is relief of symptoms and distress, no matter the phase of the illness. Because of this confusion, patients are often reluctant to see palliative nurses or physicians, who actually like to be involved as early as possible.
“She can be a big help,” says Ivy.
Charmaine directs her smile at me.
“Let me take over. Let’s have a look at that list.”
She reaches for the paper in my hands. I hesitate. Part of me is grateful for her help, but another part resists it. It isn’t just the peremptory way in which Ivy’s summoned Charmaine without informing me, it’s something deeper, a sort of hubris drilled into me from the earliest days of my medical training. I’m in charge. I can deal with this. I can fix Martha’s problems on my own. To suggest I need help means I’m weak, inept.
“We don’t want to see some nurse,” Eric says.
Charmaine sits beside Eric and takes his hand.
“You’re going through a tough time,” she says.
“You can say that again.”
“We all work as a team,” she says softly. “I’ll keep the doctor informed of our discussion.”
Yes. A team. In the relentless hurly-burly of a busy clinic, it’s easy to forget that and let my medical hubris surge to the front. In oncology, doctors are just one member of a team that includes nurses, radiation therapists, and social workers, each of whom brings special expertise to a patient’s care. I know Charmaine’s training and experience make her very well equipped to handle Martha’s symptoms, and I know she has a special gift for defusing anger like Eric’s. I also know if I don’t accept Charmaine’s help, all those patients in the waiting room will have to wait longer.
“Yes. You’ll be in good hands with Charmaine,” I say.
I hand the list to Charmaine.
“She’ll help you sort out your concerns.”
As I turn to leave the room, Eric gives me a sulky glare, like an angry abandoned child.
Outside, Ivy gently prods me towards the next room, and the clinic goes into high gear. In one room, a patient with trouble peeing. In another, a patient who demands yet another explanation of why there was a delay in her cancer diagnosis. And so it goes, room after room, patient after patient, with problem after problem: constipation, a rash, dizziness, bleeding, a swollen leg, diarrhea, headache, blurred vision, anxiety, insurance forms, and questions, questions, and more questions. How long will the side effects last? How do we know if the radiation has worked? When will I see you again, doc?
At one point Ivy and I take a brief break. As we sip tea in the workroom, and get caught up on our charting, I spot Charmaine leading Martha and Eric from the exam room. Wow. They’re chatting amiably like newfound friends met on a cruise ship. Eric sees me, gives me a warm smile and a thumbs-up sign.
Finally, the last patient leaves, and this stuttering, stop-and-go carousel of a clinic grinds to a halt. Our baskets of cheeriness, kindness, reassurance and goodwill are empty.
But they can never be, fully. I glance at the clock. It’s twelve fifty-five. In five minutes, Ivy and I are due in our Thursday afternoon clinic, where we see brand new patients referred for radiation consultation. We have five minutes to get ready. Ivy and I head to the coffee shop in a corner of the waiting room.
As we wait for our sandwiches, Ivy gives me a gentle nudge.
“Thanks for letting me bring Charmaine in.”
“Thank you. She really is an angel.”
We gaze at the line of patients at the reception desk waiting to be checked in for the afternoon clinic. These brand new cancer patients will turn into treatment patients, who will in turn become review patients.
The cycle never ends.