Preview of Fourth Clinical Simulation

Take-home Message

Graphic representation of emotional flow and turning point

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade, MD

Anticancerweb 21 (06), 2019

Charles had always been an introvert. Very early in life he had to take over his family business, although he had absolutely no passion for it. Despite being very attentive and committed to work, he was unhappy. He used to disguise his ambivalence following a compulsive routine. All days were identical, and he acted like a machine in the assembling line of his shoe factory. At times, it felt as if he was part of an act. He spent more than fourteen hours a day in the factory, and was often found thinking and rambling, locked alone in his office. Constantly surrounded by cigarette smoke, he dipped his mind in a continuous dream, planning how to escape from his undesirable reality. He had been a heavy smoker for more than 40 years and had no intention to quit. Without cigarettes, life would be unbearable. His narrative was flat and factual, hiding his feelings. A family legacy froze his life. Shoe business was in his family for five generations.To the external observer, he was a very successful businessman who improved and expanded his product line, becoming a major worldwide exporter. To Charles, however, life was a miserable imposition and he constantly felt like a failure. 

He had an arranged marriage and he never paid much attention to his children. Always methodical, every night, instead of dinner, Charles had full glass of straight up whiskey before  falling asleep. All affection had been blocked and all his professional and family relations were suffering from the same lack of meaning and importance. At the age of 65 he was diagnosed with lung cancer and later on with liver cancer (hepatocellular carcinoma - HCC).

Every time he faced a major illness, he felt guilty for being sick and tried to avoid getting his family involved, finding emotional support in Rose, with whom he had a thirty-year long affair. His non-small cell lung cancer was successfully treated with chemoradiotherapy and immunotherapy (durvalumab) but, for no apparent reason, he abruptly broke off the relationship with Rose and became severely depressed. Few months later, he was diagnosed with extensive HCC. Despite the efforts of the clinical oncologist, hepatologist and use of antidepressants recommended by a psychiatrist, he was never able to overcome his depression and emotional isolation. He ultimately died of progressive disease, not responding to any treatment. 

The exposition (PLOT 1) occurred in the doctor's office when Charles was briefed on his recently diagnosed lung cancer. He was accompanied by his wife Eleanor  who dominated the interview, not allowing Charles to express himself. The raising action (PLOT 2) revealed all his other medical problems. He was able  to describe all relevant facts of his medical history in a precise and emotionless manner. The conflict (PLOT 3) addresses  Eleanor’s unexpected reaction. It was possible to better understand the family dynamics and all her insecurities that stemmed from a loveless marriage. The climax (PLOT 4) explored the motives behind Charles double life and his affair with Rose. During the falling action (PLOT 5), Charles is dominated by a major depressive disorder, which caused an abrupt break in his relationship with Rose. He felt hopeless and lost his motivation to live. The resolution (PLOT 6) will be presented by the storyteller in a comprehensive biopsychosocial approach.

The graph presented below is a simplified depiction of the story 4 emotional flow. At each PLOT element the patient-physician relationship leads to emotions that occur along distinct time intervals (△t). The actions are responsible for the emotional flow, which is unique to each story. The continuous sinuous blue wave represents the oscillating patient’s emotional status. Despite the efforts of a multidisciplinary team, a “turning point” was never achieved. 

*              Attention: The story 4 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 4 from the beginning, just click in the numbered links located at the bottom of the homepage. 

To be continued on PLOT 1 (exposition): Burnout 

© Copyright Anticancerweb 2020

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019 (Editor)

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)