Research Assessment #2

Date: October 13, 2017

Subject: Oncology
MLA or APA citation: “A Day in the Life of an Oncologist: “How Do You What You
Do?”.” GRACE :: Coping with Cancer / Social Work, cancergrace.org/coping-with-
cancer/2011/03/16/how-do-you-do-what-you-do/.

Analysis:
This past week I was fortunate enough to have an interview with Ms. Stacy Beasley, a
nurse manager with over twenty years of oncology experience. I had asked her about the typical
work schedule for an oncologist and her response was one I was not expecting. She explained to
me that the oncologists of Texas Oncology Plano West tend to wake up at dawn and head to the
clinic. At the clinic, after answering a few phone calls and tending to overview of patient
prescriptions, the oncologists usually head to the hospital. At the hospital, the cancer specialist
checks on their inpatients and observes those undergoing chemotherapy. After making rounds at
the hospital, the oncologist goes back to the clinic and does patient checkups until their lunch
break. Then, they continue working until about 5 o’clock in the evening. However, even after the
clinic day is over, most oncologists continue working on sending patient emails and
prescriptions. The actual work day for an oncologist doesn’t end until much later. In fact, many
oncologists make weekend rounds as well and only get a few weekends off a year. I knew that a
medical specialist’s job would not be simple, but I had overly underestimated the stress and time
associated with a career as an oncologist. I wondered if this rigorous schedule was unique for
those working at Texas Oncology, or if all oncologists get very minimal free time. So, for this
week’s research assessment, I decided to study the typical work day of an oncologist by reading
oncologist Dr. West’s article.
As I began reading Dr. West’s account of a particular work day, I noticed that I didn’t
know the differences between the work done in the oncology clinic and at the hospital. Before
my interview with Ms. Beasley, I wasn’t even aware of the fact the oncologists work at so many
different locations during the day. I had assumed that a clinic and hospital were synonyms of
each other. Reading Dr. West’s article, I noticed that there are clear differences between the two.
For one, an oncologist is affiliated with one clinic while can work at multiple hospitals. Also,
patients visit the oncologist at the clinics while oncologists visit the patients at the hospital. The
work done at each institution is different as well. Oncologists perform check-ups and prescribe
medicine at clinics, while at hospitals they usually watch over treatment plans for the inpatients.
After noting the differences between the different places an oncologist works during the day, I
continued to read of Dr. West’s work day.
I noticed many consistencies between the oncologist work days that Ms. Beasley
described to the one that Dr. West recounted. Dr. West said that he needed to be at the clinic by
the early time of 7 o’clock am. This means he must wake up much earlier in order to get ready
and drive to work on time. I assume that Dr. West awakens at “dawn” just as Texas-Oncology
specialists do. Paralleling Texas-Oncology oncologists, Dr. West also travels numerous times
between the clinic and hospital to treat numerous patients. He treats patient after patient without
a break in the middle. Before his lunch break, Dr. West treated seven different patients just at the
clinic alone. Dr. West continued to work during his break, by catching up on records and
dictation and returning calls to physicians. It is no exaggeration to say the work day of an
oncologist is extremely booked and busy.
Even though Dr. West had a hectic day, I noticed that the way he spoke with his patients
didn’t hint at even a bit of stress he dealt with. In fact, it was quite the opposite; Dr. West
appeared to show optimism and gratitude at all the little aspects of his patient’s successes. Every
time that Dr. West mentioned a patient’s difficulty, he quickly backed it up with statements such
as “we are hopeful [for recovery]”. His patients shared similar ideals with each patient
expressing many signs of gratitude to the oncologist such as hugs and kind words. These warm
exchanges showed me that because cancer is a brutal disease, a positive outlook is needed from
both the doctor and the patients. In fact, the oncologist cannot be a pessimist because a part of
their job description is to emotionally inspire their patients to fight through the illness. Cancer is
much of a mental battle as it is physical. This means that not only will I need to have good
communication skills to work with my patients, but I also need to be able to demonstrate
empathy.
Even though Dr. West only posted about half of his busy day as an oncologist, I received
much valuable information from reading his post. It is true that oncology is a difficult career to
pursue and that only the most dedicated can fight through the long work days associated with the
profession. However, I also learned that the way to fight through the difficulties of the tasks and
seeing patients suffer is always showing gratitude for the little successes in life. By being a
positive individual, an oncologist can encourage her patients to be the same.
A Day in the Life of an Oncologist: “How Do You What You Do?”
