Asking and Listening

Discussing goals of care at end of life for patients with metastatic or non-curable cancer should be the highest priority for an oncologist. We are experts in this disease of the highest of stakes- life or death. Full stop.

In most cases, we are in the privileged position of knowing our patients for months or years as they navigate metastatic cancer, meeting their families, learning their stories, understanding their humanity.

Ideally, this looks like serial conversations to ask and to listen, gather and document. I try to work these conversations in at milestone moments- initiation of new therapy, disease progression, good scans, new co-morbidities, life additions or subtractions like birth of a grandchild or death of a spouse. In these moments, there is a delicate balance of suffering and hope, but we are clearly moving forward- we are treating the cancer and that is the goal.

A New Conversation

There comes a time when the cancer starts to win.

Serial progression in short time intervals, inability to recover such that life looks like being in bed for 14-16 hours of the day, or frequent hospitalizations are all signals to increase the urgency of these conversations. To enlist help from family members, palliative care providers, and most importantly the patient themselves. When the patient can describe their wants and needs, the grip of sadness and guilt on caregivers and loved ones is loosened. And when there is clarity about why treatment is continued or not continued, the inevitable suffering has definition and is maybe less traumatizing.

There is a heralding conversation where discussion turns to action. A decision is made to stop treatment. The pendulum swings from treating the cancer with medicines to improve or extend quality or quality of life to a focus on comfort without cancer medicines. This is a supremely intense discussion that takes place in the midst of routine workflows and as such, with competing attention and priority.

Code Silver

I have thought about the concept of a structural system to consider how we can do better in the more urgent moments of decisions. I call this Code Silver.

Classifying a Code in medicine signifies a drop everything mentality. Various resources, human and otherwise, make a sudden moment a priority. In a Code Blue, doctors, nurses, respiratory therapist gather with lifesaving equipment at the bedside. ICU teams and social work are on alert for the outcome. A communication system is primed to get all of those people to the right place within moments.

A Code Silver would mirror the commitment, the infrastructure, and the urgency.

In an outpatient oncology clinic, when this definitive goal of care discussion is taking place, the oncologist calls a Code Silver to immediately mobilize a team. There is a pause and a re-set for the clinical team to close a door, make sure everyone has a seat, hush the waiting room, take a deep breath.

Financial counselors are triggered to get immediate authorization to know what options are available, which facilities are accepted by insurance or not. A representative from social work and hospice is alerted and appears in person to explain options concretely to patients and loved ones. A picture emerges and a plan is formulated, calmly and competently and with the utmost respect and compassion. Water is offered; hugs are given. Questions are answered and loops are closed.

This conversation and process should be elevated structurally to the position of importance it deserves. Thought, strategy, and resources should be designated to the end-of-life logistics as much or (arguably more) than how we handle sepsis and airway emergencies. Taking time and energy to think about death belongs in more spheres of conversation, health care in particular and oncology especially.

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The People

People coming in and out of a cancer center are experiencing extreme and often divergent emotions. Newcomers are inevitably anxious, potentially disassociating, and leaving with either the worst news of their life or possibly euphoric relief.

For the veterans, they are used to the environment but spend so much time as to sacrifice normative and pleasurable routine parts of their lives. Their variability of visits range from routine check-ins, to getting good or bad news from scans, to a long day of treatment leading to a week of fatigue, nausea, and pain.

The people that work in a cancer center have challenges. Spending up to 40 hours a week adjacent to extreme feelings and high stakes creates intensity and juxtaposition; an interplay between regular life stress and conscious or unconscious existential considerations about death and dying.

As for caregivers and loved ones, the sentiments and needs will run the gamut. Firmly sandwiched in the reality of various life roles, they may be missing a work deadline or a rushing to pick a kid up from school.

We have some in complete fight of flight, some relieved and joyous with a new perspective on the importance of love and life. Others are thinking about lunch or scrolling TikTok. It’s safe to say most people would rather be somewhere else.

The Place

An ideal cancer center would start with easy parking, free valet and kind, smiling faces as greeters. Way finding would be well executed so newcomers would be assured they were in the right place.

