Apr 5, 2021
In Knuckles by Kathryn Hitchcock, a radiation oncologist and a patient learn how people are not always who they seem.
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LIDIA SCHAPIRA: Welcome, to JCO's "Cancer Stories-- The Art of Oncology," brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.
KATE HITCHCOCK: The swastikas on his knuckles kept stealing my attention. I tried not to stare, but every time he gestured to emphasize his words, my gaze snapped back there. That awful symbol multiplied across all 10 digits refused to be ignored. The blue lines were blurred, misshapen, probably jail tats.
I grew up in a prison town and then joined the Navy. You would think the inking of flesh could no longer hold any fascination for me. My appearance seemed to be equally distracting to my patient and his wife. Hair just beyond clipper short, no make up, button up shirt, and pressed slacks. I could practically see the thought bubble over their heads. Definitely a lesbian. Different word, though.
Their brows creased every time I spoke. I had learned not to expect much from people who looked at me that way but wrestled the feeling down. We had serious business.
I explained what we needed to do together-- 5 and 1/2 weeks of radiation treatments if we went through without a break. Not too tough day-to-day, but a real marathon taken together-- fatigue, loss of appetite, and loose stools. He'd have to eat as best as he could. His wiry frame didn't carry much he could afford to lose.
I glimpsed at his teeth and wondered if he was still using meth and not admitting it. We were going to have a couple of long months. He sat stiffly while I listened to his heart and lungs as if I were a ghost that would become real if he acknowledged it. I took a chance and patted his shoulder reassuringly anyway.
He was alone when he came for the first of his weekly on-treatment visits. His body language announced that he was not excited to talk with me, but I deliberately stayed away from the computer. I would be all-in on this, even if he wasn't.
Your weight is steady so far. You must be doing a good job with eating, I said. He nodded and looked at his fingernails. Any pain? Nope. Bowels doing OK so far? Yep. He sighed and looked at his watch. I knew my excellent, meticulous nurse had covered all of this already. I just had to find some way to get him to talk.
How is your wife taking this, I asked, without moving or changing my tone of voice. He was so startled, he actually jumped a little and met my eyes for the first time. Well, I think this is real hard for her. She has to work while I do this. We got to have her insurance.
Yes, that's how it is for most folks unless they're retired. Thank goodness you guys have insurance. A lot of people, spouses, or even the patients have to work the whole time to try to pay for this in cash, I said. Money's the last thing you should have to worry about at a time like this, but it's always there, isn't it?
Yeah, it is, he said, and paused. I think she might be a little depressed. I can imagine, I said, for people who have brain chemistry that turns that way, anyhow, and sometimes, I think that's all of us, this is exactly the kind of situation that can make it hard to deal with that. Yeah, I guess so, he said, pensive.
I let him think on that for a minute and then, what about you? Do you think you're feeling depressed? He shrugged with one shoulder. Wouldn't look at me. Whatever you think about that, I trust your judgment, I said. But you told me you'd use some drugs before. I know for a lot of people that's a way to try to dig their way out of depression when they can't get to a doctor for whatever reason.
I held my breath, hoping I hadn't just made things worse between us. Slowly, to my great relief, he started to nod. Yeah, I think I've been pretty far down for a long time. It's hard to get a job, he said, holding out his hands and gesturing to the Confederate flag on his neck. Once you've been convicted, it's hard.
Yeah, I've heard that, I said. Tough when people judge you by how you look before they get to know you. He met my gaze again, sharply. He knew I wasn't just talking about him.
So you know, I pressed on, there are treatments that can help get your brain where it's supposed to be. We just aren't made for this modern life we live. We are wired for chasing buffalo across the plains and taking them down with spears. Instead, here we sit on fluffy upholstery with the air conditioning blasting over us. Our bodies are comfortable, but our brains just can't deal with it sometimes. He nodded. I guess so. I guess I never thought of it that way.
So what do you think? Want to see if we can get your brain to a better place, I asked, trying not to let my voice sound too hopeful. I doubted he was ready for any sort of agenda from me. I guess, maybe so, he said slowly. Is there something we can do now?
There was. Like so many before him, he learned that when he had someone to tell about the many weights on his mind and added some better brain chemistry, the world looked like a very different place. At the start of his third on-treatment visit, he actually stood up and shook my hand. No smile, but I'd take what I could get.
We talked about the usual things. His gut was not loving the rads. I reiterated the need to stay hydrated and not work outside too long in the Florida heat. He said a friend of his had started coming over every evening after dark so they could get a little work done while it was less than 90 degrees outside. They were shade tree mechanics of some kind.