Published March 16, 2011 | By Dr West | 13 Comments

On the rare occasion I’m in a social situation with people who aren’t in medicine (yes,
I’m sure you know I don’t get out much, so this is largely from remote memory), the
most common question that follows my answer to what I do for a living is, “How can you
do what you do?”. People imagine the obvious low points of telling people about a new
cancer, about delivering bad news and discussing people’s difficult cancer-related
symptoms and potential to decline despite our best efforts. It’s fair to wonder what
keeps us going. So I thought I’d provide a brief sketch of a day in my clinic, which offers
several ups along with the downs everyone might envision as dominating life in the
oncology clinic.
Work starts at about 7AM. At least the drive in avoids the big traffic. I review my Commented [OD1]: During an interview with Texas
schedule, briefly reviewing the recent records of the people coming in that day, Oncology I was told that their oncologists start at dusk. This
most likely means different firms have different
including a more detailed review of the records of new patients, including reviewing their expectations.
scans that are usually delivered in anticipation of their arrival in my clinic. Check e-mail,
sign head shots in response to fan mail*, etc. (*in truth, it is perhaps technically more
accurate to say that I sign dozens of orders for prescription refills and lab orders). Commented [OD2]: The nurse manager at Texas Oncology
Plano West said that this is a task that usually she does.
Before clinic starts, I head to the hospital to round on inpatients of mine in the hospital. Commented [OD3]: Oncologists usually work at multiple
One is a young man with testicular cancer who is doing fine on his chemo, though he’s buildings including different hospitals, clinics, and research
grown weary of the hospital food after three admissions lasting 5 days each for inpatient centers.
chemo. Fortunately, this is his last planned round of chemo, so the end is in sight. And Commented [OD4]: At the hospital, oncologists check on
he knows I’m not responsible for the food. At least his nausea is so well controlled that chemotherapy of patients.
he’s interested in eating.
Another patient is one I’ve known for a couple of years who, over a course of just a few
weeks, developed dysphagia (inability to swallow larger bits of food). She unfortunately
was found to have clearly progressing disease around her esophagus after receiving
chemo and radiation for locally advanced NSCLC, followed by radiation to the area
when that was the only area of progression about 9 months after the initial
chemo/radiation (not standard, but a hope of pushing the envelope to cure her cancer).
When the thoracic surgeon with great experience managing esophageal disease Commented [OD5]: Multiple different talents are required
examined her to put in a stent to better open the esophagus, he saw that she actually to treat cancer effectively.
has a small tracheo-esophageal fistula, an opening between the trachea and the
esophagus. Fortunately, that is being blocked by the well-placed stent, but this was an
unwelcome complication, and I speak with her and her two children about plans to move Commented [OD6]: Part of oncologist job description is
forward with a trial of Tarceva (erlotinib) in a few weeks. However, we’re all aware of the talking with the patients and their families.
challenges we’re likely to face.
Clinic starts with a very nice, elderly patient who was recently found to have pleural
metastases when she underwent surgery that followed initial chemo and radiation Commented [OD7]: Metastatic pleural is a type of
planned as induction therapy for stage IIIA N2 NSCLC. Of course, we were all cancer that spreads from another organ to the thin
membrane surrounding the lungs.
disappointed (bordering on crushed) that she had advanced, incurable cancer and that
the scans she had after her induction therapy and before surgery hadn’t detected the
disease before she underwent surgery (the surgeon looked, took biopsies, and then
ended the surgery when he confirmed that the pleural nodules were cancer).
Immediately after surgery, I talked with her and her family about the potential value of a
different, less challenging chemo, and I started her on carboplatin and Alimta Commented [OD8]: Oncologists have to communicate with
(pemetrexed). It may have been that she was still recovering from surgery, but she had patient and family so must hone good social and empathy
skills.
a harder time than I’d have hoped or expected, so after some extra recovery time, we
agreed to have her switch to single agent Alimta, which she received two weeks ago.
Having her come in at a time when I wanted to check her labs, she relates that she did
just fine this time around, so we plan to try another cycle of single agent Alimta next
week and then do a scan. We consider perhaps returning to the doublet in the future.
We’re hopeful.
Next is a return visit by a patient with metastatic lung cancer who is on maintenance
therapy after responding on first line therapy, now positively giddy that she is feeling so
well on a clinical trial with a novel agent (called imitelstat, which is a telomerase
inhibitor). Her last scan on the trial showed stable disease. Every time she visits, she’s
effusive in her gratitude and tells me I’m a miracle worker. I half-heartedly (at best)
deflect the compliment and am happy to continue the love fest.
