Each day, I walk—and work—in the shadow of death. It is a constant presence: lurking in the background of every conversation, darkening the scans where a cancerous mass has settled and spread, following me into the exam rooms where I meet with patients in twenty-minute increments. The rooms are designed to be sterile but serene, brightly lit with cream linoleum floors and a peaceful nature scene—a field of wildflowers, a bubbling brook—hung on the wall where a patient lying on the exam table can turn her head to see it. Even the medical gowns, made of seersucker in shades of pink and white, are designed to soothe, to engender a sense of calm. As if the woman on the table could imagine she’s somewhere else, somewhere nicer, like a spa.
As if she could forget why she’s here.
As if the shadowy presence of death, creeping and terrible, were something that could be ignored.
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On this August morning in 2018, that shadow was darker and closer than ever, the fantasy of spa-like serenity nowhere to be found. The hospital’s breast cancer wardwas busy, and noisy, with the whooshing and beeping of machines, the shuffling of doctors and nurses, and the low voices and occasional sobs that the drab brown privacy curtains hung around each patient’s bed did nothing to muffle.
I took a deep breath, bracing myself for the conversation to come. Patients often fear, as death approaches, that their doctor will give up on them—that we’ll have nothing more to offer when we can no longer offer the hope of a cure. But while the time may come when a patient’s targeted therapies stop working, an oncologist never stops caring. And this visit, one of the last I would ever have with my patient, was perhaps the most important. Instead of a hopeful prognosis, or a new treatment plan, I was offering something more simple: my presence. Today I would make a series of promises: I will not leave you. I will manage your pain and ease your suffering. I will help you and your family face what’s coming. I will be with you until the end.
Ellen looked at me apologetically as I stepped around the curtain beside her bed. Her breathing was labored, and a series of tubes protruded from her abdomen and chest, a final, fruitless effort to drain the fluid that was filling her body, compressing her organs to the point of failure. Her eyes were tinged yellow with jaundice, and the skin of her sunken cheeks was as colorless as the flat, beige wall behind her bed. Her hair, which she’d always worn in a short, stylish pixie cut even before chemotherapy made her temporarily bald, was damply matted to her forehead.
Ellen’s downturn had come just four weeks earlier, six years after she first walked into my office with a metastatic, incurable breast cancer that had spread to her bones, liver, and lungs. For most of those years, I had prided myself on plotting a course of treatment that allowed her to not just survive, but truly live: working for a nonprofit, mothering four teenage girls, and traveling extensively with her husband and family. Every smiling photo from one of Ellen’s adventures—standing with her girls at the top of a mountain or laughing with her husband at the base of a waterfall—was a victory for me, too. Her treatment had worked so well, for so long.
But today, Ellen’s adventures were at an end. The room itself felt like a liminal space, a place where my patient survived from ragged breath to ragged breath, the inevitability of her death weighing heavy in the silences between. I held her hand as she asked questions to which there were no easy answers: What it would feel like as she slipped away? Would she be scared? Would there be pain? When our conversation was finished, she squeezed my hand, and I lingered for a few moments longer, holding space for the unspoken.
Finally, I leaned in to hug her goodbye, one last time. I pressed my cheek to hers. I felt the dampness of her skin, the jangle of her fragile bones. I thought about how brave she had been, how wonderful, how alive, and wished I could have given her more time.
And then she said it. Not her last words, but the ones I’ll never forget.
“I’m so sorry for sweating on you.”
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Ellen was not the first patient to say these words to me. As an oncologist specializing in the care of breast cancer, I have sat with thousands of women at the moment of diagnosis with this life-threatening disease. And in those first moments after I tell a patient she has cancer, no matter who she is, her responses almost invariably follow the same trajectory:
Am I going to die?
Why did this happen to me? I’m so sorry for sweating.
Sweating is, of course, a normal physical response to stress— and nothing causes stress like a visit to the oncologist. No other illness stokes our fears the way that cancer does, and the women I see in my practice every day are invariably frightened: of suffering, of dying, of living in remission for years only to have their cancer recur. But the emotion I encounter most in the examination room, more potent and insidious than fear, is shame. The list of things for which patients have apologized to me over the years is both endless and obscene: these women are sorry not just for sweating, but for being sick, for having to seek treatment at all. They blame themselves for missed mammogram appointments, for failing to see their own symptoms, for not accurately diagnosing themselves with cancer amid the mad rush of full-time work, motherhood, caring for elderly parents, running a household. They are even ashamed of the side effects of the treatments and surgeries that allow them to survive. One of my most remarkable patients, a tough, no-nonsense woman of seventy-five who had raised thirteen children and worked all her life on a cattle farm, turned up at her post surgery follow-up with something I’d never seen before: a flesh-colored adhesive nipple pasted over her mastectomy scar. When I asked her about it, she said she’d ordered it on the internet—for me.
“It’s so disgusting,” she said, referring to the scar. “I didn’t want to make you uncomfortable.”
In all my years of both training and practice in internal medicine and oncology, I cannot recall a male patient ever expressing this sort of shame. As a physician aiming to partner with women in their return to good health, I find this difference baffling.
As a student of medical history, I know that the discrepancy is far less mysterious.
The women who apologize to me for being sick are part of a medical legacy, passed down over hundreds of years and still visible today. From that legacy, a story has emerged. It’s a story about what a woman’s body should look like and how it should feel, in work, in play, in learning and thought, in sex, in motherhood, in sickness and in health—and yes, even on her deathbed. It is a story whose authors have long since left us, although their names and likenesses can still be seen in museums, on plaques, in textbooks that guide today’s medical students on their journey to becoming practicing physicians. And while the authors of this story were indeed men, that’s not the problem with it.
The problem is, the story is not true.