"Science is all metaphor." -Timothy Leary
I like to use analogies when counseling my patients. By phrasing medical situations or goals in language that creates a vivid picture I believe it helps patients to understand what exactly is happening to them, or what is the goal of treatment. Picturesque metaphors in my opinion are excellent teaching tools that leave a lasting impression whether it be on patients, family members or students.
Lately for some reason I've been handing out analogies like a slot machine with three 7s showing on it. Divine afflatus seems to have temporarily left the creative geniuses who deign to entertain us bumpkins and has come to roost, albeit temporarily, in mine own meager coconut. I recall three scenarios recently where I attempted to translate medical gobbledegook into radiant prose. I wonder if the gentle reader is able to match the clinical presentation listed below with the appropriate pep talk given to the patient.
Here are the circumstances. Think of each setting as a patient staring anxiously at you, wondering what this new information means to their chances for survival:
1. Classical Hodgkin lymphoma with 50% reduction in size of tumors after 4 cycles of ABVD chemotherapy
2. Newly diagnosed inoperable stage IIIB squamous cell lung cancer; no hemoptysis
3. Malignant pleural mesothelioma with decrease in size of pleural thickening and effusion after 6 cycles of chemotherapy with pemetrexed and cisplatin
The words of encouragement I gave are as follows:
1. "Sometimes we can destroy cancer as fast as blowing up a building. In your case, however, we are taking the tumor apart brick by brick. I know it seems slow, but in the end the result will be the same - no more cancer. Let's just keep chipping away at it until it is finally gone. Remember, even one person with a sledgehammer can bring down a house, if you give them enough time."
2. "I'd like to add a new agent to your regimen that attacks a very specific molecular target on the cancer cell. We call this targeted therapy, and I look at it as the difference between finding that one mouse hiding in your home and removing it versus burning the whole house down, which is how chemotherapy works. In both cases you become mouse-free - it's just that there's a little more collateral damage with chemotherapy, if you know what I mean."
3. "You know, in a boxing match the goal is not to kill your opponent, but just to knock him down so that he can't get up and attack you anymore. If you can do this, you will win. That is what we're trying to do with your tumor. We know we can't kill it, but we will do everything in our power to keep it down on the canvas, where it can't harm you."
And now the answers:
C'mon, this isn't some dumb sophomore psychology extra credit experiment! The appropriate response is matched exactly with the same numbered scenario. Anyone with a finely tuned brain should have been able to figure that out.
Or is this one of those "inside baseball" discussions that only oncologists will get? Mea culpa! Me transmitte sursum, caledoni!
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Great post. We use analogies ALL THE TIME when dealing with physician candidates too. Telling a story or using an analogy allows us to allow the candidate to make the connectionand it is more effective than we just tell them what they were thinking was a little off... some doctors have been known to be hard headed.
Good analogies. Yesterday my oncologist came in and said "Congratulations, you made straight A's, but flunked in extra credit. I'm sending you to get a CT scan." Meaning being "Blood works great, but I'm concerned about the (minor) pain.
Your analogies are perfect, and a model for other physicians. I think clarity is indispensible, and have been amazed regularly at how some fellow docs seem unable to get past jargon and think about ways make complex issues understandable. I had similar ways of explaining surgical issues and disease, and felt it invaluable.
On a marginally related note, the state of Washington, where I practice, has just made it illegal to write prescriptions in cursive.
As a surgeon who works frequently with several oncologists, I must post a word of discouragement. I occasionally see a patient with nonresectable metastatic cancer who returns from an oncologic consultation with unjustified optimism- "the cancer doc said his chemo has a 60% response rate!" While technically true, I know that the term "response" has very different meanings to the oncologist and his patient. To the oncologist, it means that in studies, subsequent imaging shows that there is less tumor, at least for a while. To the patient, chemo can be like an antibiotic for pneumonia- if it works ("responds"), he will be cured. I certainly do not want to downplay the importance of optimism, but sometimes I think you guys go too far. To an oncologist, keeping a patient with a liver full of cancer alive for 5 years is a great accomplishment (and don't get me wrong, it is amazing how much better you are doing compared to a few years ago), but to the patient, he's still dying of metastatic cancer. The only question is when. It's tough to walk that fine line.
Not that I ever want cancer, but if I do, would you be my doc?
I love this post. I am an individual with a tumor that, so far, can't be "killed" but has been "on the canvas" for several years. I wanted to respond to what JB wrote about "unjustified optimism". I do appreciate the concerns she/he mentioned because of the need for patients to be able to give informed consent before the start of a new treatment, especially one that isn't expected to provide a cancer-free existence even at best. However, I do not believe that there is ever a situation where a person with cancer can have "unjustified optimism". Look how many oncological advances have occurred in just the past five years. If oncologists can help a patient with a "liver full of cancer" live for five years, it may be just long enough for that patient to be alive when the next advance comes along that may make it possible for them to live another five years.
IF JB were to talk to some of us with incurable cancers, he might find out that we don't just view ourselves as "dying of cancer". When people ask me about my condition, I tell them that I am LIVING with cancer. To use my own analogy, I'd say that life with incurable cancer is like an ice cream on a summer day. To be sure, it will not last but it is definitely enjoyable while you have it. As a matter of fact, any of us (healthy or not) could frame our lives around the fact that life is temporary OR we can choose to focus on how wonderful it is to have been able to enjoy so much more of it than those before us would have ever thought possible.
So please, Dr. Hildreth, continue using these excellent analogies. Those of us with these hard-to-treat/untreatable cancers need to know that you don't need to be cancer-free in order to "win". In life, we don't usually get to pick all of the battles we'll have to fight; Sometimes, some people will have to deal with situations that will ultimately end in death. However, by fighting with all that modern medicine has to offer and remaining optimistic (even if it's only for the sake of those who love us) and brave, we DO win a life lived with dignity and that's even better than being cancer-free, if you ask me.
Not that I ever want cancer, but if I do, would you be my doc?
To the oncologist, it means that in studies, subsequent imaging shows that there is less tumor, at least for a while.