In family practice, the process of working through a patient’s symptoms to a diagnostic conclusion is usually a really rewarding one. Most of the time, the diagnosis is of a condition that is benign or self-limiting, or an illness that will be chronic, but not life threatening.
Less often, the diagnosis is of a life threatening disease, one which will be challenging to treat and impossible to cure. It is always disquieting for me to know a terrible diagnosis before my patient does and there is never an easy way to enter into the painful conversation that breaking bad news can be, particularly at this stage of my career in as a family physician in Marathon, Ontario a small community where I have practiced for more than 20 years. Relationships with patients are often longstanding ones that bring me joy, but also, as patients age and move into a different stage of life, sorrow.
This week was no different.
I had received the biopsy result and began planning for the next steps: calling specialists, setting up an urgent consult and sending all of the information to the specialty clinic. I wanted to have answers and a solid plan so that when I saw my longtime patient and friend the next day, we would have a plan that we could both hold on to as we moved beyond this difficult conversation and onto what will be a difficult road together.
On the day of her next appointment, I took a deep breath and opened the door to the next half hour of our lives. She smiled at me and, as always, asked how I was. It was all I could do to choke back my tears as I told her that I was sad … sad to have to tell her that the biopsy I had done three weeks earlier showed that she had a serious cancer. I did not yet share the details that it was a rarer and more aggressive form of cancer. That could wait for another day. Today she needed to hold hope. Maybe I too needed her to hold hope.
There were no “right words” as we looked into each other’s eyes, and she began to cry. “We’ve been through a lot together… we’ll get through this too.” Her language implied her understanding that she would not walk this frightening road alone. And she is right. As her physician, I will be a companion on her journey with this illness.
I have known her for 20 years – 20 years as a rural physician in this small community where the relationships are almost never just “physician-patient.” She was part of the health care community when I started into practice here and she “taught me the ropes” of clinical care in our community, helping me to quickly learn the backstory of patients that she had known for years but I was encountering for the first time. She knew who I should call for what and when. She is woven into so many of my memories of my first years in practice.
I know her whole family. She celebrated the birth of my own two boys, and over the past 18 years she has asked about them unfailingly whenever we saw each other in the clinic or out in the community.
And now, I imagine what it will be like to walk with her through to her last day. When that phase of her illness and her life arrives, I know it will be a privilege for me to be able to care for her. I see the opportunity to be involved in her care also as an opportunity to express my gratitude for her role in my life.
And as I care for her, I will be mindful of the need to care for myself, and seek the care of others, so that I can continue to hold my own grief with a measure of tenderness.
Increasingly I am aware of the grief and sadness that I carry as I reach this stage of my career in this community. I am witness to the closing chapter of many lives of which I have been a part for more than two decades now. As the demographics of rural communities has changed, so too has the rate of “life events.” Deaths now outnumber births here – a complete reversal from my first years in practice – and sadness is a more frequent visitor in my life.
Just two weeks ago, I worked tearfully to provide palliative care and walk though the approach to assistance in dying for a feisty woman whose stomach cancer was causing her slow, weakening decline. She had been a delight in my practice since I began work here and, for even longer, had been a delight in our community. Saying goodbye to her was quite heartbreaking. But as her physician, it was a privilege to support her wish to die in our community, in the way that she wished, with the people she loved with her. I wept on my own time, grateful for the opportunity to have known her over the years, and for the opportunity to play a trusted, caring role in her last days.
It’s perhaps an odd thing to experience gratitude for sadness. To me, the grief that I feel is borne of a depth of relationship that I experience with the people that I serve as a physician and with whom I live my life in this community.
Sorrow, my now familiar companion, is not, and will not be, unwelcome. I choose to know my sorrow as a reminder both of the richness of life and of the opportunity to live my full humanity through my profession as a rural family physician in this place. I am grateful.