Recently, some residents asked me why I had chosen my medical specialty.
“Why oncology?”
Why indeed…
The truth about life is that so often it is a chance encounter, an uncertain leap that takes us into the careers we “choose.” My own story of how I came to become a hematologist-oncologist is full of the randomness of my own life.
That’s not what they were asking. They were asking why anyone would choose hematology-oncology—or heme/onc, in medical parlance—given what they know. Their experience of cancer is colored by the inpatient oncology service. Too often, they take care of people near the end of life. Disproportionately, people who haven’t had good conversations with their doctor, people who may have unrealistic ideas about what’s possible, or people suffering from the unpredictable, unrelenting misery of cancer. In other words, they see the hard cases. Naturally, then, they puzzle over why someone would choose to do it full time.
So I told them what they don’t see.
When I was a young faculty member, a young lady walked into our office. She said she had Hodgkin’s lymphoma and had received some, but not complete, treatment. After starting treatment back home, she had gotten in her car with her three kids and driven a few thousand miles to set up a new life. She said it was best we didn’t contact the other facility for records. She said she knew how important the treatment was for her life. She said she wanted to live, and wanted to resume treatment. She was soft-spoken, clear and sincere, and I knew immediately she was running from something.
When it comes to Hodgkin’s lymphoma, treatment matters. History books report that prior to chemo and radiotherapy, the disease was a universal death sentence for young adults. Now, we have cure rates in the high 90-percent range thanks to ABVD chemotherapy, a combination of four drugs.
But the timing of chemotherapy matters; giving it correctly matters. You need to know what to do if the patient presents on cycle 2 day 15 with profound neutropenia, and what not to do. The right answer is: don’t stop treating.
She was a sweet and kind woman, and she was part way through a curative treatment, and it was really important that we complete it without any deviation from the schedule or plan. She didn’t have insurance, didn’t have a place to stay, had a car, three children, and a disease that could take her life.
Even though I was young, my views of the healthcare system had already cemented. I knew the system was corrupt and often an obstacle to good care. I knew it’s the doctor’s job to deliver the best care to the patient, and that the wishes of the hospital, the university, the insurance company, and the drug company don’t matter.
Any obstacle to the best outcome for my patient is an obstacle that I’m unable to accept. I had practiced, and keep practicing to this day, all the techniques to manipulate the system for the best interests of my patient. I am willing to do anything, including: playing nice, kissing up, escalating the situation, putting pressure on the system, public shaming of the organization, and advocating for my patient relentlessly. I was skilled at documenting in the way necessary to facilitate good care. I was practiced in defeating useless hospital bureaucrats, and incompetent insurance reviewers to get the right treatment for my patient.
That’s what we did for her. We bent all the rules, and we found a way to deliver good care. Per her wishes, we negotiated a way to learn enough about her past care to resume it correctly, but not enough to leave a paper trail. We helped her find a place to stay, and a way to fund her expenses. We found ways to get the treatment paid for. We helped her find someone to watch her kids when she was getting chemotherapy, and when she was recovering. My nurse and I—we were her team, unfailingly loyal, and we let her know it.
Slowly but surely, with complications along the way, we got her through the treatment, and helped her get back on her feet. Interim scans were reassuring, and we started to have the hope that she would make it.
Slowly but surely, as she got to know us, her life story filled out. She had married young, had kids early, but found she was in a bad relationship. She had been the victim of domestic violence—violence paired with cancer and chemo—and one day, when she feared she wouldn’t survive, she got in her car with her kids and drove.
Every time I saw her in the office, she smiled at me. I can still close my eyes and picture her face perfectly. She must have thanked us 100 times for our help. Despite all she had endured, she was a joyous person.
She finished her treatment. Her scans showed complete response. She gave me and my nurse a warm hug. She thanked us for all that we had done for her. She wasn’t going to be staying in the area. She had a new plan, and a new life ahead of her.
I know you want to know: And yes, she’s still alive out there. She’s doing well. So are her kids.
So why oncology? It’s hard to know why we go into whatever we do, but these are the stories they don’t see on the cancer wards. There aren’t many jobs where you can make a difference in someone’s life. Where you have to be on point with treatment, you have to know the data, but you must be willing to do whatever it takes. You save one life, you save the world? I don’t know, but I can promise you, on the hard days, I can think of her, and it sure feels that way.
A version of this story originally appeared in Sensible Medicine.
My family was always a bit of an anomaly in the backwoods of West Virginia; as the last grandchild of the clan, I had a half-dozen much older cousins who were doctors - a radiologist, a heart surgeon, a - literally - brain surgeon, even a dentist or two - but the greatest influence was Doctor Paul A, the local general practitioner, as they were called in those days.
He'd been trained in the late 'thirties, when coal-miner was the highest aspiration of anyone he knew. His family was so poor that in medical school he hitchhiked from Richmond, Virginia across the Appalachian Front and back every two weeks, bringing his laundry home for his mother - my dad's sister - to wash the required white shirt and tie, since he didn't have the money for laundry. He was the kindest, gentlest, most dignified man I ever met - and a giant. I remember how odd it was to watch him write a prescription; the pen just disappeared in his giant paw. (Thank God he didn't go into gynecology!) He told me that when he visited home, his mother always had a few dollars for him; he always wondered how she scraped it together. (I knew; her brother - my father - made bootleg whiskey and she sold it. Their other brother, the constable, kept down competition. Paul died without knowing the answer to his question, and I never told him. That's how it's done among mountain people.)
My best memory of him was when he described getting this new drug - penicillin - to try. In those days, nothing was resistant to penicillin, and after treating several cases of pneumonia - so universally lethal to old people that in those days it was called, "the old man's friend," he became famous as a "pneumonia doctor" and spent the next few years shuttling all across the coal fields treating that dread disease.
He had an abiding respect for cancer, though. He related that, after the unparalleled success of antibiotics, the doctors were told that "cancer would be cured in the next ten years." That was over seventy-five years ago. Now, with CRISPR and genetic sequencing available, that may finally just be true. Let's hope.
God bless you, Dr. Prasad, and all the good doctors out there fighting the uphill battle against our depressingly corrupt healthcare system.