Simone’s OncOpinion
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.

Thursday, May 25, 2017

Like many of you, early in my career I began to face the difficult issues inherent in end-of-life care. I accumulated a library on the issue but saw few, if any, clarifying insights. Most of such literature consists of superficial banter or a misplaced spiritual focus. I learned to go to the Russian writers for in-depth, humane descriptions of suffering and death.

Alexander Solzhenitsyn's Cancer Ward is a masterpiece that provides insight into the fears, strengths, and weaknesses of people under enormous stress because of cancer. Fyodor Dostoyevsky is a master at describing how people like us deal with their sins and challenges, and especially the value of lives, particularly in The Brothers Karamazov.

However, for the purpose of this column, the best source is the shortest—Leo Tolstoy's masterpiece, The Death of Ivan Ilyich, published in 1886. This novella in my little yellowed-page Bantam Classic pocket book edition (that I got for $1.35 in a used bookstore long ago) is only 99 pages long. It is a tour de force of artistic compression—the impact of a novel from what is essentially a long short story.

Tolstoy describes a 40-something man, Ivan Ilyich Golovin, an accomplished attorney who rose to the position of high court judge. Ivan Ilyich (I use this name format as Tolstoy did) develops a slowly progressive, ultimately fatal disease. Despite the radical changes in medicine since his time, Tolstoy would need to change none of the human essentials if he were writing it today; his description of this "worldly careerist" describes features of many of us professionals today. Ivan Ilyich is successful by societal standards. He has married "correctly," has two attractive children, and has achieved substantial professional stature. He had a good life, took pride in his work, moved in the best social circles, and derived great pleasure from playing whist, a card game similar to bridge, with his friends.

One day, shortly after being appointed to the high court, he fell and banged his side. It was sore for a couple of days then subsided. Later, he noticed a small lump in the area that was mostly painless but it remained tender to the touch. But the discomfort gradually became annoying to him and his disposition worsened, leading to frequent arguments with his wife. Finally, his wife insisted he see a doctor. Here is Tolstoy's acidic description of the visit to the doctor:

"The whole procedure was just what he expected, just what one always encounters. There was the waiting, the doctor's exaggerated air of importance (so familiar to him since it was the very air he assumed in court), the tapping, the listening requiring answers that were clearly superfluous since they were foregone conclusions, and the significant look that implied: 'Just put yourself in our hands and we will take care of everything…' [Then] the doctor said: such and such indicates that you have such and such, but if an analysis of such and such does not confirm this, then we have to assume you have such and such…and so on.

"To Ivan Ilyich only one question mattered: was this condition serious or not? But the doctor ignored this inappropriate question…one simply had to weigh the alternatives: a floating kidney, chronic catarrh, or disease of the caecum…and in Ivan Ilyich's presence the doctor resolved that conflict brilliantly in favor of the caecum, with the reservation that if an analysis of the urine revealed new evidence, the case would be reconsidered."

Over several months, the aches changed to pain that became progressively worse. He began to lose weight and developed a bad taste in his mouth, bad breath, and a poor appetite. Despite repeated visits to doctors and multiple medications, he was on a downhill path.

If Ivan Ilyich had ever thought about death, it was never his own, it was always removed from serious concern. Death happened to others and required expressions of sorrow and condolences that caused brief and unwelcome interruptions in the comforting routines of a busy life. In fact, Ivan Ilyich never deeply examined his life, his only focus being on the physical aspects. He was an opportunist, a "man on the make," in society and his profession; metaphysical issues were of no interest. His professional authority led him to believe he was special.

Even though he sometimes acts like a pompous boor, in some ways Ivan Ilyich becomes a sympathetic character because we can glimpse a bit, or more, of ourselves in him, because Tolstoy uses him to express his own fear of death and because of Tolstoy's graphic and heartbreaking description of Ivan Ilyich's suffering.

