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Terminally ill cancer patients struggle to access psilocybin
In March 2020, when the world was struck by the news of the COVID-19 pandemic, Erinn Baldeschwiler received her own gut punch. She was diagnosed with stage IV metastatic breast cancer and was given about 2 years to live.
Then 48, the mother of two teenagers had just started a new chapter in her life. She’d gotten divorced, moved to a new home, and left a small business she had spent 18 years cultivating. The prospect that her life story might soon be ending, that she wouldn’t see her children grow up, was a twist of fate almost too devastating to bear.
“Are you kidding me that this is happening?” she thought.
But she also wanted to keep learning and growing in her remaining years, to devote them to creating meaningful memories, contemplating her mortality, and trying to find inner peace.
“The last 2 years have kind of been this dance with Lady Death,” she said.
They have also been a dance with Lady Justice.
In March 2021, Ms. Baldeschwiler, along with Michal Bloom, who also has terminal cancer, and their palliative care physician, Sunil Aggarwal, MD, PhD, decided to sue the Drug Enforcement Administration (DEA) for the right to access psilocybin, the psychoactive ingredient in “magic” mushrooms.
Psilocybin-assisted therapy has been shown to help terminally ill people overcome their fear, anxiety, and despair about death and to experience the kind of peace Ms. Baldeschwiler is seeking.
Psilocybin is illegal in the United States, but the plaintiffs argue they should be able to take the substance through the Right to Try Act. The 2018 federal law says that people with life-threatening conditions who have exhausted all approved treatment options can access drugs that have not yet been approved by the Food and Drug Administration but have passed phase 1 clinical trials.
This case marks the first time patients have fought to use a Schedule I drug under the Right to Try Act.
The push to expand access to psilocybin is picking up steam in the United States. In 2023, facilitated use of psilocybin will become legal in Oregon and Colorado. Recent proposals from the Biden administration and members of Congress could make psilocybin more widely accessible in the next few years.
It is also gaining momentum outside the United States. In Canada, patients are suing the government to help patients obtain psilocybin-assisted therapy for medical purposes.
“I think what we have here is a confluence of events that are driving toward the mandatory opening of a path to access psilocybin for therapeutic use sooner rather than later,” said Kathryn Tucker, lead counsel in the case against the DEA.
Reverberations of Right to Try
The story of Right to Try began with Abigail Burroughs, who was diagnosed with head and neck cancer at age 19.
After conventional therapies failed, Ms. Burroughs’ oncologist recommended cetuximab, a drug targeting EGFR that was experimental at the time. Because the drug was available only through colon cancer trials, she was denied access.
She died in 2001 at age 21.
Ms. Burroughs’ father, Frank Burroughs, formed an organization that in 2003 sued the FDA to provide terminally ill patients access to unapproved drugs. In 2005, they lost, and subsequent attempts to appeal the decision failed.
Still, the case sparked a Right to Try movement.
“Right to Try laws swept the U.S. in a firestorm,” Ms. Tucker said.
Along with the federal law, which passed in 2018, 41 states have enacted Right to Try laws.
The movement intrigued Dr. Aggarwal, codirector of the Advanced Integrative Medical Science (AIMS) Institute in Seattle. Dr. Aggarwal had been treating patients with cannabis, and after taking psilocybin himself and finding it therapeutic, he thought Ms. Baldeschwiler could benefit.
“I always knew that the powerful medicines within Schedule I had a significant role to play in healing,” he said. “That was baked into my decision to become a doctor, to research, and to innovate.”
He applied for the right to cultivate psilocybin mushrooms, but the fungus doesn’t meet Right to Try requirements. He then found a manufacturer willing to supply synthesized psilocybin, but because it’s a Schedule I drug, the manufacturer needed an okay from the DEA.
Dr. Aggarwal joined forces with Ms. Tucker, who has spent 35 years protecting the rights of terminally ill patients. In January 2021, Ms. Tucker contacted the DEA about allowing dying patients, including Ms. Baldeschwiler and Mr. Bloom, to access psilocybin-assisted therapy.
The response, she said, was predictable.
“The DEA’s knee always jerks in the direction of no access,” Ms. Tucker said. “So it said ‘no access.’ “
The reason: In a letter dated February 2021, the DEA said it “has no authority to waive” any requirements of the Controlled Substances Act under Right to Try laws.
Suing the DEA
Dr. Aggarwal and Ms. Tucker did not accept the DEA’s “no access” answer.
They decided to sue.
Dr. Aggarwal and Ms. Tucker took the matter to the Ninth Circuit Court in March 2021. In January 2022, the court dismissed the case after the DEA claimed its initial denial was not final.
The following month, the plaintiffs petitioned the DEA to deliver a concrete answer.
In May, while waiting for a response, demonstrators gathered at the DEA’s headquarters to call for legal access to psilocybin. One of the protesters was Ms. Baldeschwiler, who choked back tears as she told the crowd she was likely missing her last Mother’s Day with her children to attend the event. She was arrested, along with 16 other people.
In late June, the DEA provided its final answer: No access.
In a letter addressed to Ms. Tucker, Thomas W. Prevoznik, the DEA’s deputy assistant administrator, said it “finds no basis” to reconsider its initial denial in February 2021 “because the legal and factual considerations remain unchanged.”
In an appeal, Ms. Tucker wrote: “In denying Petitioners’ requested accommodation in the Final Agency Action, DEA hides behind a smokescreen, neglecting its duty to implement the federal [Right to Try Act] and violating the state [Right to Try law].”
The government’s response is due in January 2023.
Ms. Tucker and her legal team also petitioned the DEA on behalf of Dr. Aggarwal to reschedule psilocybin from Schedule I to Schedule II.
The DEA defines Schedule I substances as “drugs with no currently accepted medical use and a high potential for abuse.” But the FDA has designated psilocybin as a breakthrough therapy for depression, which, Ms. Tucker noted, “reflects that there is a currently accepted medical use.”
Nevertheless, in September, the DEA denied Ms. Tucker’s petition to reschedule psilocybin, and her team is now petitioning the Ninth Circuit Court for a review of that decision.
Despite the setbacks, actions from the Biden administration and members of Congress could help improve access.
In July, Senators Cory Booker and Rand Paul introduced the Right to Try Clarification Act to clarify that the federal law includes Schedule I substances. If passed, Ms. Tucker said, it would negate the DEA’s “no access” argument.
And earlier this year, the Biden administration announced plans to establish a federal task force to address the “myriad of complex issues” associated with the anticipated FDA approval of psilocybin to treat depression. The task force will explore “the potential of psychedelic-assisted therapies” to tackle the mental health crisis as well as any “risks to public health” that “may require harm reduction, risk mitigation, and safety monitoring.”
The fight north of the border
In 2016, Canadian resident Thomas Hartle, then 48, awoke from surgery for a bowel obstruction to learn he had stage IV colon cancer.
After another surgery, his doctors believed the tumors were gone. But in 2019, the cancer came back, along with extreme anxiety and distress over his impending death and how his two special-needs children would cope.
Mr. Hartle wanted to try magic mushroom–assisted psychotherapy. The Saskatoon resident sought help from TheraPsil, a Canadian nonprofit organization that advocates for therapeutic psilocybin. They applied for access under Section 56, which allows health officials to exempt patients from certain provisions of drug law.
In 2020, Hartle became the first Canadian to legally obtain psilocybin-assisted therapy.
“It has been nothing short of life changing for me,” Mr. Hartle said at a palliative care conference in Saskatoon this past June. “I am now no longer actively dying. I feel like I am genuinely actively living.”
TheraPsil has obtained Section 56 exemptions for around 60 patients to access psilocybin-assisted therapy as well as 19 health care professionals who are training to become psilocybin-assisted therapists.
But then an election ushered in new health ministers, and in early 2022, the exemptions evaporated. Thousands of patients and health care practitioners on TheraPsil’s waiting list were left in limbo.
Health Canada told CBC News that the rule change came about because “while psilocybin has shown promise in clinical trials for the treatment of some indications, further research is still needed to determine its safety and efficacy.”
As an alternative, TheraPsil began applying for access under Canada’s Special Access Program, which is similar to Right to Try laws in the United States. But Canada’s program doesn’t apply to therapists in training, and the petition process is so slow that many patients die before requests can be approved.
“People like to pretend that the Special Access Program is not political, but it is very political,” said TheraPsil’s CEO, Spencer Hawkswell. “It means a patient and a doctor are asking a politician for access to their medicine, which is absolutely unacceptable.”
Now, TheraPsil is helping patients take the Canadian government to court. In July, Mr. Hartle and seven others with conditions ranging from cancer to chronic pain filed a lawsuit against Canada’s health ministry that challenges the limited legal pathways to the use of psilocybin. The lawsuit argues that patients have a “constitutional right to access psilocybin for medicinal purposes,” and it advocates for access to regulated psilocybin products from licensed dealers, much like Canada’s medical marijuana program already does.
In the filing, TheraPsil said that as of February 2022, it has a wait-list of more than 800 patients who are requesting help in obtaining psilocybin-assisted psychotherapy.
An uncertain future
Despite the groundswell of support, many unknowns remain about the safety of expanding access to psilocybin-assisted therapy.
When Oregon and Colorado launch their psilocybin programs in 2023, the licensed centers will provide testing grounds for the safety and efficacy of broader access to psilocybin for people with depression or terminal cancer as well as those looking to grow spiritually.
