Short abstract
This narrative describes the experience of a radiation oncologist dealing with inequalities among patients and the associated guilt of the treating physician.
One of the challenges of being a good oncologist is to be able to sympathize as well as empathize with patients. Sometimes, I struggle with the guilt of having both the means and good fortune to lead a comfortable life, recognizing that most of my patients do not. I recall one such instance, when I was in training to be a radiation oncologist, that had helped me address this issue and shape my perceptions.
It was a busy afternoon in the Outpatient Department. The next patient waiting was a frail girl in her early teens accompanied by her mother. After the initial introduction, I reviewed her diagnosis: Ewing's sarcoma, no evidence of metastasis. After further explanation about the disease, I discussed what would be considered standard of care for her treatment: chemotherapy, surgery, and/or radiation therapy followed by more cycles of chemo.
As the discussion progressed, I tried to gauge the impact of my words, prepared to modify my responses if required. The child seemed aloof and disinterested in the conversation. Her mother stared blankly, seemingly unsure of the content and seriousness of what was being conveyed. Sensing that this sudden influx of information was a bit too much to take in for her, I realized that this was not the time to get into the specifics, the intricate details of the treatment and its potential complications. As we talked, she gradually began to understand what lay ahead, the prolonged course of treatment with multiple modalities that would be the best chance for her daughter's cure. Being cognizant of the child in the room even as I spoke to her mother, I tried to involve her in the conversation and interact with her, which did not succeed. At one point, I even suggested we get chocolates and ice creams, the last trick up my sleeve to win her confidence.
After I finished, the mother responded. “Doctor,” she started, her words slow and measured. “I am a single parent with three children to take care of. You want me to be with her for nearly a year for treatment here. If I do that, I can't go to work, can I? How can I look after the rest of my children then? And instead of spending money on ice creams and chocolates, I would rather pay for our stay in the shelter here.”
Her response caught me completely off guard. Being raised by a single parent myself, I could only imagine her anguish as I pictured my father in similar circumstances, with one of his two children diagnosed with cancer. Even still, I found myself becoming more uncomfortable as I realized the situation here was one without a simple solution and without an answer that I could provide. I found myself enumerating the facilities that the institute (Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India) provided that might ease her burden in an attempt to redirect the conversation to matters over which I had some control.
“All the treatment expenses will be borne by the hospital,” I reassured her, one of the perks of working in a centrally funded institute that provided free treatment for patients below the poverty line. I also convinced her that her daughter would be admitted as an inpatient as and when required during the course of treatment and that neither food nor shelter would be a problem for them. Then I directed them to the social worker for further counseling and, composing myself with great difficulty after this encounter, I resumed the task of seeing the remaining patients waiting to be attended to.
That same day, my wife came to visit me, taking a day off from her fellowship program in a different city. We dined out, and the bill came to 2,000 Indian rupees (approximately U.S. $30). Though not a prohibitively large sum to many people, on that day, as I remembered my patient and her mother, it seemed preposterous that I would spend so much for a meal for two. I started calculating the number of days that mother and daughter could have stayed at the shelter, the chocolates and treats that the girl could have had with what I had spent. I felt ashamed for spoiling myself with such indulgences. What did I do, to enjoy such privileges when others could not afford two square meals a day?
“Calm down,” I told myself, trying to dull the chorus of guilt echoing in the hallways of my mind. “Do I not deserve a comfortable life after years of studies and hard work? Is there really a need to feel guilty? Was not inequality among men entwined in the very threads that formed the fabric of history? What role do I have in this state of cosmic injustice?” The questions started circling around my head like vultures.
“What lasting effect did I bring about when I ultimately went and bought a few treats for the child? Did it solve any of their problems? Will I be able to do the same for all my patients? Was I not trying to silence my conscience just for the time being?” I was at a loss and was unsure if I was falling into the chasm of depression to which people in my profession are heavily prone [1].
Life seemed to me like an endless puzzle. You work hard to be happy and successful, but in the end, you could struggle to find happiness in the success that you have achieved because of the knowledge that there are people, your own patients, who struggle to meet even the basic needs of living.
After much contemplation, I realized then that you do have a choice—a choice in how you perceive things, to try and trace the silver lining in each cloud rather than complain about the shadow it casts, to change things in whatever small way you could rather than be perennially unhappy about the way things are. Maybe happiness was not a destination: it was just a direction we keep moving to.
Ultimately, the girl did undergo treatment at our center and tolerated the treatment well. She was no longer aloof and had gone back in time to become the pleasant girl she once was. A social support group helped her mother find a job near the hospital, and she was able to support the rest of her family without compromising the care of her daughter.
As for me, I still dine out at fancy restaurants, though not as frequently as I did before, and I do give in to temptations occasionally and reward myself with treats I could have done without. Is it because I have grown accustomed to the voices of reproach in the back of my mind? Whether I should feel guilty for what I do is a question only I can answer. What I know now is that succumbing to guilt is no solution to the state of affairs over which we have no control. Not being able to change the world does not stop us from changing what we can. We must try and make the most out of the opportunities we have, and though we feel our small deeds of help and consolation may be inconsequential, it is ultimately the little drops of water that make up an ocean.
Disclosures
The author indicated no financial relationships.
Disclosures of potential conflicts of interest may be found at the end of this article.
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References
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