Thursday, March 31, 2005

Death Be Not Proud

The Enterprise's loudspeaker popped once and Captain Kirk's voice rang throughout the ship as he made the following announcement:

"Ladies and gentlemen, I've got some bad news and some good news. The bad news is that our engines have overheated and will explode in about an hour. The good news is that I have ordered all crew members to stop working and join me for champagne and caviar."

Shouts of "Hooray!" were heard throughout, and dancing couples appeared in the corridors. "I've never seen such a happy crowd," remarked Sulu.

"Highly illogical," said Mr. Spock.

Every so often a patient will make a comment so incongruous that it freezes me in mid-thought as if I was doing a double-take in a silent movie. This moment of paralysis is usually followed by the appearance of a ticker tape headline inside the mind announcing "THIS STATEMENT IS INCONSISTENT WITH REALITY...BE ON ALERT FOR PATHOLOGICAL DELUSIONS." Often the alarm goes off simply because a patient disagrees with what I feel is a brilliant plan to combat the malefactor cancer, and we all know that a doctor's judgment is only slightly less stupendous than his size XXL ego. Surely only a deranged mind would reject a chance to experience the wonders of modern medicine. Even more peculiar is the patient who seems oblivious to the perils that lie ahead once the body is defiled by malignancy.

As an example I offer the case of Mr. X., who had lung cancer that had spread to the liver and was recently hospitalized after developing severe back pain. As if things weren't bad enough, his latest scans showed new tumors on the spine - an awful complication that can cause terrific suffering. Two days after admission, though he smiled as I strolled into his room. "I've never felt better in my life," he said. "I feel wonderful - I'm going to beat this disease; I just know it."

As I stood there in front of him holding a radiology report that was about as encouraging as a military dispatch to Berlin in 1945, I felt ashamed because part of me wanted to ask him what on earth did he have to be so joyous about? After all, one could state that my main excuse for being so tra-la-la annoyingly cheerful is because I am not living with cancer. My patient, however, in the absence of a deus ex machina was doomed. What therefore was the source of his optimism?

Maybe my focus was off, and the question I should have asked was: what is the message here? This brief scene, hardly the pivotal sequence of events in the unlikely event our relationship was ever transcribed into a Broadway play, on the surface seemed insignificant and easy to explain. The patient was obviously in denial as a defense mechanism against the agony of looking into the future and seeing only the abyss.

That summed it up quite neatly - except for the fact that I didn't buy into this denial theory. He had no aura of fear about him - in fact, he was genuinely happy. Rather than sit on the man's bed and meow out a few platitudes of counterfeit support I decided to hold my tongue and ponder further. I considered the possibility that his Pollyanna outlook was merely a reflection of his personality, that he was one who cried "Get thee behind me!" to any dark thoughts that had the audacity to slither up from the cellar in an attempt to spread melancholy. Yes, that made perfect sense - he's that fellow with the rose-colored glasses they write country-western ditties about.

Or was it something else?

The sound of his voice stayed with me as I drove home that afternoon. Something within it seemed to be reaching out, not just to me but to the world. I remained puzzled until I finally practiced what they preach in the more fashionable medical schools, viz. the art of empathy. I put myself in my patient's place and suddenly the source of his euphoria was as clear to me as the stop sign I just ran.

He was expressing gratitude - gratitude for his remarkable relief from pain, for the powerful treatments against cancer that exist for his assistance, for the chance to be discharged and return home. In his own way he was giving thanks for the gift of life itself, even if this life was destined last no longer than the turn of an hourglass. When one lives with this deep appreciation of life every minute is a feast to be savored, every step an affirmation of the strength and independence of the human spirit. With this attitude even death itself becomes puny and pathetic, for its power over us is only through fear, and once our fear is gone, then just as the poet Donne replied about eternal life:

And death shall be no more; death, thou shalt die.

Sunday, March 27, 2005

The Gardener

By the time the man slammed the truck door with a satisfying "whump" and squinted at the cloudless sky the heat had wrapped itself around him as if he had sat too close to a campfire. He dropped the rear gate and began to carefully gather up his tools. After walking down a long set of wooden steps, he carried his rakes and shears across a narrow path to the crest of a hill where he saw a vast garden shimmering in the sunlight. Clusters of flowers bunched in front of him like giant piles of laundry. He traveled back and forth on the path, stacking bags of fertilizer next to spreaders and trimmers. When he had emptied his truck he stood smiling in front of the sea of color before him, grabbed his clippers and passed through the gate. Pulling off his gloves, he bent over a rosebush and dipped his nose into it. His eyes widened, and he quickly began to touch each flower, folding its petals between his finger and thumb. He rushed through the greenery, slapping at gladioluses and tugging on lilies. After a while he sat down at the entrance with his chin in his hands. As his shadow crept toward the beauty within, he surveyed the garden with amazement and disappointment - for it was filled with artificial flowers.

