On the way to chemotherapy

Like any other human process, chemotherapy consists of a series of steps. New patients have to get the hang of these steps, and once you do that you have a measure of security and assurance. But as a new patient you're both participant and observer, and it turns out that the particular steps that you find yourself taking also tell you a lot about the world you're now a part of. So I'll try to trace these steps here, and to say something about what those steps reflect, about cancer and cancer treatment.

When we arrive for chemotherapy, the first step is to check in. Actually that leaves out a step: the trip upstairs on the elevator. I was startled the first time we arrived because all the elevators have a seat in one corner -- a welcome sign that the people who planned the physical space were thinking about the condition of the people who'd be using it, but also a troubling sign of how frail some of those users might be or might become.

But the elevator isn't quite the first step either. The first step, if you arrive as early in the morning as we try to, is a brief wait on the first floor till the treatment floors open at about 7 AM. We wait in the Laurance S. Rockefeller Pavilion, a quite pleasant space with seating for 15 or 20 people and a small water pool on one side into which people, including me, toss coins for luck. It's not a surprise to find a Rockefeller's name on the wall; I imagine that Memorial Sloan-Kettering (MSK) does vigorous fund-raising, and there are donor names elsewhere in the building as well. The building we go to is in the East 50s in midtown Manhattan; this is expensive real estate, and every element of the massive treatment program running in this building is expensive as well. So many people get cancer; so much money is spent on the fight against it.

In any case, after the pause downstairs and the trip up in the elevator, we reach the fourth floor, where my chemotherapy takes place. This floor is focused on gastrointestinal cancer, so I imagine there are others floors, perhaps in other buildings, for people with different cancers to receive their treatments.

We arrive at the registration desk. Registration is generally quick, and the people behind the desk are responsive and friendly. I'm asked to confirm my name and my date of birth, and that's it. 

It's not just good fortune that the registration process is easy. As with the elevators, it seems clear that someone has thought about how to make the patients' experience as pleasant as possible. And something more -- someone has hired staff, and trained them, to be attentive and efficient. That takes institutional commitment, as well as good individuals, and it's reassuring.

Why do they ask the patient to confirm his or her name and birthdate in particular? We learned the first day we went to MSK that this process is repeated a lot  -- when you go to have a particular procedure done, or when your medication is being started, or after a procedure is over. It's easy to see and appreciate the logic of this procedure, which helps insure that each patient gets only the treatment he or she is supposed to have. (Long ago, in a university health clinic, a staff person called out "Stephen Ellmann" and a person sitting near me stood up. It turned out we shared not only the name but even the extra "n" in Ellmann. So I know this isn't a hypothetical problem.) But there's probably also another, worrying purpose: to measure the mental status of the patients, who may be fragile enough to be disoriented by some of the processes they go through.

And then, having checked in, we go and sit down in the waiting area. More on the waiting area in a future post.

Chemotherapy is not routine

I don't mean these blog posts to be just about my own medical details; I'd like to give a picture of the world of cancer treatment as I'm seeing it, rather than just recite the latest developments in my treatment. But I'm going to postpone the big picture posts, because this week's developments have caught my attention. I suspect it's very easy to become preoccupied with details like these, and want to resist falling into that, but still this week's story seems worth telling. 

Two days ago I had my fourth infusion. My older son Brian, my wife Teresa and I all went. After three previous sessions I felt like a veteran, and the week between the third and fourth infusions had been relatively easy. So we expected this session to be fairly straightforward too.

We drove in to Manhattan – we start before 6 AM, which definitely doesn’t make us the only people on the road but does enable us to reach the far side of Manhattan in about 45 minutes – and started on the usual process, which begins with blood testing. After the blood testing we waited, because in order to beat the traffic we’d arrived well before my scheduled chemotherapy time. So when we got to the chemotherapy suite – which actually consists of about 20 rooms or spaces, typically separated from each other by curtains rather than walls (so not terribly private) – it was well after 9 am and we’d already been going for several hours.

Then the RN who would be handling the actual chemotherapy process arrived and told us that my white blood cell count was below the lower parameter set by the oncologist for my receiving treatment. That potentially meant I wouldn’t be able to have the infusion – and also meant that my immune system had been weakened. (Meanwhile, coincidentally, the RN came down with a cold more or less before our eyes; from then on, when she came back to our space, she wore a mask.) 

