Taking a Break

Taking a Break

Richard T. Penson, MD, MRCP

Jul 25, 2013

It was an awkward moment—the uncomfortable silence and her smarting reply.

I regretted biting my lip and the nonverbal message that gesture implied. I felt bad for the obvious pain that I’d unmasked in her face. Her eyes had narrowed, and she’d withdrawn as if I’d hit her.

It is so much easier when the transitions are smooth, and expected, and a relief. But I kept eye contact, proud of what little grasp I still had of my nonverbal rhetoric, and rather stiffly leaned forward, resting my elbows on my knees as my hands summoned the wisdom of a blind seer, my fingers interlocking in a Hippocratic grasp.  

She leaned back, and I instantly swayed back, reacting to her dance around this terrible issue. She seemed to have held her breath too long, and quietly, and almost breathlessly, exhaled, “I can’t give up!”

“I don’t mean, give up.” My response was too fast, and I looked down, bit my lip again, and hated myself all the more for having done it twice. “I mean, take a break.”

She couldn’t give up, and we both knew that I couldn’t ask any more about it at this moment. The quagmire of that sinking sand was too frightening to explore, and I had to respect her “no go” prologue. In the unthinkable nightmare, there is a Gothic scene of a bereaved family, and she is the specter. She is the ghost. She blinks back reality, so desperately short of time, with so much to do, and so much to live for.

“Well, let’s think about it at least.” We both lightly sucked in our lips. Twice more she narrowed her gaze, tensing her lower eyelid, and marshaling her forehead, swallowing, and blinking her dry eyes.

But it was me who broke the silence with a faint click, a mechanical smack of my lips parting. Very slowly, I said, “I don’t mean ‘give up,’” and succeeding with the emphasis, I drove home the message again, “I don’t mean ‘give up.’ Just take a break. You are wonderful, and very special. Giving up on this—chemo; it doesn’t mean giving up on you.”

She softened. I continued, now banking to the homestraight in a supportive crescendo. “Sure, there’s other chemotherapy, but for now, we should take a break. There’s always time later.”

An image of my niece comes to mind. She is 19 and a trainee hairdresser. She recently and gleefully told me that she’s been told that if anyone is distressed to get them a cup of tea and a cookie, and that she’s tried, and it works. She can fix it.

Outside, in the corridor, jostling back into a busy clinic, I’m not expecting to be stopped by a friendly hand catching my arm. “Hey, d’you want a coffee?”

“Oh, you’re kind. But I can’t take a break right now.” I bit my lip a third time, but with a different, embarrassed guilt behind a shoddily transparent veneer, because I could take a break right now. In fact, I could use a break right now. I looked down, looked at my watch, and with a stupid flourish of theatrical arrogance said, “I’m too busy, sorry. Some other time.”

“Go on. You could use a break.” “Yeah, I could. But there’s not time. Sorry. I have so much to do.” “Well, think about it at least, sometime.” There was a pause, and the busy world of the hospital seemed to dance around us. “Are you OK?” “Sure, fine,” I replied too quickly. “OK then. There’s always time.”

“Some other time then,” I said, walking away.


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Don S. Dizon, MD, FACP

Jul, 26 2013 9:04 AM

Dear Richard,
Welcome to ASCO Connection; I loved this blog about the personal interplay we have in our own heads as we try our best to steer conversations with our patients. Eloquently stated, almost poetic. Thank you so much for sharing.

Michael Jordan Fisch, MD, MPH, FASCO

Jul, 28 2013 5:47 PM

Dear Richard, This is a fabulous essay, and it definitely resonates with me.  Thank you very much for sharing it. There are so many patients and families that touch our hearts, and innumerable words, nonverbal actions, and discrete medical acts and judgments that swirl in our mind.  Some of these things swirl for decades.  This morning, via email, I brought up one of these "swirls" with a colleague--a specific patient encounter from about 10 years ago.  My colleague, a talented young faculty from another institution, provided this reply: 
"What a tough story.  As providers, we do everything we can to help but we can't take away patients' freedom to make their own decisions.  In the end, we have to respect the path they take, even if we believe they are making a mistake.  Clinical work is certainly not for the faint of heart."

When doing work that is not for the faint of heart, it is good to have colleagues with whom to share the experience and who can provide empathy and support.  ASCO Connection is just one outlet for this, one that I'm grateful for.  Sometimes, time is scarce or the vibe is wrong for having coffee or tea.  The opportune moment might arrive 10 years or more later....right on time.    

Ben C. Creelan, MD, MS

Aug, 01 2013 5:52 PM

I can feel the intensity of the emotions in this story. I think the chemotherapy break and the coffee break was a creative juxtaposition. There seems to be a focus upon how gestures play into professional interactions, and what they reveal.

Michael Jordan Fisch, MD, MPH, FASCO

Aug, 01 2013 6:03 PM

Ben, I see what you mean with the creative juxtaposition of the coffee break and chemo break.  Dr. Penson's is a terrific writer.  This piece is provocative and intense at several levels.

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