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The Eye of the Beholder

One winter morning in 2020, I was called to the reception desk to meet my patient Esther and her husband Hertzel. Some time earlier, I’d asked Esther–somewhat awkwardly–if she’d be willing to talk to me about her experience of being diagnosed with and treated for advanced breast cancer, and she’d willingly agreed. Today was the day.

Eighteen months earlier, Esther, in her sixties, had come to my hospital’s ER at her rabbi’s urging. The examination revealed a large tumor that had broken through the skin of her upper right breast.

The growth, which smelled bad and was bleeding in spots, was fixed to the chest wall, and inoperable. The ER scheduled Esther for a diagnostic needle biopsy the next day, after which she was to see me.

The biopsy confirmed breast cancer. Fortunately, Esther’s imaging showed no metastasis beyond the axillary lymph nodes, which meant that her cancer could be treated with intent to cure.

Despite my years of practice as a breast surgeon, I couldn’t help feeling shocked by the sight of this cancer. My first reaction was: What was she thinking, coming in so late? But this was not the moment to ask.

Esther’s treatment started with twenty-four weeks of chemotherapy, which was effective: Only a thick scar remained where the visible cancer had been. I then performed a modified radical mastectomy, after which Esther had six weeks of radiation therapy before starting a ten-year course of hormonal therapy.

I’ve seen Esther multiple times since the surgery, and thankfully there’s been no evidence of recurrence.

A few months after the surgery, I finally felt it was appropriate to ask Esther if she’d be willing to talk about her experience. I was hoping to establish a timeline for her cancer—it must have developed over a very long time—and get a better understanding of her thinking as the tumor had grown.

My first question was: “How long do you think the growth had been there?”

Rather than answering directly, Esther began by telling me about her background.

She and Hertzel belong to the Hungarian Hassidic community in Brooklyn. Esther’s father survived Auschwitz, but his first wife and their four children died there. After the war, he encountered his eighteen-year-old niece, also a survivor, in a displaced-persons facility. They married and had ten children, of whom Esther, born in America, was among the youngest.

Esther recalled how her parents had mourned the childhood death of a sister. Her father died of a heart attack; her mother, of colon cancer. Each time, doctors were called in only at the end.

Esther also shared a favorite story about her husband—one she’d told me when we first met. As a nine-year-old at summer camp, Hertzel had gotten lost in the woods while picking blueberries. Four days later he was found sitting by a tree, hungry, scared and dehydrated, by a rescue-team member who’d persevered after the search was officially over.

“It was miraculous,” Esther said. She and Hertzel smiled broadly.

When Esther described the tumor, her chronology was vague—defined more by religious holidays and family events than by months or years.

She’d never had regular screenings: “I had a mammogram once, but it hurt, and I didn’t go again.” She described a friend who’d died of breast cancer despite having yearly mammograms. ”So what’s the point?”

One March–it wasn’t clear which year—Esther felt a lump in her right breast. Hertzel thought it was nothing: “Maybe she’d bumped into something at the grocery store.” Over an indefinite period, the lump grew.

Esther did link the lesion’s growth to some specific events. The mass broke through the breast skin right after she and her family had finished sitting shiva for her sister, who’d died of breast cancer. Some time later, when her great-niece got married, the growth was visible beneath Esther’s dress despite her attempts at concealment. At the wedding, her daughter told Esther that she looked beautiful, but afterwards she admitted, “Mommy, you looked bad. We were able to see it.”

It was then that Esther began seeking medical help.

At first, assuming that she had an infection, she tried antibiotic ointment.

She then consulted a distant relative, a community nurse, who advised compresses of potato and honey, and, when these failed, vinegar. A local doctor tried to drain pus from the growth, then prescribed antibiotics. Finally, just before the high holidays, Esther spoke with the rabbi, who sent her to the ER.

Only upon hearing that she needed a biopsy did she realize that she had breast cancer. As she said this, I found myself simultaneously believing her and wondering how she couldn’t have suspected the truth.

During her treatment, Esther struggled with the community’s intrusive gossip—”Blah, blah, blah,” as she called it. When her chemotherapy caused painful mouth ulcers, and other women asked about the “pimples,” Esther would reply, “I wish that was all it was.” During radiation, she made up excuses for curious neighbors who saw her leave the house early every morning, always at the same time.

The worst pressure, however, centered on whether to have a mastectomy. Although I’d advised that this was medically necessary, she still hesitated. A powerful stigma hangs over such procedures: Esther’s recently deceased sister, swayed by her children, had refused a mastectomy because of the embarrassment it would cause the family.

On the other hand, Esther’s sister-in-law, a cancer survivor herself, stated dogmatically that if there’s a lump, the whole breast must go. A lumpectomy was out of the question: “The surgeons cut and cut, and then the cancer comes back.”

