Radiation Oncology: Day 17, 18

The final two days of Rad-Onc have been wonderful. The patient who I have been following since my first week in clinic (with the large Head & Neck tumor) is now receiving treatments. I was able to go through each step of his care with the team, from initial referral and H&P, to contacting fellow physicians to review his plan, to his case presentation at our oncology team meeting, to his CT scan and radiation planning, to his mask fitting, to his simulation, and finally to his first day of treatment. It has been incredibly fulfilling to be able to follow a patient through the process of treatment; often during our third year, we take care of patients for a short while and they are lost to follow up, so we never know how effective our treatment was or how the patient is generally feeling (I love to know how my patients continue to do so this is a frustration for me). To be able to follow a patient from beginning to "middle" is very rewarding. I will be checking in with him as often as I am able to so that I may see how he responds to our treatment. With his current treatment plan, he does have up to a 50% chance of survival. I'd really like to be with him along the way to his cure.

Yesterday, I presented a lecture on chemotherapeutic agents and other modalities which enhance the effects of radiation. It was a really interesting area for me to research, and I have to say that I learned a LOT about a few chemotherapeutic drugs, especially in regards to their effects on radiation. Putting together the presentation was actually a lot of fun, but the whole presenting it and explaining it in simple terms was a bit more difficult!

The Powerpoint for My Presentation:

Chemotherapy & Radiation (2)

I have been so incredibly happy for the past 5 weeks; Maybe it has something to do with the sunshine and warmer weather, maybe it has to do with increased endorphins from working out more often, or maybe - just maybe - it's because I am working with the patients I've been made for. All I know is that I look forward to working every day and I come home from work feeling like I truly make a difference. I can't even explain how much I enjoy this...


On Tuesday, as a gift for my last full day in the clinic, the staff gave me two tickets to watch a baseball game in town. So, after we both finished work, Mike & I went downtown on Tuesday night to watch the game. After about a half hour of basking in the sunlight/relaxing/talking/watching the game, we ran into one of our friends, who invited us to his company's clubhouse for dinner and drinks. We ended up talking and meeting new people (there were several English men that Mike met, so he was happy chatting away about football and their shared English-ness all night while I mingled with new friends); All I know about the second half of the game is that we won! :)

Radiation Oncology: Day 16

Today was the day in the clinic where we check in with each of the patients who are currently undergoing radiation therapy. The main complaints are:

• Dysphagia and Mucositis - difficulty swallowing, ulcers, and dry mouths with thick saliva (in head and neck cancers).
• Shooting pains (in breast cancers - likely resulting from surgery and the impaired regeneration of nerve fibers).
• Redness, blistering, and pain on the skin overlying the treatment field (axilla for breast cancers, intergluteal clefts for rectal/anal cancers).

For the palliative patients, we find that most find real relief from pain after about 5-10 treatments. The response to radiation is so quick; it is always interesting to watch large head and neck tumors start to shrink away during the course of their radiation treatment. 

I also saw a patient who had a skin-reaction to the chemotherapeutic drug, Erbitux (Cetuximab), which is a monoclonal antibody of epidermal growth factor receptors, used most often in the treatment of colorectal cancer as well as head and neck cancers. Cetuximab works by binding to the epidermal growth factor receptor  and turns off the uncontrolled growth in cancers with EGFR mutations. Seeing as I want to become a medical oncologist, it's kind of nice to get to learn a bit about medical oncology whilst on this radiation oncology rotation!

This is really an exciting field. I love these patients, I love the staff, and I love being able to help those who are suffering from cancer. (I know, I'm starting to sound like a broken record - what can I say? I'm living my dream!!!!)

Radiation Oncology: Day 14, 15

A Few Short Stories:

1. Last night, I went to my very first pharmaceutical rep dinner party. It was phenomenal. Ethical discrepancies aside, I enjoyed an evening filled with enjoyable learning. First of all, we went to this high-class, top-end restaurant (where the average cost of one-person dining is well above $100), and the reps obviously paid for our meals. We had these delicious starters of scallops and crab cakes and mushrooms with cheese on bread and gorgeous salads and homemade bread and butter. The entire time we were at the presentation, they served us free drink as well - and only served top shelf liquors (not that I'd know, but the dirty martinis had some phenomenal queen olives and the Riesling was top notch). The meal was a choice between filet mignon, seared tuna, or chicken breast with smashed red skin potatoes and fresh asparagus. And the desert was a huge portion of either carrot or chocolate cake, already put into a to-go container (no way could any one eat the amount of food we were served in one sitting). So, food and drink was delicious. Got it. It was a beautiful venue. Okay. But why we were there was the best part of the night - the studies that were presented were so interesting. I couldn't get enough. Seriously. This thing they were "selling" seems to have a lot of potential in providing life-saving and cost-effective care to oncology patients. I was on the edge of my seat as I listened to the implications that this thing had. Seriously, I left the restaurant feeling on top of the world - I had this "a-ha" moment where it dawned on me that I am precisely where I am supposed to be right now, and I have discovered what I am meant to do with my life and it is exactly what I was put on earth to do. Not that the grey goose had anything to do with it... ;)
  * On a side note, to calm my ethical disturbance with this "free" evening, I am donating what I would have spent on the night to our local branch of the American Cancer Society.

