CancerDoc

Weakness at Work

2008-02-15T22:34:00.003-05:00

The day is long. Stressful. So-and-so has a lytic lesion at T1. Mrs. X just got intubated and is in the ICU. Mr. Y has called 10 times in the last hour about his upcoming prostate surgery. It's stressful. It's wonderful. It sucks. It's amazing.

My job is so diverse. A million different decisions occur every day. Affects so many people. Being a doctor is being a lifelong student of people. And, God, sometimes, I just want to curl up in a ball and cry. But, I keep coming back. I love it. I hate it. I need the money. Screw the money. I should have been a dermatologist.

And then it happens. A flirtation. An intimacy. You work with someone. You're getting crushed in the hospital. The job is killing you. You're there all the time. Hey, there's that nurse smiling at you. That married pulmonologist complaining about her accountant husband. The secretary with the deadbeat dad/husband.

The Weakness. It hits us all. You justify it, saying you're stressed. You say you're overworked. That no one understands you. But it's not true. I've seen it before so many times. I see it all the time now. A dalliance. A brightness to the day. A smile. A shared story.

I used to wonder how people had affairs. It seemed so abstract to me. I don't wonder any more. I see it all around me. It pulls me. It probably pulls my partner. The combined beauty and curse of our Internet modern life is that we have endless choice. Endless exposure to anything. Not just my city or even my state. Europe, the world, anonymous.

Maybe it's just the natural hormonal infidelity that grips all people in any line of work. But, I see the cliche doctor's affairs all the time. I see it. I understand it now. I've just got to avoid it all and just go home and work out or something.... just meditate. But, I see it.

The chemo part is easy. It's the living that's tough sometimes.

Does You Really Think They Look Okay?

2008-02-08T22:48:00.000-05:00

"Hmm, I don't know..."

"C'mon, Dr. ________, my husband noticed the other day. I think he's right"

"Well, uh, there's definitely a slight shift to the right and, hmm, let me see again... yes, maybe..."

"Oww!"

"Sorry" (sheepishly)

"How about the other breast?"

"That one is okay, symmetric. No problems"

"Do you feel any lymph nodes?"

"No"

"Why does the implant shift like that?"

"Well, sometimes the healing process takes months, you know... scar tissue, etc."

"I have another question..." (as she puts her bra on)

"Okay, go ahead, shoot"

"What about vaginal dryness?"

"Are you experiencing pain during intercourse?"

"Yes, it hurts when we... you know.."

"Have you tried K-Y or Astroglide?"

"Yes, but, it's not always ready... not always spontaneous. Why is that?"

"It's the tamoxifen"

"Really? Will it get better?"

"Maybe... but, the drugs basically put you into early menopause..."

"But, I'm only 32"

"Yes, I know. How about your libido?"

"It's low. Sometimes, I just don't feel like doing it. I don't feel attractive. I mean, something seems strange. And my husband just doesn't understand. He tries, but he gets frustrated."

(Pause. Silence.)

"Tell me more"

"I just don't feel whole. I know the odds are okay. But, I'm 32 for Christsakes. THIRTY-TWO. I'll never have children. My body feels disfigured. I hate this goddamn breast! I mean, look at them. They look so strange.

(More silence)

"Do you really think they look okay?"

Consumption

2008-01-10T20:25:00.000-05:00

I get it. I do now. For years, after hours, days, years, even decades of studying, then student loans, 100-hour workweeks, I always told myself that I do/did what I do/did because of love, passion, honor and so on. For the love of it. That was true, no doubt. But, now that I make a decent salary for the first time EVER and I have started paying my student loans, I understand what it is to consume, to want, to spend, quite frankly.

I don't know where it comes from. But, it comes. Like this vile force rising out of my bosom, this desire to spend, to consume, to purchase, to attain, it overwhelms me. I usually think of myself as progressive. I drive a respectable car (a Honda), I have energy-efficient lightbulbs. I give to the Sierra club and PBS. Blah, blah.

But, when I come home, when I sit in the quiet of my home, I waver between various emotions. Sadness at my day. Fatigue. Joy. I exercise. I eat. I read. I make love. I do the things that we all do. But, whether it's the new-found salary or my position or the impending burnout of my job, or a combination of all... I feel this urge to buy things, to drown my sorrows in possessions.

I'm trying to fight it. I know that it is pathetic. That it is transitory. But the cashmere sweater, the silk tie, the new suit... it somehow makes me feel better, makes me forget my problems, if only for a moment.

Yet it's dismal. Empty as the cliche goes. Money for money's sake. Mix boredom or depression, misery, etc. and you have the generic human experience. I fight it. I do. But, sometimes you just want a sweater that feels nice....

Bhutto

2007-12-28T21:17:00.000-05:00

Sad. It's sad. Why would the death of someone somewhere in Pakistan make me so sad? She wasn't a saint, despite the hagiography that CNN would promulgate on you. She had scandals, controversy, drama. Not a saint. Not by a long shot. It's not the Islam-thing. The 9/11 B.S. It's the death of someone, some-thing, something that had the potential to "turn the page". Like the end of a marriage or an affair, or recovering from a loss or graduation, there is something about moving on, about moving forward. For a person, for a country. The death of Benazir Bhutto was like ice water splashed on my chest.

Makes me fear for our future. Not for the future in little old Baltimore. I doubt someone wants to blow up Towson, Maryland. But, it just feels like we in the US need some chance to move on... from Bush, from Iraq, from "terror". Just to freakin' move on, or move back to an America that we once loved and cherished.

Bhutto's death makes that return more fragile. Sad. Real sad.

Why care about the other end of the Earth?

Because it will be at our doorstep before we know it...

Our little America. This country that I truly love.

Making Money and Slogging Chemo

2007-12-20T21:11:00.000-05:00

It's been a while since I wrote anything. I'm not sure why. I suppose I could feed some bullshit about the "emotional toll of being an oncologist"... the reality is I probably am just a combination of fried and lazy. I'm sitting here in my living room, days before yet another Yuletide moment and another New Year and there is just a whole lot to absorb about the WWI-like year I've had. I'm shellshocked, PTSD'd, thrashed.... I don't know the words for it.

Private practice oncology is a mixture of compassion, death, science, love, business, you name it. Nothing in my fellowship prepared me for it. I got a figurine from one of my patients today. This wonderful 50 year old woman with lung cancer who finds time in her day to thank me for cranking up some chemo in her veins and praying that she is a survivor. This wonderful woman, no kids, husband a fireman, trying to make the most out of limited funds and a lot of drugs, pain, wheezing, whatever. And, yet, she has time to think of me, to give me a figurine of a doctor, a "healer", as if that is the most appropriate appellation for yours truly.

Death. Lots of it. Some of my favorite patients. Some people that just struck me so hard and so fast. Struck them so hard and fast. Mary, with her lung cancer and her children and her husband with whom she was supposed to spend the "golden" years. Irma, matriarch of the family, that blessed family from Highlandtown, that nurtured her children to dream big and rise above working-class Baltimore.... Irma always asked if "you are eating well". How about Jaswinder? Can't speak much English. Shitty insurance. 3 kids. 38 years old. Breast cancer disaster. How's that for a Christmas? Makes you believe in the G-d, doesn't it?

People ask my why I've stopped writing. It's not because I lack things to say. I just feel burnt. Burnt already.

All those fucking tests. The little tests, the labs, the scans.

Oh, and the money... don't forget the money...

Yellow Week

2007-05-29T10:37:00.000-04:00

I'll call him Jack. Eighty-four years old, 57 years married to the same woman, WWII vet, all-around nice guy. Shows up one day to his primary care physician YELLOW. Eyes, skin, urine, I'm sure his tears are yellow if we checked. Pancreatic cancer. In retrospect, that's what that nagging backache was after finishing the back nine last weekend. That's why he had success for the first time in years shedding that tire around his waist. That's why he's a little more tired.

Bradley. Fifty-four, schoolteacher, 3 kids. Christian man, as if that matters (I'm Buddhist) somehow. YELLOW. Just sitting around one day, on a Sunday, kids in tow, when his wife notices a strange tinge in his eyes. Never seen it before. More pronounced in the natural sunlight of the outdoors. Hmm. Maybe it's nothing. The next day it's worse. Did you eat something weird? Nausea, anything? Nah, just yellow. Imagine the shock on those five faces when I tell them that he's got bile duct cancer. Say what? What the f-ck is bile duct cancer? Well... sir... blah, blah, blah... it sucks.

Sally. Fifty-one, mother of one, divorced, two sisters. Very, very funny woman. Coarse, crass, was once probably a really good-looking woman, but a few too many six-packs and a couple decades of Camel Lights really show themselves. But, there is something just "illuminating" about her. Call it personality. Call it spunk. She's funny. Bitingly funny. Oh, yep, and she's yellow as all get out. Some right upper quadrant abdominal pain for weeks. Liver cancer. Oh and a little cirrhosis to boot. Yikes. Double yikes...

Then there is the 74 year old woman with relapsed breast cancer and a belly swollen as all get out... the ninety year old with metastatic lung cancer... he was yellow, but the roto-rooter GI specialists took care of that blockage... well, at least for the next few weeks. then there is... on and on...

Things always seem to come in bunches. Kind of like when you just can't seem to buy a date and then other times, when you're in a great relationship and it seems like everyone and her mother is giving you the "come on" sign. Well, sometimes it seems like symptoms come in bunches.

