Monday, January 31, 2005

May I Take Your Order?

This morning I wrote a routine order in a patient's chart and suddenly thought of the warm, pink beaches of Bermuda. No one observing me at the time could have guessed that as I leaned over the nurse's station I was actually loping down the sandy dunes once again, squinting at mirror images of green sea and sky. What triggered this incongruous memory was an exchange between a tropical reveler and a barman that I heard while perched on a stool in the hotel's oceanfront watering hole:

"I'd like a glass of water, please."

"Yes ma' you are."

"There's no ice in this glass."

"You didn't ask for any."

Looking at the scribbled cursive I had just placed into the chart, I let slip a subtle grin, for I knew the instruction just written would likely be followed precisely - and likely lead to an unhappy patient. Just like the confused Bermudian mixologist, most caregivers carry out orders with the precision of a military color guard, and in my experience following every medical command to the letter can sometimes produce a noticeable knitting of the kindly practitioner's brow. The pen frequently fails to translate the actual intent of an order hatched within the tangles of a doctor's mind, therefore he will allow a certain degree of laxity in its completion, all for the sake of efficiency. He must, however, constantly be on guard during the final decoding of said order, for it takes little effort to bungle the master plan when multiple tests and treatments are being juggled simultaneously in the course of a patient's day.

As an example I offer the order that evoked the memory of the unloved glass of warm water. The patient in question was a woman whose pain was not relieved by the oral medication oxycodone. The order began as follows:

"Begin morphine sulfate patient-controlled analgesia pump with 4 mg dose", etc. This means the patient will now be able to give herself a shot of morphine by simply pressing a button at the bedside. Beneath that was the accompanying order to discontinue the ineffective pill.

This looks like a fabulous bit of doctoring, except for one small problem. It takes hours for the morphine sulfate pump to be delivered and started, but only a second for the nurse to say to the patient "I'm sorry, but your doctor stopped your pain pill. You'll have to wait for the pump."

Like a chess master scrutinizing the board before him, I pondered the chart until I realized I needed to plan a good three moves in advance in order to ensure that my patient didn't languish while the pharmacy mixed up his analgesic concoction. Therefore, the actual order was written as:

"Discontinue oxycodone after morphine sulfate pump is started."

Simple, isn't it? All one has to do to keep on top of medical orders is to visualize them being carried out and then ask, accompanied by a cartoonish shrug, "What could possibly go wrong?" By taking the time to answer this question, the doctor may prevent any bloopers or frustrating gaps in data collection from occurring. In fact, this trick has led to the appearance of other classic orders such as:

"CT scan of chest in A.M. - to be done after patient has been seen by doctor." (No one likes to round on an empty bed).

"Old records to floor - please send all records, not just most recent hospital stay." (This assures that last year's sojourn in the ICU will be remembered).

"Please check O2 saturation on room air - and record results in chart." (Res ipsa loquitor).

Since the care given in most hospitals is exemplary, these examples, rather than revealing any lapse in patient care, serve mainly to illustrate the intricate workings of the mind of the physician infatuated with obsessiveness. Still, as they say, orders are orders, and if a rather compulsive doctor regards his or her orders as meaningful as the Ten Commandments, all the better for the patient. Therefore let the words in the chart go forth with clarity and pithiness - let no mishap occur due to order befuddlement, or conjecture of the author's intention. Let every order be written as if it were to launch the king's fleet itself - and hopefully in the right direction.

Saturday, January 29, 2005

Saint Crispin's Day

From this day to the ending of the world,
But we in it shall be remembered-
We few, we happy few, we band of brothers;
For he to-day that sheds his blood with me
Shall be my brother...

-William Shakespeare, Henry V

Last month while waiting to be seated for dinner at one of those cookie-cutter type chain restaurants I spied an old acquaintance of mine - he and I had trained together. After exchanging greetings and a few observations on the pervasiveness of video games in the home we went our separate ways. While biting into a pita bread sandwich that both resembled and tasted like a UPS package I felt myself drifting backward in time to a large city hospital where I deposited the last three remaining years of my youth. My old pal and I were members of a platoon of doctors back then, engaged in surviving the boot camp for medical recruits called the internship. We were overwhelmed with desperately ill patients, subjected to surprise inspections by the commanding officer of the ICU, and always searching for a way to steal an extra hour of sleep. Unappreciated by the universe, we selfishly enjoyed the presence of our own company over all. We were truly the happy few. Now whenever we run into each other, like two old soldiers leaning on staffs, we trade tales of the glory days, thereby annoying spouses, children, food servers and anyone else within earshot. Given the right circumstances we might even salute each other and shout out the rallying cry of the intern:

"Hold hard the breath and bend up every spirit to his full height!"

Quite an inspiring phrase, that - can one not blame us if our hearts quicken when once again we clasp hands and face the breach?

Actually, one could blame us, for we were not soldiers once...and young. We were just young, whiny doctors.

Lest anyone think that anyone's blood was shed during those adolescent years of instruction, let me doff the suit of armor and tell the truth about our reminiscences.

Our gatherings are not even close to a reunion of veterans, let alone the Grand Review of the Armies. When we get together it is more like old comedians sitting around a delicatessen at closing time, because if there was one thing we used as an anodyne for the stress of being in training, it was black humor. We never thought of ourselves as soldiers in battle or martyrs tied to the stake - we were just lowly doctors-in-training, available for abuse from all members of the same smiling hospital team seen advertised on commercials. In order to compensate for our insignificant status we mercilessly mocked everyone, including ourselves. For example, once I was ridiculed for months after an incident where I tried to become that species of doctor known as the eager beaver.

The event in question occurred while I was rotating on the Coronary Care Unit. A gentleman admitted after a heart attack kept developing ventricular tachycardia, a potentially fatal arrhythmia which must be converted to normal by shocking the heart. In order to avoid any delay in treatment, we placed two conductive pads on his chest and connected them to the defibrillator, which would then allow the rescuer to simply press a button to deliver life-restoring voltage to the heart.