2. After putting off scheduling an appointment with my PCP for an infection that I've been trying to fight off, I finally spoke with him today.
  MD: So, how long have you been feeling these symptoms?
  Me: Since last Tuesday.
  MD: Last Tuesday...like, as in 3 days ago?
  Me: No, as in 10 days ago.
  MD: So why see me today? Why not push it off longer? Why have you come in to see me already?
  Me: Oh, (that's a strange way to ask me, but) it's just gotten pretty awful since yesterday, so I thought I'd better just come in to see you.
  MD: Ok. You just don't seem too worried about it...
  Me: I guess I'm not real concerned, I'd just like to feel a bit better.
  MD: ...are you from a farm?
  Me: Erm, eh, yeah, yes, I was raised on a farm...(confused look on my face as I try to figure out why in the world had he asked me that as part of my HPI)
  MD: Oh! Ha!Ha!
  Me: ...why?
  MD: It's been in my experience that people from a farm act the same; if they feel well enough to be able to get done what they need to get done, to be able to work, then they don't think they're sick enough to see the doctor.
  Me: Yeah! That's exactly how my family is, that's how I am. That's crazy how you've got that figured out.
  MD: Well, my parents were farmers, and I practiced in a rural setting for many years, so I've had a lot of experience.

...hmm...so now I see why Mike has been so upset with me for not being seen earlier! I just don't want to ever be diagnosed with "med school-itis" or the "I-think-I-have-this-rare-disease-that-I-just-read-about" syndrome. Those are some scary things! ;)

3. This week during clinic, I overheard one of the Physicists interviewing a candidate who was applying for medical school. He put up an Xray of a woman's left thorax and asked the potential student what she thought about it, then proceeded to ask a whole bunch of physics and chemistry questions regarding how xrays are taken, differences between imaging techniques, how ionizing radiation works, etc. To be fair to her, she did pretty well, but she just sounded like an overly-confident know-it-all. For the questions which she clearly didn't have an answer (and no one would expect her to - they were trick questions), she made up some stuff and wiggled around giving a real answer rather than just admitting that she doesn't know. I couldn't help but think of the reason she was interviewing as a late-entry candidate might be because no other school liked her over-confidence, either. It's a shame, she really was smart. But no one likes a pretty smart doctor who doesn't know enough to know what she doesn't know.

I came to realize that I was in her shoes not so long ago, albeit not as a late applicant. Unlike her, I had just a few general medical knowledge questions, and most of my interviews were spent in ethical scenarios and conversations so that the interviewer could get to know me. I can't believe how much I've changed since my medical school interview 4 years ago. I've really grown up, but I still hope that am that same polite and compassionate girl I was when I was accepted into med school. I sure try to be.

Radiation Oncology: Day 13

So I realized a few things today...

• This calender has been up, beside my computer, on the month of April (and its now May 9th). Not only that, but it's from 2011. I couldn't be bothered to  never got around to buying a new one. And now, what's the point? It's not like I'm actually home long enough to be bothered by it! Which is totally not like me, I am normally SO OCD...

• Marley has had so much energy lately, but I haven't made it out to the park for a long walk with her in over a week. Poor dog. Don't worry, she gets me back by waking me up several times during the night to lick my nose...ah, the simple joys in life!

• We've resigned our lease, and we'll be here for another 12 months. Crazy to think that, if things work out, a year from now we'll be sorting through our things to take with us across the pond...
• Oh and on a related note, my best friend will be moving to Texas in 19 days - we're like, really growing up. It's weird!

• Today was the slowest day of all time. I only saw four patients all day. I did catch up on a lot of those little things I've been putting off...you know, like applying for next year's loans (no big deal or anything).

• Oh and guess what? My Step 2 CK is less than 3 months away...I think its time I start to mentally prepare myself for another 6 weeks of torturous studying. Honestly, I'm still not over the psychological anguish that Step 1 studying did to me! And what's worse - after my Step 2 CK I still have to worry about that PLAB exam (that I need to take before I can begin the Foundation Programme in the UK). I guess these stressors don't really ever end for doctors though, do they?

