The streetlights in Buenos Aires are considerably dimmer than they are in New York, one of the many things I learned during my family’s six-month stay in Argentina. The front windshield of the rental car, aged and covered in the city’s grime, further obscured what little light came through. When we stopped at the first red light after leaving the hospital, I broke two of my most important marital promises. I started acting like my wife’s doctor, and I lied to her.
I had just taken the PET scan, the diagnostic X-ray test, out of its manila envelope. Raising the films up even to the low light overhead was enough for me to see what was happening inside her body. But when we drove on, I said, “I can’t tell; I can’t get my orientation. We have to wait to hear from your oncologist back home.” I’m a lung doctor, not an expert in these films, I feigned. But I had seen in an instant that the cancer had spread.
PET scans are like that, radioactive tracers that travel around the body and measure how much work different cells are doing. And cancer cells are very active workers. The scans are like the ground seen from the air at night. When there is no cancer they look like Idaho, all quiet. Really bad news looks like downtown Chicago or Phoenix.
It was a warm night for early June, the beginning of the winter in Argentina. People crowded the sidewalks, returning from work, stopping for dinner. All the everyday stuff that fills our lives, neither adding particular meaning or taking it away. We pulled into the garage with the narrow entrance; our tires squeaked on the newly painted floor. Ruth was silent. I was silent. I knew. She didn’t.
Actually, she probably did.
My wife was dead eight months later. We were back in New York. In our home. During our winter.
It didn’t take long for those films to be examined and interpreted by doctors at Memorial Sloan Kettering Cancer Center, the hospital where I’ve been a doctor for more than a decade and where Ruth had been treated when she was first diagnosed with breast cancer, three years earlier, in 2008. Only a few minutes after we parked the car, the phone in our apartment rang. It was the oncologist.
Ruth and I sat next to each other on the couch, each with a handset. The oncologist used many words familiar to me—metastasis, emergency radiation, focusing on “quality of life,” not cure. Technical jargon sneaked into my questions as Ruth’s name disappeared from them. “Could she develop cord compression?” I asked. Then her voice. “What’s that?”
Ruth’s doctor never made us wait. No gentle approach, no layer of euphemism obscuring the truth, no gingerly poke and quick retreat from the scary thing over there. He filled in answers to unspoken questions. “There’s a lot we can do.” “This is manageable.” “You might have many years.” But then circling back. “It can’t be cured anymore. Our goal now is to slow down the cancer and give you as much quality life as we can.” To paraphrase, the films meant Ruth was going to die.
When I relayed that conversation to my friends, many of whom are cancer doctors, they were pretty surprised. What Ruth’s doctor had done was unusual, or maybe even inappropriate, they told me—delivering bad news, especially over the phone, before it needed to be conveyed. When I asked them when the right time was to tell someone that death is unavoidable, they most often told me that the moment occurs after several successive attempts at stopping the cancer have failed. Only then, when the patient is cornered by cancer, that’s the time.
Doctors claim that patients aren’t ready for the bad news earlier, when they are still digesting their shocking predicament: that their lives have changed irretrievably; that their priorities, their future aspirations, their promises to their loved ones—both the explicit and, more important, the implicit ones—would go unfulfilled. They cite their own hesitations too. Doctors want to be purveyors of hope rather than despair, a motive sometimes attributed to compassion, sometimes to a starker concern that patients will find a new, more optimistic second opinion.
I’m a fan of bluntness, but I know it can be detrimental when a patient isn’t ready and can cause confusion when other doctors are shimmering with lighter scenarios. Ruth’s doctor may have done the right thing despite what my friends were telling me. There’s a famous report from the Institute of Medicine showing that nearly all adults say they want doctors to share what they know, even if the news is bad. Ruth had expressed this sentiment to me many times, as in “I don’t want my doctor knowing something about me that I don’t.”