The entrance would feel open with natural light, greenery, and fresh subtle scent. Site navigators with open smiles and helpful direction, signage that is reassuring and uncomplicated.

Waiting rooms would not have TVs or loud music, rather soft white noise or calming nature sounds. Color palette would focus on cool and healing blues and greens. Circulating staff would be armed with information and updates, all patients would know what the next step in the triage process was- who and what they were waiting on at a given moment. No one would worry that a trip to the bathroom could lead to missing the call to go back to see the doctor.

Small spaces would be tucked amidst waiting and treatment areas, so people could have private conversations, moments to collect their thoughts or find buffer temporarily before going back into public. Sleep and work pods with sound proofing would be available for caregivers or those with long treatments, serial procedures, or hours of long monitoring for clinical trials.

Healthy food and snacks would be available and free or at subsidized cost (pharma would be an excellent partner to subsidize healthy food and snacks in a cancer center). Water stations, electrolyte powders, smoothies, juices would be available at every treatment area. Cafeterias or and kiosks would offer wraps, sandwiches, bowls, soups. Snacks like nights and fruit would be passed around as would good quality coffee and tea.

Warm blankets and eye coverings would be available in treatment, along with individuals offering aromatherapy, guided meditation and hand/foot massage…(we train nurses to do this as a part of our Integrative Oncology Nurse Ambassador program).

A gift shop selling soft throws, pillows, cards, and other kindnesses would be available for patients who want a pick me up or caregivers who need a way to say what can’t always easily be said, I love you, I’m sorry, I wish this wasn’t happening.

And more

There would be space to meaningful support and sustain lifestyle change before, during, or after a cancer diagnosis. Having this within the cancer center would underscore its importance and promote it from “value add” to non-negotiable. (This is what we hope for with our Wellness and Integrative Oncology program).

A functional gym with availability of individual exercise therapists to advise and on-ramp patients to exercise on their own terms. Counseling about nutrition that goes beyond “just get in calories” and establishes that obesity as a risk factor for cancer. Services for integrative modalities like acupuncture and yoga, also cost subsidized, so that people have options beyond medications to manage side effects and to create ownership and agency within their own bodies.

Tools to process, track, and organize information would be a part of the cancer center. Data stations to suggest apps for tracking, to provide appointment summaries, double check that next appointments are in patient portals and calendars and provide tools to remind patients who to call if things go wrong. Clarity around the care team, who is the nurse, nurse practitioner, what are the off hours and where do calls get routed, which hospital to go to and how to quickly provide information so that new team knows what is. Electronic medical records and patient apps should do this but there are reasons these fail and those that are not digitally savvy. Safety nets to provide clarity in various ways should be the punctuation at the end of a visit.

And on exit, those same smiling faces should be back. To get the car, to offer a bottle of water for the road to make sure you didn’t forget your phone, your sweater and to say, “see you next time.”

I walk into the room and there is palpable tension. Mr. S. is sitting up in bed; his jaw and neck muscles are tight. His face is red.

His wife stands over the bed; hands held in the front of her body. Her posture suggests patience.

His son sits in a chair at the foot of the bed with a visitor’s sticker, marker smudged from the rain.

Mr. S is angry. He wants to go home.

A man with black scrubs told him early this morning he could go home.

4 days ago, Mr. S. was an average 62-year-old man at work as a mechanical engineer. He’d been tired and his appetite had been poor all spring. His back hurt after long days at a desk.

2 days ago, he came in with the worst headache of his life. Scans showed a large bleeding mass in his brain, other scans showed lesions in the liver and bone. He had surgery to open his skull and remove the bleeding mass in his brain. Until the biopsy was read and signed by the pathologist, we didn’t know what kind of cancer he had but we knew he had cancer and we knew it was bad. We all knew that.

Our team was advising him to stay. To be evaluated for physical therapy (none on the weekend), to see if he could be placed in an acute rehab facility near his home (we couldn’t guarantee that existed or would be covered by his insurance), to allow us to deliver the news about the biopsy and put a plan in place (but it might not be back until later in the week)….

I could see in his eyes how the walls were closing in. He sputtered and tripped over his words. The combination of his brain surgery, steroids, lack of sleep, fear worked against him. We stood above him as he pleaded his case from his bed.

