Guilt and Gratitude – The Story of Avi and His Oncologist

This article tells the story of hematologist Dr. Ilana Hellmann and her patient Avi.

It was the end of a long, exhausting day in the clinic. Someone knocked, and my assistant entered to say that Avi had called asking for an appointment. Her expression made me feel this was not a good sign, and I asked her to arrange a visit within a few days. When I first met Avi five years earlier, he was a tense, tall, thin, 29-year-old computer programmer. He had just married Talia, an artist who was short, cheerful, and able to stay positive in any circumstances. They had no children. Shortly after presenting with persistent coughing and hot flashes, Avi was diagnosed with stage four (IVB) Hodgkin lymphoma . Treatment had to begin urgently. We devised a regimen of effective drugs with difficult side effects: bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone. Alongside hair loss, nausea, lung and heart side effects, bone marrow suppression, and long-term second cancers , this combination regimen could cause male infertility. After learning this, Avi and Talia decided he should have sperm collected, but the results showed no sperm of sufficient quality for future use.

Avi's treatment was a long, difficult journey. Although his side effects were moderate and not life-threatening, he left his job and was devastated. He said he felt as exhausted as if he had run a marathon, and this caused tension with Talia. She grew tired of trying to improve Alvi's constantly gloomy mood, while Avi could no longer bear her persistent positivity. Recalling a conversation near the end of treatment, Talia said, "As I celebrated the fact that we were nearing the end, he told me how much older he felt since treatment began. I had reached a point where I no longer knew what to say".

With chemotherapy finished and Avi now in follow-up, Talia and I hoped he would feel much better. Months passed, he regained his physical strength, and he returned to work. Years later, our fear was confirmed by tests: Avi was infertile. They were devastated when I shared the results. Talia said she wanted to experience motherhood and proposed using a donor. Avi felt he could not be a father to a child who was not biologically his and suggested adoption instead. Neither felt ready to compromise, and despite all the professional psychological support they received, they felt their relationship had reached the end of the road. Eventually, Avi began missing follow-up appointments or coming alone.

When I saw Avi in the waiting room, more than two years had passed since our last visit. He had come with his mother, which seemed to support my suspicion that he and Talia had divorced. I could not help thinking that he wanted to see me because his disease had relapsed, and wondering how he would cope without Talia.

As I was lost in thought, Avi entered looking very well, with an enormous smile. After a brief physical examination and comparison of test results, everything seemed fine. Looking relieved, he asked about my everyday life, and our conversation deepened. Finally, unable to hold back any longer, I took a deep breath and asked how Talia was. Smiling, he took out his phone, showed me the baby on the screen, and said, "She's 3 months old. Her name is Lia. I thought you had a right to know." Feeling tears roll down my cheeks brought me back to myself, and I listened intently as he told Lia's story. After long conversations, he and Talia had decided to follow her wishes. Avi said his thoughts had changed completely after Lia's birth, and he felt she was his own child. As I listened, I felt several emotions at once but could not identify the strongest.

Only after Avi left and I was alone did I realize that the powerful emotion was guilt over what he and Talia had experienced, a feeling I had suppressed for a long time. Guilt was not unfamiliar: I could feel it at the end of a day because a patient had died or because I had made a mistake. But Avi had recovered, and I had made no mistake. This guilt came from something entirely different. Setting aside our ability as physicians to cure patients, it was frightening to recognize that they might continue living with life-changing or lifelong side effects.

Although I now think my reactions during our visit were excessive, I believe Avi understood how much his good news meant to me. Whether or not he realized it, he had healed me during that visit.

After this experience, I began to believe that my patients should contact me when they felt good as well as bad, and that I too needed this emotional nourishment. Patients with whom I shared this thought, who believed sharing their experiences, good or bad, might help them too, continue to inspire me on difficult days. Thank you to all my patients who, like Avi, have inspired me and will continue to do so.