2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

THE ONCOLOGIST AS THE PATIENT OR RELATIVE
and that history is not always either happy or uncomplicated.
That history, and ongoing family dynamics, can
complicate recommendations, and the recommendations
themselves can easily become the source of future family
discord as well as personal feelings of grief or guilt.
At the same time, physician-relatives of patients with
cancer are in the enviable position of being able to point the
patient with cancer in the direction of the best care, or at
least of the best caregiver, available. Although much of
cancer care is standard, not all cancer professionals are
equivalent in either expertise, competence, or compassion, a
fact that physicians are well aware of: a “doctor’s doctor” is
often defined in terms of whom a physician is willing to have
care for a relative.
A physician faces additional challenges as the relative of a
patient with cancer. Physicians are routinely asked “what
would you do if I was your ...[sister, brother, daughter, son,
mother, father]? This question is more difficult to dodge or
ignore when it comes from a relative, and the responsibility
attached to the answer differs qualitatively from that encountered
in usual practice, rightly or wrongly.
Physician-relatives also face challenges related to their
interactions with caregivers and hospital systems. If a
physician disagrees with the advice given to a relative, what
is that physician to do? If an interaction with the health care
system is a negative one, does the physician-relative claim
special attention for the patient? Under normal circumstances,
most physicians accept that their colleagues deserve
substantial autonomy in decision making and
therapeutic recommendations, and recognize that the health
care system is imperfect. Indeed, no health care system
would long survive intrusive oversight by colleagues.
Yet this dynamic frequently changes when a physician’s
relative enters the health care system, particularly that part
of the system in which the physician-relative practices. This
Authors’ Disclosures of Potential Conflicts of Interest
Author
Teresa Gilewski*
Martin Raber*
George W. Sledge Jr.*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Greek Medicine, History of Medicine, U.S. National Library of Medicine,
National Institutes of Health. http://www.nlm.nih.gov/hmd/. Accessed March
7, 2012.
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years after the Flexner report. N Engl J Med. 2006;355:1339-1344.
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Pa, America Board of Internal Medicine, 2001;4.
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Women with Breast Cancer. Institute of Medicine and National Research
Council. Washington, DC, National Academies Press, 2004.
6. Cohen JJ. Linking professionalism to humanism: What it means, why it
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may result in excessive diagnostic testing and overtreatment
of the relative, often to that patient’s detriment, a
situation akin to the defensive medicine practiced by physicians
concerned with malpractice. Physician-relatives who
are aware of this dilemma may be caught between the Scylla
and Charybdis of this dynamic, wishing the best care for a
relative but also wishing to make the best use of a colleague’s
expertise and wisdom.
The physician is also faced with the problem of knowing
too much. This is frequently the case when the physician’s
relative has a poor-prognosis cancer. In this setting, relatives
may explicitly encourage false hope, leaving the physician
in the emotionally precarious position of balancing
reality and optimism. These discussions may have long-term
consequences, not just for the patient, but for the family as
a whole: emotional wounds that never completely heal.
Under normal circumstances, the physician can go home
and unwind after a hard day at work, but when home is the
source of stress there may be no place to turn.
With all patients with advanced disease, there comes a
time when active therapy is no longer appropriate, and in
which a focus on quality-of-life measures, advanced care
planning, and hospice care become reasonable. What is the
role of the physician-relative in selecting that moment?
Indeed, is there a role?
Finally, the physician-relative must deal with his or her
own emotional needs, both during the relative’s treatment
arc and after a relative’s death. Physicians are often excellent
and compassionate communicators when dealing with
patients to whom they are unrelated; but it is the rare
physician who is capable of expressing his or her own emotional
trauma, or who is capable of instituting the healing
process we all deserve in our own most profound times of grief
and loss. Dealing with a relative’s death reminds us of our own
mortality, of that end to which we all must go.
Stock
Ownership Honoraria
REFERENCES
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Funding
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Testimony
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