It's been exactly 20 years since my first day of internship

As I reflect on my disproportionate aging since then (gray hairs >>> wisdom), here are my 10 unsolicited recommendations for any colleague embarking on residency

THE "ATTENDING ADVICE YOU DIDN'T ASK FOR" THREAD ... 1. ADMIT WHAT YOU DON'T KNOW

You've never had more info at your fingertips (whereas I showed up day 1 with so many reference books stuffed into my white coat pockets that the seams split) but specifically NEVER fabricate patient data! Rather: "I'll look it up & get back to you"

Exactly a year since the ABIM first famously advertised 👇the liberation of Longitudinal Knowledge Assessment during travel, I got an email while overseas that they'd informed my hospital credentialing department that I am no longer in compliance with Maintenance Of Certification 4.75 MOC credits (out of the requisite, previously earned 100) simply vanished (much like any hope of work/life balance on this trip, I suppose)

Yesterday my healthcare institution's media department fielded several requests from news organizations wanting to talk to an oncologist about Princess Catherine's cancer diagnosis & treatment

When speaking carefully to reporters I realized:

WORDS MATTER IN ONCOLOGY

/thread A TUMOR BY ANY OTHER NAME

Many patients with cancer have to navigate a linguistic minefield with each new scan

Even in the era where the text of radiology reports may be immediately available to read, synonyms abound to the point of confusion: mass, lesion, neoplasm, tumor ...

I'm being bombarded by questions (quite understandably) about why any patient would undergo chemotherapy if a surgery had successfully removed their cancer

I struggled to come to the same understanding when I was first being trained as an oncologist

A THREAD Not all chemotherapy is given because we can discern a tumorous mass, whether palpably on physical exam or, less superficially, visually on scans of the inside of the body

Even after an operation where a surgeon may say/think "we got it all!" microscopic residue can remain

My father died thirty years ago today

He was 49, I was 14

Most charitably it can be chalked up to my immaturity at the time of his death but it’s taken the full three decades since then for me to realize that I am not “getting over it”

I am never getting over it The knottiest problem of grief arises when any recollection of the deceased becomes inextricably intertwined with re-opening the wound of their loss; the strands become too tangled for selective recall to unbraid painlessly

WHY I (ALMOST) NEVER BOLUS 5-FLUOROURACIL

I've been pondering this thread for a while but it's become more urgent in light of another looming chemo shortage <deep sigh>, this time with an imminent dearth of THE foundational drug of GI oncology: 5-fluorouracil, or 5-FU An attending of mine from fellowship said "every patient with GI cancer deserves to receive FOLFOX" and, while that may have been a statement of its time (I trained 2009-2012, pre-KEYNOTE 177!) it still has the ring of truth today

MISADVENTURES IN AMERICAN HEALTHCARE

1. Doctor orders scan that's clearly indicated for patient & which they've had many times before (allowing for apples-to-apples comparison)

2. Despite order weeks in advance, receive denial day-before from insurer without any explanation 3. Call phone # given to appeal; get routed to a website "provider portal" with dead-end links

4. Call back to phone # & wait until human being answers

5. Human being faxes claim # to doctor's office (in 2022 AD)

6. Fax retrieved, call back with claim # & re-enter phone tree

You've been replicating DNA your entire life

But did you know that every strand is made up of 4 letters?

Here are the 4 nucleobases that you MUST know: Adenosine -- also found in the powerhouse of ATP, adenosine gets an A for energy

But be careful: too much in your veins can be heart-stopping ... literally!

TROLLEYS & ONCOLOGY

Every Ethics 101 student wrestles with the trolley problem.

In this exercise, you are placed by train tracks watching a runaway trolley race towards 5 people who are going to be crushed unless you intercede.

THREAD/ If you pull a lever, the trolley will divert on a different track, where it is bound to kill one person.

In this situation, is it better to be passive or active?

Should you pull the lever or not?

2/

Years ago I enrolled a young man on a clinical trial as his last therapeutic hope. He was not saved.

But before he died he asked me to convey the results of the research to his family posthumously.

This week, that study matured & showed a significant survival improvement.

1/ Making good on my promise, I let his widow know.

I wasn't quite sure what tone to take. Certainly it was bittersweet to share a net positive result with her when her husband had not been helped. In fact it seemed almost cruel to tell her.

