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“Why Me?”, a Question of Opportunity

But Where is My Doctor? The Increasing and Relentless Fragmentation of Oncology Care

Afternoons in the Tower of Babel: Miscommunication in the ICU

Listen to ASCO’s Journal of Clinical Oncology essay, “Market, Gift, Everyday Ethics, and Emmanuel Levinas in Patient Care” by Alan Astrow, Chief of the Hematology and Medical Oncology division at the New York Presbyterian Brooklyn Methodist Hospital.  TRANSCRIPT  Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, Associate Editor for Art of Oncology and a Professor of Medicine at Stanford University. Today we are joined by Dr. Alan Astrow, Chief of the Hematology and Medical Oncology division at the New York Presbyterian Brooklyn Methodist Hospital. In this episode, we will be discussing his Art of Oncology article, "Market, Gift, Everyday Ethics, and the Emmanuel Levinas in Patient Care."  At the time of this recording, our guest has no disclosures.  Alan, welcome to our podcast, and thank you for joining us.   Dr. Alan Astrow: Thank you for inviting me.  Dr. Lidia Schapira: Your article has a very long title, and we've got Markets and Gifts and Ethics and a philosopher. So let's start by helping our listeners and maybe our readers to really understand the intention of this essay. What is the message of the essay?  Dr. Alan Astrow: The message of the essay is that we need to be reflecting and be mindful of the values that underlie medical care as we practice every day.   Dr. Lidia Schapira: And if I were to quiz you a little bit on that and push a little bit, what are those values? And how does perhaps market conflict with ethics and mission?  Dr. Alan Astrow: Trust, caring, honesty, thoroughness, dedication to the patient, focus on the patient and the patient's needs. The problem with market or the danger of market is that it can sometimes distract us from focusing on the patient and that patient's needs.  Dr. Lidia Schapira: So how would you respond to somebody who says, but we need organization, we need markets and finances in order to have a system that provides health care? Where do you see the front of conflict, perhaps between those who are more mission-driven, as you've just beautifully articulated and have the trust in the patient's care front and center, and those who are more concerned with the productiveness and efficiency in collections?  Dr. Alan Astrow: I have tremendous respect for my administrative colleagues who are focused on keeping hospitals solvent. I worked at a hospital earlier in my career that was not focused as it needed to be on making sure the hospital had a sound strategic plan. And that hospital is now condominiums. So, absolutely, we need to be aware of financial realities and hospitals need to pay their bills. But underlying that, we can't think that the first mission of a hospital is to earn money. The first mission of a hospital is to provide service to those in need. And then our colleagues in administration have to help us find ways to do that in a manner that's financially responsible. But we think first of the patient and that patient's needs.  And patients understand that. Patients don't want the hospitals to go bankrupt, and patients want their doctors and nurses to be paid. Patients do worry sometimes, with good reason I think, that the system may be overly focused - that's the issue, it's an issue of balance - overly focused on markets, overly focused on finance. It seems as if we're living in a world in which money is driving everything. Money is speaking with too loud a voice. That's the issue. Money is important. But the needs of the patient and what our mission is to patients have to be the driving force of the hospital. That has to be the predominant voice, the loudest voice. Markets should be serving the patient and the patient's needs, not the other way around.  Dr. Lidia Schapira: I think I understand that clearly. But now let's talk about the gift that's in the title, and that, in my mind, was a very imaginative way of presenting what we bring that is not just a service. Talk a little bit about how you understand the gift of presence or the gift of caring.   Dr. Alan Astrow: The gift is when you're really lost in the task itself. When you're really focused on that patient in front of you and trying to understand the patient and trying to address the concerns that the patient has. And during those moments when you're focused on that patient, you're not thinking about money. No, you should not be. But the first predominant impulse needs to be what the underlying mission of that organization is. And in medicine, it's caring for the patient.  And so, for example, when we hear administrators saying we're going to reach out to this and that market, well, that to me shows a mistaken focus. We understand that the hospitals need to raise money from banks and other places in order to make needed capital investments. But we need to think first and foremost about the people in the communities we serve, and then the markets should be at the service of people and communities. I think in general, it's a larger issue. The power of money is speaking in too dominant, in a way, in too many aspects of our world. And medicine, above all, needs to resist that. And there's a manner in which healthcare institutions are functioning these days which I think leads patients to have reason to doubt. And so if they have doubts about what our primary interests are, they will lose trust. And the loss of trust is devastating to the medical relationship.  Dr. Lidia Schapira: Let me explore that a little bit with you, Alan. I would say that in my mind, providing that caring presence is part of the mission of medicine, but you talk about a dimension of gift. Help me and our listeners and readers understand a little bit more about the gift. You talk about the gift being something that's exchanged, that there's even a reciprocity in giving and receiving gifts. How are we to understand that perhaps through the lens of the philosophers and the big thinkers here?  Dr. Alan Astrow: I'm borrowing this from Lewis Hyde. He was referring to a traditional gift economy. And according to Hyde, who is taking this from cultural anthropologists, that in many tribal communities, tribal societies, just, for example, in the Native American cultures in our land that were not cash-based, they're based upon a notion of gift. You would provide a gift to the other without any expectation of payment, but there was a passive understanding that at some point that gift would be returned to you. And that's how these societies, according to cultural anthropologists of course, it's probably hard to pin this down, but that's the way Hyde has presented it. This was the base of the economy of gift-oriented cultures.   And he was surmising that there's always an element of gift he felt was particularly in the world of creative artists, because if the artist is just thinking about how he or she could make money, their work is not likely to be very good. The artist needs to focus first on the gift dimension to it, the part that comes to them really as a gift. Your talent is a gift, and you may be able to see that your talent as a physician is a gift. And so much of our skill really comes from the gifts that others have given us in a way.  Just think of our training. We think about how hard we worked and it's true and how many years we gave into our training. But isn't it also true that we learned from the illnesses of others? They shared their stories, they shared their experiences with us even when we didn't know that much and we didn't have that much to offer to them really. We were relatively unskilled. We developed our skills through treating people who presented themselves to us in a way hoping that we would help them, certainly. But their presence to us, since we were not well-trained at that point, was a bit of a gift. That's how I would see it.  And if you see it as a gift, perhaps it could help us in our orientation toward the service we need to provide to others, those moments when we might feel somewhat resentful. Well, maybe it's a good time to just remind ourselves a bit. Not that I don't feel resentful or exhausted or- I'm just like anyone else, but I can remind myself that yes, it's a gift to be a doctor or a nurse. I believe, I really believe that. In so many fields there's so much just about the finances and the bottom line, and that's not true about being a doctor or a nurse. That's not ultimately what it's about. And it's one of the great pleasures of being a doctor how we can help other people with our skills.  Dr. Lidia Schapira: When we hear the word "gift," unfortunately, our minds may go to things that we need to declare that could potentially be conflicts. But you're talking about gift in a totally different way. You're talking about giving the gift of our presence and recognizing the gifts that our patients give us by teaching us, by allowing us to learn from their experience through their experiences. And in your essay, you talk a little bit about appreciating this and have an impact on the culture of medicine. So, can you talk a little bit more about how this appreciation of gifts exchanged and time spent together and talents shared can impact favorably on the culture of medicine even perhaps, as you're hinting, improve our sense of wellness or reduce our risk of burnout?   Dr. Alan Astrow: When we think of our work as partly a gift we can give to others and a gift we have received from others, I believe it enhances our morale and the morale of whatever enterprise we are part of. If we all, I believe, are able to appreciate more of the dimension of gift in healthcare, it has the potential to have us see things differently, organize the way we care for patients and each other differently, and potentially transform our whole system of care. Because finally, it starts with one-to-one encounter, I believe. But the one-to-one encounter is influenced by the larger systems that shape what we're able to do. So, I think if we doctors and nurses are able to articulate a gift dimension to care, I think we can help our administrators see it that way.  Because I think my experience working with many in administration is that they have chosen to work in the field of healthcare because administration wants to see it that way, too. Many of our most talented administrators could be working in other fields - finance, law - they could be making more money in other areas. But they chose to enter healthcare because they do want to provide service to others. And it may be that many in administration, but many of those who are responsible for keeping hospitals financially solvent, are just as concerned as we doctors are by the overweening presence of financial concerns as they more and more dominate our day-to-day lives as physicians, nurses, and others in healthcare.   I don't want to sound like a Pollyanna here. We do have to be able to pay for things, no question about it, and there's no simple solution to any of these problems, and how should healthcare be paid for? Should we have single payer? These are complicated issues. But I think if we think about it, we should think about how we can organize our system of care so that we can further enhance the dimension of gift. That would be the point.    Dr. Lidia Schapira: Well, we really appreciate the depth of your reasoning. It certainly is appealing to me, and I hope that it resonates with many of our readers. You've made a very strong pitch here for humanizing and really putting mission front and forward in your incredibly erudite way.  So, Alan, how does Levinas enter our conversation? And how does Levinas enter the thinking that you had in putting these pieces together for the essay?  Dr. Alan Astrow: So Levinas is one of the great thinkers of the 20th century, and his core insight is that the reason we are here as human beings, in his view, is to bring the ethical order into being. So we're not here to earn the maximum amount of money. We're not here to face our own mortality. No, we have a specific purpose to bring the ethical order into being. And, as doctors and nurses engaged every day in actions that we're trying to help people, he would claim that we should be trying to bring the ethical order into being in healthcare in our day-to-day actions. He was very focused on the idea of face-to-face ethics, that it's in the experience of the other, seeing the face of the other, that you need to respond. We ought to respond to the needs of the other. At that moment, we're not thinking of ourselves at all. We're just responding to the needs of the other. And in that way, we are bringing the ethical order into being.   Dr. Lidia Schapira: So the dimension of gift giving is layered onto this ethical order. How do we put the two thoughts together?  Dr. Alan Astrow: When you give a gift, ideally, you're trying to think about the other. You're trying to think about what the other needs. The gift is not about you. It's about what's going to make the other happy. It's what's going to make the other feel acknowledged. That's what the nature of a gift is. And you're not really expecting anything back. In medicine, too, it's not about what the patient could do for us, it's only about what we can do for the patient and the patient's needs. So, it's a true gift of the doctor to the patient. And that's why the patient can feel trust in us because they sense that it's a gift of us to them. We are not expecting patients to do anything for us at that moment. We're not expecting them to be paying us, although we hope we'll get paid. We're not expecting them to enroll in a clinical trial, although we might eventually hope that they will. But at that moment, it's pure gift. That's where the trust comes from. The gift comes first, the others later.  Dr. Lidia Schapira: So one could argue, Alan, that that is just the ethical conduct of medicine, that there is no extra here, that there is no gift, that that is just how we should behave. So help me understand a little bit more then, about how you understand gift. From my experience, as I was taught by cultural anthropologists, gift can be a gift of time, gift can be a gift of presence. And it is those sorts of additional things that we convey through our actions or transmit through our presence. Reciprocally, we also are gifted by our patient's presence and by their gift of spending the time they have left with us. How do you understand gift?  Dr. Alan Astrow: Okay, so you're saying a gift is something extra that we add on. Okay, I can accept that. I wouldn't deny that. My point would be that, yes, a gift orientation is central to the ethical practice of medicine. Yes, it is the ethical practice of medicine. But what we're seeing in our current world is that that orientation is increasingly threatened. Isn't that what we're seeing? That doctors are selling practices to private equity? That we have more and more for-profit businesses in healthcare? And it seems in too many places, patients fear that the primary focus is not on the gift dimension, but the primary focus more and more seems to be on the mercantile aspect, the money aspect. So my point would be that, yes, we ought to know what the ethical practice of medicine is. But it's too easy to forget, isn't it? And don't we see that that's what's happening? People are forgetting. We all need to be reminded - who is going to remind us?   Dr. Lidia Schapira: Thank you, Alan, for your contribution.   And to our listeners, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcast.    The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.     Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Listen to ASCO’s Journal of Clinical Oncology essay, <a href="https://ascopubs.org/doi/full/10.1200/JCO.23.00419" rel="nofollow" target="_blank">“Market, Gift, Everyday Ethics, and Emmanuel Levinas in Patient Care”</a> by Alan Astrow, Chief of the Hematology and Medical Oncology division at the New York Presbyterian Brooklyn Methodist Hospital. TRANSCRIPT Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, Associate Editor for Art of Oncology and a Professor of Medicine at Stanford University. Today we are joined by Dr. Alan Astrow, Chief of the Hematology and Medical Oncology division at the New York Presbyterian Brooklyn Methodist Hospital. In this episode, we will be discussing his Art of Oncology article, "Market, Gift, Everyday Ethics, and the Emmanuel Levinas in Patient Care."  At the time of this recording, our guest has no disclosures.  Alan, welcome to our podcast, and thank you for joining us.  Dr. Alan Astrow: Thank you for inviting me. Dr. Lidia Schapira: Your article has a very long title, and we've got Markets and Gifts and Ethics and a philosopher. So let's start by helping our listeners and maybe our readers to really understand the intention of this essay. What is the message of the essay? Dr. Alan Astrow: The message of the essay is that we need to be reflecting and be mindful of the values that underlie medical care as we practice every day.  Dr. Lidia Schapira: And if I were to quiz you a little bit on that and push a little bit, what are those values? And how does perhaps market conflict with ethics and mission? Dr. Alan Astrow: Trust, caring, honesty, thoroughness, dedication to the patient, focus on the patient and the patient's needs. The problem with market or the danger of market is that it can sometimes distract us from focusing on the patient and that patient's needs. Dr. Lidia Schapira: So how would you respond to somebody who says, but we need organization, we need markets and finances in order to have a system that provides health care? Where do you see the front of conflict, perhaps between those who are more mission-driven, as you've just beautifully articulated and have the trust in the patient's care front and center, and those who are more concerned with the productiveness and efficiency in collections? Dr. Alan Astrow: I have tremendous respect for my administrative colleagues who are focused on keeping hospitals solvent. I worked at a hospital earlier in my career that was not focused as it needed to be on making sure the hospital had a sound strategic plan. And that hospital is now condominiums. So, absolutely, we need to be aware of financial realities and hospitals need to pay their bills. But underlying that, we can't think that the first mission of a hospital is to earn money. The first mission of a hospital is to provide service to those in need. And then our colleagues in administration have to help us find ways to do that in a manner that's financially responsible. But we think first of the patient and that patient's needs.  And patients understand that. Patients don't want the hospitals to go bankrupt, and patients want their doctors and nurses to be paid. Patients do worry sometimes, with good reason I think, that the system may be overly focused - that's the issue, it's an issue of balance - overly focused on markets, overly focused on finance. It seems as if we're living in a world in which money is driving everything. Money is speaking with too loud a voice. That's the issue. Money is important. But the needs of the patient and what our mission is to patients have to be the driving force of the hospital. That has to be the predominant voice, the loudest voice. Markets should be serving the patient and the patient's needs, not the other way around. Dr. Lidia Schapira: I think I understand that clearly. But now let's talk about the gift that's in the title, and that, in my mind, was a very imaginative way of presenting what we bring that is not just a service. Talk a little bit about how you understand the gift of presence or the gift of caring.  Dr. Alan Astrow: The gift is when you're really lost in the task itself. When you're really focused on that patient in front of you and trying to understand the patient and trying to address the concerns that the patient has. And during those moments when you're focused on that patient, you're not thinking about money. No, you should not be. But the first predominant impulse needs to be what the underlying mission of that organization is. And in medicine, it's caring for the patient.  And so, for example, when we hear administrators saying we're going to reach out to this and that market, well, that to me shows a mistaken focus. We understand that the hospitals need to raise money from banks and other places in order to make needed capital investments. But we need to think first and foremost about the people in the communities we serve, and then the markets should be at the service of people and communities. I think in general, it's a larger issue. The power of money is speaking in too dominant, in a way, in too many aspects of our world. And medicine, above all, needs to resist that. And there's a manner in which healthcare institutions are functioning these days which I think leads patients to have reason to doubt. And so if they have doubts about what our primary interests are, they will lose trust. And the loss of trust is devastating to the medical relationship. Dr. Lidia Schapira: Let me explore that a little bit with you, Alan. I would say that in my mind, providing that caring presence is part of the mission of medicine, but you talk about a dimension of gift. Help me and our listeners and readers understand a little bit more about the gift. You talk about the gift being something that's exchanged, that there's even a reciprocity in giving and receiving gifts. How are we to understand that perhaps through the lens of the philosophers and the big thinkers here? Dr. Alan Astrow: I'm borrowing this from Lewis Hyde. He was referring to a traditional gift economy. And according to Hyde, who is taking this from cultural anthropologists, that in many tribal communities, tribal societies, just, for example, in the Native American cultures in our land that were not cash-based, they're based upon a notion of gift. You would provide a gift to the other without any expectation of payment, but there was a passive understanding that at some point that gift would be returned to you. And that's how these societies, according to cultural anthropologists of course, it's probably hard to pin this down, but that's the way Hyde has presented it. This was the base of the economy of gift-oriented cultures.   And he was surmising that there's always an element of gift he felt was particularly in the world of creative artists, because if the artist is just thinking about how he or she could make money, their work is not likely to be very good. The artist needs to focus first on the gift dimension to it, the part that comes to them really as a gift. Your talent is a gift, and you may be able to see that your talent as a physician is a gift. And so much of our skill really comes from the gifts that others have given us in a way.  Just think of our training. We think about how hard we worked and it's true and how many years we gave into our training. But isn't it also true that we learned from the illnesses of others? They shared their stories, they shared their experiences with us even when we didn't know that much and we didn't have that much to offer to them really. We were relatively unskilled. We developed our skills through treating people who presented themselves to us in a way hoping that we would help them, certainly. But their presence to us, since we were not well-trained at that point, was a bit of a gift. That's how I would see it.  And if you see it as a gift, perhaps it could help us in our orientation toward the service we need to provide to others, those moments when we might feel somewhat resentful. Well, maybe it's a good time to just remind ourselves a bit. Not that I don't feel resentful or exhausted or- I'm just like anyone else, but I can remind myself that yes, it's a gift to be a doctor or a nurse. I believe, I really believe that. In so many fields there's so much just about the finances and the bottom line, and that's not true about being a doctor or a nurse. That's not ultimately what it's about. And it's one of the great pleasures of being a doctor how we can help other people with our skills. Dr. Lidia Schapira: When we hear the word "gift," unfortunately, our minds may go to things that we need to declare that could potentially be conflicts. But you're talking about gift in a totally different way. You're talking about giving the gift of our presence and recognizing the gifts that our patients give us by teaching us, by allowing us to learn from their experience through their experiences. And in your essay, you talk a little bit about appreciating this and have an impact on the culture of medicine. So, can you talk a little bit more about how this appreciation of gifts exchanged and time spent together and talents shared can impact favorably on the culture of medicine even perhaps, as you're hinting, improve our sense of wellness or reduce our risk of burnout?  Dr. Alan Astrow: When we think of our work as partly a gift we can give to others and a gift we have received from others, I believe it enhances our morale and the morale of whatever enterprise we are part of. If we all, I believe, are able to appreciate more of the dimension of gift in healthcare, it has the potential to have us see things differently, organize the way we care for patients and each other differently, and potentially transform our whole system of care. Because finally, it starts with one-to-one encounter, I believe. But the one-to-one encounter is influenced by the larger systems that shape what we're able to do. So, I think if we doctors and nurses are able to articulate a gift dimension to care, I think we can help our administrators see it that way.  Because I think my experience working with many in administration is that they have chosen to work in the field of healthcare because administration wants to see it that way, too. Many of our most talented administrators could be working in other fields - finance, law - they could be making more money in other areas. But they chose to enter healthcare because they do want to provide service to others. And it may be that many in administration, but many of those who are responsible for keeping hospitals financially solvent, are just as concerned as we doctors are by the overweening presence of financial concerns as they more and more dominate our day-to-day lives as physicians, nurses, and others in healthcare.   I don't want to sound like a Pollyanna here. We do have to be able to pay for things, no question about it, and there's no simple solution to any of these problems, and how should healthcare be paid for? Should we have single payer? These are complicated issues. But I think if we think about it, we should think about how we can organize our system of care so that we can further enhance the dimension of gift. That would be the point. Dr. Lidia Schapira: Well, we really appreciate the depth of your reasoning. It certainly is appealing to me, and I hope that it resonates with many of our readers. You've made a very strong pitch here for humanizing and really putting mission front and forward in your incredibly erudite way.  So, Alan, how does Levinas enter our conversation? And how does Levinas enter the thinking that you had in putting these pieces together for the essay? Dr. Alan Astrow: So Levinas is one of the great thinkers of the 20th century, and his core insight is that the reason we are here as human beings, in his view, is to bring the ethical order into being. So we're not here to earn the maximum amount of money. We're not here to face our own mortality. No, we have a specific purpose to bring the ethical order into being. And, as doctors and nurses engaged every day in actions that we're trying to help people, he would claim that we should be trying to bring the ethical order into being in healthcare in our day-to-day actions. He was very focused on the idea of face-to-face ethics, that it's in the experience of the other, seeing the face of the other, that you need to respond. We ought to respond to the needs of the other. At that moment, we're not thinking of ourselves at all. We're just responding to the needs of the other. And in that way, we are bringing the ethical order into being.  Dr. Lidia Schapira: So the dimension of gift giving is layered onto this ethical order. How do we put the two thoughts together? Dr. Alan Astrow: When you give a gift, ideally, you're trying to think about the other. You're trying to think about what the other needs. The gift is not about you. It's about what's going to make the other happy. It's what's going to make the other feel acknowledged. That's what the nature of a gift is. And you're not really expecting anything back. In medicine, too, it's not about what the patient could do for us, it's only about what we can do for the patient and the patient's needs. So, it's a true gift of the doctor to the patient. And that's why the patient can feel trust in us because they sense that it's a gift of us to them. We are not expecting patients to do anything for us at that moment. We're not expecting them to be paying us, although we hope we'll get paid. We're not expecting them to enroll in a clinical trial, although we might eventually hope that they will. But at that moment, it's pure gift. That's where the trust comes from. The gift comes first, the others later.  Dr. Lidia Schapira: So one could argue, Alan, that that is just the ethical conduct of medicine, that there is no extra here, that there is no gift, that that is just how we should behave. So help me understand a little bit more then, about how you understand gift. From my experience, as I was taught by cultural anthropologists, gift can be a gift of time, gift can be a gift of presence. And it is those sorts of additional things that we convey through our actions or transmit through our presence. Reciprocally, we also are gifted by our patient's presence and by their gift of spending the time they have left with us. How do you understand gift? Dr. Alan Astrow: Okay, so you're saying a gift is something extra that we add on. Okay, I can accept that. I wouldn't deny that. My point would be that, yes, a gift orientation is central to the ethical practice of medicine. Yes, it is the ethical practice of medicine. But what we're seeing in our current world is that that orientation is increasingly threatened. Isn't that what we're seeing? That doctors are selling practices to private equity? That we have more and more for-profit businesses in healthcare? And it seems in too many places, patients fear that the primary focus is not on the gift dimension, but the primary focus more and more seems to be on the mercantile aspect, the money aspect. So my point would be that, yes, we ought to know what the ethical practice of medicine is. But it's too easy to forget, isn't it? And don't we see that that's what's happening? People are forgetting. We all need to be reminded - who is going to remind us?  Dr. Lidia Schapira: Thank you, Alan, for your contribution.   And to our listeners, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at <a href="http://asco.org/podcast" rel="nofollow" target="_blank">asco.org/podcast</a>.  The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Market, Gift, Everyday Ethics, and Emmanuel Levinas in Patient Care

