The ASCO Post is pleased to reproduce installments of Art of Oncology as published previously in the Journal of Clinical Oncology. These articles focus on the experience of tolerating 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 ascopubs.org.
Athalia Rachel Pyzer MD, PhD
The old man arrived on the oncology floor with a small leather suitcase and a brown paper bag of sticky homemade pastries. His choice of hospital was no accident—it was the closest medical center to the major London airport, where he had ended his turbulent journey from his home in distinctly sunnier Cyprus. By all accounts, he had disembarked from the plane and presented a crumpled note to an airport worker that read: “I speak no English. I have leukemia. Please take me to a hospital.”
And so, we had arrived at the hospital together: he as a patient and I for my first day of work as a newly minted PGY1. We were equally unready for the weeks that lay ahead, both of us in unfamiliar surroundings and understanding little of the discussion during those first few attending rounds.
My patient had been sent here by his children with the hope of better treatment. Given the reciprocal health-care arrangements between European member states at the time, his medical care would be free of charge. Although what he and his family had done was technically legal, I recall a measure of sighing and eye-rolling on the part of the team. I had no time for eye-rolling. I was too busy chasing the briskly rounding team and illegibly scrawling snippets of what I overheard on the precarious mountain of paper charts I dutifully pushed around on a metal trolley.
An Uncomfortable Routine
As the days passed, my patient and I learned his acute myeloid leukemia had a poor prognosis, probably borne from a simmering antecedent myelodysplastic syndrome. We did not have a telephone interpretation service, relying instead on a visiting interpreter with a perpetually harried expression, whose visits had to be specially scheduled seemingly months in advance.
Through the interpreter, we discovered our patient was a fisherman who was not in any particular discomfort and was able to understand he would be receiving a low dose of cytarabine chemotherapy for his leukemia. My attending thought more intensive treatments or investigational agents were precluded by the patient’s social situation. He was alone in a strange country with no obvious support network we could reliably educate. He told us his children could not leave the family business. Their village did not even have Internet service, and the phone was never answered.
We both fell into an uncomfortable routine. I would arrive early in the morning to wage war on my patient’s blood cell counts before the decision-makers appeared for rounds. I poured in bags of platelets and red blood cells, and his leukemia would secret them away somewhere they could not be found. Every day, my Cypriot patient’s laboratory results returned my fire in a never-ending duel, taunting me as I recited his unchanging levels to my disappointed audience.
“I poured in bags of platelets and red blood cells, and his leukemia would secret them away somewhere they could not be found.”— Athalia Rachel Pyzer, MD, PhD
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We would troop into his room and deliver some pleasantries in deliberately slow English. He would respond in Greek, perhaps asking or answering a completely different question. We would examine his abdomen and then leave. The pastries on his bedside table had long since rotted, but he resisted any attempts to throw them in the trash.
By the fourth week, I had found the blood bank and could expedite my patient’s chest x-rays by telling the radiology department I was concerned about hemopneumothorax. I could not shake the feeling we were all somehow merely pretending to be this gentleman’s doctors and just going through the motions. He had a negative-pressure room, where he was receiving treatment for leukemia, and we were swiftly responding to his fevers and bouts of cytopenia. But, unlike my relationship with the loquacious bartender with T-cell lymphoma in the next room, I did not know my fisherman. I did not know his hopes and fears. I did not even know if he knew he was dying.
An Unwelcome Feathered Guest
I was on call one evening during his fourth week in the hospital when I was paged to my patient’s bedside. On my arrival, the ward sister in charge for the night sheepishly explained: “The patient has been crying and feeding the pigeons out of his window for weeks. Now there is one trapped in his room. Can you get it out?”
I was gobsmacked. Medical school had not prepared me for this. My first frantic thought was that my profoundly neutropenic patient was clearly doomed to die of pulmonary psittacosis. While I brainstormed how I was going to explain my immense failure in ensuring neutropenic precautions to my boss in the morning, I set to work with a broomstick. I shooed the frantic bird toward the window while my patient sat horrified in his chair, being wrestled into a pointless paper face mask by the ward sister, neither one of them understanding the other’s protestations.
My attending did not yell at me for having failed to protect our patient from the pigeon. However, he did chastise me for ordering an eye-wateringly expensive and entirely unnecessary laboratory test for psittacosis.
Overcoming Our Language Barrier
That evening, halfway out of the hospital, I popped into my patient’s room and found him staring mournfully at the rain-streaked and now firmly locked window. I picked up the pack of playing cards next to the bag of spoiling pastries and sat down on the foot stool, gesturing I would like to play a game. He looked at me, his wizened face gently contorting as he clearly debated attempting to overcome our language barrier. We eventually figured out how to play a version of rummy and sparred almost daily for a few weeks until he became too weak to hold his cards. Then, I just sat in his room with him for a while every evening, thinking about his uncontactable family and occasionally making pigeon noises to make him chuckle.
Looking back over the near decade since pigeon-gate (my most well-worn dinner party anecdote), the most notable change has been that our greater understanding of tumor biology has afforded us an array of new drugs to treat leukemia. And yet, in the same breath, not much has changed at all. Patients and families are still desperate for better outcomes for a disease so unfathomable that one could read a patient’s entire genome and still be surprised by how the story unfolds.
Negotiating patient care in a foreign language is still fraught with frustration and an embarrassment of small concessions—exceptions to usual, excellent patient care—that hurt both the body of the patient and the resilience of the clinician. I am reminded that it remains painfully difficult to be a new doctor in an emotionally challenging specialty such as oncology, still without your portfolio of patients who did well to bolster you during the gloomier moments.
There are many reasons I chose to train as an oncologist. However, the experience of caring for this gentleman so early in my career was undoubtedly formative in showing me how abjectly lonely it can be to be a patient, how impotent we are when distracted by just the laboratory values, and how looking after patients means more than treating a disease with a fancy drug. Sometimes, it is chasing pigeons or playing a game of cards.
DISCLOSURE: Dr. Pyzer reported no conflicts of interest.
At the time this article was published in the Journal of Clinical Oncology, Dr. Pyzer was working in the Department of Medicine at the University of Chicago Medicine, Chicago.