10 lessons from Hamilton that made me a better oncologist


Over 30,000 visitors flocked to Chicago in early June to participate in the ASCO annual meeting, the summer mecca for all things oncology. In between plenary sessions and poster presentations, some attendees found their way to one of the Hamilton Chicago performances. Having opened in Chicago about seven months ago, this version of the “hip-hop musical” has packed in audiences, striving to capture some of the success that its New York production has achieved. Thanks to some last-minute internet skills, I was one of those “past patiently waiting” attendees.
My relationship with Hamilton began around six months ago as I was strolling the streets of New York arm-in-arm with my husband, fresh from sushi and cocktails at Nobu. I convinced him to buy incredibly overpriced tickets from a third-party retailer, and off we went. Stunned into silence, we could barely speak about the show until an hour or so after we left. Where to start? And, now, I have been singing the songs in my head ever since. Lin-Manuel Miranda states that, “Sometimes a line enters your head, and you’re so grateful for it.” Anyone who has experienced the Hamilton earworm can attest to that.
I found myself absentmindedly humming the songs in clinic and began to realize how Hamilton translated into my everyday life. The love, the loss … so much could be applied to my daily work as an oncologist. During my second live experience, as I viewed a grittier cast portray the all-too familiar story, I realized how this musical can grow and change. I sobbed as Ari Afsar slayed “Burn.” I pondered loss and grief during the duels, considering a time where life seemed more primitive both medically and socially. The dueling and quick loss of one’s life stood in stark contrast to the battles my patients fight with every resource to just take one more breath.
With those experiences in mind, as well as the hours I have listened to the soundtrack, I present the ten reasons Hamilton has made me a better oncologist:
1. “Dying is easy. Living is harder.” George Washington sums up the life of a cancer patient so simply and eloquently. As we develop more cancer therapies, many of our patients with stage IV cancers find themselves living with chronic illnesses for years. This is different than the expected death sentence due to cancer from twenty years ago. For better or worse, patients live longer. With this, for many patients, comes suffering beyond my comprehension. With bravery and courage, they soldier on through third, fourth, and fifth line therapies. Some of them visit our offices every week, patiently waiting their turns to be poisoned.
This suffering is often prolonged as patients begin the hospice period. They may languish for days, weeks or months. Once the acute dying phase begins, the actual process of dying is often swift. I tell families of patients that the dying process will often be the hardest for them, not the patient. Their loved ones will finally be at peace, slipping away into a deep rest. The survivors are forced to watch and grieve.
2. “Death doesn’t discriminate between the sinners and the saints. It takes and it takes and it takes.” Burr emotionally chants this line in “Wait For It.” In our practices, we see this every day. Cancer is the great equalizer. It cares not about the contents of your wallet, one’s social status, or type of insurance. Black or white, rich or poor, any human has the ability to be affected. As oncologists, we must meet patients and families “where they are.” The longer I practice oncology, the more I realize that each patient’s starting point is so different. Once goals and expectations are established, my team strives to meet and exceed each one. We bond with these people, often experiencing the most significant highs and lows of their lives by their sides.
Unfortunately, a cancer-related illness will tragically claim many of my patients. One by one, we lose these dear patients. Death steals joy from their families, but also from me, my nurses and countless others.
3. “I’m not throwing away my shot.” My first thought was that this applied to those patients who are eager to start treatment urgently. With bounding optimism, patients and families come willingly to their first appointments. They record me with their iPhones, scribble notes and questions, and ask about clinical trials and integrative therapies. While considering this one afternoon, I reflected that it also fits with the image of a young, altruistic oncologist. He or she is fresh from fellowship, ready to build a panel of patients, and cure cancer. He or she can spend hours trying to create protocols, open clinical trials, and become an oncology super star. The patient and doctor actually have so much in common as you consider how each grasps at chances that may truly be “once in a lifetime” shots.
