Cancer Stories: The Art of Oncology

Listen to ASCO’s Journal of Clinical Oncology Art of Oncology poem, "Episteme” by Dr. Michael Slade, who is a medical oncologist at Washington University School of Medicine. The poem is followed by an interview with Slade and host Dr. Lidia Schapira. Dr Slade highlights the tension between what is known and unknown and what spoken and unspoken as physicians try to care for our patients without destroying their ability to live with their disease. TRANSCRIPT Narrator: Episteme, by Michael J. Slade, MD, MSCI  I know you know, must know. The tides have woken you night after night after night, borrowed blood flowing in and now out, unaided by your dwindling marrow. You must know your story is read and written in a perfecta tense. You must know the end somewhere deep in your empty bones.   Still, you speak of summers, of fish caught or lost beneath the calm surface of a distant lake. “There’s nothing to do in December,” you say, skin pale in the cool light leaking from the door. It’s late now, deep in the evening and my knees ache as I nod and wonder about a different world where you were not you and this was all decided months ago.   “Day by day,” I mutter and shuffle to my next door, leaving you alone to wait on the cataclysm, on that night when the blood of strangers runs wild and catches your breath, that night in the ICU, where they wait, tube in hand as you sweat and shake, where I still promise to care for you knowing, knowing you will never wake again. Dr. Lidia Schapira: Hello and welcome to JCO's Cancer Stories, the Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira. I'm a Professor of Medicine at Stanford University. Today we are joined by Dr. Michael Slade, a Medical Oncologist at Washington University School of Medicine. In this episode, we will be discussing his Art of Oncology poem, “Episteme.”  Our guest’s disclosures will be linked in the transcript.  Mike, welcome to our podcast and thank you for joining us. Dr. Michael Slade: Thank you, Lidia. It's great to be here. Dr. Lidia Schapira: It's a pleasure to have you. Let's start by talking a little bit about your relationship to writing prose, poetry. Is this something that you've always done? Do you want to share with us a little bit about what it means to you and when you have time to write? Dr. Michael Slade: I'd say, I have absolutely no formal training as a poet or honestly in anything else, but this is something I've done since college. And especially starting in medical school, this was really a deliberate practice for me to try to find a way to unload some of the harder experiences that we can go through as medical providers. Dr. Lidia Schapira: It's interesting to hear you say that. Many of our authors have talked about using their writing as a way of processing emotionally difficult experiences and just very important meaningful experiences. But there's so much artistry in your work. I just wanted to ask you a little bit more about that. How do you find the relationship to not just the writing as a way of processing, but as art that you want to share and publish. I've seen that you've published poems, quite a few of them in the last year alone. Dr. Michael Slade: Yeah, I would say the publishing piece of this came very far down the road for me, that I've been writing for over a decade before I think I even submitted anything for publication. And for me, the ability to publish is more of a- Is a way of putting yourself out there and as a motivation to really re-examine what you've written and not just scrawl it on a piece of paper and sort of stick it back on a shelf somewhere, but to be able to go back to some of these experiences and really delve a little bit deeper, both with the language, but also what was the experience? Why was this meaningful? And often things that end up in print for me are things that I've been playing with for a number of years. It is just sort of an ability to go deeper there is the reason why I have published some of these works. Dr. Lidia Schapira: I am very interested in the theme of time and your use of pronouns. There's a lot of negotiating. What is yours and what is your patients’? I assume the “I” is the oncologist, right? In this particular case, since the readership of JCO are mostly clinical oncologists, it's sort of meant to be an affiliation with a reader. And there's a lot of “I,” but then there's a lot of mine. Can you talk a little bit about how you have chosen to address the patient directly and your colleagues directly and put yourself out there using first person as well? Dr. Michael Slade: I think certainly, as I wrote this, and I tend to write a lot as I come off of sort of tough stretches of clinical work, and as I wrote this, I think, I was trying to capture a little bit of the anguish that I think a lot of us feel as oncologists, especially around this question of what we know and what is knowledge for the oncologist. The reality is the things that we know sort of above the neck tend to be very statistical, that we say, “Oh, the chances of you responding,” “The chances of you surviving,” “The chances of you being cured,” it's very numbers based, but it's probabilistic. And when we talk to patients and often when we talk to ourselves, we really use this idea of knowing in a very different way, that we know that something's going to happen because of our past experience or because of what we're seeing right in front of us. I think that's something that I think a lot of oncologists probably identify with very closely is that what do we do when we feel like we know something in a way that's almost deeper than the academic way that we speak of knowing. Dr. Lidia Schapira: Let's talk about that. And that is, in fact, the title you chose for your poem. Why not just use the word knowledge? Tell us a little bit about that choice. Dr. Michael Slade” When we talked about knowing, both academically and my background before I came to medicine, as I trained in philosophy, we talked about epistemology or episteme. Often, we talk about knowing both in medicine and in sort of the wider philosophical discussions, we talk about it in this very abstract way that if you were to sit down with a patient and really try to unpack it, they're not going to have any idea. This isn't relevant to practical life in a lot of ways. They want to know, “Am I going to be cured?” “Am I going to have this side effect?” “Am I going to make it out of the hospital?” And the type of knowing that we do within science is not that type of knowing. It's all probabilistic. And to me, I think, trying to pull back a little bit, and by using the sort of Greek root, it sort of places this idea of knowledge at a remove that I think is useful. Dr. Lidia Schapira: Mike, I've often used the analogy that poetry is almost like abstract art sometimes, because it invites the reader to imagine things. So if we think of this poem sort of as art, can we walk through this together and take it from the top and see what we see or what these ideas trigger? You start directly by addressing the I know, you know, you must know. And then you present the case, if I got this right, of somebody with a dwindling marrow, that's an empty bone, so an inefficient marrow. And I assume, since you're a bone marrow transplanter, that means this patient had a disease that was incurable here, and you sort of insist that you must know. Tell me a little bit about that tension, that emotional tension that comes up for me as I read that, those opening lines where you're sort of insisting that you must know something that you're not sharing with me that you know. Dr. Michael Slade: I think for me, that's really trying to express the gap that can emerge between those of us who do this professionally and our patients who have to live through these experiences. And we can say, “I have seen this story play out so many times, and I know things are not going well. I know how this is going to end.” But for the patient, this is, obviously, every patient is an n-of-1 with their own experience, and they may have had family members with similar diseases, they may have had friends. They may join these really wonderful patient support groups where people can sort of talk about what the process of cancer treatment is. But for the patient, they are living through it day to day. And we may feel with our accumulated knowledge that it's very clear how things are going and that either their optimism or pessimism or sort of whatever the patient's base emotional reaction is to the clinical situation is fundamentally incorrect. It's like you have to put these pieces together in the way that I do. And the reality is that there is a huge gap that can emerge between us and our patients, and it can lead to frustration and anguish and a lot of negative emotions, I think, from clinicians that aren't aimed at the patient, but they're really aimed at the fact that we feel like we're not talking about the same situation. I think that's what that first piece of the poem is really trying to capture, is that anguish at that type of gap. Dr. Lidia Schapira: And you say it very clearly. You say, “You must know your story is read and written in the perfect tense.” It's almost like you're shouting it here, right? Dr. Michael Slade: But in sort of a weird, obscure way that if you tried to tell a patient sort of a grammatical metaphor for how poorly their hospitalization was going. Most patients, unless they're English literature professors, will look at you as sort of with this, “What are you talking about?” I think, again, it's that gap. It's this very academic, removed way that we often look at this, especially when we're trying to shield ourselves from this very human anguish of knowing that there's this real person in front of you who's not doing well and that you feel like you kind of know how the story is going to end. Dr. Lidia Schapira: Let's go a little deeper into that then. It's really about your feelings then here. It's your frustration. You want the patient to mirror back to you that they get how bad this is, and they can't because they are trapped in that body, in that situation. And as you just say, and then you say in the lines that follow, “they are coming up for air.” They're thinking of the summer and the fish that may be caught or not caught. They may know it somewhere, but they can't quite recite that back to you. And that leads the writer, the author, to voice this inner tension. Did I get that right? Dr. Michael Slade: I think that's exactly it. And sort of towards the end of that verse, there's also sort of this counterfactual that certainly different choices can always be made in the course of treatment. And especially for us clinicians when we're encountering a patient who interprets their disease a little bit differently than we do, and they say, “Oh, I feel fine. Why do I need chemo after surgery?” Or, “Oh, I feel fine. Why do I need a bone marrow transplant?” And sometimes people will make choices which makes their immediate life better, but we are always stuck in this sort of feeling