Archives of The Cheerful Oncologist, Volume 2

While wandering through a department store one Saturday afternoon during my sophomore year of college I turned a corner and saw a middle-aged man drop dead. In those pre-cable television years a live event such as this was profoundly shocking, and I recall standing there frozen with fear, wishing I knew emergency medicine. Before I could even call for help a nurse rushed to the victim and began performing CPR. I felt ashamed that me, a pre-med student, was nothing more than a meddling bystander during this life-or-death struggle. I promised myself that someday I would be in charge of advanced life support procedures - known as codes - and would conduct them as masterly as seen on a television soap opera. I yearned to be in charge - to wear the special red beeper on my belt like a gunslinger patrolling Main Street. I wanted to be the Marshall Dillon of Heart Attack City - the Code Resident.

Har-de-har-har - what a difference a few years makes. These days I would no more run a code than rush the stage during the singing of La fleur que tu m’avais jetee and challenge Don Jose to a duel. Now whenever I hear the hospital operator scream over the intercom I crawl under the secretary’s desk, produce a blankie from the folds of my lab coat and cry “I want my mama!”

Good Heavenly Days! Is this an acquired trait of all oncologists, or just a quirk of your moderator? How did this former rescuer of the vital-sign depleted become such a coward? I suppose the answer to this psychological condundrum, as with many neuroses in our modern world, can be found by delving deep into the patient’s past using a painstakingly complex combination of hypnosis and Dr. Phil-like gobbledegook.

Nah, that ain’t it - it’s just that when I reflect on my record of running smooth, orderly, successful codes I always come to the same conclusion:

I’m a victim of circumstance!

Perhaps by revewing a few highlights from my former life I might be able to explain how I adopted this pusillanimous attitude. As described in a previous post, my first attempt at assisting in a resuscitation will never be written into the Annals of Brilliant Medical Decisions since I inadvertantly electrocuted my attending, but that was when I was only a lowly medical student. Surely as my billing on the marquee rose my exploits would match it.

Well, during my internship I attended many a code but always as a bystander due to the fact that every student, resident and visiting professor of ichthyology crammed into the room eager to kibitz, or just catch up on the social intrigues of the hospital. It wasn’t until my junior resident year that I actually got to wear the firecracker and be the boss-man. I quickly got into it and relished the opportunity to yell at a room full of fellow doctors as if they were carrying my rickshaw a little too slowly. Things went well, even when I was brutally awakened at 3 A.M. by the banshee howl of the red beeper.

Things went well, and I began to swagger around the place when on call [cf. inferiority complex -Ed.], until one night while running a code I discovered that the female patient, aged approximately 80, had no breath sounds on one side. The overall findings seemed to confirm the presence of a tension pneumothorax, and I had a team member insert an I.V. needle to relieve it. Somehow the patient ended up with needles in both sides of the chest and then developed subcutaneous emphysema from all the chest compressions.

The effect was unnerving. She seemed to get younger by the second, until after a few minutes her formerly atrophic breasts were inflated like two dirigibles straining to break free from their moorings. Somehow I was to blame for this unfortunate complication, and given the epidemic of black humor that had infected the hospital in those days I broke the house record for “number of jokes made at one doctor’s expense”. My erstwhile superhero status was fatally crippled , and I began to draw comparisons to some of the less dignified roles played by Jerry Lewis.

My love affair with the code was beginning to wilt - much to the benefit, I believe, of scores of future patients.

Next: Goodbye to All That C.P.R., Part Two

…they just live forever on the internet.

This is just a reminder that anyone interested in reading my old posts can find them on:

http://thecheerfuloncologist.blogspot.com/

Thanks.

P.S. I am collecting flush letters from literary agents, who seem to be scared to death of trying to pitch a book of reflections of a medical oncologist. If you are a published author reading this, you have my profound respect.

