Archives of The Cheerful Oncologist, Volume 2

We had just buckled ourselves into our seats when a distinctive purring voice came over the loudspeaker. It was the captain, who congratulated us on being the first group of passengers to fly from New York to Tokyo via sub-orbital space travel.

“Folks, we’re still trying to figure out what happened, but it looks as if we have left Earth’s orbit, and unfortunately we don’t have enough fuel to return. We can steer though and we’ll just have to keep flying until we come up with a plan. We’ll keep you posted.”

When medical oncologists decide to start patients on treatment they seek to reverse the course of the illness known as cancer, to bring patients back from an unhappy journey that is sending them further away from normal life and closer to uncharted worlds where suffering awaits and beyond that the mystery of the grave. Some patients who begin chemotherapy will quickly turn about and re-enter our atmosphere. Others will alter their trajectory so slowly as to elicit despair from their families, only to finally circle back toward the anxious faces.

Some patients continue on their way despite our best efforts to detain them, straining the necks of those who dare to follow their path in the sky, becoming a distant glow that seems a star before vanishing forever. No matter how sophisticated our prognostic panels are we oncologists cannot predict with certainty which patients will respond to treatment and which are irreversibly chained to the ship traveling toward oblivion.

This tends to annoy us.

As an example, I offer two patients from my practice, both with the same diagnosis and both with liver metastases. One was old and frail, the other middle-aged and still working. Both were treated with the most promising of treatments available. Both tolerated the chemotherapy and biological therapy well. I was certain that only one of the two had a realistic chance for remission, and I was right. I was also wrong.

The vigorous younger patient died as quickly as the last rose of summer. The elderly patient’s tumors are melting away as smoothly as a cruise ship pulling into a hibiscus-scented tropical port.

Tonight I sit in a chair on the screen porch, feeling the night breeze, attempting to focus on page 24 of an excellent novel, but instead whirling about on a merry-go-round of questions and more questions. Over my right shoulder I hear the rumble of a jetliner as it sails across the blackness. It is invisible against the sky but its sound reverberates throughout the neighborhood, as if announcing a final flight now departing. The large country clock hanging on the wall silently counts out the seconds remaining until it is time to return to work.

“Doctors perform physical examinations in order to diagnose illness or injury,” said The Cheerful Oncologist as he leaned against a wooden desk placed strategically in the front of the hall.

Thank you for stating the obvious. Perhaps you would like to proffer an opinion as to why bears wander off into the woods each morning after finishing their eggs and bacon.

“Pay no attention to any wisecracks you may hear from the rear of the hall,” he replied. “Today’s lesson is entitled Examining the Cancer Patient: The Key Findings.”

Oh, brother - good thing I brought this morning’s New York Times crossword puzzle.

“Let’s face it - as your careers progress, or for some of you court jesters sitting in the back - drag on, you will find yourself forced to abbreviate the physical examination in order to satisfy the constraints of time. Obviously patients suffering from disruptions of specific organ systems like the heart or lungs will require particular attention to these areas. But what of the patient diagnosed with cancer? How can we ensure that our exam has been accurate and complete enough to uncover clues as to where the tumor started, where it is now, and what complications has it released upon our patient?

“As an example let’s present a patient with the chief complaint of four weeks of cough - with no other symptoms. A chest radiograph reveals multiple small pulmonary nodules throughout all lung fields. The odds are that this tumor did not start in the lung - especially if the patient is a non-smoker, as in this case. Because of the paucity of findings on the x-ray, if we examine this patient’s lungs with the intention of solving the mystery we are likely to come up as empty-handed as Grandma playing a game of three card monte. ”

What? Did he just say three card monte? Hmm….need a five letter word for “Steppenwolf” author….

“Therefore, in addition to taking a careful history, we must examine the patient while simultaneously formulating a differential diagnosis for the cause of his multiple lung nodules. This patient will serve as a model for what we should concentrate on when examining the cancer patient during a busy clinic afternoon, when efficiency is of the essence.”