of, “Oh, man. If only we had done things a little bit differently.” I acknowledge that we just can't align our views of the world, but still at the same time saying, “Well, I don't know, things would have been better if you'd listened to me. Maybe you made the right choice for you and your disease process.” So it's always that gap between what we know academically and what we sort of know below the neck. And then for patients, their experience is often very different from ours because they have to live through this. Dr. Lidia Schapira: I'm interested in the physician narrator experience here, and I was really impressed by the fact that you convey the tension on the emotional load. But the only thing that you write and communicate directly to the reader is the physical aching, when you say, “it's the evening and my knees ache,” and then you say “I shuffle,” suggesting that you're physically tired. I just wonder if you could talk a little bit more about that, the way that you have inserted the fatigue factor of the narrator here, but through the description of physical symptoms. Dr. Michael Slade: I think there's a little bit of blending there, because I think on the one hand, certainly this emotional anguish, mental anguish can certainly manifest as fatigue, and sometimes can be sort of a little bit of a metaphorical blend there. But I think the other thing that we often really struggle with as physicians and as other providers is how much are we letting ourselves get into the story that the patient is experiencing, but even the story that we're trying to objectively put together. And because, for example, we had a patient who tried a treatment and they had a rare side effect, a lot of us will admit, “Hey, I had a patient with a bad outcome when they got X,Y,Z.” Even if the data looks really good because of my own emotional processing or I do my best. And I know a lot of other physicians talk about this, but if you are tired, hungry, under or over caffeinated, having bad things going at home a lot of times for us, we worry about letting our personal lives bleed into our interactions with patients. And that's really challenging because I think we are at our best when we bring our humanness into the clinic room, into the hospital room. We also have to make sure that we're not saying, “Oh, am I just down because I'm tired, and that's why I think this patient's going to do poorly?” Or is it actually supported by the evidence in front of us? So I think the way that the narrator kind of moves in and out of this piece and how much they are a part of the story is a big piece of the poem. Dr. Lidia Schapira: It is a very big piece of the poem. And as I read some of the other poems you've written, I think that I was also impressed by this construction of the boundaries and the separateness between the patient and the physician narrator and how you negotiate that when you're waiting for a result, when you're waiting for time, when you say it's really the patient's story, but it's yours too. There's a fluidity about this perspective. Did I get that right? Dr. Michael Slade: I think that's an absolutely wonderful way to describe it. I think fluidity in particular is, yeah, that we think of things as very separate from each other and that I'm me and you're you and there's your family and there's the rest of the team. But all of this stuff, not to get too sort of hippie with it, but there's so much resonance when you're in these relationships that you have with patients. And especially in cancer care, we have very deep, often very prolonged and somewhat intense relationships with patients and their families as they go through this stuff. Boundaries can become blurred. And again, I think it's challenging because sometimes we are at our best when we blur those boundaries a little bit. But there's certainly- you can be pulled into a patient's story in a way that is not helpful for you long term, but even not helpful for the patient short term. And I think that's the challenge. And you're right. I spend a lot of my work sort of thinking about this. And a lot of my professional life is also thinking about this. Dr. Lidia Schapira: I would say it a little differently. And it's that you are co-constructing an ‘us’ that is between you and they, or you and he or she, or however you see this. And that's the mind part. Others have talked about cases where there is a deep connection between physician and patient, where the physician is invited to be a co-editor of that patient narrative. I think there's a lot of richness in that. And I think that your work and your poetry certainly takes us right there.  And so with that, I want to take us to the end of the poem, which is terrifying.There's going to be, you use the word ‘cataclysmic’, which means, this is an upheaval, something violent about to happen. And the way I interpret it is your patient is neutropenic and septic and shaking and rigoring and is getting transfused. And the “They,” which isn't you or your team, it's the ‘they’ are waiting for it too and going into probably an intubation in the ICU. And then there's this promise that you won't abandon the patient while ‘they’ are going to be doing these things. And we already know how this story is going to end. Is that what you are trying to convey? Dr. Michael Slade: It's funny because until you sort of read it out, I was like, I didn't realize how much I threw our ICU colleagues under the bus as part of this poem. So if any of you guys are listening, I have immense respect and value for what you do. But no, and this is sort of the big question that we run into with these patients and what's the right response when we feel like we can see the future and then we turn out to be correct. How do we not, I guess, insulate ourselves from that in a way that's not helpful for us and it's not helpful for the patient? And yeah, so that's sort of, as I said, you read the story sort of as it was laid down, but yeah. What do you do? What's the right response when you feel like you're getting to the end and that you feel like you've seen it coming for weeks? And I think that's really the challenge. And the poem sort of suggests an answer to that question. But I think everybody kind of has their own process that they have to go through. As you see, unfortunately, as an oncologist, case after case of folks that- cancer is tough and our treatments are getting better, but I'm a myeloma physician. I have cured zero patients so far. And that's hard at the end of the story. It's always hard. Dr. Lidia Schapira: It is hard. Can you tell us a little bit about your choice of language and why you keep repeating the ‘knowing’ and then italicize it at the end, just to add another dimension of emphasis there? Dr. Michael Slade: As someone who loves language and has always been interested in it from a philosophical perspective, but literary perspective as well, there's really, really sharp limitations to what language can express. And we can unpack and define and redefine and suggest. But there's something- often, we in these situations, run up into a place where words are totally insufficient. And I feel like often what we end up doing and what I end up doing in writing but I think even in our interactions with people, we just sort of use the same words over and over again, hoping that somehow the meaning will morph mid-interaction and suddenly we'll have that connection with someone where they'll hear what we're trying to say. And for me, I kept coming back to this idea of knowing, knowing, knowing. The narrator's trying to express something that they just can't quite get their arms around. And I think the best and the closest I can get to in similar situations is something like this, is trying to write out these experiences in a way that kind of captures that feeling. I hope I at least captured a piece of it. Dr. Lidia Schapira: Certainly. I loved your writing and I think you did. Despite how difficult it is to talk about this and how difficult it must have been for you to live through it, there's a real gentleness about the way you take the reader through this. And it evolves. Really, it flows beautifully. So thank you for that. Dr. Michael Slade: I very much appreciate the writing. And I will say to the folks who read the original version of this poem, both in my personal life and then at JCO, this is not the original form the poem was in. So I think other people have layered in their experiences here. And again, I love to see this come out on the other end and say, this is more beautiful than what I started with. So I have a lot of gratitude to folks who have given me some pointers about how to improve this. Dr. Lidia Schapira: It's lovely to hear you say that. To end this, I would love to hear you tell me a little bit about comments, perhaps, that colleagues or even patients may have made based on work that you've published or what you hope that people will take away from this. Dr. Michael Slade: I had published maybe one poem back in medical school, and then I published something as a fellow. And I remember in our program, we have this big office and we basically all have cubicles, and we have sort of the computers all set up, and we're in and out, you know, seeing consults and everything else. And I had published something in JCO a few years ago, that was about indirectly the experience of trying to be on call and triage patients and all this. I had maybe three or four different fellows within the week that that was published, sort of stick their head over and be like, “I never read poetry, but I saw your name on this. So I flipped to the back of the JCO magazine and read it.” And that captured so many of the feelings that I've had this year in a way that I couldn't put on paper. Again, I've been writing stuff since college and most of it sits in a folder somewhere and it's never read by anybody. So the idea that it could go out into the world and could make people have that sort of sense of catharsis that I'm not alone in this. Somebody else has had this experience and had this feeling.  I've had that same experience with some of my very brilliant colleagues who paint or who participate in other sorts of artistic endeavors. And it's nice to know that there's a community of people out here. We're all just trying to navigate the same stuff. And if we can sort of help each other, if we can capture these experiences and retranslate them in a way that people can process their own, sometimes, grief. I think it's really wonderful. Dr. Lidia Schapira: Yes. To create a thoughtful community and accompany one another. Well, thank you for sharing your art and your wisdom and your knowing with us today, and please keep writing.  And for our listeners, until next time, thank you for listening to JCO's Cancer Stories, the Art of Oncology. Don't forget to give us a rating or review and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Like, share and subscribe so you never miss an episode and leave a rating or review.   Guest Bio: Dr. Michael Slade is a Medical Oncologist at Washington University School of Medicine.

