A Conversation with David Elkowitz
Last July, Dr. David Elkowitz was diagnosed with a poorly differentiated squamous cell thymic carcinoma. I know what this means because, before his diagnosis, he was the one who taught it to my medical school class, citing Robbins with an almost photographic memory. After his diagnosis, months passed before he gave another lecture, and when he did, he was 10 pounds lighter and had lost most of his hair from chemotherapy. The subject of the regularly scheduled lecture was anterior mediastinal masses, and here we had a patient and a doctor in one.
In the many times that I’ve visited his office, his desk has always been tidy. He admits to not owning a computer at home, and the desk that separates him from visitors to his office is bare, aside from a keyboard and a monitor. Behind him, beside a microscope and beneath two neat shelves of a few select volumes, he’s surrounded himself with photos and mementos from friends and family, along with two signs. One says “No Whining,” which he says is meant for him, not for his visitors. The other is “Essayons,” or “Let’s try,” the motto of his alma mater.
When we conducted this interview, his hair was already beginning to grow back, and he was back to full-time work. On a few occasions, he leaned in to the microphone that was recording our conversation to emphasize a point and to be sure that readers took note. Throughout the process, he has remained a teacher above all, first teaching by example, and now teaching from experience.
Adam: Last July, you were diagnosed with a thymic carcinoma, but you were still teaching at the time. Did you feel unwell before you were diagnosed?
Dr. E: For the better part of a year and a half, I had noticed these weird myalgias in my upper body, from my pectoral muscles up, along with TMJ and temporal headaches. The fact that they were alleviated by ibuprofen made me poo-poo working them up, and I chalked it all up to the price of becoming 50. But it was definitely real. I mean, I came to work with a bottle of ibuprofen, so I knew something was wrong. At the same time, roughly, I developed a very severe case of Raynaud’s. I chalked that up to some bad hab - its, you know, tobacco use. So over the last year, I weaned myself off of tobacco — I’m off it now — but it wasn’t getting better.
Adam: So what triggered a visit to a doctor?
Dr. E: In July of last year, I had three talks I was giving around the country — two in Texas and one in Washington — and I had a day off before I was set to come back to work. So I said, “You know, I should get this checked out.” I had promised my family that when I turned 50, I’d go for a colonoscopy and endoscopy, and those had both been clean, so I was on a good roll by this time. The myalgias were bad during the talks, but I felt fine otherwise. I even went for a run. So when I came back, I went for a Raynaud’s workup, which was a battery of tests and a chest x-ray. I had the chest x-ray first to rule in or rule out lymphoma, which has been associated with Raynaud’s. Afterwards, I was brought into the radiology suite. I saw an x-ray on the light board with a huge mediastinal mass, and I said to the radiologist, “Please tell me that’s not mine.”
Adam: Did you get any other imaging to confirm the x-ray?
Dr. E: A CT scan was done immediately. Then I alerted my higherups at the school. I needed a quarterback, so on a Thursday night, I went in to see a pulmonologist. I had a needle-core biopsy the next day, and a pathologist made sure there was enough sample to do not only a diagnostic but also a genetic workup. On Saturday, I had the diagnosis of a high-grade, poorly differentiated squamous carcinoma of thymic origin, otherwise known as a thymic carcinoma.
Adam: That must have been a scary period of time. How did you take it?
Dr. E: Saturday afternoon, I freaked out a little bit. I had a couple of friends in the medical field support me on Saturday and Sunday. I’ll admit those days after I got the diagnosis were not good, because even though I knew what the diagnosis meant, the sheer size of the mass — it was 15 centimeters, wrapping around vital structures — made me at that time not a surgical candidate. So that scared me a little bit. My whole family was over. The school was very supportive. I started to read a little bit, and I shouldn’t have done that. Don’t do that. Allow yourself to be a patient, not your own doctor.
Adam: When did you start getting treatment?
Dr. E: So on Sunday, you know, I had a couple of drinks. I settled myself down. One promise I made to myself was that I wasn’t going to put myself through the mental trauma of spending another month getting second, third, fourth, and fifth opinions. I promised myself that if I trusted my physicians, I was going to trust the fact that they would find the proper information and protocols on their own. On Monday, I went to see an oncologist at Northwell. She was a wonderful human being. And she was confident. She looked at me, and I think she saw that I was depressed, but she settled me right down. She said, “We are not going for just maintaining you for a few years. We are going for a cure.” And the way she said it, I trusted her. I mean, she was just awesome. Direct, truthful, knowledgeable. That afternoon, I also met with a surgeon and a radiation oncologist. I trusted all of them 100 percent. Once my team was set, I started going forward. On Tuesday morning, five days after my diagnosis of a mass, I went for chemo.
