 Dr. Ranjana Shrivastava, Ranjana is a medical oncologist and internist for Melbourne, Australia, who graduated from Monash University and did our internship residency in specialty training at various Melbourne hospitals. In 2004, Ranjana won a Fulbright award, which she completed at the University of Chicago. In 2014, Ranjana was recognized by Monash University as their distinguished alumnus of the year. Ranjana is the author of a number of books. Her most recent book, A Cancer Companion and Oncologist Advice on Diagnosis Treatment and Recovery, was brought out this year by the University of Chicago Press. Ranjana is also a regular columnist for The Guardian newspaper, and in that regard reaches hundreds of thousands of people where she writes on humanity and ethics in medicine. Ranjana presents a regular health segment on Australian television. We'll be returning to the University of Chicago to work with us in the summer intensive program in July of 2016. Today, Ranjana will speak on the topic on making a difference one paragraph at a time from oncologist to guardian columnist, Ranjana Shrestha. Good afternoon. Thank you for staying and curbing your appetite for lunch. I'll try to entertain you. A very different tone from some of the talks that have followed. In fact, sometimes I do wonder what I'm doing here amongst all you intellectual heavyweights, but Mark asked me to talk about my writing, and I thought I would take you on a journey of oncology to writing, and I continue to be an oncologist, but sort of a potted history to how I got to become a writer and what I make of it and what I see. Picture to familiarize you. I'm from Melbourne, Australia. Australian tennis open. Sydney Opera House. If you ever come to Australia, look me up. When I was a medical student, in fact, when I was a resident, an oncology resident, I should preface this by saying that I feel like my whole life I've been stumbling upon things and my life, my career certainly hasn't been the kind of deliberate consequential career that that is the envy of many people, including my own. So when I was a medical student and following that an oncology fellow, I took some time out from my training and I went to India, which was a place where I had grown up. In fact, I grew up in Patna, Bihar, which is Peter Singer showed some slides of. And I went there to work with Mother Teresa's Missionaries of Charity. I had sort of stumbled upon them as a volunteer organization where I could go. And I worked with them on the street side clinics of Calcutta. And it was one of those experiences I think that would have a really remarkable effect on me. But at the time, I didn't necessarily make as much of it as I do now, 20 years or 15 years later. Followed by that, through my training, I took some, in fact, during my oncology training, I, this is, sorry, this is a picture of the hospice at the Missionaries of Charity. As you can see, very basic, run by volunteers, and a most moving and life changing experience really for me and for many other people who work there. I came back from Calcutta and I found myself volunteering at the Asylum Seeker Resource Center when I was an oncology fellow and we got a few hours off every week. This center had just opened. I can't for the life of me remember how I, how I stumbled upon it. I certainly wasn't necessarily looking to work with refugees. And very soon found this most extraordinary sort of place, which was about 20 minutes from a first world world-class hospital looking after a vulnerable population right there in Melbourne, Australia. And the juxtaposition was just incredible. You know, back at my hospital, which I worked at during the week, I could literally spend hundreds and thousands, even millions of dollars on cancer therapies and drugs without people looking over my shoulder too much. And at this Asylum Seeker Center, I would struggle to find anti-hypertensives. I would struggle to give someone an asthma pump. A little child broke his, broke his bone once on a playground and Australia at the time had very restrictive policies that refugees and Asylum Seekers were not allowed access to Medicare, which is our universal healthcare system. And I struggle to find this little boy a place to go to get an x-ray, to get emergency treatment. And I think those things, you know, you, perhaps you expect them in another world, in a third world country, but you don't expect them in, in Melbourne. You don't expect them in Australia. And I found that very confronting. And I was, I was a, I was a young fellow at the time and, and so continued to work there. So something very interesting happened and I think it kind of, this is where my non-academic career probably started. So as an oncology fellow, sorry, I should go back. So this is, this is another picture of the, of the refugees, refugees and asylum seekers in Australia, although many of them have Medicare rights now. They're detained under very severe circumstances. And, and, and that, and I'll talk, talk a little bit more to that later on, but it's very troubling. It's troubling to a lot of people, including doctors who sometimes treat these children when they're, or I don't treat children personally, who are brought to hospital and then taken back to detention. Well, all this started a very interesting conversation with my then bosses who kind of asked me, you know, where my career was heading. And you know, I worked, I worked at a, at an academic institution much like, much like this one. And I, and I said to several people that, you know, I'd been working