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Musings of a Cancer Doctor

2022; Wolters Kluwer; Volume: 44; Issue: 5 Linguagem: Inglês

10.1097/01.cot.0000824240.62184.ed

1548-4688

George W. Sledge,

Advances in Oncology and Radiotherapy

The Beatles: The BeatlesOver the holidays I watched Peter Jackson's documentary The Beatles: Get Back, as well as a separate documentary in which the producer Rick Rubin spoke one-on-one with Paul McCartney about his music. The two shows were a revelation for an old Beatles fan. In my generation, you thought either the Beatles or the Rolling Stones were the greatest rock band of all time. As a tried-and-true Beatles fan, I consider the years from 1964 to 1969 to be the peak period for this genre. Similarly, the breakup of the Beatles in 1969 was, for many in my generation, a tragedy of epic proportions, somewhere in the range of the sinking of the Titanic. Jackson's long documentary—an exhausting 9 hours—chronicles the near end of the band's great run. The four musicians are tired of each other, and the band is clearly on its last legs. John Lennon is accompanied to the sessions by Yoko Ono, a simultaneously quiet but obtrusive presence. He has largely checked out of the creative process and is (as we now know) a heroin addict. George Harrison sulks, having spent much of the last few years standing in the background while Lennon and McCartney (the greatest songwriting team of all time) have worked their wonders. He is ready to shine, creatively, but feels ignored, to the extent that he walks away from the sessions, temporarily quitting the band. Ringo Starr has the look of someone grieving over a loss that has not yet occurred but soon will. McCartney, meanwhile, is trying to hold everything together, but in a bossy way that irritates the others. Around them float various hangers-on: producers, bean counters, a ridiculous documentary maker who films their every word (often without their knowledge using hidden microphones), managers, technicians, girlfriends (it is not just Yoko who makes her presence felt). The musicians are the center of the creative process, but they rely on a not-insignificant infrastructure. Soon they will compose their last collective music, and The Beatles will depart the stage: now they belong to the ages, one wants to say of their passing. It is a profoundly depressing piece, a sad tale of breakup as something special falls apart under the strain of a decade of continuous travel, composing, and recording. Though still in their twenties their private lives have begun to diverge, John with Yoko Ono, Paul with Linda Eastman (soon to be McCartney). They are ready to move on. Perhaps inevitable, but maybe not. Watching them filled me with sadness, and not just because of the band's breakup. We know how all this turned out, and what happened to them in the following decades. Lennon will be murdered outside The Dakota in Manhattan, done in by a mediocrity with a handgun. Harrison, who smokes throughout the sessions, will first develop head and neck cancer, survive that, be stabbed by a deranged fan, survive that, and then succumb to non-small cell lung cancer, developing brain metastasis. Linda McCartney, the love of Paul's life, and a talented photographer in her own right, will develop an aggressive breast cancer, receive both standard and high-dose chemotherapy in the 1990s, and then develop liver metastases. She and Paul will go horseback riding 4 days before she dies at the age of 56. Paul will then go to a very dark place for several years. The oncologist in me always wonders whether things would have turned out differently had Harrison and Linda McCartney developed their cancers at a later point in time. Would Harrison's cigarette-induced cancer have responded to a checkpoint inhibitor or a third-generation EGFR inhibitor? Would McCartney's aggressive cancer have responded to a novel kinase inhibitor or monoclonal antibody or antibody-drug conjugate, the transplant bludgeon replaced with a precision medicine stiletto? Might it have been cured in the adjuvant setting? Modern medicine is full of “what ifs,” such is the pace of modern discovery. So, watching Get Back is filled with anticipatory sadness, both for the lost music and the premature deaths we know are coming. And yet, and yet... If this is the Beatles at their worst, at their low point, they are still something quite miraculous, conjuring great music out of thin air. Their creative process generally starts with one of them pitching, not a song, but part of a song. They spend hours bouncing lyrics and tunes back and forth, often giving up on it only to come back later, finally finishing triumphantly with something that barely resembles the original idea. Get Back, the documentary's title, is also a recurring work-in-progress song throughout the film, right up until it is presented to the world in a rooftop concert. The song itself is interrupted by the London police, called by uptight neighbors on Savile Row who fail to appreciate history in the making. Watching them create is, as I said earlier, a revelation. The parallels to the creative process in the sciences are obvious. It goes something like this: the act of creation never occurs in a vacuum or a desert. One puts in long periods of hard work learning the basics of the field. In the Beatles case, this was thousands of hours in bars in Hamburg, Germany, learning their craft. It is the basis for what comes after; you only know what the right questions are once you have spent enough time on the stage. While history is replete with brilliant individual scientists, my experience in clinical research has been that the best ideas come from the prolonged interaction of talented individuals with overlapping skill sets, the equivalent of having keyboard, guitar, and drum players riffing on a particular musical theme, improvising, altering until they find just the right note, the right word or phrase. The musicians or scientists in turn are supported by a well-developed infrastructure which is, like the Beatles' Abbey Road recording studio, agnostic to the ideas being studied yet crucial to their success: biostatisticians, research nurses, data managers, and the like. And the patients, of course, the patients who lay their lives on the line waiting for us to get smarter. And sometimes—this happens in the middle of the documentary—one goes outside the original group to add some crucial yet thoroughly unanticipated element to the mix. In the documentary, this is a blues musician Billy Preston, an old friend of the Beatles from their Hamburg days, who drops by to say hello and ends up being conscripted into the act of creation. The joyous energy he brings to the lethargic group transforms their creative process. There is also a wonderful moment in the documentary when one of the band members wonders what it would sound like to bang on an anvil at a particular point in a song. The anvil mysteriously appears, conjured out of the ether by their road manager Mal Evans, and the sound Ringo Starr makes with it now graces the Beatles' Maxwell's Silver Hammer. Sometimes, the small tweaks matter. And finally, of course, there is the unexpected. The creative process is essentially messy. It is not something you can apply process engineering to and hope for anything other than mediocrity. The old Six Sigma idea—the rigorous removal of errors from a process, leaving an enterprise clean and pristine—is antithetical to the creative process. In Paul McCartney's interview with Rick Rubin, he said something that stuck with me: “I specialize in audacious mistakes.” I suspect that in the clinical enterprise, as opposed to the laboratory or (sometimes) in the best clinical research, we make far too few audacious mistakes. One can understand why: audacious mistakes attract lawsuits. They fail more often than they succeed. But they are crucial for creativity, and perhaps this is part of why the American health care system is, ultimately, a failure, a disastrous mess providing expensive yet ineffective care. We don't experiment enough, we don't dream enough, we don't audaciously mistake our way to the actually valuable. But we are great at wringing incremental gains out of a system created by a dysfunctional health insurance apparatus designed to maximize enterprise profits for every stakeholder except the patient. Anyways, that's what I think. But feel free to ignore anything I've said if you are more of a Stones than a Beatles fan. Or if you don't know who they actually were. In which case, I pity you. GEORGE W. SLEDGE, JR., MD, is Professor of Medicine at Stanford University. He also is Oncology Times' Editorial Board Chair. In his column, Musings of a Cancer Doctor, Sledge shares his personal thoughts on cancer research, patient care, and health care trends. Comment on this article and previous postings on his OT blog at bit.ly/OT-Sledge.George W. Sledge, Jr., MD: George W. Sledge, Jr., MD