Being an Oncologist – On the Art of Oncology, Difficult Conversations and Life

It was 2 in the morning, and oncologist Rebecca Shatsky had not yet fallen asleep. Metastatic (spread to other organs) breast cancer was what the patient had, and Shatsky could not stop thinking about them. The patient's cancer had caused no symptoms until it reached an advanced stage. Their bone marrow was weakening, and their liver was not looking good either. Rebecca Shatsky, a medical oncologist at the University of California, San Diego (UCSD), had a plan ready to treat the patient, but still felt uneasy. “To be honest, I did not know whether the treatment would work.”

Unable to sleep that night after visiting her patient in the hospital, Dr. Shatsky reviewed her next move and tried to reassure herself that it was the right one. Having someone's life depend on the decision you make puts you under considerable pressure. In the quiet hours of the night, those worries grow even larger.

• Related topic: What Is Oncology? The Roles of Medical Oncologists and Radiation Oncologists

Shatsky was not alone. Oncologists face this difficult situation every day, and many wrestle with these decisions after a long day in the clinic. Aaron Goodman, a hematologist at UCSD, knows that experience: “There is no off switch. I am always thinking about my patients, constantly,” he said.

People rarely see these private moments. From time to time, oncologists share their personal experiences, but views on the ethical, emotional and psychological effects of practicing medicine are largely inaccessible to the scientific community.

Most oncologists carry this burden home with them because they have no other choice.

Mark Lewis, head of Gastrointestinal Oncology at Intermountaion Healtcare in Salt Lake City, Utah, describes this process: “Simply put, when I have 7 patients who need my full attention before lunch, I do not even have time to notice the weight of the day. I can assess what I am going through only when I am outside the hospital and my mind is calmer.”

What Am I Missing?

Hematologist Dr. Aaron Goodman remembers the weight of every decision he makes. He concentrates on every detail of a patient's imaging, laboratory results, history and symptoms. But no matter how many times he checks and rechecks, one question keeps nagging him: “What am I missing out on in life?”

Doctors need this exhausting and comprehensive level of attention for their patients' well-being.

“If mistakes are made, it costs someone their life. Nothing can prepare me for that responsibility. Until it rests in your hands, it is impossible to understand how much trust a patient places in you.”

Goodman says this trust became clearest when he faced a decision about how to treat a patient with leukemia in remission (treatment completed, with no signs of disease).

The patient faces a high risk of the cancer returning, and you give more chemotherapy to eradicate any leukemia cells that may still be lurking. A stem cell transplant significantly increases the chance of a cure when you choose it, but the patient may also die within 100 days after the transplant.

“The accumulating scientific evidence shows that stem cell transplants help patients, but on an individual level, they can also cause harm. Some people may live for less time because of a decision I make.”

For patients with advanced cancer, oncologists may have to think several moves ahead. Planning a patient's treatment options in detail is like playing chess. Oncologists try to anticipate how a tumor will behave, what it will do, and how lifestyle factors will affect the patient's current and future responses to treatment, and then act accordingly.

Dr. Shatsky describes oncologists' efforts to develop the best possible treatment plan: “This is a game of intelligence. Like in chess, I try to outwit my opponent. But for advanced cancers, there are no clearly defined rules or a single way to manage the disease, and I have to do the best I can with the drugs I have.”

The Art of Oncology

This is the art of oncology: balancing what we know and do not know about a person's cancer with the toxicity of treatment and the patient's hopes and goals.

Dr. Don Dizon, chief of Medical Oncology at Rhode Island Hospital and director of Women's Cancers at the Lifespan Cancer Institute, will see many patients with advanced disease throughout the year. In these cases, a question he often struggles with is whether more treatment will simply cause more harm if the patient cannot be cured. Dr. Dizon recently faced this dilemma with an older patient whose metastatic disease had not improved with the initial treatment regimen. After outlining the risks that further chemotherapy could bring, he explained that stopping it and simply treating the patient's symptoms could be an option. “It is an impossible choice.”

Chemotherapy can relieve symptoms caused by tumor growth, but it can also cause side effects — and patients may be frail and may die from too much treatment.

Dr. Dizon remembers saying to a patient with advanced cancer: “I told my patient, if you really want to try more treatment, that is okay, but if you do not, that is okay too.”

The patient's answer was: “You have to tell me something definite.”

But for patients approaching the end of life, there is often no right answer to give.

