PATIENT ADVOCATE

Unfortunately, bad things often happen to good people. Our first reaction is to state the unfairness of these situations. However, the universe has no room for fairness or unfairness. Things happen - and not necessarily for a good reason.

I was reminded of this with a recent patient, whom I met in clinic. He had recently been diagnosed with an aggressive form of prostate cancer. and wanted to transfer his care to us 

I could not point to anything he had done to increase his risk for this cancer. It was caused by mutations that occurred by chance. He had lost the genetic lottery, but I did not feel that explaining this to him would provide much in the way of comfort. Rather, I tried to focus on what we might do to help him. I explained the odds were long and that he had already had a "Hail Mary" with his first treatment that took place when he was quite ill in the hospital. I was concerned about what more we could do to effectively shrink the cancer. Despite that, I explained that we wanted to be aggressive about reducing the symptoms the cancer was causing. With that, I admitted him to the hospital for further work-up and symptom management.

He and his family seemed relieved to be going back in, but I could also sense that they felt overwhelmed. I cannot imagine what it is like to be in there position. The only experience from my own life that comes close is when my mom was admitted after a surgical procedure. Fortunately, one of my med school friends knew her doctor and put us in touch. Over the course of that weekend, her doctor kept me updated and even listened to my many suggestions. I felt empowered knowing that I was playing a productive role in helping my mom get better. 

I now appreciate that families who come off as "demanding" or "difficult" are just trying to advocate for their loved ones. Let that be a reminder that we should all be so lucky to have an advocate like that. 

DEAR FELIX

Dear Felix,

Last weekend I made the short but eventful trip to San Francisco to say goodbye to you and to pay my respects to you, my dear friend Felix Feng, who was taken from this earth far too soon at the age of 48.

I first met you nearly ten years ago when we began collaborating on a team science project called the West Coast Prostate Cancer Dream Team. You were a new member to the team, having recently relocated from the University of Michigan, Almost immediately, you left your mark on the Team and helped turn it around by refocusing our projects and dreaming very big.

Countless ground-breaking papers followed, several of which you gave me the opportunity to lead. You appreciated that deep down most of us just want the opportunity to fulfill our potential. This seems basic, but far too often in life we are never given a chance to prove what we can do.

You were a guiding light for so many of us. I consider myself so lucky to call you a friend and to have had your wisdom and insights touch so much of what I have attempted to accomplish in the past decade. 

I did not make a major life decision without consulting you, Felix, during the past 10 years, and I consider you to be a member of my family. You are truly one in a million.

There are many luminaries in the prostate cancer field. Most of their contributions come from discoveries made in their own labs. You, on the other hand, developed so many careers around the globe, including those whose success did not directly benefit you. Felix, you are the epitome of a team scientist and made our field more collaborative and kinder. 

You will always be in my heart, Felix. The same goes for your family, and I know I speak for all of us when I say we will always be there for you Mary, Eric, and Emily. 

We promise to continue to build the community you helped to create and remain focused on solving the most pressing problems patients with cancer face. Thank you for always leading the way, Felix. I love you and will miss you.

Love, 

Joshi

GRATITUDE

Being grateful is an acquired taste for many people. That is because so much of our world and our lives does not conform to our notions of how we wish things were. However, sometimes gratitude sneaks up on you and shakes you awake, recalibrating your expectations and resetting your world view. That was the gift the family of one of my patients gave to me this week.

I first met Dr. P two years ago when he was diagnosed with metastatic prostate cancer. He was weak and felt ill most likely due to the renal failure his obstructive cancer was causing. We started treatment, admitted him to the hospital, and stabilized his kidney function. We were able to improve his symptoms for a few months, but then the cancer began to grow. Despite multiple additional therapies- new hormonal pills, immunotherapy, chemotherapy, injectable radiation, his cancer marched on. I had discussed experimental therapies, but he declined these because of the time commitment that was involved. It was not that he was worried about the inconvenience of additional study-related visits. He was concerned because he was the primary caregiver for his wife, who had had a stroke several years back. He was unwilling to sign up for anything that might interfere with his ability to get home to her every weekend by 3 PM, so he might relieve her in-home nurse.

A few weeks back, I met with him in clinic with his brother, sister-in-law, and son. I explained that we did not have any safe options left and that I recommended hospice. Dr. P said he understood and thanked me for all my efforts. As I stood to leave, I gave him a hug and did not hold back my emotions or my tears. 

