Oncologists are tethered to the insatiable emotional demands of a very needy patient population. While appealing to one’s vanity, these demands can consume an idealistic oncologist who is incapable of compartmentalizing life’s priorities.
Being a physician is a privilege that involves sober responsibilities—all magnified in cancer victims. The typical patient is frightened, vulnerable, and threatened to the core. They, justifiably, expect compassion, a commitment to excellence, a seriousness of purpose, and an ethos of integrity and humanity from the cancer team in general, and especially the oncologist.1
Being an oncologist involves a life with little room for frivolity or casualness, and dilettantish physicians who value style over substance should avoid the oncology specialties. Aspirants must realize that to perform in this arena is neither an ordinary responsibility nor a casual commitment; none in medicine should be, but with cancer, there is usually heightened passion and drama. What is euphemistically labeled “the cancer experience” can be an extraordinary test for physician and patient alike.
With an absence of an emotional commitment on the part of the oncologist and a failure to lower self-imposed protective barriers, both the patient and the physician suffer. Those considering oncology as an avenue of study should, therefore, be self-analytical in this regard: If one is unwilling to commit emotionally, a psychologically less demanding specialty should be considered.
With an absence of an emotional commitment on the part of the oncologist and a failure to lower self-imposed protective barriers, both the patient and the physician suffer. Those considering oncology as an avenue of study should, therefore, be self-analytical in this regard: If one is unwilling to commit emotionally, a psychologically less demanding specialty should be considered.
The fears of these patients range from low grade to paralytic. Whether cured or not, the cancer victim often dwells on a kaleidoscope of perceived threats—financial matters, family well being, loss of dignity, pain, deformity, dependency with loss of autonomy, being abandoned and alone, and obviously death itself—all of which can be catalyzed by an emotionally uninvolved cancer team that minimizes these deeply rooted concerns. The take home message is that needs differ from one individual to the other—some patients require more attention, others less, and if a physician does not have the flexibility to cater to this diverse emotional appetite, they should work in another specialty of medicine.
In addition to compromising their own professional fulfillment, the unwillingness of an oncologist to contribute to the emotional equation between doctor and patient often stymies the latter’s ability to develop hope. This is no small consideration, because in the practical world of cancer medicine, there is nothing psychologically more valuable for a patient than hope—but only when it is realistic and honest. Better for the physician to be noncommittal than to encourage false hope, which is deceptive, and perhaps even a betrayal of sorts.
Hope, Redefined
A physician’s balance between empathy and guidance throughout the cancer journey is the sine qua non of good leadership. Good doctor-patient relations come out of honest and forthright dialogue that is based on realism rather than paternalistic avoidance of unpleasant news. Such a relationship begets trust, which in turn begets acceptance of the inevitable as the patient is led to the conclusion of care, whether it is improvement or death. In order to accommodate this paradigm, however, hope must be redefined. Let me explain just what I mean.
Too often, physicians misunderstand hope by thinking only in terms of cure or remission. This flawed concept is common in the ever-optimistic oncology community. Hope can also be for less ambitious goals: for a good death, for time to mend interpersonal bonds that are in disrepair, for the resolution of feelings about divinity and a life after death, and, yes, for comforting loved ones who will be left behind. Never mind what the medical team deems important, the patient should be the author of the new standard, and it is the job of the physician to incorporate that into the dialogue and the relationship. As a result of trust and creditable dialogue, a patient should be able to completely rely on unselfish guidance in making practical choices, especially at the end of life. In this state of mind, one is better able to find closure in life and an acceptance of death, both of which add tranquility to the final stage of one’s existence.
Oncologists, even those with the best of intentions, too often fight the battle to excess and, in an effort to do something, use up valuable end-of-life time and resources. In this high-tech biomedical era, when the tantalizing possibility of miraculous cure is dangled before patient and family, the temptation to see therapeutic hope is great, even in those situations when common sense would suggest otherwise. If there are incentives for oncologists to try more treatment despite minimal odds for success, why can’t the reverse be true; that is to say, why can’t there be disincentives to go for that long shot? In deciding how much treatment is enough, the cancer physician must repeatedly address the question of what is in the best interest of the patient; that is to say, he or she should act with beneficence. Even if what is done turns out to be the wrong strategy, if the motive was for the patient’s benefit, it is morally defensible. This sounds simplistic, but in fact, pride, vanity, and perhaps even unrecognized psychic forces within physicians can complicate a patient’s life and death. Like other talented and intelligent people, physicians are not immune to the insecurity that seeks reassurance of their abilities, and whether realized or not, part of their self-image depends on success and failure in patient care.
