Originally published in "Discussions with Don S. Dizon" on The Oncologist
Being at a tertiary cancer center where women come from distances for consults and reconsults, I see a lot of patients who end up not being treated in Boston. Some become part of my clinic—women who check in every 2 or 3 months, sharing management with their local provider. I have always said that the best cancer care is local, and so many of my colleagues outside of Boston provide consistently wonderful care. However, times may be changing as clinicians are dealing with increased patient volumes and less ancillary support.
Such was the case with Gabby*. I had known her for 6 years, after she had been diagnosed with recurrent endometrial cancer. She had been through multiple therapies, and each had had success, rendering her progression-free for months that had extended into years. Until now.
During her last few visits to Boston, we had watched with alarm as her tumor markers rose despite changes in treatment, and then imaging that showed evolving metastatic disease in her liver and lungs. Although she remained symptom free, the signs were ominous—that her cancer was now refractory to treatment.
At her last visit, we decided on yet another chemotherapy. It was in a class of agents she had not seen in over 12 months, and I had hopes we could stabilize her disease. Following one cycle she had developed abdominal pain in her right side and I worried it signaled progression in her liver. A few days later, her best friend emailed me that Gabby looked terrible, that her pain was increasing, and she could no longer eat. She told me Gabby had gone in to initiate her second cycle, but that a CT scan was urgently ordered, and that she would meet with her doctor to decide what steps were next.
Not being there locally, I waited to hear the results of the scan. That afternoon, Gabby called me directly. Although she had my phone number, she never used it before, so I knew it had to be urgent. I called her back.
“Dr. Dizon—I didn’t see a doctor, just the new nurse practitioner. She just started, so I really don’t know her. Anyway, she told me my doctor wasn’t in the office, but that she had talked to the one who was in clinic. She told me that doctor said to tell me that I should stop all treatment and my cancer was much worse. She told me the doctor thinks I should be in hospice.”
I was floored.
This patient, who had been a part of the clinical practice locally for 6 years, literally had the worst news delivered to her in quite possibly the worst possible way imaginable. No one sat down with her to examine her before the scan, and someone who was new to the practice relayed the news of the covering doctor, who never came down to see her.
Ultimately, I decided to reach out to the covering doctor. I wanted to understand why she had not gone and seen Gabby—why she felt that this was an appropriate way to deliver such news. We spoke at length, and while she expressed regret over how the situation was handled, she also noted that she had been in clinic, which was overbooked, and she was already running behind: “Honestly, I didn’t see her because she wasn’t even on my schedule.”
As she said it, she realized how awful it sounded, as did I.
We talked some more, but even as I hung up the phone, I was dismayed. As clinicians, we are finding ourselves in a precarious situation; we are asked to see more patients, with each scheduled at 15- or 30-minute intervals, which never reflects the reality of clinical oncology. Our patients are complicated. One of those 15-minute visits can consist of a very serious conversation—about a new diagnosis, disease relapse, cancer progression, end of life—and such situations can never be rushed. Still, our systems do not take these in to account, and as a result, care can be compromised.
But, even so, oncology requires compassion and humanism. We cannot let our patients feel like they are just a number in our calculated RVUs. They deserve our time, consideration, and empathy—even when we are covering.
“She wasn’t on my schedule.” This can never be acceptable. Not in medicine, and certainly, not in oncology.
*Name and identifying details changed for privacy.