2/

Got sent this meme and oh boy do I have some thoughts as an oncologist

THREAD/ First of all, please don't minimize the experience of patients with cancer

It is, frankly, offensive to equate the toxicity of chemo with the side effect profile of the vaccine

Despite my best efforts to maximize tolerance, my patients can get very ill from their treatments

In no particular order, 5 abstracts that caught my eye as a GI oncologist preparing for #ASCO21

KEYNOTE-177:
meetinglibrary.asco.org/record/195775/…

#crcsm

1/ NETTER-1: meetinglibrary.asco.org/record/197214/…

cc: @NANETS1 @CureNETs @CarcinoidNETs @ncukcharity @netcancerfound @RonnyAllan1 @Globeseek @PamelaKunzMD

2/

If cancer eventually kills me I don’t want my tombstone to say “FIGHTER”

I want it to state my most obvious characteristic: “RIDICULOUSLY GOOD-LOOKING”

Seriously, this disease already does a lot that robs us of control

But you can decide how best to frame it & define yourself For instance, I’m a fan of silly GIFs:

I have a confession to make.

I've been Tweeting angry.

It's not good social media practice, in general, and it can seem unbecoming of a physician speaking in a public forum.

But allow me to explain

THREAD/ I am angry because I took an oath to protect my patients and everyday I see them needlessly endangered.

It has never been hard to keep them healthy (says the doctor who is routinely -- understandably?! -- accused of being a poisoner).

A RARE DISEASE NARRATIVE TWEETORIAL

Today, during an #ASCO20 clinical science symposium, I'm honored to comment as a patient-physician on the meaning of drug development for rare diseases

Inspired by @DavidFajgenbaum (but not half the man he is) I am going to share my own story It started with a call from the embassy.

We were moving to the U.S. and needed chest X-rays to exclude TB.

My father's CXR showed no concerning cavitation, but his right hemithorax was mysteriously opacified 👇

So as has been widely reported, personal protective equipment (PPE) is running low for medical personnel during #coronavirus #Covid_19

Today my awesome pediatrician wife & my mother-in-law used at-home materials to sew masks

STEP-BY-STEP TWEETORIAL

1/ They used 100% cotton fabric and cut one 9”x8” rectangle and one 9”x7” rectangle, as well as cutting a pipe cleaner to 6”

2/

SERIOUS THREAD FROM A DOCTOR

It may be self-evident but if you get such respiratory distress from #COVIDー19 that you are placed on a ventilator, you will be unable to speak.

I know it’s hard but, as you gather with family, tell them what you would want done in that event.

1/ Designate a surrogate decision-maker (healthcare proxy).

Better yet, document your wishes through an advance directive.

@AARP has a very helpful website where you can find appropriate forms by state:
aarp.org/caregiving/fin…

2/

I'm an oncologist and a patient with cancer.

Surely now is the time in America to uncouple employment and healthcare coverage.

In fact, it's long overdue ...

THREAD
1/ For years now, cancer patients have faced double jeopardy: their malignancies have endangered their ability to carry out their pre-morbid jobs, and when they lose those benefits, their treatments become financially toxic, often to the point of bankruptcy.

2/

Walk with me, won't you, through a thought experiment THREAD

I awake to find a tiger in my house
1/ Perhaps later, at a less alarming moment, I might concern myself with where the tiger came from. But for now I am most preoccupied with the tiger that is -- let's not forget -- NOW IN MY HOUSE.

I would not care if it were, for instance, a Bengali tiger vs. a Siberian tiger.
2/

THREAD
1/
Eponyms are falling out of favor in medicine. They aren't descriptive and essentially require twice the memory space to recall both the name & the associated term.

But pancreaticoduodenectomy doesn't exactly roll off the tongue so I suspect the Whipple is here to stay. 2/
Dr. Allen Whipple was a pioneering surgeon whose contributions to the field also include a still-relevant understanding of insulinomas (see also: Whipple's triad).

Still his incisive approach to the pancreas, small intestine, and bile ducts remains why he is best-remembered

Landed in Chicago.

Opened email to find yet ANOTHER rejection.

Went to @artinstitutechi to cheer myself up before evening meetings at #asco19.

My manuscript is no masterpiece. But I started thinking: what if our greatest artists had faced the fearsome Reviewer #2?

THREAD/ "If I wanted swirls, I'd order gelato.
Thank u, next"