At various stages of our lives, most of us experience situations or events that help us to mature and may lead to decisions that affect our futures. Two such events in my life forged my career choice as a communitybased oncologist. The first was my family’s circumstances at the beginning of my life, and the second was the end of my father’s life.
Like many others my age from Vietnam, the conditions of my homeland forced me to experience life-changing events when I was very young. Yes, I am one of those who were labeled “The Boat People,” a product of a war-torn country. My family escaped from the oppression of the Vietnamese communist regime and sought refuge on a small Indonesian island with the hope of reaching our destination in America after our fourth and final attempt. During our refuge in Indonesia, we had almost nothing, not even a full stomach before going to bed. The only thing that kept us going was our hearts full of hope, which were continually challenged by the shortage of food, shelter, and medical care. A small medical facility staffed by a single physician was unable to keep up with the increasing demand for health care. Friends and strangers alike were stricken with various diseases that ended their journey there. Our parents kept us going with their inspired words and prayers and constant hope of a better tomorrow.
This painful experience gave me a direction early in life. Although I was only 4 years old, I developed a deep respect for the physician who cared for the refugees on that small Indonesian island, especially for helping my mother narrowly escape the plague of malaria. It nourished within me the hope that one day I would be granted the privilege to step into his shoes.
My aspiration to become an oncologist budded during my father’s struggle against nasopharyngeal cancer. As the youngest in a family of 5 children while all my siblings were either away at college or living far away, I inherited the task of accompanying my father on his physician visits. I distinctly remember being overwhelmed by his diagnoses and treatment plan and other physician consultations. The one common thread was that we could always rely on his community oncologist to coordinate his care with a patient-centered approach.
Despite treatment, his health steadily declined. I felt helpless as I watched my father’s health spiral downward. I was torn between honoring my father’s wish to stop treatment and continuing with therapy that might offer a hope of remission. It was so difficult to convince my father to continue treatment when he already knew that at his stage of disease treatment was futile. He was ready to accept his fate before I was. I’d always trusted my father’s judgment, since he was not one to give up without a fight. He had a well-honed will to live despite life-threatening conditions. He had served 22 years of active military duty in a swift boat patrol unit. For this, his name was placed on the “wanted” list of the Vietnamese communist government.
My father succumbed to his illness on Easter Sunday. He struggled to attend the prayer service that morning against the advice of my mother. Even in his last remaining hours, he consoled us with his last breath, “Be strong. Don’t cry. I will be in a far better place than I am now.” The only comfort we had through that ordeal was that we had that same oncologist guiding his care from the beginning to the end.
During my first year of hematology/oncology fellowship, I was strongly considering academic medicine as a career choice. The 3 things I enjoy most in medicine are patient care, teaching residents and students, and participating in clinical trials to advance the field of oncology. Of all 3, I’ve realized that the most rewarding to me is taking care of my patients and guiding them throughout their illness.
During my first year of fellowship, I slowly realized that some circumstances in academic oncology interrupt that continuity of care and long-term patient-oncologist relationships. In the in-patient service, the faculty can change frequently and there may not be consistent care, which could delay certain planned procedures, therapy, and discharge planning. The patients in the hospital hardly see their treating oncologist; the bond and level of trust with the covering physician is nonexistent. With the lack of an ongoing patient-physician relationship, I believe there is less accountability as well, which can make patient advocacy inherently more difficult. The patients themselves feel lost in the “system.” For instance, when a patient needs a procedure completed, a port placed, or a diagnostic colonoscopy, these could be delayed due to a scheduling issue.
Physician consultation referrals can also be very difficult. The resident or fellow on the other services sometimes begrudgingly accepts the consult, which can create a lot of tension in a short period of communication. In our hospital system, certain oncology patients have an automatic consult by the palliative care team, or are referred for a consult by another service admitting them. Unfortunately, in some cases, this has resulted in the palliative care service making recommendations without consulting the patient’s oncologist. In some cases, “system” has made the oncologist a bystander while these decisions are being made, minimizing our role as a patient advocate.