Although in clinical trials psilocybin has been found to ease symptoms of depression and end-of-life demoralization for people with life-threatening conditions, it has not been adequately tested in people with a range of mental health problems, traumas, and racial backgrounds.
That uncertainty has given some people pause. In recent months, some researchers and journalists have pushed back against the frenzy over the promise of psychedelics.
In September, David Yaden, PhD, a psychedelics researcher at Johns Hopkins, spoke at the Interdisciplinary Conference on Psychedelic Research in the Netherlands. He encouraged people to pay more attention to potential adverse effects of psychedelics, which could include anything from headaches to lingering dysphoria.
“Oftentimes, we hear only the positive anecdotes,” Dr. Yaden said. “We don’t hear ... neutral or negative ones. So, I think all of those anecdotes need to be part of the picture.”
A recent piece in Wired noted that mentioning the potential harms of psychedelics amid its renaissance has been “taboo,” but the authors cautioned that as clinical trials involving psychedelics grow larger and the drugs become commercialized, “more negative outcomes are likely to transpire.”
But Ms. Baldeschwiler remains steadfast in her pursuit. While it’s important to approach broader access to psychedelics with caution, “end-of-life patients don’t have time to wait,” she said.
A version of this article first appeared on Medscape.com.
In March 2020, when the world was struck by the news of the COVID-19 pandemic, Erinn Baldeschwiler received her own gut punch. She was diagnosed with stage IV metastatic breast cancer and was given about 2 years to live.
Then 48, the mother of two teenagers had just started a new chapter in her life. She’d gotten divorced, moved to a new home, and left a small business she had spent 18 years cultivating. The prospect that her life story might soon be ending, that she wouldn’t see her children grow up, was a twist of fate almost too devastating to bear.
“Are you kidding me that this is happening?” she thought.
But she also wanted to keep learning and growing in her remaining years, to devote them to creating meaningful memories, contemplating her mortality, and trying to find inner peace.
“The last 2 years have kind of been this dance with Lady Death,” she said.
They have also been a dance with Lady Justice.
In March 2021, Ms. Baldeschwiler, along with Michal Bloom, who also has terminal cancer, and their palliative care physician, Sunil Aggarwal, MD, PhD, decided to sue the Drug Enforcement Administration (DEA) for the right to access psilocybin, the psychoactive ingredient in “magic” mushrooms.
Psilocybin-assisted therapy has been shown to help terminally ill people overcome their fear, anxiety, and despair about death and to experience the kind of peace Ms. Baldeschwiler is seeking.
Psilocybin is illegal in the United States, but the plaintiffs argue they should be able to take the substance through the Right to Try Act. The 2018 federal law says that people with life-threatening conditions who have exhausted all approved treatment options can access drugs that have not yet been approved by the Food and Drug Administration but have passed phase 1 clinical trials.
This case marks the first time patients have fought to use a Schedule I drug under the Right to Try Act.
The push to expand access to psilocybin is picking up steam in the United States. In 2023, facilitated use of psilocybin will become legal in Oregon and Colorado. Recent proposals from the Biden administration and members of Congress could make psilocybin more widely accessible in the next few years.
It is also gaining momentum outside the United States. In Canada, patients are suing the government to help patients obtain psilocybin-assisted therapy for medical purposes.
“I think what we have here is a confluence of events that are driving toward the mandatory opening of a path to access psilocybin for therapeutic use sooner rather than later,” said Kathryn Tucker, lead counsel in the case against the DEA.
Reverberations of Right to Try
The story of Right to Try began with Abigail Burroughs, who was diagnosed with head and neck cancer at age 19.
After conventional therapies failed, Ms. Burroughs’ oncologist recommended cetuximab, a drug targeting EGFR that was experimental at the time. Because the drug was available only through colon cancer trials, she was denied access.
She died in 2001 at age 21.
Ms. Burroughs’ father, Frank Burroughs, formed an organization that in 2003 sued the FDA to provide terminally ill patients access to unapproved drugs. In 2005, they lost, and subsequent attempts to appeal the decision failed.
Still, the case sparked a Right to Try movement.
“Right to Try laws swept the U.S. in a firestorm,” Ms. Tucker said.
Along with the federal law, which passed in 2018, 41 states have enacted Right to Try laws.
The movement intrigued Dr. Aggarwal, codirector of the Advanced Integrative Medical Science (AIMS) Institute in Seattle. Dr. Aggarwal had been treating patients with cannabis, and after taking psilocybin himself and finding it therapeutic, he thought Ms. Baldeschwiler could benefit.
“I always knew that the powerful medicines within Schedule I had a significant role to play in healing,” he said. “That was baked into my decision to become a doctor, to research, and to innovate.”
He applied for the right to cultivate psilocybin mushrooms, but the fungus doesn’t meet Right to Try requirements. He then found a manufacturer willing to supply synthesized psilocybin, but because it’s a Schedule I drug, the manufacturer needed an okay from the DEA.
Dr. Aggarwal joined forces with Ms. Tucker, who has spent 35 years protecting the rights of terminally ill patients. In January 2021, Ms. Tucker contacted the DEA about allowing dying patients, including Ms. Baldeschwiler and Mr. Bloom, to access psilocybin-assisted therapy.
The response, she said, was predictable.
“The DEA’s knee always jerks in the direction of no access,” Ms. Tucker said. “So it said ‘no access.’ “
The reason: In a letter dated February 2021, the DEA said it “has no authority to waive” any requirements of the Controlled Substances Act under Right to Try laws.
Suing the DEA
Dr. Aggarwal and Ms. Tucker did not accept the DEA’s “no access” answer.
They decided to sue.
Dr. Aggarwal and Ms. Tucker took the matter to the Ninth Circuit Court in March 2021. In January 2022, the court dismissed the case after the DEA claimed its initial denial was not final.
The following month, the plaintiffs petitioned the DEA to deliver a concrete answer.
In May, while waiting for a response, demonstrators gathered at the DEA’s headquarters to call for legal access to psilocybin. One of the protesters was Ms. Baldeschwiler, who choked back tears as she told the crowd she was likely missing her last Mother’s Day with her children to attend the event. She was arrested, along with 16 other people.
In late June, the DEA provided its final answer: No access.
In a letter addressed to Ms. Tucker, Thomas W. Prevoznik, the DEA’s deputy assistant administrator, said it “finds no basis” to reconsider its initial denial in February 2021 “because the legal and factual considerations remain unchanged.”
In an appeal, Ms. Tucker wrote: “In denying Petitioners’ requested accommodation in the Final Agency Action, DEA hides behind a smokescreen, neglecting its duty to implement the federal [Right to Try Act] and violating the state [Right to Try law].”
The government’s response is due in January 2023.
Ms. Tucker and her legal team also petitioned the DEA on behalf of Dr. Aggarwal to reschedule psilocybin from Schedule I to Schedule II.
The DEA defines Schedule I substances as “drugs with no currently accepted medical use and a high potential for abuse.” But the FDA has designated psilocybin as a breakthrough therapy for depression, which, Ms. Tucker noted, “reflects that there is a currently accepted medical use.”
Nevertheless, in September, the DEA denied Ms. Tucker’s petition to reschedule psilocybin, and her team is now petitioning the Ninth Circuit Court for a review of that decision.
Despite the setbacks, actions from the Biden administration and members of Congress could help improve access.
In July, Senators Cory Booker and Rand Paul introduced the Right to Try Clarification Act to clarify that the federal law includes Schedule I substances. If passed, Ms. Tucker said, it would negate the DEA’s “no access” argument.
And earlier this year, the Biden administration announced plans to establish a federal task force to address the “myriad of complex issues” associated with the anticipated FDA approval of psilocybin to treat depression. The task force will explore “the potential of psychedelic-assisted therapies” to tackle the mental health crisis as well as any “risks to public health” that “may require harm reduction, risk mitigation, and safety monitoring.”
The fight north of the border
In 2016, Canadian resident Thomas Hartle, then 48, awoke from surgery for a bowel obstruction to learn he had stage IV colon cancer.
After another surgery, his doctors believed the tumors were gone. But in 2019, the cancer came back, along with extreme anxiety and distress over his impending death and how his two special-needs children would cope.
Mr. Hartle wanted to try magic mushroom–assisted psychotherapy. The Saskatoon resident sought help from TheraPsil, a Canadian nonprofit organization that advocates for therapeutic psilocybin. They applied for access under Section 56, which allows health officials to exempt patients from certain provisions of drug law.
In 2020, Hartle became the first Canadian to legally obtain psilocybin-assisted therapy.
“It has been nothing short of life changing for me,” Mr. Hartle said at a palliative care conference in Saskatoon this past June. “I am now no longer actively dying. I feel like I am genuinely actively living.”
TheraPsil has obtained Section 56 exemptions for around 60 patients to access psilocybin-assisted therapy as well as 19 health care professionals who are training to become psilocybin-assisted therapists.
But then an election ushered in new health ministers, and in early 2022, the exemptions evaporated. Thousands of patients and health care practitioners on TheraPsil’s waiting list were left in limbo.
Health Canada told CBC News that the rule change came about because “while psilocybin has shown promise in clinical trials for the treatment of some indications, further research is still needed to determine its safety and efficacy.”
As an alternative, TheraPsil began applying for access under Canada’s Special Access Program, which is similar to Right to Try laws in the United States. But Canada’s program doesn’t apply to therapists in training, and the petition process is so slow that many patients die before requests can be approved.