My guess is that there are very few oncologists actively practicing today who have a history of cancer. I know my old boss is a lymphoma survivor, but other than him I can’t think of any other cancer specialists in this city who can claim to have experienced first hand the very disease they have chosen to spend their career fighting. It is probably unnecessary to broadcast this information during an office visit anyway- the effect might be to turn the focus away from the patient. On the other hand, it is not surprising to find that doctors are discouraged from making comments like “I know how you feel” when counseling patients since this sounds like a phony patronizing platitude the second it escapes from the lips.

Doctors who actually have gone through the trauma of cancer, though, in my opinion have earned the right to use their experience to help patients. Using the memories of their own struggle against the horrid disease as a template, they can create an inspirational talk that is very likely to succeed in forming an authentic bond with the patient and help to relieve angst and sadness. I would be remiss if I did not honor these doctors for their dual roles as patient and healer. They know better than I what the definition of empathy is: what it is like to feel the tension of the examining room, to face the business end of a needle, to vomit, to face the closing of the day wondering what the next dawn will bring.

I know it sounds crazy but because of this sometimes I feel unqualified to counsel people living with cancer. No matter how many soothing words I regurgitate I can’t really know what they are going through, even though I observe them daily. Once I had a taste of what their pain must be like (”A Walk Down the Path of Pain“), but for the most part I am living as a spectator in their world. Are these feelings of inadequacy a variation of the imposter syndrome?

This vague sense of being a poseur made my recent visit with a young woman all the more difficult. She had just been diagnosed with inoperable rectal cancer and faced months of chemotherapy and biological therapy plus the annoyance of having an ileostomy. As I tried to explain the logistics of treatment she began to sob.

“It’s so hard,” she cried, shaking her head. Her shoulders quivered beneath her gown. “I want to give up.”

Giving up was not an option that I would even remotely consider. The latest treatments for colorectal cancer have acceptable toxicity profiles and have produced a significant prolongation of survival - not that I personally know what it is like to receive them, of course. How does a doctor translate this encouraging news into words that can comfort a grieving patient without sounding pompous or callow? How do I produce a homily to console my patient using such medical jargon?

One of the reasons I love my job is that there is very little repetition in it. No two encounters, even with the same patient, are exactly the same. This gives one the freedom to use the totality of the universe as raw material when devising a plan, or in this case desperately trying to come up with something to encourage a young woman facing a harsh future. In the entertainment world this is known as improvisational comedy. In my world it is called thinking fast, and since I am no fan of hackneyed phrases I stared blankly into the abyss until I was able to put this thought into words:

“Right now you think that you’ll never be the same as you used to be, but you know what? You can’t see as far into the future as your doctors can. Think of a point far, far away - down a road so long the end is out of sight. That point is the place of healing. You may not be able to see it but we can, and we know that once you reach it you will be healthy again. You’ll be able to care for your family, to work, to enjoy life again. In order to reach that point you must walk a hard walk down this road - a road of treatments that takes months to endure. Your doctors can’t carry you - we can only encourage you as you make your way day by day down this path. This is your passage to a better life than the one you have now. If you believe this place exists, you will make it there.”

I have no idea what it is like to live with cancer. I have no idea how I would react if I ever developed cancer. What I do know, however, is just as the poet John Keats described, a little negative capability can do wonders when trying meet the expectations demanded of a modern doctor.

What do doctors dream of? Do they sink their heads in their pillows each night anticipating at least a small role in the wildest party Slumberland has ever thrown? If not assigned to be in Titus Andronicus, can they at least hope to play the disc jockey who entertains a whirlwind of beautiful people gyrating on the dance floor? Or do they settle uneasily into their beds hoping to avoid another long night of running through the halls of their old high school, late for a science test they also forgot to study for?

I can speak only for myself of course, but if other doctors are like me they frequently fall from the upright position to the supine with a mixture of exhaustion and disquiet - not every night mind you, but sometimes in the middle of the week when the work and home schedules collide in a fireball of kid’s games and telephone calls. I would be the first to acknowledge that coping with angst is not unique to those serving in health care, but in my opinion there is something particularly dreadful about lying awake at night wondering whether one’s treatments are going to help a young mother live long enough to see her daughter’s next birthday. Take that cheery thought now and repeat it for say, five hundred nights in a row and one can see why oncologists don’t have to visit a professional to look like Boris Karloff by the time they turn forty. A king’s fortune awaits the inventor who can create a pill to guarantee sweet fantasies during the nightly repose.

