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So many lawyers, so little time...

"The prospect of hanging focuses the mind wonderfully"--Samuel Johnson

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Location: Louisville, KY, United States

Gastroenterologist, cyclist, cellist, Christian, husband, father, grandfather.

Friday, February 17, 2006

Death's not my first choice but...

This is one of my favorite doctor jokes:
Q: Why do doctors go into psychiatry?

A: To get free advise.

Psychiatrists didn't find that joke very amusing 25 years ago, but now they're having the last laugh. Stress disorders, depression, ADD, ADHD, and general gloominess are so rampant in our culture that knowledge of psychopharmacology comes in handy. I know how to treat Crohns disease. I don't really know how to treat Hashimoto's thyroiditis anymore, and that doesn't bother me much. But I really wish I were a bit sharper on the treatment of lawyer-induced chronic depression (a recognized medical entity, by the way).

When I was younger I wanted to go into psychiatry, until I was seduced by the dark side of the Force, that aspect of medicine dominated by Pathways and Mechanisms, by Techniques and Procedures.

I enjoyed "fixing things" or at least sharing the illusion of it. Surgery and cardiology were a bit too intense so I opted for the more laid-back field of gastroenterology. It's been a good fit, and I'm glad I chose it. These days I've been ready for a change, and for a specialty that I never would have dreamed of being drawn to.

When I turned 40 I was chunky and sluggish and determined that I wouldn't be that way for much longer. Fueled with the energy that comes with Mid-Life Hypomania, I lost forty pounds, built up muscle, took up skiing and horseback riding, and subtracted 15 years from my physiology. I felt great.

When I turned 50 I was chunky and sluggish and determined that I wouldn't be that way for much longer. At 50 I had no more mid-life energy; I had "matured", which meant that I was just tired. What excited me the most was the prospect of catching a cat-nap. I'm 53 now, but I won't be for long, and the leaves that are green turn to brown, and I'm still chunky and sluggish and have reason to believe that I'll stay that way until I get chunkier and sluggishier and so on and so on until I die some day.

I'm not being morbid. That's just the way it is.

So I could use some free advise facing these end-of-life issues. For the first time in my life I wish I had gone into Oncology, because in facing death we face life. When we face total loss we realize which things we are carrying that are worth the weight, and which ones are not. If I knew as a fact that I had pancreatic cancer with metastasis to the liver, I would not be wondering if it were worth upgrading my TV to high-def and getting TiVo installed in my cable box. I would want to tell my wife and my daughters and my son how much I love them and how I wish I'd bother to tell them that a lot more that I ever had when I thought that I would live forever. I'd tell my friends that I consider them friends. I just assume they know that. I never come out and tell them.

Last week I was discussing with a family the outlook for a man with pancreatic cancer that had spread to the liver, and almost surely by sound of things to a few other places as well. On a physiological basis there is not a lot of good news to share; there is no good news to share, other than to discuss the advances that we've made lately in palliative care.

"But Doctor, is it right to take all hope away from him?"

Baring divine intervention, do we take away all hope by sharing with families that the 5 year survival rate for advanced pancreatic cancer is essentially 0?

What survival rate do any of us have? 40%? 80%? Last I checked the same fate awaits every single one of us. Our collective survival rate is 0. Have we no hope? Shall we delude ourselves and tell ourselves something different? Would we really want it to be different?

What hope does my patient have? He knows he's going to die, like all of us, but he knows that his time will come very soon. Does he have relationships that need to be mended? Does he have people that need to hear about his love for them? Does he need to reconcile himself to whatever his belief is concerning Eternity? Does he find comfort in the fact that his thirty year mortgage and his 1040 and his zero coupon bonds are no longer of any importance to him? Is there no hope in this?

"There's something to be said about having 'the big one' and getting it over with in a hurry", I hear people say all the time. I don't think so. I think I'd have too many regrets dying suddenly, if I were capable of having any regrets at all.

My career is being prolonged because I have the priviledge of telling the vast majority of the patients that I see that they do not have colon cancer, and that has become a great source of joy to me. I hope to be able to continue to deliver this good news to people for years to come. But it is with the unfortunate ones, the ones that I must share the unthinkable, the unhearable and the unimaginable, that I am learning the most about myself and my life.


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