Treating cancer patients in a pandemic [PODCAST]

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“As an oncologist, perhaps the hardest part I play is as witness. I am there to give a diagnosis that, more often than not, will alter someone’s life forever. For some, I see resignation—a sense that they’ve known something was wrong and that it’s what they thought they had. For others, I see an almost immediate acceptance and, with it, perseverance; they are prepared to fight, to win. But for those where cancer comes without much warning, I see terror. Cancer is a threat to who they are, how they live, and yes—how long they have. It’s hard to see someone struggle this way, knowing that no matter how much time I spend with them, holding their hand, crafting a way forward, they leave my office with cancer.”

Don S. Dizon is an oncologist.

He shares his story and discusses his KevinMD article, “As an oncologist, this is the hardest role I play.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Don Dizon. He’s an oncologist, and he wrote the KevinMD article “As an oncologist, this is the hardest role I play.” Don, welcome to the show.

Don S. Dizon: Hey, thank you so much. It’s great to be here.

Kevin Pho: So, we’ll get into your article in a little bit, but first off, can you tell me your story and share your journey to where you are today?

Don S. Dizon: Right, no problem. You know, it’s an interesting one. I grew up in the South Pacific. I grew up on the island of Guam and stayed there all throughout high school, but I always knew I wanted to do medicine, which meant I would have to travel away from home. I think my parents always thought that I would come back to the island and be a local provider. But as it stood, I was really enamored by the people I met in medical school, especially those who taught us, and they really made an impression on me. I decided early on that I wanted to try my hand at being an academic physician.

At the same time, I also remember being on the floors as a third-year and being most drawn to and struck by people who were just being diagnosed with cancer. There was something about the vulnerability, not only of themselves but of their families, and I felt, this was 20 years ago, back then, when treatments were so limited, that if I could provide any comfort, I thought that would be a really nice thing to be able to do with my career.

Jump forward, then, after fellowship at Sloan Kettering, I was provided really great opportunities and worked with really incredible mentors that really fostered this passion that I had for academic medical oncology. I ended up specializing in the treatment of women’s cancers and then morphing into other aspects of medicine, including evaluating how I could help people living with cancer in terms of their sexual function, and then finally, looking at social media, stumbled upon writing as a way to really prevent burnout by just providing that reflective aspect. And I think that’s where I am right now.

Kevin Pho: How is the pandemic affecting cancer patients today?

Don S. Dizon: I think the pandemic, especially in oncology, has been hard in several ways. Number one is, we are used to seeing our patients in person and in clinic, and we’re used to smiling and even crying with them, and touch is a big thing for me. I like to be able to hug my patients. With a pandemic, many visits are virtual now. You try to make it via video visits, but for a lot of our folks, technology is not that available, and so they’re only able to connect via phone. And when we do see those patients, it’s behind a mask these days, and it’s fist bumps or elbow bumps rather than the hugs that we’re so used to using as a way to show that we care. So I think those aspects of care have been very challenging.

I think the decision-making, both for our patients as well as for us as clinicians, is more difficult. We are now thinking long and hard about admitting people into the hospital if they need very complicated chemotherapies. We’re using a lot more oral therapies, where we used to maybe not pull those out as an earlier line of therapy. During the height of the pandemic, we were delaying surgeries and giving far more chemotherapy than was planned to get someone to the operating room.

But even now, I think every visit I have with a person, whether it be virtual or in person, ends on a COVID-19 question of safety and security, and how do I interface with the real world during this pandemic, given I have my cancer? And we’re doing a lot of virtual hand-holding. I keep stressing this notion that we’re not here to practice social distancing. It’s really physical distancing, but really stressing that that social aspect of our relationships needs to remain intact.

Kevin Pho: So, with the pandemic changing sometimes the treatment regimen that you’re giving to cancer patients, is there going to be a change in potential outcomes?

Don S. Dizon: You know, I think that’s the biggest concern right now. I think even early, given that we went on lockdown in February and now we’re heading into the fall, I’m starting to see the first few people who delayed seeking care for a malignancy, and they’re coming in with advanced disease and, in some cases, with metastatic disease. And had they presented eight months earlier, would we have been able to impact that cancer progression? And the concern is that we probably cut off in terms of the treatments that we’re delivering during the pandemic, and how it’s going to impact cancer-specific outcomes. I think it is a concern, certainly.

The other aspect of my professional life is running clinical trials, and certainly that took a huge hit during the pandemic, where some trials didn’t even open or their opening was delayed during the pandemic, and others saw their recruitment targets just fall very, very quickly because people couldn’t access their sites. And the essential workers that are all in the cancer centers, that included research staff, but they were asked to work remotely, which is fairly difficult when you’re trying to do a therapeutic trial. So I think there will be some ramifications. We’re all hanging in there to see what they are. We’re all sort of learning together.

Kevin Pho: So, let’s talk about your KevinMD article, “As an oncologist, this is the hardest role I play.” Now, for those who haven’t read your article, can you walk my audience through it and share the story of why you decided to write it?

Don S. Dizon: Yeah. You know, I think the articles that I’ve been really proud to have been picked up by KevinMD all sort of begin with a personal interaction that I’ve certainly learned something from. And it’s still striking that even 20 years after I started in oncology, I still learn from every single person I meet.

In this particular case, it was a patient who I’d known for several months, but her demeanor was, it was a difficult visit because cancer hit her so hard. She went from being well to not well, and that word “cancer” just struck such terror in her that every visit started the same. It was always an emotional journey for her, just mourning the life she should have had and the future she should have had and dealing with the present moment. And it was difficult to try to support her and provide her that hope that she was still here.