There is no quicker way to make oncologists feel worthless than to place them in a room filled with healthy people. Don't get us wrong - we love the idea of a world free from cancer, but until that miracle occurs we expect to be worked, and worked hard. Oncologists exist for two reasons - to help cancer die and to help cancer patients live. Deny us the opportunity to perform these tasks and we will shrivel like a pot of neglected geraniums. We are sustained by our duties toward our patients.

This would explain the strange sensations I had while lounging around on the beach last week. I didn't ponder much on it at first but after a few days could not help but realize that everyone at this resort looked perfectly well. It was as if I had been transported to the Land of the Healthy, which is not a particularly bizarre concept since the great majority of people one encounters during a typical day appear to be in similarly robust shape. This land, though, is not where oncologists reside and I felt as if I was on a space journey as I lay on the sand surrounded by healthy bodies of all colors (including pale and red). After spending years caring for people with cancer I felt adrift in this sea of baking merrymakers. Not one person there had any reason to ask for my assistance.

So why not just relax and enjoy the break from the stresses of the job?

Sounds fair to me - so relax I did, returning day after day to the hot sand, squeezing in between middle-aged men and teenagers, listening to idiotic conversations on cell phones (which are de rigueur apparently), watching parched families languish in the noonday sun as their orange flags marked "Beach Service" went neglected, reading the flying ads for 25 cent beers trailing behind a continuous stream of noisy airplanes. I rested well - and not a moment too long.

The oncologist on the beach is like the gardener at the flower show, for each backdrop delights the eye with displays of luster, vigor and beauty. At the end of the day however, both doctor and horticulturist hurry to the place where their tools rest, waiting to be put to use by sun-tanned arms. For those who tire of lying around, this wonderful place is where reality is sown - and the true meaning of life grows.

Saturday, March 26, 2005

Heavy Air Traffic + Thunderstorms =

...a long, long day for The Cheerful Oncologist, who dragged his weary (but tanned) corpus delecti back to St. Louis - arriving home at 2 A.M. today. I didn't even break my personal record for waiting for a flight at the airport. Seven hours of cooling the heels in a smallish airport with only one restaurant is nothing compared to the stories from some more seasoned air warriors - so technically speaking I have no right to complain!

My next essay, entitled "A Wanderer in the Land of Happiness" (or something like that) will magically appear as soon as I write it (yawn).

P.S. -to all those beachcombers reading The DaVinci Code - get a life! Try reading Young Adolf by Beryl Bainbridge, or The Mating Season by P. G. Wodehouse, or Relativity Demystified, by ... [at this point our narrator's memory failed him. -Ed.]

Tuesday, March 22, 2005

Florida Update

After years of caring for patients with malignant melanoma it is hard to avoid ruminating on this disease as I repose under the rays of old Sol. I have always considered melanoma to be the most inhumane of cancers because of its relentless attacks on any and all organs.

Thus the tubes of 30-spf and 50-spf that lie scattered about our hotel room. Is an oncologist a hypocrite if he tans? I certainly wouldn't want to be placed in the same catagory of those cancer docs who smoke cigarettes (they do exist, you know, thereby demonstrating that those college lectures in Psych 101 on cognitive dissonance were not just fluff).

I suppose the twin mantras of "protection" and "moderation", if followed judiciously, justify succumbing to the supine position for a sunshine slumber.

Signing off for now,
The Pale Oncologist

Saturday, March 19, 2005

It's Spring Break Time!

The Cheerful Oncologist wishes to announce that he has been forced to go to sunny Florida for a week of frivolous omphaloskepsis. If he can find a computer with internet access on the beach he will send updates of the tomfoolery taking place.

Otherwise, he'll see you all next weekend. Danke schoen!

The Dinner Meeting

Unlike the Prince of Wales, medical oncologists do not have particularly crammed social calendars. To use the analogy, if the Prince's evening engagements are like a vast buffet of exotic culinary creations shimmering on satin-covered tables and glowing beneath candelabras, mine is a baloney sandwich on a paper towel - with no mustard, because I forgot to buy it.

