Abstract
In Tell Me the Truth: Conversations with My Patients about Life and Death, Ranjana Srivastava seamlessly weaves personal stories with patient narratives, illustrating her growth from an idealistic trainee, uncertain of her future, to a seasoned oncologist, enlightened by what her patients have taught her. She addresses common themes that arise while caring for patients living with and dying from serious illness, including the distress physicians face when delivering bad news, unraveling the subtext behind what physicians say, and her growing understanding about the art of medicine. Each chapter highlights an individual patient she has cared for and delves into the lessons that she has learned using candor, humor, and sentiment. She unabashedly reveals her own vulnerability and by doing so, shows an earnestness with which she works to become a more compassionate physician. Through reflection and her willingness to illustrate her own weaknesses, she is able to transform the simplest interactions into deeply profound moments.
One particularly moving story illustrates an encounter with a physician who Srivastava knew as a medical student, who is now dying of metastatic colon cancer at an inpatient hospice facility. Reflecting on his hospitalization, he remarks that modern medicine has become “so enraptured with cure that it often denies care” (p. 73). He describes his experience with his doctors and nurses and explains that he “felt no warmth or eye contact, no real connection” (p. 70). The one time he makes eye contact with someone, the moment holds such promise, but rather than providing support or offering comfort, he is offered the services of a psychiatrist. Ironically, he is an eminent psychiatrist himself.
Srivastava considers sticking to the “predictable checklist” when she first enters this patient's room (p. 68). She instead chooses to inquire about how the patient is doing emotionally, and finds herself gaining insight she would otherwise have missed. Similarly, she describes several occasions in which her first instinct is to leave the patient's bedside prematurely, a “moment of temptation every doctor feels” (p. 156). By ultimately resisting this temptation, she exemplifies that there is more to medicine than just diagnosis and treatment. In one of many self-reflective moments, she remarks, “I squander many opportunities to treat the whole person, instead choosing the easy option to focus on the disease” (p. 60). This early insight is the foundation of her overarching narrative about the importance of focusing on the individual experience, hearing what is not stated, and approaching all patient encounters with thoughtfulness.
While having conversations about death and dying, Srivastava inevitably faces controversial topics, including physician-assisted suicide. She highlights the story of a young, married university professor with advanced metastatic disease who asks to speak candidly with her. Recognizing the failure of chemotherapy and the potential for further metastases worsening her quality of life, the patient finally asks, “I am not saying that I would, but how can I end it if it is no longer a life I want to lead?” (p. 160). Srivastava is initially taken aback by the unexpected question and even experiences deep visceral discomfort. Despite this, she attempts to address the patient's concerns. Rather than simply offering her opinion on this polarizing issue, she has the reader share in her struggles about what is truly best for the patient. She deftly navigates the politicized terrain by focusing on her own emotions, and offering insight into the patient's motivations, meanwhile acknowledging her difficulty reconciling these motivations with her own beliefs.
As an oncologist who is also a young wife and mother, the juxtaposition of life and death is ever present. She integrates her struggles of balancing home life with her difficulties in caring for dying patients. She describes the transition between the two as a “rapid and turbulent mid-air descent, but one that is important to keep me grounded” (p. 135). She feels that her patients give her perspective on her own life, stating that “there is little place for self-pity in a career where a thousand more real tragedies vie for attention” (p. 140). She also incorporates instances of personal loss and her own experiences as a patient, offering the reader further insight into the underlying theme of patients as people with needs that are frequently overlooked by their physicians.
At times, Srivastava vacillates between self-doubt and self-righteousness, a conflict more common to the physician experience than most probably care to admit. While several topics she discusses have the potential to stray towards the trite themes delegated to personal statements, she manages to illustrate her patients' stories and her own story in a manner that is poignant and reflective, reminding the reader that care is not synonymous with cure. Her insights should be required reading for every clinician who finds himself or herself “certifying deaths as if writing a prescription for an antibiotic” (p. 305). After one of many touching patient encounters, Srivastava remarks, “I am reminded again of the random opportunities I am provided to witness human sacrifice and resilience at its finest” (p. 114). By sharing her experience, so are all her readers.