The wife was terrified of this person who had come into the hospital as her husband and now was mad and scared and shaking. She didn’t know what she’d do at home and the idea of the help and support of the hospital felt like a lifeline. The son was scared and sad and had driven all night from the middle of the country. He kept thanking me.

By the afternoon, Mr. S was calmer. His wife and son had walked the halls with him. He was unsteady and tired. They convinced him to stay and see if he could get more strength with rest, if the support services he would be evaluated for on Monday might feel acceptable.

Bearing witness to the humanity, the fear and the love; offering calm, competence and kindness- this is what I can give in these moments where I bump up against such personal snapshots of devastation.

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Last Month, I hosted a Cancer Prevention and Survivorship Symposium.

The vision for the event was ambitious in its goal to meet various needs and disparate expectations. We invited patients, health care providers, students, and caregivers. My goal was to offer a mix of excitement, research, authenticity, and practical strategy for cancer prevention and survivorship.

As a conventionally trained medical oncologist who believes in the power of the human body and voice of the individual, I spend much of my time with patients translating biology, statistics and medical decision making to patients who tend to ask very plainly, what does this mean for me? I wanted to deliver on this sweet spot at larger scale.

We had an opening talk from an MD physician, author, and influencer who was bold, polished, professional, dramatic. She took a strong position with the audience. Lifestyle- specifically diet and exercise was in their control; proven benefits robust for prevention and survivorship. She did not apologize in her lack of compromise – no sugar, no alcohol, no inactivity. Her message was clear, do the work and do it completely.

Two research talks followed- both by PhD immunologists with labs. One described the discovery that sucralose (the main ingredient in Splenda) changed the microbiome in mice with cancer and rendered them less responsive to immunotherapy shrinking their tumors. The other showed how exercising mice on a treadmill altered their microbiome and rendered them more responsive to immunotherapy shrinking their tumors. One of these talks did the tough job of explaining complicated science to a varied audience. The other was suited for a research audience and so our group lost the plot halfway through.

We had a Q and A next. One woman asked, should we not use Splenda? Someone else asked, what should I do to have a good gut microbiome? One researcher answered, eat food. I jumped in to try to find a better way to expound on this disconnect, a significant one that I see with research and the real-world questions patients ask their oncologists. The research should be trying to build bridges in real time for real people with cancer now. It does not.

After lunch, a patient and I went on stage, and I asked her a series of questions about the challenges of being a breast cancer survivor. She was honest and raw. She described her symptoms, her toolbox. She acknowledged her privilege in how she could resource excellent food, being in nature, having a greenhouse for escape and creativity. Later, when we reviewed feedback, someone said they wished they could afford a greenhouse. Point taken.

I gave a talk on supplements and cancer. I opened the talk by describing an intersection between biology and belief. I tried to find a middle ground in describing mechanisms, highlighting research as well as the limitations of research in this space. I gave specific, decisive suggestions with tricks and hacks for organization, tolerance, consistency. These are the supplements I take and trust me; I want to prevent cancer.

The final talk was a researcher who focuses on exercise in oncology. She talked about her efforts toward offering exercise to all people with cancer, how she is moving toward the goal and many of the milestones and accomplishments that have changed this field over the last five years. These accomplishments are impressive, but we still have a mismatched supply and demand for patients with cancer who want true hand-held guidance on exercise.

The feedback we got was largely positive. But it was contradictory too. I saw a woman in clinic who told me she loved the patient who spoke, it comforted her and made her feel less alone. The very next woman I saw also attended. She said she was “completely freaked out” by that same woman’s words. Later, our dietician told me she had to talk a patient down who attended and felt so stressed out by the popular influencer’s talk that she burst into tears when she came home to find that her husband had made spaghetti and meatballs for dinner.

I’m glad we could offer this symposium, and I think we did a good job of meeting many different types of people’s questions and needs. The event was elevated and energized, not a bland corporate event.

Still, it reinforced the disconnects I see every day-the research world does not meet the questions of patients in the moment. And everyone’s needs are different; strong feelings and sensitivities exist on nearly every topic. It is impossible to please everyone, to meet everyone’s needs in the space of lifestyle and wellness. But that doesn’t mean we shouldn’t keep trying.

