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Radiation Oncology: Anthony Dragun
34 Plays5 years ago
Season 1, Episode 3: Dr. Anthony Dragun is a radiation oncologist with Cooper University Health Care in Camden, New Jersey. Listen to Anthony discuss the history of radiation oncology and the emotional side of treating cancer patients.
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Transcript
Introduction to The Wound Dresser podcast
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neary.
Guest Introduction: Dr. Anthony Dragan
00:00:20
Speaker
Today, my guest is Dr. Anthony Dragan. Dr. Dragan is the chairman of the Department of Radiation Oncology at MD Anderson Cancer Center at Cooper University Hospital.
00:00:31
Speaker
He was previously a professor of radiation oncology at the University of Louisville School of Medicine from 2008 to 2017. Dr. Dragan has also conducted extensive research, culminating in over 40 publications. Anthony, welcome to the show. Thanks for having me, John. I appreciate it.
Understanding Cancer Diagnosis
00:00:49
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Yeah, so I just wanted to start out really at the basic level.
00:00:54
Speaker
to give our listeners a better understanding of what cancer is on the molecular level and then the process that most patients, I know it's different for different parts of the body and different stages of cancer and whatnot, but what the process of diagnosis entails.
00:01:12
Speaker
Yeah, I mean, being in oncology, you know, we have these conversations with patients all the time. They're frequently, you know, upset. They're scared. They wonder about implications for their family members. Many patients are very, very shocked by the diagnosis because they don't have any
00:01:38
Speaker
history of cancer in their family. And so this is something that we don't know a tremendous amount about on
00:01:52
Speaker
a global level. I mean, we have the well-known risk factors for some cancers, but frequently cancer is a sporadic occurrence and we don't know exactly why. It's probably part of the human condition.
Importance of Cancer Screening Tests
00:02:10
Speaker
And, you know, for instance, with breast cancer, as we start to see people reach a certain age, it becomes
00:02:21
Speaker
fairly common. Breast cancers in women talk about one in seven or one in eight women will be affected by breast cancer and they tend to follow a bell curve that begins around the age of 50 and then tails off by the age of about 70 to 75. If you think about it for 100,000 years or more of human evolution,
00:02:51
Speaker
up until just about 100 years ago, the average life expectancy of a woman was relatively short. And the most common cause of a health problem or death in women was the process of childbirth. So there's something about
00:03:13
Speaker
For a lot of cancers or something about the fact that we've been able to in the modern era with modern medicine Somewhat cheat mother nature obstetric care becomes better well care and healthy lifestyles become better our overall environment becomes better the water is cleaner the shelter and You know food supply is more reliable
00:03:43
Speaker
and human beings start to survive longer and longer with an average life expectancy. And so cancer or encountering a battle with cancer becomes more and more common. So we don't know, many people think it's something that they're exposed to during that period of time, but actually I like to flip the conventional wisdom on that and think that it's not, that things in our environment that we're exposed to
00:04:14
Speaker
that we ingest into our bodies, that we encounter in our environment are actually much better, much more sanitary, much more clean today than they were say 100 years ago. The air
00:04:30
Speaker
the water. And so it's more likely that there's something that is happening on the genetic level where our cells are making a photocopy of a photocopy of a photocopy of a photocopy of a photocopy on and on millions of times. It's quite remarkable the cancer or mutation that in that photocopying process that leads to cancer isn't more common.
00:04:58
Speaker
So getting back to the molecular level, I think that what we do know is that something happens. Something happens with the fidelity of the genetic material in our cells. And then some genes are switched on, some are switched off, and you have a mutated cell. And that's where it starts. So beyond that, though,
00:05:26
Speaker
for getting diagnosed, does a person typically come through their general practitioner and then go on to a medical oncologist or radiation oncologist like yourself or who's kind of like the first point of contact in the medical community typically?
Cancer Diagnosis Pathways
00:05:40
Speaker
Yeah, it's interesting because there's basically two pathways for that again in
00:05:48
Speaker
In the Western world, where we have a developed medical system, we have two pathways. For the developing world, there's just one pathway, and I'll get back to that.
