About the Author
Kathryn Bollin, MD, is a hematology and oncology fellow
at Scripps Clinic.
A world of personal discovery often opens up during medical training. While in medical school, we endure high-volume, intensely pressured learning and discover an inner work ethic previously untapped. In residency, we learn to “practice” medicine and discover a new confidence that only emerges from real experience. For those of us who embark on fellowship training, this is where we settle in to learn the field of medicine to which our passion has delivered us.
This is akin to entering the cockpit after years of flight training on the ground. The first few weeks of fellowship are spent in awe of actually being chosen, knowing this is where we will finally get to experience the thrill of flight. As weeks progress, we sputter through a few rough takeoffs and landings, some so discombobulating that we forget the excitement we felt only weeks before.
About 6 months into fellowship we begin to soar, still guided in flight by peers and mentors. The thrill returns at this point and we find a rhythm. This is important since without a rhythmic undertone to the intensity of our days, the winds are choppy and the flight is chaotic.
As my first year of fellowship concludes, I feel like I’ve got rhythm. And I know it’s in large part due to the solid flight crew keeping me in time.
Making a New Friend
While recently rotating as the “inpatient” fellow, getting to know my crew has helped me immensely. I found this new role to be one of the most draining of my entire medical training. The hours were long and food seemed scarce, but comfort came from my supportive team and family. If not for them, this would have been a “What have I gotten myself into” month from hell. Instead, I managed to learn and even get a thrill from practicing cancer medicine from a new perspective.
As is often the case with cancer patients in a hospital, most of mine were nearing the end stages of their disease and life. Some patients entered this phase after years of struggle. However, the majority of them were newly diagnosed, diffusely metastatic, and far too young. In 4 short weeks, there were at least a dozen patients with whom I conducted a weighty conversation about their advanced, soon to be terminal, cancer.
Each discussion, patient, and family pulled at a separate heartstring. Upon meeting a patient for the first time, I would brace myself for this new role as the stoker of fear and mortality rather than the gatekeeper to hope. And each time, I called upon our palliative care nurse practitioner to help me guide my patients in their new reality. She was the copilot I needed to help provide care for these patients for whom cure was impossible and palliation essential.
Palliative Care: Background
Palliative care is a relatively new field of medicine, but one that has grown quickly for a multitude of reasons. The term “palliative care” was first used in the 1970s by Dr Balfour Mount, who became the father of the palliative care movement in North America. Dr Mount, a Canadian urologic cancer specialist, leveraged the work of Elizabeth Kubler Ross and Dame Cicely Saunders. These women studied the care of the dying in North America and helped influence palliative care’s incorporation into modern practice through hospice care and the analysis of patients’ distinct physical, emotional, and psychosocial needs.1
Palliative care is now a globally established medical specialty aimed at relieving suffering. The World Health Organization defines palliative care as “an approach that improves quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”2
In my experience, a conceptual definition often used by practitioners is that palliative care is a mechanism for “an extra layer of support.”
Integrating Palliative Care Into Oncology
Not all doctors work with dying patients. Almost without exception, in hematology and oncology, we do. Our relationships with our patients are complex. They are sometimes very brief and sometimes long term. Our conversations with patients are complicated and we rarely know in advance how the information we plan to convey will be interpreted.
In our clinics, we dance between exam rooms—in one, performing as the gladiator charged to annihilate the eternal enemy of cancer, and in the next, as the wise healer, charged to embrace, not cure, the deepest wounds at the heart of the human condition.