There is one invitation though that if viewed at the correct angle becomes an oasis of earthly delights on an otherwise dreary weeknight. That is the dinner lecture, which is provided absolutely free of charge to any and all practicing doctors who can fill out the R.S.V.P. and find the restaurant - two tasks that laypeople might take for granted, but absent-minded oncologists do not. I rarely attend these lectures, mainly out of consideration to my family, but recently received an invite that contained the two requirements for an evening of pleasure: the topic and the restaurant both were appealing. I therefore scribbled my name on a reply and circled the date on my calendar, while visions of victuals danced in my head.

When I say I don't frequently leave the homestead I mean it has been years since I entered a noisy chophouse on a Tuesday night. I presented myself to the front desk, which was surrounded by a dozen or so young hostesses all dressed in black - combining the twin business concepts of maximum assistance plus chichi attitude. It took four of them to escort me to the "private" room in the back of the place. The clinks and laughter of the paying customers eddied behind me as I walked through the doors. As I surveyed the crowd my smile immediately shifted downward a fraction, like a rock formation preparing to crash into the gorge.

The room was packed with strangers of every shape and size, all boisterously waving glasses about. They all seemed to know each other, and did not exactly turn and applaud as I entered the room. For a brief second I felt as if I should be wearing a fez. The lecture was just about to start so I was unable to find a friend let alone slap any backs. I squeezed into the only seat left in the rows of narrow tables, which was way up front and to the left of the lecturer's screen. As I looked around I recognized only a handful of the attendees. Many of them seemed to be of high-school age, or was it just my wizened visage in comparison? The speaker was introduced and I set my wine glass next to a plate of what appeared to be seaweed dip surrounded by doggy biscuits. The room settled into a sine wave of respectful attention. The lecture began.

Dinner lectures such as these are always sponsored by a pharmaceutical company - no surprise there, since doctors are not known for their legendary check-grabbing let alone paying for their own chow. The speaker always discloses any financial relationship with the company sponsoring the show and then is free to comment on the product as he likes, although it is rare for any lecturer to announce that the featured drug is about as helpful to mankind as rearranging deck chairs on the Titanic. As our expert began I realized that my viewing angle was quite skewed due to my proximity to the wall - it was like trying to read a billboard while on a merry-go-round. I settled into my salad which was on a plate shaped like an isoceles triangle. This may be the latest trend in china but I found it frustrating and was unable to keep my arugula from sliding onto the tablecloth. I thought of asking for another serving so I could push the two together, making a parallelogram. This might increase my fork-to-mouth ratio.

The lecturer droned on, and after about 45 minutes I sensed that he was only partway through his topic. This is a violation of the dinner meeting, which as any doctor knows should contain a speech of no more than half an hour so that the convival proceedings can resume during the entree, or at least dessert. The faces in the room were still rapt but I sensed an embalming of the ambience as the slides flashed on and on. If there had been a clock in the room its ticking would have echoed off the walls, each second beating out the rhythm that we were all too timid to announce: "dull...dull...dull...."

After ninety minutes - one and a half hours of attempting to decipher slides with abbreviations like CRTX and LVDI the crisis hit me. Two crucial parts of my anatomy cried out for attention, each jostling to be the first to plead their case to me. My keister was killing me, and the wine and water I had consumed had reached their final destination before returning to Mother Earth.

This was going to be trouble because the only way I could sneak out to the restroom was to pass directly in front of the speaker. Surely no guest could be so brazen as to commit such a breach of decorum. As the suprapubic aching increased drops of sweat began to bead about my temples. Just before I reached the point of no return two amazing things happened. First, the doctor on my right got up and walked right in front of our lecturer, using a pace that betrayed any attempt at hiding his intentions. Second, my entree was placed in front of me and for some mysterious reason the salmon I had ordered had turned into a big pile of beef. I don't like beef.

The night air contained just the faintest hint of flowers as I found my car. Spring was late this year and seemed to be just about ready to burst through the manicured gardens and forests of the city. It would be wonderful to once again enjoy the warming of the earth, but as I drove on home I thought of the cooling of my abandoned steak, lying on its plate, surrounded by elbows digging into their dinners. I wondered if the waiters would offer it to the dinner lecturer, for I figured by the time he finally finished his dissertation the restaurant would have long been emptied, with only a forgotten coat or two remaining in the cloak room as a reminder of the evening. Perhaps it is not so bad that only one person gets to be the Prince of Wales. There's something to be said for an early supper, a chapter or two of the latest thriller, and a quick bon voyage to dreamland.

Thursday, March 17, 2005

Where Ignorance is Bliss...