00:06:00
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But for the developed world, we have cancers for which there are screening tests, meaning to catch a disease at a point where it's asymptomatic, meaning it's not apparent to the patient, it's not apparent to the doctor. And those cancers for women, it's breast cancer with mammography for men,
00:06:23
Speaker
There's prostate cancer with a blood test for both men and women. There's colorectal cancer where there's some screening tests with checking for blood in the stool or having routine colonoscopies. To a certain extent, lung cancer screening has become a little bit more common with patients who have a heavy smoking history.
00:06:49
Speaker
Those are the main tests where we have some sort of screening test where a patient will have an encounter with their primary care physician and get to a certain age where they're eligible for one of these screening tests. They have a screening test and lo and behold it finds something that's something then
00:07:08
Speaker
necessitates a biopsy, that biopsy shows cancer and there we are. And that is a starting point that is for the ultimate treatment of that cancer that is very, very favorable because you as a patient then
00:07:25
Speaker
and as a physician, are in the driver's seat. You tend to have a lot of options with your care. You are able to take kind of one step at a time throughout that process and make decision points as to when surgery versus chemotherapy versus radiation or a combination of those are appropriate.
00:07:49
Speaker
So that's one pathway. That's a pathway that's really the product of a lot of clinical trials, a lot of population-based research that goes into figuring out effective screening tests that are going to, in my description, be a good smoke alarm when you have
00:08:11
Speaker
The smoke alarm in your house, the mark of a good smoke alarm is that it goes off every single time the house is on fire. And it doesn't go off when you just burn the toast.
00:08:26
Speaker
So the mark of a good screening test is that combination of sensitivity and specificity that results in a low risk to the patient that you're going to find something or put them through a course of anxiety or further testing that's ultimately going to show that they don't have cancer. You don't want that.
00:08:51
Speaker
But every time they do have cancer, and it's there, then it's caught. And so I think that we've gone very, very far over the last few decades in finding that right pitch or tune of those screening tests that I mentioned before. The other pathway, which is
00:09:15
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The more worrisome one is something's wrong. There's a symptom. Someone all of a sudden is becoming more and more short of breath. Someone has abdominal pain that is getting worse and worse. Someone notices something like a bleeding where there shouldn't be or a woman who has gone through menopause and shouldn't
00:09:44
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Really be going through menstrual cycles notice that she's starting to bleed again so there's something wrong and then that's brought to medical attention sometimes that comes through a doctor's office visit and that has to be worked up and sometimes it's a symptom that progresses so quickly that the person ends up in the emergency room and ultimately in the hospital.
Cancer Treatment Plans and Radiation Therapy
00:10:03
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And then you're starting with a problem from cancer, from a tumor that's causing that symptom, and then trying to work backwards and find out where that is coming from. That is the pathway that most people in the developing world follow.
00:10:25
Speaker
And that is also the pathway that frankly, for types of cancers for which we don't have good screening tests, pancreatic cancer comes to mind.
00:10:37
Speaker
brain tumors come to mind. The story of somebody who looks like they're having a stroke or they have a seizure and they go into the hospital thinking that perhaps this is a stroke, perhaps it's something else going on and then they do an MRI and find that the reason that they had the stroke-like symptoms or the seizure-like symptoms is because there's a brain tumor. So we're not there yet.
00:11:05
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with many cancers in terms of being able to catch them with a great deal of confidence very early. Once a patient is diagnosed with cancer, a treatment plan is set up. Typically, this treatment plan entails an interdisciplinary approach with different types of doctors such as cancer surgeons, medical oncologists, radiation oncologists, et cetera.