Why didn’t I stop off for coffee on my (yawn) way here? Okay - a six letter word meaning ‘nauseating‘…

“The crucial areas one must concentrate on during this exam are as follows:

Skin - think melanoma! Look for blatant melanomas, atypical moles, old scars from earlier mole removal - plus subcutaneous nodules, skin cancers, nicotine stains on the fingers (always a clue that the smoking history was incorrectly reported by the patient).

HEENT - think head and neck cancer, or lymphoma! Look for primaries in the nasopharynx, oral cavity and hypopharynx; check carefully for lymphadenopathy as well as thyromegaly; look for scleral icterus, too.

Breasts - do not neglect this exam in both men and women, although the incidence in men is as rare as hen’s teeth.”

Hen’s teeth? Hey, could that be the answer to “Rarity found on ground after poultry fight“?

“Abdomen - think masses and -megaly! If the liver is enlarged the primary may be from there or from the G.I. tract or pancreas; splenomegaly again raises the question of Hodgkin disease or non-Hodgkin lymphoma - and don’t forget to look for renal enlargement, or omental caking which is seen in ovarian and colorectal cancer, or a suprapubic mass suggesting endometrial cancer, or even bladder cancer.

G.U. and rectal exam - testicular cancer is high up on the list of possibilities for a non-smoking man with lung nodules, and of course we must always rule out a rectal mass plus check for occult gastrointestinal bleeding.

Legs - are they swollen? Could the patient have a deep vein thrombus, or even Trousseau’s syndrome which raises the spectre of G.I. or pancreatic cancer?

“There are scores of other parts to a complete physical, but for the busy clinician these tips are at least a basic template which will hopefully maximize the chance to actually find the patient’s primary site before shuffling him or her off to the CT scanner.”

Okay, just three more to go and I’m done…let’s see - a six letter word for “Gentleman’s gentleman likely found in Totleigh Towers, Market Snodsbury, Rowster Abbey, Brinkley Court and Steeple Bumpleigh…

(At this moment our back-bencher puzzle master looked up to see the unsmiling visage of his lecturer, who uttered, using a tone suggesting a judge sending a pack of pusillanimous pickpockets to the penitentiary, the following word:

“Jeeves.”)

We could never learn to be brave and patient if there were only joy in the world. -Helen Keller

As gorgeous afternoon clouds slowly tumble across the sky, sending playground lovers and other dreamers outdoors, we find our narrator trapped inside the cheerless halls of his office, struggling to finish this first day of the rest of his life, as it were…

Always one for gunnery sergeant-like efficiency, I like to read the charts of patients scheduled to see me in the office that day. I find it helpful in refreshing my memory and tracking down the little details of a case that may have been misplaced, such as labs, radiology reports, consults, H & Ps - even the charts themselves, contrary to what Mom always told us, sometimes get up and walk away, causing the doctor to sprinkle the air with certain agrarian phrases best left in the pigpen. One is always better off preparing for such contingencies in my opinion. Check, check, and double check - that’s the smartest motto.

Unfortunately on my first day in the office this little bit of clever thinking had about as much chance of reaching consciousness as the solution to Fermat’s last theorem. I stumbled into room after room with no clue as to what was really going on with my patients. For example, the first person I saw was a woman my partner had “referred” to me (just to give me something to do, I guess). She sat before me in a wheelchair, the sharp angles of her emaciated face piercing the soft light. Even a novice oncologist like me could figure out that 1.) she had been treated with harsh chemotherapy 2.) it wasn’t working, and 3.) her new oncologist had no idea what to do to reverse the course. I smiled at her, trying to stifle the panic flaring within and then had an idea. Without producing anything as obvious as a pair of pom-pons I gave her a pep rally: told her she was holding her own, that her pain was going to get better on this new pill, that she was going to benefit from an appetite stimulant…that her life was not destined to spiral toward misery if I had anything to say about it. She returned the smile and held my hand as we made plans to meet next week. I stood out in the hallway for a moment after she left and felt a different kind of flickering - the warmth that only a lesson learned can bring. I kept her chart on my desk all week as a reminder.

