cancer, etc.

Hamlet is one of my favorite Shakespeare plays. Besides the richness of language, intense drama, and so many characters with sharp life, I can relate to Hamlet’s obsessive contemplation of his own consciousness. The accepted interpretation that Hamlet destroys himself with this introspection—he thinks so much that he can never act—is my own biggest fear. A major reason I want to be a doctor is to stop only thinking about stories and instead start shaping them. But I also feel that this assessment of Hamlet attributes his failure to one misleading cause—that is, he can’t apply his thoughts to real life. As hard and real of a problem that is for many, I don’t think Shakespeare had everyone die at the end merely to say, “just don’t think; just do it already.” It’s true that the tragedy lies in the disconnect between Hamlet’s interior and the outside world. But the source of that disconnect isn’t only his inability to externalize his desires, to physically do what he mentally feels. It’s also his inability to internalize his surroundings, to absorb what he sees and hears and relate it to himself. Because he never understands what the outside world has to do with him and his identity, he can never become a part of it and so can never make any sort of impact on it.

And so after our oncology module, a compressed period where I wished I could just-do-it and thereby not feel helpless, I’m still not doing, still trying to find time and space to internalize all we’ve been exposed to and were supposed to learn. Learning about cancer comprises a slim two weeks in our curriculum, devoted to teaching us the overarching mechanism of how cancerous cells arise, spread and hurt us, and how we fight back. We received a detailed lecture on breast cancer, as a model for other cancers, and a third of each of our three workshops is a case study of a specific cancer. But mostly we just learn about cancer as a whole. After doing leukemia research and interviewing cancer patients weekly during first year of medical school, cancer remains mysterious to me and I learned anew with this module. In class we learn about it scientifically, what distinguishes it from your normal cells, how it survives, and why it’s so bad. Once as we worked through cases someone asked a question I’d wondered often before: “What actually kills you?” A lot of things, any number of things.

In class we also learn about it emotionally, hearing patients speak about their experiences and physicians lecture on palliative care. We learn big topics in forty minute increments (resting dazed for ten minutes between lectures), eat lunch, and spend the afternoon being exposed to (depending on the day) age, illness, dying and death in hospitals and hospices and nursing homes. We dedicate any and all gaps in the day to studying. It’s made slightly easier and more pathetic by the fact that we’re in a group all doing the same things.

For people in their twenties, we hear a lot about death and all that goes along with that: the preceding disease, the lives that were had and how they changed. It makes me feel I’m on the edge of a world that’s eluded my grasp for so long, that I’m growing up and into real life. Then I learn in class that one way to reduce your risk of getting breast cancer is having a child before you’re twenty-four. I’m twenty-four, and I still am a child, and I wonder what exactly I’m supposed to do with the things I know.

The language of cancer is very distinct, not just a matter of science and technical terms but also a firm foundation of key concepts, containing a lot of m’s (metastasis, malignant, mortality) and rife with percentages and units of time. Like in other areas of science, we personify it. A professor called CML a naïve cancer because it involves just one gene, making it easier to target and eradicate. In pharmacology we learn that even though some drugs eliminate mechanisms that both cancer and normal cells use, they preferentially kill cancer cells because cancer cells get addicted to one mechanism. While a normal cell can rely on other means once one is taken away, a cancer cell has lost perspective and doesn’t know what to do with itself.

I think we personify disease to understand and fight it, but we also get addicted to our language. We talk about the effects of cancer and the success of treatment in terms of five-year survival. Which isn’t a very long time to survive. But no one addresses the instinctive thought that this living five years is almost the opposite of continuing to live, since we’re beyond instinct now. We know that if your cancer hasn’t overcome everything in five years, it either wasn’t that bad to begin with or treatment is good. We know our language so well that meaning surpasses words. I think I pay close attention to words and in a little over a week I forgot how to hear them and I learned this from being told so. During a lecture on palliative care, a kind oncologist whose gray hair and matching eyes projected a natural softness told us about his wife who’d had breast cancer and subsequently acute leukemia. After being diagnosed with leukemia, someone offered her comfort in the fact that 75% of people with acute leukemia have a five-year survival. When her husband came home to find her sobbing over this, he asked her what it was that bothered her, assuming that she’d interpreted the statement as a quarter of people not achieving five year survival. Instead, she told him, “I’m 41 years old. And I only have until 46.” She thought “five year survival” meant that she’d live five more years and then it would be over. Despite that being the words’ most intrinsic meaning, I hadn’t even thought of that possibility.