“This is part of the discomfort you experience as a patient and as an oncologist, and it follows me home after I leave the clinic. At the end of the day, I need to look in the mirror and know I did the best I could.”

The Difficult Conversation

Every Sunday, Dr. Lewis feels the weight of the week ahead. His wife is a pediatrician. "Sunday scaries" is what they call it.

Lewis spoke about rehearsing how to deliver news that someone has advanced cancer or that cancer has returned in a patient who had once gone into remission, and about the tension of the sensitive conversation ahead.

For every oncologist, delivering bad news is an essential part of the job. But after spending months, sometimes years, with patients and their loved ones, Dr. Lewis says he can read the room — who is likely to prefer a more direct, realistic approach and who needs a gentler conversation. Lewis says, "The longer you know the patient and their family, the better you can gauge the best approach, and for some, you know it will be absolutely devastating no matter what."

Dr. Jennifer Lycette, medical director of Oregon's Oncology and Hematology Care Clinic, says that when preparing for a difficult conversation, she considers every possible direction it might take. Sometimes the brain gets stuck in a loop, moving back and forth between different paths over and over.

“For years, I did not know how to cope with it. My medical training did not teach me ways to handle it.”

Hours after a visit, the question that lingered in Dr. Lycette's mind was what she could have done better. She knew from experience how important it was to choose words carefully.

Early in her career, Dr. Lycette had a patient with stage 4 cancer who wanted to know more about dying. Because most people ask about pain, she told her patient that, with this type of cancer, they probably would not experience much pain.

“It will probably be like falling asleep.”

But at Lycette's next visit, her patient told her they had not been sleeping. They were afraid that if they fell asleep, they would not wake up. It was then that Dr. Lycette realized the power of the words they chose and the importance of trying to understand their patients' inner lives.

An Oncologist's Life Outside the Clinic

Sometimes an oncologist's late-night reflections have nothing to do with the cancer itself.

Manali Patel, a medical oncologist at Stanford Hospital and Clinics and the VA Palo Alto Health Care System in California, found that her patients worried about whether they would have enough to eat and whether they could get help.

“I woke up at 3 one morning, thinking about how to fund a project for patients from low-income households whom we had found were having serious problems accessing food — what funding we needed and which foundations we could work with.”

The last few years of the pandemic added another concern to Patel's list. “I do not want my patients to die from a vaccine-preventable virus (SARS-COV-2) after they have already suffered so much.”

This thought fuels her worries about how her behavior outside the clinic could unintentionally harm her patients. Should she go to a large medical conference? A family gathering? The grocery store?

Inevitable Losses and Gains

For those with metastatic disease, treatment options will eventually run out. Dr. Shatsky prefers to be open with patients about this reality: "The day will come when I tell you there is nothing more I can do for you, and you need to trust that I am being honest with you, and that is the truth."

Dr. Goodman says the devastation that bad news brings to patients and their families is incredible. He knows there will no longer be normality in their lives. "I see so much suffering. But I know that suffering exists whether I see it or not."

That is why holding on to victories can be so important. Goodman recalls a young patient who came to him with a 20 cm tumor and is now cured. "If I had not met that person and done what I do, they would have died, but now they will live their life. Yet I do not wake up at 2 thinking about that."

Shatsky says she takes great pleasure in patients who respond well to treatment and whose tumors shrink or disappear — patients who are doing really well, moments when she can help a friend or colleagues — and that these moments outweigh the pain, worry and workload. Dr. Dizon, meanwhile, handles a great deal of 'gray' work. "It is important to be useful; it is important to know that you can make a difference," he says.

There is a delicate balance. Dr. Lewis says, "I think patients want an oncologist who is interested in their outcomes and truly cares, not someone who is very sad all the time. When I lose a patient, I still grieve every loss, but I cannot mourn every patient like a family member. Otherwise, I would not be able to bear it."

What Would You Do If You Had Advanced Cancer?

Everyone experiences this differently. Dr. Dizon recalls how a friend handled the news. “They went home and were cooking.”

Dr. Dizon says the friend ultimately lived for many years. They had time to see their children marry, meet their first grandchild and prepare for the end of life, and did many things that not everyone has the chance to do.

“That is why it is important to do what you normally do for as long as you can. Live your life."

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• Related topic: Has Living With Cancer Made Me a Better or Worse Doctor?