The Cheerful Oncologist

New Address for The C.O.

2006-08-31T12:22:00.000-05:00

Just in case you find this old blog site and wonder where I am now:

The Cheerful Oncologist can be found at http://scienceblogs.com/thecheerfuloncologist/

Welcome Grand Rounds Readers

2006-03-14T09:01:00.000-06:00

If you're unfamiliar with my medical web log, this is the old site. My current location can be found at:

http://thecheerfuloncologist.blogsome.com/

Enjoy the day!

Thanks for the Nomination

2005-11-30T21:11:00.000-06:00

If you've found this site from the Medical Weblog Awards Nominees site on Medgadget, this is yet another reminder that my blog site is now found at:

http://thecheerfuloncologist.blogsome.com/

This site contains essays from September 2004 to April 2005 only. Thanks.

Just a Reminder - This is the Old Blog Site

2005-10-24T20:05:00.000-05:00

I wouldn't want anyone to miss out on all the fun and games going on over at the new blog site, so here is the URL again:

http://thecheerfuloncologist.blogsome.com/

And by the way, it's not too early to throw one's hat in the ring for the next presidential election, as shown here.

Archives of The Cheerful Oncologist

2005-06-06T15:54:00.000-05:00

This site contains the essays written from the initiation of this blog - September 2004 - up to the date I moved it over to the new blog site.

New site: http://thecheerfuloncologist.blogsome.com/

By the way, this poem is in my opinion the most beautiful verse ever written in the English language by someone not named Shakespeare.

Goodbye to St. Elsewhere

2005-04-13T09:37:00.000-05:00

The last of this series of extremely serious and heroically composed essays on the state of the modern hospital can be found at the new blog site:

http://thecheerfuloncologist.blogsome.com/

[don't forget to click on the hyperlinks -Ed.]

A Trip to St. Elsewhere: Part III - The Cafeteria

2005-04-10T22:29:00.000-05:00

The next post in our tour of the hospital can be found on my new site:

http://thecheerfuloncologist.blogsome.com

New blog site for T.C.O.

2005-04-08T14:41:00.000-05:00

As mentioned below, I am publishing on this site now:

http://thecheerfuloncologist.blogsome.com

(Let's hope the quality of the writing doesn't slip with this heartbreaking change of staggering genius).

A Trip to St. Elsewhere: Part II

2005-04-08T14:36:00.000-05:00

Thanks to Ali for recommending Blogsome. I will publish on this new blogsite from this day hence. The above-titled essay can now be found at:

http://thecheerfuloncologist.blogsome.com

Please let me know if you can't find this site.

If I ever figure out a way to move my archives there I will - in the meantime this blog site will remain open, and I'll leave notice here of the latest posts on the Blogsome site, too.

Enough is Enough

2005-04-07T22:02:00.000-05:00

The Cheerful Oncologist wishes to announce that he is in the process of firing Blogger and moving his web log to livejournal.com.

Anyone who uses Blogger can guess the reason why.

As soon as my next post "A Trip to St. Elsewhere: Part II" is finished I will announce my new blog site.

Feel free to comment on your experiences with Blogger...

A Trip to St. Elsewhere: Part I

2005-04-04T00:12:00.000-05:00

Hospitals are mysterious places. They make everyone a bit uneasy, even doctors d'un certain age who have worked there so long they don't even faintly resemble the dark-haired patrician immortalized on their I.D. photo. The long corridors of hospitals echo with strange sounds, perhaps reminiscent of a cozy visit to the local penitentiary. I still sometimes get a chill while walking down a hallway past rooms with partially opened doors. I must resist the urge to turn my head and peek at a pair of bony legs resting on a narrow bed and wonder whether they will ever support their owner again. This is the place where Disease resides, sitting close to dear friends who smile wanly and wish it would jilt them. The smells found within hospitals are often inscrutable or nauseating - in either case they can snap one to attention within a second. Despite this doctors report to work here every day - and sometimes stay throughout the night.

Part of the reason hospitals appear esoteric is that they have forbidden zones such as the operating room, where I believe no medical oncologist in my city has ever set foot. This is the sanctum sanctorum for surgeons, and I imagine that if I ever sashayed in there without first donning green pajamas and reporting to the sergeant-at-arms I would be attacked by guard dogs and put in the stocks. With my fine motor skills, even if I were invited to assist in a routine procedure like a cholecystectomy the patient would probably turn off the gas, sit up and kick me out of the room. I therefore avoid the operating suite like the Three Stooges dodge a conference on quantum mechanics.

Hospitals are also scary places, especially for oncologists. We realize that when our patients are feeling well they enjoy the dog and newspaper in the comfort of home, and when complications of either cancer or its treatment strike they require admission to the ivory tower. Entering the hospital though can frighten both patients and doctors - them for obvious reasons and us because we no longer feel assured that our patient's care is under our control. There could be an unrecognized complication lurking about, or a test or medicine might be inadvertently forgotten. This stresses us out, so we work furiously writing scores of orders, scrutinizing radiographs of curlicued bowels, and generally cheering patients on until they are ready to be carted back to the happy bungalow - preferably in better shape than when they entered.

With time even the most timid oncologists will learn how to master the hospital routine and put a little spark in their step as they go about their rounds. There is one special place, however, that can unnerve even the most jaded practitioners - a place of unspeakable tension, where green-skinned zombies strain at the leather straps that bind them, where blood and vomit, sheets, tubes and rubber gloves amass into a tornado that sucks up nurses, doctors, even little old ladies in pink volunteer jackets into a writhing, screaming mass of chaos.

Goodness gracious - am I hallucinating? Is this a dagger which I see before me?

Of course not - I'm just describing the friendly confines of the elite suite where the injured meet - the emergency room.

Hoorah and congratulations to all those doctors who toil away in the place designated as the first line of defense, but for me I still get the heebie-jeebies whenever I press the metal plate that swooshes open the door to the E.R. The scene reminds me of a sci-fi film where victim number three is about to be dispatched off to his eternal reward as he enters the laboratory in search of the missing vial of antidote.

The emergency room is never a happy place for cancer patients either. In addition to feeling terrible, they must endure the interrogation and probing of professionals who work under a palpable time constraint. Emergency rooms are where patients are triaged, too and patients with metastatic cancer who show up there may not command the staff's attention as much as the fellow in the next room with a moray eel clamped to his leg.

Nevertheless, I go to the E.R. when needed and am happy to return there at any time to serve my patients. I can still visualize my last trip to that hotbed of activity. I stood in front of the dry-erase board trying to decipher the chief complaint codes that were written there: CP (canine psychosis? ), SOB (sick of belching?), UTI (unknown tomato intoxication?) and that all-time classic SSS-SAO (sick-sick-sick; sick-all-over). I found my patient lying on the ubiquitous gurney in a room lit up like a Vegas stage show. Fortunately she made it upstairs before the last bed in the house was commandeered, otherwise she was facing a night in the hallway, also known as the holding area. I think I would rather sing "Tip-toe Through the Tulips" at the American Idol finals wearing a pink tutu than spend another night in the E.R. - too many bad memories, as the song goes.

Hospitals are formidable places but even with all their flaws and quirks, to the men and women who walk through the doors each day with a fresh uniform on or a greasy stethoscope in their pocket it is a familiar place - a community where some of the most under-appreciated work in the world gets done.

Next: A Trip to St. Elsewhere: Part II - Radiology, the Cafeteria and the Parking Lot

Death Be Not Proud

2005-03-31T00:11:00.000-06:00

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.

The Gardener

2005-03-27T15:34:00.000-06:00

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.

Heavy Air Traffic + Thunderstorms =

2005-03-26T17:54:00.000-06:00

...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.]

Florida Update

2005-03-22T07:47:00.000-06:00

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,
Sincerely,
The Pale Oncologist

It's Spring Break Time!

2005-03-19T09:53:00.000-06:00

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

2005-03-19T07:16:00.000-06:00

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.

Where Ignorance is Bliss...

2005-03-17T00:14:00.000-06:00

"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.

Now Playing at a Theater Near You!

2005-03-15T00:06:00.000-06:00

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.)

CANCER - THE MOVIE

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)

An Oncologist Goes to the Doctor

2005-03-11T19:08:00.000-06:00

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.

Medice, Cure te Ipsum!

2005-03-09T00:10:00.000-06:00

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 out...do a crossword puzzle...buy a book and read it...talk to your children...call 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.

Smoke, Smoke, Smoke that You-Know-What

2005-03-07T00:15:00.000-06:00

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.

Kicking Sand in My Face

2005-03-03T00:15:00.000-06:00

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.

The First Commandment of Oncology

2005-02-27T21:52:00.000-06:00

Several years ago I saw a man who was referred to me for further evaluation of enlarged lymph nodes in his neck. They seemed suspicious on examination, so I ordered the simplest and least invasive type of biopsy available: a needle biopsy of the most prominent node, thus sparing the gentleman from an incision in his neck.

The pathology report returned a few days later and stated that the patient had a low-grade lymphoma. I made arrangements for him to undergo further testing, and prepared to refer him for radiation therapy to the neck.

Everything seemed to be copacetic, except for one tiny problem...

I couldn't shake off a lingering doubt about the diagnosis. The proper diagnosis of lymphoma includes identifying what grade it is, and this information could not be determined on the needle biopsy. I held the path report before me and asked myself the following (oncologists often perform interior monologues, just like Hamlet):

"Forsooth! Doth this diagnosis reflect all that is true? Say, why is this? wherefore? what should we do?"

Myself considered the situation and summoned up the courage to yodel back "I ain't so sure!" This was all I needed to yank on the brakes and stop this patient from rolling on into the radiation oncology station house. I called him up and made him see a surgeon for a formal excisional biopsy of the lymph node. The next pathology report was nothing but good news for him, for it revealed that he did not have lymphoma. His sigh of relief could be heard for miles until it crashed into an identical gale emanating from the building where my office was located.

The moral of this story could be chiseled onto a tablet as this First Commandment of Oncology:

Thou shalt make certain the diagnosis is the truth before thou terrifies the patient.

In order to ensure that a patient does indeed have a malignancy, and that the exact type of cancer is identified, medical oncologists, pathologists, surgeons and other specialists must work together. They must consider several maneuvers to pin down the correct diagnosis, such as staining the biopsy specimen for immunhistochemical markers specific for a type of cancer, or even using electron microscopy on the specimen. If no agreement can be made as to what this lesion represents, they should send it out to another experienced pathologist for an outside review.

Sometimes, such as in the case I presented above, the specimen is simply inadequate to establish a diagnosis. Then the lesion of interest must either be re-biopsed, or a lesion in a different location should be considered for biopsy. Patience is required by all parties when atttempting to come up with the proper diagnosis before proceeding with chemotherapy, surgery, or radiation therapy.

The best way in my opinion to ensure beyond any doubt that a patient will be diagnosed correctly is to consider the whole person before you. Each aspect of a patient's clinical presentation is a clue as to what the final diagnosis will be. Oncologists must place these pieces before them as if they were working a jigsaw puzzle, analyze all the different parts with the precison of a watchmaker, and then solve the puzzle as if it held the secret to immortality itself. We fulfill our commitment to our patients by taking each case as seriously as did that great detective with the deerstalker cap, whose most famous quotation is:

"When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth."

Guest-Blogging for Kevin, M.D.

2005-02-27T13:42:00.000-06:00

The wise and eloquent psychiatrist Shrinkette and I are guest-blogging for Kevin, M.D. for a few days - check out both these blogs if you haven't had the opportunity to enjoy them.

In the meantime I'll be posting a piece on the number one priority of the medical oncologist - as soon as I write it! Look for it later today...

Death Comes for the Grasshopper

2005-02-24T16:30:00.000-06:00

The woods decay, the woods decay and fall,
The vapours weep their burthen to the ground,
Man comes and tills the field and lies beneath,
And after many a summer dies the swan.
Me only cruel immortality
Consumes: I wither slowly in thine arms,

Alfred, Lord Tennyson, Tithonus, 1860

I grabbed the chart from the plastic holder and paused, one hand on the door knob, quickly reviewing the latest information on the man waiting for me in the exam room. A date in the upper corner of the folder caught my eye. I glided into the room with a big grin and he looked up as I greeted him.

"Do you realize that this is the seventh anniversary of the day you were diagnosed?" I asked. "You have lived a long time - much longer than the average patient."

He bowed his head slightly before answering me and as we exchanged our congratulations I noticed his clavicles bulged from his tee shirt like two tent poles. I helped him to the table and recorded the findings of my examination with perfunctory precision - hard cervical lymph nodes, persistent left pleural effusion, colostomy in place. After shaking his hand I said I'd see him next month.

"Let me know if you run low on pain meds." He nodded to me as I opened the waiting room door for him. I then went back to my office to dictate my note. Outside my window a chickadee caroled me from a nearby branch: see-bee-see-bay. I put down the telephone and listened to its melody, and before I could regain my train of thought lines from a poem learned long ago rose into consciousness.

And though they could not end me, left me maimed
To dwell in presence of immortal youth,
Immortal age beside immortal youth,
And all I was, in ashes.

