A talk with Dr. Celine Godin
By Scott Douglas
Dr. Celine Godin is a radiation oncologist with Spectrum Medical Group in Scarborough.
The Bollard: Let’s pretend that I have cancer. At what point do I see you?
Godin: After a tissue diagnosis, meaning that we need to have proof that you have cancer. Anytime after that you might see me. It depends on what type of cancer you have.
Someone your age , given that you’re healthy, fit, the most common type would be testicular cancer. So you would probably already have had your surgery, and then you would come to me for the next phase of treatment.
Then it matters whether your cancer was very localized, or whether it had spread. That would determine if you need me and/or a medical oncologist, who is the chemotherapy doctor…. I just give radiation therapy.
In this hypothetical case of testicular cancer, how often would I see you?
You would see me once for an initial consultation [and if] my services are indicated for you, you would come back for a mapping appointment, which is when we construct a tailor-made radiation therapy plan for you based on where your cancer is within your body. And then you would come back for your daily treatments. Depending on what our goal of treatment is, and what part of the body we’re radiating, treatments are anywhere from two weeks, every day, to eight weeks, every day.
In most cases, does the patient get this block of treatment and then they’re done?
It all depends…. If the goal of treatment is cure, then we’ll map out a plan, plus or minus chemotherapy…. If it’s a definitive course of treatment, then that’s it — we’re going through this just once, and I’m going to give you as much radiation as your cancer needs to be killed without harming the normal tissues in your body.
But if you come to me and you have end-stage or very, very advanced cancer of some sort, say lung cancer that’s already gone to your bones or your brain, then my job is to figure out what I can do using radiation therapy to keep you comfortable. If you’re coughing up blood, or you have bone pain, or brain lesions, how can I make you feel better and keep you ‘you’ as long as possible with minimum other interventions or drugs?
How does radiation help do that?
It helps shrink and stabilize tumors that are in other parts of the body that can’t be removed, so they’re hurting you in some way. My intervention isn’t going to extend your life very long, but what it’s going to do is give you better quality of life.
If you have a bone lesion in the spinal cord that’s pressing on a nerve, I can shrink that with radiation therapy. It’s almost like spot welding. I can either diminish the pain, or in some cases, particularly prostate and breast cancer, I can make the pain go away altogether, and you will probably never be bothered by that again in that site.
Most palliative interventions are over in two weeks. Knowing that they don’t have long to live, and knowing that they’re not going to be around to experience the toxicities from a short blast of treatment, I can use a very high dose of radiation in those cases.
The treatments are very short — it’s about seven minutes for a traditional radiation therapy treatment. We schedule in 15-minute blocks, and we treat anywhere from 35 to 45 people a day.
Another goal is to minimize the use of narcotics. It’s not that I don’t believe in narcotics — I think that they’re a wonderful thing, and I prescribe a lot of them. But the problem with narcotics is that people get constipated and they get loopy, so you can’t drive. It’s really hard to maintain a normal life with more and more narcotic usage. So that’s one way I help people: I help them get down on their narcotic usage because I can help them with pain.
How long have you been an oncologist?
I graduated medical school in ’94, and then went through a five-year training program to become board-certified.
In that time, have there been significant advances in how you treat people?
Every year it seems like there are huge changes in our field. It takes a lot of effort and energy to keep up with it. It’s incredibly helpful to be in such a vibrant [medical] community as we have here. I don’t have to be responsible for everything. I can be very good at my niche, and I’m very grateful that I have a strong network of oncologists here in the community. We meet and talk frequently in specialty tumor boards, which are conferences held anywhere from weekly to every other week. They’re focused on a particular tumor site, and that’s where we discuss all the new breast-cancer diagnoses or lung-cancer diagnoses.
Are there things on the horizon in the cancer-treatment field that will change things greatly? Right now, it’s pretty brutal, where the treatment can seem as bad as the disease.
That’s true, it can be. But even since I started, I’ve seen vast advances in anti-nausea medication, in pain medication, and how they’re delivered.
Like anti-nausea medication, if you’re nauseated, you can take a tablet that dissolves on your tongue, and within minutes have relief of those symptoms. That’s new within just the past few years. There used to be just a couple of choices, and now there are half a dozen choices.
