24 November 2007

It's not cancer but it will be familiar!

Thursday, Nov. 08, 2007
When the Patient Is a Googler
By Scott Haig

We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.

Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible.

"This is not an acceptable form of behavior, not acceptable at all," was Susan's excruciatingly well-enunciated and perfunctory response to Junior's screaming. The toddler's defiant delight signaled that he understood just enough to ignore her back. Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.

Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.

Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.

Susan got me thinking about patients. Nurses are my favorites — they know our language and they're used to putting their trust in doctors. And they laugh at my jokes. But engineers, as a class, are possibly the best patients. They're logical and they're accustomed to the concept of consultation — they're interested in how the doctor thinks about their problem. They know how to use experts. If your orthopedist thinks about arthritis, for instance, in terms of friction between roughened joint surfaces, you should try to think about it, generally, in the same way. There is little use coming to him or her for help if you insist your arthritis is due to an imbalance between yin and yang, an interruption of some imaginary force field or a dietary deficiency of molybdenum. There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore.

Susan had neither the trust of a nurse nor the teachability of an engineer. She would ignore no theory of any culture or any quack, regarding her very common brand of knee pain. On and on she went as I retreated further within. I marveled, sitting there silenced by her diatribe. Hers was such a fully orbed and vigorous self-concern that it possessed virtue in its own right. Her complete and utter selfishness was nearly a thing of beauty.

When to punt is not a topic taught in medical school. There is but one observation that I can offer: Patients like Susan, as self-absorbed as they are, know it immediately. They can tell when you're about to punt.

I knew full well what was wrong with this woman, and I could treat her, probably as well as anyone. But treating her condition, which was chronic patellofemoral pain, would test the mettle of patient and surgeon. What we have doesn't work very well nor very quickly. The swelling takes months to go down, the muscles take even longer to strengthen. Good patients often complain, "It was better before we started," in desperation or anger, before they see improvement. But with plenty of therapy, braces, exercises and one or two operations, this knee does improve. It's often tough going, though, and patients have to stick with you. I like to be straight — "It gets worse before it gets better" is what I tell them. Susan's style, her history and, somehow, most telling, the way she treated her son said she was not going to make it through this. Not with me, anyway.

A seasoned doc gets good at sizing up what kind of patient he's got and how to adjust his communicative style accordingly. Some patients are non-compliant Bozos who won't read anything longer than a headline. They don't want to know what's wrong with them, they don't know what medicines they're taking, they don't even seem to care what kind of operation you're planning to do on them. "Just get me better, doc," is all they say.

At the other end of our spectrum are patients like Susan: They're often suspicious and distrustful, their pressured sentences burst with misused, mispronounced words and half-baked ideas. Unfortunately, both types of patients get sick with roughly the same frequency.

I knew Susan was a Googler — queen, perhaps, of all Googlers. But I couldn't dance with this one. I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help. A certain Dr. Brown, whom I'd known as a resident, had been particularly interested in her type of knee problem.

Disappointed and annoyed, Susan stopped for a beat.

"You mean Larry Brown on Central Avenue?"

"Uh, yes —" I started.

"I have an appointment with him on Friday. And, Dr. Haig?" she said, pulling Junior by the arm out my office door, "Watch out on your drive home tonight. There was an accident near your exit."

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.

5 November 2007

A stitch in time. - The Ocker Doc

This story is about one of my favourite patients. Other doctors can't stand her. She misinterprets, jumps to conclusions, is irrational, over-excitable, accusatory and demands to know things. She also has a sorry background.

She was married to a local medical figure. They had a very acrimonious divorce that was compounded by her depression. She ended up as the 'mad ex-wife'. The worst thing that can happen to such a woman is to also get sick! But she did.

Her initial outlook was excellent; "95% chance of cure" said the cancer specialist, "What are you worried about?" Perhaps being one of the 5%? And sure enough it came to pass that the cancer came back. Her specialist was away and I was on call.

The notes described a very disturbed woman with unreasonable expectations and noisy conflicts. As the next doctor, I felt apprehensive to say the least. I decided to take a low-key approach. I said hello and then let her talk.