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JCO's Award Winning podcast Cancer Stories: The Art of Oncology features stories, dialogue, and personal reflections that explore the experience of living with cancer or caring for people with cancer, hosted by Dr. Lidia Schapira.

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Love in the Time of Cancer

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. The Bomb, Andrea M. Watson. I sit paralyzed at my desk. Everyone has left the clinic. I can hear the sound of the broom in the hall as the after hours cleaning begins. No phones ring. No patients hurry to appointments. No chatter lingers in the air. The silence is oppressive, the air is heavy, and the distance from my office to the hospital an eternity. I've just hung up the phone with the radiation oncologist. His words echo in my head. "Radiation will cause more harm than good. I'm sorry. I wish there was something more I could offer." Dread rises like a tide as my last hope recedes. I want to share the burden of this terrible news. But all my colleagues have left for the day. And I am alone. I'd been taking care of Mallory for nine months when the progression of her disease took me by surprise. Her tumor had responded so well to upfront radiation followed by nine months of intensive chemotherapy. With just a few months of treatment left, the end was in sight. Mallory was an avid JRR Tolkien fan. And plans for a Make a Wish Foundation trip to New Zealand were underway. She wanted to see the Lord of the Rings filming location and visit the small hobbit village she'd read about in travel books. She wanted to wait until it was summer there, our winter time, to travel. When Mallory's disease progressed on therapy, that fall, the timeline shifted. Goals shifted. There was no realistic hope for cure. There was just hope for time. The trip became the goal. And she bravely chose to continue with aggressive treatment, hoping it would open a window of time for travel. But further progression got in the way. When the futility of chemotherapy became clear, hopes were pinned on radiation to buy time. Now hanging up the phone, I realized that this strong, brave, beautiful 16-year-old girl who had been through so much will never get to New Zealand. And I have to tell her that tonight. I start out toward the hospital. But walking through the hall, my steps slow, my chest becomes tight, and my head swims with the devastating message I carry. I stop and look blankly at the man sweeping the floor wondering if he can tell I am carrying a bomb meant for a young girl and her family. He keeps sweeping, unaware. I trace my steps, fighting back tears. Back in my office, the sobs come. I cry for Mallory, for her parents, for her little brother and her best friend, her sister, for all they would never share together and for all the sorrow they had already faced. I cry for myself and for the terrible burden of delivering the blow, extinguishing the candle of hope that this trip had become, and speaking the words they'd dreaded since the moment we met. And when the tears finally stopped, I am empty. I take a deep breath and walk out the door. Mallory is not surprised by my news. Her gaze shifts away from me to a far off place. Silent tears stream down her face. And she says, "I know." That's all she says. I meet with her parents alone in the family room. Their reaction is raw and palpable. Flooded by tears and sobbing, they cling to one another lost in a storm of grief. When her brother and sister join us, I unfold the news slowly, choosing my words with great care as the disbelief on their faces quickly melts into sorrow and then tears. My heart feels as if it will break. I sit quietly by trying to fade from the scene that plays out before me. I fight back the tears but lose. I have done my job, delivered the bomb. There is nothing more to do but bear witness. Then something beautiful happens. Mallory's parents silently hug one another with new resolve and in turn embrace their children. Without a word, they stand up and walk together into Mallory's room. Hand-in-hand, they pull her in and encircle her with fiery love. I quietly take my leave feeling the power radiating from the room as I walk down the hall and out of the hospital into the night air. Mallory's funeral program bore a poignant quote from the Lord of the Rings film in which Gandalf assures Pippin that death is not the end, but rather another path we must take. The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver grass. And then you see it. "The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver glass. And then you see it." "What, Gandalf? See what?" Pippin asked anxiously. "White shores and beyond, a far green country under a swift sunrise." Shortly after Mallory died, her sister reflected that although she never saw the lush green of New Zealand, Mallory's journey had taken her somewhere even better. Likewise, the journey of those left behind continues. Families lives are forever changed after a child dies. And our lives are never the same either. Each patient we care for can teach us lessons about how to live well even when you die young. The privilege is great and the responsibility that comes with it greater. Delivering devastating news to beloved patients and their families may be the most dark and difficult moments of one's career. But compared with the burden that families carry, it is light. And if you stay long enough and you listen hard enough, you may see the blinding love shining through the darkness. Now the end of the day. After the noise and activity fade, I find myself thinking of Mallory. Some days, it's with a renewed awareness of the heavy burden we carry. Other days, it's with a lightness of being and gratitude for those who go before us leaving their courage as testament to what they've believed in. The silence unearths a deep ache in my heart. Sometimes I cry. Then I hear the comforting sound of sweeping in the hall. I take a deep breath and walk out the door. Welcome to Cancer Story, The Art of Oncology series podcast brought to you by the Journal of Clinical Oncology. I'm Lidia Schapira, editorial consultant for Art of Oncology and your host for this program. With me today is Dr. Andrea Watson, a general pediatric hematologist oncologist working at Essentia Health in the Duluth Clinic in Minnesota and the author of The Bomb published ahead of print, February 11, 2019. Andrea, welcome to our program. Thank you, Lidia. It's a pleasure to be here. I've been looking forward to it. That's terrific. Let me start by asking you a question I ask many of our authors. People who write usually like to read. What are you reading now? Oh, that's a great question. I, on any given day, I do read quite a few children's stories. Not only am I a pediatric oncologist, I have five children. So there's a lot of bedtime story reading, which also cuts into my leisure reading. I don't have a lot of time for fiction. But right now, I am reading a book called Invitation to Love, which is by a Cistercian monk about centering prayer. And I'm in the middle of a series that he has written about the topic. And it's wonderful. That's so interesting. So with that, let's talk about your writing. You have written and published before. So tell me a little bit about how you write and when you write and why you write. Yeah, thank you. I have discovered writing in my career in the past few years, although I recall my grandmother giving me a journal when I was 12 or 13. And it was called The View From my Window. And I really have been journaling on and off throughout my life since that time. And it wasn't until I experienced a series of patient deaths that were all very close and difficult for me three or four years ago that I really took to writing as more than just journaling. And I would say looking back, it really felt like more of a compulsion than anything else. After one of the deaths, a few weeks had gone by. And I just-- I felt physically drawn to it, almost I had to get this out. And I just-- I started on my computer. And from that came the essay that you were kind enough to publish a few years ago called Let It Be Hard. And that was just such an incredibly rewarding experience for me, not only in the process of writing and processing these deaths and all of the events surrounding it, but also in the aftermath in connecting with others who had read it or who were also writers or who had a similar experience. It was a very rich, rewarding experience. And subsequently, I have come back to that kind of as needed. I had another very difficult patient death last year. And she has become the topic of this essay, which was very much more raw and intimate for me. But that's-- I guess that's where I am in my career. It's been 10 years now that I've been practicing in a smaller town in northern Minnesota. And this has been a really important way for me to stay balanced and keep coming back to work every day. That's so interesting. And I really appreciate how you take readers also to a place of deep, deep emotion. I remember in the first essay you published, you talked about how difficult the work is. And you also said, and I wouldn't want to be doing anything else. And in this particular piece, The Bomb, you walk us through the process of delivering incredibly terrible news. And you do it with such sensitivity. Tell us a little bit more about this, the reservoir of emotion and how you handle it, how you keep it from bubbling over. Well, that is the question. And luckily for me, writing is part of the answer. In this essay, The Bomb, I think I really was looking to dive into that time where you as a provider, as an oncologist, are aware of information but have yet to deliver it. And I really hadn't experienced it so intensely before this case, although it happens all the time. It happens every day as we look at scans or look at the lab reports and then meet with patients. But in this particular instance, this whole essay is about the backstory and the aftermath. But I really wanted to focus on those minutes where it's so dark. And it's so hard. And it's so heart-- gut-wrenching and heart-wrenching to carry that without being able to share it or get rid of it or change it. And for me physically, I wanted to paint that scene to try to bring people to what it feels like and physically walking from one building to the next and how everything around you is life as normal-- life as usual. The janitor is sweeping and cars are passing by. But in fact, it's this horrendous bomb that you are delivering. And then the incredible grace that comes after, I mean, for me writing really is a meditation and a way to honor these children, these families, and their strength and their resiliency. And I think without taking that time away, that time apart, to look at that and to tell that story, you don't really appreciate it. I don't. And when I am able to do that, that turns all the intense sorrow and grief and just the horror of it all into something quite beautiful. And I think many of your guests have alluded to that in oncology. Whether it's adults or children, there's such great suffering but so much life and growth and love that comes out of that that that's what I think is just an amazing aspect of what we do. And that's certainly what keeps me coming back every day and picking up a new patient and kind of moving through it again because there's no end. So you have brought up so many very deep and insightful, wise pearls there. I think this idea of connecting through love and beauty and that is sort of almost like the antidote to the sorrow. It's beautiful. But I want to take you back a little bit to this idea that you are holding this bad news, this bomb, because delivering the bomb sounds so dramatic and so explosive. Is that, in fact, the way that you experience this delivery of bad news? Well, it certainly is a dramatization of it. I wouldn't say that every day, I feel like I'm running across the field with a bomb. But when I was first drafting this essay, and I went to save it, that title just-- I said-- it just came-- it's The Bomb. That's what I'll call it. And in that case, because we had such a strong relationship, and it was just-- it felt so tragic in part because she was such a special girl and so, so just wise beyond her years and this wonderful family. She was also the age of one of my children, my oldest daughter. And that, as many of us in pediatric oncology at least know, that makes the-- it turns up the intensity. And it's a much more emotionally challenging situation. So that particular news delivery I think was probably the most poignant for me, the most difficult. And it happened as I describe it. But that's not what every day is like thankfully. No, I-- thankfully not. But what I want to bring us back because you say that the bomb is really the way it felt to you. And then you also talk about the fact that, I mean, one of the things that I loved about this essay so much is you talk about starting to walk towards the room and then having to go back to your office and close the door and sob and feeling empty. Because I do think that the emotional impact is huge on us as well as you describe as the oncologists here. And then of course, you pull yourself together in the most professional way to deliver this therapeutically. But it is important to remember that it is emotionally a very dramatic. And it feels that way. And you certainly have made that so beautifully clear to the readers. Thank you. I think one of the things I learned from the first piece I wrote, Let It Be Hard, was just that. And that was something that one of my palliative care idols said to me one day when I was struggling with this case. He said, let it-- it is hard. Let it be hard. And that I think is what got me to where I am now with the story about Mallory and that I learned from him it's OK to shut the door and cry. And it's OK if those cries are sobs. Now we can't function on a daily basis if we're emotionally out of control. And that certainly wasn't my-- what I was trying to depict. But that let-down I think and just letting it hurt is moving through it. And from that, I-- that and by the grace of God had the strength to go over and very calmly and peacefully relay this news, which, of course, as often is the case, she already knew and help be a support person as the family really absorbed the reality that was unfolding. And that's, for me, all we can do is walk through it. We can't run away. We can't escape it. And it has only made my work and my relationship with these families richer and deeper. And that's another important piece for me. With both of the families, actually, many-- three kids that I talked about in the first one and this one, we maintain a relationship with these families long after the children have died. And they are part of our healing as much as we are part of theirs and keeping that memory alive and honoring their struggle and what they taught us. So personally, for me to do this difficult, very painful work has been offset by those relationships and the knowledge that you're growing through a very difficult time, the worst time in a family's life, and a hard time in your career. But there is growth. And there is hope. And there is meaning. And you beautifully did your work as a writer by framing this high-intensity emotional moment against that sound of that gentle sweeping, the man who was cleaning the floor. And you just remind us that there is normalcy all around this chaos and this crisis. But it's a beautiful piece. Thank you so much for sending it in and for sharing your wisdom. I want to thank Dr. Watson and hope you will join me next time for another conversation about The Art of Oncology.