Paul - Oncology Day 4

aaaaaaaMy last day in oncology was, at the very least, a huge culture shock. Dr. Chang and I scurried to his last patient of the day, a 23 year-old woman with a football sized abdominal mass and multiple liver metastases. He performs the “crease sign” test. He asks the patient to relax her palm in his hand as he passively extends her phalanges in order to observe her palmer creases for color contrast against the surrounding skin. Little contrast is noted, which signifies that the dose of EPO (erythropoietin) has probably failed to mitigate her anemic condition. He will confirm this with the blood labs later.

For now, he asks how the patient feels. She is speechless for a moment, but then begins to describe a dream in which her tumor resembled sharks swimming through her bloodstream, implanting their vicious snouts in various vulnerable visceral organs. With that, it’s time to face what he defines as the toughest part of his job: Delivering Bad News. We begin our 200-foot journey to a private room where his 23-year old patient’s family awaits his arrival. In Taiwan, when a doctor requests a private conference with a patient’s family, it almost invariably means that he will have the words “impending doom” invisibly written across his forehead when he sees them. In many cases, patients’ family members must take advantage of every second that a doctor allots for their case. Hence, they choose to relinquish their right to utter privacy to achieve a higher priority – making sure they know exactly what’s going on with their loved one.

Dr. Chang sometimes feels powerless with Taiwanese patients and families for many reasons. In general, Taiwanese patients come to physicians much later than American patients do. This is well demonstrated in many epidemiological studies, one of which illuminates the stage of cancer in which oncological patients first enter the exam room. For Americans, it’s around Stage 1. Taiwanese patients, however, endure visible and tactile symptoms until Stage 3 or 4 before finally seeing a physician. Cultural differences such as the encouragement of pain tolerance and anti-pharmaceutical ideals might be two of several causes of this phenomenon.

I observed even more frustration in Dr. Chang’s expression when he described the convoluted process of delivering bad news. Taiwanese believe even less in exhibiting emotion than do Americans, and families are often outraged if they are not informed of their ill relative’s status before the patients themselves! This forces him to offer health status information to close family members first, who are universally unreliable in forwarding his vital news. It often takes several days to reach the patient, when they must begin the stages of grief and further delay their ability to make sound decisions based on Dr. Chang’s expertise. For this reason, the 8^th floor’s most welcomed visitors are Psychiatrists (yay! That’s me in the future!!!! Hold up, oh no!! What am I getting myself into??).

With all of this swarming through my head, Dr. Chang and I entered the 80 square-foot room into which 12 family members were stuffed. On the room computer, he pulled up a CT image and MRI images of their 23-yr-old daughter’s abdomen and liver.

Upon explanation and informing them of her terminal status, the room is numb and a biting silence empties the room of hope. No tears are flowing, but even without understanding the entire explanation in Mandarin, I can’t help but absorb the unexpressed anguish. My cheeks and eyebrows begin to throb and I quickly disguise my face with my H1N1 mask. Dr. Chang breaks the cold silence to rationalize his inability to administer more EPO. EPO, although good for stimulating the production of RBC’s in anemic conditions, is dangerous in cancer patients. As a cousin of VEGF (Vascular-endothelial-growth-factor), EPO has the potential to feed the tumor even more, rushing the patient to an even earlier “time of passage.” The silence was short-lived this time, and the patient’s father burst into emotion. Following his tears was the rest of the family’s, as if they had finally received the permission they needed from him to cry.

I rode the elevator down from the 8^th floor both reluctantly and thankfully. Dr. Chang has re-inspired me to be an extremely competent doctor and passionate educator. I am so thankful for this first week and have left it in a state of awe.