A Doctor's Attachments

The week before, I was spending my last day in Portugal. That was a wonderful ten days. It was a period of complete vacation mode. I didn’t have to enroll or register anyone. The only commitment was to enjoy my surroundings and company.

Now back at work, an essential part of my occupation as a physician is to enroll patients into a possible future regarding their health. As a medical oncologist, I have to paint a picture of what that future may look like. Ideally, I can attempt to guide them through some temporary toxicities to the possibility of a cure. In other situations, I may describe treatments which won't result in cure but may improve the quality of their life for some unknown duration of time. And of course, at times I have to paint a grimmer picture of treatments unlikely to help or potentially making their lives more miserable yet leave the hope that supportive care may make whatever time they have better. Then I leave it to the patient to decide if they'll accept the possibilities I have outlined. To maintain my own well-being, I cannot be attached to either their decision or the potential outcomes. I keep myself grounded by the idea that I am committed to them as human beings whom I pray the best for. I will admit that this has become more difficult as I am now taking care of patients of my own age or sometimes younger.

Returning now, I am especially conflicted with the ability to avoid attachment to a case which has evoked a lot of biases I did not realize that I carried with me. Shortly before I left on my vacation, I met a young woman of South Indian descent who had just been established with a cruelly terrible diagnosis. This woman, about ten years younger than me, was a first generation American born of a family from south India with a physician for a father. This is the same category as myself. My father had arrived in the US at a similar time, and similarly to her father, had acted as a bridgehead in his community to help other young Indian physicians to establish themselves.

So, my first unexplored bias. I realize that it is a hugely gross generalization, but I assume that South Asian "kids" of my generation behave smartly and logically as our parents generally push us into the sciences as a career. About a year prior to meeting her, this woman was identified as having a large low-grade tumor in her belly. Logically, she would have just had it taken out of course. Stunningly- to me- she did nothing about it. She trusted that it would slowly "just go away". What doctor’s kid thinks this way, I incredulously wondered.

Second unexplored bias: I am going to medically treat a young woman in a severely aggressive manner, more than I do many of my older patients. When I first met her in her hospital room, I looked at her CT scan and noted that the original tumor had metastasized to multiple locations throughout her liver. Normally I will tell a patient that, and will paint a picture of a cancer which I cannot cure, but that I would hope to get it into remission and improve their quality of life. I did not have the heart to say this to her in that hospital room. Later that week, I did tell her in my office, and she told me that she had already figured that out after googling it. Still, even after admitting the incurable nature of the cancer as it was to both myself and to her, I came up with a nearly maniacal plan to manage this cancer. I was going to treat her with an aggressive chemotherapy agent to try to shrink the primary mass as well as the liver lesions. I then pictured that the tumors would shrink enough to cut out the main mass then follow that with localized radiation treatments to the liver lesions. The main tumor would now be gone, and the liver lesions controlled without any spread of the tumor elsewhere. All the radiation treatment would likely cause such severe damage to the liver, however, that she would need a liver transplant. And voila! Cure!!! What young, intelligent Indian woman with four children would not jump at this possibility! Right?! I was enrolled. Her father was enrolled. She would think about it! What?!!

The day before I left on my vacation, she was meeting with some physicians at a highly regarded academic center. I was excited for this. Surely, they would also confirm that this idea of mine made sense. Just before I left, my office told me that she had called and canceled her appointment with me. I was actually okay with that; they must have offered her something better.

When I came back, there was a note on my desk to call this academic physician. He had agreed with my chemotherapy approach, though not the part about radiating the liver to failure and then transplanting her. By the time I came back from vacation, I had become more rational and knew that was the right decision. He was calling, however, because she had declined to follow up with them as well. He asked if I could reach out to her. With trepidation, I dialed her number. She was screening her calls but picked up when I announced my name to the system. She was calm, collected, and oh so young sounding. She said that she had always lived her life without taking non-natural substances. She tried to protect her body from toxins. She had never smoked, drank alcohol, nor taken any drugs. She did not want to introduce toxic chemicals in her body now. She was going to trust in God. This time I listened to her calmly and really tried to connect with who she is, not who I thought she should be. I explained that I would like to be the physician who is committed to her living the life she wants, no matter how short or long it may be. I look forward to being there for her and her family. And I look forward to being that for all my patients, no matter their identity going forward.