www.thelancet.com/respiratory Vol 2 January 2014 33

Spotlight

Mrs Thompson made her way across the oncology waiting room slowly, carefully pushing the wheeled walker adorned with assorted stickers and laden with two cloth shopping bags. Our nurse Barbara was preparing to check her into the examination room, a process that promised to be laborious. You have time, she knowingly informed me, realising that Mrs Thompson was the last patient of the morning and that I would like to eat my sandwich before starting a visit which could take most of the lunch hour. Barbara was correct. I have always found a full stomach made me a better listener and presumably a better physician. As I have aged, I can also add that patience comes more easily when my neck is not sore.

Mrs Thompson was a 65-year-old woman with a long history of schizo phrenia who had presented a month ago with metastatic lung cancer, the result of years of heavy smoking. Her psychiatrist had noticed her worsening cough and started the evaluation. Sadly, despite her doctor’s alertness, the cancer had metastasised to her liver. She had started palliative chemotherapy and was here for her second treatment.

Barbara had taken her time checking in Mrs Thompson and I entered the examination room well fed. I was disappointed that our medical student was on vacation, as she would miss this opportunity to observe a sated physician with the luxury of time who might for once fulfil the goals we teach.

“How are you, Mrs Thompson?”“Just a minute”, she began, “and I’ll tell you. Your father told

me to write everything down”. She began to search in the larger of her two bags for her list.

My father. On our initial visit, we had established that he had been her first psychiatrist in our shared hometown. They met in the 1960s at the start of a period of “deinstitutionalisation”, which promised (or threatened) to release many of those with mental illness from the shuttering asylums. The miracle of chlorpromazine (thorazine) combined with new programmes promised to help the mentally ill survive in the community. My father, a local boy who had finished his psychiatric residency and military service, was looking to start a practice that would not involve endless psychoanalysis of the wealthy.

“You know”, she said as she hunted, removing a worn Bible and a few expired shopping coupons, “I remember when I used to see him on Circular Street”.

The modest start of the County Medical Health Programme had been in an abandoned Victorian house on Circular Street, which a diverse group of volunteers and patients turned into a therapeutic environment. To gain support, my father used his local contacts to enlist leading community members to serve on the newly formed Citizens Committee for Mental Health. Although their eff orts pale in comparison to the

pink ribbons that now cover our town during Breast Cancer Awareness Month and their slogans would no longer be politically correct (eg, “Support Mental Health or I’ll Kill You”), they ensured that the programme survived the county budget process. They built a network which included an inpatient unit, step-down houses and an outreach programme of travelling professionals. Patients would cycle through the system depending upon their needs. Since it was an era when re-admission was not a dirty word, patients could try to succeed on their own but knew they would be welcomed back to our hospital.

Mrs Thompson looked up, her hand back in the bag.“After school we would hang out in the living room and

your father would stick his head in between his patients and make sure we were okay.”

Out came another piece of paper, this one a flyer for the Hospital’s new Community Health Center, the institutionalised successor to the old system.

“That was a terrible time. Do you remember Johnny Ward?”I nodded. Johnny Ward had been the brilliant eldest son of

a local college professor and his wife. He graduated from our high school and then died in the brutal jungles of Vietnam during another of humankind’s senseless wars. He had left upright and proud to serve his country but never came back. I had cared for his father recently as he died of cancer and knew the perpetual rawness of his family’s wounds and loss despite the many years.

“I don’t think he knew me, but we all knew him. It went to hell around here when he died. We all cried for months.”

Unlike Mrs Thompson’s, my own childhood had been idyllic, the culmination of the American immigrant’s success story. My father’s parents had arrived separately from Italy, learned English, endured the assimilation process, married, and started the family coal business. Their labour allowed my father and his two brothers to be educated, one brother becoming a paediatrician and the other an engineer. Of course, two other siblings died in infancy, while my grandfather’s life was certainly shortened by the loads of coal he carried upstairs (and I whine about a sore neck). Unlike Johnny Ward, I was several years too young to have to make the fateful decision about whether to fight in Vietnam or leave the country I loved. During my wonderfully sheltered childhood days, I would walk downtown with my father while he would alternately greet the mildly dishevelled man on the bench who was obviously a patient and the prominent of the community who I now realise were also using his services.

Next out was a frayed mitten. “Can you believe it?” she laughed. “A mitten in summer. I keep looking for the one that goes with it. You know, I never graduated from high school, but I always kept my own place.”

EssayPatient, Doctor, Father, Son

Winner of The Lancet Respiratory Medicine’s 2013 end-of-year Essay competition

David Mastrianni is a medical oncologist in his hometown of Saratoga Springs, NY, USA. He serves on the Board of Trustees of Saratoga Hospital and on the voluntary faculty of his nearby alma mater, Albany Medical College. He is grateful to Lucille Albergo for forming the remarkable oncology nursing and support staff who actually deliver the care.