When oncologists evaluate the benefits of an anti-cancer medicine one of the most important statistics they consider is whether the treatment prolongs survival. Helping patients to live as long as they can is one of the great goals of modern cancer therapy. Those who are cured of cancer obviously receive the greatest reward, just as those who are cursed with tumor progression are fated to see their life end before the "half-opening buds / Of April" push through the earth next spring. What then becomes of those whose disease neither grows nor disappears? What does it mean to be given the gift of survival without remission? The image of my gaunt patient floated in the air as I considered the parallel between him and the title character of Tennyson's poem. According to the myth, Tithonus, the beloved of Aurora, goddess of the dawn, was granted eternal life but not eternal youth, and therefore becomes a withered skeleton, "a white-haired shadow roaming like a dream / The ever-silent spaces of the East." He comes to envy "happy men that have the power to die" and begs the goddess:

Let me go: take back thy gift:
Why should a man desire in any way
To vary from the kindly race of men,

It is this kind of irony that drives physicians mad - to work so hard to lengthen the lives of patients by turning cancer into a chronic disease, only to see them slowly decay.

But thy strong Hours indignant worked their wills,
And beat me down and marred and wasted me,

Some cancers like chronic lymphocytic leukemia can be tolerated for many years without consuming the patient's vitality, but this is simply because of the natural history of the disease. Oncologists continue to search for treatments that will blunt the progression of horrid tumors such as melanoma or lung cancer. If researchers someday announce that a new medicine can stop the growth of cancer but not eradicate it, will this be a blessing or a bane? Are patients who experience a long life living with cancer lucky or unlucky? What would one choose if offered the gift from the goddess of the "rosy shadows", knowing that one's vigor would be sacrificed?

The song outside my window stopped and a gray bank of clouds drifted into view, darkening the office walls. I finished my dictation and stood to leave. Before turning, I peered briefly at the trees by the parking lot. Like a priest who held high the cup, their limbs were hanging in the late winter air, stippled with buds promising new life, a renewal repeated since the dawn of time.

Tithonus was eventually released from his living imprisonment, for the myth ends when Zeus, taking pity upon the aged lover, transforms him into a grasshopper. We who are mere mortals have nothing to fear, for no matter how long we live or how much we suffer we will never end up inside of a glass jar furiously rubbing our hind legs together. Our fate is the fate that Tithonus pleaded for yet was denied. One can imagine he sits outside our window even now, chirping his cry long into the night until the first light of his former lover bathes the distant hills:

Release me, and restore me to the ground;
Thou seest all things, thou wilt see my grave:
Thou wilt renew thy beauty morn by morn;
I earth in earth forget these empty courts,
And thee returning on thy silver wheels.

In Memorium: Hunter S. Thompson

2005-02-22T16:02:00.000-06:00

Prologue: Hunter S. Thompson, who committed suicide this week, was one of my favorite writers for many reasons. His obnoxious, irreverant behavior was the center of his wild-eyed stories about crashing political and sporting events around the world. Thompson's writing style was a pure delight - it defies description and has to be read to be appreciated. The closest analogy I can think of is if Frankenstein's monster had kept a diary, this is how it would look.

What made Thompson's dispatches so entertaining to me was the fact that I was dying to live as he did - with total debauchery - but as a pre-med student, then medical student, et cetera, I couldn't. What would the dean say if I and my buddies showed up for anatomy lab plastered to the gills, with a suitcase full of hacksaws, ether and gila monsters? Like many other studious, goal-oriented preppies of my generation, I could only experience true madness vicariously through his writings. Back then I was ambitious and serious - in other words, boring. Hunter S. Thompson was a string of firecrackers thrown into a hot charcoal grill during a church picnic; he was a man in a gorilla suit running after an ICU attending with defibrillator paddles; he was the avatar (to use one of his pet words) of insubordination, mixed with just enough silliness and insanity to awe a milquetoast like me. He is the only character I have ever dressed up as on Hallowe'en since I left boyhood.

Tom Wolfe has just called Hunter S. Thompson "the century's greatest comic writer in the English language". (He's wrong, of course - that distinction belongs to P. G. Wodehouse). Nevertheless, in Doctor Gonzo's memory I offer the following parody, as a tribute to the man who once said:

"When the going gets weird, the weird turn pro."

FEAR AND LOATHING IN THE E. R.
(written in the manner of one Raoul Duke)

Why am I here? Who is this woman in a giant muu-muu, standing before me squeezing what appears to be a copperhead snake in her hands? She spoke to me in some strange language - obviously disrespectful of the country that took her in after a long canoe trip across the oceans. I thought of screaming "Back! Get Back!" but suddenly sat bolt upright and remembered:

I am a doctor...on call in the emergency room of the world's greatest hospital. My shoes were smeared with thick crusts of vomit and blood, as were my pants, except I wasn't wearing any. I must find them, I thought. The lights above my head burned into my skull like the first kiss of the electric chair. I reached for my pistol to shoot at them, but it, too, was missing. The situation was rapidly deteriorating. I began to sweat like a champagne fountain at a coal miner's wedding.

She continued to bark at me as I stood up and surveyed the room. I had been working since six o'clock the previous evening, and felt like I had been stomped by buffaloes. I desperately wanted to claw my eyes out, but instead hunched over the desk, searching for a pack of cigarettes. What was it - 12 hours of pure massacre, or had I been trapped in this reptile pit for weeks? No one seemed to hear me as I asked for matches and a can of kerosene...

"Yes, yes," I said to the nurse. "You're doing fine, doing a fine job for all of us here." She glared at me as if she had just seen Martin Bormann in an Argentinian health club. What did she want from me? She followed me across the floor as I attempted to break into the crash cart...a nice ampule of epinephrine ought to help, I thought - perks a man up to the point where he would not hesitate to offer his aunt a quick game of Russian roulette. I looked over my shoulder at the nurse. Maybe I should inject her first - give her just enough to get her to dance on the counter top, holding a gunny sack full of live rats. I laughed hysterically at this idea until a security officer tried to club me with a sap. He missed and accidentally whacked a pizza delivery man right in the pepperonies.

I quickly grabbed a clipboard and walked into the nearest exam room. "What is your problem, sir?" It was difficult to see him through the cheap Saigon sunglasses my attorney had given me.

"My chest hurts and I can't breathe so good" he said. My God! His left arm suddenly fell off and he grabbed it and flung it at me! Another damn zombie in the emergency room - how they sneak past the metal detectors is beyond me. I rushed the gurney and toppled it over, sending the fiend crashing into an EKG machine. Musn't panic, I thought - just walk nonchalantly out of the room and down the hall to the lounge. Poor bastards... they'll find out soon enough what the living dead can do to a man's aorta with their teeth. Better let Security handle this, or better yet an armored company of Camp Pendleton's finest.

As I reached the lounge I realized that the sun was shining, meaning my hell-night was about over. All that was left to do was clean up the forty or so charts that I had tossed behind the soda machine, locate the rest of my clothes, sign in to the intern relieving me and slip out through the window in the men's room. Before leaving I decided to eat - after all, being a servant of the needy gives one an appetite like a crazed Samoan wrestler. My forged I.D. card was good for at least one more trip through the outlet store for the local waste dump, also known as the hospital cafeteria.

My surgical colleague sat next to me as I sliced up grapefruit with a stiletto. "Man, you sure had a rough night, didn't you? Last I saw of you, you were standing on a trash can during that code, screaming 'Somebody get me a chainsaw!' How long have you been on E. R. call?"

I turned my head to reply, but gasped - scorpions were crawling out of his eyes! He grinned at me like a Jolly Roger as I sprang from the table. I tossed my glass of ice water at him as he tried to grab my arm. I could hear him bleating like a goat caught in a vise as I ran through the glass doors and out to my car. I jumped into my 1971 red Cadillac convertible and sped off, playing "Mr. Tambourine Man" at full volume. I looked at my watch.

My next shift in the emergency room would start in just 23 hours and 14 minutes.

Epilogue: If any readers are unfamiliar with Thompson's bizarro world, a word of caution is advisable: his books are filled with unhealthy and illegal behavior. Take it all as a fantasy, like a trip through a haunted house - and remember, as they say on television: don't try this at home!

Twelve Strokes of the Clock

2005-02-21T00:05:00.000-06:00

The "Red Death" had long devastated the country. No pestilence had ever been so fatal, or so hideous.

*****************

But the Prince Prospero was happy and dauntless and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends...and with these retired to the deep seclusion of one of his castellated abbeys.

*****************

A strong and lofty wall girdled it in. This wall had gates of iron. ...With such precautions the courtiers might bid defiance to the contagion. The external world could take care of itself. In the meantime it was folly to grieve, or to think.

E. A. Poe, The Masque of the Red Death, 1842

Those of you who are familiar with Poe's magnificent gothic tale know how the Prince's elaborate masque ends as the "gigantic clock of ebony" in the last apartment strikes midnight. The ghastly fate the revelers meet is appalling, yet after the initial frisson of the massacre, some readers might conclude that the selfish Prince and his frivolous friends got what they deserved for trying to cheat the Grim Reaper. They found out the hard way that one cannot wall out death; it is a part of all living things, and cannot be escaped.

Given the gruesome nature of the Red Death, however, who can blame them for trying? Who among us would refuse the invitation to leave the foul, decaying countryside for the safety of the barricaded abbey?

Modern consumers of health care in some ways are like the arabesque figures imprisoned within Poe's story. They learn about good health from the moment they can read and then are bombarded with helpful information about how to prevent one affliction or another. By the time they reach adulthood many of their actions are influenced by their impact on health. They feel guilty if they do not take every precaution to keep themselves safe from the plagues that punish in this age, such as cancer, heart disease and diabetes.

We all therefore devote much of our time trying to wall out illness. We toil at building a fortress to deny the invader who in the tale "dropped the revellers in the blood-bedewed halls of their revel". The stones we cut to construct our walls are plentiful and easy to quarry: exercise, healthy diet, screening tests, abstention from tobacco, moderation in alcohol use, medications and supplements. With reasonable alterations in lifestyle choices we can someday stand in the tower of a massive citadel, protected from the "Darkness and Decay" of the epidemics around us.

This is an admirable goal. I follow it faithfully, as do millions of conscientious men and women around the world. Our commitment to preventing illness will allows the gala called our healthy life to continue. We shall dance on - or as Poe would describe it:

And now again the music swells, and the dreams live, and writhe to and fro more merrily than ever...

I commend all those who have made the often difficult choice to embrace the habits that strengthen our bodies and eschew those that expose it to the dismaying and monstrous withering of preventable disease. May those who struggle to build this wall find the insight and courage to persevere.

Lest we forget though, remember that good health can be defined as dying at the slowest possible rate. The wisest person in the world is the one who enjoys the delights of the soiree while keeping an eye on the clock, for whether one is blessed with good health or poor, when "the last echoes of the last chime" sound, the masked spectre will "come like a thief in the night". Even the strongest walls cannot deny his entry. Let us stand tall before him at the hour of his arrival, and as he takes our hand, smile and look backward upon our life with pride.

Waiting for Tomorrow

2005-02-18T12:05:00.000-06:00

Last night I had a dream that I was getting dressed to go to see the doctor. I knew I was sick, but the nature of this illness was hidden. I walked into the bathroom, glanced at the mirror and saw my reflection not where I stood, but behind me in the shower. When the fogged door opened there I was, dripping wet and sitting on a plastic chair. I did not get up, but instead called out a name.

I sat there, strands of white hair spilling over my ears, my chest sunken, my bony knees protruding like the roots of a cypress tree.

Gazing into the mirror, I saw myself as an old man.

After what seemed to be a tedious wait, a young woman came in and helped me out of the shower. She brought me a towel and a walker and I shuffled off, carefully eyeing the tiled floor in front of me. My name was written on the towel in black magic marker. The walker had yellow tennis balls stuck on the bottom of its metal legs. Neither she nor I spoke a word.

I then left the vision in the mirror and walked downstairs and out to the garage, where I climbed into my car and backed out into the driveway. Just as I started out I braked and looked into the rear-view mirror. I could see the oak tree in my back yard. Sunshine dropped through the shadows of the immense branches and formed a patchwork on the grass, and the leaves fussed from the breeze.

There were people walking all over the lawn.

I saw my son tossing a ball to a little boy in shorts, while two older girls sat gossiping under the tree. They called out "Father!" and he turned. He looked the same age as I am now, his hair dappled with gray. My wife and daugher stood nearby talking. My little girl was tall and tanned, and as she spoke my wife handed her a feisty-looking baby.

I peered into the small rectangle for several minutes, but never did catch a glimpse of anyone who looked like me. The last thing I remember before awakening was driving off down the road, unable to release even a sigh. The streets passed by silently, and I encountered no other cars on the desolate road.

What does the future hold for us? Will we cheat death for so long that we outlive the life we begged for, or will we instead be harvested early, spared from any further rendezvous with the lash? Such thoughts are but fantasies found in dreams - except for those living with cancer. For them speculation is not a phantasm. It is a daily reality thrust upon them, like an uninvited guest at the table. We who live without such a burden can honor those who do by remembering that unless one respects the future as the gift it is, waiting for it is pointless; it is worthless; it is absurd.

High in the Sunlit Silence

2005-02-16T00:07:00.000-06:00

When I was a teenager I loved to watch the television comedy M*A*S*H, which may have subconsciously spurred an interest in medicine. Part of my fascination with the show was the realistic portrayal of how the doctors dealt with the stress of working in a chaotic war zone. It seemed that the hospital was the destination for an endless caravan of wounded soldiers, all desperately in need of the unique blend of surgery and fatherly advice the show's characters dispensed. The surgeon's shifts were long and grueling, yet they never failed once to complete their duties. Nothing could disrupt their devotion to patching up the young patients - the operating room survived blackouts, bombings, belligerent patients, snipers and supply shortages. It was the paradigm of grace under pressure.