Listen to ASCO’s Journal of Clinical Oncology Art of Oncology article, "The Holiday Card” by Dr. Laura Vater, who is a gastrointestinal oncologist at Indiana University Simon Comprehensive Cancer Center. The article is followed by an interview with Vater and host Dr. Lidia Schapira. Dr Vater shares how she processed the unexpected loss of a patient and how a colleague unknowingly helped her cope. TRANSCRIPT Narrator: The Holiday Card, by Laura B. Vater, MD, MPH  I kept her family holiday card tucked into the side pocket of my black briefcase for a year and 3 months after she died. I carried it back and forth to the office each day, never viewing it but with a deep awareness of its presence. It was a transitional object, my therapist said. I took it with me for reasons that were not logical or even fully clear to me—perhaps part of me thought if I kept it in that dark space, then maybe her death was not real, after all. Death is not new to me. Much of my work as a GI oncologist is palliating my patient’s symptoms and helping them navigate the end of life. But she was not supposed to die. She was a vibrant, kind person, and I was treating her for a potentially curable condition. A team was assembled, a tumor board discussion was held, and a comprehensive plan was derived from published clinical trials and national guidelines. She was on track to finish chemotherapy and recover. She was meant to have decades more with her husband and teenage children.  This is what gnawed at me—death out of place. It was during a nap on a normal day, months into her treatment course. There were no proceeding symptoms or perceptible changes. The autopsy showed no apparent cause of death. Amid it all, her family was kind and expressed thanks. “She was grateful for your investment in her,” they said. “She felt cared for.” Rechanneling my distress, I rechecked the dose of every chemotherapy agent she received, along with each supportive medication. It was all per protocol, verified by pharmacy teams, and infused without adverse reactions. Yet, the questions remained. I continued to carry the weight of responsibility, along with the holiday card. In clinic the next week, I met a patient with the same diagnosis. Again, there was a multidisciplinary discussion, and we planned to give him the same drug regimen. After reviewing the more common side effects with him, a lump formed in my throat. “In exceedingly rare cases,” I said, “cancer treatment may lead to death.” My eyes began to water, and I pushed back the tears to answer his remaining questions. He completed the treatment and, over time, had no sign of recurrence. Many more patients followed with the same diagnosis and positive outcomes. And the card remained in the bag.  Over a year later, a senior mentor and I had a shared patient with two malignancies. We carefully discussed and managed her care, but she unfortunately had a rapid clinical decline and was admitted to the intensive care unit. Her family elected for comfort care, and she died soon after. We saw each other in the hallway the following week. “Just awful, wasn’t it?” he said. I exhaled and nodded.  Perhaps he could see the invisible burden I carried, and he sighed. “We do the best we can with the data we have, but we’re treating terrible diseases. Sometimes, bad things happen that we cannot predict or prevent. We did everything we could for her.” Something deep inside me released in that moment. Often, mentors do not realize how healing their words can be—even brief ones shared in passing on a busy clinical day. Eventually, on a quiet afternoon at home, these words gave me the courage to reach into the side pocket of my work bag and remove the white envelope. My name was written and underlined in royal blue ink. Slowly opening the card, I saw once again a snapshot of life: a beaming family with arms around each other amid a blanket of paradise-green trees. They were huddled so close that there was no space between them. I imagined how she might have felt at that moment, the warmth of her children pressing on either side and the joy spreading across her face. Perhaps someone had told a joke just moments before. My face crumpled, and I began to sob. How badly I wanted to cure her, to restore her to health, to see her year after year for follow-up, and hear about her children’s unfolding lives. And now, they were navigating the world without their mother. One of the most challenging aspects of practicing oncology is the uncertainty of it all. Even when the variables are the same—diagnosis, staging, and treatment—the outcomes are unpredictable. We, of course, know and rationally accept this as physicians. It is the nature of our work to care for diverse and varied human beings. But even so, when devastation occurs unexpectedly and without apparent reason, the toll of grief can be crushing.  It is often the support we receive from one another that helps us heal. We must remind our mentees that despite our greatest efforts in a field of extensive data, unpredictable outcomes still happen. We will have questions that may never have answers. Our minds may try to cope with this randomness in ways that are not always logical. Our grief may linger like an open wound for months or even years to come. Caring words shaped by time and experience can help us process, cope, and continue on. I am not typically a person who holds onto holiday cards, but I have a tray in the bottom drawer of my home desk with about a dozen meaningful ones. This card now lives among them. I still often think about my patient and her family, and I even look at the card from time to time. However, it is no longer in that liminal space within the side compartment of my bag. It has become integrated into my life and remains part of me—her story forever interwoven with my own. Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the oncology field. I'm your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today we're joined by Dr. Laura Vater, a gastrointestinal oncologist at the Indiana University Simon Comprehensive Cancer center. In this episode, we'll be discussing her Art of Oncology article, “The Holiday Card.”   Our guest disclosures will be linked in the transcript.   Laura, welcome to our podcast, and thank you for joining us.  Dr. Laura Vater: Hi, Lidia. Thank you so much for having me today. Dr. Lidia Schapira: It's our pleasure. So let's start by just asking you a general question that I think our authors like to share with listeners. And that is, why do you write? When do you write? When did you start writing? Dr. Laura Vater: Yeah, so I started writing, actually, during my first few years of medical school as a way to process and cope through many of the challenges and the difficulties and the emotional ups and downs of training. When I was a third year medical student, I was pregnant, and I was rotating through the high risk maternal fetal medicine rotation, and I witnessed a stillborn child, and that child was about the same gestational age that I was pregnant at that time. And I thought about that family. Had they picked out a crib, and had they chosen the color of paint for their walls? And anticipating this life and having it end in this just grief. And participating in that ritual of loss really evoked a deep emotional chord in me that I remember walking out right after that shift was about 2:00 in the morning and it was freezing cold in February. As I was walking in the parking lot, I just started crying. And I thought, I need a way to process and cope with the challenges that I'm witnessing in my training that served me very well. I always journaled through medical school and residency as an internal medicine resident, as an oncology fellow, and now during my gastrointestinal oncology practice. And sometimes I go a week or two without journaling, sometimes I'm writing every day and it kind of depends on the week, but it is truly something that helps me process and cope.  Dr. Lidia Schapira: So it's good to know that you are so comfortable with words and writing as a way of processing. But I'm curious to have you address the next layer, which is then to go back and turn it into a piece of art, turn it into a piece of writing that you want to share with others. Can you talk a little bit about that process and the role that's played in your professional development? Dr. Laura Vater: For a long time, writing was something very informal in my life, and then I started really enjoying spending time writing, and so I started participating in different writing groups. I participate in a Gold Humanism Writing Group with Judith Hannan. I did the Fall Narrative Medicine Workshop at Columbia, part of the Pegasus Physician Writers at Stanford University, where we meet every month to go over our writing. We've created a Writing for Wellness program on campus. And so this went from something very informal then something that I really was drawn to and loved, and that, really working with my peers, participating in writing prompts, reading both fiction, medical related nonfiction, and narrative stories, that's really crafted my ability as a writer to turn something that's just a reflection into something more, into something that I hope will help others. I think we all feel that way, right? If we share something that is perhaps a bit vulnerable, sometimes shrouded in shame, that perhaps it might help another trainee or early career physician through what they're going through.  Dr. Lidia Schapira: Well, maybe you're the best person that I can think of to answer this question, but tell me a little bit about how you see this narrative in oncology and narrative medicine applied to practice to training. Dr. Laura Vater: I think that it's something that is necessary. It's something that helps me to pause, to slow down, to see the humanity in my patients, and also to hold on to my own humanity. And so it's truly something that allows me to continue to practice, and I hope to practice well through paying attention to the nuances of my patients and their stories. Sometimes, I'll be sitting in a room with a person, and I'll notice the color of their glasses, or I will be moved by something, a direct quote that they say. And I think that both reading narrative essays and writing helps me to slow down and to pay more attention. I think it helps, hopefully helps me to be a better clinician, but also allows me to have more meaning in what I do. Dr. Lidia Schapira: Yeah, perhaps even we can use the word ‘joy’. It's more interesting if you're curious and open and you see these things. Can I ask you how you deal with the emotional labor and the emotional investment in your patients? You seem to be somebody who has no difficulty engaging at a very deep level. But how do you work that through and fit it into the rest of your life? Dr. Laura Vater: You know, it's interesting that you asked me that question, because over the last two weeks, that has been the question in my mind that I've been coming back to. I've been covering for a partner that's been out of town and another partner on maternity leave. And so I found that my clinical work has been a bit busier and that I've hit that point in my early career where I know my patients very well. But as a gastrointestinal oncologist, many of my patients, I'm walking through devastating recurrences of what we thought was curable pancreatic cancer is now stage 4. So I've found that even over the last two weeks, I had a few days last week where I came home after the clinic and I had nothing left in the tank. I have my husband and my eight year old daughter, and I just had a few days last week where I actually asked myself, I said, “How am I going to continue to do this work, both clinically, physically, intellectually, and emotionally exhausting days, right?” Our clinics can be all of those. Our clinical work can be all of those.  