I bring this topic up today because of a recent dream I had. This meditation was not during sleep, however, but while visiting a terminally ill patient. She and I were discussing the mundane details of her care while avoiding the gray spectre standing silently in the corner, when suddenly she smiled and told me how much she was looking forward to her new life - free from suffering and worry. Her simple expression of faith not only comforted her but shattered the despondency in the room as if from the blow of a majestic sword. As I listened to her my mind began to wander. I had a vision of a large group of people standing on a tarmac next to a jet plane. They joked with each other as they waited their turn to shake my hand. I asked each of them the same question - “What is this all about?” From each I heard this reply:

“My time here is finished. I’m boarding the next flight to eternity.”

The sense of peace flowed through them as they said their goodbyes. No one could tell me when I was scheduled to fly so I just stood aside as the airplane rose in the golden sky, a black shadow banking across the setting sun. I watched the silver arrow fade into the inscrutable deepness of the sky, then turned and shuffled back to the hospital.

All of us have a one-way ticket out of here. As we drift off to sleep tonight, let us give thanks for the opportunity to serve those who are ahead of us in line, as we ask those behind us to do the same when our flight number is called.

Spring has been lovely in St. Louis this month. It seemed to creep up on the neighborhood like a old tabby who suddenly appears underfoot, purring and mewing blossoms of quietude after the winter winds. The redbud trees lining the side streets have been flashing their slender pink arms to passing cars. The contrast between them and the banana-yellow forsythia bushes is striking - when they appear side-by-side they form a clash in colors reminiscent of a Caribbean cruise. How could one not fall into spritely dance seeing such warm beauty?

As I daydreamed out on the screen porch one evening last week I caught the scent of some Persian princess who seemed to be waiting for me at the bottom of the steps. It was an alluring perfume, candy-cane like in its sweetness - perhaps arising from her smooth neck or elegant hands. I sat up, shook my head and realized I was smelling the precious scent of the viburnum planted in front of me. It had bloomed for the twelfth spring in a row, delighting those who come out at night seeking solace, or affirmation of the goodness of life.

I knew it was the twelfth spring for viburnum because that is how long we have lived in this house. I also knew that this was the last time I was going to savor this lovely fragrance, for soon we are moving to a different house with unfamiliar plantings. How hard it is to say goodbye to the season of rebirth when it is painted all around one’s home. I thought of all of the colors and aromas in my yard - the lily-of-the-valley, the pink dogwood trees, the lilacs and the Bracken’s magnolia tree. Most of all I will miss the peonies growing in a crescent on the small hill in my back yard. There is no faster way to lift a spirit than to place a giant peony blossom on the kitchen table. Its lemon-vanilla perfume is as intoxicating as sleep itself. Next year some new family will possess all my pretty flowers -will they wander through the grass with delight, or stay indoors and watch television?

I relished in the beauty of the season as I drove to work the next day, with perhaps a thimble full of self-centered, ungracious pity for the transition looming ahead. Anyone who loves nature hates to say goodbye to it, even if only leaving a simple affair such as a memorable camping trip. I arrived at the office and walked into an examining room to greet my first patient of the morning. He was a middle-aged man who had just taken his first cycle of chemotherapy for metastatic lung cancer last week. “I’ve been doing a lot of reading on the internet about small cell lung cancer,” he replied, ” and I didn’t like what I found out about my chances.” Before I could speak he looked me straight in the eye and said:

“Do you think this will be my last spring?”

I asked God for health, that I might do greater things,
I was given infirmity, that I might do better things.

I asked for all things, that I might enjoy life,
I was given life, that I might enjoy all things.

May all doctors learn as much from their patients as I have.

