Wednesday, May 03, 2006

Escapism

a quarter of my patients have cancer of some kind.

i've spent the last few days taking them into quiet rooms, sitting them down, asking the same question over and over.

"what have you been told so far?"

they go on about how they came in with a chest infection/fluid on their lungs/etc and then i have to launch into the splendid bullshit.

"that's right. now that scan we did yesterday. well it's shown a lesion/mass/abnormality/cyst/shadow/irregular feature and we need to do a few more tests and speak to a few specialists before we can tell you exactly what it is and act accordingly."

what i want to say is that it looks, smells and tastes like cancer. you have cancer. and the pains we'll put you through to get the sample of tissue to prove this isn't going to change the fact that you have cancer.

of course we're not supposed to say that. in fact i got a telling off as a freshly qualified boy doctor for saying to a patient that although we weren't sure yet what we were concerned about was the possibility that his mass (in his pancreas) may be cancerous.

bad Dr D&C. go and kneel before the GMC with your trousers down.

don't you realise, i was told, that if you even MENTION the "C-word" then it will do more damage than the diagnosis itself.

quoi?

the word will do more damage than the cancer? somehow the word will metastasise and infiltrate all his organs? the word will cause him unbelievable pain and nausea and diabetes in a cruel twist?

no, i was told, we must wait for a tissue diagnosis.

of course said tissue sample took four weeks to get because the procedures (cameras down his to his duodenum and the probing around with a brush in various sphincter) ran into problems each time. anyway, we did finally get the biopsy, we told him he had cancer, he said he had expected that it was going to be cancer and then he died the next day.

but of course it was not the adenocarcinoma that killed him, it was the word.

anyway i must now bite my tongue. i shall wait the time it takes to get Mr K's pleural fluid back from cytology, i shall sit in patience as the lab slices through Mrs G's gastric biopsy and i shall make sure everything is ok after they've had a wash around Mr P's lungs with the bronchoscope. and then, one week on, EVEN THOUGH WE ALL KNOW NOW THESE PEOPLE HAVE CANCER, we shall tell them that they have cancer. in the meantime i shall lie every day to them, through the veil of " we need to do further tests" and "the lab is still processing the sample you poor cancer riddled bastard" before calling in the palliative care team who can start the syringe full of morphine and hasten their discharge to Rose Cottage.

excuse me, i have to go and put on my best used car dealer outfit in preparation for a day full of mendacity.

[i am listening to Primal Scream's new single. i saw this on the web today and it made me very geekily excited]

8 comments:

Shiny Happy Person said...

It's absurd, isn't it? We perpetuate stigma within medicine. I sometimes think if we pussyfooted around less, people wouldn't be so terrified of such things. By refusing to say the C-word until the last possible second, you're just feeding into the notion that it's so terrible we can't even bring ourselves to say it. Kind of similar to HIV testing. I've never understood why we're supposed to go through the whole counselling rigmarole. We dont' counsel before testing for any number of other nasty and life-threatening diseases, so why HIV? We test for Hep B/C without counselling - also life-threatening and transmitted in a socially unacceptable manner - so why not HIV? Because of stigma. You're sending out the message to people that this is something SO serious and SO scary and SO taboo that we can only talk about it in whispers.

But you have to carry on doing so because otherwise you'll get sued for putting people through the trauma of believing they had cancer when they didn't.

Julie said...

As a nurse I must say the more direct and honest approach was always best. All too often people didn't just wait until all the evidence was back, they just told people it was a cyst, lump, tumour etc and left it at that. Next thing, I am visiting them at home to find they suspect the worse but haven't been told.

Mekon said...

By looking at false positives from screening, you can get a peek at the effects of "the words". Plenty of evidence out there for clinical levels of anxiety in the short term, for sure (cancer, diabetes, etc), once the diagnostic test comes back clear, things seem to come back to normal (with cancer, at least).

You could always forward this to your snotty-nosed friend:

http://jech.bmjjournals.com/cgi/content/abstract/51/6/705

Vegas said...

If you tell a smoker they may have cancer and then the test comes back as normal, he/she is more likely to give up smoking than if you had said "there is a shadow on your lung."

If you tell a little old lady she may have cancer and the test comes back as normal, she might have spent 2 weeks worrying for no reason, but she will be very happy when you give her the all-clear and will probably relish every subsequent day of her life.

If you tell someone they have cancer and they turn out to have cancer as suspected, at least they have time to sort out hteir finances and make arrangements to get caned as much as possible before the chemo starts.

Despite all this, I am brain-washed in the same manner as everyone else to dodge the issue and only reveal the diagnosis once we have decided if/how it can be treated.

And Shiny Happy Person - I agree regarding HIV. It should be a routine tick-box test. If we found more people with it, they could be treated,kept alive and we might even stop it being passed on.

Anonymous said...

One patient stands out for me from my days as a student nurse. She had pancreatic CA. Her family had made the decision not to tell her (in those days that happened!!) She knew that the truth was being hidden from her and found a way of asking if she had an incurable disease...she asked me if I thought she should go back to work part time so that she could play more golf.
Problem is that we don't treat people as individuals....one size fits all....the latest study may say whatever you like but it may not nesessarily meet everyones needs?

Anonymous said...

Dr Dazed and Confused -
This is completely unrelated to this post, but should answer a question you asked elsewhere (you'll see why I'm being cagey if you do this).
Have a look at Dr V.Sinner's entry and comments for January the 6th.

Dazed & Confused said...

thanks anonymous. everything is clear now (again) - you should have a look at his blog again. very... interesting.

Dazed & Confused said...

SHP: absolutely agree too about HIV counselling. stigmatised beyond belief.

mekon: couldn't get the full text of your article so only read the abstract. i'm sure there's stacks of evidence on the "best" way to inform people of their life threatening diagnoses. at the end of the day it's all a bit pragmatic. it is completely different when you have to see someone daily for two weeks, when you build up a relationship with someone and effectively have to withold information from them. very difficult to reconcile especially when they break down in front of you, as the guy who has squamous cell ca (again pretty obvious from his history but only confirmed on biopsy yesterday) did last night.

there's evidence and then there's putting it into practice. can be diametrically at odds, even when it's "just" words.