SGO Wellness: On Fighting, Failing, and Finishing | Andrea R. Hagemann, MD, MSCI

My patient, Ms. L, is gaunt and distended, naked except for padded hospital socks, looking at her colostomy bag in dismay. It hasn’t put out much at all lately. I’ve caught her at the bathroom mirror as I’m rushing through morning rounds. “How are you feeling today?” I ask. “I guess ok. I am still here: not sure how I feel about that.” Her tone implies defeat and annoyance; her face expresses her pain better than the seven she chose on today’s emoji scale. The here she’s referring to is far beyond her hospital room. She gives me a cynical eyebrow raise: “How was your marathon?”

The day before, I had toed the start line of the Boston Marathon with relaxed confidence and nervous, energetic hope. Having followed my training plan to exact detail, I had expected a strong race. I’d wanted it to signify all I’d been putting into my running, career, marriage and motherhood, but I crashed and burned at mile 22. For a blurry hour, I was the one being examined, on a cot in the medical tent, waking up to a medic with a rectal thermometer prodding me while I lay incontinent of urine and feces. Today, I’m back on hospital rounds, trying to move past that scary, vulnerable place. I don’t really want to talk about it; failure still too fresh, too raw.

But her sardonic wit makes me laugh. “Well… yes, I finished. My body kind of gave up on me, though. It wasn’t pretty.” “Hmmph,” she says. “I sure know how that feels,” looking down at her abdomen in disgust and shaking her head. “Bodies don’t last forever, do they? Sure never thought this is how mine would turn out.” I tell her we need to get her bowels moving, and suggest a scan. She’s on fifth-line chemotherapy for platinum-resistant ovarian cancer, and it’s unclear whether her bone marrow and GI system will be able to take much more. “OK,” she agrees with a knowing look. “But I’m still up for the fight. Don’t give up on me. You know I won’t let the cancer win.” She smiles, softer now. “Good job finishing. I’d like to hear the story when you have some time.”

Walking to clinic, the voices start again. Ha;—good job?! You totally lost it, you completely failed. Control and discipline are essential to marathon success, and I fought but failed, pushing past that fine line of trying too hard. You will fail Ms. L, too.

So many of my patients are self-described fighters, and I’m awed by their strength. But this fighting metaphor doesn’t sit well today, and her comment echoes my own thoughts. Please don’t let me fail. Is it really a question of fighting or failing when I see how weak her body’s become? What does winning look like?

For over ten years, running has helped me make sense of my work as a gynecologic oncologist and my roles as a mother, wife, friend and teacher. I approach running like I approach my career – with goals. In medical school, running was the perfect metaphor, a source of positive mindset tricks, a fount of endorphins that gave me confidence and diligence as a resident and fellow. Now, almost ten years into a faculty position at a large academic center, I’m lucky to have local running friends who push me daily and an online running group of doctor moms. I’ve been poring over books about running, learning mantras from elite athletes, teaching trainees that their years are like a marathon training plan – show up, lean in, and you’ll make the finish. Lately, I’ve pushed myself further, pairing more ambitious running goals with loftier career goals. If I could run a personal record at the Boston Marathon, I’d clinch it all into a neat little package.

Like many of my patients before their cancer diagnosis, I felt carefree before my fall. That morning, through 16 miles, I was running my best race yet, my third Boston, my seventh marathon. All New England was out along the course, and the energy was inspiring. Glancing at my watch, I was just a bit under pace – slow it down, keep it steady, said the warning voice in my head – but I was running strong and the weather was better than expected. I could do this all day. Let’s see what happens if you keep pushing.

I was checking off milestones of the race like the milestones in a career. The church in Natick passed like oral boards. Halfway done at Wellesley like becoming an associate professor. I felt good. Trust your body, trust the training, just run a little faster. After a net downhill start, the Newton hills starting at mile 16 are what make the Boston Marathon so challenging. This is the point where even elite athletes falter, but somehow I felt immune that day as I started them. “Take that, cancer!” I was thinking, calling different patients to mind. Their battle was harder than me getting up these hills.

