Essay by Noel P. Pingoy, MD Posted online 12:09 AM, November 21, 2017; First published in September 2017
“For his anger endures but a moment; in his favor is life: weeping may endure for a night, but joy comes in the morning.” - Psalms 30:5
The terse ringing of the phone, followed by an apologetic voice of the nurse at the other end of the line nudged me to a befuddled wakefulness, and I found myself grousing under my breath
to some muted annoyance, knowing that the plans of the day have been brusquely thwarted by the all-too familiar turn of events. What had been mapped out as an easy, sunshiny, warm-as-a-pillow day, the incessant rain finally bowing down to the sovereignty of the sun after an almost 36-hour romp in southern Mindanao, turned into a mad rush to the hospital to join a grieving family at a matriarch's deathbed. I had earlier envisioned a really serious workout at Arcadia after almost 3 weeks of hebitation at St. Christopher’s Hospice in subzero Sydenham, where heated gyms were worth a fortune and a limb. A trip to the mall for some bargain books hunting would have completed the morning. But in a few minutes I was already navigating through the swelling crowd at the hospital lobby. And at the female medical ward, I was witnessing a familiar tableau wherein the grief-stricken spouse feigns a valiant façade in the presence of the similarly devastated family members.
Mrs. Santiago was one of my favorite patients, a kindly and cheerful grandmother with inoperable cancer of the liver. CT-scans have revealed metastasis to the omentum, the regional lymph nodes and the posterior segment of the right lower lung. She seemed stable during the last two months, her clinic visits were punctuated by her infectious laughter and gentle demeanor. But she had become jaundiced, given to occasional bouts of disorientation and constantly complaining of severe right upper quadrant pain. I believed it was time for her to return home now. And there I was, struck in a sort of hapless legroom of vacuous presence, barely moving, embarrassed at my own helplessness, a thousand and one thoughts racing through my mind, and still not finding words that may be fitting enough to break the ennui of whatever it was that flooded the room like the tears that stung each face around me.
I would have wanted to flee the scene and find refuge in the nurses' station, amidst the flurry of the endorsements of the ending shift, the early phone calls from the laboratory, and mainly from the fortress of the hanging metal charts that serve like a wall between the practice of Medicine and the reality of its failure to save another life.
The chart held the key to each patient's lifeblood while in the hospital: the patient's medical history, the diagnosis, the laboratory results and the management plans, each carefully worded in the most technical of language. The metaphor of a slipping life that is encapsulated in terse, technical language over sheets of white and pink newsprints did not escape me, something that unnerved me even more.
Such is a medical oncologist’s life, always hanging on a flimsy thread that separates life and death, redemption and loss, joy and grief. During my first five years of practice I was totally unprepared for the world that I was eagerly looking forward to dwell in after training. The upsurge of scientific knowledge has changed the landscape of Medicine, and the hapless clinician sometimes finds himself drowning in the overwhelming immensity of information that he has to cope with if only to keep himself up to date and offer the best possible therapeutic possibilities to his patients. Leroy Hood wrote at Newsweek about how the not-so distant future of medicine will look like. “Over the next two decades, medicine will change from its current reactive mode, in which doctors wait for people to get sick, to a mode that is far more preventive and rational,” he postulated. He calls it P4 medicine - predictive, personalized, preventive and participatory. Because of the Internet, Filipino doctors will need to deal with patients who have an enormous amount of information at their disposal. And doctors will probably need to deal with maintaining wellness more than with disease.
For the Filipino doctor, these changes require heedful efforts to update himself with the latest developments in diagnostics and therapeutics. He can no longer afford to be complacent, to take things lightly, as patients and their familiesdemand up-to-date information and no less than a thorough elucidation of the many facets of diseases and treatment. But beyond being competent, the Filipino doctor needs to cultivate compassion as a way of life. How he treats his patients, colleagues and the rest of humanity in general is reflective of the nobility of the medical profession. A doctor cannot ignore the basic tenets of human relationships and respect for others in his attempts to advance his practice. Commitment to the highest levels of professional and ethical standards is a doctor’s sacred obligation to his patients and their families, to the profession, to society and, above all, to himself. But beyond mere clinical competence, I realized that my training did not prepare me well for the equally crucial facet of doctoring as it somehow failed to address the human and psychosocial aspects of caring for people with a disease as dreadful as cancer. I am grateful to my consultants who taught me the essential knowledge and aptitude to treat cancer.
