Archives of The Cheerful Oncologist, Volume 2

One must have a mind of winter
To regard the frost and the boughs
Of the pine-trees crusted with snow;

“The Snow Man“, Wallace Stevens

I was in the country last week enjoying the remnants of a golden autumn when winter suddenly pounced, knocking both children and adults about like an icy wolf scattering the flock in woolly fold. Through the thin windows of an old cottage I watched the thermometer dial swing to the left until it rested before the number twenty. It would have been easy to remain wrapped in an afghan next to the fire for the next two days, perusing some exotic tale of the warmer climes, but I was determined to explore the river valley. I therefore tramped about the woods and against the fierce wind buffeting the open fields. When it was time to return to the city I was glad, not just because of the chance to thaw out, but because oncologists cannot help but feel sorrow when they discover how much the current season reminds them of the life of the cancer patient. Was there ever a time when winter did not produce such thoughts?

Come - take my hand and let us walk together while the falling light rolls our shadows ever longer.

Notice the skeletal fingers of the trees stretching upward, as if they could regain their lost luster if only they could reach the sun. How barren the forest seems now. One can look between the ribs of the dark trunks and see deep into the valley below. No wind, no creature disturbs the corpses of the leaves lying there. They rest in silent indignation, powerless to halt their slow transformation into earth.

The invisible, uncontrollable wind ices our faces as we crest a hill. Stay in it long enough and it will squeeze the life out of one’s limbs, as if beaten by clubs. It climbs on our backs; it sends shocks of pain through us that eventually drain the enthusiasm out of even the bravest. The look of desperation was never so intense as that on one freezing from the cold.

Our footsteps stumble on the cruel ruts left behind from forgotten summer rains. The ground hammers against ankles and knees, sends us careening off the trail, then at the next turn becomes mud. We slip downhill and hang precariously onto a sapling, our boots dangling from a ledge over a stony creek. It takes all of our strength to climb back up to the point where we can stand.

Finally, just as our journey reaches a pleasant equilibrium between labor and comfort, night falls in the middle of the afternoon, leaving us stranded on a distant hillside. The forest begins to envelope us as our vision dims. Perhaps we will wander on blindly until we find the bank of the river which leads us home. We must be prepared, however, to accept the coming night. With the power that comes only from within can we find the courage to rest peacefully against a fallen tree, our eyes turned upward toward the darkness as we await the first caress of snowflakes we cannot see.

Which is the sound of the land
Full of the same wind
That is blowing in the same bare place

For the listener, who listens in the snow,
And, nothing himself, beholds
Nothing that is not there and the nothing that is.

If I could give one blessing on this day of family and love it would be this:

To all those who awakened today under the cloud of cancer, whether as a patient fighting hard, or as a family member, or as a diligent caregiver, or a nurse, doctor, neighbor, friend from church or even just one who read a touching story in the newspaper - may you be strengthened and uplifted by the massive power that resides within the hearts of all those around you who love. They have given so much, yet each sacrifice made, each act of kindness is but a mere grain of sand removed from the boundless water’s edge. The supply of mercy stored within us is as vast as the ocean’s horizon, and like the horizon, its end can never be reached.

The author wishes to announce the first of an occasional series dedicated to revealing the secret culture of the intrepid men and women who have chosen medicine as their life’s calling, not to mention a way to pay for the kids’ orthodontia. We kick off this series with a heretofore undescribed look at one of the most sacred of all medical rituals, a ceremony practiced by doctors young and old, from every corner of the country, in every speciality where the well-being of the entire patient is of interest (which rules out dermatology, psychiatry and of course that branch of medicine where a live patient is not necessary for one to whistle while one works). We refer to what is colloquially known as passing the baton, or blowing out of here, also known as signing out. It is during this act that the crucial details of a patient’s case are outlined to the doctor assuming care for the next tour of duty. At first glance this would appear to be one of the most lethargic discussions ever chronicled, capable of dropping anyone who dares to listen in faster than a well-placed dart from a tranquilizer gun.

