9-6-09 – Validation is Not Necessarily Agreement

So far, I must say, the journey into Cancer Land has not been terribly physically demanding, as all things go. Yes, I have willingly given up feeling just fine in exchange for suffering the side effects of chemo, which are cumulative.

I am bald and my hairless skin feels like some kind of weird plastic rather than human skin at all, my levels of fatigue are rapidly escalating, I get winded with light-to-moderate physical effort, I have mouth sores from time to time, I get nauseous after each chemo infusion (usually), I have little sense of taste left, I have some degree of neuropathy (pain in my feet), and I get bouts of extreme skin sensitivity. Oh, and I tend to get neutropenic and feverish and wind up in the hospital. (Except for this time. At the suggestion of my oncologist, Dr. H, I took an oral antibiotic and managed to escape the fever and thus the hospital.)

Other than that, it hasn’t been too bad. So far.

Unfortunately, the psychological aspects of the journey have been far more difficult. They have come in two varieties. The first variety are those that have arisen from my own, internal demons. I have rehearsed them here in earlier entries. The second variety are those that have arisen from external circumstances that I have to deal with. Sometimes these overlap…and sometimes they are really pretty distinct entities.

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The standard of care for IBC includes mastectomy with full axillary node dissection. Translated into plain English, they will take off my breast and remove all of the lymph nodes in my right armpit and across the right half of my chest wall. Because this removal will break the channel through which lymph fluid flows between my right arm and the trunk of my body, my right arm, forever after, will be at risk for developing problems related to impaired lymph flow—a condition known as lymphedema.

My cancer treatment, in short, will give me a secondary health condition that I will have to monitor and be cautious about—in addition to monitoring and being cautious about a return of the cancer—for the rest of my life. I go in with one health concern; I’ll emerge with two health concerns due to the treatment I receive.

For the rest of my life, I will have to be vigilant about not allowing things to happen to that arm because the normal channels of lymph flow will be so impaired. When I fly, I’ll have to wear a compression sleeve to prevent the lymph from pooling in my arm due to the atmospheric pressure changes. I will need to treat every little scrape and cut as a potentially serious problem, since impaired lymph flow means there is more lymph fluid moving sluggishly through my arm—and lymph is a rich source of food for infection to grow in. I will need to avoid lifting anything very heavy with that arm. I will need to protect that arm from sun exposure. I will need to avoid bumping it, since bumps may cause the sluggish lymph flow to slow down even further and make my arm swell up. In order to try to promote lymph drainage, I will have to do a set of exercises every day, twice a day, for the rest of my life.

And that’s what I have to do if I *don’t* actually get active lymph disease.

If I do get active lymph disease despite all these precautions—and there is a 30% chance that I will—there are even more exercises and treatments that I will have to undertake. For the rest of my life. To manage this condition I got as a result of my cancer treatment.

Needless to say, I have not been thrilled with this prospect, so I’ve been trying to figure out how I can reduce that 30% risk of getting active lymph disease. The most straightforward way would be for me to refuse to allow them to take any lymph nodes or irradiate them. Both surgery (removal of the nodes) and radiation treatment are contributing factors in the development of lymphedema. Refusing to allow either one would reduce my risk of getting active lymph disease to 0%.

Unfortunately, if I do that I am seriously compromising my chances of beating this cancer. I know that. But it doesn’t make the prospect of developing lymphedema any easier to live with. It’s what I really want: no risk of lymphedema. *And* no cancer!

So I’ve been trying to figure out how to cut that 30% risk to a more acceptable figure. Lymph nodes in that part of the body come in three layers. I’m wondering what would happen if I only allowed them to take level 1 nodes, and we relied on radiation to “clean out” the nodes remaining on levels 2 and 3. How would that decrease my risk of getting lymphedema? How would it increase my risk of not getting control of this cancer today or having a recurrence later on? What if I only allowed them to take levels 1 and 2 nodes, and we relied on radiation to clean up the remaining nodes on level 3? Same questions.

What is even more unfortunate than my diminished prospects for beating this cancer if I refuse to allow treatment of my nodes is the fact that my medical oncologist refuses to validate my concerns about lymphedema. He brushes aside—indeed, ignores—my statements of concern, my statements that I do not want to accept ANY risk of lymphedema. He makes me feel unheard, unvalidated. And this is not the first time. It is a consistent pattern in our relationship. We talk. But we do not communicate.