Evidence-based medicine with its emphases on unassailable research designs and protocols, on highly sophisticated machines and tests in the medical armamentarium, and on thorough analyses and peer reviews became our mantra, meant to convince patients and their families of gold standards and best clinical practice guidelines as well as to set the profession apart from mere quackery or folk remedies. Evidence-based medicine has become the benchmark by which doctors protect their patients and the profession from the immoderation of traditional healing practices, from the brazen insensitivity of a small number of colleagues in the profession, and even from “anecdotal” medicine.
Armed with the best training a doctor could possibly acquire, I went home eager and optimistic only to realize that even the most sophisticated targeted therapies and nano-particle designer drugs were not enough to address the emotional needs of the patients and their families. Even the best and latest discoveries that conferences around the world have been enthusiastically talking about could not wholly assist the patients in accepting the truth about their diseases, in making rational choices on treatment and supportive care, and in adapting to the myriad spectra of signs and symptoms that breast cancer or leukemia or prostate cancer brings.
Dr. Lidia Schapira from the Beth Deaconess Medical Center in Brooklyn offers a solution that integrates the “disease model,” which embodies the medical diagnosis and the pathophysiologic mechanisms of the disease, with the “illness model,” which looks into the patient’s conceptual and experiential knowledge of cancer. She wrote “Training should be flexible and creative enough to allow us to weave there two perspectives into a unique narrative that completely captures the reality of each clinical encounter.”
Medical futility, guilt, apathy and world-weariness are ruthless certainties of practice that intimidate every medical oncologist. When I first dreamed of being a doctor, I pictured myself like I was Superman who is able to save the world from aliens and predators and resentful Lex Luthors, and even find time to rescue a hapless kitten up the tree. The road I’ve taken seems remotely detached from the picture-perfect reality TV fare especially when one thinks about the cold facts: that more than half of patients are usually seen in the terminal stage, that forty percent of Filipinos die of cancer without medical attention, that one out of two Filipino cancer patients succumbs to the disease within a year, and that most Filipinos can hardly afford the basic treatment. In this setting, a medical oncologist is constantly besieged and sometimes crushed by tsunamis of bad news, treatment failures and disease recurrences, patient suffering, financial shortfall and untimely deaths.
Most people see doctors as caring, compassionate and honest professionals who are able to guide, educate and comfort them with their knowledge and training during the most trying times. Sometimes they forget that doctors are people too, given to their own flaws and prejudices, judgments and designs for self-preservation. Physicians as no less human than the average José’s and Maria’s, in fact many of them are drawn to the profession through their sensitivities to the needs and sufferings of others. Unlike the other subspecialties like cardiology or pulmonary medicine, the care of cancer patients demands certain fortitude to get over the fact that a large proportion of patients will continue to die despite the best efforts and greatest intentions.
Everyone should realize that the care of each cancer patient is best shared by a multi-professional team, one that is competent, compassionate and committed to the highest standards of ethical practice, bereft of personal avarice and professional bigotry, whose members respect the compass, circumference and complexity of the many specializations of human care and of the wide-ranging fluxes of concerns that an individual patient and his family go through. The pathologist, the surgeon, the medical oncologist, the radiation oncologist, the nurse, the social worker, the psychiatrist, even the spiritual adviser all share the burden and the joy of a truly nurturing and supportive relationship adeptly and consider each member of the team as a peer rather than a mere subordinate or a token “technician.” That a fellow doctor once used the word in that context still, even until now, horrifies and saddens me; I had to remind him it is disrespectful of people.
