Daniel Flora, Medical Oncologist and Medical Director of Oncology Research at St. Elizabeth Healthcare, shared a post on Substack:
“‘Cancer begins and ends with people. In the midst of scientific abstraction, it is sometimes possible to forget this one basic fact.” – Sid Mukherjee, The Emperor of All Maladies
The longer I work in oncology, the more I recognize that the hardest moments in clinic rarely come from a lack of knowledge. They come from the complexity of real life. From choices that depend entirely on who the patient is, what they value, and what trade-offs they’re willing to make to protect the time they have.
The science may offer options, but it doesn’t always offer clarity.
As doctors, we’re trained to lead with data. We often talk about clinical trials, risk reduction percentages, survival outcomes, and treatment guidelines. These are the foundation of our decision-making, and they can help us guide patients through some of the most difficult choices they’ll ever face. In many situations, the data speaks clearly, and we can rely on it with confidence. But not every case is like that. Not every decision is purely clinical.
Take a woman in her early forties with lymph node–positive breast cancer. She’s healthy, raising two young kids, working full time, very much in the middle of her life. Twenty weeks of chemotherapy might lower her risk of recurrence by five to ten percent — a measurable benefit, but not a dramatic one. At the same time, it brings fatigue, nausea, neuropathy, and months spent away from the routines that give her life shape and joy.
In moments like this, shared decision-making is the whole point. It’s not a checkbox or a phrase we put in clinic notes. It’s an ongoing conversation about values, risk, and meaning — the place where we try to translate data into a real-life situation.
Even so, many of us find ourselves leaning toward recommending treatment. Not because the data demands it, but because doing less can feel unsafe, while doing more feels like action. The instinct to save a life is strong and deeply human. Yet that same instinct, born from empathy and fear in equal measure, can sometimes lead us toward overtreatment.
Overtreatment rarely comes from ignoring data. It grows out of everything else that lives in the exam room: our memories of patients who recurred, our fear of disappointing families by doing ‘nothing,’ our discomfort with uncertainty. In my case, it even comes from my own experience with losing my mom to cancer. These experiences add up, and whether we realize it or not, they begin to influence how we think and what we offer. We want to do the right thing. We want to offer hope. And we don’t want to be the oncologist who didn’t try hard enough.
Another example that comes up often is the patient with advanced cancer who has a specific, personal goal—something like making it to a daughter’s wedding or a long-planned family vacation. In some cases, there are still a few treatment options left. Each one might slow the disease a little or reduce symptoms for some time, but none are likely to change the overall course of the illness. And each comes with its own side effects: fatigue, nausea, brain fog, or hospital time that competes with the quality time the patient is trying to hold on to. The patient may physically arrive at her daughter’s wedding, but not in the way they imagined. Perhaps feeling poorly, in pain, and not truly present.
These are the situations that challenge us. It’s easy to fall into the pattern of doing something simply because we can, or because offering treatment feels more active than doing nothing. But without a true understanding of the patient’s goals, we may end up steering care based on our own discomfort rather than what the patient actually wants.
That’s why these conversations have to start with better questions. Not ‘Do you want chemo?’ or ‘Should we try the next line?‘ but ‘What are you hoping for?’ ‘What’s most important to you right now?‘ and ‘What does a good day look like for you?‘ When those questions are asked with honesty and care, they reveal the patient’s goals, and they help frame the conversation around what really matters.
Another challenge is making sure those goals are clear and realistic. Sometimes a patient’s goals are shaped by hope that doesn’t match the clinical reality. And in those moments, our role is to gently guide. Not to take away hope, but to help patients make decisions that reflect their values and priorities as they are, not as we wish they could be. This is a skill that takes hundreds of patient encounters to learn, and I will admit I still don’t feel like I’ve got it down. These conversations are not scripted; they evolve through listening, honesty, and the ability to tolerate uncertainty — a skill our training rarely teaches directly.
Of course, there are many times when treatment is the right choice. When doing more truly does offer more: more time, more energy, more life. But we shouldn’t default to more without asking why. And we should always ask whether the path we’re on still matches what the patient wants.
This job is emotional. It asks us to absorb other people’s suffering while managing our own responses to loss and uncertainty. We can’t, and shouldn’t, remove ourselves from that. But we do need to recognize when our emotions, our fear of regret, or our past experiences are starting to influence the treatment plan more than the patient’s goals are.
That doesn’t make us weak. It makes us human. But it also means we learn to slow down, listen, and reflect. To ask not only what the treatment might do, but why we’re recommending it. And to make sure the answer is grounded in the person sitting across from us.
At the end of the day, our job isn’t to do everything. It’s to do what matters for the patient. And the only way to know what that is is to listen.”
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