at the asylum seeker center and found the whole issue very confronting. And, and I said to, to a fairly eminent academic, I said, I think I'm going to write about the refugees. And he looks at me and his entire expression changes. He says, what? And I said, oh, I'm going to, I'm going to write. I'm going to write about the stuff we see. You know, look at this, it doesn't make sense to have so much inequality within several kilometers of where we work. And I'll never forget, he said, well, that's not going to get you published in the New England Journal of Medicine. And I thought, well, there I go. You know, I have failed even before I started. So, you know, isn't that the holy grail of medicine, you know, to publish in the New England Journal. So I started my career as an oncologist, sort of knowing that I wasn't heading down the academic track, knowing that I would never publish in the New England Journal of Medicine and kind of on my own wanting to become a writer, but very much loving medicine. And I'm very passionate about medicine. I love what I do. So then I finished my oncology training and came to another sort of crossroad. Do you do further training? Do you do a PhD? Do you, you know, do you try to pursue some research project if nothing else to get some more letters after your name and to get a job in a decent hospital? Or do you sort of follow your heart and see what happens? So although I have, so essentially, you know, how do you get, are there different ways of getting to the same point? And the point, I suppose, if we all remember those of us who went to medical school and you attend an interview and people say, well, why do you want to study medicine? And I guess inevitably in some way or the other, we all say to make a difference. Well, how does one make a difference? I mean, obviously, you make difference through basic research, through clinical research, through looking after patients. But are there other ways of making a difference? I didn't really know. I sort of knew that what I saw I admired in an academic hospital, but I didn't necessarily want to do that. And somehow I was getting the sense that already I wasn't following the rules and that I was supposed to be a certain kind of a doctor. And I wasn't playing by the rules. So then I ended up in Chicago. Now I have no financial disclosures of interest, but I must make a public disclosure. And you know, Mark was appalled, I think, and dismayed when I said to him, Mark, my decision to come to the McLean Center 10 years ago was was very sort of undeliberate. I stumbled upon your site and thought, yeah, this looks like a good idea. And and you know, now when I hear people about how hard they have thought about doing a fellowship at the McLean Center and et cetera, et cetera, and how they've interviewed and prepared, I sort of think should never have let me in. But the truth is that my husband was coming to Chicago to do an MBA. I had just finished my oncology training. I wasn't quite sure what to do was sort of looking around for something to do in the in Chicago that wouldn't require an American medical license, which I don't possess, literally stumbled on the site, thought, this sounds fantastic. It sounds just up my up my alley. And then decided that in order to live in Chicago, I would need some money. So figured out, well, how do I get some funding? So stumbled upon the Fulbright Scholarship Fulbright Awards and thought, this sounds like a good idea. I'll apply for one. All my life has been completely unplanned, I feel, got a Fulbright. So I thought, okay, well, I have an institution to go to, I have money to live there off I go. And as it turned out, this most casual of decisions really to accompany my husband and to spend a year somewhere else and figure out what it was that I was going to do, turned out into the most transformative decision of my life. And I really do use that word seriously. I think that being in Chicago for a year, being amongst people like you, many of whom are still here today, which is so fantastic to see, really gave me an opportunity to reflect, to reflect on what I could bring to the world, what I could bring to the world of medicine. It was also the first place where I heard from people who were writers and who were doctors as well that that I could write and people thought and many people said to me, you know, we think there's a writer in you and we think you should you could write a book. And that was incredibly, you know, when you're sort of young and trying to figure out your way, it's really important for somebody to be able to say that. So back I went to Australia and I thought quite seriously about writing and although I haven't mentioned it here, my first piece of writing, the New England Journal in fact put out a notice for looking for writers on medicine and society. And I decided to enter that the speech that I had had many years ago about never being able to write for the New England burning in my mind. So the New England wrote back and said, you're not quite what we're looking for, but we like your writing. So would you like to write for us? So that's began a very long and continuing relationship with the New England. And so if you see my piece in forthcoming piece in a couple of weeks time in the perspective section, you'll know the backstory. So anyway, so I fulfilled it had never been my dream to write for the New England, but I got in and you know, have published many pieces since and it's just such a delight. So then I wrote my first book and the first book is Tell Me the