My med oncologist—indeed, everyone—says that after surgery there are lymph specialists who can help me manage the risk—manage it in just the ways I have described to you above.

My point is that managing the risk *after* surgery is kind of like shutting the barn door after the horse is already gone. I’d really rather prevent the horse from leaving the barn in the first place.

My medical oncologist refuses to engage the issue with me starting from that premise. Instead, he just assumes that of course the horse will leave the barn and he will only engage the issue with me on those grounds. You can’t start from a different premise when talking to him, because he refuses to acknowledge such a different premise as a valid one for anyone to have.

This is not the first time that I have felt unheard, dismissed and unvalidated by him. It may turn out to be one of the last, though. Because my continually having to navigate this kind of treatment from him is not good for my mental health and is not good for my long-term recovery prospects.

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On Friday this week I had my first consult with my radiation oncologist—the person who will administer my radiation treatments. She popped her head in the examining room while I was still busy with the nurse who was taking my vital signs. I was surprised. Here was no white-coated, stiff, professional-proper woman. She was wearing a colorful, folksy dress, tennis shoes, funky socks, and a hand-made cell phone (and business card) pocket attached to a belt. Her hair was all curly and fuzzy, not politely coiffed or restrained with pins and combs. I began to warm toward her immediately, just because she looked so unconventional—so “outside the box.”

“I understand you have problems with the idea of lymphedema,” she began, sitting down on the rolling stool in front of me.

“You’ve been reading my chart,” I replied.

“I can understand that,” she continued. “I don’t like some of the side effects of my treatments for multiple sclerosis, too. But lymphedema is really quite manageable…” (So that explained her somewhat funny gait, I thought.)

“Dr. J,” I interrupted her. “Do any of your treatments for MS leave you with a secondary disease that you will have to manage for the rest of your life on top of managing your MS?”

She looked me square in the eyes as her shoulders slumped just a little. I could almost see the air going out of her.

“No,” she said. “They don’t.”

She didn’t ignore my statement as if it were invalid. She didn’t try to say, “But the standard of care for IBC is….” She didn’t cite nameless studies (no one ever gives me citations to these studies they mention, so that I can look them up) showing that there is improved loco-regional control with full axillary dissection followed by radiation.

Instead, her reply and her whole body language indicated to me that she had heard and understood *and appreciated the validity of* the point I had just made.

“That is exactly my point,” I said. “I think it’s totally unacceptable that my treatment for cancer will leave me with a secondary disease process that I am going to have to be vigilant about—even if I never actively get it—for the rest of my life. In addition to my need to be ever vigilant about the cancer itself.”

In the discussion that followed, we returned time and time again to my desire to keep the horse from ever leaving the barn. And it was very clear to me that she “got it.” She is extremely tuned in to my desire to have NO RISK WHATSOEVER of getting lymphedema. This, I thought, is someone I can work with. She gets me.

From this basis, our discussion covered a range of “what if’s” that all involved some degree of removal of my lymph nodes and radiation. We didn’t cover the issue in a systematic way. I have no clear sense of what the relative risks and benefits of a series of options might be. But we did discuss it in a general way.

She showed me my CT scans and we talked about whether nodes on all three levels appear to have been infected with cancer before I began chemo, the fact that chemo appears to have shrunk many of these nodes now and how that might change the treatment picture. A lot was left up in the air.

She gave me a referral to a lymph specialist and suggested that the best way to deal with the risk of lymphedema—if you have to accept some risk—is by proactively addressing the upcoming risk well before surgery and radiation really make you at risk—a proactive approach that makes a great deal of sense to me. She said that there are things you can do to help build new channels of lymph drainage, which will help to minimize your risk of actively getting the disease. I had heard this idea about “building new lymph channels” before, but no one had ever elaborated upon it. So I was encouraged to hear her mention it.

Granted, we were talking about managing the risk, assuming that I was going to be at risk. Assuming that the horse will have left the barn. But we had begun our talk with the understanding that I would prefer the horse never to leave. And that was important. She didn’t dismiss my desire for this as irrelevant. Then we had moved on to discussing ways of minimizing his leaving—maybe making sure he just got out of his stall but never left the barn? And now we were talking about what if we knew he was going to leave—how could we work now, before he left, to minimize the impact of his leaving?

All of this was a very different approach than the one that had been proposed by my medical oncologist: ignore the fact that I don’t want the horse to leave, let the horse leave and never try to figure out a way to minimize his leaving, then deal with the aftermath of his having left when the time comes.

