What’s your resolution for 2016?

There are many exciting aspects to the onset of a new year. It’s a time for regrouping, reconnecting, and re-establishing yourself. This is the time to take stock of personal accomplishments, pitfalls, and decide upon areas for improvement.

Although it’s a tad arbitrary to select the transition from December 31st to January 1st as “the time” to process these aspects of our lives, the passing of one secular calendar year into another is an excellent opportunity to make amends with the past and look forward to our future progress.

In past years, I’ve used this particular week’s entry to list personal New Year’s resolutions in the context of my career as a veterinary oncologist. I’ve been successful in accomplishing some, while others have been sidelined in favor of more mundane activities related to home improvement, work obligations, and family matters.

This year I’m taking a different approach. I’m still hoping to reflect on my achievements and disappointments over the past 12 months with an exacting and honest retrospective lens, but I’m also trying to do something I find exceptionally difficult, which is find contentment in the present.

I’ve always been goal driven—especially when it comes to academics. A large focus of my youth was achieving scholarly success so I would be accepted to veterinary school. My path towards that milestone was a bit circuitous, but once achieved, it turned out acceptance wasn’t an endpoint, but rather one of a thousand mile markers on a path towards an uncertain finish line.
Getting into veterinary school led to my need to achieve excellent grades and become involved in numerous co-curricular activities to ensure I was a competitive candidate for future internship and residency programs.

Matching to a residency program wasn’t the end of my path, as I convinced myself I needed to absorb every detail related to my cases and memorize minutia in order to be a successful oncologist.

Achieving board certification as a veterinary oncologist wasn’t the golden ticket, as I then pressured myself to find the “perfect” job.

I exist only in forward motion, striving towards an endpoint without accurately defining what that finish line would look like. Technically, in a professional sense, I’m already there, yet I still lack fulfillment, both jobwise and personally.

With the onset of the New Year, I’m trying to focus less on the destination and spend more time looking at my journey. Instead of resolving what to do over the next 12 months, I’m taking the time to inventory what I have to be thankful for right now.

I’m grateful for being employed. Yes, a relatively simple aspect to be happy about, but not everyone with my credentials is able to enjoy full-time employment in their chosen field. My job may not be perfect, but it’s certain.

I’m happy to have openings in my appointment book. This may seem a bit bizarre, as the overachiever in me should be happier being overbooked. However, breaks in my schedule mean I have the ability to divide my time more towards the owners and pets who need it. If an appointment runs over the allotted time, or an owner calls frantic, needing advice, I’m able to devote additional minutes of my day to their needs without taking time from another. This means I am giving more of myself to my clients and achieving a standard of care on par with what I would want for my own pets.

I am thankful for the patients with cancers for which there are no known treatment options or expectations of cure, yet I am able to maintain their quality of life for an extended period of time using creative treatment options and novel plans. I enjoy being able to learn from their care and spread that opportunity to other pets in similar situations. I’m also happy to simultaneously provide additional quality time to the owners of pets with terminal cancer.

I’m happy my own pets are healthy. The kittens we adopted last year have grown into chunky, happy, mischievous young adults, and our older girls are doing well and continue to adjust to their new siblings as best as can be predicted.

I wish everyone a happy and healthy new year filled with excitement and anticipation. I also wish everyone the ability to take stock in what it is they have, rather than focus on what it is they need to improve. Being happy in the here and now isn’t always easy, but this is a great time to start!

Happy 2016 to everyone!

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When both the owner and their pet have cancer…

A surprisingly large number of owners of the pets I see with cancer are cancer survivors themselves. Aside from how unusual I find it when people are willing to share their personal medical histories with me, I usually also feel a particular pang of sadness for their situation.

My expertise lies in diagnosing and treating cancer in animals. Despite my credentials and my experience discussing extremely complicated and highly emotional disease processes in animals, I lack the comparable skills necessary to have a similar conversation regarding aspects of human oncology.

Perhaps the reason I see so many simultaneous diagnoses of cancer in human/animal pairs is because the owners are biased. Individuals who have faced a cancer diagnosis themselves could be more likely to pursue an oncology consultation for their own pets.

