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.

9 comments:

glorified midwife said...

i worshiped Medical School gyn onc surgeon until we spent 45 minutes talking to a patient with ovarian cancer, him politely but effectively evading her "how long have i got?" question with vague, "let's hope for the best" bullshit. as we walked out, he turns to me, and says, "she'll die before christmas" (which was 2 weeks away). i lost all respect for him. and that is why i won't do gyn onc. because i would have to tell people the truth, and that would be too hard.

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incidental findings said...

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Fuck you for posting your shit, an obvious advertisement for your garbage website, on my blog. Maybe if you yourself were diagnosed with terminal cancer, you'd learn to respect this topic and not be such an asswipe as to put your shitty ad on my blog. I hope you get herpes.

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TigerLily46 said...

Amen.

The MSILF said...

Good post. (Realize it's not exactly new, but I just found it now.) Oncologists, while some are VERY good, often like to play God, are totally unrealistic, or get off on the emotional scenes. Oncology, which had potential to be a great rotation, turned out to be one of the worst I had in med school because of exactly what you are saying.

Oncologist said...

It is a disservice to the patient to base their life expectancy on statistics... you can't tell someone with Pancreatic CA or OV CA Stage IIIC or greater that they have 2 weeks to live (You will be wrong 90% of the time as there are plenty of people that will live a lot longer measuring in years) … you could say statistics say … but that’s statistics. I think Onc specialties are very tough and take special people who do not jump to conclusions based on statistics and do not give up on their patients by telling them they will die in 2 weeks ... trust me all of my Onc patients are very up-to-date on current statistics, but that is not what they are there for.

incidental findings said...

Since the posting of the previous comment, I have been trying to write a response, and I just can't do it. Really, my response is the post itself. And so far, I have yet to have a patient complain.

Tasha the Triathlon Goddess said...

Yes yes, I know I'm late her but I just found your blog. Anyway, as a younger person with breast cancer myself, who was talking to a fellow CancerChick earlier today about how much we hate that crap about "having a positive attitude is everything!" and so on - I will say that I would have zero respect for a doctor blowing smoke up my ass. "Oh, there's always hope, keep fighting!" when you know I might be gone in 6 months? Bullshit. Tell me the truth. There's that thing called the internet, and most of us are fanatical about research, we see our friends who've gone through the same stuff, we know the reality. We don't need false hope. That's different from saying oh, you'll be dead in 2 weeks. But seriously, just give it to us straight, i.e. these are the stats, this is what we can do. We'll get over it, and then be able to live the rest of our lives as we see fit. We deserve the truth. Thank you to those doctors who have the guts to give it. Really, isn't that your job?

Internal Intern said...

Just stumbled upon your blog. Nice post. I'm a medicine resident, going to apply to heme/onc next year. I just did a month of inpatient oncology at a top 20 center and I have to agree with a lot of what you say. All I did was walk around and tell patients about their prognosis. They all thanked me. I had a guy with pancreatic cancer and a bowel obstruction tell me he wanted to get out as soon as possible so he could start chemo. When I explained that it was only palliative, he was floored- the oncologists never told him.

But this is exactly why I WANT to do oncology. I will be different. I will tell it like it is. I think people appreciate the honesty as much as it sucks to hear.

The other thing to understand is that inpatient onc is VERY different from ourpatient onc. Inpatient onc is the worst. They are all there to die or because they have an infection that could easily kill them. It sucks. But outpatient is very different, especially heme malignancies where the drugs have come leaps and bounds over the last decade. The mortality of heart failure is much higher than most lymphomas now, yet you'll never hear someone say, "Oh you want to do cardiology? That's so sad." Just my 2 cents. We could use more realists in the field so it would be awesome if you would reconsider.