The Call

Still trying to stay one step ahead of the snapping alligators, so here’s another older post, hopefully worth your time — Dr. Bob


Damn!, I hate these calls…

Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections — it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use — but it is not, strictly speaking, a cancer test. It is noisy — often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection — often markedly so — and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not — and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases — always alarming on first exam, with very high PSA values — and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis — after all, cancer doesn’t get better on antibiotics — but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimism that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage — although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score — a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult — if not impossible — to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this — without robbing hope — will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard — surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted — were there some bottled genie passing out such favors — is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course — not of days or years, details or circumstances — but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion — yet it is not hard to imagine — and sometimes to sense — the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise — but almost never on the initial call. On rare occasion, there is a casual indifference to the news — prompting reflection on what strength of spirit — or dense denial — such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted — an unworthy child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned — though poorly so — with His own.

But the call of death — so confidently faced from the comfortable vantage of good health and cheap grace — will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know – -by the tutor of past and bitter experience — that faith will sustain me and mine through it all. But one cannot know what that day will be like — nor should we wish to ever know.

But for Charlie, the battle will now be enjoined — the weapons and wherewithal of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality — it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion.

May it be also for me.

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5 thoughts on “The Call

  1. It is a blessing to your patients to have you as their doctor. Some will know this but the weight of your message may deaden the awareness of others as they struggle with the news you bring them. It makes me glad anew that I have been in the food business. The worst problem we normally face is that someone is hungry and we are about to feed them. At times like you describe, the worst job in our industry isn’t as disagreeable as yours. On behalf of all those who fail to say it: Thanks for what you do.

    Two thoughts.

    First, the recent high-profile Randy Pausch story makes your reference to delivering bad news a timely topic. I watched the whole lecture, over an hour, from the Carnegie-Mellon site, and was absolutely blown away with admiration and respect for the man. Anyone who hasn’t done that needs to take a close look at their time-management habits.

    Second, having spent the last five-plus years in a post-retirement job in the assisted living environment, I have come to a sober understanding of the many ways that people face dying. I could write anecdotes forever from what I have seen, but the one lesson that needs to be more widely known is that hospice may be the least-appreciated service that the medical community has produced in recent years. At some point we all must let go of the idea that dying is optional. There are few good ways to die, but there is a multitude of terrible alternatives, many of which come with loads of avoidable anguish — financial, physical, spiritual, and psychological.

  2. Thank you for reposting this. I would have missed it otherwise. Your posts and the quotes that are at the top of your blog always give me lots to think about.

  3. My husband recently had a prostate biopsy with a doctor who had come highly recommended by his primary care physician. He made my husband very comfortable ( considering that he had only been to a doctor once in 30 years) and the biopsy was achieved with a modicum of discomfort. It was benign. We were very pleased with him and his comforting “bedside” manner.

    Now we are told that he is being let go from the practice, and the reasons we were given are that he “doesn’t bring enough people into the practice and he spends too much time with his patients.”

    We are horrified at this; it is a terrible waste of a wonderful doctor. What do you recommend we do? I suggested that my husband and the 2 other men he knows who have been to the same doctor recently, should write a letter in support of him to the university system his practice is in. Can we do more?

  4. Ouch.

    My brother-in-law was just diagnosed at the age of 60. We spoke at Christmas about peripheral health issues. I said that I had my baseline PSA done 2 years ago. He did not know what it was. I explained as best I could and recommended he get it done with a physical. He did and this is what came back. Maybe, just maybe, I helped prolong his life. It is in the early stages and very treatable according to the sister-in-law.

    All men over the age of 50 need to have this done. No sense dying young for no good reason.

  5. When I started in medicine more than 40 years ago, bad news was kept secret from the patient. We lied about prognosis and used euphemisms for cancer. My mother wouldn’t even say the word. “Mitotic lesion” was a favorite term. I remember one surgeon who used to keep a patient permanently sedated if surgery revealed disseminated abdominal cancer.

    When I became an attending oncologist I had no training in how to break bad news. It was a confrontation with a patient whose chronic myeloid leukemia and turned blastic that made me realize I was afraid to die. This was the trigger for my conversion. Until I had sorted out my own view of death I had nothing to say to my patients.

    When my own PSA came back high a few years back my Christian faith came under test. As I waited for the results of my prostatic biopsy I wondered whether it would sustain me. I found that I was able face the possibility of death as one might approach a great adventure. If that were to be my way then, although the details were obscure, I knew that I would in the end “be like Him”; if I were to be spared, then there was work enough for me here on earth.

    My continued presence to write this reveals that it was all a false alarm; benign prostatic hypertrophy was the diagnosis.

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