00:11:31
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Could you talk about the role that you play in that treatment plan and the tools you have in your toolkit when it comes to radiation therapy? Sure. What I like to do for patients who have a new diagnosis of cancer is to think of it, you have these two buckets of
00:12:01
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treatment approaches. In the one bucket, I call local therapy. That means treatment for the primary cancer where it is in the body and the immediately surrounding area. And then the other bucket contains systemic therapy. That means treatment of the disease
00:12:28
Speaker
throughout the remainder of the body where the disease might spread. And so most cancers when they're diagnosed are going to have some sort of combination of local therapy and systemic therapy. And so in the local therapy bucket is surgery, obviously it's a targeted therapy that
00:12:55
Speaker
either removes all or part of the tumor and samples some of the surrounding tissue to look at where it's spread. In the case of cancers like colon cancer, you're removing a section of the colon that contains the cancer and frequently relieving some of the symptoms from that by reattaching the
00:13:20
Speaker
the remainder of the colon together to have the organ function again. So surgery and what I do radiation therapy are really local treatments. Systemic treatments include chemotherapy being the most obvious one, but also things like hormonal therapy for breast cancers and prostate cancers. And then also newer types of
00:13:51
Speaker
drugs and agents that circulate throughout the body like targeted therapy, there are some drugs that are targeted directly toward some tumor cells that are not necessarily considered chemotherapies, and then immunotherapy, drugs that stimulate the immune system or use the immune system, the body's own immune system in a way to help target cancer cells.
00:14:16
Speaker
So generally speaking, when we look at somebody with a newly diagnosed cancer, we're working in a multidisciplinary way to figure out the sequence of and the combination of those two buckets. And sometimes you may have only one therapy from each bucket. For example, you may have a cancer that's treated with
00:14:43
Speaker
surgery and then chemotherapy alone, okay? Colon cancer comes to mind as a good example of that. And sometimes you are treating patients with surgery and radiation and hormonal therapy and chemotherapy, some breast cancers come to mind. And then in some cases you're treating patients with just radiation therapy and chemotherapy.
00:15:11
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cancers of the head and neck and cervix come to mind. But whatever it is, it's very, very likely that you're going to have some combination of one or more elements from each of those two buckets.
00:15:31
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And then how we sequence them is also a very complicated matter. It has to do with whether or not a tumor, when we see it, is surgically resectable, meaning is it likely that a surgeon would be able to remove it
00:15:51
Speaker
successfully and be able to remove the known tumor completely? Or is it a situation where you might want to start with either radiation therapy or chemotherapy to shrink a tumor and then do a surgery afterwards? So there's a lot of complexity to the matter. There's a lot of tailoring that goes into it. We also take into account
00:16:17
Speaker
an individual patient's age and their other medical problems that may complicate the matter a little bit. But in general, what we're trying to do is match the right amount of therapy for the type of tumor that we're dealing with.
00:16:36
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taking into account the patient's medical problems, their wishes, their values, and what we believe they can or cannot tolerate. So it's a lot of cross
00:16:55
Speaker
pollination of physicians and specialties that happens. You generally at a comprehensive cancer center are doing that in the setting of what's called a prospective tumor board where a patient's case, once they have a diagnosis of cancer, is presented to a panel of physicians who represent those different specialties and then they are
00:17:24
Speaker
basically working with each other in a conversation to decide on what the best approach is. And there's a lot of evidence-based medicine that plays into that. There's a lot of clinical trial data that we have for the most efficacious combination of those therapies. But many, many times, patients don't fit into a predetermined, beautifully wrapped, sweet-smelling package
00:17:54
Speaker
for us to fit them in. We have to oftentimes work around other medical problems that they have and even social problems that they have. Problems that they may have with support that they have at home for some of the complications that may occur. Transportation to and from many therapies, especially radiation therapy, which is a daily therapy that requires patients coming to the cancer center every day.
00:18:23
Speaker
All those things come into creating someone's treatment plan, and it's a very complicated and very challenging method that we use to tailor the therapy to the individual patient.