Forty minutes later she finished. Then we returned to the beginning of her story. Everything that happened was addressed. I apologised for my colleagues when she appeared to have been fobbed off. I chided her for being unreasonable when her expectations were excessive. I reassured her when she had received standard treatment. When she jumped to conclusions, I forced the conversation back to re-explain. When she misunderstood, I used different analogies. When she became accusatory, I explained the other viewpoint. I just wanted to put the past behind us. Forty minutes later I was finished!

When the old patterns had been cleared away and we had arrived at a common purpose, she turned out to be just like other patients. What common purpose was that? I promised that I would not lie or hold anything back from her ('no crap' was the phrase used), that I would treat her problems seriously and present to her the available options with my opinion and support her with whatever she chose.

Unfortunately the option that she chose made her worse. But still our relationship remains on the same footing. Physically she is worse, and she still jumps to conclusions, but the understanding forged at that first meeting remains. We speak as doctor and patient should, with a common purpose. No crap!

Who is the better doctor? If my medical knowledge is not balanced with humanity then I become useful only while a patient is treated as a curable lump of meat. Patients are more than this. Healing for all patients results from and produces proper relationships. Patch Adams said (and I paraphrase) "Doctors shouldn't just prevent death, they should improve life".

I want to be involved in that!

What can you say about a HOG? - The Ocker Doc

The sound from a motorcycle exhaust is not supposed to exceed 75 decibels. Well, strictly speaking, a Harley-Davidson is not a motorcycle, it’s a Harley-Davidson!

You will all be familiar with the machines – deep, loud bellow from a two wheeled projectile which looks to have a pot belly. To some it is the sound of heaven, to others it spells trouble. To our cancer patients from all over the island, it is the sound of the Lone Ranger. Hi Ho Silver! To the rescue!

Yesterday, I had the pleasure to meet with the local HOG (that’s Harley Owners Group) at the headquarters of the local Cancer Society where the members presented a cheque for more than $25,000 to the Cancer Society for purchase of software to assist the Department.

The software to be purchased is used for image fusion. In modern medicine, much of the information used is carried in the form of pictures. Different scans give different information. Until recently, the images were presented to doctors on paper or film. Taking the information from one scan to the other was inaccurate and awkward. Sometimes the films have different sizes, sometimes the orientation of the films is different, sometimes one scan shows the problem clearly but another shows nothing at all.

For a long time, doctors have wanted a way to put the images on top of each other, to change their sizes and orientation so that they match. In this way the information from all the available images can be combined.

The radiotherapy department likes CT scans because the CT data is used to predict the performance of radiation beams in the patient. Yet the MRI scan is much better for defining the extent of a brain or muscle tumour, or the position of a prostate containing cancer. “Fusing” the two images so that the MRI image accurately overlies the CT image means that the MRI data can be reliably transferred for more accurate planning. And better imaging means better definition of the area needing treatment. Better definition means more cancer and less normal tissue, leading to better cure and less side effects.

I would like to repay our HOGs with a promise from me and three requests to you.

I promise that we will put their donation to good use. And now my three requests. Firstly, if you see a HOG member (you’ll know them when you see them, they stand out!) say thanks. You have a 1 in 4 chance of benefiting from their generosity one day. Secondly, listen to that wonderful noise! Thirdly, look at that shine!

HOGs are fine by me.

Dad - The Ocker Doc

Father bashing has become quite a hobby in the last 15 years. Many people credit their fathers with their later success or failure.

My father was a victim of his own health. As a healthy 25 year-old final-year accountancy student, he was taking his elder sister to a dance in the nearby town of Digby (it's not on your maps because it's in Australia!). In the twilight their motorcycle sideswiped a truck. The siblings both suffered severe injuries to their right shins. But bones heal.

Dad was placed in hospital to heal, but the man in the next bed had TB. Dad ended up with TB. Before the bacterium was known, TB was called 'consumption' for good reason. Dad was sent to a sanitorium to recover. Unfortunately his immune system was not geared to fight the bug. His left lung was a mess. He was labelled as 'incurable' and expected to die soon. That's a heavy burden before your 30th birthday.

An American Army colonel, Dr Gebauer, came to demonstrate his successful operation to control TB. He called for volunteers. With 50% chance of surviving the operation but some prospect of cure, Dad thought that it was the better option! Five others undertook the same risk.

All six were successful. Five died in car accidents, none died of TB.

