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.


At 10:34 AM, Blogger Texas Libertarian said...

Doc! Good job on leading us to the sympathetic "red herring" before lowering the boom of reality and revealing one of the more useful tools of professional development.

This blog reminds me of an annual "workshop" I attend wherein various professionals, in my field, are solicited (in some cases they solicit workshop coordinators) to present their research and findings to a group of peers in much the same manner as your Tumor Board. Some of the presentations represent months and even years of research into the various scientific aspects of the study and control of in-use vehicle emissions.

The format of the workshop is such that the presenter is allowed 10 minutes to summarize their work before the floor is turned over to a couple of hundred peers who then spend the next 10 minutes (or so) ripping your hard work to shreds -- or, as you suggested, in the event of a well-received product, just a few minutes of grumbling.

When I first started attending this workshop a few years ago, I was taken aback by the seemingly vicious and uncharitable attacks on a person's blood, sweat, and tears. However, I've grown through the years to understand, appreciate, and value the necessity of unvarnished criticism from my peers.

Thanks for making me smile this morning.

Grace and Peace!


At 12:49 PM, Blogger Orac said...

If oncologists think tumor boards are intimidating to newly minted doctors, they should try having to present at surgical morbidity & mortality (M&M). Now there's some full body contact "discussion" of surgical compications!

At 5:26 PM, Blogger Michael Rack, MD said...

Great post. I didn't know oncologists in private practice went to tumor boards.

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