By Narjust Duma, MD
I started writing this story as I recovered from crying for a solid 20 minutes after one of my dear young patients switched to hospice care. He was diagnosed with diffuse large B cell lymphoma 2 years ago. When we first met, he was around 100 pounds, with severe B symptoms. After high-dose steroids and rituximab, we saw him gain strength and start treatment with R-CHOP. His lymphoma responded—interval CT scans showed a complete response. Several months after completing treatment, he called me. Just a few minutes into the conversation my heart started racing; he was describing recurrent B symptoms. We promptly brought him to the clinic, and my suspicions were confirmed. He had lymphoma recurrence.
He embarked on salvage chemotherapy followed by an autologous stem cell transplant. I used to call him on Tuesdays and Thursdays. Once, when my day was busy and I did not call at the usual time, he called our office to make sure I was OK. That is the kind of person he is.
Transplant went well, and he had a complete response once again. Sadly, 100 days later his lymphoma relapsed. This time we proceeded with cell therapy. To say I read the New England Journal of Medicine article a few times is underestimating, I went through the entire appendix of the article weekly until he discharged home. Once again, negative PET/CT scans and false hope at day 30 after therapy.
At day 90 after CAR-T cell infusion, the symptoms recurred. This time, steroids were not helpful, and in a few weeks his liver was completely involved by the lymphoma and failing. On a Thursday morning, we received his blood work; bilirubin was reaching 20. I was accompanied by our pharmacist, and we both cried for a few minutes.
As we went to see him, we saw a wheelchair in front of his room. For the first time, he could not walk on his own. We saw each other and, without words, he started crying. We have developed a special bond over the years, and words were not necessary. He saw my tears—it was clear that I did not have good news. We both hugged for a few minutes, no words, only tears. I proceeded to apologize over 10 times about pretty much everything—his night sweats, jaundice, fatigue, you name it, and I apologized for it.
He asked, “Why are you sorry?” I answered, “I do not know.” He said, “It is not fair,” and I said, “It is not! This sucks!”
We discussed hospice and added new medications to palliate his current symptoms. We both said, “See you later, kid,” as we always did, and he started his 5-hour journey home.
That evening, I cried some more with a glass of wine. I was mourning, I did not want to talk to anyone, and silence was necessary.
The next day, my eyes were still swollen, and it was not a day for contacts. I called him to make sure the hospice agency has contacted him. We talked only for a few minutes. For the first time, he did not have questions for me. He said, “I have made peace, Dr. Duma.” I had no words, only a few more tears.
My mourning was evolving. I was still sad, but I was also feeling defeated, like I had failed my dear patient. I reviewed his chart around four times to make sure we had not missed anything. It was 5 pm on a Friday. I was feeling sad, defeated, tired, and was behind on my emails. I left the hospital, picked up some ice cream, and went home to watch something happy on TV.
I enjoy working on my research during the weekends, no pager, no in-basket, and only a few emails. Weekends, when I am not in the hospital service, tend to be my most productive research time. That Saturday morning, I was not ready; I could not go back to the clinic. I was still sad. I did not have more tears, but I was not ready. Instead, I went grocery shopping, made empanadas, and exercised.
At the end of the day, my mourning transformed again, from defeat into gratitude. I realized that I was grateful to have the opportunity to be part of his journey, I was grateful he trusted me, and I was grateful for having the courage to cry.
During medical training, as in many other professional settings, crying can be seen as a weakness. During my first years of training, I cried a few times in the bathroom so that no one could see me. Many of my colleagues did the same. Crying has a liberating power. Holding back your tears can delay your mourning and affect your well-being. Today, I found crying to be courageous. It shows your vulnerability. When crying with your patients, it shows you feel with them, care for them, and you are human. The opposite, not crying, does not make you weak, either; some of us cry more than others. Mourning, on the other hand, is necessary. We need to heal before we can give more of ourselves to the next patients.
So today, cry, mourn, laugh, yell, and swear (if necessary). Emotions make us human, and embracing our humanity makes us better doctors every day.
Dr. Duma is the chief hematology/medical oncology fellow at Mayo Clinic in Rochester, MN. Her clinical and research interests include thoracic oncology, women with lung cancer, and medical education. Follow her on Twitter @NarjustDuma.