 Physicians are as empathic as anyone, but their training has been to think in terms of science, that health is a product of good biology and disease is merely a scientific problem to be solved. I think the answer to this is to have a more broad view of what it means to be a physician. You have to be a good scientist, know the human body well, know disease well, but going past that, then you have to know what it means to be a human being, what it means to patients and families to suffer with illness. I mean, it's a question of relieving their suffering through all measures, maybe not just opiate analgesia, but, you know, support and other counseling, spiritual means, family support. I mean, if you can make it better because you were there doing the intervention, whatever it is, and usually it's multiple things. It makes me a better oncologist when I address the whole person. Whether I cure them or not, treating their symptoms along the way makes a difference in their quality of life, makes a difference in their family's perception of their disease and their life, and really it gives sense to the public a message that you don't have to be miserable while you're getting cancer treatment. And I think that's an important message and it's something palliative care brings to the table. To me it's all rolled into managing and helping and providing care for an individual. I don't distinguish palliative care from curative care. I think of it all as just good medical care. There is truly science in palliative medicine. We're understanding more about the mechanism of action of medications that treat symptoms and learning a lot more about the physiologic basis of symptoms. And so just like with cancer, we are beginning to develop targeted therapies for symptoms and there's a huge amount of science to learn and to study and then to apply. So in no way do I think of it as soft. It needs to be in fact just as rigorous as the science that we study for the treatment of cancer or heart disease or whatever. I think the uninformed and the inexperienced would think palliative care is sort of a soft discipline within oncology. I probably could have been accused of that myself a few years ago too. It only takes one patient to convince you that that's completely erroneous and completely inaccurate. It only takes one example of a patient who comes in with problems that not a lot of people can take care of and who's taken better care of because you consulted an expert in palliative care to bring you 180 degrees around. Palliative medicine does not deny the very real ability we have now to take care of complicated illnesses with very high-tech expensive interventions. And I think that physicians who become good physicians know they have to understand the knowledge base to be a good physician. They have to understand the technical side of their job. But they better spend a lot of time understanding how to listen to people and how to care and how to set goals and directions so that the therapies that we've learned can be correctly and properly applied. It never seemed right to me to take care of diseases. And so taking care of patients means addressing what bothers them, not just what we think is wrong. And there's an old adage, don't just do something, sit there. That makes a lot of sense. It's really easy to listen to someone's lungs to order another task, to walk around and do things. When people are scared and you're scared, it's hard to just sit down and be there. Providers who give the best care are able to combine a group of skills that go from technical excellence and having the basic humanity of understanding how to deal with patients and willing to spend the time that's needed to deal with patients. Sometimes it's just a matter of sitting down, and I literally mean sitting down with a patient, gives a sense of you're there, you're not on your way out. Particularly taking care of the family, you do need to have certain other skilled professionals who are able to bring something to that equation that you don't have. And pediatric oncologists are very good at this, is the multidisciplinary team approach, where the team consists of the physician who's generally in some respects like an orchestra leader or maybe even a cheerleader. Often a primary nurse, social worker, chaplain, it's hard to replicate in all circumstances, but it's essential I think for optimum care. Well team work is incredibly important. Old school oncologists tended to, old school physicians tended to be very regimented where physician is king. I think we're in a new day. Those of us who are going to adapt to the new day are going to accept the fact that medicine is a team effort. As physicians and healthcare providers at many levels, we sometimes are absolutely overwhelmed by the obstructions that the system seem to create. There are changes in our healthcare environment in regards to payment. There are also systems in hospitals and nursing homes and home care which don't lend themselves to make it easy for us to provide support and care. The best doctors are able to work the system and manipulate the system in their patient's best interest. So there really isn't a reason that we need to be giving chemotherapy in the middle of the night. There isn't a reason we need to be giving most of the time blood transfusions in the middle of the night. That's part of palliative care. Those are things, small things that we can do to sort of get around the system that we've created to palliate symptoms, to avoid causing symptoms in patients. And that's part of palliative care. You may recall the story I think attributed to Gandhi, where a man walking along a beach sees starfish all over the beach and is throwing one starfish back into the water and another starfish here into the water. But there are thousands and thousands of starfish and another man comes up and says, Gee, what are you doing? There's no point in you throwing the starfish back into the water. Look at the task ahead and it doesn't matter what you're doing and to which the man responds, it mattered to this starfish. It throws another starfish into the water. I think we each, as practitioners, can do a better job with our patients. So the payoff for oncology is first sometimes you cure people and that's the ultimate wonderful thing. But along the way, whether you cure them or not, you can make a huge difference in people's lives by being there, by being honest with people, by supporting families, by helping people know that you're not going to walk away. For me, the reason I don't feel burned out is because when someone dies, I don't feel like I failed. I feel like I did everything I could do as a physician, everything I could do as a person, and that's all there is. So I don't walk away with regrets and I think that allows me to do it again and again. There's definitely a satisfaction in doing hard things well. And in fact, I mean, caring for a child in whom treatment is not effective. It's painful, but it is satisfying because unless you give something of yourself, you know, well, you're not a very good oncologist. So it takes a little piece of your heart away every time. The big payoff of us understanding the importance of palliative care, the big payoff of us approaching palliative care and the scientific means is we all become a little bit more human. I'm very optimistic that oncology is going to embrace the integration of palliative care into practice. There's a lot of move that suggests that's truly coming, finally. There is funding coming, which makes a huge impact. There are new medications, and I think there is fortunately a groundswell from patients that I think is important to demand that this be part of their care. I'm completely optimistic that palliative care will ultimately be integrated into all aspects of oncologic care for patients, both surgical oncology, medical oncology, and other disciplines like radiation oncology and immunotherapy. I don't think it's going to happen overnight, and I don't think it's going to happen without a lot of work on everybody's part. Number one, let's get competent. Let's all of us make sure we're competent. Number two, in order to try and implement all these new competencies, we have to make sure that we have found ourselves someone we admire who does this well. And number three, we have to take a hard and candid look at the environment in which we practice and choose a battle that we can win. There are many, and each of us has to choose something appropriate to our own practice environment. Somewhere along the way, most of us will get some difficult disease that we have to live with and seek treatment. I think, like me, most of us want not just treatment for the disease, but treatment for the symptoms to maintain our quality of life and support for our families, our friends, our children. If I don't make it through, I want to be sure that I leave the world knowing that the people I love are cared for and are okay. And I think integrating symptom management and whole person care in oncology specifically but medicine on the whole makes it more likely that we'll all have those choices.