Evolution of Radiation Oncology
00:18:40
Speaker
So with radiation therapy, can you talk more about how it's actually targeting the cancer? And a follow-up question of that would be,
00:18:51
Speaker
I know you have a number of medical physicists on your staff. Can you talk about the role they play in treatment? Yeah, so radiation oncology is a somewhat
00:19:05
Speaker
idiosyncratic specialty in medicine. When I used to be involved with the training of residents in radiation oncology, they were some of the best and brightest in their medical school class. And then I was telling them, OK, pretty much forget everything that you learned in medical school. And now you're going to have to fill your head with all of this
00:19:29
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data and physics and a science that we call radiobiology, which is how different tumors and different normal tissues respond to different levels of radiation. But we're very, very fortunate that radiation has been around for a very long time.
00:19:55
Speaker
And we go back to the late 1800s when William Conrad Rankin, who was a German scientist, discovered x-rays. And around the same time, Marie Curie, who was a Polish scientist living in France, discovered radium, which is a naturally occurring radioactive source. These two discoveries happened very close to one another in the late 1800s.
00:20:25
Speaker
Rankin actually won the first Nobel Prize in physics for his discovery, and Marie Curie won the second Nobel Prize in physics for hers. And right after those discoveries, radiation was employed and found to be very, very useful for a number of medical modalities, things that we don't use it for today. But if you think of the state of medicine as it was back in
00:20:52
Speaker
those times. We're talking about the era really before pharmaceuticals. Surgery was used for many things. Leeches were still being used. We had some compounding herbs that were used. The poppy plant was used for pain relief. You had things like the digitalis plant that was used for certain heart conditions, but a very, very rudimentary understanding of the way those
00:21:23
Speaker
herbs worked, the mechanism of action. And here we had radiation, which seemed to be very useful for a number of different conditions. I mean, it was used to treat infections. It was used to treat some of the more common infections of the skin, like ringworm. But it was found very, very early on to be very effective in treating cancer and tumors.
00:21:48
Speaker
You know, unfortunately, it came later that we began to understand that it was actually dangerous. And many of the early practitioners who were using radiation therapy, they actually developed consequences from handling radiation
00:22:08
Speaker
They developed cancers themselves. They developed other medical problems that were related to handling radiation because it wasn't fully understood. But that understanding increased over time. Then we got into the atomic age in World War II and had a better understanding of it. And through the production of nuclear energy and as byproducts of nuclear weapons production, we actually found that there were more
00:22:37
Speaker
radioactive elements that were a little bit safer to use than radium, than some of the natural occurring elements such as radium. Some of these were produced as byproducts of the war effort. And as we got more of an understanding about those, we started to develop this science that we call radiobiology, where we start to look at
00:23:03
Speaker
the way radiation affects different types of tumors, the way it affects different types of tissues. There are some tissues in the human body that are very resistant to radiation such as the bone or blood vessels. And then we have other tissue in the human body that's very sensitive to radiation that can be damaged very easily by radiation like the kidneys and the lungs. And so we start to really develop that understanding of
00:23:31
Speaker
how radiation affects the human body and subsequently how it affects different tumor tissues over that period of time of the hundred years.
00:23:44
Speaker
And then we sort of level off between about the 1960s through the early 1990s. There was a sort of leveling off where we had a pretty good understanding of radiation and radiobiology, a pretty good understanding of the physics behind it.
00:24:05
Speaker
But delivery systems of radiation that were very, very crude by today's standards. You know, we're doing things just like with any other technology, a very low computing ability back then, the ability to actually measure accurately the dose that you're giving in a particular volume of tissue.
00:24:31
Speaker
the evenness of that dose through the tissue. Very, very difficult to measure. But then, as we get into the late 1990s, there's kind of this explosion of tech that comes into medicine, just like it was kind of coming in on board with the internet coming on board. Medical imaging becomes a lot more sophisticated.
00:24:54
Speaker
And we start to see a real big renaissance in radiation medicine that's really rooted in our harnessing of technology. And so now, and that really has progressed, I would say, in a logarithmic way, just the same way that
00:25:16
Speaker
You know, your cell phones progress and computing power progresses. I think they call it Moore's law where technology increase doubles every 18 months. So as that technology Renaissance goes on.