"A person is never happy except at the price of some ignorance."

-Anatole France

Those who are considering a career in medical oncology need more than intelligence, diligence and imagination to succeed. Doctors who walk through the doors of a cancer ward should bring the twin virtues of empathy and composure with them in order to care for the patients lying within. What does it mean to practice medicine with these traits? By first reviewing the definition of these words one can appreciate their importance in the field of clinical cancer care:

empathy: "an individual's objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others."

composure: "steadiness of mind under stress; self-possession; a calm and tranquil state of mind."

Empathy is therefore the ability to imagine oneself as the patient and ask, "How would I feel if I had this illness?" Composure is the mental strength used to reject communicating such emotions as shock, displeasure or arrogance when exposed to beliefs or actions that conflict with one's own code of values.

Given the stresses of clinical medicine, most physicians have ample opportunity to hone these skills daily in their work. I can imagine no better way to display these two important traits than to care for patients who have delayed seeking medical attention - who have concealed the signs of cancer from the outside world. Such patients usually stupify their doctors, who cannot believe that anyone suffering from obvious symptoms would not reach out for assistance. These patients may be unable to accept the diagnosis of cancer - called denial. Some of the research published about denial suggests that it "may at times be a healthy and adaptive response to illness", allowing patients to cope more effectively. This reaction should be distinguished from avoidance, seen in patients with what I refer to as ignored cancer. Avoidance is defined as postponing the day of reckoning by concealing a tumor from family and friends. By the time an oncologist sees a patient with ignored cancer, the disease is at risk of being so advanced as to be incurable. This is called a tragedy.

There is a danger, however, in encountering such patients, namely that doctors may become so angry as to sever the bond needed between each in order to provide compassion, counseling and other humane care. It would seem natural for physicians and even family members to react with shock and derision at patients who have avoided seeking medical attention. To respond in such a manner is foolhardy and serves to only uncover weaknesses in character. We are better off to use the skills of empathy and composure, but how do doctors learn to set aside their prejudices? Must they attend a course on learning coping skills? Is there a secret to caring for patients who have secrets?

Hey, what do I know? I'm just a country doctor, not a psychiatrist!

This doesn't mean I don't have an opinion, of course. Let me give an analogy about meeting patients who have delayed their diagnosis of cancer:

A patient who is found to have an ignored cancer is like an automobile accident. Shock and disbelief fill the mind. Anger is directed at others for the predicament. Emotions run high. Fingers of blame are pointed. Pain and suffering occur. People are inconvenienced. Sometimes life is never the same.

No matter who is to blame for the calamity though, somebody has to show up and clean up the mess, triage the injured and get traffic flowing again. This is what oncologists do. We are the traffic cops and tow truck operators of the cancer universe. We get people moving again down the road to good health whether they come to see us early or late in their illness, without holding a grudge against them.

Empathy and composure are the keys to aiding an accident. Doctors who embrace these traits will not let petty emotions distract them from finding the healing that their patients also seek, even those patients who wait until the last minute to disclose their desperate need.

Tuesday, March 15, 2005

Now Playing at a Theater Near You!

The following fantasy is brought to you by:

Chemo4Victory Films, a wholly-owned subsidiary of T.C.O. Pictures, Inc.

(Agents and producers who read this are asked to contact the screenwriter's attorney, Mr. Dewey Cheatham N. Howe, for information about the screen rights, etc.)


Plot Summary

Prologue: The delightful village of Blissful consists of cottages and townhouses carved out of the rolling hills beneath the Gray Mountains. It is home to a lively population of professionals and office workers who on a typical day can be seen bustling about the streets, where the shouts of children playing in school yards can be heard half-way down the valley. The candy cane scent of honeysuckle mingles with the smell of innocence found in each yard. Steaming platters of beef warm the air of many Sunday afternoon dining rooms, and afterward men and women alike enjoy a smoke on the front porch. In the evening the taverns are filled - teenage boys hang out in the street, taunting any patron who lurches or stumbles on his way home. Blissful is named by the governor as the "Most Typical American City" for 2005.

Act I - The Attack: Unknown to the village, the pounding of hooves rumbles across the prairie grass in the valley as dark clouds roil in the distant sky. A large army of assassins on horseback charges toward Blissful. Their black armor flailing in the wind, they begin to climb the hills. Some warriors carry standards with words on them - Lung and Breast are frequent. One lone rider on a giant black stallion has Stomach woven on his tremendous cape. All are marked with the letter C on their chests.