When we later looked at the blood work charts ourselves, it was clear enough what had happened. The chemotherapy is expected to weaken your immune system and sure enough, week by week, it had. The break I’d had after the first two weeks had helped restore some of my white cells, but not enough, so when the third infusion hit, I was starting from a lower point than I had in week one, and the third week’s impact took me below the doctor’s limit.

What to do? I didn’t want to miss a treatment, and apparently that made some difference to the doctors’ thinking. What they decided to do was to go ahead with the treatment, and then send me the next day (that was yesterday, New Year’s Eve, and apparently took a lot of scheduling effort behind the scenes) for an injection meant to stimulate my bone marrow to produce more white blood cells. But that injection itself can have side effects, and for those side-effects two different Sloan-Kettering people suggested that I take Claritin D. They both said there was no scientific evidence that Claritin D would work, but that many patients said it did. So now I’m taking Claritin D, as a modern folk remedy. And I’m taking it to counteract the side-effects of another drug that I’m taking to counteract the side-effects of the chemotherapy. There’s a lot going on!

Meanwhile, after the chemotherapy we had one more stop to make, for an ultrasound of my legs. The ultrasound wasn’t a surprise; my right calf muscle had been stiff for several days. I hadn’t known what to make of this, but finally called it in to the medical team the day before the chemotherapy, and they, probably out of an abundance of caution, decided that after the infusion I should go upstairs one floor for an ultrasound. Which was the right choice, because it turned out I had a blood clot in that calf (but only there, which of course is good). 

Having a blood clot means going on a blood thinner to help break up the clot – and I’m dismayed that I’m now taking one of those drugs that are so depressingly advertised on TV. A blood thinner also means I have to be careful about getting cut or getting bruised – marking the end of my NFL aspirations. Why do I have a blood clot? The nurse from the medical team said that people with a cancer diagnosis have more frequent blood clots than others; I’m not sure whether that’s the result of the cancer itself or of the chemotherapy or some combination of the two. But I take it I’ll be on blood thinners now more or less indefinitely.

None of this is particularly bad. And all of it the medical team was ready to deal with. But it was certainly more than the three of us had expected as we went into town on Wednesday morning. And it taught us all a lesson: chemotherapy is not routine.

My cancer diagnosis

On November 25, 2015 I learned for sure that I had liver cancer. Actually this had been pretty clear for a week or two already, but that was the day my wife Teresa and I received the biopsy result. The biopsy confirmed the evidence from an ultrasound and two CT scans that I had cancer, and also enabled the doctors to tell us what type it was: cholangiocarcinoma. This particular cancer, a very rare one, comes from the bile duct; the bile duct, as I’ve now learned, is not just one large pipe for delivering the bile to perform its functions elsewhere in the digestive system but an entire network of capillary-size uptake tubes pervading the liver. I have growths in different parts of my liver, which means I have stage IV cholangiocarcinoma. But at the same time the various scans have not found that the disease has escaped the liver and lodged anywhere else, and so on the scale of stage IV’s, I am not at the upper (worse) end.

The doctors at Memorial Sloan-Kettering concluded that what I needed was to start chemotherapy without delay, and I had my first infusion on December 4, the day after my last class of the fall semester. I’m doing three three-week cycles, two weeks on and one week off; three days ago, December 23, I had the first infusion of the second cycle. At the end of these cycles, they’ll do another CT scan, and then we’ll see where things stand. As I understand it, depending on the results at that point the doctors may want more of the same; more of the same plus additional interventions; or a switch to one or more other treatment approaches.

Those are the basic medical facts. I haven’t yet said anything about how profoundly my wife, family, friends, colleagues and students have been supporting me; nor anything about the experience of entering the immense institutions devoted to treating cancer; nor about the day to day issues of dealing with the illness and the side-effects of its treatment. All of that and more I hope to write about in coming posts. I want to provide this account of my encounter with cancer, but I’ll end this post by emphasizing that my main goal is not to provide this account but to fight the disease in every way possible and be around for many years to come, living a life free of, or at least not dominated by, this illness. 

