From integrative to multidimensional medicine.

A patient of mine, Joan, a physician in her late 40s, had been diagnosed with stage 2 breast cancer. I’ll never forget our first visit. As I took her history, inquired about her life, work, and family, and conducted a physical exam, I was amazed by her detachment from her diagnosis, her emotions, and her body. For Joan, breast cancer was an unpleasant bump in the road, an irritating diversion from her whirlwind of daily activities. It was something to be eliminated as quickly as possible, with minimal feeling or introspection. Joan took great pride in her ability to see 40 patients a day while also serving on numerous hospital committees. She was thrilled with technology that made her more efficient, which I could definitely understand. I was surprised, however, when she told me that she wanted a mastectomy rather than a lumpectomy with radiation. She said, without blinking an eye, that she “didn’t want to waste time on radiation treatments.” Then she added, “Who needs a breast, anyway?” She wanted to know— and I am not exaggerating—if she could receive her adjuvant chemotherapy treatments on Fridays, during her lunch hour, so she could work a full afternoon. When I gently inquired about her emotional state and her interest in diet, exercise, massage, or other complementary therapies, she rejected them outright, declaring them “a complete waste of time.” The very next day, I saw Emily, another professional woman in her late 40s who had stage 2 breast cancer. Her tumor had been excised with a lumpectomy, leaving a 4-cm scar and a significant dimple in her breast. She was referred to me to discuss adjuvant treatment. By all standard measures, Emily’s tumor characteristics and prognosis were virtually indistinguishable from Joan’s. But their personal responses were radically different. After saying “Hello,” Emily burst into tears. She sobbed, explaining that her diagnosis was causing her life to “fall apart.” She now felt “imperfect” and “damaged.” She feared dying of cancer, and leaving behind her husband and children, even though she understood intellectually the odds of this were relatively small. Through her tears, she said she wanted to explore every complementary and alternative therapy available, including some even I had never heard of. While the stories of these 2 women might seem dramatic, they are not uncommon. They also point to some interesting and important ideas about the purpose, meaning, practice, and evolution of medicine, which I will address in this editorial.