“People like to pretend that the Special Access Program is not political, but it is very political,” said TheraPsil’s CEO, Spencer Hawkswell. “It means a patient and a doctor are asking a politician for access to their medicine, which is absolutely unacceptable.”
Now, TheraPsil is helping patients take the Canadian government to court. In July, Mr. Hartle and seven others with conditions ranging from cancer to chronic pain filed a lawsuit against Canada’s health ministry that challenges the limited legal pathways to the use of psilocybin. The lawsuit argues that patients have a “constitutional right to access psilocybin for medicinal purposes,” and it advocates for access to regulated psilocybin products from licensed dealers, much like Canada’s medical marijuana program already does.
In the filing, TheraPsil said that as of February 2022, it has a wait-list of more than 800 patients who are requesting help in obtaining psilocybin-assisted psychotherapy.
An uncertain future
Despite the groundswell of support, many unknowns remain about the safety of expanding access to psilocybin-assisted therapy.
When Oregon and Colorado launch their psilocybin programs in 2023, the licensed centers will provide testing grounds for the safety and efficacy of broader access to psilocybin for people with depression or terminal cancer as well as those looking to grow spiritually.
Although in clinical trials psilocybin has been found to ease symptoms of depression and end-of-life demoralization for people with life-threatening conditions, it has not been adequately tested in people with a range of mental health problems, traumas, and racial backgrounds.
That uncertainty has given some people pause. In recent months, some researchers and journalists have pushed back against the frenzy over the promise of psychedelics.
In September, David Yaden, PhD, a psychedelics researcher at Johns Hopkins, spoke at the Interdisciplinary Conference on Psychedelic Research in the Netherlands. He encouraged people to pay more attention to potential adverse effects of psychedelics, which could include anything from headaches to lingering dysphoria.
“Oftentimes, we hear only the positive anecdotes,” Dr. Yaden said. “We don’t hear ... neutral or negative ones. So, I think all of those anecdotes need to be part of the picture.”
A recent piece in Wired noted that mentioning the potential harms of psychedelics amid its renaissance has been “taboo,” but the authors cautioned that as clinical trials involving psychedelics grow larger and the drugs become commercialized, “more negative outcomes are likely to transpire.”
But Ms. Baldeschwiler remains steadfast in her pursuit. While it’s important to approach broader access to psychedelics with caution, “end-of-life patients don’t have time to wait,” she said.
A version of this article first appeared on Medscape.com.
In March 2020, when the world was struck by the news of the COVID-19 pandemic, Erinn Baldeschwiler received her own gut punch. She was diagnosed with stage IV metastatic breast cancer and was given about 2 years to live.
Then 48, the mother of two teenagers had just started a new chapter in her life. She’d gotten divorced, moved to a new home, and left a small business she had spent 18 years cultivating. The prospect that her life story might soon be ending, that she wouldn’t see her children grow up, was a twist of fate almost too devastating to bear.
“Are you kidding me that this is happening?” she thought.
But she also wanted to keep learning and growing in her remaining years, to devote them to creating meaningful memories, contemplating her mortality, and trying to find inner peace.
“The last 2 years have kind of been this dance with Lady Death,” she said.
They have also been a dance with Lady Justice.
In March 2021, Ms. Baldeschwiler, along with Michal Bloom, who also has terminal cancer, and their palliative care physician, Sunil Aggarwal, MD, PhD, decided to sue the Drug Enforcement Administration (DEA) for the right to access psilocybin, the psychoactive ingredient in “magic” mushrooms.
Psilocybin-assisted therapy has been shown to help terminally ill people overcome their fear, anxiety, and despair about death and to experience the kind of peace Ms. Baldeschwiler is seeking.
Psilocybin is illegal in the United States, but the plaintiffs argue they should be able to take the substance through the Right to Try Act. The 2018 federal law says that people with life-threatening conditions who have exhausted all approved treatment options can access drugs that have not yet been approved by the Food and Drug Administration but have passed phase 1 clinical trials.
This case marks the first time patients have fought to use a Schedule I drug under the Right to Try Act.
The push to expand access to psilocybin is picking up steam in the United States. In 2023, facilitated use of psilocybin will become legal in Oregon and Colorado. Recent proposals from the Biden administration and members of Congress could make psilocybin more widely accessible in the next few years.
It is also gaining momentum outside the United States. In Canada, patients are suing the government to help patients obtain psilocybin-assisted therapy for medical purposes.
“I think what we have here is a confluence of events that are driving toward the mandatory opening of a path to access psilocybin for therapeutic use sooner rather than later,” said Kathryn Tucker, lead counsel in the case against the DEA.
Reverberations of Right to Try
The story of Right to Try began with Abigail Burroughs, who was diagnosed with head and neck cancer at age 19.
After conventional therapies failed, Ms. Burroughs’ oncologist recommended cetuximab, a drug targeting EGFR that was experimental at the time. Because the drug was available only through colon cancer trials, she was denied access.
She died in 2001 at age 21.
Ms. Burroughs’ father, Frank Burroughs, formed an organization that in 2003 sued the FDA to provide terminally ill patients access to unapproved drugs. In 2005, they lost, and subsequent attempts to appeal the decision failed.
Still, the case sparked a Right to Try movement.
“Right to Try laws swept the U.S. in a firestorm,” Ms. Tucker said.
Along with the federal law, which passed in 2018, 41 states have enacted Right to Try laws.
The movement intrigued Dr. Aggarwal, codirector of the Advanced Integrative Medical Science (AIMS) Institute in Seattle. Dr. Aggarwal had been treating patients with cannabis, and after taking psilocybin himself and finding it therapeutic, he thought Ms. Baldeschwiler could benefit.
“I always knew that the powerful medicines within Schedule I had a significant role to play in healing,” he said. “That was baked into my decision to become a doctor, to research, and to innovate.”
He applied for the right to cultivate psilocybin mushrooms, but the fungus doesn’t meet Right to Try requirements. He then found a manufacturer willing to supply synthesized psilocybin, but because it’s a Schedule I drug, the manufacturer needed an okay from the DEA.
Dr. Aggarwal joined forces with Ms. Tucker, who has spent 35 years protecting the rights of terminally ill patients. In January 2021, Ms. Tucker contacted the DEA about allowing dying patients, including Ms. Baldeschwiler and Mr. Bloom, to access psilocybin-assisted therapy.
The response, she said, was predictable.
“The DEA’s knee always jerks in the direction of no access,” Ms. Tucker said. “So it said ‘no access.’ “
The reason: In a letter dated February 2021, the DEA said it “has no authority to waive” any requirements of the Controlled Substances Act under Right to Try laws.
Suing the DEA
Dr. Aggarwal and Ms. Tucker did not accept the DEA’s “no access” answer.
They decided to sue.
Dr. Aggarwal and Ms. Tucker took the matter to the Ninth Circuit Court in March 2021. In January 2022, the court dismissed the case after the DEA claimed its initial denial was not final.
The following month, the plaintiffs petitioned the DEA to deliver a concrete answer.
In May, while waiting for a response, demonstrators gathered at the DEA’s headquarters to call for legal access to psilocybin. One of the protesters was Ms. Baldeschwiler, who choked back tears as she told the crowd she was likely missing her last Mother’s Day with her children to attend the event. She was arrested, along with 16 other people.
In late June, the DEA provided its final answer: No access.
In a letter addressed to Ms. Tucker, Thomas W. Prevoznik, the DEA’s deputy assistant administrator, said it “finds no basis” to reconsider its initial denial in February 2021 “because the legal and factual considerations remain unchanged.”
In an appeal, Ms. Tucker wrote: “In denying Petitioners’ requested accommodation in the Final Agency Action, DEA hides behind a smokescreen, neglecting its duty to implement the federal [Right to Try Act] and violating the state [Right to Try law].”
The government’s response is due in January 2023.
Ms. Tucker and her legal team also petitioned the DEA on behalf of Dr. Aggarwal to reschedule psilocybin from Schedule I to Schedule II.
The DEA defines Schedule I substances as “drugs with no currently accepted medical use and a high potential for abuse.” But the FDA has designated psilocybin as a breakthrough therapy for depression, which, Ms. Tucker noted, “reflects that there is a currently accepted medical use.”
Nevertheless, in September, the DEA denied Ms. Tucker’s petition to reschedule psilocybin, and her team is now petitioning the Ninth Circuit Court for a review of that decision.
Despite the setbacks, actions from the Biden administration and members of Congress could help improve access.
In July, Senators Cory Booker and Rand Paul introduced the Right to Try Clarification Act to clarify that the federal law includes Schedule I substances. If passed, Ms. Tucker said, it would negate the DEA’s “no access” argument.
And earlier this year, the Biden administration announced plans to establish a federal task force to address the “myriad of complex issues” associated with the anticipated FDA approval of psilocybin to treat depression. The task force will explore “the potential of psychedelic-assisted therapies” to tackle the mental health crisis as well as any “risks to public health” that “may require harm reduction, risk mitigation, and safety monitoring.”
The fight north of the border
In 2016, Canadian resident Thomas Hartle, then 48, awoke from surgery for a bowel obstruction to learn he had stage IV colon cancer.
After another surgery, his doctors believed the tumors were gone. But in 2019, the cancer came back, along with extreme anxiety and distress over his impending death and how his two special-needs children would cope.
