THE ONCOLOGIST

The oncologist

 

 

This is Dr KEVIN Ryan MD MBA FACP and hematologist oncologist here, medical oncologist professor and retired colonel and cancer survivor and this is when tumor is the rumor and cancer is the answer. This show is Modeled after my nonprofit book of the same name available on the web site of the same name… you can find it on the web site and a lot more, interviews, films excerpts on the site and it is also available on Amazon in all formats All shows are also on my blog off the web site  same name  and on www.w4cs  and in a few days Iheart radio

Think of these next shows as a look into the mind of physicians and especially the oncologist How and why do they so the voodoo that they do

 

 

 

Why Oncology?

 

 

The roads chosen for a career in Oncology are diverse. Some choose research; some enjoy a mixture of the laboratory bench and bedside. Others choose full time private practice as opposed to academics while others go into the big business of biotechnology research and have a path marked by brilliant entrepreneurial zeal. Owing to the military paying for medical school, I had my road chosen for me as a largely clinical route with significant exposure to all of the others-especially clinical research and teaching.

While oncologists are not all the same, most cancer clinicians are quite similar in their heart of hearts, their thought processes and I think in many ways their spiritual view of all of this. I have found that most of my colleagues share an immense sense of purpose and meaning in their practices and research.

The most frequently asked question I have received from trainees and colleagues alike is “How can you do it, Why do you do it?” usually followed by “I could never do oncology”

This is the best answer I have been able to muster.

There is an indefinable but unmistakable nature to being human. It is unique to the species, reproducible and immensely sensitive. The human mind and heart connect as a somewhat huge spider web of the finest silken threads capturing and suspending every experience of life in the chambers of consciousness. Life-threatening situations, such as the diagnosis of cancer, pull upon all of those threads thus bringing ones’ world into unparalleled focus.

I have never seen this nature more vividly than when my patients faced the enormous fear malignancy evokes. I have seen the diagnosis cement the realization that we are all connected and, in a practical sense, underscore the insight that we are and always can be truly knowable. In the practice of oncology, patients and providers alike quickly accede to the marvelously hidden plot, the master illusion whereby we appear to differ.

Cancer respects no organ or person. Furthermore, the oncologist must have intimate knowledge of all the fields of medicine, radiology and pathology as well as a finger on the pulse of breakthroughs in basic science. They have an armamentarium of diagnostic tools unmatched in depth and elegance and the field is perhaps better organized than many internationally in terms of asking the next best clinical question through cooperative research and clinical trials.

Once the team of caretakers and cared-for coalesces, a dance begins. It is a dance whose rhythm is the beat of the patients’ trek to garner knowledge and quell anxiety by doing so. It can be hero making.

Cancer unravels, mocks and challenges the norm more than any other malady. The wonderfully divine plan of human existence at the cellular level is never clearer than in the thick of the battle of fighting cells that mimic the norm.

When tumor is the rumor and cancer is the answer, the sweetness of the privilege of simply being alive is immediate. The solace and comfort offered by the health care team, family and loved ones is more pressing. In facing the possibility of premature death, the pulse and zeal for life as well as perhaps redefining it beats more soundly. What truly matters can become so transparent. There is also a sense of camaraderie in fighting a war of great and personal consequence and not having to do it alone with both people and science as allies. Oncologists have a ringside seat as the heroes and the health care team “box with God”. More than once, although frequently bruised, battered and stunned, the team wins a round, and with increasing frequency, the match. That is some of the  “Why Oncology”…for me.

 

 

MD – What Is In A Name?

 

 

Since the beginning of time, the world sets physicians apart as magnificent demagogues (MD) for many understandable reasons. I am not talking about arrogance, per se. The enormity of knowledge acquired, the responsibility, and immense emotions entailed leads to a very circumspect world for the physician. It is a world that patients really could not understand easily. Enhancing this is the reality that patients often lean more towards being a patient than a participant. Although understandable, other than when the competency of the patient is in question, it is best for all if the patient and family deeply participate in their cancer care. There is always a better outcome when the other “MD” is exposed- the Magic Decoder ring. Becoming the master of our journeys occurs when we all share in the secret handshakes of what initially is overwhelming information and in time everybody gets in the boat, grabs an oar and pulls hard.

However, many physicians are not that eager or aware of the necessity to crack the code and share the secret handshake. There is considerable variance in this regard depending upon medical specialty. It should come as no surprise that some fields attract abstract thinkers more than immediate-action, black and white problem solvers. Some fields of medicine attract urgent “fix it” types; some attract urgent “find it” types. Some medical specialties are appealing to “hand holders” and some physicians prefer a practice more removed from patient contact, let alone in depth emotional engagement.

 

What About Oncologists?

