As doctors, we dream about having the time to get everything right

Time matters for cancers and strokes. It matters to bureaucrats, too. And it mattered for one patient I had who wanted to hand down a gift to his family before he died....

 

 

He had been a fit, young man when what he thought was a case of food intolerance turned out to be an aggressive cancer. His surgeon performed a meticulous operation but cautioned him that it might still not prove enough. It wasn’t long before he and I teamed up to care for what would prove to be a terminal illness.

Ranjana Srivastava MBBS (Hons), FRACP, Medical Oncologist Department of Medical Oncology, Southern Health, Melbourne, VIC. [email protected]

He was a skilled and self-taught craftsman. An acrimonious divorce had split the family and he decided to build a table for his young daughter.
For the timber, he chose oak. “Unlike me, it will age gracefully.” He pictured her colouring at the table, later studying at it and one day, gathering her own children around it.
“Maybe it will tell them stories their grandfather never could.”
Chemotherapy kept him well for many months, in which his vision for the table began to come together and I found myself celebrating with him that he might just see his project through.
When the table was upright but needed a lot more work, a neighbour’s offer of help was declined. “I want her to know I did this all on my own.” His clinic visits soon became the impetus to complete another part of the job so he could bring photos to show me the results.
He knew his disease was progressing before the scans did; the vigorous polishing and waxing was taking his breath away.
“I need your help,” he announced. “I want to continue chemo just in case but it can’t interfere with my work.”
It was a tall order. “Personalised medicine” means tailoring the most precise drug to the diagnosis, not getting a huge oak table built in the nick of time. But we all tried.
To give him productive daylight hours, I saw him early in clinic, the nurses sped through his treatments and palliative care visited late.
One day, he said: “I can either have chemo that isn’t working or make the table perfect.” Just like that. I couldn’t and didn’t argue.
Free from tests and treatments, his quality of life surged and the table flourished. Admiring the pictures, I asked if he’d prefer not to return to clinic since it took hours out of his day. He looked at me in surprise and I sensed, dismay.
“What’s stopping chemo got to do with seeing you?”
“You have an excellent GP,” I said reassuringly, knowing she was doing home visits.
“But no one knows my story like you.”
The appointments stayed and the first few times I wondered what form our conversations would take. With no chemotherapy-related toxicities to combat and his symptoms at bay, it was pointless to ask what the last session was like and tedious to establish if there was anything else bothering him.
I decided I’d let him navigate our future conversations, which is when he taught me about the shared language of medicine and woodwork. I learnt about fixed and flexible joints, span and girth. I learnt that getting shingles wasn’t painful if you intended to line your roof with them.
I learnt that a Garnier limb wasn’t a new prosthesis made by a beauty company but an engineered tree bolt. In between, he let slip his sorrow about his daughter, the renunciation of anger and his thoughts on an afterlife. Our conversations weren’t long or typical but somehow, they felt right.
I told him I hated seeing him fade, but in response he produced the final pictures of his table, beautifully finished, the ultimate tribute to his daughter.
“This is what I have lived for.”
I was speechless.
At our last visit, his mother wanted a word. She was a midwife, she said, well aware of the precious allocation of a doctor’s time. She wanted me to know that the last few “technically unnecessary” visits had nourished her son’s hope by allaying his greatest fear. “He doesn’t fear death as much as abandonment.” I didn’t have the heart to say how guilty I had sometimes felt admiring his table, torn between the desire to give him my time and the need to treat other patients. This was her way of acknowledging my dilemma.
Time. The billion-word Oxford English Corpus nominates time as the most frequently used noun in the English language. Medicine must surely make a hefty contribution to this nomination for there is scarcely a word that weighs more heavily on a doctor’s mind. Putting in an IV takes time, arguing for earlier surgery takes more time and explaining something properly to a patient takes the most time of all. Time counts during a stroke.
Time is money, the bureaucrats chant. If only there was the time to do everything right and get everything right, we dream.
Discharge summaries would be clearer; communication would be smoother; collectively we would be better read and better behaved. In fact, it has become accepted wisdom that the doctor-patient relationship would be a different entity if we just had the time. But the truth is that time is finite and doctors have to figure out how to use it judiciously.
This is why I found a recent essay by a fellow oncologist especially instructive. Dr Christiane Voit was as impressive as they came and her diagnosis of ovarian cancer didn’t stop her from publishing and speaking at conferences that I attended.
Earlier this year, her disease progressed, allowing her to spend time with her five-year-old daughter, who finally had the privilege of “not having a mother who has to work constantly but can spend mornings in bed with her, giggling, cuddling, listening to the birds.”
Writing in the Journal of Clinical Oncology, Voit lamented the ignored warning signs by her doctors and missed her patients but it’s what she concluded as a doctor-turned-patient that is most powerful.
There is something oncologists need to keep in mind: all of our patients have mothers and fathers, many have children, and all of them are going through this very tough, emotional experience that nobody ever really wants to deal with. Remember this.
Oncologists have all dealt with the time pressures caused by deadlines for abstracts and presentations, the sheer volume of clinical work, and countless other pressures.
However, for the patient who may be facing their own mortality, time with their treating oncologist is critically important: they need it to understand their disease and to acknowledge their thoughts or fears.
Voit deteriorated and her essay was published posthumously. I wonder what she made of the rhetoric of patient-centred care that often stands in contrast to the reality of healthcare systems that favour processing patients over caring for them as individuals.
I wonder if the next patient who has stopped chemotherapy but wants to build a table for his daughter will still hold my attention. I’d like to think so, which is why amid the reminders about improving efficiency, I now keep a copy of Christine Voit’s essay on my desk.
Source: The Guardian.

