Tommy (name changed) was seventeen years old when I met him. He had more difficulties and trauma in his first seventeen years of life than most people have in their entire lifetime. He was a survivor by necessity because of adverse childhood experiences. Tommy wasn’t easy to get to know because of his tough exterior. I attributed his demeanor as a mechanism to protect himself from any more disappointment and pain.
By the time I met Tommy, he had already seen many doctors for vague symptoms over a period of years. Eventually, he had a surgery referral after a mass was found in his chest. The biopsy revealed an unusually slow-growing cancer called a germ cell tumor.
Tommy was alone when I spoke to him the first time. His mother wanted to be there but had to work to pay the bills. Tommy barely responded to my questions. He would not look me in the eyes. Because of the unusual age and presentation of this type of tumor, I asked him about certain symptoms or changes in his body. He proclaimed with exacerbation with every question, “No, I don’t have that symptom. I am fine!” His biopsy did not make sense with the story he was giving me, so eventually, I said that I needed to do a complete exam to sort things out. He was reluctant but finally did cooperate. I discovered that he had a very large, softball-sized testicular mass during the physical exam. Now, this made more sense to me. His chest mass was metastatic from a very slow-growing testicular mass that he probably had for quite a long time, given his symptoms.
I asked him how long he had noticed a change in his body, and he just shrugged and looked disinterested. He had been asked directly about such changes in his body several times, and he had denied any issues repeatedly. He refused to discuss it from that time forward. He refused to allow anyone to examine him again, except for a quick listen to his heart and lungs. He was stubborn about this and remained so going forward.
Unfortunately, the late diagnosis of this particular type of tumor made it incurable. If the tumor had been diagnosed months or years before this, it could have easily been treated with surgery alone because this is the primary treatment modality. By the time slow-growing tumors widely metastasize, they are incurable because the growth is too slow to be affected by chemotherapy or radiation. Chemotherapy and radiation work by disrupting the DNA in tissues that are dividing more rapidly, but they do very little in these slow-growing tumors.
I have many fond memories of Tommy. He spent a lot of time in the hospital and was usually alone, so I had the privilege to get to know him very well. We developed a close bond. His tough exterior was only part of the story. We had long talks about things that he enjoyed, like fixing old beater cars, sports, and food. We discussed spiritual things and what we thought the afterlife was like. He died with the same no-fuss attitude. He was very courageous even when dying at such a young age.
It is easy to get frustrated with the stubborn people in our life. After all, they are often their own worst enemy because they refuse to ask for help. Stubborn independence can literally cost a person their life. However, I was not upset or frustrated with Tommy because I knew he was a survivor. Tommy did whatever it took to prevent himself from ever feeling vulnerable again. Tommy survived difficult situations as a young child rather than giving up. He figured out how to cope, relying only on himself when no one was there to help him.
I enjoyed my time with Tommy and navigating the patient-doctor relationship by remembering that his most significant need was to feel in control, and his biggest fear was feeling vulnerable. We got along well when I focused on his needs, not what I thought he needed. After all, I could not have convinced him to change anyway. I allowed him to be independent and maintain his dignity above all else. Rather than be in constant conflict with Tommy, I spent the time getting to know him. I will always remember and admire his strength and courage.