We talked about the radiation plan for me. She was very frank and very up front about the fact that because of the amount of radiation I will be getting, I am likely to experience the extreme effects of radiation treatment very early on. I will hurt like hell. My skin will blister and peel as if I had a severe sunburn—and when that happens we won’t stop. We will go in and burn me some more. I will itch like hell but I cannot scratch. The radiation treatment will fry my thyroid as a secondary effect, and given that I have been borderline hypothyroid for years, this is likely to tumble me over the edge. The radiation treatment will also fry a small section of my right lung and make it scarred and useless.

(All this, in the name of health, I thought. Just writing it, here, makes me want to sob. Cancer treatment should be better than this.)

I told her I wanted my daily radiation dose to be divided into two and administered twice a day rather than once. As I understand it, this will reduce the damage to the skin and the damage to the lung. A twice-a-day schedule is what is used at the IBC Clinic that M.D. Anderson runs. That’s what I want.

She admitted to me that they know that twice-a-day administration rather than the usual once-a-day reduces the long-term side effects, one of which is the chance of getting lymphedema.

I didn’t ask her, but I wondered: If they know this—if they know that a different administration schedule will reduce the severity and likelihood of these nasty side-effects—then why do they persist in doing once-a-day radiation? Why do they show such a disregard for the long-term health and welfare of their patients?

Unlike many of the people I have encountered who talk about “studies show,” Dr. J was actually willing to look up a study on the Internet and print it out for me while I was there. I was very impressed. I was even more impressed when I got a phone call from her at home the next day, apologizing for giving me that article because it did not address the issues we had been discussing in the way she thought it would.

We discussed my diet and my weight loss. I explained that I’m eating a mostly vegan diet, now, but not adhering to it so rigidly that I can’t enjoy an occasional slice of pizza with a friend. She said that her nutritionist had said the same thing about the diet she should follow for her MS—a diet that includes no dairy.

“How can you live without cheese?!” she asked. “I mean, sometimes it just comes down to a quality of life issue. Even if it makes my MS worse, how can I enjoy life if I never get to eat cheese?”

I said that I wholeheartedly agree!

I left my consult with Dr. J feeling pretty good. “Here’s someone who hears me when I say something. Someone who will begin a conversation by validating what I want, and then explore with me how close we can come to getting me what I want.”

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When I got home, I decided to write an email to my medical oncologist, Dr. H, in which I made it very clear that my goal is to have NO RISK AT ALL of acquiring lymphedema. Given that goal, I said, I also want to explore other options such as only allowing partial axillary node dissection and finding out how that would change our radiation treatment plans and how it would affect our chances for loco-regional control and long-term, disease-free survival.

Today I got this message from him: “Next time I see you I will refer you to one of our lymphedema experts and she can advise you on how you can minimize your risks – this should help.”

No acknowledgement of the baseline point of my wanting to avoid ANY risk. No acknowledgement that my wish to have “no risk at all” is a valid desire for me to have. No acknowledgement of my desire to explore a variety of options regarding surgery and radiation treatment plans in order to manage the risk up front rather than after the fact.

Only an assumption that we have to do a full dissection (the horse leaving the barn is the only scenario he can imagine) and that dealing with the aftermath of that event is the only worthwhile response.

I was furious. In a flash, I went from calm and having a good weekend, to being furious. I wrote him a quick email reply, but realized that this was not good enough. So I called him at home.

I told him that I felt he wasn’t hearing my concerns and validating them. I said that I am working really hard to come to an acceptance of the risks I need to assume in having the axillary dissection, but to do that I need to feel heard and understood where I am, so that I can make my way to a better place with accepting these things. Heard and accepted. No “ifs,” “ands,” or “buts.”

His response was to launch into another dissertation about how studies have shown….

I interrupted him and said, “Dr. H. Dr. H. You’re doing it again! You’re not demonstrating any appreciation of my position, of my concerns. You aren’t validating me where I am. You are making me feel dismissed and ignored.”

He said that this (axillary node dissection) is the standard of care for IBC and he doesn’t feel comfortable doing less than the standard of care.

I said that I know what the standard of care is. I’ve read the studies. I know. He doesn’t need to keep repeating them to me. He’s preaching to the choir. So stop it, already.

