I was just writing to say thank you

And other music to a doctor's ears

Six or seven years ago, an 80 something year old man entered my office. He looked unwell. His face was ashen, coated in cold sweat; He had lost weight, and his clothes hung loosely. I knew something was wrong. He knew something was wrong. It was lymphoma.

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In medicine, there's a line between being close to someone, caring about them, worrying about them, and being too close. You have to maintain distance so that you can be objective. You need to stay cool if and when things fall apart. Patients need you to care about them, but they need your decisions to not be overwhelmed by emotion.

That's why inevitably, every few years a doctor tells the story of their wife, mother, sister, or father, who became unwell, and they found themselves pushing for treatments they never otherwise would have prescribed. Love can lead to bad decisions--- I suppose that's true both in life and medicine.

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The older man was joined by his daughter, and we quickly figured out the type of cancer he had, and discussed the best available therapies. We were all concerned that because of his age, because of his condition, he might not be able to tolerate the treatment. But I already knew then what I know now: Don’t count anyone out. Although age is an important number, it's not the only consideration, and people can always surprise you.

Most importantly, I knew that clinical trials and protocols have their limits. They don't have to be followed exactly; you can adjust, improvise, start slow. They are recipes to learn from, not to be chained to. I brought all these lessons to our visits , and we discussed a path forward that was highly uncertain, but would try to preserve quality of life, while still aiming to cure the disease. We would start low, and escalate if we could.

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The initial therapy was remarkable. The patient told me the week after he got the first dose, he chopped down a tree in his yard and turned it into firewood. He was back on his feet, his energy was better, and he had essentially no side effects of the therapy. It felt like magic, not medicine.

And for the first few months things went exceedingly well. We quickly escalated the dose. On most visits, he was joined by his daughter, and sometimes even his granddaughter, and we struck up conversation. They learned a lot about my life, and I learned a lot about theirs. We were becoming close.

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A year passed, life moved along for both the patient and I, when his cancer returned. But it wasn’t the same variety; it’s tempo; it’s personality was different; We re-biopsied, and it was similar, but not the same. Very quickly, I realized what had happened. There was one on top of the other. Two cancers, two branches, sharing the same root.

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I was close, but had I become too close? He was older now, in his late 80s. Yes, the first treatment went well, but could he take more? We were between Scylla and Charybdis— the therapy could hurt him, even kill him, as could the disease. He wanted my recommendation. What would you do if I were your father? But I knew I didn’t want to make such decisions for my father.

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Better to lose a few sailors than the entire ship, and so we pulled closer to Scylla, and tried again. This time too, there were surprises. But slowly and surely, we passed the rocks and the sea opened up. He felt better and better still. And the treatment continued for some time.

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We saw each other for a few more years, and he was doing well; Each of us ended up moving to new places and new adventures. I switches jobs and we fell out of touch.

Then one day, I opened my email, and there was a note from the daughter. It was an update with pictures; Now he is in his 90s, and is still doing well. So is his daughter, granddaughter and great-grand kids. I was just writing to say thank you, the note read.

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With each passing year, I think more about the eternal dilemma of a doctor; How to be close, but too close. To be empathetic but preserve objectivity. You are always striking that balance. I am not sure you ever figure it out, but that's the joy and challenge of this art.