Fascinated by this contraption, I marveled at how it jolted the patient both off the bed and back into the world of the living. One afternoon our man developed the fluttering rhythm while our attending cardiologist was lounging at the nurse's station. We all dashed into the room and instantly noted the problem oscillating across the patient's monitor. Unfortunately our leader had not been briefed about the labor-saving device and as I fired up the machine he placed his hands on the victim's chest and cried "Give me the paddles!"

I confess I too was a tad excited, for after hearing the word "Give" I promptly hit the switch, sending greased lightning into both patient and physician. Witnesses still talk about the backwards high jump record set on that day. I, of course, was equally electrified - with mortification. From that day on the attending wore leather gloves, and once the story got out my friends displayed their amazing gift of narrative by repeating it to any person not considered to be totally deaf.

I can imagine what the old warriors felt as they bent over a crackling fire and recounted their years of glory in the field for God and crown. In contrast, no matter how stressful our time together was, we never had to face an opponent trying to detach arm from body with a broadsword. We simply worked at a routine job interrupted by episodes of humor, or terror. Come to think of it, that is not an unrealistic description of a soldier's life. If there is one thing our respective bands share it is a tender memory of the times when we laughed together. That is one of the reasons why we still wear the white coat today.

Thursday, January 27, 2005

The Case of the Strange Sprain

Two days ago a slender middle-aged man walked into a local emergency room, complaining of neck pain after taking a spill in his brother's front yard. X-rays of the cervical spine were unremarkable, and the patient was discharged with a standard information sheet for home care of a neck sprain and told to follow-up with his primary care physician.

He replied that he did not have a family doctor, and was therefore given the name, address and telephone number of the physician designated by the hospital to be "on-call" for emergency patients on that date, January 24th, and was instructed to see him the next day should his neck continue to hurt.

When he discovered that the doctor's office was twenty miles away from the emergency room he had just visited, the patient did not complain nor ask to see someone closer.

The following day the patient appeared unannounced in the follow-up doctor's waiting room wearing a bulky cervical collar and complaining of a sore neck. He asked to see the doctor and presented his E.R. discharge sheet as proof of his diagnosis. After a rather long wait, the doctor whose name was on that piece of paper walked into the waiting room and addressed the patient.

There are some days when the twirling roulette ball hits the chosen number time and again, when every bet placed brings in a winner. It is during such a streak that a person's confidence may mutate into thoughts of infallibility, that his ambitions may soar beyond the gravity belt of common sense that keeps him secure in his wits. The man at the window thought he was having such a splendid day as he greeted the doctor. He did not realize it yet, but his most recent wager was about to bust. By sheer coincidence the hospital had paired him with the worst possible doctor around when it comes to a pain in the neck - a completely unhelpful, ungracious, uncaring, inflexible creep.

The man in pain was about to meet the pain man - and get the old heave-ho.

Mr. Drug Addict, meet The Cheerful Oncologist.

If there ever was a specialty where a little training in drug-seeking behavior might be a good idea, it is medical oncology. We cancer docs dispense narcotics like the local movie house sells popcorn, and frankly, it is one of the most important treatments we can offer our patients. We are extremely cautious in our use of pain pills. Rarely, and I mean extremely rarely, we come up against a scam artist, and when we do it is up to us to slap our lethargic cheeks and recognize the start of the con game. I did not immediately sniff out the ruse being performed in my office, but as I interviewed the injured soul some curiosities about his story were raised, such as why he bypassed six hospitals to go to one located forty miles from his home. Possessing a naturally helpful disposition, I at first tried to find him a specialist who could treat his neck, but while sitting at my desk looking up telephone numbers I suddenly had the notion to follow one of the Basic Laws of Medicine:

Don't even attempt to make a diagnosis until you have all the facts of the case!

With such sage counsel bubbling throughout the cranium I decided to pay a visit, via the miracle of the Internet, to the patient's hospital records. After a couple of clicks my lips were lo-and-beholding with amazement. The unfortunate neck-twister had been to that very same emergency room last November, and the year before - always with the same complaint! In fact, he had received x-rays of his long-suffering neck on each occasion. "Well, I'll be a monkey's uncle!" was the phrase of the day at that point. I printed out his radiology reports and headed back out front.

It was a brief but emotional reunion for the two of us - he with an increasingly anxious look on his face, like one who has just walked into church without his trousers on - and me, the Perry Mason of medicine, cross-examining the witness until he abruptly paid his respects and beat a hasty exit.

All's well that end's well, I suppose - I avoided becoming another victim of a classic flimflam by a dope fiend, and perhaps my opponent will re-think his strategy of promulgating perpetual pain to every emergency room in town. The moral of the story is clear:

Learn everything you can about your new patient.

Sometimes the secrets to a successful outcome in medicine, like clues hidden around the old dark mansion on the night of the crime, require the protagonist to play dual roles - that of doctor and detective.

Tuesday, January 25, 2005

Cancer and the Ordeal

For oft, when on my couch I lie
In vacant or in pensive mood,
They flash upon that inward eye
Which is the bliss of solitude;
And then my heart with pleasure fills,
And dances with the daffodils.

"I Wandered Lonely As a Cloud"
-William Wordsworth, 1804

There are weekend afternoons when one wants nothing more than to plop down onto well-stuffed chintz, toss a couple of pillows over the weary frame, and rehearse a certain vapid look popularized long ago by the poet of the lake. After scrubbing the pots, carting Junior off to his afternoon game, and enduring another mind-numbing shuffle down the aisles of the mega-market I think one has earned the right to a quiet hour alone. An ambitious soul may find this intermission wasteful and prefer to flit about, solving the problems of the world, or if none are apparent, creating some. Anyone so engaged in such meritorious pursuit who seeks my counsel can find me on the sofa.

Ah, the couch - that horizontal parking space where one can relax the mind and let it wander for hours through fields of lemony flowers, or in my case exactly one daffodil before I lapse into unconsciousness. I would not guess that all practitioners of the art of napping use the pastoral setting for their musings, but it cannot be denied that two centuries after Wordsworth's vivid stanzas were written they remain one of the most beloved depictions of lollygagging ever memorized by a freshman. How delightful it is to replay soft scenes from a lifetime of adulation while thumb-sucking in a quiet corner, the faithful hound or tabby lying nearby in respectful imitation.