00:25:31
Speaker
With radiation therapy, it being a very tech-heavy specialty, so does the complexity of what we do, the reliance on technology of what we do, the kind of support staff we need to have behind us as physicians. And you mentioned medical physicists. The machines that deliver radiation therapy, the bulk of radiation therapy nowadays,
00:25:58
Speaker
are called linear accelerators. They are extraordinarily complicated pieces of technology, very, very expensive, very difficult to maintain, and
00:26:14
Speaker
the radiation safety that goes into delivering the right dose of radiation with every single treatment in a highly reliable way and targeting that really takes a team of people working on it.
00:26:29
Speaker
You know, I may be the face of the patient's experience in his or her radiation therapy course, but there's a whole team of people behind me that the patient doesn't really see. And those are people like medical physicists who help to keep the machines calibrated accurately and to help with radiation planning. There's a whole field called dosimetry, which is
00:26:57
Speaker
sort of an outcropping of medical physics, which is a type of occupation where they're working with physicians in the virtual world, in the computer world, to design specialized treatment plans based on a patient's imaging with the physician to choose different angles, different
00:27:26
Speaker
energies of radiation to maximize the dose to the target and minimize the dose to surrounding normal tissues. And then we have radiation therapists who are hands, as you will, to actually deliver the treatment on a day-to-day basis to position the patient appropriately and make sure that they're
00:27:55
Speaker
in the exact same position for treatment every single day. So it has really become from literally the doctor having a needle that was made out of radium and probing it into a tumor in the early 1900s or a doctor sort of standing there with a rudimentary x-ray machine and sort of pointing it over
00:28:24
Speaker
a cancer or a tumor and using a stopwatch in the early 20th century to a room and a team of people that looks like something out of Star Wars.
Emotional Aspects of Cancer Treatment
00:28:41
Speaker
I want to switch gears a little bit now and talk about the emotional side of cancer and the process of treating it. I want to read a quick excerpt from your bio on the MD Anderson website. And you say, I hope my patients would say that I took my time with them, that I held their hand.
00:29:04
Speaker
that they felt emotionally so much better after visiting with me than before and that I didn't make them wait. I feel like that's if I were in a position where I needed treatment, just reading that, I definitely would want to follow up with you. But there's a certain I decided to read this because there's a certain depth to it. And can you just kind of talk about the I guess the emotions associated with with treating a cancer patient?
00:29:35
Speaker
Sure. It's definitely, you have to use both sides of your brain. So I just talked about all of the science that goes behind a complex specialty like this and the kind of very, very focused, disciplined attention to detail that one has to have in
00:30:02
Speaker
designing and implementing a plan of radiation. But when it comes right down to it, people are people. And a human being is a human being. And the humanism that's involved in caring for patients with cancer is the most important part of it.
00:30:28
Speaker
educating patients as to what to expect, empathizing with them to the degree that you can, trying to understand what their concerns are, what their barriers are to deciding on a certain course of treatment or to making it through a difficult course of treatment.
00:30:56
Speaker
If you can't do that, then all of the scientific knowledge that you have and all of the expertise that you have to do or plan a course of treatment won't matter. Getting patients to trust you and to buy into the
00:31:20
Speaker
kind of things you're going to be doing to them, and the explaining exactly how this is going to work, what to expect. Patients want to know what the side effects are going to be. Managing those expectations over time is the art of medicine. So you have the science and the art, and it really does
00:31:50
Speaker
require both. And to a large extent, it's the art that's more important. There, you know, it seems to me that the, especially in
00:32:08
Speaker
the days that we live in today where so much emphasis is placed on technology in so many aspects of our lives, that the time that you take with somebody, the amount of explanation that you can do in boiling down a lot of the information into digestible bites, being able to understand or have an intuition for
00:32:38
Speaker
the kind of language that a patient is going to be able to understand. And I don't mean that with a foreign language, I just mean in terms of being able to explain things in lay people's terms. Those skills are even more important than the mastery, I would argue, than the mastery of
00:33:08
Speaker
the data and the mastery of the techniques and the technology. Because if you can't do that, you're not going to be able to build that kind of trust to deliver the kind of care that can be delivered. So I've always placed a lot of emphasis when I'm training young physicians or right now,
00:33:35
Speaker
being the leader of a department where other doctors are part of that. I've always placed a big emphasis on the focus on patients as people and as human beings and treating people the way that we would want to be treated ourselves or want our own family members to be treated.