Hospitals are fascinating places - I could dilate on them for hours, until the first rays of rosy-fingered dawn bathe the gray eastern sky, which usually occurs while the doctor is slumped in a chair in the Trendelenburg position, slowly relaxing the grip on his umpteenth cup of coffee as Mr. Sandman dumps a beachful in his bleary eyes. It would be difficult for me to calculate the number of hours I have spent inside the walls of these institutions of mercy without the help of a Univac or some other such behemoth of artificial intelligence, and Gawd-help-us if I ever decided to chronicle all of the maypole dances, potlucks and other jocular gatherings I have missed because I was “on call.” It’s a good thing I love my job more than life itself. Who says movie stars have it all? I get to jump out of bed each daybreak and drive the buggy to the only place in the world where people are encouraged by trained professionals to pass gas.

Alas though, it is time to say “Ta-ta” to our visit to St. Elsewhere. Our tour concludes today and unfortunately must be scored as only mediocre since the docent neglected, with a rather annoying smirk I might add, to take us through several sections of the place. The laboratories, doctor’s lounge, waiting rooms, operating rooms and foyer were passed over, which reeks of a sleazy attempt to stiff the consumer. Even the cheapest vacation package to Paris includes a peek at the Mona Lisa, for Pete’s sake.

As we search for a way out of this man-made maze called the hospital (I confess once I left scraps of a Philly steak sandwich as markers all over the 10th floor of one building while blazing a trail to to elevator), let us take one final, tender gaze at this tribute to science, diligence, compassion and most importantly, evolution (let me know if anyone ever unearths a Surgi-Center manned by Australopithecines). I can think of no better way to say goodbye than to head for the trusty family station wagon and wave a cheery adieu to the tranquil palace in the rearview mirror. This of course means we must find our car in the hospital parking lot. Wish me luck.

I recall exactly the first time that I became aware of a hospital parking lot. I had just finished working the graveyard shift as an orderly while on summer break from college, and as I hiked to my ‘73 Caprice Classic (maroon), parked but a mere tee shot, then 3-wood-7-iron-sand-wedge-three-putt away from the entrance, I happened to pass a small lot right next to the place. It was packed with sleek, freshly laundered convertibles and Teutonic chariots. Casual strollers risked a nasty case of whiplash by craning the neck to see which vehicle was the most elegant. I stopped and with breath-holding awe approached a silver Mercedes coupe’. Reaching a respectful distance from the car I peered through the window and saw an engraved plaque on the dashboard with the doctor’s name on it, written in loving, nay, adoring script.

Holy Moses, I thought - this is the doctor’s parking lot! Why the Commissars from administration let the doctors have their own enclosure was the last thing that entered my mind on that morning. Remember, in those days doctors didn’t have to even find their own charts - they were stacked on a little cart in the hallway each morning by the day shift nurse, ready for use during morning rounds. Being a layperson however, I did feel a twinge of disgust fly in amongst the flock of admiration chirping away in my gullible head - I mean, come on, who says that doctors have to have their own special lot? It just ain’t fair, and how soon till I get my magnetic passcard so I can glide my shining-example-of-capitalistic-exploitation into this royal corral?

Many summers have passed since I held that job, and now I go about my rounds in a Tin Lizzy that is not ostentatious, but certainly would not ever be confused with the neighborhood teenager’s jalopy. Some of the hospitals I visit have special gated lots and some don’t. It makes no difference to me, since one of the most exciting aspects of modern life in this country is finding a good parking spot. I still feel a little funny though when I park next to some sleek roadster with plates that say “MBA DOC.” That seems to be somewhat extravagant to me, and those who know me best would agree that one could sell sno-cones in the infernal regions before the day came that I tooled around in such a paragon of profligacy. I am happy just to be here. I ain’t going to toot my own horn, that’s for sure. Just call me Joe Anonymous.

(If I do get a plate though I’ll put this on it: VALUES - better off using an obscure literary allusion. Wouldn’t you agree, Count Mippipopolous?)