What sets this narrative apart from most treatments of death in the artistic and medical literature is that everything is described as seen and experienced by the dying patient. The viewpoint is personal and specific instead of generic, making it more poignant, and Tolstoy's artistic genius creates the mood, intensity, and relentless clarity of a dying man…it is hard to watch, but hard to look away.

There are several circumstances illustrated by Tolstoy's story that will be familiar to most doctors and nurses.

Ivan Ilyich says this can't be happening to him…it was only a little bump, after all. We are familiar with denial and the attempt to apply reason to what doesn't lend itself to reason. He also points to his living an exemplary, if unexamined, life and the injustice of this happening to him. The application of justice is, of course, also fruitless. He is tormented by the lack of an answer to "Why me?" He simply cannot grasp the reality of dying.

He dreams of cures though he eventually comes to acknowledge the fact that he is dying. He thinks about "the big lie." All around him doctors, family, and friends talk about his recovery and that the next medicine may do the trick. But it is all a big lie. He knows he is dying but nobody is honest with him. He is "trapped in a mesh of lies." This leads to his isolation, his sense that no one understands and he is all alone facing "It," which is what he calls death. Everyone around him is thinking beyond his death: the funeral, how they will get along without his income, will they get promoted when his job is filled, and so forth. He realizes that is what people do, that is what he did, because they are not dying. He comes to understand that, ultimately, everyone faces "It" alone. Near the end, he asks everyone to leave him alone.

Everyone lies to him except Gerasim, a farm boy who is brought in to care for him. He alone understands and accepts what was happening. When Ivan Ilyich thanks Gerasim for his kindness and help, the boy says, "We all have to die someday, so why shouldn't I help you?" By this he meant, Tolstoy tells us, that he did not find his work a burden because he was doing it for a dying man, and he hoped that someone would do the same for him when his time came.

Ivan Ilyich's last few days were horrible. He dreamed he was being stuffed into a black bag and he screamed in pain for 3 days before he died. An epiphany and relief came in the last moments before his death. He finally could admit to himself that perhaps he did not live a "good" life. All those honors and high stations and high society now seemed so pitifully irrelevant at this moment. He comes to admit that he could have done better, an admission of his smallness and an understanding of what is really important in life. Thus, his physical crisis ends at the same time as his moral crisis.

We are fortunate to have a contemporary writer with some of the writing skills of Tolstoy and the same uninterrupted gaze at death. Atul Gawande, MD, a physician and gifted writer has written many books, and he writes regularly for The New Yorker magazine. His article on the topic of end-of-life care is Letting Go, published in the May 26, 2010, issue.

"What should medicine do when it cannot save your life?" He tells stories familiar to any oncologist and most physicians about patients who are going to die because therapy is no longer effective, and how patients, families, and caregivers deal with it. He includes himself among doctors who on occasion recommend treatments they know will neither cure nor extend life with even a modicum of quality. He graphically describes the wrenching challenges for families and caregivers facing death and helplessness.

Gawande's article is excellent and I urge you to read it as well as Tolstoy's novella. I believe both can help us manage patients at this stage with a bit more compassion and truth, but mostly, to spend a few more unrushed minutes with the patient.​


Tuesday, April 25, 2017

This column is one in a series on the importance of leadership in cancer research and clinical programs. Trying to understand leadership, good and bad, has been an endlessly fascinating journey for me. And I am not alone. The shelves in the business section at Barnes and Noble are filled with books on the subject and airport concessions, even in smaller airports, always have such books. The Harvard Business Review reliably prints many articles, universities offer continuing education courses, and celebrities give well-paid lectures on leadership. Why is the subject so popular? The answer is easy: because leadership is difficult and because leadership is so important to any enterprise.

A parenthetical note of caution here about business books: I have read my share and found the majority to be useless. They are filled with simplistic nostrums, are endlessly repetitive, and have an almost total dependence on anecdotes (case studies), which by their nature are totally retrospective and uncontrolled. Only a small percentage of books provide an enlightening synthesis or novel viewpoints, so caveat emptor.