I heard myself breathing more heavily than those around me. I felt the heat and humidity rising and was surprised to see my pace wasn’t slowing even though my mind said to slow down. Just keep going, suddenly confused as I was starting to weave. I heard myself apologizing to the runners I bumped into, but I’d lost distance from that voice and couldn’t really care. My neck started bobbing despite struggling to keep it upright. Gatorade. Water. Anything. I saw the corner of Beacon street – it’s downhill from here – just keep…

I didn’t fall; someone must have caught me.

I’ve never felt such intense relief as I did when I hit the cot of the medical tent at mile 22. It’s over, it’s done, you don’t have to push anymore. “What’s your name?” “Stay with me, Andrea. I’ve got you.” My legs were cramping, and I let out a half moan/scream when the medics stretched my calves. I tried to look at my watch: blurry nonsense; maybe from the shock and relief of all the ice volunteers were pouring over me. Relief turned to the sharp realization that my race was over. What?! I’ve always been able to make it. The anger, the frustration, the disappointment I felt toward my body was so strong, with more physical pain than I’d known to be possible, that I sobbed and screamed all at once. So many expectations – the PR, the next job, the next paper, the next grant – were supposed to all come together in this perfect, hard, gritty race. I’d be a better mom, wife, doctor if I could have just pushed a little harder… Now: the storybook ending gone, done, over. I rolled over and let my eyes close, with profound relief that I might never have to get up again. Scared that I might not get to see my family, but weak and angry enough that it didn’t matter.

I was jarred awake by intense rectal pain, and horrified to realize three medics were looking up my shorts and wiping away urine and stool. “103, her temp is 103. We may need an ambulance here.” “I’m so sorry,” I said, apologizing for the mess my body made.

“I’m so sorry you’re going through this,” a medic said, with true compassion in her eyes. All I could do was look back at her and squeeze her hand and let them take care of me. And I sobbed, recognizing myself in those faces, recognizing my own words in her voice. How many times have I been that voice for so many women? Had I thought I’d never be on the other side? I looked up at the bright, blue, hot sky with its message to me loud and clear, and accepted helplessness, not really surprised at what had happened after all.

“I’m sorry to meet you like this,” I’ve said a lot. “I’m sorry to tell you the cancer is back.” “I’m sorry to tell you, I don’t think more treatment will help.” I’ve tried not to take lightly the privilege an oncologist has of talking with people about life goals in the face of death. I’ve become hyperaware of the significance of the moment people learn they have cancer. As oncologists, we watch our patients’ faces after those words leave our mouths and enter their minds, knowing it’s hard to process much else. The moment they realize their body has a cancer in it, an ugly and invasive other that’s maneuvering, outsmarting, lurking, trying to take over a body that was doing and feeling and living perfectly fine. They’ve lost control, just like I did in Boston. The moment their life’s course takes an unexpected turn, changes pace, or worse, when mortality ceases to be an abstraction. They end up in my office, operating room or chemo chair when they’d rather be anywhere else, just as I felt on that cot. But there they are. I take their hands and say, “stay with me. I’m going to do my best to help. Here’s what we’re going to do next.”

“Next step, salty soup,” the medic said. As I drank, I wondered, what is this cancer inside of me that pushes me to need to be faster, stronger, better? Why, when I’ve achieved so much, do I feel like I’m failing? Why did these questions have to get so entangled in my hobby that the woman who’s always been in perfect control just flat-out failed? Having been told I could excel, I love to be in control. And so I achieve one goal and immediately find a new, harder one. In academic medicine, there is always the next paper to write, the next grant to apply for, promotions and positions to tackle… better, faster, stronger, more.

I’ve seen my patients at their most vulnerable, scariest times and watched them confront their own mortality. I’ve ridden the highs and supported through the lows. As a surgeon, I’ve grabbed the highs whenever I can, spending hours debulking ovarian cancer, rejoicing because skill and perseverance win over cancer, and my patient will live longer for it. I’ve also had this feeling at the end of an interval workout having nailed my paces. It’s how I’d expected to feel at the end of the Boston Marathon.

I’ve hesitated to share my own lows, thinking I’m the only one struggling, everyone around me winning, while I’m failing. As mortality met me that day in the tent, just as it creeps into my patients’ lives at inconvenient, less than picture-perfect times, there was no denying the depth of this low point. It was embarrassing, messy, and disorganized. A painful, rectally felt recognition that at 40, even in the best shape of my life, my well-trained body will fail just like anyone’s. I’d tried denial coming off the Newton hills, and now I was regaining my energy, feeling a strange mix of gratitude and anger.