I enjoyed a similar repose recently, and between ignoring the interjections of children and the jarring sing-song of the telephone I recalled (pensively, no doubt) an incident from my youth. I had no idea why it surfaced, but soon connected the dots and realized that once again the disease I loathe had invaded my solace.

What I remembered was an event from my Boy Scout days in which certain members of the troop were inducted into the organization's national honor society, called The Order of the Arrow. The induction ceremony, known as the Ordeal, takes place at night. Scouts who best represent the Oath and Law of the troop are secretly voted into the Order by their peers, and on that evening a moving ritual takes place. I recalled how the moon hung just above the trees that night as we lined up in a giant semi-circle. Drums beat out a melancholy march while a guide dressed as a Native American walked silently in front of us. When he passed in front of a chosen scout a hidden signal was given, and the guide would knock the boy out of the line with a mighty push, turn solemnly, and resume his stride. As those honored scouts were taken off into the black forest the remaining members stood by quietly, wondering who was next. I quivered under the stars that night, and it was not from the evening chill - I was petrified that I was going to be tapped by the imposing warrior, yet also desperately hoping that I would be selected.

As I lay on my couch, some thirty years later, I considered the meaning of the ceremony. Standing side by side with friends, one is frightened that a symbol of power would suddenly turn and smite him without warning, before one is able to brace for the blow.

Suddenly the metaphor was clear...

This arbitrary culling of people reminded me of how cancer strikes the innocent.

Many patients who follow a healthy lifestyle have been cut down in their prime by the inexplicable fury of a malignancy, felled like saplings before the woodsman's blade. No explanation can satisfy the question as to why one is singled out for an early grave. Just as the feathered brave passes by each scout during the Ordeal, so cancer floats over neighborhoods and homes, hovering softly before drifting downward toward an unsuspecting sleeper. Why one person is afflicted and another not is beyond my understanding. It is as mysterious to me as the ceremony of the Ordeal.

Eventually I was tapped into The Order of the Arrow - a thrill that over the years has dimmed within the inward eye, as all memories do. Cancer, however, creates memories that last long after those of childhood have receded - sometimes it even intrudes upon these happy reflections. If so, it is better to blind the inward eye, rather than suffer the fate that Wordsworth recalled:

Turn wheresoe'er I may,
By night or day,
The things which I have seen I now can see no more.

The curse of the oncologist is not that he no longer enjoys the visions of his youth, but that he sees this vile disease trespass onto his memories. He rarely finds comfort when lounging on a sunny afternoon. The mind whirls with a vortex of incongruities; his time on the couch is short.

Sunday, January 23, 2005

The Tumor Board

When a newly bred medical oncologist receives the final kick-in-the-pants goodbye from the university and toddles off to join the adult workforce, he is released from the scrutiny of mentors who for years have watched him like a prison guard on yard duty. The young doctor, sporting a fresh suit of clothes and a few dollars in his pocket, has gained his freedom. He can now fulfill his life's dream - to practice medicine without hearing the sounds of tut-tutting from graybeards or snide commentary from overtrained peers.

Our young oncologist, at last in charge of his patients' care, surveys his domain with pride. He decides now which x-rays to order, what treatment to use, and when to calm anxious faces in the assembled crowd. As the leader of this expedition he sets the course and commands a crew of nurses, technicians and other assorted Sherpas as the journey upward toward excellence in medicine begins. Once labeled merely a fellow, he is now an attending physician and in complete control, no longer forced to justify his displays of genius to any guru or wisenheimer.

Oh, what a lonely trek it is up the rocky mount of medicine when you march in isolation.

Day after day our freshly-ironed oncologist, head tucked into one text after another, toils into the long shadows, looking for solutions to the perplexing illnesses of his patients. Should he change to a newly published treatment for a certain vexatious cancer or continue using what the old cap-and-gown gang insisted upon during his training? If he orders the latest fancy scan will it provide clear, detailed images of tumors, or head-scratching reproductions of the Cubist masters? Decisions pile up before him like the blinking lights of holding telephone calls, each one flashing with impatience.

No matter how much our novice enjoys his solitude, his judgment and technique will soon be broadcasted throughout the medical community. Ironically the announcer will be the youthful doctor himself, for sooner or later he will participate in a ritual that could be called the "powwow of cancer care", a weekly parley of rival oncologists where difficult or intriguing patient cases are shared. This conference, created in the spirit of improving patient outcomes, is an hour devoted to honest discussion, bad coffee and the occasional touche' of sarcasm.

This meeting is known as the Tumor Board.

At the opening gavel of the Tumor Board our oncologist will narrate a short vignette that begins with a listing of some unfortunate's symptoms and ends with his plans for bringing justice to the malefactor currently residing within said victim. This sounds like nothing less than an inspiring way to spend the dawn, huddled together like generals peering over a giant map of the French countryside, but woe to our newly-commissioned attending if he is not well-prepared to explain the rationale of his master plan!

The term pregnant pause was never better illustrated than in this meeting, for if Dr. Kildare's proposed treatment is outdated, overzealous, unjustified by medical evidence, or just plain kooky, both ancient mariners and disgruntled competitors alike will suck in enough wind to thin the oxygen in the room as they prepare to lambaste our gentle friend for his ineptitude. I myself have attended Tumor Boards where so many eyebrows were raised it looked like an advertisement for the local plastic surgeon.

Thus lies the paradox of this valuable but frustrating conference. If our novice announces a plan that is well-received by his comrades he hears mostly grunts and dead silence, a sad reminder of the lack of respect afforded medical rookies. On the contrary, if he is deemed idiotic by the members of the Board he will be buffeted with helpful advice at the cost of two noticeably singed ears. Is it no wonder that some oncologists shun the surveillance of their handicraft found within the pronouncements of the Tumor Board? Why should an up-and-coming sensation be subjected to possible ridicule after finally escaping the confines of the ivy tower?

