Mon­day, Jan­u­ary 9, 2012

I arrived at the Memo­r­ial Sloan-Kettering Can­cer Cen­terat 9 am for my Princetern­ship shad­ow­ing Dr. Ariela Noy, a hema­tol­o­gist and med­ical oncol­o­gist spe­cial­iz­ing in lym­phomas. Before I was able to meet Dr. Noy, I got a glimpse of the admin­is­tra­tive side of hos­pi­tals as two of Dr. Noy’s incred­i­bly help­ful and very friendly assis­tants nearly pulled hairs wrestling with admin­is­tra­tive hurdles—and there were a lot, as one might expect from such a large hospital—so that I could com­plete the required HIPAA train­ing regard­ing patient pri­vacy. Once this was done and I was cleared to enter the clinic, things became much more straight­for­ward. I was warmly greeted by Dr. Noy at her clinic and pro­ceeded to shadow her for the entire after­noon until 6 pm as she saw patient after patient, vir­tu­ally non­stop (she men­tioned that she only had enough time at lunch for half a PB&J sandwich).

See­ing first­hand an expe­ri­enced oncologist’s approach to clin­i­cal work was quite an enlight­en­ing expe­ri­ence. Before meet­ing with each patient, she effi­ciently and thor­oughly pored over each patient’s med­ical his­tory and test results; that the X-rays were acces­si­ble online was one tech­no­log­i­cal con­ve­nience she clearly appre­ci­ated and made a point of to show to me. I was impressed with the com­pre­hen­sive nature of her inquiries into her patients’ health; I would have expected spe­cial­ists to nar­row their focus only to their field of spe­cialty, but Dr. Noy was care­ful to find out, with the aid of a long check­list, a vari­ety of med­ical prob­lems that her patients were hav­ing in addi­tion to lym­phoma. Indeed, many of the patients had mul­ti­ple can­cers and other dis­eases, for which she offered as much advice as she could and tried to refer them to other spe­cial­ists. She also pointed out the impor­tance of doc­u­men­ta­tion in a med­ical set­ting, as evi­denced by the copi­ous notes she took at every meeting.

Dr. Noy def­i­nitely set an exam­ple for me in her inter­ac­tion with patients. She was very direct in telling her patients what they needed to hear, but she also took the time to lis­ten patiently to some talk about com­pletely unre­lated matters—several of them were suf­fer­ing from depression—and  con­versed freely with oth­ers on top­ics rang­ing from par­ent­ing to yoga. She also offered philo­soph­i­cal insights as pep talks to some of her depressed patients; per­haps my favorite was one in which she reflected that the human body should not be treated as a piece of china, never to be touched, but some­thing to be fully lived in, even if it meant get­ting dents here and there. When I asked her about how she han­dles the emo­tional dif­fi­cul­ties of car­ing for patients, her response was that she did not make them sick to begin with, and that she was there only to make them bet­ter, which made the job ulti­mately reward­ing. Such was the phi­los­o­phy with which I hoped to go into med­i­cine, and I was reas­sured to hear that it still held for her even after many stress­ful years of expe­ri­ence in the field.

Tues­day, Jan­u­ary 10, 2012

Lawrence and MSK Staff

After quite a strug­gle get­ting out of bed at 6:40 am, I man­aged to make my way to the hos­pi­tal for an 8:00 am con­fer­ence fea­tur­ing a pre­sen­ta­tion by Dr. Mor­ton Cole­man, direc­tor of the Cen­ter for Lym­phoma & Myeloma at the neigh­bor­ing New York Pres­by­ter­ian Hos­pi­tal, on dif­fer­ent anti-angiogenic ther­a­pies for myelo­mas and lym­phomas. It was inter­est­ing to see the dif­fer­ent approaches to treat­ing can­cer that have been tried and encour­ag­ing that some of them have pro­duced promis­ing results, but Dr. Cole­man did raise a per­ti­nent, con­cern­ing issue of phar­ma­ceu­ti­cal com­pa­nies often overly pri­or­i­tiz­ing new, poten­tially prof­itable treat­ments over already exist­ing ones that are just as effective.

Right after the con­fer­ence ended at around 9:00 am, I joined a lym­phoma in-patient care team headed by Dr. Jonathan Schatz. The envi­ron­ment here struck me as markedly dif­fer­ent than that of Dr. Noy’s clinic yes­ter­day, right from the very begin­ning when I was instructed to wear a mask tightly around my face before enter­ing the room of the first patient, who had AIDS and lym­phoma and might have had con­tracted tuber­cu­lo­sis. Indeed, using hand san­i­tizer and wear­ing a mask (and even an iso­lat­ing gown and gloves, in the case of one patient who might have con­tracted a “super­bug”) was required before enter­ing any of the rooms with obvi­ously very ill, bedrid­den, and some­times immuno­com­pro­mised patients. What impressed me most was the team dynamic, as Dr. Schatz would be briefed by his team mem­bers in a “House-esque” fash­ion before each visit and they would bounce ideas off each other in dis­cussing treat­ment approaches; they were all very friendly and enthu­si­as­tic about explain­ing the med­i­cine to me so that I was not left com­pletely clue­less. As they only had six patients, it only took them an hour to fin­ish there round, and I def­i­nitely found myself wish­ing I could have spent more time with them.

