My day began and ended at the bedside of a woman who was suffering. For nearly a year, cells had been proliferating inside her body, growing imperceptibly at first but crescendoing to a loud, agonizing climax. Now, to describe her as “an uncomfortable-appearing female” in the written medical record would have been a gross understatement. And there was not just one woman; rather, there were two women, in different rooms, in different hospitals, each approaching the end of her pain.

The two women had undergone physical transformations in parallel, their abdomens swelling synchronously as I had observed them both during the preceding months. The first woman was my patient, in the last throes of being ravaged by an aggressive angiosarcoma, a tumor that had replaced her liver and flooded her belly with ascites until her skin was drum tight. The second woman was my wife, giving birth to our second child after a difficult pregnancy.

These two women had shared my longstanding worry about their outcomes, but as I stood beside each of them in turn, moving from the intensive care unit in the morning to the obstetric ward in the evening, I witnessed their paths diverge to the diametric opposites of death and life. The timing was eerily simultaneous. While my son's first moments were spent having a nuchal cord disentangled, elsewhere the noose of end-stage cancer tightened mercilessly around a young mother. He entered the world at almost the exact instant when she made her premature exit.

I had seen my patient's death approaching from a distance. From our initial encounter, I was sure that her tumor, having already metastasized at presentation, was going to kill her. With the inevitability of Chekhov's gun, it was only a matter of time before the final disaster, and my sense of foreboding progressed along with her advancing disease. But I could not have predicted that her tragic end would intersect precisely with a blissful beginning, posing the ultimate challenge to my notion of work-life balance. Throughout fellowship, I had struggled to maintain a great divide between my occupation and my family. Then that awful, wonderful day, with its tumult of feelings and obligations, proved to me that the barrier was permeable. The horrors encountered in my job were not so easily contained, and they could coincide with my most precious joys.

The addition of a healthy child to our family would in no way compensate for the wrenching loss levied against another. This was not an equation to be solved like emotional algebra, yet I had to acknowledge a deep conflict. I was ecstatic yet grieving, apparently in danger of betraying two commitments. In mourning, was I guilty of not properly celebrating the birth? Or was I rejoicing despite my patient's death? Never before had I experienced such extreme feelings at the same time, and the dissonance was unsettling.

Perhaps my immaturity as an oncologist in training was partly to blame for the confusion. I have since been told by more experienced physicians that I do not actually mourn when a patient under my care succumbs to their disease; removed from the true despair reserved for a loved one, I should feel only an attenuated sadness, and to claim otherwise would be maudlin. To a certain extent, this distinction seems semantic, but I can acknowledge the difference. Admittedly, I do not experience a patient's demise with the same devastation that accompanied, for instance, the death of my father, a sorrow that can still feel acute decades later. A series of equally profound losses would surely cripple me as a caregiver, given the distressing frequency with which my patients are terminally ill.

That said, I fear becoming insensate more than I fear the pain of repeated bereavement. If I do not feel somber at the time of each patient's death, then I will have become unresponsive to the mortal struggles that drew me to this precarious specialty in the first place. Even in my inexperience, I can already foresee a career spent reconciling resilience with compassion, donning emotional armor while hoping to retain some modicum of vulnerability.

As my patient's death threatened to loom over the joy of my son's arrival, I was reminded that the human toll of the terrible diseases we treat can haunt us. In his magnificent chronicle of cancer, The Emperor of All Maladies, Siddhartha Mukherjee includes an account of his own daughter's birth, which he rhapsodizes as “perhaps the singularly transformative event”1 (p398) of his life. Mukherjee describes inhabiting the dual personae of father and hematologic oncologist as he cuts the umbilical cord, eager to preserve the protean immunity of infant blood for possible use in future transplants, “the shadows of malignancy … lurking”1 (p399) in his psyche. If the darkness of disease can intrude on such a transcendent moment, what hope do we have of ever banishing it entirely from our consciousness? For all the attempts to legislate work-life balance, which imply a separate peace to be found away from medicine, perhaps this double act is impossible to achieve, and we can never entirely shirk our identity as cancer doctors.

