Dr. Tom Duffy, A 30 Year Perspective on
Hematology
February 3, 2008
Welcome to Yale Cancer Center Answers with Drs. Ed Chu and Ken Miller. I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Miller is an oncologist specializing in pain and palliative care. If you would like to join the discussion you can contact the doctors directly at canceranswers@yale.edu or 1-888-234-4YCC. This evening Dr. Miller is joined by Dr. Thomas Duffy. Dr. Duffy is Professor of Internal Medicine and Hematology and Interim Section Chief of Hematology at Yale School of Medicine.
Miller
Tom, thanks for joining us.
Duffy
Thanks very much.
Miller
I have to make a little admission here, 20 years ago I was a house
officer here and was thinking a lot about what I was going to do
with my career. There were a few people who were role models that
helped me decide to go into hematology and oncology, and you were
one of them, so I want to thank you.
Duffy
That is very lovely and kind of you.
Miller
It is a great opportunity to have you on the show and talk about
your incredible career that you have. Can you tell us a
little bit about your own journey through medicine?
Duffy
Sure. I was very fortunate having gone to Hopkins Medical
School. I went there in the late 50s, early 60s, and then did
my house staff training in internal medicine, on the Osler's
Service, and hematology. My mentor at that time was one of
the greats of American Hematology, C. Lockard Conley. I
finished my training there and then was on the faculty for a few
years before coming to Yale. I came to Yale at the invitation
of the relatively new chief of medicine at that time, the dynamic
Sam Their, and joined one of the world's leaders in molecular
hematology, Bernie Forget, in the division of hematology at Yale. I
have been at Yale now since 1976. It has been a long period
of time and a wonderful period of time. My career in some
ways is a more modern career in hematology as well as in internal
medicine or in medicine. Prior to this latter portion,
individuals chose a single pathway in medicine and stayed in that
particular arena for the rest of their lives. It has always
been my contention that the attractiveness of a career in medicine
is that there is such a breadth to what one is able to explore.
Miller
Let me delve a little deeper into that. In many ways,
doctors have become more and more sub-specialized. For
example, if someone does internal medicine, then they do hematology
and they might do certain types of leukemia. I get the sense
that you can actually explore different parts of medicine, is that
what you mean?
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Duffy
What I mean by that is that I started off with my major focus in
internal medicine and it has always remained my major focus. It is
my belief that the care of patients in sub-specialized realms is
often times as important a component to success in that therapy as
attention to details that are the foundation of their management,
rather than the imposed super-specialized attention to those
details. I always instruct house staff that on the leukemia
floor, yes there are realms that the hematologist must focus upon,
but what makes a very important difference in the outcome of a
seriously ill patient is the general medical attention. That
medical attention is a combination of both the physician as well as
the nursing staff. You know as well as I do that what happens
on our oncology and leukemia floors, hematology malignancies, that
nurses play a dramatic role in the day-to-day care, not only
of the physical well being, but of the emotional and mental well
being as well.
Miller
On that issue of physical and emotional well being, for patients
who are very ill and are hospitalized, let's say with leukemia, we
have gotten so technologically oriented with computers and test
results, are we doing as good a job as was done 20 years ago in
terms of emotionally caring for the patients?
Duffy
I think we are doing a better job, we are aware of it, I do not
know that we necessarily participate in it. I have been in
receipt of what I now recognize as a truly important opportunity
for me, and I would hope for an audience as well.
About 2 years ago, I was part of a team that was taking care of a
lovely individual who was suffering with acute leukemia. He was
admitted to the Yale-New Haven Hospital for induction chemotherapy,
the rigors of which I think you recognize and have participated
in. Unknown to me, during this 37-day hospitalization, the
patient had secretly brought a mirror into the hospital and was
sketching himself on almost a daily basis. He is not an
artist professionally, although he is a furniture designer.
At the end of what was a successful induction, he sent me a CD
containing all of these charcoal portraits. These portraits are
unique in so far as I know of no other trove of such material and
they are remarkable. He was able to capture the innumerable
different emotions and fears, but there is also a documentation of
what we do to our patients physically. There is literally a
diminishment of this man physically as he moves through the
prolonged hospitalizations. Looking at those portraits, I
went back in order to parallel the portraits with what was going
on. In reading the charts I noted the obsession with which all of
us documented the numbers and the complications, but there is
virtually nothing that addresses where the patient is emotionally
in relation to his illness. This is not to say the doctors
were not addressing it, but it does give a very strong indication
of what our priorities are, and one could argue that those are the
necessary priorities, but it is dramatic how much these portraits
have meant to me. It is easy to have this dual focus, but one
aspect of the focus can overshadow the other.
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Miller
It sounds like this will make for a wonderful meeting hopefully
attended by doctors, house staff and young doctors as well.
As you look back on the notes that you wrote in the house
staff role and at the pictures which obviously are very soulful,
what would you recommend to your house staff caring for a patient
who is admitted with leukemia, anything different?
Duffy
Part of one's role as an attending on a floor is that one has a
wonderful opportunity, an opportunity that most of us do not seize
upon, but I believe that you are in a more organized fashion.