This week is Yellow Week. Stent here, ERCP there, chemo, radiation, Whipple, unblock, reblock, percutaneous. Jaundice (as being yellow is termed officially) is never a good thing. It's downright disturbing and scary. For doctor as well as patient. There is something so profoundly upsetting as such a change in appearance as COLOR. Something that just screams of illness, that dehumanizes and debilitates and changes forever our perception of ourselves and others. Jaundice. Even the word stinks.

When to Be the Doctor, When to Be the Patient

2007-05-17T09:19:00.000-04:00

This past week has been surreal for me. Cast for the first time in my life on the receiving end of bad news rather than the delivering end, it's opened my eyes again on the nature of the "doctor-patient" relationship and the boundaries, emotional and physical, of our knowledge and our profession.

Someone really special and dear to me learned this past week that her mother, a healthy, health-conscious, vivacious 64 year old woman with no medical problems had a potentially fatal disease: hepatocellular liver cancer. This is usually something that occurs in patients with known liver disease, hepatitis or cirrhosis.

Devastating. You know, as many times as I've given bad news, I've never sat with someone I knew and loved and received some bad news, or, for that matter, received my own bad news. I've seen the hollow devastated looks on patients' faces. Seeing it on my friend was something totally different.

When my friend, Elephant Number 5, died last year, it was different. She was in the "fighting" phase. I wasn't there for the diagnosis. She was already pushing forward, had battled the disease for years when I met her, and was resigned to this being the end of her life.

This is different. Shock. Flabbergasted. Compounded by the fact that my friend is ALSO an oncologist. A doc. She knows the score. She knows that this is probably fatal. I don't think I'll ever get the sound of her sobs and crying out of my head. I've always thought that things would be easier because I'm a doctor, but that's just a pile of crap.

What's more painful is watching someone you care about run around like crazy, just crushed and frantic, and you just don't know what to do. You just listen and cry and hold hands and listen more and buy food and listen. I've had to try to put away my "medical" hat and just be a friend. There are enough experts working on this case. We're trying not to be that stereotype of the doctor who is a nightmare patient or family member, just torching the medical staff with questions and second-guessing. But it's hard... sometimes, the medical staff sucks...

For months, my friend's mom had nausea. We kept telling her that maybe she needed a scan. Hell, we're oncologists. All we ever see is cancer. We kept wondering why a scan hadn't been performed. And now that it shows this, we just keep wondering and banging our heads and second-guessing everything.

I know that this is what we all go through in our lives as we face illness and death. It's scary. No amount of education or status or training takes that fear away. We all have this one precious life on earth and it is sacred. And it hurts. It really does.

I don't think I'll forget that the next time I talk to a patient. I'll look for that fear and hope in their eyes. Hopefully, they won't see it in mine also.

Thailand and Medical Tourism

2007-05-14T13:16:00.000-04:00

I just got back from several weeks of vacation in Thailand, the homeland of my parents, also where my brother lives and works. See the family, tour the countryside, a temple here, beaches there, easy smiles and many drinks with pink umbrellas. Overall, a wonderful trip. Much has changed about this Third World country since I was a child.

Bangkok is filled with state-of-the-art shopping centers, high tech freeways, savvy urban dwellers and an ultramodern, brand spanking new airport. In some ways, the whole place was almost MORE modern than where I live in the US. The people so forward looking, so tech-focused.

Another thing caught my eye as I appreciated how far Thailand has come from its poverty of the last century. ALL OF THE SUPER-NEW HOSPITALS EVERYWHERE...

I asked my brother, "what's going on with all of these mega-hospitals?" He answered, "medical tourism". Thailand, like India, has become a destination for medical tourism from around the world. Many of the physicians, like my father, are US trained, having come to America during the Vietnam War. Now, fully trained, many have returned to a booming Thailand to work in the private, for-profit hospitals. These are opportunities that didn't exist when they were growing up.

Thailand is extremely friendly to tourism and foreigners. It is stable politically, or at least, it has been until this past year or so (with some ethnic/religious tension in the South). And, while parts are developed, it is still Third World by many standards and remains quite inexpensive in Western eyes (and pocketbooks).

So, you have had an explosion in the development of for-profit healthcare, that caters to the West. Indeed, 60 Minutes, the American news show, did a profile on medical tourism and cited Bumrungrad Hospital, a prominent private hospital in Bangkok. Some insurers on the West Coast of the US will pay for patients to go to Thailand rather than get care in the US. A total knee replacement or a coronary bypass procedure are probably a third as expensive in these countries as they are in the US. Indeed, my sister-in-law's father had his bypass done in Bangkok by a Thai surgeon who had spent decades at the Cleveland Clinic in Ohio.

So, is anything wrong with this? It's cheap for the US people. It redistributes wealth to a poorer country like Thailand. The care is good. I'm not sure how I feel about this.

One problem in my mind is that this takes something that is already a problem in the US and transplants it to another country. Namely, the proliferation of highly expensive, boutique medical care at the expense of preventive care. Also, it provides yet another service for the wealthy and insured at the expense of the indigent and unconnected. As hospitals in Thailand and/or India make a dash for the dollars and euros from Western countries, as they tailor their services to meet the needs of the more lucrative foreign market, what is to happen to their own people, the majority of whom are quite poor and lack basic medical care?

Indeed, funding for HIV prevention and other basic health services in Thailand have been recently cut, even as these for-profit skin centers and plastic surgery units have proliferated.

One of the major problems with the US health care system, as I've delineated elsewhere, is the stratification of health care based on wealth and insurance status. Some people get gold-plated, very expensive, often unnecessary health care, while others get nothing. Both get care that is focused on end complications, rather than preventive medicine. It is simply more lucrative and sexy to "treat" disease than prevent it.

I hope that this medical tourism will be a passing fad. It is just a symptom of the greater pathology within the American medical system. It threatens the viability of the health care delivery system in Thailand and other Third World nations.

It's one export from the US that the world can do without.

Impaired

2007-04-08T22:40:00.000-04:00

I remember when I was growing up, myself the son of a cardiologist, growing up amidst a community of physicians and lawyers and successful businessmen... I remember every now and then, at the annual Christmas party hearing the whispers of so-and-so's divorce... of Dr. You-Know-Who's affair and sex addiction, of little Johnny having to sign up for the military for medical school because Uncle Blah gambled the family fortune away in Vegas.

Whispers. Knowing looks. Disapproval in a sort of Scarlet Letter kinda way. That tsk-tsk sentiment of pity mixed with schadenfraude and disgust. "So-and-so is impaired... (whisper), he's at Betty Ford... he's getting sued by his secretary for sexual harassment."

It seemed so juicy, so carnal yet entirely remote from my otherwise unremarkable suburban adolescence. The kind of thing that you just love to hear about but can never in your wildest dreams imagine happening to you. Why do people become impaired? Addicted? Self-destructive? Why?

Is it the circumstances of a life or something innate? Nature versus nurture. I guess I always used to think of addiction or self-destruction as a human frailty that was entirely under self-control. A form of personal weakness to which I was immune. Yet another form of hubris.

Now, looking back, facing my depressing Fridays, feeling this urge to drown my tough days sometimes with a swig of Jack Daniels, I'm no longer so judgmental about all those poor souls that I witnessed growing up. Now, sitting through friends' and friends' parents' divorces and mix-ups, experiencing my own losses and pitfalls, just growing up and experiencing life a little bit, I wonder how any of us avoids a mid-life or late-life crisis, physically or mentally.

Judgment is so easy when you are young. It is so easy when life is green and fresh and filled with endless blue sky. How different after a wound or two.

Physician, heal thyself. I understand now what Hippocrates was talking about. I'll put the glass down now and go for a walk.

It's a Good Friday

2007-04-06T22:26:00.000-04:00

As a non-Christian, I sometimes wonder why this day is called "Good Friday"? What could have been "good" about the death of Jesus Christ? It seems like a strange name to me. Always has. It's weird. Although I am not religious, for some reason, Good Friday and Easter have always gotten me thinking about religion and life, more so than any other holiday on the calendar. More than Christmas, more than Thanksgiving, Passover, Kwanzaa, etc. There is something about the story, the history of Jesus that just gets me thinking this time of year.

I suppose it's the story of compassion throughout the New Testament that registers with me so profoundly. Forgiveness. Turning the other cheek. Love of our neighbor. These are important concepts to anyone. Perhaps more so for a physician. Even more for an oncologist.

Today was an amazing day. It's been just over a year since my friend, Elephant Number 5, as I refer to her in a prior post, died of complications from a bone marrow transplant. One year. Sadly, I've been so busy, I haven't thought of her that much. Someone so sweet, so gentle, so important to my life, yet forgotten amidst the business and daily trauma of my life.

One year ago. She would have wanted me to drink a beer for her on this day or watch a sunset or drink a beer AND watch a sunset. She was lyrical like that. Spiritual. Funny. Fun.

What is life, except a string of seemingly unconnected experiences that add up to a tapestry of a life? We are all alone in the end. All alone in this absurd life, filled alternately with tragedy and happiness. Alone in our search for meaning in a short stint of breathing.

I'm not sure if being an oncologist has helped or hurt me spiritually.

I miss naivete sometimes.

I miss that nervousness I used to feel in college before a date with a girl.

I strangely reminisce randomly on the past even though I'm only 34.

I digress.

Good Friday.

I guess it is a Good Friday.

A Friday to think, to feel.