Mr. Hartle wanted to try magic mushroom–assisted psychotherapy. The Saskatoon resident sought help from TheraPsil, a Canadian nonprofit organization that advocates for therapeutic psilocybin. They applied for access under Section 56, which allows health officials to exempt patients from certain provisions of drug law.
In 2020, Hartle became the first Canadian to legally obtain psilocybin-assisted therapy.
“It has been nothing short of life changing for me,” Mr. Hartle said at a palliative care conference in Saskatoon this past June. “I am now no longer actively dying. I feel like I am genuinely actively living.”
TheraPsil has obtained Section 56 exemptions for around 60 patients to access psilocybin-assisted therapy as well as 19 health care professionals who are training to become psilocybin-assisted therapists.
But then an election ushered in new health ministers, and in early 2022, the exemptions evaporated. Thousands of patients and health care practitioners on TheraPsil’s waiting list were left in limbo.
Health Canada told CBC News that the rule change came about because “while psilocybin has shown promise in clinical trials for the treatment of some indications, further research is still needed to determine its safety and efficacy.”
As an alternative, TheraPsil began applying for access under Canada’s Special Access Program, which is similar to Right to Try laws in the United States. But Canada’s program doesn’t apply to therapists in training, and the petition process is so slow that many patients die before requests can be approved.
“People like to pretend that the Special Access Program is not political, but it is very political,” said TheraPsil’s CEO, Spencer Hawkswell. “It means a patient and a doctor are asking a politician for access to their medicine, which is absolutely unacceptable.”
Now, TheraPsil is helping patients take the Canadian government to court. In July, Mr. Hartle and seven others with conditions ranging from cancer to chronic pain filed a lawsuit against Canada’s health ministry that challenges the limited legal pathways to the use of psilocybin. The lawsuit argues that patients have a “constitutional right to access psilocybin for medicinal purposes,” and it advocates for access to regulated psilocybin products from licensed dealers, much like Canada’s medical marijuana program already does.
In the filing, TheraPsil said that as of February 2022, it has a wait-list of more than 800 patients who are requesting help in obtaining psilocybin-assisted psychotherapy.
An uncertain future
Despite the groundswell of support, many unknowns remain about the safety of expanding access to psilocybin-assisted therapy.
When Oregon and Colorado launch their psilocybin programs in 2023, the licensed centers will provide testing grounds for the safety and efficacy of broader access to psilocybin for people with depression or terminal cancer as well as those looking to grow spiritually.
Although in clinical trials psilocybin has been found to ease symptoms of depression and end-of-life demoralization for people with life-threatening conditions, it has not been adequately tested in people with a range of mental health problems, traumas, and racial backgrounds.
That uncertainty has given some people pause. In recent months, some researchers and journalists have pushed back against the frenzy over the promise of psychedelics.
In September, David Yaden, PhD, a psychedelics researcher at Johns Hopkins, spoke at the Interdisciplinary Conference on Psychedelic Research in the Netherlands. He encouraged people to pay more attention to potential adverse effects of psychedelics, which could include anything from headaches to lingering dysphoria.
“Oftentimes, we hear only the positive anecdotes,” Dr. Yaden said. “We don’t hear ... neutral or negative ones. So, I think all of those anecdotes need to be part of the picture.”
A recent piece in Wired noted that mentioning the potential harms of psychedelics amid its renaissance has been “taboo,” but the authors cautioned that as clinical trials involving psychedelics grow larger and the drugs become commercialized, “more negative outcomes are likely to transpire.”
But Ms. Baldeschwiler remains steadfast in her pursuit. While it’s important to approach broader access to psychedelics with caution, “end-of-life patients don’t have time to wait,” she said.
A version of this article first appeared on Medscape.com.
‘No one’s talking about it’: Infertility and one specialty’s onerous board exams
It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.
The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.
“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”
The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.
The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.
“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”
However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.
The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.
But will the changes last? And will they help reduce the burden these exams place on families and family planning?
Inside board certification before the pandemic
While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.
Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.
“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.
“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”
For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
A balancing act: Board exams and family planning
Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.
She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.
While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.
“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”
During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.
This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.
One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.
“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”
Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.
“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”
This pressure to push through can be intense.
Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.
Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.
Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.
“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”
Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.
This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.
But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.
Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.
According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.
In other words, when it comes to family planning, there’s often no good option.
Change on the horizon
When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.
By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.
The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.
For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.
“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.
Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.
Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”
Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.
“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”
Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.
“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.”
The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.
Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.
“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”
Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”
The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.
“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”
A version of this article first appeared on Medscape.com.
It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.
The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.
“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”
The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.
The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.
“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”
However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.
The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.
But will the changes last? And will they help reduce the burden these exams place on families and family planning?
Inside board certification before the pandemic
While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.
Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.
“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.
“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”
For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
A balancing act: Board exams and family planning
Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.
She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.
While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.
“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”
During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.
This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.
One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.
“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”
Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.
“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”
This pressure to push through can be intense.
Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.
Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.
Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.
“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”
Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.
This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.
But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.
Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.
According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.
In other words, when it comes to family planning, there’s often no good option.
Change on the horizon
When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.
By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.
The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.
For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.
“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.
Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.
Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”
Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.
“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”
Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.
“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.”
The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.
Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.
“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”
Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”
The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.
“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”
A version of this article first appeared on Medscape.com.
It would be impossible for her to fly the 2,500 miles from New York to the test site in Tucson, Ariz., when she could go into labor at any moment. She asked the American Board of Radiology – which oversees the process – if she could take the oral exam on Zoom or shift the timing a few weeks earlier or later.
The response: If she decided not to sit for the exam in person on the date specified, she would have to wait an entire year for the next test.
“I felt: Angry. Sad. Helpless. Inconsequential,” Dr. Dover tweeted. “But I will not be silent.”
The experience motivated Dr. Dover and six colleagues to conduct a study about how radiation oncology’s onerous four-exam board certification process has disproportionately burdened women.
The study, published online in Practical Radiation Oncology on Nov. 3, 2021, revealed that almost 60% of the early-career female radiation oncologists surveyed had delayed or were timing their pregnancies to accommodate their board exams. Women who chose to delay pregnancy were 2.5 times more likely to experience infertility.
“When we started doing the study, we didn’t realize just how common it was for people to wrap so much of their [family planning decisions] around taking these board exams,” said study coauthor Adrianna Henson Masters, MD, a radiation oncologist at Springfield (Ill.) Clinic. “How crazy is that? And no one’s talking about it.”
However, once the study appeared online, physicians took to Twitter to comment on the challenges of the board certification process, while others demanded change. One radiation oncologist even shared her decision not to have a child until she passed her board exams.
The study also got the attention of the American Board of Radiology, which governs certification for the specialty. In a response, leaders of the organization agreed that “the issues raised are significant and worthy of thoughtful consideration” and highlighted how, in light of the COVID-19 pandemic, the board has provided greater flexibility to the exam process – transitioning to remote testing and offering two dates for each exam in 2021.
But will the changes last? And will they help reduce the burden these exams place on families and family planning?
Inside board certification before the pandemic
While other specialties require one or two exams for board certification, radiation oncology is the only medical field that requires candidates pass four exams – three qualifying written tests, followed by a certifying oral exam. Since 2004, these exams, which cover physics, radiation biology, and clinical radiation oncology, have taken place over 3 years at specific locations across the country.
Radiation oncology residents have reported spending hundreds of hours preparing for each of these high-stakes evaluations. Fail or miss one and an already time-consuming process draws out, with major repercussions for career advancement and earnings.
“Passing and achieving board certification is the capstone of medical specialty training and, for many, is a prerequisite for attaining partnership or a promotion,” said study coauthor Chelain Goodman, MD, PhD, a radiation oncologist at the University of Texas MD Anderson Cancer Center, Houston.
To top it off, this process may be contributing to the gender disparity in radiation oncology, the study suggests. Only 25%-30% of practicing radiation oncologists are women, making it one of the lowest-ranking specialties when it comes to female representation.
“I think [this exam process] creates some disincentive when female medical students see that these are issues that early-career radiation oncologists are facing,” said Dr. Dover, who practices at Memorial Sloan Kettering Cancer Center, New York. “[Students may instead] choose a specialty that they believe will be more supportive of them and their family planning goals. That’s definitely a big concern for a field that wants to attract the top candidates.”
For those who do pick radiation oncology, the system of board exams often requires prospective parents to choose among three options: Try to time delivery before or between exams, put off pregnancy or adoption until exams are done, or delay board certification.
A balancing act: Board exams and family planning
Like Dr. Dover, Dr. Masters opted for door No. 1. She tried to time the birth of her daughter to fall several months before her first board exam.
She hoped her careful planning would reduce the stress of both major life events. But that was not the case. At 35 weeks, Dr. Masters found herself in the hospital with preeclampsia and symptomatic hypertension.
While receiving a magnesium sulfate drip to prevent a seizure, she frantically typed her patient list before her vision got too blurry to see the screen.
“That is ridiculous,” Dr. Masters said. “But so is a system that makes this the expectation [for pregnant physicians].”
During her hospital stay, Dr. Masters was induced. She suspects the stress of prepping for the board exam coupled with being pregnant and continuing to work long hours as a resident contributed to her pregnancy complications.
This juggling act can bleed into exam day as well. When interviewing women for their study, Dr. Masters and colleagues uncovered personal accounts of the challenges pregnant women and new mothers faced during their exams.
