How We Do Harm (20 page)

He became interested in cancer while working at New York City hospitals.
As the field of oncology came into existence in 1973, Ultmann was one of its founders.
He was a coauthor of the specialty’s first-ever board-certification exam.

Ultmann had a rectangular face (wide jowls, a square shock of hair).
His speech was precise, Teutonic, his manners courtly.
I met him during my second year of med school, during the first day of his legendary pathophysiology class.
Ultmann’s research was in lymphoma, a cancer of the immune system that would ultimately kill him.
His other interest was politics.
You could argue that the two interests were inextricable from each other.

Lymphoma was particularly important politically: it was a battlefield where the government-funded war on cancer was scoring a victory.
Many forms of lymphoma lend themselves to treatment.
Massive tumors can literally melt away, and in some cases patients get long-term responses, even cures.

An enormous amount of research money was being pumped into the field.
Grand promises were being made, and victories were needed to allow the establishment to perpetuate the claim that the cure was around the corner.

Ultmann could spend the morning making rounds at UChicago and late afternoons behind closed doors on Capitol Hill or on the NIH campus in Bethesda, Maryland, cutting deals in rooms that were still filled with smoke, lobbying for money for the cancer program, helping shape the scientific agenda of the National Cancer Institute, kissing the hands of the right grandes dames, flattering the needed politicos, getting drug companies to write the right checks—and unabashedly taking a cut for the University of Chicago.

*

THE
University of Chicago was—and still is—the kind of place that makes the extraordinary seem ordinary.
When I was there, one could become blasé about seeing a Nobel laureate on the quad.
Sightings of the writer Saul Bellow, economist Milton Friedman, physician Charles Huggins, or geneticist George Beadle were almost everyday occurrences.

Huggins liked to hang out with students, introducing himself as “the SOB who won a Nobel Prize for cutting off a poor bastard’s balls.”
Huggins, who was eighty when I met him, won the 1966 prize for physiology or medicine for discovering that an endocrine disruption could be used to control the spread of malignancy.
This was more than cutting off balls: it was a new paradigm in cancer treatment.

When I was an undergraduate living in a dorm called Burton-Judson Courts, George Stigler, an economist who would win a Nobel Prize in 1982, was one of our dorm fellows.
Basically, this meant that he hung out and ate lunch with the undergraduates.
At one point, he and I debated the US government’s bailout of Chrysler.
Stigler thought it was wrongheaded to protect a company that was unable to function on its own.
I thought it was essential because I knew a bunch of people who worked on the Chrysler assembly line, and the prospect of their being out of work struck me as unacceptable.
This was an interesting friendship: a free-market economist and future Nobel Prize winner and a kid from Burlingame Street, struggling to preserve his footing in two worlds.

Another acquaintance, Leon Jacobson, was one of the first doctors to use chemotherapy successfully.
He used nitrogen mustard, a derivative of a World War I poison gas, to treat leukemia and lymphoma.
He was also the discoverer of something he called erythroprotein, a hormone that induced the body to produce hemoglobin.
Later, the protein would be renamed erythropoietin.
Jacobson also discovered the basis for bone marrow transplants—and he served as chief physician of the Manhattan Project.

At the University of Chicago you could take a course taught by Arthur Rubenstein, an endocrinologist, who discovered how to measure insulin in the blood; or Arthur Herbst, who linked clear cell cancer of the vagina to DES (diethylstibestrol, a synthetic estrogen); or Seymour Glagov, who linked cholesterol to heart disease; or Donald F.
Steiner, who discovered the precursor of insulin and how the human body synthesizes insulin; or Elwood Jensen, who pioneered studies of the estrogen receptor; or Janet Rowley, who showed that a transposition of chromosomes could produce a form of leukemia; or Janet’s husband, Donald Rowley, who invented the saltwater gelatin that is used on an EKG.

*

NATURALLY,
Ultmann’s pathophysiology class focused on lymphoma.
As a scientist and a clinician, Ultmann saw lymphoma as a set of distinct diseases that each carried different risks.
He showed that therapy had to be determined based on disease type and its stage.
Treatment had to be interdisciplinary, combining chemo, radiation, and surgery, and the only way to find out what worked was through rigorously designed clinical experiments, where one group gets Treatment A and another gets Treatment B.