Additionally, many physicians are extraordinarily competitive, and the instinct to “fight on” can be strong. Some oncologists seem to feel obligated to explore every avenue of treatment, no matter how unlikely the benefit. Aside from this being void of beneficence, it is financially an unsupportable strategy. My plea in this regard is for an early reality check, since the treatment decisions made near the end of life are prone to propel a dying person in a senseless direction.
A vulnerable cancer patient’s reliance on his oncologist can be extraordinary, and it is not unusual for the patient to look to that physician for advice and counsel on a variety of health-related matters—psychiatric, nutritional, and some unrelated to the primary disease of concern. This role of the “perceived expert” on all matters medical must be handled with tact, realism, humility, and always with graciousness. It’s a simple thing to disavow expertise but, while doing that, to show obvious interest by offering suggestions on some questions and promoting appropriate referrals when indicated. In this day and age of subspecialization, it is important to remind ourselves that we are still physicians and we should attempt to care for the “whole patient.”
End of Life
Importantly, during the final approach to death, the oncologist is often the go-to person for a variety of matters. While many patient concerns can and will be handled by the supporting team, the majority of the questions asked are well within the purview of a mature and receptive oncologist. The patient and family should feel as if their physician is involved with and overseeing almost everything that’s happening, and importantly, the oncologist especially should welcome discussing death with a cancer victim. From a patient’s perspective, who better to talk to about death? With a well-crafted discussion, there often follows an element of surrender to the reality of death, understandably sometimes accompanied by anxiety, but usually without terror. More often, the surrender is followed by acceptance and a sense of calm—in the vernacular of the hospice philosophy, a tranquil comfort, rather than turbulant and rampant fear of the unknown. This passage from realization to acceptance is essential to the willingness of a patient to cease trying to hold their mortality at bay.
What ought a cancer patient reasonably expect of the system, the cancer team, and, especially, the cancer physician? What ought a cancer physician be able to expect of the patient? What are the physician’s responsibilities to the patient? To the family? How much information about the disease is enough, how much is too much, and, importantly, how much is too little? Where do optimism and encouragement end and the gravitas of realism begin? How specific and how graphic should the doctor be? Is pessimism allowed, and, if so, should it be shared with the patient? How forcefully should the case be made for the recommended treatment; that is to say, should the physician attempt to alter the patient’s search for autonomy when they are disinclined to follow physician recommendations?
Because of the natural instinct for self protection, is it justified for the cancer physician to remain emotionally detached, and in doing that, fail to provide an intensity of feeling that might be more helpful to the patient during treatment and even on into the dying process?
What is the cancer physician’s role when treatment fails or, due to the advanced state of the disease, when no treatment is given? How important are quality of life and quality of death and, specifically, what is the cancer physician’s role in the dying process? Is death solely within the dominion of spiritual forces, or is there a place for the physician as a taker of life, that is to say, the catalyst to death. If not an active player, should a physician even introduce the possibility of patient-induced death i.e., suicide? The oath that we have lived by clearly says “no” to the taking of life by the physician, but should this part of the oath be adapted in search of modern relevance? That certainly has happened in several European countries and in four U.S. states (Washington, Oregon, California, and Montana), in which there are laws condoning varying degrees of physician involvement with induced patient death, a high percentage of which are related to uncured cancer.
Finally, because of the natural instinct for self protection, is it justified for the cancer physician to remain emotionally detached, and in doing that, fail to provide an intensity of feeling that might be more helpful to the patient during treatment and even on into the dying process?
These questions and many others randomly flow through the lexicology of cancer management. The answers often cannot be rigid because so much of human nature varies from individual to individual—patient and physician alike—and there should be a somewhat tailored approach for the individual patient; however, a consistent pattern should underlie it all, and the standards by which these questions are answered should be established by a medical profession that understands and advocates what is right as opposed to what is wrong.
Dr. Sessions is professor of otolaryngology at the Medical University of South Carolina in Charleston.
Reference
- Sessions RB. The Cancer Experience: the doctor, the patient, the journey. Chapter 2. Lanham, Md.: Rowman Littlefield; 2012.