I have had patients and their families do strange things during a consultation.   Patients taking notes and recording what the doctor says are pretty commonplace these days, as are answering a cell phone and arguing with a spouse over what really happened while giving a history.

Some patients go to great lengths to disconnect from the process, filing their nails, or flipping through a magazine.   I’ve watched babies’ diapers being changed, snacks being eaten and business conducted by text messaging.  I have probably encouraged this informality—I have a consultation room furnished with a comfortable couch and chairs, with soft lighting.  I think it’s nice for patients to meet their doctor and nurse for the first time with their clothes on, as if they were home in the family room.

I thought I had seen everything, but I learned yesterday that I had not, because yesterday, for the first time in my career, a patient fell asleep during our initial consultation.

Now I am not saying that I give the most interesting speeches on the planet about the risks, benefits, alternatives and side effects of radiation therapy.  In fact—a little confession here—I have given the spiels about the various treatments of prostate cancer and breast cancer so many times, that occasionally, just rarely, after an afternoon meal during the dog days of summer I have found myself drifting off midsentence and righting myself with a jerk.  Not very subtle, I know, but forgivable, especially during the early sleepless nights of motherhood combined with career. No one has ever actually complained that I fell asleep during the consultation, so I suspect that my heavy nodding head and half closed eyes were taken as a Yoda like signs of wisdom and empathy rather than tactless boredom.  At least I hope so!

So yesterday was a watershed moment in my lifetime of treating cancer patients.  A middle aged woman, otherwise in excellent health, had been given the diagnosis of breast cancer after a routine screening mammogram.  She underwent a lumpectomy and was found to have ductal carcinoma in situ, the earliest detectable form of breast cancer, stage 0.  She was referred to me for consideration of postoperative radiation therapy, and was seeing me for the first time with her husband accompanying her.  She was lucky—her cancer was detected so early that the likelihood of relapse was low, no matter what treatment she chose.

As I launched into my time worn discussion of her good prognosis, and the finer points of radiation therapy, she suddenly interrupted me, saying, “I just got back in the pool and swam for the first time since my surgery.  I love to swim.  It’s great exercise, but now I am really tired. Do you mind if I lie down on the couch here?”

There are many reasons why I am not a psychiatrist but generally speaking, I am okay with couches.  I said, “Sure!” and continued to talk.  As I neared the topic of CT scan based treatment planning, to avoid treating her heart and left lung, I noticed that her eyes were closed.  A few minutes later, a slight snore escaped her lips. Her husband sat at rapt attention, but my patient was out like a light!

I am choosing to take this as a sign that she was very, very comfortable with me.  But in the meantime, I think it might be time to spruce up my dog and pony show, for sure.

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.