After class, I came up to Ultmann to ask a question, and we ended up talking for about fifteen minutes.

“Ott-i-ss, I can already tell you are going to become an oncologist,” Ultmann said, concluding that conversation.

This was the beginning of a friendship.
It was obvious from the start that we understood each other’s origin.
He was a refugee, as, in a sense, was I.
Affirmative action gave me the opportunity to become a doctor.
He attended school courtesy of the GI Bill.
With his goodwill, Herr Doktor Ultmann let me know that he understood where I came from and what I had to do to survive.

During my third year of med school, I was assigned to him for an internal-medicine rotation.
Ultmann was like no other attending I ever saw.
His formality was extreme, aggressive.
You presented the patient to him in front of the patient, at the bedside, without notes: “Dr.
Ultmann, this is Mrs.
So-and-So.
Mrs.
So-and-So is fifty-five years old.
She comes to us with the chief complaint…” You had to do all that knowing that Ultmann would crush you verbally if he detected imprecision.

He either liked you or didn’t like you.
If he didn’t like you, it was because you weren’t trying.
Tardiness was not tolerated.
Neither was frivolity of any sort.
Both connoted disrespect.

Once, a resident put a smiley face on a patient’s record, causing Ultmann to go bananas: “This is a legal record, this is an official record, how dare she desecrate the record!”
To him, desecration of a record was a form of denial of humanity.
He was not just treating cancer.
He was trying to eradicate lies, complacency, and disrespect.

His rules were straightforward: You don’t deviate from the science.
You don’t make it up as you are going along.
You have to have a reason to give the drugs you are giving.
You have to be able to quote literature that supports what you are doing.
You have to tell patients the truth.

His moral principles, to me, were jesuitical.

*

WHEN
I call him from Case Western to say that I am ready to go into oncology, Ultmann shifts into Socratic questioning of my motivations.
It’s not enough that I am going into oncology per his prediction.
I have to go into oncology
for the right reasons.

“Ott-i-ss, why do you want to do oncology?”

“Oncology has the right mix of science, medicine, and public policy.”

Most people in high school thought that I would become a lawyer and a politician.
Though I am going into medicine, in oncology, I will have the opportunity to use my God-given gift of speech.
As an oncopolitician, Ultmann appreciates this.

That oncologists make decent money also influenced me.
I prefer to give money as little thought as possible, but at that time I was deep in debt.
I wouldn’t pay off med school bills until age forty-three.

“We want you to apply to Stanford, UCSF, University of Chicago, Memorial Sloan-Kettering Cancer Center, Dana-Farber, Mass General, University of Pennsylvania, Johns Hopkins, and the National Cancer Institute.”
We
is Herr Doktor Ultmann, a royal
we.
“You will get a letter of recommendation from us.
You will keep detailed notes.
Every time you see a place, you will rank every one of them until that point.
Then you will call and tell us what your choice is.”

That Ultmann writes my first recommendation likely determines the seriousness with which my fellowship application is taken at every one of these places.
I meet with the director of each of these top institutions, and the choice seems clearly mine to make.
When I return to Case Western, I call Ultmann.

“Dr.
Ultmann, my first choice is Memorial Sloan-Kettering.”
It’s an understandable choice.
Memorial is a venerable academic institution.
Just being considered for a fellowship there is an honor.
Training at Memorial opens doors.

If the silence on the other end is an indication, Ultmann disagrees.
I can see that I have made a mistake.

“If you go to Memorial, we will never speak with you again,” he says finally.

“But, Dr.
Ultmann, that was one of the places you wanted me to interview.”

“Precisely.
We wanted you to
interview
there.
We didn’t want you to
go
there.”

“In that case, my first choice is the National Cancer Institute,” I say, regrouping.

Suddenly I can see what Ultmann is thinking.
Memorial is the place to learn to become a consummate clinical oncologist.
NCI is the place to become a researcher.
This has to be determined by his view of my strengths and weaknesses, his vision for my career.
Perhaps he would have chosen Memorial for another of his protégés.