But the learning point about that was, everyone evolves as they go through this cancer experience, and this woman certainly did. I still remember, she came in for one of her visits, and she wasn’t crying. She was very logical, and she was very, for lack of a better term, put together. And it turns out she had had an epiphanal moment with a family member who said, “Why you? Why not somebody else?” I mean, there are no answers as to why you’re the person who got cancer. And she just adopted this way of thinking about it: It is what it is, and this is what I’ll do, and this is what I have to do until I can’t do it anymore.

And it was just that whole process of trying to be the wind in someone’s back, or trying to get them through, just to feel better about themselves even while they’re doing that. That can be sometimes very difficult, but she taught me that people can change, and their viewpoints on things change. Sometimes it’s for the better, as in this person, where she actually found peace, but it’s not that way all the time.

Kevin Pho: As an oncologist, you see the most emotional cases. You see the sickest patients. Now, sometimes doing that over a virtual setting can be very difficult. How do you maintain that connection with patients when you’re really dealing with the most serious situation that these patients have ever faced?

Don S. Dizon: You know, I think that’s probably one of the hardest things. I recall just being in the hospital during COVID-19 and having to tell a person that their cancer had progressed and that’s why they were in the hospital, and then her turning to me and saying, “Can you please speak with my family?” who couldn’t be in the hospital. Doing this on a phone is very difficult, because the cues that I use to sort of pace the discussion and pace the conversation, you can’t do that on a phone call. And even with a virtual visit, you don’t know who else is in the room unless you’re sitting right in front of the camera, and so it’s almost my op-ed.

So I’ve learned that the only way to show empathy and to illustrate connectedness, even through a remote visit, is, hey, I just have to remember that I have to be honest with what I’m thinking with a patient or their family members, and to go slow. And then one of the things that I’ve gotten accustomed to doing is just asking for that teach-back. Tony Back from the University of Washington taught me that, to sort of say, “So, I just want to make sure we’re on the same page. What are you going to tell your daughter that we spoke about today?” I think that level of TLC is even more important when that person isn’t sitting in front of you.

Kevin Pho: I talked to a lot of physicians on this podcast, and a lot of them are helpless, given the fact that they can’t touch their patients. They can’t see their patients face-to-face. And I can imagine, in oncology, that situation is exacerbated even more. Can you speak to your feelings of frustration? And you mentioned how writing was an outlet for burnout. Do you feel that a lot of oncologists are going through similar feelings, and how are they handling it?

Don S. Dizon: You know, I think what the pandemic has really put into stark view is how a field, any field in medicine, but certainly in oncology, really is all-encompassing. Before the pandemic, you thought nothing about coming to work at 7 a.m. to maybe a tumor conference and not leaving until 7 p.m. because you did have that administrative meeting. I have young kids. My youngest twins are 12, and they were homeschooled during the pandemic. And it forced you to recognize, for better or for worse, that you do have a life outside of oncology.

And looking at that life, for a lot of my colleagues, has made them question how much energy has gone into their career, and has really forced them to think about their values and what their priorities are. I think a lot of us are struggling with that sort of eyes-wide-open view of medicine in America and wondering, could I ever go back to the way things were? Could I ever go back to a place where I was expected to be in the office from 7 a.m. till 7 p.m. five days a week, rather than being able to work virtually, coming in at 10 a.m., still doing my work, but needing to be home at 5? Institutions, and certainly Brown has done it for me, have made accommodations for everything that faculty are going through, but it has really put into stark contrast how much emotional and physical and mental work goes into taking care of people, whether that’s oncology or cardiology or even internal medicine.

So when I think about how people are handling that stress, I think it runs the gamut. I think there are some who are still struggling, because during the pandemic, there is no break. It’s sort of, you go to work, and then you do have this whole set of other responsibilities, especially if you’re not living alone, of what else is required. And I worry about that. I worry about that a lot.

I know some of our folks have actually started to take vacations. Even though it’s not that big vacation to Europe or Hawaii that they wanted, they have really prioritized taking those four days off at any one time and going out and doing something that’s non-technology-driven. Because I think the other aspect that’s causing a lot of frustration and burnout right now is the fact that one can actually get on their computer for a meeting at 9:00 a.m. and literally go the entire day on a computer, running meeting after meeting after meeting. And certainly that is my lived experience as we come into it today.

And it is not uncommon, I’m certain for you as well, where you start and you’re not out of that office, which ends up being your room or your office at home, and you’re not out of there until 6 p.m. at night. A friend of mine said it really well. It’s like, we’re not working from home anymore. In a lot of ways, we’re living at the office. And I think that that’s been very difficult.

Kevin Pho: Sure. We’re talking to Don Dizon. He is an oncologist, and he wrote the KevinMD article “As an oncologist, this is the hardest role I play.” Don, is there something that you’ve learned over the last few months that you could teach the other clinicians who may be listening to this podcast?

Don S. Dizon: If there was something that I’ve learned these past few months, it’s the importance of looking up, you know what I mean? It’s sort of like recognizing that with all the stress and all of the pressure that’s here, literally to stop, look at that sky, and smell the flowers, and realize that we’re all going to be OK. And at the end of the day, the things that matter to you are the things that you can actually hold in your hands, and everything else can wait. That’s the God’s honest truth.

Kevin Pho: Sure. And my final question: Do you have a take-home message that you want to leave with my audience?

Don S. Dizon: Sure. I would actually say, just remember that your job is a job, but it cannot hug you at night.

Kevin Pho: Wise words. Don, thank you so much for sharing your stories and insight. Thanks again for being on the show.

Don S. Dizon: Thank you so much, Kevin.

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