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January 01, 2013
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When clinicians become patients, treatment journeys help shape their approaches to care

Perspective from Itzhak Brook, MD, MSc
Perspective from David Carbone, MD, PhD
Perspective from Jennifer Kelly, MD, PhD
Perspective from Robert Klitzman, MD
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Hollye Jacobs, RN, MS, MSW, has had to deliver bad news more times than she can count.

As an adult and pediatric hospice nurse, social worker and educator, she counseled and consoled hundreds of children and adults who struggled to come to terms with cancer diagnoses. She also taught medical students at the University of Chicago Pritzker School of Medicine on how to do the same.

“There’s a real art to it,” Jacobs told HemOnc Today.

Hollye Jacobs, RN, MS, MSW, an adult and pediatric hospice nurse, social worker and educator, documented her physical, mental and spiritual journey through breast cancer treatment in a blog called The Silver Pen.

Hollye Jacobs, RN, MS, MSW, an adult and pediatric hospice nurse, social worker and educator, documented her physical, mental and spiritual journey through breast cancer treatment in a blog called The Silver Pen.

Source: Photo courtesy of Hollye Jacobs, RN, MS, MSW, reprinted with permission.

Yet, no amount of training prepared her for the words she heard as she sat in a surgeon’s office in fall 2010, this time as a patient.

A mammogram and hand-held ultrasound revealed four lesions in Jacobs’ right breast and three more in her left. When the surgeon explained she would not be able to provide an official diagnosis until comprehensive pathology results became available 2 days later, Jacobs issued a plea.

“I’m one of those people who really like to know what I’m going to be told, before I’m told,” she said.

The surgeon replied: “I think I am going to tell you that you have breast cancer.”

Role reversal

As the surgeon outlined a treatment plan — immediate mastectomy, 3 to 4 months of chemotherapy and 6 weeks of radiation — Jacobs’ mind began to race.

How would her husband, who happened to be out of the country on the day of her diagnosis, cope with the news? How would she tell family and friends? How would she continue to be a good mother to her 4-year-old daughter?

Her ability to help others as they braced for similar difficult journeys led her to answer each question with the same six words: “We know how to do this.”

Not all clinicians who suddenly find themselves on the other side of the provider–patient equation maintain that sense of confidence.

Many struggle as much with the role reversal as they do with their disease.

Trained to remain stoic and maintain an appropriate emotional distance from their patients, some physicians are afraid to appear weak or vulnerable. Some find it difficult to relinquish control, micromanaging so many aspects of their care that it strains their relationship with their medical team.

Pamela F. Gallin, MD

Pamela F. Gallin

“We are the worst patients,” Pamela F. Gallin, MD, author of How to Survive Your Doctor’s Care. “We are the most challenging. The reason is that we know too much. Or, rather, we think we know too much. A little knowledge is a dangerous thing. We know that our treatment comes down to the judgment of another physician. That doctor will have to decide whether our diagnosis is 1, or 1A, or 1B. This is frightening to us, because we know that if that doctor makes the wrong choice, it could affect our entire treatment and outcome. We are control freaks.”

Another factor is diligence, said Gallin, professor of ophthalmology and professor of pediatrics at New York Presbyterian Hospital, the Edward Harkness Eye Institute and Children’s Hospital of New York Presbyterian.

“It is generally much better to have a diligent physician than a brilliant one,” Gallin said. “The best physicians are the ones who chase down every detail and account for every possibility. No matter how good the other physician is, we will always wonder whether he is as compulsive about the details as we are. We can’t know.”

A shared journey

Based in part on her experience at the bedside, Jacobs opted to document her physical, mental and spiritual journey through treatment — and now survivorship — in a blog, The Silver Pen.

“I believe that breast cancer happens within the ecosystem of family, friends and community,” she wrote in her introductory post on Nov. 2, 2010. “Consequently, I decided to take the holistic approach and write about breast cancer with style and a sense of humor.”