Adam: And how did you feel when you started chemo on that Tuesday?
Dr. E: I gotta tell you, I was in a great mood that morning. Great mood. I have a picture from that morning that I can share with you. From that day on, positive attitude. That’s not to say — like, this weekend, I started thinking again about my mortality. But all in all, I decided to fight this. I decided to go into battle instead of just going through the motions.
[Photo caption: Dr. Elkowitz and his son on the morning of his first chemo treatment. "You can see in my face that I was in a great mood that morning."
[Photo caption: Biopsy of Dr. Elkowitz's thymic carcinoma.]
[Photo caption: Dr. Elkowitz and his son on the morning of his first chemo treatment. "You can see in my face that I was in a great mood that morning."
Adam: That’s interesting, the way you phrased that. In a sense, you had to surrender being your own doctor and hand yourself over to others. And yet you weren’t surrendering to the disease. It must have been difficult to learn how to fight the right battles.
Dr. E: I never really thought about it until you just posed it that way. I knew I was going to fight the disease. And the only way I knew how to fight it was to have a good attitude and get back to work. But I had to relinquish some control in terms of what I was going to research and what I was not going to research.
Adam: It seems that you realized quickly that you didn’t want to fight yourself. You just got out of your own way.
Dr. E: I knew enough about medical oncology to make me dangerous. And I decided very early on that I was not going to be my doctor. I was going to trust my doctors. That’s not to say that I didn’t ask questions. I asked questions. But I tried hard not to second guess their judgment, and I really tried hard to be a good patient. In fact, when I was being treated by a lot of the staff there, many of them didn’t know I was a physician or part of a medical school.
Adam: People dealing with cancer often say that they’re fighting it, and it’s hard for somebody who has not had cancer to imagine what that means. What kind of a fight is it?
Dr. E: The irony is that when I had this mass in me, I was running six, seven miles. I gave presentations in that month of July. I was feeling good aside from the Raynaud’s and the myalgias, which were alleviated by medication. I didn’t feel awful until I started treatment. So I think fighting cancer is really two things: It’s fighting the side effects of treatment, and fighting this whole idea of your own mortality.
Adam: Many people fight off those thoughts of their own mortality by distracting themselves, and sometimes work is the distraction that they need. But what’s really interesting about your situation is that you’re a pathologist — your job involves teaching us about cancer. In fact, the first lecture that you gave to our class after you began your treatment was about mediastinal masses.
Dr. E: The way I reconciled that paradox was very simple. My work — being around the administration, faculty, and students — was part of my treatment plan. Of course, I couldn’t have come back to work at all without the mental and physical support of my wife and children at home. But I wanted to use my issue as a tool for better understanding of the material, of what it means to be a physician, and of what it means to be a patient. I felt that that would be the greatest gift I could give to the students. So I had no problem talking about anterior mediastinal masses when I came back; or, in the case of the first-years, using a poorly differentiated squamous carcinoma as an example of grading or staging. I had no problem doing it because, again, I really wanted to give back to the students not only the knowledge but also the insight into what it is to be a great physician — it’s a lot more than just knowing your material — and what it’s like to be a patient.
Adam: Do you feel that as a pathologist you were always at a distance from disease, looking at slides through a microscope?
Dr. E: I gotta tell you, I’ve been in academics for 18, 19 years, but very early on in my career, certainly during my residency and fellowship, we’d sign out 50 to 100 cases per day, maybe 30 cancer cases. And all they’d be is slides on a tray. And I know looking back at that time, yeah, they were patients, but you never really had the time or allowed yourself to think that these people were scared. After the sign-out, it was just out of sight, out of mind. Because the next day, you have another 50 or 100 cases. And here when they signed out my case on Saturday and they gave me that diagnosis, I was shattered. I know my wife was shattered. My kids were upset.
Adam: I suppose if pathologists internalized every case that they diagnosed, they wouldn’t be able to do their job.
Dr. E: They couldn’t do their job effectively. Maybe they can, but I know I couldn’t. I’ll speak for myself. I knew I couldn’t, and I didn’t. But after my diagnosis it became very evident to me that every disease that we learn about has families and patients attached to it with real feelings and real emotions. I always felt that if you were a competent physician and knew your material well, all the other stuff made no difference. But my doctors are not only competent, they have the “it” factor. They can look in my eyes, and without saying a word …I have full trust and confidence in them. This total rapport between us, it’s awesome.