In making her decision, Esther felt she had no one to turn to. Her parents were dead, and she feared the outcome of a family meeting. Ultimately, to my relief, she accepted my advice. Esther preempted gossip by getting a prosthesis, so that, in Hertzel’s words, “You walk down the street, and no one would ever know.”

She summed up her decision philosophically: “Now I’m part man and part woman, but healthy woman.”

As our meeting drew to a close, she shared a conversation from before her diagnosis.

“My sister asked, ‘What does the thing on your breast look like?’ ” she recounted. “I said, ‘It looks like a flower, a nice flower.’ ”

It shocked me that, in Esther’s eyes, the massive, ulcerating growth I’d found so horrifying was beautiful–”a nice flower.” In that moment, however, I realized this was her breast, her body and her humanity. Her perspective might differ radically from mine, but it deserved my respect—like the lives and experiences of every other woman under my care.

When first inviting Esther to share her story, I’d explained that it was part of my ongoing project: interviewing women who’d had locally advanced breast cancer and illustrating their stories through art.

An accurate visual image is critical to portraying such cancers, but because photography can be unnecessarily disturbing, I’d asked then-medical student Lucy Rose, an accomplished artist, to create watercolor paintings based on photographs of each woman’s cancer, including Esther’s.

As Esther and Hertzel prepared to leave, I showed them Lucy’s painting. Hertzel’s face lit up just as it had when Esther told of his being found in the woods.

“That’s exactly what it looked like!” he exclaimed.

Esther held the painting up to the light and studied it carefully.

“May I take it home?” she asked. “I want to show it to my grandchildren.”

Christina Weltz, a breast surgeon, has practiced at Mount Sinai Medical Center in New York City for twenty years. “One of my greatest joys is connecting with and being there for my patients during a very difficult time. My hope is to convey some of their stories through writing.”

About the artist:

Lucy Rose is a lifelong multimedia visual artist with an affinity for creating beauty out of materials that some would consider unsettling. She graduated from Icahn School of Medicine at Mount Sinai in 2020 and is currently an ob/gyn resident at Montefiore Medical Center in the Bronx.

Comments

8 thoughts on “The Eye of the Beholder”

  1. What a beautifully told true story of serious health issues but with so
    much hope running through it. Esther's story is very difficult to read
    and yet her courage shines through it all.
    The sensitivity of Christina Weltz, the surgeon consulted at a late stage
    of Esther's diagnosis is truly the main reason for so much of the hope.
    I don't come from a medical background and nor have I had to face
    anything near like the struggles that Esther faced. I do some from a
    visual art background and the image painted by Lucy Rose is very
    powerful. For Christina Weltz to be taken aback by Esther's
    description of the growth as “it is like a flower, a nice flower” is so
    understandable. And instead of just going with a photograph
    ,Christina Weltz had the foresight to ask an artist to paint it. An artist
    sees beyond the surface and gets behind a subject. Lucy Reid has
    done that in that powerful image. I am sure Esther's grandchildren
    must have been mesmerised.

  2. Like Dr. Christina Weltz herself, my first reaction to reading her beautifully rendered narrative of her Hasidic patient Esther’s experience with breast cancer, was, “What was Esther thinking, coming in so late?”
    On the same day, September 9th, that Pulse published Dr. Weltz’ account, the New York Times reported that New York Governor Kathy Hochul had declared a state of emergency over the state’s growing polio outbreak. The article quoted the state health commissioner: “On polio, we simply cannot roll the dice. Do not wait to vaccinate.” The same article noted that anti-vaccine sentiment has spread among “large numbers of Hasidic Jewish residents.” Had Esther, her husband and children, I wondered, been vaccinated? If not, what were they thinking?
    Two days later, Sunday’s NYTimes’ front page featured a lengthy investigative article entitled, “Failing Schools, Public Funds/Hasidic Students in New York State Are Deprived of Basic Skills.” While the article’s thrust is how the Hasidic schools – whose classes are taught in Yiddish – leave students “without a basic command of English, math or science,” it also provides insights into the perspectives and culture informing Esther and New York’s other approximate 200,000 Hasidic Jews who “wear the same modest dress as their ancestors did, and … live in largely insular enclaves devoted to preserving centuries-old traditions… Hasidic people follow strict rules aimed at recreating a way of life that was nearly wiped out in the Holocaust.”
    “Oh, what medicine it is to tell our stories,” the novelist John Barth wrote, a truth that Dr. Weltz clearly embraces and that is made evident by Esther’s reply to the question, “How long do you think the growth had been there?” Esther’s replies – reaching back in time to the Holocaust, Auschwitz, to the deaths in Brooklyn of a sister and both parents, with doctors only being summoned too late – followed by recounting the “miraculous” rescue of her future husband Hertzel as a boy lost in the woods for four days, provide far more insight into “What was Esther thinking, coming in so late?” than any purely clinical timeline of a tumor ever could.
    “I see through my eyes, not with them,” William Blake wrote, and so does Esther, who told her sister that what Dr. Weltz had found to be a “horrifying… massive, ulcerating growth,” looked, to her, “like a flower, a nice flower.” This revelation prompts an epiphany in Dr. Weltz that one can only hope is experienced by every physician: “I realized this was her breast, her body and her humanity. Her perspective might differ radically from mine, but it deserved my respect – like the lives and experiences of every other woman under my care.”
    If all Americans agree about anything today, it’s that we’re living in a profoundly divided nation, a nation whose citizens show little respect for those with radically different perspectives from their own. The clinical skills of Dr. Weltz and Esther’s other cancer treatment providers are what healed her and made it possible for her to show her grandchildren Lucy Rose’s painting of her tumor. I don’t believe in thinking of cancer or any other disease as a metaphor but I do believe Dr. Weltz’ listening skills and subsequent epiphany can serve as a template for our nation to heal itself, to at least attempt to understand what those we perceive as the “other” are thinking before it really is too late.