Truth. And it's really a book about sort of some of the moral and ethical dilemmas of being an oncologist, what it feels like to sit on the other side of the desk to give bad news, to constantly give bad news, to deal with that whole dilemma of not extinguishing hope while trying to prolong life or trying to tell the truth in fact. And it was quite an honor in fact to be shortlisted for a literary prize that was won by a former prime minister of Australia for his biography that he had written with another author, Malcolm Fraser was a prime minister. And so he sort of won the prize on the night and I said to Malcolm Fraser, I said, you don't need the publicity, I do. And he was very apologetic, lovely man who just died recently. But publishing that book made me sort of made me realize that I could do it. It was it was an achievement that was that was important to me because I'd never quite realized until then how to quite encapsulate my ambition and make something of it. So it was important from a very personal perspective for me to get a book out. My second book a couple of years later was a was this one dying for a chat, which was really it's a little penguin special. I don't know whether you have them here. They're like 80 pages. They're supposed to be read on a bus or a tram or a train, one time read. And they're they're they're really kind of cute books. And this book is essentially about better end of life, achieving better end of life care by having advanced care directives in place. And it explains so it describes the story of a woman that I looked after she was 90 years old. And in a story that will be very familiar to you. She sort of went through the labyrinth of the hospital system because nobody ever stopped to say, What would you like? What are your wishes? Not not so much. What would you like or what we can give you? But but how can we make this work for you? And she died in intensive care. And I made the point that when she died and she was actually my patient. So there's a lot of me a culprit in this. I make the point that what we lost the patient, the family was incredibly dissatisfied and couldn't believe disbelieving that she had died. The bureaucrats came after us, you know, we had spent months in hospital at great cost, just like it is here. The nurses were angry with the doctors, because the nurses felt that we should never have given her the kind of care that we did. And so I make and you know, and it left a bad taste in our mouth because we had lost a patient. So I made the point, well, who's happy? You know, here we have a world class system. We have spent hundreds and thousands of dollars, if not more, the best medicine in the world. And there is not a single person who's happy. And so that was dying for a chat and incredibly, even to this day, um, it won it won an award called the Human Rights Human Rights Literature Prize. It's it's an Australian Human Rights Commission, the Commission that that gives out prizes for for writing. And it was it was quite interesting, because you know, if you ever look at their website, you'll see the kind of books that they had their award prizes to, often to do with things like anything ranging from domestic violence to refugee asylum seeker sort of writing. And I thought, wow, I didn't think I would see a day so soon, we're talking about end of life care and good doctor patient communication, which lies at the heart of this could actually be considered a human right and something that is worth awarding a human rights award to. So that was a really that was a really nice acknowledgement I felt for us as a profession, for the kind of work that that we are trying to do. Very quickly, these are my these are my other two books. The cancer companion just came out last month by the UFC Press, which was which was really lovely and and and so humbling. I'm talking a little bit about my writing career. So after my first book came out, I got a call on Christmas Eve from from the editor of the Melbourne magazine, which is which used to be it's now defunct, a really glossy lovely magazine, lots of beautiful advertising and a couple of meaningful articles hidden in there. And the editor says to me, he says, I'll come clean with you, I haven't read your book, but my wife has and she thinks it's great and she thinks I should hire you. So the power of a spouse who reads. So I was hired. So, you know, I thought it was a joke and the Melbourne magazine was my first sort of big time exposure to to writing, to writing for a public audience. And so all of a sudden, after having written for the New England Journal and in the perspective section for all for many years now, I had to figure out, okay, well, how do I write for a general audience? And one of my greatest fears when writing, when taking on this job was that I was also a practicing oncologist in Melbourne and I kept thinking that people would write to me for second opinions, people would ask me, you know, whether their colleague was treating them correctly, etc, etc, and it would just be a minefield. In all the time I wrote for them, I think it was nearly two years, it didn't happen once. What did happen was hundreds and hundreds of people wrote in, they wrote handwritten letters, spidery handwriting from 80 year olds who wrote to share their story and to say, the column you wrote reminded me of the time when I was ill or my dad was ill or my husband was ill and this is what happened to me. And I was struck, I had never ever thought that reading a column could be so cathartic to other people. You