Editor’s note: The Young Fellows Association (YFA) of the American College of Surgeons (ACS) offers an annual essay contest, which helps support a young Fellow’s attendance at the annual ACS Leadership & Advocacy Summit in Washington, DC, with a $500 cash prize and free registration to the meeting.
More than 15 entries were submitted to the YFA Advocacy and Issues Workgroup, and these essays can be viewed on the ACS website.
The theme of this year’s competition was Our Patients: On Becoming the Surgeon Advocate, Leader, and Learner, and the winning essay was written by Alexandria C. Lynch, MD, MPH, FACS.
He was intelligent, well dressed, and he had a family. He shared smartphone photos with me of his wife and children shortly after I explained that his biopsy results confirmed the diagnosis of prostate cancer. His pathology returned as adenocarcinoma with a Gleason score 4+4=8, which was low volume but aggressive.
As a urologist who treats prostate cancer patients in a rural community, this post-biopsy discussion has become a common occurrence. Most patients initially are surprised by the confirmation of disease, and when the biopsy results are low-grade non-aggressive prostate cancer, I spend most of the consultation explaining that prostate cancer is extremely common and when treated properly and quickly will not limit the patient’s life expectancy. I couldn’t recommend surveillance in his case and explained that he would need additional testing.
When he returned after MRI (magnetic resonance imaging) scans of his pelvis and bone, we found no evidence of metastasis. After he visited the radiation oncologist, he returned to my office. We reviewed the risks of surgery, his option for radiation as a primary treatment, what he should expect, and the need to convalesce postoperatively.
He laughed and said, “I’m sure I’ll be up and back to work way before that.” To which I replied sternly, “No, you will need time to heal. There are no exceptions.”
Strains on surgeon-patient relationship
I joked with him that I would be counting on his wife to make sure he adhered to the postoperative care plan. He glanced at his wife who was dabbing a slow stream of tears from her cheeks, and he attempted to smile in her direction. I reached out to her and grasped her hand as I have done so many times before with my patients’ loved ones, and he consented to a robotic prostatectomy. Over the next few weeks, he proceeded to cancel and reschedule the operation four times. When I received the notification that his surgery had been rescheduled again, I requested that he return for another visit. When he finally returned to my office, I was professional but swift, starting with a brief synopsis of his medical history and ending with an emphasis on the word aggressive.
“I just couldn’t do this month,” he spat back at me without an explanation or an apology. His wife glanced down at the floor. Clearly, the rapport we had established eroded during the stint between visits. Nonplussed and bothered by his lack of concern, I explained that I was worried and that he did have options. If he no longer wished to proceed with surgery, the option for radiation was still available. When he still had no response, I asked him if he wanted to go for a second opinion. I used words like “urgent” and phrases like “window of opportunity” in an effort to reconnect with him. After some time, he broke.
“Listen, Doc, I don’t care about my life. Just give me a few more months, and I will let you remove anything that you want.” He leaned toward his wife for support, and she reciprocated by pressing her palm onto his arm. I took a moment to adjust to the new tone of the room. He was not afraid of the operation and understood the risks. He needed to work, and he did not want to tell me or anyone that he was in danger of losing his home.
Empathy and advocacy
How had I missed this? This family did not appear to be in need. His children were in college, and he was employed. I had no reason to inquire about his financial health, and I was unsure if he would qualify for assistance. What I did know was if he didn’t act soon, his treatment options would change.
I went to our cancer liaison and was relieved to find out that he did meet the requirement for assistance of the Ascension Health Hospital System and the American Cancer Society. We were able to cover his mortgage payment and his living expenses during his convalescence period.
In the end, he did well after surgery. I wish I could say that this experience was unique, but the number of patients who are unable to take time off to care for themselves increases each day. I am sure that many people choose to delay or forgo treatment completely because of similar issues. Taking the time to assess a patient’s financial health and advocate for assistance can have a tremendous impact on their care and, possibly, save their life.