We admitted the patient to our service from the emergency room to treat her for thrombocytopenia (an abnormally low platelet count) and spontaneous bruising. The patient, in her fifties, was otherwise healthy. True, she had been treated for stomach cancer nearly seven years ago, but it was in remission and had been for a while. She had no issues eating or drinking, no problems going to the bathroom, no blood in her stool, no vomiting, no bloating, no severe acid reflux. In other words, she had no residual gastrointestinal symptoms.
Over the next two days, we ordered other labs, and their results concerned us. Not only were the patient’s platelets low and getting lower, but other blood markers were abnormal, too. Her fibrinogen, a protein that circulates in the blood and helps the blood clot, was also dangerously low. Her INR (international normalized ratio), which measures the time it takes for the body to create clots, was high. These aberrations indicated disseminated intravascular coagulation (DIC). In this disorder, the bloodstream rapidly forms clots, thus exhausting the body’s platelets and clotting factors. With fewer available platelets and clotting factors, patients also experience bleeding. DIC induces a terrifying, circular, and deadly process of clotting and bleeding. As one study showed, if the underlying cause of this brutal pathology is not controlled, mortality is over 20%.
A plethora of disorders, including bloodstream infections and malignancies, cause DIC. But the patient did not have a bloodstream infection — all of her blood cultures were negative and she had no symptoms of an infection. On day two of her hospitalization, we obtained a CT scan of her abdomen and chest, looking for a malignancy. Tragically, metastatic gastric cancer lesions riddled her liver while a recusant growth consumed her stomach leaving little normal tissue in its wake. Unfazed, she calmly stated she understood and asked what her next options were. Though her husband seemed more shaken by the diagnosis, he, too, wanted only to know what came next. This was a diagnosis she had faced and survived before. She believed strongly she could survive it again. We told the patient and her husband that we would contact her oncologist, the same one who had treated her gastric cancer originally. She would, we explained, help us figure out what treatment options existed. It was as if there was a transient release of pressure in the room; they trusted the oncologist and were glad that we were getting her involved. Since it was late in the evening, we promised to reach out first thing in the morning.
On the third day, I called the patient’s physician. Because she was busy seeing patients in clinic and unavailable to take my call, I left a message with the secretary asking that she call me back as soon as possible. The secretary also took down the patient’s information so the oncologist could at least look at the scans and laboratory results to get an understanding of what was going on. When we rounded that morning, I let the patient and her husband know of this development; all of us expected the oncologist would reach out to our team later in the day. But by the end of day three there was no word. I spoke with my attending physician about our dilemma. Since we were not oncologists, we could not prescribe chemotherapy and we didn’t know what the appropriate treatment should be for the patient. All we could do was treat the DIC by transfusing platelets and control the patient’s pain and nausea. Suspended in a kind of medical purgatory with our patient and her husband, we waited for some direction. Our attending physician reached out to the oncologist that evening via email. Perhaps a fellow faculty member’s missive would indicate the urgency of the matter.
But day four brought more of the same. None of us had heard anything from the oncologist after three calls that day. The patient and her husband became understandably more frustrated and their future seemed much more opaque. The patient’s husband pulled us aside and sternly rebuked us. How could we let her sit here like this with no treatment? What was our plan to help her? How were we going to deal with this resurgent cancer diagnosis? With no good explanation we deferred and equivocated, stating that we were doing our best to get in touch with the oncologist who would hopefully give us some guidance soon.
On day five the patient’s mental status deteriorated. She drifted in and out of sleep. Three meal trays came and went untouched. We called another oncologist and asked him to see if he could get in touch with the patient’s primary oncologist or at least recommend some kind of treatment — later in the day he told us that perhaps there were some options but it was not his area of expertise. Not to worry, he assured us, he had spoken with the primary oncologist and she would be in touch with us soon. But she never called. The patient’s husband expressed more and more frustration and anger. Why did the oncologist, someone they had known personally for years, not even come to the bedside to see them? Why did her office not return even the husband’s calls, let alone our own? It was not just a personal affront to them but a professional affront to us. We felt helpless.