A willingness to pursue an appointment with a veterinary oncologist doesn’t equal a guaranteed decision to purse treatment. I meet many owners who have endured cancer treatment themselves and are subsequently vehemently opposed to pursuing similar options for their own animals. They are certain there will be severe side effects and an eminent decline in quality of life, and do not appreciate the potential benefit. Their goal in meeting me is to garner support for their decision, despite any assurance I can provide that the goals in veterinary oncology are very different from those on the human side.

Other owners possess remarkable optimism. They comprehend the risks of treatment but understand that those possibilities are rare in companion animals. They successfully set aside their own negative experiences with cancer with the goal of prolonging a good quality of life for their pets.

Occasionally I encounter cancer survivors who possess a deeper motivation to treat their pets. Individuals who not only draw parallels between their pet’s diagnosis and their own, but push further to pursue all available aggressive avenues of treatment, because as long as their pet is beating cancer, they are as well.

To them, their pet’s battle represents an intimate connection to their own diagnosis. The animal’s ability to endure its diagnosis and survive is intimately associated with their owner’s perception of (and subsequent fight against) their own mortality.

I’m here to expose this as an unfair burden for a dog or cat to bear. Connecting one’s own survival to that of their pet’s is a concept contrived from emotion, not science. Despite it being logically unpalatable, I can appreciate the thought process.

What bothers me most about this ideology is that it contradicts so much of what I’m most passionate about: educating people that a diagnosis of cancer in a pet is not the same as for a person.

Yes, similarities exist on a molecular level between human and animal cancers. We frequently, and appropriately, use animals as models for human disease. However, the emotional, financial, and overall consequences of the diagnosis are varied between the two species.

Our companion animals do not understand cancer; they do not fear the word, nor do they wish to fight against it. They live in the moment, exist for the here and now, and plan for nothing in the future. Their worry about survival is primitive, not existential.

As such, my responsibility as a veterinary oncologist is to provide owners with options to help their pets live longer, happier, and good quality lives with cancer. To adequately do so, I must accept a lower cure rate from my treatment plans and a more conservative approach to their disease. If longer survival is the outcome of my plan, I am happy. But I am happiest when an owner considers the time spent following their pet’s diagnosis of cancer as stellar, rather than simply being numerically prolonged.

It’s virtually impossible for an owner to be able to completely remove the bias of personal experience with cancer when considering how to approach his or her own pet facing a similar diagnosis. Experience is what allows them to interpret their challenge in a context that makes sense to them.

Experience also affords me the vantage point of urging an owner to keep their own diagnosis of cancer separate from their pet’s, and remember the many happier connections they have to their existence.

A letter to myself as a first year resident in medical oncology

Dear me (you),

I’m writing to you from the future—approximately ten years from where you are now. You’re a few months into your medical oncology residency, just beginning to assimilate to the flow of your daily responsibilities as a doctor committed to the diagnosis and treatment of cancer.

You hate living in upstate New York, and are dreading the upcoming winter and the associated endless piles of snow and sub-zero temperature nights guaranteed to envelope your existence over the next three-plus months.

You’re starting to refrain from feeling pure panic every time your pager goes off, but remain tethered to its incessant bleating. You constantly worry about memorizing every miniscule detail of cancer biology and metastasis.

You’re indelibly etching median survival times, remission rates and durations, and percent chance of side effects of chemotherapy drugs on the exhausted neurons of your cerebrum. You agonize over dose volume histograms and p-values and whether or not you will know the correct answers in rounds the following day.

You view your elder resident mates with awe, stunned by their experience, poise, and certainty by their career paths. You fear you came to this life by chance rather than choice. You ask yourself daily, “What kind of an oncologist do I want to be?”

You’re concerned about having enough money to pay rent and your cell phone bill, and still have a measly few dollars left over to go out to dinner once in a while. The federal government recently started knocking at your door, looking for the first of many paybacks for the thousands of dollars they so willingly lent to get you where you are.

You think you are too old and fear you will never find a husband or be able to start a family. You stare at imaginary wrinkles on your face, and contemplate what it will mean to be (gasp!) 32 years old and just starting to contribute to a retirement plan.

You spend an inordinate amount of time considering your highly anticipated “first real job,” half dreaming of the benefits associated with earning a real paycheck and mostly terrified of the thought of being in charge of complicated cancer cases all by yourself.