In fact, I said, the real standard of care for IBC starts with psychology. It starts with making sure that the patient feels heard and understood and validated in their concerns. You meet them where they are. You don’t dismiss them with a wave of your hand and a referral to someone who won’t do for them what they are expressing an interest in having.

Only when they feel understood and accepted right where they are can you talk about providing them with something that may be less than what they had expressed an interest in having. Only when they feel understood can you move on to the mechanical aspects of treating the disease. And he is not doing that. He has never made me feel understood. And I need that from him.

I told him about talking with Dr. M, the hospital psychiatrist, who validated my concerns about chemo by saying, “Hell yes, they’re toxic! They’re poisons! Look at the name! Cytoxan! Toxic to cells!” I said that when M said that, then I knew that he understood my position, that he validated it. And that, I said, helped me begin to move toward accepting the risks involved with chemo.

I pointed out to him that since I’ve been on chemo, I have not once complained about the side-effects. I have not once blamed him or any of the treatment team for any side effect I’ve had—even when I wound up in the hospital twice. That’s because in accepting the need to do chemo, I accepted full responsibility for whatever happens as a result. The responsibility for living with the side effects—I accepted that. It was my choice. I chose it. Mostly it’s worked out OK, so far. A couple of things are not so OK, but that’s not anyone’s “fault” but my own. It was a chance I took, in accepting chemo. And that’s OK. I accept the side-effects.

I told him that I’m struggling mightily to come to the same kind of acceptance with the 30% chance that after axillary node dissection I will have some form of active lymph disease—a disease that will be a lifelong legacy of my treatment. And I will have a 100% chance of having to act, for the rest of my life, as if I could get active lymph disease at any time.

But when I received his email so quickly dismissing my concerns (by not even acknowledging them) and saying he’d refer me to a lymph specialist, it pushed me back, psychologically, to a more entrenched position rather than helping me work my way out of it.

I told him about talking with Dr. J on Friday about the kinds of secondary diseases her treatment for MS has given her. When she responded, I said, at that moment, I knew I could trust her, could work with her. Because I knew she understood me.

In fact, I told him, Dr. J and I spent the better part of our consult talking about axillary node dissection, the various layers that might or might not be dissected, the radiation therapy plans, etc. We could have that conversation, I said, because I felt that she understood my basic position. So we could have a conversation that started from there, and moved forward.

But his email, I said, had only helped to push me back into a more entrenched “no risk = no dissection” psychological position—a position I’m struggling very hard to move away from.

I reminded him of a message I sent to the whole team a couple of weeks ago in which I used the analogy of cancer treatment being like standing a patient up against a wall and giving him a Tylenol for side effect management, followed by a certain number of whacks with an 8-lb. sledge hammer…a message in which I begged for improved communication (which clearly has not happened).

I said, “You know what the perfect response would have been from you all? I would have laughed my ass off if I’d come to my next appointment and you’d approached me carrying an 8-lb. sledge hammer! We wouldn’t have needed to have any further discussion about it, because I would have known that you understood my position.

“That’s what I need to know…but I never get that from you. That you know, appreciate, and respect what I am feeling and thinking. That you can validate me.”

Dr. H said that he can’t agree with everything I might want to do. I said that I’m not asking him to agree with me. Only to meet me where I am, psychologically, as a patient and validate my concerns. And then, after I am comfortable knowing that he has heard me, help me move to a better place with what needs to happen.

[Dare I hope he will help me try to explore an accommodation between my most extreme position (no risk whatsoever = no nodes removed or irradiated) and the standard full axillary dissection (complete risk = remove and irradiate all nodes)? If I can’t even get heard—a most basic need—then how I can hope to have my needs met at this more advanced level?]

He protested, finally, after all these minutes of my telling him what he needs to say, that he knows lymphedema is a serious thing. Then he tried to launch into the “but it’s no big deal because it’s so manageable” line again…the dismissive line that says, “but your concerns really aren’t that important or real.”

He said that he gets hundreds of emails every day and can’t respond in detail to all of the many fine points I bring up in mine. He has to respond with only one or two lines, or he’d be there all day.

I said I understand that. But, I said, he chose the wrong one or two lines to write in his email to me today. What he wrote was dismissive and not helpful. What he could have chosen to say, instead, was, “I can understand your concern. It’s a big thing, to have to take on this risk. Let’s talk about the whole issue when we meet next time.”