In my own case, an interest in the qualities of effective leaders has been greatly intensified beyond sporadic reading. It helps for me to review my own experience of watching great leaders in action, assessing my own role as a leader of academic programs and hospitals, and through my consulting work, which provides opportunities to examine in detail the work and effectiveness of many leaders in health care.

In an earlier column, I described what some experts believe makes a great leader, or rather, what kind of performance and outcome is apparent in very successful leaders. This is an important distinction. It is much easier to identify an effective leader after the fact than before or during his or her tenure. This raises interesting questions, such as: Are leaders made or born? Can someone be taught to be an effective leader? Can one identify an effective leader beforehand? Are all effective leaders "successful?" I hope to shed a bit of light on these issues from the literature and personal experience.

Are leaders born?

Yes, partly. I agree with Bill George, a former corporate CEO. In his book, True North: Discover Your Authentic Leadership, he expresses in several ways that the core characteristics of leadership, the soul of leadership, cannot be taught. I have come to believe that what is true for most skillful activities is also true for leadership. Not only is one's DNA a major influence, but George points out that personal crises and other life experiences early in life and later also prepare one to be an effective leader.

Although I loved the game, no matter how hard I tried, I could never have been a competitive college football player. I was the wrong size and shape, terribly slow, and had other interests that were more important to me. A friend once told me of a conversation he had with a CEO of a large corporation. He asked the CEO how he could tell if a candidate was likely to be an effective leader. He replied, "Simple, I just asked them what they did in high school." He was making a point that the signs of an aptitude for leadership show up early.

Can one teach effective leadership?

Only partly and only if the basic soul of leadership is already there, I believe. One can be taught certain techniques and skills through mentoring and graduated experience. But that is a refinement of the basic foundation of good instincts about human nature, character, ambition, and self-confidence. I also believe one can teach, or try to teach, a potential leader that unless he/she gets pleasure out of seeing those being led succeed and get the glory because of his/her efforts, a leadership position may not be a good choice, no matter what other talents are in place.

Can one identify an effective leader beforehand?

This is very difficult and typical search processes often fail to identify the right leader for the specific job. In my view, the best predictor of an effective leader is evidence of effective leadership in the past. This seems to be a catch-22: "I don't know if you will be an effective leader unless you have already been an effective leader. How can one become an effective leader if one never gets the chance?" But this is not as dumb as it sounds. If someone has had experience as a leader, even in a voluntary or relatively minor position, it usually means the person wanted to be a leader and went after the job, or was recognized by others as someone they would like as their leader. If he/she were successful in that role, that provides a degree of greater security in the evaluation.

In my personal experience, there are two top reasons for the failure of leaders. First, a candidate is hired for the wrong reasons, e.g., an outstanding scientist is hired to be chairman of a department or a dean primarily because of a long bibliography and an expansive CV. These are poor indicators of an aptitude for leadership, yet are often the most powerful influence on the decision to hire. Second, the candidate likes the position for its stature and power, but doesn't really like (or understand) the job of leadership. This type often is just a boss or even a bully, but not an effective leader that leads the team to perform at its best.​

Are all effective leaders successful?

No. This is one of the great faults of business books on leadership. Too often, the only measure of an effective corporate leader is an increase in market share or stock price. In academia, it is grants obtained or papers published. Books don't sell if they describe the leader who, despite seemingly insurmountable obstacles, managed to bring his so-so team to a much higher level of performance than expected. Or the leader who inherited a staff ill-fitted for the job, but was able to rearrange the workforce and workflow to help them perform at their very best. The athletic directors of college sports know this well. They often hire a coach who has turned a chronically losing team at a second- or third-tier sports college into one that wins half its games. They recognize the coaching talent despite the mediocre player talent.

In summary, effective leaders are born with an innate aptitude shaped and grown by life experiences and refined by mentorship and experience; all three are necessary. Although not fail-safe, one makes a better bet on a prospective leader who has a record of successful leadership in the past, no matter at what level. Finally, excellent and effective leaders may not be judged successful by the world's standards, but they may have done an excellent job with the resources and conditions provided—and they usually know that in their hearts.