Adam: Between Thursday and Saturday — I mean, Saturday was the big day, but how did you handle the two nights of sleep before that? You talked about what happened during the days, but what was going through your mind at night?
Dr. E: Oh, this is good for the students. So remember: Everything’s about a differential. From Thursday to Saturday, I was going through a differential in my mind. On Thursday, I was diagnosed with a mass. At first, with the chest x-ray, I was thinking, Okay, it’s either a thymoma or lymphoma. And if it’s lymphoma, it’s most likely nodular sclerosing, maybe a B-cell lymphoma. Two hours later, I saw the results of my CT scan with contrast, and it showed a malignant mass, 15 centimeters, with lymph node involvement. So my brain shifted gears to, Oh, thymoma is a lot less likely—it’s still in the differential, but lymphoma is much more likely. And out of lymphomas, I was thinking it would be nodular sclerosing. On Friday, I went in for the biopsy, and when they woke me up after the biopsy was over, the interventional radiologist said to me, “Your mass was so fibrotic that we had to use a special needle to pull tissue out.” So at that time, I was actually in a good mood, because I thought to myself, It’s nodular sclerosing, with sclerosing explaining the fibrosis of that mass. By Saturday I got back the results.
[Photo caption: Biopsy of Dr. Elkowitz’s thymic carcinoma]
[Photo caption: Biopsy of Dr. Elkowitz’s thymic carcinoma]
Dr. E: Oh, this is good for the students. So remember: Everything’s about a differential. From Thursday to Saturday, I was going through a differential in my mind. On Thursday, I was diagnosed with a mass. At first, with the chest x-ray, I was thinking, Okay, it’s either a thymoma or lymphoma. And if it’s lymphoma, it’s most likely nodular sclerosing, maybe a B-cell lymphoma. Two hours later, I saw the results of my CT scan with contrast, and it showed a malignant mass, 15 centimeters, with lymph node involvement. So my brain shifted gears to, Oh, thymoma is a lot less likely—it’s still in the differential, but lymphoma is much more likely. And out of lymphomas, I was thinking it would be nodular sclerosing. On Friday, I went in for the biopsy, and when they woke me up after the biopsy was over, the interventional radiologist said to me, “Your mass was so fibrotic that we had to use a special needle to pull tissue out.” So at that time, I was actually in a good mood, because I thought to myself, It’s nodular sclerosing, with sclerosing explaining the fibrosis of that mass. By Saturday I got back the results.
Adam: That was the doctor in you. What was the patient in you thinking?
Dr. E: Saturday and Sunday were not good days. Yeah, those were not good days. Because then the hopefulness of nodular sclerosing, which has the best prognosis of any of the malignant options, was gone. Saturday and Sunday were tough. But my family was around me. I had close friends who were physicians around me. They spent time with me and my family at home and really helped me a lot. But then Monday night, after I met my team and I was comfortable with them, and knowing that I was going to start chemo on Tuesday morning, I had Chinese food and I had a good night. I went in there with a great attitude. I became notorious. I had a hundred students clogging up the waiting room, and it was awesome. From that point on, I’ve had bad days, but very few and far between. Even this last weekend, I started thinking — because I was getting a cough and having this shortness of breath, so I started to think about my mortality, you know, Is it back? But by and large, I’ve had a lot of great days since the first day of treatment.
Adam: Do you have a strategy for dealing with those thoughts?
Dr. E: Yes, I actively put them out of my brain. That’s it. It takes effort. I put it out of my brain actively, and I think about something else. It’s a real active process. And I always go back to the confidence I had in my physicians, in my surgeon in particular, who said, “You’re cured, we got it.” And my oncologist was saying, “It’s working.” I think about them. But it’s active. You actively gotta move on.
Adam: Can you talk about your decision about whether to tell the students what was going on?
Dr. E: That was never even a thought in my mind. Students, faculty, and administration are like my family at home. I spend so much time with you guys here. You guys were going to see me without any hair, drop 10 pounds, anemic, walking up the stairs taking breaks. I mean, you guys are not stupid. You were going to see that I was sick. What am I going to do? Hide it? I couldn’t. Plus, I knew this was a teaching moment, a chance to make lemonade out of lemons.
Adam: From the beginning, you knew?
Dr. E: I didn’t pull any punches with you guys. And the outpouring of love and concern from the administration, the faculty, the students, and the community including the health system was so intense. I had so many visitors that there wasn’t enough room for other patients’ families in the waiting room. It was an intense, loving response. It was very, very good. Very good. Yeah. True gift.
