Footprints on the sands of time

Abstract

While deciding whether to pursue a doctorate of medicine (DM) in Medical Oncology, I talked to numerous people. Most had limited knowledge, some mentioned the potential for significant earnings, others spoke of the emotional toll caused due to the nature of the field, and there were discussions about interdepartmental interference. However, one conversation that particularly stands out is the one I had with a close friend of mine from the United States of America (USA). Dr. DJ Shah left India after completing his Bachelor of Medicine, Bachelor of Surgery (MBBS), to pursue a residency in Internal Medicine in the USA. After finishing his residency, he planned to specialize in Pulmonary Medicine and Critical Care. He explained that he chose critical care because many of the patients he saw were acutely ill. They would either recover and not return, or their condition would deteriorate, and they would pass away. In the latter scenario, an emotional attachment might not be as strong, considering most patients in the intensive care unit (ICU) are intubated, hindering verbal communication, a critical element in forming deep connections. Conversely, he pointed out that oncology presents a different dynamic. Patients you would meet would most likely not be acutely sick, but in a state of shock due to a serious diagnosis. In this field, you would console them, treat them, and accompany them on their journey. Over time, they may be cured or gradually move toward the end of their life. In the latter situation, the experience could be emotionally taxing, both for the family and the treating oncologist, as a personal connection would have been forged during the long journey. He shared a story of a friend at MD Anderson Cancer Center, renowned for cancer treatment in the USA. This friend often struggled with the realization that even at a world-class hospital with exceptional resources, there were cases where treatment fell short, and all that could be done was inform the patient that their time was limited. Despite various perspectives, I ultimately chose to pursue oncology for my DM course. The initial transition was challenging, and I was adapting to a new hospital, environment, and a diverse set of patients. However, I gradually acclimated and found my place. After a month at the Tata Memorial Hospital (TMH, Parel, Mumbai, India), I received the unexpected news that my next two months would be spent at the Advanced Center for Treatment, Research and Education in Cancer (ACTREC) in Kharghar (Navi Mumbai), approximately 35 km from TMH. This facility had a distinct atmosphere, located away from the city’s hustle, offering patients with cancer a serene campus with green spaces and the peace they deserved. They had a building named “Asha Niwas,” which was home to patients with cancer and their families who came for treatment from all over India. During my exploration, I stumbled upon an inauguration stone bearing a name I was familiar with. The name was found in all the books I had read during the many train journeys I took in my post-MD period: Sudha Murthy, the chairperson of Infosys Foundation. This was a moment that excited me, and I could not resist taking a photograph. Days passed, and I adjusted and began to enjoy the new working environment. Many patients sought treatment there. Initially, all faces were new, but eventually, many became familiar. Among the faces, one stood out—a young man in his twenties accompanying his mother. I first noticed him when I heard him speak Tamil in the outpatient department (OPD) room where the most common languages spoken were Hindi, Marathi, and English. They were talking in Tamil with Dr. Anbu, one of our Tamil consultants. Although I had not directly interacted with them, their faces became familiar over time. Time passed, and during one of my night shifts, these familiar people arrived at the casualty with worried faces. Addressing her as Shakuntala (name changed), I assessed her condition. She was a patient with metastatic breast cancer who had undergone multiple lines of treatment. She presented with spikes of fever, and her laboratory tests indicated neutropenia. Febrile neutropenia in patients with cancer requires prompt treatment; otherwise, their condition can worsen quickly. I explained the situation in English and Hindi, admitting her to my ward. During this process, I discovered that they were conversing in Malayalam, my mother tongue, not Tamil as I had presumed. However, I chose not to reveal my origin immediately. In the weeks that followed, Shakuntala’s condition improved, and her febrile neutropenia resolved. During ward rounds, she inquired whether I was Malayali. This surprised me, as my accent had been shaped by years in Hindi-speaking Madhya Pradesh and Gujarat. She explained that my use of “La” in addressing her tipped her off, as Hindi lacks this particular “La” sound and I had pronounced her name in a way only a Malayali could have. This shared bond of language deepened our connection. I also wondered how many languages our brains are capable of learning as Shakuntala knew Malayalam, Tamil, Hindi, and English quite well. She hailed from Palakkad, underwent treatment in a renowned Kochi hospital, and after progressing on multiple therapies, she turned to TMH, Mumbai. As many doctors do with cherished patients, I memorized her details, even her patient hospital identification number (ID). Her recovery from the febrile neutropenic episode led to her joyful discharge. Before leaving, they asked for my mobile number, which I gave after explaining that I might not be able to answer at all times if I happened to be busy managing a patient in front of me. Time passed, and they returned to the OPD for her ongoing cancer treatment. Their cheerful demeanor stood out. Brief chats ensued whenever we crossed paths. After two months at ACTREC, I returned to the bustling atmosphere of TMH, Parel, resuming routine work. One evening, while conducting ward rounds around 8 p.m., I received a call. Shakuntala’s son was on the line, and even before picking up, I sensed something was amiss. His voice was stifled with tears, initially making it hard to understand him. Eventually, he conveyed that his mother was admitted again, and she was critically ill this time, with doctors expressing the seriousness of her condition. He implored me to speak to the treating doctors to explore any potential avenues. Dr. Nach, my friend, was now overseeing her care. I immediately contacted him, seeking information. He revealed that lung metastases were the issue, describing her condition as grim. Her lungs were almost entirely covered in metastases on the X-ray. He did not hold out much hope. I was faced with the difficult task of relaying this information to Shakuntala’s son. I listened to their concerns, attempted to console them, and explained the situation as honestly as I could. The next two days were consumed by busy duties at TMH. Shakuntala remained on my mind, and I decided to call Dr. Nach for an update. Unable to reach him, I accessed the electronic medical records with the patient ID I had memorized. Entering her patient ID, I discovered that she had passed away that morning. I was at a loss for words. Sorrow, disappointment, and helplessness overwhelmed me. I turned to the lines of my favorite poem “A Psalm of Life” by H.W. Longfellow, as I often do during moments of sadness: Dust thou art, to dust returnest, Was not spoken of the soul. Act-act in the living present, Heart within and God overhead. Two days later, while walking the streets near the hospital, I decided to message her family. I sent a text expressing my deep condolences and regret for the late message. I conveyed that they had given their all to aid her in her battle with the disease. I prayed for their strength during this trying time. Her son responded with gratitude, thanking me for the message and the care I provided during her hospital stay. Time passed, and with their contact saved, I noticed occasional WhatsApp statuses from her son. Their small, happy family had undoubtedly been deeply impacted by her passing, leaving a void that words could not fill. As I reflect upon this chapter of my journey, I’m reminded that medicine is not just about treating ailments; it is about connecting with individuals at their most vulnerable moments. The path forward promises to be both challenging and rewarding, filled with more stories to tell, more hands to hold, and more lives to impact. Let us, then, be up and doing, With a heart for any fate; Still achieving, still pursuing, Learn to labor and to wait. -A Psalm of Life (H. W. Longfellow) Financial support and sponsorship Nil. Conflict of interest There are no conflicts of interest.