There was one event, however, that rocked the surgical suite more than any other crisis ever broadcast on the show, and like most viewers on that day I was shocked by the tragedy. Part of the reason why the moment was so dramatic was that it consisted merely of an item of news delivered to the operating room staff by the company clerk.

The news was that Colonel Henry Blake, the freshly discharged commander of M*A*S*H 4077 had been killed in an airplane crash on his way back to the states.

I will never forget the looks on the surgeon's faces as they absorbed this devastating shock of the loss of their likeable leader. Because the doctors remained silent after hearing the news, the effect was stunning. They took this blow as stoically as Caesar took the dagger of Brutus, pausing briefly to stare at nothing and no one, then leaning over the open wound to carry on. This was an inspiring show of fortitude, but at the time I also thought it was unrealistic - how could anyone remain quiet in such a time of grief? Are doctors so obsessed with their work that they avoid showing any signs of human frailty? Could this reaction eventually lead to what our psychologist colleagues call repression?

The years passed, and by some miracle not seen since the parting of the Red Sea I was accepted into medical school, and furthermore, mirabile dictu, matched at a reputable internal medicine residency. I now viewed the bustling world not as a layperson, but through the goggles of an authentic physician, albeit a greenhorn. I slowly learned how to survive the hospital's routine, which apparently was modeled after the Hanoi Hilton's. After months of exhausting service comparable to the barbarity suffered by the good surgeons of the 4077th, we residents became inured to the bellyaching of patients, fellow physicians, spouses and pets. Our work was an addiction. The outside world faded from our sights as quickly as if we were rocketing away from Mother Earth.

On January 28, 1986, while on morning rounds in the intensive care unit, the space ride came to an abrupt, awful end. The universe awakened and stomped our little hideaway into an unrecognizable heap, and we realized that we were still citizens in a massive living thing called America. The question I posed all those years before - does the news of a tragedy stop a doctor in his tracks - was answered that day.

When the space shuttle Challenger exploded shortly after takeoff we not only stopped, we forgot why we were in the hospital in the first place.

Residents, attendings, nurses and anyone else close by on that day huddled around the nearest television as the drama unfolded. We watched the horrific moment again and again. The event staggered us so much that it transcended sadness and became baffling - we simply could not fathom what our eyes had just witnessed. We suspended our work that morning because we had just been shown a parallel universe, previously unknown to inexperienced minds - a strange world where a song of triumph disappears while it is being sung, a world where certitude is but a wisp of floating silk waiting to be swept away by the pitiless wind.

Like the rest of America, I experienced this heartbreak once more on September 11th, 2001. Again doctors stood in disbelief before the television, unfocused and afraid. We sank with despair on that day and hated ourselves for returning to the exam room - but return we did. We could have cancelled our clinics, but instead we went back to work on one of the worst days in the history of our country. I understand more clearly now why the doctors on M*A*S*H kept working on that fateful day. After catching their breath they looked down at their hands and saw them move; they opened their mouth and heard their voice. The surgeons searched within themselves and concluded that their only usefulness, their only worth in the world was if they kept the promise they made to another human in need. That promise is what fuels the doctor's engine for the magnificent journey called his career. It is the only thing that can lift him high enough to slip the surly bonds of earth and touch the face of God.

The Last Call

2005-02-14T00:03:00.000-06:00

The high points of a doctor's post-graduate training are so few in number they can generally be recalled in the same amount of time and with the same enthusiasm it takes to flush a toilet. There is one event, however, that stands like a sequoia in the vast forest of memories preserved within the young doctor's mind - the night of his last call. Every doctor remembers the final time he entered the healing palace as the resident on-call. He drifts about the halls that night like a specter under the fluorescent lights, exploring the wards he once haunted. Like most nights on-call though it is a time for survival, not reminiscence. The goal is to live through the night without losing one's temper, mind or car keys.

It was with true dread that I stared at the doors of the hospital all those years ago on the last day of my three years of servitude. The season was glorious spring, when flowering crabapple trees delighted the weary eye and a young doctor's thoughts turned to shouting a hearty sayonara to the apprenticeship and hightailing it to fellowship or private practice. My sights though were only on the imposing brick building rising before me, for when it came to lucky omens I had just been handed the Monkey's Paw. Some residents spend their final hours grooming little old ladies on the geriatric service. My last supper was to take place within a more ominous painting. I walked into the lobby and gazed at the portrait of the President hanging above a collection of flags, releasing a sigh as I trudged upstairs.

According to the schedule, my last night on call was to be at the Veteran's Hospital.

Those doctors who have trained at the VA hospital know what it means to roam the halls where any minute one expects to encounter a human head bouncing down the stairs or see flames shooting from the oxygen mask of a surreptitious smoker. I therefore swept all bad thoughts away, steeled myself and went about the business of the day which consisted mainly of tracking down the reasons why exactly the old soldiers were there in the first place. The afternoon chugged by without incident, although our medical student was nearly asphyxiated when he walked into a lounge hosting the weekly bingo-game-and-cigarette-exchange. The only casuality before sundown was a jug of urine. One of my patients had diligently carried it from home to the hospital but had forgotten to give the specimen to me.

"What did you do with your 24-hour urine sample?" I asked. I needed to know if it contained any abnormal protein, which could indicate the presence of multiple myeloma.

"I gave it to the lab technician. Thought that would be faster than trying to find you."

Like an Olympic skier leaning into the final turn, I slalomed down the stairs to the laboratory in an attempt to rescue the precious carafe, but to no avail. By the time I crashed through the doors it was already lost. I argued with the staff in an attempt to get them to find the cursed bottle but they just gave me a look like a police officer about to conduct a sobriety test. The hospital once again held illimitable dominion over all. I furled the flag and crawled back to the floor.

Evening fell, and I soon collapsed into the recesses of the beastly place. I lay fully dressed on my on-call cot, two beepers clipped to my belt, which made me look rather like a tot carrying a pair of six-shooters. Even the VA settles a bit at night and before long my eyes were dead to the world. Unfortunately at the same time the eyes of one grizzled trooper also decided to shutter permanently, and a nurse who noticed the apparent lack of respiration dialed the operator to send in the Marines - or in other words "call a code".

I had just reached that part of a dream when after several frustrating attempts, one has convinced oneself that he can soar off into space by flapping the arms. Suddenly a horrific wailing pierced the skull and cut short my maiden flight. My red beeper was shrieking, signaling a cardiac arrest somewhere in the hospital. The operator called out the location over the tiny speaker but the sound was so bad it seemed as if she was reading back an order from a drive-through restaurant. I sped down the hallway. When I arrived at the emergency no one was there but the nurse and the veteran playing the non-speaking role. I of course had to do all the work that night - intubating the patient, starting his I.V., giving him the juice - both liquid and electrical, until the Three Fates made their final decision. Hours later I staggered into the nurses' station and according to witnesses downed a two-week-old can of soda that had been left behind the copy machine.

The following morning after a brief search my medical student found me lying supine on the floor of the conference room, humming "Don't Sit Under the Apple Tree". He gently shook me awake and we waddled off to breakfast. The last I heard of him he was running a Botox clinic in Honolulu.

Thus ended my last night of call. As I was helped out to my car I swiveled for one last look at the object of my detention. The stony facade seemed to fix me in its gaze, as in The Fall of the House of Usher. It was almost twenty years before I laid eyes on it again, and as I drove by the barren landscape, I could swear the old relic winked at me. I smiled back and realized that like two old prize fighters sitting in a diner we could now laugh about the punches we threw back then. The forecast was once again balmy, for our scars no longer ached - we were at peace.

The Living Canvas

2005-02-11T15:42:00.000-06:00

Last summer while driving through the farmlands of Missouri we plowed into a thunderstorm spawned from towers of clouds that lined the late afternoon horizon. We drove steadily on through the storm and soon the dark wall receded. I peered with anticipation through the wet sunshine and saw a giant arc of color off in the distance. "Look at the rainbow!" I called out. My children, always on the alert for an opportunity to confirm their suspicions about my childish behavior, ignored me. Not to be daunted, I increased the volume and resumed the science lecture. One could sense they were silently laughing.

"Over there on the right - can you see it?" I asked. Remnants of youthful innocence stored within them must have awakened, for they slowly turned to the window and scanned the sky. "We don't see anything," they replied. I tapped the windshield and said "There! Over there!", but they still were blinded. Finally they identified the radiant bands sweeping across distant clouds. I marveled at their obtuseness, but forgave them and motored on. As the rainbow vanished I considered how a keen sense of perception adds so much more to the enjoyment of life. How many other delights, such as the meadowlark's song, or the cotton-candy scent of honeysuckle, languish as we limp through another day? Consider the world I work in - cancer medicine. Would refined skills of observation make one a better physician?

I am not sure that success depends entirely upon a doctor's power of perception and insight, but I do know one thing - it makes his job a lot easier. A physician gains a special benefit by remaining vigilant, and that benefit is this:

The doctor who sees the clues contained within an illness also sees into the future, therefore, one who perceives the future can prepare for the tribulations it contains. The hints a patient reveals in the course of a visit can predict what direction his illness is turning. For example, last week I entered an exam room to see my patient sitting in a chair with a cane by his side. I smiled at him, because it was the first time since he had started treatment that he was not in a wheelchair. X-rays confirmed that his lung cancer was shrinking rapidly, and he made plans to travel this spring. While examining a different patient I noticed that her bulky abdominal mass was markedly smaller just one week after receiving treatment for chronic lymphocytic leukemia. This response, while welcomed by all, seemed unusually rapid to me. I checked her blood chemistries, and her potassium, uric acid and creatinine were all high - consistent with the complication called tumor lysis syndrome. By suspecting this problem I was able to prepare to relieve it.

Other clues foreshadow distress in the times ahead - I recall the patient who told me he had stopped balancing his checkbook because it was too difficult to complete the task; he was soon diagnosed with brain metastases.

A patient constantly exhibits signs of the state of his illness - signs that if read correctly, can be useful in planning future care. He is like a distant rainbow or a magnificent painting, an extraordinary composition to study if only noticed. A skillful doctor, like a master artist, develops a keen eye for the details arranged in the living canvas before him. He studies the patient as thoroughly as he would scrutinize the Mona Lisa, looking for clues as to what truths lie within such an awesome work of art. His work is tiring, but like a long walk through the Louvre, it is a source of endless satisfaction.

Moving the Chains

2005-02-09T01:05:00.000-06:00

One of the goals of modern cancer therapy is to pound away at a tumor with different tools in an attempt to prolong life - to turn cancer into a chronic disease. Ironically, this exposes the patient to a Hobson's choice of suffering from the effects of treatment, or from the cancer if its growth is not thwarted. The fine line between helping and harming a patient is one of the oldest dilemmas in cancer care and must be considered in every move the doctor makes in the contest against a clever foe. A good oncologist must become a strategist, an expert at seeing the playing field before him, a master interpreter of the opponent's plans and a genius in calling the best play, so to speak, to ensure victory.

That's right - an oncologist is basically a football coach in a lab coat.

The fight against cancer is obviously not taken as sport, but like the clashes that occur on cool, sunny afternoons in October it is a match between two adversaries. Similar to the fall pastime, each head coach has his game plan before him and rallies his team with shouts of inspiration, asking his players to give their all for the cause. Unlike a football game, though, when the coach says "Now go out there and kill 'em!" he really means it. Playing against cancer is the ultimate death match.

With a little imagination one can envision how the game develops:

First, think of the oncologist as the coach whose team has the football on the 20 yard line in overtime. The distant end zone, where victory lies, represents either cure of the patient or at least prolongation of life. The team has only four downs to go the required 80 yards, otherwise possession changes, and cancer has never failed to score when given the ball. The four downs allotted the Crab Busters represent the four stages in a patient's plan of therapy. Each down can be described as follows:

First down - this is the time to call the best play in the book, for some initial treatments can wipe out cancer like a fullback plowing through the crowd at a garden party. Some tumors, like testis cancer or Hodgkin disease, are so susceptible to chemotherapy one can call a quarterback sneak and still reach the end zone. Many others, though, require a more complicated strategy involving fake handoffs and long passes. The goal on first down is to gain as much of the necessary yardage as possible.

Second down - if the team doesn't score with the preferred treatment, the oncologist must now take a hard look at his clipboard and pick the second best therapy he has. No two patients are alike, and therefore salvage treatments do vary. The coach must take into consideration such factors as the patient's overall condition before sending in the play. Some second down plays are simply straight forward rushes, such as single-agent chemotherapy; others such as stem-cell transplantation for relapsed lymphoma, are works of subterfuge and precision as beautiful as a successful flea-flicker.

Third down - by now if the tumor has not been outplayed the chance of fans joyously tearing down the goalposts dwindles. Although some cancers such as ovarian carcinoma respond to many different kinds of chemotherapy and can be subdued for years, most others, like an enemy coach who decodes the other team's signals, become resistant. This is the down where experimental therapy should be considered. The playbook has been exhausted - it is now time to innovate, such as drawing a saber from the folds of the uniform, or setting the field on fire.

Fourth down - as sad as it seems, there comes a time when the oncologist must realize that he can no longer prevent a tumor from achieving its perverted goal of committing suicide by killing its host. In many cases there is nothing more to be gained by exposing the patient to the side effects of a futile Hail Mary pass. A more humane move would be to refer the patient for hospice care and begin to concentrate on providing quality of life, rather than obsess over its length. A few patients will not accept this advice and will seek out unproven cancer therapies. While an oncologist should respect the wishes of his patients, he is not required to advocate any treatment not supported by medical evidence.