One woman described being granted lactation accommodation ahead of time, but when she arrived for her first two written exams, the testing center had no record of her request. She ended up breast-pumping in a coat closet next to the cleaning supplies while her male coresidents ate lunch and reviewed their notes.
“I started my physics exam in tears, completely anxious,” she reported. “I didn’t get to eat lunch. I was physically uncomfortable and emotionally wiped during both exams.”
Another woman had contractions during her written clinical boards, but “thankfully” passed her exam and gave birth 2 days later.
“It might sound crazy that we would put ourselves through things like that just to take an exam,” Dr. Dover said. “But because it does have the potential to sharply shape our early professional trajectory, we push through it. Otherwise, we’re going to be left behind by our male peers.”
This pressure to push through can be intense.
Still recovering from a difficult pregnancy, Dr. Masters returned to work when her daughter was just 5 weeks old. Although not ready to return to work, she felt too scared to ask for more time off after seeing other new mothers receive negative comments about not working hard enough.
Enter door No. 2: The pregnancy and postpregnancy experiences were so traumatizing that she decided to put off trying for a second child until after her exams.
Now board certified and 38 years old, Dr. Masters is worried she won’t be able to conceive as easily as before.
“So, we’re stuck in limbo, starting the process again and being nervous about it because what if it’s not so easy at this age?” she said. “And what if it could have been easy, in different circumstances, with a different specialty?”
Dr. Masters’ concerns are justified. Of the 126 women interviewed for the study, those who delayed pregnancy because of the board exams were significantly more likely to have fertility problems (46% vs. 18%), and 20% reported experiencing infertility.
This finding dovetails with previous research showing that almost 25% of female physicians who attempt to become pregnant are diagnosed with infertility – nearly twice the rate of the general population. This high rate of infertility has been attributed to professional pressures and stress, long hours on the job, and delaying pregnancy during medical training.
But choosing door No. 3 – focusing on family over exams – has downsides as well. Board certification is a prerequisite for almost every partnership position or promotion track within academic medicine and delaying certification can significantly hinder a physician’s career and finances.
Radiation oncologists who aren’t certified often remain in salaried positions until they can make partnership and earn a portion of the practice’s profits, “which could easily change your annual compensation by six digits,” Dr. Dover said.
According to the team’s study, annual compensation typically increases by $30,000-$50,000 after board certification, with some reporting an increase of over $100,000. That salary hike also impacts physicians’ ability to pay off medical school loans, make financial investments, and afford the cost of childcare.
In other words, when it comes to family planning, there’s often no good option.
Change on the horizon
When the pandemic struck, the American Board of Radiology quickly went into triage mode, postponing in-person board certification exams scheduled in 2020 and brainstorming solutions.
By June, the organization announced that the exams would switch to a virtual format in 2021. Each test would be offered twice – once early in the year for candidates like Dover whose postponed 2020 exams had ultimately been canceled, and then again for those already planning to take their tests in 2021.
The shift to remote testing was a boon. Taking the tests from home not only allowed candidates to forgo the cost, stress, and time of travel, it also mitigated the burden of juggling pregnancy and parenting needs.
For example, Courtney Hentz, MD, a pediatric radiation oncologist at Loyola University Chicago, Maywood, Ill., and a study coauthor, was given the choice to take a virtual exam in one day with two breastfeeding breaks or to spread the exam over 2 days with one breastfeeding break each day.
“Transitioning exams to a virtual format has been a really big achievement that the American Board of Radiology should be applauded for,” Dr. Dover said.
Not only that, offering the exams multiple times a year has “significantly increased flexibility for candidates as they juggle completing residency, starting at their first practice, and balancing time with their family,” Dr. Goodman added.
Brent Wagner, MD, MBA, executive director of the American Board of Radiology, Tucson, Ariz., said in an interviewthat remote exams are here to stay. “I don’t foresee us ever going back to in-person board exams,” said Dr. Wagner, a diagnostic radiologist. “Administering exams remotely last year worked better than I could have expected.”
Dr. Wagner said the American Board of Radiology also plans to keep two dates for the oral certifying exam for the foreseeable future, though will revert to one date for the written qualifying exams.
“In a perfect world, we’d offer an exam every quarter,” he said. However, providing multiple dates for the written exams “is not practical with a cohort of a few hundred people,” given the staff resources needed to create and score twice the number of items each year. The board did not rule out reassessing this decision in the future, “as examination development software improves and more resources become available.”
Another big change, proposed by Dr. Dover, Dr. Goodman, and others, would be to combine the four exams into fewer tests, such as consolidating the three written exams into one. Such a shift would allow physicians to launch their careers sooner and begin focusing on other career-advancing endeavors such as research and publishing. It would also significantly improve radiation oncologists’ quality of life.
“The amount of time that you spend studying for these very high-level, high-stakes exams really puts a toll on your mental health,” Dr. Dover said. “The longer it’s dragged out, the longer you’re dealing with that, and it contributes tremendously to poor job satisfaction and work-life balance.”
The American Board of Radiology said it is discussing options for consolidating the exams, but the challenge with combining the three written exams into one comes down to scoring. “We need to get a statistically valid result in all three categories,” Dr. Wagner said.
Another recent change: The American Board of Radiology is now allowing residents flexibility on the sequence of the written exams.
“In the past, we said you had to pass the physics exam before moving on to clinical radiology, but now we’re letting residents decide the order for themselves,” Dr. Wagner said. “This change may introduce more flexibility for someone who missed their first opportunity to take the physics exam but is ready to take the clinical exam.”
Dr. Wagner added: “We’re learning as we go, and I tell our staff that there’s no reason we should think we’re done making improvements. It’s going to keep getting better.”
The recent changes have already made a difference to radiation oncologists. And many hope to build on this new foundation to move the specialty toward a more family-friendly, equitable culture.
“I think as people in a caregiver profession, it’s hard to prioritize doing things for yourself or your own family sometimes; it’s hard to speak up and say: ‘We need something different,’ ” Dr. Masters said. “I think we have [an opportunity] to capitalize on the momentum we have now.”
A version of this article first appeared on Medscape.com.
Are oncologists any better at facing their own mortality?
Douglas Flora, MD, an oncologist with St. Elizabeth Healthcare, in Edgewood, Ky., considers himself a deep empath. It’s one reason he became an oncologist.
But when he was diagnosed with kidney cancer in 2017, he was shocked at the places his brain took him. His mind fast-forwarded through treatment options, statistical probabilities, and anguish over his wife and children.
“It’s a very surreal experience,” Dr. Flora said. “In 20 seconds, you go from diagnostics to, ‘What videos will I have to film for my babies?’ “
He could be having a wonderful evening surrounded by friends, music, and beer. Then he would go to the restroom and the realization of what was lurking inside his would body hit him like a brick.
“It’s like the scene in the Harry Potter movies where the Dementors fly over,” he explained. “Everything feels dark. There’s no hope. Everything you thought was good is gone.”
Oncologists counsel patients through life-threatening diagnoses and frightening decisions every day, so one might think they’d be ready to confront their own diagnosis, treatment, and mortality better than anyone. But that’s not always the case.
Does their expertise equip them to navigate their diagnosis and treatment better than their patients? How does the emotional toll of their personal cancer journey change the way they interact with their patients?
Navigating the diagnosis and treatment
In January 2017, Karen Hendershott, MD, a breast surgical oncologist, felt a lump in her armpit while taking a shower. The blunt force of her fate came into view in an instant: It was almost certainly a locally advanced breast cancer that had spread to her lymph nodes and would require surgery, radiotherapy, and chemotherapy.
She said a few unprintable words and headed to work at St. Mary’s Hospital, in Tucson, Ariz., where her assumptions were confirmed.
Taylor Riall, MD, PhD, also suspected cancer.
Last December, Dr. Riall, a general surgeon and surgical oncologist at the University of Arizona Cancer Center, in Tucson, developed a persistent cough. An x-ray revealed a mass in her lung. Initially, she was misdiagnosed with a fungal infection and was given medication that made her skin peel off.
Doctors advised Dr. Riall to monitor her condition for another 6 months. But her knowledge of oncology made her think cancer, so she insisted on more tests. In June 2021, a biopsy confirmed she had lung cancer.
Having oncology expertise helped Dr. Riall and Dr. Hendershott recognize the signs of cancer and push for a diagnosis. But there are also downsides to being hyper-informed, Dr. Hendershott, said.
“I think sometimes knowing everything at once is harder vs. giving yourself time to wrap your mind around this and do it in baby steps,” she explained. “There weren’t any baby steps here.”
Still, oncology practitioners who are diagnosed with cancer are navigating a familiar landscape and are often buoyed by a support network of expert colleagues. That makes a huge difference psychologically, explained Shenitha Edwards, a pharmacy technician at Cancer Specialists of North Florida, in Jacksonville, who was diagnosed with breast cancer in July.
“I felt stronger and a little more ready to fight because I had resources, whereas my patients sometimes do not,” Ms. Edwards said. “I was connected with a lot of people who could help me make informed decisions, so I didn’t have to walk so much in fear.”
It can also prepare practitioners to make bold treatment choices. In Dr. Riall’s case, surgeons were reluctant to excise her tumor because they would have to remove the entire upper lobe of her lung, and she is a marathoner and triathlete. Still, because of her surgical oncology experience, Dr. Riall didn’t flinch at the prospect of a major operation.
“I was, like, ‘Look, just take it out.’ I’m less afraid to have cancer than I am to not know and let it grow,” said Dr. Riall, whose Peloton name is WhoNeeds2Lungs.
