BEHIND CLOSED DOORS
During this particular M.D. Anderson round, the conversation begins, as all of the one-hour sessions do, with a brief recap of a patient case that has touched some chord or sparked a larger discussion within the hospital. Confidentiality is protected, as patient names are never used during rounds.

The doctor leading the session, James Cox, MD, chief of the radiation oncology division, describes the case of a 50-something woman who traveled from another state several years earlier to pursue aggressive treatment for lung cancer. But the combination of chemotherapy and radiation took a toll. Dr. Cox explains that, despite the woman's commitment to continuing treatment, some of the technicians involved worried that her body badly needed a break.

From there, the group of more than 50 hospital clinicians embarks on a wide-ranging conversation. First, they discuss the challenges of treating a fellow clinician; the woman was a nurse. Then they talk about the stress involved when not everyone on the medical team agrees on the best course of treatment. They wonder if a patient might admit concerns to a social worker or a radiology technician - concerns that might never be voiced to a physician.

Dr. Fisch then asks if any clinician has encountered the opposite scenario: a patient refusing a clearly beneficial treatment. That's when Dr. Komanduri weighs in, speaking from the back of the room. He had developed a good rapport with the patient in question, which was in part what made the refusal so puzzling, he tells the group. And the man had a highly treatable form of cancer.

Dr. Komanduri pauses at times as he speaks. "Our relationship really had to evolve," he recalls, "from one where I felt like he was making the wrong decision to one where I had to live with the decision he had made without saying, 'I told you so.'?"

The man relapsed about two years later, and the Hodgkin's disease returned. He didn't survive. Did they ever, asks Dr. Fisch, discuss the radiation decision? "It was the elephant in the room," Dr. Komanduri answers. "I felt like any mention would have been devastating to him."

Plus, he points out, it will never be known if the radiation would have made a lifesaving difference.