A skilled oncologist, like a hard-nosed football coach, knows when to play it conservative and when to go for broke. He plots his strategy against the enemy and then stands on the sideline as the drama unfolds, hoping for the best, but unable to enter the playing field. The patient alone must carry the ball, and his doctor must always remember that the greatest coach is the one who embraces his players in victory or defeat and says "You did your best."

Deciding to be Undecided

2005-02-07T01:06:00.000-06:00

Time for you and time for me,
And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

T. S. Eliot, The Love Song of J. Alfred Prufrock, 1919

I frowned as I stared at the jumble of golf clubs peeking out from my bag, pondering which weapon to use on what looked to be a spine-tingling second shot over a pond the size of Lake Michigan. As I made the necessary mental calculations involving distance, wind, and more importantly, my famous slice, I heard the voice of one of our foursome cry "C'mon and make up your mind!" Ignoring the rube, I let several more ticks of the clock pass before selecting a club. I then approached the ball like Pharoah lording over the prostrate Moses and with one swing launched a perfect parabola that peaked near the heavens but ended where only minnows and frogs are happy. I wondered if I had made up my mind too hastily.

While waiting for the laughter around me to die down I thought about the problem of indecision and how it applies to my own vocation. It should come as no surprise that the cancer specialist is asked to make tough decisions every day. He must weigh the benefits of treatment against its risks and then determine if this therapy is safe to give to his patient. There is the possibility that treatment may lead to severe side effects, or even death. It is no wonder then that medical oncologists are often found slumped in their office with chin on hand, as deep in concentration as any man dreamed of by Rodin. They are truly under enormous pressure, and not just because a nearby statue has toppled.

Could there be a species of oncologist, however, that lacks the nerve to press the launch button and send a volley toward some hostile tumor threatening dear old grandmother? As I addressed the fiendish ball (a new one, since his twin now slept with the fishes), I recalled a man sent to my office last week for a second opinion. He was recovering from a successful operation to remove an early stage rectal cancer, and had seen a medical oncologist for advice on whether or not to take several months of adjuvant chemotherapy and radiation therapy. Since this visit was to receive a second opinion, I asked him what conclusions were advanced during the first.

"Oh, he didn't really say anything," he replied. "He said I could take chemotherapy if I wanted to, but that it was up to me."

Had a paparazzo surreptitiously snapped my face at that moment he could have sold it for a pretty sum (if I was a star), for I gave the patient a look like a fellow who has just seen a parking attendant back his Ferrari into a hot dog stand. Delving deep into the manual on tact and diplomacy, I was able to politely ascertain that his erstwhile doctor had taken no stand on the situation on the table - that is, should this gentleman endure six months of mementos such as diarrhea in order to improve his already favorable prognosis? The answer to this dilemma was clear to me: the current data on his stage of rectal cancer were encouraging enough to obviate the need for any adjuvant therapy.

No church bells pealed, however, when I revealed my impression to the man since he still had to live with the small chance that the malignancy could return, but in general he was satisfied with our time together. All that was left to do was dissect the reasons why my rival had vacillated at the moment of decision. I began to formulate hypotheses as I stepped onto the green, my scorecard blackened with strokes and penalties. At last an easy decision awaited me - I yanked my putter out of the bag and prepared to send the traitorous sphere into the pit with one sweep of the pendulum.

Assuming cowardice is not the flaw when an oncologist fails to deliver an opinion, what then makes a highly trained specialist tongue-tied when a plan of action (or no action in this case) is desperately called for? I worried about certain defects known to appear in the physician if his career careens, such as passive-aggressiveness, or indifference. No oncologist could maintain his practice for long if he sank into this kind of wickedness, and I doubted that my competitor was actually deranged. Rather, I suspected he had floated up into the seductive cloud of indecisiveness that tempts all physicians. High above the laboring crowd, a doctor who asks his patients to choose their care can rest easy, knowing that if the outcome is unfavorable he cannot be blamed. He lives without fear of making a mistake, and therefore is technically immune from any retribution. Such an oncologist is agreeable at all times to all people, for he is but a messenger - an attendant lord in the royal court, his head safe from the chopping block. There are many ways to decribe a "no opinion" oncologist, and Eliot did it best:

Deferential, glad to be of use,
Politic, cautious, and meticulous;
Full of high sentence, but a bit obtuse;
At times, indeed, almost ridiculous--
Almost, at times, the Fool.

Decisions in cancer care are often agonizing for the oncologist, patient and family, but they must be rendered. In the kingdoms of old no great battle was ever won by a declaration from the Fool. A wise doctor will recognize this and summon up the courage to give his opinion and then stand by it - perhaps not with regal splendor, but with enough dignity to warrant a cheer from the brigade of warriors massing around him.

A Soft Answer Turneth Away Wrath

2005-02-04T01:16:00.000-06:00

"Speak when you are angry and you will make the best speech you will ever regret."

-Ambrose Bierce

Once upon a time a fire broke out in a house, and as the fire chief arrived he could see many people hanging out of the windows upstairs, hollering for help. He quickly drew up a plan and his team of firefighters went to work with ladders and hoses. There were more people to be rescued than rescuers, and some victims had to wait their turn. Some residents became irritated and insulted their saviors, calling them slow, or clumsy. As the blaze was extinguished, a crowd gathered around the chief and bitterly criticized his leadership. When he defended his plan they accused him of being rude and unsympathetic. The chief tossed his helmet to the ground and lashed back at the residents. He blistered their ears, calling them ungrateful.

Some patients, like the sooty patrons of the house in this fable, have limited insight into the work involved in trying to save a life. They may be rude, demanding or unappreciative of their doctor's efforts. They might even be so blind as to fail to see that they have just been pulled from the consuming flames. How the doctor reacts to the cavils of the very same people he is sworn to help can determine both the success and the length of his career. No doctor enjoys caring for an obnoxious patient, no matter how infrequently this creature is found. If, however, a physician gives in to the temptation to humble the insolent, he places his calling in peril, and not just because of the possibility of being denounced to the State Board (cf. Blair, Eric Arthur 1903-1950). More importantly, once a doctor blows his stack he now has two adversaries competing for his attention - disease and anger.

All doctors experience "one of those days" when they cannot seem to please a patient or family member, or when they run into someone whose cup runneth over with churlishness. Since doctors tend to be self-centered and overrate their social skills, they interpret a negative reaction as an affront. They become incensed that anyone would dare to question their judgment or compassion - why some kingpins would even go so far as to call it lese-majeste'. Although it is acceptable as it is unavoidable that some hackle-raising will occur at this time, the doctor must quash anger before it bursts through the cracks. Anger is not only unprofessional, it is like smashing The Portland Vase in a fit of rage - one feels a savage sense of satisfaction at first, but then try to leave the museum without the guards noticing. A doctor who erupts at a patient will have to face the consequences sooner or later. His most precious commodity - his reputation - will sink like a torpedoed freighter if he fails to control his temper.

What then, could our beleaguered fire chief have done to soothe the irate crowd short of submitting his resignation? Well, for starters he could have summoned up what seems to be a rapidly disappearing attribute in these days of reality television - self-discipline. It takes only a moment of deep-breathing to delay the wrathful response, and by then hopefully another helpful concept, like a record plopping on the old jukebox, will begin to play in his mind - perspective. Keeping everything in perspective should be a constant goal of the doctor as he counsels, so that those in need understand that treatments such as chemotherapy, with all their distressing side effects, are necessary to achieve the prime goal of remission.

If these techniques are still ineffective in getting the villagers to drop their scythes and torches, try my personal favorite defense - humor. The use of humor in oncology has been neglected and is just now being recognized as an effective way to help patients cope with their illness. When applied appropriately it is a great way to raise spirits and give hope - especially if the boss tries a little self-deprecating jesting.

Finally, the doctor's last defense in a midst of a potential confrontation is this, as best relayed by the character Sgt. Barnes in the movie Platoon:

"Take the pain! Take it!"

In other words: shut up, Doc, and let the rant burn out on its own. Remember, this too shall pass, and the head will rest easier on the pillow tonight knowing that once again anger tried to take command of an emotional situation, and once again it failed like the miserable chump it is.

The Conundrum of Remission

2005-02-02T00:15:00.000-06:00

One of the basic tasks a medical oncologist must perform is to determine whether a patient's cancer has responded to treatment. This evaluation is usually made by measuring the size of a tumor on physical examination or x-rays, and if the lesion is at least half its previous size a partial remission is said to have occurred, which is an encouraging result. Even better, if the mass is gone then the remission is labeled as complete. Patients whose tumors shrink less than half, remain the same size, or increase in size are formally deemed nonresponders, and using this system of reckoning, thought to face a grim future. For many years formal clinical trials of chemotherapy reported repsonses in this objective manner, as a way to predict which patients have the best chance to extend their lives. Once a tumor is measured on an imaging study, the answer to the question "Did the treatment work?" must be communicated to the patient and family.

I am the doctor who walks into an examining room and delivers this news.

Obviously my job is easy if the report is reassuring, but what if the cancer has not responded to therapy? When an x-ray reveals a meager response, how does an oncologist share this information without delivering a crushing blow to the hopes of his patient? The truth is, the manner in which I counsel a patient is one of the little-known quirks of the field of cancer care. Depending upon my facial expression, my body language or my demeanor in general, my answer - even if it contains discouraging news - may still calm the anxious face in front of me. Like an actor I may choose the role I wish to play that day - rescuer or villain, optimist or cynic. I can attach my own personal slant to the interpretation of the x-rays that may cause the patient to vow to fight on, or simply give up.

On this day - strange but true - I am the ultimate spin doctor.

There is a problem, however, in using the response rate to predict survival. Many new treatments available in the battle against cancer, such as monoclonal antibodies or growth factor inhibitors, nicknamed targeted therapy, can aid a patient without significantly reducing the size of a tumor. Cancer growth can sometimes be arrested, leading to a noticeable improvement in the patient's symptoms. This outcome has been enthusiastically described as "turning cancer into a chronic disease". In this setting it matters less that the tumor has shrunk but that it is no longer growing out of control.

If a patient can actually co-exist with cancer, then the significance of the response on x-ray lessens. Now, living with cancer no longer becomes an all-or-nothing game, where only those who rid themselves of the disease completely have any chance for a future. Even if an x-ray shows no signs of remission, if a patient feels better after receiving treatment my job is to provide encouragement and hope.

The treatment of cancer is changing - from a game of pure chance to a game of skill - a long campaign, with many battles, retreats when necessary, and an ever-shifting strategy against a faceless enemy.

Cancer therapy is not like playing the lottery, won by only a handful. To me it is like a long run to the top of a mountain called Cure. Some patients travel only a short distance before they drop from exhaustion. Others can sprint for miles, barely visible to the eye as they climb upward into the furrows and ledges. Some even reach the summit. All who attempt this ascent, whether it ends close to the base or on the bright peak, deserve to be called the bravest of the brave.

May I Take Your Order?

2005-01-31T17:08:00.000-06:00

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'am...here 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.

Saint Crispin's Day

2005-01-29T01:12:00.000-06:00

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.

The Case of the Strange Sprain

2005-01-27T01:31:00.000-06:00

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.

Cancer and the Ordeal

2005-01-25T00:15:00.000-06:00

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.

The Tumor Board

2005-01-23T10:14:00.000-06:00

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.

Visions of Tomorrow

2005-01-20T15:14:00.000-06:00

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.

Dr. Osler's Advice Column

2005-01-19T13:15:00.000-06:00

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 cheerfulness...help 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.

In the Temple of the Giants

2005-01-18T03:00:00.000-06:00

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.

Do You Want the Good News or the Bad News?

2005-01-13T03:03:00.000-06:00

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.

You Be the Doctor

2005-01-11T23:48:00.000-06:00

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...

Listening to Mini-Me

2005-01-10T21:16:00.000-06:00

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.

Cancer and the Wall of Apathy

2005-01-09T03:30:00.000-06:00

. . . 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.

Why I Am an Oncologist

2005-01-08T17:34:00.000-06:00

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.

Okay, So I'm Not Sherlock Holmes!

2005-01-06T22:22:00.000-06:00

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)
Allergies
Medications
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.

How Did Your First Day Go?

2005-01-02T22:14:00.000-06:00

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.

New Year's Eve with Friends

2004-12-31T19:30:00.000-06:00

The halls are quiet today. I can hear my footsteps tapping on the tile as I make my way around the wards. All but two of my patients have managed to rally enough to escape, thus avoiding one of the most stale and depressing celebrations ever offered in a hospital - New Year's Eve.

Nurses and doctors look upon this holiday as an unlucky turn of the wheel which assigns them to duty on the one night when song and laughter waltz together under the cold winter sky, and families gather around bright fires, keeping an eager eye on the ticking clock. Those who must work tonight will huddle briefly around a radio for the countdown, then return to the harsh lights of the emergency room, or wander down a darkened corridor to answer a patient's call. Perhaps they pause and reflect on what they are missing - thinking of their children, up late tonight spilling popcorn on the sofa, or of parties of long ago when a midnight kiss between friends left a hint of romance on the lips. New Year's Eve is a time for new friends to meet and old friends to remember, and most people trapped in a hospital shift are denied both pleasures.

For the oncologist, however, the last day of the year is full of friends. They greet me in the waiting room of my office or as they step up onto the examining table. They wait for me in the halls of the hospital, or call my name as I enter the cafeteria. We all like to talk about ourselves and on this night my friends press closer, anxious to share their story. Each one relates a unique history, and their first words are always the same:

"This was the last year I was alive."

