On The Road Again

On the road again
Goin’ places that I’ve never been
Seein’ things that I may never see again,
And I can’t wait to get on the road again.  Willie Nelson


If someone had told me even ten years ago that I would retire young and become an itinerant radiation oncologist I would have thought he had lost his mind.  As the career medical director of community based cancer centers, I was used to running the show.  And as the saying goes, I ran a “tight ship.”  Consultations were performed and documented in a timely fashion, day of the request if the situation was urgent, or within a few days if not.  The patients were given time to think about their treatment, but simulations could be done the same day as the consultation, or as soon as the patient agreed to treatment, and the new start times were never more than a week away. Patients were seen every week, or more frequently if needed.  I had the best team of radiation therapists, physicists, nurses and front office people that anyone could ever ask for.  But in early 2014, I like to say I retired.  But the truth is, I quit.

Articles about physician burnout are legion, and I have avoided adding to that literature in this blog. The truth of the matter is that we, as radiation oncologists, are a very privileged group.  We are privy to the most intimate details of our patients’ lives; we practice in a highly technical and ever changing environment which challenges us to be constant and consistent learners; our hours are regular and we are very well paid as a medical specialty.  And most importantly, we cure cancer.  What could be better?  But after thirty years in the field, I was tired.  2013 was a terrible year for me—in December of 2012 I lost a close friend, Catherine, and then my little dog Jack, and then in January my mother, and shortly after that my work partner Dr. William Spanos, the best colleague and friend a physician could ever hope for.  And in between, some very beloved patients who I had followed and treated for years.  I was done.

But a calling is a calling, and somehow, between the enchanted mountains of New Mexico and the healing hours spent on horseback and with my dogs, and the otherworldly sunsets and the pleasures of growing a vegetable garden, I needed to get back to doing what I do best—helping cancer patients.  So here I am, a “locum tenens” radiation oncologist, working for an agency, going where I am needed, for a few days, or a few weeks at a time.  On Sunday night I “saddled up” the old Suburban and headed to Las Cruces, NM to provide a little relief to the solo practitioner stationed there.

Today I saw an elderly woman who had just been diagnosed with locally advanced and metastatic lung cancer.  Despite the effects of her disease—weight loss, shortness of breath and pain—I could see that she had been and still is a beautiful woman.  I can’t cure her—no one can.  But I could promise her that I could make her breathing a little easier, and relieve the painful metastases in her lumbar spine. As I sat with the patient and her husband, I knew with certainty that I no longer had to be “in charge” or command my own practice.  I knew that I could help her.  And I knew, beyond question, that I had begun to love my profession again. For that I am very grateful.

The Leaky Roof

In this dry Southwestern part of the United States, there are only two seasons:  fire season and rainy season.  Fire season will end in another month, hopefully without further casualties or homes lost. The rainy season will start, such as it is.  Here we average 9 inches of rain a year, and we are perpetually unprepared.  The roads, slick with oil from a summer of busy vacationers’ rental cars, become virtual “Slip ‘N Slide” games for unsuspecting drivers who, not used to navigating in “weather”, hit their brakes hard and the famous freeway pile ups begin.

My small radiation therapy department was designed to give patients a sense of quietude and peace.  From the laminate flooring which absorbs sound, to the Japanese vases on the hall tables, to the landscape photographs which line the walls, each element was chosen to calm the anxious spirit of the newly diagnosed cancer patient.  Most of the department’s day to day functions take place on the second floor of the building, where offices and exam rooms and our consultation area are simple, functional and comfortable.   To get treatment however, the patients must descend down a floor to the “vault”, since the shielding of a linear accelerator cannot be retrofitted easily to an existing space.  Even the elevator down is “Zen”, wood paneled and carpeted, moving slowly and unjarringly to the lower level where the patient receives the radiation.  When the patients exit the elevator, they enter a sun filled anteroom, then walk down a ramp into a large well lit room with a state of the art linear accelerator.  The walls of the anteroom and the ramp are furnished with spectacular photographs of Bryce National Park, taken by a well known landscape photographer, who also happens to be a radiation oncologist, who is still working as such despite his beloved avocation of landscape photography because he is still paying the legal bills of his daughter, who famously refused to dry clean a certain blue dress, lest she be called a liar by those who sought to protect a President.

Our “vault” was an “add-on” to the building in 2008.  As such, there is a junction between the vault structure and the building itself.  Shortly after we opened in October of 2008, we realized that the roof was leaking precisely at that junction.  By November, mornings after a big rainstorm, we would exit the elevator into a large puddle.  By January, the puddle had become a river, flowing down the ramp towards $2.5 million worth of equipment.  This was not good.  We complained, and the builders of the “vault” did their best to seal the leak, to no avail.  The university got involved—after all, it was THEIR building.  A lawsuit ensued.  Meanwhile, we solved the problem by stationing a large gray rubber garbage can directly outside the elevator, lined with sheets of plastic which ascend to the ceiling and disappear behind the ceiling tiles.  Now, when it rains, the garbage can fills up.  It is the duty of the maintenance man to empty the garbage can every morning during our season of rain.

Somehow, our garbage can and plastic sheeting do not fit with the “esthetic” of our very Zen-like department.  But like anything else in a landscape viewed daily, they have become mundane, ordinary and invisible to our therapists, and even our patients once they’ve had those first few treatments, when the whole process is new and very frightening.  Four rainy seasons have come and gone, and at last report, the litigation has been “continued” until next spring.  Meanwhile, I fantasize that my department is an anchored antediluvian world where wickedness will soon be washed away by the great flood of floods.  I imagine myself as Noah, and reluctantly consider an ark (while replaying in my mind the great Bill Cosby routine where God asks a recalcitrant Noah, “NOAH….How long can YOU tread water?”).  If the waters breach the top of that garbage can, millions of dollars of equipment will be ruined, and our department will close until the damage is repaired and a new linac installed and commissioned.

How many University bureaucrats does it take to fix a leaky roof?  You tell me!