In this edition, Jennifer Lycette, MD, talks about her childhood in Alaska and bringing cancer care to rural Oregon.
Tell us about your childhood. Where did you grow up?
I was born and raised in Anchorage, Alaska. I lived there until I was 18 and left for college.
How did your family end up in Alaska?
My parents met when they served in the Army during the Vietnam War – my father was a helicopter pilot and my mother was a nurse. In 1970, they retired from the Army and moved to Alaska, where my father found employment as a helicopter pilot when the oil pipeline was being built, and my mother continued to work as a nurse in the local hospital’s cardiac care unit.
Life in Alaska sounds rugged and remote, but Anchorage is a medium-sized city of about 250,000 people. Looking back, I had a pretty typical 1980s childhood, just with more snow. In the winters, when my brother, sister, and I walked to school, we took a shortcut across a frozen lake – even though our mom thought it was too dangerous. The lake was so solidly frozen that people drove their cars across, so it was safe enough for us. Now I enjoy torturing my children with stories of how their mom had to trudge through the snow to school, so they don’t have it so bad.
When did you know you wanted to go into medicine? Did your mom have an influence on that decision?
At age 12, I decided I wanted to be a doctor. After that, everything I did was geared toward that goal. My mom’s nursing career definitely had some influence. As a kid, I tagged along with her when she had to stop in at work, and I remember always feeling comfortable in the hospital setting. It’s interesting, because my sister’s memories are much different; she did not like going to work with my mom at all. She went another route and became a landscape architect, and my brother became a commercial airline pilot in Seattle.
Once you started your medical training, why did you decide to pursue hematology?
My interest in hematology progressed through my clinical rotations during medical school at the University of Washington and my internship and residency in internal medicine at Beth Israel Deaconess Medical Center in Boston. From the beginning, I was drawn to opportunities to improve delivery of care for patients diagnosed with malignancy in the hospital setting. I remember observing the phenomenon that any time a patient was given a new cancer diagnosis in the hospital, the whole team would seem to draw away from the patient. I always felt like it should be the opposite – we should all be stepping forward and embracing that patient.
Also, I was in my intern year about 20 years ago, when the initial successes of imatinib therapy in treating patients with chronic myeloid leukemia were happening. It’s hard to describe now to trainees who have never known an era without these therapies how life-altering and paradigm-changing they were. Patients who had been told their only option was heading toward allogeneic hematopoietic cell transplant could now take a pill. I thought, “This is the future of cancer care, and it’s so exciting. I need to be a part of this.” The combination of science and humanity led me to decide to apply for a hematology/oncology fellowship during my second year of residency.
You’ve been practicing as a community hematologist/oncologist in a rural area in the Pacific Northwest for years. What drew you to working in these areas?
I think my familiarity with a rural environment – thanks to my childhood in Alaska – prepared me for working where I do now. That interest was cemented during medical school; I was enrolled at the University of Washington School of Medicine through a program called WWAMI, which stands for Washington, Wyoming, Alaska, Montana, and Idaho. In this medical education program, which is designed to increase the number of physicians in rural care, the University of Washington admits a certain number of students from Alaska and the other member states (none of which have their own medical schools) through a partnership program.
Enrolled students complete their first year of training in their home states (for me, I was one of 10 Alaskan students training in Anchorage), before converging with the other groups in Seattle to start the second year of medical school en masse. WWAMI is all about providing students with the experiences and opportunities to picture themselves in settings other than large, tertiary centers. One of my rotations during my second year brought me to the Annette Island Reserve off the southwest coast of Alaska, working with a family medicine practitioner in the Metlakatla Indian Community (population less than 1,500). I remember having to take a small commuter plane from Anchorage to Ketchikan, and then an even smaller seaplane from Ketchikan to the island.
I think being part of that program instilled in me a desire to eventually return to rural community practice. While my life circumstances didn’t lead me back to Alaska, I do feel that part of being here in rural Oregon is continuing that mission and paying it forward, in terms of the opportunities that were afforded me to go to medical school as part of the WWAMI program.
Where do you practice now, and what does a typical day look like for you?
