I admitted Mr. J overnight with decompensated cirrhosis. Just reading about him in the chart, he looked complicated: a long-time user of injection drugs, hepatitis C, with resulting liver disease. However, from the moment I met him, he was the sweetest and most respectful man, constantly thanking me in a soft-spoken voice.
Over subsequent days, his family came in and it was a pleasure to get to know them. He was a grandfather, with a new grandchild on the way. His daughter raved about how great he was with the kids. He talked openly about his desire to get off heroin so that he could enjoy his time with his new granddaughter.
During the course of his admission, we took multiple images of his belly that showed a big liver mass. Further workup revealed hepatocellular carcinoma. We sat down and I broke the news. Over the next week, he had a lot of questions. We talked openly about his cancer — openly using the “C word” — and the options he might have for treatment.
It was shocking to me, then, when, on the day of discharge, another doctor came into our work room and said to me, “Do you know Mr. J doesn’t know that he has cancer?”
That's absolutely impossible, I thought. We’ve been talking about it all week! He had cried openly at the bedside with me. I showed him his images. The hematology/oncology team had come to speak to him, the “cancer doctors,” as I specifically referred to them. If this was true, I was shocked, even embarrassed. Was I really that bad of a communicator? How could he not have understood?
I marched into his room. “Mr. J, I want to apologize if there has been any confusion. I want to clarify — one of the other doctors just told me that you were confused about whether you have cancer. I want to apologize to you if I was not clear on prior days but you do have cancer in your liver. Was that unclear to you? If so, it is my fault and I apologize.”
He said to me, “No, no, I heard what you said, Doc. I guess I just wasn’t sure if we knew for sure that it was cancer. I mean, we don’t really know, do we? It still might be something else?”
I was flabbergasted. I felt like saying, “Yes, Mr. J, we do know! There is no doubt whatsoever in anybody’s mind that this is cancer!” If it weren’t for the fact that he was such a lovable, nice guy, I would almost have been annoyed at how dense he was being.
The more I practice, the more common I realize situations like this truly are. Our brains work to protect us. Mr. J wasn’t dumb. He wasn’t a bad listener. I wasn’t a bad communicator (in defense of my own ego). Mr. J’s mind adapted to protect himself emotionally from a diagnosis that was destroying his own perception of his future. His chance to be a grandfather. His chance to finally achieve abstinence from a substance use problem that had long complicated his life. His chance simply to have more time.
In the end, it really doesn’t matter whether Mr. J conceptualized his disease as cancer or not, whether or not he chose to use that word. The mind is powerful. It can protect us, it can deceive us, and it can heal us in times of greatest medical and emotional need. Perhaps Mr. J’s mind — whether I see it as denial or simply a different perspective — gave him more solace than I could as his doctor. He reminded me that if I am to impact the body effectively as a clinician, I must first and always address the mind.
All names and identifying information have been modified to protect patient privacy.
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