00:34:03
Speaker
most frequently that involves your time and your investment of emotion in their care.
Balancing Emotion and Empathy in Cancer Care
00:34:14
Speaker
And there is a, you know, somewhat when you're getting started out in medicine and this doesn't just go for, um,
00:34:29
Speaker
cancer care, but in any medical specialty, there's, I find with young physicians, especially today, there's a little bit of a hesitancy or a shyness or reluctance to let the patient into your heart and invest emotionally in your patients.
00:34:53
Speaker
And I think it's wrong. I think that for the overwhelming majority of time that medicine or that doctoring was a thing or an occupation or a vocation for our history as human beings, the largest part of that has always been the emotional
00:35:23
Speaker
connections that you can make with patients and providing the kind of wisdom to guide them, but the empathy to see the world and see the expectations and live that to a certain extent through
00:35:46
Speaker
their experience. So I happen to take care of a population. My practice is mainly made up of breast cancer patients. And with this particular population, it tends to hit women in the prime of their life. So they very, very frequently have young children or children who they've raised who are going off to college.
00:36:13
Speaker
many times they're in the phase of their life where they're becoming grandmothers for the first time. And many times it's diagnosed earlier when they haven't even had a chance to have a family, to have a career. And recognizing
00:36:34
Speaker
the crisis that this is for that individual person and not taking it as any less and not taking anything that you do as a physician, as routine and really living that experience to the extent that you can, I think is a gift. It's a gift that you give to the patient and it's a gift that you have
00:37:02
Speaker
for your career because it's the most satisfying part of what I do. I'm very, very blessed to be living in the era where we have the kind of technology that we do, but the most satisfying part of the job that I have is
00:37:19
Speaker
sitting with a patient, laughing with them, sometimes crying with them, but definitely experiencing their journey with them through that process. That's what I get up for every day. I don't
00:37:41
Speaker
Necessarily no and that's the thing. I mean so much of my day is attempts to be structured with appointments and things like that, but it's the I find it's the Walking into the room and not knowing what story is going to come out of that experience and being a part of that story is really the most fulfilling aspect of this job and
00:38:07
Speaker
I think you said some really, really beautiful things there, honestly, especially about letting the patient into your heart and how that's sort of an art. I think that really hits home with me. I wanted to ask you though, kind of on the other side of that, if you really invest in your patients and have the emotions, how do you kind of balance that out with
00:38:34
Speaker
Like a not getting really wrapped up in outcomes and be like being able to check that at the door when you need to go home and be dad or a husband or and whatnot. Yeah. I mean, if you, if you find the answer to that, please let me know. No, I mean, I think it's, um,
00:38:55
Speaker
There's a natural way that you develop that over time to try to compartmentalize things. I mean, you see in the world of cancer, you see many victories and you experience some very devastating defeats.
00:39:21
Speaker
And I would say that that's the case in many fields of medicine. I mean, whether the operation goes well for a patient who's having a knee replacement or doesn't, or you see them, you're able to treat their heart disease or it's frustrating.
00:39:42
Speaker
It is something that is a, you can't really have these ironclad walls that exist, right? And to a certain extent, you know,
00:39:57
Speaker
Why is that an expectation? Does the attorney, the trial lawyer who goes in to argue, does a ton of preparation and going in to argue a very, very difficult case where someone's life might be on the line and either wins or loses, does he or she not have that same issue? Does the trial lawyer
00:40:22
Speaker
basketball star who has to go in and perform on a week to week basis and maybe make it to the playoffs and the championships and the pressure that's involved in that. Do they not have the same pressure to try to compartmentalize what they're doing there versus their life? I think there's a natural
00:40:44
Speaker
Bleeding over that that occurs and you know sometimes you have really good days and sometimes you have you know days that are down the you know. Realizing that that this is a always keeping in perspective that this is a long.