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As a medical oncologist, I think about cancer and cancer prevention even when I’m not thinking about it.

Although we know of hundreds of risk factors for cancer and we have collected billions of statistics about who gets what cancer and when, there is enormous mystery to how things play out in individual bodies. There are lifelong smokers that live to their 90’s. There are twins who have grown up with the same DNA, the same risk factors and the same lifestyle; one gets cancer and the other doesn’t. We have information about mutated genes that predispose people to cancer and can be detected by blood tests, but the how, when and why cancer presents in one individual or another is unpredictable.

It is straightforward to ignore this mystery and focus on a rigid set of dos and don’ts.

It is also straightforward to embrace this mystery; I’m going to live my life and hope for the best.

What is not straightforward is to develop a cancer prevention action plan that considers variables but is not de-railed by them.

A cancer prevention action plan has strong structure and also soft parts that change over time. It pulls stability from what we know but acknowledges what we don’t know. There is room for new data and also for behavior change. It considers the resources of time and money, gender, ethnicity, socioeconomics, and the pitfalls of the medical system (Yikes). This plan cannot succeed without the planner/the person taking the primary role of responsibility. It is helped greatly by an engaged health care provider(s) and a health system that delivers affordably and competently.

Such a plan needs constant attention. It is never complete. It requires commitment, discipline. Multiple stakeholders should be involved and engaged. And even with all of that, this action plan may fail. You may still get cancer. There is actually a pretty good chance of it, especially if you live long enough.

The first pillar of the action plan centers on engaged medical relationships and preventative screenings. This is a place where we have data and where rigid dos and don’ts have a home. Everyone should have at least one engaged medical provider that has access to real-life medical infrastructure, meaning the ability to order labs and tests- to see patients in a clinic or admit them a to hospital, to document in a medical record that is as universal as possible. Preventative screening tests for breast, lung, colon, prostate, and cervical cancer are the cornerstone of this pillar.

The next pillar of the action plan considers known medical conditions with general and personal risk factors. It also relies on engaged medical relationships. Additionally, this pillar requires that the individual experiences agency in their body, how things feel, when they notice things are on or off and how they report that information. Family history will inform if early preventative screening is indicated or if specialty care should be enlisted. Co-morbid medical conditions direct when medications are needed to treat chronic diseases, reverse metabolic abnormalities, control inflammation. New pain or weight loss can be promptly reported and investigated. Incidental findings on labs or scans can be worked up.

The last pillar of the action plan is the lifestyle. We have the most control here. There are rigid dos and don’ts at play in this pillar too: don’t smoke, manage your weight, eat healthy and unprocessed food, don’t drink much or at all.

If we look and listen carefully, we can be aware of roadblocks and try to give them space. My patient told me recently that she could not cut down to less than 5 cigarettes a day. When she tried, she always landed on eating more to manage the stress around being a caregiver and working 2 jobs. The pounds on the scale crept up, her knees hurt, she walked less. We can miss out on making this third pillar accessible to more people because we deny the complexity and the interconnected difficulty of taking care of ourselves. Of how HARD it is to start this and/or to keep it up for decades. There is room for adjustment, for doing our best, for this to evolve.

There is fun to be had here, improvements to see and feel. There are deep dives into how we move our bodies, what and when we feed and hydrate, the nutrients and supplements we use to augment food. There is richness to make our lives better, to feel strong and smooth in our bodies, to own our lives, our physical vigor, our emotional equilibrium.

We find ourselves back to the uncertainty of cancer no matter what pillar we follow. Some rigid rules, some living your life and hoping for the best. Finding an action plan that has structure but softness, where taking care of oneself feeds multiple pathways of health, where taking care of oneself is the empowerment and the joy.

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I take this advice like a tincture. And I wish I could pass it like a note or put it on a t-shirt. In life, probably. But in the hospital definitely. Let me try to paint a picture.

I have a team with me, some combination of residents, fellows, nurse practitioners and physician assistants. They too may know the patients and their families well or be meeting them for the first time. I may also be meeting these team members for the first time or possibly have known them for years.

