My personal care physician sent me a text after my cancer diagnosis while I was still in the emergency room.

Not a message through the patient portal. A text directly to my phone. It said she was sorry, that she was here for me, and that we would figure this out together. That is not a clinical protocol. That is a relationship.

Dr. Azucena Del Real has been my primary care physician for three years. She also cares for my wife. She knows us, not just our charts: my hypertension, the recent-onset Type 2 diabetes she caught early, the medications, the comorbidities, the history. When the CT confirmed cancer on April 14, she did not have to be briefed. She already knew the whole patient.

In medicine, that kind of knowledge has a name: continuity of care. In a fragmented specialist system, it is rarer than it should be.

A stubborn advocate

Del Real’s father was a dermatologist who made Sunday house calls to small towns in Guanajuato, in central Mexico, compounding his own medications because his patients couldn’t afford commercial prescriptions. He died when she was nine. “Since I can remember,” she told me in a 2023 interview, “it’s been like I’m going to be a doctor, I’m going to be a doctor, I’m going to be a doctor,” emphasizing how stubborn she became in her pursuit.

She completed medical school in Tijuana in 2013 and spent five years qualifying for a U.S. residency. This included taking the medical licensing exams, completing a master’s in clinical research at UC San Diego, and working as a technician at a diabetes research organization, where she monitored patients’ insulin levels at 5- to 15-minute intervals, around the clock. That experience matters now. She doesn’t manage my diabetes from a textbook; she managed it first at the lab bench. She completed her internal medicine residency at the University of Texas Rio Grande Valley School of Medicine in Edinburg in 2022 and joined Texas Tech Physicians of El Paso’s Transmountain clinic shortly after.

Del Real entered medicine having already seen the system from the inside of the insurance apparatus. Somewhere between medical school and residency, she also worked as a high-risk case manager for an HMO in San Diego, approving or denying transfers, identifying why patients kept returning to the hospital, and arranging transportation for those unable to get to their appointments.

Del Real told me that internal medicine is not always well understood in this community. “We are family doctors, too,” she said, “though we see only adults—adults with preventive needs, with screenings, with highly complex diseases.” She divides her practice between the outpatient clinic and inpatient hospital medicine at the Hospitals of Providence Transmountain campus, where she manages direct patient care and co-manages patients in the surgical ICU. She also trains the next generation of hospital specialists, supervising medical residents who came to El Paso from around the globe.

During active cancer treatment, an oncology team manages tumors. The primary care physician manages everything else. In my case, that means multiple concurrent lines of comorbidities: blood sugar control through the metabolic stress of chemoradiation, blood pressure management against a chemo drug’s impact on the kidneys, coordination of pain management, and oversight of a prescription burden that is about to become substantial. None of these items appear on an oncologist’s daily agenda. All of them fall to Del Real.

Her philosophy of care is built around a single question she asks every patient before they leave: What do you know? “I take the time and I say, why are you here? What is happening? And then we leave with a closing conversation to make sure we both understand.” For a cancer patient navigating a system that rarely speaks to itself, the PCP who asks that question—and means it—is the difference between understanding what is happening to you and being processed by it.

Insurance

Overseeing my cancer involves more than medical responsibility. It also involves insurance responsibility.

The health plan for Texas Tech Health El Paso employees is an HMO, or health maintenance organization. In an HMO, the primary care physician serves as the plan’s gatekeeper: every specialist referral, imaging study, and procedure requires PCP authorization before the plan will cover it. The theory is that a knowledgeable gatekeeper prevents waste and unnecessary care. In practice, for a cancer patient, this means that a physician who already knows the clinical urgency must still file paperwork and wait for an insurance company that does not.

My appointment with the radiation oncologist was delayed by two weeks due to paperwork. That is not a complaint. It is a documented fact about how the system operates. An American Society for Radiation Oncology survey of 754 radiation oncologists found that 92 percent reported that prior authorization causes treatment delays, affecting more than a third of their patients on average; 68 percent said those delays lasted five days or longer; and 7 percent said prior authorization has contributed to a patient’s death.1 A Memorial Sloan Kettering study of 178 cancer patients found that 69 percent experienced a prior authorization delay, 73 percent of those delays lasted two or more weeks, and 89 percent of respondents trusted their insurance company less after the experience.2

HMOs defend this system as evidence-based utilization management. Critics call it a cost-avoidance mechanism dressed as clinical oversight. A NORC survey found that most Americans blamed insurance industry profits for coverage denials.3

Del Real has navigated this from both sides of the desk. She knows how authorization decisions are made because she made them. When she files a prior authorization on my behalf, she is not learning the system; she is renegotiating with one she once worked inside.

