The Clinical Progression course passed through my life before I realized my temporal estrangement from it. The course did, however, form an integral lining of my armamentarium of lived social experiences expressed as a contextual expectation of clinical, didactic demands and challenges. The course also served as a communication bridge between my incessant frustrations on the one hand and on the other, the professional, clinical expectations of a future career that looked hazy on the horizon.
The course was broken into six blocks: Bronchitis, atelectasis, wound infection, cardiac heart failure, gastric ulcers, and cirrhosis. The class lasted seven weeks during the summer of 2019, with students required each week to hand in assigned type-written essays based on these topics, treating two broad topics per week. We had, on the contrary, two weeks to turn in the third assignment. Finally, we had a week to do a research on and prepare for a class presentation on wound VAC (vacuum-assisted wound closure).
Thus the first two weeks saw us conducting research in response to a series of assigned questions, questions whose answers pushed students beyond the inflexible exclusivity of assigned, recommended textbooks.
Overall, we spent a day per week either in the CEC or Sim where, among other things, we spent three to four hours, with a thirty-minute break, taking an exam first thing in the morning, practicing wide range of clinical skills, reviewing exam questions, and discussing course materials. A clinical professor, Kerri Reid, oversaw and conducted this largely self-study class. She brought her broad clinical expertise and rich background in didactic knowledge to bear on the class. Prof. Reid was a nucleating force for this class. The low student-faculty ratio enhanced learning and in-class interaction and communication. This ultimately translated to clarity of instruction and a conducive ambience for imparting, sharing knowledge in a non-anagogical manner.
The relative open-endedness of the expected answers gave students investigational latitude to research their topical answers by freely swinging between libraries of peer-reviewed articles and accessing assigned, recommended textbooks. Technically speaking, though, the assigned, recommended textbooks provided stereotypical explanations to otherwise complex scientific and theoretical and psychosocial questions, unlike the libraries of peer-reviewed articles which offered a more technical nuance, perspectival insights, and variegated broadness in their richness of experimental, statistical, methodological, and philosophical approach to the human condition.
Why did we have to take this class in the first place since not every nursing school, including those in Colorado, requires this of its students? Was it an official requirement students had to meet in order to qualify them to take the NCLEX upon graduation? Was it a money-making scheme? Was it a form of remedial punishment or comeuppance for a student’s presumed intellectual laziness? Was it a strategic calculus meant to prevent students from frittering away time, a way to prevent the prior knowledge of students from going musty? The fact that I had studied these topics before and had to pay from my scrimpy savings to study them again sapped my psycho-emotional wherewithal.
Of course the school’s interest, brand, continued accreditation, and academic standing in the community of nursing institutions of learning across the nation are at stake here. Perhaps because of its strong desire to see itself ranked among the best or the best, and to maintain the professoriate’s highest standards in nursing education in the nation, it makes the extra effort to produce the kinds of students whose rigorous academic training and high NCLEX pass rates protect its brand, accreditation, and name recognition from the corruption of students whose academic performance one way or the other compromises or threatens the viability of these objectives.
Whatever the reason or reasons, it is too premature for me to declare a definite stance on whether this class qualitatively added to the store of my accumulated knowledge. I don’t even think a stronger case can be made in defense of using this class to protect students’ knowledge from the encroaching juggernaut of forgetfulness―or of rustiness. Even if the student forgot the structured content of these courses that made up the didactic chrysalis of this class while passing through the rituals and rigor of knowledge accumulation, namely of enduring the structured formality of his or her nursing education along the way, it was still the student’s sole responsibility and self-interest to thoroughly revise these topics prior to sitting for the NCLEX.
One thing is certain, though, which is that the time I spent researching the topics took my mind off unnecessary preoccupations and lethal infatuations with the challenges of life. The laxness of this class however drove me to explore theoretical, psychosocial, scientific, clinical, and technical questions in excruciating attention to detail, than I would have peremptorily done if the Clinical Progression class had been invested with the stifling formality of a regular semester, say Fall or Spring, but, as it were also, I had time to turn the questions and their prospective answers over in my mind.
Locating answers from the point of view of textbooks and peer-reviewed articles was made relatively easy for me because, in the particular case of the latter, I knew where exactly to go with astonishing celerity and pragmatic urgency, given that I have spent a big chunk of my intellectual life proofreading or editing textbooks and scholarly articles meant for publication and peer review, respectively, as well as for my own personal edification and avocational interest in the art of journalistic composition.
