The Hardest Job in Medicine

DOI: 10.1200/JCO.2009.25.1371 This was not how I was supposed to meet my new patient Bruce. I had been called recently by his internist, who alerted me to his situation: vigorous man in his early 60s, a lifetime of good health, came to see the doctor for mild abdominal discomfort and weight loss, a computed tomography scan showed tumors in the liver and the pancreas, the diagnosis appeared to be pancreatic cancer that had spread to the liver, an incurable situation. A blood marker of that cancer, named CA 19-9, was very elevated at 200,000 (normal less than 35), solidifying the diagnosis. Bruce was set to see me, a medical oncologist, in my office in a few days to discuss his treatment options. But, it was not to be. Cancer makes the appointments, patients and doctors follow fast afoot. I received the call from Bruce’s doctor while in the hospital at the end of a long day. “Bruce was admitted last night through emergency. He’s in severe pain, deeply jaundiced, the disease is just growing so fast. Nice man. Lovely family. Tough situation. They’re waiting to see you.” Click. As the dial tone droned on, it blanked out my thoughts and vibrated in synch, like a tuning fork, with my sinking spirit. Eventually, I put down the receiver and got in motion, steeling myself to do the hardest job in medicine. I found Bruce in bed, sleepy from the morphine dripping in his vein to kill the pain, yellow from the bilirubin building up in his bloodstream. His wife Joan was seated, her upper body draped over him like a blanket. They greeted me cordially but I immediately palpated their fear of what I was going to say. I pulled up a chair, pulled out paper and pen, and discussed and diagrammed how Bruce’s cancer had spread from the pancreas to the liver, how the tumors in the liver were causing his pain and impeding the normal flow of bile, leading to his jaundice. I told them how the elevated CA 19-9 was consistent with the diagnosis of pancreatic cancer but that we would get a biopsy to prove it. The lighting in the room was soft. The conversation was calm; there was a give and take, some levity and the initial forging of an intense bond. Then Joan asked about the CA 19-9. “Was it rechecked? What is it now?” I hesitated, and they saw it. I did not want to deflate them further. “Not important,” I said and tried to move on. Joan looked me squarely in the eye and said, “I want to know.” “700,000” was my reply (it was the highest I had ever seen). “Oh my god,” she said as the emotional dam broke, giving way to the pent up terror and shock that needed to be released. The hardest job in medicine just got a whole lot harder. As Bruce drifted off on a morphine cloud, Joan asked to talk with me outside of the room. “What you’re telling me is that my husband’s got cancer and it’s the worst of the worst. How much time? How much time does my husband have?” she implored. “Every cancer has an average survival and then a much broader range, with some people living shorter, others living far beyond the average; every patient is unique,” I said. “How much time?” she pressed. “The average is 6 months, but I’m not even sure he will make it out of the hospital. We have to hope that the treatment slows the growth of the cancer so that he improves enough to be discharged. That is the first hurdle. Pancreatic cancer is a very difficult cancer to treat. It might not happen, and he could succumb.” She asked, “If we did nothing?” “Days” was my reply. We spent time talking about Bruce, their life and family and some about mine. We agreed to keep Bruce comfortable above all else. I told her, I needed to tell Bruce much of what I just told her, and I did. His response, “just do what has to be done. I’m going to make it.” I recently saw Bruce in my office, a year and a half after our initial conversation. He comes for weekly chemotherapy treatments, works full time, has traveled abroad, and looks fit. Is he cured? No. How long will he live? I don’t know. How did this happen? I cannot say. From time to time, Joan drops in to bear hug me, look me in the eye and say “I love you.” The hardest job in medicine is sometimes the very best.