You stress over where you will live when you are finished, where you will purchase your first home, and whether or not your current mode of transportation, an old, but moderately reliable Honda Accord, will survive until the end of your residency.

I’m here to tell you to stop worrying.

Ten years affords me the wisdom and patience to understand that you don’t need to know it all—not during your first year of residency, or second, or third, or beyond.

I look at you with the knowledge that your stress won’t lessen with time, and your life will only become increasingly complicated. Your current concerns will be reduced to fleeting afterthoughts when you contemplate them from where I stand.

One of the most important pieces of wisdom I can pass along to you has nothing to do with your ability to accurately recite survival times or understand the molecular biology of carcinogenesis. The most valuable tool I’ve amassed over the years is the ability to say “I don’t know.”

Yes, first year resident me, you need to know a lot, but you don’t need to know it all. The patients you will meet over the years will frequently confuse you and cause you to second-guess the facts you’re agonizing over right now.

They will live longer than you ever expected and they will die from complications you couldn’t predict. They will have inconclusive biopsy reports. You won’t be able to look them up in any one of your textbooks because their signs and test results won’t match anything you’ve seen or heard of before. You will constantly second-guess yourself, your co-workers, and your patients’ owners. You will meet patients you won’t be able to save. You will see them die.

To my first year resident self, I wish you could take time to listen to my words and remember to breathe. I want you to look around and embrace the wonder of your current environment. Notice how the most esteemed medical colleagues surround you in your profession. You have instant and easy access to advanced diagnostic tools and clinical trials. You are given immense responsibility, but you always have back up. This is your time to drink it all in and savor the pure pleasure of learning.

Most of all, you have time. There’s plenty of time to study and socialize. There’s time to take a day off now and then. There’s time to find the husband and start a family. There’s time to remove even just a few pounds of the pressure you’ve placed on yourself.

Remember your friends and count on your family. Ten years will pass and you will no longer dread an endless snowy winter because you will wish time could somehow cease to continue accelerating exponentially as you age.

I know you will hear my words, but I also know you won’t listen to me. I already recognize what kind of oncologist you will become. I’m proud of you as a doctor, but I mourn the sacrifices you’ve made to become the person you are today.

…and suddenly I’m distracted by a quiet but persistent voice, whispering words I’m desperately trying to decipher. It’s the voice of someone claiming to know a bit about myself, ten years from now.

Have you always wanted to be a veterinarian, but couldn’t because of this one thing???

When someone I’ve met for the first time discovers I’m a veterinarian, reactions vary from detached amusement to wild-eyed enthusiasm. The latter is far more common as there appears to be unexplainable mystique and awe surrounding veterinary medicine as a career choice.

About one in five people I meet will exclaim, upon hearing what I do for a living, “I wanted to be a vet myself!” while simultaneously flashing the broadest, most pride-filled, fervent smile possible. It’s easy to share in their instant passion for my work, and I’ll often respond with a resounding, “That’s amazing!” or “What a coincidence!”

However, our connection is typically sustained for only a few fleeting seconds. Almost as rapidly as the explosion of cheer erupts from their mouth, a peculiar gravity overtakes their expression, and a cloud envelops our joy, masking it with sadness.

Invariably, my new VTBBFF (veterinarian-to-be-best-friend-forever) will solemnly whisper something along the lines of, “But I could never deal with putting animals to sleep.”

I’m never certain how to proceed from that moment. If their concern for becoming a veterinarian had to do with the expectations associated with the many rigorous years of study, or passing board exams, or even anxiety at the sight of blood or an animal in pain, I would feel better equipped to respond. When the principal association of my chosen career path is causing the death of my patients, I’m at a loss.

Euthanasia is an integral part of my job. Though certainly not a top activity to participate in, I respect the tremendous privilege associated with my ability to relieve suffering and allow animals to die with dignity. The word euthanasia translates to “good death,” and this is the most fitting description of the service I provide.

But euthanasia represents only a small fraction of the many complex aspects of veterinary medicine. And it’s certainly not the primary attraction of the profession for those of us who choose this path. Our training, motivation, and desire lie in curing disease and healing sick pets. We are scientists who look to use our intelligence and compassion to help animals feel better. Death is a part of our position, but it is not something that sustains our motivation.