She never set foot in my office again. Whatever winds control the course of life pushed her away from us and off toward a horizon too distant to find with the spyglass we possess. Only her face remains now, poised high on a thin neck, balanced above her doll-like body resting in a wheelchair. I see that face often - in the eyes of those who lean close to me, in the shadows of darkened hospital rooms, even in the mirror. It is the face of change - the last murky view into the chrysalis before it cracks and is swept away by the beating of wings. Wise beyond compare is the doctor who remembers this before stepping out onto the stage and into the audience’s stare.

The rest of the afternoon glided by like a dump truck making a sharp turn on the ice. Slowly (but hopefully not as slow as watching you-know-what dry) I was on my way to becoming fast yet meticulous, non-judgmental yet savvy, and closer to acquiring the most valuable skill the clinician can ever hope to obtain.

What virtue could this be, that the best of physicians must wield? If you haven’t guessed by now the answer is located here, gentle readers, and I do beg thy pardon if I spake not in troth.

Before long the lights were snapped off and I was back in the parking lot, no worse for the nine hours of wear and tear. My suit did look as if I had just finished tunneling out of Alcatraz, but I didn’t care. Home and dinner awaited, and it was with not just an ordinary sigh of relief that I roused the squirrels under the hood of my cruiser and drove off in the general direction of the sunset.

I had just entered the highway when my pager went off, displaying a message that no matter how hard I tried to misunderstand successfully relayed the concept of urgency, not to mention “must see today”. Giving the rear view mirror a look best described as constipated I headed for the closest exit with the same amount of glee General Eisenhower had when informed of the weather forecast on June 5th, 1944.

The first day on the job is always a memorable one. Lucky is the one who doesn’t have to repeat such experience every six months. I’m going on seventeen years in the same ditch, and I’m still digging, Laudate Dominum.

As we pick up our story, our narrator wanders over to the hospital for the first time as an attending…

Those of you who have started a new job after receiving only a cursory tour of the building where you will work can appreciate the strange look I had pasted on my face as I loped down one hospital hall and back up the other on my first official trip to the sanctum sanctorum of healing. I was searching for the ward where my first consult awaited me and every corner I turned revealed the same anonymous blend of clutter and emptiness that defines most hospital units. Unlike the men’s clothing stores I frequent, where one can barely get the trailing mocassin across the doorway before being assaulted by sales clerks sporting enviable pompadours, the nurses’ stations I crawled up to were either as empty as Grant’s Tomb prior to his demise, or teeming with personnel all presenting their backs to me for inspection. In my paw I held a slip of paper with the name and room number of a patient who, as my secretary breathlessly related to me, lay desperately ill with a seemingly inscrutable cluster of symptoms. With a whisper she described how the finest specialists in the city stood in a solemn circle around this poor fellow’s bed, all hemming and hawing with indecision, as groups tend to do when asked to make a group decision. Not until one of the more vocal members of the clan cried out “Let’s get that celebrated new oncologist to consult on the case!” did anyone give this pitiful sufferer more than one chance in ten to live long enough to pay his bill. A dozen bearded faces turned toward this wildcatter and, after the obligatory pause of disdain, launched a dozen slow nods of approval. A hushed call was placed and Bob’s your uncle - there I was at the desk holding my first official chart in trembling hands. I lifted the plastic cover as if the map to El Dorado rested within and took a peek. Gasp! That hissing sound emanating from deep within was my ego deflating quicker than the merger of a balloon and a well-aimed dart.

“Consult Hematology for anemia” was scribbled on the order sheet. I suddenly entertained thoughts about my secretary that were undoubtedly a breach of decorum, even after omitting the part where she gets a quick demonstration of how to use a coconut cream pie as makeup. To put this into translation, an oncologist who gets an anemia consult is like a costermonger at the intersection of 44th and Broadway who receives a request to wipe the mustard off of a customer’s mustache. It is a humiliating consult for the simple fact that any doctor with a standard medical education can solve the mystery (if any) of anemia with deductive reasoning. The problem is, no one cherishes the joy of deductive reasoning any more (unless they happen to reside at 221B Baker Street).

“What a revoltin’ development this is!” died on my lips as I entered the room.