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. The Bomb, Andrea M. Watson. I sit paralyzed at my desk. Everyone has left the clinic. I can hear the sound of the broom in the hall as the after hours cleaning begins. No phones ring. No patients hurry to appointments. No chatter lingers in the air. The silence is oppressive, the air is heavy, and the distance from my office to the hospital an eternity. I've just hung up the phone with the radiation oncologist. His words echo in my head. "Radiation will cause more harm than good. I'm sorry. I wish there was something more I could offer." Dread rises like a tide as my last hope recedes. I want to share the burden of this terrible news. But all my colleagues have left for the day. And I am alone. I'd been taking care of Mallory for nine months when the progression of her disease took me by surprise. Her tumor had responded so well to upfront radiation followed by nine months of intensive chemotherapy. With just a few months of treatment left, the end was in sight. Mallory was an avid JRR Tolkien fan. And plans for a Make a Wish Foundation trip to New Zealand were underway. She wanted to see the Lord of the Rings filming location and visit the small hobbit village she'd read about in travel books. She wanted to wait until it was summer there, our winter time, to travel. When Mallory's disease progressed on therapy, that fall, the timeline shifted. Goals shifted. There was no realistic hope for cure. There was just hope for time. The trip became the goal. And she bravely chose to continue with aggressive treatment, hoping it would open a window of time for travel. But further progression got in the way. When the futility of chemotherapy became clear, hopes were pinned on radiation to buy time. Now hanging up the phone, I realized that this strong, brave, beautiful 16-year-old girl who had been through so much will never get to New Zealand. And I have to tell her that tonight. I start out toward the hospital. But walking through the hall, my steps slow, my chest becomes tight, and my head swims with the devastating message I carry. I stop and look blankly at the man sweeping the floor wondering if he can tell I am carrying a bomb meant for a young girl and her family. He keeps sweeping, unaware. I trace my steps, fighting back tears. Back in my office, the sobs come. I cry for Mallory, for her parents, for her little brother and her best friend, her sister, for all they would never share together and for all the sorrow they had already faced. I cry for myself and for the terrible burden of delivering the blow, extinguishing the candle of hope that this trip had become, and speaking the words they'd dreaded since the moment we met. And when the tears finally stopped, I am empty. I take a deep breath and walk out the door. Mallory is not surprised by my news. Her gaze shifts away from me to a far off place. Silent tears stream down her face. And she says, "I know." That's all she says. I meet with her parents alone in the family room. Their reaction is raw and palpable. Flooded by tears and sobbing, they cling to one another lost in a storm of grief. When her brother and sister join us, I unfold the news slowly, choosing my words with great care as the disbelief on their faces quickly melts into sorrow and then tears. My heart feels as if it will break. I sit quietly by trying to fade from the scene that plays out before me. I fight back the tears but lose. I have done my job, delivered the bomb. There is nothing more to do but bear witness. Then something beautiful happens. Mallory's parents silently hug one another with new resolve and in turn embrace their children. Without a word, they stand up and walk together into Mallory's room. Hand-in-hand, they pull her in and encircle her with fiery love. I quietly take my leave feeling the power radiating from the room as I walk down the hall and out of the hospital into the night air. Mallory's funeral program bore a poignant quote from the Lord of the Rings film in which Gandalf assures Pippin that death is not the end, but rather another path we must take. The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver grass. And then you see it. "The journey doesn't end here. Death is just another path, one that we all must take. The gray rain curtain of this world rolls back and all turns to silver glass. And then you see it." "What, Gandalf? See what?" Pippin asked anxiously. "White shores and beyond, a far green country under a swift sunrise." Shortly after Mallory died, her sister reflected that although she never saw the lush green of New Zealand, Mallory's journey had taken her somewhere even better. Likewise, the journey of those left behind continues. Families lives are forever changed after a child dies. And our lives are never the same either. Each patient we care for can teach us lessons about how to live well even when you die young. The privilege is great and the responsibility that comes with it greater. Delivering devastating news to beloved patients and their families may be the most dark and difficult moments of one's career. But compared with the burden that families carry, it is light. And if you stay long enough and you listen hard enough, you may see the blinding love shining through the darkness. Now the end of the day. After the noise and activity fade, I find myself thinking of Mallory. Some days, it's with a renewed awareness of the heavy burden we carry. Other days, it's with a lightness of being and gratitude for those who go before us leaving their courage as testament to what they've believed in. The silence unearths a deep ache in my heart. Sometimes I cry. Then I hear the comforting sound of sweeping in the hall. I take a deep breath and walk out the door. Welcome to Cancer Story, The Art of Oncology series podcast brought to you by the Journal of Clinical Oncology. I'm Lidia Schapira, editorial consultant for Art of Oncology and your host for this program. With me today is Dr. Andrea Watson, a general pediatric hematologist oncologist working at Essentia Health in the Duluth Clinic in Minnesota and the author of The Bomb published ahead of print, February 11, 2019. Andrea, welcome to our program. Thank you, Lidia. It's a pleasure to be here. I've been looking forward to it. That's terrific. Let me start by asking you a question I ask many of our authors. People who write usually like to read. What are you reading now? Oh, that's a great question. I, on any given day, I do read quite a few children's stories. Not only am I a pediatric oncologist, I have five children. So there's a lot of bedtime story reading, which also cuts into my leisure reading. I don't have a lot of time for fiction. But right now, I am reading a book called Invitation to Love, which is by a Cistercian monk about centering prayer. And I'm in the middle of a series that he has written about the topic. And it's wonderful. That's so interesting. So with that, let's talk about your writing. You have written and published before. So tell me a little bit about how you write and when you write and why you write. Yeah, thank you. I have discovered writing in my career in the past few years, although I recall my grandmother giving me a journal when I was 12 or 13. And it was called The View From my Window. And I really have been journaling on and off throughout my life since that time. And it wasn't until I experienced a series of patient deaths that were all very close and difficult for me three or four years ago that I really took to writing as more than just journaling. And I would say looking back, it really felt like more of a compulsion than anything else. After one of the deaths, a few weeks had gone by. And I just-- I felt physically drawn to it, almost I had to get this out. And I just-- I started on my computer. And from that came the essay that you were kind enough to publish a few years ago called Let It Be Hard. And that was just such an incredibly rewarding experience for me, not only in the process of writing and processing these deaths and all of the events surrounding it, but also in the aftermath in connecting with others who had read it or who were also writers or who had a similar experience. It was a very rich, rewarding experience. And subsequently, I have come back to that kind of as needed. I had another very difficult patient death last year. And she has become the topic of this essay, which was very much more raw and intimate for me. But that's-- I guess that's where I am in my career. It's been 10 years now that I've been practicing in a smaller town in northern Minnesota. And this has been a really important way for me to stay balanced and keep coming back to work every day. That's so interesting. And I really appreciate how you take readers also to a place of deep, deep emotion. I remember in the first essay you published, you talked about how difficult the work is. And you also said, and I wouldn't want to be doing anything else. And in this particular piece, The Bomb, you walk us through the process of delivering incredibly terrible news. And you do it with such sensitivity. Tell us a little bit more about this, the reservoir of emotion and how you handle it, how you keep it from bubbling over. Well, that is the question. And luckily for me, writing is part of the answer. In this essay, The Bomb, I think I really was looking to dive into that time where you as a provider, as an oncologist, are aware of information but have yet to deliver it. And I really hadn't experienced it so intensely before this case, although it happens all the time. It happens every day as we look at scans or look at the lab reports and then meet with patients. But in this particular instance, this whole essay is about the backstory and the aftermath. But I really wanted to focus on those minutes where it's so dark. And it's so hard. And it's so heart-- gut-wrenching and heart-wrenching to carry that without being able to share it or get rid of it or change it. And for me physically, I wanted to paint that scene to try to bring people to what it feels like and physically walking from one building to the next and how everything around you is life as normal-- life as usual. The janitor is sweeping and cars are passing by. But in fact, it's this horrendous bomb that you are delivering. And then the incredible grace that comes after, I mean, for me writing really is a meditation and a way to honor these children, these families, and their strength and their resiliency. And I think without taking that time away, that time apart, to look at that and to tell that story, you don't really appreciate it. I don't. And when I am able to do that, that turns all the intense sorrow and grief and just the horror of it all into something quite beautiful. And I think many of your guests have alluded to that in oncology. Whether it's adults or children, there's such great suffering but so much life and growth and love that comes out of that that that's what I think is just an amazing aspect of what we do. And that's certainly what keeps me coming back every day and picking up a new patient and kind of moving through it again because there's no end. So you have brought up so many very deep and insightful, wise pearls there. I think this idea of connecting through love and beauty and that is sort of almost like the antidote to the sorrow. It's beautiful. But I want to take you back a little bit to this idea that you are holding this bad news, this bomb, because delivering the bomb sounds so dramatic and so explosive. Is that, in fact, the way that you experience this delivery of bad news? Well, it certainly is a dramatization of it. I wouldn't say that every day, I feel like I'm running across the field with a bomb. But when I was first drafting this essay, and I went to save it, that title just-- I said-- it just came-- it's The Bomb. That's what I'll call it. And in that case, because we had such a strong relationship, and it was just-- it felt so tragic in part because she was such a special girl and so, so just wise beyond her years and this wonderful family. She was also the age of one of my children, my oldest daughter. And that, as many of us in pediatric oncology at least know, that makes the-- it turns up the intensity. And it's a much more emotionally challenging situation. So that particular news delivery I think was probably the most poignant for me, the most difficult. And it happened as I describe it. But that's not what every day is like thankfully. No, I-- thankfully not. But what I want to bring us back because you say that the bomb is really the way it felt to you. And then you also talk about the fact that, I mean, one of the things that I loved about this essay so much is you talk about starting to walk towards the room and then having to go back to your office and close the door and sob and feeling empty. Because I do think that the emotional impact is huge on us as well as you describe as the oncologists here. And then of course, you pull yourself together in the most professional way to deliver this therapeutically. But it is important to remember that it is emotionally a very dramatic. And it feels that way. And you certainly have made that so beautifully clear to the readers. Thank you. I think one of the things I learned from the first piece I wrote, Let It Be Hard, was just that. And that was something that one of my palliative care idols said to me one day when I was struggling with this case. He said, let it-- it is hard. Let it be hard. And that I think is what got me to where I am now with the story about Mallory and that I learned from him it's OK to shut the door and cry. And it's OK if those cries are sobs. Now we can't function on a daily basis if we're emotionally out of control. And that certainly wasn't my-- what I was trying to depict. But that let-down I think and just letting it hurt is moving through it. And from that, I-- that and by the grace of God had the strength to go over and very calmly and peacefully relay this news, which, of course, as often is the case, she already knew and help be a support person as the family really absorbed the reality that was unfolding. And that's, for me, all we can do is walk through it. We can't run away. We can't escape it. And it has only made my work and my relationship with these families richer and deeper. And that's another important piece for me. With both of the families, actually, many-- three kids that I talked about in the first one and this one, we maintain a relationship with these families long after the children have died. And they are part of our healing as much as we are part of theirs and keeping that memory alive and honoring their struggle and what they taught us. So personally, for me to do this difficult, very painful work has been offset by those relationships and the knowledge that you're growing through a very difficult time, the worst time in a family's life, and a hard time in your career. But there is growth. And there is hope. And there is meaning. And you beautifully did your work as a writer by framing this high-intensity emotional moment against that sound of that gentle sweeping, the man who was cleaning the floor. And you just remind us that there is normalcy all around this chaos and this crisis. But it's a beautiful piece. Thank you so much for sending it in and for sharing your wisdom. I want to thank Dr. Watson and hope you will join me next time for another conversation about The Art of Oncology.