Indeed, hardly felt I had done much for him, especially since most of the treatments I had recommended had not worked at all to slow down his disease.

A few weeks later, his sister-in-law emailed me letting me know there would be a visitation and funeral the next day. She said, "I thought you would want to know." 

I cleared some time in the morning and headed over to the visitation. There, I met his two sons again and other family members. I told this sons how proud he was of them and how he always talked about them. I thanked his brother and sister-in-law for being there for him on hospice. They, in turn, thanked me for what I had done. When I lamented that I was not able to do as much as I would have liked, his daughter-in-law interjected, "Dr. P had one goal - outlive his wife so he could remain his caregiver. You helped him achieve that!"

I am not sure I have ever been given a greater gift from a patient's family than the knowledge of what his goals were and how I helped to make that goal a reality. It reminded me of the importance of asking patient's what they hope to achieve and to not overestimate what they expect when faced with a terrible diagnosis. It was also a reminder of all the things to be grateful for in my life - my family, my health, my work.

I left the church that day in a new frame of mind - a more grateful frame of mind. I pray that the lesson I learned there persists. What a life.

THE ROAD TO TAKE

Robert Frost famously wrote that taking the road less travelled made all the difference, but sometimes it is difficult to decide between two paths that each appear untrodden in their own unique ways. This dilemma is personified by the college decision before Nicholas. Fortunately, he has two wonderful options: the University of Michigan, one of the best universities in the country, and Syracuse University, whose Newhouse School of Communication is one of the best journalism programs in the country.

I would like to think I always have my children's best interests in mind, but - like other parents - I have my own biases. The desire to hold on to one's child for just a little while longer can be strong, and this sentiment can sometimes color one's advice. However, ever since Nicholas received both acceptances, I have tried to be as neutral as possible. 

In making, his decision, I have asked him to think about how far away from home he feels comfortable moving, where he would like to spend the next four years, and what he is looking for out of college. It is clear that he will be able to pursue a career in journalism after going to either place. The path towards that career at Syracuse might be more straightforward than Michigan, which does not have a journalism program. However, a Master's in journalism after Michigan is a very viable option. 

Personally, Syracuse would be the road less travelled. Professionally, Michigan would be the road less traveled for a journalism career. These dualities and complexities are inherent in life, and often there is not one right choice. That is what makes life special. In many ways, it is reassuring that no matter what he decides, there will be a path forward. 

The dilemma of choice often comes up when I talk with my patients about navigating different treatment decisions. They often ask me what I would do or what I would tell my father to do. I tell them I am not sure because my dad is his own man, and I am not a cancer patient. However, the best advice, I believe, I give them is to ask themselves how they wish to spend the next few months or years  - on treatment or off - and what choice would they regret more if it did not work out. Considering these two variables can often be clarifying, and I hope my patients sleep better with their decisions.

My patients often provide me with life advice, too, and remind me that we are never alone. I still recall the words of one of my patients from Portland - Dr. K. - whom I visited at his home after he enrolled on hospice. When I expressed trepidation about my upcoming move to Ann Arbor, he sought to allay my fears, saying, "Change is hard, but you and your family will get each other through this." Such simple words, but they have been so true and so comforting these past four years. I want Nicholas to know that whatever he decides, we will all help each other navigate this next phase.

I hope Nicholas finds clarity and peace with his decision. Roads are rarely one way. Going far from home may be the right decision. If it does not work, we may not be able to catch him before he falls. However, if that were to happen, we will be there to help him get back up again. 

Despite how competitive careers in journalism or broadcasting are, there are several reasons I do not envision Nicholas falling or failing, whichever college path he chooses. He is comfortable in his own skin and laser-focused on his schoolwork and on telling important stories. He is empathetic, curious, and experienced as a journalist and broadcaster, having written for his school paper the past two years and having started a media organization, Gryphon Sports Live, at his school. These are massive accomplishments, and he is an exceptional young man!

Parents try to provide their children with all kinds of opportunities. Perhaps, by disrupting his young life with our move four years ago, the best "gift" I have given Nicholas is the belief that he is capable, strong, and ready to navigate and thrive in unfamiliar territory. Now, it is ultimately his decision to pick which untravelled path feels best. I know he'll make the right decision, and I look forward to watching him continue to develop into an amazing young man - from nearby or from afar. I love you and am so proud of you, son!

