 I think as medical oncologists, radiation oncologists, surgical oncologists, we have a very tough job to accompany a person into this very scary arena of life-threatening illness. It's a great challenge. We did a study to examine how people die at our teaching hospital. And the Royal Victoria Hospital is a superb, excellent academic institution. When we did the study, which was in 1973, we uncovered significant deficiencies in meeting not only the psychosocial needs, which we'd expected, but also meeting the physical needs. There was poor control of pain and other symptoms. But I have to say we just weren't aware of and unnecessary significant suffering. In looking for solutions, I visited St. Christopher's Hospice. Cecily had opened St. Christopher's six years earlier. And I was very impressed by their radically improved symptom control. By the attention to the whole person, by attention to the needs of the family, enabling them to make something out of this very important time in the family experience. My concern about the hospice model was that roughly 80% of us die in institutions in the western world. To duplicate a system capable of handling the 80% of us who die in institutions isn't cost effective. I felt at that time that someone needed to do a pilot project to see if you could do what Cecily had done in a freestanding hospice in the context of teaching hospital or a general hospital. With a home care program, a consultation service to the acute care wards, a palliative care unit, as we call it, a specialized ward, and also a bereavement follow-up program in addition to teaching and research activities. Beds are always tight and so you have to be able to make, particularly if you're going to be in a tertiary care hospital, you've got to make a pretty sound argument. Well, the arguments, it turns out, are very sound. These become critical teaching patients because some of the most dramatic differences that we can make in the life of a patient, paradoxically, ironically, can be made with these patients who, if you think about it, were the patients for whom it was commonly said, there's nothing more we can do. What a tragic betrayal of ignorance to say there's nothing more we can do. If you're looking at the goals of the person, the sufferer, there is always more to do. And the more to do is to simply accompany at the very least and then to attend to the whole person needs of that patient and family. We became interested in the determinants of suffering right from the first. I guess my assumption had been similar to that of my colleagues that as the end of life approached, suffering would increase. In fact, it became evident early on that some of the people who were nearest the end of life were paradoxically having their best time in life. And how could that happen? So we became interested in the determinants of quality of life. We developed the McGill quality of life instrument, which was the first to show that the existential or spiritual or inner life domain was and is a significant determinant in people throughout illness. And in oncology patients throughout the disease trajectory from diagnosis to cure or death, it's a major determinant. Suffering can arise in any domain of the person, certainly in the physical domain if there's nausea and vomiting and neuropathic pain. It's not very easy to experience wellness, but with that under control, which it should be in the vast majority of situations possible to do, then it becomes clear that the psychosocial, existential, spiritual aspects of the person's experience of their illness directly modify their suffering. And so attention to those aspects actually can lower the doses of opioids necessary for pain control, for instance. Practical stuff. We're not talking about airy-fairy, how many touchy-feely soft stuff here. We're talking about what influences the experience of every patient that I see. When I was exclusively doing surgical oncology, every patient that I saw. So as an oncologist, I can't heal another. The most and the least we can do as caregivers is hold the space where healing can happen. The person, the sufferer has to discover that within themselves. But we can be catalysts through good symptom control and through presence. Learning to relate to other people in a way that is present to them can certainly be taught. If we think about it, we teach the opposite all the time. We teach every time we go on rounds and there are 20 of us and we stand at the foot of the bed and discuss the person as if there are cabbage lying there and with no eye contact, no mention of name, no, no, this is just an interesting case of whatever. We teach the opposite and we produce yet another generation of poor communicators. Our first response when somebody comes out with the sort of milk and motherhood statement you've got to attend to the whole person, my response is terrific and where am I going to get the time to do that? I've got another 40 patients get real, I've got another 40 patients waiting. It doesn't take more time. It means having eye contact at the same level so that I'm not always looking down at the person. It's sitting down. Like anything else, we have to meet the person where they are, not where we think they should be. I think we often fail to realize the damage that we can do. We either are acting as a facilitator of healing or we're acting as a catalyst for wounding. Movement towards what's essentially called total pain, movement toward anguish. We're either doing one or the other and the more aware we are of that we may be more able to help to create and hold that space where healing can occur. It's the difference between disease and illness. As oncologists we tend to focus on disease processes and on disease on investigating, diagnosing, prolonging life and curing. For the person who comes into our clinic, the focus is non-disease. The focus is on my experience of illness and of course I'm concerned about my disease but my subjective experience is and the meaning this disease has for me colors everything. I will always celebrate the biomedical model of disease as foundational to our understanding but it's only the foundation. If the house only has the foundation it's missing quite a bit. I love being a surgeon. It's very rewarding or disappointing but it's certainly concrete. Many of the interventions that have the greatest potential to support or influence the experience of illness for the patient are a lot less concrete. They may be more subtle and more simple. The most potent tool that the oncologist brings is themselves because if they're present to the person and the person is aware of that I thou bond as Martin Buber said this is an enabling presence that makes things possible. Makes it feel safe. We don't heal out of power. We heal out of recognition that we're in the same boat as that person we're with. Four years ago I was found to have a scrimacell carcinoma the esophagus that was full thickness infiltration and so had an esophagectomy and they got into bleeding and it had a splenectomy and developed a pseudosys to the pancreas as they transacted the tail of the pancreas with the bleeding and one thing and another. I was in the surgical intensive care unit. The entourage came in and stood at the foot of the bed and one young resident came up about to the level of my knee and there was no eye contact. He looked at the urine hanging from the catheter bag at the side of the bed and looked at the vital signs on the flow sheet. Not one word was addressed to me. There was absolutely no eye contact. There were no more than six feet from my face to where they were and yet for them it was as if there was a plexiglass wall between us and as if I couldn't hear, why would I not be able to hear? And they left to go on to the next bed. The one of the residents said to the person next to them, oh it's too bad you know, well he could have two or three good months left and then they went on. So I think it's made me a little more aware of that kind of thing. Whatever our models of care and their fallible human and full of holes, the thing that the ingredient that's common to them all that is the hopeful ingredient is made up of good people that can change how that model of care feels and how it operates and can correct deficiencies that they see. You could say this won't do. That suffering is unnecessary. Is the bottom line here how many dollars healthcare can make for us or is the bottom line human suffering? Is the bottom line the quality of life of that individual? These are important questions we should be asking ourselves.