Finally, on day six, our attending got in touch with the patient’s oncologist and during a phone conversation asked about possible chemotherapy options. She replied, “What chemotherapy? There is no chemotherapy option! There’s no treatment option whatsoever.” By this time our patient was more somnolent, more often unconscious than conscious. She labored to breathe as her pale and gaunt face withered away. She was dying. I spoke with the husband and told him that we had finally heard from the oncologist: no chemotherapy options existed. We could only make her comfortable as she passed from this world. It was as if he knew this was coming, throwing his hands up in the face of this tragedy and walking out of the room in tears.
At the end of the week, the patient died.
We were indignant. Clearly, the oncologist abandoned her patient. Despite the close relationship they once had, she had not come to see the patient nor reached out to her or her husband to explain the situation. Anger permeated our team’s discussion that evening as the two residents on my team and I packed our bags and headed out of the hospital. We swore we would never do that to our patients.
One cannot know for certain what was going through the oncologist’s mind as her patient’s illness evolved. And it is difficult to malign such behavior without knowing all that was happening at the other end. Did she feel overwhelmed by the grief of her day-to-day job? Because of her closeness to the patient and the patient’s husband, did she want to avoid telling them the prognosis and outcome? Whatever the case may be, it was wrong of her to vanish when the most trying time came. Yet it is worth exploring what may have occurred.
In his book Thinking, Fast and Slow, Nobel laureate Daniel Kahneman, an economist and psychologist, explains that psychological literature supports the concept of familiarity breeding comfort. Repetition, he states, “induces cognitive ease and a comforting feeling of familiarity.” He describes how, in an experiment run at the University of Michigan and at Michigan State, psychologist Robert Zajonc and his team placed Turkish words in ad-like boxes in the student newspapers. Different Turkish words were shown at different frequencies, some once, some up to twenty times. The investigators then sent questionnaires to the students asking about their impression of the words. Kahneman writes, “The results were spectacular: the words that were presented more frequently were rated much more favorably than the words that had been shown only once or twice.”
Medical training is nothing if not a long series of repetitions, of exposures to similar diseases and situations. An oncologist sees cancer and its morbid consequences every day. This may not breed the kind of positive reactions that Kahneman describes, but it likely elicits an increasingly tepid and nonplussed response from the physician. Poor outcomes or test results shock less than they would most others. Perhaps our patient was one of ten with similar diagnoses witnessed by the oncologist in the last month, and one of a hundred in the last year. And maybe that led to a dismissal of this fatal and unconquerable diagnosis. Why invest time in another situation like this when failure is guaranteed?
Danielle Ofri, a clinical professor at the NYU School of Medicine, thinks about this slightly differently. In her book What Doctors Feel, she references a 2012 study on the nature of grief and patient loss in the lives of oncologists. The oncologists in the study attempted to compartmentalize their sadness and grief in order to keep them separate from their work and their personal lives. But they failed terribly. Dr. Ofri writes,
The pervasiveness of death often led to a relentless sense of grief among the oncologists, not just for the patients who had died but for the patients who they knew would be dying soon…. Grief ate at these doctors, distracting them from both their families and their patients. Many reported withdrawing from emotional involvement with their patients and that their patients had noticed they weren’t fully present.
The problem, in Dr. Ofri’s eyes, is an overwhelming amount of grief thrown at the physician on a day-to-day basis. It is certainly possible, in the particular circumstance I described, that the oncologist felt too sad and too upset to come see the patient.
Interestingly, both of these theories are rooted in the same etiology: overexposure. It is a conundrum of our nature as human beings. Repetition either exhausts us or anesthetizes us. Do we need to limit physician hours or days worked? Do we need to limit physician obligations during the day to allow for these kinds of important conversations? I don’t know the answer. Until we figure out a solution, reason and empathy must keep watch over our conditioned responses, lest we abandon those most in need of our help.