Deny and delay

As of this writing, Del Real has submitted eight prior authorization requests for me to see specialists or for procedures. Two, including my radiation oncologist visit and a PET scan, were initially denied due to what can best be described as coding errors by a third-party contractor that is neither the physician nor the insurance company.

The Fox Cancer Center, rising outside my office window two years before it opens, will not fix America’s prior authorization system. That is a federal and state policy problem that no single institution can resolve. What a comprehensive cancer center can do and what individual specialist practices cannot is build the kind of integrated care team that absorbs the administrative burden on behalf of the patient: a dedicated navigator, a coordinated authorization workflow, a case management infrastructure that moves at the speed of the disease rather than the speed of the queue. The argument for the Fox Cancer Center is partly about equipment and clinical expertise.

It is also about this: cancer patients in El Paso and their doctors should not spend their time fighting paperwork.

Dr. P.J. Vierra is a writer with Texas Tech Health El Paso’s Office of Institutional Advancement.

The views and opinions expressed here are those of the author, writing as a patient and a journalist, and do not represent the official position of Texas Tech Health El Paso. Clinical decisions should be made in consultation with a qualified healthcare provider.

The day before commencement, campus held the particular stillness that follows the end of a semester. Classes were over. The classrooms and labs were empty, but the sidewalks belonged to the seniors of Texas Tech Health El Paso’s four schools, in caps and tassels, white coats and spring dresses, and suits and ties, claiming spots in front of sand-colored, Spanish Revival buildings with red tile roofs for photographs they will keep for decades.

I was walking. It was a warm May afternoon, and the desert willow trees along the campus paths were in bloom, their pink-purple trumpet flowers arriving just as Chihuahuan Desert’s heat began to settle in. The palo verde trees still wore their spring yellow. Just as colorful were the students gathered near El Intercambio, the campus art installation at the heart of the inner quad, where nursing students adjusted mortarboards and tassels while medical students laughed at each other’s medieval soft velvet tams. You could read the whole of medicine in their hoods: kelly green for the physicians, red for the nurses, yellow for biomedical researchers, lilac for the dentists.

I watched them the way writers do: with attention, and the odd awareness of knowing more about a scene than the people in it.

I saw hope. As a former college instructor, I recognize the particular exhaustion and joy of a class at its moment of completion. These are people who made a deliberate choice, at some point in their lives, to devote their careers to other people’s health. They will spend the next thirty or forty years in rooms like the one I sat in on April 14, when I received my diagnosis. Some of them will treat patients like me. One of them may change how cancers like mine are treated.

That thought stayed with me. Because I have cancer. And one form of it could, in the right future, disappear almost entirely.

Mine is classified as head and neck: a category that includes cancers of the mouth, throat, tongue, larynx, and the surrounding lymph nodes. The NIH recognizes more than 200 distinct cancers; head and neck accounts for about four percent of all U.S. diagnoses, with an estimated 71,000 new cases in 2024 alone.1

Every year, an estimated 3,200 El Pasoans are diagnosed with cancer, and approximately 67 are diagnosed with oral cavity or pharyngeal cancer, the category that includes my tumor.2 El Paso’s rate runs below state and national averages, a pattern consistent with the Hispanic health paradox, but oral cavity and pharyngeal cancer rates are rising among Texas men. The HPV-driven surge reshaping the national curve has not bypassed this city.

One to two El Pasoans are diagnosed with throat cancer each week. That week in April was mine.

My cancer began at the base of my tongue. I have named the tumor Boris.

Boris likely started growing in mid-2024. The cells of my throat encountered an error they could not repair: a protein signal that told them to divide without limit and to survive without consequence. Healthy cells divide when necessary and die when instructed. Boris’s cells broke both rules. My immune system should have shut him down. Boris persuaded the immune surveillance system there was nothing to see here. Move along. Over two years—silently, painlessly—Boris grew to roughly the size of a large grape. Then he issued instructions to a neighboring lymph node.

The head of our dental clinic named this second tumor Natasha. Natasha is what I felt on April 1. Boris, I still cannot feel.

I began researching the differential diagnosis in early April, using an AI tool I deploy for doctoral-level work. I call it Clio. The name is not a designation of personhood. AI has no sex, and the possession of language, however fluent, does not make a large language model human. What Clio has is speed and range. It walked me through lymph node differentials, cranial nerve anatomy, and the conditions that could explain a neck mass in a 64-year-old male. The output was accurate, a starting point I confirmed against primary sources. Clio, like any research assistant eager to please, needs guardrails.