SOMETIMES, WICHAS COME TRUE

Last Friday, we came together to celebrate the installation of the Wicha Family Professorship in Oncology, and I was honored to be named the inaugural holder of this Chair. It was a beautiful night - one of the best of my life. I am so glad I was able to share it with so many friends and family in person and online, including dear friends from medical school and residency who flew in for the ceremony.  

You can watch the recording here.

Foundational to this award was all the ways my families - from birth, to marriage, to medical training, and my faculty career - have helped to shape the story of my life thus far. I will not recapitulate my full remarks here, but suffice it to say that I came away from that evening even more grateful and humble.

I was reminded that night that I have lived a full and happy life because of so many people who cared for me, inspired me, and believed in me. We are all a product of our environments, and mine have been transformational.

So any men and women - including Dr. Grover Bagby at OHSU and Dr. Max Wicha here at U-M (pictured below) - have taken me under their wings and made me who I am. What could I have possibly done to deserve such amazing mentors?

As I move forward and begin my term as the Wicha Family Professor of Oncology, I will not lose sight of what it took to make it to this honor and all the many people who made my story possible. Sometimes in life, wishes come true, but sometimes Wichas come true, too!

RUNNING FOR THEIR LIVES

Each year, the high school students of Canton and Plymouth in Southeast Michigan put on the SJ5K race to benefit a small group of families in need in their area. This year one of the beneficiaries of the fundraiser was one of my patients, Dale Palmer.

I met Dale over two years ago right before COVID. He and his wife are educators, and they asked very thoughtful questions at every visit, including the first. It has been a privilege to know him.

When the Palmers told me recently that their community was putting on the race to benefit them, I did not hesitate to sign up. For me, running has always been about more than putting one foot in front of the other. Rather, running is about clearing one's head, pushing one's self to the limit, and finding inner peace. Sometimes, one also has a chance to give back just by running a race.

The morning of the race was cool, rainy, and overcast. However, that did not deter several thousand people from cramming into the stands of the football stadium to hear from the families who were chosen as beneficiaries prior to the race. 

I am biased, but Dale's wife Norma gave the best speech describing the man Dale is and what all he had been through. I am certain that all of the students - and all of the adults for that matter - came away from those speeches with a better sense of how fragile life is and how lucky they are to be healthy and alive. I know I do.

At last, we took off running. I was in the front pack, surrounded mostly by high school students who zoomed by. Over time though, I caught many people who had been ahead of me. I finished in near record time for me, and I like to think that Dale was pushing me forward every step of the way.  

This was not my fastest 5K race, but it was the most moving race I have ever participated in. I have been honored to know Dale and Norma. They remind me what is important in life - community, family, and giving back. This will not be my last SJ5K.

TOGETHERNESS IN 2021

The last two and a half years have been the most difficult of my life professionally. A move and restarting a lab from scratch is hard enough. However, when one adds a once in a century, global pandemic entering its third year that impacts every aspect of how we practice medicine and do research, life and work become unimaginably hard.

We achieved some great things at work last year - new publications, clinical trials, grants, and awards. However, most importantly, everyone on my teams stayed safe and healthy. Moreover, somehow we found a way to expand our clinical team with a new faculty recruit and significantly expand our laboratory from three people at the beginning of the year to ten people - the largest we have ever been in my 14 years being a principal investigator.

Spending time in person with the exceptional teams I am lucky to be a member of at the Rogel Cancer Center was definitely the professional highlight of a very difficult 2021. Hoping for more togetherness in 2022! Lucky to call this place home and these people my friends!

BAD THINGS DO HAPPEN TO GOOD PEOPLE

This title is taken from a recent podcast from the Apsen Institute with the author and theology professor Kate Bowler. She was diagnosed with metastatic colon cancer in her thirties, which caused her to reflect on her own life. That thoughtful reflection was captured in her book, "Everything Happens for a Reason (And Other Lives I've Loved)." As an oncologist, parent, spouse, and parent, I found her words and personal story to be truly remarkable, and she presented a vision of life as a gift -  a vision that I constantly try to remember.

One simple thing I take from Ms. Bowler's writing and her words is that she wants us to be grateful for the things we will miss - when they go away - before they have actually gone. I wish that for all of us.

WHAT WE LOST AND WHAT WE GAINED IN 2020

2020 was an unimaginably difficult year for so many reasons. The year was shaping up to be a challenging one even before COVID because we had just moved to Ann Arbor in the summer of 2019 and were still quite unsettled. Any sense of disorientation was magnified several orders when the COVID pandemic began to rage in March, 2020.