know, when you write you're always thinking about what you can bring to, you know, how you can do a good job, but you don't, I mean at least I never thought about the kind of response it would trigger in the public and it was quite moving and humbling and, you know, people wrote in with practically every kind of experience, you know, pages and pages worth of letters and emails. It was lovely and I made sure that I responded to every single one of them because I felt that people had taken a lot of time writing to me. So then along came the Guardian in 2013 and the Guardian would used to be the Manchester Guardian and then it became the Guardian. Now it's published in Australia, UK, the US has a Guardian edition. So the Guardian came to Australia and I decided that I would try my hand at writing for the Guardian or at least that was my wish because by that time the Melbourne magazine had folded and so the Guardian kind of was establishing itself in Melbourne there in Australia and you know for a while it's actually really difficult to get in anywhere as a writer and one of the things I learned is that a doctor badge can get you in many places but it's a little bit difficult trying to get into mainstream media to write especially for a prominent publication. So I kept haranguing the Guardian. I put a notice on my calendar and so every few weeks I would ask can I write for you, can I write for you. So eventually I think they're just tired of me and they said well why don't you submit a piece why don't you pitch us something. So I did and they published it and then I a month later so then I had to be I began looking out for cues because you know a newspaper thinks what's in it for me you know how will I get more readers. So I've always been a very curious person about the world and so you know I would pick out something from a newspaper from the headlines or you know something about perhaps emergency department waits becoming longer and getting longer in the public hospital system oh my god everything is falling apart and I would say to the Guardian let me give you my perspective on why that's happening and that's how initially you know I would always be very tentative around them thinking well I don't want them to I want them to say yes but I can't ask them too often so you had to figure out a time where you wouldn't be forgotten but you weren't being a nuisance. That time roughly was about four to six weeks I think. So then Christmas is a good time for me so one day before Christmas the Guardian said to me we're going to take you on because we get good feedback from your columns it's something different and I took a great deal of care in writing about things that matter to ordinary people and you know I've had a very strong sense that we do such great work and if you look at what we have talked about in the past couple of days it's wonderful and we have great intentions there are smart ideas but unless we bring patients along if people along even before they become patients that's how we're going to make change. So then I started writing for the Guardian a couple of years ago now and these are some samples of kind of the the sort of things that I picked up on and that I and that I write about. So this one is from June 2015 so just this year so what happened was if there's any oncology so you may have heard anywhere along the lines some melanoma drugs came out and they came out with a great deal of fanfare because for the first time we were seeing that we could not only treat melanoma but potentially improve people's survival. Now that is unprecedented in melanoma which is which is a nasty disease. So a couple of articles had come out while I was here other people had written them sort of celebrating what a miracle drug this had been. The problem one of the problems with this miracle with these miracle drugs was that it didn't work in many people and in those in whom it worked there was some progression free survival benefit sometimes there was a small overall survival benefit too and the cost one of the drugs was about on a per gram basis something like 400 times more expensive than pure gold. So we're talking about seriously expensive drugs that don't prolong survival for a very long time and so this whole issue of societal cost. So I was at ASCO in Chicago and I get I get some desperate calls from the Guardian to say can you write a balanced article can you write a piece on this and I said I can write a piece on this but I won't be celebrating the miracle in the same way as you know there was breathless press around around these drugs and I said well hang on we just need to take a step back and think about whether it's even affordable for example in the third world and you know in India in most places there is no morphine there is no morphine available for palliative care. How do we reconcile drug availability here in the first world people are queuing up to you know to want to get this melanoma drug approved in somewhere like Australia. How do we reconcile this with global equality etc etc. So I wrote a piece about you know as you can see why I won't be rushing to tell my cancer patients there's a cure and I brought up all these issues that I was that I was just telling you about because I think for the public it's important for people to appreciate the nuances of any drug approval process or why sometimes for example we have a we have a government funded healthcare system which is incredibly generous the envy of much of the world but it has rules and regulations around it so why is that you