Sunday, December 24, 2006

The Train, The Train

Being sort of obtuse, I often find it useful to try to explain things to patients and their families using metaphors that make sense to the two Betz cells desperately clinging together for survival in my skull. I guess that is also the reason I pepper these random blog posts with pictures --- it seems I never graduated from the Dr. Seuss phase of my life.

In any event, I am not infrequently faced with presenting options regarding chemotherapy. I am not a medical oncologist, but it is certainly common (and, I think, normal) for patients to ask the opinion of the guy they let open their body cavities when they are weighing the pros and cons of chemotherapy. Given my innate inability to think creatively, I of course turned in my search for a suitable metaphor to that great guiding light of my misspent youth -- TV. Being a mere youngster at age 44, that means that glorious period in TV history dominated by the master of schlock, Aaron Spelling --- big hair, big b**bs, small plots. All in all, probably very bad juju for a teenage boy.

But which of these great shows would be best as a starting point? Starsky & Hutch, The Love Boat, Dynasty, TJ Hooker, Vega$? No, I had to look to the epitome of Western civilization in the 1970s -- Fantasy Island! Who could forget Tattoo shouting "Boss! Da plane! Da plane!" Ah, memories --- what, you haven't watched these over and over yet?

Da plane! That was it! And so, for a while I thought that taking a plane ride would be a reasonable way to explain chemotherapy --- you pay (a high) price for a ticket to reach a certain destination, and you cannot reach that destination easily in any other way. But I found as I thought about it that a plane ride really doesn't explain easily the potentials that a course of chemotherapy, or radiotherapy for that matter, can present. Fortunately, I didn't blow a fuse coming up with another, similar yet hopefully more helpful metaphor. And I can still pretend I'm Tattoo ---- Da Train! Da Train!

I think I can best explain what chemotherapy means to (most) patients is by describing that it is sort of like taking a train ride. One can get on a train in, say Denver, and plan to travel to Chicago. But there are two important things to remember about that train:

  1. There is no way to play "catch-up." In other words, if you plan on making it to Chicago --- if you plan to achieve the maximum benefit from a proposed course of therapy --- you have to get on in Denver, as there is no way to run the train down in Omaha and get on there without a whole lotta cost to your potential outcome.
  2. The train makes stops. If you get on the train with full intentions of making it to Chicago, but for one reason or another --- if you are simply flat done in by the therapy --- there is no train conductor that will force you to continue all the way to your destination. You can get off in Omaha or Des Moines, or anywhere else you feel like.
Of course, some train rides are considerably longer --- and more exhausting. Some trips require the traveler to get off and reboard a different train, or even change courses entirely. And some patients require series of different "rides" on different trains in order to reach their ultimate destination.

Some patients, presenting with disease that is beyond our current therapies, can never reach the destination they desire more than any other --- a cure. This is the most difficult scenario for me to approach of all, as it feels as if I am walking a tightrope between offering a pessimistic outlook and one that is overly optimistic. However, if we appropriately counsel these patients that a reasonable degree of palliation while trying to preserve a reasonable quality of life is a worthy goal, then they can "board the train" with realistic expectations ---- and when it is plain that staying on the "train" has limited or no potential for further "travel," it is easier for the patient and their family to get off the ride and stop the treatment.

And then, at the risk of stretching this metaphor to a breaking point, neither we nor they will "Train in Vain."