We are doing daily rounds, the fabric of hospital medicine. Each patient will have a primary team serving as quarterback. For our rounds, the oncology service is the primary team; every patient we see has cancer.

Multiple variables feed into the flow; consultants from specialty services, like cardiology, also do daily rounds and make suggestions. The machine of hospital discharge- nurses, social workers, discharge planners, insurance companies- evaluate, comment, and question multiple times a day. Ancillary services like physical and occupational therapy see the patients and make suggestions that feed into the discharge plan and the primary teams to do list.

The momentum of the illness, co-morbidities patients bring with them to the hospital like diabetes or heart failure, and the acute issue- why they came to the hospital this time, a blood clot or an obstruction in the belly, have their own trajectory, their own flow. Other variables feed into this sub-flow, imaging studies, procedures, trials of antibiotics and errors of pain medicine regiments.

Our jobs, our deliverables for daily rounds are numerous. We are to see each patient, analyze their problem list, process and interpret new testing, come up with a plan, and take steps to translate plan into practice, the practice of medicine. This means prescribing and adjusting medicines, refining a diagnosis or creating a new diagnosis based on exam, labs, imaging and biopsies, ordering more of these, or planning for some form of discharge and follow up.

For patients and loved ones, these elements exist upon a powder keg of emotion and fear. Every new variable- the human ones like the subtle eye contact between the resident and the fellow, or the data-based ones like a new sodium level, can shift the patients concerns and questions. The most well-meaning of words, from anyone in scrubs or a version of a white coat, can create a domino slide. A nurse talking about what happened to her father-in-law. A respiratory therapist making a diagnosis. A surgical resident describing how he interpreted a CT scan. A promise of discharge tomorrow. A guarantee a procedure will take place. A definite dinner tray.

I am not suggesting evasion, aloofness, or chill. I believe that transparency, advocacy, and empowerment make up the language of the provider-patient relationship. And I know that our health care provider system utilizes hierarchies where representatives are charged with much of the communication for the final decision makers (think residents and advanced practice providers). These final decision makers are typically less than present emotionally and physically (think, many attending physicians past their first flush), so these representative words and encounters are with the best of intentions. However, I believe words spoken without care or confirmation in the hospital make up 50% of the patient distress and erode 50% of the efficiency of the process.

Here is how I choose my words with care starting from the moment I walk into the room. It is clear, it does not overpromise, and it leaves room to explain and confirm when the necessary information comes together in the hospital setting.

-A clear introduction (I’m Dr. Francis, one of the medical oncologists doing rounds for the weekend).

-A connection to their personal care team (I’m Dr. X’s partner, and all of our communication is documented and linked).

-An honest admission of what I know. And what I don’t know. (I’ve reviewed your chart and been briefed by our team of residents and advanced practice providers, but I am new to your case today.)

-The game plan for rounds (We’re making morning rounds to check in on what’s happened overnight and refine the plan for today).

-The larger big picture (You came in with a blood clot that is likely due to your cancer- you are doing well on blood thinner, and we’ll hope to get you on oral blood thinners than consider discharge home).

-Offer to answer questions (Always with strong eye contact, never making promises that I cannot control personally or clinical decisions that are not mine to make).

-Repeating the introduction. (I’m Dr. Francis, Dr. X’s partner).

-Closing the loop on the daily plan. (Our team is around all day and will come back to check in on X, Y, and Z later this afternoon).

Say Less…. then Maybe Say More.

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Her chart revealed that she carried a mutation predisposing her to breast and ovarian cancer. When I asked the sequence of events leading to discovery of the genetic mutation, she told me she was tested after her younger sister was diagnosed with breast cancer and tested positive for the mutation. Her sister, 35 years old, living in Canada and raising two small kids, told her to get tested. The younger sister dove into navigating her treatment and tried to stay afloat.

My patient understood that she should get tested herself and went to see her PCP. Tests were ordered and appointments were made. Months passed, life kept up its relentlessness, and it all took time. Eventually, she found that she carried the same mutation. Scans were ordered, the first scan required another scan, another month passed. And then quite suddenly, she was on the phone getting the same news her sister had gotten just one year before. She had breast cancer.