Radiation Oncology: Day 7-12

The past few days in the Radiation Oncology clinic have been a lot of fun. I have had the pleasure of meeting several survivors who were 5+, 8, 12 years out of treatment, some long term cures. "This man here" - points to the attending - "saved my life. I wouldn't be here today if not for him!" Seeing those patients inspires me in so many ways; to see what current patients are going through (physically as well as emotionally), it is absolutely humbling to see that some can make it out alive and well, with an admirable outlook on life and a satisfaction with living each day to its fullest. I love meeting these patients. They are amazing.

That being said, I have met many patients who are on our service for palliation. These patients are much more difficult to spend time with, for purely selfish reasons; it is incredibly difficult to attempt a trusting, understanding, and compassionate relationship with someone who may not be around next week/month. It can be emotionally draining. But these patients need a kind, compassionate, and dedicated physician at this time more than ever in their life. Roughly half of the patients on the service receive palliative radiation to attempt to alleviate pain or bothersome symptoms (such as confusion and personality changes due to brain mets). And radiation almost certainly provides good relief for these patients, which makes it very rewarding as a physician. 

I recently sat down and chatted with a very lovely young lady. She has these gorgeous, big brown eyes and a smile that lights up a room. She was wearing a cute outfit, complete with cute little flats and a color-coordinated hat to cover her hairless head. She had come up with an idea to cure cancer - to use what we have in nature to our advantage, exploit its natural ability to suppress cellular growth (she spoke about a specific plant). This theory certainly has some scientific backing, and could be a good avenue to pursue. After all, some of our oldest chemotherapeutic agents are derived directly from nature, such as the nitrogen mustard and vinca alkaloids. "Maybe this is why I got cancer," she said, "so that I could meet you and pass my idea on to you and your expertise." What a phenomenal attitude to have. Although I am sure that she has her difficult moments, when she can't seem to make the tears stop and searches for some reason why such bad things happen to good people, she does her best to remain optimistic, to keep hope alive. 

Last week, I went to a Cancer Fundraising Event with a bunch of girls from the clinic. It was so much fun, with such a good turnout. It raised around $30,000 for cancer patients from our area to use. The spotlight speaker was a young lady with Stage IV Lung Cancer with an amazing personality. She spoke of her struggles, her current battle, and about enjoying the little things in life, to cherish each moment. She talked about her Bucket List, and how each of us need to make one because, "after all, we're all terminal, really." I don't think there was a dry eye in the house by the end of her talk. What an inspiration. How beautiful to see so many people gathered together, donating their time and money to help find a cure for cancer. 

Radiation-Oncology: Day 6

Just another day in the wonderful world of Oncology!

I seriously love this job. Today, my attending asked me if, after 4 years of undergraduate education and 3 years of medical school, I was still excited about becoming a doctor...Without hesitation, I replied with childlike enthusiasm: "Yes! Of course! I could never imagine doing anything else for the rest of my life!" The reason he asked me this was because of a recent poll (which was released on Friday) regarding physicians' salaries and quality of life. One question which was asked in the survey was: "If you could do it all over again, would you still go in to medicine?" and the overall result was that only 54% said yes... Kind of a scary thought, knowing that about half of physicians wouldn't go into medicine if they could do it over again...

It is an interesting survey. To see some other results (including salaries for various specialties, compensation, quality of life, hours per week of patient contact, hours per week of paperwork, etc), click here.

I'm not ashamed to admit that I was excited to find that the books I purchased online last week arrived...I finally have the USMLE Step 2 Prep Book that corresponds with my Doctors-In-Training Review Course. This Mass Gen Pocket Medicine reference book (that fits perfectly into the pocket of a white coat) will undoubtedly come in handy when I am an Acting Intern on the medical wards this fall; I'm sure it will be useful when I am an actual intern as well.

I mean, who needs to buy new clothes when you can spend $80 on a few more medical reference materials?!

Radiation-Oncology: Day 2-5

So the rest of my first week on Radiation Oncology involved doing the things that the physician does. As such, I met several patients in the clinic, either as a primary consult or as a six month follow-up.

One man I had the pleasure of meeting has a very large tumor in his neck. So large, in fact, that it has started to consume his mandible, and he is having significant difficulty with swallowing (and has lost around 20 pounds in the past 3 months). He also had what we not-so-technically label "hot-potato speech", where he talks like he has a hot potato in his mouth (muffled voice). What was particularly frustrating is that although he had taken the initiative to be seen by a physician in a timely manner (several months before our encounter), the physician he spoke to suggested that the mass was caused by a dental abscess and simply prescribed antibiotics without further investigation. This doctor was not an American-licensed physician, just to make that clear! So he came to us with a very advanced, and aggressive, tumor instead of a smaller, more curable tumor. We will radiate the tumor area after he undergoes teeth extraction. He will likely need plastic surgery to reform the mandible after radiation. But his prognosis is not very good, maybe at around 15-30% 5-year cure. It is horrifyingly sad, knowing that the patient had the initiative to be seen to at the onset of this illness, but it was brushed off inappropriately and has significantly impacted his chance of survival.