Experience doing this has helped me a lot, although the art of writing does not always come easy for those of us whose first and second languages are not even English. In other words, I was more than familiar with the general itinerary of the Clinical Progression class in terms of its research outcomes and programmatic expectations. One particular research article Prof. Reid assigned the class, C.J. McDaniel’s and K.K. Browning’s “Smoking, Chronic Wound Healing, and Implications for Evidence-Based Practice,” caught my attention. We were required to read this interesting article as part of the wound VAC assignment. To put it simply, this article deepened my understanding of the dangers cigarette smoking poses to wound healing. If there is anything to take away from this class then it is the priceless information I picked up from this article.
It was not as if I was completely ignorant of the dangers of cigarette smoking to health―to the physiological integrity of smokers and passive smokers alive. I had direct knowledge of the lethality of cigarette smoking to health in general terms but the topical specificity and investigational focus of the article on the deleterious effects of nicotine, hydrogen cyanide, and carbon monoxide, a trifecta of products from tobacco, on wound healing is spectacularly worrying, even frightening―to say the least. However, this newfound knowledge does not detract from other dangers of cigarette smoking. The link between cigarette smoking and lung cancer, a well-established fact, is public knowledge. I complemented my reading of this assigned article with Siddhartha Mukherjee’s 2011 Pulitzer Prize-winning The Emperor of all Maladies: A Biography of Cancer. He writes:
"It remains an astonishing, disturbing fact that in America―a nation where nearly every new drug is subjected to rigorous scrutiny as a potential carcinogen, and even the bare hint of a substance’s link to cancer ignites a firestorm of public hysteria and media anxiety―one of the most potent and common carcinogens known to humans can be freely bought and sold at every corner store for a few dollars."
He notes elsewhere:
"Many of the cigarette makers had not only known about the cancer risks of tobacco and the potent addictive properties of nicotine, but had also actively tried to quash internal research that proved it. Document after document revealed frantic struggles within the industry to conceal risks, often leaving even its own employees feeling morally queasy."
This situation, of the preceding quote, is not dissimilar to the national opioid epidemic where, among other outrageous and scandalous misdeeds perpetrated by pharmaceutical companies, the latter reportedly bribed doctors to prescribe the drug to patients against the backdrop of aggressively marketing this drug despite knowing the addictive properties of opioids and despite their knowledge of patients abusing the drug (Ornstein & Jones, 2018; Armstrong, 2019). Katherine Eban’s Bottle of Lies: The Inside Story of the Generic Drug Boom explores other explosive controversies in the pharmaceutical industry, a story that most people may not be familiar with. It turns out generic medications and their brand-name equivalents are not always identical in their pharmacologic attributes and therapeutic outcomes. This is sensational―to say the least.
In addition to reading Mukherjee following my successful completion of the summer class, I also read Rebecca Skloot’s The Immortal life of Henrietta Lacks, Ron Powers’s The Chaos and Heartbreak of Mental Health In America: No One Cares About Crazy People, and Bryan Stevenson’s Just Mercy: A Story of Justice and Redemption. I also re-read Atul Gawande’s Being Mortal: Medicine and What Matters in the End and David Olusegun’s and Casper Erichsen’s The Kaiser Holocaust: Germany’s Forgotten Genocide and The Colonial Roots of Nazism.
And several science-related peer-reviewed articles!
The wide-sweeping brush of Mukherjee’s holistic, biographical treatment of the subject of cancer is incomparably superior to other accounts I have perused in the past. In fact, I have learned more about cancer from this book than anywhere else. His mastery of the English language and knowledge of scientific and non-scientific literature is very impressive. I was taken by the auctorial majesty of his literary language and wealth of information―historical and contemporary.
From these books I also learned more about informed consent, physician-patient privilege (confidentiality), pharmacology, the pathophysiology of cancer, pharmacogenomics, hospice care, patient-centered care, pain management, the political economy of health care in the US, therapeutic communication, the human genome project, mental health and its relationship to modern capitalism and the prison-industrial complex, biostatistics, drug discovery, social justice and patience advocacy, patients’ rights and responsibilities, health disparity, medical ethics and eugenics, clinical trial methodology and design, unethical human experimentation, and related topics.
