We are 20 minutes into the visit. My patient is 77 years old, a retired school administrator. She was sent to the oncology clinic for a new diagnosis of lung cancer with metastases to the liver and bones.
I was asking my usual questions – how did this all begin? – and I was hearing the usual answers. The cough that didn’t get better with antibiotics. The unintentional weight loss. The chest x-ray that looked “fuzzy.”
I continue: How many packs of cigarettes a day, and for how many years? Any family history of cancer?
These were my standard questions. They were met by hers: “How did I get this?”
I recently hosted aon common, difficult questions we hear in hematology and oncology. How long do I have to live? What would you do if this were your family member?
This was another. There are variations to be sure. How, why, why me, what did I do, what didn’t I do, did my doctor miss it, if I had this or that test would they have caught it sooner?
When I was an internist, I talked about prevention. Meeting a new patient meant sizing them up for risk factors. In their habits I saw opportunities for healthier choices. In their family histories I gathered warning signs.
Now, I ask the same probing questions, but the purpose is not the same. Smoking, alcohol, family history, I ask these of everyone, I reassure them. It’s no longer about assessing risk. It’s not to place blame. But they read into the fact that I am asking, because they have asked themselves the same.
They ask why.
I try not to overdo the pity. I say that I’m sorry this is happening, but I don’t dwell. What I want to convey is the opposite – it’s normalcy. What I want to convey is: I’ve seen this a million times. This is where we are, and here is where we go. We don’t dwell or regret or wonder what if. My patients don’t want sympathy – at least, not from their doctor. They want a plan.
They ask: How did I get this?
It’s bad luck, I say. It’s a genetic mutation causing a cell to replicate.
My answers do not always satisfy their questions. Because it’s not a question seeking an informational answer. The truth is, medically and existentially, I don’t know. None of us do. The question is an existential itch no medical jargon can scratch.
I have a modern Hippocratic oath tacked to a wall in my room. “I will prevent disease whenever I can, because prevention is preferable to cure,” it says. True, but that offers little solace to those who already have the illness. Yes, we need prevention. And we need a path forward when tragedy has already struck.
I am humbled when I meet a new cancer patient because the visit is a metaphor for a nonjudgmental life. There’s something beautiful about meeting someone exactly where they are, where decisions made in the past are as irrelevant to me now as they were to the cancer.
When they inevitably ask “how did I get this?” and I answer, what I’m really saying is this: I don’t care what you did, or didn’t do, or how we got here. But we are here, and so I am here with you, and from now on the only place we care about is here and now, the only direction forward.
Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz and listen to her each week on the Blood & Cancer podcast.