Lessons From Black Ice

Early in my career, an injury from a fall on black ice led to years of intermittent, often debilitating pain—and it quietly shaped how I came to see my patients. Living with pain taught me how completely it can disrupt plans, erode a sense of agency, and make it nearly impossible to imagine a future, insights that later deepened my understanding of patients facing cancer-related suffering. I’m sharing this story because it clarified my conviction that while we cannot always control how disease responds to treatment, we can profoundly influence quality of life. As we start a new year, I hope this reflection reinforces the value of earlier, integrated supportive and palliative care—so more patients are able to live as fully as possible alongside their treatment.

It seemed the safest place to walk. The sidewalks of Beacon Hill in Boston were deep in snow that to a transplant from San Francisco seemed impenetrable. So, I headed to the middle of the shiny black street, hurrying because I was late for work. 

The next thing I knew, I had landed hard on my back, legs in the air. I struggled up, embarrassed, with some back pain but more confusion. I learned later that Black Ice was to blame. 

Over the rest of my intern year in medicine at MGH, I made things worse. We lifted every patient every morning to listen to their lungs and heart, and after 5 months of that, my back started to go into spasm. I thought I was just worried about transitioning to the resident role. This was the spring of 1974, and I was among the first four women interns in the MGH medicine class. We were chosen geographically, I think, since one was from Boston, one Texas, one Chicago, and I was often referred to as “the Californian.” I didn’t want to let down the side, to show any weakness. But one afternoon after rounds the medical student I worked with pulled me aside and whispered, “Dr. Abrahm, do you realize you’re listing to the left?” My slipped disc, caused by the fall and lifting all those patients, had caused so much spasm that I couldn’t stand up straight anymore. When the spasm worsened later that day, I was admitted to MGH, because the orthopedist I saw thought it was dangerous for me to be home alone. After the acute crisis passed, I found a friend to stay with me at home and was fortunate that after weeks of bed rest, my back spontaneously healed enough that I could walk and work again, completing my residency and the rest of my training on time. But the back pain persisted.
 
I finished my training and, bad back and all, took a position as an Assistant Professor at the University of Pennsylvania in the Hematology and Oncology Division of the Department of Medicine there. I studied hematopoiesis in the early days when we didn’t know how blast cells matured and “knew” to leave the marrow. And I cared for patients with sickle cell anemia, other hemoglobinopathies, and those with various forms of cancer. I had few pharmacologic tools to ease their suffering, so I learned to use hypnosis for their symptoms. I lost patients who could not tolerate what could have been curative therapies because the standard antiemetics of that time were wholly inadequate. Ondansetron had not yet become available, let alone the NK-1 inhibitors. Patients chose coffee enemas in the Caribbean rather than platinum with just dexamethasone, prochlorperazine and lorazepam to ease the nausea and vomiting. I even had a patient I had just met ask me to kill him because of intolerable pain – he had been receiving only ibuprofen for metastatic prostate cancer pain.

The only answer was to make myself an expert in pain and symptom management for patients with cancer. I took courses on pain management at Harvard, studied the literature on antiemetic therapies, and took a sabbatical in 1992 with the innovative team led by Dr. Kathleen Foley at MSKCC. She not only asked patients what their pain level was, but added “Is that level acceptable to you?” Later, 1997-2000, I was a scholar of the Project on Death in America. It was the 50 or 60 graduates of the Project who created the fields of Palliative care and Supportive Oncology in the United States. It was during the first retreat I attended as a Scholar that I finally realized how my own pain had led me from oncology and hematology to Supportive Oncology. We were asked why we wanted to take care of the dying, to focus on relieving suffering. Most of my colleagues were interested in the end-of-life part of the journey. They
wanted to bring dying back from hospice programs into the mainstream of medicine and nursing, and that is what they did.

I was the only one in my group who was an oncologist, and who wanted to ease the suffering of my patients from diagnosis of cancer on, throughout the course of their cancer, whether or not they were cured. I reflected on why that was, since none of my oncology colleagues had that focus—theirs was on curing the cancer, or at least prolonging their patients’ lives as long as possible.
 
As I reflected, I understood for the first time that it was my own experience of twenty years of pain, of intermittent helplessness, ruin of any plans I had made for that week, that enabled me to see the lives of my patients differently from that of other clinicians. I understood the despair of the patient with sickle cell anemia, whose intermittent crises caused not only severe, disabling pain but opportunities lost; despite their best efforts, they were helpless to craft a future in the face of their disease. And I felt I needed to address the pain of my cancer patients, because from personal experience I knew that unless it was manageable they could never achieve what they hoped to achieve. I felt strongly that while I was not in control of how their cancer responded to treatment, I could help them have the best possible quality of life for whatever time they had.

I created an interdisciplinary cancer clinic in which we addressed the psychological, social, emotional and spiritual needs of our cancer patients. To share with my oncology colleagues what I’d learned, I wrote “A Physician’s Guide to Pain and Symptom Management in Cancer Patients”, the first edition of which was published in 2000. I had the fortune of moving to Dana-Farber Cancer Institute in 2001 to start their Palliative Care program and have learned so much there over the past 25 years. I smile as I look back at the various editions of the book, how proud I was of that first edition, and how little I knew then. We’re working on the 5th edition now, and a website, www.janetabrahm.com, to bring what we know to the broad oncology community, many of whom do not have a palliative care partner.

It all started with black ice. I will be forever grateful.