 

Oncology is a mixed bag. It tends to attract deep thinkers but certainly not to the exclusion of all other fields of medicine. Oncologists tend to be folks who like to box with God. They are intellectual problem solvers who love to master immense and diverse amounts of knowledge and who live to ask the next best question. Although it has improved and there are many notable exceptions, oncologists’ strongest suit tends not to be in depth personal emotional or spiritual engagement with their patients. Frequently, oncology support staff, nurses and front office alike soar like angels in this regard. By no means am I implying that oncologists do not feel deeply nor fail to understand the profound emotional aspects of their practice. In fact, I think they do. Rather, owing to time constraints, frequently pressing urgency in diagnosis and treatment, self-protection and an appropriate need to remain somewhat distant emotionally, in depth engagement of patients in manners discussed in this book are not overwhelmingly preeminent.  Furthermore, there is simply not enough time to do so.

Oncologists are not only not immune to stress, they are magnets for it, as are many other physicians. In oncology however, one faces terrorism of the highest and most clever degree every day as discussed in the chapter “The Enemy”. Accrual of new patients to an oncology practice is usually for ominous and frightening reasons. Patients do not become cancer patients for routine, typically reversible diagnoses. It is not largely about some surgical procedure or therapy where of course, “everyone always turns out just fine”. New patients become a lifelong affair and interactions with family and support systems are intense and long term. Loss of patients is often owing to death.  Fear, both physical and spiritual, is commonplace. Thus, stress is frequently a disease that affects the patient, their loved ones and supporters and the oncologist and their staff.

Let us just pull back the protective white coat on this phenomenon of stress for a moment. Hans Selye spent almost five decades studying stress since the 1930’s. A noted psychologist, Herman Feifel observed the intense enmity and perhaps fear physicians characteristically have of death. Sociologist Renee Fox’s work echoed similar conclusions when it focused on those physicians conducting pioneering work. As discussed in the section Clinical Trials, research and implementation of research results are the hallmark and mainstay of this field of medicine more routinely than many others. The tempo and intensity of moving information from the laboratory bench to the bedside is enormous.

Stress is essential for life. Without the eternal struggle between tension and release, joy is muted, passion subdued, biological and personal growth is stunted, and life is a bore. However, out of balance, stress can be damaging. Today’s oncologist must deal with insurance companies and HMO’s exerting various levels of control regarding patient treatments owing to reimbursement issues. Oncologists’ typically work very long hours and the demands for rigorous documentation can be pressing. Fortunately, technology is beginning to ease that burden with digital patients’ records. Compounding this is some natural professional disgust with the everyday business pressure foisted upon the oncologist unlike ever before.

Thus, there are sufficient ingredients in the mix that do not foster an environment allowing lengthy visits with patients. The sheer patient volume necessary to maintain a practice can be overwhelming simply not affording sufficient time to meet the entire emotional, psychological, spiritual and at times, educational needs of the patient and family. All the while, the oncologist is the authority, the mentor, the captain of the ship. To whom do they talk.? Other physicians? Not likely and what little data is out there confirms that.

The intellectual orientation of a physician starts to form early. Medical School is a culture that reinforces the concept of immensely delayed gratification. Loyalty to the guild takes on almost priest like proportions. The sheer level of physical and mental labors is staggering. Governance of the mind is often by way of an addictive technocracy whereby dependence on data, tests and technology tends to supplant other more creative and less didactic techniques of collecting information and solving problems. All of this combines seductively and may lead physicians in training to be unaware of and underestimating personal needs and the power and promise of human relationships. Medical school sentiments of privilege, honorable responsibility and excitement quickly mellow.

Although these notions have broad applicability among many physicians groups, a primary source of tension in oncology is the physicians’ changing role from “curer,” to “life-prolonging champion of the fight against the disease”; and to “sustainer,” when active therapy is no longer useful. This is difficult, heady stuff. Most surveys to date note that “not enough time” is right at the top of challenges and easily competes with the need to keep up with new medical information, dealing with difficult patients or family members, the number of patients who don’t get better, and the amount of paperwork.

In 1991, one survey reported “burnout” in over 50% of the more than 1000 long term clinical practice oncologists responding. The incidence of burnout was lower among university-based oncologists. University oncologists’ time is somewhat protected, their practice entails a large portion of teaching and competent residents and fellows often assist research and physician load. Three of the major stressors identified by the respondents were dealing with dying patients, reimbursement issues, and a heavy workload. The researchers suggested that the lack of preparation for dealing with the emotional aspects of oncology contributed to job stress and burnout.

In a subsequent similarly sized study of British oncologists, the prevalence of psychiatric disorders among this British sample was 28%. Clinicians who felt insufficiently trained in communication and management skills had significantly higher levels of stress than those who felt sufficiently trained. The authors concluded that improved training in communication skills might provide a useful tool to lessen the stress of practice.

As is intuitively obvious, being in the Captains’ chair and dealing with repetitive human suffering and frequent losses takes its toll. Just as one cannot deny their creativity, one cannot escape the pressure of simple human sorrow. The first response of oncologists is to detach in order to remain effective. However, too often this means to become disaffected, unengaged, and non-communicative as regards the issues addressed in this book. In time, everyone loses.

