I trained in a large university teaching hospital in Montreal. Our patient population was cosmopolitan. We learned how to interpret the silence of one ethnic group, the screams of another. The atmosphere was a tolerant one. Empathy abounded, yet patients had to adapt to us, come on time, wait their turn, and accept any piece of information or advice that we, with our white coats, had to offer. We supplied them with the facts, often without being asked. Although patient autonomy was respected, there was no question about who had the upper hand. Medicine and its practitioners were from the dominant culture.
Recently, things changed for me. I have become an immigrant physician, having moved to Israel 3 years ago. Knowing that I had come to an advanced medical system, I nevertheless felt that I had something to contribute. I brought my own brand of "good medicine" with me, hoping, of course, to do good.
A 70-year-old man came to my hematology clinic in September with a new diagnosis of lymphoma, only he didn't know that. Mr. D came armed with a discharge summary stating that he had had laparotomy for intra-abdominal adenopathy. The pathology report showed that he had diffuse large-cell lymphoma. I asked him what he knew of his diagnosis, and he answered that he had been told that he had an infection.
I searched his face for signs of dissimulation, disingenuousness. Mr. D did not seem to be the kind of man who would mislead himself or want others to mislead him. Nearby, his son sat and smiled knowingly. I took this as a sign that I might speak the truth. I did. I gently told Mr. D that he didn't have an infection, that it was a tumor, a tumor with a name: lymphoma. I explained to him that there is an effective treatment and that many people do well with this disease. I believed in what I was saying. I thought that he did, too. We talked some more. He was neither naive nor primitive. A 50-year veteran of Israel, he had worked in the university for several years. I assumed he understood. We made plans for further tests and for the start of treatment.
A week later, I received a phone call from Mr. D's family physician, an immigrant like myself but from Russia. He informed me that our patient was in a deep crisis, a broken man, pessimistic and refusing treatment. The physician asked me about the prognosis, and I replied in optimistic but realistic terms. He said he would try to convince the patient to return to the clinic.
Later, I heard that Mr. D had canceled his appointment for treatment. I asked the social worker to intervene. When she reached him, he told her that he was weak, that his fate was sealed, that there was no point. His son subsequently disclosed to her that I had been too blunt, too direct. Distressed by my miscalculation, I called Mr. D myself, asking him to reconsider. He repeated that he was too weak and would not tolerate any chemotherapy. I told him that we could tailor the treatment to him. I suggested that being a newcomer, perhaps I had not explained things clearly, and maybe he had misunderstood the message I had tried to convey. He agreed that this might have been the case. I wondered to myself whether the fact that others had not been truthful with him made him suspicious of me and my optimistic forecast. I invited him back to the clinic on Wednesday, just to talk. He said he would try. His tone was noncommittal.
I realized that this was not the first time my way of involving patients with their illness and treatment had backfired. My own set of ground rules ("Thou shalt not administer chemotherapy without informing the patient that he or she has cancer") was being questioned. I considered it honesty, an absolute value. Here, it was called being too direct. I had sometimes observed a conspiracy of silence between the physician and family. But I could see now that the patients might also collude. I had so deeply internalized "the patient's right to know" that I never even considered an equal and opposite right not to know.
I sat at my desk and considered euphemisms that I could have used. I understood that on the edge of the cultural gap on which I stood, I no longer had the upper hand. When I had moved to the Middle East 3 years earlier, I brought with me my household belongings, my children, my McGill University diplomas, and my Royal College qualifications. They all found their place. But I also brought my culture, my professional style. These had not yet found their place. All of the drugs and the doses were the same, but some of the norms were different. Friends of mine had worked in unusual places—with native Indians, in Africa. They were forced to adapt. So would I.
I recalled his imagery.
His fate was sealed.
Yom Kippur lay around the corner, and he believed it applied to him.
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