Beautiful Imperfections

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Richard M. Boulay, MD

As I was chosen to begin with Judy her cancer journey, I was also honored to help close it.

—Richard M. Boulay, MD

The ASCO Post is pleased to reproduce installments of the “Art of Oncology” as published previously in the Journal of Clinical Oncology (JCO). These articles focus on the experience of suffering from cancer or of caring for people diagnosed with cancer, and they include narratives, topical essays, historical vignettes, poems, and photographic essays.

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Judy repositioned the oxygen mask and then pressed her thin arms against the white linens of the hospital bed to lift herself up. “Would you consider…I’m not quite sure how to ask this…” she began with an uncharacteristic stammer. “Would you consider singing at my…funeral?”

I fiddled with the stethoscope in my pocket, and, trying to hide my awkwardness, I managed to reply, “I’d be honored. Is there something you had in mind?”

“No, not really,” she said, replacing her oxygen mask while half dropping back onto her hospital bed. “Nothing sad, though,” she continued, seemingly breathing easier. “I want people to celebrate my life. I want people to wear white. Sing something beautiful, like Bach.”

Transformative Power

Judy’s journey with cancer began over 7 years ago after a prolonged workup for irritable bowel syndrome. I explained to her that ovarian cancer symptoms mimic benign diseases and can be easily misdiagnosed as a bowel or bladder abnormality. The many months of discomfort, invasive testing, and misdiagnoses initially led her to mistrust the medical community; however, Judy quickly went from anger to acceptance, her resentment of the limitations of modern medicine replaced with a deep love for the world around her—her grace startling in its transformative power.

She soared through her aggressive debulking surgery and returned to the rigors of yoga post haste. Her monthly hospitalizations for intraperitoneal chemotherapy were attended by a grateful staff that looked forward to spending a few days in the company of a beloved patient. As the drip began, she would gesture to the window at the beautiful blossoms of the cherry trees. In remission, she spent time caring for other patients who carried the burden of their disease or treatment far less deftly than she did. Through parable and philosophy, she taught anew these patients and their medical staff the simple but profound joys of the beauty of each day.

A Lasting Tribute

When her disease recurred and intensified, her love of family, friends, and life grew only stronger. At age 72, as she prepared to leave this life, she bestowed upon me a lasting tribute: the opportunity to be the single voice singing her farewell—and all I wanted to do was run away.

It’s not that I couldn’t sing; I am a classically trained singer who performs regularly. It’s not that I wouldn’t sing; I recognize the deep honor of this request. It’s just that, perhaps, I shouldn’t. There are no less than a million reasons why I would gladly have traded this distinction for a seat in the congregation. My schedule is full: No doubt I would have to cancel patient office hours or reschedule surgery just to get to the service, an annoyance to affected patients and staff alike. And where could I warm up before the service? In the car on the way there? In the stairwell at the hospital? And what about allergy season? Will I squeak my way through the entire song? Then there is the whole emotional thing; it’s hard to sing through a giant lump in your throat. There was a whole lot stacking up against the perfect tribute that Judy deserved.

I was not really bothered, however, by schedules, warm ups, allergies, or even throat lumps. These hurdles were smoke screens masking my true avoidance: Why should I be recognized to celebrate a life that I was unable to save?

I know that most patients with this disease are not cured, and I understand that Judy outlived many, but I had the skills and training to cure so many others. Why could I not save the life of someone I had grown to respect deeply and love? It wasn’t that I didn’t try hard enough; she had an optimal surgery, and her chemotherapy treatments were cutting edge. The successes Judy had had along her cancer journey were shrouded in the shame of my imperfect work. If I couldn’t cure her, how could I face her family and lead a celebration of her life? Was I not the reason we were here in the first place? I had failed. I did not deserve this consideration.

Adapting to an Imperfect World

As I struggled to reconcile my guilt over my imperfection and failure, I wondered, why would she choose me? The past 7 years of Judy’s life were a testimony to adaptation to an imperfect world. She looked beyond the prolonged time to diagnosis and forgave those who diligently sought the cause of the symptoms she presented with yet missed her advanced cancer. She faced each new physical insult, the surgical scars, the chemotherapy-induced baldness, and the colostomy, with poise, managing to live well and beyond her accumulating frailties. What she “adored” (her word) remained at her side: her loving family, especially her grandchildren, her dog, yoga, her world, her God—all were manifest in splendor and beauty and wonder; each imperfection rendered invisible by the glory of the whole.

It was now my turn to learn from her teaching and to shed my vain and destructive self-image of the perfect physician; that Doc wasn’t who I was or who I could ever be. It was time to forgive my human limitations and to see my own frailties and know that, rather than being consumed by them, I could choose to find beauty and harmony within them. I released the self-imposed burden of attaining perfection and accepted my vulnerabilities, seeking the poise and grace Judy had shown so many times before.

The Beauty of the Whole

In the end, I chose to sing, “If With All Your Hearts You Truly Seek Me,” from Mendelssohn’s Elijah. The simple, elegant message and soaring, joyful melody of the music echoed Judy’s philosophy of life. As anticipated, the memorial service was scheduled smack in the middle of an operating room day. Between patients, I left the operating room, donned a dark suit and white shirt, and dashed from the hospital locker room to my car, where I warmed up my voice. On the way to church that morning, snow lay on the daffodil and forsythia blooms—an oddly imperfect beauty and a wonderful metaphor for all the wisdom that Judy had gently bestowed.

The bereaved gathered, as they do, in small conversational groups in the hallways leading to the chapel. I sequestered myself in an anteroom to prepare for the task at hand, but what I heard outside sounded different from other funerals. Rather than in hushed tones, people spoke openly, eagerly sharing the joys Judy brought to them. There was lightness and laughter in these conversations. A quick peak around the doorjamb revealed spring colors in flowers and fabrics as well as a swiftness of foot as congregants greeted each other.

Seeing Judy’s son, I quit the shadows to express my deep condolences to him and his family. He, in turn, shared his profound thanks for my role in keeping the family intact for all these years; for the seven more years Judy had with her beloved grandchildren, family, and friends; for 7 more years of Mom. And as I was chosen to begin with Judy her cancer journey, I was also honored to help close it. That which began in anger and fear ended in joy and song, and each imperfection along the way faded through forgiveness and love into the beauty of the whole. ■

Richard M. Boulay, MD, is Chief, Division of Gynecologic Oncology, Obstetrics and Gynecology, and Gynecologic Oncology/Gynecology, Lehigh Valley Health Network, Allentown, PA.