For the rest of my day, I attended con­fer­ences and lec­tures, which intro­duced me to the aca­d­e­mic in aca­d­e­mic med­i­cine. I met up with Dr. Noy at 10:30 am and took a taxi ride with her down­town to a clinic, where she gave an hour-long talk on HIV-related can­cers. This was a par­tic­u­larly intrigu­ing sub­ject for me, as I had not been pre­vi­ously aware of the con­nec­tion between HIV and can­cer devel­op­ment. In the after­noon, I also attended a research pre­sen­ta­tion by a doc­tor from the National Insti­tute of Health on the process by which trans­mem­brane pro­teins are inserted into the mem­brane. Not sur­pris­ingly, this lec­ture was heav­ily mol­e­c­u­lar biol­ogy and I was mostly just left with the impres­sion that biol­o­gists must have quickly got­ten tired of com­ing up with cre­ative names for all the myr­iad pro­teins in the cell, hence pro­tein names like Get1, Get2, and Get3. Finally, at the end of the day, I lis­tened to a pre­sen­ta­tion by Dr. David Meltzer, an M.D./Ph.D. holder from the Uni­ver­sity of Chicago who has made a name for him­self ana­lyz­ing the eco­nom­ics behind med­ical care, on the effects of increas­ing spe­cial­iza­tion in med­i­cine on qual­ity of care and med­ical costs. Fol­low­ing some eco­nomic analy­sis, he found that spe­cial­iza­tion has gen­er­ally improved med­ical prac­tice from the per­spec­tive of physi­cians, but not for patients who are fre­quently admit­ted to hos­pi­tals, for whom deal­ing with mul­ti­ple doc­tors can prove incon­ve­nient and com­pro­mise qual­ity of care. Dr. Meltzer finally pro­posed a new model involved strat­i­fy­ing patients based on their likely fre­quency of hos­pi­tal vis­its that would avoid such prob­lems. I def­i­nitely enjoyed this pre­sen­ta­tion, as it was pro­vided me with a new socioe­co­nomic per­spec­tive on med­i­cine I would not have oth­er­wise con­sid­ered as a science-oriented person.

Wednes­day, Jan­u­ary 11, 2012

I began my day at 8:00 am with a return to the in-patient care ward, now with a lym­phoma team led by Dr. Steven Hor­witz. This team was assigned to the patients who were the most ill, and before vis­it­ing each patient, the doc­tors would spend at least fif­teen min­utes dis­cussing all the fac­tors that needed to be con­sid­ered to decide on a course of treat­ment. Not sur­pris­ingly, the rounds for this team took sig­nif­i­cantly longer than those for the team from the day before. Again, the doc­tors were very friendly and took the time to explain con­cepts to me, such as the process by which the sever­ity of the patients’ can­cer was deter­mined and the pur­poses of dif­fer­ent tests such as PET and CAT scans.

At 10:30 am, I left the team to attend a sym­po­sium with Dr. Noy on chronic lym­pho­cytic leukemia (CLL), the most com­mon form of leukemia. At this sym­po­sium, doc­tors from var­i­ous med­ical insti­tu­tions pre­sented research find­ings on the dis­eases. Per­haps the pre­sen­ta­tion I found most inter­est­ing was one that cov­ered the effec­tive­ness of mul­ti­ple ther­a­pies of the dis­ease through pro­tein inhibition.

At 12:30 pm, I returned with Dr. Noy to her clinic, and just as in the first day, I sat in on patient vis­its. Each patient obvi­ously pre­sented with dif­fer­ent health prob­lems, and with each one I learned a lit­tle more about med­ical treat­ment. Per­haps the tens­est moment was when Dr. Noy received the blood test results of a patient she had already fin­ished see­ing ear­lier and was shocked to find the level of one par­tic­u­lar dis­ease marker in that patient to be ten times nor­mal; she urgently con­tacted hos­pi­tal staff to arrange for the patient to be trans­ferred for imme­di­ate care. In the time between vis­its, Dr. Noy was kind enough to search for and give me med­ical arti­cles per­tain­ing to a par­tic­u­lar med­ical inter­est of mine, gene ther­apy, as well as clar­ify sci­en­tific con­cepts from the sym­po­sium ear­lier in the day. I might also add that I got to meet a high school senior—and Prince­ton applicant—also shad­ow­ing Dr. Noy and had an enjoy­able time talk­ing to her about col­lege and, of course, sell­ing her on Prince­ton (as did Dr. Noy).
 
At 6:00 pm, just like that, My Princetern­ship was over before I knew it, and I was left wish­ing that I could have stayed longer to absorb all the infor­ma­tion there is to know about med­i­cine. As it stands, I learned more about can­cer in a clin­i­cal and aca­d­e­mic set­ting than I pos­si­bly could have hoped for from just three days. I def­i­nitely emerged with a greater desire to become an oncol­o­gist in the future for the oppor­tu­nity to make a dif­fer­ence in the lives of patients. I am very thank­ful to Dr. Noy for tak­ing the time out of her incred­i­bly busy sched­ule to pro­vide such an edu­ca­tional expe­ri­ence for me. With­out a doubt, the lessons I learned dur­ing this time will stay with me through­out my future years in the field of medicine.