David Perez
On the surface medical oncology does not seem an attractive career choice. Medical oncology refers to the treatment of cancer by drugs, including chemotherapy. This carries the connotation of patients suffering miserable side effects of treatment and ultimately treatment does not prevent death from the disease. During my training at the University of Auckland Medical School I had no particular awareness of oncology as a career choice as students were not placed on an oncology attachment. Following graduation I spent a year working in a provincial hospital, Taranaki Base Hospital in New Plymouth, then I returned to Auckland Hospital where I was assigned to work for six months on the oncology ward. Oncology wasn’t a popular attachment and I wasn’t overly happy about the prospect. Paradoxically working in oncology proved to be a positive experience and I learnt a lot that had not been highlighted in medical school. This reflected the medical school curriculum of the 1970s which taught a great deal about disease and treatment but not so much about the experience of illness and the impact on the whole person. This unplanned experience in oncology stimulated sufficient interest to consider oncology as a career choice.
Medical oncology was just emerging as a dynamic clinical discipline in the early 1970s. In terms of treatment chemotherapy was creating minor sensations for the treatment of previously fatal conditions such as lymphomas, Hodgkins disease, testicular cancers and the cancers of childhood. For some of the more common cancers, such as breast cancer, cure was more elusive but chemotherapy could still produce good remissions. Pharmaceutical companies were lining up to develop new cancer drugs and we had high hopes that cures would eventually be possible for some of the common cancers. This buzz in cancer treatment circles was equalled by exciting developments in cancer research.
From the patient perspective oncology posed many challenges for the young doctor. In my day medical school did not prepare you to handle the acute distress associated with a new diagnosis of incurable cancer, how to handle anger in patients or families, how to present information about prognosis, how to present and negotiate treatment options in a non-prescriptive manner, how to handle the issue of complementary therapies, how to talk about dying and many other issues. These challenges are the hardest aspects of oncology and by comparison managing difficult treatments and side effects seemed more straightforward. Paradoxically, managing these issues well can bring great rewards. The majority of young doctors quickly decide that oncology is not for them but a minority become captivated by the oncology world and this proved to be my happy fate.
The six months I spent on the oncology ward sparked a developing interest in whole person care, the great resilience of the human spirit, the importance of team work, the importance of good communication and explanations, the importance of the therapeutic relationship and the importance of putting effort into achieving small improvements even when acknowledging that the war will be lost. Other positives included the fact that increasing numbers of patients were cured, people with cancer generally seemed to be ‘real’ people, humour was more evident than elsewhere in the hospital, the doctor-patient relationship commonly extended over 1 to 2 years and, lastly, staff in oncology were very supportive of each other. Role models were another strong feature of my experience. The power of role modelling should not be underestimated and encouragement from someone you respect can be compelling.
Following my initial specialist training in medical oncology in Auckland, I moved to Sydney to take up a research fellowship at the University of Sydney. My research involved mechanisms of chemotherapy action and how to maximise damage to the tumour while avoiding severe side effects. At this time in the late 1970s chemotherapy remained the big hope for improved outcomes in cancer treatment. This included the emergence of post-operative chemotherapy for patients with breast cancer who had been cleared of all visible cancer by surgery but were still considered high risk for relapse of their cancer. This posed the dilemma of recommending toxic chemotherapy to people who were well and without any obvious evidence of residual cancer for the sake of reducing the risk of future relapse. As with all preventive treatments this is demanding territory for communication skills. Around this time screening for cancer, particularly for breast cancer, was emerging as another strategy to reduce the impact of cancer.
Following my time in Sydney I moved to London in 1981 to take up a clinical fellowship at the Royal Marsden Hospital which was an institution dedicated to cancer research and treatment. The Royal Marsden was involved in research into high dose chemotherapy followed by bone marrow transplantation to rescue the patient from the life-threatening inhibition of bone marrow function, blood production and immunosuppression. Ultimately, high dose chemotherapy became established for the treatment of some leukaemias and lymphomas but disappointingly proved not effective for the commoner cancers such as breast cancer.
In addition to the impressive developments in research and cancer treatment at the Royal Marsden there was ground-breaking research activity in psychological support for those suffering from cancer. The impacts of cancer are not confined to the physical illness and there are commonly major negative effects on psychological, emotional, social, fitness for work or normal duties and, as more recently understood, spirituality. London was also at the forefront of the Hospice movement with St Christopher’s Hospice leading the western world in the provision of high quality care for those with a terminal illness. New Zealand was catching up with establishment of Hospices in the 1980s, but this was twenty years behind the British initiatives. Hospices have contributed greatly on many fronts by demystifying the process of dying and trail-blazing holistic care for those who are dying. This has had a positive spin-off for oncologists by expanding our view of the needs of those with terminal illness and supporting us in our management of this challenging aspect of medicine. The promotion of holistic care for those with cancer, including the terminal phases, in the latter part of the twentieth century has been a powerful contributor to the improved care of those with cancer.
My specialist training in medical oncology finished in 1984 and I returned to Dunedin to take up the post of medical oncologist at Dunedin Hospital and senior lecturer at the University of Otago Medical School. I was literally the second vocationally trained medical oncologist in New Zealand. Dunedin was foreign territory to me but its charms soon showed and I have spent the last 33 years here. Medical students are always stimulating and challenging and my work in the Medical School provided a helpful foil to the demands of oncology practice. Today’s education of medical students has a much stronger emphasis on the patient’s perspective of their illness and what they hope to achieve from medical care. Previously the doctor’s agenda took precedence but now the patient’s agenda is acknowledged and is built into the medical management plan. The partnership between doctor and patient is fundamental to good oncology practice and is a welcome change to the philosophy of western medicine. The impact of this change will not happen overnight but is slowly and steadily changing the doctor-patient relationship.
Dr David Perez is a recently retired medical oncologist at Dunedin Hospital and Director of the Early Learning in Medicine Programme, Faculty of Medicine, University of Otago (Dunedin, New Zealand).
Read the second part of this article here.
It is so encouraging to read of this change in focus in cancer treatment, and in the training of doctors.
Clearly great work by Doctor Perez.