When we were finished, he got up and headed toward the door but paused with his hand on the knob. I saw your technician, the lady who gives me my treatment, I saw her looking at my tattoos yesterday. I was wondering if you could tell her for me that that's not who I am anymore. I was full of hate back then, but I'm not too proud to say I was wrong. I was going to get rid of them-- do that laser thing. But now all that money is going to my cancer bills, he said, searching my face for some sign of understanding.
I just blinked for a moment. This was more words than he'd given me in our entire acquaintance, all at once. There was a lot to unpack there, and I wanted to get it right.
I finally decided on a reply. She grew up in the South. I think she gets it. You've been nothing but polite to everyone here. I'll make sure she knows, though. That therapist had a best friend whose granddad was a vocal segregationist but whose parents doted on both women as though they were twins. She knew people could choose to be better than their upbringings.
He nodded. I've changed a lot. Sure, I said. None of us is who he used to be. We just have to try to keep moving in a good direction. Yeah, it's hard to know what that is sometimes, but I'm trying. Thanks for understanding.
Of course, I said. Just remember this conversation later when I do or say something stupid, OK? Sure, Doc, he said. I guess I can spot you one. He smiled then for the first time since I'd met him, and it was truly beautiful.
His wife was with him on the last day of treatment. She talked to me this time, instead of looking at the wall while she spoke. She even smiled a little. He cradled his diploma carefully in his lap. We give people a certificate when they finish their last radiotherapy treatment-- tangible recognition of what they've endured.
Thank you for taking care of me. Sometimes doctors try to get rid of me because of how I look, he said, fiddling with the snap back of his mesh trucker-style hat. Well, I guess I can sympathize. Sometimes people don't have much use for me because of the way I look, too, I told him honestly.
Yeah, when my wife and I first met you, we wondered what we were getting into. He laughed, and I laughed with him, remembering the furrowed brows. She looked a little embarrassed but smiled shyly. We thought about changing doctors. I'm really sorry about that. We just haven't known anybody like you before. I'm really, really glad I stayed.
Well, I'm glad I've made it worth a try. We're all learning as we go, aren't we?
Yeah, he said. I'll tell you, this cancer's been good for one thing. I understand a lot more of what's important in life. There's so much I can leave alone now. I feel like one of those great old guys who love their gardens and their grandkids, and really, they love people, too, everybody. They just laugh at the rest of us running around and worrying about who deserves a nice car or who should get to be the head of the Parent Teacher Association. They're just happy.
Well, I hope that rubs off on me, I said. Maybe I can get a little ahead of the usual schedule in figuring that out because of you. I appreciate you're talking to me about it.
I appreciate you, he said, one arm out in the offer of a hug but holding back a little, prepared for rejection of his kindness. I took him up on it.
LIDIA SCHAPIRA: Welcome to "Cancer Stories." I'm Lidia Schapira, your host for this program and the consulting editor for "Art of Oncology." With me today is Dr. Kate Hitchcock, a radiation oncologist and an assistant professor at the University of Florida College of Medicine. Dr. Hitchcock is the author of "Knuckles," that was published in JCO's, Volume 39, Issue 3 on January 20th of '21. Welcome, Kate.
KATE HITCHCOCK: Thank you so much for having me.
LIDIA SCHAPIRA: It's a pleasure to have you. And before we start talking about "Knuckles." I love to ask our contributing writers a little bit about what they're reading and what drove them to write? So in this case, let's start with the first question. Are you a reader, and what are you reading now, and what's on your table?
KATE HITCHCOCK: I am so much a reader. It is a little out of control, in truth, as it is with a lot of serious readers. I always have two or three books going, at least. Right now, those include my book in Spanish. I'm learning Spanish, since there are a lot of Spanish speakers in Florida, and I want to try to meet them halfway. So I'm reading a novel in Spanish right now that is fluffy, light read, but enjoyable while I'm building some vocabulary.
I am reading a book of collected stories from my old ship from when I was in the Navy that's called "King Paul's Reactor and Engineering Memories." It's from the Enterprise, specifically. A lot of sea stories, written down by my shipmates, and that's a really fun read. But yeah, those are my two main books right now.
LIDIA SCHAPIRA: So when I was looking up your bio, I saw that you have a PhD in biomedical engineering. So in addition to a career in the Navy, it seems, you've done a lot of things. Tell us a little bit about that and how your past experiences outside of medicine inform your relationship with your patients.
KATE HITCHCOCK: Well, I would say the most important effect that they have on my relationship with my patients is that the Navy teaches you very quickly to do very complicated and very emotionally difficult things with people who are nothing like you. And I think that's part of what I was trying to capture in the story that we're talking about today. What a gift that is to have been through that experience of not only working but living very closely with people who grew up completely differently from me, who have completely different cultures than I knew up until that time.
And what that allows me to do now, as a doctor, is try to meet people where they are. And that is it. Boy, that is the art of medicine right there, because I can have the best treatments in the world. If I can't convince my patients that they're the best thing, if I can't convince them to make it through hard treatment, which radiation often is, then all the science that I have isn't good for anything.
