the war on cancer.

They're common enough phrases: "She's battling cancer." "He beat cancer." There's no one that hasn't heard that phrase from a friend, family member, or the media. Or patients in my case. I'm trying to remember when it first started to bother me. I suppose it was around the time when I realized that not everyone does 'beat cancer.' I don't know why we choose to use this phraseology for cancer. If a diabetic patient "beats" diabetes (which few actually do), it's because they strictly maintained their medication regimen, started exercising daily, lost 100 pounds, and are exactly compliant with their diet. Diabetes is something that is actively fought by lifestyle changes. Beating diabetes can be done. (I should clarify that I mean adult onset, or non-insulin dependent diabetes in this description). Diabetic patients can DO something about their diabetes. This is not the case with most kinds of cancer.

The vast majority of times cancer is something that we can't prevent. It's unsuspecting. It hits people with no warning. Twice this month in the emergency room we found "suspicious masses" randomly when we scanned the patient. Often times patients won't know they're sick until the cancer has spread so far that it is beyond cure. When a loved one survives cancer, it is truly a miracle and a gift. I have taken care of enough cancer patients at this early stage in my career to understand that there is a resilience that comes into play in the treatment, therapy and survival of cancer. I'm not trying to minimize that struggle and challenge. What irks me about the phrase "They beat cancer" diminishes the same struggles and strength that were present in the patients that die from cancer. Is beating cancer about survival or is it about endurance?

Although this is a topic that has always chafed me, I was fighting back tears one day in the ER last month as it triggered a whole new frustration at the culture of cancer. A woman with stage 4 lung cancer with metastasis (spread) to the bone and brain (probably one of the worst cancer prognosis possible--very aggressive and at the point where little can be done to cure). The kicker? She had never smoked. She had only been diagnosed 4 months ago and had undergone persistent radiation and chemotherapy since that time. She came in to see us when she stopped being able to walk. Her husband explained her medical history to me, and I turned sympathetically and put my hand on her shoulder. She had tears in her eyes "I'm so ashamed... I'm so ashamed that i can't beat this..." An anger surged up as I realized how unjust our system is to this woman. Here she was with no strength, completely wiped out, and we as a society have robbed her of her peace. Why is she in a position where she feels like she's failed herself and her family by having cancer? Why are we so afraid of death?

Juxtaposition

In the last 5-10 years I've often been struck by the contrast between two objects, two worldviews, or just two worlds.

With some time on my hands today, I headed to one of my favorite parks to read for a couple of hours. I started with "Half the Sky,"--a book recommended by a fell0w India-lover. I've been slowly working my way through this discussion of human trafficking and the massive injustices towards women in developing countries. As I was processing these stories of horrific oppression, beatings, abuse and rape, I switched to my second book: "Sacred Marriage." Tears came to my eyes as I realized that the expectation and goal of love and respect that I have of my coming marriage is a secondary point overseas. Many women would dream of just not being abused by their husband. I know in the US we don't have perfect marriages, but I live in a country where abuse isn't a socially acceptable practice in marriage (although I'm not naive about it's prevalence).

I was humbled when I realized (as I have countless times since I set foot in India for the first time) that to be educated at all, let alone to be a doctor is a privilege. "Half the Sky" talks a lot about how poor, uneducated girls are targeted--the more educated the girl, the more likely she is to know that it's possible to fight back. I remember the little girl, angry that she would be unable to move past 10th grade because then she would have to get married, and the 'lazy boys' got to continue their education. That encounter left me feeling so powerless and upset. And yet so unsettlingly grateful for the opportunities and value in which I was raised, and the loving and respectful man that I'm marrying. It's the tension that I hope to always live in.

a wake up call

"The patient I saw today bikes! I wonder if he rides on this trail!" I thought casually as I ran down my newly discovered path. Instinctively I shot the idea down. "That's not real." I reminded myself. As I caught the direction that my thoughts were leading me, I was shocked at how 6 weeks of studying and 2 days of fake, standardized patients had trained me to see the key points instead of the whole story. When we're given exams, we're expected to take a clinical vignette and pull out all the high yield information and ignore the rest. During my clinical skills board exam, I was instructed that it's less important to empathize and more important to get the information you need quickly as we only had 15 minutes with each patient. After 6 weeks of dwelling in that mindset, how do we avoid an overlap into our patient care?

The better I've gotten at knowing "what's important," the worse I become at hearing the 'unimportant details.' The details that are meaningless to the medical diagnosis are often the most important factors for my patients. This is part of the essay that I wrote with frustration several months ago:

"As I mulled over the nomination to Gold Humanism Honor Society and the prompt for this essay, I couldn’t help but to remember all of the ways that I fall short in compassion, empathy, and patience. The countless days where I’m tired and my patience runs low with both colleagues and patients. The annoyance I feel when I walk into a room that’s full of family members with lists of questions when I have far too many notes to write before rounds. The urge to interrupt and cut off my long winded, lonely patients as they wax on about their long list of complaints.

I was frustrated and disappointed in myself as I realized all the ways that I fail to be empathic and fail at the very thing that drew me to medicine. But then I realized that what matters most in medicine is how we react when we’re tired, sleep deprived, busy and feeling burned out. My short-comings don’t define who I am as a future physician, but how I act on these emotions that will determine the type of doctor I become."

I was told by a mentor last year that if you aren't careful, you'll wake up in 10 years and be a doctor that you never planned on becoming. Compassion and care are something that need guarded and attended to. Perhaps this is an area that I need to attend to more carefully if I desire to preserve the gifts given to me in stewardship.

"Into the water--the clinical clerkships"

Another NEJM essay that puts words to the surreal experience of the third year of medical school:

"There's nothing particularly natural about the hospital — ever-lit hallways, the cacophony of overhead pages, near-constant beeps and buzzes, the stale smell of hospital linens. This unnaturalness was strikingly apparent to me when I arrived as a third-year medical student — freshly shaven, nervous, absorbent — for the first day of my surgical clerkship.

As I joined my team, my resident was describing a recent patient: “He arrived with a little twinge of abdominal pain . . . and he left with a CABG, cecectomy, and two chest tubes!” This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote — slouched in his chair, legs crossed and coffee in hand — seemed oddly . . . comfortable.

As the year — known at Harvard Medical School as the Principal Clinical Experience — proceeded, the blare of announcements dulled to a low roar, the beeps and buzzes seemed increasingly distant, and the stale smell of hospital linens became all too familiar. Occasionally, however, there were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time. These moments were often lost amidst morning vital signs, our next admission, or the differential diagnosis for chest pain.

At the end of the year, we were asked to reflect, in writing, on our first year in the hospital. What eventually filled my computer screen had nothing to do with vital signs or chest pain.
I began to write, “I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently' because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips. I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.' I have said nothing about that incident. I have delivered a baby. Alone. I have sawed off a man's leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night. I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

In a 2005 commencement address, the writer David Foster Wallace told the story of two young fish swimming along.1 An older fish swimming by greets them, “Morning, boys. How's the water?” As the young fish swim on, one looks at the other and says, “What the hell is water?”

The third year of medical school is like being thrown head first into water. Although the impact is jarring, eventually the experience becomes natural. We become comfortable — legs-crossed, slouched-in-a-chair, coffee-in-hand kind of comfortable. Occasional moments, however, remind us that we are immersed in water. If we focus on them closely, we see that our lives are filled with these moments. The challenge is to collect them in a meaningful way — to spend time with them, wrestle with them, allow the discomfort they generate to sit inside us.