Big Failures and Small Satisfactions

We diagnosed Mrs. R with breast cancer last year around the same time. We have been treating her for diabetes and hypertension for several years, but Mrs. R never once complained about a lump in her breast. We also failed to perform a routine clinical breast examination. Suddenly last year she hesitantly told me, “I don’t know how to say this to you. I am thinking of you like my own son and saying this. I have a small peanut sized swelling in my right breast. I don’t know how to handle this. Will you help me?” From here all subsequent events flowed in a frenzy from a detailed physical examination to referral to the tertiary care hospital, a diagnosis of advanced breast cancer stage IV, till radiation therapy to remove some tumor in the breast. Mrs. R was given a bad prognosis and was told that nothing much can be done about her cancer as it had spread to her lungs and all bones. 

 

Through this entire ordeal Mrs. R and her 28 year old son S would regularly visit me and sit and talk to me to understand their situation better. They would go to a cancer specialty hospital in Chennai, almost 80 km from their village, and come back and the very next day and meet me to discuss what their doctor said. The specialists would throw on them some very complex explanations and descriptions, which they would bring to me so that I can cut it up into bite size piece which they can understand and assimilate. Over the past few months Mrs. R has been deteriorating significantly and S and I had forged a strong friendship over our frequent interactions. 

 

Last year S got married. It is not uncommon in families of patients with such serious and terminal illnesses to finalize unfinished business, in this case S’s wedding. S invited me for the wedding. Through all this Mrs. R put up a very brave front. I have seen S to be a fantastic son, always caring, compassionate and available. From bringing a vivacious Mrs. R to the clinic during her pre-cancer days, to physically supporting her step by step now during her frail times, S has always been there. But after marriage, the necessity to earn a stable livelihood pushed S to take up a job in a neighboring state for a salary of 35,000 rupees. In his home town he wouldn’t get more than 15,000. This was more than double his income and the newly married S with his wife and newborn son couldn’t miss out on the opportunity. Now that Mrs. S had delivered their first born son she was also away in her mother’s place. So, Mrs. R was all alone at home. Her husband had taken to drinking after her diagnosis and everyone in the family was grieving her impending demise in their own way. S would call and talk to me worrying about his mother being alone in the village while he is away. I would reassure him saying that in rural life there is a distinct advantage as doors are seldom closed and someone or the other is constantly available for help if she needs it. 

 

On Sunday, it was a routine clinic. S came to the clinic, almost physically carrying Mrs. R. Even from the distance in the gate, I could not that Mrs. R was very sick. He came and placed her on the bed. I examined and noticed that she was severely dehydrated and warm. We started an intravenous infusion and gave her some fluids to correct her dehydration. Mrs. R hadn’t had anything to eat for 2 days and had been delirious and ill all day. Last evening she had fallen while going to the toilet and fortunately she had not broken any bones. After starting her intravenous infusion and writing a prescription for pain medicines to give her pain relief and comfort, I moved to the consultation room to see the next patients. Before the next patient could come in S rushed into the room and sat in front of me. He sat silently there and I looked up and smiled at him. Even as I smiled at him, he broke down and started crying. “Doctor, I cannot see my mother suffer like this. Please do something to end her misery. My father has always been a drunk and never cared for us. My mother has single handedly brought up my sisters and me and gave us such a good life. Today she is suffering and I am unable to do anything. Please help her.” Saying this Mr. S cried and sobbed. I held his hands and sat silently with him. His whole body was shaking, and he could not control himself and was letting out loud gasps and sobs. I placed a hand on his shoulder and tried to calm him. S is not just a patient’s son. We had become friends. I was moved beyond myself to see him cry like that. Mrs. R was in the next room, so frail and almost in the last phase of her life. The situation was too gloomy. I had tears in my eyes. We both sat there holding hands, S crying and I with tears down my cheeks. This went on for 5 minutes. Then he composed himself wiped his eyes and got up. “I am so sorry doctor. I know I have wasted your time. But I did not know whom to share my pain with. I cannot talk to my wife. She has just delivered our son and is in her mother’s place. I cannot talk to my sisters. They are each in their own marital homes. I cannot talk to my friends, they won’t understand. We want to keep my mother’s diagnosis private, because if we share with people, they will ostracize us and stigmatize us. So I cannot share with my neighbours. The pain and suffering of my mother has been bothering me so badly. You are the only person with whom I can talk about this. I am so sorry”. I got up hugged S and told him that he should not say such things. It is my responsibility to listen to him and support him emotionally. S walked away and I couldn’t shake the intensity of this episode from my mind throughout yesterday. 

 

Yesterday morning, I was quite disillusioned about what I was doing in the rural clinic. I was asking myself several questions – is what I am doing here meaningful? Am I improving anyone’s quality of life by doing this routine primary care? However hard I try, I cannot bring blood sugar of diabetic patients under control. However much I insist, I cannot make people take their medicines regularly. Whatever I say, there is no impact on people’s diets and physical activity. What is the purpose of all this? I go into this phase now and then, a phase of intense self criticism and self-doubt. In the evening on my way home, I was thinking about S. Mrs. R is dying. I wish I could have screened her for breast cancer much earlier, picked up her early breast lesion which could have cured her. I missed it. It is a failure of primary care, further reinforcing my doubt of the futility of my work in the area. But then I also think about S. I had the opportunity to be there for him. He said I was the only person with whom he could talk and share about his insecurities, concerns and pains. We sat there are two brothers holding hands, crying and grieving a mother, him a biological mother, and me a woman who had adopted me as her son. I felt that this one role that I played in S’s life justified my presence in the area. It is harsh to want anyone to be in S’s position just to justify my role as a primary care physician. I don’t want that for anyone. My failure to prevent advanced breast cancer in Mrs. R can never be offset by being a comforting presence for S. But that is the life of a primary care physician - one that is riddled with big failures and small satisfactions.