In interest of patient privacy I shall not describe my brief encounter with this gentleman except to say that he was ancient, and had apparently assumed the left lateral decubitus position for the remainder of his existence, and had a beard that mirrored his hair style (or was it vice-versa?), and was as taciturn as an owl on sentry duty challenging an approaching shadow. Despite the lack of bonhomie in the room I was able to plunge ahead and, deerstalker cap or not, find the cause of his anemia in due course. It seemed that he was losing blood through the upper G.I. tract due to the fact that his daily dose of 2400 mg of ibuprofen had been inadvertantly continued by the admitting physician, and no one had yet been able to decipher the connection between the decrease in hemoglobin and the increase in dark, tarry stools. All I had to do was pen a couple of quick orders and Bob’s your uncle once more - the end of the beginning had begun, and now I could skip back to the office, (perhaps humming “Begin the Beguine“).

Again, those of you who remember that first day on the job and how you felt when the lunch whistle blew, announcing that the day was half over - didn’t you get a giddy quiver in the heart when you realized that you were going to survive without committing some faux pas that would be retold at the company picnic for years to come? I had a similar feeling as I headed back for a well-deserved lunch, courtesy of the delightful hospital cafeteria. I gave an oleaginous greeting to my secretary and told her I had finished the consult. She gave me a smile that even dear, sweet Alice herself would find suspicious and reminded me that I had office hours beginning at 1:00. I salaamed to her and, grateful for the chance to catch my breath, eat and make a couple of half-time adjustments in the game plan, walked to my office. Even before I neared the doorway I could detect a repugnant odor wafting from within.

Sitting in my chair, leaning against my microwave oven, were a couple of employees on their lunch hour, each with a fashionable ladies’ cigarette clamped on their mouths like a lamprey on a juicy lake trout. The atmosphere, which was already cloudy to begin with, turned threatening.

It seemed that my first day on the job was going to rival one of Job’s typical afternoons with the wife and kids. I drove the sinners from the room, turned on a fan and raised my voice to heavens, thusly:

“My sighing comes before my food; and my groanings are poured out like the waters!”

A knock at the door shattered the silence and I heard the unmistakable voice of my secretary warble “Your first patient is here.” As I arose from the kneeling position, I knocked my sandwich off the desk. I stared at it for two or three seconds longer than required, then walked out.

Next - Private Practice: The First Day, Conclusion: Now I Lay Me Down to Sleep…

What else is summer good for but using all of one’s magical powers to levitate out of the city for as long as the sober judges of one’s conscience will allow? Unlike those coy but suspiciously lazy lilies of the field, we citizens of the modern world work hard week after week and allow ourselves only a modicum of frivolity - almost always taken on the weekend, when we desperately need to catch up on sleep [Medice, Cure te Ipsum! -Ed.]

Anyway, in order to follow my own prescription for R & R, I am in the country as I type, enjoying a relaxing day off. Unfortunately it is raining so hard I expect to see Noah himself running down the road with a couple of well-stuffed suitcases, followed by a pair of aardvarks, no less.

So much for summer fun. The Cheerful Oncologist’s regular drivel will resume tomorrow, assuming I can float my way back to the big city. Arrivederci!

As part of a continuing series we bring you another delightful story from the memory of The Cheerful Oncologist (before incipient dementia pillages the old frontal lobes).

Gosh, but it seems just like yesterday that I jolted awake after a restless night amidships the slumber sloop and faced the bloodshot sun on my first morning in private practice - a “real doctor,” as they say in waiting room magazine articles. After years of soporific study, receiving verbal abuse from bearded residents wearing clogs, and sprawling across messy nurses’ stations littered with half-empty cups of fossilized coffee, I was finally at the threshold of glory that can only rest upon the shoulders of the attending physician, who wears the long white coat, not that may-I-take-your-order-madam silly white jacket of the intern. As I stood in front of my closet on that remarkable day I had no idea that this career kickoff would leave an impression worthy of being included in these chronicles. Therefore, gentle readers, with your kind permission let me relate some of the highlights of my inauguration into the majestic world of private practice.