Henrietta Lacks’ “immortal” cells, the so-called HeLa cells, for one, revolutionized medical science as we know it today, contributing to the study of space biology and the role of immunity in organ transplantation and effects of atom bombs, cancer science, cell lines, the development of drugs and monoclonal antibodies and vaccines including the polio vaccine, gene mapping and regulation, in-vitro fertilization, cloning, and so on. It therefore came as a huge surprise to me that Mukherjee, one of America’s leading and respected cancer scientists and researchers, should skip over Henrietta Lacks in his comprehensive The Emperor of all Maladies. Skloot (2010) writes:
"Researchers were using that growing library of cells to make historic discoveries: that cigarette caused lung cancer; how X-rays and certain chemicals transformed normal cells into malignant cells; why normal cells stopped growing and cancer cells didn’t. And the National Cancer Institute was using various cells, including HeLa, to screen more than thirty thousand chemicals and plant extracts, which would yield several of today’s most widely used and effective chemotherapy drugs, including Vincristine and Taxol."
Skloot notes further elsewhere:
"Henrietta’s cells couldn’t help bring youth to women’s neck, but cosmetic and pharmaceutical companies throughout the United States and Europe began using them instead of laboratory animals to test whether new products and drugs caused cellular damage. Scientists cut HeLa cells in half to show that cells could live on after their nuclei had been removed, and used them to develop methods for injecting substances into cells without destroying them. They used HeLa to test the effects of steroids, chemotherapy drugs, hormones, vitamins, and environmental stress; they infected them with tuberculosis, salmonella, and the bacterium that causes vaginitis.
"At the request of the U.S. government, Gey took Henrietta’s cells with him to the Far East in 1953 to study hemorrhagic fever, which was killing American troops. He also injected them into rats to see if they’d caused cancer…"
How on earth could a keen observer such as Mukherjee have missed this important figure in the history of modern science and cancer research? “Henrietta’s cells helped launch the fledgling field of virology, but that was just the beginning,” Skloot reminds her readers. “In the years following Henrietta’s death, using some of the first tubes of her cells, researchers around the world made several important scientific advances in quick succession.”
Even his discussions on the human genome project, in retrospect, are woefully inadequate. Given that cancer research, and given that cancer-based and –driven drug discoveries are derived from a minute portion of the human race, mostly from those of European ancestry, one wonders how much Africa can contribute to the human genome given that Africa is the most genetically diverse continent? Wapner (2018) writes: “Over the next few years, scientists came out with a frenzy of discoveries about our DNA that could possibly lead to new treatments for diabetes, cancer, psychiatric illnesses and other serious diseases. But they were drawing from a small slice of the world: Nearly all of the published work was based on populations with European ancestry. By 2009, fewer than 1 percent of the several hundred genome investigations included Africans.” This means among other things, that African patients, those with cancer, say, are treated with medications tested on populations outside the African genome. Nigerian-American epidemiologist and scientist Charles N. Rotimi, the Director of the Trans-National Institutes of Health, is working to change this. Rotimi has since secured a grant to undertake his audacious project, called Human Heredity and Health in Africa (H3Africa). He has brought African scientists on board.
Mukherjee’s overreliance on and infatuation with white men, even of dead ones, who exerted enormous influence over cancer research, genetics, and science―to the relative exclusion of women who made pioneering contributions to cancer science, cancer research, and cancer pharmacology―is understandable only to the extent that one cannot overlook or ignore the contributions of these men, dead or alive. Women have done much―and continue to do as much as men―to elevate the profile of science and therefore deserve all the accolades that come their way.
Many women have made important contributions to cancer science and research as well. Jane C. Wright , Sandra M. Swain, and Jewel P. Cobb, to name but three, have made important scientific contributions to the fields of cancer research, science, treatment, and pharmacology.
Two writers referred to Wright as “the Mother of Chemotherapy” (Skinner, 2010; Piana, 2013). Cavallo (2014) writes: “Jane played a pivotal role in the development of methotrexate among other chemotherapeutics, and this is a drug that today is among the greatest of all cancer drugs ever developed…Methotrexate forms the backbone of the first curative treatments for breast cancer and other cancers, as well as treatment for other serious diseases such as rheumatoid arthritis. And Jane did all this in the premodern era of molecular biology.”
“Indeed, Dr. Wright was one of the first researchers to analyze anticancer agents by comparing tissue-culture response to patient response,” writes Swain. “She developed new techniques for administering chemotherapy…and she was among the first small cadre of researchers to carefully test the effects of drugs against cancer in a clinical trial setting…In 1949, she began working full time with her father, who had founded the Harlem Hospital Cancer Research Foundation a year earlier. Together, they tested different potential anticancer agents in tissue culture and in patients, an important contribution at a time when few guidelines for chemotherapy existed. They pioneered combination chemotherapy and conducted some of the first research on the administration of a series of chemotherapeutic drugs in a specific order… they were among the first researchers to test triethyl-enemelamine, a nitrogen mustard-like chemical synthesized during World War II, in patients with cancer.”
