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JCO's Cancer Stories: The Art of Oncology podcast series consists of author interviews and readings of the section’s content. This platform provides authors with the opportunity to comment on their work, offers better accessibility for readers, and stimulates moreconversations. Art of Oncology publishes personal essays, reflections, and opinions in the Journal of Clinical Oncology, giving our readers a chance to reflect on important aspects of practice and help shape our professional discourse. We hope you enjoy listening to these thought-provoking stories.

 

Dr. Lidia Schapira

Cancer Stories is hosted by Dr. Lidia Schapira, MD, FASCO.

Dr. Schapira is the Associate editor for JCO’s Art of Oncology. She is a Professor of Medicine at Stanford University School of Medicine where she serves as the Director of the Cancer Survivorship Program. 

All guests on ASCO podcasts agree to provide evidence-based information to our listeners. Guests agree to provide objective commentary free from commercial bias, and they agree to respect patient privacy. Conflict of Interest disclosures in connection with the content of the podcast will be provided with each episode.

 

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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. Guests' 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.

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May 3, 2018

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.