The most common cause of oropharyngeal cancer today is human papillomavirus (HPV), a virus so prevalent the CDC estimates virtually every sexually active person contracts at least one strain in their lifetime.3 HPV-related head and neck cancer has been rising for two decades as tobacco-related cases declined.4 HPV-positive oropharyngeal cancer carries a five-year survival rate of 80 to 85 percent; HPV-negative disease runs closer to 50 percent.5

This cancer is largely preventable. Gardasil 9, approved through age 45, protects against the HPV strains driving virtually all oropharyngeal cancers. A 2025 study found measurable reductions in oropharyngeal cancer incidence among vaccinated populations under 45, the first real-world evidence that the vaccine is already bending the curve.6

The students posing near El Intercambio yesterday are my heroes. They will spend their careers in exam rooms, research labs, operating suites, and dental clinics. Every HPV vaccine conversation they have with a parent, a teenager, or a hesitant patient is a Boris that does not get born. A Natasha that never arrives.

That is not an abstraction. That is the work.

I read the science as a writer. The next entry begins where the science got personal.

* * *

Dr. Vierra is a writer with Texas Tech Health El Paso. The views and opinions expressed here are those of the author, writing as a patient and a journalist, and do not represent the official position of Texas Tech Health El Paso. Clinical decisions should be made in consultation with a qualified healthcare provider.

* * *

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How to follow A Journey Here. This Substack is its own section of The University Historian. To get only these cancer‑journey entries by email, click “Subscribe,” then go to your subscription settings (or visit theuniversityhistorian.substack.com/account). Under “Emails enabled for,” leave A Journey Here checked and uncheck the other sections. You can change this at any time.

How to follow the whole archive. If you want both the illness series and the institutional history — entries on UTEP’s past, Texas Tech Health El Paso, and the Fox Cancer Center, along with historiography and method — simply keep all sections checked. You’ll receive every new post from The University Historian in your inbox.

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For one year, I played a patient.

Not in any dramatic sense of stage and screen. It was in the classroom. I was a standardized patient at Texas Tech Health El Paso, an actor trained to sit across from medical students and present scripted symptoms so that future physicians can practice what cannot be learned from a textbook: how to take a history, how to conduct an examination, how to look at a person and say what the evidence suggests. I did it because I believed in it. Medical education requires practice, and practice requires a body in the room willing to be examined, questioned, and occasionally misdiagnosed.

I was good at it. I gave the students something real to work with.

I did not expect the simulation to become real—that I would find myself in an actual emergency department, with an actual first-year medical doctor, known as a resident, on the other side of the table, facing symptoms not scripted for me.

The resident I met with was in the middle of his twelve-hour shift and ten months out of medical school. (They’re called “residents” because new doctors used to literally live at a hospital as part of their training after graduation.) As a writer for the university’s Office of Institutional Advancement, I am used to interviewing residents. I know what the first year looks like from the outside—the rotations, the supervised handoffs, the accumulated weight of patients, each someone’s first.

This resident was a native Texan who had chosen El Paso in “The Match”—the annual ritual in which newly minted physicians learn where they will spend the next three years or more, perfecting their skills before they can practice on their own. As a medical student in East Texas, he had traveled to El Paso to intern at University Medical Center of El Paso and, based on that experience, decided this was where he wanted to be. El Paso County is a federally designated Health Professional Shortage Area. Here, Texas's physician-to-patient ratio is already 26 percent worse than the national average, and nearly half of Texas residents who complete residency elsewhere leave the state. He was deliberately choosing here over somewhere easier.

Between his patients, as I waited for test results, we talked about his education and life as a first-year resident in El Paso. The last conversation—the one at the end of his shift—was the one neither of us wanted.

My journey to UMC’s emergency department had begun two weeks earlier, on April 1, when I found a lump on the left side of my neck.

I noticed it the way you notice something you have been half-noticing for a while—the morning it finally refused to be ignored. Dense to the touch, tucked near the jawline. No pain. No fever. I am a writer, which means I am professionally, if not overly, skilled at rationalizing. I went about my life. I went to work. I gardened at home. I read and wrote. The lump stayed.

I opened a conversation with Clio, an AI assistant I developed as a research tool. I named it after the Greek muse of history. I treat Clio the way I treat any capable graduate assistant—highly useful, rigorously trained, but requiring consistent verification. I reviewed every source Clio cited, as I would for any research assistant, whether carbon- or silicon-based.

I asked Clio to work through lymph node differentials, cranial nerve anatomy, and the range of conditions that could explain a neck mass in a 64-year-old male with my symptom profile.