But accountancy was now a thing of the past and life was more difficult. Marriage and four children meant that his first holiday with Mum occurred after 19 years of marriage.

Finally at the age of 59, life was settling down. While visiting the rented family home, Dad and his best friend took his new Volvo for a drive. The only eyewitness said that the car was up on two wheels as it went around a bend and into a very large gum tree. Death was quick.

I was not there and couldn't be found. The local priest looked for me in church but couldn't see me. He informed the congregation of the need for their prayers. Discovery was quick, but not painless. Mum never forgave the priest, but I didn't mind so much. You can dress the news up, but when you come to say "Your father is dead", the suffering is the same. The news that that lump is cancer is very similar, I think. But I think that suspecting the truth beforehand actually makes the shock less.

I regret that I did not know my father better. I cleaned out his desk after his death. I was struck by the similar way that we both thought. And now I regret not knowing him better. Mind you, the fault is all mine. Brash youth who knew everything better his parents - every child repeats the mistake. Mike and the Mechanics had a song called "The Living Years". The chorus goes:

"Sing it loud, sing it clear, You can listen as well as you hear, It's too late when we die, to admit we don't see eye-to-eye".

Need I say more?

Hobbies - The Ocker Doc

Have you got any? I don't really have one. I've dabbled in a number but none have stuck with me through the years. Black & white photography, pottery, screen printing, the list goes on.

What happened? I went to medical school! Until that point I had the time to devote to hobby. Up to that point I had a life!

Medical school is very similar to other university courses, except for one thing. The breadth of work to be covered is much greater. The corollary is lack of time - it takes a lot and most of that is spent reading.

So you spend 5 years (didn't do my medical degree in NZ!) reading Anatomy, reading Pathology, reading Physiology, and just when you decide to do something for a change - you read Pharmacology or Oncology or Psychiatry or Surgery or Obstetrics or Clinical Endocrinology …. get the picture? As my old Dad used to say, there are more subjects than you can poke a forked stick at! And each topic has its own remnant of the Latin language and characteristic names to be learnt. You pick up useful titbits of information such as the fact that Hansen's disease is tuberculosis and is caused by a nasty bacterium called Mycobacterium tuberculi - great for a trivia contest??!!

This is a pleasant walk down memory lane, but what does this have to do with hobbies? Medical school is the start of a lifestyle. Internship, residency and specialist training all require lots of reading. And then one day you are finished and have successfully passed your examinations. What most of us fail to realise is that by this stage we have a hobby. A major hobby.

Its called reading medical literature. And it gets in the way of life and other hobbies. This is one of the problems with a doctor's view and experience of the world.

After exiting from the training situation, I have made a conscious effort to find some hobbies for myself that will carry me to and through retirement. I haven't been very successful yet.

I have been thinking about some hobbies. When younger, I derived a lot of enjoyment from motorcycle riding. Thoughts about finding a similar machine to restore have been creeping in. I can just imagine what my wife will say when she finds out. I know what my boys will say!

House of God Rules - The Ocker Doc

'The House of God' is a book about the first year doctor. The author writes about the American experience. My first year wasn't all that different.

The author, Samuel Shem, meets his mentor at the start of the year. The Fat Man, as his mentor is called, has a series of rules that cover almost every situation. I apply one of the rules is my practice. The rule says "Remember it’s the patient with the problem". This rule has a positive and negative aspect.

On the positive side the rule pushes me to tell the patient what is happening. This takes time. It is also quite difficult because each patient is so different in learning, approach, experience and readiness. I would be kidding myself if I believed that I did better than a poor job. Communication between similar people is so error prone, that adding cultural and professional difference along with the anxiety of a cancer diagnosis can only make it worse. Nevertheless I try!

The negative aspect of the rule is that it removes me from patient's experience. I don't have cancer. I'm not getting treatment. There is no comparison between my hope that treatment will work and their hope that treatment will work. There is most definitely no similarity between our reactions when the cancer returns.

That brings me to John. He was young. He was an asset to his family. He was a righteous man involved in seeing that people were treated right. He impressed me as a man who knew where he fitted in his world. Communication was easy because he wanted to know what was happening. But it was also difficult because he didn't really think in a medical way. He taught me about New Zealand history as much as I taught him about his cancer. That's the positive side.