Monday, April 10, 2017

​Changes in leadership are common at government agencies and the academic medical centers influenced by them. Having observed such changes recently, I have begun to ask myself what makes a good leader of these organizations and, better yet, what makes a great leader.

Leadership matters; it matters a lot. This is so whether the organization is a business, a practice, a hospital, an academic institution, or a government agency. Books on business success, including leadership, seem to be everywhere. Typical is the book, Winning, by Jack Welch, the former CEO of General Electric, which became a bestseller. While books on leadership of non-profit organizations, particularly those in health sciences and healthcare, are almost non-existent, leadership qualities are shared in both venues. So let's review what some gurus of management have had to say on the subject.

One of my favorite sources of business management wisdom is Peter Drucker. This legendary sage understood and clearly described the features of running successful businesses. He is famous for believing that integrity and high ethical standards are central to good business practice because it is the right thing to do, but also because it is good for the long-term health of an organization. Here is an excerpt from his work.

"What would I look for in picking a leader of an institution? First, I would look at what the candidates have done, what their strengths are—you can only perform with strength—and what have they done with it? Second, I would look at the institution and ask: 'What is the one immediate key challenge?' I would try to match the strength with the needs. Then I would look for integrity. A leader sets an example, especially a strong leader."

Drucker then quotes a famous and successful business leader whom he asked what he looked for in a leader. And the man responded, "I always ask myself, would I want one of my sons to work under that person? If [the leader] is successful…would I want my son to look like that?" Drucker then concludes, "This, I think, is the ultimate question."

He continues, "In human affairs, the distance between the leaders and the average is a constant. If leadership performance is high, the average will go up." And finally, "Effective leaders delegate, but they do not delegate the one thing that will set the standard. They do it."

Another well-known management expert, W. Edwards Deming, also held this last principle. Deming is best known for being the American consultant who revitalized Japanese industry after World

War II. "It is the responsibility of management to discover the barriers that prevent workers from taking pride in what they do. Rather than helping workers do their job correctly, most supervisors don't know the work they supervise. They have never done the job." Deming goes on to say that such supervisors often use numbers or quotas as the only basis for judgment, without understanding the nature of the work.

The greatest leader in American history was, in my view, Abraham Lincoln. This view was cemented in my opinion by a book that focused on his leadership and political skills and, of course, on aspects of his personal character that shaped the former (Lincoln: A Life of Purpose and Power). Lincoln's integrity, vision, and bedrock principles were combined with uncommon political skills acquired in his Illinois years and with a keen sense of public opinion. These enabled him to navigate skillfully the most difficult and treacherous times of our country. He devoured information from all sources and sent aides into the field to obtain first-hand information that helped him make astute strategic decisions. He was an uncommon leader who engaged some political enemies in his administration because he believed they were the best people for the jobs.

In my experience, it has been clear that the ill effects of poor leadership, at any level from CEO to department head to housekeeping, insidiously permeate an entire institution. This invariably leads to inefficiency at best, and at worst leads to falling dominoes of lost opportunity or catastrophe. Effective leadership is often subtle but direct, nuanced but clearly understood. What makes great leaders is not a secret. They not only have grace under pressure, which means both courage and character, but they remain focused on the important aspects of an issue in the midst of chaos. Great leaders repeatedly articulate a consistent, simple public vision by example, conviction, and actions. If the troops don't know what is expected of them, what direction is set or what the leader values most, that is the leader's fault.

However, this vision must be backed by public acts, not just words. There are many opportunities to demonstrate one's vision, both subtle and overt. Whom the leader hires, fires, and promotes sends the most effective signal, but smaller acts can indirectly express his or her values. Great leaders take satisfaction in the success of team members and try to hire people who are better than they are.

