Nurturing Empathy: An Oncologist Looks at Medicine and Himself

Empathy in medicine matters. A doctor reflects on his experience as a patient and the need for clinicians to re-engage with patients empathically while giving the best care possible. In addition, we must begin teaching our students and trainees medical humanities as early as we can, because empathy can be nurtured.Empathy in medicine matters. I should know—I have been a practicing oncologist for 35 years—but it was only when, in a matter of seconds, I went from doctor to patient that I grasped its true significance.A hiking trail that I had taken for granted for years betrayed me one day. The stones on a steep path that felt solid beneath my feet suddenly shifted, and I slipped hard, slid fast, and fell off a cliff. My right foot landed on a rock slab, crushing my right ankle badly, with five fractures.I was taken to the emergency room of the hospital where I worked. My orthopedic colleague, Dr. R, took me to surgery, but as a result of excessive and traumatic swelling of the joint, he could not repair my ankle. He explained that cutting through the edematous muscles and tissues would impede healing and increase the chance of infection. He was only able to temporarily stabilize my fractures using an external fixator, for which metal-alloy rods were drilled through my heel bone below and the shinbone above and then fastened together by bolts and screws. He explained that the definitive surgery would take place only after the swelling was gone. “The next operation won’t be easy, though,” he warned me, “so I am referring you to an ankle orthopedist, Dr. M,” who I knew practiced in a large medical center in a city far from ours.Seeing my alarm, Dr. R softened his tone. “Just try to put up with pain for a while,” he said. “It’s not pancreatic cancer, you know. You will get better in time.”I was not sure how to react to his words, which were meant to comfort me. It is true what he said—I was far luckier than any of my patients with pancreatic cancer—but that thought also brought some unpleasant memories of how some of my patients with pancreatic cancer had suffered. Would I suffer the same pain as my unfortunate patients, no matter how temporary? How capricious would my pain be? Doctors sometimes say things without thinking, and heaven knows how many times I may have said similar things myself in my own practice.It was through my experience after sustaining this injury that I became aware of the behavior of some clinicians—of some colleagues—that I still find incomprehensible. After their initial bursts of concern, they forgot to check on my welfare. We could tolerate the incompetence of our colleagues (as long as it is feasible), yet when it comes to those who are handicapped, there is a certain lack of empathy. Psychiatrist Howard Shapiro put it best: “Handicapped doctors are treated like drug addicts,” he said. “Get them out of sight.”Although it was not easy, I assiduously followed Dr. R’s advice to reduce my swelling: diligent wound care and the constant elevation of my foot on four to six pillows day and night. My edema subsided, but the hardware attached to my foot was taxing and painful. I had access to narcotics, but they made things worse. I found that the codeine combinations dulled my brain and caused nausea and abdominal bloating.Ultimately, I saw that Dr. M, the ankle orthopedist, was my best chance of freedom and rescue from the current situation, and I made the difficult trip to see him. As a fellow physician, I assumed he would surely empathize and understand my suffering.To my shock, my belief and relief proved utterly wrong. He was unfeeling and appeared more interested in my fractures than in me. It was as if he had failed to notice that the joint was attached to a living being. He did not bother to touch me and was aloof with regard to the concerns I raised. I got the feeling that, to him, I was just a technical challenge and nothing more.“I have looked at your x-rays and scans,” he informed me, “and you have a hell of a lot of fractures.” He then scheduled my surgery. I told him I was an oncologist, unsure if he was aware of my profession. “That won’t change your surgery,” he said.After I settled in a hospital bed, a young doctor came to my bedside. “I am an orthopedic resident assisting Dr. M today,” he said. He wanted to discuss one of my medications, an anticoagulant. “Why are you taking it?” he asked. “Did you have thrombophlebitis?” Then he was blunt: “Have you stopped it? We can’t do surgery if you haven’t. We can’t risk hemorrhage on the operating table.”I was glad that he was careful about me before the operation. I assured him that I did not have thrombophlebitis and that my local orthopedist gave me the drug in the hope of preventing it. I also told him that I had stopped it before coming in, as I was advised. Those were all the answers the young doctor was interested in, and he did not ask me any more questions about my health. He, too, didn’t even touch me. I could see that the young doctor was copying his mentor, Dr. M, well. The former’s only concern seemed to be the anticoagulant that was noted in my record.When the resident finished, a nurse gave me an injection. After that, I did not know what had happened until I woke up in the recovery room. I was confused at first and wondered why I was in this strange place. Then I noticed a familiar face—it was Ara, my wife. “You have been in the recovery unit for 6 hours waiting to get a room on the floor,” she said. “Surgery went fine.” I reflexively looked at my right leg. It had a white cast, and the