Why do trips to the cafeteria have to be so emotional? There is no reason why modern hospital cafeterias should resemble photos of East Germany during the heyday of Soviet rule. The food and beverage centers of today’s modern institutions of healing should be designed to please the eye with a layout worthy of the priciest Feng Shui consultant. The cafeteria should be a masterpiece of gustatory serenity - there is no reason to expect anything less, no reason except “if wishes were horses,” as the old rhyme goes…

Let’s face it - hospital cafeterias are catering to a captive audience. Their main goal - preventing starvation - is noble but just as easily accomplished with a gooey glob of artery-congealing biscuits and gravy as with a tender lattice of arugula. Budget constraints alone prevent them from offering such items as “phyllo-encrusted Chilean sea bass on a bed of basmati rice with a Thai curry reduction,” and anyway who has time to sop up such fare when a sick grandmother or hot gallbladder awaits upstairs? A hospital cafeteria’s mission statement, however, can put that of the most foppish of five-star beaneries to shame. The wording is complex and somewhat baroque, but at the risk of frustrating even the most intellectual members of my reading audience I shall reproduce this mission statement without any explanatory notes. It is as follows: “Eat up.”

When one boils away all of the skin and fat of the typical cafeteria it is easy to see what two essential ingredients remain, two that determine whether one’s visit there will be pleasant, or more like following a line of elephants in a parade. These ingredients are, naturally, the food and the patrons. A minor disturbance in the karma of either of these two can deflate even the toughest cardiac surgeon, just like a fallen souffle’. Some doctors avoid the dining hall completely rather than risk sitting next to some sullen colleague still reeling from the morning’s disasters, or some meek, harmless-appearing soul who suddenly belches and starts shoveling in his lunch like Grandma stuffing the Thanksgiving turkey.

I must admit my own dining habits have changed after years of examining the cafeteria’s daily offerings with jaundiced, if not lemon-meringue-pie-eyes. Just as an angler attaches the same lucky lure each morning on the lake, I select the same sandwich for my daily feedbag. It’s boring, but at least I know what I’m in for, and the total fat, trans-fat, cholesterol, heavy metal and arsenic content of the thing are low enough to allow my life insurance agent a restful slumber. The same cannot be said for my fellow diners, many of whom pile on the vittles as if Mount Vesuvius was going to erupt at any minute and turn us all into objet d’art for a distant expedition. Being a stout disciple of the live-and-let-live wing of dietary critics, I shall comment no further on the alleged unhealthy eating habits of doctors. After all, they should know better.

What makes our time in the hospital eatery so unique is the opportunity to engage in conversations ranging from playful banter to an impassioned defense of one’s decision to proceed with chemotherapy in some antediluvian nursing home resident. In fact, my time together with peers has come a long way from the old medical school lunch hour which, due to my own bleak pecuniary resources, consisted of a automat sandwich and an apple while rushing down the hallway to Gross Anatomy. Now I can sit around the Round Table for hours rehashing last night’s scores or dissecting the peculiarities of anyone not sitting within earshot of our bull session. With such camaraderie, the afternoon flies by and certainly brightens the mood for all, but does produce one small problem which eventually rouses the members from their torpor as if a small fairy had flown into each ear and whispered the following message:

“GET BACK TO WORK YOU SLOBS!”

I love going to the hospital cafeteria. It’s where I am reminded that I no longer have to sit next to a goggle-eyed 4th grader with a milk mustache while opening my Gilligan’s Island lunchbox and staring with disbelief at yet another soggy braunschweiger sandwich. It’s where I can feel good about my parsimonious diet as I pass by table after table of trenchermen laden with french fries and Moon Pies. It’s where I go to replenish my body and brain before returning to the challenges of the day. In fact, I can think of only one drawback to eating the same food day after day, year after year: it is as boring as shaving, as washing dishes, as every other task in a typical day.

Tomorrow I’m going to spice up my life, and grab a slice of pizza.

Next: Goodbye to St. Elsewhere: The Parking Lot

If one were to ask a friend what they were doing on July 1st twenty years ago I would bet in most cases the reply would include the words “foggiest”, “idea” and “haven’t”. Now ask a friend what they recall from a distant vacation and suddenly one is inundated with tales of waltzing on the beach by the light of the ocean moon. So it is with events in life that are so intense that they weave themselves into a tapestry that hangs on the walls of Memory forever.

