Questions for the Oncologist

"Questions for the Oncologist," by Barry Meisenberg: an oncologist struggles to answer a patient's "Why me?" question.

Transcript

Narrator: Questions for the Oncologist by Barry R. Meisenberg, MD (10.1200/JCO.22.00158)

Go ahead, ask me anything. Decades of meeting beseeching eyes has prepared me. Ask me anything except that one thing. That one thing that neither colleagues nor study has helped me comprehend.

Ask me instead about prognosis; I will be honest, but gentle. Ask me about side effects; I will use a small spoon so as not to overfill your vessel. Unfold your notebook. Ask me anything:

"-how many cases like mine have you seen before? -what is the nectar of the bone marrow? -what (and how) should I tell the children? -is it wise to lay in the sun?

-is it safe to have sex? -should I get the vaccine? -what's next if this doesn't work? -what if it were your wife?"

Go ahead, ask me anything. But please, don't ask me that one thing. Don't ask, "why me?" You wouldn't like the answer. I don't.

I could fill your notebook with a tale of random errors in the genes. Tiny rivulets of mutation that flow into a tumultuous river. But, I don't think of them as errors. Rather, they are Nature's engine of biodiversity. Individuals suffer, so that species survive.

"Bad luck" is a second-rate explanation, I know. So please, don't ask me that one thing. Search for a better answer within, as I have. Unsuccessfully, so far.

Dr. Lidia Schapira: Welcome to JCOs 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.

I'm your host, Lidia Schapira. And with me today is Dr. Barry Meisenberg, Chair of Medicine and Director of Academic Affairs at Luminous Health. We'll be discussing his Art of Oncology article: Questions for the Oncologist. Our guest has no disclosures. Barry, welcome to our podcast.

Dr. Barry Meisenberg: Good morning. Thank you very much.

Dr. Lidia Schapira: It's a pleasure to have you. And before we start to talk about your poem, and the reason for your wanting to share this with a broad readership, mostly of Clinical Oncologists, let me start by asking if you are a poet and if you often write to reflect on your experiences as a physician, or for other reasons?

Dr. Barry Meisenberg: Well, I will never give myself that label of poet. I have written several, what I would call reflections on what it is to be an oncologist, which this section of the JCO covers so well.

Sometimes I've submitted work and said it was a poem and the editor said, 'No, this is a vignette.' Another time I thought it was a narrative and someone said, 'We liked your poem.' So, increasingly, I've entered this area reflecting a career's worth of introspective thoughts about what it is we do.

Dr. Lidia Schapira: So let me ask you, given your very particular vantage and your experience, why do you think it's important for us to write and read reflections? What does narrative give us as physicians, as cancer doctors?

Dr. Barry Meisenberg: Well, I think it gives us the other parts of our brain and the other parts of our personality as humans. The most humanistic of all the sciences is medicine. We can't neglect that. Mostly for our own health. But also, I think it makes us better physicians when we think about what we're doing.

You know I think it was a physician author, who said that we walk around in the midst of stories. Every one of our patients has a story, sometimes multiple stories, and if we miss that, and don't really capture that, then we're just sort of functionaries.

Dr. Lidia Schapira: Such an important thought. There's definitely plot. There are characters. There's the scenery. There's all of this very rich life and human content and I couldn't agree with you more.

So, before I ask about this particular essay, what are you reading now or what have you read in the last year that you would recommend to your colleagues?

Dr. Barry Meisenberg: Well, it's interesting you say that because, recording here in April of 2022, I've talked to many of my neighbors about their pandemic hobbies, both medical and nonmedical, and they're, you know, learning to bake, reteaching the piano, and working on developing their rhomboids.

I've been doing a deep dive into the history of other pandemics. I may be little obsessive, but I've been reading about pandemics throughout history, and just appreciating the fact that human nature hasn't changed very much, nor has medical behavior.

So, in Defoe's book, I think it's called Journal of a Plague Year, which by the way, is not history, is a fictional journal but based on reality. We have the same sort of medical charlatanism. We have false hopes. We have people trying to beat the quarantine for their own good.