When she told me this, she described guilt, confusion, anger. She wished she could go back and get tested immediately, re-tell the story so she had elective mastectomy and never got breast cancer at all. A different story where her younger sister had saved her life, spared her of months of pain and an altered existence. She wanted the version where medical advance prevailed and instead she was a shell of a woman who could barely get through a day without crying.

I thought deeply about this interaction. I wondered if there was someone that should be more responsible for this than just these sisters. Two women overwhelmed, one by life plus cancer and the other by life plus an illusion of good health.

With health care systems and workflows that are bloated and inefficient, could this have possibly gone better?

If we mandate reporting of communicable disease, should genetic predisposition have a mandate or at least a better safety net?

Days later, I had another young woman across from me in clinic. She also had localized breast cancer, was through surgery and radiation, starting hormone therapy intended to reduce her risk of recurrence. She had genetic testing done at diagnosis. She was told it her testing was normal but for one element, called a variant of uncertain significance (VUS), which was explained to her as something that should not be there but was not currently attached to any specific cancer outcome. She had felt reassured and trudged onward.

Six months later, she got a series of emails and phone calls from the company that did her genetic testing. The VUS was being re-classified as a pathologic (disease causing) genetic mutation. The company walked her through the change. If a critical number of a particular VUS occurred in the population with cancer, they were re-classified as pathologic mutations. She was suddenly saddled with predisposition to cancer in her breasts (she had a lumpectomy as opposed to mastectomy or bilateral mastectomy) as well as in her colon as a result of this new classification.

She was also told to inform her family so they could consider being tested. She dove diligently into this task and showed me the Excel spreadsheet she had crafted for family members. She executed thoughtfully and comprehensively. I felt overwhelmed and exhausted for this woman, who had taken on this complicated task in the midst of her own cancer treatment. I wondered about the many others who would not be as resilient or action oriented as she. And I thought of those on the other side of a less urgent call to action, with a cancer diagnosis coming on the heels of learning about a gene mutation.

To me, these scenarios represent the beyond and between of cancer. Beyond the cancer, more destabilizing forces of unknown and uncertainty. Between the cancer, more murkiness and panic.

In oncology, we overstate the certainty of genetic tests on one hand and undersell the importance of personal responsibility and accountability for our health on the other. I listened to both of these women, sat with their sadness and regret and exhaustion. I applauded the creativity and effort of the family Excel spreadsheet. And now that I’m on Substack, I wrote and shared. Thanks for reading.

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One problem may be the term Integrative. It’s vague. It oversteps. It under explains. BUT…it does leave room for the power of the term-it blends, it spreads, it incorporates. And that is vital in a field like Oncology where much of the research, teaching, learning and patient care has little of that give, that space.

Integrative Oncology, in part, uses certain modalities to address symptoms and quality of life in people with cancer. What are these modalities and what makes them integrative? This is where it gets circular. Defining a word with the same word is not useful. Sometimes I say holistic. Sometimes I say lifestyle. Sometimes I say, NOT pharmaceuticals. I don’t say alternative. Complementary seems unimportant. Nothing completely satisfies.

I do think the point gets across- try this and see if it helps your symptoms. It won’t harm you. It may help with other parts of your life, your overall health, your stress reduction. It may enhance your body/self-awareness. You may be able to build on it as a practice, a habit, a tool. It may empower you to make other lifestyle change, the small and consistent efforts in diet and exercise that help everything. Yes, this is Integrative Oncology!

The desire to not take more medicine is a big part of this conversation. In conventional medicine, the tool in hand is medication. It may be stating the obvious (or not) to say that many patients, especially cancer patients, do not want to be on more medications. Particularly, people who have recently been on the motherlode of medication (chemotherapy, immunotherapy) with a side dish of three or four supportive medications like steroids.

With all of that said, in my experience, Acupuncture is a hero of Integrative Oncology. It represents Integrative Oncology with integrity. It blends, it spreads, it incorporates. It rarely harms. It can help with lots of things. It enhances body/self-awareness. It can be a practice, a habit, a tool.