Similarly, Dr. Hendershott’s experience gave her the assurance to pursue a more intense strategy. “Because I had a really candid understanding of the risks and what the odds looked like, it helped me be more comfortable with a more aggressive approach,” she said. “There wasn’t a doubt in my mind, particularly [having] a 10-year-old child, that I wanted to do everything I could, and even do a couple of things that were still in clinical trials.”
Almost paradoxically, Mark Lewis’ oncology training gave him the courage to risk watching and waiting after finding benign growths in his parathyroid and malignant tumors in his pancreas. Dr. Lewis monitored the tumors amassing in his pancreas for 8 years. When some grew so large they threatened to metastasize to his liver, he underwent the Whipple procedure to remove the head of the pancreas, part of the small intestine, and the gallbladder.
“It was a bit of a gamble, but one that paid off and allowed me to get my career off the ground and have another child,” said Dr. Lewis, a gastrointestinal oncologist at Intermountain Healthcare, in Salt Lake City. Treating patients for nearly a decade also showed him how fortunate he was to have a slow-growing, operable cancer. That gratitude, he said, gave him mental strength to endure the ordeal.
Whether taking a more aggressive or minimalist approach to their own care, each practitioner’s decision was deeply personal and deeply informed by their oncology expertise.
Although research on this question is scarce, studies show that differences in end-of-life care may occur. According to a 2016 study published in JAMA, physicians choose significantly less intensive end-stage care in three of five categories — undergoing surgery, being admitted to the intensive care unit (ICU), and dying in the hospital — than the general U.S. population. The reason, the researchers posited, is because doctors know these eleventh-hour interventions are typically brutal and futile.
But these differences were fairly small, and a 2019 study published in JAMA Open Network found the opposite: Physicians with cancer were more likely to die in an ICU and receive chemotherapy in the last 6 months of life, suggesting a more aggressive approach to end-of-life care.
When it comes to their own long-term or curative cancer care, oncologists generally don’t seem to approach treatment differently than their patients. In a 2015 study, researchers compared two groups of people with early breast cancer — 46 physicians and 230 well-educated, nonmedically qualified patients — and found no differences in the choices the groups made about whether to undergo mastectomy, chemotherapy, radiotherapy, or breast reconstruction.
Still, no amount of oncology expertise can fully prepare a person for the emotional crucible of cancer.
“A very surreal experience”
Although the fear can become less intense and more manageable over time, it may never truly go away.
At first, despair dragged Flora into an abyss for 6 hours a night, then overcame him 10 times a day, then gripped him briefly at random moments. Four years later and cancer-free, the dread still returns.
Hendershott cried every time she got into her car and contemplated her prognosis. Now 47, she has about a 60% chance of being alive in 15 years, and the fear still hits her.
“I think it’s hard to understand the moments of sheer terror that you have at 2 AM when you’re confronting your own mortality,” she said. “The implications that has not just for you but more importantly for the people that you love and want to protect. That just kind of washes over you in waves that you don’t have much control over.”
Cancer, Riall felt, had smashed her life, but she figured out a way to help herself cope. Severe blood loss, chest tubes, and tests and needles ad nauseum left Riall feeling excruciatingly exhausted after her surgery and delayed her return to work. At the same time, she was passed over for a promotion. Frustrated and dejected, she took comfort in the memory of doing Kintsugi with her surgery residents. The Japanese art form involves shattering pottery with a hammer, fitting the fragments back together, and painting the cracks gold.
“My instinct as a surgeon is to pick up those pieces and put them back together so nobody sees it’s broken,” she reflected. But as a patient, she learned that an important part of recovery is to allow yourself to sit in a broken state and feel angry, miserable, and betrayed by your body. And then examine your shattered priorities and consider how you want to reassemble them.
For Barbara Buttin, MD, a gynecologic oncologist at Cancer Treatment Centers of America, in Chicago, Illinois, it wasn’t cancer that almost took her life. Rather, a near-death experience and life-threatening diagnosis made her a better, more empathetic cancer doctor — a refrain echoed by many oncologist-patients. Confronting her own mortality crystallized what matters in life. She uses that understanding to make sure she understands what matters to her patients ― what they care about most, what their greatest fear is, what is going to keep them up at night.
“We’re part of the same club”
Ultimately, when oncology practitioners become patients, it balances the in-control and vulnerable, the rational and emotional. And their patients respond positively.
In fall 2020, oncology nurse Jenn Adams, RN, turned 40 and underwent her first mammogram. Unexpectedly, it revealed invasive stage I cancer that would require a double mastectomy, chemotherapy, and a year of immunotherapy. A week after her diagnosis, she was scheduled to start a new job at Cancer Clinic, in Bryan, Tex. So, she asked her manager if she could become a patient and an employee.
Ms. Adams worked 5 days a week, but every Thursday at 2 PM, she sat next to her patients while her coworkers became her nurses. Her chemo port was implanted, she lost her hair, and she felt terrible along with her patients. “It just created this incredible bond,” said the mother of three.
Having cancer, Dr. Flora said, “was completely different than I had imagined. When I thought I was walking with [my patients] in the depths of their caves, I wasn’t even visiting their caves.” But, he added, it has also “let me connect with [patients] on a deeper level because we’re part of the same club. You can see their body language change when I share that. They almost relax, like, ‘Oh, this guy gets it. He does understand how terrified I am.’ And I do.”
When Dr. Flora’s patients are scanned, he gives them their results immediately, because he knows what it’s like to wait on tenterhooks. He tells his patients to text him anytime they’re afraid or depressed, which he admits isn’t great for his own mental health but believes is worth it.
Likewise, Dr. Hendershott can hold out her shoulder-length locks to reassure a crying patient that hair does grow back after chemo. She can describe her experience with hormone-blocking pills to allay the fears of a pharmaceutical skeptic.
This role equalizer fosters so much empathy that doctors sometimes find themselves being helped by their patients. When one of Dr. Flora’s patients heard he had cancer, she sent him an email that began. “A wise doctor once told me....” and repeated the advice he’d given her years before.
Dr. Lewis has a special bond with his patients because people who have pancreatic neuroendocrine tumors seek him out for treatment. “I’m getting to take care of people who, on some level, are like my kindred spirits,” he said. “So, I get to see their coping mechanisms and how they do.”
Ms. Edwards told some of her patients about her breast cancer diagnosis, and now they give each other high-fives and share words of encouragement. “I made it a big thing of mine to associate my patients as my family,” she said. “If you’ve learned to embrace love and love people, there’s nothing you wouldn’t do for people. I’ve chosen that to be my practice when I’m dealing with all of my patients.”
Ms. Adams is on a similar mission. She joined a group of moms with cancer so she can receive guidance and then become a guide for others. “I feel like that’s what I want to be at my cancer practice,” she said, “so [my patients] have someone to say, ‘I’m gonna walk alongside you because I’ve been there.’ “
That transformation has made all the heartbreaking moments worth it, Ms. Adams said. “I love the oncology nurse that I get to be now because of my diagnosis. I don’t love the diagnosis. But I love the way it’s changed what I do.”
A version of this article first appeared on Medscape.com.
Douglas Flora, MD, an oncologist with St. Elizabeth Healthcare, in Edgewood, Ky., considers himself a deep empath. It’s one reason he became an oncologist.
But when he was diagnosed with kidney cancer in 2017, he was shocked at the places his brain took him. His mind fast-forwarded through treatment options, statistical probabilities, and anguish over his wife and children.
“It’s a very surreal experience,” Dr. Flora said. “In 20 seconds, you go from diagnostics to, ‘What videos will I have to film for my babies?’ “
He could be having a wonderful evening surrounded by friends, music, and beer. Then he would go to the restroom and the realization of what was lurking inside his would body hit him like a brick.
“It’s like the scene in the Harry Potter movies where the Dementors fly over,” he explained. “Everything feels dark. There’s no hope. Everything you thought was good is gone.”
Oncologists counsel patients through life-threatening diagnoses and frightening decisions every day, so one might think they’d be ready to confront their own diagnosis, treatment, and mortality better than anyone. But that’s not always the case.
Does their expertise equip them to navigate their diagnosis and treatment better than their patients? How does the emotional toll of their personal cancer journey change the way they interact with their patients?
Navigating the diagnosis and treatment
In January 2017, Karen Hendershott, MD, a breast surgical oncologist, felt a lump in her armpit while taking a shower. The blunt force of her fate came into view in an instant: It was almost certainly a locally advanced breast cancer that had spread to her lymph nodes and would require surgery, radiotherapy, and chemotherapy.
She said a few unprintable words and headed to work at St. Mary’s Hospital, in Tucson, Ariz., where her assumptions were confirmed.
Taylor Riall, MD, PhD, also suspected cancer.
Last December, Dr. Riall, a general surgeon and surgical oncologist at the University of Arizona Cancer Center, in Tucson, developed a persistent cough. An x-ray revealed a mass in her lung. Initially, she was misdiagnosed with a fungal infection and was given medication that made her skin peel off.
Doctors advised Dr. Riall to monitor her condition for another 6 months. But her knowledge of oncology made her think cancer, so she insisted on more tests. In June 2021, a biopsy confirmed she had lung cancer.
Having oncology expertise helped Dr. Riall and Dr. Hendershott recognize the signs of cancer and push for a diagnosis. But there are also downsides to being hyper-informed, Dr. Hendershott, said.
