Making Tough Decisions A Candid Discussion Between Oncs

Drs Mark Lewis and Don Dizon discuss what keeps them up at night.
www.medscape.c...
-- TRANSCRIPT --
Mark A. Lewis, MD: Hello. I'm Dr Mark Lewis, director of gastrointestinal oncology at Intermountain Healthcare in Utah. Joining me today is Dr Don Dizon, head of community outreach and engagement at the Legorreta Cancer Center, and director of medical oncology at Rhode Island Hospital. We are speaking at the 2024 ASCO Annual Meeting in Chicago, and we'd like to address an important question many doctors are familiar with: What keeps you up at night?
Don, I know you and I are both addicted to social media. We're not talking about our smartphones and the light they emit right in front of our faces as we're trying to have our head hit the pillow, but on a deeper, more philosophical level. I think our field carries a large amount of emotional weight. Open-ended question, but what is it, off the top of your head, that keeps you up at night?
Don S. Dizon, MD: It's poignant, and I think it's a very common scenario that I've run into recently that illustrates what we as oncologists have to grapple with. Oftentimes, the question we all have is, is it better to do nothing or do we need to do something?
Lewis: Yes.
Dizon: It can play out with the 92-year-old grandmother presenting with a treatable cancer who's just incredibly sick. The question is, do you go by what the literature is telling you, which is someone who may be nearing the end of her life through natural causes? Do you just let her go? Or do you intervene with something that's treatable but not likely to kill her either?
Lewis: Right.
Dizon: Or it could be the young mom who is terminal at diagnosis, and you know in your heart that nothing you do is going to help her. To admit that to a family, and even to her, is often very painful. I don't think we, as oncologists, give ourselves a space to acknowledge that, so we make emotive decisions.
Lewis: Yes.
Dizon: It's the adage of, you're damned if you do and you're damned if you don't, so you might as well try to do something. I am often reminded of where the literature is about treatment being a double-edged sword.
Lewis: I don't know about you, but I had formal ethics education in medical school. One of the exercises they put us through was the trolley problem, which goes far beyond medicine. We are standing by the track with a lever in our hand, and if we do nothing, we know that the disease is going to kill our patient. If we intervene, it's almost like we're violating the first rule of medical ethics, which is, first, do no harm.
When we pull that lever of chemotherapy, you and I both know all too well that we can inflict toxicity, and on some level, that just feels wrong. As a physician, and certainly as an oncologist, we come up against that all the time.
I'll tell you what keeps me up: I hate to overpromise and underdeliver. There are a couple different levels. First, you and I are here at ASCO, so I'm going to leave this meeting, I think, filled with novel findings I can tell my patients about.
My first concern is, can I actually execute? Can I actually give them these new treatments we're hearing about? We still have problems with drug shortages of backbone agents. I'm sure in your field, especially, to not have access to something like cisplatin is just mind-boggling. Can I really, in good conscience, tell them, hey, there's this new treatment and I can give it to you. That's one area.
There's also the haziness of informed consent. As part of respecting autonomy, we're supposed to sit down and tell people the risks and benefits. I don't know about you, but when I start thinking about the list of everything that can go wrong, it's like commercials for drugs where there's that kind of breathless audio underneath and it tells you all the adverse events.
Transcript in its entirety can be found by clicking here:
www.medscape.c...