These friends, you see, were my patients - now gone.

When an oncologist reaches out to one living with cancer he does not know whether his hand will be grasped vigorously or dropped. If the clasp occurs it usually forms a lasting bond, for as a friendship develops the voices of his patients find a place to rest within him and speak out, even after life has ended. Cancer leaves behind indelible impressions on all it touches. It makes patients immortal in the mind of the doctor, whether he acknowledges it or not.

I therefore can see my friends all around me on this wondrous night. As the new year dawns let me recall their struggle with respect and admiration; let me entreat for solace for their families; let me pray for courage to face the challenges that lie ahead.

Let an oncologist honor his friends, present and past, with a simple motto: "You are worth it."

The Angry Husband

2004-12-28T15:38:00.000-06:00

"When I go I'm taking that doctor with me."

Thus spoke a retired police officer one afternoon to his surgeon, who probably considered this blunt statement as merely a catharsis of anger, not a serious threat. The surgeon certainly didn't see any need to ring the authorities or even call the intended victim - in fact it was not until the following week, when he happened to run into "that doctor" in the parking lot did he mention the gentleman's unique promise, sporting a rather sardonic smile as he talked. The poor designee promptly dropped his tranquil demeanor and began to pepper his friend with urgent questions regarding the officer's mental status. The doctor in question, now laden with twenty fresh pounds of nausea, began to eye the space around him like a young wildebeest in the lion's den.

The doctor in question was me.

As I remembered the case I realized my predicament had formed from an unfortunate merging of misunderstanding with misfortune. The officer's wife had been my patient and had fought a difficult cancer for weeks, achieving the most precious of goals - a complete remission. Despite her gruff disposition (a trait both spouses had mastered), the necessary treatments were agreed upon and delivered, and now the storm of cancer had abated. All was well again in the world. Peace reigned throughout the body.

The officer's dear wife, alas, was destined for only a brief armistice. Within a month she developed a change in her laboratory values - a subtle sign to me of possible turmoil within. I tried to keep up hope since she certainly felt well, but as summer approached I became more suspicious that her disease might still be alive. If this were true her life would be lost, for no further treatment could eliminate the invader if it survives the initial killing blow.

I approached this potential crisis with the optimism of the young doctor, yet with the trepidation felt when inexperience clashes with rancor, and basically did nothing that would upset the patient. My counseling was rudimentary and any words of comfort I gave did little to assuage the anger boiling within both patient and spouse, who were convinced that cure was a certainty. I counseled caution - to wait it out and see if the tests stabilized, or the patient developed symptoms of concern.

Then as all doctors who are not employed by either royalty or state leaders do, I left for my summer vacation. When I returned, my partner informed me that the patient indeed had relapsed and died a few days after...and that the family "took it hard".

Upon hearing this I suddenly gained the most unwanted form of wisdom ever found within a medical career: the gift of 20-20 hindsight. I now realized all the warning signs my patient displayed and what I should have done about it but did not, out of fear of facing her ire. I choked in a crucial time because I was scared to have to wade once again into the muck that was her cancer, knowing full well that she was doomed.

I neglected my duty out of a little fear, and now had to live with a greater one.

Walking quickly to my car each day I learned to scan my surroundings, looking like a cheap actor in a self-defense instructional tape. As the weeks went by eventually I convinced myself that the threat was simply a venting, and forgot about the angry husband.

About one year later I ran into that same surgeon and was impelled to ask him if he had heard from the officer recently. His reply left me standing in stunned silence: "Oh, he died of gastric cancer a few months ago."

This ends the story of The Angry Husband. To this day I am uncertain as to what message is contained within it - but whether I am enlightened or not, like Moses before the burning bush I kneel in respect of this formidable opponent...this pestilence that strikes with random fury. May all oncologists prove themselves worthy when the day of reckoning comes.

Saying Goodbye

2004-12-26T18:45:00.000-06:00

Have you ever wondered what is on an oncologist's mind when he visits a patient for the last time?

No matter how sympathetic he is, someone in my profession who constantly views the face of the dying must eventually become inured from heartbreak, or otherwise risk losing the ablility to carry on with his duty. I too have learned to fashion a mask of impassiveness, molded from years of exposure to patients lost, to be worn at the hour of greatest sorrow. I dare not walk into a hospital room without it for fear of embarassing myself with a maudlin display of emotion, which could be interpreted by the family as a sign of irresolution or frailty. It is better to play the role of the "professional" at all times.

Surely therefore I pride myself on my ability to stand far away from grief - all the better to not be harried by it as I attempt to continue on with my busy day.

Surely I can minister to the dying without fear of breaking down this facade of calm concern.

Yes, surely I can - but the price paid is horrendous.

My face may appear composed, but let me share with you the truth: trapped within it are the tears of a thousand deaths. No oncologist can call himself a true professional who does not weep for the loss of life wreaked by this curse.

I weep for my patient who lies helplessly in a room he didn't ask to live in.

I weep for the person who sits by the side of the bed, stunned by the awful transformation of a spouse, parent, or child.

I weep for pain of not being able to do anything further to save a life.

Sometimes my breath is taken away by the awesome power of this disease to spirit off a good soul - away from a life no longer whole.

At the final goodbye, if the patient is conscious I will speak to him or her, ensuring that pain is under control. What should be said to the family is said: thanks for all their loving care, reflections on the life of the patient and on the relief soon to come. It is an emotional meeting and I find myself pausing, waiting for the ability to continue with composure - loyal to the code of the unflappable doctor. It is a time for a hand on the shoulder or a handshake, or a hug.

Inside I feel as if a part of me was left behind in that room...as if cancer has exacted its price also on the doctor who dares to defy it. If this were true, the day would soon come when there were no more oncologists, for after scores of goodbyes we all would eventually drain away, sealed forever within the memories of those we served.

Fortunately oncologists draw our strength from an inexhaustible well, for day by day as we give of ourselves to our patients, from them are we replenished.

Season's Greetings from Sir William Osler

2004-12-24T07:52:00.000-06:00

In the spirit of the times, I wish you all a

Merry Christmas

or

Happy Hanukkah

or

"Have a Good One" (official holiday greeting for the non-religious)

Sir William Osler (1849-1919), the father of modern medicine and called "the most influential physician in history", was not only a brilliant healer, scientist, writer and teacher, but a prodigious font of memorable quotations. I plan to share with you some of his best words of medical wisdom in a future post but for today please accept a preview of the baronet's keen and insightful tongue:

"Courage and cheerfulness will not only carry you over the rough places in life, but will enable you to bring comfort and help to the weak-hearted and will console you in the sad hours."

(hmm......sounds like a good motto for the blog site)

"Live neither in the past nor in the future, but let each day absorb all your interest, energy and enthusiasm. The best preparation for tomorrow is to live today superbly well."

(see why I admire him?) and finally:

"There is a form that springs from the heart, heard every day in the merry voice of childhood, the expression of a laughter-loving spirit that defies analysis by the philosopher....Bubbling spontaneously from the artless heart of a child or man, with egoism and full of feeling, laughter is the music of life."

Whether this time of year fills you with memories of joy or memories of loss, may this music find your ears and bring you peace.
-The Cheerful Oncologist

The True Meaning of Healing

2004-12-23T19:11:00.000-06:00

The winter sun was hanging just above the treetops, bathing the exam room with honeyed light as I sat beside a patient with cancer who was about to receive discouraging news. After two successful rounds of chemotherapy new tumors had been discovered in his liver and lungs. In order to have any chance for further life I would need to find an alternative treatment, one that would now be considered successful if it merely halted the progression of his disease. The chance for cure was gone. I began to steer our discussion toward the truth he must face.

Sometimes a talk with a patient is like a game of cards, where each person plays with the goal of winning the other over to his point of view. I had just laid out my best hand and expected my patient to agree that my plan aimed for goals that were now limited but realistic.

His reply to me was unexpected: "I know I am going to be healed."

I had just been trumped, and temporarily lost the power of speech.

As I wondered how to respond I knew that refuting his statement would be discourteous. Although I felt that his disease was beyond any hope of eradication, to argue with him over the issue of the miraculous cure would imply that there is no place for faith in the care of a cancer patient. To deny the value of faith is wrong in my view - faith is a great source of comfort to the patient. It is a great source of peace - and of healing. This led me to consider the nature of healing itself. Even though my patient was referring to healing of the body, could there be other types of healing hidden within this ordeal? Could he actually be right - that he was destined to be healed, but not in the sense he thought?

We doctors tend to focus our efforts only on restoring the body - on disease removal, which we then are proud to call "healing". My patient may very well become the recipient of an inexplicable cure, but even one who beats the odds will someday reach the end of life and die, despite continued pleas for more healing. This limit is the destiny of all patients - and their doctors, too. Perhaps we all should therefore reflect on whether healing is confined only to the restoration of physical health - or does it transcend this boundary?

As I prepared my response to my patient I considered what I had overlooked:

I thought of the healing that comes when we believe our life has been blessed by the God who provides eternal life.

I thought of the healing that comes with the final relief of our pain and suffering, for as we die our disease dies also, never to torment us again.

I thought of the healing that comes when we accept our fate and are released from the anguish of demanding more time.

I thought, most importantly, of the healing that comes with an appreciation of the greatest gift a dying patient can ever receive - the love of his friends and family. Whether the life lived was one of acclaim or obscurity, rare it is to find one who dies forgotten.

Healing is more than just a purging of illness...it is peace of mind, which provides a greater benefit than the doctor's potions. Peace of mind is the elixir of renewal, which lifts the sun up over the horizon in the morning, showing the world that we are ready to meet the day's challenges. It is the healing that once applied, never dies.

When is No Treatment the Right Treatment?

2004-12-20T16:08:00.000-06:00

Imagine yourself the son or daughter of a hard-working man who put in his years of labor and skill without complaining, a father who in his day could hoist you and your squealing brother up over his shoulders with ease, a husband who adored his wife but couldn't say so, a master griller in summertime, a buddy to his buddies, a die-hard fan...

...and a man who loved his cigarettes.

Imagine now sitting beside him in a dreary hospital room as he labors for breath and strength, crushed under the weight of that disease which silently grew within him, only to burst forth like a sudden flame from smoldering embers.

How would you react if the medical oncologist on the case recommended not treating your father's cancer? This seems incompatible with the healing art, which exists only to improve the life of one who suffers. What is behind such a decision?

I often see patients who have lost the ability to take care of the daily activities we all take for granted, such as dressing oneself, because of the beating cancer inflicts on the body. An even worse scenario is when cancer unites with a chronic illness such as emphysema, which can rapidly drain whatever meager reserve the patient has left. In order to reverse this decline the cancer must be stopped, which usually requires the use of chemotherapy. The risk of complications and death from chemotherapy in a weakened person is high. It is a risk that in many cases cannot be hazarded, and withholding treatment then will not only prevent toxicity but spare the patient from becoming a statistic loathed by all oncologists - a "treatment-related mortality".

Withholding treatment, however, means that the cancer will still grow. This paradox is just one example of how cancer harbors its own unique form of distress for the patient and family - and for the oncologist who is now hindered in the wielding of his therapeutic sword. This choice must be considered, though. I have seen many a patient start out on chemotherapy with the highest of expectations only to die the next week from immunosupression.

Which option is worse, then - letting the cancer progress and avoiding the risks of treatment, or taking a chance on chemotherapy and an early demise?

Oncologists live with this dilemma every day, and when we make a final decision it is not imperiously like Solomon in his temple, but in concert with the patient and loved ones. The task is not easy but is vincible if four straightforward questions are asked:

1. What does the patient want? (if he or she cannot answer the reason why is usually not encouraging - cf. comatose)

2. What are the chances that the treatment will reduce the cancer? (anything less than 20% is typically not worth the risk)

3. Is life prolonged on this treatment, compared to providing supportive care only? (an answer of "no" is a compelling argument against)

4. What is the risk of severe toxicity and death? (patients who are bedridden, or spend most of their waking hours at rest are at higher risk)

All it takes is one conference...or two...or three or more, and soon the right decision will be manifest. As an oncologist I can provide informed consent and (purportedly) sage counseling, both of which will hopefully lead to a choice that is acceptable to all. Throughout this process, whether the discussion goes smoothly or painfully, my obligation to the patient will be more likely to be fulfilled if I follow one of the Laws contained in that classic satire on medicine, Samuel Shem's novel The House of God:

"The patient is the one with the disease."

...and the doctor is merely his servant.

Doctors and Their Books

2004-12-17T22:41:00.000-06:00

"Medicine is my lawful wedded wife, and literature my mistress. When one gets on my nerves I spend the night with the other...neither one loses anything by my duplicity."

Anton Chekhov, the Russian physician and celebrated writer, said this in 1888. He was referring to his dual careers in medicine and writing, a combination of loves that has always attracted me. This post, however, is not about the physician as author - that topic must wait for a separate puff of afflatus to fill the sails of my mind. Today my interest is in the physician as reader. As you know, it is hard to become a doctor without developing accomplished, if not magnificent skills in reading. After using these skills in years of study, the young doctor then enters practice and finds that the required reading material has only multiplied. So many charts, reports, journals, articles and textbooks lie heaped on his or her desk there doesn't seem to be enough hours in the day to cover it all - let alone read for what my grade school teacher used to call "pleasure". This is sad, because in my opinion pleasure reading is one of the keys to a fulfilled life.