Then we entered the negative side. The cancer came back. Did I do anything wrong? No. Was I slack? No. Would I do it the same next time? No. I just didn't recognise the rogue cancer early enough. I felt uneasy during the whole treatment but I didn't recognise why. So in the end, John and his family paid the price of this failure. To say that I felt bad rates as an irrelevancy. I understand how his kids feel because I have been in the same situation.

There are no winners. Him, me, his wife, his kids, your country - we have all lost. This disease is a wanton beast. So what do I do differently? I am more suspicious, I'm on my guard looking for the rogue cancer that needs special handling. I also have to work harder not to withdraw from the next patient. The next patient still requires their doctor. I have to start over.

Shame John can't.

If Only I was 21 - The Ocker Doc

All doctors have a favourite patient. I haven't seen mine for 4 years. I can't even remember what he looks like. I just remember his approach to life. Why do I remember? Because I want to be like him.

Imagine that! Wanting to be like a cancer patient.

This man was a patient when I was a 'young' doctor. Actually this is untrue for I was never a 'young' doctor. I reached the status of a junior doctor when I was 'old'. If the truth be known, at least half of the consultant that I worked for were younger than me. This is the result of a first career in teaching (another story!).

I looked after him in hospital during radiation therapy. He had had a small lung cancer removed 6 months before. The operation had gone well. Unfortunately he developed headaches and difficulty with his arm, similar to the problems of a stroke. His general practitioner was very good and he had the diagnosis made quickly after a CT scan (previously known as a CAT scan, and the brunt of many animal jokes!). He had a cerebral metastasis … sorry, a small piece of the lung cancer had entered the blood stream and lodged in the brain.

The immediate but temporary solution is steroid tablets to reduce the associated brain swelling. Pleasingly he recovered with these tablets. The longer lasting solution lies in radiation therapy to the brain. Depending on the circumstance, surgery to remove the brain lump might be also undertaken. It wasn't in his case.

He lived some distance from the radiation unit (Nelson Bay, NSW that beautiful summer destination in Australia) and so was staying in the hospital during the radiation therapy. We spent some time talking, as his medical needs were very minor.

Later I saw him regularly as a senior training doctor (also older by this time!) in the clinics. He was always on a high from living! Why is life so good? I asked. He replied that when he was in hospital some one said to him that no matter what happened with his cancer, he still received his remaining days one at a time. I was told to make sure that each one was a good one, he said. I have, and guess what? What? Each day is better that the last one - I wish some one had told me this when I was 21!

He didn't say it, but he was glad I had told him at 61 also.

It shouldn't happen this way - The Ocker Doc

It shouldn't happen this way. Kids are not supposed to die before their parents. Parents are supposed to die first.

The death of a child causes many problems. I remember reading that the separation rate among parents in this circumstance is extremely high. The death of a child is seen as a waste of life - decades of lost potential. Someone must be responsible. Parents play the 'what if' game.

What if we hadn't hurried him to get to school on time? What if I had checked the baby before I went to bed? What if I had been a better parent and recognised her bad health earlier? The sad thing is that there is always at least one aspect of a child's death that can be used for self-blame by the parents.

Our third child had fits when a few months old. Because Mrs Ocker Doc is actually a Dr Mrs Ocker Doc, the 'what if' game had a whole new aspect! The self-blame was substituted with a litany of medical conditions that cause fitting in infants. Many of these rare conditions start with fitting but end with degeneration and death. Fortunately it turned out to be Benign Epilepsy of Childhood, and child #3 is normal … or at least has no major problems!

One of the hardest things for modern First World people to grasp is that we do not have control over every detail of our lives. Things just happen. When the people of the First World find that life is beyond their control, guess who gets the blame? "How could a loving God do this?" Now this attitude is not fair. We think that the Almighty has total control over bad things while we are solely responsible for the good things. The Almighty is on a hiding to nothing!

What is the benefit of a child who dies early? Is the life wasted? To answer 'yes' means that there must be a point after which that life has not been wasted. Is that point conception, birth, 21 or 'three score and ten'?

Literature is made up of short stories and 'War and Peace' epics. And the whole range in between - suspense, travels, sagas, cheap thrills, reflections. People's lives are the same. I don't believe that anyone's life is wasted. Some are short stories, some are long stories. What makes the story worth knowing is the quality of the love and relationship that they have been involved in and responsible for. Very short lives can be very sweet short stories.

