Out Living

My wife and I were watching Ryan Seacrest’s awkward banter with Miley Cyrus two nights ago, and as 2014 happened I silently shuffled out of the first half of my training as a cancer doctor and into the second half.

It may seem like an arbitrary transition, but in my mind it’s one of the top ten most important moments of my life, despite the complete absence of pomp or circumstance.

My relationship with cancer is complicated.

Part of the story is, when I was in high school, my dad broke the news to my family that he had prostate cancer, which turned out to be early stage and he was cured with surgery. He had already had thyroid cancer about 10 years prior but had also been cured of that, and I wasn’t totally aware of it because I was four years old. When I was in college he told us he had lung cancer, and despite the fact that it was diagnosed at a pretty early stage, they weren’t able to cure that one and four years later it took him.

Now I’m more often on the delivery side of this type of news, and it’s not that much easier.

A few times in the last 6 years I’ve had a chance to answer the classic conversation starter, ‘so, what do you do?’ When I was an internal medicine resident, there was no trepidation answering this question. The answer was usually met with one of the following:

  1. ‘Wow, it’s such a long road to become a doctor. Hopefully it will be worth it for you.’ (On the whole, it has been.)
  2. ‘Do you think Obama will be able to fix the health care system?’ (I’m not sure, but that would be great. Or at least if someone could.)
  3. ‘Hey, you must be tired.’ (Yeah, but it’s not much harder than having a newborn baby every few months, which is better than it used to be.)

When it comes up in conversation that you’re a cancer doctor, you may get one of these responses.

  1. Horror or disgust: “How do you deal with such horrible things every day?” (The vast majority of things I deal with every day are the opposite of horrible.)
  2. Anger: “How have we spent billions of dollars on research for cancer and we still haven’t found a cure?” (Research is hard and expensive) or “I’ve heard that chemotherapy really doesn’t help anyone, and that it’s mostly just drug company marketing.” (Mixture of false and slightly less false.)
  3. Sympathy: “I can’t imagine having so many patients die.” (You don’t need to feel sorry about this, I’m not the one who’s dying.)

And then there’s the quiet head nod, lips pursed, like whomever asked the question wants to say something but doesn’t quite have anything that matches so they just pause awkwardly and wait for someone to interrupt the conversation or for some other distraction to happen.

One of the conclusions I draw from this difference is, in general, a lot people believe a diagnosis of cancer is the hopeless end of the road. I don’t think it’s outrageous to say that for a majority of cases, this really isn’t true.

A diagnosis of an incurable cancer (which applies to many stage IV cancers) is tragic and the amount of fear struck in the heart and soul of the diagnosed is very well-placed. But I think this fear needs to be fear of the appropriate thing, and I think we need to talk about the rest of it.

It’s not a war. Living with cancer does not make a person a soldier.

Tenacity is a wonderful trait but electing to stop chemotherapy is not the same thing as giving in.

We can name the fear, and sometimes it’s fear of pain, sometimes fear of chemotherapy; very often it’s fear of the unknown or fear that a mistake has been/will be made or fear that what actually happens when we die isn’t what we’ve always thought happens when we die, and now it’s concretely important rather than abstractly intriguing. Often naming the fear gives us the handhold we need to explore it, or face it more confidently, or find the solution for it.

Sometimes we can’t. Sometimes an incurable cancer means our life is going to be shorter than we thought it would be. That’s why I think this conversation is important.

There’s a period of time between an incurable cancer diagnosis and the moment when a life ends, and that entire period of time contains life. Sometimes this time is months, sometimes it’s years, sometimes it’s weeks. Far too often we doctors, we patients, and we patients’ families are so distracted by the perceived inevitability of death that the life contained therein passes by, and sometimes we forget to live it.

Don’t forget to live it.