The solution of the physician to detach may lead to losing some of the comfort they sought out in pursuing a career in medicine. They may lose the quiet comfort of knowing they have been effective in alleviating suffering. One is on sacred ground when intimately involved with the sufferer and taking action to alleviate that suffering. Here is the rub. Chemotherapy, potions and pain meds may enormously mitigate distressing symptoms but anxiety and emotional anguish are insidious tormenters not as easily diagnosed or treated by formula. Physicians can have an enormous impact in these areas.

I am not inventing any new ideas. There are no truly new lessons to life or truly original emotions. There are variations on universal themes. Pain, whether it is psychic, emotional or physical, is the same in any language. Effective and broad reaching communication, sympathy and empathy, coupled with dispensation of in depth information are  benign opiates patients and families are happy on which to depend.

Studies have shown that a lack of formal training in communication skills heightens physician’s daily stress. Every day oncologists are bringing bad news, discussing prognosis, complicated therapies, treatments of pain and suffering and a dizzying array of future pitfalls and milestones. So what to do? It starts with enhancing communication skills to decrease stress for all. The key is to engage the patient and family. The time spent reaps immense rewards for all and, in effect maximizes not only the quality life for family and patient, but for the physician and staff. In the final analysis, it actually saves time to invest time.

However, enhancing these skills starts with dissecting and discovering all that needs talking about. Data are easy for the oncologist. It comes as quickly as does fear to patients and families. One first must know what to talk about before teaching how to talk about it. This book informs the patient and presents a wealth of information to help them participate more fully in the journey and perhaps more deeply develop appropriate relationships with their health care team..

Doctors are hard-wired to keep up with the latest advancements through reading, and continuing medical education. Perhaps many can view this book as a form of critical reading and continuing medical education. The syllabus was suggested by excellent experts; a few thousand patients.

Enormously successful politicians, pundits and prophets all know that we can enhance our sense of competence and lessen our feelings of anxiety when we feel understood and understand. The doctor must impart a wealth of information to their patients and families. In like manner, there is an enormous amount of needs and knowledge that the patient wants the doctor to address. What the patient does not know to ask yet can be a source of even greater anxiety.

Let us be reminded that it is hard to feel overwhelmed when you are in familiar territory. It is easy to be overwhelmed when you are on unfamiliar ground no one wants to traverse. This cuts both ways for patients, families and physicians. When there is a canyon of uncovered ground, conflicts and crisis can grow which sadly rarely are brought into the open, let alone the examining room. There are the usual culprits. Fear, time constraints, lack of information on the part of the patient and family and lack of eager engagement and pursuit of patient and family intellectual involvement by the health care team top the list.

Certainly, there is a wealth of information routinely disseminated by the health care team in most encounters. Rather, it is the depth, the intimacy, the focus and the scope that have the greatest positive impact. Granted, there is simply often not enough time to time to engage everything by even the most enterprising, experienced and engaging health care teams, and there are plenty. Thus, this book may help. Consider it a field manual, survival guide and reference.

Patients should never feel abandoned. However, abandonment usually carries a realistic component of personal responsibility. The traveler who refuses to seek direction, the motorist leaving for a journey low on gas, the camper without basic overnight survival gear and the homeowner who leaves the doors unlocked are inviting problems. Patients and families alike must minister somewhat to their own needs. Self-care begins with self-esteem. It is empowered by knowledge; knowledge of needs versus wants and knowledge of enemies versus allies. Patients must have knowledge of resources that are available and the lessons of history by those sufficiently similar to themselves that they may apply to themselves. Others have walked a similar road before and patients must know and truly understand that. Thus, this book.

The past generation has seen enormous advances in technology. Generic medical school training has continued to progress with more in depth education and attention to the nuances of patient and family communication. More attention to interfacing with those who are enormously frightened is the norm. Internal medicine residencies are also moving forward in this regard. Lastly, fellowship training in oncology has begun to pick up the cue of improved communication with families and patients as well as with oneself as the often captain of the health care team. But there is a lot of ground to cover. When one looks in the oncology world at all the presentations from the podium, abstracts presented and published, poster, plenary and “meet the professor” sessions and published articles, one finds a slowly growing but still small body of work such as this book.

So is this really such a big deal? Yes! Cancer is one of the great anathemas. Not too many utterances can whip up a faster frenzy of emotion, thought and agitation than “You have cancer”.  Knowledge is our greatest asset; patient knowledge.

Cancer is both incubus and pariah. The mere mention of the word strikes fear in the hearts, minds, and souls of millions of patients and families per year. These souls are awash in a tumultuous sea of blinding anxiety and pounding waves of enormous ignorance. The vast majority of non oncology providers avert from its care and quickly defer to the too few medical oncologists whose job it is to fight this sort of terrorism on its most personal and persistent level. The patients are not the only ones who carry a burden in the battle. Perhaps if we all understand this, we can pull the oars together and share the journey.

 

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