An unfortunate taste from the past

Just for fun, I've been rereading the Lord Peter Wimsey detective novels by Dorothy Sayers, which I probably last read when I was a boy living in England for a year back in 1963-64. They're quite engaging in many ways, at least if you happen to have a soft spot for England back between the two World Wars. Wimsey and his counterpart Harriet Vane are smart and funny, and the books' patient (one might say slow-paced) encounters with a rich slice of English life are intriguing too.

But here's one feature that's not so good: Dorothy Sayers was an anti-Semite. I have the impression that British society of this period was pervasively anti-Semitic, so in this respect as in so many others she is capturing the spirit of her age. But she does so without compunction. In one novel, for instance, she has one of her characters say that "A good Jew can be a good person." That's better than saying that a good Jew can't be a good person, of course, but not that much better. In fact, in each of the 5 books I've read so far, there's at least one gratuitous remark about a Jew, or about Jews. I hope it is fair to say that attitudes of this sort became impossible to hold, or express, after World War II. But I'm not absolutely sure.

When is a cognitive heuristic actually right?

We now know quite a lot about seeming deficiencies in human reasoning – departures from pure rationality that appear to be regular features of how we think. If these are regular but erroneous features of our thinking, why do we have them? The basic answer, as I understand it, is that they are generally serviceable, and enable us to handle the bulk of what we must address each day quickly and reasonably well. The fact that they are misleading in circumstances where we actually need to think carefully is a cost that’s worth bearing for the gains these thinking patterns give us most of the time.

But this is a bit of an odd explanation. If a particular tool of thinking is in fact mistaken, how can it be helpful most of the time? This defense seems a bit like the explanation of the merchant who is selling each item at a loss – that “we’ll make it up in volume.” No, we won’t; we’ll just (back in the field of cognition) be regularly wrong.

So what is it about the heuristics that makes them usually helpful?

That’s a big question, and I certainly don’t have a general answer – and I’m far from an expert on human cognition. There may be an extensive literature on this very question, which I’m overlooking. But anyway here’s something I’ve thought about this question, and about one cognitive trait in particular: the tendency people have to treat a risk of loss as more significant than a potential of gain. Tomer Broude and Shai Moses of Hebrew University in a recent paper describe an implication of “Prospect Theory” in these terms: people “will often invest more in the prevention of loss than in the generation of gains of the same amount.” (Broude & Moses, at 5.) So, it seems, people will spend more on public health if they are told “Failure to spend X will result in 25 % more illness than there would otherwise be” – a loss – than if they are told “Spending X will enable 25 % more people to avoid illness” – a gain. (Broude & Moses, at 10, cite a study to this effect, though the phrasing of the “loss” and “gain” that I’ve offered here is mine.)

In this imagined choice, the two options are in fact the same, though they are being described differently, and it is irrational not to see them as the same. Any decision made without grasping that the two options are the same will be a flawed one because the decisionmaker doesn’t understand the situation. So it’s clear that the tendency to care more about avoiding losses than about achieving gains can be the source of erroneous decisionmaking.

Then why is this tendency something that’s part of our cognitive make-up? Actually, it’s probably not part of everybody’s cognitive make-up; those who care more about avoiding losses than about making gains are, more or less by definition, risk-averse, and not everyone is that risk-averse. There may well be opportunities available for those who are not risk-averse, but why are the rest of us (certainly including me) inclined the other way? How can this tendency serve us well, most of the time?

It seems to me that most of the time it is likely to be accurate that risking a loss of X will do us more harm than seeking a gain of X will bring us benefit. Why would the risk of losing $25 matter more than a putatively equal chance of gaining $25? For at least two reasons.

First, if the stakes really are $25 each way, then we need to assess how much we need our last $25 versus how much good it would do us to gain $25 more. Obviously the answer will vary depending on our life circumstances. As a general matter people who are able to do so probably measure their spending in light of their current income and wealth. That means that losing $25 may immediately impair the balance in our life, since we’ve planned our spending in light of having that money. But we probably haven’t  planned our spending in light of getting an extra $25, since after all we don’t know that we’ll get the extra money. That means the benefits of that gain are naturally more nebulous, and certainly not essential to maintaining the basic balance we’ve achieved. People with an appetite for risk may weigh these costs and benefits differently, and I’m not saying that being risk-averse is the only reasonable approach. But it is one reasonable approach, and apparently the more common one – and it’s hard, I think, to say that it is “irrational.”  