And so I actually took some time over the weekend. I've been intentional for a very long time about how can I connect with patients deeply to know them as human beings, help them to walk through really awful things, but then be able to have both health and wellbeing and joy in my own life. Because I think we deserve that. We deserve the health that we strive so hard to give to others. It's something that I'm still processing through. Things that help me cope? Of course, I regularly go to therapy. I think that really helps because I have a lot of patients who do pass from their cancers. And I also write. Writing is a tool that I come to, and sometimes it's even writing, “I'm emotionally exhausted today. And this and this, and this happened.” And sometimes it's being in nature, sometimes it's listening to music, sometimes it's just doing nothing. Reading a book I've read before or watching a show I've read before.   But I keep coming back to this idea of, there's this thought of we all develop some emotional calluses. The things that evoke emotion in us when we are first learning medicine, when we're medical students, are not the same things that may evoke emotion in us as we progress through our careers. For me now, it's often a person that I have a deep connection with that I've known over time. And in that moment when something really devastating happens, I'm finding that that is probably the most emotionally difficult thing, especially if that person is particularly young or has young children. And so I'm increasingly trying to find ways to cope with that, because we need to do that to protect our longevity, to be able to do this work.  Dr. Lidia Schapira: Yeah. And to stay fresh for our patients as well. I think that we are a culture that is immersed in grief, and we volunteered for this work. But I think we volunteered perhaps when we didn't quite understand all of the areas that this grief and the sorrow and this immersion into that culture can really deeply penetrate. It sounds like you have used all of the possible resources, and you're incredibly open and frank about it. I wonder if in your institution, people talk about it as frankly as you do. Dr. Laura Vater: I have had mentors who have talked with me. I have the benefit of being trained through residency and fellowship at the same institution where I work. So I've known some of my mentors for almost 10 years, more than that. And so sometimes I will ask them, “How do you cope with this?” Some of my peers are incredibly funny and, not in a- sometimes sarcastic, yes, but not in a demeaning way towards patients, but they just bring a lightness to the clinic. Especially in the world of gastrointestinal oncology, where a mentor once told me that eight out of ten of my patients will not live long term. And so a lot of what I do is palliative care and end of life care. And I think we knew that. Like you said, we know what we sign up for. But sometimes the reality of that can be much, much different than that.  I do reach out to my mentors. I try not to burden them. But sometimes if we're in a clinic and I notice that we have a down moment, I might say, “Wow, I'm dealing with this.” And they'll sometimes share an experience from their early career or even recent and I think that's healing. There is something about being vulnerable with your peers, whether that's through writing and formally publishing a story and reading a story of someone you've never met, or even in those moments in the clinic or in the hospital where you share something with your residency team or your colleague that can be very healing. Dr. Lidia Schapira: And even being able to open yourself up and be vulnerable together, or cry with somebody, or cry reading somebody else's story. There are some essays that have been published in The Art of Oncology that make me cry every single time I read them. And it's a way of feeling that I'm sort of in solidarity with a colleague's pain, or that I feel sort of understood, or that I have a community of peers, people who are also drawn to these very tense, emotionally intense situations, but find meaning in it and find meaning and keep going back to it on a very intentional basis. And I think you're probably one of the club.  So let's talk a little bit about your essay, this beautiful essay about this holiday card that you kept tucked in your briefcase until it was the right moment when you could process something that was deeply, deeply painful to you because it was a death that was out of place, that wasn't supposed to happen. Tell us a little bit about how this became a story for you. Dr. Laura Vater: I still remember the moment that I woke up to an email from this patient's husband, unfolding that this patient had unexpectedly died the night before. And that was the first email that I read that morning. It was early, and I remember pacing in my office until it was late enough that I could call him. And, of course, then came all of the questions and all of the uncertainty and unfortunately, without answers ever being found. And just like before, when I was a medical student, I needed somewhere for this to go. I needed somewhere for this to go. And so this became even that day, journaling about this experience, in a way, of course, that protected my patient's identity. And as things unfolded over the next few months, I kind of came back to the same word document. And just anything that came into my mind as I was processing through this went there because I knew it needed a safe place to go.  And then months later, this was something I talked about through therapy over many, many months, actually, and then eventually to this encounter I had with this mentor who provided very healing words in a moment when he had no idea that I was processing all of this about a different patient. And how that eventually led me to be able to pull the card from my bag and really grieve, really allow myself to grieve in that moment. You don't stop grieving, but it helps you to find a healthy way to process through something very difficult and be able to cope and continue on and hopefully share with others that these things we go through in medicine, we're not isolated in our experience. You're not alone in what you go through when something like this happens early in your career. These are normal things that you're going to think, and it may take months or even years to process through. Dr. Lidia Schapira: Yeah, I think the healing intention of your mentor's words or of a senior colleague or somebody just willing to sort of stand with you or be with you and share that is something that is so incredibly valuable. Maybe some of our listeners can think of moments where somebody has been there for them or where they have been there for somebody else. Laura, I think that there's one or two books there hidden in your files. Maybe that's next. I mean, just the evolution of the process and the formation of your professional identity, your clinical persona, and the intention and attention you bring to the work. Is there a book in the making? Dr. Laura Vater: Thank you, Lidia. That's very kind of you. I'm hopeful that at some point there may be a nonfiction book. I didn't share this with you yet, but I also write fiction. I've actually completed one novel, and I'm working on my second novel. Writing has become something that I never anticipated myself spending much of my time doing in my non clinical space, but much of what my fiction writing is really about the mental health of clinicians and well being, and also many of these challenges that we face. And so hopefully more to come in the next few years with those, yes. Dr. Lidia Schapira: Yeah. I look forward to another conversation and to reading more of your work. Laura, this has been a lovely conversation. Thank you. Dr. Laura Vater: Thank you, Lidia. Dr. Lidia Schapira: And to our listeners, until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Show Notes:  Like, share and subscribe so you never miss an episode and leave a rating or review.     Guest Bio: Dr. Laura Vater is a gastrointestinal oncologist at the Indiana University Simon Comprehensive Cancer Center.

Listen to ASCO’s Journal of Clinical Oncology Art of Oncology poem, "Rain Talk” by Dr. Karl Lorenz, who is a palliative care and primary care physician and Professor of Medicine at Stanford University. The poem is followed by an interview with Lorenz and host Dr. Lidia Schapira. TRANSCRIPT Narrator: Rain Talk, by Karl A. Lorenz, MD, MSHS   Rain splattering, a cacophony of glassy dollops plopping, sliding, colliding, crashing, plashing melted pearls. Drops careening, onto the ground now streaming, seeking, trickling, slowing, flowing into a rill of connections.   Water nourishing blades of grass becomes a field of forage, or the smallest sprout of a redwood fairy circle. Life springs forth from the pitter patter, as words too, joined in thoughts, converge, merge, spill, flow into action.   You lay cancerous, stoically shrouded. I stood frozen, purged of words, anxious amid the pulse, beep, thrum, dry rustle of nurses’ coming and going. A stiff-coated doctor fractured the quiet— “I wish things were different.”   Her words fell stinging. Fighting soul ache, I gripped your shoulder. Grimacing, muffling sobs, as gasps, a gurgling cry, erupted into a torrent of tears clouding sight. Reaching, we grasped hand over wrist over hand.   Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I am your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today we're joined by Dr. Karl Lorenz, a palliative care and primary care physician and a Professor of Medicine at Stanford University. In this episode, we will be discussing his Art of Oncology poem “Rain Talk”.  At the time of this recording, our guest has no disclosures.  