Tough bananas, I say. If a doctor truly wants to be first-rate he must constantly display his work to the inspection of others. Each oncologist possesses his own interpretation of the medical literature; each has a unique insight into the particulars of a difficult case and is eager to share his expertise. A smart attendee of the Tumor Board will swallow his pride and use the wisdom and experience of his colleagues to his advantage and toward the attainment of the ultimate goal - the best care for his patients.

Thursday, January 20, 2005

Visions of Tomorrow

My clinic today was brightened by several encounters with patients eager to share with me their happy news. First, a retired pipefitter announced with a mixture of pride and relief that his youngest of five daughters was engaged to be married this fall. After lunch I ran into a dearie who grasped my hand and told me she and hubby had just plunked down a hefty sum for an Alaskan cruise in August. My last patient of the day, a high school English teacher, was trying to coordinate some time off this spring in order to attend her daughter's college graduation. These people all emitted that quiet glow found in those fortunate enough to be distracted from the day's frustrations by thoughts of future joys. Coincidentally, they all asked me the same question:

"Do you think I will live long enough to see this?"

The human spirit contains enough strength that when released, like the ineffable birth of the universe, can expand to overcome almost all hardships - danger, discomfort, disappointment - nearly every worry the shaper of life can conjure up to provoke us. Not even the spectre of disease can separate a parent or spouse from an incandescent devotion to his or her beloved. The power within the soul, however, cannot exterminate the malignant parasite that slowly consumes the cancer patient from within. Viewing the future stretching out before them, basking in the radiant joy that awaits, they are unable to perceive the day when falling shadows will sunder them from all they hold dear.

"Do you think I will be alive then?"

How do I answer this question?

In addition to being the chief strategist behind the plan to kill cancer, the oncologist is also given a set of pom-poms and told: "Get out there and fire up the crowd!" He must become a tireless advocate of good cheer, for if the doctor - the presumed authority in a patient's case - becomes disheartened, why should anyone else be encouraged?

Is it my responsibility to prepare the patient for the worst and crush their hopes, or to keep on the bright side and be evasive, ignoring the fact that these happy plans may soon deflate like last week's birthday balloons?

My problem is that as I stand side by side with a man or woman who asks for nothing more than a chance to experience another day, I see too much. Discussing the future with a cancer patient is like watching a race between two warriors, each desperate to reach the finish line and declare victory - one celebrating all that is blessed in life, the other eager to cackle over the grave. Nothing I do today can guarantee that my patient will live to fulfill plans for tomorrow. I stand helplessly by the wayside - but not without a voice.

If there ever was a occupation where a certain phrase of the ancient poet Horace is taken seriously, it is medical oncology. His words are known to all:

"Carpe diem, quam minimun credula postero."

This is nice, neat advice but when you've got cancer what have you got to lose by living for today and tomorrow?

I therefore tell my patients to get out, to get together, but also to get going with their plans and live their lives as they do now - with every hope that the future will find them smiling with family and friends. Whether they make it to the ceremony or not, I want them to face the future as the rest of us do - with confidence in the worth of modern medicine, with determination that no illness can break our will, and with delight in every day that the sweet fruits of the world are within our grasp.

Wednesday, January 19, 2005

Dr. Osler's Advice Column

As part of a continuing series, your moderator offers today selected quotations from the father of modern medicine, Sir William Osler. The great physician and healer left us with scores of insightful and well-stated maxims in a broad range of catagories that can inspire both health care professional and layperson. Please feel free to assimilate and then disseminate these entertaining words.

"By far the most dangerous foe we have to fight is apathy - indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self satisfaction."

"With half an hour's reading in bed every night as a steady practice, the busiest man can get a fair education before the plasma sets in the periganglionic spaces of his grey cortex."

"We are all dietetic sinners: only a small percent of what we eat nourishes us, the balance goes to waste and loss of energy."

"The chief function of the consultant is to make a rectal examination that you have omitted."

"To know just what has to be done, then to do it, comprises the whole philosophy of practical life."

...and my favorite aphorism of all (note the connection to your moderator's moniker):

"Hilarity and good humor, a breezy enormously both in the study and in the practice of medicine."

If there ever was a speciality that begged for good humor, it is medical oncology. Heaven knows it isn't easy, but this recorder of the vicissitudes of life will do all in his power to live up to the title of this tiny corner of the blogosphere.

Tuesday, January 18, 2005

In the Temple of the Giants

I walked into the doctor's lounge the other day and suddenly felt like a pan-pipe tooter in the halls of Mount Olympus. Instead of the usual tableau of snoozing anesthesiologists in the corners and scrub nurses sneaking sodas from the refrigerator, all the giants of medicine were there. They draped themselves about the couches and chairs, chatting with fellow colleagues, or back-slapping each other with that hail-fellow-well-met ferocity found in the supremely confident.

I could see Cardiology slathering a bagel with ambrosia, while Obstetrics sat next to him reviewing last night's scores. Across the room was Pulmonary, yakking with Urology about some mutual patient; leaning idly against the counter, General Surgery nursed a quiet cup of nectar. Across the room the king of the gods - Cardiothoracic Surgery - was in his court, issuing maxims to the small crowd of admirers gathered around him.

How did it ever come to this, that I, Oncology, was fitted with a shepherd's rags? Was I not charged with a noble responsiblity - not pursuing the cause of say, diarrhea, but engaged in a mountaintop-worthy battle against a seemingly omnipotent foe? Do my patients not cry out in great numbers in the fields, or across the vast waves for merciful Oncology to save them from the sweeping fury of cancer?

Of course they do. It's just that as deities go, we oncologists are far from divine in our ability to answer the prayers of our suppliants. Our therapies don't work all the time - often not even half the time, compared to a surgeon given the task of amputating a limb - hard to imagine that not coming off all right, eh? Perhaps that is one reason why our fellow healers, when grabbed by the sleeve to hear us prattle about the latest improvements in the treatment of melanoma, give us the same look used to silence the family dog.