At the same time, we have just public-oriented behavior as well, feeding those who couldn't be fed or who would become orphaned by the plague. The same thing is true of the 14th-century plague.

It's just remarkable how little we've changed as a species, all the behaviors on display today, both good and bad, were on display then. And so, I've been reading quite a bit about pandemics.

Dr. Lidia Schapira: It's so interesting. Now, with that, let's focus on your beautiful poem, the question that you can't answer after all your scientific work and after your decades of clinical experience, "Why me?".

Tell us a little bit about what inspired this poem that I found so moving, and I'm not a great reader of poetry. But this one message was so clear that I think most of our readers will understand the sentiment. What inspired you to write it?

Dr. Barry Meisenberg: Well, I woke up with this one. Sometimes that happens, you wake up with a poem that is nearly fully formed, or a narrative is nearly fully formed in your mind.

Although I did get some excellent suggestions from my reviewers that I do appreciate. And I realized only after it was on paper, that seven years ago, I wrote a piece for a different oncology journal about this issue of random chance. And you may remember, in 2015, there was an article, or a science magazine published an article by Thomas Heti and Bert Vogelstein about their mathematical calculations of errors in stem cell division.

They didn't do any new experiments. They accumulate what was already known, and they were able to correlate that with the incidence of cancer from the cancer databases. And their conclusions were, when stem cells make random errors, there's more likely to be cancer.

Now, they didn't cover every type of cancer. They covered several. And they came up with this idea that cancer is stochastic, that is a random process. Now, stochastic is not a poetic word. And so, we didn't use it in the poem, but random, and that was covered extensively in the New York Times and other media, and a big debate about what it meant.

So, I wrote an essay about that, and I realized it's been on my mind all this time, and whether it's a helpful notion or a harmful notion. Helpful in that patients can understand you didn't do anything to give yourself cancer, despite all the media noise about that, but harmful, potentially harmful, in this idea that maybe my life doesn't have meaning if this is just a random process.

And so, I talk to patients about this when appropriate, because many of them have thought about it. So, it's sort of been on my mind since this article I wrote in 2015. And I must say, it disturbs me that I don't have a good way of explaining that or helping patients overcome this.

Dr. Lidia Schapira: So, when a person asks you why me in some way, I mean, you, first of all, you tell us that you have answers for most of the other questions, what is my prognosis? You can answer. How do I tell the children? You can answer. Is it safe to have sex? You can answer.

But the "why me" question is still with you and still troubles you. What is it, in your view, that a person is really asking you? What is the question behind the question when they say 'why me?'

Dr. Barry Meisenberg: Well, that is the question. And then I think what they're saying is what does my life mean? Yeah, if the answer to Dr. Vogelstein is correct, that it's stochastic, doesn't mean my life doesn't have a meaning. I hope people wouldn't draw that conclusion.

So, random things happen to people, both nice people, and mean people all the time. I remember when I was in New York doing a year of research at Sloan Kettering, there was a helicopter accident, and it didn't just kill the people in the helicopter, but a piece of the blade broke off and spun out over Manhattan, killing someone who was about to walk into a retail store, totally random. It had an impact on me in how all our lives hang by a thread, or it can, and cancer is like that.

Dr. Lidia Schapira: What I hear in the "why me" question is also sort of a plea for, please reassure me and keep me safe, because this happened, and you have no explanation, I have no explanation. So, it's interesting that you talk about life's meaning. I see it more as a cry for help. If I can't deal with the uncertainty and the chaos of the universe.

Dr. Barry Meisenberg: That's an excellent perspective. And you may well be right, at least for many people. It's almost like a real issue of faith and religion, or more faith and religion. When I say in the piece, 'you have to look inside for that answer, why me and what your life means?' Yeah, people ask questions for a reason. Some of it is just fact downloading, the risk of mucositis, how to treat mucositis, and so on. But other, the more important questions are these.

