Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Thursday, September 22, 2011


Analogies are as dangerous as they are beguiling, which is why I always try and understand the comparator in depth before I make the comparison.  But lately one analogy keeps coming unbidden into my consciousness.  It is summarized by a single word: blacksmith. Are we the blacksmiths of the 21st century?


What do I mean by that? Blacksmiths were, at one time, ubiquitous. They were literally to be found in every village in every land. If you don’t believe me, look up “Smith” in a phone book: the name is a vestigial reminder of an historical reality.


For centuries they were the civilization’s “techie” types. Indeed, in pre-industrial society they were the main creators of high-end objects.  They were respected, well compensated, had their own guilds and their own special knowledge base and techniques. They were certainly more useful to society than the average pre-20th century physician. If you were a blacksmith two centuries ago you could recommend the profession to the next generation in the confident expectation that a good job would always be available. In fact, it was inconceivable that the world might not need blacksmiths.


And then, in the course of a lifetime, everything changed.  The industrial revolution and mass production eliminated most of what blacksmiths did on a day-to-day basis. Blacksmithing as a profession nearly disappeared. One sign of this, curiously enough, comes from Boy Scout merit badges: in 1911, blacksmithing was one of the original merit badges awarded. In 1952 the Scouts discontinued the award.  There was no one left to teach a Boy Scout blacksmithing. That world had vanished.


So are cancer doctors, especially medical oncologists, the blacksmiths of the 21st century? Not for the next few years. The rising tide of cancer patients resulting from long-term demographic trends (my aging fellow Boomers) combined with an avalanche of new drugs pretty much guarantee full-time employment for the foreseeable future.


I can imagine several scenarios where we will no longer be that important or common. Immunize everyone to nicotine’s addictive effects, and you need a third fewer cancer doctors. Some all-purpose prevention agent aimed at emerging adenocarcinomas, or nanobots eliminating small clusters of cancer cells, or improved imaging techniques capable of accurate and early detection of sub-millimeter tumors: then close the curtain on our particular guild.


Yes, these might do. But it’s the unforeseeable that always gets you in the end. I doubt many blacksmiths saw Henry Bessemer’s steel process replacing locally produced wrought iron, or Henry Ford coming in his Model T, or the Sears Roebuck catalogue arriving in the mail, yet those were the “killer apps” of the day that helped do blacksmiths in. I similarly doubt whether we know what is in store for us 25 or 50 years from now. Our gnat-like imaginations never visualize much of the future. Even the most adventurous science fiction author tends to undershoot tomorrow’s reality, and by and large they don’t write onco-narratives.


And if we do persist in roughly our current numbers, will being a cancer doctor mean the same thing as it does today? Information technology alone has the potential to radically alter what it means to be an oncologist. How long will it be before IBM’s Watson computer, with its rapidly improving word processing capability and infinitely scalable data base, turns us into simple conduits between insurance companies and patients, technicians signing orders generated in some data warehouse in Shanghai?


I’d like to think I’m irreplaceable, and I’m sure blacksmiths felt the same way, but no one really mourned their passing.  Cancer won’t go away: it’s built into our very genes. But I doubt the cancer doctor of 50 years from now will bear much relation to that of today, if he exists at all.


Before I go too far with this analogy, what actually happened to blacksmiths? Well, some of them became auto mechanics, and some machinists creating fine tools.  The smart guys got out and did something else. The profession as a whole dwindled and nearly disappeared.


Nearly, but not entirely.  The last few decades have seen a renaissance in blacksmithing. They are now high-end artisans creating expensive and beautiful works for the luxury crowd. ABANA, the Artist-Blacksmith’s Association of North America, now claims 5,000 members, which means there are more, because they (like oncologists) probably are not all equally religious about paying their professional dues. Dear Boy Scouts of America: bring back that Merit Badge!


Maybe that’s how we’ll end up, as high-end artisans creating expensive and beautiful (body) works with stem cells directed down specific morphogenic pathways with concoctions of gene therapy, cytokines and hormones: plastic (molecular) surgeons. Don’t sell that infusion chair quite yet. Perhaps the old cancer work will be retained for sentimental reasons as an occasional sideline in unusual cases. It’s a thought, but it won’t keep me awake at night. I suspect I will have retired before then.