The Bomb

Norman Wolmark

Conversations with the Pioneers of Oncology: Dr. Norman Wolmark

The Boy I Never Knew

Compassion and Compassionate Use, by David J. Einstein

Searching For Evidence-Based Reassurance Where None Could Be Found

One doctor finds respite in an unusual situation. Read the related article "A Pathologic Fascination With Humanity" on JCO.org   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on his podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  Cancer Stories, The Art of Oncology podcast series presents Robert Bailey reading the essay, "A Pathologic Fascination with Humanity," written by Timothy Gilligan, published on February 1, 2018.  A Pathologic Fascination with Humanity, by Timothy Gilligan.  That was not what I expected to find myself feeling as I lay on a gurney, awaiting my first screening colonoscopy. I was in the pre-procedure area, and a nurse was coming to put an intravenous tube in my arm. Then I would be wheeled to the procedure room, where I would receive sedating medications. And then I would have a long, flexible tube explore my insides, bur I found myself not at all worried about that.  What I felt was a huge weight lifted from me. For the first time that I could remember, I was in a situation in which I could not get any work done, no iPhone email, no editing a book chapter or closing a patient record on the computer, no reading, no writing, no returning patient phone calls, emails, text messages or communications via the electronic health record, no pages asking me to change the date on someone's chemotherapy orders or to confirm that I really, truly did not want intravenous contrast with the scan I had ordered without contrast for a patient.  I felt I had permission to stop thinking, so I lay back, closed my eyes, and took a deep draught of this freedom from responsibility. I was particularly delighted when the gastroenterologist explained that the sedating drugs would impair my judgment so that I should not do anything important or potentially dangerous, such as driving, after the procedure.  Five hours to be completely unproductive, what a gift. It was the best part of my week.  I found myself wondering why I had let my life become like this, and I know I'm not alone. These are the components of modern medicine-- 100 emails a day, sometimes more, a cacophony of access points through which people make contact, an expectation to be on all the time, lest we leave a patient less than 100% satisfied and then face the dreaded drop in our patient satisfaction score.  If 89% of my patients report that I always communicate well, I'm in the top 10% of the nation. But if only 80% say I always and 20% say I usually communicate well, I drop into the bottom 50%. And God forbid I fall another 2% and only 78% say I always communicate well. I'll find myself in the bottom quartile of American physicians.  The good news I received this week is that none of my inpatients had returned the survey. I was safe. It was almost as good as being sedated for the colonoscopy.  One of the challenges in oncology is learning to help patients manage the burden of cancer without becoming overwhelmed ourselves. There are days when we give several different people life-altering bad news, and if we allow ourselves to be fully present, we sit with them holding and considering this huge weight and planning how to cope and move forward.  On top of this age-old responsibility, we are now rated and measured constantly. Patient satisfaction, relative value unit productivity, and expectations to remain the same workflow with fewer and fewer hands on deck. And looming over everything, will we meet the budget?  Is that why we went to medical school, to make budget? Or did we have some loftier goal? The holy grail when I was training was to find cures, now, it is balancing the books.  Don't get me wrong, I love medicine. It makes me sad when I hear colleagues say that they would advise their children not to choose a medical career. I don't feel that way. If mine decide they want to be physicians, I will encourage them to do so, and I will tell them to take several accounting classes in college to make sure that they are fully prepared.  With all these extrinsic pressures though, it makes you wonder what a career in medicine is all about. Our institution recently offered free access to an online webinar called Making Physicians Better, which featured horror stories of physicians acting unprofessionally. It advised faculty on how to teach professionalism.  I worry because a number of studies in the social science literature report that it is more effective to call attention to good rather than to bad behavior. Stories of bad behavior encourage people to think of bad behavior as normal. If others are doing it, I guess it's OK for me to, seems to be a human response.  I found myself reflecting on what inspired me to reach for a high level of professionalism. I remembered my residency program director coming into the emergency room of a patient of his showed up there so he could help guide the care. I remembered him making house calls on one of his patients, whom I also cared for.  I remembered my mentor and fellowship saying he wanted to hire oncologists who lay in bed at night reflecting on whether they had made the right decisions with their patients that day. I remembered my medical school mentor telling me stories of how he had risked his reputation with colleagues and supervisors to do what he thought was best for his patients.  I thought of the dedicated colleagues I now work with, who despite the stressors of the system, consistently put patients first. I remembered the warmth and kindness my infectious disease attending from New Zealand showed to patients dying of HIV/AIDS when I was a medical student.  These are the kinds of physicians I want to be. It is much easier to define a path if you navigate toward something desirable rather than away from something repugnant. But what is the antidote to all this pressure to see more patients, create more revenue, satisfy everyone, complete all the paperwork, make the budget?  I remembered the beginning, when I was applying to medical school. At one school, my first faculty interview was in the Nuclear Medicine Office in the basement of one of the medical buildings. I navigated my way to the office and knocked on the door. No one answered. I tried again. Five minutes later, the door opened, and the irate radiologist asked, where have you been?  He asked me why I wanted to be a physician. I told him that I thought medicine was intellectually fascinating and that I aspired to work to improve public health. Those are completely invalid reasons to become a doctor, he responded. Medicine is only interesting while you are learning it, he told me. Once you're in practice, it's just the same thing over and over again.  You become an expert, which means you already know what you need to know. And as for public health, he said I should go to the public health school instead. The public health official wants everyone vaccinated, he said, whereas the physician wants everyone except his patient vaccinated.  There was only one sound reason to go into medicine, he said. You should only become a doctor if you have a pathological fascination with humanity. He told me that my life as a doctor would be run by my patients and that the only thing that would keep me engaged would be if I were endlessly interested in people.  It is ironic that I heard this from a radiologist, and 25 years later, in the middle of my career, I realized that he was correct, not about everything, but about what sustains a career in medicine.  The day after my benzodiazepine and opioid-induced mini vacation in the colonoscopy suite, I was back in clinic, immersed in caring for people with cancer, hearing about their symptoms, their fears, their hobbies, their children, their vacations. I do have a pathologic fascination with humanity and that's what keeps me going.  I'm Lidia Schapira, your host for Cancer Stories, the Art of Oncology podcast. I want to welcome our guest for this podcast, Dr. Timothy Gilligan, associate professor of medicine at the Cleveland Clinic and author of the essay, "A Pathologic Fascination with Humanity," published in the February 1st issue of JCO. Welcome, Tim.  Thank you, Lidia. It's a pleasure to be here.  You have written an essay that really resonates with a lot of readers. It starts with this amazing scene, where you tell us you find peace on the gurney waiting for a colonoscopy. Tell us a little bit about what led you to write this and what you've heard from colleagues.  So I mean, it really was a striking experience, to be having this experience that most people kind of dread and instead, just to feel so relieved. When my iPhone was confiscated from me and I could no longer check my email and text people, I was surprised at just how freeing it was and to just be able to lie down and feel totally forgiven for being unproductive.  And I think for me, writing comes-- like, I relate to the whole idea of the muse. It's almost like giving birth, like there's something that needs to come out, and this felt like a story that I needed to tell.  When I first wrote it, I actually was reluctant to publish it, because I thought, this is just personal about me. No one else is going to care about it. But a couple of my friends said, no, you really should submit it, so I did.  And we are so lucky that you did. So you have some wonderful deep reflections in there that I wanted to ask you a little bit about, and they have to do with how complicated our lives are professionally, how we are judged or valued or evaluated by some very, it sounds like bizarre mechanisms. Tell us a little bit about that.  So yeah, I think, my sense for physicians is that we tend to be self-motivated people. We've pushed ourselves our whole lives to get into a good college, to get into a good medical school, to get through our good residency program and to get through our training and to impress our patients and our peers.  And so for instance, for me, when I went to medical school, I really preferred going to schools that didn't grade, because I felt like I push myself hard enough without this external metric constantly being applied to me. And there are a number of medical schools that don't grade in the early years, it turns out, as many of our listeners will know.  And now, I found myself in this context, and a lot of my colleagues obviously, too, where we're constantly being measured and judged and told that we're inadequate if we don't meet certain metrical standards that are being set for us. And it's not that I object to the idea of measurement. I'm all about quality, and it's very hard to improve if you don't measure how you're doing, but I think the psychological experience of constantly being rated, in some levels, is kind of degrading.  Like, if everything you do, there's someone standing next to you saying, on a scale of one to 10, you just did a seven. You just did an eight. It's a little infantilizing and it doesn't, I think, make physicians feel like they're getting the respect of people who work hard and don't need to constantly be reminded.  And so it's a delicate thing. Some of the metrics are important, but it's created in an environment that, I think, is degrading at some level for doctors, and it contributes to burnout, which is something I'm very worried about.  So on a more serious note, help me understand what you think went wrong along the way. People started to introduce these metrics for some good reasons, as you say, to help people improve, perhaps, but something's gone wrong. What do you think it is?  I think it's complicated, and I'm not inclined to blame other people for my problems. So in some sense, I feel like we, in medicine, bear some responsibility for not maybe taking responsibility for fixing our own shortcomings and that's part of the reason that we now have a bunch of external people doing it for us.  But the rise of administrators-- I've seen graphs that look at the number of clinicians versus the number of administrators in health care, and health care is increasingly dominated by non-clinical people, it feels like. And they're trying to come in and measure our quality and help us improve quality and it's hard to do that without measuring everything that we're doing, but it's not being done in a way that takes into account the day-to-day day experience, I think, of the people practicing.  So I think, for me, one answer is, as physicians, we need to play a front and center role in quality improvement and patient experience and clinician experience and really try to own our environment and own responsibility for it, because if we don't do it ourselves, then other people will do it for us, and the way they do it is often not very palatable for us.  I know you've been very interested and a champion, really, in promoting the teaching of communication skills. Do you incorporate some of this into your teaching? Do you have your students or your peers, who are going through these workshops or trainings, actually think about how they're viewed and how they're evaluated?  It's interesting, to some extent, because when we-- our hospital, it's actually been mandated that all the physicians go through communication training. And so we've tried to be very thoughtful about making it an experience that would be a good experience for them, something they would enjoy and find helpful and meaningful and relevant.  And they often show up very annoyed, thinking that they're only being told they have to work on communication skills because their scores aren't high enough. So we actually have tried to dispel that. And one thing that we did is we really focus on having clinicians teach clinicians, so that the people teaching skills were people who were also seeing patients and knew what it was like to have a backlog of patients and trying to catch up and not being able to spend all the time in the world and having to document.  And so it felt to them like, I think, the people teaching knew what this was like. But it was a hurdle we had to get over to get people to stop talking about the scores and the metrics, because they were frustrated by that. And I think that if you focus on the metrics, that's not the best path towards improving performance all the time.  In your essay, you take the reader back to the sense of needing to reconnect with your sense of vocation, I think. What comes through is a real optimism and sort of this interest and intellectual and total engagement in being curious about who the patient is. Tell us a little bit about how that's resonated with readers and with colleagues.  Yeah, I've been heartened at how many lovely emails I've gotten from people around the country. My fellowship program director wrote me and old friends where I trained wrote me and people I've ever met before have, saying that it resonated with them.  And a couple of lines that stood out for people-- I think one thing I've heard a lot is what I wrote about, it's easier to improve if you're navigating towards something you desire rather than away from something repugnant. So it's been helpful to get that feedback.  I think, for me, what ultimately recharges our batteries, or my batteries anyway, in medicine is the human connection with the patient rather than some scientific fascination with the illness. And I think we can get separated from that. There are a lot of distractions, charting, and these metrics and all that stuff.  I think that when we can help people reconnect with just the meaning of the relationship with the individual person who's fighting an illness and any loved ones who they have with them, that that's ultimately where we get the most satisfaction at the end of the day.  I recently had lunch with a medical school classmate, who I thought put this very well. He said to me that he had been doing a primarily administrative job and had gone back to clinical work. And one of the reasons he was really happy about that decision is he said when he went to bed at night, he felt like he'd done something worth doing, I think, those human moments, working one-on-one with people.  So with all the wisdom and lessons learned, how can we find a little bit of that warm sense of vocation and peace without having to lie on a gurney waiting for a procedure, feeling physically drained?  I had a number of colleagues write me that I needed to find a better way to relax. That if I view going to a colonoscopy as going to the spa, that I need to revisit my life. I think it's hard. I think all of us who sign up for clinical careers know it's going to be long hours and hard work.  I think the couple of things that I find-- well, I think there are three things that I find helpful, so one is to talk to colleagues. And because I think, one of the wonderful things about medicine, I find, is the camaraderie and the teamwork. And to make time to talk about our experience with each other and what's working for us and what's frustrating, I think in those conversations and connections, we have opportunities to recharge our batteries.  I run the training program where I work in the fellowship of hematology oncology, and I stress to our fellows that I think to survive a career in medicine, you need that something outside of medicine that you love, whether it's music or a sport or something to do with your family or something that's really for you. For me, I'm a fanatical tennis player, but it can be a lot of different things for different people. I think that's really important to get your head out of the medical space for a while.  And then also, with patients, I think we get trapped in this problem-solving mindset, where we look at the patient as a list of problems that we need to address. And that's, I think, as not as rewarding and a way to spend our day. If we can see them as a human being and connect with them as a person and learn about them as an individual, take a little time to find out who they are when they're not sick and what's going on in their life, I think that also we find meaning and depth in those connections and that helps sustain us, as well.  So those are the three things that I'm hopeful about. I'm hopeful that the electronic medical records will get better. They're a major source of burnout that there's not an obvious fix for that right now. But I think that over time, I'm optimistic that the people who design these things will get better at it.  And your love for the profession and for humanity really, really sparkled in this essay. So the other comment I just had listening to you is how important it is to create a community of colleagues. And we hope in a way, that through these essays and these podcasts, we also will stimulate dialogue and connection, perhaps even among people who don't know themselves but who read and have access to the same wonderful material.  So thanks, Tim, for all the work you do every day, and thank you very much for writing and sending that beautiful essay. Thank you, and that will end this podcast.  Thank you.

