A Balancing Act
Authors: Mark A. Lewis
Journal: Journal of Clinical Oncology (2012)

DOI: 10.1200/JCO.2011.41.5695 My day began and ended at the bedside of a woman who was suffering. For nearly a year, cells had been proliferating inside her body, growing imperceptibly at first but crescendoing to a loud, agonizing climax. Now, to describe her as “an uncomfortableappearing female” in the written medical record would have been a gross understatement. And there was not just one woman; rather, there were two women, in different rooms, in different hospitals, each approaching the end of her pain. The two women had undergone physical transformations in parallel, their abdomens swelling synchronously as I had observed them both during the preceding months. The first woman was my patient, in the last throes of being ravaged by an aggressive angiosarcoma, a tumor that had replaced her liver and flooded her belly with ascites until her skin was drum tight. The second woman was my wife, giving birth to our second child after a difficult pregnancy. These two women had shared my longstanding worry about their outcomes, but as I stood beside each of them in turn, moving from the intensive care unit in the morning to the obstetric ward in the evening, I witnessed their paths diverge to the diametric opposites of death and life. The timing was eerily simultaneous. While my son’s first moments were spent having a nuchal cord disentangled, elsewhere the noose of end-stage cancer tightened mercilessly around a young mother. He entered the world at almost the exact instant when she made her premature exit. I had seen my patient’s death approaching from a distance. From our initial encounter, I was sure that her tumor, having already metastasized at presentation, was going to kill her. With the inevitability of Chekhov’s gun, it was only a matter of time before the final disaster, and my sense of foreboding progressed along with her advancing disease. But I could not have predicted that her tragic end would intersect precisely with a blissful beginning, posing the ultimate challenge to my notion of work-life balance. Throughout fellowship, I had struggled to maintain a great divide between my occupation and my family. Then that awful, wonderful day, with its tumult of feelings and obligations, proved to me that the barrier was permeable. The horrors encountered in my job were not so easily contained, and they could coincide with my most precious joys. The addition of a healthy child to our family would in no way compensate for the wrenching loss levied against another. This was not an equation to be solved like emotional algebra, yet I had to acknowledge a deep conflict. I was ecstatic yet grieving, apparently in danger of betraying two commitments. In mourning, was I guilty of not properly celebrating the birth? Or was I rejoicing despite my patient’s death? Never before had I experienced such extreme feelings at the same time, and the dissonance was unsettling. Perhaps my immaturity as an oncologist in training was partly to blame for the confusion. I have since been told by more experienced physicians that I do not actually mourn when a patient under my care succumbs to their disease; removed from the true despair reserved for a loved one, I should feel only an attenuated sadness, and to claim otherwise would be maudlin. To a certain extent, this distinction seems semantic, but I can acknowledge the difference. Admittedly, I do not experience a patient’s demise with the same devastation that accompanied, for instance, the death of my father, a sorrow that can still feel acute decades later. A series of equally profound losses would surely cripple me as a caregiver, given the distressing frequency with which my patients are terminally ill. That said, I fear becoming insensate more than I fear the pain of repeated bereavement. If I do not feel somber at the time of each patient’s death, then I will have become unresponsive to the mortal struggles that drew me to this precarious specialty in the first place. Even in my inexperience, I can already foresee a career spent reconciling resilience with compassion, donning emotional armor while hoping to retain some modicum of vulnerability. As my patient’s death threatened to loom over the joy of my son’s arrival, I was reminded that the human toll of the terrible diseases we treat can haunt us. In his magnificent chronicle of cancer, The Emperor of All Maladies, Siddhartha Mukherjee includes an account of his own daughter’s birth, which he rhapsodizes as “perhaps the singularly transformative event” of his life. Mukherjee describes JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 30 NUMBER 15 MAY 2