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She did so because she wanted loved ones to hear about her experiences in her own words. Jacobs wanted to make sure she remembered the details of the conversations she had with her doctors, colleagues, family members and friends.

“Anytime you have an emotional conversation it is so easy to forget things,” she said.

Jacobs also wanted to share what she calls “silver linings” — the kind gestures, tender moments and pleasant surprises — that offered comfort, provided hope and helped her maintain a positive attitude.

She found the endeavor incredibly cathartic, and it continues to influence how she approaches her personal and professional lives.

“Cancer is as much an emotional journey as it is a physical journey,” Jacobs said. “Regardless of how sick I felt, I could always find silver linings. I still look for them every day.”

Work informs understanding

Jacobs used her medical training to guide her experience with cancer, but Mark A. Lewis, MD, used his to help diagnose a premalignant condition.

Lewis, assistant professor in general oncology at The University of Texas MD Anderson Cancer Center in Houston, was in residency at Baylor College of Medicine in Houston when red spots appeared on his face. Then, a day before his oncology fellowship began at Mayo Clinic in Rochester, Minn., he awoke with severe pain in his lower right side. He thought he had appendicitis, but tests revealed a high calcium level instead.

Mark A. Lewis, MD

Mark A. Lewis

“It was almost comical,” Lewis told HemOnc Today. “Medical students are renowned for turning into hypochondriacs. Of course, I went to my primary care physician within the first month of my oncology fellowship and said, ‘I think I have a cancer syndrome.’”

Lewis expected to be ushered out of the office with directions to stay away from his medical textbooks for the rest of the night.

Instead, his PCP listened, smiled and offered reassurance, saying: “I think that’s unlikely, but we will take your concerns seriously.”

“I just wanted him to listen to me, and he did that,” Lewis said. “Frankly, his reaction was entirely appropriate. He said, ‘Let’s not jump to conclusions. Let’s look at the actual data.’”

The data proved Lewis’ instincts correct.

Tests revealed adenomas on his parathyroid gland. An ultrasound of his pancreas showed islet cell tumors.

Lewis — who had a frame shift mutation in chromosome 11q13 — was diagnosed with multiple endocrine neoplasia type 1 (MEN 1), a rare group of disorders that causes tumors in the endocrine glands.

The diagnosis meant Lewis’ personal and professional backgrounds meshed in a way he never imagined.

“In my first weeks of my fellowship training, I had been seeing patients with pancreatic neuroendocrine tumors who had a remarkably similar family history to my own,” he said. “I had just been diagnosed with high calcium levels. All the experiences and family histories of my patients sort of merged with my own experience and family background. I realized I had what they had.

“My work informed my personal understanding,” Lewis added. “I honestly believe if I wasn’t a cancer doctor, I wouldn’t have sorted this out and I would have been in the dark about what was wrong with me.”

A sense of empathy

Lewis and his care team continue to monitor the tumors on his pancreas to see if they grow or metastasize. So far, none have become overly invasive.

“I’ve chosen to postpone surgery as long as I can,” he said. “Time will tell if it is the right decision. It is similar to the discussion I have with my patients. What course to take? What treatment to take? There are short-term risks with the toxicity of chemotherapy weighed against the potential long-term benefits.”

Lewis said he is fortunate and does not pretend to understand “what it’s really like to have cancer.” Still, his experience has made him more empathetic when caring for patients.

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“I better understand the fear and the uncertainty that patients deal with,” he said. “You come to the realization that there is a lot of risk to mitigate in oncology, whether taking action or choosing surveillance. There is a risk in treating and there is a risk in not treating. You have to be comfortable tomorrow with the decisions you make today. That’s the main thing I’ve learned, and that’s what I try to impart to my patients.”

‘A strange gift’

When Lewis received his diagnosis, he debated when — or if — he should broach the subject with his patients.

“You try to project that image of being a confident doctor,” he said. “Your patients are coming to you for treatment and information, and at first, I didn’t want them to have a mental perception of me as a sick and fallible person.”

He initially decided to avoid discussing his condition with his patients.

