The Day I Knew I Wanted to Be a Head and Neck Surgeon

Twenty years from now you will be more disappointed by the things you didn’t do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails.

- Mark Twain

Head and Neck cancer surgeons know when “The Questions” are coming. A casual conversation eventually turns to “What do you do for a career?” The pleasant exchange is replaced with talk of disfigurement and life-threatening illness. The person’s brow furrows. “How can you deal with that day after day? Isn’t it depressing? Why didn’t you pick something happier for a career?”

These are legitimate questions. As a medical student many years ago, I enjoyed every rotation and wondered how I would ever narrow down my choices and pick a specialty. Eventually, I decided that I was most content in the operating room. Even when I knew I would become a surgeon, there were still dozens of trajectories which my career might have taken.

One day in 1980, as a 25-year-old senior medical student, I was in a departmental conference, listening to a visiting out-of-town cancer surgeon. He ran through his slide show, describing a procedure he had devised to restore voice for patients who had undergone removal of their voice boxes. It was a complex operation that involved the creation of tubes of lining tissues that shunted air from the trachea to the back of the throat that could then exit through the mouth, thus allowing the person to speak.

It was interesting, but at my level of training, I was confused by approach and the diagrams. I was years away from doing any type of surgery on my own. At some point during his talk, I probably checked my watch, wondering when the conference would be over.

Then, the visiting surgeon flipped the controls and adjusted the volume on a 16-mm movie projector. The light flickered as the film moved past the bulb. There, on the screen, was a man who had undergone a total removal of his voice box. The surgeon asked him a question, and the patient responded by holding a vibrating device against his neck to create an artificial, machine-like sound that he shaped into words. He was understandable, but his voice sounded synthetic.

The next scene showed the same patient after he had undergone the voice-restoring procedure. This time, he answered questions by bringing his hand up to his neck and covering his stoma to redirect air from his lungs through the shunt and into his throat. He was able to talk! The sound was natural and fluent.

I was enthralled by his ability to speak and by his big smile at the end of the movie. Once the presentation was complete, the senior surgeons asked technical questions about the operation and whether it might cause more problems than it solved. I, on the other hand, was amazed. All I could think was, “I want to do something like that!”

Although the procedure described by the visiting surgeon never caught on (there are much simpler techniques today), that movie steered me toward a career devoted to patients with head and neck cancer. I can trace the rest of my life to that day. A few weeks later, I was humbled when a cancer patient’s family included me in their circle while making difficult end-of-life decisions. That sealed it.

I have loved my work even on the many days I when I have found it overwhelming. When someone asks me my story, I tell them about that lecture. I describe the movie and the man’s huge grin. Over the decades, I have been privileged to see similar grins on my own patients. It has, indeed, all been worthwhile.

#cancer #career

Horseshoes

Those who suffer illness learn by hearing themselves tell their stories, absorbing others’ reactions, and experiencing their stories being shared.

- Arthur Frank, The Wounded Storyteller

We stand together at the clinic room door, preparing to enter. “Tongue cancer. This is an 78-year-old man with an oral cavity mass and some memory loss. He had an ulcer on the side of his tongue for a few weeks which was biopsied by an outside doctor. No imaging yet. The lesion is tender. His wife died several years ago. He’s in there with his daughters.”

I nod at the resident. He is solid and introspective. I look at Tanya, the medical student, who is standing in our little circle of white coats. “Any other details I should know about him?” I ask.

“Not really,” she responds. “He’s very quiet and lets his daughters answer for him. He is aware of his memory problems and knows that he needs surgery. He’s pretty healthy.”

“Okay,” I say. I knock and open the door. My new patient sits in the exam chair. His two daughters smile when I walk in; one has a notepad in her lap. We all shake hands.

“I’m Doctor Campbell. You’ve already met Dr. Richardson and our student, Tanya, right?”

“Yes,” they acknowledge.

The resident and the student are attentive. The resident sits at the computer, ready to work on the Epic note that will tell the billing system what we have accomplished. Tanya stands near the daughters. Everyone leans in.

As I often do, I open with, “Let’s jump to the end. So, from what Dr. Richardson has told me, you have a very early cancer. Stage I – the earliest we see. You will need surgery, but you have an excellent chance of being completely cured of this with surgery alone. Depending on what the pathologist tells us, you probably will not need radiation or chemotherapy.”

The patient smiles weakly and looks at his girls, possibly seeking reassurance. "That's good news, Dad!" His daughters are clearly happy to hear this.

This is where I usually review the medical history and then wash my hands to begin the examination. However, I want to know a bit more about what he has heard and processed. In addition, I have two trainees in the room who might benefit from seeing how personal stories can interweave with illness.

I sit before him. “Where did you grow up? What did you do before retirement?” I ask him.

He tells me that he grew up a few blocks from where he lives now. He never moved away. “I worked in a factory in my home town. Before I retired, I worked in sales for a while." I note that he tells the story without enthusiasm. His daughters confirm his story. Well, I think, his long-term memory is intact. 

"Here's another question," I say. “What kinds of things did you do for fun?” 

At this, he lights up. “I loved horseshoes!” he says as the girls nod. "You know horseshoes? I had 18 ringers in a row one time! Can you imagine that? 13 another! You have to know how to throw the shoe!” He partially stands, bracing himself on the chair and letting his right arm swing free. With a gnarled hand, he demonstrates his technique in slow motion. “You grip the top of the shoe like this…” he pretends to be holding a horseshoe… “and bring your arm up like this. Here's the twist so that the shoe leaves your hand flat. It makes one rotation in the air before it reaches the stake. Then, plonk! It drops down and you score! Then you do it over-and-over.”

“Are you still competing?” I ask.

“Nah," he responds. "Not for a few years.” The room goes silent.

“Dad, tell him about being in the state tournament.”

"Oh, yeah!" He lights up again as he describes some of his adventures. The worrisomely quiet man has become irrepressible. The key to him was horseshoes.

We go on to schedule his surgery. A discussion that might have been anxiety-provoking is easy and collaborative. The daughters ask excellent questions and the patient listens. He asks how soon we can operate. Soon, we are shaking hands again and they are on their way.

“What did you learn?” I ask Tanya. 

“That was really interesting,” she says. “Now I know more about managing tongue cancer.”

“But,” I ask, “do you know more about horseshoes?”

She laughs. “I sure do,” she says. “That was amazing. He really seemed to enjoy talking about his story.”

And so he did. By drawing out his narrative and putting his cancer in the larger context of his life, his passion had driven the conversation. It took only a couple of questions for him to go from hesitant to animated; from being a man with a memory problem to being a former state-level athlete; from being identified as a tongue cancer to being a person with tongue cancer.

The approach satisfied me, lifting me for the rest of the day. I felt renewed.

#cancer #aging