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"Don't quit." These are words of wisdom passed down from one oncologist to one in training. Two months into my fellowship, I had the opportunity to listen to Dr Siddhartha Mukherjee speak at my home institution.
“Don’t quit.” These are words of wisdom passed down from one oncologist to one in training. Two months into my fellowship, I had the opportunity to listen to Dr Siddhartha Mukherjee, Pulitzer Prize—winning author of “The Emperor of All Maladies,” speak at my home institution. This was his simple answer to a very complex question: I had asked him what advice he had for a first-year fellow. The message behind that simple statement speaks volumes abut how difficult and taxing an oncology fellowship can be. It is amazing that after 4 years of medical school, 3 years of internal medicine residency, and countless interviews that quitting would even be an option. We work so hard to become a fellow, to become an oncologist, but when we get there, sometimes we wonder what we got ourselves into.
As an internal medicine resident, you essentially have an idea of what your day will entail when you wake up. You arrive for work, see your patients, go to morning report, round, attend conference, rinse, wash, and repeat. There are days when things are different; a transfer to the intensive care unit, a difficult family talk is all par for the course. Things change when you become an oncology fellow, though. It is difficult to label them as good or bad, but perhaps it’s best summarized that the unexpected is now a routine. The average day as an oncology fellow is best described as riding a rollercoaster in the dark, without sound. There is no clicking in anticipation of the big fall, no ledge in front of you to warn of the impending drop lurking ahead.
As the consult fellow, when the pager goes off, anything can be waiting at the other end of the phone. If it’s a benign hematologic issue, a thrombocytopenic patient is intellectually stimulating and patients rarely fear seeing the hematologist. However, when the oncologist comes into the room, the intensity and attention are heightened. Patients truly listen to every word, hanging on what is being said. You don’t notice this on day 1, nor does it take until the end of your fellowship; but at some point it clicks in your head. This is the worst day of this patient’s life, and I am playing an integral role in it. Cancer is now a stigma that they carry, a survivor is something they long to become.
Words that had different meanings to patients become routine; cycles, palliation, neutropenia are all terms that oncology patients understand but were likely foreign to them prior to their diagnosis. We introduce this metamorphosis to them, changing their vocabulary and views on their mortality. We are there for the worst day of their life, more times than not. It is difficult, it is draining, and it can become very emotional. Remember to lend a shoulder to cry on, a hand to touch, and silence to let them absorb the news. Our patients are human, and we are strangers entering their lives, seeing them at their height of emotional vulnerability. Show them that you are human and that you care. Unless we have been through the diagnosis ourselves, we can never truly understand, only empathize. There will be days when you will sit in your car for an extra moment, or sink further into the couch than normal. A long stare at a PET scan will not change that progression, will not make the tumor marker go down. Silently asking yourself why you are doing this is normal (I hope!) and something that we all experience. It lets you know that you are human, that bad days for you are not nearly as bad as they are for the patients who are receiving that news.
The other side of that coin is why we are able to continue with this job and don’t flee to a specialty with less stress or leave medicine altogether. The good news, the post chemotherapy visit with a patient can be amaz - ing. We all love to show a clean PET scan, or a neg ative tumor marker. I have observed my attending physicians and notice myself linger in the room with these patients, soaking it in. We walk with a spring in our step into their room, excited to deliver that good news. Tears flow, smiles break out, and what follows is rarely a hard discussion. We all exhale, and breat he easier, whether we notice it or not. The follow-up patients who are no long er receiving chemotherapy are terribly nervous when coming to the cancer center. Oncology center emesis has been described prior to our modern-day anti-emetics; stress-induced hypertension is now routinely seen as patients fear the devil they know making a return with a vengeance. Oncologists rarely speak of their failures, of the early stage patient in which things went terribly. We instead remember the exceptions, the miracles, and the patients that prove the textbooks and us wrong.
As oncologists, we have to be optimistic, as our treatments are not 100% effective for all patients. That is why our ultimate goal while training should be to further the field, to make advances in treatment options and therapeutic decisions. The National Comprehensive Cancer Network (NCCN) states that the best treatment for a patient is a clinical trial, and that is something we should all think about for every patient we evaluate. Clinical trials offer advancements in the field and are the reason why we have the therapeutic choices available today. Without oncologists screening appropriately and patients choosing the unknown for their future, the field will become stagnant. It is our responsibility as fellows to start thinking this way early in our careers so not only will our patients have better outcomes, but also the oncology fellows that we will someday train will have more options and better choices than we do today.
This is an essay written at the end of the first year of an oncology fellowship that was filled with ward months seeing leukemia, lymphoma, solid malignancies, and multiple hematologic abnormalities. In the future, I may look back at this essay and see myself as naïve, truly optimistic, and not yet weathered and jaded from years of success and failure. What I have learned can be summarized here, as many of us do while looking at consults or book s, by skipping to the end. Remember: don’t quit! There are good days and bad days for us, but no matter how high the high or low the low, the patient is the one with the disease. Screen and enroll patients in clinical trials, as research brought us the treatment choices we have today. Dr Michael Craig, one of my mentors in fellowship, left a note near the fellows’ microscope. I have stared at acute leukemia through those eyepieces, and made therapeutic decisions and diagnoses that changed people’s lives. The note encompasses what we do, what we represent as oncologists. It reads: “Cancer sucks. What can you do? Call me with questions.”
Brendan Curley, DO, MPH is a hematology/oncology fellow at the West Virginia University School of Medicine, Mary Babb Randolph Cancer Center, Morgantown, WV.