February 2004

We Give Treat

By Michael J. Katin, MD

History repeats itself to the point of becoming more redundant than most of the thoughts in these columns, but yet another example is that many physicians entering residencies in radiation oncology are now coming from diverse backgrounds rather than going directly into this specialty from medical school and internship. Twenty years ago this same pattern could be observed, but for a totally different reason. Today the reason most residents have had previous life experiences (graduate work in basic science, surgical residency, President Protempore of the Senate) is that with 50-100 applicants for each residency position, it is critical to have some distinction to stand out from the rest (April 2002 column). Twenty years ago many of the physicians who applied to radiation oncology residencies had wandered in to a specialty that was a mystery to most of the rest of the medical community. Most other physicians didn't have the slightest idea what we did, and when they started to even come close to understanding, we'd change the terminology.

Applicants came to radiation oncology with varying expectations, but all seeking to escape the tyranny of their former specialties. Just as the United States developed its unique culture from the contributions of immigrant populations, so did the specialty of radiation oncology change based on this input. No longer was it based heavily on hardware, but due to the influence of those of internal medicine specialty backgrounds, the emphasis was now on evaluation of the patient as an entity. Were it not for stabilization by radiation oncologists of surgical extraction, the work up and contemplation of the patient soon would have exceeded the length of treatment, if, indeed, treatment would have ever happened.

It was in this environment that my approach toward our specialty was nurtured,and when I first went into practice I learned from many of the physicians in the community that this was considerably different from their experiences with radiation oncologists in the hospital settings in which they had practiced prior to relocating to Florida. One of them very vividly remembered the radiation oncologist in his hospital whose approach was directly down to business, usually seeing the patient and starting treatment within 2 minutes. The discussion with the patient and family and the informed consent would usually consist of three words: "We give treat." This is definitely not to place any criticism on the syntax, since, I assure you, after four months of intensive study of this persons's native language I would be fortunate to be able to inquire about the whereabouts of the nearest bathroom in time to still need to use it. The point is that there was the logical conclusion that the patient had come to the radiation therapy department to receive treatment, and there was no reason to not just go ahead with it.

This seemed somewhat barbaric, since it had now become mandatory to double and triple check everything that the referring physicians had already done, to make sure the patient and all first- through third-degree relatives understood all the ramifications and alternatives, and then to give out literature and access to support services prior to a final decision. It turned out, of course, that the vast majority of patients who came in to see you had already been thoroughly worked up and screened and if they weren't interested in receiving treatment they wouldn't have been there in the first place. The patients who actually needed this thorough evaluation and discussion were those who never made it to you at all (a conundrum).

I learned as years went on that this legendary radiation oncologist from "up North" was so far ahead of us he could no longer be seen by the Hubble telescope. It seemed impossible that we could ever return to those days. There are still many prominent practitioners in our field who would continue to support a very compulsive and comprehensive approach to the patient, for fear of ever being accused of being "just a technician." In other words, if the surgeon has already decided a patient needs treatment and we agree with the surgeon, are we not just carrying out his or her order? No matter what, we'll never be just technicians, if, for no other reason, it wouldn't be possible. I know that if I ever tried to work a 2004-era linear accelerator (e.g., the Gladiator X15-3000B) with multileaf collimators, respiratory gating, and electronic portal imaging, the result would be my destroying myself and all life forms within 100 yards.

Fortunately, the philosophy of patient care is now going full circle, and we may be able to get out of the mindset that we might be just rubber-stamping somebody else's decision, whereas in fact we're probably doing the right thing for the patient. One of the most frustrating conditions to treat is anorexia nervosa, making most of the diseases we face seem straightforward. Patients are usually subjected to extensive analysis, family discussions, and support services. There is now an approach to this dreaded condition, the Maudsley method, that is getting excellent results. The patients are forced to eat.

This is considered a revolutionary approach, and, in our current era, this may be the case. If this type of therapy spreads to other problems, we can envision alcoholics being encouraged not to drink alcohol, school dropouts forced to go to class, and Britney Spears to avoid wedding chapels. Patients with heart disease need to get stress tests and intervention, and patients with cancer need to get appropriate chemotherapy and radiation therapy. It doesn't get any easier than that.

You go eat.

We give treat.

The author thanks Dr. Lawrence Seidenstein for his insight and inspiration

email: mkatin@radiotherapy.com