The history, the mechanism, the scientific evidence, the experiential and anecdotal responses I’ve seen in the last ten years, these are all interesting and worth writing about and discussing. But putting that aside, Acupuncture is an ancient practice of mind and body INTEGRATION. It blends with oncology care without harm and with a peaceful and holistic vibe. It can help with a variety of common symptoms, symptoms that have a wide berth (think room for different responses in different bodies) among individuals. It is passive and relaxing. The patient is in control of the when and where. Yes, this is Integrative Oncology!

We have offered acupuncture as a service within our Wellness and Integrative Oncology Program for over a decade.

I’m exploring Substack to share my perspective and reflections as a conventionally trained medical oncologist and hematologist with an interest in the in between spaces of cancer and health care.

I’m starting with short pieces once or twice a week. If you like what you are reading, please share.

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A biopsy establishes a cancer diagnosis. It refines the characteristics of the cancer in order to understand the prognosis. It sets up the treatment plan. And it is the anchor to which human beings cling for describing what is happening when asked by friends and loved ones.

If the cancer returns, the biopsy will re-frame and re-shape what is next. If that cancer returns again…and again, the biopsy can help human beings process the forward march of cancer to gather support, strength, acceptance, hope, rage, fear, despair.

If communication around this anchor is respected and treated as such, the biopsy can be the platform for the most excellent of cancer care.

I did not always realize this. Like other professional self-discoveries, it seemed to crystallize out of nowhere on a random weekday afternoon. It seems pre-determined, this click of weaving the rigor of my education into the softness of my human skills.

A biopsy starts the cancer story. It also continues the story. And quite often, it frames the ending of the story. For every progression or recurrence, we re-visit this place.

A pause

A re-set

Knowledge

Science

Questions

Repetition

More questions

More knowledge

Comprehension

Shared Decision Making

A plan

In Oncology, a biopsy is the gold standard for where to start.

I’m exploring Substack to refine my voice and point of view, to share my perspective and reflections.

I’m starting with short pieces once or twice a week as I get to know the platform and open up this new channel of my brain and heart.

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I am an Integrative Oncologist

I am a conventionally and rigorously trained medical oncologist and hematologist. But I’ve always felt different.

I remember in medical school, during a second year filled to the brim with classroom learning, we finished a unit on Pulmonary medicine. Theoretically, we were taught the science of our respiratory system. I memorized proteins and anatomical structures. I sat through lectures where research faculty showed busy slides of charts and graphs that made my brain feel thick. A strong memory persists from that warm and dimly lit lecture hall of me wondering: “But why do we cough?” “What is breathing?” I had no idea.

Years later, as a medical resident in the VA hospital in Washington DC, I found myself taking care of a quadriplegic veteran in the ICU for over a month. He had no ability to communicate or move. He had FULL CODE status, meaning resuscitation using CPR, intubation, defibrillation with any decline. With the macabre humor that comes with high stress and poor sleep, we called this patient “The Torso”. I silently cursed getting awoken at 2AM to pound his chest and use chemicals to keep him alive. I was struggling to understand what life force is, what is communication and medical literacy, how can we lose our empathy and ignore the mismatch of medical resources. I had no idea.

As a developing medical oncologist and hematologist, I did just that- developed. I found my power in cultivating relationships with patients and families where I could guide conversations around goals of care. I took a stand with other doctors when I felt my patients were not being valued or respected. I honed a respect for the unknown, for the individual, and for the holistic nature of health and wellness even in the gravest and most complex of diseases, cancer.

About a decade into my career, I was able to formalize my identity as an Integrative Oncologist. At my institution, I started a program called Wellness and Integrative Oncology. I saw patients who wanted more guidance on food, exercise, non-pharmaceutical methods to manage symptoms like nausea and pain and anxiety. I spent time listening and helping support autonomy, empowerment, out of the box decision making. But most importantly, I started honing an ethos that pulled at me since that afternoon in the warm and dimly lit lecture hall. I saw things differently.

I’m diving into Substack to refine my voice and point of view and to share my reflections. I have several evolving projects that I hope to describe on this platform too.

I’m planning to post short thought pieces once or twice a week and tailor my content to the health politics, stories from my clinical experiences, and specifics around my new ventures which aim to address unmet needs in the oncology space.

Please subscribe to Cancer Beyond and Between: Reflections from an Integrative Oncologist.