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.
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).
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.
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.
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.