The invaders swarm into town, slashing some townspeople and snatching up others. The villagers wilt beneath the onslaught. Some of the dark riders named Lymphoma grip necks or waists and refuse to let go. They drag their victims through the street, squeezing them tight, careful not to kill them. As night falls, flames flicker in the reflections of shattered glass.

Act II - The Call for Help: The first light of dawn reveals a vast camp high in the peaks of the Gray Mountains. A sentry hears the sounds of footsteps and challenges - he meets a tattered messenger from Blissful, who relates the attack, then falls into the dust. On his back a hideous beast gnaws at his neck. It wears a medallion entitled Melanoma. The sentry rushes into a large building. Soon a tremendous army is mobilized. The soldiers and officers all wear crosses of red on their uniforms. Tanks and airplanes take off toward the village; artillery is towed down the mountain pass. The roar of the division thunders off the cliffs as it rolls toward the village.

Act III - The Battle for Blissful: By noon the assault is raging - the screams of dropping bombs compete with the shrieks of the wounded. The Healing Army dispatches its different brigades to exterminate the invaders. Chemotherapy shoots flamethrowers in all directions, sometimes burning both villain and villager together. Surgery rides with giant swords, hacking the fiends off of citizens; the deadly humming of Radiation can be heard as it points its giant beam at a fleeing group named Seminoma. Biological Therapy releases locusts that swarm around the enemy, sparing the villagers. The afternoon boils with the heat of a thousand battles

Climax: The point of exhaustion has been reached. As shadows darken the streets and fields, the two armies halt and face each other. The devastation is widespread. As the leader of the Healing Army surveys the scene, he comes to a horrifying conclusion:

Most of the villagers who were assaulted are dead and only a fraction of the dark army's warriors have been killed. The grinning invaders stand at a distance like obsidian chess pieces, waiting for the next move. The two formations withdraw into the twilight.

Epilogue: High in the mountain camp, scientists conduct experiments with new weapons: anti-angiogenesis agents, growth factor inhibitors, gene therapy. The village slowly repopulates and soon laughter is heard once again in the homes of Blissful. A tall tower is built at the edge of town, and each night a volunteer scans the distant horizon, his arms aching from the heavy binoculars that search for a distant cloud of dust. He cups his ears to listen for the faint sounds of drums in the night.

(with apologies to the following people: Dante Alighieri, Sherwood Anderson, J. R. R. Tolkien, Ian Kershaw, Ernest Hemingway, Winston Churchill and M. Night Shyamalan)

Friday, March 11, 2005

An Oncologist Goes to the Doctor

I believe I can state with complete honesty that I have never seen a barber that looked like he needed a haircut. This makes sense to me. A barber in need has but to plop himself in one of his fellow clipper's chairs, peruse a copy of Esquire for a few minutes and voila - his topmost part once again glimmers like the curls of Michaelango's David; then it is back to work chopping away at teenage brush or delicately snipping the last surviving stalks of the septuagenarian.

Contrast this with physicians, many of whom look like they should be wheeled into the nearest emergency room. Who knew that legions of doctors live in denial of their own various medical problems? I have seen trenchermen waddle around nurse's stations like bears navigating an icy river. Others slump over charts, grimacing as they scrawl out orders rivaling those from a World War II Enigma machine. Doctors love to avoid becoming patients. I believe the medical term for this is neglect. After looking at one particularly gruesome mug - sallow, waxy complexion, dark bags under the eyes - I asked myself, "Why doesn't this guy get a checkup, for crying out loud?"

Unfortunately I was peering into my bathroom mirror at the time. All I had to do was grin and they could have used me as a poster for socialized medicine.

Rather than call for make-up I decided to take this advice. I made an appointment with my doctor and within the month, dressed in jeans and a tee shirt I strolled into the waiting room of his large office. As I introduced myself to the receptionist she asked for my insurance card and said, "Mr. Hildreth, please take a seat. We'll call you when we're ready." I found an empty chair next to a large man in camouflage overalls and an orange baseball cap. We looked like Laurel and Hardy on a deer hunt. Like most of the crowd in the room we nervously eyed the door to the exam rooms. A nurse soon appeared and bellowed out a name. An elderly woman sitting next to her jumped, ripping her copy of Time in half.

Did I hear correctly? She called me mister - Mr. Hildreth. Why, I'm a layperson again!

