37. Slender and fair, she wore her thick auburn hair pulled back and falling to her shoulders. She was seriously ill.
Nine days earlier, doctors at the National Cancer Institute had removed a cancerous lump from her right breast and taken out the lymph nodes under her right arm. Now she was to receive radiation therapy and a year of chemotherapy -- starting that day.
She sat in a stark white examining room, facing Dr. Marc Lippman, head of the cancer institute's breast cancer section. He asked if she had any questions before she began chemotherapy. She asked whether the medications would make her infertile. "I still harbor a hope that I might have a child someday," she said.
Lippman told her there was a 50-50 chance that the drugs might bring on menopause, which would rule out pregnancy.
Then he asked her what she was going to do about her hair. She replied that she intended to cut it short and get a wig. He nodded approvingly. The consultation ended after Lippman gently examined her right breast and the draining scar where her lymph nodes had been.
Lippmann had urged me to visit the center to experience what the doctors there face every day. I left the room with him, shaken. I had to sit down.
"Good," he said. "Now you see how it is."
Already you're rooting for her," he continued. "Now imagine how you'd feel if the treatment seems to work and she goes for years without a recurrence of the cancer. By this time you've really gotten to know her and you like her more than ever. Then suppose one day she comes in for a check-up and her cancer is back.
"You know that this is the end of the quality of life as she knows it . . . Imagine that you have to make a difficult decision about her treatment. How objective could you be?"
Lippman's point is simple: Cancer doctors are not immune to the pathos and human tragedy they see each day, but unless they learn to deal with their own emotions, they cannot continue.
It is a lesson he learned only slowly over a period of years. And it is a lesson that the cancer institute now tries to teach its young specialists early, before they find themselves in trouble.
Every July, 14 young physicians arrive at the National Cancer Institute to spend three years learning to take care of cancer patients. Although their academic credentials are impeccable and all have spent several years in residency programs at major teaching hospitals, they almost always are completely unprepared for what lies ahead of them.
They are well versed in the theory of cancer medicine but trained to believe that they should not fail and that death is a failure. They are trained to believe they should not have any feelings or, if they do, they should not talk about them.
And they are confronted with a group of patients who are frightened, who often have unrealistic expectations, who want to cling to them and solicit every special attention they can get.
The first thing that happens, said Lippman, is that the patients try to "seduce" their doctors, by which he means they try to "appear special, more in need" than other patients. A female patient with a male doctor may make sexual overtures or just appear a little undraped in her doctor's presence. Older women may be maternal and flatter the young doctors, saying, "Your mother must be so proud of you."
Patients let their doctors know they are wealthy or powerful or have politically powerful friends. Some give their doctors gifts; others are demanding and belligerent.
Lippman ruefully tells the tale of one woman at the breast cancer clinic who said to him, "You're such a wonderful doctor. The nights you're on duty, I feel extra safe." He was pleased and flattered and, deep in his heart, he knew she was right.
But then he got to talking with the other doctors on the ward. To their dismay, they learned that the patient had told each the same story. Each had believed he personally was special to her.
Facing incidents like these, the young doctors are bewildered, frequently not knowing what is going on and at a loss to cope with their own reponses. "If you're not supposed to have feelings, you're really in trouble," said Lippman.
Then there is the very real tragedy of cancer. The doctors have to watch patients they know and care for die. And there is no escape.
"Oncologists see things that are extremely painful," Lippman said. "There are times when I see one tragedy after another. I will see a patient who was fine yesterday but who woke up today with a stomachache and I know that that's it. Never will she feel good again."
No physican could fail to be affected. According to Lippman, nearly every young doctor exhibits some dysfunctional behavior during his first year at the NCI. Some eat too much, others eat too little, some start to drink, others get divorced, others run obsessively.
In 1968, shortly after one oncology fellow committed suicide, the cancer institute began offering counseling sessions with a psychiatrist. It is an unusual program, one offered by few cancer centers.
Dr. David Rubinow, who conducts the sessions, said that what he hopes to do for the physicians is to help them maintain their equilibrium, avoiding becoming what he calls a "heartless healer" or, alternatively, becoming emotionally devastated.
"How do you manage your relationships with your patient so that you are sensitive to your patient and yet do not feel a devastating sense of loss when the patient dies?" he asks.
Dr. Theodore Lawrence, a second-year fellow at the cancer institute, said one of the most valuable things he learned from Rubinow was that his emotional state upon talking to a patient frequently reflects the patient's emotions.
For example, he said, he would sit down with a patient who appeared calm and collected and start to feel extremely anxious. What was happening, he learned, was that the patient's calmness was a veneer, and that actually the patient was "quivering with anxiety." With that realization, Lawrence was able to directly address the patient's concerns.
Another thing Rubinow does is to encourage the doctors to confront their own mortality in order to understand their patients and to be able to discuss the idea of death with them.
"The bottom line," said Rubinow, "is to recognize that the physician is a very powerful figure, particularly to patients with cancer. He will at times be responded to in primitive and powerful ways. This is not the same as a lawyer-client relationship."
All this is not to say that physicans will be able to avoid the grief and pain of dealing with cancer patients. And, of course, there are rewards. Some patients do get better and others, Lippman points out, frequently end up teaching their doctors about how to deal with life and death. But there will always be the pain.
"It should hurt sometimes," said Lawrence, "and it does."