Why am I writing all this? Friends of ours from the West Island discovered their baby daughter dead in bed yesterday. She was 2 months old. I'm about to ring them. What do I say to them?

The biography of Jeannie - The Ocker Doc

I played a small part in Jeannie's life

I first met her when caring for her father with poor lungs. The next week I changed terms and found her at another bedside. Her husband was hospitalised for prostate cancer treatment at the same time.

They were a good couple. They had faced a large share of adversity. Their children had left, but they fit together and still loved each other. Her husband was in and out of hospital.

I had so much medical work to do that each day at 5pm I would stop being a doctor and sit with each patient "chewing the fat" about the day. She was always around when I did my socialising rounds. They lived within a block or two of the hospital.

I learnt that Jeannie had had cancer also. And not once. Twice. Believe me, this is nothing like winning Lotto twice.

She just wanted him at home, and managed to do this with the help of the Palliative Care team who visited her regularly. Eventually he died. Jeannie was lonely but thankful for the good time that they had had together.

I didn't see Jeannie for 2 years or more.

Then a friend mentioned that she was in hospital. That day I did all my socialising with Jeannie! One of her cancers had not been cured. It had seeded her liver and was making her sick. She battled through several courses of chemotherapy. Initially there was a marked reduction in the liver masses and she felt better.

Later the liver masses resumed their march. Jeannie was in a bad way. She said that she was finished with her life. She felt that she had completed writing the last chapter. Despite the hardships, she liked the story of her life with her husband and children living beside the hospital in the working class suburb. She had no reasons left to continue living. Life wasn't any fun and she had no wish to have extra time for its own sake. She wanted to close the book.

I visited her everyday to sit, hold her hand and talk. As she deteriorated it became obvious that despite stating that she had nothing left to live for, she was fighting. I don't mean that she was fighting with a positive mental attitude. She was appeared to be forcing herself to continue breathing. For 5 days I watched this. Finally I said to her "Jeannie, why are you doing this? It's all right, we are here with you and we are happy for you to go. You're not alone."

She seemed to take a break from her task of breathing. “I've fought all my life, Doc. I just don't know how to give up.”

We didn't give up either. We nursed her body and spirit until will power was no longer sufficient. I felt privileged to help her close the book. I hope that this page honours the book of her life.

Last Rites - The Ocker Doc

Few patients ask to pray with their doctor. Godfrey was an exception. He had spent most of his life in the Christian missionary service, or rather his life was a missionary service. He had founded a Bible College.

I heard about him at church. He replaced the regular minister one Sunday night. The congregation was very impressed with the 'old missionary'.

Two weeks later he came to clinic in pain. He had prostate cancer that had spread to his bones. Radiation therapy to the sore spots was very successful in relieving the pain - as it usually is. He agreed that the aim of treatment was his comfort. He was very matter-of-fact that his lifespan was firmly in the hands of his God. At the very end of the consultation he asked, "Will you pray with me?" I did.

Between follow-up visits a medical friend working at a nearby hospital called one night. Godfrey had broken his leg. An orthopaedic surgeon had fixed the unstable bone. Although this solved the immediate problem, he did not recover well. He was not walking, and was nauseated. Now doctors have a saying "to a hammer, everything looks like a nail"! Which means that the care of an orthopaedic surgeon is focused, not unexpectedly, on bones and he wasn't getting good care. I'm the same with non-cancer bone conditions, by the way.

I stopped in on a social visit. As much to support my medical friend who was floundering, as to see that Godfrey was getting appropriate treatment.

It turned out that he had liver secondaries and kidney failure. Liver secondaries in prostate cancer usually signify impending death in the next few weeks, while kidney failure usually causes death in a few days. The kidney problem is treatable but the liver secondaries are not. I discussed these things with him. He decided that treating the kidneys would only prolong the inevitable. And he thought that the kidney death sounded easier.

The next day he was very agitated and despondent. We talked about the agitation. He couldn't put a finger on it. On a hunch, I said to him "Are you worried that your Christian commitment may have been misplaced all these decades?" He felt ashamed, he doubted his commitment and his God.

