“Can we connect via video?”
“Doctor, I don’t have the energy. Please, just stay on the phone?”
All day I’ve been alone in a scrubbed office with a phone, printer and computer. It has been a rapid adjustment to telehealth consultations, which felt welcome at first.
Many of my patients are frail and elderly. It typically takes them far longer to arrange transport, navigate the stairs and catch their breath than it does for me to deliver my assessment.
To banish this inconvenience and still get the job done seemed a win-win prospect. I could get used to this, I gleefully thought on the one day when my virtual clinic ended before the real one ever did.
For some weeks now I have reassured patients at home that their scans are stable, their cancer is responding, or that I will email their insurance forms. I have allayed anxieties and reassured patients that, as odd as our distancing feels, it isn’t permanent.
Despite widespread enthusiasm for the idea, consulting via video link has been difficult in practice. Unstable internet connections, poor confidence, the lack of a smartphone and individual preference have all contributed. Where there is an established relationship of trust a phone call has done the job, which made me temporarily forget the matter of new patients whose cancer will not wait for a pandemic to pass.
“Doctor, are you there?”
I am listening to her and staring at a busy screen, piecing together a story of an aggressive cancer in an elderly and malnourished patient who sounds breathless from the effort of speaking. She is a tireless volunteer now compromised by her own unrelenting fatigue, an epicure who can’t bear the sight of food.
She tells me that jabs of pain surprise her; I make a sorry face she cannot see. She says her spirits are fine; without looking into her eyes I have to accept this as being true.
“How much do you weigh?”
“I don’t know but my bones are showing.”
At times like this, a picture really is worth a thousand words. She is clearly ill but simultaneously thoughtful and measured. If she is anxious, her voice doesn’t tremble. If she is afraid, I can’t tell. Is she of a philosophical bent or merely resigned to her fate? The answers to all these questions would ordinarily lie in listening and looking.
“I have accepted that I am far too weak for any treatment.”
“From what you describe, I agree chemotherapy would be harmful.”
While it’s not completely unheard of to deem patients unfit for treatment based on description alone, it isn’t the best medicine and the burden weighs heavily on me.
Her next question magnifies the load.
“So, I guess all that’s left to know is how long I have to live. My other doctors said to ask you.”
In medicine, there are few more sacrosanct occasions than when a patient must confront the knowledge of a terminal diagnosis. No matter how much someone has mulled, anticipated or dreaded the news, its actual delivery is a watershed moment.
Patients and their loved ones remember every tiny detail. If the doctor spoke gently and held a hand or remained standing, in a rush to leave. The nurse who magically appeared with tissues. The cleaner who could only articulate her sadness by rearranging the flowers. The tearful intern.
Time and time again we see how the manner in which bad news is delivered impacts the outlook of patients. Indeed, I have learnt this from my own misfortune – and now I wonder how I can possibly do justice to a dying patient I have never met.
Thoughts go tumbling through my head. What if I distress her? Wouldn’t it be better if her son joined her? (But he is immunosuppressed and staying away.) What about palliative care? (Home visits are limited.) Should I ask her to come in person? (She couldn’t possibly manage.)
So, as absurd and unreal as it feels, there isn’t a doubt in my mind that her legitimate question deserves an honest answer.
Slowly, I say that while an individual’s prognosis can be hard to get right, the signs are worrying. Her organ function is failing; she is losing weight and is very tired. I expect that the next few weeks will see her deteriorate further and there will soon come a time when she will need help, in which case a hospice may be her best choice.
“So, we’re talking weeks.” I strain to hear the lament or question in her voice; instead there is acceptance.
My silence is my acquiescence.
“I see,” she says softly. I grip the phone a little harder, as if it will transmit some of my empathy.
A hospital emptied of its “regular” patients has lost its rhythm. I miss the sound of chatter, footfall and complaints about how everyone is always running late. And I realise something I have never previously had to think about, that patients derive as much solace from the sight and touch of professionals as they do from the interventions we visit upon them.
No one competes for a hard chair and faded magazines in a crowded clinic but there is something fundamentally soothing about these rituals that I sorely miss and I know my patients do too.
Medicine always feels incomplete without patients but sometimes it feels plainly wrong. I tell her how sorry I am that this is happening to her now and that I admire her stoicism. She sounds pleased.
I don’t sleep well for the next few nights as I turn the entire conversation in my head, second-guessing myself. I call her again and she says she has indeed deteriorated but is still comfortable, entirely at peace with her fate and that her grandson has moved in.
Reluctant to admit there is nothing left for me to do for a patient I never met and increasingly cognisant that there will be more such encounters to come during the lockdown, I ask if there is anything else. I have little idea how I will fulfil any request but it feels right to offer.
She surprises me with a sudden emphasis in her voice.
“Doctor, you must stay safe. You’re all doing a great job and you must look after your own health. On behalf of the community, I thank you.”
Her words, unexpected and selfless, feel like a benediction and make me marvel that the patients for whom we do the least are the ones who thank us the most.
The spotlight in these times is on frontline professionals but, judging by the remarkable interactions of late, I suspect we might be lesser beings without the courage of our patients.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death