Brain tumor, pathologic leg fracture, leukemic blasts, swollen spleen, intubation, dialysis, DO NOT RESUSCITATE, FULL CODE, lung biopsy, hand holding, crying, living, dying...

It's all just a normal Friday. Random... very human.

The Hurting

2007-03-16T20:45:00.000-04:00

"It hurts"

"He's my life, I can't let him go"

"Is it really that bad?"

"I don't know what to do... should I put him in the nursing home? I just can't take it anymore..."

"I'm ready to die... really, I'm ready"

"Forget it. No way. No hospice. He's going to go out fighting."

"I'm too young to die"

"Phew... thank God, thank God!!! Remission!!!"

"Why did this happen to us?"

Just a sampling from my week. A small sampling. One week. Just another week in the life of an oncologist. My first impulse is to reach for a drink. Seriously. I just want to numb it. I can't bullshit and say that I feel everything for every patient, but man, oh man, it just hurts sometimes.

Cancer is brutal. It robs our dignity. It sucks our lifeblood. It dehumanizes. Yet, it's just amazing how people are sometimes. So funny, so noble, so ironic. Sometimes so angry, so bitter, so vitriolic... yet, all of it, just so, so human.

I feel like crying every Friday. I hang on for the week, just holding on to my sanity and emotions until the cathartic drive home every Friday at around 6 PM. Just reviewing all the sadness of the week.

The woman who survived breast cancer for 10 years only to get a new diagnosis of metastatic esophageal cancer. The 50 year old nonsmoker with Dana Reeve-like metastatic lung cancer. The guy cured from lymphoma who develops leukemia from the prior chemotherapy. The young married guy with myeloma and now the elimination of ever having children. The blood clots, the ulcers, the pneumonias, the kidney failures... the montage of character actor illnesses that accompany every cancer diagnosis.

I hate it. I love this job. I'm depressed. I'm fulfilled. Fuck this shit. Yet, I show up every Monday. Cancer is a bitch, as many of my patients have told me. Damn straight, man. Damn straight.

The Status Syndrome

2007-02-24T13:09:00.000-05:00

For a number of years, a British physician and epidemiologist, Michael Marmot, has been studying health disparities throughout the United Kingdom and the world. In a book published a couple of years ago,The Status Syndrome, and in a recent article in JAMA, he outlines a phenomenon that he names the "Status Syndrome."

What is it, exactly? It is a disparity in health that relates to discrepancies in social standing, money, power, influence and level of self-esteem. Apparently, Academy Award winners live a few years longer on average than nominees. Independent of salary, higher educated individuals live longer than less educated people. However, money is not the only issue. There is something else, something intangible yet familiar to all of us that is embodied in the idea of "status" or social worth. The JAMA study showed that class for class, individuals in the UK had better health outcomes than their socioeconomic peers in the US despite our spending TRILLIONS more per year on health care. Countries with much, much lower GDPs per capita such as Greece or Israel have higher life expectancies than we do. Furthermore, the point has been made by Marmot and others that countries with little income disparity, such as Canada, Japan and Sweden, have better overall health than countries with wide and gaping disparities in income.

What is behind this phenomenon? Well, no one knows, quite honestly. But, science and pop culture have merged a bit in the past decade on the concept of stress. Since time immemorial, humans have noticed that less anxious, more socially integrated, happier people who feel good about themselves and their lives seem to do well. People under dramatic stress or trauma or who have suffered a loss often seem to have more medical problems or die sooner. Almost any of us can point to a friend or a family or an urban legend about so-and-so dying after his or her spouse died or of someone who "aged so quickly in a year" and on and on.

Well, research is catching up with this. There are studies that look at telomeres, the endings on chromosomes, which shorten with each replication of DNA. Some of these studies have shown correlation between more rapid telomere shortening and a history of stress or trauma. We are learning more about "inflammation" and its role in heart disease, cancer and other medical problems. Inflammation is driven by diet and activity but also hormones and our own bodies’ reactions to events. Some of our most effective medications, such as aspirin, decrease inflammation and it's thought that this may underlie the role of anti-inflammatory drugs in prevention and treatment of illness.

What's the bottom line? Well, I suppose there are really two bottom lines, at least. One is a personal bottom line. Namely, that we as individuals, in wanting to promote our own health and longevity and quality of life, should seek out behaviors that reduce stress, provide meaning to our lives and give us a sense of direction and autonomy. We should promote the usual healthful behaviors of diet, exercise and social interaction. Also, that money alone and the accumulation of wealth is not the answer. At least on a personal level. Rather, it is the satisfaction that comes with self-esteem, purpose and usefulness that may improve both our psychological and medical well-being.

From a societal standpoint, we have only to look at countries such as Sweden or Canada or Japan. Granted, they are more homogeneous populations than the US, but philosophically, there is something different between those countries and US. One aspect, in my opinion, is LESS of an emphasis on self-importance. Whether it is Canada's universal health system, Sweden's social safety net or Japan's stereotyped philosophy of "the nail that sticks out gets hammered down", there is on many levels more of an emphasis on community and group responsibility in those countries than in the US. While this allows for dynamite corporations and fabulously wealthy and entrepreneurial individuals in our country, it also accepts and allows for a much larger population of downtrodden and dispossessed people.

As a nation, I suppose we should aim to promote policies that reward innovation but at the same time attempt to reduce broad income and social disparities. Whether it's universal health or balancing our budget or providing for a social safety net, I think that our government at every level can enact policies that not only save money and provide services but also can actually save lives and help us live longer and healthier. I believe the data is becoming clearer and clearer in that, although the US allows for enormous success personally, our American way of life fractures us socially and widens both our financial as well as our physical health. In social policy as well as in science, it is not enough to simply look at single variables and outcomes. Humans are complex organisms and societies multiply that complexity many-fold. By focusing on the overall goal of longer life, better well-being and more equality in our health care delivery as well as being honest in looking at our neighbor countries and peers for what they are "doing right", maybe our government and ourselves (we make our government) can actually wake up and realize that there are better ways to live. It will probably save a few bucks also.

This is Why People Distrust Research and Turn to Alternative Medicine...

2007-02-15T21:55:00.000-05:00

A recent Washington Post article described a recent article in the medical literature challenging the long held notion and recommendation that pregnant women should limit their fish consumption. The recommendations from a variety of agencies, including the Environmental Protection Agency and the Food and Drug Administration, that pregnant women limit fish intake comes from a long history of calculations based on the presence of methylmercury and PCBs and their purported effect on neurological function. These recommendations are very well meaning, based on sound science and logic.

So, imagine the surprise when a longitudinal study observing a large cohort of women who consumed a variety of fish showed that the highest consumers had children with the highest neurological function. Granted, there are a variety of biases that are associated from such studies and this is far from a gold-standard randomized controlled study of fish consumption in this population, but the findings are thought-provoking on the one hand and confusing to the public on the other.

Whether it is hormone replacement therapy, fish oil, garlic, multivitamins, and Celebrex or fish consumption during pregnancy, there are just so many conflicting studies on a variety of topics that are near and dear to the public. This is natural. This is science. There is nothing wrong with this and, ultimately, the beauty of science and research is that the truth eventually emerges.

The problem is that, in this day and age of the Internet and the need to publish quickly, there is just a complete flood of information that reaches the public, often via the pages of the New York Times or CNN, and that these studies are taken as the word of God. The public then stands confused when a conflicting headline is showcased months or years later.

I think that, in some ways, this constant conflict of thoughts and ideas that are aired constantly in public only serves to undermine medicine and our confidence in medical science. It drives, in my view, the increasing confidence of patients in "alternative" medicine or anecdotal therapies. I can't tell you how many times patients come to me on all kinds of pills and therapies that I know nothing about. Drugs that they read about on the Internet. Attitudes from extremely intelligent people that "doctors just don't know everything.."

I agree. We don't know everything. Often, we know nothing. I'm not sure what the solution is. Maybe it is limiting what gets published and released in the media. Maybe it's better science education and background for the common layperson. Maybe it's more nuance in our discussion of health. Maybe it's just waiting and thinking and just not sensationalizing every little new discovery that confuses patients and doctors alike. Alright, I'm taking my multivitamin and fish oil now. Oh, and my baby aspirin.

Cost, Quality and Access

2007-02-01T23:22:00.000-05:00

"Cost, Quality, Access..." I can still hear it now. My college professor of Social Medicine speaking about the tradeoffs between these three aspects health care. "You can emphasize low cost, high quality OR universal access, but it's nearly impossible to have all three." This was in the heyday of Hillary Clinton's attempt to revise the health care system. She was trying to educate a young student in the perils of American health care. It seemed so abstract, our class sitting there debating the pros and cons of the Oregon Health Care plan, the Canadian health care system, universal vaccination, the rights of citizens, the rights of corporations to make profit, the responsibilities of government for people's welfare and on and on. So abstract.