            There’s a second reason, however, that may be even more important. That is that the future is actually not very predictable. When we are told that we might gain $25, we must know that whoever is telling us this could be wrong. Unless we are experts on the steps to be taken to achieve that gain, we inevitably face the possibility that problems will surface that we never thought of. (If something sounds too good to be true, as the saying goes, it probably is.) Now of course it is possible that the chance of losing $25 has been overestimated – but then it’s also conceivable that the risks, either the amount we might lose or the likelihood of our losing it, have been underestimated instead! Since in real life we generally don’t know what the exact probabilities of either gain or loss are, if we’re initially inclined to care more about potential losses these uncertainties give us additional reason to follow this inclination.

            The rich literature about cognitive heuristics suggests that human reasoning is much more fallible than we might like to think. But if other heuristics also have sound bases in experience, as I’ve tried to show that the “over”-valuing of risks does, then maybe we are not as fallible as we have been coming to believe. Perhaps we need to understand, instead, why particular traits of human reasoning actually often work out well in the world, however flawed they may be in laboratory study. Of course, even if this is so, we’ll still know that we are capable of a lot of irrationality!

           

Are good scholars more likely to be good teachers?

What should we make of a recent study, The Teaching/Research Trade-Off in Law: Data From the Right Tail (January 2015), that finds that, at the University of Chicago Law School, faculty members' teaching evaluations rise in correlation with how much they publish (69)?

The study's authors, Tom Ginsburg and Thomas J. Miles, both members of the Chicago law faculty, are open-minded and careful in their reading of their data, and readily acknowledge that the University of Chicago might be atypical. (78) They report that many studies of the impact of scholarship on teaching in academia have concluded that these two have little or no relationship to each other. (52) Meanwhile, Chicago's faculty members are so productive as scholars that the entire environment at Chicago may be unique. The average number of publications per year for each faculty member is 4.63; the median is 3 (56-57) -- and that's a lot of publishing. Perhaps Chicago's students are so accustomed to having ardent scholars as teachers, and so convinced themselves of the value of scholarship, that they are a specially welcoming audience for this group of professors -- a possibility the authors note. (72) Perhaps Chicago's scholars are unusually good teachers as well, another possibility the authors allude to (but don't assert is correct). (57-58)

But suppose what is true at Chicago is true more generally. What would that tell us?

First, it would be clear that being a productive scholar does not prevent someone from being a strong teacher as well. We don't know if this is in fact generally the case, but if it is, that's important. 

Second, it would remain likely, nonetheless, that time matters. The Chicago faculty in this survey don't seem to teach very much; on average, the study looked at the work of each professor over about 5 years, and during that time "[t]he average professor taught an average of 10 courses and the median professor taught 9." (53) That appears to mean that the typical Chicago professor teaches two courses a year, a number that I think faculty at many other schools would envy. (The authors note that "[a]ll of the regressions in [one aspect of their study] suggest that teaching multiple courses in a single term may reduce the quality of teaching." (74)) Moreover, Chicago faculty in general have limited administrative responsibilities. (56) They have a lot of time to perfect their scholarship and their teaching. Less time, one suspects, leads to less perfection -- though it seems from the data that Chicago's faculty/administrators sacrifice scholarly productivity (63) but not teaching quality (73). 

Third, it would remain quite unclear whether scholarship promotes teaching. I find the idea that writing about issues promotes understanding and that this understanding promotes exposition in class intuitively appealing. But it may not be correct and of course the correlations the study authors have found do not directly prove causation.

Perhaps there is some other factor which makes people both productive scholars and effective teachers. Once this idea is stated, it strikes me as having intuitive appeal too. Maybe Chicago's faculty have a combination of intelligence, demonstrativeness (to catch students' and readers' interest) and focused energy. Traits like these would make these people good at a range of occupations; two of them would be teaching and scholarship, but that might not be because teaching and scholarship actually build on each other, or (more to the point) build on each other in some specially powerful way.