I end with two qualities that help distinguish a great leader from a good leader, especially in the not-for-profit world. First, though he remains confident in his final decisions, he must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views. Second, he knows that at some time he will be asked to compromise basic principles. If his values cannot be sustained because of the environment, the great leader may choose to lose favor, be fired, or quit over a key principle. If the position or stature or pay means so much that the leader will not put his job on the line for a core value, he is no longer free and has taken a step onto a slippery slope. Great leaders have the mindset upon taking a position of holding core values and principles dear, no matter what the cost. 


Monday, March 27, 2017

I am not sure how I get there, but now and then I find myself facing a stone wall with a large gate. There is a woman sitting in a guardhouse the size of a telephone booth. I walk up to the gate and greet the woman. I start a conversation. Here is the first one.

JVS: I always thought the gate would be pearly, but it is just rusty iron.

Woman: The gate you refer to is further up the path, and it is not pearly; it is made of titanium—lightweight, shiny, and rustproof. This is the triage gate.

JVS: This gate is open so may I go on?

Woman: No, you may not. You are not dead yet and only the dead may go further.

JVS: I am here because I have some very important questions for St. Peter. He was known in his day as Simon Peter and I think we may be related; my father's name is Peter (from the Greek for stone) Simone. He must have passed through this gate almost 50 years ago.

Woman: Yes, he did. Nice man.

JVS: You saw him? Was he OK? Was he allowed past through the pearly— sorry—the titanium gates?

Woman: Everyone who passes through this gate is OK. And I can't say what happened to any of them after they pass through, but I wouldn't worry about him.

JVS: But I must ask these very important questions of St. Peter because he will be the last authority I see before "The Decision," and I do not know if he will let me through the titanium gate or point me to the sign, "All ye who enter here abandon all hope."

Woman: Maybe I can help you with your questions.

JVS: But these are detailed questions about the medical profession. I am a physician.

Woman: I know all about you, even about that incident in Kyoto.

JVS: Uh-oh.

Woman: My scanner identified your DNA as you walked up and my computer had your entire history in 6 milliseconds.

JVS: How can you "scan" my DNA; you didn't take a tissue sample. And I don't see a computer.

Woman: We have had non-invasive DNA scanners forever; they are entirely biological and small enough to be implanted in my eye. The computer is also biological and is in my brain. No cables to fool with and no stupid IT department required. Every staff member here has this equipment and we are all connected wirelessly.

JVS: That is astounding! You must have a gigantic memory.

Woman: You can't even imagine.

JVS: Well, OK. I guess I have no choice but to ask you the questions.

Woman: That's right, and you better get on with it. We need to finish before the evening rush.

JVS: Well, the first question is…wait a minute, do you know what I am going to say before I say it?

Woman: Yes, but go ahead; I enjoy the exercise.

JVS: I am worried about the state of the medical profession back home. We find ourselves in the middle of an econocentric society, one that often measures success by how much money and goods one accumulates. And we doctors end up focusing on financial issues and dealing with payers. I am ashamed to admit that, at times, money becomes a main focus of the practice overriding prudent medical judgment, sometimes consciously, sometimes not.

Woman: Your worries are justified. What have you done about it?

JVS: Me? Well, nothing. What can I do about it?

Woman: It is not my job to tell you what to do.

JVS: What about St. Peter? Can he tell me?

Woman: No. He answers to only one question—"Which way?" But there are others above who may respond to your questions and, as you know, we are all connected wirelessly. Who would you like me to ask and what is your question?

JVS: (Pause)

Woman: Well?

JVS: I'm thinking. OK, I would like to ask Sir William Osler the following question—Sir, you set very high standards for the practice of medicine. What can myself and my colleagues do to protect the noble values of our profession? I know we have lived in a different eras, but you must have dealt with this issue.

Woman: [After a pause, she speaks with a male voice.] Physicians in all eras have dealt with this issue. Doctors' behavior is subject to the bell curve of human nature, just like the population at large. A minority consists of idealists who are willing to forego personal gain and safety for the good of patients and the profession. At the other end is a minority essentially wedded to the business of medicine. For them, there is never enough income and, using self-serving rationale, they willingly sacrifice the good of patients and society for personal gain.