know why how do we reconcile how we approve drugs which drugs we used to treat which patients and so on. So this was a column that was particularly well received and I think the Guardian was quite relieved because I think that the previous columns had been slammed for being a bit too breathless in their enthusiasm. This was a particularly a column that was particularly well received and according to the Guardian who by the way interestingly so the Guardian tells you a lot of stuff a lot of data they can tell you obviously how many people click on your article so at that point where this picture was taken there were 41,070 people it can tell you how long people spend on your column so when they click on it do they spend five seconds do they spend eight seconds where did they read up to before they decided to decided to click off and so on. So this was a column that apparently wasn't only read the whole way as most of these columns are but featured as the top Guardian article all around the world for three days running and it goes it goes to show really not so much about what about my writing but about what alternative therapies do and they polarize people and so you know 2,197 comments till that day because there are people just fighting with each other about whether alternative therapies work or don't work. But I think you know it it would be very difficult to have that sort of an impact on a patient by patient basis talking about the dangers of exotic alternative therapies and of why as doctors we are so wary of people who who peddle false hope and false treatments because we are often left to pick up the pieces. This is another this is another piece so when I was leaving Chicago I was pregnant with twins unfortunately I lost them both I have three healthy children subsequently but it's obviously you know losing a pregnancy is affects you deeply on so many levels and so on the 10th anniversary of that loss I decided to deal with I decided to write a column about it it certainly wasn't planned I I sometimes share personal details about me but this is probably the most personal column that that I've ever written and it was describing the immediate sort of the experience of losing the twins and and living the experience as a patient who was also a doctor and so I talked about a few things including the fact that the obstetrician who discovered that the twins were dying he wept he he didn't know what to say and I made the point that it was the first time in my life that I had seen a doctor cry a doctor crying with the patient over some over a loss and it and you know and it changed my world as to what a difference that made to my experience as a patient and you know it doesn't mean that that we must sob and weep with every patient but it really highlighted the the power of emotion and emotion when a doctor shows it when a patient is is is suffering and I also wrote in the piece about how there is this whole industry around grieving isn't there you know when I lost when my husband and I lost the twins there was no end of well-meaning brochures and books and things that came our way you know people were sliding things under our door because everyone in the world thought that you needed counseling to get out of to get through this and I made the point that I shunned all of them and I wrote and it was cathartic and it was my way of getting over it and it's okay it's okay not to join the industry of of grieving and and not to diminish the good work that people do but I think often and especially being an oncologist I see all the time how cancer patients are meant to do certain things and there is a certain way of being a patient and of course that's not true and so trying to say to people that even I you know as as a doctor I decided not to do what the industry told me to do and I'm okay and that it's okay to take one's time over grief or whatever it is that you're going through and not live by some kind of mandatory rule so this was another very popular column for obvious reasons that the guardian editors are great at bringing at coming up with the titles I seldom do but my favorite part about this which I which I wrote to mark about was that this was so this was syndicated very widely the guardian is picked up all around the world this one was on the front page of the North Korean Times and I loved it I loved the thought of a dictator like Kim Jong-il reading this over his breakfast cereal and so being think about it so I thought that was pretty cool very quickly some other things I have done so this was a recent protest by by pediatricians these all pediatricians and nurses of the Royal Children's Hospital about refugees in detention and so slowly I think what my writing has evolved into being is talking about topics that are important that are socially important but not necessarily medical you know and one of the things that people often say is well should doctors stick to medicine but I think you know as doctors we are still citizens of the world and we have views and we have we have ethical dilemmas and we have problems when children are in detention or you know when adults are not looked after and it's okay to speak up and so I think that you know it's been a wonderful platform but also a platform of responsibility couple of other things so so this is this is a lawyer John Fane is his name he's very popular in in Melbourne and in Australia he's a great presenter and and I co-host something called a conversation hour with him which is a which is an hour on radio where there are guests now these