Well, it ain't so abstract anymore. Every day, I seem to confront the realities and limitations of our health care system. And I'm as perplexed as anyone else as to what the answer is. I'll give you my examples from this past month alone... I one guy who is deciding whether to take a pill for chemo that Medicare covers but is clearly inferior or have to put up 20% of the cost of intravenous chemo that would put him easily into remission but would amount to probably $10,000. He's a machinist and his wife is sick and he has no kids and his insurance sucks. What do you say to this kind of thing? Go broke or take shitty treatment. Or take another patient of mine. He has private insurance, but it only covers labs drawn at a particular university system. The nearest blood drawing area is dozens of miles from where he lives. He's 76, can't see, lives alone and, yes, has a blood disorder that just happens to require very, very frequent blood draws. So, I see him, wait for the labs to be faxed from this other place, try to make some decision in some timely fashion and then enact it. Usually requires a form of injection growth factor that isn't covered by his program to be given in the office unless he wants to cough up that 20%. Oh, but it covers it being "self-injected", but he has bad arthritis, and, yes, did I mention he couldn't see?... well, that's life. Never mind that he fought in the Korean and Vietnam wars and worked as a civil servant for a number of years. Or the Mexican illegal immigrant who rolled into the hospital with a cough and left with the diagnosis of metastatic kidney cancer. Can't get medicines, can't get surgery, can't even get an office visit paid for, can't go home to Mexico. He just waits. And waits. He's a nice guy and so respectful, but I just sit there impotent to do anything. I can't take a huge financial loss to treat him. I can't stop thinking about him. No one wants him, even the university hospitals in our city. Yep. Stinks.

Cost. Quality. Access. Currently, we have the worst of all worlds. We have the most expensive health care on Earth, some 14-17% of GDP going towards health care. We have spotty quality. Yep, you heard it. Yes, we have more MRIs in Maryland than in all of Canada and you have people lined up around the corner to install high tech stents, pacemakers, dialysis, catheters, etc. We've got high tech alright. But, how about infant mortality, or vaccination strategies or public health or just plain lifespan. Based on everything we know about science and public health measures, we do a crappy job of implementing care that would help millions of people. We pay through the nose for a cardiac bypass, but pay primary care docs 10 bucks to spend an hour trying to help us stop smoking or lose weight. We don't go for the most quality for the MOST PEOPLE. We go for the absolute PREMIUM care for a chosen few, adequate care for the majority and severely, disastrously poor care for the chosen slobs. Finally, access. Well, everyone knows about the 30-40 million uninsured. But, the grim fact is that the uninsured utilize even more care sometimes than the insured. They lack primary services and therefore utilize emergency care more frequently. Emergency rooms are packed to the hilt with uninsured patients who use the ER for their primary care, driving up costs enormously, overwhelming docs and resulting in often-disastrous outcomes.

What's the solution? I have no freaking idea. All I know is that people need to be aware of the tradeoffs between these issues. In my opinion, the only way to improve things is to accept that dreaded, hush-hush outcome that has rarely been mentioned for nearly a decade... RATIONING. Yep. Rationing. Any system that provides universal health care for the entire population and doesn't completely bankrupt the Treasury is going to require rationing. It simply has to. But, rationing isn't what you think. It isn't the managed care kind of rationing where some phone tree or technician either argues with you or ignores you in order to minimize your use of the system.

No, rationing is maybe something different. It means taking what we ALREADY know about effective treatments and implementing as many of those as possible FIRST, before turning to more expensive treatments that benefit fewer people. Something akin to the Oregon Health Plan that came about in the 90's. What that plan basically tried to do was to come up with a list of treatements... a list of treatements of all the known medical conditions, bone marrow transplants, diphtheria vaccines, gallbladder surgery, hair removal, etc. Take a panel of medical experts, ethicists, business people, lawyers, government agencies and other stakeholders and come up with a list from 1 to whatever, listing the treatments from most effective to least effective. Most effective might be something like the polio vaccine. Helps everyone, costs pennies. The least effective might be some totally rare experimental bone marrow transplantation for a super rare disease like aplastic anemia. Take that list, take your state budget and find some point on the list where below that point, you just can't pay for the treatments solely by government, because the benefit is outweighed by the cost. Everything above the list is covered by the government. Everything below, well, you're on your own. There is, in effect, "rationing" of care.

Yes, it is fraught with problems. Wealthy people could find ways to circumvent the list. There would be bias in favor of the rich. But, honestly, there already is a many-tiered system of care in this country based on wealth. It's just more opaque and more fraudulent. I've always liked the Oregon Health Plan. Somehow, it just seemed logical and fair and would control cost while providing broad care to the most people with the most beneficial treatments.

But, alas, I don't think we'll get there. Too many stakeholders, too many powerful interests. The states, however, are experimenting with different things in the absence of national leadership. Who knows? Maybe something will happen before the Baby Boomers impoverish the government. I can dream, though. I can dream of a day when I close up my oncology shop, because most cancers have now been prevented by public health measures curbing smoking, excessive drinking and obesity. How people will prevent heart disease and when there will be no more disfiguring breast cancer surgeries or big scars on peoples' chests where their lung cancers have whacked out. Ain't gonna happen. I know that. But I can daydream. Gives me something to think about while I'm pushing more chemo.

Six Months Under My Belt and I'm Coming Up for Air

2007-01-19T13:07:00.000-05:00

It's been quite a six month stretch. No blogging, just working. These first few months of practice have been both entirely predictable in many ways and totally surprising in others. First, the predictable: sometimes long stressful hours fraught with uncertainty about knowledge, compassion, talent and/or any number of other attributes that a competent oncologist is supposed to have. Lack of experience leading to frantic running back and forth to Google and PubMed and UpToDate in an attempt to understand what I'm supposed to be doing (all this after already 4 years of med school and 7 years of training). Some politics with dealing with referring physicians, competing groups, academic centers. And so on and on.

Now for the less anticipated things. Well, first of all, commuting sucks. It's better now that I have books on tape, but after not having to commute much for most of my life, even the 30 minute drive to my outer office is somewhat painful. I can't imagine how people drive for hours and hours when they live far out in the suburbs or exurbs or whatever it's called. I guess I should have known about commuting, but, hey, I've been locked up in one hospital for the last 7 years. Give a brother a break.

Two, I kind of like the "business" side of things. Yes, for all my railing against the system, for all my complaints about the inefficiencies of things (and there are still many, many inefficiencies), the fact is that running a private practice is like running a corporation. Whether it's ethical and meaningful and trustworthy has less to do with the inherent nature of the "industry" and more to the individuals. Enron versus Google for instance. Both money-making giants, one a lot more corrupt than the other. But, being involved in the design, structure, development and delivery of medical care under the control of your own hands is, after years under the yoke of hierarchical and sometimes nonsensical training, quite, well... refreshing. There is just something to being part of an organic process, a growing organism that you can shape so directly with your input, your attitude, your know-how. When I mean the "business", I'm not talking about money. I'm talking about the "ownership" aspect, as in "taking ownership of our own lives" kind of thing, or "ownership society" a la the hated Dubya. It's just plain nice to talk with partners about how and what we want to do in the future and just go out and do it. No grants, no blah-blahing, no kowtowing to superiors... just a small, nimble organization hoping to develop a good way of helping people and a culture of success and caring.

That brings me to number three. The money. After a month, the money becomes meaningless. Seriously. Money is kind of the thing that matters a ton when you don't have it. When I was making the $35,000/year resident salary while working 110 hours a week, I would think sometimes how it must be so nice to make a bigger salary, all the freedom, the satisfaction. How in some ways my disgruntlement at times was related to feeling underappreciated. Don't get me wrong, you make peanuts as a medical trainee, after spending your whole life studying and accumulating $150,000 in debt to go to school. It can be daunting at times. But once you make a little more money, unless you have a ton of other financial needs, the luster of it fades quickly. Honestly, my lifestyle hasn't changed a bit. I just have finally started paying off some loans and saving for the first time. It's just a little security but it really doesn't make me any happier and it certainly isn't a driving force to continue my work. The bottom line is that no amount of money makes working so hard worthwhile if you don't love it.

Number four. I LOVE IT 80% of the time, loathe it 10% and am somewhat numb 10% of the time. I thought those percentages would be different when I started. I won't tell you how different. Anyway, being a doctor is great. It is the most challenging and interesting thing ever. Far more challenging than my training. Medical training is stressful in terms of the hours spent and the insecurity of learning while taking care of generally sick inpatients. However, there was usually a "superior", someone who had both the final say and the final responsibility. Now, I am that person. It's nice to sort of know what to do, but sometimes the burden of the responsibility, especially in cancer care, is a bit heavy. Also, the paperwork... yuck. The paperwork truly is burdensome. When it's just me and a patient in an exam room, I'm in heaven. When it's this form or that, or dictate this or sign that, it's torture. Administrative issues are really painful.

Five. Politics. Not the Iraq war kind, but the medical-industrial complex kind. The there-is-a-lot-of-dinero-on-the-line kind. There is this palpable tension between doctors and the hospitals and the insurers. A strange love triangle that is unsurprisingly devoid of love and affection. I assumed there was more politics in the academic center. In a way, there is more in practice. And, it's somewhat less transparent. In academics, you have smart and not-so-smart professors pushing for glory, publications, promotions, lab space, etc. It's predictable and you can sort of understand the game that is afoot. In practice, it is a little more opaque. Yes, money is at the center, but it is sometimes hard to assess other doctors, patients, insurers and hospitals in terms of their motivations, maneuvers and manipulations. Not to get all Machiavellian, but with a lot of money on the line in medical care, a shrinking pie and some greedy folks, sometimes it's hard to know how much you have to fight to "get patients". After all, a doctor who sees no patients has no practice, and therefore has nothing. It's complicated. I'll allude to it in future blogs.