The remainder is the great middle that consists of individuals who have some features from both extremes, but lean more or less toward one extreme or the other. That is where hope lies, not with the idealistic saints, but with those on the "good" side of the great middle group. They are pragmatic but have mature, well-informed consciences that lean toward idealism and the option for the patient. And the group is large enough to be influential. They need to know they are not alone and they can make a difference. The better professional associations may be able to foster and support this group; but, unfortunately, membership organizations often pander to the lowest common denominator. They offer glitzy programs on or near the beach and pass out trinkets and shoulder bags, which some doctors collect. You and others of like mind have your work cut out for you.

JVS: Thank you, sir.

Woman: Satisfied? [In her own voice.]

JVS: Well, it was helpful, but somehow I expected something more specific.

Woman: You can ask someone else, but only one more; it's getting late.

JVS: Yes, the evening rush.

Woman: Well, we don't really have any evening since time does not exist here, but we try to use terms familiar to the souls coming through. Who would you like to question next?

JVS: I'm not sure; maybe William Carlos Williams. I admire him enormously both as a physician and a poet, but on the bell curve he may be too close to the border between the great middle and the idealists. He wrote about the practice of medicine:

"I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness that was affecting them, it was as though I were re-awakening from a sleep. For the moment, I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself, as from any other sleep, rested."

I think if I asked him that might be his answer. It is admirable, but so personal that it might be of little help to me.

Woman: How about Don Berwick?​

JVS: But Berwick is alive.

Woman: So? He does live in your era.

JVS: Yes, I guess Osler was right. Medicine has had, and still has, heroes like Berwick as well as its scoundrels. I guess we must look within ourselves and our profession, as it is today, to find and encourage those who have studied and work at sustaining the more noble values of our profession. We must look to them for leadership and support. This has been a valuable experience; it has given me a lot to think about and ideas for some actions I might pursue. I guess I will head back. Thanks for your help.

Woman: You are welcome.


Tuesday, February 28, 2017

What influences us to choose the specialty of oncology has always interested me. Today, there are many training programs and role models for medical students and house officers to emulate. But when I completed my internal medicine residency in 1963 and started a fellowship in pediatric hematology (that's another story), there were few formal training programs in oncology; ASCO did not exist; there were no subspecialty board certifications for hematology, medical oncology, or pediatric hematology/ oncology. At that time in the late 1950s and early 1960s, there were many locations where only radiation oncologists and surgeons gave chemotherapy.

The relatively few full-time medical oncologists often arrived at their professions via other medical activities. The migration from hematology was the most common, but others came from a variety of specialties and activities as diverse as endocrinology (studies of hormone-dependent cancers) and from World War II studies of toxic compounds like mustard gas. As with physicians today, the choice of subspecialty in the early 1960s was influenced by a mentor, a patient, a family member, personal traits, or by unique or serendipitous circumstance. In my own case, the example and mentoring of Donald Pinkel, MD, the first director of St. Jude Children's Research Hospital, made me a committed oncologist, scientifically as well as clinically.

Choosing medical or pediatric oncology was unusual and no easy matter in those days: medical and pediatric oncology were viewed with condescension by the pooh-bahs of academic medicine because they were "unscientific;" medical and pediatric oncology were mostly poor sister add-ons to hematology in medical schools (they thrived mainly at cancer institutes); the foundation of clinical trials was being laid with fits and starts; diagnostics for most cancer were primitive by today's standards; disfiguring and debasing gonzo surgery, including "super-radical" mastectomies and the fabled "hemicorpectomy," was common; and the prevalent radiation oncology equipment was the cobalt-60 machine.

But the most defining feature of that time was the treatment—it wasn't very good and the great majority of patients died relatively quickly. Because of the stress of dealing with so many dying children, it was not unusual for pediatric oncologists to change specialties; some of my own colleagues switched to radiology, dermatology, neonatology, and radiation oncology.

