Eric Tian

This past week has been exhausting.

I was placed at a hospital that specialises in cancer care. Brilliant, hardworking staff work here, yet given the terminal nature of the conditions, there are very few wins to be had. This is to be expected, I guess. But there is something about rocking up every day, rounding for hours, doing all you can, knowing that most of these people don’t have much time left. Some are younger than 40.

On the last day, we wrote two death summaries. The families told us they were good deaths, and I think I understood. A single room with a large window, surrounded by loved ones, with morphine flowing through the veins. Could be far worse. But still, deaths are deaths. I had talked to one of them the previous day. It’s hard to enjoy the weekend after that.

As a result, I have had no energy to write. This morning, I woke to find I had missed three consecutive posts. What alarmed me was that I hadn’t even realised.

They say the first step to getting out of a rut is to stop digging. Only then can you change directions, and move towards a more ideal path.

Let this be a step.

In medicine, every decision carries a risk. And there are few areas where this is more relevant than in oncology.

• Surgery removes cancer cells but risks infection, bleeding, anaesthetic risks, and blood clots.
• Chemotherapy kills cancer cells but carries serious toxicities including febrile neutropenia, alopecia, and anaemia.
• Radiotherapy irradiates cancer cells but can cause long-term skin damage, fatigue, and delayed wound healing.
• Even a simple CT scan to stage a cancer has 10-20mSv of radiation – equal to about three years of background radiation.

With all these risks, it sounds easier to do nothing. A very reasonable decision. Why risk all this?

But the thing we forget: doing nothing carries a significant risk as well. The cancer progressing further. No action is still an action.

The real question is then: what risks will you bear for a given outcome? For most people, the greater the outcome – say, a complete remission – the more toxicities we risk.

The mistake is thinking that doing nothing is a safe way out. All our actions, and equally all our inactions, have consequences we must bear.

From Ryan Holiday’s The Obstacle Is the Way:

There is an old Zen story about a king whose people had grown soft and entitled. Dissatisfied with this state of affairs, he hoped to teach them a lesson. His plan was simple: He would place a large boulder in the middle of the main road, completely blocking entry into the city. He would then hide nearby and observe their reactions. How would they respond? Would they band together to remove it? Or would they get discouraged, quit, and return home?

With growing disappointment, the king watched as subject after subject came to this impediment and turned away. Or, at best, tried halfheartedly before giving up. Many openly complained or cursed the king or fortune or bemoaned the inconvenience, but none managed to do anything about it. After several days, a lone peasant came along on his way into town. He did not turn away. Instead he strained and strained, trying to push it out of the way.

Then an idea came to him: He scrambled into the nearby woods to find something he could use for leverage. Finally, he returned with a large branch he had crafted into a lever and deployed it to dislodge the massive rock from the road. Beneath the rock were a purse of gold coins and a note from the king, which said:

“The obstacle in the path becomes the path. Never forget, within every obstacle is an opportunity to improve our condition.”

The prognosis: less than three months to live.

Her response, amidst tears, after expressing her wish to be discharged from hospital: “I feel unbelievably lucky. I have a lovely family I’m going home to.”

Death has a way of narrowing down what is truly important.

In the last 50 years, medicine has seen:

• Genomics and personalised medicine, allowing therapies to target an individual’s unique genome.
• Immunotherapy for cancer, making previous metastatic diseases curable.
• Robotic surgery, enabling unprecedented levels of precision with minimal invasiveness.
• Stem cell research and therapy, promoting the regeneration of cells and tissue.
• Dramatic declines in heart disease, smoking, and deaths from HIV/AIDs.
• Advancements in biotechnology, including robotic prostheses and 3D printing, allowing us to recreate broken body parts.
• Gene editing through CRISPR-Cas9, creating treatment and cures for germline genetic diseases.
• The normalisation of digital health and telemedicine, making medical care accessible to far more people.

And this is just the tip of the iceberg.

It is easy to ruminate on how our world is regressing. Harder to recognise that in a short period of time, we have progressed an unbelievable amount. Half of these things would have been utterly unthinkable 100 years ago.

