fonte: jco.org

Riches of Poverty

Jose´ Henrique M. Scheliga
From the Hospital Geral de Jacarep-
agua´ , Rio de Janeiro, Brazil.
Submitted January 27, 2010; accepted
March 18, 2010; published online
ahead of print at www.jco.org on May
3, 2010.
Author’s disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: Jose´ Henrique
M. Scheliga, MD, Hospital Geral de
Jacarepagua´ , Av. Menezes Côrtes
3245, Rio de Janeiro, Brazil, 22754-130;
email: scheliga@iis.com.br.
© 2010 by American Society of Clinical
Oncology
 

For the past 20 years—since I began my profes-
sional practice as a clinical oncologist—a ritual is
repeated practically every year in May. I close my
work schedule for aweek, leave everything set formy
absence fromhome, and depart for theUnited States
to attend the AnnualMeeting of the American Soci-
ety of Clinical Oncology (ASCO).
At this meeting, physicians and scientists of
international renown from centers of excellence
dedicated to the investigation, teaching, and treat-
ment of cancer meet to present the results of their
current research and to discuss the future of oncol-
ogy. Hailing primarily from the developed nations
of theNorthernHemisphere, their names are famil-
iar tome frombooks and articles that I have andwill
read throughout the year.
At this meeting, with pride and confidence,
inductive reasoning leads to scientific knowledge
and the best evidence-based medicine.
At this meeting, with the pragmatism and ob-
jectivity characteristic of Anglo-Saxons, I learn the
updated pathways, pathophysiology, and prognoses
of themany different types of cancer and guidelines
that will dictate the best oncologic treatments. Each
year, the return home leads to attempts on my part
to incorporate, in the best possible way, this newly
acquired knowledge into the reality ofmy daily prac-
tice providing personalized and individualized care.
My challenge is enormous. My country, a devel-
oping nation, possesses more needs than resources,
making treatment of the disease just one among
many problems to be solved. The hospital where I
work is entirely supportedwith public funds and is
dedicated to the general care of the population,
oncology being only one of many other medical
specialties available. The number of practicing on-
cologists pales relative to the demand, creating in-
creasingly grave work overloads.
My patients are largely from less privileged
classes, revealing great economic, educational, cul-
tural, and social disparities between us. As a result,
discussions about treatment and therapeutic op-
tions are difficult. The doctor-patient relationship is
based not on the sharing of informed decisions, but
on simple faith and trust, on their part, in my pre-
sumed professional ability and willingness to help
them in the best possible manner.
In addition, becausemy patients, their relatives,
and I share the emotionalism and sentimentalism
common to Latin cultures, conversations about
prognoses and life expectancy are not particu-
larly welcomed.
When using my clinical reasoning to determine
the best treatment for each individual patient, I can-
not ignore the panoply of other nonmedical factors
in the decision-making process. How far from the
hospital does the patient live?Which mode of trans-
portation will he use to come to the hospital? How
long will it take for him to get there? What are the
sanitary conditions in his home? How good is the
patient’s diet? Can the patient understand and ade-
quately follow a prescription with multiple steps?All
these questions need to be evaluated and considered
when trying to determine each patient’s ability to
deal with and handle the potential adverse effects
and risks associated with his treatment.
Finally, and not infrequently, while trying to
explain to a patient what his treatment will entail, I
am constantly fielding requests to assist in the reso-
lution of issues more relevant to their day-to-day
needs, such as preparing written statements to
obtain paid familymedical leave, filling out forms
for free public transportation vouchers to enable
themto come to the hospital during treatment, and
directing them to organizations that donate wigs,
breast prostheses, colostomy bags, and other medi-
cal necessities.
Throughout all of these years, the process of
attending ASCO’s annualmeeting and then return-
ing post-ASCO meeting to the realities of my daily
practice, with all its contrasts and challenges, has
been fairly constant with few changes.
What has changed during this period is me—
and the way I deal with and respond to this process.
The first years were a time of awe filled with the
wonders, the promises, and the infinite potential of
science. One day all this will be mine. One day I too
will be able to do this in my country, in my hospital,
with my patients, each and every day.
Unfortunately, reality interfered with these dre-
ams and what followed were years of envy, frustra-
tion, and disappointment. After all, these dreams
would never be mine; they would not be my reality,
my daily experience.
So what then is the point? What’s the meaning, the purpose
behind all this?How can I respond to the needs ofmy work and tomy
life expectations?
The answer lies where it has always been, though hidden and
forgotten amid the hustle of everyday life,within truths that are simple
if not immediately evident. It can be found in T.S. Eliot’s (1888-1965)
query, “Where is the wisdomwe have lost in knowledge?Where is the
knowledge we have lost in information?” It can be found in Carl Jung
(1875-1961),who tells us that tomature is to learn to deflate one’s own
expectations, to play down one’s ego, to serenely accept one’s limits. It
can be found in Thomas Gray (1716-1771), who reminds us, “Full
many a flower is born to blush unseen, and waste its sweetness on the
desert air.” And it can be found in Sir Thomas Hutchison (1871-
1960), who advises, “From inability to let well alone; from too much
zeal for the newand contempt forwhat is old; from putting knowledge
before wisdom, science before art, and cleverness before common
sense, from treating patients as cases, and from making the cure of the
disease more grievous than the endurance of the same, Good Lord,
deliver us.”
Finally, the answer lies in the pure satisfaction of a job well done
and in the simple pleasures of being thanked at the end of the yearwith
chocolates, a cakemade fromscratch, a pair of socks, a disposable pen,
or a request for a photo together.
Throughout all of these years, a lot has changed within me, and
for a variety of reasons. One of these reasons ismy annual attendance
at ASCO, for it has certainly helped me become a better physician.
However, and more importantly, I believe the process of attending
and returning home, year after year, has helped me become a bet-
ter person.