Why shadowing Vinay Prasad convinced me to become an oncologist

A day at San Francisco General Hospital

Colton Lipfert is an incoming medical student at an east coast medical school. He has worked in the vkprasadlab for the last few years and recently shadowed.

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When I finished shadowing Dr. Vinay Prasad, I was convinced I had to become an oncologist. When I told him this, he was a little surprised. The day’s work had been downright ordinary for him. For me, though, it was exactly what I had been looking for.

Our day began at the outpatient clinic of the UCSF’s San Francisco General Hospital. We sat down at the computers in the doctor’s work room and Dr. Prasad (coffee in hand) showed me the list of the 8 patients he was expected to see before noon. The first was an older black man with a rare and aggressive lymphoma. He had gone into remission two years ago—this visit was to confirm that he had stayed that way.

We both greeted the patient warmly, with big smiles and firm handshakes. After a little small talk, Dr. Prasad asked the patient if he was experiencing any symptoms? “None,” he said. No night sweats? Any weight loss? “None at all,” he said.

“That’s great,” Dr. Prasad said. “If you're doing well after two years, you are out of the most risky window for your cancer to return. But we will keep seeing you to make sure it stays that way for 5 years.”

Relief washed over the patient, like a weight had been lifted from his chest. “Oh, thank you God, and thank you doctor.” It wasn’t even ten AM and I was already feeling the gravity of the work.

This is the bright side of oncology: seeing the mass on the scan shrink; telling a patient that they’re in remission; in a word, victory. This, along with the intellectual demands of the field, is what drew me to oncology. What worried me was the flip side, the inevitable tragedy of treating cancer. When patients slowly wither away from a terminal diagnosis; when we do everything within our power and it’s still not enough; when we fail. I was shadowing Dr. Prasad to see if I could handle this side of oncology.

At 12:00, we crossed the street to enter the inpatient part of the hospital. We stopped by the cafeteria for a quick lunch (a tray of jerk chicken, broccoli, and brown rice for just $7) and continued up to the heme/onc room. The fellow—a heme/onc doctor in the last part of his training—sat in a swivel chair waiting for us.

We introduced ourselves in between bites then went over the patients. The fellow presented the 7 cases that had needed a heme/onc consult. He had only been recruited 6 months ago, but he had a solid grasp of each patient, with just a couple questions. Dr. Prasad and I sat back and took in the information. At least, I pretended to understand what was happening. Besides a few words, it was all Greek to me.

The three of us took the elevator down to the radiology department to examine the patients’ CT scans. The radiologists were surprised to see us. When I asked why, Dr. Prasad told me that visiting in-person became a thing of the past after the pandemic. Now it’s all emails and Zoom meetings. He made a point, though, of meeting his colleague face-to-face, and everyone we visited was both shocked and delighted that we made the time for them.

We went up 4 floors to see the patients. One was an older man with GU cancer. He was frail and bedridden, but he mustered the strength to fist bump all three of us when we entered. Dr. Prasad was optimistic about his prognosis. The issue, he explained, was that the best treatment was horrifically expensive, around $300,000 a year. He doubted that the hospital would allow us to prescribe such a costly drug. To his surprise, they did. This man without insurance would get the most expensive and effective medicine on the market.

The next patient was a middle aged woman with an aggressive lymphoma. Dr. Prasad and the fellow agreed that they needed a PET/CT scan to confirm whether the cancer was at an earlier or late stage. The problem was that the nearest radiology department with a scanner was at another hospital that refused to see her. It didn’t matter that this was a routine and necessary scan: there was no way we could get her on the screening schedule. People often talk about the inequalities in healthcare, but rarely discuss how arbitrary it can be. Why was the system willing to spend more than $100,000 on a cancer treatment but not $2000 on a needed scan? Only the Lord (and the administration) knows.

After seeing the patients, we visited the internal medicine team rooms to talk to the residents who were taking care of our patients. They were packed into embarrassingly small, windowless rooms with the ventilation of a coal mine. Despite that, they were cheerful. Dr. Prasad explained our treatment plans to the teams and asked if they had questions. To me, it was a glimpse into the sheer size and scope of the hospital machine. Many teams, working in parallel, provide care for patients in need. Like a factory, but fewer robots (and also with more complaining).

We finished around 3:00pm. The fellow said he would put in the necessary orders and update us tomorrow on the progress. He would call Dr. Prasad later with questions. On the ride back, I thought about whether I could handle the depressing nature of Oncology. I think so. I felt for each of the patients, but I didn’t get sucked into the sadness of their situations. Most of that is probably inexperience and naiveté, but there is something about treating cancer that is so big, so sad, so inevitable that doing anything other than accepting the situation as it is seems futile. Maybe my attitude will change—I would be surprised if it didn’t—but for now, I know what I want to do.

Colton Lipfert (foreground, grey shirt, glasses) with Vinay Prasad (background, blue jacket, no glasses)