WITH FRIENDS LIKE THESE ...

"Are we still friends?"

It's the half-joking question I pose as I walk into the exam room of the patient to whom I have just administered chemotherapy. The first treatment is always instructive and clarifying for both of us, preceded by the hazy prophesying of informed consent. I like to mock the television commercials for prescription drugs, so artfully composed by the pharmaceutical companies, who run a breathless audio description of their product's most fearsome side effects with deliberate incongruity beneath video of smiling attractive couples on adventurous vacations. But if I'm honest, I'm guilty of the same salesmanship, rushing through the litany of potential outcomes (and similarly likely to mention death as fleetingly as possible) before advising my patients to sign on the dotted line with the assurance that, in my professional medical opinion, the benefits likely outweigh the risks. For all the talk of darkness, the future looks bright.

How differently things can seem at our next encounter, ideally meeting again during a scheduled office visit but sometimes in the ER, on the hospital ward, or in the ICU. That laundry list of possibilities with which I deluged them at our prior appointment has now been narrowed, distilled into a present reality that might include intractable nausea, cholera-like diarrhea, or febrile neutropenia. Clouds have intruded on a sunny forecast, and it's time for the weatherman to accept blame.

I do my best to survey the damage, even quantify it (although I have yet to meet a patient who describes their disabling paresthesias as grade 3 neuropathy); make adjustments (I have great empathy for the coach whose team is losing badly at half-time); and then move on, mingling my regret with the sincere hope that things will be better the next time, learning from the past lest we be doomed to repeat it.

So when I ask the patient if we're still friends, it's a feint towards an admission of guilt. I recognize this is the life cycle of an abusive relationship: I inflict harm, I ask for forgiveness, I try to re-establish trust, and then I do it all over again. We even number the chemo treatments in cycles, reminding ourselves of time's flat circle, the not-so-merry-go-round. Along another axis, it can be seen as a roller coaster: a plunge into toxicity, an ascent back to baseline, and then another precipitous decline.

The ethics lessons from first-year medical school resound accusingly in my head: primum non nocere --  First, do no harm. As a student this seemed a self-evident, easy morality (and boy, don't I sound sophisticated saying it in Latin?!). But it turns out to be a precept that's extremely hard, if not impossible, for a medical oncologist to follow. I am a blunt instrument, and I cause collateral damage despite my best intentions to take careful aim at an often-elusive target inside another person.

In truth, this is not friendship but it is undeniably intimacy. I have a fiduciary responsibility to these people who were unfortunate enough to fall under my care, who tell me their secrets while wearing flimsy gowns in cold rooms, who make their lives and bodies an open book to me that I might help them. In return for their faith and transparency, I try to make their lives longer, or at least better. I just wish I didn't have to make it hurt so much. With friends like me, who would want friends?