Get Permission

The swastikas on his knuckles kept stealing my attention. I tried not to stare but every time he gestured to emphasize his words my gaze snapped back there. That awful symbol, multiplied across all 10 digits, refused to be ignored. The blue lines were blurred and misshapen, probably jail tats. I grew up in a prison town and then joined the navy. You would think the inking of flesh could no longer hold any fascination for me.

My appearance seemed to be equally distracting to my patient and his wife. Hair just beyond clipper-short, no makeup, button-up shirt, and pressed slacks. I could practically see the thought bubble over their heads, “Definitely a lesbian.” Different word, though. Their brows creased every time I spoke. I had learned not to expect much from people who looked at me that way but wrestled the feeling down. We had serious business.

I explained what we needed to do together. Five and a half weeks of radiation treatments if we went through without a break. Not too tough day-to-day, but a real marathon taken together. Fatigue, loss of appetite, and loose stools. He’d have to eat as best as he could. His wiry frame didn’t carry much he could afford to lose. I glimpsed at his teeth and wondered if he was still using meth and not admitting it. We were going to have a long couple of months. He sat stiffly while I listened to his heart and lungs as if I were a ghost that would become real if he acknowledged it. I took a chance and patted his shoulder reassuringly anyway.

Kathryn E. Hitchcock, MD, PhD

Kathryn E. Hitchcock, MD, PhD

An Uneasy Alliance

He was alone when he came for the first of his weekly on-treatment visits. His body language announced that he was not excited to talk with me, but I deliberately stayed away from the computer. I would be all-in on this even if he wasn’t.

“Your weight is steady so far. You must be doing a good job with eating,” I said. He nodded and looked at his fingernails.

“Any pain?”


“Bowels doing ok so far?”

“Yep.” He sighed and looked at his watch. I knew my excellent, meticulous nurse had covered all of this already. I just had to find some way to get him to talk.

“How is your wife taking this?” I asked, without moving or changing my tone of voice. He was so startled he actually jumped a little and met my eyes for the first time.

“Um, well I think this is real hard for her. She has to work while I do this. We gotta have her insurance.”

“Yes, that’s how it is for most folks unless they’re retired. Thank goodness you guys have insurance. A lot of people’s spouses, or even the patients, have to work the whole time to try to pay for this in cash,” I said. “Money’s the last thing you should have to worry about at a time like this. But it’s always there, isn’t it?”

“Yeah, it is,” he said, and paused. “I think she might be a little depressed.”

“I can imagine,” I said. “For people who have brain chemistry that tends that way anyhow, and sometimes I think that’s all of us, this is exactly the kind of situation that can make it hard to deal with that.”

“Yeah, I guess so,” he said, pensive.

Making a Breakthrough

I let him think on that for a minute and then: “What about you? Do you think you’re feeling depressed?”

He shrugged with one shoulder, wouldn’t look at me.

“Whatever you think about that I trust your judgment,” I said, “But you told me you’d used some drugs before. I know for a lot of people that’s a way to try to dig their way out of depression when they can’t get to a doctor for whatever reason.” I held my breath, hoping I hadn’t just made things worse between us.

Slowly, to my great relief, he started to nod. “Yeah, I think I’ve been pretty far down for a long time. It’s hard to get a job,” he said, holding out his inked hands and gesturing to the Confederate flag on his neck. “Once you been convicted, it’s hard.”

“Yeah, I’ve heard that,” I said. “Tough when people judge you by how you look before they get to know you.”

He met my gaze again sharply. He knew I wasn’t just talking about him.

“So you know,” I pressed on, “There are treatments that can help get your brain where it’s supposed to be. We just aren’t made for this modern life we live. We’re wired for chasing buffalo across the plains and taking them down with spears. Instead here we sit on fluffy upholstery with the air conditioning blasting over us. Our bodies are comfortable, but our brains just can’t deal with it sometimes.”

He nodded. “I guess so. I guess I never thought of it that way.”