Fourth, the study does not tell us anything about the relationship between scholarship and clinical teaching. The Chicago clinicians weren't included in the study at all; the authors explain that this is because clinical "courses differ from traditional academic teaching, and clinical faculty often do not publish scholarly articles." (78 n.1) I'm not familiar with Chicago's clinical faculty rules, but it may be that clinicians there are not expected to be scholars as well as teachers and case supervisors. 

Suppose it turns out that Chicago's clinicians are also very effective teachers, but that their effectiveness doesn't correlate at all with scholarship. That might offer more reason to believe that the true reason for faculty members' teaching effectiveness is, as I suggested earlier, that they have a special combination of intelligence, demonstrativeness and focused energy. The clinicians may build their teaching effectiveness through their simultaneous engagement in the cases their students are handling under the clinicians' supervision; that practice engagement may have the same synergistic impact on teaching as scholarship may for their classroom colleagues.

Fifth, we would not know whether the courses the Chicago faculty in the study are teaching are the best ones for the students to be taking. So, as the authors also acknowledge (48), what the study tells us is that Chicago's non-experiential courses are well taught by its scholarly faculty, not that "law schools are teaching the right things that students need to practice." We wouldn't know, in particular, that the balance of doctrinal and experiential, skills-focused courses is what it should be.

In short, we would -- and do -- have a lot still to learn.

When plagiarism isn't plagiarism -- answer: in much of the work of lawyers

According to a recent study (as summarized by Adam Liptak in the New York Times), in Supreme Court majority opinions over almost 70 years (1946-2014) “the average rate of nearly identical language between a party’s brief and the majority opinion was 9.6 percent.”

It’s a little difficult to know what this means. Liptak says that “[t]he study and related findings … looked for passages of at least six words with an overlap of at least 80 percent.” So if a Justice wrote a six-word clause, of which 5 words were the same as those in a party’s brief, the study would have counted it as an instance of nearly identical language. Since many Supreme Court opinions quote at some length from statutes or precedents, it seems possible that quite a lot of the reported overlap consists simply of use of governing legal language, as Liptak notes.

Liptak reports that Justice Thomas’s use of nearly identical language is “unusually high” (11.3 percent), but while Justice Thomas apparently writes this way more than the others on the Court, the differences do not seem vast: Justice Sotomayor is at 11 percent, Justice Ginsburg at 10.5, and the Court’s average was 9.6 percent. So it’s hard to tell whether the data really shed any substantial light on Justice Thomas’s overall work as a Justice.

But what’s noteworthy is that judges’ use of others’ language seems to be generally (though not universally) accepted as perfectly appropriate. Similarly, lawyers regularly use published form documents as the basis for those they have their clients sign, and I think that it is also commonplace for lawyers to borrow arguments wholesale from either published sources or colleagues’ past matters – and in both forms of writing I believe the borrowing lawyers do not footnote to their sources. There may be some outer limits on such practices, but it seems fair to say that a significant amount of what lawyers and judges do with words would be plagiarism if it was done in the pages of a scholarly journal, or a newspaper. (Of course lawyers sometimes use words not as advocates or judges but as scholars or journalists, and in those contexts the rules of plagiarism apply to lawyers exactly as they do to others.)

Why don’t the rules of plagiarism apply to the work of lawyers and judges as they do to the work of scholars and journalists? Presumably because what we want from lawyers and judges is results. When a lawyer drafts a document, much of what he or she is doing is employing tools – legal terms – to accomplish an objective. It would make no more sense to bar the lawyer from using language someone else had developed than it would to prevent a carpenter from using the correct tool. (At least provided, in each case, that the original developer had made his or her tool available, or put it in the public domain.) Similarly, when a judge deploys borrowed language to lay out the foundation for a conclusion, he or she may rightly be seen as simply using the tools at hand.

We do, certainly, want more from lawyers and judges than mere use of tools. Creativity, judgment and wisdom are also part of the law. But our collective practice seems to reflect that we think we can still look for creativity, judgment and wisdom even while recognizing that a substantial amount of the work to be done is the employment of tools, and that as a result we should regulate the ethics of using words in law practice quite differently than we would in domains where the plagiarism rules hold full force.