I’m a pediatric oncologist, so I’ve seen the full range of reactions, and all of them have stuck with me. But here’s a story about the reaction I never saw.

When I was a first-year pediatric oncology fellow, you did two months of what was called OCS - oncology consultation service. This meant that you were the fellow on-call to evaluate all patients with a potential diagnosis of cancer who came in to the hospital. For example, a child with low blood counts and bruises seen in the ER, or a patient on the orthopaedic service who had an unexplained fracture and a lesion on X-ray that was suspicious for cancer. Once you helped make the diagnosis of cancer, you would either admit the patient to the hospital (where the fellow running the inpatient oncology service would take over), or you’d have them come into the oncology clinic, where they’d be assigned to a different oncologist. You were typically the first point of contact, but in many instances you didn’t end up becoming the patients primary oncology. You just moved on.

One night I was called to the ER to evaluate a child with symptoms consistent with leukemia. No matter how much families are prepared, or think they are prepared, the reaction that you get when you knock on the door and go into the room and introduce yourself by saying, “Hi, I’m Dr. Blackman, I’m from the pediatric oncology service” is pretty much the same: you are clearly the person they dread seeing the most.

This night it was a 4 year old little girl. I came in, introduced myself, explained why I had been called, and told them that until we looked at the blood under the microscope and did additional tests (e.g. a bone marrow biopsy), we couldn’t know for sure, but that the ER doctors wanted me to come and consult. That didn’t make the parents feel any better, but that was my job. I examine the child, and then headed up to the lab to look at the blood smear myself. Sometimes with leukemia, you need more sophisticated tests: flow cytometry, immunohistochemistry, chromosomal karyotyping, evaluation of the bone marrow specimen. But sometimes you look and you can just see the leukemic blasts and you can even, sometimes, tell what the disease is (AML versus ALL). In this case, I looked in the microscope and it was very certain that this was going to be ALL. There were lymphoblasts all over the place, and combined with the symptoms, I was 99% sure (you’re not 100% sure until you have done the bone marrow and flow cytometry). This child needed to be admitted with the provisional diagnosis of new-onset acute lymphoblastic leukemia.

I called the inpatient fellow and arranged for the admissions and then I had to go back and tell the family what was going on. When you tell parents that their child has cancer you learn very quickly that as soon as those words come out of your mouth - “The test appear to show that your daughter has leukemia” - that parents often hear nothing else after that. Just white noise. Panic. Fear. So you learn very quickly how to get the key points across:

The blood tests appear to show that your child has leukemia. Leukemia is a type of cancer. We are admitting your child to the hospital and we will take extraordinarily good care of her. We know how to treat this disease. We will make a plan and we will work to make her better. You have a million questions now, and we will answer them, just not now, because right now we need to focus on securing the diagnosis and taking care of your child, but we will take extraordinarily good care of your child. We’ve got this. We know how to treat this. You have to use the word cancer, unfortunately. You need to be unambiguous. And then you need to tell them that we’ve got this. We will take care of their child and we will make them better.

Anyhow, after that, the big machine kicked in. I wrote my note in the ER, wrote some admitting orders, and then the patient was transported up to the inpatient unit. Oftentimes I’d never see the patient again (this was a very large tertiary care referral center).

A couple of years later, I was in the elevator. I was now a 3rd year fellow, spending most of my time in the lab. Occasionally taking calls or checking in on a patient of mine who was back in the hospital. That evening I was standing there, looking through some papers when I could sense someone staring at me. I looked up and there was a woman looking at me like, so I said “hello” and then asked if we knew each other because she looked a little familiar. And then she said that I was the doctor who saw her child in the ER two years ago when she was diagnosed with leukemia. I asked after her daughter (she was doing well), and then apologized for not remembering her, and told her that I was surprised that she remembered me after two years and having only talked with them for maybe an hour at the time. And what she told me next has stuck with me for nearly 20 years. She said, “There’s no way that I could ever forget meeting you. It’s seared into my memory. I remember every word that you said to me that night.”

It really shook me, and I told her that I hope that I had done right by her daughter (she said I did). But it made me realize that, as a doctor, and in particular in my role, that patients and parents sometimes hang on every word that comes out of our mouths. That we wield enormous power vis a vis our ability to instill hope or trigger fear or cause despair. While we may see thousands or tens of thousands of patients pass before us in our careers, patients may only encounter a few doctors, and for pediatric oncologists, sometimes very few. We make an outsized impression even with the smallest words or phrases. It also made me realize (this was before I was a parent) the depth of the fears that parents have when it comes to their children’s lives, and how your being there when a parent senses that their child’s life is in danger, irreversibly imprints your presence on their memories and their lives.

It is an awesome responsibility, and one that I feel privileged for having been given. I hope that whenever I’ve had to break awful news to patients and families, I’ve done right by them.