Karl, welcome to our podcast, and thank you for joining us. Dr. Karl Lorenz: Thank you for inviting me. It's such a pleasure. Dr. Lidia Schapira: I'd like to start by asking you a broad question about the role of literature and poetry in your career as a physician, educator, and palliative care physician. Tell us a little bit about the history and trajectory of your participation in the arts. Dr. Karl Lorenz: Yeah, thank you. Well, arts have had varied expressions in my life. I was a musician for many years, and I'd like to mention that because there's so many similarities between the types of art and overlap, and I think, what they teach us and how they engage us. But I was an instrumental musician for a long time, and then actually I studied opera and sang choral music in Los Angeles, which was really wonderful. I became a writer, I guess at some point. I was an English major as an undergrad. And the funny thing is I was an English major because I thought, “Oh, you know, I want to be a doctor. I'm not going to get to do this again.” And of course, that turned out not to be true, but it also was a portal, I think, into the emotional and meaning based motivations that I had for entering medicine anyway, which is an interesting place to start, right? And thinking about what drives us toward medicine, but also what sustains us. And in the time after entering medical school, I've had a bit of a drought with regard to writing. I wish that I had had more mentoring when I was actually studying medicine and training, but you're just scrambling to live during those years. Afterwards however, those experiences were so powerful that I did find myself scribbling from time to time, not necessarily constructively. And over the years, I learned that maybe I could do a little bit more with that. Dr. Lidia Schapira: So tell us a little bit about the origin of this beautiful poem. Is it something that you scribbled in response to a particular event and then came back to months or years later? How does this emerge? Dr. Karl Lorenz: So I've always aspired, or at least in recent years, especially aspired, to be more of a writer. Writing is such a craft, but for me, because I haven't treated it as such, I find myself writing under circumstances that are more emotional or spontaneous. I don't say that with any pride. It's just the truth. I think those things are a font of inspiration for writers in general, but certainly it's also a craft. So for me, I was standing on the porch of our house in North Carolina in the middle of an incredible downpour. But it was atypical in that the sun was shining at the same time, and it was such a beautiful sight. I found myself taking pictures of the water dripping off of the bushes and the eaves of the house above a lake. And just the emotions sort of welled up in me, and I wanted to capture that. So I started writing, and this poem sort of spilled out, not in this form, actually, it was quite a bit different, but I was capturing the sensory experience of standing in that rainstorm protected under the porch. And that's actually where some of the onomatopoeia comes from. The words and their collision, at least in the first stanza, were very much about what I was experiencing standing under that porch in the rain. Dr. Lidia Schapira: They're very powerful, and rain is such an amazing metaphor. So before having me tell you what this said to me as a reader, why don't I go and ask you about bringing rain and water as a metaphor into what seems to me, reading this, a very intimate experience at the bedside, where you, the narrator, or where the narrator is really the loved one of the patient lying on the bed. Tell me, did I get that sort of right? Dr. Karl Lorenz: I'm sure you've had many of those experiences, Lidia. And, yeah, the rain is a good invitation for that, right? It does bring life. I think that was part of the emotion I was experiencing into the eaves just to see it coming off of those green leaves on those plants or just that particular place where this cabin sits is actually technically a rainforest, western North Carolina, up in the Appalachians. And so it's just, it's lush, it's fecund, if I could use that word. It's bursting with life all the time. And so that conjunction is really so much what the metaphor was about for me at the time. And then the sounds themselves are physically confluent. And so I think that's where language emerged as the vehicle for metaphor, because for me, those things have been so much characteristics of conversation and communication.  Dr. Lidia Schapira: To go back to rain as water, I mean, we think of water as something that just flows through our fingers. And then you contrast that with a tempo, the force, the splashing, the colliding of the rain droplets. But it's all very life affirming. And again, I want to contrast that with what you're telling us later, which is water sort of as tears emerging in response to something that clearly is very devastating for the narrator and brings forth and evokes the grief about the anticipated loss. Tell us about mixing these things together. Again, I'm just filtering through my imagination as a reader, which is something that poetry gifts us, right? It helps us just create in our own minds the scene. But I wonder if you, as the poet, can tell us what you intended. Dr. Karl Lorenz: I think those tears are a sign of pain, but aren't they also life giving? I mean, it's when we acknowledge loss that it becomes real, and then we can do something about it. And I guess as a palliative care doctor, that's always the place that I want to take patients to, not because I want them to lose. They're not going to lose because of me. It's actually when we acknowledge loss that we win in a sense, because then we can respond in a way that is life giving out of that loss, which we can't avoid most of the time. Sometimes we can, and we make wrong judgments about that. But many times I see it work the other way, that we don't come to terms with loss. Then we miss those opportunities to express love, to experience forgiveness, to build or renew, invigorate relationships, to make memories, to leave legacy, etc. And so those tears really are life giving in the sense that they are a place of acknowledgement where that kind of life begins. Dr. Lidia Schapira: I wonder also a little bit about your perspective here as a narrator. I see you more as the doctor who is at the bedside empathically saying, “I wish things were different.” And yet here the narrator is not the doctor. So it's not seen through the eyes or the lens of the palliative care clinician or the oncologist or critical care doctor, that it is from the person at the side of, or the loved one of the patient who is on the bed stoically shrouded, as you say. Tell us a little bit more about your choice of that perspective for your narrator here.  Dr. Karl Lorenz: Oh, that's interesting. I don't know that I've thought about that myself. I guess I've had losses in my own life. And that's a really interesting point that you make. I guess maybe in writing the poem, I saw myself as kind of standing in the corner of the room with somebody that I love. No, that's interesting. I don't think it was conscious, actually, until you asked that question that I saw myself in the room as a narrator. I suppose it comes because of the fact that this is a poem that's rooted in personal experience. Yeah, I have been in the doctor's role many times. I've also been in the family role. And so I have seen it both ways. Dr. Lidia Schapira: And I would say that to me as a reader, it also was an active empathic imagination, because one of the things that empathy involves is sort of really taking the perspective, imagining we are in somebody else's shoes. So here I thought it was very beautiful when you talk about soul ache, fighting soul ache, I gripped your shoulder, and then it is the grasp hand over wrist over hand. So there's the visual of the bodies coming together in an embrace. Was that based on a scene you imagined, or again, did it just kind of pour out of you almost like the rain poured onto the porch on that day? Dr. Karl Lorenz: I'm a very touching person in the sense of I hug, I grasp, I hold. Touch has always been a tool that we use in medicine. I think it's one that we should be both cautious about, but also not overly cautious about. I think it's just a human expression and it's important, right? And so I have been touched physically in ways that are so profound and meaningful, and I think sometimes I have given touch in a way that is also in that regard. And so it's really just a human experience. Touch. Yeah. I guess this poem is about these different ways that we make those profound connections. It's a different form of communication.  Dr. Lidia Schapira: It's an incredibly sensory poem. At least it was for me, because between the touch at the end and the last stanza and the sound, you really are engaging the reader in incredibly profound ways. There's a lot of vitality for me in this poem. It's just beautiful. And again, the sound of the rain that I think of as water, an element that flows, but producing such a crashing, loud noise. And then this encounter in what may be an ICU or a hospital ward. I mean, it clearly is a medicalized setting, right. With so much drama, it is really very beautiful. Tell me a little bit about how you plan to use this poem in your art as a clinician, as a teacher of young clinicians, or perhaps as a colleague. I find this very beautiful piece, and I wonder what your intended use is.  Dr. Karl Lorenz: Oh, boy, that's a great question. The funny thing is, I think I have used art and poetry and film in medical teaching in the past. Now so much of what I do is more cerebral, health services research. Of course, I still do clinical teaching. We find ourselves so busy and distracted. I would love to use this in teaching. I haven't actually thought about using my own poetry or writings in teaching, but yeah, this is probably a good one to try that with. I love Akira Kurosawa. I've used Kurosawa films about perspective and actually culture and its role in medicine. And I definitely have toyed with a lot of these modalities, but using my own art or poetry in this case, that's sort of scary. I guess I could do it.  Dr. Lidia Schapira: I think you can. And I have a final question, which I feel compelled to ask as a host for this particular podcast, and that is that once you had this poem and decided to share it with the world and publish it, why did you choose an oncology readership for your poem? Can you talk a little bit more about why this is perhaps important to put in an oncology journal that has built its reputation on delivering sort of the best science in the field? I certainly have been outspoken about the importance of having this sort of little space for the soul of our colleagues and our readers and our investigators. But I wonder if it was intentional that you said, “This is something either I'm gifting this to you guys,” or “This is something that you need. You need to remember all of the tears and the love and the soul searching that accompanies being that patient in the bed.” Dr. Karl Lorenz: Well, I love JCO and the oncology community and how my colleagues are working to refine the science and the excellence of clinical care. Yes, there is a science of the soul and a science of communication and a science of caring, and I think our patients want us to practice in an elevated way across all these dimensions of what they need. And I think that's maybe the reminder or the embrace. We can't do one without the other. And I do mean that we shouldn't do the art without the science or the science without the art. And so I love that marriage about medicine, and I love that marriage about the practice of oncology. What better place for it to be? A poem that captures that in the spirit of one of the hardest moments in our encounter with patients should go in a place where it's understood. Dr. Lidia Schapira: Well, thank you, Karl. Is there any final message that you want to convey? Or is there something that I haven't asked you that you'd like to talk about before we close? Dr. Karl Lorenz: Maybe I just express gratitude. So often we write and we just don't know that we have an audience. I feel that way. And so to know that it connected with you or with other readers is just such a pleasure, because I think we write, and maybe it's healing for us in a way, but it's also healing for us to know that it's healing for others. So, thank you. Dr. Lidia Schapira: What a lovely way to end this idea of community, and I think that's one of the intentions that we have through this podcast, also of connecting people to others and helping us all reflect together and feel accompanied by colleagues. So, thank you for sending this to JCO.   And to our listeners, until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individuals' individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Like, share and subscribe so you never miss an episode and leave a rating or review.     Guest Bio: Dr. Karl Lorenz MD, MSHS is a palliative care and primary care physician and Professor of Medicine at Stanford University.

