The Puzzle Table

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I would nod to myself when I saw her reach across the table and pick up a tiny piece; the peripheral neuropathy was not so advanced that her fingertips could not grasp it.
— Jennifer Lycette, MD

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The ASCO Post is pleased to reproduce installments of the “Art of Oncology” as published previously in the Journal of Clinical Oncology. 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. To read more, visit and search “Art
of Oncology.”

The puzzle table sits off to one side of the infusion room. The chairs are now vacant, and the flat, white expanse of the table shows through the jagged outline of the emerging pattern. I think of her, my patient, who will never sit there again.

She would hurry to claim the table as soon as I had finished her history and physical each week, a shy smile on her face. The nurses knew to look for her there, rather than waiting in the exam room, when it was time to start her intravenous line.

On her treatment days, any time I passed through the infusion room, I would see her absorbed in the study of the puzzle before her, with her intravenous pole as her companion. The plastic catheter snaking down from the medication bag to her body did not get in her way. She would look happy and relaxed, not like she looked when we were in the exam room—tense and fearful. I would nod to myself when I saw her reach across the table and pick up a tiny piece; the peripheral neuropathy was not so advanced that her fingertips could not grasp it.

More Than Just Pieces

The puzzle table is popular in our infusion room. It has developed an importance that was brought to our attention repeatedly when we held patient focus groups to help plan the space for our new facility. “What about the puzzle table?” “Where is it going to go?” “There is going to be a puzzle table, isn’t there?” Groups of patients and advocates crowded around the blueprints to determine the perfect spot for the puzzle table in its new home.

I didn’t appreciate the significance of the puzzle table until I found myself one Saturday sitting with my Dad in the waiting room of the cardiology procedure unit, my Mom having been just whisked back for an emergency pacemaker. Being a weekend, the waiting room was empty other than a lone soul curled up on a couch facing the wall on the far side of the room, the form obscured by a blanket. The physician side of me told myself I had nothing to worry about; pacemakers were routine, and this tertiary hospital placed thousands of them in a year. The daughter side of me worried anyway.

I looked at my Dad sitting in the chair next to me, a stoic air around him. The emptiness of the room with its deserted sofas, tables, and chairs furthered a sense of apprehension. I wanted to say something to comfort him, but I dismissed each sentence that came to my mind, not wanting to resort to platitudes. The silence felt too heavy to lift with words. My eyes wandered around the room for inspiration and landed on a stack of puzzles. I thought of my patient.

“I think I’ll start a puzzle,” I said. “Want to help?” After a few minutes, he joined me. For the next several hours, we worked mostly in silence. I can’t remember the picture on the puzzle, but I can remember that as we worked, the tension and worry gradually lessened. After the 2-hour mark, I didn’t know if my Dad had noticed the time had passed the point at which the cardiologist had told us the procedure would be finished. My mind started to run through various complications that I could not keep out of my too-vivid doctor’s imagination. But each time one of these catastrophic, albeit unlikely, visions made its way into my consciousness (Ventricular fibrillation! Arterial rupture! Anaphylactic reaction to anesthesia!), I would focus on the puzzle in front of me and would be able to dismiss it from the front of my mind.

Other Side of the Waiting Room Doors

We were both engrossed in the puzzle when the cardiologist suddenly appeared, walking across the room to us. My heart rate accelerated at the same time as I stopped breathing. I mentally willed him to tell us that all was fine but braced myself for the possibility of bad news. We were fortunate—all had gone well.

Alas, in oncology, we do not yet have implantable devices to take over the regulation of what goes wrong in a cancer cell. It wasn’t too long after my experience on the other side of the waiting room doors that I found myself meeting with my patient’s family and had to tell them all was not well.

I understand now the puzzle is not there to be finished. It serves just by being present.
— Jennifer Lycette, MD

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My patient is gone now, but I cannot walk by the puzzle table without remembering her. I am grateful to have this memory of her. I think I understand now why she always rushed to start a puzzle. I think, perhaps, it allowed her to pass the time in the infusion room without her mind running away with thoughts of the chemotherapy dripping into her veins and the prognosis of her cancer. To take things 1 minute at a time, 1 second at a time, 1 puzzle piece at a time. To live in the present moment, and not the fear of the next moment.

As I see other patients and families sitting there, whether chatting and working in groups or sitting alone in comfortable silence, I still see her, too. I notice at the end of the day, when the infusion room is empty, that the puzzle is never completed. I understand now the puzzle is not there to be finished. It serves just by being present.

Uncertainties and Possibilities

I think about the puzzles we take on each day as oncologists. There are some cancers with curative chemotherapy regimens. We know what those puzzles look like when they are solved and how to solve them. Other times, we are faced with puzzles that no one has yet been able to solve or even puzzles that have never been seen before. There are many pieces that appear similar but have slight variations. Each one looks like it could be a potential fit. But until we decide on a piece and try it, whether or not it will fit will not become clear. If it doesn’t fit, we take the piece out, set it aside, and try another. Sometimes we get lucky, finding a series of pieces that fit perfectly together. But then, just when we think we can see a glimmer of the completed picture, we either run out of pieces or cannot find another fit.

My patient had done well through many lines of palliative chemotherapy, with few complications, over a span of years. I knew we were running out of pieces, and I knew she knew we were running out of pieces, but she only wanted to focus on the piece at hand. We had discussed what would happen when the time came that we ran out of pieces, but she never wanted to dwell on it. I don’t think this was denial. I think it was courage. The ordinary yet extraordinary bravery of the quiet and steady reaching for the next piece.

At the end of the day, the infusion room empties of patients and staff, and the unfinished puzzle reminds me of uncertainties and possibilities. I walk over and search for one more piece to click into place before turning out the lights.

At the time this article was published in the Journal of Clinical Oncology, Dr. Lycette was a medical oncologist at Columbia Memorial Hospital/Oregon Health and Science University Knight Cancer Collaborative in Astoria, Oregon.