The Dressing

While fingering my rather threadbare collection of men’s shirts (so I’m no Jay Gatsby), I realized that I had forgotten to obtain a long white coat in which to stagger my new staff with, not to mention that part about glory awaiting on the other side of the doorway. Being a newly minted attending I couldn’t just show up for work in a pink oxford button-down with a flamingo-encrusted bow tie, so I decided to put on a suit. This seemed to be a sound compromise that would likely have the patients and nurses buzzing with gossip about the “handsome young doctor,” even if I did look like I was loaded with brochures about variable annuities. The only problem was that it was July and the only summer suit I owned was a tan cotton number last worn during the wedding reception of Cousin Jimbo approximately two wives ago. Never one to let foreshadowing interfere with making an idiotic decision, I donned the togs and headed down to breakfast.

Let it be recorded evermore in the annals that my wife, upon seeing me slide into the kitchen wearing this ensemble, acquired an unusual smile and belted out several stanzas of “I Believe in You” while performing the fox trot with a box of Froot Loops. I was not amused, and quickly drove off before I realized that another small detail had slipped past the safety net underneath my absent-mindedness: I had no idea how to get to the hospital from my house.

The Drive to Work

Had you been one of those early birds lining the trees of our fair suburbs, bursting with ideas about how to lay claws into a meaty breakfast, you might have heard the putt-putt of a small foreign coupe’ as it wandered along curves and hills, a bit of hesitation in its step. Aye, that was me on the road that morning, trying to decide which route would be the most direct to my beloved destination. I chose to jump on an obscure highway then enter a street that (unknown to me at the time) was vying for the title of “Most Traffic Lights in America,” although in retrospect it could have challenged all comers for “Greatest Number of Bus Stops,” too.

Now I knew how Henry Stanley felt when he reached Lake Tanganyika. My little journey took so long I could have written an addendum or two to Einstein’s Special Theory, if I had been able to recall what was so special about it. By the time I finally arrived at the hospital I was as hysterical as a barrel above Niagra Falls containing a rhumba of rattlesnakes. I hurried through the silent glass doors and sneaked into the main office, then found my private office. There I found my partner sitting on the edge of the metal desk I had just inherited from a former billing clerk, wearing a grin that only an upcoming three-week vacation can produce. He greeted me, sang my praises and dashed off to catch his plane. I opened a drawer or two and felt my suit jacket hugging me like a lovesick python. Not want to be caught in a dreamy state of thumb-twiddling, I turned to get up and dropped my jaw at a most unusual item in the corner.

It seems that my new office was also the employee’s break room, for there on a faux-wooden cart, smeared with fingerprints, was a microwave oven. The glory that was Greece began to slowly slide down the back of my shiny suit into the plastic wastebasket plopped next to my clangy, dented desk. I took my jacket off, tossed it on the floor and peered out into the hallway. In the distance I could hear squawks of laughter. My first day on the job had begun.

Next - Private Practice: The First Day, Part Two: If It Can Crawl Through Your Front Door…

Have you ever found yourself in a situation where you, having been charged with the responsibility of delivering a precise yet lively, complex yet inherently logical sales pitch, pause for a moment during all the blabber and think to yourself:

“How can I keep talking this up when I know it’s a pile of crap?”

If the answer to the above is in the affirmative, then welcome to the frustrating world of the medical oncologist. We sit down every day with patients afflicted with a seemingly endless variety of tumors and promote treatments that can make cancer disappear, shrink cancer, stop cancer from growing, slow down the progression of cancer, improve the quality of life of cancer patients, but in many cases cannot accomplish the main and only objective that counts - curing cancer. This limitation of modern treatments is perfectly understandable - after all, it is not year 3005, when The History Channel offers such evening programs as: “Before the Cure: When Cancer Ruled the Earth.” Don’t get me wrong - I have nothing but gratitude for chemotherapy regimens and biologicals that do eliminate a legion of malignancies right here today. It’s the rest of the horde - the adenocarcinomas, the metastatic melanomas, the refractory lymphomas, to name a few - that discourage oncologists as greatly as a captain who watches his lifeless schooner drift in the pale calm under a fierce Pacific sun. We oncologists demand perfection from our treatments and do not receive it. We therefore feel foolish sometimes when we counsel patients about taking a chemotherapy regimen that doesn’t have a whole lot to offer.