LIDIA SCHAPIRA: That's so interesting, and it made me pause and think about how all of that informed your encounter with this patient, who is the protagonist of your story. So tell us a little bit about what made you see the story in these encounters and when you thought about telling the story and actually sharing the story with others? Because many of us write, perhaps, to process difficult experiences, to achieve clarity. But then to bring it out and share it with others through publication requires many different steps. So walk us through that, from this encounter, this patient to the story.
KATE HITCHCOCK: I would say this encounter with this patient started as my time with my patients usually does, which is in me trying to figure out who they are. And I have to be a very quick study there because cancer doesn't wait. You've got to get people in treatment. And a lot of times, coming into the radiation oncology clinic, they have lots of preconceived notions about radiation. And it's a very scary thing for a lot of people because they haven't learned about it in school very much.
So I very quickly need to figure out who they are, where they're coming from, so I can figure out how to talk to them. And the process of doing that is the joy of my work. I love meeting new patients and hearing about how they see the world and how it's different from the way I do. And so many times, in fact, just about every time, I wish I could capture that experience of getting to know them and share it with my loved ones, share it with my friends, because the joy of it is just, ah, it is just indescribable.
So I think that's where it started with this particular patient, was realizing, boy, this is going to be one of the more challenging times, that I really need to do a good job at this. I can save this man's life. This is a very curable cancer, and he's going to die if I don't treat him. So somehow, I have to figure out a way to get us there.
And it was a tall order, as I hope I captured well in this story. Because it was so hard and because I constantly sort of think back over those experiences later, the writing of this story was good for me, too. It let me kind of process what went well, where there are things I could have done better. And I hope that that's something I can bring to my future patients.
LIDIA SCHAPIRA: So you start with these amazing visuals-- the swastikas on the knuckles, then the Confederate flag on his neck. But it's not just about him. It's about you plunge into this two-sided checking each other out. And you see the patient and his wife looking at you, and you use the expression, I think, their brows creased every time I spoke. And I'm quoting you here, "I had learned not to expect much from people who looked at me that way but wrestled the feeling down." I was just blown away by that phrase. Tell us a little bit about what was going on there.
KATE HITCHCOCK: That moment happens every time. I always-- my heart is always in my throat a little bit as I go to put my hand on that knob to walk into the exam room. And that started back in medical school, where there were practice patients, trained actors who are on the other side of the door. It was a zero stakes situation, but still that feeling of walking in and not knowing what you're going to encounter on the other side of that door, ooh, that is a powerful moment.
And I know it is for my patients, too. You know, they're sitting there. They hear voices in the hall. They are going through one of the most difficult times of their life, and whoever comes through that door is either going to save them or fail to save them. What a moment that is. It's just so full of emotion.
And I think the big thing from the doctor side of it is just to try to figure out how to get past that initial reaction, that initial set of presumptions we have about each other. And of course, all of us have that in life. We all have preconceived notions about other people. First impressions are so, so important, and this is just a very high-pressure version of that.
LIDIA SCHAPIRA: And then you go on to say, and you can tell, I love your writing, so I'm going to keep quoting you to you. "Tough when people judge you by how you look before they get to know you." I was just very struck by how direct you are and how quick you are to figure out that what's on the line is building rapport and trust. And you come at this from so many different ways.
And then you take us through the sequence of the visits, when he comes in not just for the initial consult but also for the exit consult but for the checks, the weekly checks. And you try to address mental health and you address the acceptance and show support and praise. Tell us a little bit about all of that with this patient. What were the moments that were really key for you, and were there moments when it didn't go well?
KATE HITCHCOCK: Sure, there are always moments when things don't go quite like you wanted them to, and you have to figure out how to recuperate from those. I would say the hardest ones for him, as is true for a lot of patients, is those moments where he was most worried about what I was thinking about him. And so I had to choose my words so carefully to not reinforce maybe ideas he had about my preconceived notions or about the way that the world views him that would not be constructive to our relationship together, would not help us get where we needed to be.
For example, mental health is a huge issue in the way that people accept it all over this country and a lot of other countries, too. It's a very delicate topic to bring up, but it plays into every interaction I have with my patients. Of course, they're stressed out. Of course, a lot of them are experiencing symptoms of depression that make it hard for them to get their cancer treatment. Sometimes it's a matter of trying different approaches to that topic until I find one that works.
And in this case, as I wrote about in the story, that was through talking about his wife's feelings, first. He was so worried about how she felt about everything, and a lot of cancer patients, or really any patients who have a serious illness, that's really the number one thing on their minds is they feel like they're being a burden to their families. And if I can address that and figure out a way to, if I can't improve their financial situation or anything material with it, if I can at least give them some tools to think about in a way that makes them feel better, that is really constructive to what we have to accomplish. And luckily, in this case, I think I was able to do that.