I suspect the other reason we get the glare is because of the drubbing we give our patients - the toxicities of chemotherapy. Who would not look askance at a doctor who eschewed the scalpel for a bag of poison? Is this anyway to be kind to people in need?

Until we come up with a bona fide cure for the cursed disease, we oncologists will always have a self-esteem problem. We may dream about sitting on the highest throne in the pantheon, but by Jove, some of our colleagues believe our place is by the ashes of the hearth.

Many strides of course have been made in the search for the cure for cancer, but in the world of the gods it is not enough to show progress. We must show a complete elimination of the disease, or perhaps a metamorphosis - changing breast cancer into a lowing calf, for example, would be a sublime myth to pass on to the generations. Until that day occurs, oncology has been hereby relegated to a minor constellation in the starry night.

I didn't always feel like this. In fact, when I started my training I was on cloud nine, running morning rounds with the team, seeing patients in the clinic, attending lectures purported to be fascinating. As I recall, it was only three months into my fellowship when innocence was shattered. I was musing at the nurses' station one afternoon when a sharp voice cried out over the hospital loudspeaker: "Dr. Hildreth report to the Emergency Room, STAT!"

I leaped from my chair like a wallaby in a thunderstorm and sped down the hall. As I rushed by, various helpful personnel hailed me with greetings like "Hey, don't you know they need you in the E.R.?" My mind raced with the possible scenarios that were unfolding there. What crisis awaited me, to broadcast such an alarm to the entire hospital? I pleaded for strength, wisdom, courage. It is always the oncologist who is asked to perform miracles, I thought, and began to recite the Serenity Prayer.

Blasting into the ward, I announced my presence and inquired as to the problem. A rather annoyed intern looked up from his chart and replied, "Oh, good - you're here. We need you to make the patient in room four a no-code. He has metastatic lung cancer and is going to be admitted."

Like Saul, the scales fell from my eyes and needless to say, the view from this formerly lofty perch was not inspiring. Since that day I have harbored a smallish but powerful nugget of skepticism about the prestige of the oncologist in the grand array of specialists. Nevertheless our work, our search for the cure, will continue - even to the Gotterdammerung of medicine. The final outcome will not be revealed in my lifetime nor in the lifetime of my grandchildren, but when it does occur I will wager that the legions of oncologists who spent their lives toiling against cancer will be pleased to see their names finally added to the register of heroes.

Thursday, January 13, 2005

Do You Want the Good News or the Bad News?

Let's face it - the job of an oncologist could be interpreted by one viewing it through a jaundiced eye as an exercise in futility, especially if this opinion is based on the unusually brief life span of Uncle Joe after he was taken under the caring wings in the summer of '89. True, our triumphs have been modest for many decades but we feel there is no reason for pessimism.

"Oh, really?" sneers the skeptic. "Show me what percentage of patients with metastatic cancer are being cured today."

"Vescere bracis meis!" cries the cancer specialist. Our modern treatments, based more and more on blocking esoteric messengers lurking throughout the cancer cell's command and control center, have produced many encouraging results. Newer treatments have fewer side effects; supportive care has improved tremendously; more and more oncologists are walking into the exam room with the following pronouncement on their lips:

"I've got good news for you!"

Oncologists, long condemned to waddle about in the lowest caste of medical society, are beginning to swagger with a new-found confidence in the efficacy of our weapons. Many of the old nostrums have been replaced with combinations of chemotherapy and targeted therapy agents that are more effective in either shrinking the tumor or simply stopping it from growing. In either case life is prolonged as the disease becomes a chronic condition, to be treated when necessary - so there, you cynics!

What's not to like about this new paradigm?

Am I brimming with vainglorious delight, or what?

I guess I can't hide it any longer.

You see, my pride in the improvement of cancer care is still a hollow one. To illustrate this let me tell you what happened in the office today. I saw a patient of mine with metastatic colon cancer who had just completed his first treatment with a new, highly active combination of chemotherapy and biological therapy. As he jumped up on the examining table he said "I think my lump is smaller, Doc."

This was unlikely to be true. The patient had a bulky midline abdominal mass that protruded from his belly like one of the unfortunates slated for an early death in the movie Alien. Such a huge tumor would typically require at least eight weeks of treatment before I would even dare to check for any reduction in size. Nevertheless, as he lay there and exposed his belly I could see his assessment was right even before palpating the area. The mass, just two weeks after the first treatment, was about half its original size.

With a smile I performed the sacred rite reserved for those who wear the vestments of the Order of Anti-Mitosis-and-Angiogenesis: "I saith unto you my son - I bear tidings of good news."

Yes, I gave him the good news and he and his family rejoiced in this evidence of an early remission. As he walked away I thought about the many months of improving health that lie ahead for him now that it was clear he was responding to treatment: relief of pain, a good appetite, return of vim and vigor - even prolongation of life. As he walked away from me I gave thanks for his reversal of fortune.

As he walked further down the hall, I became aware of a grotesque transformation. I could see his withered frame lying in a curtained room, and could hear soft sobs shattering the quiet. I felt the knotted twig of a bony hand in mine.

This vision of things to come is the bane of the oncologist. I knew all too well that his treatment for colon cancer was not curative no matter how upbeat the news was today, and was haunted by the grief that awaited this man. I delivered hope to a patient whose life was already marked for sacrifice. Because of the continuing limitations of modern treatment, I could not give out the best news of all. As I stood there I felt like a sideshow barker, touting the latest potion to the crowds...not believing a word I said.

This is just one of the many paradoxes the oncologist muses on as he or she goes about the day, assembling a plan to defeat an intelligent enemy, and preparing to play the role of a messenger of hope in a drama that for many cannot be rewritten - no matter how ill-fated the ending.

Tuesday, January 11, 2005

You Be the Doctor

Here's a one question quiz, just to get your lateral thinking skills percolating:

A 57 year old man with stage IV non-small cell lung cancer metastatic to the upper thoracic spine and contralateral lung has recently finished a course of palliative chemotherapy. His follow-up scans show stable disease, which means the tumors are not 50% smaller, but also not 25% bigger.

