Reflections in a Head Mirror

“Doctor, what did you need to take out during the surgery?”  

“Let me show you.”

I pull out a dry-erase pen. During the post-operative discussion in the Family Center, I often draw out the procedure on a white board. I sketch the basic relationships between the structures and show what was removed and what was preserved.
 
“We removed this area and the lymph nodes from these areas of the neck." I erase the structures that were taken out. "When you see him he will have an incision here.”

The drawings serve as an additional communication technique. The families seem to appreciate and understand them and they are usually much simpler to interpret than photographs.   

Early in my practice, I developed a series of quick line drawings that depict the regions where I spend my professional time: the oral cavity, the pharynx, the larynx, and the neck. I use the pictures in my office notes and in hospital charts and almost all of my notes have at least one drawing. They serve to remind me what I saw and what I need to check at the time of the return visit.  

Believe me, I am no artist. Nevertheless, every few years, my residents ask for a demonstration of how I create my drawings. I am gratified when they discover this simple means of communication. I think some of them enjoy it as much as I do.

We baby boomers are in for a lot of shocks over the next years. One surprise might be too few cancer specialists to take care of us.  

An article in the March 2007 issue of the Journal of Oncology Practice predicts that there will be between 2500 to 4000 too few medical oncologists by the year 2020. The problems swirl around the fact that training programs are not expanding, the U.S. population is aging, and older individuals develop most new cancers.  

Another issue is the increasing number of cancer survivors. The United States currently has about 10 million cancer survivors, a number that is expected to double over the next 15 years.  

What can be done? Oncology training programs could increase the number of new oncologists, but even that would not cover the expected demand. Nurse practitioners will see more and more patients. Many cancer survivors will get their follow-up from primary physicians.  

Personally, I regularly encourage medical students to consider careers in cancer specialties. I tell them that cancer physicians assume demanding, rewarding and critically needed roles. Of course, knowing that the lifetime cancer risk is one-third for women and nearly one-half for men, there is a significant probability that I, too, will need a great cancer doctor myself someday.

Several days each year, I teach high school health classes about smoking. The kids, no doubt, understand that a middle-aged physician is going to tell them that smoking is bad. As I begin, they are polite but disengaged. As I run through statistics about teen tobacco use, they look around, stifle yawns, and do their math homework. Then I show them videos I made of some of my patients.  

One woman in her late 40’s had a recurrent cancer. She is lying in a hospital bed, gaunt, pale, and exhausted. She has a feeding tube in her nose. Her voice is hoarse and her movements deliberate. On the video, I ask her if she thinks her smoking had anything to do with her cancer.   “Oh, definitely,” she responds. Then, spontaneously, she continues, “Every time I see someone smoking, I’d just like to tell them about me and how much I have suffered.” She takes a deep involuntary breath and begins to cry. I have watched the scene dozens of times and it still affects me.

As she wipes her eyes, the kids in the classroom are transfixed to the screen and absolutely silent. I honestly do not know if this woman, now long dead from her cancer, has had an impact on individual kids’ smoking behavior, but I like to think that her testimony has made a difference in at least a few of their lives.    

As physicians, we continually encourage our patients to undergo regular cancer screening and to pay attention to recommendations about diet and exercise. What if our patients actually listened to us?  

The American Cancer Society recently issued recommendations for yearly MRI scans of the breast in addition to mammograms for high-risk women. These $1,000 to $2,000 tests are effective and increase detection of pre-clinical cancers.  

However, as one of the co-authors of the report recently described, we currently do not have enough MRI capacity or radiologists to interpret the volume of tests that would be generated by complete compliance with the recommendations.  

Quick reactions:  

She grips my hand. Hard.  

“Doctor, what does this mean?”  

She is looking for an honest answer. I have been her physician for ten years and she has fought off cancer twice, first with radiation and then surgery. Now her cancer has returned.  

“Doctor, my grandchildren are just now growing up.”  

She is looking to the future. She is in her seventies and in good health otherwise, but she senses the clouds gathering that threaten her future.  

“Doctor, I want to go back home to visit my sister.”  

She is looking at the present. She wants to spend time with her far-distant sibling before it is too late for each of them.  

“Doctor, you have helped me before.”  

She is looking to the past. She hopes that good fortune and technology can sustain her once again.  

“Doctor, please.”  

She looks intently at me. The harder she grips my hand the more I am humbled.