It might be easier to list the ways in which COVID has not affected our lives, rather than the way it has. Our clinics shifted to virtual using the "Lombardy Model" based on the strategy used in Lombardy, Italy, one of the regions hit hardest early on. In Italy, they staggered the workforce in order to avoid exposing their entire medical teams at once - kind of like sending in different battalions of troops to take enemy fire at the front in shifts. Our clinic moved to that model, and for several weeks Kathleen and I had no in-person outpatient visits. 

The kids school was shut down as they made the switch to virtual or "zoom" school. Greenhills was still able to provide a decent learning experience for Nicholas. However, Cate's experience in Ann Arbor Public was definitely affected, especially since her regular teacher went out on maternity leave.

Much of our year has spent in front of screens and apart from those we love. Movies, concerts, and so much of the fun we took for granted shifted to online.

Restaurants - those that were not shuttered - shifted to carryout or delivery, and I cannot recall the last time I ate out in person.

Our democracy and institutions decayed under Trump and his collaborators in the Republican Party, and he somehow survived impeachment despite damning evidence. Fortunately, the voters' voices were heard on November 3, 2020, election day, also known as one of the happiest days of my life. Somehow, various functionaries did not cave to his demands as of this writing, and Joe Biden is set to become the 45th President in three weeks' time.

The saddest week of my family's life took place in September, 2020 when my teenage niece Jasmine ended her life. Words cannot convey the grief and pain of that week and the weeks that have followed. I came to realize that the only way through calamities such as this is through the love and empathy of others. So many people I know or my family knows were there for us in so many ways. I will never forget their kindness, and I will try to never take my family and children for granted. 

Going down to San Antonio during COVID to support Joselyn was the hardest thing I have ever done, but it is one of the things in my life that I am so glad to have done. Whatever small degree of comfort I may have provided to her and my family was far outweighed by the love I felt from them. Fortunately, I was able to see my mom, brother, and my dad - whom I had not seen in almost two years, as well.

Finally, we were plagued by power failures in 2019 in Ann Arbor. Therefore, we broke down and bought a generator for our house in 2020. However, fittingly for 2020 and the Michigan power grid, we experienced a power outage on our last night in Glen Arbor in our rental home for approximately five hours. 2020, man!

These are many of the things we lost, but we also found many things this past year. I worked on being a better husband and dad. Though, I still have a long way to go, I am encouraged that my family has stuck together and been a source of strength for each other.

Three of our federal grants were funded, and we added a new person to our lab. I made new friends at work and took on new leadership roles. 

My friend Kate introduced me to Marilynne Robinson and her Gilead series, which I have loved. My friend Pam introduced me to Mary Oliver, and I have begun to devour all of her poems. 

I think this Mary Oliver poem captures the essence of this tragedy-filled year. I can only hope that we come out of this year stronger and that we never take for granted our freedom, our health, and those we love. What else is more important in life?

ME IN 120 SECONDS

It is hard to believe that I have been a cancer researcher for 17 years now. During that time, I have worked in three medical centers and directed two laboratory teams - first in Portland and now in Ann Arbor. 

During that time, I have give innumerable presentations about our work. However, COVID has made all of our presentations virtual on formats like Zoom. While platforms like this have been invaluable for continued communication and "meetings," they do not take the place of a face to face meeting. Furthermore, staring into a screen and watching one's self can evoke a sense of self-consciousness. Simply put, I will try to minimize Zoom use when this pandemic is over!

Our cancer center recently put on a virtual retreat for basic scientists like me, and they asked us to record a two minute "elevator pitch." distilling our work down to the essential. Yes, I realize that these pitches are usually much shorter, but I used nearly every second of the allotted time for mine!

THE LONG ROAD

Today, I experienced two firsts in clinic since joining my new institution. My nurse alerted me that one of my patients had died. Later that day, I had to tell a patient and his wife that his cancer was progressing and that we had no more treatment options to slow down his cancer.

Obviously, I have dealt with these issues before, but COVID makes these experiences so much more challenging with the need to distance, the inability to talk face to face, and because it is unsafe to hug or console patients.

In such times, our words and how we deliver them become even more important. Therefore, I tried my best to listen to the concerns of these families and to express the sadness I felt at not being able to do more. 

We often congratulate ourselves for our professional victories: a new grant funded a new manuscript accepted. However, we should measure success by the quality and quantity of our patients' lives. That is why we come to work, and if we are not moving the needle on that, then everything else we do is insignificant.

