• palliative care
• oncology
• geriatric medicine

Sir William Osler, the Father of Modern Medicine, is often said to have remarked, “The good physician treats the disease; the great physician treats the patient who has the disease”. That was one of the main messages that I took from my Internal Medicine internship.

The Internal Medicine internship is one of the most important of the Medical Oncology Residency and its length reflects just that. I participated in this internship from January 2017 to June 2018 at the University Hospital Center of the Algarve. As an oncology intern, I had a special interest in hospitalised patients to study metastases from a still unknown primary or occult neoplasia. There were also hospitalised patients for other reasons that, during the hospitalisation, received an oncological diagnosis. For whatever reason, the entire diagnostic march in search of the histology of the primary neoplasia aroused much curiosity.

Analysing the patients observed by the team which I joined, we verified that from the 176 hospitalised patients in the time period previously described, 11 received an oncological disease diagnosis during the hospitalisation with a mean age of 73 years (44–87) (3 women and 8 men). Regarding the reason for hospitalisation, nine were hospitalised for neoplastic disease study and the remaining three were hospitalised due to community-acquired pneumonia. Of the 11 patients, 2 were diagnosed with haematological neoplasia. All nine patients diagnosed with solid neoplasia had metastatic disease. Regarding the destination, three patients died during hospitalisation (two without histological confirmation given rapid deterioration) and five were referred for palliative care and passed away within 3 months after discharge. Only three patients started disease-directed therapy and are currently being followed up in medical oncology department (a case of melanoma, a neuroendocrine and a lung adenocarcinoma). All of the diagnosed cancers were in advanced phases of the disease and none of them were included in the screenings advocated by the General Directorate for Health.

Given the high mortality during hospitalisation and immediate post-discharge and the reduced number of patients who have initiated the disease-directed therapy, it is important to avoid behaviours leading to diagnostic or therapeutic obstinacy in these cases. Before starting the study, it is imperative to ask the following questions: Why am I going to study this patient? Why am I going to put the patient through an extensive diagnostic course of examinations, which are not risk-free and can cause discomfort? Whatever the situation, the answer must always be the same: I must initiate the study if it entails taking a later attitude with benefit to the patient. It is important for the professional to know how to manage his/her own ‘anxieties’ and have the awareness that he/she will not always have an answer to all questions, which does not imply that the patient’s comfort is compromised.

It is also worth remembering the importance of a comprehensive geriatric evaluation that, in many cases, may assist us in deciding whether to proceed with the diagnosis.1

At the end of the training period, perhaps the most important message that I’ve taken is to avoid futility, that is to say when we are not able to achieve the desired end, to benefit the patient. Internal Medicine will always play a fundamental role in this matter; it is in this specialty that the foundations of an oncologist are built, one who does not only see lung, prostate or breast cancer but who is able to make decisions based on the patient before him/her, considering the patient’s antecedents, wills, familiar and social background, and that, based on all these factors, takes the action which most benefits the patient (or at least the one he/she believes will).

Quoting Osler, “Medicine is a science of uncertainty and an art of probability”.2 However, with respect to comfort, dignity and wills expressed by the patient, there should be no uncertainty that they will be preserved.