On a dark February night in an obscure intensive care unit in a hospital in a small town in Massachusetts, I was sitting next to my mother’s bed. She was delirious and tired after a four-year long battle with her recurrent metastatic breast cancer. In the previous year, she was getting admitted to the hospital almost on a monthly basis and each time with new and different symptoms. First, it was her hip fracture that was caused by the cancer spreading to her right hip. She ended up with an unconventional hip replacement surgery at a big hospital in Boston. Then, it was the seizure caused by the cancer spreading to her brain and the radiation therapy that followed. Finally, there were the fractures of her both arms that simply occurred while rolling in bed. That night I learned that the cancer was in her liver and everywhere else!
I was in my internship year in my Internal Medicine residency. Since I was the only physician in the family, I was happily assigned to stay with her that night. She was not acting herself and I felt that no one was doing anything to help her. I wanted her to get better but she was obviously tired. I was not able to see the big picture! I asked the nurse why they did not check her ammonia level and then convinced her to get an order from the physician to get it done. When it came back elevated, I wanted them to treat it but my mother was not conscious enough to take any medication orally. “Then, may be we should pass a naso-gastric tube”, I told the nurse. I saw the nurse trying to put the tube down my mother’s nose that night. I saw her getting agitated and suffering. Tears started flowing over my cheeks because that was the last thing I wanted to do: to make her suffer more because of my selfishness. I asked the nurse to stop and it was then that I understood that she was dying.
Her visits to her Oncologist had been usually optimistic. She used to like the Oncology Fellow. Every time she went there they discussed the next treatment option: Chemotherapy, hormonal therapy, and radiation therapy. I remember her vividly sitting helplessly in her wheel chair with her hand to her cheek and her head tilted as if she was saying “can’t you see I am so tired of all of this”. I do not recall her Oncologist or his fellow ever explaining the big picture to us. Looking back now, I can see it clearly.
My mother was the most important person to me. Now, I am married and have a small family. I am a physician; a Nephrologist. I talk to patients about life changing therapies: chemotherapy, dialysis and transplant. Therapies that are not much different from the chemotherapy and radiation therapy my mother used to get. I try to look at the big picture but see myself sometime missing it. I try to remind myself and my patients that dialysis and transplant are not for everyone who has kidney disease as chemotherapy is not for everyone who has cancer. Yet, dialysis centers and cancer centers are spreading all over the country. They are profitable to many for-profit companies that made healthcare their business.
Thinking about my mother almost always helps me zoom out to see the big picture. I see how these companies make money of many sick patients that will likely not survive more than few months at the most. I observe the pharmaceutical companies charge thousands of dollars for medications that only extend the survival of a cancer patient for few days. Yet, I have also been on the other side. I was the son of that woman who did not want to let go until it was too obvious.
Many of us are still forgetting to zoom out, patients and physicians alike! I still see my mother sitting in her Oncologist waiting room. I wonder if she would have chosen to take all of those medications if she was presented with the big picture. People have different prospective on life. But we usually tend to trust physicians to do the best for us.
I question why some Nephrologists offer dialysis to patients who will not survive more than few weeks, why some Oncologists propose chemotherapy to patients with terminal cancer, why some Orthopedic Surgeons perform a hip replacement surgery and then discharge the patient on hospice care, and why some Cardiologists do not follow up on congestive heart failure patients unless they want to pursue a procedure? Are we, the physicians, toy-soldiers manipulated by few giants to battle the powerless in a permissive environment? An environment that stripped Medicine from its humanistic nature and made it a business! And how long will this environment be permissive? Will we see the big picture and stand by the powerless to correct it or will we wait for the giants to decide for all of us how the new environment should be?