As sad as today was, I will carry these feelings with me tomorrow and each day moving forward. These tragedies are a reminder of how much more we have to do. I, for one, am ready for this fight.

PROFILES IN RESILIENCE

I have thought a lot about resilience lately - what with a global pandemic, economic collapse, and schools and my lab shuttered for three months. 

Today's New York Times had a very thought-provoking essay on this topic that I highly recommend. In summary, the author contends that our childhood experiences, our close personal connections, and our sense of purpose make a great difference on how resiliently we behave. It reminded me of Viktor Frankl's wonderful book, "Man's Search for Meaning."

Frankl was an Austrian psychiatrist. All his life, he found himself asking, "What do I want from life." When he was imprisoned by the Nazis and taken to Auschwitz, he quickly realized that that being there was not really what he had asked for in life. However, he used his time in the camp to understand human survival amidst tragedy and adversity and take his life and work in a new direction. He had modified his perspective to ask, "What was life asking of me?"

I received another inspiring message from the wife of a former patient from Oregon this week. She wrote to let me know that he husband had finally passed away around Easter and that she had struggled with writing to let me know.

Ultimately, she decided to compose the message below:

Dear Joshi,

I hope this finds you and your family safe and happy in your new home and careers. I have composed this letter many times over - and still there is no easy way to tell you that --- made his transition from this life in April on Easter Sunday. Without sounding like a Hallmark card or too maudlin I want to express what your presence in this journey meant to us.

More than your guidance and kind, loving care, you infused each meeting with a sense of calm. --- came away from every appointment with that calm, feeling empowered and hopeful. At our first introduction you explained that this cancer would allow --- the time to do the things and be with the people that mattered most to him. He took that to heart. --- was able to be available to his disabled daughter during a very difficult time in her life. He also connected with several old friends --- some going back almost sixty years. They all came away with their lives enriched by each other. And we made sure that our time together was quality time. Life isn't about waiting for the storm to pass. It is about learning to dance in the rain. We danced in the rain.

Thank you does not begin to express my gratitude for who you are and in our lives. Blessings to you and all those you love.

Much love,

---

The part about the storm and dancing in the rain had me in tears. I had thought that it was my job to comfort her, and yet her words were like a salve in a deep and festering wound and a good reminder for us all to stay positive and keep going.

I called her a day after receiving her message. It was like talking to an old friend. With her permission, I shared her message with my lab team, and I also shared the beautiful words about the storm and the rain on social media. Needless to say, people were blown away.

We find a way to survive – not by ourselves – but with the help of others. Here’s to passing it on.

OLD FRIENDS

In recent weeks, I have received several letters or holiday cards in the mail from former patients from Oregon. There are no words to describe the joy that those letters have brought to me because those words reminded me just how close we had become - more like friends than doctor and patient.

There was the update from one of the few patients with metastatic prostate cancer that I may have cured. He was excited about a new grandchild and a book he was hoping to get published. There was the card from the wife of a dear patient who passed away last summer prior to my departure. She wanted to check in to see how I was doing and to say that she looked forward to supporting our research. Then, there was one of my longtime patients who is the biggest Oregon Ducks fan whom I have ever met. He called into my oncology clinic here in Michigan just to let me know that he missed me and hoped that I was doing well.

Men, women, young, old, all white. However, these are men and women with whom I have a visceral connection. We lived through some of the most intense moments of their lives and shared many memories, smiles, and hugs. I miss them just as I miss my old life.

Before we moved, I ran into a friend at Grant Park. I told him that I was sad to leave my friends in Portland. Without missing a beat, he said, "Don't look at it that way. You will always have us here in Portland. You will just have a chance to make some new friends, too!"

I hope his wish comes true and that I find an equally supportive and caring network of friends in Michigan. It takes time, so I am just taking one day at a time. In the meantime, I will be sure to continue to check in with my old friends "back home," including those families whom I came to love through work.

WHY I AM AN ONCOLOGIST

This weekend, I was deeply saddened to hear news about three individuals close to us whose lives were affected by cancer. The father-in-law of a dear, old friend had experienced a recurrence of his cancer and was now on hospice; the mother of one of Nicholas' friends had been diagnosed with a large ovarian tumor; and one of Cate's good friends had just undergone surgery to remove a brain tumor. To say that I was stunned would be an understatement, but my feelings pale in comparison to what those families are feeling tonight.

