Getting Started

The story begins with presenting symptoms. The patient (Frodo) discovers he has been burdened with a ring of great destructive power, the cancer. He has acquired this innocently—it is an inherited cancer—not through his own deeds. His family physician (Gandalf, the wizard) performs the initial diagnostic tests and identifies the true nature of the ring, through a signature revealed when it is heated in a flame. Gandalf recognizes that he and his patient do not have the resources to manage the problem on their own. With what seems like precipitous haste, Frodo finds himself propelled from all he knows and holds dear in the Shire, as Gandalf refers him on to the specialized diagnostic center of Rivendell, the home of the Elf Lord, Elrond. As a strange assemblage debates his case, Frodo finds himself in the unaccustomed and alien environs of a multidisciplinary clinic.

Membership of the Multidisciplinary Team

Elrond, who convenes the meeting in Rivendell, recognizes that no one specialist has all the resources to address Frodo’s problem. Frodo will need a team around him, and they will need each other. He reminds them, “You will unite, or you will fall.”² Elrond sets up a multidisciplinary meeting of the free peoples of Middle Earth to decide on an initial course of action. The core team consists of the following members. Aragorn is exiled heir of the thrones of Gondor and Arnor (the lead surgeon) with a mix of superb technical skill with a sword and the insight of the Elves who raised him. Boromir is a man of Gondor (also a surgeon), brave and skilled in battle, and ultimately heroic in his defense of the hobbits. Unfortunately, he struggles to see the big picture, and is reluctant to accept the leadership of Aragorn and the advice of the Elves. Gimli is a Dwarf (the radiation oncologist), happy in underground bunkers with complex machinery, very dangerous at close range with his axe, and undaunted by seemingly impossible odds. Legolas is the Elf Prince (the medical oncologist), the eyes and ears of the company, able to approach the unseen enemy at long range with his bow, delivering combination therapy with multiple arrows. Gandalf is the wizard (the family physician), who continues to have an important role in protecting and advocating for Frodo and guiding the company. Elrond is the Elf Lord (the diagnostic specialties). The so-called backroom elves provide a long-range view and are aware of hidden foes. Galadriel, Elf Queen of Lothlorien (the specialist nurse), is skilled in reading hearts and minds, and she provides Frodo with information and support, while assisting the team on their journey.

Noncore members are added as the story progresses, and the need arises for their services. Supplementary members of Frodo’s team will include: Omer (the neurosurgeon), who says, “Aim for their heads,”⁴ and Theoden (the plastic surgeon). Acting under guidance from Aragorn, they provide vital input, without needing to take over the whole case. Eowyn, Lady of Rohan (a social worker), is skilled in both the pragmatic and emotional aspects of supportive care. She is keen to have a more active role in the battle, and vanquishes an important foe that “no man” can conquer.⁴ Faramir (a clinical psychologist) meets with Frodo when Frodo is lost in the wilderness, and after an initial period of suspicion, provides a listening ear and understanding. Arwen (chaplain or pastor) protects underlying values and is an important source of dignity, hope, and inspiration, especially for Aragorn. The Ents (medical administration) spend a lot of time talking as they struggle to recognize that they own the problem, and can contribute to the solution, but once activated, can rapidly rearrange the landscape.

Creating an Appropriate Meeting Environment

Tolkien describes the House of Elrond as a place “of reflection…visited on the way to all deeds.”¹¹ The meeting takes place in calm surroundings well removed from everyday life. Despite the urgency of their flight from the Shire, the timelessness of Elvendom encourages reflection. Introductions and credentialing are vital: Boromir challenges Aragorn’s presence at the Council when he asks, “What would a ranger know of this matter?”² The medical oncologist (Legolas) affirms Aragorn’s need and right to be there, and identifies his leadership potential.

Appropriate seating in a circle rather than in rows allows the full history to be presented, with contributions from each member making up the full picture. The diagnostic work-up is reviewed and alternative strategies to destroy the Ring are canvassed. The resources of the patient (Frodo) are considered. Bilbo, a cancer survivor, provides background knowledge and emotional support for Frodo; an endorsement of Elrond, Gandalf, and Aragorn; and gifts of weapons and protective clothing. The team acknowledges the support of the nonprofessional caregivers (Sam, Merry, and Pippin), and formulates an initial plan. The Ring will be taken to Mordor and destroyed in Mount Doom, a perilous endeavor to which Frodo must actively consent: “I will take the ring, although I do not know the way.”² The Fellowship will reassemble in subgroups on many occasions, in corridors, and in haste, when new challenges arise, and plans will be changed many times through the journey.

Development of an Effective Multidisciplinary Team

A new multidisciplinary group will not necessarily develop automatically into a smoothly running team. Tolkien and Jackson reinforce Tuckman’s^12,13 observation that teams are not born fully formed at their first meeting, but rather develop through a series of stages. In the forming stage, individuals assemble and the agenda is developed (first half of FOTR). In the storming stage, conflict arises (the Council, and second half of FOTR). In the norming stage, intimacy begins to develop and functional roles are defined (TTT). In the performing stage, the team is effective and efficient in delivering outcomes (ROTK). During the reforming stage, the team dissolves and moves on to new challenges (ROTK after the coronation).