That, dear reader, is where we are wrong, for a signout session is full of high drama and intrigue. It’s just that the casual listener is unable to decipher the abstruse jargon and sarcastic innuendo that goes on during the verbal jousting between the departing doctor and his traditionally unhappy replacement. Picture this scene taking place in some pizza-box laden corner of a nurses’ lounge. On our left we see a giddy sleep-deprived resident who can hardly wait to read the last name written on his grimy piece of paper so he can then jump into a battered 1988 Camry and make a beeline for the upper bunk. Over on our right we find a beleaguered soul staring blankly into space as he writes. This person, obviously the on-call doctor, is easy to identify by his unwrinkled shirt and his poorly disguised look of agony, often seen in paratroopers who forget to attach their chute to the static line. What controversy could possibly exist in such a mundane activity?

After twenty years of being victimized by these charlatans I can answer this question easily, namely that doctors tend to view the signing out procedure like a lioness stalking a wounded kudu, and one can very well guess which is the predator and which is the entree in this little tete-a-tete. Let us therefore parse the signing out procedure for what it really is: a sales transaction where the seller (going off-duty) is eagerly trying to gain the upper hand by using every trick in the book on the buyer (coming on-duty). For any young doctors out there reading this, I provide this compilation of schemes to be aware of:

1. The Early Sign Out. On the day of the transfer would it be asking too much if you would at least wait until the sun has crested the skyline before hovering over the on-call physician with your sign-out list? During my residency we used to vamoose so early our patients started reading their own x-rays just to keep up to date. Upon hearing of our little chicanery the Chief quickly put an end to it in his typically graceful way.

2. The “Cast of Thousands.” C’mon now, do I have to see every single blue-haired granny admitted for some R & R from her loony husband? How long is this list anyway? Aren’t there some patients who can be followed by “telephone rounds,” which means if they don’t telephone you, you don’t know they exist?

3. Late Arrivals. There is nothing more depressing than to get a call from your colleague that starts as follows: “I just spoke with the E.R. at Pigeon Forge and they’re transferring this guy to you - he should arrive in about five hours.” Egad - there goes my plans for dinner and a movie.

4. Scut Work? No, Not That! Beware of the peer who casually asks you to check on the results of biopsies, cultures or other results that could bog down your entire weekend. Please, please tie up all loose ends of patient care before jetting off to Crapsville, leaving us poor on-call slobs up to our tongue depressors in work.

5. The Psych Alert. As a courtesy to the covering physician we (discreetly) ask that you notify us of any and all patients and family members who are off their rocker, or uttering voodoo curses, or seething with anger, or simply in a coma. Think of all those World War II movies where buddies look out for each other when on patrol. Do we deserve any less?

6. The Maiden Voyage of the Titanic. This is otherwise known as the impending disaster, where a patient isn’t doing so well, but gosh, it’s time to go home, so the departing physician reassures his covering partner with the gentlest breezes of euphemisms that this patient is tucked in for the night. One can imagine what happens in Act II as the on-call physician, just minutes ago burrowed under the sheets and drooling on his pillow, is now racing down the hallway toward that same Mrs. Jones, billed as “a mild case of bronchitis” at quitting time but now sitting bolt upright in bed, her eyes coming out of her head like the Bride of Frankenstein as she gasps for oxygen.

I could go on, just as I’m sure others can add to this list, but for now that is enough. When it comes to accepting the sign-out list from a colleague, my advice is the same as with any transaction where the phrase “slimy weasel” may surface in the aftermath: Caveat Emptor!

The cherubic face of the medical student before me showed a crease of anxiety as I patiently waited for him to answer my question. We were huddled in the doctor’s lounge staring down at a couple of plastic cafeteria trays loaded with delicacies from around the globe, ostensibly there to eat a hasty lunch and then skedaddle back to the office for more of that “duty and humanity” stuff. Those students who have come within earshot of my sonorous voice, however, know that I love to teach using the Socratic method, known in the olden days of medical school as “pimping the student.” I therefore had decided to use this intermezzo to quiz my apprentice. The question I had just asked, which I surmised was strangling every neuron in his brain as he wriggled into the same posture as that of Michaelangelo’s statue of Moses, was the following:

“Suppose every scanner and x-ray machine in town breaks, and you need to find out if the cancer treatment you have given your patient is working. What is the most important piece of information you can obtain in order to make an accurate conclusion?”

Remembering that college kids don’t get into medical school without a quiver full of cleverness, I wasn’t surprised by his answering my question with a question. He asked, “Can I interview and examine the patient?”

