The Oncologist’s List

Lists guide our lives.  Some are easy, even fun, like a menu or shopping list.  Some are simple tick-offs for work, like my wife’s honey-do list.  Others are frightening, like a draft list.

Some are melancholy, such as the inventory in a Will.  We are inspired by our bucket-list.  Finally, some are exciting, but stir conflict, like awedding invitation list.

I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up.  That is my patient’s list of daily X-ray reports.

Our Electronic Medical Record (EMR), as based around a home page or “Inbox.”  This is a continuously updated assembly of data and messages from our practice and patients.

There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.

Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me.  Not so the eighth list, just four from the bottom:  Radiology Documents.

These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients.  Every 24 hours, between 15 and 30 new reports pop-up.

Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.

One click on each line yields a neat, formatted, typed report. These are more than just data.  More than simple facts.  These are final, cold, hard answers to the biggest questions of all.

Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs?  Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?

Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?

Each line on my Radiology list is a patient’s line in the sand, a division between the past and future.  It measures life lived and life to come; health, disease and prognosis.   Will a child grow up with her mother?  What about the dream of a house by a quiet shore or joyous holidays in a holy place?

Will his next visit to church be to walk at his grandson’s wedding or will he ride the aisle in a casket? Will she take that ultimate trip to explore an ancient battlefield or climb a foreign peak?  Does tomorrow promise healing and hope, or threaten weakness and pain?

This I know and feel as the mouse guides the cursor across the screen.  Always there is a moment of hesitation, a small twist in my throat, a pull into memory and stiffness in my hand.  What calls will I make?  Will I give or will I take?

On the other side of the list, wait patients, families and friends.  Will it be healing or decay?

Physicians cope in several ways with the responsibility of determining good news or bad. The simplest is to focus on the disease, instead of the person. If you look at the biology of cancer and not its social or psychological affect, it is much easier to discover and give bad news.

Doctors understand whatever the emotional burden, making and communicating diagnosis and prognosis, is their job.  Someone has to do it.  Nonetheless, no matter how factual you try to be, how matter-of-fact, in the end you care about your patients and so humanity leaks in, staining your soul.

I remind myself that the longer I wait to tell each patient the news, the more they will fear the worse and the harder it will be.  Do not procrastinate, patients need to know.  I try to keep up with the list, not get behind, even during the course of a single day.

If I delay, eventually there are so many reports, so many patient calls, that the very length of the list is an arduous burden.

Prepare for the answer; when ordering the test explain to the patient what results are likely and what we will do with whatever result.  Still, sometimes I am surprised by the “answer” and find myself making phone calls or holding patient meetings, the direction of which I did not anticipate.

Just opened my Inbox.  The counter next to “Radiology Documents” says that seven reports wait.  Center myself.  Deep breath.  Point the arrow.  Click.

Lives change.

James C. Salwitz, MD is a medical oncologist in private practice for 25 years, and a clinical professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

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