The Puzzle Table

Mar 13, 2018

How a puzzle table helped both an oncologist and her patient.

Read the related article "The Puzzle Table" by Jennifer Lycette on JCO.org.

 

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Cancer Stories-- The Art of Oncology podcast presents Pamela Hayden, reading the essay "The Puzzle Table" by Jennifer Lycette, published December 1, 2017.

The puzzle table sits off to one side of the infusion room. The chairs are now vacant. And the flat, white expanse of the table shows through the jagged outline of the emerging pattern.

I think of her, my patient, who will never sit there again. She would hurry to claim the table as soon as I had finished her history and physical each week, a shy smile on her face. The nurses knew to look for her there rather than waiting in the exam room when it was time to start her intravenous line.

On her treatment days, any time I passed through the infusion room, I would see her absorbed in the study of the puzzle before her, with her intravenous pole as her companion. The plastic catheter snaking down from the medication bag to her body did not get in her way.

She would look happy and relaxed, not like she looked when we were in the exam room, tense and fearful. I would nod to myself when I saw her reach across the table and pick up a tiny piece. The peripheral neuropathy was not so advanced that her fingertips could not grasp it.

The puzzle table was popular in our infusion room. It has developed an importance that was brought to our attention repeatedly when we held patient focus groups to help plan the space for our new facility.

What about the puzzle table? Where is it going to go? There is going to be a puzzle table, isn't there? Groups of patients and advocates crowded around the blueprints to determine the perfect spot for the puzzle table in its new home.

I didn't appreciate the significance of the puzzle table until I found myself one Saturday sitting with my dad in the waiting room of the cardiology procedure unit. My mom had just been whisked back for an emergency pacemaker. Being a weekend, the waiting room was empty, other than a lone soul curled up on a couch facing the wall on the far side of the room, their form obscured by a blanket.

The physician side of me told myself I had nothing to worry about. Pacemakers were routine. And this tertiary hospital placed thousands of them in a year. The daughter's side of me worried anyway.

I looked at my dad sitting in the chair next to me, a stoic air around him. The emptiness of the room, with its deserted sofas, tables, and chairs, furthered a sense of apprehension.

I wanted to say something to comfort him. But I dismissed each sentence that came to my mind, not wanting to resort to platitudes. The silence felt too heavy to lift with words.

My eyes wandered around the room for inspiration and landed on a stack of puzzles. I thought of my patient. I think I'm going to start a puzzle, I said. Want to help?

After a few minutes, he joined me. And for the next several hours, we worked mostly in silence. I can't remember the picture on the puzzle. But I can remember that as we worked, the tension and worry gradually lessened.

After the two-hour mark, I didn't know if my dad had noticed the time had passed the point at which the cardiologist had told us the procedure would be finished. My mind started to run through various complications that I could not keep out of my too-vivid doctor's imagination.

But each time one of these catastrophic, albeit unlikely, visions made its way into my consciousness-- ventricular fibrillation, arterial rupture, anaphylactic reactions to anesthesia-- I would focus on the puzzle in front of me. And I would be able to dismiss it from the front of my mind.

We were both engrossed in the puzzle when the cardiologist suddenly appeared, walking across the room to us. My heart rate accelerated at the same time as I stopped breathing. I mentally willed him to tell us that all was fine but braced myself for the possibility of bad news. We were fortunate. All had gone well.

Alas, in oncology, we do not yet have implantable devices to take over the regulation of what goes wrong in a cancer cell. It wasn't too long after my experience on the other side of the waiting room doors that I found myself meeting with my patient's family. And I had to tell them all was not well.

My patient is gone now. But I cannot walk by the puzzle table without remembering her. I am grateful to have this memory of her.

I think I understand now why she always rushed to start a puzzle. I think, perhaps, it allowed her to pass the time in the infusion room without her mind running away with thoughts of the chemotherapy dripping into her veins and the prognosis of her cancer, to take things one minute at a time, one second at a time, one puzzle piece at a time, to live in the present moment and not the fear of the next moment.

As I see other patients and family sitting there, whether chatting and working in groups or sitting alone in comfortable silence, I still see her, too. I notice at the end of the day when the infusion room is empty that the puzzle is never completed. I understand now that the puzzle is not there to be finished. It serves just by being present.