One doctor finds respite in an unusual situation. Read the related article "<a href="http://ascopubs.org/doi/full/10.1200/JCO.2017.76.6477" rel="nofollow" target="_blank">A Pathologic Fascination With Humanity</a>" on <a href="http://JCO.org" rel="nofollow" target="_blank">JCO.org</a> The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on his podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer Stories, The Art of Oncology podcast series presents Robert Bailey reading the essay, "A Pathologic Fascination with Humanity," written by Timothy Gilligan, published on February 1, 2018. A Pathologic Fascination with Humanity, by Timothy Gilligan. That was not what I expected to find myself feeling as I lay on a gurney, awaiting my first screening colonoscopy. I was in the pre-procedure area, and a nurse was coming to put an intravenous tube in my arm. Then I would be wheeled to the procedure room, where I would receive sedating medications. And then I would have a long, flexible tube explore my insides, bur I found myself not at all worried about that. What I felt was a huge weight lifted from me. For the first time that I could remember, I was in a situation in which I could not get any work done, no iPhone email, no editing a book chapter or closing a patient record on the computer, no reading, no writing, no returning patient phone calls, emails, text messages or communications via the electronic health record, no pages asking me to change the date on someone's chemotherapy orders or to confirm that I really, truly did not want intravenous contrast with the scan I had ordered without contrast for a patient. I felt I had permission to stop thinking, so I lay back, closed my eyes, and took a deep draught of this freedom from responsibility. I was particularly delighted when the gastroenterologist explained that the sedating drugs would impair my judgment so that I should not do anything important or potentially dangerous, such as driving, after the procedure. Five hours to be completely unproductive, what a gift. It was the best part of my week. I found myself wondering why I had let my life become like this, and I know I'm not alone. These are the components of modern medicine-- 100 emails a day, sometimes more, a cacophony of access points through which people make contact, an expectation to be on all the time, lest we leave a patient less than 100% satisfied and then face the dreaded drop in our patient satisfaction score. If 89% of my patients report that I always communicate well, I'm in the top 10% of the nation. But if only 80% say I always and 20% say I usually communicate well, I drop into the bottom 50%. And God forbid I fall another 2% and only 78% say I always communicate well. I'll find myself in the bottom quartile of American physicians. The good news I received this week is that none of my inpatients had returned the survey. I was safe. It was almost as good as being sedated for the colonoscopy. One of the challenges in oncology is learning to help patients manage the burden of cancer without becoming overwhelmed ourselves. There are days when we give several different people life-altering bad news, and if we allow ourselves to be fully present, we sit with them holding and considering this huge weight and planning how to cope and move forward. On top of this age-old responsibility, we are now rated and measured constantly. Patient satisfaction, relative value unit productivity, and expectations to remain the same workflow with fewer and fewer hands on deck. And looming over everything, will we meet the budget? Is that why we went to medical school, to make budget? Or did we have some loftier goal? The holy grail when I was training was to find cures, now, it is balancing the books. Don't get me wrong, I love medicine. It makes me sad when I hear colleagues say that they would advise their children not to choose a medical career. I don't feel that way. If mine decide they want to be physicians, I will encourage them to do so, and I will tell them to take several accounting classes in college to make sure that they are fully prepared. With all these extrinsic pressures though, it makes you wonder what a career in medicine is all about. Our institution recently offered free access to an online webinar called Making Physicians Better, which featured horror stories of physicians acting unprofessionally. It advised faculty on how to teach professionalism. I worry because a number of studies in the social science literature report that it is more effective to call attention to good rather than to bad behavior. Stories of bad behavior encourage people to think of bad behavior as normal. If others are doing it, I guess it's OK for me to, seems to be a human response. I found myself reflecting on what inspired me to reach for a high level of professionalism. I remembered my residency program director coming into the emergency room of a patient of his showed up there so he could help guide the care. I remembered him making house calls on one of his patients, whom I also cared for. I remembered my mentor and fellowship saying he wanted to hire oncologists who lay in bed at night reflecting on whether they had made the right decisions with their patients that day. I remembered my medical school mentor telling me stories of how he had risked his reputation with colleagues and supervisors to do what he thought was best for his patients. I thought of the dedicated colleagues I now work with, who despite the stressors of the system, consistently put patients first. I remembered the warmth and kindness my infectious disease attending from New Zealand showed to patients dying of HIV/AIDS when I was a medical student. These are the kinds of physicians I want to be. It is much easier to define a path if you navigate toward something desirable rather than away from something repugnant. But what is the antidote to all this pressure to see more patients, create more revenue, satisfy everyone, complete all the paperwork, make the budget? I remembered the beginning, when I was applying to medical school. At one school, my first faculty interview was in the Nuclear Medicine Office in the basement of one of the medical buildings. I navigated my way to the office and knocked on the door. No one answered. I tried again. Five minutes later, the door opened, and the irate radiologist asked, where have you been? He asked me why I wanted to be a physician. I told him that I thought medicine was intellectually fascinating and that I aspired to work to improve public health. Those are completely invalid reasons to become a doctor, he responded. Medicine is only interesting while you are learning it, he told me. Once you're in practice, it's just the same thing over and over again. You become an expert, which means you already know what you need to know. And as for public health, he said I should go to the public health school instead. The public health official wants everyone vaccinated, he said, whereas the physician wants everyone except his patient vaccinated. There was only one sound reason to go into medicine, he said. You should only become a doctor if you have a pathological fascination with humanity. He told me that my life as a doctor would be run by my patients and that the only thing that would keep me engaged would be if I were endlessly interested in people. It is ironic that I heard this from a radiologist, and 25 years later, in the middle of my career, I realized that he was correct, not about everything, but about what sustains a career in medicine. The day after my benzodiazepine and opioid-induced mini vacation in the colonoscopy suite, I was back in clinic, immersed in caring for people with cancer, hearing about their symptoms, their fears, their hobbies, their children, their vacations. I do have a pathologic fascination with humanity and that's what keeps me going. I'm Lidia Schapira, your host for Cancer Stories, the Art of Oncology podcast. I want to welcome our guest for this podcast, Dr. Timothy Gilligan, associate professor of medicine at the Cleveland Clinic and author of the essay, "A Pathologic Fascination with Humanity," published in the February 1st issue of JCO. Welcome, Tim. Thank you, Lidia. It's a pleasure to be here. You have written an essay that really resonates with a lot of readers. It starts with this amazing scene, where you tell us you find peace on the gurney waiting for a colonoscopy. Tell us a little bit about what led you to write this and what you've heard from colleagues. So I mean, it really was a striking experience, to be having this experience that most people kind of dread and instead, just to feel so relieved. When my iPhone was confiscated from me and I could no longer check my email and text people, I was surprised at just how freeing it was and to just be able to lie down and feel totally forgiven for being unproductive. And I think for me, writing comes-- like, I relate to the whole idea of the muse. It's almost like giving birth, like there's something that needs to come out, and this felt like a story that I needed to tell. When I first wrote it, I actually was reluctant to publish it, because I thought, this is just personal about me. No one else is going to care about it. But a couple of my friends said, no, you really should submit it, so I did. And we are so lucky that you did. So you have some wonderful deep reflections in there that I wanted to ask you a little bit about, and they have to do with how complicated our lives are professionally, how we are judged or valued or evaluated by some very, it sounds like bizarre mechanisms. Tell us a little bit about that. So yeah, I think, my sense for physicians is that we tend to be self-motivated people. We've pushed ourselves our whole lives to get into a good college, to get into a good medical school, to get through our good residency program and to get through our training and to impress our patients and our peers. And so for instance, for me, when I went to medical school, I really preferred going to schools that didn't grade, because I felt like I push myself hard enough without this external metric constantly being applied to me. And there are a number of medical schools that don't grade in the early years, it turns out, as many of our listeners will know. And now, I found myself in this context, and a lot of my colleagues obviously, too, where we're constantly being measured and judged and told that we're inadequate if we don't meet certain metrical standards that are being set for us. And it's not that I object to the idea of measurement. I'm all about quality, and it's very hard to improve if you don't measure how you're doing, but I think the psychological experience of constantly being rated, in some levels, is kind of degrading. Like, if everything you do, there's someone standing next to you saying, on a scale of one to 10, you just did a seven. You just did an eight. It's a little infantilizing and it doesn't, I think, make physicians feel like they're getting the respect of people who work hard and don't need to constantly be reminded. And so it's a delicate thing. Some of the metrics are important, but it's created in an environment that, I think, is degrading at some level for doctors, and it contributes to burnout, which is something I'm very worried about. So on a more serious note, help me understand what you think went wrong along the way. People started to introduce these metrics for some good reasons, as you say, to help people improve, perhaps, but something's gone wrong. What do you think it is? I think it's complicated, and I'm not inclined to blame other people for my problems. So in some sense, I feel like we, in medicine, bear some responsibility for not maybe taking responsibility for fixing our own shortcomings and that's part of the reason that we now have a bunch of external people doing it for us. But the rise of administrators-- I've seen graphs that look at the number of clinicians versus the number of administrators in health care, and health care is increasingly dominated by non-clinical people, it feels like. And they're trying to come in and measure our quality and help us improve quality and it's hard to do that without measuring everything that we're doing, but it's not being done in a way that takes into account the day-to-day day experience, I think, of the people practicing. So I think, for me, one answer is, as physicians, we need to play a front and center role in quality improvement and patient experience and clinician experience and really try to own our environment and own responsibility for it, because if we don't do it ourselves, then other people will do it for us, and the way they do it is often not very palatable for us. I know you've been very interested and a champion, really, in promoting the teaching of communication skills. Do you incorporate some of this into your teaching? Do you have your students or your peers, who are going through these workshops or trainings, actually think about how they're viewed and how they're evaluated? It's interesting, to some extent, because when we-- our hospital, it's actually been mandated that all the physicians go through communication training. And so we've tried to be very thoughtful about making it an experience that would be a good experience for them, something they would enjoy and find helpful and meaningful and relevant. And they often show up very annoyed, thinking that they're only being told they have to work on communication skills because their scores aren't high enough. So we actually have tried to dispel that. And one thing that we did is we really focus on having clinicians teach clinicians, so that the people teaching skills were people who were also seeing patients and knew what it was like to have a backlog of patients and trying to catch up and not being able to spend all the time in the world and having to document. And so it felt to them like, I think, the people teaching knew what this was like. But it was a hurdle we had to get over to get people to stop talking about the scores and the metrics, because they were frustrated by that. And I think that if you focus on the metrics, that's not the best path towards improving performance all the time. In your essay, you take the reader back to the sense of needing to reconnect with your sense of vocation, I think. What comes through is a real optimism and sort of this interest and intellectual and total engagement in being curious about who the patient is. Tell us a little bit about how that's resonated with readers and with colleagues. Yeah, I've been heartened at how many lovely emails I've gotten from people around the country. My fellowship program director wrote me and old friends where I trained wrote me and people I've ever met before have, saying that it resonated with them. And a couple of lines that stood out for people-- I think one thing I've heard a lot is what I wrote about, it's easier to improve if you're navigating towards something you desire rather than away from something repugnant. So it's been helpful to get that feedback. I think, for me, what ultimately recharges our batteries, or my batteries anyway, in medicine is the human connection with the patient rather than some scientific fascination with the illness. And I think we can get separated from that. There are a lot of distractions, charting, and these metrics and all that stuff. I think that when we can help people reconnect with just the meaning of the relationship with the individual person who's fighting an illness and any loved ones who they have with them, that that's ultimately where we get the most satisfaction at the end of the day. I recently had lunch with a medical school classmate, who I thought put this very well. He said to me that he had been doing a primarily administrative job and had gone back to clinical work. And one of the reasons he was really happy about that decision is he said when he went to bed at night, he felt like he'd done something worth doing, I think, those human moments, working one-on-one with people. So with all the wisdom and lessons learned, how can we find a little bit of that warm sense of vocation and peace without having to lie on a gurney waiting for a procedure, feeling physically drained? I had a number of colleagues write me that I needed to find a better way to relax. That if I view going to a colonoscopy as going to the spa, that I need to revisit my life. I think it's hard. I think all of us who sign up for clinical careers know it's going to be long hours and hard work. I think the couple of things that I find-- well, I think there are three things that I find helpful, so one is to talk to colleagues. And because I think, one of the wonderful things about medicine, I find, is the camaraderie and the teamwork. And to make time to talk about our experience with each other and what's working for us and what's frustrating, I think in those conversations and connections, we have opportunities to recharge our batteries. I run the training program where I work in the fellowship of hematology oncology, and I stress to our fellows that I think to survive a career in medicine, you need that something outside of medicine that you love, whether it's music or a sport or something to do with your family or something that's really for you. For me, I'm a fanatical tennis player, but it can be a lot of different things for different people. I think that's really important to get your head out of the medical space for a while. And then also, with patients, I think we get trapped in this problem-solving mindset, where we look at the patient as a list of problems that we need to address. And that's, I think, as not as rewarding and a way to spend our day. If we can see them as a human being and connect with them as a person and learn about them as an individual, take a little time to find out who they are when they're not sick and what's going on in their life, I think that also we find meaning and depth in those connections and that helps sustain us, as well. So those are the three things that I'm hopeful about. I'm hopeful that the electronic medical records will get better. They're a major source of burnout that there's not an obvious fix for that right now. But I think that over time, I'm optimistic that the people who design these things will get better at it. And your love for the profession and for humanity really, really sparkled in this essay. So the other comment I just had listening to you is how important it is to create a community of colleagues. And we hope in a way, that through these essays and these podcasts, we also will stimulate dialogue and connection, perhaps even among people who don't know themselves but who read and have access to the same wonderful material. So thanks, Tim, for all the work you do every day, and thank you very much for writing and sending that beautiful essay. Thank you, and that will end this podcast. Thank you.

