To the Last Drop

Get Permission

Daniel Rayson, MD

Daniel Rayson, MD

It was 2:15 PM, and my afternoon clinic had not yet begun. The morning had been particularly trying as a result of disastrous clinical developments for two of my long-standing patients.

Jessica had metastatic breast cancer, and I had been taking care of her for 7 years. Multiple lines of palliative treatment at times of disease progression had kept her life rolling along despite the dissolution of her tumultuous marriage and the anxiety she experienced with every cough, ache, scan, and clinic visit. Her teenage daughter would accompany her to clinic visits, scribbling notes and clarifying expectations. She would repeat my words as a gently enveloping echo chamber, making sure that, at least for now, her mom heard what I was saying. 

That morning, I met her son for the first time: a man-child of 15 years who stood up when I entered the room, gave me an unexpectedly powerful handshake, and quickly sat down again to stroke his mother’s temple. The pallor of his palm highlighted the fluorescence of her eyes and the sickly yellow-gray of her skin. Her eyes usually pierced through me with unanswerable questions, but now they were unfocused and gazing beyond the clinic room, staring at something deeply elsewhere. 

An hour later, I saw Lisa, whom I had known for a shorter time. She also had metastatic breast cancer, but her triple-negative disease had led to fewer treatment options when she presented with dyspnea and a computed tomography scan documented lymphangitic carcinomatosis. Corticosteroids as well as first-line chemotherapy managed to rescue her from immediate threat. 

For Lisa, a chaotic life fraught with tangled relationships, intermittent substance abuse, family disengagement, and financial destitution had finally settled down when she was accepted to the art college as a mature student. She expected to return to school once things had stabilized. This was a follow-up visit to touch base and plan the way forward. The clinic nurse had mentioned the new headaches but not Lisa’s drooping left eye, ataxia, and increasingly disorganized thinking over the past 2 weeks. She looked at me by tilting her head up slightly to compensate for the ptosis. For a long time, she did not say anything; then, she asked, “What the hell is happening to me, Doc?” 

In for the Fight of His Life 

TONY WAS MY FIRST new patient that afternoon. He was 24 years old, with a watermelon-sized abdominal mass. Over the past months, he had developed progressive upper abdominal pressure, and his meals were not settling normally. His coworkers noticed he listed to the right whenever he sat down, and his family thought he was getting thin. Progressive nagging from all sides had finally brought him to an ultrasound, which revealed a massive tumor. Further imaging detected bone, liver, and lung metastases, and a biopsy confirmed an aggressive neuroendocrine tumor. 

Once the door closes, forcing us to lock eyes with the patients and families waiting for us, the true work begins.
— Daniel Rayson, MD

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The discordant laughter spilling out of the room stopped abruptly as soon as I walked in, 2 hours late. I met the two sides of his divorce-fractured family, seemingly held together by the sheer force of his warm smile. He was the master of ceremonies, gently guiding the discussion, at times forcefully rebuffing questions from family members he did not want answered. Over the course of the hour, I felt my energy waning, and my voice became increasingly detached. Someone else seemed to be reviewing the pathology, the extent of disease, treatment options, and palliative goals that lay ahead. Something outside of me took control of the discussion, trying to protect me from the reality that this young man, along with everyone who loved him, was in for the fight of his life. 

As the day slowly closed, I wandered back to my office. I fumbled for the keys to the door and collapsed into the chair in front of the computer screen on my desk. For the longest time, there was nothing. I stared at the screen, keyboard silent, eyes trying to focus beyond the heavy darkness that had invaded my body and mind. I got up from the chair and started pacing the office, when my Fitbit announced another 10,000-step day with its vaguely uncomfortable buzzy vibration on my wrist. I stopped pacing and stared down at the digital device, flashing congratulations on my commitment to fitness. I wanted to rip it off and smash it against the wall. Aerobic exercise only goes so far. 

All About the Clinic Room 

THE WEEKEND BEFORE, I had finished reading Siddhartha Mukherjee’s The Gene: An Intimate History. In it, he describes the brilliant and dysfunctional pioneers of molecular and clinical genetics, much as he did with the pioneers of clinical oncology in The Emperor of All Maladies. One cannot help but be inspired by the corrupt majesty that has led to the evolution of modern cancer medicine and the single-minded and often fanatical determination of the pioneers. 

“The single most important attribute of a medical oncologist is psychological and emotional resilience, and the sixth sense to know when it is wearing thin.”
— Daniel Rayson, MD

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But, in the end, it’s all about that clinic room, isn’t it? Once the door closes, forcing us to lock eyes with the patients and families waiting for us, the true work begins. Describing the latest developments in oncology is relatively easy. Individualizing these developments while adjusting for disease, functional status, age, comorbidities, goals of care, idiosyncratic treatment toxicities, and financial resource limitations within the fraught atmosphere of a cancer diagnosis is treacherous. Trying to set realistic expectations by framing therapeutic and molecular knowledge in a package of words that allows a patient and his or her loved ones to hope for what is possible, strive for what is reasonable, move beyond what is unknowable, and accept that which is terminal is hard work. Even when we somehow manage to balance all these elements, patiently recalibrating with every shift in the treacherous dynamic that is metastatic cancer, a surge in the disease process can send everyone tumbling into the abyss at any moment, the impact of the fall perhaps softened by the work we do to prepare and protect as many as possible from a disease that has a mind of its own. 

Empty Flask of Compassion 

EARLIER THAT WEEK, a colleague recounted a story about a discussion between a philosopher and a medical oncologist. The philosopher explained that a person wakes up with a full flask of compassion each morning. As the day goes by, these drops of compassion are spread where needed, and for most people, when they get home from work, there remains a significant residual ready to be doled out the next day. However, for oncologists, all the drops are given out in the course of their routine work. At the end of their day, only the empty flask remains. Sometimes we run out before the end of the day. We return home craving silence from our family and go to sleep, empty. 

I have often told trainees the single most important skill of a medical oncologist is the ability to think on one’s feet while one’s every word, shift in body language, and change in conversational tone are being analyzed and evaluated by the patient and family in front of us. Continually answering multidimensional questions coming from different perspectives in a way that lets life and hope continue until the next clinic visit is exhausting. In the next breath, I tell them the single most important attribute of a medical oncologist is psychological and emotional resilience, and the sixth sense to know when it is wearing thin. 

For most of us, at some point in our careers, our job can be dangerous. There is danger when the weight of our words threatens to crush us as they fill the room. There is threat when the situational burdens become too entrenched and the existential crisis too wide to cross without a net. It is not a job for the faint of heart, the frail of spirit, or the fragile of psyche. The number of steps I take in a day has no meaning. I need to know when my flask is almost empty. There is no app for this. ■

At the time this article was published in the Journal of Clinical Oncology, Dr. Rayson was practicing at the Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada.

Acknowledgment: Dr. Rayson would like to thank Wojciech Morzycki, MD, for sharing the story about the drops of compassion. 




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