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Finding the time; using it wisely
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For years, a common complaint from physicians and patients alike has been the limited time available for each clinic visit. In academic medicine — especially for a young attending like myself, who doesn’t carry a packed and full panel (at least not yet) — this problem is at least partially alleviated. When I’m precepting patients with fellows, or when I have my own transplant consultations, I find that I have enough time to add an extra pause after conveying a test result, or to ask an extra question that might not be immediately relevant to the management of the problem at hand.
Dealing with patient worry
In my non-transplant clinic 2 weeks ago, I went with one of the fellows to see a woman in her 30s with chronic myelogenous leukemia. (Of note, I have rapidly and oddly developed a panel of 30-somethings with CML during the last few months — I am not sure why I am seeing so many new diagnoses in this age group.) For this particular patient, we had previously discussed the efficacy and risks of the available tyrosine kinase inhibitors for the treatment of CML, especially in light of the two recent articles in The New England Journal of Medicine looking at dasatinib and nilotinib for front-line CML treatment.
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In this patient’s case, we elected to start nilotinib. Long-term follow-up data are not as robust or mature as they are for imatinib, but I am becoming increasingly convinced of the superior shorter-term efficacy and relatively favorable side effect profile of this drug. In any case, our patient was coming back for follow-up after her first few weeks on treatment. During the visit, she mentioned, as many patients do, that she wished we (the scientific community) knew more about contributing environmental etiologies for these diseases. I had some extra time that morning, so I talked about the principles of observational epidemiology and probed further. Why did she ask the question?
It turned out that she used to drink Diet Coke and wondered if aspartame caused her CML — and if she was therefore responsible for her own disease. I paused to give respect to this weighty burden that she had been holding for some time, and that she now offered to me for my analysis. I told her, of course, that we had no convincing evidence linking Diet Coke to CML, and that her diagnosis was in no way her fault. She burst into tears of relief, as she released this incredible amount of guilt that had clearly been with her over the last several weeks. It was a powerful moment, and I remember feeling pleased that there was something I could do, besides prescribing nilotinib, to relieve her suffering.
Making reality-based decisions
A few weeks later, I saw a patient with a complicated history for a new stem cell transplant consultation. He had intermittent access to medical care and his case had progressed to being an aggressive lymphoma from a previously undiagnosed indolent lymphoma. He had been treated appropriately by his referring physician, first with R-CHOP, and then, following progression after three cycles, with salvage R-ESHAP. The most recent scan showed that his disease again progressed following attempted salvage treatment.
There had been many challenging features to this patient’s management. He was in his late 60s, from another country, and with little social support; he was not married and had no family living nearby. Two neighbors had become good Samaritans and helped to take him to his appointments and to check on him when he was feeling unwell. In fact, that morning they had driven him 3 hours to see me in my office. Over the last few months, the patient had been in and out of the hospital several times. His intercurrent diagnoses included pneumonia, malnutrition, heart failure and acute kidney injury, all of which he had largely recovered from, to varying degrees.
I decided that based on his current lack of disease chemosensitivity and his marginal performance status, he was not a candidate for an autologous transplant. Because of two observations, though — the patient seemed to want additional treatment, and there were other treatments available for this (theoretically) treatable disease — I came up with a collection of non-transplant therapies, including a clinical trial at our institution, for the patient and his referring physician to consider. I felt like I was doing the right thing, and in my fantasy, I imagined that the patient’s disease would respond, his functional status would improve, and perhaps transplant might later become an option.
That afternoon, I read a beautiful article by Atul Gawande in The New Yorker about palliative and end of life care (if you haven’t read it, I strongly suggest that you do). In it, he described the case of a young woman with metastatic lung cancer, who went through a series of increasingly ineffective therapies that, in combination with her relentlessly progressive disease, eventually brought her to the edge of death. In the end, her primary care physician intervened and helped her to avoid a transfer to the ICU that would have brought with it more suffering, so that she might die with some peace and dignity instead.
The article had some additional meaning for me, in part because the PCP in the article had been my chief resident and later my own personal physician. As a resident, my goal had been to be the kind of doctor that he was for his patients. The central story aside, the point of the article was not to advocate a nihilistic approach, but rather to extol the virtues of well-delivered palliative care, as well as the benefits of carefully reassessing goals of care at each step along the way. Gawande cited a study that actually showed that patients who received palliative care lived longer than those who didn’t. (In the weeks since the article came out, an NEJM article has been published that showed a 3-month survival benefit to early palliative care in patients with advanced non-small cell lung carcinoma. This was a model in which well-delivered palliative care could actually be given alongside disease-directed chemotherapy.)
When I reflected on the article, I didn’t feel nearly as smug about my therapeutic cleverness from earlier that morning with the patient with lymphoma. The ways in which I discussed prognosis and eventual possible outcomes, and the way in which I addressed his social issues and supportive care needs, were inadequate compared with the time I spent thinking about his chemotherapeutic options. I don’t think that my patient’s decision to pursue further treatment, or the chemotherapy choices that he took home, were necessarily wrong, but I think that I could have provided better service by more carefully considering the host of important external factors and supportive care issues that were also in play.
Many times I remind myself that I am a doctor first, and not just an oncologist. Precious are the minutes that we have with our patients in the clinic rooms, and we need to use the time wisely.
William Wood, MD, MPH, is an assistant professor at the University of North Carolina Chapel Hill and is a member of the HemOnc Today Editorial Board.
For more information:
- Gawande A. Letting Go: What should medicine do when it can’t save your life?. Published Aug, 2, 2010. Accessed Sept. 3, 2010.
- Hagop K et al. N Engl J Med. 2010;362:2260-2270.
- Saglio G et al. N Engl Med. 2010;362:2251-2259.