JC, a 71-year-old male, working as systems engineer, has been living with monoclonal lym phocytosis for the past three years. Initially, his studies determined that the lymphocyte phe notype corresponded to B chronic lymphocytic leukemia, which initially did not require treat ment. Among his medical history, the only nota ble condition was moderate hypertension with no impact on target organs. Over the past eight weeks, there has been a dramatic increase in lymphocytes, with splenomegaly, and a decrease in hemoglobin levels, prompting the decision to start treatment. The patient was evaluated as fit from the perspective of his performance status. In two consultations, approved first-line thera pies, their advantages, disadvantages, and po tential adverse effects were explained. Eventu ally, in mutual agreement with JC, the treatment regimen of obinutuzumab (a monoclonal anti- CD20 antibody) and venetoclax (a BCL2-targeted agent) was prescribed¹.

Following the initial antibody administration, despite instituted prophylaxis, the patient de veloped tumor lysis syndrome, requiring rasbu ricase treatment. He also developed peripheral cytopenias and persistent fever. He received the febrile neutropenia empiric treatment in accor dance with institutional guidelines. Red blood cell transfusion support was required. Platelet levels significantly declined, although transfu sions were not deemed necessary. After a week of hospitalization, the patient was discharged with partial recovery of his blood cell counts.

During the first post-hospitalization consulta tion, the patient and his wife attended along with their 40-year-old son, filled with unease over the complication that had arisen. Although during the initial meetings there had been discussions regarding potential complications, including tu mor lysis syndrome, it wasn’t long into the con sultation when questions arose, giving rise to this contemplation. What if we had chosen a different treatment? What if we had initiated treatment earlier, when the spleen wasn’t enlarged; could that have miti gated the effects of tumor lysis? More persistently, the patient’s son, who had not been present at the initial encounter, mentioned that he had con ducted online research about his father’s condition, and his investigations had left him with doubts about the management of the situation.

The bond between patients and the health care team has notably evolved in recent times. While in the past, it was grounded in a pater nalistic and authoritative model, with a verti cal vector that descended majestically from the doctor to the patient, nowadays, there has been an evolution towards a more cross-cutting, back-and-forth approach, with an emphasis on shared decision-making².

Within this bond, there are several variables that create distortions and tensions, likely stem ming from a decline in the quality of communi cation, a lack of empathy, time constraints dur ing consultations, and external interferences in the bidirectional relationship between patients and caregivers. As A. Agrest pointed out, the once coveted social recognition associated with being a physician, coupled with respect and compen sation, has shifted towards a realm of suspicion. It has also ushered in a slew of demands and in creased pressures, exacerbated further by con sultations with “Dr. Google.” In this way, patients exert a sort of intellectual and even moral scru tiny upon the physician³.

Today, the word of the healthcare team is met with doubt, cross-referenced with internet searches, and weighed against the opinions of various individuals with diverse backgrounds and abilities. It is crucial, therefore, to acknowl edge that there are other players in this relation ship with patients, a group that can be broadly termed “the environment.” This environment is characterized by its potential to be highly influ ential in sowing doubts or even rejecting con ventional treatments. In the case of patient JC, his environment was represented by his son. While absent from the initial consultations, his words and actions towards the patient carried a significant presence, sowing the concerns that needed clarification.

It must be acknowledged that this environ ment can also be supportive, collaborating with the healthcare team and providing strong sup port in the decisions made along the way, particularly in clinical conditions that can endure for an extended period.

The context of patients, especially those fac ing complex health imbalances, and even more so for oncology and hematology patients, must be taken into consideration from the outset of the relationship. In the consultations that for mally establish the mode of care, communica tion channels and action plans regarding diag nostic and treatment aspects are clearly needed also from the beginning. Patients often come accompanied, and these companions are just a sample of all the voices that surround the daily life of the afflicted. This is an echo of the real ity where the disease takes center stage and permeates every layer of the affected person’s thoughts.

During the phase of contractual moments, there must be a clear communication regarding plans and strategies while simultaneously es tablishing a framework for communication with the individuals surrounding the patients. It is of paramount importance to underscore, through insistence, that any events that occur are rooted in the present disease, irrespective of whether a particular adverse effect is caused by a drug or a combination of drugs. Every event has its origin in the presence of that specific ailment. It is not uncommon to hear the phrase, “It’s not the cancer that will kill me, but the cancer treatment.”

When undesirable effects occur, when re sponses do not align with expectations, it is at that juncture that questions beginning with the aforementioned tense, the past subjunctive plu perfect, come into play⁴. This verbal tense can lead to a zone of unease in communication with the patient, especially when unwelcome news must be conveyed. To prevent this, it is of vital importance to maintain a connection with the patient’s caregivers, establishing lines of inter action with the environment, always with the patient’s knowledge and authorization but as a form of prophylaxis against the “what if we had done that…” scenarios that may arise. In some sense, for critical situations, advanced illnesses, and end-of-life scenarios, it becomes evident that the survivors of this triad, the patient, the doctor, and the environment, will predominant ly be the caregiver and the environment.

Recognizing and averting potential grievanc es can even help alleviate the discomfort that often permeates the relationship, a discomfort that, when taken to extremes, can result in legal disputes.

In the labyrinth of patients’ and their com panions’ thoughts, the shadows of uncertainty intertwine in diverse ways, giving rise to disturb ing thoughts. At times, they find themselves en snared by a lingering question, one that persists until the panorama from the outset is clarified, perhaps like a recurring echo: “What would have happened if a different path had been chosen at that past crossroads of possible treatments? Would this present, with its mysteries and tribu lations, be different, perhaps devoid of adverse effects or with better responses?”

Each past determination, with all its shades and lights, has led the patient to their current point. The choices of yesteryears are unchange able, and thus, the possibilities of various sce narios were initially opened up, with the pa tient also having to trust in the guidance of the healthcare team in this model of shared deci sions.

There’s a popular saying that it’s easy to cri tique Sunday’s soccer results with Monday’s newspaper. In the medical field, especially in situations where life is at stake, it is imperative to exercise prudence and continuously facilitate a channel of communication that prevents the arrival of the moment when the past subjunc tive pluperfect is associated with a complaint. This is particularly crucial when the results of a specific treatment are known, and reflection comes into play. Transforming unease critically depends on the necessity to reaffirm the infor mation presented previously. It is also essential to remain vigilant because, despite being aware of its existence and consequently establishing prevention, the syndrome of the past subjunc tive pluperfect tends to rear its head. What mat ters is reassuring the patient and strengthening the bond with the mentioned tools.

Preventing the “past subjunctive pluperfect syndrome” is not a simple task. It requires es tablishing effective communication from the very beginning of the relationship and considering the patient’s environment to maintain a line of communication and trust even with that other sphere. It is striking that doctors have been highlighting these issues for a long time, and the difficulties persist with the same or even greater intensity. In 1972, Florencio Escardó spoke of creating an “existential unity” with the patient’s family group, where efficient and affectionate communication could take place (empa thy was a term not used at that time). He also cautioned about the phenomenon of the patient as a consumer in the mechanistic reality of the surrounding world⁵.

Time, perhaps, gives the illusion of being circular, and issues that repeat in the medical profession’s practice resurface. Names of presti gious doctors who have reflected from their professional wisdom yet refer to situations similar to those more than half a century after Escardó’s publication. Or perhaps, it’s worth the effort to persevere and return from the past subjunctive pluperfect to the present indicative, at least to a somewhat more auspicious tense.