4. “Talk less. Smile more.” Enough said. Just as Burr advises Hamilton, we oncologists are well-served by following this advice. Often eager to fill awkward silences with our patients and families after delivering news, we chatter on. We would be smarter to take the advice from our first clinical medicine rotations: stop and listen patiently. Patients will tell you what’s wrong and what they need.
5. “Just stay alive. That would be enough.” Eliza begs her husband in the manner that many spouses and family members beg their loved ones in our offices, hospitals, and ICUs to stay alive. Too many families skip over quality-of-life issues, substituting quantity instead. When did simply “being alive” become enough for us? Just breathing is literally enough for so many. Sadly, quality should take center stage for our patients and their families. It is never too early to ask a patient what his/her goals of care are.
What does living truly mean to them?
6. “I imagine death so much it feels more like a memory.” When I first heard Alexander Hamilton sing this line, I gasped. In one brief statement, he captures depression at its core. The gut-wrenching darkness that consumes so many of us can invade our lives. The depression that creeps in for families and caregivers, as well as the deep darkness that affects so many oncologists is tangible at times. I lose about forty patients per year and sign condolence cards almost weekly. Our jobs require a deep connection to sadness and sorrow, such that death truly feels like a memory.
For our many patients who worry about prognosis all night every night, this statement also reflects the potential pervasiveness of thoughts of death. One of my patients described his evenings as “spiritual warfare” as he fights dark thoughts. Death begins to seep into conversations in much the same way as one may plan for a visit from an old childhood friend.
7. “There are moments that the words don’t reach. There is suffering too terrible to name … the moments where you’re in so deep, it feels easier to just swim down.” Angelica beautifully touches on the deep suffering that affects us as humans. As an oncologist, there are times where I am speechless. Tears may fill my eyes as I pull up a CT or MRI. I may hold back sobs as I grasp a hand of a dying patient. As I prepare a young adult with children for inpatient hospice, I can’t help but think of this line. The only feasible way to cope with your emotions while working as an oncologist is to “push them down” and move on to the next room.
8. “Ev’ry day you fight like you’re running out of time.” Burr chides Hamilton in “Nonstop” with this line. It follows the chanting of “Why do you assume you’re the smartest in the room?” as the music crescendos. As oncologists, we feel pressed for time at every turn. We need patients to have more time on a specific treatment before their scans progress. We need more time for our patients to qualify for clinical trials. We need more time before the FDA approves a novel treatment. Our patients, sadly, are always running out of time. This infectious “hurry up” spills over into every aspect of our lives.
9. “Who lives, who dies, who tells your stories?” As hard as it may be, dying patients should be advised to leave a legacy to their families. For those with small children or grandchildren, it may be a book of memories or a video. Oncologists and palliative care teammates are in unique situations to counsel families. We know when patients are starting to “run out of time,” or lose abilities to speak or act in a manner that would be conducive to leaving a message. By bringing the topic of death up in an appropriate manner, we can assist families with messages and goals that may have great impact on their families for years. By assisting them with recording thoughts for their children, siblings, and future family events, they grasp some control over their legacies. By thinking ahead to the grief, then attempting to replace it with moments of joy, we can change the course of another person’s life.
10. “Look around, look around at how lucky we are to be alive right now.” We have more cancer treatment options than ever before. Every month my inbox fills with FDA approval alerts for new cancer therapies. Immunotherapy has revolutionized the field of oncology. Personalized therapies based on tumor profiling have become mainstream. Thousands of clinical trials are available for cancer patients. Navigating the ASCO annual meeting would overwhelm any clinician, given the volume of material. At the risk of sounding like a Pollyanna, it truly is the best time to have cancer.
With the sadness we experience daily while caring for patients with cancer, we must make time for fun. I can think of few ways that are better than sneaking in a visit to see the musical or downloading the original cast recording or mixtape to sing along. Meanwhile, join the Hamilton-obsessed with some of the Hamilton hashtags on social media such as #HAM4ASCO, #HAM4peds, or #HAM4Med.
Ashley Sumrall is an oncologist.

Anne Joustra

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