“So what do you think? Want to see if we can get your brain to a better place?” I asked, trying not to let my voice sound too hopeful. I doubted he was ready for any sort of agenda from me.

“I guess maybe so,” he said slowly. “Is there something we can do now?”

There was. Like so many before him, he learned that when he had someone to tell about the many weights on his mind, and added some better brain chemistry, the world looked like a very different place.

The Power of Change

At the start of his third on-treatment visit, he actually stood up and shook my hand. No smile, but I’d take what I could get. We talked about the usual things. His gut was not loving the rads. I reiterated the need to stay hydrated and not work outside too long in the Florida heat. He said a friend of his had started coming over every evening after dark so they could get a little work done while it was less than 90 degrees outside. They were shade tree mechanics of some kind.

When we were finished, he got up and headed toward the door but paused with his hand on the knob. “I saw your technician, the lady who gives me my treatment, I saw her looking at my tattoos yesterday. I was wondering if you could tell her for me that that’s not who I am anymore. I was full of hate back then but I’m not too proud to say I was wrong. I was gonna get rid of them, do that laser thing, but now all that money’s going to my cancer bills,” he said, searching my face for some sign of understanding.

I just blinked for a moment. This was more words than he’d given me in our entire acquaintance, all at once. There was a lot to unpack, there, and I wanted to get it right.

I finally decided on a reply. “She grew up in the South. I think she gets it. You’ve been nothing but polite to everyone here. I’ll make sure she knows, though.” That therapist had a best friend whose granddad was a vocal segregationist, but whose parents doted on both women as though they were twins. She knew people could choose to be better than their upbringings.

He nodded. “I’ve changed a lot.”

“Sure,” I said. “None of us is who he used to be. We just have to try to keep moving in a good direction.”

“Yeah, it’s hard to know what that is sometimes, but I’m trying. Thanks for understanding.”

“Of course,” I said, “just remember this conversation later when I do or say something stupid, ok?”

“Sure doc,” he said, “I guess I can spot you one.” He smiled then for the first time since I’d met him, and it was truly beautiful.

Embracing Kindness

His wife was with him on his last day of treatment. She talked to me this time instead of looking at the wall while she spoke. She even smiled a little. He cradled his diploma carefully in his lap. We give people a certificate when they finish their last radiotherapy treatment, tangible recognition of what they’ve endured.

“Thank you for taking care of me. Sometimes doctors try to get rid of me because of how I look,” he said, fiddling with the snap-back of his mesh trucker-style hat.

“Well, I guess I can sympathize. Sometimes people don’t have much use for me because of the way I look, too,” I told him honestly.

“Yeah, when my wife and I first met you, we wondered what we were getting into.” He laughed and I laughed with him, remembering the furrowed brows. She looked a little embarrassed but smiled shyly. “We thought about changing doctors. I’m sorry about that. We just haven’t known anybody like you before. I’m really, really glad I stayed.”

“Well I’m glad I’ve made it worth the try. We’re all learning as we go aren’t we?”

“Yeah,” he said. “I’ll tell you, this cancer’s been good for one thing. I understand a lot more what’s important in life. There’s so much I can leave alone now. I feel like one of those great old guys who love their gardens and their grandkids. And really they love people, too. Everybody. They just laugh at the rest of us running around worrying about who deserves a nice car. Or who should get to be the head of the parent teacher association. They’re happy just so long as people act right.”

“Well, I’ll hope that rubs off on me,” I said. “Maybe I can get a little ahead of the usual schedule in figuring that out, because of you. I appreciate your talking to me about it.”

“I appreciate you,” he said, one arm out in the offer of a hug but holding back a little, prepared for rejection of his kindness.

I took him up on it. 

DISCLOSURE: Dr. Hitchcock reported no conflicts of interest.

Dr. Hitchcock is Assistant Professor in the Department of Radiation Oncology at the University of Florida, Gainesville, Florida.

Originally published in the Journal of Clinical Oncology © 2020. American Society of Clinical Oncology. All rights reserved.