As an oncologist I trade in bad news of the worst kind, but giving it is still stressful | Ranjana Srivastava

Usually, I cast a calm eye on all that awaits me; after all, it’s what I’m trained for. But some days are more difficult than others

Shortly before I turn into the hospital, I pass a pizza shop with its huge, unmistakable letters selling the enduring appeal of a generous slice of pizza to fix all kinds of wrongs. The store is always closed at that hour, so I have never been inside, but it’s become a kind of constant in my life because it’s my cue to start thinking about the day ahead.

As I pass the pizza shop, I start thinking about the day’s list of patients – the newly diagnosed and those months or years into treatment, some coping well, many facing difficulties, if not of the body then the mind. Some patients take just minutes, thankful for good news and reluctant to question it too closely. Others take an hour, forced to come to grips with worsening circumstances they didn’t expect or had hoped not to entertain.

In medical parlance, this is a “metastatic” clinic. It means that every patient here has incurable cancer, the kind that can be well-managed but not permanently cured, although it’s troubling that many patients are unaware of this fact.

Normally, I cast a calm eye on all that awaits me; after all, it’s what I am trained for.

But today, at the mere sight of the pizza shop, and without warning, my pulse quickens, and my bounding heart threatens to burst through the seat belt. Sweat beads my brow and my cheeks feel warm. The sensation completely knocks my equilibrium, but I am able to identify something I’ve heard countless patients describe as acute anxiety. I keep driving and just as quickly as it had appeared, my anxiety dissipates, but not before I hear an inner voice chide:

“You can’t possibly be anxious, you’re the oncologist!”

Every part of my training knows this to be false. Oncologists trade in bad news of the worst kind. It’s not just dealing with mortality but everything in between: the patient who is alive but miserable, the one who should speak up but doesn’t, someone who needs to make a decision but can’t, the tense children, the unpaid bills, the lost relationships. Just the other day, I found myself saying to a patient: “Isn’t it good that your cancer is stable?” She replied: “But my friends have left me.”

It’s well known that when giving bad news, oncologists experience anticipatory anxiety. Their anxiety peaks during the clinical encounter (the patient’s anxiety peaks later) and the stress of the encounter can affect appetite, mood and sleep for days afterwards. Communicating bad news is a skill, not a gift, but learning it does not necessarily ease the stress of repeated encounters. Years spent as a clinician don’t attenuate the risk either. I know this and yet, there is an ingrained urge to deny it.

I have known the patient I’m seeing today for years. Modern medicine has allowed him to live a relatively normal life within the confines of what one might call normal when every decision is somehow dictated by the reality of an incurable disease. He sometimes muses that he inhabits two worlds, one containing illness and the other his family. He relies on me to keep him safe in the first world so he can cherish the second. His faith in me is complete. Meanwhile, I savour the academic challenge of keeping his disease at bay but frequently feel exposed to its emotional consequences.

Recently, out of nowhere, he developed kidney failure that has left experts scratching their heads. Today, it’s my job to tell him that the merry-go-round of tests has again proven inconclusive. He doesn’t mind the tests but what eats at him is how in this modern day, no one has an answer. Surely, doctors without answers are a thing of the past, he marvels, although I keep telling him that we are still no match for the human body’s ingenuity.

Today, I am due to confess that things look serious. I have to give bad news but make it sound like it’s not so bad. For in the back of his mind there is a frightening corollary – if the news is bad, will they give up on me?

On one hand, just the thought of his anxiety is right to provoke my anxiety but then, he isn’t the first of my patients in a predicament, so why the palpitations and why this sense of doom? After all, if this occurred with every patient, I couldn’t function as an oncologist.

What does this illness mean for me? Why do I feel the way I do? What will this death represent for me? Experts say that only those who have thought about these questions can deal with the job of caring for the terminally ill.

My patient’s illness has shown me the true meaning of resilience. It’s not just bouncing back from one mishap but understanding that life itself is fragile. But whether we are cursed by mutated genes or bad luck, we have it within ourselves to rise to challenges we barely thought possible. His capacity to combine illness with goodwill and generosity and an acceptance of uncertainty inspires me. I often think that people like him help us become better versions of ourselves.

Which is why the prospect of losing him at a relatively young age makes me sad. I think of his children, long braced for a downturn, and his wife who has been quietly grieving all these years. His illness can’t be easy but there will be a permanence to his death. I guess I am not ready to concede his mortality because I am reluctant to contemplate my own.

And yet, what is my metastatic clinic if not an opportunity to be immersed in a series of lessons about what really matters? Every day, there is kindness, gratitude and love on display. Maturity and wisdom too. While there is every risk of patient care turning transactional in a busy healthcare system, one just has to pause now and then to take in human relationships at their best when times are bad.

In clinic, I say that I don’t know why his kidneys are failing but I’m glad he feels well. I explain that at this stage, his problem is concerning but not life-threatening and I will keep thinking about the next step. In past times he has revealed he wouldn’t know what to do if I said we had reached the end of the road.

He visibly relaxes at my reassurance. “I just need to know you’ve tried your best; you can’t control anything else.”

I stop to think about the courage it must take to utter those words and am humbled.

“So, you’ve got this?” he asks, just to be sure.

“For now, yes”, I reply, as he picks up his belongings and I prepare to meet the next patient.

• Ranjana Srivastava is an Australian oncologist. Her sixth book, A Better Death: Conversations in the Art of Living and Dying Well, will be published in June 2019


Ranjana Srivastava

The GuardianTramp

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