Lastly, dealing with the dreaded Pharma reps. Painful. Very. Unbearable. Yet... yet, there is some use SOMETIMES. Most of the time, you feel like you're dealing with total charlatans who sneak around plying some snake oil. But, every now and then, someone is actually helpful. They sometimes provide useful (and often biased) information on a drug or a side effect or a way of getting a drug to an uninsured patient. Yes, there is ultimately something in it for them and yes, I've had reps offer me chances to "speak on the lecture circuit" and make cash, but every now and then you have a relatively decent rep who is reasonably intelligent who is also helpful... okay, I confessed it.

So, I finished half of a year in practice. I had to go underground for a while. Overwhelmed, just processing, mentally fried. Hopefully, I'm back. Passed my boards. Taking my first vacation tomorrow. Just felt like my old blogging self. 2007 is hopefully going to be a good year. CancerDoc is hopefully coming back. There is just too much out there to talk about.

Obamamania

2006-10-22T22:40:00.000-04:00

I seem to have seen Barack Obama everywhere lately. NY Times, on the cover of various magazines, on "Meet the Press" this morning. Caught up in the swirl of life, Iraq looming somewhere remotely in my consciousness, vaguely aware of the possible changing of power in Congress coming up (like, who cares?), I'm somewhat distantly cognizant of politics and our civic discourse lately. No matter where I turn, it all seems the same. I read the paper daily... I skip it a couple of days, I come back to it in a week or so. It's all the same. Scandal there, something pornographic in either pop culture or our politicians daily. A murder somewhere, a school shooting. Deaths in Iraq. Nuclear weapons. I swear. It's like Groundhog Day, every day, all year. Politicians seem to babble about the same thing. Abortion. Minimum wage. Terror. Medicare. Welfare. Immigration. The same stuff that was being debated in my college dorms ten years ago.

So, there was something kind of refreshing in listening to Mr. Obama on TV these last couple days or reading a bit about him in the papers or leafing through his new book, "The Audacity of Hope" in the book store. Dunno quite what it is. It's not because I believe in the same stuff he does. Actually, I'm not really sure what this two-year senator from Illinois even believes in. It's not that he's multiracial or younger or from Harvard. It's not even that he's articulate.

I think what struck me most was an observation that he relayed first in the pages of his book and more recently illuminated in interviews on TV. Namely, and I paraphrase, that so many of our current debates... the debates between the Clintons and the Bushes, the liberals and conservatives, the right-to-lifers and pro-choicers... so many of these debates seem like replays of the 60s. So many of the theoretical constructs seem mired in the well-trodden logic of four decades ago. Very little of that logic resonates with my generation, "Generation X". So much of it centers around the "Baby Boomers". Like much of everything that goes on in this country, be it Social Security or the war, at the heart of the demographic appeal is the Baby Boomer generation.

Yet, I believe that so many in the country, young and old alike, seek something past the ideology of prior years. So many of us I think are "post-ideological". Globalization, trade, outsourcing, China, terror, global warming... these issues seem outside of the tired and worn-out roles of Democratic, Republican and Green Party hacks. Obama stated that he felt people nowadays were not just searching for the "center", but in reality, were searching for "pragmatism". Whether it's the market economy or government regulation, entrepreneurs or social workers solving problems or whatever, what we need in this century is a more practical, problem-oriented approach to the huge issues of the world. Climate Change, Terror, the Role of Big Government, Trade, Religious Fervor, Population Growth, Health Care... and on and on. There are so many big problems facing this country and the world. With the growth and dissemination of knowledge and power on the Internet and globally, it just isn't up for a chosen few individuals or nations to solve the problems of our day.

I don't know if Barack Obama would make a good leader. I hope so. His rhetoric is pretty good so far. But, we've been down these paths before. Rather, I think what appeals to me is the sense I get from listening to him that maybe, just maybe, a new generation is on the cusp of taking power. A generation that is focused more on finding real solutions to problems, across ideology. A generation that grew up in the shadow of our somewhat self-indulgent Baby Boomer parents and our selfless "Greatest Generation" grandparents. A generation that is maybe a little less ideological. That is respectful of marriage as well as homosexuality and "alternative lifestyles", that is religious, but also tolerant. That is socially conscious, but entrepreneurial and trusting of capitalism to a certain extent. A generation that is willing to consider all possible solutions to all imaginable problems.

Maybe that's just the dreaming Progressive in me.

I'm Just a Rookie

2006-10-18T20:49:00.000-04:00

It's set in. Insidiously. Gradually. Inexorably. As some of you have commented in the past weeks, I've been a little absent from the blogosphere lately. I wish I had some pithy comment as to WHY or some good reason. I guess I've just been getting busy with the beginnings of my long journey down this road called "private practice". I think I'm a little shellshocked at finally being the person ultimately responsible for so many sick people with life-threatening illnesses. Dude, this is scary.

You know, it's funny. I make all these somewhat self-congratulatory observations on issues that come across my eye in the New York Times or Washington Post. I feel educated, just finishing my training at one of the top institutions of this country. I felt like I was "on top of my game" coming out of fellowship. Yikes. I think the Greeks had a term for this... HUBRIS.

My first months in practice have been a lot of things. Exhilarating, exhausting, frightening, funny, sad, predictable in many ways, completely horrifying in others. I'm still getting used to the feeling of moving from one room where a young patient is gurgling on their own vomit, dying from metastatic breast cancer, three kids in tow, husband, picket fence, to the next room, joking with the "cured" early stage colon cancer patient to the nurses' station where I have some yucks about my weekend to my house where I have this ever present urge lately to throw back a couple of beers nightly (I don't, mind you... well, sometimes I do).

It's almost comical... almost. I saw so many patients in my seven years of training. I pretty much saw everything medical that I could imagine. Or so I thought. I guess you get used to hearing about how you're a hot shot so many times that you start to believe it a little bit. But, being out in the "real world" is something very different.

You know, behind the verneer of confidence in your doctor's eyes lies just a little bit of terror. Trust me. Just that little feeling like "I'm an imposter". I really don't know what the hell is going on but I'll fake it or punt until the next visit or step out of the room and look it up on the Internet. It's crazy. It's one thing if I'm dealing with coughs and colds or sprains and bunions. But, this is chemo and death and tumors and horrors.

Sometimes it seems like there is no break. Like I just gasp in relief when I look at the next patient on the list and it's someone with chronic leukemia or a run of the mill blood disorder. What a break. It's getting a little easier, though. I'm not staying up all nights reading furiously. I'm relaxing a bit more on the weekends. I don't need to get up at 6AM every day now. I'm sleeping okay for the most part.

But, it's there. Just that little panic, that obsession, that fear that I'll completely screw up someone's life, mess up their wedding, their Bar Mitzvah, their vacation, their kids, their opportunity to have kids, their life.

Honestly, sometimes being an oncologist is tough, draining. But, in truth, I love it. It's like crack cocaine in a way. Sometimes, when the day seems long, when I just dread one more conversation about death or hospice or the future, I look into the eyes of my patient and see THEIR compassion for me. I feel human. I feel humbled. I feel like a doc. That's the only way I can explain it.

It's a nice feeling.

Perils and Promise of Monopolization

2006-09-21T12:20:00.000-04:00

Two recent developments in the news have made me think about the growing consolidation of corporations and their impacts on our lives, both for good and bad. Take the spinach crisis that emerged a week ago or so in the US. It appears that at least one and maybe more industrial farms are implicated as sources of the E. coli-laden spinach that affected more than a dozen states across America, resulting in numerous hospitalizations and a nationwide recall on all spinach products.

How does this come about? How is it that our FDA gets the point where it says that NO ONE in the US can eat any spinach "until further notified?" Consolidation, that's why. With modern large-scale industrial farming, something like 70% of all spinach consumed in the US comes from California. Why is this so? Well, these large corporations enjoy economies of scale; can provide low-cost, relatively high quality products with quick distribution. By the way, this was a large-scale organic farm, if I remember correctly. So, many of our "organic" or "natural" products are being produced at large industrial farms. Whole Foods and Trader Joe's both buy from such companies.

The downside is obvious. With less diversification of our food resources, we are prone to health breakdowns like the one that occurred this past week. Furthermore, some argue, such as in Michael Pollan's "The Omnivore's Dilemma", that increasing homogenization of the food that we eat is in itself detrimental to our health. Rather than eating locally grown, seasonal foods like our forebears did, we are all stuck with the same diets, whether they are McDonald's, organic or vegan. The sources are the same. This is 1) potentially a health risk during contamination episodes like the E.coli problem or Avian flu, 2) limits biodiversity and impacts other plant and animal species and 3) potentially promotes unhealthful farming techniques, like feeding cattle corn instead of their traditional, evolutionarily-developed grass.

A second article in the NY Times got me thinking of the impact of monopolization from a different perspective. Wal-Mart, in a bid to assert more influence in the competitive health care market, has begun to offer generic prescription drugs. This will place a large amount of pressure on other pharmacies and insurance plans to keep up with Wal-Mart's demands. Wal-Mart is such an enormous player economically in the world that this action alone may have substantial effects on the health care industry in this country.

Although I have some problems with Wal-Mart's health care policies, I have to agree that this decision to support generic drugs is an important and positive development. Many generics are quite cheaper than their brand name competitors but equally effective. Pharmaceutical companies fight tooth and nail to maintain individual patents or suppress generic drug makers. In the end, costs skyrocket but health benefits are not necessarily improved.