“I think sometimes knowing everything at once is harder vs. giving yourself time to wrap your mind around this and do it in baby steps,” she explained. “There weren’t any baby steps here.”
Still, oncology practitioners who are diagnosed with cancer are navigating a familiar landscape and are often buoyed by a support network of expert colleagues. That makes a huge difference psychologically, explained Shenitha Edwards, a pharmacy technician at Cancer Specialists of North Florida, in Jacksonville, who was diagnosed with breast cancer in July.
“I felt stronger and a little more ready to fight because I had resources, whereas my patients sometimes do not,” Ms. Edwards said. “I was connected with a lot of people who could help me make informed decisions, so I didn’t have to walk so much in fear.”
It can also prepare practitioners to make bold treatment choices. In Dr. Riall’s case, surgeons were reluctant to excise her tumor because they would have to remove the entire upper lobe of her lung, and she is a marathoner and triathlete. Still, because of her surgical oncology experience, Dr. Riall didn’t flinch at the prospect of a major operation.
“I was, like, ‘Look, just take it out.’ I’m less afraid to have cancer than I am to not know and let it grow,” said Dr. Riall, whose Peloton name is WhoNeeds2Lungs.
Similarly, Dr. Hendershott’s experience gave her the assurance to pursue a more intense strategy. “Because I had a really candid understanding of the risks and what the odds looked like, it helped me be more comfortable with a more aggressive approach,” she said. “There wasn’t a doubt in my mind, particularly [having] a 10-year-old child, that I wanted to do everything I could, and even do a couple of things that were still in clinical trials.”
Almost paradoxically, Mark Lewis’ oncology training gave him the courage to risk watching and waiting after finding benign growths in his parathyroid and malignant tumors in his pancreas. Dr. Lewis monitored the tumors amassing in his pancreas for 8 years. When some grew so large they threatened to metastasize to his liver, he underwent the Whipple procedure to remove the head of the pancreas, part of the small intestine, and the gallbladder.
“It was a bit of a gamble, but one that paid off and allowed me to get my career off the ground and have another child,” said Dr. Lewis, a gastrointestinal oncologist at Intermountain Healthcare, in Salt Lake City. Treating patients for nearly a decade also showed him how fortunate he was to have a slow-growing, operable cancer. That gratitude, he said, gave him mental strength to endure the ordeal.
Whether taking a more aggressive or minimalist approach to their own care, each practitioner’s decision was deeply personal and deeply informed by their oncology expertise.
Although research on this question is scarce, studies show that differences in end-of-life care may occur. According to a 2016 study published in JAMA, physicians choose significantly less intensive end-stage care in three of five categories — undergoing surgery, being admitted to the intensive care unit (ICU), and dying in the hospital — than the general U.S. population. The reason, the researchers posited, is because doctors know these eleventh-hour interventions are typically brutal and futile.
But these differences were fairly small, and a 2019 study published in JAMA Open Network found the opposite: Physicians with cancer were more likely to die in an ICU and receive chemotherapy in the last 6 months of life, suggesting a more aggressive approach to end-of-life care.
When it comes to their own long-term or curative cancer care, oncologists generally don’t seem to approach treatment differently than their patients. In a 2015 study, researchers compared two groups of people with early breast cancer — 46 physicians and 230 well-educated, nonmedically qualified patients — and found no differences in the choices the groups made about whether to undergo mastectomy, chemotherapy, radiotherapy, or breast reconstruction.
Still, no amount of oncology expertise can fully prepare a person for the emotional crucible of cancer.
“A very surreal experience”
Although the fear can become less intense and more manageable over time, it may never truly go away.
At first, despair dragged Flora into an abyss for 6 hours a night, then overcame him 10 times a day, then gripped him briefly at random moments. Four years later and cancer-free, the dread still returns.
Hendershott cried every time she got into her car and contemplated her prognosis. Now 47, she has about a 60% chance of being alive in 15 years, and the fear still hits her.
“I think it’s hard to understand the moments of sheer terror that you have at 2 AM when you’re confronting your own mortality,” she said. “The implications that has not just for you but more importantly for the people that you love and want to protect. That just kind of washes over you in waves that you don’t have much control over.”
Cancer, Riall felt, had smashed her life, but she figured out a way to help herself cope. Severe blood loss, chest tubes, and tests and needles ad nauseum left Riall feeling excruciatingly exhausted after her surgery and delayed her return to work. At the same time, she was passed over for a promotion. Frustrated and dejected, she took comfort in the memory of doing Kintsugi with her surgery residents. The Japanese art form involves shattering pottery with a hammer, fitting the fragments back together, and painting the cracks gold.
“My instinct as a surgeon is to pick up those pieces and put them back together so nobody sees it’s broken,” she reflected. But as a patient, she learned that an important part of recovery is to allow yourself to sit in a broken state and feel angry, miserable, and betrayed by your body. And then examine your shattered priorities and consider how you want to reassemble them.
For Barbara Buttin, MD, a gynecologic oncologist at Cancer Treatment Centers of America, in Chicago, Illinois, it wasn’t cancer that almost took her life. Rather, a near-death experience and life-threatening diagnosis made her a better, more empathetic cancer doctor — a refrain echoed by many oncologist-patients. Confronting her own mortality crystallized what matters in life. She uses that understanding to make sure she understands what matters to her patients ― what they care about most, what their greatest fear is, what is going to keep them up at night.
“We’re part of the same club”
Ultimately, when oncology practitioners become patients, it balances the in-control and vulnerable, the rational and emotional. And their patients respond positively.
In fall 2020, oncology nurse Jenn Adams, RN, turned 40 and underwent her first mammogram. Unexpectedly, it revealed invasive stage I cancer that would require a double mastectomy, chemotherapy, and a year of immunotherapy. A week after her diagnosis, she was scheduled to start a new job at Cancer Clinic, in Bryan, Tex. So, she asked her manager if she could become a patient and an employee.
Ms. Adams worked 5 days a week, but every Thursday at 2 PM, she sat next to her patients while her coworkers became her nurses. Her chemo port was implanted, she lost her hair, and she felt terrible along with her patients. “It just created this incredible bond,” said the mother of three.
Having cancer, Dr. Flora said, “was completely different than I had imagined. When I thought I was walking with [my patients] in the depths of their caves, I wasn’t even visiting their caves.” But, he added, it has also “let me connect with [patients] on a deeper level because we’re part of the same club. You can see their body language change when I share that. They almost relax, like, ‘Oh, this guy gets it. He does understand how terrified I am.’ And I do.”
When Dr. Flora’s patients are scanned, he gives them their results immediately, because he knows what it’s like to wait on tenterhooks. He tells his patients to text him anytime they’re afraid or depressed, which he admits isn’t great for his own mental health but believes is worth it.
Likewise, Dr. Hendershott can hold out her shoulder-length locks to reassure a crying patient that hair does grow back after chemo. She can describe her experience with hormone-blocking pills to allay the fears of a pharmaceutical skeptic.
This role equalizer fosters so much empathy that doctors sometimes find themselves being helped by their patients. When one of Dr. Flora’s patients heard he had cancer, she sent him an email that began. “A wise doctor once told me....” and repeated the advice he’d given her years before.
Dr. Lewis has a special bond with his patients because people who have pancreatic neuroendocrine tumors seek him out for treatment. “I’m getting to take care of people who, on some level, are like my kindred spirits,” he said. “So, I get to see their coping mechanisms and how they do.”
Ms. Edwards told some of her patients about her breast cancer diagnosis, and now they give each other high-fives and share words of encouragement. “I made it a big thing of mine to associate my patients as my family,” she said. “If you’ve learned to embrace love and love people, there’s nothing you wouldn’t do for people. I’ve chosen that to be my practice when I’m dealing with all of my patients.”
Ms. Adams is on a similar mission. She joined a group of moms with cancer so she can receive guidance and then become a guide for others. “I feel like that’s what I want to be at my cancer practice,” she said, “so [my patients] have someone to say, ‘I’m gonna walk alongside you because I’ve been there.’ “
That transformation has made all the heartbreaking moments worth it, Ms. Adams said. “I love the oncology nurse that I get to be now because of my diagnosis. I don’t love the diagnosis. But I love the way it’s changed what I do.”
A version of this article first appeared on Medscape.com.
Douglas Flora, MD, an oncologist with St. Elizabeth Healthcare, in Edgewood, Ky., considers himself a deep empath. It’s one reason he became an oncologist.
But when he was diagnosed with kidney cancer in 2017, he was shocked at the places his brain took him. His mind fast-forwarded through treatment options, statistical probabilities, and anguish over his wife and children.
“It’s a very surreal experience,” Dr. Flora said. “In 20 seconds, you go from diagnostics to, ‘What videos will I have to film for my babies?’ “
He could be having a wonderful evening surrounded by friends, music, and beer. Then he would go to the restroom and the realization of what was lurking inside his would body hit him like a brick.
“It’s like the scene in the Harry Potter movies where the Dementors fly over,” he explained. “Everything feels dark. There’s no hope. Everything you thought was good is gone.”
Oncologists counsel patients through life-threatening diagnoses and frightening decisions every day, so one might think they’d be ready to confront their own diagnosis, treatment, and mortality better than anyone. But that’s not always the case.
Does their expertise equip them to navigate their diagnosis and treatment better than their patients? How does the emotional toll of their personal cancer journey change the way they interact with their patients?
