The List

Lists guide our lives.  Some are easy, even fun, like a menu or shopping list.  Some are simple tick-offs for work, like my wife’s honey-do list.  Others are frightening, like a draft list.  Some are melancholy, such as the inventory in a Will.  We are inspired by our bucket-list.  Finally, some are exciting, but stir conflict, like a wedding invitation list.  I have a list, which makes me slightly anxious, a little depressed, and which takes modest courage to open up.  That is my patient’s list of daily X-ray reports.

Our Electronic Medical Record (EMR), as based around a home page or “Inbox.”  This is a continuously updated assembly of data and messages from our practice and patients.  There are medical orders to approve, questions from nurses and patients, billing inquiries, documents to sign, lab results and emergency alerts about patients in trouble.  Except for the drudgery of pushing through a pile of CMS documentation, those lists have scant emotional impact on me.  Not so the eighth list, just four from the bottom:  Radiology Documents.

These are the results delivered electronically of any MRI, CT scan, bone scan, chest X-ray or other imaging study, that I, or other doctors, have ordered on my patients.  Every 24 hours, between 15 and 30 new reports pop-up.  Opening this section I see three columns; the patient’s name, the date the test was performed, and the type of test.  One click on each line yields a neat, formatted, typed report. These are more than just data.  More than simple facts.  These are final, cold, hard answers to the biggest questions of all.

Is Sue’s cancer is responding to therapy? Does Pete’s shortness of breath mean “just” pneumonia or a blood clot, or has his kidney cancer has metastasized to his lungs?  Did Sid pull his back shoveling snow or is that sharp pain a vertebra fractured by prostate cancer?  Is Alan’s forgetfulness fatigue, Alzheimer’s or perhaps something more insidious, the bloom of glioma cells deep in his brain?

Each line on my Radiology list is a patient’s line in the sand, a division between the past and future.  It measures life lived and life to come; health, disease and prognosis.   Will a child grow up with her mother?  What about the dream of a house by a quiet shore or joyous holidays in a holy place?  Will his next visit to church be to walk at his grandson’s wedding or will he ride the aisle in a casket? Will she take that ultimate trip to explore an ancient battlefield or climb a foreign peak?  Does tomorrow promise healing and hope, or threaten weakness and pain?

This I know and feel as the mouse guides the cursor across the screen.  Always there is a moment of hesitation, a small twist in my throat, a pull into memory and stiffness in my hand.  What calls will I make?  Will I give or will I take?  On the other side of the list, wait patients, families and friends.  Will it be healing or decay?

Physicians cope in several ways with the responsibility of determining good news or bad. The simplest is to focus on the disease, instead of the person. If you look at the biology of cancer and not its social or psychological affect, it is much easier to discover and give bad news.  Doctors understand whatever the emotional burden, making and communicating diagnosis and prognosis, is their job.  Someone has to do it.  Nonetheless, no matter how factual you try to be, how matter-of-fact, in the end you care about your patients and so humanity leaks in, staining your soul.

I remind myself that the longer I wait to tell each patient the news, the more they will fear the worse and the harder it will be.  Do not procrastinate, patients need to know.  I try to keep up with the list, not get behind, even during the course of a single day.  If I delay, eventually there are so many reports, so many patient calls, that the very length of the list is an arduous burden.  Prepare for the answer; when ordering the test explain to the patient what results are likely and what we will do with whatever result.  Still, sometimes I am surprised by the “answer” and find myself making phone calls or holding patient meetings, the direction of which I did not anticipate.

Just opened my Inbox.  The counter next to “Radiology Documents” says that seven reports wait.  Center myself.  Deep breath.  Point the arrow.  Click.  Lives change.


  • Wow. Just reading this made me so anxious. It must be brutal for you to do on a daily basis. Nevertheless, giving good news must bring such a high. I remember getting good news from both my oncologist and my breast surgeon and hearing their elation. I also remember feeling paralysed until the phone rang.
  • Ray Nolan
    As I try to adjust to my 'new' life without Dee I cant help recalling the 'one on on' meeting we had in Sept to discuss my wife's prognosis. When you gave me the news that things were not going well and we should consider calling Hospice I was stunned. I left our meeting totally confused, saddened and afraid, "how could we have only 1 1/2 months left? We lasted almost 6 months but even that feels like a blur. I don't know how you do you job but I'm certainly you do it and do it so well. Each patient and their family sees their case as the only one in the world, their world; how you deal with many cases is beyond my comprehension.
  • Janet Visokay
    I totally agree with Ray. I have been down this path with you and Joe for less than a month. The ending came so fast in a blur. How you and some other doctors do this is amazing. You were a great comfort to us and Joe trusted you completely. If this horrid disease hits me, you are the person I head to. Thank you Dr. Salwitz you have more compassion than anyone I know. I am sorry your list continues to be so long. There has to be a cure and then you will sigh and have a good long needed vacation :)
  • meyati
    On my second visit, I told Dr. G that I find it amazing that he could be so simpatico-empathetic, not depressed, caring, confident, didn't treat me like a child, not burnt out-. He told me it was like a calling for him. At the end of the visit- he surprised me with a hug, and thanked me for caring and being aware. I saw him depressed once. The annual scan showed the nodules burnt out-gone, but the radiologist decided that a tonsil stub was some form of cancerous tissue. He just had a loss of energy, while he explained the facts. I got hold of my ENT, and it was out in 24 hours, and the lab report was normal tonsil stub tissue. Priceless for the 3 of us. This is much better than "watching". Now he has energy back when he sees me. My first oncologist was just off-more than burnt out, so I doubly appreciate my current oncology medical team, which includes my dentist. .
  • penelope egan
    to say thank you, just doesn't cover it, but that's all your patients and their families can say...thank you! Your writings are so filled with compassion.... May you find time to unwind in your tightly wound world ... I'm waiting for you to turn to fiction where you may create your own endings...and we can live in make believe land for a while... fondly penny egan
  • There are no words to say how much I appreciate my oncologist but I do worry about him. He finds the work rewarding and feels that giving someone a death with divinity is an honor. Thank-you for doing this very special work. It is not death that I am afraid of it is the suffering. There is the pain of the unknown. There is physical pain and the everchanging landscape of cancer. It takes a very special person to work with cancer patients. Take special care of you so you can take care of those in need of tender, loving care.
  • I posted this on my FB page - too good to not share. I save your essays until I have time; then I savor them. And I offer up a prayer of thanks, to whoever's listening, for you and all doctors who care as much as you do.

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