Listen to ASCO’s Journal of Clinical Oncology Art of Oncology article, "Just Humor Me” by Dr. Stacey Hubay, who is a Medical Oncologist at the Grand River Regional Cancer Center. The essay is followed by an interview with Hubay and host Dr. Lidia Schapira. Dr Hubay share how even though cancer isn't funny, a cancer clinic can sometimes be a surprisingly funny place. TRANSCRIPT Narrator: Just Humor Me, by Stacey A. Hubay, MD, MHSc   Most of the people who read this journal will know the feeling. You are lurking at the back of a school function or perhaps you are making small talk with your dental hygienist when the dreaded question comes up—“So what kind of work do you do?” I usually give a vague answer along the lines of “I work at the hospital” to avoid the more specific response, which is that I am an oncologist. I have found this information to be a surefire conversational grenade, which typically elicits some sort of variation on “wow, that must be so depressing” although one time I did get the response “Great! I’m a lawyer and a hypochondriac, mind if I ask you some questions?” After I recently dodged the question yet again, I found myself wondering why I am so reticent about telling people what I do. While discussing work with strangers in our hard earned free time is something many people wish to avoid, I think for me a significant motive for this urge to hide is that I do not actually find the cancer clinic to be an overwhelmingly depressing place. Admitting this to others who are not engaged in this work can lead to at the very least bafflement and at worst offense to those who believe that laughing while looking after cancer patients is a sign of callousness. I am an oncologist who laughs in my clinic every day. Of course, the oncology clinic is sometimes a bleak place to work. Cancer has earned its reputation as a fearsome foe, and the patients I see in my clinic are often paying a heavy toll, both physically and emotionally. Many are grappling with their own mortality, and even those with potentially curable cancers face months of challenging treatment and the torture of uncertainty. Yet somehow, perhaps inevitably, the cancer clinic is not just a place of sadness and tears but also a place of hope and laughter. Although most of us recognize humor and use it to varying degrees, few of us consider it as an academic subject. A few lucky souls in academia have taken on the task of developing theories of humor, which attempt to explain what humor is, what purpose it has, and what social function it serves. Although there are almost as many theories of humor as there are aspiring comedians, most explanations fall into one of three categories: relief theory, superiority theory, and incongruous juxtaposition theory.1 Relief theory holds that people laugh to relieve psychological tension caused by fear or nervousness. I suspect this is the most common type of humor seen in a cancer clinic given the weight of fear and nervousness in such a fraught environment. The second category, people being what we are, asserts that sometimes we laugh out of a feeling of superiority to others. It goes without saying that this sort of humor has no place in the clinician patient interaction. Finally, we laugh at absurdity, or as Kant put it, at “the sudden transformation of a strained expectation into nothing.”2 This last category is also surprisingly fruitful in the oncology setting. Laughter in the cancer clinic is still to some extent considered taboo. Near the start of my oncology training, I remember laughing until my stomach hurt with my attending staff in the clinic workspace between seeing patients. What we were laughing about escapes me now, but what I do clearly recall is an administrator in a buttoned-up suit striding over to us in high dudgeon. “Don’t you people realize this is a cancer clinic?” she admonished us. “This is not a place for laughter!,” she added before striding off, no doubt to a management meeting or some other place where the policy on laughter is more liberal. At this point, my attending and I looked at each other for a beat and then burst into helpless gales of laughter. We do not tend to think all that much about why we are laughing at something, but looking back now, I think at least part of the reason was the absurdity of a person so unfamiliar with the culture of the cancer clinic presuming that physicians and nurses somehow park their sense of humor when they arrive at work and turn into a herd of gloomy Eeyores.  We oncologists are starting to come clean about the fact that we laugh in the clinic and there is now a modest amount of work in the medical literature addressing the use of humor in oncology. One survey of patients undergoing radiotherapy in Ottawa found that a stunning 86% of patients felt that laughter was somewhat or very important to their care, whereas 79% felt that humor decreased their level of anxiety about their diagnosis.3 If we had a drug that decreased anxiety levels in 79% of patients, had minimal to no side effects when used correctly, and cost the health care system zero dollars, should not we be using it?  Sometimes, it is the patient or their family member who introduces an element of humor into an interaction as on one occasion when my patient was filling out a pain survey which included a diagram of the body on which he was asked to circle any areas where he was having pain. As his wife ran through a detailed list of his bowel habits over the past few days, the patient circled the gluteal area on the diagram he was holding, pointed to his wife and said “I’ve been suffering from a pain in my ass doctor.” His wife looked at him pointedly for a moment before the two of them started laughing and I joined in.  Sometimes, a patient’s use of humor serves to level the playing field. Patients with Cancer are vulnerable, and the physician is an authority figure, meting out judgments from on high. My patient from a few years ago was having none of that. I met him when he was referred to me with widely metastatic lung cancer, a diagnosis typically associated with a dismal prognosis. The patient, however, was not buying into any of the usual gloom and doom that is customary for these interactions. As his daughter translated the information I was providing, he tilted his chin down, fixed his gaze on me, and proceeded to smile at me in a disarmingly friendly way while simultaneously waggling his generous eyebrows up and down throughout the interview. Over the course of 45 min, I became increasingly disconcerted by his behavior until eventually, I was unable to finish a sentence without sputtering with laughter. If you think you would have done better, then you have clearly never been on the losing end of a staring contest. By the end of the interview, all three of us had happily abandoned any hope of behaving with more decorum. Laughter and the use of humor require a certain letting down of one’s guard, and the fact that all three of us were able to laugh together in this interview took me down from any pedestal onto which I might have inadvertently clambered. One study from the Netherlands noted that patients used humor to broach difficult topics and downplay challenges they faced and concluded that “Hierarchy as usually experienced between healthcare professionals and patients/relatives seemed to disappear when using laughter.  If applied appropriately, adding shared laughter may help optimize shared decision-making.”4 Although it could be a coincidence, it is worth noting that several years after meeting this patient, I discharged him from my practice because he had somehow been cured of lung cancer. Perhaps laughter really is the best medicine.  On other occasions, it might be the physician who takes the plunge and uses humor during a clinical encounter. The same Dutch study by Buiting et al noted that 97% of all specialists used humor in their interactions and all reported laughing during consultations at least occasionally. One of my colleagues, a generally serious sort whose smiles in clinic are as rare as a total eclipse albeit not as predictable, managed to win over his patient with a rare outburst of humor. During their first meeting, the patient listed off the numerous ailments he had experienced in the past including his fourth bout with cancer which had prompted this appointment. As he finished reciting his epic medical history, my colleague looked at him somberly over the rim of his glasses for a moment and asked “Sir, I must ask—who on earth did you piss off?” The patient was so tickled by this interaction that he recounted it to me when I saw him a few weeks later while filling in for my colleague. Although humor is a powerful tool in the clinic, it is of course not something that comes naturally to all of us. Attempts at humor by a clinician at the wrong time or with the wrong patient do not just fall flat but can even be damaging to the physician-patient relationship. Even if a physician uses humor with the best of intentions, there is always the possibility that they will be perceived by the patient as making light of their situation. As Proyer and Rodden5 point out, tact is essential and humor and laughter are not always enjoyable to all people, or to borrow a phrase frequently used by one of my patients, “about as welcome as a fart in a spacesuit.” Socalled gelotophobes have a heightened fear of being laughed at, and with them, humor and especially laughter must be wielded with great care if at all. All I can say in response to the legitimate concern about the use of humor being misconstrued is that as with any other powerful tool physicians learn to use, one improves with time. As far as PubMed knows, there are no courses in medical faculties devoted to the fine art of the pun or the knock-knock joke. But even if we physicians cannot all reliably be funny on command, perhaps there is something to be said for occasionally being a little less self-serious. One must also be mindful of patients with whom one is not directly interacting—to a patient who has just received bad news, overhearing the sound of laughter in the clinic corridor has the potential to come across as insensitive. Moments of levity are therefore best confined to a private space such as the examination room in which physicians and patients can indulge in anything from a giggle to a guffaw without running the risk of distressing others. The final reason I submit in support of laughing in a cancer clinic is admittedly a selfish one. While humor has been shown to have the potential to reduce burnout,6 the real reason I laugh with patients in my clinic is because it brings me joy. The people at parties who think my job must be depressing are not entirely wrong. I have noticed that when I have a positive interaction with a patient based on humor or laugh with a colleague about something during a meeting, I feel better. Surprise! As it turns out, this is not just an anecdotal observation. In 2022, a study was published whose title was “Adaptive and maladaptive humor styles are closely associated with burnout and professional fulfillment in members of the Society of Gynecologic Oncology.”7 The SGO has not to my knowledge been widely recognized up to this point for their sense of humor, but I have a feeling that might change. Humor is an essential part of the way I approach many situations, and given that I spend the majority of my waking hours at work, it is neither possible nor I would argue desirable for me to leave that part of myself at the entrance to the cancer center. So to the administrator who admonished my mentor and me to cease and desist laughing in the cancer clinic, I respectfully decline. My patients, my colleagues, and I will continue to laugh together at any opportunity we get. Joy in one’s work is the ultimate defense against burnout, and I for one intend to take full advantage of it.  Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I'm your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today we're joined by Dr. Stacey Hubay, Medical Oncologist at the Grand River Regional Cancer Center. In this episode, we will be discussing her Art of Oncology article, “Just Humor Me.”  Our guest disclosures will be linked in the transcript.   Stacey, welcome to our podcast, and thank you for joining us. Dr. Stacey Hubay: Thank you for having me. It's a pleasure to be here.  Dr. Lidia Schapira: It is our pleasure. So let's start by chatting a little bit about what humor means to you and what led you to write this piece and share it with your colleagues.  Dr. Stacey Hubay: I didn't realize how important humor was to me until recently. I just finished a Masters in Bioethics, which was 20 years in the making, and this was the first time I'd been writing anything that wasn't a case report for many, many years. And there was actually specifically a course called “Writing in Bioethics,” and this was the first thing that came to my mind. And I realized sort of how much humor there is in my day to day work life, which, because none of the other people in this bioethics class of 10 or 14 people were working in oncology, they were surprised. So I thought it would be interesting to write about that. And then when I started thinking about it, I realized how integral it is to most of, I guess not just my practice life, but the way I deal with life. And then I could see a thread going back all the way to the beginning of my practice in oncology, and I'm like, “I should write about this.” And I don't think it's unique to me either. I think it's probably many of us in this field. Dr. Lidia Schapira: It is. So let's talk a little bit about humor in the practice of such a serious specialty as we tend to think, or people tend to think of, as in oncology. You talk about humor also connecting you with joy and practice, can you tell us a little bit more about that? Dr. Stacey Hubay: I'm just as surprised, probably as anybody, at least when I first went into this field, which is now more than 20 years ago, how much happiness I found in the field. I meant what I said in the beginning of this essay. When I run into people or strangers, you're getting your hair cut or you're at your kid's volleyball practice, and people always say, “Oh, so what do you do?” And I always say, “I'm in healthcare.” And if they start drilling down, eventually I have to admit what I do. And I say, “I'm an oncologist.” And immediately the long faces and people say, “That must be so terrible.” And I'm like, “Well, it can be, but it's not as bad as you might think.” And they're like, “Oh, it must be very difficult.” And I know that avenue of conversation is closed once or twice. I think I did try saying, “You know what? I have a surprising amount of fun in my clinic with my patients.” And they were aghast, I think is the word I would use. And it made me realize sort of what a taboo it is for many people, including maybe some of us in the field, to admit that we sometimes enjoy ourselves with our patients in our clinics. Dr. Lidia Schapira: So let's talk about that. Let's talk about joy, and then from there to laugh. I think the reason why laughter seems sort of stranger than joy is laughter assumes that we see some levity, humor. And some people would say, there's really nothing funny about having humor. And yet you seem to see it and find it and share it with your patients. So take us into your exam rooms and tell us a little bit more about your process. Dr. Stacey Hubay: It's funny, when I think about the humor in my clinics, I don't see myself as the one who's necessarily sort of starting it, although maybe sometimes I do. I think perhaps it's just that I'm more open to it. And I think it's frequently the patients who bring it in with them. Obviously, we know patients in the oncology clinic, they're often very nervous. It's a very anxious time for them. And we are in a position of power compared to our patients, they're very vulnerable. And so sometimes the patient makes a joke, sometimes I wonder if it's a way of testing if that kind of relationship will work with you. They're kind of testing you to see if you will respond to that. And it's also a way of them relieving their own anxiety, because one of the theories about humor is just a way of alleviating tension. It makes sense that oncology is a place where humor would be welcome, because it's one of the most tense places, I think, in medical practice, although I'm not sure it's present in other places like at the ICU.  So the patient often brings it in, and then you respond to it, and if you're on the same wavelength, it sort of immediately establishes this kind of trust between you and the patient. It's not something you can do with everybody. Sometimes some people will not be open to that at any time. And some patients, you have to get to know them quite a bit before that starts to come into the mix. But I find with most people, if you follow them for long enough and you have a good working, therapeutic relationship with them, just like you would the people you like, your friends, your family, that comes into a relationship almost unavoidably. And I used to think, “Oh, I'm not supposed to do that,” when I first came into practice. I'm a serious oncologist, which I am, and I can be a serious oncologist. And I also just didn't have the bandwidth for it. I think I was so kind of focused on, I have to know what I'm doing. Early in my practice, I didn't have the mental energy to devote to that. And then as that part became easier, I became kind of more open, I think, to that, coming into the interactions with my patients. And over time, I started realizing that was probably what I enjoyed the most about my working day. At the end of the day, I'd come home and tell stories, and my kids would be like, “It sounds like you have fun at work.” And I go, “You know? I really do. Surprisingly I do.” Dr. Lidia Schapira: That's so very cool. I think there's so much wisdom in what you just told us, which is that at the beginning, especially when in the first few years of your practice, you really are so focused on being clinically competent that you may be just very nervous about trying anything. And then as you relax, you actually say in your essay that for some people, this may bring relief and may level the playing field. So if there is an opportunity and you're loose enough to find it, you may be able to keep that conversation going. It made me wonder, I don't know if you've had any experience yourself as a patient or accompanying a family member as a caregiver to a medical visit. Have you used humor when you are the patient or when you're accompanying the patient?  Dr. Stacey Hubay: That's an interesting question. I haven't been a patient apart from my routine family medicine visits for quite a long time. But when I was much younger, I was a teenager, I did have that experience. I was maybe 15 or 16. I had some parathyroid issues. And I remember seeing these specialists in Toronto, and they were very serious people. I remember thinking, if I want to become a physician, because it was at the back of my mind at that time, I'm going to be a lot more fun than these people. I'm going to enjoy myself a lot more. And little did I realize how difficult that actually was at the time. But I found them kind of very serious and a little bit intimidating as a 15-year-old kid. I hadn't reflected on that before. I'm not sure if that's something that I'm deliberately pushing back against. I think now if I see a physician as a patient, I probably am much more willing to bring that in if the physician is open to it. But you can usually tell many physicians, you meet them and you're like, “You're not going to even try that kind of thing.” But if they're open to it, I think it would bring me much more fun as a patient as well.  Dr. Lidia Schapira: Yeah. Do you teach your students or trainees or members of your team to use humor? Dr. Stacey Hubay: That's a very interesting question. How do you do that? So I mentioned, I just finished this Masters of Bioethics, and one of the excellent courses in it was how to teach bioethics, which really was a course about how to teach anything. And most of us who are in medicine, we've spent a lot of time teaching without being taught how to teach. In my own practice of teaching, we mostly use one on one with people coming into our clinics and seeing patients with us. And I think mostly some of it's through observation. I will say to people who work with me that we all have to find our own style. It's important, no matter what your style is, to try and connect with patients, because you're trying to create a therapeutic alliance. You're on the same side. The way that works for me is you don't laugh with people you don't trust. When you're trying to make a plan with people in these difficult situations, I think if you've already formed this alliance where they realize you're with them, they're more likely to believe you and trust your recommendations. I tell trainees, I'd say, “This is my way of doing it. And if it works for you, that's wonderful.” But I can see that for some people it's difficult.  Although even the most serious clinicians, one of my very good friends and colleagues who I mentioned in my essay and I talked about, he doesn't make a lot of jokes with his patients, which is perfectly reasonable, but the occasional time he does, the patients were so struck by it because they knew him as such a serious person. They bring it up, “Remember that time my doctor said this,” and they thought it was a wonderful thing. So it's difficult to teach. It's just how would the Marx Brothers teach someone else to be the Marx Brothers? It can't be done. Only the Marx Brothers are the Marx Brothers. Not that I'm comparing myself to the Marx Brothers by any means, but I think you find your own style. Maybe what I'd like to show trainees who come through with me is that it's okay to enjoy the patients, even in a very serious discussion. Dr. Lidia Schapira: Yeah, I would almost say that it speaks to the fact that you're very comfortable with your clinical persona in that you can allow yourself to be totally human with them. And if human means that you can both sort of align around seeing some humor or cracking a joke, that is perfectly fine. I have a question for you, and that is that a lot of my patients in my practice, and maybe some of our other listeners come from completely different cultural backgrounds, and many don't speak the same language as I do. So for me, thinking about humor in those situations is impossible just because I just don't even know what we can both accept as funny. And I don't want to be misunderstood. Tell me a little bit about how to think of humor in those situations. Dr. Stacey Hubay: That's a good point you make. It makes me think about how when I read Shakespeare's plays, we all think his tragedies are fantastic. And when I read his comedies, I'm like, “This isn't very funny.” Or if even when you watch sort of silent movies from the 1920s, I'm like, “Did people really laugh at this?” So you're right. Humor is very much of its time and place and its culture. And even people from the same time and place might not share the same sense of humor. That being said, somehow it still works with the people who are open to it. Somehow it's not necessary, because you've made a very witty joke, or vice versa, that we all understood all its complexities. It's more the sense that we're laughing together.   