Dr. Lidia Schapira: And that's one of the beauties, I think, of poetry and why we love to publish great poems because it's almost like a bit of a Rorschach too, right? You can read into it, you can interpret, you can use a poem as a way of exploring an important topic, and bringing perhaps to the surface some of the questions that you also deal with, as a human, instead of only your skill, as an oncologist or as a physician used to counseling people.

Dr. Barry Meisenberg: I think that is one of the values of poetry. I run a program here at this health system that we call the Diastole Hour because it's important for relaxation. You can't live your whole life in systole. That's the message.

And we use poetry a lot, mostly written by patients about their medical experiences, sometimes written by doctors about what it means to be a doctor or be a better doctor. And then, of course, some art that covers medical topics. And the whole goal is to train that other part of our brain to make us better at the business part of being a doctor, and I think the two are related.

Dr. Lidia Schapira: Do you read poetry with your fellows or with your trainees or junior faculty? How do you incorporate this kind of thinking in their professional life? How do you use it to build a community?

Dr. Barry Meisenberg: Well, that's a great point. I wish we could do more. So, I read some poetry. I am not trained in it and I tend to look for poems that one doesn't need to be an expert in the classics to understand and we use them at this event I've told you about. But also, I've been known to sneak them into Grand Rounds presentations and other venues, trying to make people pause and think a little bit about it. There's some wonderful poetry about the physician experience, for sure. And I sort of collect them.

Dr. Lidia Schapira: What are some of your favorite pieces?

Dr. Barry Meisenberg: There's a neurologist named Ginsburg, who has written, I remember one poem, in particular, called "Line Drive". And it's about a man, presumably, based on a true story, who is explaining to someone their brain tumor anatomy during a hospital visit, and pointing at shadows, but recognizes that he doesn't actually do any touching. He doesn't enter their lives. He doesn't answer all their questions like the one we just talked about. And then he's driving home, and he stops at a little league Park and watches some boys play baseball. And one of the boys is struck by a line drive. And he's so moved, by the way, his teammates gather around him and offer support and touch him and help him that he drives back to the hospital to redo the consultation he had just finished doing, but this time with the touching. I thought that was a wonderful poem.

Dr. Lidia Schapira: It's an amazing poem.

Dr. Barry Meisenberg: I read that poem in Abu Dhabi, actually, to an audience, few of whom knew baseball, so I sort of had to explain it to an audience of oncology professionals. I might have missed my mark, I don't know, but I wanted them to understand certainly the importance of entering patients' lives.

Dr. Lidia Schapira: Have you always felt this way about using narrative and poetry as a means of reflection, self-expression, and dialogue? Or is it something you came to later in your life as a more mature professional?

Dr. Barry Meisenberg: Definitely the latter. I mean, I was fortunate in that I had good cultural capital growing up, but I didn't really incorporate it into my other life, my professional life until I'd say the last 10 years or 15.

I've always been an admirer of Shakespeare, by the way, he wrote about the plague a little bit too, indirectly. And then one time I actually wrote an essay about this: I was given a poem by a patient, who was from Ireland and this is sort of like the national poet of Ireland. And it was his way of telling me, he didn't want any treatment. And the poem is about loss and lamentation that accumulates through life, and all his friends were in the graveyard.

He wasn't interested in therapies that are designed to induce a response rate. He didn't want any treatment. The way he communicated that was through a poem. And I began to understand that really in a more realistic way that poem can do that.

Dr. Lidia Schapira: Well, thank you so much for your insights. It's been a wonderful conversation. Is there something else you would like to tell our listeners and perhaps even a thought for future readers of the poem?

Dr. Barry Meisenberg: By the way, I should say that the name of that poem I just referred to is called "Oft, in a Stilly Night". It's the first line of an Irish folk song. But I would hope people take the time to indulge. Many medical journals have sections like this, they're usually short. And I will tell you, that's the first thing I read in these medical journals. I hope people will follow that pattern.

Dr. Lidia Schapira: Thank you so much, Barry. It's been a lovely conversation. Thank you for your work, and thanks to the readers. And more next episode of Art of Oncology.

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