Two months after his last chemotherapy treatment, during a routine follow-up visit he complains of five days of severe pain in the right sacroiliac region, radiating somewhat laterally to the right flank.

As his medical oncologist, what would you do next in order to find the cause of his pain?

A. CT scan of the lumbosacral spine
B. MRI of the lumbosacral spine
C. CT scan of the abdomen/pelvis
D. Bone scan
E. Fusion PET/CT scan
F. Rent several old episodes of Marcus Welby, M.D. for guidance
G. None of the above

The answer can be found in the comment section.

Thank you for playing You Be the Doctor. Today's episode was brought to you by The Cheerful Oncologist, who reminds you to take care of yourself before you end up in my waiting room...

Monday, January 10, 2005

Listening to Mini-Me

The little voice that resides way up high in my head, assigned the thankless role of acting as my better judgment was busy last weekend. I could hear him screaming and carrying on while I went about my rounds as the on-call doctor. Reproduced below are just a smattering of the admonitions he delivered, edited for family listening:

"If I've told you once I've told you a thousand times - don't let other doctors do your work for you!"

"Oh, so you're going to make an assumption, eh? You know what happens when you assume, don't you - you make an [vulgar colloquial adage censored -Ed.]

"I don't care what time of night it is! If you allow anger to influence your decisions you are a pathetic loser!"

My, but he's unpleasant, isn't he? Even worse, I pay him a royal fortune for his gratuitous verbal abuse, the little homunculus. Why don't I throw him out the left ear, you ask?

You see, he's saved my keister many a time with his obnoxious advice. Can I share with you the most recent example?

The case in point was that of a young college-aged patient who presented with a three week history of mild fatigue, sore throat, enlarged cervical lymph nodes and fever. The patient had seen the family doctor and was thought to have mononucleosis, but was asked to see my partner next week to investigate an abnormality in the white blood cells.

So far, a straightforward course it would seem...

I got involved because late Saturday night the patient drove 60 miles to another town where the parents lived, and then went to the local emergency room to get another opinion. The E.R. doctor yanked me out of the blissful fields of dreamland to announce via telephone that he wanted to transfer the patient to St. Louis because "blasts" were found in the peripheral blood.

Blasts, my friends, don't go with mononucleosis. As I sat up in bed and tried to raise the shades of my bloodshot eyes, I began to respond to the gravity of the situation. I responded (ahem) like the true professional I am - I began to whine. Who wants to see a patient with acute leukemia in the middle of the night anyway? Mercifully this caterwauling also awakened my better half - that little voice of reason who never seems to shut up when all I want to do is tell someone to get lost and then go back to sleep.

After getting chewed out by my doppelganger, I decided to take his advice and accepted the patient in transfer. The sin of Making a Decision in Anger was quashed, and of the three maxims dusted off for my education I was now one for one in compliance.

Unfortunately my batting average was about to plummet.

When the patient arrived in our emergency room the doctor there called with good news - this patient clearly had mononucleosis; why, he couldn't even understand why the patient was here in the first place. I rallied upon hearing this report and asked him tuck everyone away for the night. With not an insignificant smile I curled up under the soft folds and once again aimed the beacon towards Slumber Mountain.

The sin of Making An Assumption had just been committed.

The next day I interviewed the patient just as the Infectious Disease consultant had finished his evaluation. He was convinced that the ailment was indeed mononucleosis - nay, emphatic about it. With such reassurance I wasted little time performing such meaningless tasks like a careful physical exam or a thoughtful review of the laboratory test results. I told the patient a happy trip back home awaited the coming of the next dawn.

I had just committed the flagrant medical foul known as Relying on Other Doctors to Do Your Work.

I suppose you can guess the rest of the story. The following morning when the pathologist reviewed the patient's peripheral blood smear he saw nothing but blasts - with Auer rods, which clinched the diagnosis of acute non-lymphoblastic leukemia. I then sheepishly had to explain how this patient's world was now going to be turned upside down, in a battle to defeat a vicious enemy, instead of enjoying a quiet convalescence at home.

I guess we all have the voice of prudence and perspicacity lying in the recesses of our minds, ready to jump up and defy us in moments of laziness, contentiousness, or hubris. Given the many challenges that await us daily, I predict our ears will soon be burning with good advice from within. Let's hope we have the good sense to listen.

Sunday, January 09, 2005

Cancer and the Wall of Apathy

. . . if someone had come and told me . . . that they would leave my life whole, it would have left me cold: several hours or several years of waiting is all the same when you have lost the illusion of being eternal.

-Jean Paul Sartre, "The Wall"

What happens to the emotional strength of a health care worker, be it doctor, EMT, nurse or other, who sees death day in and day out, year after year? How does one, after exchanging job descriptions at a cocktail party or in the bleachers, reply to this follow-up question:

"How do you do it?"

How do we do what? Do you mean jumping into the chaos of illness over and over again in an attempt to halt some poor soul's path toward the tomb? I'll be darned if I know...

Perhaps the answer will appear if we start out with more questions:

Are we health care providers blessed with divine guidance that fires our souls, or is it supreme patience that allows us to ignore the sorrow raining down all around as we go about our rounds? What motivates us to dare to attack the quagmire of cancer - must we deny the fact that we too are destined for death in order to help the dying?

What if our capacity to care, though is not a product of love, but of a hardening of the heart? What if our ability to cope with dying patients is not a manifestation of compassion, but of a deadening of the human senses - a cold chill of apathy? Such a phenomenon, called "psychic numbing" by Robert Jay Lifton, M.D., was seen after the atomic explosion in Hiroshima by many of the doctors caring for bomb victims.

With our relentless exposure to victims of cancer are we are at risk of growing insensitive to suffering? Does this then make us more efficient caregivers?

The quotation above is from Sartre's short story about a political prisoner named Pablo Ibbieta, who is sentenced to die at dawn by a firing squad during the Spanish Civil War. During the long dark wait he realizes that his death is imminent and begins to hallucinate that he has already died. He accepts his own death, and begins to interact with his cellmates and the doctor sent to observe him as a dead man would. Having lost the illusion of immortality, he finds life on Earth grotesque and absurd. He no longer cares what happens to himself.

