It had been a busy day. He was the last patient of the day.

In the oncology outpatient department, we have forms for documenting a patient’s medical history. The form has specific sections that need to be filled out in a set order. First, we start with the presenting complaint, followed by the history of presenting illness. Next, we document the patient’s past medical and surgical history, followed by sections for menstrual history, addictions, current medications, and their frequencies, and finally, personal details such as marital status, number of children, and occupation.

I’m not too fond of that form and never follow it in order. I find it ridiculous. I mostly start with the introduction, personal history, etc. Sometimes, I feel as if I can tell if the patient is hungry or has been waiting for a long time by their facial expressions. Sometimes, instead of starting their history, I send them to eat something or have some tea, as I have nothing to offer them except water or biscuits.

I believe I can read facial expressions most of the time. I am very focused on people’s facial expressions, so when someone has their face covered or is wearing a mask, I struggle to understand what they are trying to communicate because I mainly rely on lip reading. My friends, who are aware of this, make fun of me because they find it entertaining that I pay so much attention to people’s lips while they are talking.

Anyways, coming back to the patient, he was a middle-aged man but looked much younger. His brother accompanied him, and both of them seemed quite anxious.

I closed the door because there was too much noise in the department. I then briefly introduced myself and asked the patient why he was so anxious. He explained that he had never been to a big hospital in a city before, as he had never been sick in his life and he belonged to a small city. Additionally, no one in his family worked in medicine, so he was unfamiliar with hospitals.

I don’t remember exactly what I said to him, but I can recall that I went outside the room to get some water for him. After having a glass of water, he felt slightly better. When I asked for his name, it was interesting to find out that he had the same name and was nearly the same age as my dad. When I inquired about his occupation, he told me he was a government servant and a school teacher, which happens to be the same job as my dad’s.

I found it quite interesting and shared these facts with him, which made him start smiling too. He began telling me about his school, the subjects he taught, and other things. His brother was also listening to our conversation and seemed quite comfortable too. His brother said, “You are a daughter to us too. Look, my brother has the same name and the same occupation as your father.” My mood improved, and I started enjoying that casual conversation with them, although I was tired and thinking that I would try my best to complete the last consultation of the day as soon as possible.

Sometimes, I get too comfortable with patients, especially those who seem well, and forget the fact that I work in oncology.

I asked him about his family. Despite being my father’s age, he had very young children, four or five. The eldest one was in school, and the youngest was just two years old.

I began taking his medical history, which goes back one year. He started experiencing blood in his stools. He didn’t have any other systemic symptoms. He tried various remedies. He took stool softeners, supplements, tranexamic acid, smoothies, and a lot of herbal medications, but none of them worked.

He went to multiple local doctors. All of them told him he had hemorrhoids. He used multiple gels, ointments, and oral tablets, but nothing worked. Someone suggested surgery.

Finally, he thought of having a hemorrhoidectomy. He came to Islamabad. A doctor tried doing his surgery but was unable to perform it. He advised him to see another physician. He came to our hospital and had a scope done, which showed an anorectal mass, and a biopsy was taken.

He held a few documents and a chest X-ray PA view in his hand. I looked at them. There were some blood tests done from an outside lab. The complete blood picture showed microcytic hypochromic anemia; the rest were fine. He did not have the biopsy report with him. I looked into the EMR. The biopsy had come out to be malignant melanoma. He handed me the chest X-ray film, which had been performed outside. When I looked at the X-ray, there were multiple cannonball lesions in both lungs. I started feeling dizzy.

Now I was the one who needed water. My mouth felt extremely dry. I couldn’t hear what he was asking me. I was looking at his lips but couldn’t make out the words.

He started asking me what was in his report. I tried to compose myself, completed the history, and took him to the attending. He told him that he had cancer which had spread to his lungs already.

His staging CT scan was performed, which showed extensive liver, lung, and bone metastasis. Such a severe cancer, and that too stage four, notorious for its poor prognosis.

All about his disease, stage, and treatment plan was explained to him.

I remained silent throughout the entire consultation.

I was worried about him. Seeing stage four cancer is not new to me as I encounter it daily. However, to see a school teacher, belonging to a lower-middle-class family, and a father of four or five kids, so young and with the same name as my father, was a different and sad experience. How could he afford immunotherapy, the most expensive cancer drugs in Pakistan? What would happen to his children? Who would take care of them? How would he arrange the money?

All of these thoughts made my mind spin.

I thought about my father, a government servant and teacher from a lower middle-class family with socioeconomic status, a number of kids, and affordability issues.

The thoughts made me nauseous.

We referred him to a public-sector hospital where he might be able to obtain those drugs at a minimal cost or possibly for free. They have compassion programs that support some non-affordable patients.

I wonder if he will be able to get those drugs. Will they benefit him? Will his disease progress or not? Will he develop brain mets or not? For how long will he survive? What about his children? Who will raise them?

Sometimes God tests those who have no one but Him.

Damane Zehra is a radiation oncology resident in Pakistan.