“As I got deeper into my training, I realized this was sort of a strange gift,” he said. “I now had the ability to really turn around a conversation and connect with a patient empathetically.”

He still saves the subject for certain circumstances, reserving it for when a patient ends treatment and enters a period of surveillance.

“I found that was the right moment to tell them,” Lewis said. “They worked hard to get to the point where I find myself right now. My diagnosis does not currently require any therapy. I’m watching and waiting to find out when I will need treatment, and that is the privileged condition that many of my patients have to work hard to attain. I found, at that moment, it’s helpful to confide in them about how to face an uncertain future.”

Lewis’ message often has more to do with emotional health than physical health.

“I can talk in very real terms about fear and how to manage it and not allowing it to ruin your life,” he said. “The worst thing for a patient is to fight through all the rigors of treatment and find themselves so paralyzed by the terror of a recurrence that they cannot enjoy the rest of their life. That’s what I want to prevent.”

He also revealed his diagnosis in an editorial that appeared in the Journal of Clinical Oncology in 2011.

“I was completely floored by the response,” he said. “So many people in the oncology community, often complete strangers, contacted me via email. Even within my own clinic, I was totally taken aback at the number of people I work with every day who either had a history of cancer or were dealing with cancer themselves, unbeknownst to me.”

A liberating experience

Krenie Stowe, MD, JD, had a similar experience.

Stowe, a pediatrician at Rayford Medical and Urgent Care Clinic near Houston, has practiced medicine for nearly 20 years.

When she was diagnosed with stage II breast cancer in February, she decided to share her diagnosis — and subsequent updates about her treatment — with her colleagues, her patients and anyone else who was interested.

“I was emailing 300 to 400 people regularly,” she said. “I’ve gotten incredibly positive responses. People begin to open up. They tell me, ‘I had colon cancer’ or ‘My mother had a certain type of cancer.’ I heard from people who had only spoken to their spouses about their cancer. There is a tremendous amount of secrecy in illness.”

Before Stowe began her six-cycle round of chemotherapy, she shaved her head. Some of her colleagues questioned whether it was appropriate for Stowe to be so open while working with children.

“I told them, ‘The kids need to know what’s up. I have the disease. I am taking medicine. It makes my hair fall out. I hope it makes me better,’” she said. “My journey was very much helped by the fact that I was so open. I found it liberating.”

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Doctors treating doctors

Most clinicians do not know firsthand what it is like to battle a life-threatening illness. At the same time, many oncologists are unaccustomed to caring for fellow physicians.

Adam Boruchov, MD, a medical oncologist for the Saint Francis Hospital and Medical Center in Hartford, Conn., said he makes a conscious effort to talk with all patients the same way, even those with medical backgrounds.

That is because even doctors can struggle to cope with the emotional strains of cancer diagnosis and treatment.

“It is unfair to tell another doctor, ‘You know all about this’ or ‘You understand what’s happening,’” Boruchov told HemOnc Today. “Just because a patient is physician does not mean he or she is emotionally prepared for a diagnosis of cancer, and you should not assume they are up to date on the prognosis and treatments. They’re not thinking about what they learned in medical school.”

One of Boruchov’s most prominent patients is David Hull, MD, FACS, director emeritus of the transplantation surgery program at Hartford Hospital. Hull was diagnosed with lymphoma in 2008.

“He is a brilliant transplant doctor, but he deserves to hear the news in as simplistic terms as possible,” Boruchov said of Hull. “I encourage him to ask me to get more specific or speak in more detail if he wants. I do my best not to treat him differently than I would a nonphysician patient.”

After Hull’s diagnosis, he visited five nationally renowned cancer institutions for additional opinions. He was distressed by how he was treated.

“Two had positive attitudes,” he said in an interview. “I was surprised by the number of doctors who would frown, be negative or be unsupportive. I didn’t need any of that. I needed to get better.”

Hull eventually began chemotherapy in October 2008.