Navigating the diagnosis and treatment
In January 2017, Karen Hendershott, MD, a breast surgical oncologist, felt a lump in her armpit while taking a shower. The blunt force of her fate came into view in an instant: It was almost certainly a locally advanced breast cancer that had spread to her lymph nodes and would require surgery, radiotherapy, and chemotherapy.
She said a few unprintable words and headed to work at St. Mary’s Hospital, in Tucson, Ariz., where her assumptions were confirmed.
Taylor Riall, MD, PhD, also suspected cancer.
Last December, Dr. Riall, a general surgeon and surgical oncologist at the University of Arizona Cancer Center, in Tucson, developed a persistent cough. An x-ray revealed a mass in her lung. Initially, she was misdiagnosed with a fungal infection and was given medication that made her skin peel off.
Doctors advised Dr. Riall to monitor her condition for another 6 months. But her knowledge of oncology made her think cancer, so she insisted on more tests. In June 2021, a biopsy confirmed she had lung cancer.
Having oncology expertise helped Dr. Riall and Dr. Hendershott recognize the signs of cancer and push for a diagnosis. But there are also downsides to being hyper-informed, Dr. Hendershott, said.
“I think sometimes knowing everything at once is harder vs. giving yourself time to wrap your mind around this and do it in baby steps,” she explained. “There weren’t any baby steps here.”
Still, oncology practitioners who are diagnosed with cancer are navigating a familiar landscape and are often buoyed by a support network of expert colleagues. That makes a huge difference psychologically, explained Shenitha Edwards, a pharmacy technician at Cancer Specialists of North Florida, in Jacksonville, who was diagnosed with breast cancer in July.
“I felt stronger and a little more ready to fight because I had resources, whereas my patients sometimes do not,” Ms. Edwards said. “I was connected with a lot of people who could help me make informed decisions, so I didn’t have to walk so much in fear.”
It can also prepare practitioners to make bold treatment choices. In Dr. Riall’s case, surgeons were reluctant to excise her tumor because they would have to remove the entire upper lobe of her lung, and she is a marathoner and triathlete. Still, because of her surgical oncology experience, Dr. Riall didn’t flinch at the prospect of a major operation.
“I was, like, ‘Look, just take it out.’ I’m less afraid to have cancer than I am to not know and let it grow,” said Dr. Riall, whose Peloton name is WhoNeeds2Lungs.
Similarly, Dr. Hendershott’s experience gave her the assurance to pursue a more intense strategy. “Because I had a really candid understanding of the risks and what the odds looked like, it helped me be more comfortable with a more aggressive approach,” she said. “There wasn’t a doubt in my mind, particularly [having] a 10-year-old child, that I wanted to do everything I could, and even do a couple of things that were still in clinical trials.”
Almost paradoxically, Mark Lewis’ oncology training gave him the courage to risk watching and waiting after finding benign growths in his parathyroid and malignant tumors in his pancreas. Dr. Lewis monitored the tumors amassing in his pancreas for 8 years. When some grew so large they threatened to metastasize to his liver, he underwent the Whipple procedure to remove the head of the pancreas, part of the small intestine, and the gallbladder.
“It was a bit of a gamble, but one that paid off and allowed me to get my career off the ground and have another child,” said Dr. Lewis, a gastrointestinal oncologist at Intermountain Healthcare, in Salt Lake City. Treating patients for nearly a decade also showed him how fortunate he was to have a slow-growing, operable cancer. That gratitude, he said, gave him mental strength to endure the ordeal.
Whether taking a more aggressive or minimalist approach to their own care, each practitioner’s decision was deeply personal and deeply informed by their oncology expertise.
Although research on this question is scarce, studies show that differences in end-of-life care may occur. According to a 2016 study published in JAMA, physicians choose significantly less intensive end-stage care in three of five categories — undergoing surgery, being admitted to the intensive care unit (ICU), and dying in the hospital — than the general U.S. population. The reason, the researchers posited, is because doctors know these eleventh-hour interventions are typically brutal and futile.
But these differences were fairly small, and a 2019 study published in JAMA Open Network found the opposite: Physicians with cancer were more likely to die in an ICU and receive chemotherapy in the last 6 months of life, suggesting a more aggressive approach to end-of-life care.
When it comes to their own long-term or curative cancer care, oncologists generally don’t seem to approach treatment differently than their patients. In a 2015 study, researchers compared two groups of people with early breast cancer — 46 physicians and 230 well-educated, nonmedically qualified patients — and found no differences in the choices the groups made about whether to undergo mastectomy, chemotherapy, radiotherapy, or breast reconstruction.
Still, no amount of oncology expertise can fully prepare a person for the emotional crucible of cancer.
“A very surreal experience”
Although the fear can become less intense and more manageable over time, it may never truly go away.
At first, despair dragged Flora into an abyss for 6 hours a night, then overcame him 10 times a day, then gripped him briefly at random moments. Four years later and cancer-free, the dread still returns.
Hendershott cried every time she got into her car and contemplated her prognosis. Now 47, she has about a 60% chance of being alive in 15 years, and the fear still hits her.
“I think it’s hard to understand the moments of sheer terror that you have at 2 AM when you’re confronting your own mortality,” she said. “The implications that has not just for you but more importantly for the people that you love and want to protect. That just kind of washes over you in waves that you don’t have much control over.”
Cancer, Riall felt, had smashed her life, but she figured out a way to help herself cope. Severe blood loss, chest tubes, and tests and needles ad nauseum left Riall feeling excruciatingly exhausted after her surgery and delayed her return to work. At the same time, she was passed over for a promotion. Frustrated and dejected, she took comfort in the memory of doing Kintsugi with her surgery residents. The Japanese art form involves shattering pottery with a hammer, fitting the fragments back together, and painting the cracks gold.
“My instinct as a surgeon is to pick up those pieces and put them back together so nobody sees it’s broken,” she reflected. But as a patient, she learned that an important part of recovery is to allow yourself to sit in a broken state and feel angry, miserable, and betrayed by your body. And then examine your shattered priorities and consider how you want to reassemble them.
For Barbara Buttin, MD, a gynecologic oncologist at Cancer Treatment Centers of America, in Chicago, Illinois, it wasn’t cancer that almost took her life. Rather, a near-death experience and life-threatening diagnosis made her a better, more empathetic cancer doctor — a refrain echoed by many oncologist-patients. Confronting her own mortality crystallized what matters in life. She uses that understanding to make sure she understands what matters to her patients ― what they care about most, what their greatest fear is, what is going to keep them up at night.
“We’re part of the same club”
Ultimately, when oncology practitioners become patients, it balances the in-control and vulnerable, the rational and emotional. And their patients respond positively.
In fall 2020, oncology nurse Jenn Adams, RN, turned 40 and underwent her first mammogram. Unexpectedly, it revealed invasive stage I cancer that would require a double mastectomy, chemotherapy, and a year of immunotherapy. A week after her diagnosis, she was scheduled to start a new job at Cancer Clinic, in Bryan, Tex. So, she asked her manager if she could become a patient and an employee.
Ms. Adams worked 5 days a week, but every Thursday at 2 PM, she sat next to her patients while her coworkers became her nurses. Her chemo port was implanted, she lost her hair, and she felt terrible along with her patients. “It just created this incredible bond,” said the mother of three.
Having cancer, Dr. Flora said, “was completely different than I had imagined. When I thought I was walking with [my patients] in the depths of their caves, I wasn’t even visiting their caves.” But, he added, it has also “let me connect with [patients] on a deeper level because we’re part of the same club. You can see their body language change when I share that. They almost relax, like, ‘Oh, this guy gets it. He does understand how terrified I am.’ And I do.”
When Dr. Flora’s patients are scanned, he gives them their results immediately, because he knows what it’s like to wait on tenterhooks. He tells his patients to text him anytime they’re afraid or depressed, which he admits isn’t great for his own mental health but believes is worth it.
Likewise, Dr. Hendershott can hold out her shoulder-length locks to reassure a crying patient that hair does grow back after chemo. She can describe her experience with hormone-blocking pills to allay the fears of a pharmaceutical skeptic.
This role equalizer fosters so much empathy that doctors sometimes find themselves being helped by their patients. When one of Dr. Flora’s patients heard he had cancer, she sent him an email that began. “A wise doctor once told me....” and repeated the advice he’d given her years before.
Dr. Lewis has a special bond with his patients because people who have pancreatic neuroendocrine tumors seek him out for treatment. “I’m getting to take care of people who, on some level, are like my kindred spirits,” he said. “So, I get to see their coping mechanisms and how they do.”
Ms. Edwards told some of her patients about her breast cancer diagnosis, and now they give each other high-fives and share words of encouragement. “I made it a big thing of mine to associate my patients as my family,” she said. “If you’ve learned to embrace love and love people, there’s nothing you wouldn’t do for people. I’ve chosen that to be my practice when I’m dealing with all of my patients.”
Ms. Adams is on a similar mission. She joined a group of moms with cancer so she can receive guidance and then become a guide for others. “I feel like that’s what I want to be at my cancer practice,” she said, “so [my patients] have someone to say, ‘I’m gonna walk alongside you because I’ve been there.’ “
That transformation has made all the heartbreaking moments worth it, Ms. Adams said. “I love the oncology nurse that I get to be now because of my diagnosis. I don’t love the diagnosis. But I love the way it’s changed what I do.”
A version of this article first appeared on Medscape.com.