For the past six years, I have been working in Astoria, Oregon, on the North Oregon coast, near the mouth of the Columbia River. I’ve been part of a joint collaborative program between Oregon Health & Science University (OHSU) in Portland and Columbia Memorial Hospital, the local hospital in Astoria, to build a comprehensive rural cancer center. Two years ago, we opened our new building, a 12-chair medical oncology infusion center with on-site radiation oncology services.
Our center also is invested in supportive services, with a Cancer Resource Center available to all patients, where we offer dietician-taught healthy cooking classes, yoga and other gentle exercise classes, acupuncture, art therapy, and other educational services – all free of charge.
Prior to our center’s opening, there were no radiation oncology services in the area, so being a part of bringing comprehensive cancer services to this region has been an exciting and rewarding career achievement.
What is the size of your patient population?
The town itself is small, just under 10,000 people, but we draw from a rural catchment region of about 40,000 people from at least four different counties in the surrounding areas of the North Oregon Coast and Southwest Washington state. It’s more accessible for residents of those surrounding counties to come to us than to drive all the way to Portland, which would be the closest tertiary center for cancer care. In addition, much of our population lacks transportation resources. Before we established the cancer services here, some people were forgoing care altogether. That may sound unbelievable in the U.S. today, but it’s true. We see a lot of older patients who live alone, are homeless, are uninsured or underinsured, and families who don’t have a car or cannot afford the gas for a 200-mile round-trip to “the city.” Sometimes it’s hard for me to impress the effect of these barriers upon my metro colleagues. I don’t think I truly understood it myself until I lived and practiced in this community.
In your experience, how does caring for hematology patients living in rural areas differ from caring for those living in more metropolitan areas?
That’s a great question, and there are so many layers to it. What I’ve found most striking is that, for so many of the patients I’ve seen, a cancer diagnosis is the event in their adult life that brings them into medical care. They’ve gone their entire adult life without seeing doctors because they didn’t think they needed to, despite higher than average rates of risk factors such as tobacco use, alcohol use, and obesity. They believed they were healthy, and then they receive this catastrophic cancer diagnosis. Many of our patients are referred from the emergency department after they present with advanced symptoms. In those cases, not only are they diagnosed with cancer, but then we uncover all the other health issues that might be occurring – like diabetes or congestive heart failure – because they hadn’t been seeing a primary care physician.
Unfortunately, this means that, by the time they present to our clinic, their disease is often already quite advanced, and their comorbidities can be quite advanced as well. I’ve had several patients with head and neck cancer who presented to the emergency department only when the cancer had progressed to the point that their airway was threatened.
So, typically, this is a very sick population, and one that, I think, perhaps previously wasn’t coming to light because of their limited access to care. The people I’ve had the privilege to care for are incredibly grateful to have cancer services in their area. For example, I treated a man with advanced lung cancer who benefited with about six months of good, quality life from palliative chemotherapy. When we sat down to talk about going into hospice care, he actually thanked me. He told me that if our center hadn’t been there, he wouldn’t have done anything. He would have rather died immediately than have to travel for cancer treatments. It made me wonder, How many others like him made that choice before we were here? That’s humbling.
Many of our patients have expressed the same sentiment, telling us, “I’ll come here because you are here, but I’m not going to go to the big city.” I think that’s representative of much of the rural U.S. where there aren’t accessible cancer services. It’s striking and such a change from the metropolitan practice, where patients are “doctor shopping” and scouring the internet for information.
“Before we established the cancer services [in Astoria], some people were forgoing care altogether. That may sound unbelievable in the U.S. today, but it’s true.”
What challenges do you encounter that are unique to more remote areas?
Our access to certain resources is limited. The local hospital that we work with has been designated a Critical Access Hospital, a distinction given to rural hospitals by the Centers for Medicare and Medicaid Services that have limited services but where the hospital’s presence is critical for the region. It has only 25 beds (in the entire hospital!) and no oncology unit, so we cannot deliver inpatient chemotherapy.