A couple of short sentences. They indicate that my concern is validated. They indicate that we can talk more later. If he’d done that, we wouldn’t have been having this whole conversation right then.

He indicated, then, that we have a fundamentally different view of what is happening in cancer treatment, which is certainly a true statement. He said he doesn’t agree with the language I use about chemo being toxic and dangerous. (I note that I didn’t talk much, in this conversation, about this issue. But I did quote Dr. M validating my position about that. As do most people who are not in the business of dispensing chemo.)

I said that I realized that in his patient notes for me, this whole conversation will probably go down—again—as “patient is having continuing trouble adjusting to her diagnosis.” In point of fact, I said, the cancer is one issue that I am dealing with, but the cancer treatment and what it means is another one. That is a distinction, I said, that I understand he is reluctant to make. (But if he *could* make it, it would go a long way toward reassuring me that he really does understand me. I fear that is a hopeless dream.)

In the end, I said, I don’t need him to agree with me. I do need to feel that I have been heard and that he respects my position—without his launching into an immediate response that is either intended to talk me out of it (citing the standard of care or the nameless studies that show….) or else intended to offer me something less than what I have said that I want to achieve (ignore that I want X; offer me Y). And I have not been getting that. I stressed over and over again that I need that from him.

In the end he apologized for not making me feel heard and said he’d try to do better in the future. I said I’d try to do better, too.

I hope things change. If I want to live, I have to feel that I can communicate—not just talk—with my oncologist. I have to feel that he/she hears and understands me and appreciates all of my concerns as highly valid and relevant concerns. That he or she can sit with me there, if need be, as I muster the psychological strength to move to a different place.

And maybe, just once in a while, it will turn out that I won’t have to move to such a very different psychological place because my concerns can be addressed, at least in part, through adopting a slightly different treatment plan. Maybe my oncologist will be able to bend and flex a little, too. Maybe all of the changes won’t always have to come from me. Maybe all of the problems won’t always be chalked up to the patient’s “failure to cope with her diagnosis.”

I have always liked Dr. H, from the first day I met him, but I cannot go through the next years of treatment and monitoring with him if the level of communication that we have remains what it has been for the last eight weeks. It will destroy my soul. I will not thrive, as a patient, under these circumstances. And I want to thrive.

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Out here where I live, there are no county water and sewer lines, so everyone has wells and septic tank systems. As most people know, septic systems have to be managed well. All of the bacteria that help to digest the household waste need to be strong and healthy, otherwise the system dies and it can cost you thousands of dollars to fix the problems that this will cause.

One way to keep the bacteria healthy is to be very careful about what you pour into the system. Dairy is hard for the bacteria to digest, so you don’t pour sour milk down the drain. You also avoid caustic chemicals, if you can, because they too will kill the bacteria.

I think, if I were to ask Dr. H about the care and feeding of my septic system, he would heartily agree that I don’t want to pour poisons down the drain. In this situation, he and I could both agree upon what constitutes a toxin, based on the action it has on the system to which it is introduced.

When it comes to the substances that are being introduced into my body via chemo, he has a fundamentally different orientation than I do. I see the substances as potent toxins—necessary evils in my fight against cancer. The hospital psychiatrist, Dr. M, agreed with me, as do most people who are not in the business of administering chemo.

Chemotherapy is the administration of highly toxic substances into the system of the human body in what everyone hopes will be sub-lethal doses for the system, but doses lethal enough to kill the cancer.

In Dr. H’s way of thinking, these drugs are not poisons and toxins. He told me today that he doesn’t think that’s a useful way of talking about them.

But I found out last week that the toxins that we are introducing into my body every two weeks, which are getting flushed out of my body in my urine and feces, will kill my septic system. To try to prevent this, I need to give my septic system a bacterial boost once a month.

Dr. H may not be willing to admit that chemo agents are toxins when they are introduced into the human body. Will he admit that they are toxins when introduced into a septic system? And if he will admit the one but not the other, why not?

I am not suggesting that the toxin, when introduced into a human body, is not a potentially useful and necessary thing. I am only saying that it is, nevertheless, a toxin. Dr. H does not want to admit this. And to me, this bespeaks a certain lack of humility about what he is doing, as an oncologist. A certain lack of a sense of perspective. A certain myopia.

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To validate something is to confirm that it is sound, well grounded, based on good reasons, weighty, or effective. It is not to confirm that one thinks it is ultimately correct or desirable.