hardware was gone.I realized that Ara had been sitting by my side all through this time except when I was on the operating table. I felt a pang of guilt. A vivacious, beautiful woman who looked elegant had become haggard, her eyes sunken, face dry. What had I done to her? Why had I gone for that cursed hike?Finally, I got a room at midnight. By then I had begun to experience pain again, but this pain was of another kind, gnawing and oppressive. As the muscles and tissues of my operated ankle swelled more and more because of the cutting, they were compressed by the hard cast surrounding them. It felt worse than when I had the fixator, which at least provided room for the swelling to expand. I wanted to forestall the pain’s ascending severity. I pressed the call button for the nurses to get an injection of morphine with an antinausea medication.“Someone made a mistake in keying in your narcotics,” a nurse said. “I have called for a reorder.” Then there was more delay. “Only one pharmacist is on call at night,” she informed me. “He is swamped, and dispensing morphine has stringent rules.” She was genuinely sorry and offered me an oral codeine combination, which I accepted, but all it did was make me more miserable with nausea and abdominal bloating and little pain relief. Soon the pain got more severe, and I felt like a condemned prisoner without hope. By the time a nurse give me a narcotic injection, it was at about 3 a.m.—3 hours after my request.Following the injection of morphine, I became peaceful and went to sleep. I wished I had stayed that way, but I was startled awake at 6 a.m., after Dr. M came in for his morning rounds. Without so much as a “good morning,” he held up an x-ray in front of me. “Here is a copy of your x-ray after surgery,” he said and then went on to quickly describe what he had done. “I have put in 2 plates and 14 screws to align the bones and some bone grafts to fill the gaps.”My eyes were blurry from the light, and I was still hazy from anesthesia, exhaustion, and narcotics. I could not take it all in at the time and only later understood what happened, with my wife’s help. After he finished telling me what he had done, he hurried to leave my room. Holding the doorknob on his way out, he said, “You can go home this morning.”I hadn’t even had a chance to tell him about my ordeals at night. Ara, concerned about my pain and debility, pleaded my case: “He is too sick to travel, and we live far away.” Dr. M did not appear moved by what she said and barely talked to her. “He can rest in a hotel as well as he can in the hospital,” he replied. “I will check him in the office in 2 days.”“You can talk to the discharge planner,” he added, as he walked off.I later discovered that he had admitted me as an outpatient case, and I had already spent the required night. One might read this story and see how unfair this discharge was and that I had the right to complain about it; however, when you are sick, you are vulnerable, doctor or not. You sign all the forms a hospital puts in front of you because you have to, and this absolves the hospital of any questionable conduct.I wish I could say that my experience was unique in patient care, but it’s not. I think I would be correct in assuming that numerous patients would identify with me. Sadly, as I looked back at my practice, I saw that Dr. M’s behavior is partially explained by the silence of our colleagues. After all, neither I nor the other physicians had ever reproached another who had fallen short on bedside compassion.True, the advances in specialization and technology are saving lives or improving the quality of our lives, as they did mine. And my doctor was technically accomplished. Still, empathy is an integral part of care. Lack of empathy obviously compounds the distress of the patients, but what is not obvious is that it can have corrosive effects on the doctor’s mindset. Nine medical specialty groups have found that 45 procedures and tests currently performed by doctors have no demonstrable benefit or can be harmful to patients. Although some tests and treatments are done with good intentions, others, unfortunately, might be done for reasons that are less than altruistic. I believe that an empathic physician would try very hard not to subject his or her patients to tests or treatments with little benefit for them.If we are to preserve our voice in health care, we clinicians must re-engage with our patients empathically while giving our best care possible. Otherwise, the public will become increasingly disenchanted. In time, they may put greater demands on us, demands that are less than empathetic to our complaints about medical practice.Equally important, we must begin teaching our students and trainees medical humanities as early as we can. The humanities should not be optional but rather a standard part of the curriculum. I believe this is important because empathy can be nurtured. Ample stories in the literature illuminate the subject of medical education. An example is Anton Chekhov’s classic short story “Ward No. 6,” in which a doctor who was indifferent to the dehumanizing treatments of his patients ends up, by quirk of fate, being a patient in his own hospital. He is horrified by the pain and indignities heaped on him, the same pain and indignities his patients suffered routinely for years under his watch. A terrible, agonizing thought torments him: “How could it have happened that for more than twenty years he had not known it and had refused to know it?” Any medical student who is asked to contemplate this cannot help but get some sense of empathy for patients.     