Spotlight

34 www.thelancet.com/respiratory Vol 2 January 2014

I thought of my graduation from our local medical school. I had been drawn into medicine by my admiration for my father and uncle, both of whom served on the volunteer faculty. Most of the lessons I learned have long since vanished or proved wrong, but my memories of the faculty remain. I remember Dr Hines walking into a locked isolation room that held a wasted man dying of the disease we would later know as AIDS. While we all stood in the anteroom in spacesuits, Dr Hines refused to wear more than his usual clothes, sat by the bedside and held the withered man’s hand to give him the first human touch he had felt in months. He refused my admiration, growling “if this thing is that contagious, we’re all dead already”. I remember the late nights when Dr Scharfman, his brilliant mind trapped in his own body by a neurodegenerative disease, allowed me to push him in his wheelchair to visit his patients. My favourite memories also include rotating in our own hospital with my father and his partner, a crusty Irishman named McKinley. My father had me see the “single most important patient in my career”, a miserable demented man whose family insisted upon keeping him alive. After my somewhat puzzling visit, my father put his arm around me and made me promise I would never let him end up like this poor fellow. For his part, McKinley took me in to examine a very large and occasionally violent delusional man with the instructions to “slow him down if he comes after me, so I can escape”. We survived the encounter and McKinley’s sole evaluation of my month’s eff ort was the two lines, “You can pass him. He tolerated his father well.” I hope the current generation of students in our modern system of teaching have the same role models.

Mrs Thompson sat up straighter, still without her list. “I always worked, too. I am very proud of that.”

“And you should be. That is a major accomplishment.”Me, too. Above all, practising medicine is work. McKinley

emphasised that lesson at my graduation party in my parent’s home with family, friends and many of my teachers. Before I was allowed to join the festivities, McKinley brought me into the kitchen where he had placed a local boy who needed some stitches in his scalp removed. “See your patient before the party, son.”

When my work became oncology, my father and I began a good natured debate about the relative curability of cancer and mental illness. By this time, his own career had led him to open a new psychiatric hospital and I admired their eff orts to integrate his goals of “never treating patients at the expense of their humanity” into a corporate structure.

Finally, out came a piece of lined paper, carefully folded into a small square.

“Here it is”, she said with satisfaction. “I knew it was here. Good.” She paused and looked straight at me before unfolding it.

“I was sad when your father got sick. He had cancer, right?”I nodded. We had been together one summer night and

he seemed well. The next day, shortly after he turned 60, the

glioblastoma in his non-dominant frontal lobe which had grown undetected even by his physician son suddenly bled, causing him to lapse into a coma. Thankfully, it was resected by our local neurosurgeon called in from his own family party. He awoke with that portion of his brain missing, causing McKinley to pithily observe how little you actually use as a physician. After his treatment plan was explained to him, my father informed me that the medical science of oncology was not ahead of psychiatry and claimed victory in our debate. He dutifully took his radiation and chemotherapy, but returned to eating sausage and eggs for breakfast despite his elevated cholesterol, cancelled his colonoscopy, and refused to save any good wine. Predictably, he died almost exactly 1 year later in his own bed, surrounded by his family.

“I was sad when he died, too. A few of us from Circular Street came to the wake.”

“That took courage. Thank you.”Mrs Thomson’s own cancer would probably claim her

life over the next year. Her cancer was created in the toxic environment produced by years of smoking, a habit very much linked to mental illness. Despite the tremendous advances in many areas of oncology over the past decades, relatively little has yet changed for patients like her.

“Personalised medicine” for Mrs Thompson consists of traditional chemotherapy with a great deal of attention to the process of getting the cab, working the elevator, seeing the doctor and nurses, establishing the intravenous line, taking the right medications, getting home, and having a visiting nurse. Even when our scientists bring us better treatments, the success of the transition from laboratory bench to clinic will still often be found in these details.

The paper unfolded. Part of me was afraid that her list would include prognostic questions. On another occasion I might have used this opening about death to bring up Mrs Thompson’s own reality. Like so many doctors and nurses on the front lines, I have been worn down by being told how we fail our patients and society by not discussing end-of-life issues. We try, but the truth is that these talks are hard and painful. And today she was directing our visit.

Mrs Thompson read from the worn lined notebook paper. “The real thing I want to know is if I can put off my next treatment in 3 weeks for a day. It’s the opening of the County Fair. I’ve never missed it, but I won’t go if you say it will hurt me.”

I recalled that my father, despite his wisdom, had needed my reassurance at the end of his life that missing the last few days of his chemotherapy pills had not caused his cancer to recur.

“That’s fine”, I replied carefully. “Being one day late will not aff ect your treatment.”

“Good”, she said, standing up and grasping her walker. “I’m ready now.”

David M Mastrianni