I love to read. I have read for pleasure as long as I can remember. There was a time, though, when I did not use my leisure time for reading, because I had to choose between reading and sleeping. This interlude in a doctor's life is called the residency, when the hours worked in a week come perilously close to the total allotted in the calendar. This is a time of concentrated exhaustion, when a long trail of newly published books floats past the young doctor's life without fear of being netted. There is simply not enough time to seriously enjoy reading during the training years.

What happiness must arise then, when servitude finally comes to a close and the glory years of the doctor's life beckons...

...except now he or she must still wrestle with the daily schedule, unexpected emergencies, family obligations, personal matters, to name a few, in order to find a quiet hour to soak up a good book.

Still, doctors are well-read, even in today's hectic world. With this in mind, I would like my readers to share something about the books they have had a personal relationship with, so to speak. I want to know what doctors and other medical professionals feel about the books in their lives - are they enriching themselves as they deserve, or watching reruns of Spongebob Squarepants? Do they love books as a true bibliophile does, or are they just name-dropping when they brag that they read The DaVinci Code on the beach in Jamaica?

If you feel like commenting, please answer these three requests:

1. Name a book that you cherish and cannot wait to read again.

2. Name a book that you refused to finish, or simply could not bring yourself to complete.

3. Name a book on your shelf that you cannot wait to dive into.

If the responses are remarkable enough perhaps I'll even share my answers...until then remember what Sir Winston Churchill said on this topic:

"If you cannot read all your books, at any rate handle, or as it were, fondle them - peer into them, let them fall open where they will, read from the first sentence that arrests the eye, set them back on their shelves with your own hands, arrange them on your own plan so that if you do not know what is in them, you at least know where they are. Let them be your friends, let them at any rate be your acquaintances."

"Good Doctors Leave Good Tracks."

2004-12-16T18:07:00.000-06:00

This saying was the mantra of the most influential teacher I ever had - the doctor who taught me how to persevere through the daily sturm und drang of caring for those living with cancer. His theory was that you can always tell when a good doctor has been involved in a patient's case by the type of "trail" he or she left behind after the work was done - a ship's wake, if you will, that represents the effect the doctor had on the patient's life, a trail that does not always guarantee a healthier patient but that shows the world the type of doctor who captained the mission. This imprint reveals the depth and worth of the doctor's effort. The converse of the apothegm therefore is just as true: "Lousy doctors leave behind lousy work."

With a little training anyone can become an expert in deciphering the tracks of a doctor. It seems to me more apropos to illustrate the marks of a praiseworthy one, rather than try to describe the flotsam left behind by a hack - after all, I wouldn't want to be accused of being cynical!

Well then, let's take a look at the trail a perfectly wonderful physician leaves behind at the end of the day. These are the clues you have hired a good one:

The Written Word. There is no easier way to separate good and bad doctors than by the dictated reports, handwritten orders and notes, and letters they produce - by the ream, I might add. Good doctors have legible handwriting, no matter how much of a hurry they are in. They take the time to document the important facts of a patient's illness and the information relayed to the patient. Counseling sessions are put into the written record - the risks, possible side effects and alternatives of a treatment are recorded. The medical record should be inscribed so that a new doctor could pick it up the next day and know immediately what the case is all about.

The Spoken Word. I have already commented on the importance of proper communication with patients in an earlier post, but let me add this: a good doctor speaks clearly and respectfully, avoids medical jargon and slang, shuns a prejudicial attitude, never assumes that one attempt at explanation will be sufficient, nurtures assurance and hope in a time of dread, and tries to share the joys of jocularity when appropriate. It's as easy as that!

Critical Thinking and Investigation. Good doctors never assume that the patient's symptoms are due to the same old run-of-the-mill maladies that they see day after day. They excel at what is called lateral thinking - thinking "outside the box" of routine illnesses. They question themselves - "Do I have the right diagnosis?" They order tests that seem to fit the patient's clinical presentation, not just to get a nice peek at every organ in the body. When they are stumped, they research the question - and keep searching the medical literature until they are satisfied that they have a handle on what the problem is. If not, they ask an expert. A good doctor gets smarter every year by his commitment to lifelong learning.

Following-Up. Lastly, it is tedious but vital that doctors review the results of all the tests they order, that they keep in contact with sick patients who might suddenly get worse, that they double-check their plan of attack for an illness (especially cancer), and stay knowledgeable with current medical news and new developments. As the great physician Sir William Osler said, "To study the phenomenon of disease without books is to sail an uncharted sea..."

Osler was a bedside healer by the way, not just a laboratory researcher and the second part of this quote is "...while to study books without patients is not to go to sea at all."

Every morning a doctor sets sail into the vast and deep blue of medicine, eyes on the horizon and on the sky, with the hope that the voyage will be untroubled and lead to a life saved, a burden eased, a soul comforted. By watching the foamy trail left behind, we who are in need of the doctor's mastery can determine whether he or she is the right skipper for the journey.

Nightmares of an Oncologist

2004-12-14T15:52:00.000-06:00

You don't hear much about this in the media and therefore, dear reader, perhaps you have concluded that the mood of doctors is calm and secure, but let me reassure any doubters out there:

The practice of medicine still is intellectually and emotionally grueling.

Far be it from me to whine about a career that I enthusiastically volunteered for, but would it be fair to allow me to "share" with you some examples of why oncologists sometimes do not sleep restfully? It isn't just because so many of our patients succumb to their illness. It is the way in which such a life was lost - the slow, relentless deterioration of a once healthy being - that breeds fear, anger, distress, pity, and hopelessness in both the patient and the doctor. I suppose these emotions are not unique to my profession, but are they encountered on a daily basis in other specialties? Wouldn't such continuous exposure to sorrow turn any oncologist to ashes?

Well, maybe not - this stress hasn't broken me yet and doesn't appear to be crippling our profession, as cancer providers are more confident than ever in the many new treatments available.

Even so, there are certain traumatic events in the professional life of a medical oncologist that haunt slumber. They are the oncologist's nightmares. They have visited me in my past.

I await their inevitable return with patient frustration.

Rather than dilate upon this any further, let me illustrate, with a brief explanation of their effect, the four worst nightmares of my career:

Patient Suicide: Three times in my career have my patients violently taken their own life after being diagnosed with cancer and before receiving any treatment. One of the patients had an indolent lymphoma, which is associated with years of remaining life. Why, I asked myself did he do it, especially after I told him about his relatively good prognosis? My initial shock of each patient's death led me to blame myself - I felt that my counseling skills must be pitiful if this is the result of a visit with me.

Treatment-Related Death: I have sat by the side of a smiling patient receiving chemotherapy on a bright afternoon only to be standing helplessly next to her in the ICU at 3 A.M,. as she dies of septic shock. Oncologists cannot predict with exact precision which patients will survive treatment, so we must use our best judgment in choosing a course of care, sometimes treating those with a higher risk of complications. Whether a patient is lost due to infection, pulmonary embolus or renal failure the end result is the same - we have failed in our mission to kill the patient's cancer, and we feel worthless.

Hostility: There is nothing more traumatizing for me than to have to meet angry people and try to convince them that I am the one to entrust the care of their loved one. It is a miserable experience to deal with hostile patients or families, and feels like trying to hold a discussion in a burning building with a gun pointed at your heart. The reason why it upsets us so much is not their ire, which is easy enough to understand, but because we often get irritated at being treated in such a manner, and an angry doctor is a inferior healer.

Irreversible Decline: How would you like to take a job where you meet delightful and interesting characters - former World War II veterans, teachers, grandparents, retired musicians, book lovers, ministers - and get to watch them slowly, inexorably lose their appetite, energy, weight, strength, hair and ability to share their lives with their loved ones? I realize this is what every caregiver and family member must suffer when their beloved is afflicted with cancer. It is a tragedy beyond measurement. An oncologist, however, feels that he or she has the power to stop this misfortune - if only the right treatment was given at the right time, with the right amount of luck or heavenly blessing. So we offer treatment, and if it is ineffective, if death then begins its unrelenting assault, gradually transforming robust flesh into a gaunt visage, and all we can do is watch it happen...

That to me is the oncologist's worst nightmare.

Since I have not named this blog The Frightened Oncologist, you may ask "How do you reconcile these distressful aspects of practicing medicine with your chirpy title?"

Ha!

Ever heard of the term fortitude? "Strength of mind that enables a person to encounter danger or bear pain or adversity with courage."

That, my readers, is the secret - if you don't have fortitude, you won't last long in this profession. Fortitude is the power that allows an oncologist to extract himself from the wreckage of discouragement, find another bicycle, and begin again to pedal uphill toward the place where his responsiblity and his patients await.

Communicating With Patients

2004-12-10T20:37:00.000-06:00

Medical oncologists spend a tremendous amount of time communicating vital information to patients and their families. In order to begin a treatment designed to attack cancer, much must be done to educate them about the goals of treatment, the limitations, the risks and side effects, and the logistics of the treatment schedule. This information must also be given in such a way that not only are patients enlightened about their therapy, but that all involved are satisfied that the oncologist is indeed:

A. competent - not ill-prepared

B. confident - not vacillating

C. compassionate - not callous

D. considerate - not inflexible

Since I have a keen interest in improving the care of cancer patients let me, T.C.O., provide some simple advice on how a doctor might fulfilll the basic requirements of effective patient communication.

The Cheerful Oncologist's Tips:

1. If feasible, always sit down when counseling - it sends the message that you are not in a rush to get out of the room.

2. At the beginning of the visit, learn the identity of all who are in the patient's room - relatives, friends, ministers, etc. It is courteous, and you never know who might be in there with the patient. It could be someone important in providing care, such as the patient's power of attorney.

3. Don't speak too rapidly, or shovel out reams of facts about the patient's case. People under stress cannot process a lot of data. Take it slowly, with pauses at crucial points in the relaying of information - especially if it is bad news. We all need time to react and it is doubly hard when stricken with a serious illness.

4. Never, never use medical jargon without immediately translating it into common English. It amazes me that some doctors still assume the average lay person is bilingual!

5. Look the patient and family in the eye! You wouldn't want to give the impression that you're lying to them or that you have no faith in the treatment you are proposing.

6. Of course, leave time for questions. If you know of a vital question that hasn't been asked, ask it yourself and then answer it.

7. Give some encouragement, for cryin' out loud! We oncologists are in the profession of killing cancer, relieving suffering, and prolonging lives - if we believe that our treatments can meet these goals then why keep it a secret? Why not make an effort to lift everyone's spirits, so that we all start out with dreams of recuperation, if not healing, if not triumph?

8. At the end of the visit go around and shake everyone's hand. Again, it is polite and it sends the message that this patient's welfare is now your mission.

Successful communication with patients is not difficult when you, the doctor maintain two visions - first of patients and families leaving despair and fear behind as a result of your counseling, and second of you, the doctor sitting in the chair occupied by your patient. Yes, just sit for a minute in this chair and imagine yourself waiting...waiting for the door to open, waiting for the battle of your life, for your life, to start.

You sure would want a good communicator now, wouldn't you?

A Walk Down the Path of Pain

2004-12-07T21:22:00.000-06:00

"Oh Doctor, come hold my hand a while as I travel down the path cancer has chosen for me."

I hear these words echoing in my brain, as if from the pale lips of cancer patients waiting quietly in the hall for me to finish my paper work, waiting to guide me into the world of suffering that for me is just a job, but for them a grim reality. They stand silently, like Virgil awaiting Dante, ready to lead me down into the abyss where their tormenter resides.

"You, who claim to be an expert on this disease that has ruined us - what do you know of pain, or of dejection? Show us where you have earned the right to carry our lives in your arms."

True, there are times when I feel ashamed to be lecturing or coaching my patients - attempting to relate to those in pain. Why should they listen to my advice when I have no idea how it feels to endure such agony?

Much has been written about how to diagnose and grade pain, about how to get patients to communicate their pain, and of prime importance, how to effectively relieve pain. We oncologists prescibe pain medicines of all kinds - pills, liquids, patches, intravenous medications. Some of us are better than others at monitoring the efficacy of our remedies, as adjustments must be frequently made to keep up with pain's galloping through the patient. Very few of us, however, have ever experienced the relentless pain associated with malignancy.

Does this make us lesser physicians?

"No," we argue, for all of our training has provided us with a keen sense of how to identify pain in a patient and how to attack pain, usually with narcotics. Pain management is now a respected speciality, replete with new treatments for the sufferer.

Yet still...would a little pain in the doctor's life make him a more sympathetic healer?

My reason for bringing this up is that last year I developed an inguinal hernia. This hurt enough to be annoying but did not cause enough pain to interfere with work, or even a family holiday at Disney World (although I can now speak with authority against riding the Space Mountain roller coaster with a such a condition). Like a good patient I saw a surgeon and had an open surgical repair, which left me with an eight centimeter incision. Like a bad patient, I decided to not take any pain medicines during my recovery. After all, I come from a long line of ignorant, stubborn patients who hate to take pills. Plus I'm an oncologist, and many of us loathe taking narcotics due to the disturbing side effects they create. I therefore treated my pain with a couple of ibuprofen and an ice-pack. I, the defiant one, scoffed at any discomfort. I, the tough oncologist, laughed in the face of pain.

I, who care for people living in pain, journeyed a little down that path they are forced to march every day - just a little ways down the path...for a few days.

The pain was unbearable.

I couldn't find a comfortable position, couldn't concentrate, couldn't even watch Night of the Living Dead on DVD without heavy, aching pain squeezing my groin. Even now I can't adequately describe what it felt like. It was impressive though, and it made me think.

