Doctor, where art thou?

DOI: 10.1200/JCO.2012.48.2059 The inbox of my work e-mail was neatly organized into folders—an attempt to keep some semblance of control over my life as a hematology-oncology fellow in a busy academic medical center. Recently, with my training near its end and with the knowledge that I would be leaving the university, I decided to clean out the thousands of emails I had accumulated. At first, I found this easy, clicking the “Delete” button again and again with a growing sense of satisfaction and accomplishment...until I reached the “Patient e-mails” folder. I found myself staring at hundreds of e-mails with familiar names. No different than tombstones at a cemetery, these e-mails were neatly lined up, organized by date and a few subject words. I clicked the “From” button, rearranging the e-mails by sender, and suddenly, the stories returned. KV (cholangiocarcinoma): questions about pain, diarrhea, shingles, mouth sores, Ativan; then silence. BD (pancreatic cancer): e-mails about nausea, weight loss, rearranging Monday’s chemotherapy appointment, lab results, fatigue; silence. EH (lung cancer): an inquiry about an appointment time, an episode of confusion, a fall, pain, hospitalization; silence. MP (renal cell carcinoma): low blood counts, a note of thanks, a Happy New Year greeting, a request for a second opinion, pain; silence. What happened in the space of those silences? I realized that, for the most part, I never kept in touch with my patients once chemotherapy stopped working, instead handing off care responsibility to my hospice and palliative care colleagues. As I read through those e-mails and recalled my relationships with those patients, I wondered if this well-meaning transition, although in many ways appropriate, should be reexamined for its effects on patients, doctors, and the doctor-patient relationship. My eyes returned to two particular patients— L.B. and M.M.—and I couldn’t help but smile but thinking about them. L.B. was a bright, well-respected physician with a horrible cancer. He came to our hospital for a second opinion and stayed under our care as we enrolled him onto a clinical trial. It was the first time I had taken care of another physician for an extended period of time, and I got to know L.B. well. I met his family and talked to him about his practice and the challenges of transitioning away from it prematurely. I fielded many of his calls and e-mails, and he was kind enough to allow me to be his primary oncologist. In return, I allowed him as much control as possible in his care. L.B. did well at first, with the tumor shrinking and pain abating, which allowed him to travel. He continued to chair national meetings and to bring gifts of fruit baskets for all of us in the clinic. But inevitably, as he and I had known from the start would happen, his cancer began to grow once again, and soon a permanent abdominal drain was required. A new course of chemotherapy was useless and then came weight loss, fatigue, thrush, blood clots, and pain. We met and spoke about hospice. He agreed that it was time, and we made a referral. He jokingly said that he would not bother me so much anymore, because the hospice doctor would take over. That was the last time we spoke until I received an e-mail from his wife informing me of his death at home, followed several weeks later by a card from his family thanking me for his care. At the same time, I was taking care of M.M., a recently retired school teacher, avid golfer, fisherman, and tennis player. His cancer, originally diagnosed as localized and treated with liver surgery, had returned and was no longer curable. M.M. was stoic, calm, and accepting of his diagnosis. His wife was obviously in love with M.M. and shocked and confused about their new predicament. She told me during our first meeting that they were looking for a doctor who would be with them “throughout his illness,” until the end. I promised that I would do just that. And indeed I watched him go through months of chemotherapy as well as yoga, acupuncture, daily tennis, and numerous fishing trips (we joked that he fished more in one year than most people do in a lifetime). Eventually, his cancer, too, progressed. As I was trying to manage M.M.’s pain and arrange for initiation of palliative radiation, I left for vacation. On my return, I found that M.M. had been referred to palliative care by one of our nurses and JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 31 NUMBER 12 APRIL 2