If we do seek a single-minded escape from the grim realities of our profession, then an obvious psychologic disadvantage is that we are conditioned to multitask. Our responsibilities as physicians often demand that our attention is divided, and the needs of our patients can invade our most private moments, whether at work or at home. The shrill, pulse-quickening tone of a pager can interrupt a hospice discussion and a bedtime story alike, summoning us jarringly to another place. Of course, it is appropriate to treat the quite literal life-and-death situations of our patients with such urgency. In less pressing moments though, the modern physician is still frequently interrupted and also deluged by information, from new laboratory results for individual patients to the overwhelming tide of reports of therapeutic advances and novel diagnostic tools.

Processing all these data is essential to good patient care. The margin for error in tending to the sick can be frighteningly slim, so few facts can be neglected or overlooked. Meanwhile, the fracturing of our attention span yields ever-smaller opportunities for true concentration on the task at hand: not dividing by zero, but dividing toward zero. Proportionally more effort is required to attend meaningfully to a single item amid so many distractions, which invite mistakes and shallowness where accuracy and depth are needed. The workday becomes a long juggling act, exhausting to execute flawlessly, and it is fantasy to pretend that the intensity of this high-wire performance can be suddenly switched off after leaving the clinic or hospital. It is no wonder that after work, we would seek some respite from these weighty responsibilities, which, in my case, comes most satisfyingly from enjoying the company of my loving wife and children.

I strive not to burden my family with the emotional fallout of my profession. They did not choose to live so close to death. But they are also, I must selfishly confess, my daily escape from pathology. A bastion of wellness and warmth, they insulate me from the atrocities of cancer. My 4-year-old daughter is only dimly aware that her father takes care of “sick grown-ups,” as she calls them, and certainly she does not realize that her daddy frequently makes those grown-ups sicker with his well-intentioned treatments. Her innocence and faith in my goodness provide an excellent remedy for a poisoner's queasy conscience.

Nonetheless, it still requires effort to dispel thoughts of illness from my happy home. A bruise glimpsed on a child's shin, although almost certainly incurred through careless play, quickly conjures a differential diagnosis for ecchymosis, then consideration of the possibility of thrombocytopenia, then, through paranoid leaps of logic, the likelihood of leukemia. Through selection bias, I have seen the worst-case scenario occur so often that it has skewed my perception of reality. Not everyone harbors a mitotic catastrophe waiting to be discovered, I must constantly remind myself.

I was naive to think that my work in oncology, with its constant sobering reminders of mortality, would not come to affect everything that I do. The day of my son's birth was a particularly dramatic collision of the professional and personal spheres I had hoped to keep separated, but which are destined to overlap. Placing such emphasis on an untenable split existence led to the mistaken belief that being an involved parent and a responsible physician were mutually exclusive. In truth, each role we play on and off the job enhances the other, and they cannot—should not—be held apart. The happiness I felt as a new father did not negate my sadness after my patient succumbed to her angiosarcoma, but grief made me savor the gift of life all the more gratefully. The highs and lows of our experiences are not strictly additive, cancelling each other out to a zero sum of numb neutrality; instead, they are peaks and troughs to be navigated in series, with the depth of a valley making the view from a summit that much more precious to behold.

My greatest mistake early in my oncology training was in adhering to a binary logic, assuming that I had to be emotionally engaged either in my work or in my life outside of it. This view was needlessly reductive, and the same illusion of dichotomy is omnipresent as we shape our demeanor as clinicians. Should we be sensitive to our patients' tragedies, sharing genuinely in their disappointments, or should we remain implacably calm during crises, in the hope of inspiring confidence?

The proper response, I suspect, lies somewhere between weeping pathos and robotic impassivity. Computers may be able to process only zeroes and ones, but we human oncologists can, thankfully, blend sentiment and information into a nuanced, personalized reaction to our patients' needs. Such a humane response requires us to enrich our work with our lives outside the hospital and clinic, to be compartmentalized yet whole—to be balanced.

© 2012 by American Society of Clinical Oncology

Author's disclosures of potential conflicts of interest are found at the end of this article.

The author(s) indicated no potential conflicts of interest.

1. S Mukherjee : The Emperor of All Maladies: A Biography of Cancer 2010 New York, NY Scribner Google Scholar

COMPANION ARTICLES

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ARTICLE CITATION

DOI: 10.1200/JCO.2011.41.5695 Journal of Clinical Oncology 30, no. 15 (May 20, 2012) 1891-1892.

Published online April 16, 2012.

PMID: 22508820