In other ways, I often wonder to myself if the global dominance of Wal-Mart is a good or bad thing. I enjoy getting cheap products all in one spot from a Target or Wal-Mart. Deep down, I realize they are pressuring small vendors around the world with their purchasing power. Yet, at the same time, I think they provide real service and cost-benefit to us, the consumer.

I guess my point is that there are plusses and minuses to consolidation of resources and economies of scale. No kidding. I guess I've steered away from my prior knee-jerk reaction to "corporate" influences. Sometimes, business and the "invisible hand" of Adam Smith are the most efficient ways to stimulate progress and development. I think my main beef is not with companies or marketers or business people. Rather, it is with our own government. Our own watchdog institutions such as the EPA or FDA or Justice Department.

Whether it's our own Department of the Interior interfering with its internal auditors or Congressmen who move back and forth from government to the Lobby de jour or our academicians and scientists who have stock options or honoraria from the very companies whose products and drugs they are supposed to evaluate "objectively", it is the growing conflicts of interest in all aspects of our society that is most disturbing to me.

We must not forget that the FDA and USDA emerged shortly after Upton Sinclair's "The Jungle" shed light on the dismaying practices of the meatpacking industry. That the SEC gained strength after the stock market crash of 1929. That we needed antitrust litigation to break the power of Standard Oil. That perhaps humans are meant to simply repeat our mistakes over and over again. That the endless cycle of progressivism alternating with conservatism is simply the way of life.

I just hope we don't all have to get the E.coli runs to bring back Teddy Roosevelt.

Utopia, USA

2006-08-05T18:23:00.000-04:00

One of the comments on my last blog was about how "idealistic" my suggestions sound in relation to being a good health care consumer. I think that that attitude is part and parcel of why we have such a fractured system. People expect a fair, equitable, well-meaning, beneficent health system to just be available to them at a low cost and for little responsibility on the part of patients and consumers.

My point of the last couple blogs and indeed this entire blog is to illustrate some of the realities in the system and to let people understand the larger forces at work in our system and how they affect the delivery of care. There are so many economic and political undercurrents to the simple office or hospital visit that is entirely opaque to the average person. I think it's clear that patients are unhappy with many of the problems in the system. Our health care industrial complex is expensive, unwieldy, has poor outcomes and limited access. It's great for the wealthy few and frustrating for the average many. But, quite honestly, only the patients, only the populace, once informed, can effect change by voting with their wills and their wallets.

You can't expect companies and insurance organizations and pharmaceuticals to not pursue their own interests. That is the nature of a corporation. Government and governmental policy are mere reflections of the voters. My sincerest hope is that, by providing some of this insight, people become motivated to push for change at their local and state level. That people learn to take responsibility for their own health, to make positive lifestyle choices and to be good consumers of health care.

If that's living in Utopia, USA as one of the last commentators opined, then call me Citizen Numero Uno of Utopialand. Peace.

The Drug Lunch

2006-08-05T07:41:00.000-04:00

One of the most insidious and pernicious practices that exists in the medical marketplace is the "drug lunch". Hovering out there, somewhere between the largesse of the "consulting fee" and the banality of the penlight is the pharmaceutical-sponsored lunches that occur in private practices and academic institutions throughout the country and world, every day of the week.

What is it, exactly? A company, under the approval of the physicians and/or administrators, is allowed to provide lunch to any number of people, ranging from under a dozen to hundreds. Why would any company spend up to thousands of dollars a day on a limited group of doctors, you ask? Access. Marketing. Influencing of prescribing practices.

Take my field, for example. Oncology. Some blockbuster drugs, like Avastin (bevacizumab) or Tarceva (erlotinib) cost thousands of dollars a month when prescribed. Granted, they are amazing drugs for certain conditions and are welcome additions to the oncologist's armamentarium against that scourge that is cancer. But, if a drug rep can influence just a couple doctors to prescribe a bit more of these drugs, even just a couple times a month, it MORE than makes up for the cost of a piddly lunch. If you can influence several physicians or, better yet, influence a "thought leader" whose recommendations then affect hundreds or thousands of other doctors, then, well, you can do the math...

Drug companies spend BILLIONS of dollars per year on marketing. Some estimate that the total expenditures of Pharma on marketing rival their expenditures on research and development. Once again, I'm not down on marketing in general as a means of promoting a business. There is a reason Betamax lost to the inferior VHS or why Windows crushed the Mac. Spreading the gospel through marketing is a time-honored and critical way of selling a product.

The problem lies in the unique nature of medicine and the supposed "objective" stance that we expect our physicians to have when looking at our case, our medical problem, our illness. Let's face it. Drug companies wouldn't be spending so much time and money on pens, lunches, consulting fees, commercials, advertisements, etc. if they didn't work, if they didn't add to the bottom line.

There has been increasing scrutiny from outside groups regarding these practices. This is a good thing. I wish our government and physician groups like the AMA would take principled stands and attempt to ban these practices. It's hard and allowing "self-policing" is often a slippery slope. Take my own practice, for example. I just joined a group. Love the people. Love the staff. There has been a long history of drug lunches there. The staff gets a free lunch every day of the week and for those that make under $40,000 or $50,000 per year, a free lunch every day of your work life adds up. Hell, it adds up for anyone, regardless of income. So, as the new guy of the docs, do I try to "ban" these lunches? Of course not. I need to fit in the culture. The staff's opinion and loyalty is critical to my own success. Does the practice really want to spend thousands per year to feed the staff daily? No. Do I want to piss off any of my new partners? Of course not. You don't sign up for the US Army one day and then the next start telling the top brass how you're anti-war...

So, I elect to limit my own exposure to the reps. I don't eat their food, ever. That way, I won't feel obligated. I refuse their entreaties, their trinkets, their "CME" or continuing medical education (Pharma sponsors up to 80% of all educational activities for physicians in this country). I try to maintain my own code of ethics. Hopefully, it will slowly inspire the staff, as I get to know people and gain their trust. Already, I sense the frustration by the drug reps that can't have access to me. Many of them just barge into my office and start yapping away or leave their info on my desk. It's annoying. Oh, and don't even get me started on how they're all 1) good looking, 2) well-dressed and 3) quite slick. Don't get me wrong. They're nice and are just doing their job. But, the fact that there are nearly 100,000 reps in this country is just absurd. And, my profession is the major catalyst for the perpetuation of this absurdity.

So, in keeping with my last couple blogs, here is some advice to patients and consumers out there:

1) Try to get some idea of any conflicts of interest in your physician or in the academic center or facility that you use. If it's a private practice, try to see if the doctors own the same lab or imaging center that they refer to. It's hard and not transparent, but if it ever feels to you like your doctor is ordering too many tests or overprescribing needless medicines to you, that's a danger sign.

2) Try to get a feel for any clinical trial investigators that you may encounter if you enter an academic institution. Do you think they have conflicts of interest? Many of these are now being reported as part of institutional policies. For example, faculty as part of the American Society of Clinical Oncology have to report "conflicts of interest", stock, honoraria, etc. in the beginning of some talks and papers. You can sometimes look for recent papers by oncology faculty in the Journal of Clinical Oncology (JCO) and at the end of articles, you'll see a listing of their conflicts.

3) Look for the reps swarming in offices and institutions. Are they in the clinic? Are they there at times other than lunch or trafficking heavily in patient areas? This is inappropriate, distracting and just plain rude. Complain about it or demand something different.

Here is some reading on this subject:

A NY Times Article on the entire practice of drug lunches and some recent movements to ban their presence.

A Baltimore Sun Article along the same lines...

An article in the New England Journal of Medicine on another topic: pharmaceutical tracking of physician prescribing habits. Drug reps use this to pressure docs with data on their prescribing history. When you feel a bit guilty about eating free lunches for years, and the rep starts barking at you about how you never prescribe "X" drug, well, you get the picture...

For physicians reading this, here is the AMA website where you can ask to block the use and access of your prescribing data. Remember, it's the AMA that often sells our damn data to drug companies in the first place!! Oh, also, historically, they also blocked Truman's initial attempt to create a national health care system.

This other NY Times Article is on how many drug reps come from the ranks of cheerleaders and how that upbeat personality is very helpful in marketing.

So, just to finish. I'm not saying that drug reps are bad people. They are just doing their jobs. We, as physicians, bear the responsibility to regulate ourselves and practice a high level of ethical conduct. It's critical. The drug lunch is just a symbol of the increasing corporatization of health care and medical delivery. The marketplace has always been a part of medicine, from the times of the snake oil salesmen and the bloodletters. But, now, I and many of my colleagues feel that any resistance at all on the part of academia or watchdog groups has been brushed aside in the pursuit of ever-vanishing health care dollars. This endangers all of us. It endangers our health. It endangers our souls.

Some Early Challenges

2006-07-25T12:27:00.000-04:00

So, as I'm wrapping up my first week in private practice, I've noticed some important features of community care that are important to think about for both patients and providers alike. One, care is quite fractured in the US. The people we refer patients to and who refer patients to us... this is an arbitrary process that relies on personal whim, business relationships and reputation for quality care. I suppose it's no different in any other sector of the economy, but is quite interesting when juxtaposed against the backdrop of illness, particularly cancer. Two, lack of efficient and universal medical records is a huge detriment to care. I thought the clumsy, cumbersome system of my former university was a pain, but the multiple systems in the different hospitals I now go to and the myriad, incongruent, non-user friendly electronic record systems that are in place just complicate care. They create gaps for mistakes to be made. Third, there is broad discrepancy in community standards of care. Quality control and continuing education are variable and therefore quality varies. Granted, I'm already becoming exponentially out-of-date the farther I am from my training, but I've already observed some practices that fall a bit outside the cutting edge of the university system.