My belief is that the impact may be stronger if one integrates
those discussions into the daily encounters that we have with our
house staff, students, etc. The amount of medical information
and the amount of science that needs to be covered leaves very
little opportunity for a discussion that is textured in relation to
all of this. A lovely house officer and I at Yale, Dr.
Kirkpatrick who is now in Wisconsin, put together a paper that was
published around 2 years ago called Well Rounded. It
was an attempt to introduce how one could work this into daily
rounds and those hurried encounters with patient. We move as
rapidly as possible in order to cover the large number of patients
and major problems that have occurred in the last 24 hours, which
need to be addressed and corrected within the next 24 hours.
One could say that attention to the details of a patients
life is often times omitted because of this. This paper was
an attempt at addressing how, in the course of those encounters,
there are still many opportunities to address concerns of the
patient. The attending should assume, what I think is a proper
responsibility, of establishing the tone that brings into
consciousness the need to consider, integrate and help resolve
issues to support the patient as they go through the rigors of
chemotherapy.
Miller
I am personally impressed with the number of medical students here
at Yale, and the emphasis they put on dealing with the psychosocial
and emotional issues of patients. It is more than I saw when I was
in medical school a long time ago. We all deal with our own
issues as they come up, and we are reminded when a family member is
ill that all of our patients were well, and then all of a sudden
life changed. We're all very much alike, our patients and us.
Duffy
I agree with you. Yale medical students are very
fortunate. The whole curriculum has been dramatically altered
and is certainly different from the curriculum in which I was
trained. A significant amount of time is devoted to the
psychosocial aspect of their patients' lives. There are even
courses that address the spiritual aspects of patient's
lives. There is a student generated class, although I must
give credit to one of the members of the faculty Dr. Fortune, that
is a course strictly related to those other dimensions of illness
that have been classically omitted from the medical curriculum.
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Miller
We would like to remind our listening audience to e-mail your
questions or thoughts to canceranswers@yale.edu. We
are going to take a short break for a medical minute. Please stay
tuned to learn more from Dr. Thomas Duffy, Professor of Internal
Medicine and Hematology at the Yale School of Medicine.
Miller
Welcome back to Yale Cancer Center Answers. This is Dr. Ken
Miller and I am here with Dr. Tom Duffy, Professor of Hematology
and Internal Medicine at Yale, talking about trends in oncology and
patient care. Tom, I have enjoyed at conferences, you're sharing of
stories, saying "I had a patient 15 years ago…," Let's do a
little bit of that. Lets talk about, for example, leukemia,
chronic myelogenous leukemia; any memories of patients who were a
victory or a non-victory, things you remember?
Duffy
Chronic myelogenous leukemia represents one of those almost
luminous moments when treatment is successful in oncology and
hematology. I'm put in mind of chronic myelogenous leukemia, which
interestingly enough one of my medical school colleagues died with
early on in his career, because there was no cure for it. The
care of chronic myelogenous leukemia, prior to the recent molecular
solutions to the disorder, was exemplified in a young woman who
developed chronic myelogenous leukemia during the latter portion of
her pregnancy. It is not a leukemia that kills immediately
and the chronic phase of the disease could be handled
symptomatically. She gave birth to a child with no
problems. We were able to subdue the advancement of the
disorder simply by reducing the white cell count but not
eliminating the real pathology. But at that time, patients
were faced with a true dilemma, a tragic choice that needed to be
made. Bone marrow transplantation had come in as a possible
solution cure for the disorder; however, she was the mother of a
young child and needed to make a choice. Did she choose to
save her own life by undergoing the bone marrow transplant, which
at that time still carried with it a 40% chance of death, or
did
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she await what was a symptomatically controlled disorder that
would evolve into a more aggressive acute leukemia, which we were
unable to cure. This woman chose to undergo a transplant at
that time and died in the course of the transplantation; certainly
a tragic outcome. Chronic myelogenous leukemia is a real testimony
to how successive generations of physicians and scientists build on
the shoulders of previous generations. We now have an
identification of the molecular abnormality and lo and behold we
have a designer drug that we can administer to our patients.
Chronic myelogenous leukemia may well be a disease which can now be
cured with the ingestion of an oral drug, not the administration of
the ablating chemotherapies that we formerly used for the treatment
of chronic myelogenous leukemia. For individuals who are in
the field of hematology and oncology, the perspective of what is to
occur is really so extraordinary. It offers our patients literally
a transformation.
Miller
Someone now with chronic myelogenous leukemia would be treated
with this pill?
Duffy
Exactly, and we have innumerable patients who are being treated
with pills. Of course they are not necessarily all cured, but
a significant number are at least without evidence of that
molecular abnormality and are remaining free of that abnormality
for a prolonged period of time.
Miller
Let's talk about a different leukemia. Someone with CML, you
would put on a pill, but there are other diseases and sometimes we
just watch people. If a patient came to you with chronic
lymphocytic leukemia, what's involved in that, in that first
meeting with someone who has this disease, would you perhaps tell
them you are going to watch it?