“No,” I said. “You don’t have to because you’ll know the answer before you even walk into the exam room.”

“What about lab tests?”

“Not necessary. Here’s a clue - think about what it means when you have cancer and it begins to die. How does your life change?”

His eyes began to petrify which I suspect would have caused the casual observer to remark vigorously “how much that young man over there reminds me of Degas’ absinthe drinker.” I found the resemblance uncanny to say the least and decided I had better either take the bottle away from him or give him the answer, when suddenly he brightened.

“Your life changes for the better - which means….” He was so close to the truth yet still it eluded him as if he was trying to catch minnows with his hands. As I revealed the solution to the puzzle he cried out “Of course!”, startling an elderly physician sitting next to him who reminded the whole room of that certain dinner painting by Caravaggio. We both laughed and made our way past the crowded tables back to the office.

If you think you have an answer to this puzzler feel free to leave it in the comment section. The Cheerful Oncologist will provide his own answer shortly, as soon as he can remember it…

UPDATE: I botched the name of the artist of “L’Absinthe” - it was Edgar Degas (since corrected)…to Maria from intueri: No, the patient didn’t code!… to Ali: of course he’s in the room - what do you think this is, a Twilight Zone episode? HINT: The patient hadn’t been seen for a month…the information I needed was already in the chart as I entered the room.

AND NOW THE ANSWER: kudos to Barbara C, who correctly guessed that I had glanced at the patient’s weight before opening the door. The comment by Dreamer is not inaccurate - patients do lose weight on chemotherapy, especially patients with incurable cancer who can shed a tremendous amount in an impossibly short time. Where I come from this is called dying, which makes it all the more rewarding to see a patient start to put on the pounds again. Why all of a sudden do they gain weight?

Because they’re going into remission. Yep, after years of observing this phenomenom I am ready to reveal it to the world, and as my old professor would say after listening to this brilliant deduction:

“Thanks for stating the obvious, Craig.”

I had just popped out of an exam room, bursting with the fierce energy that radiates from mind and body when working in perfect harmony (also known as having a good day at the office) when I caught my nurse placing a chart quietly on my desk. She backed out of the room like gentle Rosencrantz and Guildenstern taking their leave from the evil Claudius. Not considering myself as particularly wicked, I wondered what gave rise to her timidity. I glanced down. The chart, which bore the name of a beloved patient of ours had the word “Expired” and today’s date written across the front.

Somewhere deep inside me I heard the sound of a tree falling. Its crash shook me as I stood there, leaving me more exposed to the fury of the skies. I placed the chart on the top of a pile of tan folders and went on to my next appointment.

Later that day I experienced a flashback: I recalled attending a dinner party during my fellowship given by a retired Tennessee family practictioner. He had enjoyed a long and prosperous career and fascinated the table that evening with tales of medicine “back in the day”, when he would deliver country babies at night by the light of his car’s headlamps since many families had no electricity. He told us that on the day of his retirement he received a citation from the town signed not only by his long-time patients but by his patient’s children and their children, all of whom had grown up under his gentle care. He had ministered to some folks for nearly fifty years.

Fifty years! What a contrast to the career of medical oncologists. Unlike family doctors who get to watch many of their healthy patients grow to be old and healthy, oncologists seem to be constantly running a crisis center. We scramble throughout the day putting out the fires of suffering, taking calls from emergency rooms holding more patients in search of relief, monitoring a dozen situations in our treatment rooms, always bracing for the next catastrophe. While we toil the silent killer inside our patients rages against the deadly molecules assaulting it. Both patient and cancer struggle to survive the assassin’s strike.

Then after a period of time, it is over. The day comes when most of our patients, to put it bluntly, really don’t need us anymore for they are either in remission or dead. Even those incurable cancers that we are trying to turn into a chronic, livable disease, that require months and months of intense care, will someday take the lives of our patients. Even those who have been cured of their disease and must be followed for long-term complications will eventually return to their primary care physicians, reveling in the thought that they are finally free from our scrutiny.

Can we blame them? Wouldn’t we be thrilled to forget our anniversary date of being diagnosed with cancer, it had been so long in the past? I’m sure many patients when asked who their oncologist was would love to reply with a smile “You know, I can’t remember his name.” Rather than complain, oncologists should consider this their highest honor.