While the support of mentors, our personality type, and the other factors noted above often influence our career decisions, I believe the picture is more complex. I would guess that each of us could easily recall distant and seemingly unrelated personal experiences that instilled in us "life lessons" that helped us navigate this challenging field. Such recollections are seen, of course, through the fog of passing years. So with selective hindsight and a bit of puckish reconstruction, I have listed in roughly chronological order some of the character-shaping lessons that I believe helped me to choose in 1967 to become a full-time pediatric oncologist.

Family Culture

I attribute my father's influence for my values. But in this context his example of a deep mistrust of material possessions and of living within or below one's means served me well and later provided me the option of enabling me to take extended postresidency training and an academic career which, of course, I did. The lesson: Live below your means and keep your options open as long as possible.

High School Football

All the coaches were "old school" in the early 1950s. Pre-school summer practices were brutal: twice a day in full pads and uniform in the August heat and humidity with no drinking of water during practice (I did say old school), and punishing scrimmages to see who could "take it." We had snug-fitting leather helmets with no facemasks; I think all they protected was our ears from being torn off while blocking. We all talked about quitting, but few did. I wasn't a very good player and I rarely started, but I played well enough and the experience was invaluable. The lesson: I was capable of persevering under severely trying circumstances (handy insight for an oncologist).

Holding Retractors

Like many medical students, my choice of specialty changed several times before I made my final decision. I loved surgery…in theory. But after hours of holding retractors and doing all the other related chores (not very well), I decided that surgery wasn't for me. I didn't see myself getting enough satisfaction out of the operating room to make up for the rest of it. The lesson: The manual and technical aspects of medicine did not suit me as well as the intellectual. When I met the chief resident of the service, he said: "Do you want to be a cutting doctor or a thinking doctor?" He sifted me out with one question.

Homer

No, not the Greek poet. Homer was a 5-month-old African American baby under my care during the pediatric elective of my medicine residency. He was a beautiful, chubby, happy baby that was always glad to see me. He had pyloric stenosis that eventually was surgically fixed without incident. For reasons I can't explain, caring for Homer helped me realize how much I liked taking care of kids; I still think of him years later. The lesson: Patients had much to teach us about ourselves, including what direction to take in our medical development.

Serendipity

Three examples: I moonlighted to support myself and my upcoming new family. I took call in an industrial clinic and later worked the night shift as a hospital lab technician; that stirred my interest in hematology, which ultimately led to a career in oncology. One of the best available hematology fellowships happened to be only two blocks from my residency institution so I could go to an interview at no cost; it also happened to be in a pediatric department (Irving Schulman, MD, an eminent hematologist, was chairman), which ultimately turned me into a pediatrician. A colleague in the department (Charley Abildgaard, MD) was asked to look at a "hematology" job at a place I had never heard of then, the 4-year-old St. Jude Children's Research Hospital in Memphis. He was a Californian and suggested that it might be a better fit for me. I subsequently spent 24 great years at St. Jude. Each of these serendipitous events had a profound impact on the course of my career. The lesson: Planning is important, but chance can play a major role in a career; one should keep an open mind and not plan too rigidly.

The Chicago Cubs

Finally, I learned to read newspapers for pleasure from the sports pages of the Chicago Tribune. The Chicago Cubs' games were broadcast all summer; there was no TV and the radio announcers' dramatic renderings of the play made me a passionate fan. I suffered many years of the Cubs' legendary futility—they last won a World Series in 1908 and last played in one in 1945, when I was a 10-year-old. And even after leaving Chicago, I could not remain completely detached from their fortunes or switch allegiance to another club. Maybe it was because I was born a few blocks from Wrigley Field. Maybe, as someone once said, a sports allegiance passionately held at 8 years of age is ingrained for life, like it or not. In any case, being a Cub fan entails accepting many defeats while retaining unquenchable hope. The lesson: Being a fan of the Chicago Cubs was excellent preparation for a life in oncology.​

In summary, we all can point to major influences that led us to become oncologists, but I believe there are many seemingly minor factors as well. These "minor" factors may in the long run have been at least as important as the "major" factors, if not more so … and certainly are more interesting.