Doctor Gordon Kauffman is with the departments of Surgeries and Humanities at the Penn State Hershey Medical Center. In his piece titled "Communion," he remembers the details about one patient's journey with breast cancer. He wonders about her life beyond the hospital walls... and realizes there is a delicate balance of empathy and loss of objectivity.
Scroll down to watch Dr. Kauffman deliver his "Communion" essay in the video.
Or, read the piece below:
She strikes me as a strong woman when I first meet her in my clinic, a tall, composed brunette whose green eyes are glazed from fear and apprehension. Her attire perfectly matches her professional bearing. Her husband is well built and is wearing chino trousers and a bright striped button-down shirt with no tie. His brown eyes are clearer than hers, but his fingers are persistently fidgeting. The lump she found in her breast has proved to be malignant, and the tumor is invasive. It has the potential to spread!
When I examine her, a mass is palpable, about two inches in diameter. I know that she is carefully assessing my facial expressions for any sign of caution as I examine her breasts and the areas under her arms. I have to maintain a neutral expression regardless of my findings. They know from various things they have read that finding no palpable lymph nodes is encouraging, and this is, perhaps, the only bit of positive news they have received in several days.
I know that neither she nor her husband will retain much of my explanation during this first meeting. Where does a physician begin and end these discussions? Although I have often had the “difficult discussion”, it is always stressful for everyone. Since receiving the diagnostic report from her primary care physician by phone a week ago, she and her husband have been attentive to information about the short- and long-term risks and benefits of different forms of therapy. Her anxiety wanes during our discussion; in fact, I sense the seed of a smile on her lips occasionally.. His countenance, however, falls. I know that he is oblivious to specific points of the discussion. When she looks at him, his outward appearance reflects more than stoicism; he is terrified! His fidgeting has given way to numbness. Their questions focus on a single concern: will she survive?
Following a week of reflection on the panoply of therapeutic options, she has chosen to receive chemotherapy prior to surgical intervention, hoping for a measurable reduction in tumor size that will allow for less cosmetically maiming surgery. It is not vanity, rather an attempt at salvaging a reasonable self-image. I agree with their decision, and they seem relieved. She is stronger today; her statements are resolute. Her voice reflects acceptance of the situation, and her face appears softer. She will accept the paleness of anemia, the gut-wrenching dry heaves, and the alopecia that accompany chemotherapy, hoping for a remission that might not materialize. I am struck by how her strength of character and personal determination inspire me.
A month later I see her at the mid point of her chemotherapy to examine her and review the recent breast MRI. Her eyes reveal an apprehension about what I might see on the images and feel with my fingers. Her demeanor is more melancholy than usual. Her husband again fidgets. How burdensome must be this ambiguity of not knowing whether she is a “responder” to chemotherapy. The ravages of the chemotherapeutic valley can be appreciated only by those who have actually walked it. I tell her that I have professional insights into her path, but I admit that only she knows the truth about that experience. I hope she understands my feeble attempts to appreciate what occurs after needles and drugs invade her veins.
Two weeks later, in the evening darkness of the office, tired from an unusually strenuous day, I find an e-mail from this couple. They have sent some professional photographs with a simple message, “Thanks for being there”. Her face is angelic, her smile bright, her teeth perfect and white. Her dimples are clearly evident, her neck has beautiful poetic lines, and she is wearing a colorful turban that accentuates the natural curves of her countenance. There is a bit of apprehension in his smile while holding her.
From time to time I wonder what happens at their home. Does she ever drop her guard and share her anguish with him? He with her? Does he hold her head when she vomits after each treatment? Do they eat together? Do they think about what chemotherapy is doing to her potential of having a baby? Are they intimate? Does either of them have a single hour in the day free from anxiety about the future? As I reflect on these dimensions of their private life, I realize how delicate the balance is between empathy and loss of objectivity. This is a crucial exercise in self-awareness for every surgeon.
Written by Gordon L. Kauffman M.D.
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