Please forgive us though if we stand at the window of our office and watch new mothers carrying in their babies, or elderly couples helping each other down the entrance ramp, and sigh with the thought of that day when we will no longer be needed. Don’t think that we are discouraged - if nothing else, oncologists understand the nature of our profession. We realize that after decades of service, the only citation coming to us is the one that hangs in our memory and in the memories of all those lives we tried to help during a time of anguish. Why does this please us? Because we know that if we remain true to our calling only two words need be written on this commendation:

“Well done.”

[Gentle reader, nota bene this post has footnotes. Grazia! -Ed.]

The big hand was on the four I think, and the little one in-between the one and two when I finally snapped and unleashed a parabola of curses at the four walls of my office. Despite my colorful, inventive phrasing the walls laughed not. I sighed and swiveled to the left, knocking my bottle of water onto the formerly dry carpet. It was one of those days, one of those disgusting mid-week days when nothing seems to go right and the sun either sets so fast one has to walk mournfully through a darkened parking lot at five o’clock in the afternoon, or it sets so slow the day seems to drag on forever, as phone messages and undictated charts pile up on the desk like hay. With an air of frustration I began to ruminate, then like opening a bottle of forbidden perfume I submitted to the ultimate seduction of the self-centered loser. I threw myself the proverbial pity party.

Yes, I confess that I sat there and reviewed all the unfortunate events that had occured that day, letting the lava of self-righteous anger flow out of me, burning everything in its path. My list of complaints were as follows:

I had to get up early to go to Tumor Board, and I was tired. (1)

I nicked myself shaving this morning. (2)

I stubbed my toe getting out of the shower, then almost tripped going downstairs to the kitchen. (3)

My trousers seemed rather snug around the waist - most likely a reflection of the incompetence of my cleaners. (4)

We were all out of cranberry juice and I had to drink orange juice with my oatmeal. (5)

The Wall Street Journal wasn’t delivered, so I had only the local paper to read. (6)

Traffic was ridiculously slow on the highway - all this stop-and-go nonsense, which made it hard to relax. (7)

I seem to be somewhat constipated after last night’s meatloaf dinner. (8)

Dozens, if not a myriad of ill patients awaited me in my clinic - each requesting giant hunks of my precious time. (9)

After a good stewing about I found my thoughts drifting randomly to other topics, and realized that my rant was over. I can’t say that I felt any better after cataloging my bad luck - as a matter of fact I developed an unpleasant, queasy feeling, as if I had cheated on an examination, or kicked the dog. I couldn’t exactly identify the origin of this angst, but figured it would come to me soon enough - like at bedtime, which is a fine time to hold up the mirror and examine the person staring back. This might cost a little sleep, but they say it’s worth it to take a good look at oneself every now and then. One just might find a hidden room, long ignored, bulging from within, with a golden sign on the doorway. Read it out loud and then drift off to sleep in peace, for the sign says “Blessings.”

(1) Of course I’m not complaining. Even if I faked a disability it takes so long to get benefits these days one could die before getting the first check.

(4) Yeah, I know I’m getting a spare tire, but can you imagine how awful I would look if I lost 50 pounds, not to mention what would I do with my snappy wardrobe?

(9) Ain’t it great? I’m still needed in this world! I’m still somebody important, with something to contribute! You like me - you really like me!

After seeing a string of frail, exhausted patients I looked forward to my next appointment, which was with a man who had received radiation therapy for an early stage seminoma several years ago. He now was approaching his 30th birthday and I intended to use the occasion to congratulate him not only on his cure but on his exceptional overall health.

He sat across from me and stared at the wall as I recited a list of superlative results. His blood pressure, weight, cholesterol, lab tests and x-rays were all as pristine as a Marine Corps sergeant’s. By the time I finished my praise, though I detected a sullen look crossing his face.

“You don’t seem very happy with this good news,” I replied. “Is something bothering you?”

He crossed his arms and looked right at me. “What makes you think I want to be healthy? I could care less about that - in fact, I completely ignore everything they say you’re supposed to do to stay healthy.”

I tried not to look surprised as I prepared to answer him. This attitude in cancer survivors has been well documented. Psychological distress leading to depression and anxiety has been called “the legacy of cancer“, and usually does not lead to impairment. I questioned him further.

“What could you be doing that is unhealthy? Your physical exam results are super.”