So it is with doctors and their hospitals. Doctors can remember every ward, emergency room and stairwell they ever spent more than a day navigating (by the way, interns use stairwells when going off-duty in order to escape before being confronted with a new problem while waiting for the !@#!&! elevator to appear). Hospitals are memorable places, where death and birth pass each other in the halls on the way to their next assignment. The impression left on patients, families and health care workers by hospitals is indelible - I can still clearly see the room in the emergency ward at Iowa Methodist Medical Center where a teenage girl was brought in by helicopter in July 1978 after being crushed in an ATV accident. I had a summer job there as an orderly. She died in that room, surrounded by a crowd of shouting and sweating people. I remember… I remember…I will never forget that sweet girl, Julie Stone. It was the first time I had ever seen desperation displayed on a physician’s face.

Since this is the second part of our tour of St. Elsewhere, however, let us walk away from the scary places and visit one of the more amusing chambers of the hospital. Come with me down these echoing stairs into the lovely suite known as Radiology, where the internal secrets of even the most electrifying celebrities are exposed with all their flaws. If the owners of these various organs have avoided the evils of drink and smoke, however, there is no reason why their lungs and liver should not look as pristine on x-rays as those of Mr. Universe himself.

My own safaris to Radiology have not been all that jolly. During medical school I spent my rotation trapped in a reading room so small I half expected the intercom to deliver a message from Mission Control about our lunar landing. Not only was it cramped in there, but the attending liked to chain-smoke unfiltered Camels as he taught us how to read CT scans. This was but a minor distraction, although we all sped home after the first day and drew up our wills. The radiology department did not exactly earn the title “Beloved by All” during the residency, either, for it was during this stretch that I learned how to find and read my own damn x-rays, owing to a lack of coherent personnel in the department. This shortcut produced at least two undeniable results: 1. I was never late for lunch, and 2. the odds of a patient slumbering through the night with an undiagnosed pneumothorax increased nine-fold. Surprisingly, it was after becoming an attending that radiology entered the Dark Ages of customer service. For example, the following dialogue was recorded I believe during the first Clinton administration:

Cheerful Oncologist (rummaging through files of manilla x-ray folders), sotto voce: How poor are they that have not patience!

Radiology Librarian (threateningly): What are you looking for?

Cheerful Onc. (brows furrowing): I’m looking for Mrs. So-and-So’s x-rays.

Radio. Librar.: Don’t go through the files! I’ll get them for you! (leaves, without eating roots or shoots, I might add, in a huff)

C. O.: Lasciate ogni speranza, voi ch’intrate!

R. L.: Don’t talk back to me, buddy!

So it went, year after year, as I tried to hunt down x-rays for review while avoiding the headhunters in the film library. It was a lesson in survival for me. I searched for a friend in Radiology like a Casablanca spy seeking letters of transit. I began to send members of my staff in my place, which led to bitter denunciations of my lack of courage, but better them than me to face Godzilla, Mothra and the other movie stars in the department. After all, I was aging rapidly and needed to watch my blood pressure. Just when I had resigned myself to a destiny chained to the the beast called Aggravation, the radiology department blessed its patrons with the most precious gift of all:

It disappeared.

Now by the miracle of the internet, all imaging studies are digitally transferred to the hospital website where they may be viewed on any computer, anywhere, anytime, by any interested party with the proper security clearance. There is no reason to pass through the heavily guarded doors of the department any more, unless one wants to stand around with one’s hands in one’s pockets like an eager fan holding the 1,758th position in line to see a game on opening day. I worry that future generations of doctors will not get to enjoy the kindling of the same relationships we ancient mariners have developed over years of sparring with the radiology department. Is nothing sacred? Next thing we know, we’ll press a button and our lunch will appear on our desk, complete with a tasty space beverage. Wouldn’t that make a trip to the cafeteria nothing more than a wistful memory? Oh, perish the thought, if not the food!

Next: A Trip to St. Elsewhere: Part III - the Cafeteria and the Parking Lot

Thanks to Ali for referring me to this new blog host. Let’s hope it works better than the old place, which seemed to specialize in losing copy as soon as it was written.