Patients and their families should be well aware of their right to a second opinion, or a third, or even more. A doctor who is easily offended by a patient’s tactful request for an opinion with another physician is to be avoided; beyond dodgy personal issues like inadequacy, insecurity and insensitivity belies a particular physician’s need to exert his egocentric view of the world at large.
But patients and their families should also be cautioned that a second, or third, opinion is not necessarily the better one. Prudence and careful weighing in of information, together with the doctor’s demeanor, are vital for a nourishing relationship in the cancer setting.
Any professional who claims to be able to handle all the tasks as proficiently and as carefully as a multidisciplinary panel must be viewed as delusional, dangerous and detrimental to the patient’s well being given the myriad needs and issues of cancer patients. A doctor once told me he was trained to believe that the multidisciplinary approach to cancer care does not work in the Philippines. “I can perform the endoscopy myself, send the specimen to the pathologist for reading, operate on the patient and give adjuvant treatment like chemotherapy,” he boasted, “I can do these tasks all by myself, I don’t need to refer to someone else.”
The need for a team approach should at the very least be discussed with the patient and his family; the final decision to pursue referral to other professionals is the patient’s domain. Another human being’s pursuit of happiness, one that is free from sickness, separation, pain and even the quotidian disquiet of everyday life can only be decided upon by the informed-person himself. Neither the surgeon, medical oncologist nor other clinicians can assert moral ascendancy over the other colleagues, over their patients and loved ones, and simply, over life itself.
Who argues for the patient when something out of standard care is proposed? I heard one doctor once lectured on “Why believe on guidelines? Don’t follow clinical practice guidelines when you have your winning ways!” Who ensures that checks and balances are in place? Who guides the patient and his family sort through the many data that are spread out before them? Who helps the patient navigate through the maze of the latest clinical evidence in diagnostics and therapeutics considering that cancer care is easily the most dynamic among the fields of Medicine today? Who sits down with the patients and their families to hold their hands while discussing the validity or futility of a treatment option when doubt sets in? Who advocates for the patient when medical prudence and ethical diplomacy are blatantly swept under the rug and deliberately ignored? Who referees for the family when medical people quibble over pedantic issues like comfort zones, personal and professional turfs, institutional and organizational quirks, even joyrides of the ego? Who stands beside the patient when the assholes of this world assert their winning ways? And who stays with the patient and his family until the very end?
Some of my older colleagues took Medical Oncology as a career path with a sense of optimism about the future and about the promise of medicine to alter the natural history of cancer from a debilitating and fatal illness into a controllable chronic disease for many patients. Most of them are dreamers, others are explorers, and a few even consider themselves dragon slayers. Most medical oncologists in my generation on the other hand often view the subspecialty as an opportunity to look after the needs of people during periods of intense vulnerability. Of course, complete response is something that everyone yearns to achieve, no matter how elusive it might be. Paradigms have shifted actually. While cancer physicians breeze through the day with unsullied dedication to the profession, they often have little time to debrief themselves, to process their own sorrow about a patient’s suffering and death. The next patient simply needs his time. Whatever time is left of him is appropriated for red tape, guidelines, administrative matters and the fear of a litigious environment. Thus, personal unresolved emotions are abandoned in favor of patient care and institutional demands. As in many of life’s invitations, these rain checks are bound to stack up, drench the wretched doctor with languor and disquiet, while allowing these unresolved emotions to overflow. When compassion is exhausted and burnout is at work, the doctor becomes a callous, distant and technical creature of discomfort, on the verge of an emotional breakdown, set to burst into smithereens at the slightest provocation. Then he realizes he had not acted on his best judgment and consequently feels guilty about everything. And the vicious circle ensues.
Every medical oncologist must recognize these issues in order to achieve renewal and well-being. There are approaches through which doctors in danger of burnout could channel their emotions; journals speak about limiting workload, designing flexibility in scheduling, even developing coverage systems with colleagues. Other avenues include pursuing self-care activities, cultivating personal relationships, developing a life philosophy that promotes balance between personal and professional lives, and engaging in spiritual practices.