Caring for patients with cancer has been a central part of my life for the past 17 years. Therefore, it feels very strange to not have seen a patient in clinic since we moved in July. Thankfully, I am set to start clinic again in January, and I will resume patient care hungry to meet new families and to try and make a difference in their lives.

When I heard the news from our friends of their cancer stories, I felt a sense of duty to reach out and to try to help in any way I could. Being an oncologist to me means providing comfort, information, and solace while one is prescribing treatment and even more so when treatment is no longer effective or safe. This is the only way I know how to practice medicine, and it is what I wish for every cancer patient, even if they are not my own.

Just like a friend or a loved one, it is a privilege to get to know patients and to try to win their trust. Often this does not come easily because patients often feel poorly or have had bad experiences with the medical system. Our job is to right those wrongs and to help patients and families achieve small victories that allow them to forget about their cancer - at least for a little while. In short, it is our job to try to help give patients back what the cancer has taken away.

I will remember this weekend for a long time. It is a reminder that life is until further notice and that there is no greater cause than being there for the ones one loves. These are lessons that I will take to my grave, and I can only hope that the doctor who comes to be my caretaker learns that lesson along the way.

COMING HOME

Last week, I did something I have never done before as an oncologist. I made a home visit to see one of my patients - a dear patient who had recently enrolled on hospice.

The reason for my visit was not to tend to his symptoms or to make medication adjustments. Rather, I visited him and his wife so they could say goodbye and thank you.

Dr. X and his wife had both been physicians in the Portland community until they retired in the past decade. Around that time, he was diagnosed with prostate cancer. Unfortunately, despite early surgery, his cancer returned and eventually became metastatic. That is when I met them roughly four years ago. We tried everything imaginable to control his cancer and keep him alive. Some treatments worked better than others, and some treatments were also more toxic than others unfortunately. Through it all, he was resolute and never complained.

At our last visit three weeks ago, I gave him the bad news that the cancer was progressing and that there was nothing more I could do to try to slow it down. I did let him know that we would continue to be aggressive about reducing his symptoms, and that is when we decided to start hospice.

That visit was even more sad because I also had to let him know that I would be moving to accept another position at a different institution out of state. He and his wife expressed understanding, but I could tell that they were concerned about how his care would be managed after I left. I re-assured them that I would still be here for two more months without letting them know that that is all the time I thought he might have left. We hugged at the end of that visit and said a brief goodbye.

Since that time, Dr. X became weaker, and his wife feared he did not have long to live. They had hoped to see me at a previously scheduled appointment three weeks later, but it seemed unlikely that he would have the strength to come. His wife said that they just wanted one more opportunity to see me.

Cate's futsal practice on Friday nights is not too far from where they live, so I told my nurse to let them know I would stop by while she was at practice. As I drove up to their house, I was struck by how beautiful their street and yard was. Inside, I was greeted by both doctors and their grown son who was slightly younger than me. Grandkids also peaked out from behind corners and ran away when I caught their glance.

We visited for almost an hour and a half, and I learned more about their own life stories and how they came to the US from India and settled in Portland. They talked about how difficult it had been to make their way in this state when it was even less diverse and much less welcoming to people who looked like us. They gave me this beautiful plate and a card.

The card was brief, but it ended with words of encouragement, "Change is hard, but your family will support each other and get through this transition."

That night, I had come to help them with their transition to death and to offer my support. However, it was they - who were now facing the biggest transition of their lives - who had sought to comfort me one last time through their own stories of overcoming challenges.

Not a clinic goes by when my breath is not taken away by the grace, dignity, and kindness of the men and families for whom I have the privilege to care. Dr. X and this home visit were a clear reminder that anything I give to my patients is far outweighed by the lessons I have learned from them and the kindness they have shown me.

If home is where the heart is, heart is what I found on that home visit.

GRATEFUL

Today, I was scheduled to see one of my dearest patients who was nearing the end of his life. However, today he suffered a fall at home and was taken to an outside emergency room. A scan revealed a subdural hematoma - bleeding between the skull and the dura, or lining around the brain. Fortunately, Mr. H was stable in the hospital, and neurosurgical intervention was not required.

I called his wife during his scheduled appointment time, and she said they were hoping to get answers to a few questions about the end of his life by. Since the outside hospital was near my home, I told her I would just stop by to see them in their hospital room. 

There were many things I could have been doing this Friday evening, but nothing seemed more important than meeting with this family tonight. I met with them and their son and answered all their questions. I gave them all hugs as I left for the evening. 