After a week of seeing patients and answering millions of questions I relished the thought of going through this visit anonymously. I smiled slyly and wondered how long I could go without anyone knowing my true occupation; after all, we medicos have big egos. Maybe I wouldn't be able to carry out the charade. I decided to give it a try - to fake being a normal person and see if the employees treated me differently than if I had brought a bullhorn and announced "WATCH OUT - I AM A DOCTOR!" Of course when my physician walked in we spoke as peers, but otherwise I kept my mouth shut. I simply hoped for a quick and easy office visit - not unlike the children's book that inspired my lifelong devotion to the healing profession. In fact, I chronicled a few observations from this typical office check-up - merely for general interest, not necessarily to be remembered as the complaints of a whiner:

1. The quickest way to get one's name called is to start reading magazine articles with titles like "Keeping Your Love Life Hotsy-Totsy", or "Medical Oncologists - Why They Deserve Our Everlasting Praise".

2. Exam room posters displaying illustrations of male anatomy or people choking do not exactly create a cozy atmosphere.

3. Male patients who must undress should remember to wear white boxer shorts, not the red ones with the blue whales on them (nolo contendere).

4. Any staff member who avoids eye contact does not have to worry about what to wear at the Employee of the Year banquet.

5. Is it just me, or do medical office personnel use the same tone of voice as my 5th grade teacher - the one who could drop a goose in mid-flight just by calling the roll?

6. This isn't a recording studio - the walls are thin enough in most offices to permit one to hear how Mrs. Jones' hemorrhoids are behaving this month. (I must remember not to speak with the same voice I use to call the hogs back from the hollow).

7. Nurse practitioners, interns, medical students and other supporting cast members should identify themselves before sticking their hands in a patient's armpits or other delicate intertriginous areas. It serves to reassure us that the whole episode isn't going to end up on some reality TV show.

8. Patients who read of a new medicine have a better chance of getting helpful advice from the doctor if they bring the information with them, rather than say "You know, doc, it's that thing they gave to all the baboons in China." This doesn't narrow it down much.

9. I miss the good old days when doctors all got free health care. Now we stand in line to shell out our 25 bucks to the cashier like we were at the two-dollar window at the track.

10. It's okay for doctors to pry into patient's lives. Tell us our blood pressure is too high, that we drink too much, that we need to stop smoking and exercise more - we can take it. We want to confess everything! As a wise physician once said, "Catharsis is the first step toward continence". (Funny how these guys come up with such alliterative apothegms).

The saddest part about my visit to the doctor was the ending, for as I swung through the revolving doors and stepped onto the tarmac-like parking lot my beeper went off, just as it has done for the past twenty years. My masquerade was over. I had crossed the river Lethe but had failed to drink from it, thus ensuring that my former life as Mr. Hildreth would rest in memory like a beloved costume from a party long ago, never to be worn again.

Wednesday, March 09, 2005

Medice, Cure te Ipsum!

I could tell at a glance that my patient had lost weight. He was heavy to begin with which made the difference in his appearance more dramatic, plus his pants displayed that the general theory of relativity was not an idle daydream cooked up by a bored patent officer. The sagging trousers had succumbed to the alluring pull of gravity as he hopped up on the exam table. I examined him and saw that his feeding tube was in proper position.

"Your pants are too big for you! Are you using your jejunostomy?" I asked. He replied that he wasn't, which seemed to explain the lighter version of him that sidled into the office that day.

"You need to keep up your good nutrition," I said. "If you feed yourself regularly you'll help the cause. I need you to take care of yourself just as much I take care of you."

He pledged to restart his liquid meals and joked with me as he gathered his newspaper. I followed him out into the hallway where he turned to me with a grin and said, "So I take care of me and you take care of me, but who takes care of you?"

I laughed at the remark but then stopped in mid-chuckle as if I was a cartoon character who had walked off a cliff and just realized it. I stared at the wall like a mounted fish, and began to consider his question.

Yes, who does take of doctors? Do we just assume that doctors are infallible, that they are immune from illness, stress, pain or depression? Of course not - so where do physicians go to refuel themselves, to rekindle the fire that drives them to serve those who struggle against misery and infirmity?

Much has been written about the impaired physician, the definition of which centers around aging, illness and alcohol or substance abuse. Many resources are available to care for them, but what of the vast majority of doctors who are not sidelined by such problems? Who looks after the "normal" doctors, who toil year after year with little recognition of their work? How do they keep themselves fresh and interested in their career, let alone life? Who is their caregiver? The traditional sources of support for workers - family, friends, colleagues, faith - are certainly important in fulfilling the lives of doctors, but is that it? Is there anyone else (short of a visit from God) who is willing to help protect, nurture and defend us? Where is the fons et origo of our strength, wisdom and fortitude?