  3. I am not a doctor, but I am religious, and have greatly appreciated the sensitivity with which this history has been told, reflecting the that with which Esther was treated. It brings out powerfully how profoundly differently we can perceive things, and the way in which our ways of seeing can be shaped by things generations ago. It also suggests how vital are the attitudes of friends, families, and whole communities. Overall, this seems to me to be the sort of story that has the ability to raise consciousness not only within medicine but also far more widely.

  4. I am not a doctor, but I am religious, and have greatly appreciated the sensitivity with which this history has been told, reflecting the sensitivity with which Esther was treated. It brings out powerfully how profoundly differently we can perceive things, and the way in which our ways of seeing can be shaped by things generations ago. It also suggests how vital are the attitudes of friends, families, and whole communities. Overall, this seems to me to be the sort of story that has the ability to raise consciousness not only within medicine but also far more widely.

  5. I found it hugely interesting the role culture plays in this story, most especially a culture amongst women that is detrimental to good health. And within that culture, I never expected the overriding barrier to looking for medical help for breast cancer would be shame – and woman-to-woman shame, not coming from the men. As evidenced by the rabbi taking her for medical assessment. I love how the article/story shows such deep respect for this culture, and I share that respect. It’s why it is so important to collect stories from people who delay seeking medical help when clearly something is horribly wrong. That said, I was fascinated by the beauty this woman saw in her flowering wound, later on expressed as art. While it’s hard for me to understand not seeking help, I found myself envying – in a good way – the mind and spirit that saw beauty in this growth, and there is a lovely lightness of spirit overall. If nothing else, this story teaches me to never assume reasons why people do what they do. In a million years I could not have come up with this most interesting background story. Thank you for this research.

  6. I’m a general internist, hospitalist since about 1990. About 20 years ago the oncologists transferred a woman in her sixties with a similar presentation. The surgeons and oncologists “had nothing for her”.
    She wept as she described her lonely prayers to her god, at first in church, later, when the tumor became necrotic and malodorous, at home, alone.
    “ What I don’t understand,” she said despondently, “is why He did not hear my prayers and help me.”
    The nurses and doctors avoided her. I asked if she’d like us to contact her minister, to which she replied angrily: “God has abandoned me. He can’t help me.”
    I could not think of any way to respond, be helpful beyond medical palliation. I do not remember her “disposition” or saying goodbye.
    I think over the past 10 years I’ve learned a bit more about, for lack of a better term, spiritual empathy. Today I would sit quietly, as I did then, and quietly say something like: “I think Jesus suffered too. I wonder what higher purpose God has for you in your suffering.”
    Note:
    I’m not remotely religious. In any way. But over my life, which might be on the wane as they say, I’ve been somehow interested in things spiritual, and in understanding other peoples stories. At the bedside this translates into stretching empathic dialogue into areas important to the Patient and Family/Friends/Community. I am not a priest of any kind. But a few “words” in another’s “language”….often brings at least a little smile.

  7. It was interesting reading about the multiple reasons she ignored the possibility of cancer and, even then, feeling that an operation for it would shame her family. When I was growing up, a friend’s mother ignored an open, foul smelling growth on her breast until it was too late for her in those earlier years of cancer treatment. In our small town the unspoken question was how did her husband miss seeing it and not encourage her to go for help sooner. For some reason she felt too much shame to go to the doctor in a town that would never have condemned her but would have commended her courage.

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