Why I didn't do oncology

When I was in medical school, I was rounding on the internal medicine service, and our afternoons were pretty light. I was checking up on some tests and how my patients were doing, when I ran into Dr. Lanky. As you might expect from the nickname, he was tall and wiry. We was also the chief of oncology and generally well-respected.

"Hey, IF, I'm rounding on consults. If you're not busy, you can come along if you want." He sipped his coffee and motioned me along. I had planned on hiding in the library for the rest of the afternoon, but I liked Dr. Lanky. He was always good with students, and since I was interested in Heme/Onc, this would be a great afternoon for me to learn, and if not to learn, then at least to schmooze.

Regardless of whether you liked or hated Dr. Lanky, everyone respected him. He usually rounded on consults by himself, and so getting to round with him was a distinct privilege. I didn't need much convincing. He also knew I was interested in Heme/Onc so he thought he'd show me the life.

"What about the other students?" I asked as I chased after him in the hall.

"Where are they now? Nah, let's just do you and me." Wow. Face time with the chief of oncology. I felt pretty good. So, I started seeing his consults with him, which amounted to me following him around. I did a little bit of scut, but not what you'd expect for a medical student rounding alone with a division chief. We read charts, checked labs, looked at films, and reviewed path slides. Finally, it was time to see patients. All along the way, Dr. Lanky explained the pathophysiology, the natural course, the prognostic factors. But it all meant nothing until we talked to the patients.

In one afternoon, we talked to 5 patients and families, and we told them that they had terminal cancer. He offered many tissues, held many hands. Room after room, it was one terminal diagnosis after another. Some were offered palliative chemo, possible palliative radiation. Some were offered a Hospice referral.

None of it was easy. One patient was a peek and shriek from the surgeons. They'd done an ex lap only to find diffusely metastatic colon cancer. Another was a 46 y/o lady with stage 4, poorly differentiated, non-hormone responsive, breast cancer. She had her two little daughters sitting on the edge of her bed. One was a 78 y/o gentleman with unresectable pancreatic cancer. His wife burst into tears and grabbed her husband's arm. "Please, please don't leave me," she cried. He tried to smile and comfort his wife. Then he thanked us.

Five cases, all equally tragic, each one enough to destroy a man's faith in God. After the last one, I left the patient's room in tears. Dr. Lanky finished up his note and turned to me.

"You okay?"

"Yeah. It's just that... it's so tragic." What tipped me over the edge was the breast cancer lady, who upon hearing the bad news grabbed her two, beautiful little girls and clutched them so tight. The confusion was all over their faces. "Mommy, why are you crying?" It was too much to bear. I had to leave.

Dr. Lanky put a hand on my shoulder. "We're not made of stone. We're people too. You shouldn't feel ashamed to cry. I'm proud of you. Compassion is a noble thing."

That one day rounding with Dr. Lanky cemented in me the desire to do Heme/Onc. It only took one afternoon to win me over. Playing such a sacred role in people's lives usually requires vows of chastity and obedience.

And over the past three years since that afternoon, I've come to understand that Dr. Lanky was the exception and not the rule. I've seen the handiwork of oncologists, and I want none of it.

All through medical school, we learned about informed consent and patient autonomy. Then something like oncology comes along and all that medical ethics stuff is in the shitter. 'Oh, I don't tell them they're dying.' 'Oh, you can't give them statistics.' 'She'll be dead in 6 months, but if I tell her that, she'll be miserable.' And some of it even sounds reasonable till you meet a 54 y/o woman with stage IIIb small cell lung cancer who's talking about whether her grandkids will go to college when they grow up.

'You can't destroy their hope,' is the universal cry. How dare I tell a patient that her radiation is strictly palliative. How dare I explain that the five year survival for pancreatic cancer is zero. To me, it's like being on an airplane where all its engines are out, and we're about to crash. Then, the flight attendant says over the speaker, "Now, as you may know, we're having some engine difficulty, but we're doing our best to work on this problem, and we're implementing some procedures that have worked in the past. I'm confident that we'll come through this okay."

Oh, it's not lying per se, but it's not really the truth either. And no matter how calm it may make me, I don't want to be balancing my checkbook when I die. My last thought would be, "That lying bitch! We're crashing!"

And seeing the world of oncology, offering up so much false hope, and seeing how different this was from Dr. Lanky, I couldn't bear it. I cut Oncology out of my career plans and re-excised for margins. I'm not saying oncologists are bad or anything like that, but this idea of not destroying hope is pervasive throughout oncology and all medical specialties that deal with potentially life-threatening disease.

I was talking to an ethicist a while ago about this, and he said something profound: "We are always hoping for cure, and view death as failure. But just because we can't cure, that doesn't mean we can't give patients real hope." There's so much to hope for other than cure, but that's all we've ever cared about, and we've ignored all that other stuff.

I think Dr. Lanky would be disappointed that I'm not pursuing Onc, because he knows as well as I do that I could never be one of those false hope oncologists. I'd tear myself apart. But by the same token, the idea that I could ever be involved in such a case, even once, is more than I could stand.

And so, the oncologists that take care of my patients every now and then will criticize me for talking to my patients about what lies ahead, but as much as they yell, my patients always thank me for giving it to them straight. I'm not mean about it, or hopeless. But I feel that in their hearts, people want to know the truth. So I give them as much truth as they want. And at night, alone in bed, I can sleep with a clear conscience.

Addendum - I'd like to note that I do not go about trying to dishearten my patients or destroy their hope. I simply find out what they know and don't know, what they'd like to know, and provide whatever information and support that I can. Sometimes, it's telling a patient that chemo is rough, but can have good results. Sometimes, it's telling a patient that the chance of remission is very slim. And when I was working with Dr. Lanky, we weren't out to crush people's hope. Each case was very much terminal, and even then, we offered most palliative options, and some even hope for remission, albeit with long odds.

I don't want you to think that I'm out there, ruining the work of good oncologists who give their patients truth, and in that, deserve trust. I simply wished to say that what I see from a lot of doctors is an unwillingness to be truthful about prognosis. What's the point in knowing prognosis if we never share that? And to those oncologists that work hard to treat their patients respectfully and not patronizingly, cheers.

As far as my unwillingness to do oncology, I've come to realize I have a delicate soul, and I could not suffer the weight of deception. In all things, I strive to be square with God. And the thought that one day, I could become like those oncologists I despised, that thought was too much to bear.