Fortunately he was wrong. "Godfrey, go back over your life. What does you life's story tell you? Were you wrong?" No, I wasn't. "This is the anxiety that everyone suffers at the end - did I do it right? Could I have done it better?" He nodded his head. I quoted him a verse from Matthew's epistle 'Well done, you good and faithful servant'. "That's what He will say to you".

Godfrey relaxed. He nodded in agreement. The next day he was calm and serene. His entire family came to see him and was happy that he was settled. It tired him out but he said goodbye to each one. Then, after they had left, he closed his eyes and went to meet his God. He was ready to go home.

People in Glasshouses - The Ocker Doc

My first patient as a 'real' doctor was a very rare bird. All through my training I had read about the rare diseases - and had seen a few. But I wasn't prepared for the first!

This lady has a cancer that is associated with a skin condition. My very large cancer text (over 2500 pages would you believe and bigger each edition!) said that the skin condition was found in 2 families from Liverpool. I remember these 'Trivial Pursuit' facts - which infuriated those training with me! The treatment elsewhere was standard. She came to settle near her family with her three children.

She had a bigger problem that cancer though. She couldn't swallow. Not food, not water, not saliva. A small tube connected her stomach to a liquid food pump. If you like medical acronyms it's a PEG or percutaneous endo… gastrotomy tube. There, another trivia fact! That diverted the food and water but not the saliva.

A call from 300km away said that she had become ill with pneumonia after repeatedly breathing in the saliva, and could they send her back.

From here on the story switches to the children. Their mum arrived in a very sorry state. She was crook. Barring a miracle, she looked like she was going to die… soon.

I introduced myself to the kids, their cousin, uncle and aunt. "So tell me, what have you been told about your Mum's condition?" Their answer was 'nothing'. As a parent and ex-teacher, I am suspicious of 'nothing' for it usually means something. The aunt and uncle confirmed their ignorance. NOTHING!!

So what do I do now? "I would have called a social worker and handed the family over to them" was the serious suggestion of one of my senior colleagues. Standing there I had a mental picture of three kids on train tracks about to be hit by a train and their world shattered. They had little time to learn the truth, absorb it and then act.

Unfortunately I have been in that position. My father died in a car accident and I discovered this in church with a priest's announcement from the pulpit. It is not pleasant. It makes saying good-bye hard. It leads to unfulfilled regrets.

They wanted to look at her chest x-ray first. So that was where we started. Every question was answered. Can Mum hear me? Is she in pain? Will she die? Every one answered. We talked for over 2 hours. I didn't think that I had really done enough. Time was too short. Isn't it always?

I arrived home late and my wife was angry. I explained and she forgave me.

"People in glass houses shouldn't throw stones". One day I hope that my family will be treated the same and have their grief eased by a doctor who stays back to do the job that needs to be done. All the more I hope for doctors who will tell us earlier about the train that's obviously going to hit us.

My Wife - The Ocker Doc

The Ocker Doc is married to ….. why the Ocker Doc-ette, of course! Yes, we are one of those families with little hope – two doctors! You can imagine the dinner table conversations. Our kids have very abnormal vocabularies. How many kids? SIX!!

The next question to follow goes along the lines of “don’t you know what causes it?” Well, of course I do! My third son was mortified one day to find out that after six children his mother wasn’t a virgin. Obviously we have some work to do there!

So what sort of a woman marries the Ocker Doc? I have wondered about this frequently. Those of you who are acquainted with the Ocker Doc know most definitely that on the physical attraction scale he rates about 1 out of 10. The stocks of good looks were decidedly depleted when it came to my turn. I know it wasn’t the money!

Anyway the important thing is what I think of her!

I often tell patients that life is assessed in the answers to four questions – Where do you go when you die? What sort of a mother are you? What sort of a wife are you? What sort of a friend are you?

I have the answer to one of those questions. She is the wife of Proverbs (last chapter, look it up). I have never doubted that she would be or is my partner, my other half. From the start we have been friend and friend.

Every so often we fall back in love with those urgent compelling feelings, but in the other times there is the decision of love. Whether in the same house or in different countries, the bond holds strong. When separate the separation creates longing. I believe her instinct. She is the expert in the relationship, she knows what we are missing and need.

You see the kids are sourced from this wide and deep pool of respect and affection. The pool was always been full no matter how much we take out!