Clio’s response: A lump in the neck is a common clinical complaint. The overwhelming majority of such lumps are benign, most commonly representing enlarged reactive lymph nodes responding to nearby infection.

In its own sycophantic way, Clio tried to reassure me. But there was no infection. Within days, new symptoms arrived in a cascade along the left side of my face. First, my ear felt permanently plugged, as if I had been on an airplane that never landed. Then a high-frequency tone appeared and seemed to grow louder. Pressure along my jawline. Stiffness in my neck. Hoarseness that crept in gradually enough that I almost convinced myself it was allergies. Then one morning, the left side of my face felt numb. Not painfully, just quietly, the way a limb feels when you have slept on it.

That is when I went to UMC’s emergency department.

The resident ordered a CT. As we waited for results, he took my history—when the symptoms had started, how they had progressed—and performed a neurological examination. His supervisor, known as an attending physician, arrived and examined me as well. I was struck by how precisely the attending’s exam mirrored the resident’s: the same sequence, the same questions, the same hand gestures, but with the ease of someone for whom the sequence had become second nature. Residency, I remembered, works by absorption. The resident was learning the attending’s economy of motion the way I once learned to present symptoms to students believably—through repetition, through the body memorizing what the mind could not fully anticipate.

I had spent a year teaching medical students how to be in that room. Now I was in the room without a script.

After several hours of waiting for test results, the resident walked in and closed the door.

I found myself thinking about what I knew from the other side of the standardized patient table. The students who did it well were the ones who could tolerate the uncertainty of a silence, who did not rush past the hard sentence to avoid the discomfort of its landing. I wondered whether he had practiced this. I hoped someone had let him practice this.

Before sharing the test results, he asked what I had been thinking and what had brought me in. I told him. He listened the way residents do when they listen well: completely, without rushing to the next sentence.

Then he said he wanted to be straightforward with me: the results were more serious than he had hoped. He paused to let this sink in. He described how the CT had found a mass at the base of my tongue, roughly the size of a grape. Some of the lymph nodes on the left side of my neck were involved, indicating that some cells had spread into the lymphatic system. He said it was likely squamous cell carcinoma—the most common type in this part of the throat.

He asked what questions I had, even if they were not fully formed. And then he waited for whatever I would say next, which is the step most residents do not execute correctly, because the silence is genuinely hard to hold. When I had said what I could, he told me he had already contacted specialists and what I needed to do next.

I reached out to shake his hand. He will be a good doctor. He handled my silent pauses correctly.

Before he came into the room, I was the cancer writer—the observer, the one on the outside of the experience, translating it for everyone else. When he walked out, I had changed chairs. I was, for the foreseeable future, a cancer patient. My objective now was to become a cancer survivor.

But I am still a cancer writer. I just have a different point of view.

The good news, if there is any, is that the road to becoming a cancer survivor exists. Squamous cell carcinoma of the head and neck is a disease with a real treatment protocol and a real survival rate. The survival rate, however, varies by stage. Until that is known, my five-year survival rate ranges from 50 percent to 95 percent.

Outcomes improve with earlier-stage disease, surgery, modern chemoradiation, and a care team that has done this before. A 50 percent chance of beating this is not the number I would have chosen. For now, what matters is that the road runs through surgery, chemotherapy, and radiation, and whatever the next two years bring. People walk this road every day, and most of them arrive on the other side.

I have spent three years covering this institution’s cancer programs—the physicians, the researchers, the Fox Cancer Center rising from the ground beneath two towering yellow cranes on Hope Court, the people this community calls cancer warriors. I have written about cancer from the outside for long enough to know exactly what I did not understand about it. I am about to understand it differently.

This series is that understanding made useful. I will write about what is happening to my body in language anyone can follow. I will write about the medicine, not as a patient passively receiving it, but as a researcher who has spent months reading the literature and who intends to keep reading it. I will write about what it is like to navigate a serious diagnosis at a moment when the comprehensive cancer center this region has needed for generations is two years away from opening.

I will not always write about hope. Some entries will be harder than that. But the orientation of this series—the direction it faces—is toward something worth reaching.

That journey here begins.

How to follow A Journey Here. This Substack is its own section of The University Historian. To get only these cancer‑journey entries by email, click “Subscribe,” then go to your subscription settings (or visit theuniversityhistorian.substack.com/account). Under “Emails enabled for,” leave A Journey Here checked and uncheck the other sections. You can change this at any time.

How to follow the whole archive. If you want both the illness series and the institutional history — entries on UTEP’s past, Texas Tech Health El Paso, and the Fox Cancer Center, along with historiography and method — simply keep all sections checked. You’ll receive every new post from The University Historian in your inbox.

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