You start out with the older medications, which are the least expensive ones, which is so important because I see so many people that don’t have a drug card. But it’s really nice to know that if the older, cheaper ones don’t work, you’ve got other choices that are all good choices.
The same with pain medication — they can be delivered by tablet or by a patch, which is fairly new. I still talk to doctors who aren’t aware of these basic ways to keep people comfortable and manage very, very easily managed pain. I spend a lot of time talking to primary-care types who have patients who are really, really disabled from their cancer, and they don’t know that I can help.
It’s incredibly gratifying to see someone coming into your office in a wheelchair, or using a cane, and they’re on this whole list of medications, and by the time you’re done with them, in less than two weeks, they’re walking, they’ve tapered down their pain medication, they’re driving, they’re laughing.
Chronic pain is one of the worst things you can live with, and no one should. There’s not enough attention directed to alleviating it.
I’m curious about the whole pot thing. I have a friend who had Hodgkin’s Disease, and he was given THC pills, and they did nothing for him, but smoking pot helped.
Marinol — that’s the name for the THC pills — is terrible. I hate it, because you can’t titrate it — you can’t take it by exactly how much or how little you need. Smoking a joint is perfect. If you need one hit, that’s all you need; if you need a whole joint, fine, use it.
I’ve written probably half a dozen prescriptions for it. Once or twice a year, someone will ask me for it. Patients are incredibly shy about asking for it. It’s legal, we can do it in this state. I write in big letters, ‘PATIENT HAS END-STAGE CANCER,’ if for some reason they get busted.
There are people in this country who would love to haul my ass into court for that. There’s this whole federal-state schism that we haven’t figured out. It’s really, really unfortunate, because I’ve known a lot of people who have used pot to help with their nausea or pain or just to get some appetite.
The Canadians have figured out how to do it — they grow it, they monitor it, the government takes care of it. We’re just very fucked up in this country. I can write you prescriptions for morphine and codeine and methadone – you name it – but not pot in some places. It’s very sad, because it works great, it’s cheap, it’s easy, and you inhale it. When you’re nauseated, the last thing you want to do is swallow more stuff. For a lot of people, one or two tokes, and you’re good. But the Marinol, it’s all or nothing when you take one of those tablets.
You were saying how nice it is to see how much improvement you can bring to someone in a short time. I was curious why someone would choose oncology — you could be an orthopedist and bring quick relief to people, and you don’t have to deal with the fact that a lot of your patients are going to be dead soon.
I had a big melanoma operation when I was 23 or 24. It was a really eye-opening experience. When other people heard that I had cancer, I had friends who totally disappeared, and then I had other people, who I thought were just acquaintances, who appeared and provided a lot of emotional support.
I sort of processed all that while I was in the middle of going to college to become an engineer. I did that for a few years and hated it, so I sat down and thought, ‘What else can I do with my life? What can I do that would be endlessly stimulating; that would let me work all over the place; decent money, lifelong earning?’ I went through a checklist of what I liked and didn’t like, and came up with going into medicine.
So I sat down with a pre-med advisor at USM and mapped out a ten-year plan of what I needed to do. In the third year of medical school, I was doing clinical work, taking care of someone in the hospital who was having radiation therapy, so I sort of nosed my way around the radiation department. It was like, ‘Wow, this is the place for me!’ There are all these science geeks, there’s lots of math, and the vast majority of patients are treated on an outpatient basis, even though it’s hospital-based, so you still get a lot of contact with hospital medicine, which is good to keep your skills up. And you’re helping people, in a really measurable, demonstrable way.
How do you not become immune to the suffering and potential death of your patients?
The best way to describe how I handle that is that when I’m at work, that’s about all I think about and all I deal with, but when I walk out the door, I can pretty much turn it off. It’s almost like flipping a switch. I can compartmentalize, and that’s good and that’s bad. That’s my survival technique, and it’s the most common one of the people I work with.
Some of us do wild and crazy things on weekends, like back-country skiing or ferocious bicycle rides; everybody has an outlet of some sort. My outlet is being outside and being in touch with the natural world, and as corny as it sounds, remembering that this is all part of the cycle of life. In the summer, [my partner and I] spend as much time as we can at our camp. Not in isolation, but in solitude. That’s how I recharge.