A Pathological Fascination with Humanity

The Arc of Therapy

Conversations with the Pioneers of Oncology: Dr. Robert Young

John Minna

Conversations with the Pioneers of Oncology: Dr. John Minna

Franco Muggia

Conversations with the Pioneers of Oncology: Dr. Franco Muggia

Saul Rosenberg

Conversations with the Pioneers of Oncology: Dr. Saul Rosenberg

The Cattle Don't Care

How a puzzle table helped both an oncologist and her patient. Read the related article "The Puzzle Table" by Jennifer Lycette on JCO.org.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  Cancer Stories-- The Art of Oncology podcast presents Pamela Hayden, reading the essay "The Puzzle Table" by Jennifer Lycette, published December 1, 2017.  The puzzle table sits off to one side of the infusion room. The chairs are now vacant. And the flat, white expanse of the table shows through the jagged outline of the emerging pattern.  I think of her, my patient, who will never sit there again. She would hurry to claim the table as soon as I had finished her history and physical each week, a shy smile on her face. The nurses knew to look for her there rather than waiting in the exam room when it was time to start her intravenous line.  On her treatment days, any time I passed through the infusion room, I would see her absorbed in the study of the puzzle before her, with her intravenous pole as her companion. The plastic catheter snaking down from the medication bag to her body did not get in her way.  She would look happy and relaxed, not like she looked when we were in the exam room, tense and fearful. I would nod to myself when I saw her reach across the table and pick up a tiny piece. The peripheral neuropathy was not so advanced that her fingertips could not grasp it.  The puzzle table was popular in our infusion room. It has developed an importance that was brought to our attention repeatedly when we held patient focus groups to help plan the space for our new facility.  What about the puzzle table? Where is it going to go? There is going to be a puzzle table, isn't there? Groups of patients and advocates crowded around the blueprints to determine the perfect spot for the puzzle table in its new home.  I didn't appreciate the significance of the puzzle table until I found myself one Saturday sitting with my dad in the waiting room of the cardiology procedure unit. My mom had just been whisked back for an emergency pacemaker. Being a weekend, the waiting room was empty, other than a lone soul curled up on a couch facing the wall on the far side of the room, their form obscured by a blanket.  The physician side of me told myself I had nothing to worry about. Pacemakers were routine. And this tertiary hospital placed thousands of them in a year. The daughter's side of me worried anyway.  I looked at my dad sitting in the chair next to me, a stoic air around him. The emptiness of the room, with its deserted sofas, tables, and chairs, furthered a sense of apprehension.  I wanted to say something to comfort him. But I dismissed each sentence that came to my mind, not wanting to resort to platitudes. The silence felt too heavy to lift with words.  My eyes wandered around the room for inspiration and landed on a stack of puzzles. I thought of my patient. I think I'm going to start a puzzle, I said. Want to help?  After a few minutes, he joined me. And for the next several hours, we worked mostly in silence. I can't remember the picture on the puzzle. But I can remember that as we worked, the tension and worry gradually lessened.  After the two-hour mark, I didn't know if my dad had noticed the time had passed the point at which the cardiologist had told us the procedure would be finished. My mind started to run through various complications that I could not keep out of my too-vivid doctor's imagination.  But each time one of these catastrophic, albeit unlikely, visions made its way into my consciousness-- ventricular fibrillation, arterial rupture, anaphylactic reactions to anesthesia-- I would focus on the puzzle in front of me. And I would be able to dismiss it from the front of my mind.  We were both engrossed in the puzzle when the cardiologist suddenly appeared, walking across the room to us. My heart rate accelerated at the same time as I stopped breathing. I mentally willed him to tell us that all was fine but braced myself for the possibility of bad news. We were fortunate. All had gone well.  Alas, in oncology, we do not yet have implantable devices to take over the regulation of what goes wrong in a cancer cell. It wasn't too long after my experience on the other side of the waiting room doors that I found myself meeting with my patient's family. And I had to tell them all was not well.  My patient is gone now. But I cannot walk by the puzzle table without remembering her. I am grateful to have this memory of her.  I think I understand now why she always rushed to start a puzzle. I think, perhaps, it allowed her to pass the time in the infusion room without her mind running away with thoughts of the chemotherapy dripping into her veins and the prognosis of her cancer, to take things one minute at a time, one second at a time, one puzzle piece at a time, to live in the present moment and not the fear of the next moment.  As I see other patients and family sitting there, whether chatting and working in groups or sitting alone in comfortable silence, I still see her, too. I notice at the end of the day when the infusion room is empty that the puzzle is never completed. I understand now that the puzzle is not there to be finished. It serves just by being present.  I think about the puzzles we take on each day as oncologists. There are some cancers with curative chemotherapy regimens. We know what those puzzles look like when they are solved and how to solve them.  Other times, we are faced with puzzles that no one has yet been able to solve or even puzzles that have never been seen before. There are many pieces that appear similar but have slight variations.  Each one looks like it could be a potential fit. But until we decide on a piece and try it, whether or not it will fit will not become clear. If it doesn't fit, we take the piece out, set it aside, and try another.  Sometimes we get lucky, finding a series of pieces that fit perfectly together. But then, just when we think we can see a glimmer of the completed picture, we either run out of pieces or cannot find another fit.  My patient had done well through many lines of palliative chemotherapy, with few complications over a span of years. But I knew we were running out of pieces. And I knew that she knew we were running out of pieces. But she only ever wanted to focus on the piece at hand.  We had discussed what would happen when the time came that we ran out of pieces, but she never wanted to dwell on it. I don't think this was denial. I think it was courage-- the ordinary yet extraordinary bravery of the quiet and steady reaching for the next piece.  At the end of the day, the infusion room empties of patients and staff. And the unfinished puzzle reminds me of uncertainties and possibilities. I walk over and search for one more piece to click into place before turning out the lights.  [MUSIC PLAYING]  I'm Lidia Schapira, editorial consultant for JCO's Art of Oncology and the host of this podcast. With me today is Dr. Jennifer Lycette, who is an assistant professor at the Knight Cancer Institute at the Oregon Health and Science University and the medical director of oncology services at Columbia Memorial Hospital. Dr. Lycette is the author of "The Puzzle Table," published in the December 1 issue of JCO. Jennifer, welcome to our program.  Thank you for having me.  It's a pleasure. We really enjoyed "The Puzzle Table," and the reviewers also loved it. So tell us a little bit about the inspiration for this wonderful essay.  Well, I think it was a combination of how this patient affected me and remembering her in a moment that was very personal as I wrote about with dealing with the illness-- not a cancer illness, but a medical situation with my family member, my mother. And the story kind of wrote itself in my mind, I guess, is sometimes how stories come to me. And after a time, I got to a point where I wanted to put it to paper.  It's such a wonderful concept-- the idea that the story wrote itself. And there came a point where it just needed to gush out and find paper or screen or whatever it is these days we do with our stories.  So the story centers around the puzzle table, which is actually a piece of furniture that sits in your infusion unit or in the waiting room and seems to be sort of a focal point for patients to gather and pass time. Tell us a little bit about this particular patient that you honor and remember and how she used the puzzle table.  Well, she was a very quiet, shy woman. And she was really known by all the staff for her love of the puzzle table. And we would even joke about how if we didn't see her in the waiting room, we knew we could find her at the puzzle table.  And it wasn't something I really thought about for her until, again, I was in this other moment with my family and how the puzzle affected us. And so it just really caused me to reflect on why it was such an important part of her day in the infusion room and became, in a way, a special memory of her. Because I think for all of our staff, including myself, we have a fond memory that when we see the puzzle, we can't help but remember her.  That's a lovely image. And so let's talk a little bit about your personal experience you relayed in this reflection that you and your dad found yourselves in a waiting room, waiting for your mom to have a cardiology procedure. And for those hours you spent, you also gathered around a puzzle. And that helped you pass the time. Tell us a little bit about that.  Sure. So my father is not in the medical field at all. And as we were waiting for my mother to finish with this procedure, I could sense how apprehensive he was. And I could also sense that it didn't matter what I would say. Of course, he was going to continue to feel that way until it was finished.  And it was a weekend, so the area was completely deserted. And so as I wrote about it, I was kind of glancing around the room in desperation of what to do in this moment. And I saw they had puzzles out. And I just said to my dad, hey, let's do a puzzle.  And while we were doing that, in my mind, actually, I was making this connection with my patients. And so it was, again, just one of those moments I think that happens to us a lot in practice where we have our own separate lives. But at the same time, I think our experiences are always with us at the same time.  Yes. I think we tend to talk about dividing lines and boundaries. But, in fact, all of these experiences make up who we are. And we don't dissociate. We are one person.  So let's reflect a little bit more about how you compare all of these pieces of the puzzle as you're putting together a patient's history and deciding on treatment as an oncologist and also how the pieces of the puzzle, as you say, somehow never are solved, it seems, until time goes by. Tell us a little bit more about what you were thinking when you were comparing the pieces of the puzzles to how we solve the mysteries of the care that each patient receives.  It's as you say. As I was writing the piece, it struck me that the puzzle was actually a very good metaphor for what we do in oncology. And for this particular patient with metastatic breast cancer, of course, we have many lines of therapy in the metastatic setting.  But we don't necessarily have head-to-head comparisons of which one to choose for each patient. So we're very much using our experience and knowledge of toxicity and knowledge of the patients. And sometimes, we try one thing, and it doesn't work. And we move on to something else.  And in metastatic breast cancer, of course, we often have more time to do that than with other cancers. But it struck me that often, it's as if we're putting a puzzle together.  But at the same time, in the back of our minds, we have the knowledge that at any time, we know what piece might not fit. Or we're on a time clock, if you will, but we don't know when it's going to end. And so that metaphor was what I was trying to get across in the piece.  Yes, and you did that so successfully. And then the other aspect of the writing that is, to me, so beautiful is that you help us as readers understand that focusing on each piece of the puzzle one piece at a time has an enormous calming effect on the person. Was that your intention?  Yes. And I'm glad to hear it came across in that way. Because especially with this woman, she, as I wrote about, wasn't someone who every visit wanted to talk about prognosis or dwell on prognosis. But I felt very sure that she understood.  And we talk a lot about mindfulness. And we have a wonderful social worker in our clinic who tries to help us as staff with doing that for ourselves but also for our patients to help as a coping skill. And it struck me that that's what the puzzle was, I think, for my patient-- was in some ways, a mindfulness tool. And I didn't really make that association until I was using that tool myself with my dad.  That's so interesting. And also in your writing, you honor the patient and talk about the fact that what she displayed was a form of bravery and courage and that it also shows just how well, I think-- if I may just tell you the thoughts that I had as I was reading this-- shows that she knew herself. And she was more comfortable moving those pieces around and being busy and perhaps really dreaded the moments where there would be dialogue or conversation.  Or she felt, perhaps, even she would be forced to speak about a future that looked not only uncertain but grim as time passed. Does that resonate with you?  Yes, it does. I think that's exactly what I was trying to get across in how I would observe that she was really a different person in the infusion room. If I saw her across the room, she would be very relaxed, doing the puzzle, chatting with the nurses. But in the exam room, she was very tense and fearful.  So it was a very interesting difference in the way I would observe her. And it was, I think, very helpful to be able to see her in that other situation to know that that was her actual self. And what I was seeing was just a very small moment. And, of course, we often only get very small moments with our patients in the exam room.  Yes. This comes across so clearly. Well, the piece is really beautiful and just beautifully constructed. It starts with the puzzle table. And then you guide the readers through all of this reflection of the patient story and your story and your connection through puzzle solving to the lived experience of patients who need to find ways of going from one anxious moment to the next.  And then you finish with the scene, again, almost like a theatrical or choreographed scene, where you turn the lights off. And you put one final piece of the puzzle into place before turning the lights off and going home.  It's really a beautiful piece, Jennifer. And I'm so grateful that you sent it to us. And I hope the readers enjoy it as much as I did. Do you have any final message or words for those who are listening?  Well, first of all, thank you. And I'm very grateful to have the opportunity to share my writing. And I think in terms of final words, I would go back to what you said about how we try to all set boundaries to help ourselves but that we are one person.  And I think that for me, I would share that I have been practicing in a small rural community now for a little over four years. And I've actually found that opening myself up to some of that overlap has actually been a very helpful thing as an oncologist and a person. And so I don't think we always have to have such rigid boundaries. And again, I just thank you for letting me share my writing through JCO.  Thank you, Jennifer. That was Jennifer Lycette talking about her essay "The Puzzle Table." Join me next time for another conversation about the stories and the art of oncology.

