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Massachusetts General Hospital, Editor-in-Chief, The Oncologist
During the past few weeks, I again had the opportunity to attend on the general medicine service of my hospital, and greatly enjoyed the experience of dealing with the new housestaff and their always fascinating patients. Perhaps the most interesting aspect of the rotation was the chance to talk with patients from many different backgrounds and with many different life stories. Nothing can replace the experience of ward medicine. In several instances, these casual conversations with patients revealed deep-seated and unexpected sorrow. Tapping that well of sorrow was essential to understanding both the medical and spiritual states of two patients, whom I will briefly describe.
The first patient, a 50-year-old man admitted for evaluation of chest pain, was a successful private psychologist who described a recurring tightness in his neck and chest associated with lightheadedness, a symptom complex he had experienced intermittently for a decade. The symptoms were atypical for angina, and his work-up, including stress test, did not confirm ischemia. We were struck by his rather emotionless description of his pain, and his willingess to volunteer few details of his life, beyond the past use of drugs and alcohol. He was reserved to the extreme, almost stoic, a surprising affect for a professional psychologist. On the day of his discharge, I happened to sit down in his room and asked him about his work and his family life. He had begun experiencing pain and anxiety attacks 9 years ago. These symptoms began when his son was killed at the age of 18 in a golf cart accident. He had been divorced years before, and had raised his son with great devotion. The loss had been devastating, leading to a withdrawal from a very successful professional practice and a growing problem with alcohol and drugs. In the past several years, his life had come back together, and now included a new wife and a 4-year-old child. Still the lingering sorrow of his loss pervaded his life, and stood as an obstacle to a fuller investment in his work and family.
The second patient, a 58-year-old woman, experienced a different kind of loss, but a no less profound sense of despair. She had been a strong, apparently healthy homemaker, the matron of a large and loving family, until the onset of progressive angina 6 months before. She had undergone a coronary bypass 5 weeks prior to this admission, but at this time was readmitted for poorly described "pain." To the housestaff this patient seemed frustrated and angry, and incapable of giving a consistent story. Restenosis? New angina? Pericarditis? On careful history taking, the pain apparently localized to the abdomen, was transient, and did not seem at all like angina, and the absence of ischemia was borne out by stress testing. She had a past history of diverticular disease, and the pain was tentatively ascribed to this abnormality. However, it became clear in further conversations with her family that our difficulties in communicating with this seemingly intelligent woman were part of a larger problem: she had become increasingly withdrawn and sad at home, shunning conversation, crying, and increasingly convinced that she had made the wrong choice in having surgery. Her loss of strength, her slow recovery, and her inability to resume an active life confirmed for her what seemed to be an irreversible change in her health and a devastating loss, and led to a great anger towards the doctors that had promised her a full recovery. I sat with her and said, "You seem terribly sad." Tears, frustration, and anger poured forth, but most of all, fears that her good days were over and irretrievably gone. I responded with a recounting of my own recent experience with major surgery. Once past the tears, our discussion of the slow pace of recovery from anesthesia, surgery, and her own unrealistic expectations, seemed to surprise her and give her new hope, but clearly the emotional aspect of her recovery had been neglected.
Upon further reflection I realized how often we professionals fail to understand and anticipate the implications of loss, and the resulting sorrow that inevitably accompany tragic events. Sorrow seems to be the common denominator. I remember so many others on this ward rotation; the young man who survived acute leukemia as a teenager, but lost his prowess as an athlete and turned to drugs.
Illness and accidents change our lives forever. Former sources of pleasure and pride are swept away and are replaced by pain and disability. The psyche changes, and cries for help, poorly formulated and difficult to recognize but nonetheless important, require a response. As cancer specialists, we see this sorrow in our patients every day, but often forget to break through its surface. It is there in the symptoms and the affect, in the difficult family relationships, and in the anger that is expressed in so many forms. It demands our time, our understanding, and our compassion. Assume it is there, because it is often a significant part of the "medical" problem.
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