guests are not medical in fact they're seldom medical they range from from authors and and advocates so there's a will self over there the tall gangly guy who came in with his e-cigarette he's a famous booker prize winning author talking about his book there is a former health commissioner and so talking about and so what happens is not only do you talk to these people about what they do but you also have time to talk about medical issues and and I use those 10 minutes in public advocacy so at the start of the conversation now which has been a wonderful way once again of reaching a general public this is just very interesting so this guy here is a former defense minister of Australia and I probably none of you necessarily follow Australian news but but an election was fought on the basis of the fact that the government of the day accused refugees who were coming into Australia of throwing their children overboard into the ocean in order to seek asylum in Australia a huge staggering claim that parents would dump their children in the water but by virtue of that fear mongering which happened on the eve of the election the government won by a thumping margin because you know it played to I guess you know the fear amongst many people about how asylum seekers and refugees change our way of life so I asked the defense minister a really simple question when he came in to speak on the conversation hour plugging his book and I said to him you know how did he feel because he was the one who also kind of sanctioned these claims and I said how did you feel as a parent did you feel as a parent that they stood up to this this this claim look true and to my astonishment I would probably never have asked him he got really hot under the collar and it was a more spirited discussion about about you know he didn't answer the question it was typical politician but you know defense of of the whole practice so it was very interesting very quickly this was something very dear to me so one of the other things I've done through the media is I get to do a lot of sort of facilitating and presenting this girl here is Kate Richards who if if any of you want to read an excellent book by a doctor who became a severely psychotic patient is called madness and memoir by Kate Richards so I Kate and I used to sit in a lecture theater together we were students till she became psychotic and obviously as we have heard mental illness completely upturned Kate's life she subsequently had to leave medicine and and and now she writes and so I got to interview her and it was wonderful it was a sold out audience and it was about the lived experience of mental illness but also from a doctor's perspective so it was it was a wonderful opportunity once again to tease out the nuances of things like that that I probably wouldn't get to do in in bedside medicine very quickly I'll wind up so you know this is just a picture of A.S. Rock just because you've seen so many pictures of me something to something to remind you of Australia people often ask me you know what it is what it's like to write I thought that was that was a good that pretty much sums it up before I finish in terms of you know we all worry as doctors or nurses or we all worry about making an impact in the world and it can be really difficult I think you know if you publish a journal a publisher paper in the journal you have an impact factor and you know how many times your article has been quoted and you get approached you get approached to talk at you know other academic institutions and so on and so forth and sometimes I find myself wondering you know what's what sort of impact does a column like this make or is it sheer indulgence on my part makes me happy but here is an email that I quickly want to read out to you because I think it really sums up the essence of why I do what I do Dear Dr. Srivastava I sorry it's just taking me sorry I just wanted to send you a message to thank you for your columns in the Guardian I'm a very young patient with stage 4 rectal cancer involving my liver and lungs I was highly chemo respondent but now my time is limited there's not a lot of writing on cancer that I respond to or that I think really gives me a better perspective on my cancer than I already have after many many months of living with a death sentence but your writing always moves me and teaches me something different I learn about medicine and the health care system and more importantly the act of living and the reality of dying I also really appreciate you talking about things from the medical professional side of things I have the most wonderful oncologist whom I adore and a surgeon a liver surgeon who is dedicated and focused on trying to do the impossible for me he actually operates on my horrendously screwed up liver to give me a chance there's always a feeling however as a patient that at the end of the day the kindness and the affection that your doctor show you is just a thing that they put on to make you feel like they care because that's what they've been taught at school but you've taught me that doctors are as human as they seem it must be an obvious thing to you but one that's easy to forget between the scans and the constant navigation of your body as a complicated problem rather than as a vulnerable human being I think I'll I will end there but I thought that was that was an email that was um particularly inspiring my last slide I think you know going back to talking about a difference I thought I love that slide thank you for listening to me my Twitter handle is Dr. Ranjida