So can the oncologist become guilty of an existential defense against the pain of caring for the dying. If he accepts the finality of death but rejects the goodness of our world, the worth of a human life, the joy each man and woman has been allotted by the spinner of our days, he lives as Pablo Ibbieta. Focusing on the inevitable death of his patients, he snuffs out the candle burning within that keeps fearful shadows from dominating his thoughts. Losing the illusion of being eternal, he compensates by adopting a callous weighing of life, as on the butcher's scale. Those who are marked as doomed are tossed aside as worthless scraps. His work, reflecting the staleness of his spirit, becomes mundane and blotched with indifference.

It takes all the power coiled within a health care professional to not let this cynicism ruin his or her pledge toward those in need. How one stores this power, measures the energy, and unleashes it against the Pandora's box of doubts fluttering about the mind when a patient falters or dies is a topic difficult to share. It is highly personal, idiosyncratic, and difficult to translate let alone teach. Those who have succeeded in a health care career understand how hard it is to share their emotions.

Anyone who has the capacity for unlimited compassion, however, must use it even if they cannot describe how they came to possess it so that the afflicted may receive the mercy they cry out for.

Unlike the character in Sartre's story, the oncologist or nurse or paramedic is not under an announced sentence of death. They go about their days with blissful ignorance of a day marked with their name on some distant calendar. For them life still has value. Let this be an inspiration for our good works to continue without estrangement or apathy. Let no bitterness from a patient's death seep into our hearts and poison us. Let us awake each morning with a vow to not waste the day wallowing in angst or indifference, but instead with a vow to use our time well, towards the benefit of one worse off than us.

Several years of waiting is all the same when you have lost the illusion of being eternal.

Several years of serving is not the same. It leaves a mark on the world that lasts long after the servant is gone.

Saturday, January 08, 2005

Why I Am an Oncologist

As the massive train entitled "My Career" chugged along during my third year of medical school, I heaved a sigh of relief. I had finally gained control of the locomotive and settled in, a master conductor now in charge of the journey toward the specialty to which my eternal fidelity had been pledged - Pediatrics. Despite receiving some thinly disguised ridicule from my friends the precocious ophthamologists, I prided myself on my choice. I loved caring for babies and kiddies. In fact, working around the squealing cherubs seemed to rejuvenate me, as if a distant memory of blissful days when life was all diapers and mush had been unlatched. My course was set - the fait accompli was acknowledged and I prepared my sculptor to carve my likeness with a small teddy bear clamped onto the stethoscope.

Pediatrics was hereby tapped as my life's calling. Now all I had to do was finish the rest of my schooling and coast the mighty train toward a top residency program. I began to wear bow ties with little dinosaurs on them.

It was with this admittedly smug attitude that I started my next rotation - on the Cancer Ward, a sober floor placed in a small corner of the hospital. This ward was legendary in breeding agony - uncontrollable sobbing, dark shadows lining the face, shoulders sagging, near apocalyptical melancholy - and that was just in the medical students.

Fighting this aura of foreboding I steeled my nerve, stashed a few happy thoughts in a safe place for future emergency use, and stoked the engine for a four-week tour of the land of the doomed.

My speeding train was about to lurch violently off the tracks.

The first few days on the ward were uneventful. The daily routine was quite predictable. Patients would arrive sick from either one of two possibilities - their cancer or their chemotherapy. No surprises seemed to vex the staff here. I spent my time as efficiently as I could, given the fact that our attending seemed determined to conduct morning rounds at a speed reminiscent of the deciphering of the Rosetta Stone. I began to display the typical signs of a student working on the Ward - a sort of shuffling, reserved attitude of helpless resignation.

Then a patient named Connie checked in.

Connie was a young woman with Hodgkin disease who had relapsed after a prolonged course of chemotherapy including a bone marrow transplant. Seriously ill, her lungs were riddled with tumor and she struggled for breath as she walked. She entered the Cancer Ward in an attempt to reverse this ominous course and I was given the task of attending to her needs while our team devised a plan to attack her malignancy. She wanted to get out by next week if possible, the intern explained to me, as she was anxious to resume her studies.

She was anxious to resume her studies. "What studies?" I asked.

As I stood in the hallway, the resident supplied the answer that forever changed my life:

"She is a fourth-year medical student here."

There is a small window in the development of a young man or woman that opens at a time when a desperate need is present for direction, passion, or a true destiny. Some never even recognize this event, let alone succeed in satisfying the emptiness that cries out "What is my purpose in life?" Lucky is the one who hears the answer; blessed is the one who realizes it as the truth. On that day I was too dumbfounded to grasp that from a distant summit my name had been called. A medical student was being denied the chance to become a healer because of a vile, contemptible disease and I was witness to it. Why was she selected and not me? What could anyone do to prevent this tragedy from unfolding? I pondered on this until my thoughts became a whirlpool of confusion.

Over the next month I cared for Connie and listened to her dreams of a life that we both knew would never be written. I was both her comforter and her torturer - she never knew when I walked into her room whether I was going to chat, or stab her with a needle. The irony of our friendship was obvious as we confronted each other day after day - me ascending to a shining future, she descending into the darkness of ruined promises. A profound sense of shame ran through me, but at the same time my work became more meaningful.

My time on the Ward ended and I moved on. Although I sampled from many interesting medical specialties that year, even before I heard of Connie's death I knew my direction had changed. My arms were now linked with those living with cancer. An unanticipated collision had fused two souls together and started a young doctor on his mission. Connie never realized it, but the final spark of her life was used to light a fire within me that still burns brightly. I hope to continue to use her flame to light the long path down which the oncologist must travel.

Thursday, January 06, 2005

Okay, So I'm Not Sherlock Holmes!