He let a smile flicker for an instant. “Too bad for me. Listen, I don’t want to live to be old. I saw what happened to my father, who’s now dead. I see my mother going downhill fast - I am not going to let this happen to me.”

“So you’re not watching your diet like we’re all supposed to?”

“Not a chance - I eat junk food constantly.”

“Do you ever exercise? Do you wear seat belts? Drink alcohol?”

“Doc, I live for now. I mean, I’m working and all that, but I’m also partying. I’m not hanging around long enough to end up in a nursing home, lying in my own urine.”

Well, there is something to be said for avoiding that. I tried to reason with him, using the approach that he since had been cured of cancer he owed it to himself to take care of his body now. This had about as much effect on him as if I had been speaking Farsi.

I expressed my concern over his bad habits, but also told him that unless we doctors stand out in our patients’ driveways with picket signs we can’t control what they do in their own homes. Despite his neglect, he was in good shape, with a better LDL cholesterol level than mine, and no family history of premature coronary artery disease. As we shook hands and headed out to the desk I could not resist the following retort:

“You’d better buy some long-term health insurance anyway - I think you’re going to live to be an old man.”

He stopped and turned. “How do you know that?”

Now it was my turn to smile. “Well, assuming you’ve inherited your parent’s excellent genes, I can think of only one way to guarantee yourself an early death - and you aren’t doing it.”

“What is it, Doc?”

Like the Sphinx of antiquity, I left him standing there staring at my mysterious, leonine face. He’ll figure out what vice I’m referring to soon enough, and hopefully he’ll understand how wonderful it is that he has avoided it.

All day our sails stood to the winds, and made
Our voyage prosp’rous. Sun then set, and shade
All ways obscuring, on the bounds we fell
Of deep Oceanus, where people dwell
Whom a perpetual cloud obscures outright,
To whom the cheerful sun lends never light…

-The Odyssey [translation, George Chapman (1559-1634)]

Hallowe’en has come and gone, and once again it was difficult to avoid being haunted by ghosts. After the last of the trick-or-treaters had floated up to the doorbell, after the dog had eaten most of the jack-o’lantern’s face, after the lights were finally turned out and I was huddled in a cozy chair looking forward to a final hour of quiet reading before bed, I felt an eerie presence hovering over me. It was not a traditional ghost - a disgruntled relative, or one of those made-for-television auras - that caused me to close my book and tremble as if the proverbial Raven had just flown into the room with a Dear John letter from the other side.

It was memory itself that sent shivers in all directions - the memory of patients who once stood before me and are now gone.

…There cluster’d then
Youths, and their wives, much-suffering aged men,
Soft tender virgins that but new came there
By timeless death, and green their sorrows were.

Like Odysseus, who was shocked upon seeing the shades of his old comrades, of his enemies, even of his own mother, I cannot help but remember the many who came to me suffering from the plague of cancer and whose life-thread was snipped far too early by the Fates. On this dark evening of haunting, when the wind seems alive with shadows and shrieks of laughter pierce the neighborhood, my former patients approach this chair softly, full of dignity and sorrow. They stand before me and pronounce their fate:

“I who died so quickly I could not wait for my treatment…”

“I who withered like some alien being throughout my illness, never able to turn back toward vigor, or serenity…”

“I who seemed to improve, then suddenly tumbled over like a cornstalk buffeted by the winter wind…”

“I who went into complete remission and, having survived the ordeal of Charbydis turned to sail home, only to die in the jaws of the Scylla of relapse…”

No words can lift these empty hearts, and it is useless to try, just as Odysseus discovered when praised the dead Achilles on his “renewed life of command beneath” the earth. Achilles’ reply was:

“Urge not my death to me, nor rub that wound,
I rather wish to live in earth a swain,
Or serve a swain for hire, that scare can gain
Bread to sustain him, than, that life once gone,
Of all the dead sway the imperial throne.”

The hour is late now. No noise is heard from the dim streets. The distant ticking of a clock see-saws through the sleepy house. The time for reading has now passed. With some effort I arise and head upstairs to bed, but before ascending the stair I turn and face the ghosts of Hallowe’en.

“Do not be offended by my presence. Do not smile as if you possess some great secret - I also know that someday we will all be together, but until the tolling of that bell is heard, my obligation is to the living. Now go.”