The ASCO Post is pleased to reproduce installments of the Art of Oncology as published previously in the Journal of Clinical Oncology. These articles focus on the experience of suffering from cancer or of caring for people diagnosed with cancer, and they include narratives, topical essays, historical vignettes, poems, and photographic essays. To read more, visit jco.org and search “Art of Oncology.”
Timothy Gilligan, MD
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 preprocedure 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. But 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 e-mail. No editing a book chapter or closing a patient record on the computer. No reading. No writing. No returning patient phone calls, e-mails, 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 closed my eyes and took a deep draft 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 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 am not alone. These are the components of modern medicine: a hundred e-mails 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 a survey. I was safe. It was almost as good as being sedated for the colonoscopy.
Challenges in Oncology
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 maintain 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 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 worried 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.
High Level of Professionalism
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 if 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 in 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. They 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. My first faculty interview was in the nuclear medicine office in the basement of one of the buildings. I 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?”
“It is much easier to define a path if you navigate toward something desirable rather than away from something repugnant.”— Timothy Gilligan, MD
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Why Go Into Medicine?
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 are 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 public health school instead. 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, I realize 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. ■
At the time this article was published in the Journal of Clinical Oncology, Dr. Gilligan was practicing in the Department of Hematology and Medical Oncology, Taussig Cancer Institute, Center of Excellence in Healthcare Communication, Cleveland Clinic.