As doctors, we dream about having the time to get everything right

Time matters for cancers and strokes. It matters to bureaucrats, too. And it mattered for one patient I had who wanted to hand down a gift to his family before he died.... He had been a fit, young man when what he thought was a case of food intolerance turned out to be an aggressive cancer. His surgeon performed a meticulous operation but cautioned him that it might still not prove enough. It wasnt long before he and I teamed up to care for what would prove to be a terminal illness. Ranjana Srivastava MBBS (Hons), FRACP, Medical Oncologist Department of Medical Oncology, Southern Health, Melbourne, VIC. [email protected] He was a skilled and self-taught craftsman. An acrimonious divorce had split the family and he decided to build a table for his young daughter. For the timber, he chose oak. Unlike me, it will age gracefully. He pictured her colouring at the table, later studying at it and one day, gathering her own children around it. Maybe it will tell them stories their grandfather never could. Chemotherapy kept him well for many months, in which his vision for the table began to come together and I found myself celebrating with him that he might just see his project through. When the table was upright but needed a lot more work, a neighbours offer of help was declined. I want her to know I did this all on my own. His clinic visits soon became the impetus to complete another part of the job so he could bring photos to show me the results. He knew his disease was progressing before the scans did; the vigorous polishing and waxing was taking his breath away. I need your help, he announced. I want to continue chemo just in case but it cant interfere with my work. It was a tall order. Personalised medicine means tailoring the most precise drug to the diagnosis, not getting a huge oak table built in the nick of time. But we all tried. To give him productive daylight hours, I saw him early in clinic, the nurses sped through his treatments and palliative care visited late. One day, he said: I can either have chemo that isnt working or make the table perfect. Just like that. I couldnt and didnt argue. Free from tests and treatments, his quality of life surged and the table flourished. Admiring the pictures, I asked if hed prefer not to return to clinic since it took hours out of his day. He looked at me in surprise and I sensed, dismay. Whats stopping chemo got to do with seeing you? You have an excellent GP, I said reassuringly, knowing she was doing home visits. But no one knows my story like you. The appointments stayed and the first few times I wondered what form our conversations would take. With no chemotherapy-related toxicities to combat and his symptoms at bay, it was pointless to ask what the last session was like and tedious to establish if there was anything else bothering him. I decided Id let him navigate our future conversations, which is when he taught me about the shared language of medicine and woodwork. I learnt about fixed and flexible joints, span and girth. I learnt that getting shingles wasnt painful if you intended to line your roof with them. I learnt that a Garnier limb wasnt a new prosthesis made by a beauty company but an engineered tree bolt. In between, he let slip his sorrow about his daughter, the renunciation of anger and his thoughts on an afterlife. Our conversations werent long or typical but somehow, they felt right. I told him I hated seeing him fade, but in response he produced the final pictures of his table, beautifully finished, the ultimate tribute to his daughter. This is what I have lived for. I was speechless. At our last visit, his mother wanted a word. She was a midwife, she said, well aware of the precious allocation of a doctors time. She wanted me to know that the last few technically unnecessary visits had nourished her sons hope by allaying his greatest fear. He doesnt fear death as much as abandonment. I didnt have the heart to say how guilty I had sometimes felt admiring his table, torn between the desire to give him my time and the need to treat other patients. This was her way of acknowledging my dilemma. Time. The billion-word Oxford English Corpus nominates time as the most frequently used noun in the English language. Medicine must surely make a hefty contribution to this nomination for there is scarcely a word that weighs more heavily on a doctors mind. Putting in an IV takes time, arguing for earlier surgery takes more time and explaining something properly to a patient takes the most time of all. Time counts during a stroke. Time is money, the bureaucrats chant. If only there was the time to do everything right and get everything right, we dream. Discharge summaries would be clearer; communication would be smoother; collectively we would be better read and better behaved. In fact, it has become accepted wisdom that the doctor-patient relationship would be a different entity if we just had the time. But the truth is that time is finite and doctors have to figure out how to use it judiciously. This is why I found a recent essay by a fellow oncologist especially instructive. Dr Christiane Voit was as impressive as they came and her diagnosis of ovarian cancer didnt stop her from publishing and speaking at conferences that I attended. Earlier this year, her disease progressed, allowing her to spend time with her five-year-old daughter, who finally had the privilege of not having a mother who has to work constantly but can spend mornings in bed with her, giggling, cuddling, listening to the birds. Writing in the Journal of Clinical Oncology, Voit lamented the ignored warning signs by her doctors and missed her patients but its what she concluded as a doctor-turned-patient that is most powerful. There is something oncologists need to keep in mind: all of our patients have mothers and fathers, many have children, and all of them are going through this very tough, emotional experience that nobody ever really wants to deal with. Remember this. Oncologists have all dealt with the time pressures caused by deadlines for abstracts and presentations, the sheer volume of clinical work, and countless other pressures. However, for the patient who may be facing their own mortality, time with their treating oncologist is critically important: they need it to understand their disease and to acknowledge their thoughts or fears. Voit deteriorated and her essay was published posthumously. I wonder what she made of the rhetoric of patient-centred care that often stands in contrast to the reality of healthcare systems that favour processing patients over caring for them as individuals. I wonder if the next patient who has stopped chemotherapy but wants to build a table for his daughter will still hold my attention. Id like to think so, which is why amid the reminders about improving efficiency, I now keep a copy of Christine Voits essay on my desk. Source: The Guardian.