My concerns about lymphedema are valid. My desire to avoid even the RISK of having lymphedema is a valid concern. It needs to be treated as such.

However, Dr. H appears to be unable to validate. There is only one way of viewing a problem—and that is his way, which he legitimates with references to “the standard of care for IBC” or with references to “studies show”—studies whose specific citations he never gives me, when I ask.

I have an advanced degree, too. My degree is in religious studies, and religion is something that is of deep interest and importance to me. I think it is a fundamental human activity or drive—and I think that it is of ultimate significance in its own right, quite aside from how human beings behave or what human beings do.

I also have a friend who is a militant atheist. In fact, I’ve got two of them. Every once in a while they’ll tear off on a rant against religion. They’ll cite any number of evils that have been—and continue to be—perpetrated in the name of religion. They’ll cite any number of absurdities promoted by religions or embraced by people in the name of religion (whether specifically promoted by the system or not).

My response, at these times, is to try to validate what they are saying—or at least a lot of it. Because I do not deny that there is some truth to what they say. I do not hide from the brutal truth that religion is not all lightness and roses. However, I don’t think that what they say is all of the truth. I don’t think that all of their criticisms are the sum total of the true things that can be said about religion.

If I were to respond by ignoring their position statements, their concerns, their critiques, and if I were to respond by saying instead, “Well, studies show religious behavior is of inestimable value in….” there would be no more conversation. Communication would be cut off.

Instead, when I respond by validating where they are coming from, insofar as I can, we then have a basis for continuing to talk. To really communicate. I acknowledge the value of their ideas, their attitudes, and I agree with as many points as I can. On the basis of this, our dialog grows. I am eventually able to express my own ideas, where they may differ from my friends’. We’ve had some really good conversations this way.

Validation doesn’t necessarily mean agreement. It only means acknowledging and respecting where the other person is coming from. Respecting that other position as a valid place to be, as a place that is important and meaningful for the other person. And using that recognition as the premise upon which you are willing to engage with the other person.

I wish that Dr. H could do as much for me when it comes to my perceptions about what cancer treatment is like. That he could do as much for me when it comes to my great, great fears about taking on ANY RISK for lymphedema.

I know that I need to be in a place where I can peacefully accept all of the risks associated with the various phases of my cancer treatment—just as I have come to peacefully accept the risks of taking chemo. I also know that it’s possible there are some slight up-front modifications to the treatment that might decrease the level of risk I will have to take on. (Note that this is different than saying I should just take on the full risk and then manage it after the fact.) I would like to explore whether some of those up-front modifications might be viable in my case.

And when I have done my homework, when I have explored all options, then I will make a decision about what kind of risk I am willing to live with for the rest of my life. I will adjust psychologically to accepting ultimate responsibility for how the next phases of my treatment turn out, based on that level of risk. And we will move on.

It is difficult enough for me to do this, because of the inherent scariness of the situation. The openness of Dr. J helped me to make some forward movement on this whole issue. But the heartbreaking monovision and lack of communication skills evinced by Dr. H only makes it more difficult for me. Fighting his brand of negativity is a battle I do not need.

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Before this situation with Dr. H erupted today, I was wondering how to share with you all the ruminations I have been entertaining about having cancer—about what that means. How knowing that I have cancer and will always have to be vigilant about its return impacts who I am—or who I always thought I was. How I live my life—or how I always thought I should live my life. What I believe—or always thought I believed. How I have always pictured myself dying—and what may well happen instead.

How I believe that for several years I’ve been setting myself up to get this cancer—and I mean that in more than just a physical, bodily sense. How I’ve known for at least a year that something big was going to happen to me—though I didn’t think it would be anything like this.

I’ve been wondering how to confess to you, in this public journal, some of the deeper secrets of my soul. These are the kinds of things that having cancer forces you to confront. And I have begun confronting them. Working with them.

Instead, in my daily life and ergo in this journal, I have been forced to focus my attention yet again on the immediate issues at hand—issues brought about by my cancer treatment.

This is a distinction that Dr. H refuses to make. He thinks that my issues surrounding cancer treatment are simply me having difficulty accepting my diagnosis. I keep trying to explain that the diagnosis is one thing, but the treatment is another. In his mind, they are not. The diagnosis leads inexorably to the treatment to such an extent that they are all one in his mind. He cannot separate the two, and he cannot appreciate how I can distinguish between them.

What we have here is a failure to communicate.