00:41:02
Speaker
game that this isn't going to be solved. Cancer is not going to be solved in my lifetime, accepting that. There are going to be aspects of cancer care that are solved and pieces of that puzzle that are solved, which is so exciting to be a part of that. But realizing that we're not going to wave a magic wand and solve it.
00:41:31
Speaker
And when I see a new patient, whether that patient is at a stage where she can be cured of her disease and I'm playing a part in that, or whether it's a situation where that person is terminal and I'm going to be a part of that, understanding and setting those expectations and understanding what my role is
00:41:58
Speaker
in that person's life. That person does want me to be a good listener. They want me to have empathy. Most of all, they really want me to be able to solve their problem. In some cases, I can't take it completely away. I can't wipe the slate clean, but many times I can focus on an aspect of that
00:42:19
Speaker
disease that's really causing them a problem or that's really dangerous to them. And I can take that off the table. And it doesn't mean that they're not going to have to deal with some other aspect of the disease at some point in time. But I can help them in that there's a beginning, a middle and an end to that particular role that I play. And the more you do that and the more patients that you see and, you know, the more experience that you get,
00:42:47
Speaker
the better able you are to balance that with your life. Fortunately, your life is evolving over this period of time too. So when you're a young physician, you may or may not have a significant other, you may or may not be married, and then you're starting out your practice and then maybe you're layering on your first child.
00:43:10
Speaker
and then you're sort of, the two things are happening on the same track, on two different tracks, excuse me, but they're happening at the same time and they're both evolving over the same time. An interesting part of that is that when I first got into radiation oncology, I thought I would be, I was really, our specialty, you treat both adults and pediatric patients when you're going through training.
00:43:39
Speaker
And I really found the pediatric care very rewarding. And then I had my first child during my residency training and I found that I could not emotionally, I couldn't handle that the same way anymore. And so my perspective changed. And so I decided to focus a little bit more on adult medicine.
00:44:03
Speaker
And that to me was a crossroads that I had to decide, okay, is this something that you still can do? Or is it something that's going to be too taxing for you to have a family and have that? And in my case, I found that it was. So there are these kind of decision points that you make.
00:44:23
Speaker
as you're evolving in your training and maturing in it and then maturing in your career as to how you can balance those things. So it's not something that you can be prescriptive about and say, okay, here's how you balance these two things. I think that you have to pay attention to both of them. You have to drive the car with both feet. But you can find that balance, you can find that harmony. And I've been in situations where I've,
00:44:54
Speaker
had, you know, patients, patients of mine who are friends or family members or colleagues who then that relationship with them changes. And now they're not just a colleague anymore. They're also a colleague and a patient.
00:45:07
Speaker
And how do you balance that? And I've gone to patients who I was very good friends with, I've gone to their funerals and mourn their loss. So it's very, very difficult, especially the more advanced you get into your career to not have those interactions. And the only way you can do that is put a shell around yourself.
00:45:33
Speaker
And it's not really possible to do that and to have a successful, rewarding career, in my opinion. I mean, because everybody thinks of the downsides, the potential downsides to having those types of relationships and types of connections that go beyond just the doctor-patient relationship. And everybody thinks, well, how would you handle it? Well, my contention is, how do you handle the opposite?
00:46:00
Speaker
How do you handle basically cocooning yourself and protecting yourself from those things? There's a downside to that. There's a loss to that. So I found over the course of my career that being able to experience that as part of life, as part of why we're here, has been the way I've chosen to pursue the practice of the specialty. And it's been very rewarding.
00:46:31
Speaker
It's very insightful. I think, I think you're right. A lot of people try and warn a bit too much about, you know, that you need to kind of just protect yourself and shield yourself. And maybe sometimes you just kind of have to dive in to, to make things happen. I mean, I wonder, I wonder how.