Duffy
Chronic lymphocytic leukemia is really a fascinating disorder.
Chronic lymphocytic leukemia is the disorder where therapeutic
intervention may well not be indicated. In fact, there is
excellent evidence that patients' with chronic lymphocytic leukemia
at certain stages will live out a normal life span. Chronic
lymphocytic leukemia, or CLL, is a disorder mainly of the
elderly. So decisions regarding how it is to be managed need
to be adjusted to the age group in which it occurs. Chronic
lymphocytic leukemia, when it rarely occurs in the 40 or
50-year-olds, obviously there will be some truncation of their
life, and the question is how aggressive are you upfront in order
to guarantee that they will not have an abbreviated life span. This
is a circumstance where all of the new discoveries and prognostic
features in CLL are helping immeasurably. Although, I don't
know as a practicing hematologist that it has made a dramatic
difference. This is one of those disorders in which the
initial observations aligned with the most modern molecular
findings don't really change dramatically what my recommendations
are for the management of the disorder. That is to say that
there are some disorders where one wants to get observations over a
period of time. Chronic
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lymphocytic leukemia is not a disorder which kills on
Saturday. It plays out over a course of many years if not
several decades. I have patients with chronic lymphocytic
leukemia whom I initially started taking care of 30 years ago and
now, 30 years later, their picture is unchanged. That is not
to say that I have not had patients with chronic lymphocytic
leukemia who have died in the course of only a few years, so the
responsibility of the physician is to correctly characterize the
disorder. A simple characterization is almost simplistic. One
simply watches the number of leukemic cells that are present and we
use a simple gauge. If you double the number of leukemic
cells in the course of 12 months, it is a no-brainer to say that
this disease is moving more rapidly than most patients who maintain
a stable number of cells. The other question is that there
are now many more options for treatment and the major dilemma is
how much therapy upfront should be used with the trade off of
complications versus the policy of watchful waiting.
Miller
As a practicing hematologist how often do you use your gut
feeling?
Duffy
I guess the answer to that will be dependent upon what constitutes
one's gut feeling. What many people would believe is one's gut
feeling is basically what is generated from one's experience.
I might question what it is that I offer in the modern era after a
long career in hematology. What I would say is that I actually
possess a great advantage as do other physicians who have spent
several decades taking care of patients. We have seen the course of
the disease as it plays out in a patient's life. One of my
discussions with the house staff and medical students is that they
are disadvantaged in a certain way, yes they may know how the
disease presents, but most don't have an understanding of how that
illness will play out over the course of a few weeks, a few months
or even a year. I used for one of my discussions in a
clinical ethics seminar the course of a patient whom I took care of
with an illness that I knew from the outset would likely have an
ending within a year to a year and a half. Having that
knowledge allows one to actually orchestrate what is going to
occur, anticipate what the problems are and address them. That gut
involvement is actually based upon what I have known to be the
natural history of disease. There is another very important
aspect to this and that is in the whole realm of issues at the end
of life and knowing how a disease evolves. An individual at the
height of the illness and suffering might ask for the end, but if
one can say to them that they don't need to worry, this suffering
will end and you will have a good quality of life thereafter,
that's an invaluable input to patients who are suffering with
serious illness. The converse is also just as important, witnessing
somebody at that height of suffering and knowing that it is only
the prelude to further suffering, and counseling them that perhaps
it's time for all of us to recognize that we are prolonging
suffering rather than prolonging life.
Miller
These are very hard topics for all of us as clinician's. You
are a master at
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working with patients honestly and being a role model, but how
have you gotten better with time in helping people through these
crises?
Duffy
I would say that I am unquestionably better for it, myself.
There have been innumerable studies that demonstrate and document
that many individuals are unhappy with their health care at the end
of life, with the failure to address pain adequately, and we are
doing a better job now, but we have a long road to go. The
other aspect of that is the failure to communicate adequately with
patients and carry out what it is that they desire from us. I
currently head an end of life working group at the Bioethics
Consortium that is looking at those particular issues. What I have
come to understand in my own self is that physicians need to
recognize that no one confronts death or dies with ease. In
fact, I would take it a step further and say that we need to
address not only the conscious problems, but also try and unravel
some of the unconscious dimensions to this problem. Paul
Berg, a professor at the Law School, has written a book that
addresses the problem and takes it into the realm that death for
all us is a taboo of sorts and in failing to acknowledge the
hugeness of that challenge, we do not do for our patients what it
is that we could achieve.
Miller
It is very thought provoking and needs to be talked about
more.
Duffy
I would love to.
Miller
I hope you will come back. I would like to thank Dr. Tom
Duffy for joining us on Yale Cancer Center Answers. It has
been a terrific and very enlightening discussion as always. From
the Yale Cancer Center, I would like to wish all of you a safe and
healthy week.
If you have questions, comments, or would like to subscribe to our podcast, you can go to yalecancercenter.org where you will also find transcripts of past broadcasts in written form. Next week, we will meet Dr. Evelyn Shatil who will discuss the memory loss that is sometimes associated with cancer treatment.