Covenant with patients

“I am a cancer doctor. My primary allegiance is to my patients, not to the hospital where I work, the financiers of the hospital, industrial sponsors, or the granting agencies, and not even to my profession. It is the patients first”- the covenant I took, while I struggling to complete the courses of Kochi Marathon.

Woke up at 3:00 AM for the race. As I was away in Buffalo for the winter, and not practiced running for a while, I was totally out of shape for the marathon. I started the run with significant doubt about my ability to complete the race- similar to many of the patients when they begin their cancer journey. After the initial excitement of the lineup and the flagging off ceremony, one gets into a steady state of running. Random thoughts come through every runner's mind; some positive, but mostly negative thoughts. The thoughts of a patient I unsympathetically broke the bad news of cancer and the discussion on the corporatization of healthcare in a symposium I attended the day before bothered me throughout the race.

I usually set aside Saturdays for research. This routine was broken the day before the race for an urgent consultation of a newly diagnosed oral cancer patient. It was a middle-aged lady accompanied by her son. Having walked into my office with the word "cancer" written boldly above the front door of our office, I assumed that everyone knew their diagnosis. After clinical examination, as I was in a hurry, without a tinge of sympathy, I spurted out that though it needs a biopsy to confirm the diagnosis, the ulcer on the tongue is a cancer.? I could see the raw expression of fear in her eyes, while the son gave a nervous smile. I quickly recognise the error for not preparing the patient and establishing the sacred patient-physician rapport before breaking the bad news.?

Recalled an incident that took place nearly 40 years ago. I requested my pathology professor to review the pathology slide of the thyroidectomy I had to undergo for suspected cancer. Through the side eyepieces of the microscope, the professor showed me classical epithelium that forms neatly formed papillae. She said "these are common features of benign thyroid tumors", the diagnosis I was hoping to hear. Then asked me to focus my attention on the protective capsule our body makes to contain the tumor. "Moni, can you see this breach in the capsule?". She then took her eyes off the microscope and looked at me. “This is the tell-tale sign of papillary thyroid cancer.“ I could feel the whole room spinning around me and a whale of dark cloud surrounding me. Thank God, I was sitting on a chair. I could see embarrassment of my professor for breaking the bad news in such a crude fashion, similar to how I handled my patient.

That evening I had to attend a symposium on geriatric oncology as a panel member. The moderator displayed the title of the panel discussion "Geriatric Oncology-business case". I felt a bit out of place to discuss healthcare economics. The moderator showed a survey results showing that 30% of the participants in the survey expressed the need to establish new geriatric oncology service in cancer centers. The data also showed that the participants are willing to pay an additional 30% for that service. The discussion then went on to Average revenue per occupied bed (ARPOB), a metric used to assess the financial performance of hospitals.? Based on the data, the moderator wanted to know from the panel members, most of them directors of different cancer centers, whether they would be inclined to establish geriatric oncology in their hospitals. This implies that the more money one spends (through an additional service) better clinical outcome one may receive. Improvement in Indian healthcare system needs significant infusion of investment from external agencies, as happening now. This investors expect return of investment, and the ROI comes from higher ARPOB.? This conventional wisdom of current healthcare economics is inaccurate. The ARPOB can be increased not necessarily by increased revenue per patient but through improvements in the efficiency of the system. The services like geriatric oncology through coordinate the fragmented care and avoid duplication of services, early discharge and improved disease outcomes, lowers the cost of care for an individual patient but increase the throughput of the hospital and hence the revenue. Similar observation was made by Jennifer Temel in the study on early introduction of palliative care in lung cancer. She has elegantly demonstrated that introduction of palliative care not only improving quality of life but life expectancy itself. I recalled my failed attempt to convince the corporate hospital administrators to establish palliative care in one of the cancer centers I worked, as the perception in the shortsighted administrators that it lowers ARPOB.

I woke up from my trance at the halfway mark turn. I saw the 2:15 hour pace setter just crossing me. Realised that I'm running too fast, slowed down and refreshed at the next hydration point.

For an ill prepared runner like me, the second half is always a challenge.? Kochi marathon has one of the most picturesque routes. It starts from the marine drive in the mainland, crosses the Veduruthy bridge, across the backwaters to reach Wellington Island and encircles the manmade island where the Cochin port and navel base are located and returns to the marine drive. While the early morning breeze from the Arabian Sea caress the sweaty body.

The return climb over the Venduruthy Bridge was a torture. Often felt like giving up and getting a ride on the rescue bike, similar to many of patients wishing to give up during the long course of cancer treatment. I paused to catch my breath on the bridge; then saw a fellow runner slowdown and encouraged me to keep going. I saw a fellow runner struggling to recover from cramps. There is nothing much one can do other than spray analgesics and some encouraging words. Saw one person stopping traffic to let an old lady cross the road and another runner chasing a puppy away from the road traffic. Often challenges in life brings goodness in us. I've seen this trait in many of my cancer patients and their families. Despite their personal challenges they help fellow patients. As one of my colleagues pointed out "there are many memorial cancer hospitals, but not a diabetic or heart hospitals"!!

The music and sound of drums at the finish line become louder and louder. While crossing the finish line, seven minutes longer than my target time, I took this covenant “I am a cancer doctor. My primary allegiance is to my patients, not to the hospital where I work, the financiers of the hospital, industrial sponsors, or the granting agencies, and not even to my profession. It is the patients first”. After all, we all signed up for the profession to care the patients- the subspecialty, hospitals, investors, and grants all came later.