NCI is undeniably the place where the specialty of medical oncology had been invented in the 1950s and 1960s.
In 1988, it was still the headquarters of the war on cancer, the place where bold strategies were being forged and where new drugs were being developed, the place where the cures would come from.
At Case Western, I heard Emil Frei, a former NCI researcher, give a talk titled “How I Cured Childhood Leukemia.”
And he had, together with colleague Emil Freireich.
(Along the way, this duo of physician-scientists erected articles of faith that would guide oncology for over half a century.)
Vincent DeVita, the NCI director and a friend of Ultmann’s, was also one of the developers of the MOPP regimen for the treatment of Hodgkin’s lymphoma.
MOPP is a four-drug combination chemotherapy regimen consisting of the drugs mustargen, oncovin, procarbazine, and prednisone, which was developed for the treatment of Hodgkin’s Lymphoma.
NCI breast cancer researcher Mark Lippman did original work on blocking estrogen receptors in breast cancers.

The institute’s influence extended into academia, too.
It funded cancer centers as well as groups of physicians who banded together into “cooperative groups” to conduct clinical trials.
Since the field of medical oncology was invented at NCI, all institutions that developed cancer programs by necessity had to hire people who had trained at NCI.
More than half of the NCI-designated cancer centers were run by people who had trained at the institute.
Former fellows ran the cooperative groups, too.

The institute controlled the purse strings for basic and clinical cancer research done in the United States.
Some of this research was transforming medical practice.
For example, the Pittsburgh-based cooperative group called the National Surgical Adjuvant Breast and Bowel Project had caused surgeons to abandon the brutal Halsted mastectomy in favor of conservative procedures followed by radiation.

Even outside oncology, NCI’s impact was massive.
In the 1950s, NCI pathologist Alan Rabson showed that the herpes virus hides in nerves, then comes to the surface in skin eruptions.
In 1988, I knew that NCI retrovirus researcher Robert Gallo had discovered the HTLV-3 virus that caused AIDS.
Later, the virus would be called HIV.

The institute’s fellowship program was unique.
A standard fellowship lasted two years and was entirely about clinical work.
The NCI fellowship consisted of a year in the clinic, followed by two years of research, which could be anything from heavy-duty bench science to number-crunching in epidemiology and biostatistics.

“Where will you be tomorrow afternoon?”
Ultmann asks, concluding our telephone conversation.

“I will be doing intensive care rotation at the VA.”

“What’s the number there?”

*

A
day goes by.
I am resuscitating a lung-cancer patient.
A secretary—a black woman with a Southern accent—interrupts me to say, “There is a Dr.
Broder from the National Cancer Institute who wants to talk with you.”

“You’ll have to take a message,” I say, returning to the grim, futile business.

After it ends—the patient dies—I call and get patched through to Broder, director of the NCI Clinical Oncology Program.

“Dr.
Brawley,” says the voice on the line.
I had met Broder at the interview, and he looked as if he could go from morose to Groucho Marx funny in the space of one sentence.
“I have been instructed to offer you a job.”

After accepting the job, I call Ultmann.
The pronouncement I hear over the phone will guide my career:
“Ott-i-ss … Now you know that oncology is an ole boys’ club.
You are now part of that ole boys’ club, and your job—and your payback—is to get as many blacks and women into the club as you can.”

Chapter 13

Snuffy’s War
ON JULY 1, 1988,
when I showed up on the NIH campus as a new fellow at the NCI and a fresh conscript in the War on Cancer, I believed that the cure was just around the corner.
The war rhetoric was in the air.
Not knowing what we didn’t know, many of us believed that the cure could emerge in any clinical trial.
A genuine war was being fought, directed by aggressive generals.

This was a medical war of unprecedented proportions.
Until the War on Cancer, progress in medicine was usually haphazard.
Insights could be generated by individual scientists working at the bench.
Treatments were proposed, tested, rejected.
Some—such as the Halsted mastectomy—lingered too long out of deference to esteemed professors who championed them.