What's for Dinner - The Ocker Doc

Those of you who have had the misfortune to meet the Ocker Doc at dinnertime will know that you shouldn't get your hands in the way! The Doc and food see eye-to-eye. It's not the way to his heart - it just maintains guard duty! Dieting is not the Doc's favourite pastime.

Lois is a Sydney-sider (or a "Sudknee"-sider in the local NZ lingo). A pleasant and cheerful woman from the southern suburbs, Lois' only problem was a long-term investment that had paid off. No, she wasn't working the stock market - she was a smoker.

Smoking is a strange activity. Placing your head over a fire and breathing in - can you see the sense in that? Fortunately there is a nicotine kick in it or no one would bother, and then where would the habit be?

Anyway, Lois was a good woman who happened to smoke. She was feeling unwell one day and noticed some blood on coughing. Now I tell you there are few things in the world to get your heart racing better than coughing up blood! We doctors call it 'haemoptysis' but apart from 'haem' meaning blood, I can't tell you what a "ptysis' is. Probably the sound a Roman makes when coughing! Lois entered the medical system quickly.

To cut a long diagnostic story short, Lois had lung cancer - and it had spread to the lymph nodes in the chest. Unfortunately it was inoperable. So she was sent into the clutches of the radiation oncologist. (In the pantomimes, this is where the crowd hisses and the villain appears dressed in black!)

What can you say about lung cancer? Nasty piece of work! In any one year, for every 100 people who develop lung cancer about 97 will die of lung cancer. Now if you were a betting person, you would hate those odds. OK with your money, but not your life.

The oncologist offered her radiation treatment. It wasn't fun - feeling tired, difficult to swallow and going backwards and forwards to the radiation unit every day for 6 long weeks. Not that getting the treatment took long, but the waiting time was longer than the treatment. The staff looked after her well but she still felt bad. After 2 months all the side effects abated and Lois was back to her normal self.

I saw Lois while on holidays. She had put on about 15 kilos! Are you on steroid tablets? I asked. "Oh no, I just have a good appetite. Anyway you told me to enjoy myself! And I just love the taste of food; it's my favourite thing!"

Ah, a kindred spirit!

Why cancer medicine? - The Ocker Doc

In medical school I wanted to be an Intensive Care specialist. Long way from a cancer specialist!

To be a specialist, you have to have a personality 'defect', well more of a particular personality profile. Surgeons are men of action, physicians are men of thought and learning, anaesthetists are outdoors people. This doesn't prevent them from being different, but often they run to stereotype.

What are cancer doctors' defects? There certainly is the 'cancer saviour' type. But that is, most definitely, not me.

I looked after my first cancer patients in my second year as a doctor. It was one of the horror terms - rarely less than 30 inpatients and topping out at 45. I found that I was occupied for 8 hours of the days just serving their medical needs.

I got no satisfaction from that job. So each day at 5pm I switched my pager off, finished the remaining work and then walked in to spend time with the patients. Basically I socialised after hours!

I discovered that they were all common folk with big problems. They weren't all the same. They covered the whole range of humans - married, single, divorced, professional, labourers, old, young, male, female, catholics, protestants, whites, blacks, asians, etc. Their differences were fascinating. And yet their reactions to cancer were remarkably similar.

Most people will say that they couldn't cope if they had cancer. But almost every patient seemed to cope. And not only cope, but also to find that life was getting better as a result! That is what attracted me to cancer – sorry, the people with cancer.

Of course it is one thing to find that you like working with a group of patients, you also have to think that you have something to offer them. I thought that I had two advantages. Firstly my mother had died of cancer and my father of a car accident, so I understood something of survivor guilt. Secondly I had another career before medicine that gave me a different perspective on people and their needs.

The first advantage forced me to accept that death is inevitable. The only questions are how and when. Cancer gives you just one advantage. The how and when are much more predictable. And because its CANCER, everyone knows you're going to die soon (good thing that often they are wrong). So you can prepare. But to gain this advantage the doctor must tell you what's happening early.

The second advantage gave me the skills to talk to all patients and to understand that they are all capable of understanding this cancer problem. When I wanted to know, I asked the patient. I discovered that they all want to know about their cancer problem. I say 'all' but of course there are the once-a-year patients who don't!

So here I am in cancer medicine. I still like the people I meet in work time. I still work very hard to gain their understanding.

And I still spend too long talking with them!