And I talk about a gentleman that I met in my practice in this essay, and he didn't speak English, so his daughter was translating for us. And nobody was making any kind of verbal jokes or humor. And this was the first time I was meeting him in consultation, and he just kept making funny faces at me the whole time I was talking, and I didn't know what to do. I was completely bamboozled by this interaction. And it actually ended up being sort of one of the funniest visits I'd had with a patient. By the end of it, I could barely get a sentence out. And I thought, this is absurd. This is a very serious situation. This poor gentleman has stage 4 lung cancer, brain metastasis, but he just wouldn't let me be serious. So I think that humor can transcend cultural, linguistic boundaries amazingly enough. Again, if the person was open to it, this person was almost determined that he was going to make me laugh. It was like he'd set out that by the end of his visit, he was going to make sure that we were having a good time. And I was just, “I'm helpless against this. We're going to have a good time.” I remember coming out of the room, the nurses I was working with, they're like, “What was going on in that room? Is he doing well?”I'm like, “Well, in a way, yes, he is doing well.”   At the end of this visit, we were all in a very good mood. But I'll sometimes use sign language, or I'll make some stab at French or whatever it is that the patient speaks, and then they just laugh at me, which is also fine, because they can kind of see that you've made yourself vulnerable by saying, “You know, it's okay if I can't speak your language.” And they just smile and laugh with me. So it's not that it's a joke so much, it's more that they just feel comfortable with you. But you're right, it is more challenging. It's something I wouldn't usually do in such a situation unless I had gotten to know the patient, their family, reasonably well.  Dr. Lidia Schapira: Let's talk for a moment about wellness and joy in practice. What gives you the greatest joy in practice?  Dr. Stacey Hubay: Undoubtedly the people that I see and I work with. When you go into medicine and you train, we all train in academic settings. And I had excellent mentors and academic mentors, and the expectation, because you're trained by people who are good at that kind of work and succeeded, is that you might want to pursue that, too. And it took me a while to realize that that's not where I get most of my joy. I like being involved with research and I appreciate that people are doing that work and I love applying that knowledge to my practice. But I get my joy out of actually seeing patients. That wasn't modeled a lot necessarily to us in the academic setting. It's taken me quite a long time to realize that it's okay to lean into that. If that's what I like about my practice and that's what I can bring to the interaction, then that's what I'm going to do. And I started looking back, it would have been nice to realize, it's okay. It's okay to be a clinician who really enjoys seeing patients and wants to do a lot of that. Again, different kinds of people become physicians, but a lot of the people we had as mentors, they had chosen academic careers because, not that they didn't like patients, they often did, but they really wanted to pursue the research aspect of it. And they would try to cut down on their clinical work and say, “It's nice if you don't have two clinics, you can focus on the research.” And I think to myself, but I like doing the clinics and I like seeing the patients, and it would be a shame to me if I didn't have that.  It's not just the patients, but my colleagues as well, who are also great fun to have around, the nurses we work with. Really, it's the interactions with people. Of course, we get joy from all kinds of other things. In oncology, it's good to see patients do well. It's wonderful to apply new knowledge and you have a breakthrough coming from immunotherapy to lung cancer, melanoma. That sort of thing is fantastic, and it gives me joy, too. But I have the feeling that when I retire at the end of my career, I'm going to look back and go, “Remember that interaction with that patient?” Even now, when I think of when I started in clinical settings as a medical student, I remember, I think it was my first or second patient, I was assigned to look after an elderly woman. She had a history of cirrhosis, and she was admitted with hepatic encephalopathy and a fractured humerus after a fall. I didn't know what I was doing at all, but I was rounding every day. And I went to see her on the third day, she was usually confused, and I said, “How are you doing?” She looked at her arm and she said, “Well, they call this bone the humerus, but I don't see anything particularly funny about it.” I thought, “Oh, she's better.” That's actually one of the earliest things I remember about seeing patients.   Or the next year when I didn't realize I was going to pursue oncology. And I was rotating through with an excellent oncologist, Dr. Ellen Warner at Sunnybrook, who does breast cancer. We were debriefing after the clinic, and she said, “Someday, Stacey, I'm going to publish a big book of breast cancer humor.” And I thought, “I wonder what would be in that book.” And that's when I got this inkling that maybe oncology had just as much humor in as every other part of medicine. And that proved to be true.  Dr. Lidia Schapira: What was it, Stacey, that led you to bioethics? Tell us what you learned from your bioethics work. Dr. Stacey Hubay: I think it's because basically I’m a person who leads towards the humanities, and for me, bioethics is the application of philosophy and moral ethics to a clinical situation. And I think medicine, thankfully, has room for all kinds of people. Of course, you have to be good at different things to be a physician. But I always imagined myself, when I went to school, that after a class, you'd sit around a pub drinking beer and discuss the great meaning of life. And I thought, this is my chance to pursue that. And I was hoping to kind of– I didn't think of it as that I was going to this because I was interested in humor and joy in oncology, although I obviously am. I was thinking that I would be able to make a difference in terms of resource allocation and priority setting, and I still want to pursue those things. Things often lead you down a side road. And bioethics, for me, has sort of reminded me of what I like about this work. And because I was surrounded by many people who are not doing that kind of work, who were surprised how much I liked it, it made me think very carefully about what is it that I like about this. So the bioethics degree, it's finally allowed me to be that person who sits around in pubs drinking beer, discussing Immanual Kant and Utilitarianism and whatever moral theory is of flavor that particular day. Dr. Lidia Schapira: What led you to write this particular story and put it in front of your medical oncology colleagues? Is it your wish to sort of let people sort of loosen up and be their authentic selves and find more joy in the clinic? Dr. Stacey Hubay: That’s a good question! The most immediate impetus was I had an assignment for my degree, and I thought, I have to write something. But I'd been writing down these sort of snippets of things I found funny. Occasionally, I just write them down because they were interesting to me. And because we often relate stories to people, “What did you do today? What was your day like?” And because you tell these stories over and over, they develop some kind of oral, mythical quality. You're like, “Here's what I remember that was funny that happened, and it might have been many years ago now.” And I think I'd been thinking a long time about writing it down and sort of organizing it that way. And I guess having to produce something as part of this degree program was an impetus for me. But I'd always wanted to do it. And I think the main thing was I wanted to make it clear to myself what it is I like about it. It's actually made it, for me, much more clear. It was sort of a nebulous thing that I like my work and what is it like about it. And this is what I like. I like the joy I get from patient interactions. And then a secondary goal is I hope that other people, if they were to read this, they realize it's okay for us to have joy in our work as oncologists. And there is a lot of doom and gloom in the world and in our practices, but there's always, always a chink that lets the light in, there's always some humor in what we do. And so I hope that if other people can find that, too, that they enjoy their practice and they last a long time and ultimately help patients through this difficult journey. Dr. Lidia Schapira: Are you somebody who likes to read stories? And if so, what stories have you read recently that you want to recommend to our listeners? Dr. Stacey Hubay: Oh, I am reading The Master and Margarita because three different people recommended this novel to me over the last three years. When a third person did, I thought, “That's it. Got to read it.” It's a Russian novel from the 1930s that was banned until, I think, the ‘60s or ‘70s. It's like a satire of Russian society in the ‘30s. And actually, what I like about it, I haven't finished it. I'm a third of the way through, as I think it's one of the so-called classic novels, people tell me, but that's funny. A lot of the classic novels are kind of tragedies or romances, and this one is sort of absurd black humor in the face of a difficult situation, which I guess is related to oncology, again. So this sort of oppressive, difficult society, the 1930s and Soviet Union, how do you deal with that? With humor. So I'm quite enjoying it, actually. So I recommend that one.  Dr. Lidia Schapira: Well, you're an amazing storyteller, and I really enjoyed our conversation. Is there any final message that you want to convey to our listeners? Dr. Stacey Hubay: If you have a chance to become an oncologist, you should do it. It's just the best career I can imagine. Dr. Lidia Schapira: Well, with your laughter and with that wonderful wisdom, let me say, until next time, to our listeners, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcast. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Show Notes: Like, share and subscribe so you never miss an episode and leave a rating or review.   Guest Bio: Dr. Stacey Hubay is a Medical Oncologist at the Grand River Regional Cancer Center.