During their education medical students learn the proper way to interview patients, in order to obtain crucial information that pertains to the problem at hand. As those of you in the health care field know, this process is called obtaining the History, which has seven standard parts. They are to be documented in the chart, usually in the following order:

Present illness (a narrative of symptoms)
Past Medical History
Family History
Social History
Review of Systems

We were all taught in school to do a thorough job taking a history, for often embedded within this morass of information are clues that will lead us toward the correct diagnosis. Unfortunately many doctors develop a rather cavalier attitude about the history as they ripen in their careers. Taking a history is tedious, and if the interviewee should look upon this occasion as a invitation to dictate their life story, the doctor will soon decide that the fewer the questions asked, the faster he can get out of the room and on to the next crisis. Shortcuts are found, such as copying the answers recorded by the admitting nurse. Eventually whole sections of the history are skipped in the name of conservation of energy. Such time-saving maneuvers seem to be a neat trick but I believe that one is always better off to put the deerstalker cap on, pull up a chair and listen to the patient's story - for sometimes one small detail can solve the Mystery of the Dyspneic Man.

I was reminded of the importance of taking a complete history by the following case, in which a patient was diagnosed with a malignant mesothelioma without any apparent exposure to asbestos. As you know, asbestos exposure is essential for the development of the cancer. Just for fun, let me present a few details to you and then see if you can figure out what I forgot to ask. I might add that once the key piece of information was revealed I felt like an idiot for not thinking of it, as it immediately answered the question as to where he was exposed to the deadly mineral.

Here are the clues:

The patient is a 60 year old man with a pleural-based mass, a large mediastinal mass and a pleural effusion. Biopsy of the pleural mass revealed mesothelioma.

He has a history of smoking. He works as an manager for a construction firm but does not visit construction sites until they are finished - denying any exposure to asbestos through his job.

He denies helping with any demolition of a friend's house, or working in the railroad as a teenager, or living in a home where asbestos was present or brought home on work clothes. He simply cannot think of any time in his life when he was around such materials that could contain asbestos, and I was stumped at the end of our interview.

One week later, he volunteered a new piece of evidence about his past.

Upon hearing this new tidbit I slapped my head and cried "Come Watson, come, the game is afoot!," lit my pipe and stepped out of 221b Baker St. into the dense fog.

If you would like to guess what part of Mr. Dyspneic's past I forgot to query, feel free to comment below. I'll be happy to pay homage to the first correct answer!

1/7/05 Addendum: answer is posted in comment section.

Sunday, January 02, 2005

How Did Your First Day Go?

Say, do you remember the day you started your first full-time job? Do you remember how you dressed particularly carefully that morning, and how you felt light in the head and heavy in the bladder as you strolled awkwardly down the hall to meet your co-workers? By the time the afternoon shadows crossed your desk you were likely grinning with relief and chanting "I can do this!" more sincerely than a late-night infomercial. Before you knew it you were home, eating a slice or two and talking on the phone with your mother about your new boss. What a restful slumber you got that night! Why, as you sailed off to dreamland you even scolded yourself for worrying about your ability to handle this new chapter in your life.

Now if I was jealous of all you folks out there in the spiffy world of business, computers, law and any other job where wine is served with lunch I might just offer this following heartfelt message of congratulations:

Go jump in the lake!

Far be it from me, however, to douse the spotlights shining on these fond recollections of the dawn of your career. After all on television shows doctors seem to have fun too, springing out of elevators to rescue white-haired grandmothers, and shaming angry young men into dropping their weapon so they can have their face sutured. It seemed their first day on the job was so chock-full of action you would soon find it for sale as a paperback at Wal-Mart.

Well, I don't play a doctor on T.V. but I'd love to tell you about my first day on the job.

Let me think of how to start the tale...

I was a 26 year-old medical student on my first real working day, unqualified to practice the trade I had just spent eight years studying for. Having been anointed incompetent, I was therefore sentenced to three years in an internal medicine residency in a brave attempt to implant such Arthurian skills as wisdom, steadfastness, charity, et cetera so that the governing bodies would minimize their teeth-gnashing when they awarded me an actual license.

With cries of "Godspeed!" then this neatly pressed ambassador of Good Health climbed into his Corolla on a June morning many years ago and rattled off to his first day as a real doctor. I really didn't think it was necessary to memorize the complex of buildings that formed the Great City Hospital, so that morning I pulled into the behemoth for the first time.

Approximately one hour later I stepped out onto the 13th floor where to my delight my boss the director of residents was waiting to greet me - by name, too! What a personal touch he had! He guided me into the intern's orientation session, where upon my entry my comrades went out of their way to disprove the theorem that medical school relieves one of the obligation of sarcasm.

Oh, forget it...

Rather than drag out this sentimental narrative, perhaps it would be more instructive if I were to convert my memories into a short series of reminders designed to help future interns who might be in need of a bit of practical advice on that first day. Without further ado, here they are:

1. The intern's lunch is actually not supposed to come from "whatever you can find on the patient's tray".

2. An intern who wears a white tunic looks like a sous chef, not Dr. Kildare.

3. If the student comes to you and announces "I can't get a blood pressure on her" it is best to skip the rest of Jeopardy! and investigate chop-chop.

4. Any patient admitted at night with both fever and headache gets a free lumbar puncture, but not until 5 A.M.

5. Coffee can be kept potable by adding either orange juice or chocolate milk to it, but not both.

6. No song has ever been recorded that can gladden the soul at 3 o'clock in the morning.

7. The first thing to do at a cardiac arrest is to make sure you are not touching any part of the bed made of metal.

8. Never announce to the Chief Resident that your patient is now on "vulture precautions".

9. If you meet a female patient with golden slippers and blue hair, you may as well don a tuxedo and call yourself "Jeeves" for the rest of her stay.

10. If nothing else, remember the intern's Golden Rule: "A shower is worth an hour of sleep."

Mercifully all young doctors survive their first experience on the wards even if it lasts well into the next day. I guess what makes the intern return day after day to the ivory tower for more drudgery is the sense of pride he feels in his work.

Nah, that can't be it. What makes an intern return is the chance to laugh at it all with his fellow doctors. I came back, and I'm still laughing...and still working.