TASTE OF MY OWN MEDICINE

In medical school, the clinical curriculum obliges you to rotate through all the disciplines. Even if you enter pre-ordained to become a dermatologist -- having dreamt of nothing but acres of clear skin since your own pimply adolescence -- you’ll still be forced to try your hand at other specialties. You move from the ponderous mental exercises of localizing lesions in neurology, trying to explain a patient’s functional deficit as if their brain was a black box (when nowadays an MRI allows a peek inside), to the physical exertions of orthopedic surgery, holding limbs akimbo at unnatural angles while bone saws whir to life and drown out the classic rock blaring on the OR stereo (orthopedists love power tools and power chords in near-equal measure).

This mandatory smorgasbord means that, before you settle on a single dish, you know you’ve had the opportunity to try them all. The comprehensive tasting reduces “what if?” daydreams, minimizing envy of your adjacent diners. Having sampled the diverse ways to tackle aching joints, there’s less buyer’s remorse for the rheumatologist, later inundated in their clinic with incurable cases of osteoarthritis, who might have instead been a contender installing gleaming new hip prostheses in the operating room.

No rotation challenged me more than pediatrics. The inpatient wards were proof, room after room, that kids can get sick, really sick, upending our equivalence of youth with vitality, even invincibility. The oncology ward in particular was filled with bald heads and brave faces, making me ashamed first for my own relatively easy waltz through childhood and then for the self-pitying overestimation of my adult problems. I might fret over my hair graying or thinning or both, but at least it had been allowed to take root. Some young scalps have barely sprouted fuzz before the follicle growth is arrested by chemo.

I sought escape in the outpatient clinic, but that was overwhelming too, a raucous waiting room filled with desperate parents unable to coax their children into taking their prescriptions. The drugs came in a Wonka-like array of flavors, but, for all the forced whimsy, there was no hiding the fact that it was still medicine. One of my fellow students -- deliberately childless, destined for a quieter professional life in ophthalmology plucking cataracts from age-dulled eyes -- asked why it was so hard to get the kids to take their doses. Our preceptor, smiling knowingly, made us taste them all, so that we might understand the challenge. It was well-intentioned hazing, the taste as indelible to the initiate as the smack of a fraternity bat to a freshman pledge. Clindamycin was especially awful: no amount of saccharine could mask the metallic flavor, just as no amount of steak sauce can salvage a rubbery ribeye. Mary Poppins was wrong about sugar helping the medicine go down.

Although ultimately --  perversely? -- I found it somehow more palatable to dispense chemo to frail adults than antibiotics to their resilient grandchildren, a sense of inequity crept in. As an oncologist, you have to speak authoritatively about drugs you’ve never received. Sure, you have studied the pharmacology as part of your doctorate and then gained real-world experience from past administrations of a drug, but there’s still the gaping difference between a pilot’s understanding of flight and a hawk’s. The raptor doesn’t have to know about lift, drag, pitch, & yaw; it just feels the air beneath its wings, rides the thermals, instinctively plots its angle of attack. The patient, of course, is more prey than predator, and their doctor can only observe their treatment course without totally sharing in the experience: birdwatching.

Most oncologists know not what we say when we talk about chemo. We’re teetotal bartenders slinging artisanal cocktails, concocting doublets and triplets as we pull ingredients off the pharmacy’s top shelf. But instead of vermouth and bitters, it's cyclophosphamide and epirubicin. When we talk about picking your poison it's not quite a selection between strychnine and curare, although we do give arsenic (with tremendous success!) to select leukemia patients.

Now, after this surgery, I still cannot attest as to what it feels like to receive toxic chemotherapy. Here, again, I realize my tremendous good fortune to have had a neuroendocrine tumor; almost all of the patients with the other, more common variant of pancreatic cancer -- adenocarcinoma -- will receive an intravenous chemical called gemcitabine at regular intervals for up to 8 months post-operatively. Chemo in that context is called 'adjuvant', from the Latin root adjuvare, meaning to 'help toward'. The idea is that the chemotherapy adds to the surgery's odds of securing a cancer-free future, propelling that group of patients back to normalcy after minimizing their likelihood of recurrence. In truth, though, even that single chemo agent can be hard to tolerate -- and, with a need for multiple doses, pose yet another daunting series of hurdles to clear after the Whipple. Worst of all, adenocarcinoma cells can still persist to recur with distressing frequency, even after the double whammy of surgery & chemo.

So no, this medical oncologist still cannot tell his patients that he knows the taste of his own medicine. Nor he can promise all of them a durably healthy future. But he can say, with the deepest empathy, that he understands what it's like to take decisive, extreme action against cancer's clear & present danger.

Mark LewisComment