A Teachable Moment, or One to Be Ignored?

A Teachable Moment, or One to Be Ignored?

Don S. Dizon, MD, FACP, FASCO

Dec 11, 2018

Originally published in "Discussions with Don S. Dizon" on The Oncologist. 

I love medicine. The chance to interact with people at their most vulnerable, to learn about them and their loved ones, to help them through a diagnosis of cancer, to provide hope in the present and a way to envision the future—it truly is a remarkable thing. Most days I still consider how lucky I am to be doing such important work. I’ve learned I am human, and that it’s not antithetical to the practice of medicine. I try to be conscious of my own emotions and of my own biases, so that at the end of the day, I can feel good about the care I’ve rendered—to know that I’ve treated patients as equally as possible, and that I’ve not determined a course of treatment based on my own impression of “what’s best for them.” Still, in medicine, as in life, patients are also people, and people aren’t perfect. They have their own thoughts and wishes, they have read the literature to reach their own conclusions, and they have their own prejudices, too. In those times, I will admit that even after more than two decades as a doctor, I still struggle to respond.

Such was the case with June*. I had met her several years ago, while she was in the hospital. She was in her sixties, of Japanese descent. She spoke some English and told me she had moved here later in life. Though she never married, she had found a community of friends and had settled comfortably. She did well until a few weeks prior when she had the onset of abdominal swelling. Initially she thought she had eaten something terrible, but then the pain and vomiting started, and after one restless evening, her friends had taken her to the emergency room. She was found to have ascites by imaging and her bloodwork suggested cancer.

We were called to see her after the diagnosis was established—high-grade carcinoma, favoring a Mullerian origin. Given what we knew, I agreed that the likely diagnosis was ovarian cancer. I called a consult and she was seen by a colleague, a wonderful gynecologic oncologist from Mexico. Following an exam and review of the imaging, he called me.

“Yes, I agree—ovarian cancer. But the imaging suggests the disease is widespread. I think she would benefit from neoadjuvant chemotherapy,” he said. We talked more about it and together we rendered our joint opinion—first chemotherapy, then surgery. I had hoped we could still cure her of what appeared to be stage III disease.

She wanted to go home and take care of a few things so opted not to start chemotherapy in the hospital. I felt it was reasonable; she had her ascites drained and was much more comfortable. While I thought chemotherapy should start “sooner rather than later,” I saw no reason we needed to start immediately.

A few days later she came to my office to make plans about treatment. She was doing okay, and she told me she and her friends had read up about ovarian cancer. She was glad we weren’t doing surgery right away—in fact, she was not so sure she wanted to have surgery. “I need my income,” she said. “Taking 6 to 8 weeks to recover from surgery isn’t possible.”

“Well, I am glad you’d like to start with chemotherapy. I and your gynecologic oncologist feel it would be best. The goal of surgery is to take out all of the disease, and given your scans, reducing the cancer you have now would result in better chances of us doing just that.”

I noticed her scowl when I mentioned my colleague—an expression that remained on her face as I talked.

“Can I be honest with you?” she asked.

“Of course,” I replied.

“I need another surgeon. That one was nice enough but you can’t trust them,” she said.

“I’m not sure what you mean,” I said. It was all that came to mind.

“His accent made it hard for me to understand him,” she stated. “But then, I find all of them hard to understand. And he seemed a bit young. I’d like a surgeon with far more experience. And one that speaks English.”

I understood then. She wanted a different gynecologic surgeon—someone experienced and someone without an accent. I sensed the irony because she herself was Asian. I wondered if she had ever experienced discrimination, to know that she was being judged by her appearance and by how she spoke, not by her abilities or her achievements. I bristled at first, recalling the times it had happened to me—I was too young, I didn’t dress like a doctor, and once, because I was Asian.

I struggled to respond. Part of me wanted to confront her—to defend my colleague as the gentleman and talented surgeon I knew him to be, to point to his accolades and to introduce her to his patients, who universally loved him. I wanted to tell her how wrong she was to judge a man by his accent, or by his age.

I didn’t though. One of the first lessons I learned in medicine was that there is a time and a place for everything, and this was not the time to call someone out for her biases (or more frankly, her prejudice). This was a time to show compassion and to ensure she, and all patients that came after her, was treated with dignity and respect, and received the care that all of us would want—and deserve.

So in the end, I put my hand on hers and explained, “Well, if you want a new surgeon, then I can arrange for a second opinion. For now, I want to get you started on treatment, so that you can feel better. That’s our number one priority.”

*Name and details changed for privacy.


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