So, what to do? What are some important things that patients should ask of their physicians and hospitals when you get sick?

1. How does your doctor keep up with the pace of medical change? Does he go to meetings and read on the Internet or is he/she still reading age-old textbooks and quoting out of date literature? This is CRITICAL. Medicine changes so, so rapidly and it is easy to get out of your element. The only way to maintain even a semblence of quality is to use technology to keep up with the rapid dissemination of information. For example, the way we treat certain types of breast cancer or lung cancer has dramatically changed in just the last 3-5 years. If you've been resting on your laurels a bit, you might give suboptimal advice. Patients focus so much on a doctors "medical school" or maybe their residency. But, as any doc worth his or her salt will admit, the best physicians are the ones to keep up to date. Resting on a prestigious past is the first way to become a hack.

2. What are the financial incentives involved? It's a touchy subject, no doubt. I'm not sure the best way to ask or inquire. But, is there some type of quid pro quo between referring docs? Are needless consults called to people whose role in your care is unclear? Is there any self-referral bias going on? As the medical system faces more financial constraints, it becomes easier to step over the line. All of us as patients have to be aware.

3. What is a doctor's experience with your disease? Ask honestly how many times he or she has seen "your case" or done your procedure or operation or whatever. Brains are important. Judgment is key. But, repetition is also critical. Someone who has just seen a lot of your case is important. So, if it's rare, then clearly the academic center is the place to be, because there are often certain doctors who just treat one type of disease. However, if something is more "bread and butter", the converse might be true. Sometimes, someone who does high volume in the community might be better.

Just more ideas as I try to muddle through this thing called doctoring.

Week One Under the Belt

2006-07-07T12:56:00.000-04:00

I'm wrapping up my first week in private practice. To reiterate, I've joined a small five-man hematology/oncology group in Maryland. As I searched for a future job, I agreed in my mind to a few key principles. One, I wanted direct patient care. I'm a doctor after all. Two, I wanted some "control of my own destiny", so to speak. After years of training, debt and taking orders from superiors far and wide, I wanted some autonomy, some sense of dexterity in making decisions about my future and my patients' care. Three, I wanted a large enough group where I could enjoy some regularity in my quality of life. Four, I wanted a small enough group where I wouldn't feel like another cog in a machine. Five, I wanted a nice working environment where nurses, doctors, patients and staff treated each other with mutual respect.

So, I've settled here. After one week, I can already appreciate the vast differences between private practice and the academic environment. There are positives and negatives to everything in life and this is no different. First the positive. It is much, MUCH more efficient. Seeing patients quicker, in a more friendly, more personal way is just plain easier when the staff and docs are committed to such care. Granted, we have a financial incentive to give good care, but I think also that the focus is on more humanistic treatment also. Two, there is less ego in this setting. We're all on the same team and all pulling for the same goal. In the academic environment, there is almost a disincentive sometimes to do patient care. It distracts from research and grant writing. Also, there is always a battle between individuals and departments. For us, we sink or swim together. Doctors, staff and patients all have to be on the same page. Three, people are happy to do their jobs. When I ask a nurse or another doc or a consultant to see someone, they do it with a smile. In the academic world, because often there is no financial incentive to see people, people are just plain resistant or angry to do more work than necessary. They "block" or "turf" as we call it.

The negatives are predictable. We lack the resources to provide certain high end care. There aren't as many minds together working on the same problem. There aren't as many layers of residents, fellows and other trainees to pick up mistakes sometimes. Then, there is the flip side of the whole financial thing. We are unable to provide care unless we are sure someone can pay for it. That is an unfortunate reality. And, truthfully, I can imagine how some unethical individuals might "overutilize" or just plain bilk the system to make money.

So far, nothing has surprised me. I think I would apply these priniciples to all my patients and even my own mother.

1. If you have a routine, "standard" medical problem and want a more personalized treatment setting, I think private practice or a small group offers a more individualized experience and doesn't sacrifice care.

2. If you have some rare disease or need a complicated procedure or diagnosis, you might be better off in a tertiary care, academic center where all the resources can be brought to bear on your problem. It might be impersonal, but there are more minds available to figure out a strange thing.

3. Experimental therapy is of course more available in a university setting, but the caveat is that it is in the direct interest of the faculty to "put you on study" and so you must be aware of the biases.

4. Pharma is EVERYWHERE. They crawl all around the university, trying to enlist "thought leaders" so as to have their products promulgated throughout the world. They are all over private practices, providing lunches and "education", in the hopes of increasing prescribing patterns of the doctors. Some of these drugs nowadays can cost $60,000 for 6 months of FOLFOX therapy for colon cancer or even $7000-8000 for 30 pills for Sutent for kidney cancer. Is it worth it? Perhaps. But, someone has to foot the bill and our government can't decide what steps to take to prevent going broke.

5. The bottom line is that we, in all aspects of life, not just medicine, have to be aware of the incentives involved. Money is always an incentive. Prestige and fame are others. When you go to a stockbroker, realize what their commission will be. When you come to a doctor, understand if they have some heavy financial stake in their own recommendations or if they have to make tenure by publishing studies requiring your entry into their trials. I've come to think that only by creating the right combination of incentives can we design a system ultimately that combines patient personal responsibility with compassionate universal care.

6. I alone am responsible for my own ethics, my own care of people, my own interaction with colleagues.

Let's see what next week brings.

The Commons

2006-06-29T05:34:00.000-04:00

I saw a very disturbing documentary last night, "The Future of Food". Produced in 2004, it chronicles the consolidation of the food industry by giant agribusinesses, such as Monsanto or ConAgra or ADM, and the implications of such consolidation for our future "food security". Genetic modification (GM) or genetic engineering (GE) of food staples like corn and wheat and soybeans is a major international issue. A couple of key issues came up as the discussion of plant biotechnology was elucidated. Giant multinational corporations, in the hopes of capturing large markets, produce genetically modified strains of food in the hopes that certain traits, like pest resistance or drought resistance, will result in dominance of their product in the marketplace. There isn't anything inherently wrong with this, except that during this process, the genetically modified foodstuffs are patented and legally controlled. This has a couple of ramifications. The biodiversity of our food resources narrows and while, in the short term, this allows perhaps for greater crop yields, in the long term, this can expose us to greater threats of crop failure due to genetic monotony. Another ramification is that it is very difficult to prevent contamination of non-GM food from GM food. In many sites around the world, including Canada, Spain and Mexico, it has been documented that there has been cross-contamination of non-GM crops by GM crops. This is important also because there isn't necessarily longitudinal data that indicates the longterm safety of GM crops. Who knows if any of these Frankenstein foods are harmful to us? We just don't know. I'm not saying that some of these products aren't beneficial. But, just like the idea of global warming, is it really smart to experiment with our very lives without perhaps a little more caution?

I think this issue gets to a critical issue that is dear to me, which is the concept of the "Commons". The whole concept of genetically modifying our food and subsequently patenting it, indeed, effectively attempting to OWN nature itself, strikes me as abhorrent. As the biomedical industry has raced to patent our very DNA, charging fees for the study and use of our own biology, as people attempt to own more and more of our natural resources, I wonder if the very concept of common resources is intact. By the "commons", I mean things that most any human can agree are essential to our survival. Perhaps not sufficient alone, but certainly essential and basic. Water for example is a "common" and its privatization around the world in the next decades will be a source of strife, for sure. Just read "Water Wars" by Vandana Shiva and your eyes will open to the challenges Third World countries face as their natural resources are plundered internally and externally. Another would be something like public lands, parks, rivers, landmarks, etc. Another would be the biodiversity of our agriculture. Another would be the preservation of the global climate for future generations. Things like our own genetic code and that of the other species on the planet. These are all things that we as humans must strive together to preserve and protect. That we can never own, but rather that are shared and treasured by all people for all time. Things that are essential to life and from which we draw our very sustenance.

To me, this isn't a Republican or Democrat issue. This is simply an issue of what is available for "ownership" in the first place. How do we "own" a cancer causing gene or a type of wheat or a ten thousand year old river? When does this sort of thing become ridiculous? Consolidation, in my opinion, whether in medicine or agriculture or media or energy, is a very important issue. Is Wal-Mart good or bad for us in the end? Is ExxonMobil? There is nothing inherently wrong with the consolidation of business interests. That is, by definition almost, what businesses are meant to do, they are meant to grow and expand and dominate their markets. Any investor knows that. The problem is that such growth ultimately is amoral. Not immoral, but simply amoral. The pursuit of profit and growth can be a good or bad thing. It is for our society and populace to try to decide the limits on such activity.

http://www.southendpress.org/2004/items/WaterWars
http://www.centerforfoodsafety.org/
http://www.thefutureoffood.com/

Friendship, Love and Health

2006-06-16T11:57:00.000-04:00

This past week, perhaps this entire past month, for me personally has been filled with incredible moments of emotion and self-reflection and feeling. I've thought long and deeply about the role of love and feeling in our lives, in the whole tapestry of our lives, not just in the romantic, familiar sense that we all are accustomed to seeking. I've thought about the connection between love, friendship, happiness and our own health. Our own physical as well as mental health. I've had just a tremendous succession of roller-coaster like ups and downs emotionally in the past months, but the central building theme has been the power of my own emotions to so dramatically affect they way I see and feel about life in general. It helps that I have amazing friends, the kind that aren't just good when you're in revelry mode, but who are there in the clutch and who, quite frankly, just completely call your bullshit.