Swain (2013) provides additional documentary evidence to support a 1951 research paper Wright co-wrote with her father that points to their seminal work as “the first evidence of the efficacy of methotrexate against solid tumors…Dr. Wright was among the first researchers to systematically document the correlation between chemotherapy responses in patients and in primary tissue culture grown from biopsied samples collected from the same patients.” Wright counted breast cancer among the spectrum of solid cancers. Wright (1984) herself notes of her work in this regard: “This was the first time a chemotherapeutic agent was demonstrated to produce remissions in cancer of the breast.”
According to an edition of the New York Times, Wright, the Director of Cancer Research at the N.Y.U. School of Medicine, and her team invented a nonsurgical technique that employed a catheter system “to deliver heavy doses of anticancer drugs to previously hard-to-reach tumor areas in the kidneys, spleen and elsewhere” (Weber, 2013). She was a founding member of the American Society of Clinical Oncology (ASCO), the only woman and African-American oncology pioneer on the seven-member team that, in 1964, came together and created ASCO. President Lyndon B. Johnson appointed her to the President’s Commission on Heart Disease, Cancer and Stroke in 1964. The Commission’s mandate entailed reinforcing effective communication among hospitals, research institutions, and health care professionals. A network of cancer treatment centers evolved from this initiative across the country.
Thus writing a tome on the history of cancer without mentioning Wright and her influential research work on cancer is disingenuous, a situation not unlike writing about the history of DNA without mentioning Marie M. Daly and Rosaline Franklin. Nobel Laureate Watson (1962) acknowledges the contributions of the scientific work of Daly (and her colleagues) to his and Francis Crick’s own scientific work leading to the structural unraveling of DNA, in his Nobel acceptance speech. Daly, like Henrietta Lacks, was African American, the first woman to receive a doctorate in chemistry in the US (Science History Institute, 2019).
Finally, the scientific work of the Harvard-based Cameroonian-American Wilfred Ngwa (and his colleagues)―a medical physicist who works in the field of radiation oncology―involving the use of nanotechnology to treat cancer is indeed promising. Ngwa and his team have developed nano-sized drones to deliver drugs to cancer cells in addition to targeting and killing these cells (Dwyer, 2016). This technology is more appropriate for treating malignant cancers rather than local ones. The so-called “blobology,” otherwise called cryo-electron microscopy, promises to revolutionize the fields of cellular research, molecular biology, biochemistry, neurodegenerative diseases, cancer, etc. (Baker, 2018). The rich ethnic and racial tapestry of the American body politic itself constitutes a great wellspring of innovative ideas, creativity, and collaborative accomplishments. This is why it just does not make sense to leave anyone out of the grand narrative of the American success story on scientific and technological accomplishments.
I therefore think Prof. Reid’s strong recommendation that I boost my confidence in my acquisition of clinical skills is an excellent advice. This may help me attain the heights of these brilliant men and women of science who have given so much to the world. Furthermore, her temperance and proctorial professionalism during my competency performance examination (CPE) in the seeming claustrophobia of the CEC somehow got me through the clinical labyrinth of the testing. Prof. Fara Bowler’s momentary engagement with me prior to my testing steadied my nerves, making it possible for me to approach CEC with a slice of an uncluttered mind. In the meantime, Prof. Tammy Spencer worked tirelessly to get me a clinical placement for my upcoming OB class.
Social worker Ms. Dora Safoh never refrained from reminding me that her office is always open if I ever wanted to come in for a discussion regarding my progress and resolution of any outstanding questions I may have.
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Baker, M. (2018, September 25). Cryo-Electron Microscopy Shapes Up. Retrieved from https://www.nature.com/articles/d41586-018-06791-6
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Piana, R. (2013). Jane Cook Wright, MD, ASCO Founder, Dies at 93. The ASCO Post. Retrieved from https://www.ascopost.com/issues/march-15-2013/jane-cooke-wright-md-asco-cofounder-dies-at-93/
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Wapner, J. (2018). Cancer Scientists Have Ignored African DNA in the Search for Cures. Retrieved from https://www.newsweek.com/2018/07/27/cancer-cure-genome-cancer-treatment-africa-genetic-charles-rotimi-dna-human-1024630.html
Watson, J.D. (1962). The involvement of RNA in the synthesis of protein. Retrieved from https://www.nobelprize.org/uploads/2018/06/watson-lecture.pdf
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