Also, any patient needing specialty care from surgical oncology, gastroenterology, infectious disease, otolaryngology, or an intensivist (all specialties we do not have yet), needs to be transferred to another facility, which is not always straightforward. Sometimes, it’s a medical emergency to transfer a patient, yet I’m told that there are no available beds. Or at first, the transfer is not accepted, because someone doesn’t understand why I need to request the transfer. Often, these challenges entail hours on the phone with transfer centers and colleagues.
Also, in the beginning, some of the hospital staff were not familiar with hematologic cancers. Once, during my first few months here, I was called to the emergency department to consult on an older patient whose labs were concerning for acute myeloid leukemia. I talked to him about transferring to Portland for care, because I did not have the ability to do induction chemotherapy here, but he wasn’t sure he wanted to pursue it. He was a marginal candidate for an intensive induction because of his age and comorbidities, so we decided together on local admission to stabilize him, perform a bone marrow biopsy, and provide supportive care until he could finalize his decisions – all standard stuff. However, when I went to do his admission orders, the hospital told me that acute myeloid leukemia was not a diagnosis that met criteria for admission!
It was a big shock to me, but after discussions with the staff, it became clear that they didn’t have an understanding of acute leukemia because, before our services were out here, it simply wasn’t something treated here. The usual admissions were the “bread-and-butter” internal medicine diagnoses, such as chronic obstructive pulmonary disease, pneumonia, and congestive heart failure.
In addition, they had a misconception of what a hematologist/oncologist could safely do in the clinic, versus when I needed to appropriately admit patients to the hospital. It was almost like they were saying, “Oh, we have a hematologist now, she’ll take care of all this stuff.” And I had to push back and say, “Hey, I can’t do this alone. No one could do this alone. I need the hospital’s help. There are times I’m going to need to admit my patients.” I had to constantly educate the staff and advocate for my patients to change this mind-set. Admissions to the hospital are not failures of care.
So, that day, I explained to the staff what acute leukemia is and how it presents, the possible supportive care needs such as blood transfusions and antibiotics, and the potential complications like cytopenias, sepsis, tumor lysis syndrome, and renal failure. As soon as we had that discussion, they let me admit the patient, but that experience opened my eyes about the challenges of caring for patients with hematologic malignancies in rural settings.
Have you ever considered leaving the rural area to practice in a metropolitan area?
I’ve had experience in both settings. Before I accepted my position at OHSU, I practiced for seven years in the Portland metro area, so it wouldn’t be completely foreign to go back. At the beginning of my career, I could never have foreseen this situation – opening a new center in a rural Pacific Northwestern area – but when I look at my background and my training and the different steps of my career, it seems like somehow it was all leading here.
Of course, we never know what life will bring. For now, however, my husband and I have no plans to uproot our family for “the big city.”
Do you have any advice for maintaining a healthy work-life balance?
For the past several years, my husband has been a stay-at-home parent for our family, which helps, but it is still tough to find a balance for myself. I always struggle with it, but I read some helpful advice some years ago that stuck with me. In my previous practice, a colleague and friend had a sign on her office door that said, “Don’t postpone joy.” So, I’d tell people that, when weighing a decision between a work or life responsibility, think about that: Don’t postpone joy in your life.
What brings you joy in your life outside of medicine?
Our children are 16, 12, and 9, so to be honest, my husband and I spend a lot of time just trying to keep up with their activities. It keeps us quite busy. We’re lucky to live in a place where nature is easily accessible, so we enjoy getting out and hiking or going to the coast as a family on weekends – especially if all the kids are getting along. It’s hard to beat living 15 minutes from the Pacific Ocean.
The other thing that nurtures my soul is writing. I’ve published creative nonfiction and narrative medicine essays starting in 2016, including a Perspective essay for the New England Journal of Medicine (“Neglected: Cancer Care and Mental Health in Rural America”), and I started my blog, The Hopeful Cancer Doc, in 2017. Through writing, I’ve made connections with people all over the world. It’s amazing. Writing is the best tool I’ve found for myself to combat isolation and burnout.
What is one thing most people would be surprised to learn about you? Do you have any secret people wouldn’t expect of you?
I’m afraid of flying, which is ironic because both my father and my brother are pilots. I think the aviation gene skipped me.