It made me think, even one year later, of pain and how it devastates a human life. Pain consumes a person's spirit and wraps itself around the waking mind like iron chains. It robs the sufferer of the ability to accomplish tasks, or even interact with loved ones. Pain is evil.

Having written this, I shall pledge to always remember what it was like to be in pain, as I pledge to remember what the good men and women in my care are going through on this day, and the many evenings to come.

The Nervous Patient

2004-12-01T13:58:00.000-06:00

A cancer specialist requires a certain amount of calm and equanimity, what I call the proverbial reassuring manner, in order to provide effective care. The reason why is blatantly obvious. Our patients battle horrific diseases that often leave them weak and depressed. Many times they are faced with no hope for cure. Is it no surprise, then, that some of them become nervous? And if you, the patient, are aflame with anxiety, would you enjoy listening to a loudmouth, restless, high-strung oncologist who likes to quote discouraging statistics, and is adept at inappropriate smiling?

Of course not. This is why we cancer docs must teach ourselves to counsel with tranquility. It is not easy to learn at first - a young oncologist is lucky if he or she trains under a professor who has mastered the art of giving out bad news in a way as to not cause a family riot. With time and experience, though, most of the great oncologists develop the poise needed to deal with high-stress encounters with desperately ill people.

Still, though, there are some patients who are so tormented with worry that their emotions make the doctor a nervous wreck. I met one such nice gentleman this week.

My new patient, just diagnosed with metastatic lung cancer, was attempting to deal with the panic that comes when one in perfect health last week is now sitting on the edge of a hospital bed, listening to descriptions of his various organs bulging with tumors, all documented clearly by a CT scan. My patient's anxiety was not only apparent, it somersaulted all over the room. He peppered me with questions, starting out with "Are you sure this is cancer and not an infection?" Classic Kubler-Ross stuff, I thought to myself. As I discussed what I knew about his situation with him, sitting calmly beside him in a chair, I used my most reassuring if not downright serene manner. I explained the facts of his case, came up with a plan to help him, outlined the logistics of the next several day's worth of tests, and did my best to raise the flag of encouragement over his bedpost.

Except, it didn't work worth a hoot.

The more I tried to allay his fears, the more nervous he became. He sat rigidly in his chair, repeating questions that I had answered earlier. Clearly, I thought to myself, he is overwhelmed, and it is time to call it a day. Let the passing of a night hopefully bring solace to him, and pick up our conversation tomorrow.

Great idea, except now I began to feel anxious.

I felt that because I left him as nervous as when I entered the room that I had failed, maybe not in my primary mission, which was to dispense essential information about the cancer, but in my inability to inspire confidence or at least a modicum of hope. The more I flapped my gums, the more my words just sounded annoying.

With this in mind, I unleashed the secret weapon of the medical oncologist, the mysterious strategy we cancer docs keep hidden from public view, to be used only in the event of a dire emergency, such as this one:

I scheduled an office visit for the patient and his whole family.

If there's one thing I have learned about caring for the nervous patient it is that the best way to relieve distress is to form a bond of friendship with him or her. To form such a bond, continue to counsel the patient - it is as simple as that! By sending the indispensable message "I care", the doctor creates trust, trust that the patient knows his doctor will act in his best interest - will become his advocate, in good times and in bad. My feeling is, the more time spent supporting the patient, the more confidence the patient will have in your support. Thus is revealed one oncologist's answer to the problem of the agitated patient: keep talking - and keep listening.

Death of a Colleague

2004-11-22T12:38:00.000-06:00

While attending a meeting recently I ran into a doctor from the university where I completed my medical oncology training. He filled me in about the professors we both knew, and then I inquired as to how an old pal from the fellowship years was doing - pretty routine chit-chat up to this point. The reply I got stopped me in mid-breath: "He died two years ago."

When an announcement like this touches the ears it instantly short-circuits the brain. For a brief moment one cannot make any sense of the information received. I understood what the phrase meant, yet was simultaneously puzzled, because it was inconceivable that my friend was dead. It cannot be true, I thought. Yet in some remote gyrus where maturity resides the shock was already processed, and waves of pain familiar to all who have received bad news began to vibrate through me. I was crushed by this news, and obviously wanted the details of his death.

I was told that my colleague, who had trained in medical oncology with me, had died of cancer after battling it for almost two years. My old friend, who had devoted his life to treating people with cancer, had succumbed to cancer. The irony in his story is almost unbearable - a doctor cut down in the prime of his career by same enemy he was sworn to destroy.

For the rest of the day I found myself unable to concentrate, as thoughts of my friend swept through my head. I was ashamed that I had not kept in touch with him over the years - he died two years ago, yet I never knew until today! I regretted not being able to speak to his wife, to comfort him in his time of need, to pray for him, to mourn him. As I reflected I kept thinking how unfair this death was - this man, a servant of those living with cancer, surely was worth keeping alive! Why was he taken so early in his life?

My ruminations then turned trite, as I declared "Why him and not me?" We were both the same age, and if oncologists can be stricken with a senseless death from cancer at any time, why was he chosen? A profound sense of awe came over me, a fleeting impression of the power and command death has over our emotions.

I was reminded that there is no easy way to endure the sorrow that comes with what is commonly called the "vicissitudes of life". It is certainly beyond my understanding. What does one do with this tragedy? How does one honor the memory of a colleague without descending into bathos?

I didn't brood on this question for long, for the answer to me was simple: go to work, and keep smiling. Do your duty, whatever it may be - and be glad that you awakened this morning in good health. Fulfill your mission in life - and delight in the wonder of it all. Remember your partner by doing his work, caring for patients as he would have continued to do, had he lived. Above all, spread a smile or two as you go about your day - it can lighten the load of those who suffer, your burden included!

New Treatment for Lung Cancer: A Hint of Good News?

2004-11-15T11:53:00.000-06:00

Those of you who are familiar with the malignancy known as NSCLC, or non-small cell lung cancer, are well aware that patients with advanced stage disease or metastases have a dismal prognosis. Most studies with combination chemotherapy produce a median survival of 9-10 months and a one-year survival of 30-44%. The percentage of patients alive two years after diagnosis is 11-19%, depending upon the size of the study and other malleable variables.

Once a patient's disease is refractory to chemotherapy, that is, once the lung cancer begins to grow after a combination of two drugs have been given, "second-line" chemotherapy is often recommended. The agent used for second-line treatment is either docetaxel or pemetrexed, which both produce a similar response rate of only 9%. The median survival time with either drug, however, is 8 months and the one year survival is 30%, compared with 4.5 months and 11% for supportive care, respectively. Because of these statistics they are FDA-approved and in wide usage.

The results of second-line therapy, while appearing meager to the lay reader, are embraced by oncologists like a parent reuniting with a lost child. This should give an idea as to how awful the outcomes were prior to the release of these "modern" chemotherapy drugs, when largely ineffective agents were used. We therefore with gusto recommend chemotherapy to our lung cancer patients, automatically exposing them to all of its various annoying, humiliating and sometimes deadly side-effects - all for a few more months of life.

This is the background I took with me to New York last week, where I attended a lecture describing a pilot study for the second-line therapy of NSCLC. In this trial patients were treated with the esoterically named agents erlotinib and bevacizumab, given simultaneously. The results were eye-opening for me, as this new combination produced a 20% response rate, a median survival of 12.6 months, and a one year survival of 52%. Why are these data provocative to a medical oncologist? They appear to be an improvement, but what's all the hubbub over these agents with the tongue-twister names?

The answer is: erlotinib and bevacizumab are not chemotherapy drugs!

They represent a new class of anti-cancer treatment called targeted therapy. This type of agent blocks a specific molecular target found on the cancer cell, which then inhibits cellular growth and division (mitosis) and promotes programmed cellular suicide (apotosis), among other functions.

Targeted therapy compounds such as erlotinib and bevacizumab also have the advantage of not causing the distresssing toxicities of chemotherapy so familiar to us all: they do not cause hair loss, vomiting, anemia, or fatigue. Their side-effects for the most part are mild, and include rash and diarrhea (trust me folks, this is mild stuff).

So keep an eye out for more encouraging news about targeted therapy agents. I predict that their role in the treatment of cancer will expand tremendously over the next several years, and that their value will increase as they are used earlier in the course of a patient's disease. Let's hope I'm right!

The Doctor Who Hated Cancer Patients

2004-11-04T12:51:00.000-06:00

Gentle readers, may I share with you a curious phenomenon that I have observed in my practice of medical oncology? Although it sounds as hideous as it is strange, I have worked with several doctors who have such a nihilistic attitude toward the treatment of cancer that they harbor prejudice and ill will against their own patients fighting the disease. Fortunately such a breed of physician is a rara avis in the world of clinical medicine, nevertheless, it is distressing for me to have to work side-by-side with a referring doctor who is not on my side. How could any doctor not wish the return of good health to one struggling with cancer? Rephrasing the question, why would a purported healer denigrate my professional attempts at healing?

Perhaps by describing the three main species of medical misanthropes I have encountered, the reasons behind such immature behavior will become evident.

The Ignoramus: who specializes in professing no knowledge whatsoever of the proper diagnosis or treatment of cancer. By feigning ignorance, he can justify his decision to not evaluate symptoms or findings on exam that might lead one to suspect a malignancy. The Ignoramus is recognized by his utter lack of interest in learning anything new in my field; for example, if I were to announce to him that a cure for a deadly form of cancer has just been approved and is in my office, ready to be given to his patient, his response would likely be, "OK, well thanks for calling." How does this doctor advance his basic fund of knowledge if he cares little about what happens to his own patients? Is this an example of what they called "passive-aggressive behavior" back in freshman psychology?

The Pessimist: always scanning the blue skies for that tiny black cloud which will give him the pleasure of proclaiming the day is going to be ruined by rain. The Pessimist just can't accept the fact that some modern cancer treatments are costly, that they work only temporarily, that they prolong life in less than all patients, that they do not come with a guarantee of success. Hey, for crying out loud- we oncologists realize we have a long ways to go - last time I checked I didn't see that coronary artery disease was cured, either! I find I must always quote survival data to this doctor in order to receive his blessing of approval prior to my involvement in a case, as if there are no other possible benefits to treatment. There's no quicker way to disappoint The Pessimist than to call with good news, because in his melancholy world cancer is a disease that is better left untreated.

The Sadist: the less said about him, the better. I know it seems unfathomable, but there is a species of doctor who delights in the misery of his patients. He expresses this subtly - by his demeanor, his body language, his choice of words - all designed to inflict emotional harm on the patient and especially the family. He never fails to illustrate how much of the patient's suffering has been caused by the oncologist's treatment. I therefore spend much time trying to rally again those dejected and depressed by cancer, and then by their doctor. Maybe this behavior is just an example of schaudenfreude unchained, or maybe it is simple revenge for perceived past injustices. Whatever motivates him, I can state with great confidence that my success in dealing with The Sadist lies in avoiding him as much as possible!

Could it be that I'm just too sensitive, that in any medical profession we must be ready to battle wits with skeptics, worrywarts, killjoys and jerks? Fine, then let us have at it - I will gladly lift up my smiling sword of hope against the frowning Dr. Scoundrel! At least I'll know whose side the patients will be cheering for.

Reflections of Autumn - and Cancer

2004-10-26T15:31:00.000-05:00

I took a long walk through the crisp forests of Missouri last weekend, marveling at the bronze and yellow-gold giants of autumn. They towered over me, lightly swaying in the October breeze as I tramped along. Fall is especially a poignant time for me, and not just because of the pleasure of scanning the brilliant countryside stained with color. No, this season also reminds me of my profession. It announces the death of summer - the slow transformation of green life into dark, skeletal corpses. This allegory is familiar to the oncologist, who all too often sees the same change in his patients. As I stepped on a vast carpet of fallen oak leaves I continued the metaphor. These leaves, which once shimmered in the blue dome of a hot July afternoon, now rested quietly on the forest floor. Could any cancer specialist not see the obviously painful comparison? What do we do with such a gloomy conceit on a sunny October day?

What I did was to consider my patients, some doing well, some struggling to live, and wondered how many of them would soon, like the scene before them, float downward from life and lie on the shady hillside, joining the limitless pile. I recalled that leaves are delightful when turning color, but once on the ground they are either a nuisance to be raked, or to be crushed by the boot on the way home. They are forever forgotten - who ever remembers on which branch they hung? Upon this reflection, I saw the contrast. The lives of my patients were more memorable than that of these trees. Their lives touched other lives - including mine. To each who was in my care I mouth a promise: "I will not forget you."

My time in the woods is therefore a lovely sorrow, a walk filled with thoughts about the beauty of the afternoon and of the disease that pervades this time of year. I suddenly have a vision of an empty chair placed in the midst of this dense forest, waiting to rest a weary traveler. Many have found an end to their suffering by stopping here. Today I walk on, through the timbers and into the meadows beyond. I know the chair remains in the woods, among the dead leaves. Perhaps someday my journey will lead to it. Until then the work and the daydreams of the oncologist carry on.

The Cancer Patient's Guide to Informed Consent

2004-10-14T20:43:00.000-05:00

We've all heard about the doctor's obligation of educating a patient about the potential benefits and possible risks of a particular operation or procedure. This is called "informed consent", and is usually completed by the patient signing a written form that delineates the pertinent information needed. The process is typically quick and tidy. The cancer patient, however, faces a host of possible side effects and toxicity when starting chemotherapy or biological therapy, and must agree to receive a treatment that almost always comes with no guarantee of success. Not only that, if severe toxicity occurs, the patient already struggling against cancer may die. This seems like a daunting challenge for the oncologist to ensure that the patient and family truly understand what the realistic goals of treatment are, and what the likely adverse effects will be. In fact, it is impossible to anticipate and relay every conceivable complication of a treatment, as some side effects are so idiosyncratic as to be unpredictable.

