The Doctor (1991) and Laryngeal Cancer

Jack MacKee is a brilliant, armoured heart surgeon who teaches his residents that caring about patients gets in the way. He develops a persistent cough, then coughs blood. A tumour is found on his larynx, the voice box in his throat.

He becomes a patient in his own hospital: the forms, the waiting rooms, the gown, the doctor who talks past him. The film has been used in medical education for decades, and the reason is simple. The way he has spoken to patients for twenty years becomes unbearable when it is aimed at him.

Spoilers throughout. Jack's diagnosis and what it does to him are both discussed here.

Most cancers on this site are quiet at the start. Laryngeal cancer is different, and that is the useful thing about this film.

The larynx contains the vocal cords. A growth on or near them changes the sound of a person long before it changes anything else. So the voice becomes an early-warning system that other cancers simply do not have.

NCI's advice is to check with a doctor about a change or hoarseness in the voice. The rough guide used in UK practice is three weeks: hoarseness that has lasted longer than that, with no cold to explain it, gets looked at rather than waited out.

The trap is that a rough voice is easy to live with. People blame shouting, smoking, a cold, air conditioning, getting older. It is an annoyance, not an alarm, and that is exactly how a symptom gets ignored for months.

NCI names these signs of laryngeal cancer, any of which can also be caused by something harmless:

• A sore throat or a cough that does not go away.
• Trouble or pain when swallowing.
• Ear pain.
• A lump in the neck or throat.
• A change or hoarseness in the voice.

Ear pain is the one people find surprising. Pain from the throat can be felt in the ear, so persistent one-sided earache with a normal-looking ear deserves a proper look at the throat.

NCI says that using tobacco products and drinking too much alcohol can affect the risk of laryngeal cancer. It also says that smoking and drinking make treatment less effective, and that patients who keep doing both are less likely to be cured and more likely to develop a second tumour.

For anyone doing both, this is the single most useful line in the whole page. Stopping smoking lowers risk. So does cutting heavy drinking. Neither is a guarantee, and both are worth doing anyway.

There is no screening programme for laryngeal cancer. The CDC supports screening for four cancers only: breast, cervical, colorectal and lung. Nobody is going to check your larynx because of your birthday.

That is less bleak here than it sounds. A disease that changes your voice early is one that gives you a reason to go in. The whole strategy is to treat that change as a symptom rather than a nuisance.

Jack's route from symptom to diagnosis is fast and frictionless. He is a senior surgeon in his own hospital. He knows who to call, and he is somebody people call back.

The film is interested in his emotional education, not in that advantage, so it never names it. Most people do not have it. Most people go through a receptionist, a general practitioner, a referral, and a wait.

That gap is worth naming out loud, because it changes what you should do. If your voice has been hoarse for weeks, say so explicitly, say how long, and ask what the referral route is and how long it should take. Being specific about duration is what moves a request up a list.

The film shows almost nothing of treatment. Laryngeal cancer treatment can affect speech, swallowing and breathing, and living with those changes is a long project involving speech and language therapists. None of that is on screen.

His transformation is also faster and tidier than most people's. The humiliations he experiences are real. The clean moral arc that follows them is a screenplay.

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The Doctor is a good film about how doctors talk to people, and a thin one about cancer. It is worth watching for the first thing and not the second.

The medicine underneath it is unusually clear-cut. There is no screening test for laryngeal cancer, but there is a loud early symptom. A voice that has been hoarse for more than about three weeks, with no cold to explain it, is a reason to be examined.

• https://www.cancer.gov/types/head-and-neck/patient/adult/laryngeal-treatment-pdq
• https://www.cdc.gov/cancer/prevention/screening.html

This page discusses The Doctor for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].