While I’ve tried to meet people where they are in accepting their diagnosis, I’ve also struggled to empathize with people at the end of life who insist that death isn’t inevitable. I’ve struggled with colleagues who insist that if we persist, innovate, study, we will prevent death. I’ve struggled watching my running partners push too hard and crash. Who am I to judge? It just happened to me, too.

In Boston, it seemed a lifetime had passed, but I looked out and saw runners still on the course. “I think I want to go now.” Before the medics let me leave, a therapist appeared (this is the Boston Marathon – organizers know what head cases we all are.) She wanted to make sure that, if I left, it would be from a place of strength, and not of despair. I shared my reflections and realized she was right. I’m still here, and I have a choice: strength or despair. I told her, my kids should see that when you’re down you get back up again, as gracefully as possible. When I know my patients aren’t going to achieve their original goal of a cure, I ensure that they will still finish with dignity, and I’d like the chance to do the same. I tell her I wouldn’t push it anymore, at least that day. She said she could see that I’d probably be ok and let me leave.

Embarrassed to see I was soiled with feces, I recalled how often my patients apologize for undignified things their bodies do. “Don’t apologize,” we say, and mean it. Did I somehow think I’m immune? Had I taken my health, or more importantly, others’ vulnerability, for granted? The medics covered me with a jacket and several Mylar blankets (my temperature was down now, and I started feeling cold), and I gave them all a hug. Did they know how amazing they were? Is that the gratitude I brush off when my patients thank me?

I felt broken but very much alive as I started back up again. Less than four miles to go; you can do anything for four miles. I walked, jogged a bit, tried to keep all my Mylar on, smiled, and high-fived as many people as I could. The crowds were still out, still cheering. “Two miles and you will have FINISHED the Boston Marathon!” someone shouted encouragingly to me. Right on Hereford, left on Boylston, and the crowds, for my official time of 5:20:17 (note to runners – my PR that day was a 3:35 and had trained to beat that), were incredible. I put my arms up high as I crossed the finish line, found my family, and hugged them so tight, grateful to be alive. Scary, humbling; a different definition of winning.

That was yesterday. Now clinic is over, and I’m back with Ms. L to review her scan, which shows worsening cancer and a foreboding partial large bowel obstruction. She asks again about my body failing, so I share. “I think,” I say carefully to her, “that you’ve already won. Each day you’ve woken up, or stood up after a sleepless night, pushed through another surgery or another chemo round, you have chosen strength despite knowing your body has this cancer in it. That has been you at your best, beating cancer all along.” I lift her gown to reveal her ostomy bag and several faded vertical midline incision scars. “These scars are proof that you’ve already survived so much more than we both ever thought possible. Maybe now your body is telling you to give yourself grace.” She nods and takes a deeper breath than she had before. “I’ll talk to my family. I think they want me to keep pushing, but I’m ready to be done.” She winks at me. “Strength, not despair.” We make a plan so she can go home and have those important discussions. “Hey doc,” she says with a laugh, her good old satirical self back, “way to get up again, even if you were full of shit. And, maybe I shouldn’t spend my last four miles in the hospital. Can you help me get home?” We shared a hug. I called the hospice consult, walked back to my office, and laced up my shoes for some recovery miles.

With time, I have come to realize my body didn’t abandon or betray me. It sent me a powerful message about being human, about slowing down and enjoying the race, especially through the tough hills of life and work. Shortly after my marathon crash, I learned I didn’t get the big grant, and I realized my heart wasn’t in the push for a bigger, different job; just a few more embarrassing, imperfect experiences with nothing to add to my resume. But to call those failures is missing the point. Writing the grant focused my research goals, and interviewing helped me define what I want from the next stage of my career. Our definitions of fighting, failing, and finishing strong have to change as life circumstances change. We walk a fine line between the possible and impossible, between life and death, every day, and the fact that we push a little harder and show up with compassion probably helps more than we know, regardless of the outcome. Strength, not despair.

Andrea R. Hagemann, MD, MSCI, is a gynecologic oncologist at Washington University School of Medicine in Saint Louis, MO.