Propelled in part by the unalloyed hopes I cultivated in medical school, I got through my internal medicine residency training largely free of questions about medicine’s limitations. Ailing strangers entered my life in the hospital and I helped them leave nearly restored to health. This was exactly the kind of physician I expected to be. That changed when I met Janice Wilson during my current fellowship in cancer (hematology and oncology). Janice (not her real name) became pregnant with her first child near the end of 2014. A few months before her baby’s due date, her right breast began to feel different and she detected a small lump. At first, she shrugged it off, thinking it was part of the normal changes that occur during pregnancy. But the lump continued to grow. Her obstetrician noticed it during a routine examination. An ultrasound revealed a mass with features that suggested cancer. Janice had a biopsy performed the day before she delivered her baby. Other tests followed quickly, with devastating news: The cancer had spread to her lungs and liver. Chemotherapy was aimed at slowing down her cancer and improving her symptoms, but it was too late to eradicate it. At a time when most new mothers were learning how to breastfeed, Janice was wrestling with the reality that she wouldn’t be present for her son’s most basic milestones. A little more than a year later, cancer had spread into Janice’s brain and throughout her abdomen. The ravages of the disease and the sedating effects of the high-dose opiates needed to control her pain had made it difficult for Janice to think. Her husband and sisters had become responsible for making further decisions regarding her care. When I entered Janice’s room for the first time, it was to start a discussion about hospice care and the futility of further therapy. Her family wasn’t interested in that. Instead, they wanted to talk about new treatments for her. After all, Janice had cooked Thanksgiving dinner for the family only weeks before and they were set on restoring that person. I couldn’t blame them for trying to find some light in a situation that was hurtling towards complete darkness. But I couldn’t give it to them. As much as I wanted to offer even a modicum of hope, I continued to push forward with the conversation about palliative care. It was as if the unceasing suffering of cancer that I had witnessed in the first few months of my fellowship had hardened me. One purpose of medical school is to inspire action in the face of daunting illnesses, and to meld that action with compassion and humanity. The medical knowledge accumulated from textbooks and experience is intended to embolden a physician as he or she ventures into the realm of disease. All of this is designed to help physicians provide their patients with refuge and reassurance when faced with a malady like cancer. Yet standing there in front of Janice and her family, everything I knew about her cancer stopped me from offering them any possibility for further curative treatment. That stood in stark contrast to what I thought was my principal task as a physician: making things better again. I felt like I was giving in to Janice’s cancer. But what I was really doing was finally acknowledging medicine’s limits and refining my conception of a healer’s role. As much as physicians are trained to fight, we must also learn acceptance — acceptance of the moment when further interventions will be futile; acceptance that letting go is not an admission of failure. Caring for Janice Wilson will always be for me a vivid reminder that medical care must include discussions about the end of life. The realization that no treatment could halt Janice’s rapidly declining health was devastating for her family, who had resolved when she was first diagnosed to support her courage and her desire to live until the end. I was humbled by my acceptance that medicine could do nothing for Janice than keep her comfortable and help her achieve a peaceful death. Without that realization, though, I could never have helped her family make the difficult decision to pursue an end of dignity and comfort. I learned from Janice and her family what thousands of physicians before me have learned at one time or another — that medicine doesn’t always have to achieve a cure to make things better. I’m just fortunate to have had this reckoning so early on. Source