Adam: Occasionally there’s this dynamic where the patient sometimes needs to help the caregivers to overcome the grief surrounding the illness. In other words, the patient can end up comforting friends and family, rather than the other way around. Did you ever feel like you needed to reassure other people that you’d be all right?
Dr. E: No. The students, the faculty and the administration, whenever they came to see me, were terrific. I don’t think they ever wanted me to use my energy to heal their own issues. As for family, you never know what this truly does to your wife and your children, because as they’re being strong for you, they internalize a lot of stuff. They deal with a lot without trying to put the burden on you. I know my wife and my children did that and are doing that. I just want to let them know that I really do love them and appreciate that. They were incredibly strong. They had their moments, but very rarely, if ever, around me. Everyone was very strong around me.
Adam: During one of the times we talked before, you said that the experience made you a better teacher. What has changed?
Dr. E: Let me be perfectly clear. I was getting more from teaching than I was giving. I am sure of that. We have a lot of talented faculty and certainly pathologists who could have done those sessions. They may not have done it in my style, but they certainly could have relayed the content. My choice to come back was part of my own treatment. In fact, it was a little bit selfish of me, because the students had to sit there and listen to a person who had trouble projecting, who was out of breath, whose appearance might have been distracting. I don’t care what you guys say, whether you disagree with me on this or not. I knew this was going to be an important part of me healing faster. Having the opportunity to teach was just as important as the drugs going into me. I feel very strongly about that.
Adam: Was that something that you’d always considered on your own? Or was that something that doctors or oncologists had suggested?
Dr. E: On the contrary. I was encouraged to take it a little bit slower, to get rest, to take care of myself. What people didn’t realize was that my coming back and having the opportunity to do those sessions was taking care of me. It was keeping me in the game.
Adam: Last time we spoke, we talked about how illness or adversity can change your perspective on life. You mentioned that sitting in traffic used to be a frustrating experience until you weren’t able to drive for a while. And then, when you were able to drive again, you felt grateful for sitting in traffic. Were there other moments like that during your treatment and recovery?
Dr. E: There were a lot of little things that I missed, or that I didn’t expect to miss. I missed mundane things like having hair on my body, having an appetite, and being able to taste food. I missed the ability to go for a run. Sitting in traffic was part of the experience of driving to work independently, and my illness made me realize that I had taken all of that for granted, even the frustrating parts.
Adam: Did it make you love and appreciate your family more?
Dr. E: Loving my family was never difficult for me. I lost my sister at an early age, when I was 24, and I still think about her a lot, so I’d already worked through a time like that. No, appreciating my wife and children wasn’t hard for me to realize.
Adam: What did you do when you had all that time off?
Dr. E: I didn’t have the energy to do anything. I watched movies, slept, or made the effort to rehabilitate myself, maybe walk a thousand feet. It was an ongoing struggle to even eat. It was an hour-long ordeal just to get something down. It was an hour-long ordeal for me to walk down the stairs and out the door. Everything was an hour-long ordeal, and I had to sit and rest. I mentioned this to your class, but the one thing I gotta tell you guys is that words mean something in medicine. When somebody says, “I’m fatigued,” what does that actually mean? Last year, you and I could have gone together for a five-mile run, and when we came back, we’d be fatigued, but we’d feel great. It’s a good fatigue. Or maybe you as a physician can prescribe me a medication where, as a side effect, I might feel fatigued. And I might say, “Yeah, I feel a little tired.” Or maybe medical students studying 29 hours a day, eight days a week, are wiped out and feel fatigued, but they go to sleep and they wake up feeling okay. Or maybe you’re on chemo, and you feel fatigued. And that fatigue is like this: Even when you go to sleep, you still feel like hell.
Adam: You’ve often said to us that attitude is a choice. What do you mean by that?
Dr. E: I said to you that I started thinking about my own mortality. Negative thoughts. I’m human. I understand that’s going to happen from time to time. But you have a choice to dwell on them or to move on. That’s what I mean. Whatever is happening, there’s enough good going on, and I have a positive attitude. Today I’m a little out of breath. I have this chronic cough. I don’t feel 100 percent. But instead of dwelling on that, I’m here at work. I’m talking to you. I helped two students in my office with content questions. That’s a privilege and a great thing. I’m in a better place now than in the morning when I wasn’t feeling that great. No matter what your circumstances are, don’t complain. There are people who have it worse off.