There is hope in human ingenuity.

Some thoughts on political and religious volatility:

“I am, at the Fed level, libertarian;
at the state level, Republican;
at the local level, Democrat;
and at the family and friends level, a socialist.
If that saying doesn’t convince you of the fatuousness of left vs. right labels, nothing will.” – Nassim Taleb

“I am a libertarian with a small ‘l’ and a Republican with a capital ‘R’. And I am a Republican with a capital ‘R’ on grounds of expediency, not on principle.” – Milton Friedman

“There is no left or right, only up or down.” – Ronald Reagan

“I am a Jew by birth, a Christian by conviction, and a Muslim by culture.” – Reza Aslan

“I don’t think it’s necessary to have one religion. My family is Muslim, I went to Catholic school, my friends are Jewish, and my girlfriend is vegetarian. We study together, we pray together, we eat together. This is what religions should be doing. They should be bringing people together.” – Riz Ahmed

In my deepest moments of laziness, I draw inspiration in thinking of what people have achieved in far more precarious situations than my own.

J.D. Salinger worked on The Catcher in the Rye while serving in World War II, carrying parts of the manuscript in his backpack while landing on the beaches of Normandy. He continued to put pen to paper while fighting through the Hurtgen Forest, scribbling between battles. His book, published when he was 32, has sold over 65 million copies to date.

During the same war, Viktor E. Frankl and his family were sent to the Theresienstadt Ghetto, where his father perished from starvation, and later Auschwitz where his mother and brother were murdered in gas chambers. When Viktor was finally released, he became head of neurology at a major Viennese hospital, where he developed logotherapy and existential analysis, key concepts even in modern psychology. In nine days, he also wrote Man’s Search for Meaning, which has sold over 16 million copies to date and is one of the most recommended books of all time.

So when I compare my modern struggles and excuses to them, I quickly realise my stupidity and get back to work.

They say that comparison is the thief of joy, but I think it can also be the birth of inspiration.

One of my fondest memories is math class on Friday, November 11, 2011. The class started at 11:00am and for the next 11 minutes, our class of 25 did nothing but watch the clock. If a student pulled out a textbook, our teacher, an athletic 6’2″ middle-aged white male, would yell at them to put it away. And so we sat – waiting, holding our breath. The minute before 11:11 was the longest minute of my life.

When the monumental time finally arrived, the class erupted: a mix of cheers, wonder, and amazement. My teacher burst into tears in front of us.

We all recognised there was something beautiful in that minute, 11:11am at 11/11/11, a minute unique to human civilisation, one that would never be seen again.

From Murakami’s Confessions of a Shinagawa Monkey:

“I believe that love is the indispensable fuel for us to go on living. Someday that love may end. Or it may never amount to anything. But even if love fades away, even if it’s unrequited, you can still hold on to the memory of having loved someone, of having fallen in love with someone. And that’s a valuable source of warmth. Without that heat source, a person’s heart—and a monkey’s heart, too—would turn into a bitterly cold, barren wasteland. A place where not a ray of sunlight falls, where the wildflowers of peace, the trees of hope, have no chance to grow. Here in my heart, I treasure the names of those seven beautiful women I loved.” The monkey laid a palm on his hairy chest. “I plan to use these memories as my own little fuel source to burn on cold nights, to keep me warm as I live out what’s left of my own personal life.”

A senior monk and a junior monk were walking together when they encountered a rushing river. As they were preparing to cross, they saw a young woman also attempting to get past. The young woman asked if they could help her cross to the other side. The two monks hesitated because they had taken vows not to touch a woman.

Then, without a word, the older monk picked up the woman, carried her across the river, placed her gently on the other side, and carried on with his journey.

The younger monk was stunned at what he had witnessed but said nothing for many miles. Finally, after several hours, he confronted the older monk.

“As monks, we are not allowed to touch a woman, how could you then carry her on your shoulders?”

The older monk looked at him and replied, “Brother, I set her down on the other side of the river, why are you still carrying her?”