“So, what do I say when they call me for surgery?”
“Well, that shouldn’t happen because I will talk to them.”
“But if they do?”
“Don’t attend the appointment.”
“Just like that?”
“Yes, you wouldn’t recover well from a major operation.”
“I agree, doc.”
My patient, in her 60s, has two separate cancers, neither curable, both life-threatening. Keeping her well is a balancing act, hence my advice to avoid operating on one cancer at the cost of withholding treatment for the other. She also has long-term depression, and has dependant relatives who are also unwell and never come with her.
Misfortunes shouldn’t have to compete to be meaningful but a combination that fills me with dread is cancer and untreated mental illness.
Cancer attracts significant government and philanthropic money, public sympathy and a support network deep and wide. When a patient is diagnosed with cancer, there is a clear pathway of care even though the road can be unnecessarily bumpy. Between the researchers who come up with discoveries and clinicians who use them on patients are any number of people who enrich the ecosystem: nurses, social workers, allied health and volunteers. Just last week I shared my umbrella with an octogenarian who has sat with inpatients every week for 20 years.
Mental illness is the poor cousin to physical conditions. Although it is the subject of greater awareness and increased funding, as they say, there is many a slip between the cup and the lip. It is difficult for people to access comprehensive care and practically impossible to receive continuity of care, arguably the most important part of recovery. In an excellent public hospital system in so many ways, I find the gap in outpatient care and support services for mental illness incomprehensible.
This leaves my (already disadvantaged) patients with a dual diagnosis in the invidious position of receiving the same treatment as a prince for one illness and a pauper for the other.
Having emailed the surgeon and receiving an immediate acknowledgment, I turn to my patient.
“Now that surgery is off the table, let’s talk about the rest. You need radiation for a growing lump. For this, we need to pause your other therapy.”
Sensing her hesitation, I reassure her that I will personally clarify things with the many people peripherally involved in her care before consolidating her visits to one clinic and one team. At some point, as I am juggling typing and talking, she asks what “all this” means but with no time left to ascertain what she really means, I say something anodyne. She thanks me graciously and leaves.
I feel self-satisfied, even a little smug at how much was achieved in our allocated 20 minutes which became 40.
She had avoided major surgery that might well have proved fatal. The radiation oncologist had issued her an urgent appointment. And she had met a specialised cancer nurse who would be an ongoing help.
If I had to rank the patients I helped on the day, I would put her at the top. So, the blow is especially devastating when just hours later, I receive a text from the clerical staff.
“The patient is so upset that she has asked to cancel all her appointments.”
My only possible conclusion is that the patient is upset with me.
An explanatory email from the patient follows. “I have nothing against the doctors, but everything is too much, and I just want to be left alone.” This only exacerbates my guilt.
Then, this text from a colleague who has intuited my alarm. “I guess we will have to wait until she has a crisis.”
An avoidable crisis is what every oncologist desperately works to avoid, so the patient’s decision to opt out of treatment right after meeting me strikes me as a personal failure.
Thankfully, I suppress the instinct to call her. The last thing an overwrought patient needs is to be browbeaten into submission, even if it is to protect her own health.
I wonder if I could have taken things even more slowly (and kept other sick patients waiting) and been more attuned to her emotions (at no additional cost).
And I regret that my fervour for treating her cancer got the better of my duty to protect her mental health. But I can’t help thinking that what brought her undone was the cognitive overload of my consultation layered on top of brittle mental health never adequately addressed.
When someone mentally unwell is diagnosed with a physical illness, mental healthcare should be expanded; instead, the vulnerable just grow more vulnerable.
Everyone I know struggles to access timely psychological and psychiatric assistance. But in a cancer clinic where there is also a race against time, the practical reality is that people give up – both doctors and patients. If one would not expect a mental health professional to treat cancer, shouldn’t the reverse also apply?
This is why every public hospital cancer service would be enriched by an embedded counsellor or psychologist. Most patients would be well-served, with only those needing step-up care referred to a dedicated psychiatrist for periodic guidance. Given the ubiquity of mental illness and its many intersections with cancer, this would be money well spent.
I confess my problem to a nurse who gives it a day before contacting the patient. I hate to ask how much listening and understanding it took to get there but have never been so relieved to receive a simple text.
“Just confirming your patient has agreed to attend all her appointments.”
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is Every Word Matters: Writing to Engage the Public