But I realized that I need not venture farther than my own office. I now find joy in every encounter with the patient and his family, realizing that each meeting shapes not only their lives but also mine. Each session has taught me that the fundamental tools in my trade are my senses: sight, hearing, touch. There are times when I am thankful to the late Dr. Alex Panuncialman, former dean of the Davao Medical School, for instilling in every medical student the value of fortitude, of looking beyond mere anatomy and physiology. With the most trivial things in life, he taught me how to look closely, to listen intently and to feel deeply, which are what he called the basic skills of a doctor. In talking with my patients and their families I do not simply give medical options and technical expertise, but I also give of myself. These sessions that sometimes last for hours have a clever way of teaching me how to be truly human, how important human relationships are, and how powerful human connections can be.
But most colleagues often ask, Don’t I ever get tired of listening to heart-rending stories? Of course, I do. Over the short clinical practice I have, I realized the power of telling stories to overcome a bruised heart, to calm down a raging anger and confusion at the mere thought of cancer, to lighten another’s husband load while seeing his wife slowly waste away, or to simply take away a patient’s mind off the distressing cycle of pain and medication and pain over and over. It pays to spend time and simply listen. Sometimes words are not even necessary, the doctor’s presence and touch can mean a million things. Holding a hand and simply not letting go are in my experience more than enough to reassure the patient that he is cared for. Authors simply call it the gift of presence.
The Dalai Lama once wrote “In the practice of healing, a kind heart is as valuable as medical training, because it is the source of happiness for both oneself and others. Not only do other people respond to kindness even when medicine is ineffective, but cultivating a kind heart is a cause of our own good health.”
I left the hospital long after the ink had dried on the requisite papers, thinking about the happy times I had with Nanay Santiago. I remember how her face would light up when she spoke of her grandchildren. Oh, she was lovingly proud of them. It was as if the room radiated with so much warmth and joy every time she remembered them. With heavy feet that seemed like tons and an even heavier heart I muttered a silent prayer for her, thanking her for her trust and goodwill.
Then I remembered about her other passion: gardening. She would often gush about her euphorbias and san franciscos before a consult ends. “Takes the mind off my cancer, Doc” she would nonchalantly say. And as if a salve was pressed on my heavy heart, even in death there are lessons that patients teach me.
On my way to the hospital after that interrupted bliss by merely thinking about this benign day, I caught a glimpse of allamandas (Allamanda cathartica) blooming outside the fence, stretching and tilting their bright golden yellow campanulate flowers amidst their short-petioled, oblanceolate, dark green leaves towards the balmy summer sun. It was as if the Psalmist whispered these words to my ears” “Weeping may endure for the night, but joy comes in the morning.” In that moment, a smile was drawn into a sullen face – mine – Nanay Mrs. Santiago is happy where she is now I told myself, beyond the pain and desolation and cares.
When I went home I saw that the yellow bells were still there. I heard their message that morning, loud and clear, never been eloquent, like trumpets of God shouting for joy. In this profession, especially in caring for cancer patients, joy it seems is hard to find in the daily routines of doctoring, but I am becoming skilled at stumbling on it bit by bit, meaningfully, beyond the choking tears, the indignant looks and the tormented moans, one toxic morning at a time.
*Shorter versions of this piece appeared in Dagmay and ANI34.
Dr. Noel P. Pingoy is an internist, hematologist and medical oncologist based in Koronadal City and Gen. Santos City in Mindanao. When he is not reading peripheral blood smears or giving chemotherapy, he writes occasional essays to find meaning in the struggles, heartbreaks and breakthroughs in his subspecialties. He is a proud graduate of the Davao Medical School Foundation. He has won a Palanca for an essay and was a fellow for Creative Nonfiction at the 2006 National Writers Workshop at Silliman University in Dumaguete.