Barriers to effective team function identified in the medical literature are clearly demonstrated in Tolkien’s trilogy, and these challenges must be addressed along the journey.

Nonprofessional Caregivers Are Also Vital Team Members

Frodo would not have made it to Mordor with the assistance of the professionals alone. He was dependent for a much greater period of time on the support of his intimate caregivers, Sam, Merry, and Pippin. There is some tension between these two groups. Because of the conflict with Boromir, the Fellowship splits up at the end of FOTR.² The remaining professionals work at gathering support in the background, with Merry and Pippin, on the west bank of the Anduin River.³ Frodo, who discharges himself to outpatient therapy, is accompanied by Sam, and later Gollum, on the east bank.³

Thereafter, it is Sam who bears the brunt of Frodo’s declining strength and increasingly disordered thoughts. That “Frodo wouldn’t have got very far without Sam”³ is undeniably true. Sam performs practical day-to-day tasks in difficult circumstances: he provides food and water, body warmth, clothing, and shelter. He nags Frodo about the need for sleep. He lifts Frodo’s spirits with appeals to the heroic nature of the struggle: “ I wonder if we’ll ever be put into songs and tales.”³ In moments of despair, he reminds Frodo of the values which they are protecting: “…that there’s some good in this world and it’s worth fighting for.”³ His efforts to preserve enough bread for the return journey are acts of hope. Like many caregivers, he struggles with the desire to take away Frodo’s burden. In the end, he has to carry Frodo up Mount Doom: “I can’t carry it for you, but I can carry you.”⁴

For his efforts, Sam is rewarded with mistrust, and at times rejection, as Frodo claims that Sam does not understand what is needed. As caregivers report, those closest to the patient are often on the receiving end of emotional outbursts in dark times.²⁶ Anxiety and depression are as frequent in the caregivers as in cancer patients,²⁷ and caregivers are also in need of support and direction from the professional team members. In times of crisis, Sam reminds himself of Gandalf’s initial instructions when setting off with Frodo: “Don’t you lose him, Samwise Gamgee!”² After the destruction of the Ring, the emotional connection between Frodo and Sam is restored, and indeed strengthened, and they are reunited with the professional caregivers who continue the process of healing.⁴

Merry and Pippin provide some light relief in an otherwise black tale, reminding us of the patient’s need for friendship, good food, rest, and fun. Pippin, in his interactions with the far-seeing stone of Saruman (the Palantir), does as many Internet-searching friends do—he sees things he would rather not have done, yet which may provide forewarnings that change the direction of the journey. The hobbits feel that they are in the way of the professionals much of the time, asking stupid questions, yet each has his role to play in supporting key team members. They are, in fact, fundamental to the rousing of the Ents. Medical administration responds, as is often the case, more to complaints of caregivers than staff. The challenge for the team is to engage appropriately with all who can assist the patient in their journey.

It’s Not Over When It’s Over

When the Ring is destroyed, the hobbits return home, yet like many cancer survivors, they find themselves irrevocably changed by the experience, with a kind of post-traumatic stress disorder.²⁸ For Frodo, in particular, it is hard to “pick up the threads of an old life,” and he recognizes that “there are some hurts that time cannot mend.”⁴ The other hobbits are ready to move on, but Frodo struggles to make new bonds. He continues to require help from the Fellowship: the opportunity to take up the journaling of his experiences where Bilbo has left off, the ongoing care of Sam, and a retreat offered by Elrond and Galadriel to “lay down your sweet and weary head.”²⁹ Our responsibilities to our patients extend long after acute treatment is over, and follow-up needs to be coordinated within the team to avoid both duplication and gaps.

What of Gollum?

Gollum is also a survivor, but unlike Bilbo, he has walked alone with the burden of the ring: “No loyal friend was ever there for me.”³⁰ His disturbed psyche may relate in part to the fact that his possession of the ring was of a much greater duration than Bilbo or Frodo (more than 400 years). Possession was also the result of his active, albeit ignorant, choices. Illness attribution, as is seen in smokers with lung cancer,³¹ may increase distress, and needs to be addressed sensitively by the team. When handled gently by Frodo, Gollum agrees to guide Frodo on a path into Mordor that no one else on the team could have done, because he alone had “been there.” In the end, his promise not to let Sauron have the ring is fulfilled,³² and Frodo is saved. Survivors who have been injured while bearing the cancer confront us, yet also assist us to improve safety and quality of care for current patients.

There and Back Again

Health professionals often hear it said when patients’ problems seem insurmountable, “Don’t go there, keep your distance,” or “The patient is the one with the disease.”³³ In a successful quest however, a patient is supported and guided to whatever end awaits him or her by a team of caregivers both professional and intimate, and a multidisciplinary team goes safely “there and back again”³⁴ with reliance on each other and in fellow feeling with the patient.

As our patient had identified, the trilogy deals with many of the issues around effective teamwork in cancer care, consideration of which may provide insights that could improve outcomes for patients and providers alike. In these movies, Jackson hopes that, in his interpretation of Tolkien’s tale, we might “touch myth and confront universal issues, perhaps even draw strength for our own lives.”²⁵ We welcome you to share our reflections with your team and your patients, with similar hopes.