Hoping within reality.

Mr. Woodrick (not his real name) walked the halls of the cancer ward each morning with the pace of a man determined. With his brow furrowed and left arm swinging (the right preoccupied with an IV pole carrying cytarabine) he buzzed by our team as we rounded, making us smile. “Hey Docs,” he would exclaim with a smile and vigorous head nod. His gray hair was gelled tastefully, and he wore the perfect amount of cologne. The white New Balance sneakers he wore looked brand new and subtly squeaked with every other step. He would be willing to stop for a moment, if appropriate, but clearly had an agenda. His black windbreaker pants could be converted into shorts and he paired them with knit collared shirts of all colors. On rainy days, he wore a light gray pullover sweatshirt with no hood. It had the type of fraying at the top that announced a lifetime of usage, the type a trendy clothing store might try to replicate. It was obvious that he had given a lot of thought to what to pack for the hospital when his outpatient hematologist gave him the bad news. His wardrobe also led me to suspect that he was someone that had never been hospitalized—never converted to the hospital gown and booties, never removed from normal society. I knew he gave his hospital stay a lot of thought because he admitted to spending the night before his admission lying awake, nervous, in anticipation. Despite this, he approached his treatment with an open mind and eagerness. He took, and read, the patient information resources. He recorded his questions on a yellow legal pad and put on thick, black glasses to take notes during rounds. I had learned to enjoy his positive attitude and personality immensely over the past few days, even thinking to myself, “I hope I can be that positive if I ever get cancer.” This was my second stint on the Red Service as an intern, treating patients with leukemia and lymphoma. On rounds, I had used and heard the phrase, “Patient here on 7 + 3, still neutropenic” too often for one lifetime. The most difficult part of the rotation was meeting patients like Mr. Woodrick who were directly admitted to begin treatment for acute myelogenous leukemia, otherwise known as AML. I have read and been told AML is a rare disease; it seems all too common after rotating here. These patients entered the hospital doors as human beings but left weeks—sometimes months—later as shriveled shadows of their former selves. All too often, they failed to make it out alive. As one post-treatment bone marrow biopsy after another showed disappointing news, I increasingly avoided eye contact with my patients. I approached many days with the intent of being emotionally unavailable—nothing more than a manager of disembodied diseases, laboratory abnormalities and symptoms. I became less enthusiastic to get to know my patients and even less zealous to discuss their prognoses. The latter particularly troubled me. As someone who considers himself a proponent of goals of care discussions, transparency, shared decision-making and patient empowerment, I easily sensed the inadequacy of my patient care. Feelings of guilt, sadness and hopelessness tarnished my previously established intentions. It was all too often simply easier to hope against hope, ignore, and move on. I met Mr. Woodrick in the face of this crisis in my development as a physician. On our first night together, I greeted him in a flat, dry manner, hoping to collect all necessary information and leave the hospital as fast as I could. He, in turn, shot up from the leather chair, turned off the television and greeted me with a firm handshake. He looked me in the eyes and leaned forward. He did not question my age, role in the hospital, or why he had to repeat his entire medical history to another stranger. He simply sat back down with legs neatly crossed and welcomed me kindly. Shortly, he began asking me questions in such a genuine fashion that warmth spread across my face in the form of a smile. “What happens next? Do I just wait in my room before then? What is chemotherapy?” I watched as his tense shoulders assumed a more natural position and heard the pitch of his voice drop as I thoroughly answered his questions. “I’ll be up early to get started,” he said confidently. I left the room and walked slowly back to my work space, smiling. I did not know how much time had elapsed, but had no desire to check my watch. One day, we did not see Mr. Woodrick in the halls. I noticed immediately but figured he was taking it easy as it was Saturday. When we walked into his room to visit, there he was—dressed in his running outfit with pictures covering the walls. The photos were new, as was the elderly woman sitting next to his bed. He quickly sprung up to greet us and introduced his mother. I could tell he had a different agenda that morning as his interactions were much more intentional than usual. He took us through pictures of himself with co-workers at a party, at a restaurant with his mother, and with his friends at a cigar bar. After we exchanged pleasantries, Mr. Woodrick sat, looked my attending physician and me square in the eye and asked, “In some ways I don't even want to know, but Doc…can you tell me where I'm at long term?” I froze with fear and denial, as I knew his prognosis was grim. His hematologist had obviously told him his “blood disease” had worsened, requiring intensive chemotherapy, but he now voiced a need to have things spelled out to him. The timing of his question made perfect sense during this momentary break in action with chemotherapy then up and running. My attending appropriately filled the void in the room, gracefully explaining that without treatment he could expect to live a few more months and that with treatment we were hoping for a year or two on average. “That's shorter than I expected…” said Mr. Woodrick, trailing off. He continued to smile, as always, but flushed and looked uncomfortable—his face darker than usual and brow wrinkled. His eyes found the floor and mine eagerly followed suit. The man sitting before me with plenty to live for had just seen most of his life vanish. His mother remained next to him but seemed to recoil from our discussion, reclining back in her chair with a look somewhere between confusion and disgust. We finished our exam in silence and reminded him to stay positive. I was fearful that the next interaction I had with Mr. Woodrick would be with a dejected man who had lost any and all hope. As we quickly debriefed in the hallway on the way to the next patient’s room, I stated that I felt horrible for Mr. Woodrick. Moisture welled up in the corner of my eyes as I walked alongside my intern colleagues, resident, and attending physician. When asked to explain further, I burst into tears, finally uttering the words I had been trying to say: “He's just a good guy.” I felt the warmth of embarrassment wash over my body and wished I could disappear. Deep down, despite all I thought I stood for, I had hoped to avoid any serious discussion with Mr. Woodrick because I did not want to tell him the truth: I did not want to let him down. I blew my nose and gathered myself. There were more patients to see. As I peered up from the trashcan, I saw Mr. Woodrick racing past me in the hall pushing his IV pole. He had a huge smile across his face and waved to me on his way by.