Most people are familiar with how the health care system sometimes discriminates against obese people. Doctors may insist a patient lose weight before they will address a health problem, even if the patient’s weight has nothing to do with the problem. Well, it also happens with cancer. Here’s how it works.
Let’s imagine a 23-year-old lumberjack. He is healthy in every way. While he is out in the woods, cutting down trees with his chain saw, he is attacked by a piranha that latches onto his face and won’t let go. His comrades call 911, and he arrives at the emergency department with the piranha still attached.
The physician examines him and says, “Lo! You have a piranha attached to your face! I will surgically remove it and give you some cream and antibiotic tablets and you will be on your way!”
Now let’s imagine that the lumberjack is 90 years old, retired, and he has recently had treatment for a cancerous lesion. He is feeling pretty well, though, and in fact sustained the very same piranha injury as the young lumberjack while he was out in his back woods trimming some trees with his chainsaw. His 90-year-old wife, who was helping him load the trimmings into the tractor and haul them to the trash pit saw the whole thing and called 911 in a timely manner.
When he gets to the emergency room, however, the physician says, “Ah, there’s something on his face. We see this a lot with elderly cancer patients. Our recommendation is that we make him comfortable and tape a plastic bag over it so that he can shower without exposing the wounds to infection.”
And his family says, “Are you out of your mind? He has a piranha attached to his face. Get it off!”
And the medical team give each other significant looks, and they say, “We’re going to call the social worker up to talk about options for your grandfather. We’re very sorry this happened.”
And that’s what I’ve gone through with my mother, over and over again. Last year I had to listen to doctors telling me she wasn’t going to walk after breaking her hip and had no treatment options left for the cancer and needed to be in a nursing home. She recovered, got back on her feet, and responded well to the same cancer therapy she’d been on before. (Most of her “recurrences” have been triggered by the doctors discontinuing therapy.)
This time, it’s pneumonia, and I feel like I’m in some kind of surreal alternate reality trying to convince the doctors to just treat the pneumonia, when they keep trying to tell me that Mom is ventilator-dependent and simply too weak to breathe. I can’t micromanage the care. I have no idea what types of tests or treatments they may be overlooking because of assumptions made about her condition. But I do know that a person who had no breathing problems before she went into the hospital, and was even a regular exerciser does not go from that to respiratory crisis and ventilator dependence in TWO WEEKS just because she is old and weak.
Do the doctors listen to me? No, they never listen, because it’s new doctors every time. If we could work with the same team from one crisis to the next, they might get it. But instead every crisis has a new team, and from their point of view, my mother is just some kind of anomaly or exception that does not disprove their overall philosophy of treating older patients with cancer.
And if other patients don’t have stubbornly aggressive families full of health care professionals who will advocate vigorously for them to get that damn piranha off, then their practice of giving up on cancer patients can become a self-fulfilling prophecy.
The thing that gets me is that these doctors who are specialists in other fields like pulmonology or orthopedics or whatever don’t actually know shit about cancer. They try to tell me that the lung problem is maybe cancer related. What?!? No, it f—ing isn’t! This is multiple myeloma–it does not cause respiratory failure, most especially when there isn’t one single bone lesion. (If not for the chemo, she might be getting a bit anemic by now because her bone marrow isn’t producing enough healthy blood cells. She would certainly not be suffering complications from advanced cancer or be at the terminal stage.)
Same thing with the kidney failure. The nephrologists, who got paid something like $300/minute to consult on the case, said that the kidney failure was probably cancer related, and would not get better. Cancer related? No, it f—ing isn’t! Myeloma can cause kidney failure, but only in very advanced stages of the disease, when the blood levels of calcium are high from all of the dissolved bone. Fortunately, I ignored that asinine consultation, and Mom’s kidney function began improving literally the next day, and has been improving every day since then.
Why didn’t the nephrologists diagnose her with kidney injury from the chemotherapy treatment she’d just had, which is a common, well-known complication of the treatment, and instead reached for a lame-ass cancer explanation? I don’t know! I wish I did.
I’ve been told that doctors don’t want to get families’ expectations too high, because we might be disappointed. But what are we, FIVE YEARS OLD, that we are worried about disappointment, here? If my mother dies, I am going to have larger grievances than having had unrealistic hopes during her illness. I’m going to, you know, actually miss her and stuff. It’s really kind of a self-centered attitude among doctors to think that a family’s grieving process is really all about them. Are we going to be angry? Yes. You know why? Because people get angry when they go through a major loss. Are they going to be angry at the doctors and hospital that didn’t save their loved one, even if it doesn’t make sense? Yes, they are. I’ve seen it before. Get over it. As a physician, you can’t expect to be loved and appreciated all the time, and pre-emptively stomping on people’s hopes is not the same as doing right by them.
(Paradoxically, I’ve been told by someone who was a caregiver for a younger cancer patient that doctors were unrealistically positive about that patient’s prognosis, so there’s definitely an age element. And also a “doctors are making shit up as they go along” element.)
All I can do about this is refuse and redirect when it seems like what I’m hearing doesn’t make sense. But doctors have a great deal of power to set the tone and frame a discussion, and it’s really hard to gainsay them when they get into that mode. It’s stressful and exhausting and frustrating, and there’s no payoff when they’re wrong. They don’t come in and say, “Wow, I totally called this thing wrong. I almost sent your loved one home with a piranha stuck to his face because I thought it was a cancer lesion.”
Noooo…instead, they come in and say, “Wow, we never expected your loved one to pull through. This is obviously an inexplicable miracle or possibly due to my brilliant doctoring and there is no lesson here that I need to learn for the future.”
Maybe some doctors can learn from patients, but when it comes to the conduct of clinical practice, only doctors can really influence other doctors. They need to get started on that.