Just Give Me the Gist of it Please

I recently saw an orthopedic specialist who proposed to operate on my arthritic feet, which have been quite done in by my favorite pastime for thirty five years of jogging miles on pavement combined with the wearing of high heeled shoes to work every day to make my short self taller and thus more powerful. The surgeon described to me in detail a procedure designed to take the pressure off the big toe joint, and increase the mobility.  When I got home, my husband had many questions such as “will this be done under general or local anesthesia?” and “will you need to wear special shoes afterwards?” and “how long before you can swim?”  I stared at him slack jawed—I had not written down a list of questions before my visit, and I certainly couldn’t answer his.  How quickly does the doctor become just like her patients who can’t remember what they have been told, despite the consultant’s serious attempt to educate and inform?  Very quickly, it seems.

Some of my patients have taken the opposite approach to the consultation visit, presenting  with dossiers full of notes and questions and treatises printed from questionable internet sites.  This causes me to settle deep into the comfortable chair in my consultation room—I know that I’m in it for the long haul.  I’ve grown to expect this at the first visit, but when the habit extends to the weekly “on treatment” visits, I know I am in trouble. The French have a saying for a particular type of patient—the patient that comes in with a long list of detailed handwritten notes each time he or she is seen.  They call it “La maladie du petite feuille de papier”, or “the sickness of the little piece of paper.”  The great Sir William Osler commented on this type of patient in his aphorism Number 309—”a patient with a written list of symptoms—neurasthenia.” Translate that to mean “anxiety disorder.” I recently had a breast cancer patient whose husband came with her for each on treatment visit.  They had matching notebooks and matching pens, and they each studiously, meticulously and separately transcribed every word I that I uttered into their respective college ruled 100 page blue books.  And when we were all done they asked me the questions that I had just painstaking answered, because neither of them had heard a word I had said—they were too busy writing!

There must be a happy medium in there somewhere.  If you (or I) have specific questions about the risks, benefits and side effects of a proposed treatment, by all means, write them down and get them answered!  But I do not need to see your journal of the quality, quantity, consistency and timing of your daily bowel movements.  Really I don’t.  Just give me the gist of it, please!

Cancer is Not a Lifestyle

I’m not sure when I stopped being merely opinionated, and became a true curmudgeon. But I think it was about the same time that medical students started telling me that radiation oncology is one of the “lifestyle” specialties in medicine. According to the National Resident Matching Program, this year radiation oncology ranked 5th on the list of the most highly competitive residency programs, right after (and in order) dermatology, orthopedic surgery, otolaryngology, and plastic surgery. How, when and why did this arcane little specialty become so popular?

When I left internal medicine for a second residency in radiation oncology thirty years ago, we were thought of as the weird guys in the concrete shielded basement who spent all day pushing buttons to “zap” patients with evil rays which were just as likely to kill them as to cure them. When did this all change? When I was a resident in medicine, I knew that I wanted to take care of cancer patients. I had applied for, and been accepted at an excellent fellowship in hematology/oncology. During my senior medical residency, I realized that as a cancer doctor, I should know something about radiation therapy since it was one of the three modalities used to cure cancer, along with surgery and chemotherapy. There was no elective time in my upcoming fellowship, so I asked my Chief of Medicine if I could spend a month in the basement with the weird guys who pressed buttons. In medical school then, as now, no time had been relegated to teaching medical students about the therapeutic use of radiation. He said “yes”, and the rest, as they say, is history. Back in those days we had no good antinausea drugs, and we had no medications to boost a patient’s white count after a strong dose of chemotherapy. After receiving curative doses of chemotherapy for leukemias and lymphomas, patients would spend days if not weeks in laminar flow rooms, “hot and low”, meaning febrile and neutropenic, hoping that their bone marrow would recover before infections took their lives. We were curing cancer, but often at a terrible price. In that hospital basement, the early days of breast conservation therapy for early stage breast cancer were playing out before my eyes. Happy women who had been offered the choice of lumpectomy and radiation over mastectomy cheerfully bared their breasts in follow up clinic, exclaiming “Look at THESE!” I made the leap, and never looked back. Lifestyle had nothing to do with it.

So what do dermatology, orthopedic surgery, plastic surgery, ENT and radiation oncology have in common? In the first four, physicians who choose these specialties can virtually, if they choose, limit their practices to regular hours and high paying procedures where oftentimes they are paid cash for their services. Even though it would seem that orthopedic surgeons and plastic surgeons are amongst the first responders for the so-called “train wrecks” that are brought to the ER, in reality they can choose to do only the “elective” aspects of their fields, such as sports medicine and cosmetic surgery. And we all know what Botox and “fillers” have done for dermatology—they’ve practically put the plastic surgeons out of business! Radiation oncology has the advantage of regular hours (our patients are nearly always outpatients) and high reimbursement (our medical reimbursement system is based on how many procedures one performs, and the planning and delivery of radiation are considered procedures). And if you love computer games and movie special effects, effectively hitting your “target”, the cancer, while dodging the normal tissues, that radiation beam can become your personal “Avatar” in the war against an extremely formidable enemy.

But here’s the thing, kids. In dermatology and those other highly desired specialties, you get to “hit and run”. You don’t need to follow your patients long term, unless you want to. You help them, make them beautiful, cure their acne, fix their broken bones and tendons, give them new breasts, or eyelids, or noses, or even rear ends! You give them better hearing, or better breathing, or better speech. You make them young again; you make them run again. But if you want to cure cancer, it’s a whole different ballgame. Your patients may have side effects, difficult side effects, which you must manage on a daily basis for six to eight weeks. Your patients may have late effects, years after the radiation, just when they think that life is good again and they are home free. Your patients may actually die, either from their cancer, or from your treatment.

Think about that when you think about “lifestyle” specialties. If you can live with that, and maintain a cheerful countenance with a generous helping of compassion for the next thirty to forty years, then by all means, join me.