My First visit with Each New Cancer Patient and Family

From the first minute of the first doctor visit, sick, frightened patients are on hyper-alert, whether their perceptions and observations are correct or not.

The companions in their loved one’s hospital room or in the doctor’s office carry with them a horrifying vision of suffering, pain, and ultimate death.

Their loved one has been cursed with the word CANCER; their heads are filled with the unjust horrors perpetrated by an uncaring Inquisitor of Fate.

This was anxiety no gentle hand on the knee could allay.

Kind eyes and a fancy suit were inadequate.  A ‘pitch’ to sell myself as competent and caring was in itself diversionary, a kind of slight of hand, and an unfair tool to calm fears that deep and pervasive.

Instead, I recognized the reality of their fears, and admitted my own if our roles were reversed.   Then I offered a deal.

I required that everyone in the room to put aside their terrors and try to listen carefully for a few moments.

In return, I promised clear, completely honest review of what their diagnosis was, what it meant in terms of their anatomy and body function (physiology), and precise explanation of ways a cancer could threaten the patient I was addressing.

This initial explanation had an incredible, unanticipated impact on me.  I remembered every word of my initial interview with every new patient for decades.

This completed, I’d ask for questions.  There usually weren’t any.  Everyone was waiting for the gory, scary stuff hiding on the second page.

I proceeded to outline the natural history of the patient’s tumor, based on the biology of each patient’s tumor cells.  This provided a rough timeline of what lay ahead.

Patients were astounded to learn that most adult cancers take a decade to grow from a single cell to the size of a small marble.  That took much of the fear out the diagnosis:

I reviewed the diagnostic studies, which indicated the extent and location of their tumor. I showed patients their survival curves—a graphic description of the risk of death from a similar cancer with, and without, treatment.

I then described the details of what I felt to be the best treatment to attempt to cure, or more often to prolong the life of my patient. I outlined the major side effects of treatment, answering questions from the cousin whose uncle had fared badly after chemotherapy.

This approach fulfilled several objectives.  First, patients—and family—got to know this stocky guy who was proposing to take charge of a life snatched away by the mention of the word “cancer”. Second, it gave everyone in the room breathing space, time to quiet whatever horrors they brought with them to the consultation.

Sometimes I had to repeat, review or expand explanations until there really were no more questions.

The cost of this effort was time.  Even after years of practice, when I had become more efficient at presenting the necessary data, the final determinant of the cost in hours and minutes were the patient and family.  I wasn’t done till the maelstrom of fears were calmed by facts, commitment, and an operating plan.

How did this affect my office staff?  They were incredibly understanding and loyal.  If someone had to leave at an absurdly early hour like five p.m. we would arrange for whatever studies were necessary during my “teaching” session. Then they’d leave me to close the office for the day.

What about patients, anxiously waiting to be seen? After their first visit, they understood that they had been recipients of all the time their problem required.  And nobody made a peep.  All knew that if their illness required too much time, they would receive it unfailingly.  And everyone had my home phone number from day One.

How did this affect my life?  I was late for Everything!!! In the evening, I often made house calls to patients when I was not convinced that everyone in the house understood, and accepted our plan.   So I was late to see my family.  I didn’t see any of my girls’ baseball, or gymnastics, or swimming games on week-ends, because I did this every day.

Was there a more time-efficient way to do this?  Could handouts, or recorded lectures, or slide shows do the same thing?  I thought not.

A sick person in fear for his or her life had chosen to come to me for help.  It was therefore my responsibility to foster a feeling of deep, honest connection and to leave patient and family with a new, more structured and less terrifying understanding of their illness.