I then see a new patient, a lifelong never-smoking Asian woman with a new
adenocarcinoma. She looks and feels very well, but she unfortunately has metastatic Commented [OD9]: Adenocarcinoma is a type of cancer
disease documented on her imaging. Though we need to frame the discussion of what that forms in mucus-secreting glands throughout the body.
treatment can do with the limitation that it isn’t curative, we talk about the very
significant chance that she has an EGFR mutation or ALK translocation that could be Commented [OD10]: Oncology team has to make
associated with a high probability of having a long and very good response to one of connections from evidence to possible body problems.
these generally well tolerated oral agents. I’m going to send her tumor tissue off for
molecular testing and plan to see her back next week to review the results. If she has
an EGFR mutation, I’ll start her on Tarceva (erlotinib). if she has an ALK translocation,
I’ll start her on chemo but plan to enroll her on a trial with the ALK inhibitor crizotinib as
soon as she qualifies. And if she has neither, I’ll pursue chemo, but we’ll discuss the Commented [OD11]: Made detailed plan on how to tackle
details of that at the next visit, if that’s what it’s looking like. There’s only so much we cancer on a case based scenario. Oncologist must be
organized and ready to tackle any situation.
can cover in an initial visit. She’s disappointed about the cancer not being curable, but
she has a realistic hope that her cancer may have a marker associated with a more
favorable prognosis.
Following her, I see a very young man newly diagnosed with a metastatic squamous
cell NSCLC. He’s starting a clinical trial of first line carboplatin/Gemzar (gemcitabine)
with or without the investigational PARP inhibitor iniparnib. He’s happy to have been
randomized to the arm getting the novel agent with standard chemo: he’s hopeful. We
also work on his pain control, which hasn’t been as good as I’d like, since he has
extensive bone metastases (we’re also going to start XGEVA (denosumab) for that). I
start him on long-acting narcotics, discussing the yin/yang of bowel medications along
with that. His pain control may be a work in progress for a while, but we’re both looking
forward to it improving over time. I’ll be following him closely.
My next patient is a woman who underwent surgery for a cancer of her renal pelvis, the
collecting system of the kidney, which was followed by adjuvant chemotherapy. She
was diagnosed and treated over two years ago, and today her follow up scans look Commented [OD12]: Even looks at patients of the past;
great, with no evidence of cancer. We both know that she’s still at some risk for Must have a large amount of patients in total.
recurrence, but each favorable scan as more time goes by increases her odds. I’m very
optimistic. Her life is back to normal, and her biggest issue is her desire to retire sooner
than she thinks she’ll really be able to. I’ll schedule one more scan in a six month
interval, which I’ll go over with her, hoping to give her the same good news. I get a hug.
I then see a patient of mine with advanced NSCLC who started on hospice a month ago
after deciding that she didn’t want any additional treatment, which I felt was a very
reasonable thought, since she’s been on and off of treatment (which has also often
been effective) for about 3 years. She relates that she’s been extremely happy with Commented [OD13]: Cancer is a chronic disease so
hospice and the care they lavish on her, noting that her team has great experience. We oncologists are in their patient’s life for a long time.
discuss the unfortunate fact that far too many patients don’t start on hospice until they’re Commented [OD14]: A care center for terminally ill.
extremely debilitated, missing the opportunity she has to develop a relationship with her
team before her needs become more pressing. We discuss and adjust her pain
regimen, and I add another medication for her cough, and then we agree to have her
come back to see me in another 4-6 weeks, as long as it isn’t a burden for her to come
in. I know that if it’s a hassle for her, I can work with the hospice team via phone and fax
to optimize her care. Commented [OD15]: Has to work with different
organizations for patient’s benefit so oncologists must be
Last before a lunch break is an ex-biker, ex-hippie who I’m treating for mucinous well with group work and cooperation.
bronchioloalveolar carcinoma (BAC) that recurred, as I’d feared, within just a few
months after his pneumonic BAC was resected. We’d checked him for an EGFR or
KRAS mutation, as well as an ALK translocation, and he was negative for all of these,
so I started him on carbo/Alimta with Avastin (bevacizumab). He’s done pretty well with
treatment, but it knocks him down for several days after each treatment, a little more
than I’d prefer. Nevertheless, I’m happy to report that his CT that he just had completed,
which followed two cycles of treatment, shows a very good partial response. He’s not
interested in making any changes. He and his wife share a tearful hug. I get a big hug,
from each of them.
When I say lunch break, it unfortunately doesn’t necessarily mean that there is time to
leave the building and get lunch. Today that break (an hour on the schedule, but with
inevitable delays in the back and forth of the day, it’s about 40 minutes) is primarily to
catch up on records, return a phone call from a referring physician, catch up on
dictations, etc. Lunch will wait until a lull, as I have complete confidence, as you should
too, that I will not starve by delaying a meal for a few hours.
Though there’s more to the day, there’s already enough to cover just the morning, so I’ll
continue with afternoon coverage later. But you can already see that there are many
hopeful and even joyful moments in the oncology clinic.