Perhaps this is a subject for debate. If so, let me fire off the first affirmation: Who takes care of doctors? Doctors take care of themselves.

The happiest doctors, in my opinion, are those who work side by side with a wonderful partner - a partner who listens to their concerns, provides them with wise counsel, helps them relax in times of stress, flashes a bright sense of humor, and always makes sure that they find the way back home. That partner is themselves.

Doctors are proud people to begin with and if they also are smart they will form a bond of respect with this noble healer who works so hard, so that there will always be someone around to monitor for stress, discouragement and laziness, someone who will whisper in their ear:

"Eat healthy...go work a crossword a book and read to your your parents...get some sleep..."

As my patient left the office I thought once more of his query and smiled. The prime objective of patients when they hire physicians is to make sure they are doing everything possible to bring about healing. The best doctors are those who not only strive to heal patients, but who also take the same advice they dispense daily. They work in pairs with their better halves - their values.

Monday, March 07, 2005

Smoke, Smoke, Smoke that You-Know-What

Medical oncologists are often asked to see patients who have abnormal physical findings or x-ray results but have not yet been diagnosed with a particular type of cancer. Sometimes when a malignancy presents in multiple locations it is difficult to determine where it originated. If the source of the cancer can be found then the treatment can be better tailored for that specific type. Since doctors love to show off their powers of deduction and intuition they usually rise to this challenge and begin to hunt for the clue that will solve this mystery. The denouement can be surprising and sometimes change a patient's prognosis for the better. For example, I remember a patient who had to undergo exploratory surgery for a pancreatic mass after a needle biopsy was unrevealing. He was found to have pancreatic lymphoma, not the typical devastating diagnosis of carcinoma. He achieved a complete remission with relative ease.

Before recommending scans or operations though oncologists must conduct the ancient and hallowed rite called the taking of the history. During this crucial interview they seat themselves before the patient, nodding in a rhythmical cadence while they listen as if wearing a Roman collar. Crucial information about the patient's symptoms and medical past are recorded and then a key question is asked which brings a pause, like a penitent admitting a mortal sin in the dark-curtained booth. The confessor's response can frequently portend both the final diagnosis and the prognosis. The question is, "Do you smoke cigarettes?"

Patients who answer yes can be considered to have lung cancer until proven otherwise.

I happened to meet such a patient recently who had multiple lung nodules on chest x-ray. The source of these nodules was not apparent and I considered several possiblities, but as we reached that point in the interview and he replied that he had smoked for over thirty years I realized it would be foolish to consider any other type of cancer - he just looked like someone with lung cancer.

"Doc, I haven't been sick my entire life but for the last couple of weeks I've been coughing and getting short of breath," he said, "and my right hand is cramping up on me." On exam his right hand had more than muscle spasms - it was nearly paralyzed. Within a day he was diagnosed with non-small cell lung cancer. The remainder of his life could now be seen as clearly as a mountain appearing out of the misty clouds, a coffin resting on its peak.

How did this man end up sitting in my office rubbing his claw-like hand, waiting for me to schedule a CT scan of his brain to confirm what I almost assuredly knew? Would he have chosen to smoke all those decades ago if he knew he would die from lung cancer? It seems unlikely that any sane person would but one forgets the stranglehold myopia has on the young, who are essentially incapable of visualizing themselves as old let alone dying.

Those who take up smoking in their teenage years may know it is unhealthy, but can they actually perceive how awful the consequences will be if they contract a tobacco-related malignancy?

I imagined my patient as a young man just out of school and starting his adult life, buying his first pack of cigarettes after work and unwittingly taking the first step toward a ghastly and ignoble death. An allegory about cigarette smoking suddenly appeared before me:

Deciding to smoke is like standing before the road that represents one's life, admiring two giant limosines parked side by side. A chauffeur stands beside each open door, beckoning riders to enter. One vehicle is marked No Smoking and the other has a sign on it that says Smoking Allowed. Some people choose the former car and others enter the latter and light up as the limos take off. Both cars speed down the road of life which wanders through hills and valleys, curves and straightaways, all signifying the major events of life - the highs and lows, the difficult times and periods when life was easy. The cars climb up higher and higher - the road becomes narrower. Up ahead the riders see a nasty hairpin curve. It is marked with a huge sign consisting of one letter only - "C". As the limosine full of nonsmokers hits the curve it squeals, fishtailing across lanes before finally regaining control and continuing to hum on down the highway.