I have also seen many patients with prostate cancer, breast cancer, rectal cancer, lung cancer, vaginal cancer, and lymphoma. And I am learning a LOT! While I don't feel like this is where I perfectly belong, I DO love the patients and learning more about radiation. It is pretty fascinating!

Radiation-Oncology: Day 1

I began my elective clerkship in Radiation-Oncology last week. This is definitely an area of medicine which we aren't taught much about while in medical school. I'll admit that I felt quite overwhelmed the first day; there are so many aspects of this branch of medicine which are simply overlooked during medical school. Honestly, I haven't had any sort of physics class since my Junior Year of Undergrad; at least we were required to have taken physics during our undergraduate years, before going to medical school, so that I do have some background in physics! I also have taken a lot of math courses through the years (and I'm actually fairly good at math considering I went into biology/chemistry/physiology and medicine!), which definitely helps to better understand physics...

Day 1: The morning was spent learning what the Radiation Technologists do, which includes friendly conversation with patients while they are properly positioned prior to the radiation treatment. On the patient's first day in the clinic, the techs and the physician select a position in which the patient will be during each following radiation treatment. They create a mold of the patient's legs so that the position of the legs is the same during each treatment. They place a small dot tattoo where the cross-hairs of different stationary lasers in the room meet, which allows them to ensure that the patient is in the proper position during each treatment (so that the radiation goes precisely where it is intended to go). For prostate cancer patients (and for a vaginal cancer patient), we also monitor the bowel and bladder positions prior to treatment. This is done by using an ultrasound machine to examine the expansion of the bladder and bowel. It's an important consideration because the prostate and vagina are quite mobile relative to the size of the bowel and bladder. Also, since the bowel and bladder cannot really tolerate the doses of radiation that we prescribe for the prostate, we need to ensure that the radiation beams are reaching their target (prostate) and not instead hitting another structure (such as the bowel or bladder). The techs are quite fast when it comes to placing the patients in the proper positions, and they are so good with the patients; they really bond with each patient, which makes the job so much more enjoyable. 

The afternoon was spent learning the basics about the medical physics behind radiation. I learned a bit about how using different sources as energy for radiation affects the penetration and preciseness of the beams (examples include photons versus protons versus electrons as a source). One of the PhD students went through the computer analyzing software that is used to determine the radiation fields and movement of the leaflets to obscure or enhance radiation to different areas, and how the Medical Physicists double-check to ensure that the algorithms produce the best treatment plan possible for each patient. 

There are different ways to go about administrating radiation, and there is a highly effective way to ensure that a vital structure which cannot tolerate much radiation (such as the spinal cord) does not get much of a dose while a near-by structure can still be treated with an optimal dose of radiation. This is accomplished by using what is called IMRT (Intensity Modulated Radiation Therapy). IMRT is really, really cool. It's nothing short of amazing to me, to be able to be so precise in administration of radiation so that the morbidity associated with radiation can be lessened. Other forms of external beam radiotherapy include: Conventional External Beam Radiation Therapy, and Stereotactic Radiation. Another form of radiation therapy, which is a targeted therapy, is called Brachytherapy. This involves the placement of a source of radiation inside of the body so that radiation can be administered to the desired area through the brachytherapy device. I have seen this technique used often in breast cancer and prostate cancer, but I have also seen it used to treat vaginal cancer. Another form of targeted radiation therapy is Radio-isotope therapy. This therapy involves administration of a radio-isotope through either infusion or ingestion, and the chemical properties allow the material to be taken up by selected cells. This therapy is most often used in the treatment of thyroid cancer and bone metastases. 

The guys (and one girl!) in the medical physics program are incredibly smart. They greatly enhance patient-care by acting as another safety guard against morbidity and mortality associated with high-dose radiation. I'm also quite impressed by their knowledge of anatomy. They are yet another example of the importance of integrated teamwork to ensure the best outcomes for our patients.

I went home after my first day on Radiation-Oncology and read for hours about different radiation techniques and the physics behind radiation, feeling quite overwhelmed by the physics and mechanisms of treatment which correspond with radiation therapy. This clerkship will be quite useful for me as a future oncologist, so that I will better understand what my patients will be going through while in the care of a referred Radiation-Oncologist.