I think about the puzzles we take on each day as oncologists. There are some cancers with curative chemotherapy regimens. We know what those puzzles look like when they are solved and how to solve them.

Other times, we are faced with puzzles that no one has yet been able to solve or even puzzles that have never been seen before. There are many pieces that appear similar but have slight variations.

Each one looks like it could be a potential fit. But until we decide on a piece and try it, whether or not it will fit will not become clear. If it doesn't fit, we take the piece out, set it aside, and try another.

Sometimes we get lucky, finding a series of pieces that fit perfectly together. But then, just when we think we can see a glimmer of the completed picture, we either run out of pieces or cannot find another fit.

My patient had done well through many lines of palliative chemotherapy, with few complications over a span of years. But I knew we were running out of pieces. And I knew that she knew we were running out of pieces. But she only ever wanted to focus on the piece at hand.

We had discussed what would happen when the time came that we ran out of pieces, but she never wanted to dwell on it. I don't think this was denial. I think it was courage-- the ordinary yet extraordinary bravery of the quiet and steady reaching for the next piece.

At the end of the day, the infusion room empties of patients and staff. And the unfinished puzzle reminds me of uncertainties and possibilities. I walk over and search for one more piece to click into place before turning out the lights.

[MUSIC PLAYING]

I'm Lidia Schapira, editorial consultant for JCO's Art of Oncology and the host of this podcast. With me today is Dr. Jennifer Lycette, who is an assistant professor at the Knight Cancer Institute at the Oregon Health and Science University and the medical director of oncology services at Columbia Memorial Hospital. Dr. Lycette is the author of "The Puzzle Table," published in the December 1 issue of JCO. Jennifer, welcome to our program.

Thank you for having me.

It's a pleasure. We really enjoyed "The Puzzle Table," and the reviewers also loved it. So tell us a little bit about the inspiration for this wonderful essay.

Well, I think it was a combination of how this patient affected me and remembering her in a moment that was very personal as I wrote about with dealing with the illness-- not a cancer illness, but a medical situation with my family member, my mother. And the story kind of wrote itself in my mind, I guess, is sometimes how stories come to me. And after a time, I got to a point where I wanted to put it to paper.

It's such a wonderful concept-- the idea that the story wrote itself. And there came a point where it just needed to gush out and find paper or screen or whatever it is these days we do with our stories.

So the story centers around the puzzle table, which is actually a piece of furniture that sits in your infusion unit or in the waiting room and seems to be sort of a focal point for patients to gather and pass time. Tell us a little bit about this particular patient that you honor and remember and how she used the puzzle table.

Well, she was a very quiet, shy woman. And she was really known by all the staff for her love of the puzzle table. And we would even joke about how if we didn't see her in the waiting room, we knew we could find her at the puzzle table.

And it wasn't something I really thought about for her until, again, I was in this other moment with my family and how the puzzle affected us. And so it just really caused me to reflect on why it was such an important part of her day in the infusion room and became, in a way, a special memory of her. Because I think for all of our staff, including myself, we have a fond memory that when we see the puzzle, we can't help but remember her.

That's a lovely image. And so let's talk a little bit about your personal experience you relayed in this reflection that you and your dad found yourselves in a waiting room, waiting for your mom to have a cardiology procedure. And for those hours you spent, you also gathered around a puzzle. And that helped you pass the time. Tell us a little bit about that.

Sure. So my father is not in the medical field at all. And as we were waiting for my mother to finish with this procedure, I could sense how apprehensive he was. And I could also sense that it didn't matter what I would say. Of course, he was going to continue to feel that way until it was finished.

And it was a weekend, so the area was completely deserted. And so as I wrote about it, I was kind of glancing around the room in desperation of what to do in this moment. And I saw they had puzzles out. And I just said to my dad, hey, let's do a puzzle.

And while we were doing that, in my mind, actually, I was making this connection with my patients. And so it was, again, just one of those moments I think that happens to us a lot in practice where we have our own separate lives. But at the same time, I think our experiences are always with us at the same time.