As I was leaving, his wife thanked me for everything I had done for them. With tears in my eyes, I thanked her everything they had given me. What I could not enunciate in that moment was what exactly I was grateful for. A few hours later, the reasons seem much more clear.

Mr. H and his wife were in their early seventies, but I could tell from our conversations that they supported progressive causes, had a strong sense of justice, and that they were interested in trying to make the world a better place. No doubt this was shaped by their life experiences and the way they were raised. There was an affinity and an understanding between us that I have found to be extremely uncommon in my own life with the average person.

One might have guessed that Mr. H reminded me of my own father. However, what really drew me to Mr. H and his wife was that they made me think about myself - the person whom I hope to grow up to be and the marriage I hope to say I had at the end of my life. Needless to say, I have a long way to go to come close to approaching them.

They say it is better to give than receive, but even a lifetime of caring for extraordinary men and women like this family will never repay the debt that I owe these wonderful families for what they teach me every week. Tonight, I was reminded of that debt and how I am obligated to pay forward the kindness and example of patients like Mr. H and his wife with my own patients and my friends and family. That is the least I can do for those who have given me so much. What a life.

THE SYMPATHIZER

In recent years, the Vietnamese-American writer Viet Thanh-Nguyen has written several wonderful books about his experiences in Vietnam and coming to America during the war, including The Sympathizer and The Refugees. The former is about a Vietnamese General who is caught between two worlds, and I could not help thinking about this book when I meet Mr. D, who was a former Vietnamese General, himself.

The General was in his mid-60s and had been living in America with his son for several years when he was first diagnosed with prostate cancer about 5 years ago. Despite surgery, his cancer had returned, and he was referred to my care. He spoke very little English, and so we always arranged for a translator at his visits. However, at the end of each visit, the General always said, "You are MY doctor. Thank you, MY doctor." It was his way of showing me his gratitude and the respect that he thought I deserved.

Unfortunately, Mr. D's cancer was quite resistant to treatment, and it morphed into an even more aggressive form called neuroendocrine prostate cancer. Despite our best efforts to slow the cancer down with chemo, it continued to grow and left him weak and in pain.

Because of his deterioration, I asked him to bring his son, who worked as a mechanic and who had not attended previous appointments, the next time he came in. It was at this visit, that I gave them both the bad news that his cancer was no longer treatable and that I thought we should focus on maximizing his comfort and quality of life at home with hospice.

The General was obviously upset about this, but not for the reasons you might have suspected. He said he had lived a long life for which he was thankful, but he also recounted many of the hardships from that life including a gun shot wound during the war and seeing his country come apart. He fanned his arms to describe how we are all connected and said he had one final wish - to go home again to Vietnam.

I sympathized with him and his son and explained that I was concerned about his ability to make it home to Vietnam safely. He was insistent, however, and I said I would do anything I could to help him. For his pain, we called in strong narcotics, and we arranged for equipment at home.

The day of his trip, I received an urgent page from my nurse. The General had arrived at the airport, and his weak and cachectic appearance had startled the airline staff at the check-in desk. They were concerned that the General might not make it to Vietnam without experiencing a medical emergency - a concern I, too, shared. However, I knew that getting home was the General's final wish - a wish I knew I had to do everything in my power to help grant.

My nurse Pam helped to draft a letter to the airline, to which I affixed my signature. Pam somehow got the letter into the right hands at the airport, and the General was permitted to fly home.

Last week, Pam reached out the General's son to see how he was doing. His son said that they had made it to Vietnam two months ago without needing to divert the plane. Upon landing in Vietnam, the General was taken directly to the hospital to treat his uncontrolled pain. He died there in the hospital a few days later.

There are many definitions of home. Certainly, a sterile hospital bed does not generally meet that definition. However, the General was no usual man. It was home that we were able to get him and where he took his last breath.

THE NEXT BIG CHALLENGE IN YOUR LIFE

I have become quite the fan of podcasts in the past year. My favorite episode - one that I keep coming back to - is a talk by David Brooks on the Aspen Ideas Podcast called, "The Second Mountain: The Next Big Challenge in Your Life."

You can watch the entire episode here:

In the podcast, Brooks first talks about the first mountain - a very self-centered and personal ascent to gain notoriety or expertise in one's field of study or job. That is a natural ascent for nearly all of us who are lucky enough to work in a field that allows for growth and skill acquisition. However, after climbing that mountain over several years, one's perspective changes. What seemed so important - personal success, fame, power - lose their luster. It is at this time, when one is in "the valley" phase after descending from one's first mountain, that true reflection can happen.