In 2010, Hull’s lymphoma became more aggressive, and he stopped responding to new rounds of chemotherapy. As much as he tried to maintain a traditional working relationship, Boruchov quickly realized Hull was no ordinary patient.

Hull was working full time, even as his health failed, and word of his condition began to spread.

“The hardest thing about treating David was that he is such a prominent surgeon in the Hartford area,” Boruchov said. “He trained at least half the surgeons at the local hospitals. I know a lot of those guys, so I would have surgeons coming up to me asking, ‘What’s going on with David? What’s happening with David?’ There is a lot of pressure taking care of such a well-known person in the medical community.”

To the brink and back

Hull was in desperate need of an allogeneic stem cell transplant, but he would not be a candidate until his cancer went into remission or at least responded on some level to chemotherapy.

“I don’t care what you do,” Hull told Boruchov. “I don’t care what trial you put me on, what drug I take, how sick I get or how long I stay in hospital. You get me in remission so I can get a transplant.”

The last round of chemotherapy Hull underwent proved successful.

He then received an allogeneic stem cell transplant, only to develop graft-versus-host disease (GVHD). The condition progressed to grade 4, stage IV steroid-refractory GVHD, which is associated with a survival rate of less than 10%.

As Hull went through treatment, Boruchov did not mention that specific statistic, but also was sure to never overestimate the slim chances of success.

“If you take away hope from a patient, they die,” Boruchov said. “There is often a fine line between being honest and maintaining hope. Sometimes those goals are not in alignment, but when the odds are against someone, you cannot focus only on the actual statistics. You hope there is a window, and you do everything in your power to get them through that window.”

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Hull agreed to nontraditional therapies, including a drug Boruchov had evaluated in a study while he worked at Memorial Sloan-Kettering Cancer Center.

The therapy helped Hull beat the odds for the second time in 2 years.

Hull said his recovery affirmed his approach to caring for patients when both science and statistics suggest they have little chance to survive.

“Sometimes the outcomes are not there, and telling patients they are not going to survive is hard,” Hull said. “Most doctors have a problem with it. They tend to find others to take care of that patient and simply give up the relationship with the family. I have never done that. Certainly now, I stay with my patients and their families even longer.

“I’ve always been a passionate person, and I have always thought of myself as a doctor who spends a lot of time with my patients,” Hull added. “I feel less stressed about finishing up my day and heading home. I want to make sure my patients and their families are onboard with what we are doing.”

The experience also proved profound for Boruchov.

“If we didn’t have those kinds of patients who beat the odds once in a while, I don’t think any of us could be oncologists for long,” Boruchov said. “You live for these patients, and you love when you get them. That’s the kind of patient that keeps you doing your job. So many people don’t get through something like this. Once in a while a miracle happens. It really keeps you going.”

References:

Jacobs H. The Silver Pen website. Available at: www.thesilverpen.com. Accessed Dec. 12, 2012.

Lewis AM. J Clin Oncol. 2011;29:3103-3104.

For more inforamtion:

Adam Boruchov, MD, may be reached at Saint Francis Medical Group Inc., Cancer Center, 114 Woodland St., Hartford, CT 06105; email: aborucho@stfranciscare.org.

Pamela F. Gallin, MD, may be reached at Harkness Eye Institute, 635 W. 165th St., New York, NY 10032.

David Hull, MD, FACS, may be reached at Hartford Transplant Associates, 85 Seymour St., Hartford, CT 06106.

Hollye Jacobs, RN, MS, MSW, may be reached by email at hollye@thesilverpen.com.

Mark A. Lewis, MD, may be reached at Department of General Oncology, 1327 Lake Pointe Parkway, Suite 200, Sugar Land, TX 77478; email: malewis1@mdanderson.org.

Krenie Stowe, MD, JD, may be reached at Rayford Medical & Urgent Care Clinic, 25440 I-45 North, The Woodlands, TX 77386.

Disclosure: Boruchov, Gallin, Hull, Jacobs, Lewis and Stowe report no relevant financial disclosures.