Yes. I think we tend to talk about dividing lines and boundaries. But, in fact, all of these experiences make up who we are. And we don't dissociate. We are one person.

So let's reflect a little bit more about how you compare all of these pieces of the puzzle as you're putting together a patient's history and deciding on treatment as an oncologist and also how the pieces of the puzzle, as you say, somehow never are solved, it seems, until time goes by. Tell us a little bit more about what you were thinking when you were comparing the pieces of the puzzles to how we solve the mysteries of the care that each patient receives.

It's as you say. As I was writing the piece, it struck me that the puzzle was actually a very good metaphor for what we do in oncology. And for this particular patient with metastatic breast cancer, of course, we have many lines of therapy in the metastatic setting.

But we don't necessarily have head-to-head comparisons of which one to choose for each patient. So we're very much using our experience and knowledge of toxicity and knowledge of the patients. And sometimes, we try one thing, and it doesn't work. And we move on to something else.

And in metastatic breast cancer, of course, we often have more time to do that than with other cancers. But it struck me that often, it's as if we're putting a puzzle together.

But at the same time, in the back of our minds, we have the knowledge that at any time, we know what piece might not fit. Or we're on a time clock, if you will, but we don't know when it's going to end. And so that metaphor was what I was trying to get across in the piece.

Yes, and you did that so successfully. And then the other aspect of the writing that is, to me, so beautiful is that you help us as readers understand that focusing on each piece of the puzzle one piece at a time has an enormous calming effect on the person. Was that your intention?

Yes. And I'm glad to hear it came across in that way. Because especially with this woman, she, as I wrote about, wasn't someone who every visit wanted to talk about prognosis or dwell on prognosis. But I felt very sure that she understood.

And we talk a lot about mindfulness. And we have a wonderful social worker in our clinic who tries to help us as staff with doing that for ourselves but also for our patients to help as a coping skill. And it struck me that that's what the puzzle was, I think, for my patient-- was in some ways, a mindfulness tool. And I didn't really make that association until I was using that tool myself with my dad.

That's so interesting. And also in your writing, you honor the patient and talk about the fact that what she displayed was a form of bravery and courage and that it also shows just how well, I think-- if I may just tell you the thoughts that I had as I was reading this-- shows that she knew herself. And she was more comfortable moving those pieces around and being busy and perhaps really dreaded the moments where there would be dialogue or conversation.

Or she felt, perhaps, even she would be forced to speak about a future that looked not only uncertain but grim as time passed. Does that resonate with you?

Yes, it does. I think that's exactly what I was trying to get across in how I would observe that she was really a different person in the infusion room. If I saw her across the room, she would be very relaxed, doing the puzzle, chatting with the nurses. But in the exam room, she was very tense and fearful.

So it was a very interesting difference in the way I would observe her. And it was, I think, very helpful to be able to see her in that other situation to know that that was her actual self. And what I was seeing was just a very small moment. And, of course, we often only get very small moments with our patients in the exam room.

Yes. This comes across so clearly. Well, the piece is really beautiful and just beautifully constructed. It starts with the puzzle table. And then you guide the readers through all of this reflection of the patient story and your story and your connection through puzzle solving to the lived experience of patients who need to find ways of going from one anxious moment to the next.

And then you finish with the scene, again, almost like a theatrical or choreographed scene, where you turn the lights off. And you put one final piece of the puzzle into place before turning the lights off and going home.

It's really a beautiful piece, Jennifer. And I'm so grateful that you sent it to us. And I hope the readers enjoy it as much as I did. Do you have any final message or words for those who are listening?

Well, first of all, thank you. And I'm very grateful to have the opportunity to share my writing. And I think in terms of final words, I would go back to what you said about how we try to all set boundaries to help ourselves but that we are one person.

And I think that for me, I would share that I have been practicing in a small rural community now for a little over four years. And I've actually found that opening myself up to some of that overlap has actually been a very helpful thing as an oncologist and a person. And so I don't think we always have to have such rigid boundaries. And again, I just thank you for letting me share my writing through JCO.

Thank you, Jennifer. That was Jennifer Lycette talking about her essay "The Puzzle Table." Join me next time for another conversation about the stories and the art of oncology.