Mentioning euthanasia as a reason to never pursue a career as a vet is akin to deciding against becoming a singer because of a fear of being rejected by a record producer. Or not wanting to pursue teaching because you’re afraid of the challenging students you might face. It’s focusing on the damage rather than celebrating the positive.

There are burdensome aspects to every profession, but they should not outweigh the remarkable potential of the more rewarding qualities of the job. Singers, teachers, and veterinarians toil diligently at their respective crafts because they truly believe in their endeavors. The negative aspects are neither pervading nor permanent, and in the right environment can be capitalized to increase satisfaction and to strive to be better at what you do.

I understand some individuals view the inability to euthanize animals as a deal breaker for choosing veterinary medicine as a career path. I wholeheartedly agree, if your primary association of veterinary medicine were with euthanasia, you would be unable to sustain yourself in this emotionally complicated profession.

But if the association is centered on euthanasia, and this occurs at the expense of considering the many other wonderful and rewarding aspects of the profession, I would urge you to consider spending some time working in a clinic alongside the doctors entrusted with this precious gift.

Allow yourself the chance to better understand the breadth of responsibilities veterinarians hold. Even better, allow yourself the opportunity to explore your own capability to endure something you’re convinced would prevent you from pursuing your ideal career path.
And if your principal association to hearing me say I’m a veterinarian is immediately thinking about how difficult it is to put an animal to sleep, please take a second to pause and consider the impact those sentiments could have on someone who is dedicated to preserving the health and wellness of their patients.

Their death isn’t my primary focus.

And I don’t want it to be yours either.

What happens when you care too much?

There is a quote from a prominent veterinary oncology text taped above the computer monitor in my office stating: “True oncological emergencies are rare. Emergencies of emotion, however, are quite common.”

I realize this expression may not resonate well with an owner of a pet with cancer and could even be misconstrued in an offensive manner. Yet, I personally do not see vindictiveness in the words, and I certainly do not display them with any malicious intent. For me, they serve as a reminder of how important it is to “Keep calm and carry on,” as they say.

Truth is, I find it far too easy to become caught up with the circulating emotions of my day and allow them to influence my life at, and outside of, work, and to lose sight of how my chosen profession represents only one aspect of the person I am. Those two sentences help ground me when I otherwise feel helpless to the turmoil of the day.

Compassion fatigue is defined as a deep physical, emotional, and spiritual exhaustion accompanied by acute emotional pain. It can also be described as an extreme state of tension experienced by individuals who help people in distress, including preoccupation with the suffering of those being helped to the degree that it is traumatizing for the helper.

Typically, compassion fatigue is thought of as a condition pertaining to people working in the human medical field, but is now becoming more recognized in veterinary medicine. I often wonder, how can one discern when the line is crossed between caring enough and caring too much?

Veterinary medicine, as a whole, is a profession not built on gratitude. Veterinarians do not garner the same respect and admiration as our human MD counterparts, yet our degree requires similar undergraduate and graduate school degrees. Veterinary specialists complete internships and residency programs of similar caliber to human doctors while competing for far fewer positions in each category overall, and once completing those programs, compete for far fewer jobs.

I also find that some owners are quick to find fault with veterinarians for a misdiagnosis or for what they perceive as a poor recommendation or communication, or, worse yet, claim vets are more interested in generating revenue than maintaining the best interests of their pet. Although there are probably some truly dishonorable veterinarians out there practicing medicine, having worked in several hospitals over the past few years, I can’t say I’ve met one myself.

Veterinary oncology is not a glamorous specialty by any means. In fact, on the worst of days, it can be downright draining. Obviously the good far outweighs the bad, or else none of us could continue on this path for our livelihood. But there are many times when an owner’s feelings trump rational thinking, and in an instant, I am forced to step out of my role as medical advisor and transform into a psychologist or grief counselor.

From experience, I can say this is not something taught from a book or a lecture in vet school; it’s learned experience combined with basic emotional capabilities as well as a little bit of luck at times. We may be able to give ourselves to our owners and our patients, but I have to question, to what expense are we doing so?