LIDIA SCHAPIRA: So when I hear you talk, and you come across as somebody who's really mastered many techniques. You clearly have mastered the physics of radiation and the art and science of communication. But one of the things that I found so enormously compelling about your story is that you make yourself vulnerable, too. Your hesitation or your vulnerability comes across, and you put it right out there. Can you talk a little bit about that?
KATE HITCHCOCK: I think that's so important. And it's a difficult thing to do, because we, as doctors, we're just people. And we have to set aside our egos sometimes and make ourselves vulnerable to our patients. And I think I figured out when and how to do that, at least part of the time.
And it's not an easy task. You know, doctors, when we're talking to each other, both to our coworkers and in social media and so on, we talk a lot about do we put ourselves out there on social media? Do we let our patients have ways to contact us that might be outside of work?
And I think the problem there is twofold. One, that you're opening yourself up to harassment and problems. This gentleman certainly could have come back to me in a way that would have hurt my feelings or caused me problems in other ways. But also, we're still coming away from the old approach to doctoring in which the doctor was this unapproachable being, who had to think of themselves as being a little omnipotent, a little removed from the rest of society, and they wanted their patients to think of them that way.
And through time here, we're growing to where doctors and patients are much closer. It's not this paternalistic relationship that it used to be. And I really think part of that is the doctor has to have some skin in the game.
We have to be able to talk about how we feel about things and the problems that we're having, if our patients are going to trust us with their lives with critical decisions. And I have found that doing that in a careful way, not making the conversation about me but talking enough about myself that they see me as somebody who is a person who is really invested in their future, it really pays off.
LIDIA SCHAPIRA: I agree with you. And at the beginning, you hint at the fact that you were, in a way, at the margin. And you bring that up because you say they're looking at me in this way. I'm dressed this way. I'm a lesbian to them, but they were probably thinking about this using a different term. That is pretty raw. How has that experience-- I mean, you put it out there in your first paragraph. So it's right there in front of the reader. So how have those experiences in a way deepened, perhaps, your compassion for others, who are themselves different or are viewed or are likely to be judged quickly by others. Tell us a little bit more about that, because I think that it adds another dimension, another depth, even, to the essay.
KATE HITCHCOCK: Absolutely, I think people who have grown up in a marginalized way for whatever reason bring a lot to any sort of situation where personal interactions are important and especially where lots of different people have to come together. And I think medical schools are starting to figure that out. This process of getting people into medical school-- they are really starting to value true diversity, not just we're getting the guy from the lacrosse team instead of from the football team, but really trying to get people from a broad array of backgrounds.
And one of the reasons is exactly the one that you mentioned, which is that when you've grown up in a way where you were discriminated against, it makes it a lot easier to anticipate the sort of mental barriers to good care that your patients might have. So, so important in this country where there are a lot of marginalized populations, who don't have good relationships with the health care system overall, and that's very much to their detriment. They are the ones who are paying the price for that. And I think the burden is on us, as physicians, to try to figure out how to overcome that.
And luckily, I do think I have a convenient tool there, having grown up in a place where, I think it was pretty obvious that I was different, even from a pretty young age. And I got bullied a lot and ran into problems there. Of course, my experiences isn't their experience, but at least I have a place to start in thinking about where they're coming from.
LIDIA SCHAPIRA: So to wrap it up, I must say, I was very moved, too, with the ending that you have for the story. The first line is so confronting, the swastikas, and I immediately ask myself, would I ever have the compassion and the kindness and the discipline to really work through my reactions to get to the point where you did, which is that not only did you help him, but he offered you his hand halfway through treatment. And then he ends by offering you a hug, which you accept. So I'm just getting goosebumps thinking about this right now, and I've read and reread your essay a bunch of times. So let me give you the last word, and tell us and our listeners what that final interview was like.
KATE HITCHCOCK: That final conversation together was pure magic, you know? There was no certainty going into it that it would go the way that it did. We were both a little unsure of each other, and especially with his wife there, who hadn't sat with us very much through the course of treatment and had to rely on his interpretation of the situation. But that magic is-- that's it. That is everything right there.
I think part of what I was trying to capture in this story is that this is what we need in the country right now. This is the only way that things get better. We can't lecture each other into accepting the way other people think about things. We have to find this moment over and over again. That's it.
LIDIA SCHAPIRA: Well thank you, I and our readers and reviewers understood your message very clearly. And we thank you so much for sending us your work. So thank you, Kate, for being with me today. And I hope you continue to write, and let's keep reading and talking. Thank you very much for your time today.
KATE HITCHCOCK: Thank you so much. I really appreciate it.
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