The other vehicle flies off the cliff like a condor soaring over a valley, then tumbles down the mountainside, disintegrating as it rolls. Muffled screams echo briefly across the canyon before falling silent.

Not all smokers die of cancer, of course, and not all cancer victims are smokers. But those who decide to become addicted to the "coffin nail" should take a moment to ask themselves:

"Is it too late to change cars?"

Medical oncologists are like homicide detectives. We can find out how a death occured and why it occured. We just can't bring the deceased back.

Thursday, March 03, 2005

Kicking Sand in My Face

The patient sat across from me in the room as I read the consultation report from her visit to the World's Greatest Hospital. She didn't look sick but in fact was suffering from inoperable primary liver cancer - a type of malignancy unresponsive to standard chemotherapy. Her tumor was so widespread as to preclude any attempt at eradication with modern treatments such as chemoembolization, therefore I had promptly sent her off to the academic cancer center to determine if she could enroll in a clinical trial. At the center they were offering treatment with a novel targeted agent, but there were no guarantees of response - the study was designed mainly to see if the therapy had any effect against the tumor.

The consultant had given my patient a consent form for the trial, but as I questioned her about it she gave me a determined look.

"I've decided against taking that treatment."

I asked her why and she replied that she didn't like all the testing that had to be done as part of the study. Although I was disappointed this seemed to be a legitimate reason. After all, who am I to push an experimental treatment on a reluctant patient? The only problem was that I still didn't have any recommendations for treatment that I felt even a modicum of enthusiasm for.

Just as I was about to launch into a discussion of the use of supportive care, she interrupted me.

"The doctor there said I could take some new kind of chemotherapy if I wanted to - look at the report."

I glanced down and realized I hadn't finished reading the final page. Sure enough, he had suggested treatment with a drug called liposomal doxorubicin. I felt a twinge of panic as I placed the chart on the stand. Liposomal doxorubicin? Why hadn't I looked into that? As I discussed the possibility of using this drug I felt like that 97 pound weakling in the Charles Atlas ads from long ago - a "skinny scarecrow" oncologist compared to the muscular professor from the mecca of medicine.

Still...despite my wide-eyed admiration of this sage and ingenious recommendation, somewhere deep in the vaults of my brain a skeptical neuron stood up and shouted for his comrades to awaken. Before my patient could even stand up to leave a spark appeared in my eyes and I began to rub some second thoughts about this therapy out of my chin. I told her I would consider giving her liposomal doxorubicin but first wanted to investigate its success rate. She agreed with this plan and arranged to see me in a few days.

No matter from which lofty peak a new treatment recommendation comes - even from Olympus itself - the doctor in charge of a patient's care is obligated to investigate said treatment to determine if it has been proven to be effective in clincial trials. This is called practicing evidence-based medicine. It is the polar opposite of the recommendation that starts out with the phrase "Heck, I treated a patient once with [insert dubious therapy here] and he did fine - lived for twenty years after that..."

Being a disciple of this evidence-based method of practicing I looked up the precious liposomal doxorubicin chemotherapy for hepatocellular carcinoma (it took me ten minutes just to type it into the search engine) and lo and behold! The agent has been studied in at least three clinical trials, and not only did the response rate range from 0% to 10% (trust me when I say zero percent response is not an auspicious beginning for a new cancer treatment), all three papers concluded that l. d. has no benefit for patients with liver cancer.

Now what we have here is called a failure to communicate...a showdown at sundown...a standoff between the expert opinion of The Professor versus the clinical evidence unearthed by the lowly country doctor. This is a tricky situation because it is generally useless to impugn an academic physician. Their lapidary reputation is impervious to one chip from the hammer of a 97 lb. oncologist. My strategy therefore was to use the same approach that has led to continuous success from the dawn of my career: I let the truth be my guide.

I had a heart-to-heart with my patient and explained that the drug in question simply has not been shown to provide any meaningful benefit to patients, despite being given to dozens of them. She understood completely and was actually grateful to not be exposed to a therapy that had such a meager chance of helping her. She left the office that day with a better understanding of the complexity of her illness, but as she turned at the door she replied:

"I'll be back next week to hear about what treatment you have found for me."

Yes, evidence-based medicine is a wonderful thing for doctors. It gives them the opportunity to strain the eyes peering at a monitor long after the Great Hunter has risen in the winter sky, to hear the night wind outside the window muss up the bald heads of trees, to see the night janitor walk into the office and ask:

"Doc, are you still here? Why don't you go home?"

That sounds like a wonderful idea - after this next abstract I will go.

I promise.