How a puzzle table helped both an oncologist and her patient. Read the related article <a href="http://ascopubs.org/doi/full/10.1200/JCO.2017.75.7872" rel="nofollow" target="_blank">"The Puzzle Table"</a> by Jennifer Lycette on <a href="http://JCO.org" rel="nofollow" target="_blank">JCO.org</a>. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer Stories-- The Art of Oncology podcast presents Pamela Hayden, reading the essay "The Puzzle Table" by Jennifer Lycette, published December 1, 2017. The puzzle table sits off to one side of the infusion room. The chairs are now vacant. And the flat, white expanse of the table shows through the jagged outline of the emerging pattern. I think of her, my patient, who will never sit there again. She would hurry to claim the table as soon as I had finished her history and physical each week, a shy smile on her face. The nurses knew to look for her there rather than waiting in the exam room when it was time to start her intravenous line. On her treatment days, any time I passed through the infusion room, I would see her absorbed in the study of the puzzle before her, with her intravenous pole as her companion. The plastic catheter snaking down from the medication bag to her body did not get in her way. She would look happy and relaxed, not like she looked when we were in the exam room, tense and fearful. I would nod to myself when I saw her reach across the table and pick up a tiny piece. The peripheral neuropathy was not so advanced that her fingertips could not grasp it. The puzzle table was popular in our infusion room. It has developed an importance that was brought to our attention repeatedly when we held patient focus groups to help plan the space for our new facility. What about the puzzle table? Where is it going to go? There is going to be a puzzle table, isn't there? Groups of patients and advocates crowded around the blueprints to determine the perfect spot for the puzzle table in its new home. I didn't appreciate the significance of the puzzle table until I found myself one Saturday sitting with my dad in the waiting room of the cardiology procedure unit. My mom had just been whisked back for an emergency pacemaker. Being a weekend, the waiting room was empty, other than a lone soul curled up on a couch facing the wall on the far side of the room, their form obscured by a blanket. The physician side of me told myself I had nothing to worry about. Pacemakers were routine. And this tertiary hospital placed thousands of them in a year. The daughter's side of me worried anyway. I looked at my dad sitting in the chair next to me, a stoic air around him. The emptiness of the room, with its deserted sofas, tables, and chairs, furthered a sense of apprehension. I wanted to say something to comfort him. But I dismissed each sentence that came to my mind, not wanting to resort to platitudes. The silence felt too heavy to lift with words. My eyes wandered around the room for inspiration and landed on a stack of puzzles. I thought of my patient. I think I'm going to start a puzzle, I said. Want to help? After a few minutes, he joined me. And for the next several hours, we worked mostly in silence. I can't remember the picture on the puzzle. But I can remember that as we worked, the tension and worry gradually lessened. After the two-hour mark, I didn't know if my dad had noticed the time had passed the point at which the cardiologist had told us the procedure would be finished. My mind started to run through various complications that I could not keep out of my too-vivid doctor's imagination. But each time one of these catastrophic, albeit unlikely, visions made its way into my consciousness-- ventricular fibrillation, arterial rupture, anaphylactic reactions to anesthesia-- I would focus on the puzzle in front of me. And I would be able to dismiss it from the front of my mind. We were both engrossed in the puzzle when the cardiologist suddenly appeared, walking across the room to us. My heart rate accelerated at the same time as I stopped breathing. I mentally willed him to tell us that all was fine but braced myself for the possibility of bad news. We were fortunate. All had gone well. Alas, in oncology, we do not yet have implantable devices to take over the regulation of what goes wrong in a cancer cell. It wasn't too long after my experience on the other side of the waiting room doors that I found myself meeting with my patient's family. And I had to tell them all was not well. My patient is gone now. But I cannot walk by the puzzle table without remembering her. I am grateful to have this memory of her. I think I understand now why she always rushed to start a puzzle. I think, perhaps, it allowed her to pass the time in the infusion room without her mind running away with thoughts of the chemotherapy dripping into her veins and the prognosis of her cancer, to take things one minute at a time, one second at a time, one puzzle piece at a time, to live in the present moment and not the fear of the next moment. As I see other patients and family sitting there, whether chatting and working in groups or sitting alone in comfortable silence, I still see her, too. I notice at the end of the day when the infusion room is empty that the puzzle is never completed. I understand now that the puzzle is not there to be finished. It serves just by being present. I think about the puzzles we take on each day as oncologists. There are some cancers with curative chemotherapy regimens. We know what those puzzles look like when they are solved and how to solve them. Other times, we are faced with puzzles that no one has yet been able to solve or even puzzles that have never been seen before. There are many pieces that appear similar but have slight variations. Each one looks like it could be a potential fit. But until we decide on a piece and try it, whether or not it will fit will not become clear. If it doesn't fit, we take the piece out, set it aside, and try another. Sometimes we get lucky, finding a series of pieces that fit perfectly together. But then, just when we think we can see a glimmer of the completed picture, we either run out of pieces or cannot find another fit. My patient had done well through many lines of palliative chemotherapy, with few complications over a span of years. But I knew we were running out of pieces. And I knew that she knew we were running out of pieces. But she only ever wanted to focus on the piece at hand. We had discussed what would happen when the time came that we ran out of pieces, but she never wanted to dwell on it. I don't think this was denial. I think it was courage-- the ordinary yet extraordinary bravery of the quiet and steady reaching for the next piece. At the end of the day, the infusion room empties of patients and staff. And the unfinished puzzle reminds me of uncertainties and possibilities. I walk over and search for one more piece to click into place before turning out the lights. [MUSIC PLAYING] I'm Lidia Schapira, editorial consultant for JCO's Art of Oncology and the host of this podcast. With me today is Dr. Jennifer Lycette, who is an assistant professor at the Knight Cancer Institute at the Oregon Health and Science University and the medical director of oncology services at Columbia Memorial Hospital. Dr. Lycette is the author of "The Puzzle Table," published in the December 1 issue of JCO. Jennifer, welcome to our program. Thank you for having me. It's a pleasure. We really enjoyed "The Puzzle Table," and the reviewers also loved it. So tell us a little bit about the inspiration for this wonderful essay. Well, I think it was a combination of how this patient affected me and remembering her in a moment that was very personal as I wrote about with dealing with the illness-- not a cancer illness, but a medical situation with my family member, my mother. And the story kind of wrote itself in my mind, I guess, is sometimes how stories come to me. And after a time, I got to a point where I wanted to put it to paper. It's such a wonderful concept-- the idea that the story wrote itself. And there came a point where it just needed to gush out and find paper or screen or whatever it is these days we do with our stories. So the story centers around the puzzle table, which is actually a piece of furniture that sits in your infusion unit or in the waiting room and seems to be sort of a focal point for patients to gather and pass time. Tell us a little bit about this particular patient that you honor and remember and how she used the puzzle table. Well, she was a very quiet, shy woman. And she was really known by all the staff for her love of the puzzle table. And we would even joke about how if we didn't see her in the waiting room, we knew we could find her at the puzzle table. And it wasn't something I really thought about for her until, again, I was in this other moment with my family and how the puzzle affected us. And so it just really caused me to reflect on why it was such an important part of her day in the infusion room and became, in a way, a special memory of her. Because I think for all of our staff, including myself, we have a fond memory that when we see the puzzle, we can't help but remember her. That's a lovely image. And so let's talk a little bit about your personal experience you relayed in this reflection that you and your dad found yourselves in a waiting room, waiting for your mom to have a cardiology procedure. And for those hours you spent, you also gathered around a puzzle. And that helped you pass the time. Tell us a little bit about that. Sure. So my father is not in the medical field at all. And as we were waiting for my mother to finish with this procedure, I could sense how apprehensive he was. And I could also sense that it didn't matter what I would say. Of course, he was going to continue to feel that way until it was finished. And it was a weekend, so the area was completely deserted. And so as I wrote about it, I was kind of glancing around the room in desperation of what to do in this moment. And I saw they had puzzles out. And I just said to my dad, hey, let's do a puzzle. And while we were doing that, in my mind, actually, I was making this connection with my patients. And so it was, again, just one of those moments I think that happens to us a lot in practice where we have our own separate lives. But at the same time, I think our experiences are always with us at the same time. Yes. I think we tend to talk about dividing lines and boundaries. But, in fact, all of these experiences make up who we are. And we don't dissociate. We are one person. So let's reflect a little bit more about how you compare all of these pieces of the puzzle as you're putting together a patient's history and deciding on treatment as an oncologist and also how the pieces of the puzzle, as you say, somehow never are solved, it seems, until time goes by. Tell us a little bit more about what you were thinking when you were comparing the pieces of the puzzles to how we solve the mysteries of the care that each patient receives. It's as you say. As I was writing the piece, it struck me that the puzzle was actually a very good metaphor for what we do in oncology. And for this particular patient with metastatic breast cancer, of course, we have many lines of therapy in the metastatic setting. But we don't necessarily have head-to-head comparisons of which one to choose for each patient. So we're very much using our experience and knowledge of toxicity and knowledge of the patients. And sometimes, we try one thing, and it doesn't work. And we move on to something else. And in metastatic breast cancer, of course, we often have more time to do that than with other cancers. But it struck me that often, it's as if we're putting a puzzle together. But at the same time, in the back of our minds, we have the knowledge that at any time, we know what piece might not fit. Or we're on a time clock, if you will, but we don't know when it's going to end. And so that metaphor was what I was trying to get across in the piece. Yes, and you did that so successfully. And then the other aspect of the writing that is, to me, so beautiful is that you help us as readers understand that focusing on each piece of the puzzle one piece at a time has an enormous calming effect on the person. Was that your intention? Yes. And I'm glad to hear it came across in that way. Because especially with this woman, she, as I wrote about, wasn't someone who every visit wanted to talk about prognosis or dwell on prognosis. But I felt very sure that she understood. And we talk a lot about mindfulness. And we have a wonderful social worker in our clinic who tries to help us as staff with doing that for ourselves but also for our patients to help as a coping skill. And it struck me that that's what the puzzle was, I think, for my patient-- was in some ways, a mindfulness tool. And I didn't really make that association until I was using that tool myself with my dad. That's so interesting. And also in your writing, you honor the patient and talk about the fact that what she displayed was a form of bravery and courage and that it also shows just how well, I think-- if I may just tell you the thoughts that I had as I was reading this-- shows that she knew herself. And she was more comfortable moving those pieces around and being busy and perhaps really dreaded the moments where there would be dialogue or conversation. Or she felt, perhaps, even she would be forced to speak about a future that looked not only uncertain but grim as time passed. Does that resonate with you? Yes, it does. I think that's exactly what I was trying to get across in how I would observe that she was really a different person in the infusion room. If I saw her across the room, she would be very relaxed, doing the puzzle, chatting with the nurses. But in the exam room, she was very tense and fearful. So it was a very interesting difference in the way I would observe her. And it was, I think, very helpful to be able to see her in that other situation to know that that was her actual self. And what I was seeing was just a very small moment. And, of course, we often only get very small moments with our patients in the exam room. Yes. This comes across so clearly. Well, the piece is really beautiful and just beautifully constructed. It starts with the puzzle table. And then you guide the readers through all of this reflection of the patient story and your story and your connection through puzzle solving to the lived experience of patients who need to find ways of going from one anxious moment to the next. And then you finish with the scene, again, almost like a theatrical or choreographed scene, where you turn the lights off. And you put one final piece of the puzzle into place before turning the lights off and going home. It's really a beautiful piece, Jennifer. And I'm so grateful that you sent it to us. And I hope the readers enjoy it as much as I did. Do you have any final message or words for those who are listening? Well, first of all, thank you. And I'm very grateful to have the opportunity to share my writing. And I think in terms of final words, I would go back to what you said about how we try to all set boundaries to help ourselves but that we are one person. And I think that for me, I would share that I have been practicing in a small rural community now for a little over four years. And I've actually found that opening myself up to some of that overlap has actually been a very helpful thing as an oncologist and a person. And so I don't think we always have to have such rigid boundaries. And again, I just thank you for letting me share my writing through JCO. Thank you, Jennifer. That was Jennifer Lycette talking about her essay "The Puzzle Table." Join me next time for another conversation about the stories and the art of oncology.

The Puzzle Table

Emil Freireich

Conversations with the Pioneers of Oncology: Dr. Emil Freireich

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