I’d like to hear your thoughts about the broader health care system. You no doubt know some of the main complaints of patients — not just the waiting, but then once you get in to see the doctor, you’re there because something is wrong, and as soon as the doctor walks in the door, you get the impression he wants to be somewhere else.
What I do is sit down and shut up. I ask a ton of questions, but I also just sit and listen, and try to make eye contact, and I never stand up unless I’m going to examine them.
Is that something that’s recently been promoted in the profession? I’ve noticed in the last few years that most of the doctors I’ve seen sit on a stool that’s lower than what I’m sitting on.
Exactly. Studies have asked patients to rate their perception of the amount of time the doctor spent with them, and they’ve had doctors spend the same amount of time in the exam room sitting down, standing up, and standing up with their hand on the door. The perception with the hand on the door was that the doctor was spending less time.
Even if I’m intending to spend only a minute with someone — and sometimes that’s all I need for people under treatment, if everything is fine — I sit on a low stool. It’s really important to let them know, ‘This is your time. I’m hear to listen to you.’
I’ll also ask, ‘Have you done anything fun lately?’ or ask about recent trips, and try to find out what’s important to them, and make notes about that. If someone’s cancer has returned or it’s end-stage, if it’s really important that they get to a certain wedding or make a certain trip, I’m going to do everything I can to make sure you do that.
In the world of cancer, it’s a real perspective-changer about what’s important and what’s not, so we often talk about big stuff, like, ‘How do you want to die? Do you want to die at home? In a hospital?’
Do you ever feel like patients treat you differently because you’re a woman?
Once in a while. In VA hospitals, I’ve had guys call me ‘sweetie.’ I let them know it’s ‘Doctor Sweetie.’
Getting back to the U.S. health care system, from your perspective, what is most wrong with it?
The most wrong is where our priorities are, which are on mopping up after somebody already has the disease process well under way, or trying to mop up, and therefore spending tons of money, instead of focusing on well care and prevention: well baby care, well family care, taking care of kids in school, teaching them healthy habits.
What about the way that we fund health care, the health insurance system in the U.S.?
I wish that we could get rid of insurance companies. I wish that the state or federal government could take over insurance, like the way that we do public education. There shouldn’t be that barrier to care of not having insurance. When you don’t have insurance, if you have a problem, then you often wait until it’s too late, and then it becomes an enormously costly problem, and the chance of success of eradicating it are very close to nil.
Have you had a chance to read about the study that just came out comparing the U.S. system to British health care?
I downloaded the article from [the Journal of the American Medical Association], but have read only the abstract. But I found it fascinating, because they started out with the premise that Americans spend about $5,000 per person, per year, on health care. Brits, even the lower socioeconomic status ones, spend half that, and still their health is better.
It’s not that we’re spending money on health. We’re spending money going to doctors and having procedures, not spending money on prevention. It’s more, ‘Fix me, I’m broken.’
Disease care rather than health care.
Exactly. It’s not even health care maintenance. I’ve tried in my own company to promote a health care maintenance program, and it falls flat. There’s just no interest, even though it would lower our insurance premiums and all that stuff. The vast majority on the committee say, ‘Maybe we should make that for new hires.’ And these are physicians talking about other physicians!
What do you think of DirigoChoice?
I think that’s it a really good first step at addressing the problem. It needs some tweaking, but I think we need to give it a chance to work, and we need to keep working on it.
How should it be improved?
I don’t know. I’ve not heard that many complaints about it.
Well, the insurance companies sure complain about it.
Right, but I don’t care about them. Frankly, I think that they’re vipers.
But it matters what they say in terms of sustainability. As a self-employed person, I have DirigoChoice, and my greatest fear about it is that it will just go away.
I agree, and that’s why I support the efforts of the Baldacci administration to support it. It’s a socially responsible thing to do, and it annoys me that Republicans and the insurance companies get all up in arms about it.
Yeah, it’s going to eat into your profits — too fucking bad. You are making money off the misery of others. Now you might make a little less. Too bad.