I remember when I first started in oncology; I had joined the faculty at Brown three years after fellowship and was seeing a patient* with newly diagnosed breast cancer. She was in her 40s, an advertising executive, married, with two small kids. The diagnosis was unexpected (as it usually is), with a lump found while showering. She had come to see me after surgery, where she was diagnosed with stage II breast cancer.
We had talked about her tumor pathology and breast cancer stage, and I had given treatment recommendations—a consultation that lasted well over an hour. At the conclusion, I made arrangements to see her in three weeks, where we would confirm the plan and likely initiate chemotherapy.
The next week, my colleague (and chief surgeon) came to my office to tell me that this patient asked for another oncologist.
“Did she say why?” I asked, somewhat flustered. I could feel my face turning red and my heart race because I was embarrassed that one of my first patients in a new practice had left—essentially “fired” me. “I mean, I answered all of her questions, and she said she was comfortable with what I said. We talked for over an hour!”
“She told me she wanted someone with more breast cancer experience, that’s all,” my colleague informed me. “She told me she actually liked talking with you and thought you were smart. But, ultimately, Don, she wanted to see someone else.”. And then, as she turned to walk out of my office, she added: “Quite frankly, it was her choice and that choice isn’t about you.”
Now that I am a “seasoned” (a much better word than older, I think) oncologist, I realize that patients will do what they feel they must. Whether it is to seek a second opinion or transfer care to another provider for whatever reason, patients will not necessarily stay and get their care with me. And I have learned that that is okay. It’s not about me, after all. It is about a patient finding a place where she can feel confident and comfortable with her care.
With time, I have learned to accept the requests for a second opinion, and, yes, even the transfer of care to another partner or center. Most patients I meet will stay, and to be allowed a part of their lives is a tremendous privilege. Others will leave, and for them, I try to do what I can to ensure they do not encounter barriers.
The bottom line for me is to realize that patients are consumers of health care. They are seeing us because they need to—and in our field, that need is especially critical because of the gravity of a cancer diagnosis and the sense that some (if not most) patients have—that they have only one life, and only so many chances to get it “right.” They are not in cancer clinics to make us, their clinicians, feel good about ourselves. Indeed, the time of “doc as deity” has long passed.
This came back to me recently, after someone close to me was diagnosed with an advanced stage cancer*. She had seen an oncologist, but the meeting did not go well. She told me later that she was more confused than she was before, and she still could not make sense of what he had recommended, let alone what her prognosis was. She had sat in silence and was spoken to.
Hearing this, I suggested she see another doctor; get a second opinion.
“Oh, I don’t think I should. He has a great reputation in this town—not the best bedside manner, but really smart. I don’t want him to find out I saw someone else. He might not want to treat me,” she said.
As she talked, I was keenly aware of one thing—she was scared. But, she was not exactly scared of her cancer; she was scared of being considered rude or impolite. She wanted this doctor to like her, so he would take care of her. If she saw someone else, this doctor might “wash his hands of her case” and send her on her way.
It was my turn to be frank. “You’re the one with cancer. You’re the one who needs treatment, and you’re the one who needs information. We are oncologists; we know our field, the science, and the best treatments. We can also talk to you about prognosis and what might lie ahead. But, we aren’t living with this diagnosis, aren’t the ones who are going to the infusion suite for treatment. You are. The bottom line—we are here to help you. It’s not the other way around.”
I encouraged her to be honest with her doctor about seeking other opinions. Though she was reluctant, she did it and to her surprise, he welcomed the notion—even provided names of colleagues at his center and in the surrounding area. “He was totally fine with it!” she stated with a look of relief.
My friend ended up staying under the care of her first oncologist, and over time, they developed an easy rapport. After a few months, she would call him by his first name and would recount to me the stories they would share at each visit. When she finished treatment, he declared her “cancer-free.” She cried on his shoulder. It seemed that they had reached a point where the doctor-patient relationship meant something, and she was grateful for it.
I guess this is one of the lessons in oncology. Clinicians cannot and should not claim “ownership” over their patients. We are here to provide—treatment, information, assurance, and comfort. But, sometimes, patients need something else—maybe it’s a fresh perspective on their case, clinical trials, or even someone they might feel more comfortable with. Some patients will opt to stay under our care, as my friend decided with her first oncologist. Others will decide to seek care elsewhere, like my own patient long ago. In the end— it’s a choice that our patients will make. And we should make it easier for them to make them because cancer is hard enough—and our patients should not have to deal with the stress that comes from making sure they are making their doctors happy.
So, when patients decide to seek care elsewhere, so be it. It’s not about us.
*All patient details changed to protect privacy.