It seems that everywhere I turn, there is some treatise, or TV show or conversation being had about love and feelings. Not the Dr. Phil variety of schmaltzy experience tailor-made of TV, but of a richer, more nuanced and more scientific variety. National Geographic had an article on the biology of "love", describing our modern scientific or quasi-scientific understanding of the chemistry of attraction, attachment and sex as well as the impact of certain feelings on our own health and welfare. Another favorite magazine of mine, The Atlantic, had a similar article on love, this time including the rise of modern electronic love, on the Internet and how that is changing our society and the rules of human interaction. Finally, this past week, I watched a PBS special by Andrew Weil, the Arizona physician who specializes in "alternative" medicine and a more natural, holistic approach to health. He focused on traditional medicine and some of its virtues, but then shifted toward natural remedies and finally focused on the importance of our psychology, our mental fitness in this singular existence that we all face.

Now don't get me wrong. I believe traditional medicine is invaluable. You don't cure polio by just thinking peaceful thoughts. A bypass surgery is a bypass surgery. All of these things have their extremely important roles in our modern health care system. But, when I think of our modern culture and modern stresses, I can't help but wonder about how big a role emotion has in the rise of certain problems.

Take for instance the role of simple touch in our lives. We know that people who have pets or who are married live longer than single people. We know that having a dog or other animal comfort us during recovery from open-heart surgery can sometimes speed rehabilitation. We know that at the turn of the 20th century, "eating" disorders were uncommon, that for instance, in Argentina, anorexia and bulimia were rare, but with the rise of the modern expectation of thinness in women, those rates in South America and in the world have just completely skyrocketed. We know that there are two populations in the world, Okinawa and Sardinia, with the largest numbers of very healthy centenarians (100 year olds). Not only do they have vigorous lifestyles filled with exercise and healthful eating, but they also have cultures that respect the elderly and the process of aging and that the psychological expectation of eternal youth is simply nonexistent. We are all very familiar with the concept of spouses who die within very short time frames from each other. And on and on.

We know that feelings of warmth and love and friendship enhance our lives. But, they enhance our health and welfare also. There is a physiology to human interaction, to the basics of human touch in its simplest form. Laughter clubs and National Hugging Day are organic grassroots movements that simply express our most basic desire for human interaction. Unfortunately, in this advanced society of ours, as we spend more time in our own climate-controlled cars, looking at our self-directed TiVO and Netflix, as we stare into the breadth but isolation of the Internet, we distance ourselves from basic human contact.

I think that the incredible interest by the public in alternative medicine and holistic approaches to health care is fueled by a conscious and/or unconscious dissatisfaction on the part of all of us with some of the failings of our health care. It is impersonal, cold, analytical and unfriendly. Gone are many of the days when the physician was a pillar in the community, when he or she knew and cared for a wide spectrum of society and was fully integrated into the social fabric of a community. Today, we are lucky to know even a few of our neighbors much less get the same doctor on each visit to the clinic.

Once again, I'm not saying that choice is a bad thing. It is fantastic that we can do so many things nowadays that were unthinkable even when I was a child. But, with everything, there is a tradeoff. And, fundamentally, humans have evolved as social beings. We require one another and have relied on each other throughout our societal growth over the last few thousand years. Only in the last century or so has it become so easy and natural to remain isolated in our own lives. I believe that this isolation, this lack of interaction, love, friendship, and romance ultimately is detrimental to our health and the health of society as a whole.

After the last few months, I've been lucky to connect and reconnect with so many important facets of my life. The decades can go by and you can go for a long time without coming up for air, coming up to see the people that really touch your life, both personally and professionally. For this moment in time, I have a few wonderful, inspiring, healing friends and family that have touched me, grounded me and energized me in ways that are indescribable. This has made me think, just think so much about the importance of our connections in our lives and how easy it is to lose those connections, to withdraw into a solitary life. For the rare person, solitude is gratifying and comforting. But for most of us, we simply need others. Just need those simple conversations, those hugs, those kisses, those laughs in order to get the most of our brief lives.

Physician, heal thyself, Hippocrates once wrote. It's easier when you have the right people in your corner.

For more information, check out:

http://www.laughteryoga.org
http://www.nationalhuggingday.com
http://www.drweil.com/u/Home/index.html
http://www7.nationalgeographic.com/ngm/0602/feature2/index.html
http://www.theatlantic.com/doc/prem/200603/online-love
http://okinawaprogram.com/
http://www7.nationalgeographic.com/ngm/0511/feature1/

Looking Back On My Medical Training

2006-06-06T16:05:00.000-04:00

So, some recent comments by readers on my last blog got me thinking about what has changed in me personally, good and bad, over the past 12 years or so since I started medical school. Questions like "Did you get hardened?" or "Did you get jaded?" are both easy and very difficult to answer. It is like looking at the soldier who comes back from a war like Iraq or Vietnam. Has he or she become hardened or more worldly or more realistic or more cynical or just older and wiser? All of these words are charged in their own ways. There impact on us has as much to do with our own perceptions and personal feelings as it does with the people we observe and try to understand.

Medical school, like marriage or buying a car, is somewhat of a leap of faith. You spend a lot of time preparing and testing just to have the chance to embark on a career as a physician. As you study and sacrifice various things along the way, certain mindsets start to predominate. For the most part, physicians are a relatively high-achieving, hardworking, self-disciplined lot. This can make for tremendously dedicated people, but can also make for somewhat entitled and self-important people. Like any group of "successful", high prestige occupations, it is often populated by people who have confidence and sometimes overconfidence in their beliefs and/or abilities.

As we hit medical school, filled with heroic TV exploits of shows like "ER" and buoyed by the hopes and dreams of friends and families, it is all but impossible not to get swept up in the drama, the self-importance, the idealism and the beauty of medicine. Getting your first white coat, often in a formal ceremony, is a moment of pride and fear and hope and triumph as we embark for the first time on this very noble calling. However, like soldiers who just finish basic training and land for the first time in the "shit", new med students show up on the chaos/battlefield of the hospital wards as complete newbies, unprepared for the clash of reality with their idealism.

Gone are the textbook cases and neat summaries that you learn on in the first couple years. There are conditions that border on the absurd, the foul smells, the gaps in our system, the indigent patients that sometimes seem so alien culturally, the complete lack of glory at times in the mundane things you do to keep a hospital afloat. There is hierarchy, endless hierarchy. Sleepless nights and strange orders. All of this combines to change the initial viewpoint. Is this good? Bad? I don't know. It simply is.

Sir William Osler, a oft-quoted and well-respected physician, once said (and I paraphrase), "To take care of patients and never read is like sailing the ocean without a compass, but to read alone and study but never care for people is as if you never set out to sea in the first place." I believe this to be true. As in almost any endeavor, like the Iraq war, or Medicare reform, or affirmative action or the budget deficit, there is a stark difference between theory and reality, between the dreams of politicians and analysts and pundits and the truth on the ground or in the average home or in the peoples' hearts.

In medicine, it is simply not possible to practice without really immersing yourself in the day to day care of people, in their imperfect diseases and suffering and emotions. For many young doctors, this is an embittering, brutal, exhausting process, one that leaves you "toxic" and spent, anxious only to leave the hospital. Often, personal lives are damaged, personalities can change and there is a marked transformation until one day, you no longer think of yourself as a student at all. You are finally the physician, decisive, seasoned and experienced.

However, as training finishes, you can go one of a couple ways. Some, unable to recover from their experiences, can calcify their frustrations and become crusty, judgmental and prideful. Others, anxious to forget their experiences, can leave clinical medicine, preferring research or industry or business or whatever. But, some, hopefully many, can reflect on their experiences, can look on the moments of hardness, the tears, the complexity of the system, the absurdity of medicine sometimes and can come out the other end a more whole person. Still in touch with the idealism that once started the whole shebang, but tempered by the practicalities of care for real everyday people.

Much of who a physician ends up being depends on their own background, their own expectations and their own hopes for the future. Like a friend has told me over and over again, "if we want the world around us to change or our relationships to change, we must start with ourselves." That is certainly true for doctors and other health care professionals. It is very easy to gripe about this and that. I have done it numerous times in this blog and will do so in the future. But, like any good citizen of this country or any member of a family, we've always got to look inward to see how we can become better, more effective, more humble, more helpful.

So, in the last decade or so, have I become more jaded? Yes, at times. At times more cynical. Perhaps smarter, certainly I've been humbled by both my patients, my colleagues and just time itself. But, I'm still hopeful. Very hopeful. Not in a Pollyannish way that everything will just work out on its own, but rather in a practical, determined way that involves my working every day to create the environment around me that lives up to my ideals in medicine. And being a doctor is one of the biggest privileges in the world. There is no other job where you can meet so many different people whom you would otherwise never meet in your life.

Talk to me in another 10 years. We'll see how I feel then. :) CancerDoc

P.S. If you ever want to read a humorous and only slightly dated book on the life of medical residents and the "changes" that occur in the first year of internship, read Samuel Shem's "House of God"... very hilarious, very accurate in terms of emotions and even the way we sometimes talk in the hospital and very poignant.