I have spent the past 11 years trying to become a successful prostate cancer researcher and oncologist. There are many who are more accomplished than me, but I have been very fortunate to successfully obtain grants, publish manuscripts, and gain some degree of respect by my peers. While I am grateful for all those things, I often ask myself what would truly make me feel fulfilled? What mountain do I want to climb next?

There is probably not one right mountain, but what I keep coming back to is that fulfillment lies in making that ascent with the right climbing party. What does that look like? It would be a group of people who put excellence first and ego second. People who want to scale the greatest heights that others view as unascendable. People who view the journey as being as important as the destination.

I often think of soccer when I think of this second mountain, and Barca is paradigmatic. The best players come to that club not to finish their careers but to really let their careers begin. For it is by playing with the best in one of the most storied clubs that one can truly take off. I think of youth players like Messi, Iniesta, or Xavi, but also players like Rakitic, Neymar, and Suarez who learned to play at the highest level imaginable. I suspect for them, the privilege of playing at Barca with such a tremendous collection of individuals has been a reward in itself. I, too, dream of this sort of transcendence when the entire team is pushing in the same direction, where each person has a part to play, and where great victories are almost a given. That is my second mountain - to continue to grow and improve while also improving those around me.

Now, I just need the courage to take that first step.

ENDOWED

There are many surprises in life that are quite unpleasant. Because of this, I was thrilled to recently learn that my university had awarded me an endowed chair for prostate cancer research! 

I had always known that receiving a chair was among the highest honors a university can bestow on a faculty member, but I never imagined I would be the recipient of such an honor. Creating such an honor requires a donation of several million dollars to create an endowment, or research fund that is invested. In times of good stock markets and wise investing, the endowment generates interest that the recipient may use for any research purpose: salary, research supplies, etc. This unrestricted fund enables one to have breathing room and to take risks with these dollars that come with none of the strings normally attached to grant awards.

To say that I breathed a sigh of relief upon learning of this award from the Kuni Foundation and Kuni family would be an understatement. Running a lab is like running a small business, and it is no small feat to balance one's books and keep the lights on- especially when one is also trying to juggle patient care and administrative responsibilities. 

That there were so many other deserving individuals at my institution, that the Kuni family-whom I have known for years- believed in me, and that our cancer institute director Brian Druker chose me for this honor is truly humbling. 

Upon receiving the award, I promised that I would work hard to be worthy and that I would dedicate myself everyday to trying to improve the lives of men and their families who are affected by prostate cancer. I cannot think of a higher calling, and this award will remind me daily that to whom much is given, much is expected.

Onward!

WHEN BREATH BECOMES AIR

Every once in a while a book comes along that inspires you and moves you in a way that you forgot was possible. The memoir When Breath Becomes Air written by the late neurosurgeon Dr. Paul Kalanithi is one of those books.

What made the book so compelling was the juxtaposition of this young surgeon-scientist's promising future and the utter unfairness and cruelty of his diagnosis of metastatic, terminal lung cancer at the age of 36. Despite his medical training, there was no preparation for such a fate. However, how the author responded to such a grave situation serves as a wake-up call to us all. Life is until further notice, and despite-or rather because of-life's ephemeral quality, we must immerse ourselves in what gives our life meaning. For the author, it was continuing his training as a surgeon and becoming a father despite his terminal diagnosis.

He chose both these routes not because they were easy. Rather, he chose these routes because they were hard and because life-in his opinion-was not about avoiding painful situations. Instead, painful experiences teach us about what really matters in life.

As a youngish, Indian-American physician-scientist and part-time writer, I was moved by Paul's words and by the intimate self-portrait he painted in When Breath Becomes Air. I could not stop thinking about my own children while reading it, and the heartbreak Paul must have felt when he had to say goodbye to his infant daughter Cady. Paul's death-like many of my patients' deaths-reminds me that what matters in life is the legacy we leave behind through our deeds and actions. None of us knows when his or her last day will be, which means that we are all still works in progress. We can start each day anew and constantly strive to leave the world a little better than we had before.


We can also express our gratitude more openly to the ones we love before it is too late, and appreciate all the joys and wonders that life brings. Nothing I can write here captures Paul's spirit more than the final passage of the book he wrote to young Cady:

"When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing."

Buy this book now, and by all means pay full price! It will be the best money you ever spend. Thank you for your example Paul, and may you rest in peace.