These thoughts slip me because the days are crammed. One went like this. We begin the morning with a workshop on lung cancer (the cancer that takes most lives, with an overall survival rate of 15%) and brain metastases. If cancer has traveled from your lungs to your brain, they will irradiate your entire brain (our notes remind us that these patients will experience cognitive defects). It’s deemed prophylactic, and after treatment you can expect to live for one year. Following workshop, we listen to the lecture on breast cancer, which feels both scarier and less so by nature of being so prevalent in the population and mainstream culture. I know several people with breast cancer (seems like many in comparison to the number of people I know who have other illnesses, which are few) and somehow that commonness made me complacent. I am surprised to find that despite improved screening and detection, the percentage of survival isn’t as high as I expected. A quarter of women diagnosed with breast cancer die from it. We then hear from a breast cancer survivor, someone in our Yale community, who speaks to us for a near hour about her experience. From this I realize the more significant thing I’d forgotten was the visceral challenge of being ill with something that has any chance of killing you, no matter how positive the eventual outcome. In another workshop our teacher mentioned a procedure having a 5% risk of mortality, which is low, but well, “high if it’s your risk.” It’s true that on a daily basis we all face some slight percentage of dying, but cancer means having this overshadowed by something concrete and pseudo-quantifiable and personal and internal.

One thing I appreciate in medicine is individual context amidst the absolute values of care and quality of life, and there are few places wherein relativity is as palpable as cancer survival. While cure is always the ultimate goal, cancer can be so ominous that small advances are noteworthy. For colon cancer that's spread so that it's incurable by surgery, chemotherapy can prolong life significantly, “in some cases, up to two years.” A new treatment for kidney cancer is seen as an enormous breakthrough because it prolongs survival by 50%—increasing it from two months to four. Of course four versus two is a lot when it’s all you have, and who’s to say how much worth lies in any amount of time. Still, here relativity can feel like a copout.

Later that afternoon, as part of our pre-clinical curriculum we speak to a patient whose care is palliative, meaning being treated not for cure but for comfort. Ours is an 83 year old man with the mischievous sparkle of a teenager, coated with a brand of boyish charm that only comes with experience. He’d been diagnosed with lung cancer that he didn’t want to treat. He’d lived long enough, he felt, and if it’s time, it’s time. Then he came down with some sort of abdominal infection that doctors told him would kill him within a day, and still he didn’t want treatment. He hadn’t been seeking to die, but nor did he seek to live. He said goodbye to his family, and then the infection miraculously cleared on its own, leaving him alive, albeit with cancer still. When we see him, one of the first things he says is that the idea of dying in one or two days didn’t bother him. “Does that bother you?” he asks, pointing at me as I’m still maneuvering to find the right position in a narrow chair. I’m confused as to what he’s asking and I interpret it to mean, does his acceptance of his death bother me? Which is not a normal question to ask at all, but I don’t have the two seconds it takes to overthink the question even more than I already have and realize this isn’t what he means. So I respond with a quick no and during the ensuing chorus line of no’s from my classmates that might’ve just been nervous echoes of my response, I realize what he’d actually meant. And no, I do not want to die in the next couple of days. I’m completely happy with the life I’ve led so far but that doesn’t mean it’s done. If it were to happen, I’d be grateful for all that I’ve had in 24 years. But yes, I would be bothered.

In the evening, I have a meeting for the geriatrics interest group, and after talking to Don about the day he asks why I like old people. They’re different from me and I have no idea what it’s like to be them. I think maybe they’re honest not because they have nothing to lose but because they know what honesty gives. They carry everything with them that I am still looking ahead to, and they carry so much. They’re living with what I work for each day: experience, and they take that with them to each next day, because despite all they’ve lived they haven’t stopped living anew. At the meeting we talk about our screening of Rolling, a documentary where three people in wheelchairs tape their daily lives. None of them are “old.” Dr. Berland, the filmmaker, tells us the film is being promoted by the geriatrics group because it’s about facing change with dignity, and independence. I’m struck by how very different each person is, done not purposefully but truthfully. One tells us in an off-center closeup that he has so many blessings, and that nothing can take those from him. But “being blessed doesn’t mean it doesn’t hurt.” Like that Whitman line about how he’s a contradiction, and that makes sense because he’s large and he contains multitudes. That’s what each day feels like, a multitude.

And all I can do is sit with my books, which can feel empty and wrong even if necessary and engaging. After that day I go to the architecture library to study about breast and lung cancer in detail, making semi-meticulous notes from the textbook and lecture notes and workshop we’d had in the morning, putting together the details of screening, diagnosis, subtypes, staging and treatment. That we have this knowledge is beautiful, but cancer is so mysterious and we know really so little. When we first start learning about diseases we learn what begins them and here often we only know the end. All this crammed in one day, and no time at the end to think about what it means and how to use it. For lack of time and energy, I furiously scribble down events and details, with hopes of returning to fill gaps, but so much will be lost. Another day brings more, the feelings will gain different nuances, the way I started writing about my dad’s truck and he sold it before I finished the story. I’ll forget how it all started, what it was like to not know and to be introduced into these big things, encased in a hospital room and a one hour interview, to learn from these people as med students and as people. If I leave it for too long, I may look back and think I’m past the age to absorb it. As if reflection on the beginning only saves you from a blurry end where you can’t look back and remember, if you do it before you’re twenty-four.