I am Passionate About…

A few days ago I decided that since I have been officially retired for two months, it was time to change my profile on the LinkedIn social network.  After all, the purpose of that network is to link business and professional people to potential opportunities and ideas.  I needed to let contacts know that I am no longer with the University where I practiced for the last seven years, while at the same time, just labeling myself “retired” seemed far too final.  LinkedIn, as it turns out, has a “prompt” on each member’s profile page which encourages us to say succinctly what we’re all about.  The prompt is “I am passionate about…”  It took a few moments for my brain to dispel romantic visions of the great love stories of all time–Catherine and Heathcliff?  Zhivago and Lara? Scarlett and Rhett?  The realization dawned on me that what LinkedIn was alluding to was professional and not physical.

What I am passionate about, and remain so despite the significant burn out that led to early retirement, is community based cancer care.  Contrary to what I believed during my residency, when I referred to patients being admitted by LMD’s (local medical doctors) from St. Elsewhere, over the course of a long career I have come to believe that most cancer patients are served best by being treated in their own communities.  Certainly there will always be patients whose presentations, diseases and complications merit immediate referral to a tertiary care center, however most patients with typical presentations of common cancers are also people who have jobs, who have children and/or elderly parents to care for, who have concerns about the financial burdens of treatment, and for many elderly patients concerns about transportation to and from treatment.  Our job, as community based cancer specialists, is to make sure that the treatment being provided measures up to the standards of care and safety that we have learned from our colleagues in major academic practices.  In communities with limited resources, this can be challenging.

For physicians and community leaders interested in creating a community cancer center the key ingredients are simple. First, you need a mission.  Decide what the goals of your center will be and write them down.  Create a statement.  An example could be:  “Our mission is to deliver medically and technologically advanced cancer care to residents of this community in a supportive environment close to home.”  These goals will be your guiding light as you proceed.  Second, you need a building.  Although many of the functions of a tertiary cancer center can be spread out into the community, we are not yet at a point where we can deliver “virtual cancer treatment.” Many pre-existing buildings can be modified to accommodate chemotherapy and even radiation therapy, at a fraction of the cost of new construction. Third, you need equipment.  Specifically, in order to deliver radiation therapy you need a multipurpose linear accelerator, capable of delivering highly focused stereotactic radiation as well as standard of care intensity modulated radiation therapy and superficial electron therapy for skin cancers.  Although it makes a good PR campaign to have the latest “sexy” name in equipment, much of this highly specialized equipment is not designed for a general practice. You will need infusion equipment and likely some laboratory equipment.    Fourth, you need highly trained and certified personnel to administer chemotherapy and radiation therapy, and particularly in the case of radiation, to insure quality. Fifth, it is my opinion that community cancer centers benefit greatly from affiliation with university practices in terms of access to clinical trials, to tumor boards, to advanced pathological diagnosis and to the expertise of specialists in each disease site.  Finally, and perhaps most importantly, you need the support of the community. To paraphrase Hillary Rodham Clinton who said, “It takes a village to raise a child”, I would say that it takes the dedication of a community to create a successful cancer center.

The future of cancer treatment, indeed of medicine in general, is unclear however we must not lose sight of the fact that patients are more than their cancer diagnosis, their chemotherapy recipe or their radiation dose prescription.  We need to keep them in their jobs, with their families, functioning as normally as possible under difficult circumstances, throughout their treatment and afterwards.  My own experience has shown that this is achievable in a personalized setting in the patient’s community.  That is what I am passionate about.

This piece is condensed from a longer talk I gave in Jamaica in October 2013.  For the full transcript feel free to email me and I will send it on.

Best Dick

In some of my previous entries, I have mentioned how important it is for patients to bring a friend or relative to their first appointment.  Most of the time, we welcome the spouse or best friend who is able to hear and process the information we are giving, especially if the patient herself or himself is still in the “deer in the headlights” phase of cancer awareness. Personally, I don’t mind if you bring a recording device—I realize that there are complex facts to be absorbed and difficult decisions to be made. There are occasions, however, where the addition of extras can be counterproductive. Bringing your mother in law along with your grandchild still in diapers can be distinct distractions to the doctors and nurses involved in your care, especially if the latter leaves stains on the newly upholstered chairs.  There are those “significant others” who are actually adept at alienating the people you most want to make friends with. Those are the personalities that can make your doctor and nurse retire to the back room where they punch holes in the drywall while considering their escape plan.

First there are those I call the pirates.  These are the people who commandeer the ship and make it all about themselves.  Each time I ask the patient a question regarding a symptom, the pirate pipes in about the time he or she had that very same symptom, and what it meant.  If I ask about a family history, I get the story about the time the pirate’s Aunt Nellie had this same kind of cancer, and about all of the terrible awful side effects she had from treatment.  These are the guys and gals who will tell you that your patient can only have an 8:15 appointment; because that is the only time their ship can sail over to radiation therapy to give the friend or spouse a ride.  They are often pleasant but always insistent—they want to make sure that I know how disruptive this disease has been to their sense of self importance and their place in the patient’s universe. By the consultation is over, I have a complete medical history on the pirate, and know their allergies, sexual deviations and food preferences, whether I actually know about the patient or not.

Worse are the pit bulls (and I mean no offense to the breed—you know I speak metaphorically here.)  These significant others come in with the assumption—no, the CONVICTION– that the doctor is negligent, ignorant, and literally out to harm their spouse or friend.  They are prepared to fight to the death.  When I ask the patient a question, the pit bull answers with a snarl.  The pit bull assumes that he must protect the patient at all costs, even if that means literally biting the hand that is offering help.  These are the friends and relatives who are actually dangerous.  They are usually engineers, scientists, professors, and mathematicians who have been on the internet, calculated the risks, and are going to teach you how to do your job so that they can make sure you don’t kill their special person. They are smart and they have done their homework.  They have completely forgotten that I am here trying to help.

We had such a pit bull recently, who accompanied his girlfriend, a lovely patient with cancer of the pancreas.  For the most part, I have stopped giving my email address to patients and families due to their propensity to spam me and my unwillingness to read every internet joke every passed around, and don’t even get me started about those chain emails. In a momentary lapse of judgment, I did however give mine to her significant other. After all, his earnestness was compelling. He wrote to me daily with each incident that his girlfriend experienced, his theories of why she experienced that particular thing, and his antidote for the problem.  And each time I replied with advice, he wrote me back with the reasons that I could not possibly know what I was talking about. Despite our differences, in the end, we tamed him with kindness.  His girlfriend did well through treatment, and four months later she is still in remission.  Our pit bull became a pussycat.

One thing I will never forget is his email signature. Improbably, and without a trace of irony he signed each email, “Best, Dick.”  Really?  I sure hope so, for her sake!