00:46:50
Speaker
wise it is to think that whatever career we choose, we can go about it in a mechanical way that protects us from becoming emotionally involved in.
Connecting Emotionally with Patients
00:47:06
Speaker
the experience. Does a clergy, does a member of the clergy, is it possible for them to do the same thing? If you're a hockey superstar, are you able to just mechanically be the best player but not emotionally be involved in
00:47:30
Speaker
the wins and losses, or the ups and downs of a game or a season. So human emotion is not something that doctors can check at the door. It's unrealistic to expect that. And not even preferable to want that. I don't think we'd want a world where we knew that our doctor, if we were coming in as a patient, where we knew that our doctor was
00:47:59
Speaker
Checking his or her emotions at the door or or or walling themselves off to a certain degree i think patients understand that i'm not i can't be there a spouse i can't be their mother i can't be their father you know i can't be there for them in that regard but.
00:48:15
Speaker
I think that they intuitively understand that. But I really believe that patients want you to connect with them. They want you to be emotionally invested in them because they believe, and I think rightly so, that that's tied with you doing a better job for them.
00:48:32
Speaker
If you really care about them, you're going to go the extra mile. You're going to call them in the off hours when they have a question. I think that it's natural for them to think that you're going to spend that extra time on their treatment plan to make everything that's just right.
00:48:49
Speaker
You know, I often have this, there's always this inevitable way that the conversation leads when I'm meeting with a new patient for the first time. And we go through all the options and everything like that. And then they say, you know, and that's all well and good. But if I was your mother or your sister, what would you tell me to do? And I, and I often turn the tables on them and say, I don't hold some special recommendation in my back pocket that I only give to my family.
00:49:16
Speaker
And I say, if you were my mother or my family member or my sister, I would give you these same options. And my mother or my cousin or my sister, if they had the same situation that you had, each one of those people may make a different decision. But I would present the options the same to all of them. And so I'm automatically treating you the same way with my family member.
00:49:43
Speaker
So I think that our perception as physicians, and I've seen this from young physicians as I've trained them over time, is that
00:49:58
Speaker
conventional wisdom that we're supposed to do this and not that and go here and not there. It's not necessarily what patients want. And many of the times all those things are tied together from the patient's perspective.
Reflections on a Career in Oncology
00:50:16
Speaker
I often say think about yourself, what would you want when you're sitting with a doctor in crisis? You want them only thinking about how they're gonna target your tumor or do you want them thinking
00:50:28
Speaker
about what's going on in your life and how you're going to handle this and what you're going to need. I heard you were a caddy back in the day. I don't know if you had a funny story from that. Oh, caddy. Yeah, I think it was my first job where I made money was caddying. It was nice because it was all cash. I didn't even know what that meant at the time, 14, 15 years old.
00:50:54
Speaker
I would say this, that I tended to see that there was an inverse relationship between the expensiveness of the golfer's clubs and their ability. I tended to see that over time.
00:51:12
Speaker
And I found that for some people, you know, it's the art of managing expectations and trying to, you know, provide service to people. I often said that one of the best things that prepared me for a life of medicine was actually waiting tables. One of the early jobs that I had was, you know, and caddying's not far off of that. You know, you're basically, you're at the service of the,
00:51:40
Speaker
of the customer and you do what they say without question and you don't argue with them.
00:51:47
Speaker
And if there's another way that they should go, you have to find a tactful way of letting them know that. And so I do think that people that I've seen who have the most, I'd say, emotional quotient, the highest emotional quotient of the doctors that I've trained have spent some sort of time in the service industry where they've been
00:52:16
Speaker
They've encountered difficult circumstances that they have to manage with people's demands or emotions or things like that. And the golf course, you'll find plenty of that. Yeah, I was, uh, I've guided at a course over here for eight years by my house. So I definitely know what you mean about the clubs. Uh, Dr. Anthony Dragan, thanks for joining the show. Thank you so much for having me on John. I really appreciate the opportunity.
00:52:50
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.