This fact does not relieve oncologists of the responsibility of providing adequate explanation of the details of any anti-cancer treatment. "So what's the problem?" we ask. "Explanation for us is easy - we've done it hundreds of times." Yes, but listening to informed consent for the first time can be confusing, frightening, and depressing for the patient, especially if the consent talk is disorganized or incomplete. Since our mutual goal is to move forward together to forge the best possible outcome for the cancer patient, it therefore seems appropriate to create a basic guide to informed consent. This brief guide contains helpful questions and subjects that should be covered when receiving informed consent about a potential treatment, whether that treatment is chemotherapy, hormone or biological therapy, or the newer class of agents called targeted therapy. By using this outline, the patient can ensure that the important topics are covered by the oncologist.

These are the highlights of informed consent that should be covered in the counseling session.

The Goals and Limitations of the Treatment: What are the chances of the treatment working? Can my cancer be cured? If not, does treatment prolong life? Will my symptoms improve with treatment? Will the cancer disappear completely - a complete remission? How long does a complete or partial remission last? What will my life be like while on therapy?

What happens when the cancer is found to be growing again? (This is a frequent question, but one that does not always have a straightforward answer, since it involves speculation by the oncologist).

The Risks and Side Effects: the risks that should be discussed include death, hair loss, vomiting, anemia, fever, infection, bleeding, mouth sores, diarrhea, damage to the skin, heart or nerves, allergic reactions and fatigue. This unhappy and only partial list highlights why informed consent is no fun to give nor receive - but it is necessary to prepare for potential future problems. A written list of side effects should be given, and solutions to the side effects should be discussed.

The Logistics of Treatment: How many days per month will I take treatment, and when does the treatment cycle restart? Where will I be treated - in the office or hospital? How long will each treatment last? Who and what should I bring to my office visit? How often will I come to the office in between cycles? Will I need a portacath (an implantable venous access device) for IV access? How much does treatment cost, and what is my personal cost?

Alternatives to the Treatment Recommended: Is this the best treatment available? What other treatments could be used? Are there any new therapies available, or is a clinical trial (research study, often with newer agents) open for my disease?

I realize this list is not comprehensive, but it is a good start for anyone facing the challenge of cancer therapy. By empowering the patient and family to ask these questions, the potential for misunderstanding is reduced and the chance for a more tolerable experience is strengthened. Asking thoughtful questions also brings out the best in every oncologist, as we are eager to share the increasingly hopeful news about the fight to subdue this wretched affliction.

How to Get Your Doctor to Listen to You!

2004-10-06T13:31:00.000-05:00

Have you ever been diagnosed with a serious illness, or known someone facing such a health crisis? Do you recall how anxious you were to get the true facts about the situation? At such a time we all rely on our doctor to communicate clearly the details of the illness and the plan to treat it. Unfortunately, many doctors possess meager skills in counseling; others are talented speakers but poor listeners, and all doctors are rushed for time. This often leads to an unsatisfying visit.

A patient or caregiver always has the right to ask multiple questions about the diagnosis, prognosis and treatment of an illness - I get asked these questions every day, and have learned to answer them as faithfully and completely as possible. Notice I said I have learned - when I started my career I too was a novice at patient counseling. Caring for cancer patients creates expert listeners of most oncologists.

Thus I am amazed when I hear again and again that a doctor "didn't say much" about a patient's recent diagnosis. Is the physician really ignorant or too busy to educate the patient, or is the subject bypassed because he or she has nothing encouraging to say? It is unfortunate that some doctors look at the disease cancer with nothing but hopeless nihilism.

Therefore, as a public service, The Cheerful Oncologist, with only a modicum of sardonic delight, would like to reveal some helpful tips in ensuring that your doctor doesn't race in and out of an office or hospital visit without adequately answering your questions. These little secrets, some practical and some psychological, increase your odds of gaining the answers you need without resorting to exhortation or outright hostility, which tends to freeze the doctor with suspicion and make the tongue spout vague platitudes. No matter how extraordinary these tips seem, take it from one who has had them used on him - they work! I only ask that you apply them judiciously, as overusage can be interpreted as adversarial, and lead to mistrust. Remember, our common goal is to care for the patient with excellence and compassion!

The Practical Tips

1. At the beginning of the visit, tell the doctor you have questions - this warns him or her that counseling will be a part of the visit.

2. Write down your questions, and give a copy to the doctor so you both can go through the list together.

3. Do not be shy about asking the doctor to repeat the answer, or phrase it in more easily understandable language. A good doctor does not assume patients understand esoteric medical terms.

4. Invite the doctor to sit down, which brings all to eye level, and creates a less hurried setting.

The Psychological Tips (which create leverage - use with caution!)

1. Bring lots of family to the visit - the more the merrier. We docs tend to spend less time counseling the solitary patient.

2. Don't hesitate to announce any relatives in the room who are attorneys, whether they litigate or not. Attorneys get the doctor's rapt attention! If you don't have a lawyer in the family, dress all males in suits - looks impressive, if not intimidating.

3. If any family member is a doctor - sibling, offspring, nephew, niece - let it be known at once, whether they are in the room, or live nine states away. Rare it is to find the physician who would disappoint a physician's family member.

4. Produce a tape recorder, and say, "You don't mind if I record this, doctor? My family will want to hear what you have to say." This is the ultimate weapon against the lackadaisical counselor!

Now go, and be an advocate with confidence!

Facing Your Own Death

2004-09-28T20:19:00.000-05:00

It is hard not to think about death in my business. Often I have pondered on my porch, Poe-like, how I would cope with the knowledge that my death was scheduled to occur in the near future. Would I abandon my patients immediately, and retire? Would I follow the Kubler-Ross steps in predictable fashion - or as an iconoclast, first accepting the inevitable, then becoming irreconcilably angry? How could I, or anyone, continue to interact with friends and family?

We are all so proud of our enlightenment and insight into human life, a product of modern collegiate and post-graduate education - but human death? Most of us cannot fathom the concept of our death. Our ordinarily brilliant minds clang with terror when considering the image of it. Such fear I believe is unhealthy because it robs us of the power of understanding - by that I mean a mature contemplation of death that can lead to proper planning for the future, or a deeper appreciation of the blessings surrounding us - in short, a richer life.

Fear of dying therefore seems to be hidden inside many of us - myself included. My career as a cancer specialist would seem to only increase my angst about death, since I see it every day, yet it was actually relieved when I met a patient who showed what it means to face the end with courage.

The last days of this patient, whom I shall call Mark, are worth sharing with anyone who is searching for a way to cope with a life-limiting illness. Mark was diagnosed in his thirties with a rare type of pancreatic cancer that took his life within six years. We initially thought his tumor could be resected, but at the time of surgery he was found to have tiny but widespread liver metastases. Mark's chance for cure was lost on the day he planned to be rid of his cancer. Although he lived for years after that, it was always while taking various chemotherapy regimens that often left him pale and bald. Eventually his liver metastases became resistant to all treatment, and it was time to move on to supportive care.

Mark was now faced with his upcoming mortality - the most profound experience in human life. What was his reaction to this inconsolable news? As his doctors, nurses, wife and family began to despair, he surged ahead with strength I had never before seen in a dying patient, and may never again. Mark faced his death with fortitude, grace, and a calm determination to carry on with his duties as a manager, husband and father.

St. Francis of Assisi, while hoeing his garden one sunny afternoon, was asked what he would do if he were suddenly to learn that he would die before sunset that very day. He replied, "I would finish hoeing my garden." This too was Mark's answer to the Spectre: "I shall keep living my life on my terms until I feel the grasp of your cold hand." He continued to drive himself to work. After arriving at the office he would rest for several minutes, gathering the strength to get out of his car and walk. Emaciated, with a faltering voice, he carried his load day after day, until he finally collapsed. Mark died two days after his last day at work.

Mark died three years ago, yet he still lives - inside of me. He has become my afflatus, my inspiration on living a life not measured by years, but by deeds. If there is one thing I learned from him it is this: life is only fulfilled when the mind and body are in motion. As long as I can stand and think, I will keep moving - see patients, laugh at jokes, wrestle with my sons, walk the dog, meet my wife for lunch, call old friends - get out and be a part of this great world, not wail in my chair how unfair it all is.

As St. Francis also said, "O Divine Master, grant that I may not so much seek to be consoled...as to console." This should be the prayer of every oncologist.

The Oncologist as Soothsayer

2004-09-22T20:46:00.000-05:00

Is it compassion, or a morbid fascination with death that compels a medical oncologist to volunteer to predict how long his or her patient will live? It is almost a cliche' to say that the oncologist is always asked to provide the number of weeks, months or even years a cancer patient has to live. Since no honest mortal will admit to possessing the gift of prophecy, why do we attempt to answer this question? Any specific length of time given is obviously a lie, yet we oncologists continue to pronounce the forthcoming date of demise with Olympian solemnity, sending the whole room into a stone-faced silence, or we awkwardly yammer on about the statistics of survival: median, one-year, relapse-free, until everyone (the doctor included) is confused.

I realize that end-of-life plans must be made, and courage must be summoned to face the grief ahead, but predictions of survival are not only notoriously inaccurate, but also tend to add needless stress - especially if delivered in a rather cavalier manner (no need to look grim in front of the anxious family) that only induces shock. Predictions are an act of cruelty. They mark the future as a time of painful waiting, as if a calendar date circled in black is hung on the kitchen wall - ripping hope out of the hearts of the patient and loved ones.

Despite this, it is impossible for an oncologist to not comment on the request for predicting the length of time a patient has to live. It is a reasonable query, asked by concerned and loving caregivers. Often when I respond with a number it is because the end of life is very near, and I believe the family is better off forewarned and emotionally prepared, rather than stunned by the sudden announcement.

I personally have found it more helpful to use this occasion as a chance to sow encouragement, and shift the focus of all onto the life of the patient. Treatments are changing constantly, and who can say that a new drug may not lengthen the life of a seriously ill patient in the months or years ahead? I tell patients that if the cancer they have is associated with an average survival of 12 months, that means that half of the group is still alive after a year - why not cheer for the patient to be in that group?

It is a waste of a medical oncologist's career to not use any appropriate opportunity to encourage, to build up, to look for good news to share, to predict that relief of suffering, if not recovery, is just around the corner. It is easy to be the bearer of bad news in this world - but an oncologist should always carry the light of hope inside, and shine it on the cancer patient just when his or her world seems darkest.

Why do we fear the word "hospice"?

2004-09-10T15:05:00.000-05:00

I just found out today that one of my patients, who is slowly dying from multiple cancers, has been enrolled in our hospice program without being told he is going into "hospice". At the request of his family, the "H" word was not spoken in his presence, as if this will shield him from emotional harm or depression when he begins to receive end-of-life care. This seems absurd to me - my patient knows that when he stops seeing his oncologist in the office, his treatment is over. Why would he be frightened about a compassionate program designed to help him live with dignity in his own home? Why do families fear the concept of hospice?

To me it seems that some caregivers live in dread of the idea of stopping a patient's chemotherapy, because to them it marks the beginning of the end of life. By not admitting that treatment is no longer delaying the growth of the cancer, they maintain the illusion that nothing has changed in the patient's prognosis. This does nothing to prepare the family for the inevitable - in contrast, it weakens their ability to cope, to reflect, to love.

Why do some of us avoid using this word in front of the cancer patient? Perhaps it is because "hospice" has become a euphemism for "execution". Many family members believe that enrolling in hospice seems to imply that a patient has been branded as dead, and is no longer permitted to enjoy the daily pleasures of life. Families therefore hide the dying process from the patient, creating a tense masquerade of home life that compounds their own distress.

I believe in speaking the word "hospice" when discussing the options for the care of the cancer patient who is finished with treatment. When faced with a choice between admitting the reality of the situation, or denying it, choose to speak the truth. It may seem an ordeal at the time, but the emotional release gained from deciding together to face the future honestly will strengthen the bond between the patient and his or her family, and perhaps ever so gently soften the grief to follow.

Welcome to The Cheerful Oncologist

2004-09-10T12:40:00.000-05:00

If only for your reading pleasure, come and occasionally visit inside the cluttered but navigable, sardonic mind of a medical oncologist who simultaneously fights cancer and writes pithy pieces of prose about life in our self-conscious, post-modern world.

If cancer has ever touched close to you, or if you are interested in reading one doctor's ongoing story about treating cancer, this may be a site of interest. Too often in this country information about living with cancer and treating cancer is lacking, and I believe ignorance leads to prejudice against the cancer patient. Ignorance also foments unrealistic expectations, anger, crippling emotional distress. This is detrimental to good care.

Perhaps I could also compose a paragraph or two that illustrates the daily struggle to co-exist with hypocrites, phonies, egomaniacs, condescending liberals or just general idiocy. The amount of material I have to work with is staggering, is it not?

I was labeled "The Joking Oncologist" many years ago, due to my twin passions of killing cancer and making people laugh. Could a love of humor be a psychological defense against the sorrow of watching decent people die, day after day? Does this internal conflict represent the duality of the mind - the battle between the rational and the unfettered beast within us? Or am I just plugging one of my favorite novels - Steppenwolf?

If that's the case, then why not let Hesse speak for me:

Better learn to listen first! Learn what is to be taken seriously and laugh at the rest.

That's my weltanschauung - first published in 1927!