Unusual cause of neonatal cyanosis

We present a case of a full-term female neonate who presented at 6 h of age with severe cyanosis and was partially responsive to oxygen supplementation. An echocardiogram showed an isolated congenital severe tricuspid valve insufficiency due to rupture of the papillary muscle of the anterior tricuspid valve leaflet. Magnesium sulfate was infused to lower the pulmonary resistance and thus enhancing the antegrade pulmonary blood flow. Ductal patency was secured by prostaglandin infusion thus providing an additional pulmonary blood flow through the ductus arteriosus.The above measures were adequate to stabilize the patient with no further deterioration or the need for other supportive measures such as Nitric Oxide therapy or extracorporeal membrane oxygenation (ECMO). Therefore, early diagnosis and adequate measures to improve the pulmonary blood flow are mandatory, important pre-operative measures in the management of these patients.     

Blocking “don't eat me” signal of CD47-SIRPα in hematological malignancies,an in-depth review

Hematological malignancies express high levels of CD47 as a mechanism of immune evasion. CD47-SIRPα triggers a cascade of events that inhibit phagocytosis. Preclinical research supports several models of antibody-mediated blockade of CD47-SIRPα resulting in cell death signaling, phagocytosis of cells bearing stress signals, and priming of tumor-specific T cell responses. Four different antibody molecules designed to target the CD47-SIRPα interaction in malignancy are currently being studied in clinical trials: Hu5F9-G4, CC-90002, TTI-621, and ALX-148. Hu5F9-G4, a humanized anti-CD47 blocking antibody is currently being studied in four different Phase I trials. These studies may lay the groundwork for therapeutic bispecific antibodies. Bispecific antibody (CD20-CD47SL) fusion of anti-CD20 (Rituximab) and anti-CD47 also demonstrated a synergistic effect against lymphoma in preclinical models. This review summarizes the large body of preclinical evidence and emerging clinical data supporting the use of antibodies designed to target the CD47-SIRPα interaction in leukemia, lymphoma and multiple myeloma.     

Prophylactic Peritoneal Dialysis After the Arterial Switch Operation: A Retrospective Cohort Study

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Banking a fillet flap to aid in reconstruction following a hindquarter amputation

A hindquarter amputation and hemipelvectomy for recurrent malignancy presents a reconstructive challenge to the plastic surgeon. Tumour resection leaves a considerable defect, with exposure of bone, neurovascular structures, pelvic and abdominal organs. A free lower leg fillet flap is a recognised method of providing soft tissue coverage, but ischaemic time is often lengthy as described in the literature. We present a unique method of providing soft tissue coverage using a free lower leg fillet flap, and minimising ischaemic time by banking the flap on the ulnar artery during the hindquarter amputation and tumour resection.Level of Evidence: Level V, therapeutic study.     

Multiple contrast type tests for the evaluation of animal carcinogenicity studies

The Cochran–Armitage (CA) test is frequently used for testing the dose–response relationship in tumor incidence. This test is based on a weighted linear regression of proportions. It is well known that the CA test lacks power for nonlinear tumor outcomes. For general shape of outcomes, Hothorn and Bretz (2000) proposed a multiple contrast (MC) test. This test suggests the use of the maximum over several single contrasts, where each of them is chosen appropriately to cover a specific dose–response shape. In this work, two new test procedures are proposed and they are compared to the CA and MC tests using power.     

Novel Risk Factors for Progression of Diabetic and Nondiabetic CKD: Findings From the Chronic Renal Insufficiency Cohort (CRIC) Study

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