My First Patient

DOI: 10.1200/JCO.2012.43.0041 You can care for hundreds of patients as a resident and fellow before you truly see your first patient. The first patient I saw as an attending oncologist was an elderly man who came to my office full of hope shortly after undergoing complete resection of an intrahepatic cholangiocarcinoma. After scanning his medical records, I spent hours preparing for his arrival, reviewing the literature, and contemplating the best approach to his treatment. Despite the scant research results dictating my decisions, I prepared answers to his most likely questions about statistics, prognosis, and subsequent management. Mr D and his wife of 47 years sat timidly in the clinic room as I walked in and confidently introduced myself, despite secretly praying they would not assume I was a medical student. I listened intently to his story about abdominal pain and weight loss, which had prompted numerous tests and procedures. I discussed the rarity of his cancer; only approximately 3,000 cases of cholangiocarcinoma are reported each year in the United States, collectively representing less than 3% of GI malignancies. When Mr D’s wife asked me why her husband had developed this cancer, I launched into a review of data, identifying various risk factors linked to cholangiocarcinoma, such as inflammatory bowel disease, congenital cysts, hereditary syndromes, obesity, gallstones, and the obsolete contrast dye Thorotrast (Tenneco Resins, DE). Mr D and his wife stared at me with a glazedover look that indicated they were not hearing what I was saying. To them, my recitation of statistics was irrelevant; Mr D did not fall into any of these highrisk categories; instead, he was one of the majority of patients without any clear reason for developing this horrific cancer. Mr D and his wife wanted to hear from me that there was hope. They wanted me to reassure them that his tumor had been caught early, and because I am a specialist in this type of cancer, I would be able to give them the years they deserve together—additional time to watch their four grandchildren grow up and a chance to make it to their 50th wedding anniversary. When the security blanket of the attending’s authority was removed, I felt completely alone. I was accustomed to regurgitating each patient’s story to my supervisor, who would then offer commentary or an anecdote and put a seal of approval on my thought process and management plan. In uncertain and difficult cases, I always had someone else to rely on to help formulate an approach. But now, with nobody specifically assigned to validate my plan, I was left to my own devices, and I began to secondand third-guess myself. My plan had been to happily march through 6 months of adjuvant therapy, with the inevitable dose reductions and delays resulting from myelosupression or, at worst, an infection. My plan had been to follow published surveillance guidelines from the National Comprehensive Cancer Network, including a medical history and physical examination, laboratory tests, and imaging studies every 3 to 4 months. My plan did not include what actually transpired: regretting that I had not pre-emptively scheduled a routine follow-up appointment to review his first postoperative computed tomography (CT) before starting his adjuvant treatment. My plan also did not include dreading the unexpected telephone call to Mr D’s wife to announce that they would need to come to the clinic to review the test results in person. After receiving the results of postoperative CT scans and labs, I soon realized that my anguish over the details of adjuvant therapy had been unnecessary. As I sat alone at my desk, amid still-unpacked boxes of new office supplies and recently framed diplomas, I repeatedly scrolled up and down the CT images that I knew would result in life-changing news for Mr D and his wife. The new pulmonary nodules and lymphadenopathy were small, but the weight of their implications felt oppressive. In my head, I practiced the speech about changing goals of therapy that I had given hundreds of times before. This time, however, delivering the speech felt different. As an oncology fellow, the uncomfortable pause at the end of difficult discussions was always so easily filled with, “I’ll go get my attending physician, who will be able to answer any more questions that you might have.” Now, with nobody to save me from that moment, I stayed seated in a chair next to the couple, held Mr D’s hand, and shared their grief over the uncertainty I had just revealed. Even though this moment was familiar, JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 22 AUGUST 1 2012