SAYING THANK YOU BEFORE IT'S TOO LATE

One of my dear patients recently went on hospice. We met each other over eight years ago after I first started at my current job, and therefore it was very sad to say goodbye.

Mr. S. was one of the most selfless patients whom I have ever met. He enrolled in over four clinical trials in his lifetime. Moreover, he was always kind and courteous to me and the entire staff. He always thanked me even when the news I had to deliver was not what he wanted to hear.  He even brought in donuts for the nursing staff on days he received chemotherapy. When I got word of this, I said jokingly to my nurse, "Where is my glazed donut?" She shared this anecdote with the patient, and thereafter he made sure to include a glazed donut earmarked for me whenever he brought treats in.

Our last clinic visit was quite sad. I told him that I was sorry that the day had come when I could do no more to treat his cancer. I told him that I would continue to treat his symptoms with palliative care and hospice but that cancer medicines would cause more harm than good. We said our goodbyes and gave each other a good, long, tearful hug.

A few weeks later after he enrolled on hospice, my nurse told me that he had invited her to a party that his RV club was putting on for him. Camping and RV'ing were one of his main hobbies, and we often planned our treatments around these trips. In the party, he told his friends how lucky he was to have them and how grateful he was for the care he had received. He told my nurse that he could really sense how hard it was for me to give him the news about hospice and how much I felt for him.

After hearing this story, I decided to reach out to him before it was too late. I always send a note to families after patients pass away, but in this instance I felt the need to reach out to the patient, himself. I sent him a card that described my admiration for him.  I told him that anything I did for him paled in comparison to everything he had taught me about grace, class, and resilience - especially when faced with a terminal illness. I told him that I drew strength from him and that he was the reason I wake up every morning asking myself the same question: what will you do to cure cancer today? The answer is always the same - never enough and not soon enough. Godspeed Mr. S.

MINDFULNESS

Recently, I started taking a class in Mindfulness based on the teachings of the American psychologist Jon Kabat-Zinn. I signed up for the class because it feels like each year is more challenging than the last. There are more duties and expectations at work and home but no more time per day to complete all these duties. In this situation, stress is created by the disconnect between what we and others expect of ourselves and the reality of what we are actually capable.

Kabat-Zinn's teachings remind us that the present - the here and now - should be our chief concern. We should focus completely on what is before us, rather than dwelling on what is in the past or becoming consumed by the uncertainty of the future.

This is easier said than done, especially when one is busy and feeling overburdened. However, I have found that focusing through meditation has had a significant impact on my ability to work and parent more effectively. The verdict is out on whether it will help my marriage.

There is so much beauty in our daily lives, but it is so easy to miss these moments when one is not fully engaged or when one is distracted. It is also easy to focus on the negative when one does not slow down and appreciate everything that is positive in one's life.

I hope I can continue these practices - not only because they make me more efficient, but also because they make me feel more connected with others and with my life. It is a significant time commitment to try to stretch one's brain through these techniques. However, it is really no different than an exercise or stretching routine that so many of us who are getting older already do on a daily basis.

So, here's a challenge. Turn off the phone and TV. Sit quietly and just focus on one thing - breathing -for ten minutes per day. I promise that this alone will not solve your problems, but it will certainly bring both your problems and their solutions into focus.

LIKE TURNING THE SOCCER SWITCH OFF

This weekend Lionel Messi suffered a knee injury during a game against Las Palmas that will rule him out for the next two months. It was a sad and terrifying sight to behold as he fell to the ground unable to carry on. This is especially true when one considers how much Messi means to his team and to the game of football, in general.

I cannot think of another athlete whose absence for an extended stretch of time - let alone one game - brings so much sorrow to football fans worldwide. This is because Messi epitomizes everything that is great in sport - sportsmanship, skill, and a serious competitive side.

The game will be a little emptier for the next months, a little less joyful. It truly does feel like the game has been turned off - or at least turned down - due to Messi's injury. Here's to a speedy recovery so that Messi can get back to thrilling fans of Barca and the game of soccer worldwide!

DO NO HARM

That brain surgery is fraught with disaster and complications should come as no surprise. However, we rarely hear about that side of this field. That is, until the wonderful confessional book Do No Harm by the British neurosurgeon Henry Marsh pictured above.

Marsh's book recounts his experiences operating on brains and spinal cords for over forty years in England and elsewhere. Unlike most medical books that focus on the heroic, this book also highlights how harrowing the experience of brain surgery can be to both the patient and the surgeon.

Mistakes in medicine are inevitable. Yet, there is no organ less forgiving of mistakes than the brain. Certainly, there are portions of the brain that when traumatized do not lead to permanent damage. Then, there is the rest - what Marsh calls "eloquent brain" - that whose damage leads to significant disability. Unfortunately, very terrible diseases often lurk in or near eloquent brain - tumors, aneurysms, strokes. While the latter is the domain of the neurologist, the former two are the domains - and perhaps cemeteries - of brain surgeons.

How does one venture into these territories day in and day out? It takes more than hubris. It takes courage and the conviction that the benefits of intervention outweigh the risks. Marsh acknowledges that it is heroic to take on challenging cases that others might pass on. However, he clearly reminds the reader that thoughtfulness and cautiousness must also be considered if we are to truly operate under the principle of "first, do not harm" -  a first principle of Medicine that is laid out in the Hippocratic Oath that all doctors take at some point in his/her training.

I often think of this Oath and this principle of avoiding interventions when harming the patient seems much more certain that helping him. Oncology is not brain surgery, but certain parts of the body, like the nerves or bone marrow, do not forgive or forget the poisons to which they are exposed. Because of this, I do have an abiding belief that it is much worse to harm a patient with an intervention than to withhold a toxic, unsafe therapy that has the potential to improve longevity by a few months.

My patients often disagree with this approach. This is because, although there are risks with dangerous treatments like chemotherapy, the risk of a poor outcome without no treatment is a certainty.

It is within this context that life and death medial decisions are made every day. Marsh reminds the practitioner and patient alike of the gravity of Medicine and our choices. Let us remember his words when making these shared decision, and let us first do no harm!