Nevertheless, as the wise old sage once proclaimed, “Oncologists are hewed from resolute timber, even if they bellyache like a kid who just missed the height cut-off for some emetogenic amusement park ride.”

We keepers of the flame of hope for those living with cancer will not falter even as we rail against state-of-the-art treatments that produce only modest results. In our view, anything that can improve the lives of our patients must be considered. But forgive us if we sometimes daydream about what it would be like for surgeons to have to deal with similar limitations in their art.

Try this example: a patient with painful cholelithiasis visits a surgeon, who says that the best treatment available for the problem is to open up the belly and trap the gallbladder between two metal plates so that the stone is crushed.

“What if it fails?” says our patient.

“Well, then we’ll try the next best option,” sayeth the sawbones. “I’ll inject a solution of arsenic directly into the gallbladder, which may wither it along with the stone.”

“Yea, but what do we do if that fails?”

“The last resort would be to open you up again and tie off the cystic artery, which will kill the gallbladder but put you at risk for death from blood poisoning.”

“Gadzooks, Doc! Why can’t you just cut the gallbladder out?”

“No one has ever found a way to do this procedure, I’m afraid,” he replied. “We can only hope that as research continues, someday we’ll find a cure for cholelithiasis that will be safe and effective.”

And with that, the patient left the doctor’s surgery and drove his team down the narrow cobblestone streets back home to his village.

That is how I feel when I look into the faces of my patients who have just been diagnosed with a recurrence of cancer that will snuff out their unique lives long before the flame runs out of wick. Until the day comes when the final secrets of the malignant cell are uncovered we oncologists will continue to stumble on with our potions, hoping that some distant dawn will contain within its glorious pink clouds a miracle for those who suffer.

After two weeks of getting sand in the suit by day and stars in the eyes by night, my idyll by the blue water of the north has ended, and yours truly is (gulp) back at work, sitting on the familiar low stool next to patients both well and not well, listening to them try to put their agonizing symptoms into words that can express the unique suffering that cancer induces. After trudging through another day of catch-up this leads this former fisherman and beachcomber to ask the following about summer vacations:

Is it possible to shift one’s attention from a glorious holiday back to the day job without moping around the office like a jilted 9th grader?

Answer: at first it isn’t easy - just like a butterfly looking down at its cocoon, I find myself recalling scenes from the vacation and wondering “Was that really me? Did it really happen?” There are times in our lives when we experience such intense emotions that the episode, whether it be a trip, summer job, romance, etc. records itself into our memory so vividly that it can be rewound and replayed at leisure like a selection from a movie collection stacked in the family room. Once these reflections flood the consciousness though, they can produce not simple joy, but a paradoxical emotional reaction consisting of swirls of happiness and wistful melancholy pirouetting about each other as we remember how wonderful it was to be together, yet how painful it was to say goodbye. Thus we experience one of life’s most poignant sensations. Taking it to the extreme, this feeling was eloquently described by Dante in his Inferno, when the murdered lover Francesca laments:

…Nessun maggior dolore
che ricordarsi del tempo felice
ne la miseria;

(”There is no greater grief
than to recall a time of happiness
while plunged in misery;”)

Well, after all… it was only a vacation…let’s not get carried away. But that’s how much it hurts when we visit a place we love like no other and must leave it - in my case for a whole year. As summer begins to wind down this month, let us all vow to fully enjoy what time is left. Let us work on making memories that will entertain us as we’re shoveling snow in January. Let’s all go jump in the lake, and get ice cream cones that we don’t need, and watch the August sun turn into a glowing pumpkin as it sinks into the trees, and feel the blistering heat of the day loosen its grip on the neighborhood as welcoming, breezy dusk settles in. Let’s find Cassiopia among the endless diamonds of the night sky, and listen to the sassiness of the whip-poor-will while walking under the ghostly light of the full moon.

Autumn will be here soon enough, with its own gang of merry-makers. Let us do all we can to cling to the current season before it slips from our grasp and shrinks into the distance like the vision of the lake in our rear-view mirror as we slowly begin for home.