Editor's Note Long and winding road

In 1979 I was a junior faculty member in the oncology department at the University of Miami Sylvester Comprehensive Cancer Center. Having somehow landed in the education division, I had the dubious honor of teaching the cancer segment of the sophomore med student pathophysiology course. Education was a welcome relief from the demands of patient care, and this pursuit took on greater momentum when I received a call from a neurology resident friend of mine who said, “Our department just bought a portable video camera for training. Let’s tape something.” My “Spielbergian” genes immediately sprang to attention and I decided to produce a series of video sound bites from patient interviews to assist in teaching the mechanisms of cancer-related symptomatology. I always liked Frank Netter’s CIBA collection of medical illustrations; this would become the video version.

To begin, I sought a patient with esophageal cancer — looking for a classic story of progressive dysphagia. I soon met Mr J, a very asthenic, reserved, indigent African-American man in his late sixties. With my buddy neurologist as the cameraperson, we taped away. The result was initially somewhat disappointing. The patient had a difficult time explaining his symptoms, which were in no way similar to classic teaching. Try as I might, the interview remained awkward at best, but just when I was preparing to pull the plug, we struck educational gold.

“They didn’t tell me I had cancer,” he said. The patient’s face was contorted with rage. “I found out when I realized that everyone in the radiation therapy waiting room had cancer. The doctors never told me.” The man was quiet but angry as hell, as he issued a blistering indictment of the medical care he received, eloquently elaborating on this in great detail. In later years, even when I was regularly producing educational videos with the UM audiovisual staff using much more sophisticated hardware, I continued to show med students that grainy camcorder video of Mr J, because they needed to know that physicians have particularly serious responsibilities for effective patient communication when cancer is involved.

In 1988, I shifted my emphasis to audio production, figuring that real people are too busy to watch TV, and all of us are stuck in our cars. (I also subsequently learned that television is best watched without sound, particularly during election years.) It was with considerable enthusiasm that I conducted my first audio interview with the “father of breast cancer clinical research,” Dr Bernard Fisher. Much to my dismay, Bernie, in his burly and inimitable way, informed me that “researchers do research and are not in the business of telling people how to practice.” Nothing I did or asked could prompt this legendary figure to comment on the clinical implications of the then groundbreaking NSABP trials demonstrating an advantage to adjuvant chemotherapy and tamoxifen in patients with node-negative tumors. Fortunately for me and our series, subsequent interviewees began to chat openly about how they take care of patients and what they really think about emerging clinical research. Now, on a good day, I can even get Bernie to open up a bit.

One of the coolest things about my unexpected career is that I can directly observe oncology history evolve. Sometimes things happen very quickly. Consider the following two audio interviews with Gabe Hortobagyi this year, in which I posed the same query:

Question: Right now, in your own clinical practice in a nonprotocol setting, if you see a postmenopausal woman who’s been on adjuvant tamoxifen for two or three years, how do you approach the decision about whether or not to switch to an aromatase inhibitor?

Answers from Dr Hortobagyi:

February 26, 2004, Miami Breast Cancer Conference
I raise the issue with all of my patients who are currently on adjuvant tamoxifen, but I am not yet prepared to switch because of the immaturity of the data. I’m starting to talk to them about the promising new data, but I will wait for more mature reports before I start switching.

October 18, 2004, Breast Cancer Update Working Group Meeting
For patients who are on tamoxifen for any length of time, our practice today is to switch to an aromatase inhibitor.

Gabe reiterated these views at a recent CME conference our group held in Chicago. After the meeting I asked Jay Harris, another panel member, about these provocative comments. “People have tremendous respect for Gabe and listen very carefully to him,” Jay told me. “We have learned over the years that what Gabe says usually comes to pass.”

This December marks my 25^th year as a professional listener, and I truly love my work. People have so much to say, and there is so much to learn. On this “golden anniversary” of what has become a fascinating educational path, the traditional Hebrew greeting “Mazel Tov” seems very appropriate. The phrase means “good luck” and reflects the truth that one must be blessed with great opportunity to do great things. A recent external independent survey demonstrated that more than two thirds of oncologists in the United States listen to our various audio programs, including this one, the grandmother of the others. It’s an honor and privilege to pose the questions I think you might ask if placed in the same situation.

— Neil Love, MD
NLove@ResearchToPractice.net

Home · Search