‘The Big C’ is Failing

By |September 15th, 2011

Watching the Big C feels like a chore lately.

It reminds me of the feeling I used to get when I had to see and examine a patient in the hospital, under my care for some administrative non-reason, who didn’t need to be in the hospital IMO,  and whose hospital presence took time my time away from patients who needed my attention. But because I was responsible, I’d go and see her every day just the same, and listen and examine, make notes and occasional suggestions.

The show is terrible. There, I said it on the Internet.

In the most recent episode, Cathy (the melanoma patient who’s said to be responding to a treatment about which viewers know nothing) runs into her oncologist at the pool where she symptom-freely coaches a swim team. The doctor, portrayed by Alan Alda, has a young wife who talks openly about sex with her husband and invites Cathy to a meal in their home.

So Cathy’s two for two for eating meals with her oncologists – one in each of the Big C’s seasons so far. Pretty much any cancer patient can tell you that’s highly unusual. Most people have trouble getting to see their doctors in the office for sufficient time, no less in their homes or in restaurants.

Second problem: the doctor’s wife speaks quite crudely about her husband’s talents in the bedroom. Really I wouldn’t care, except that as much as I’ve worked with and known some older male physicians and their wives, and seen some stuff, I’ve never, ever, heard a doctor’s wife, or a drunk doctor’s wife, or a doctor’s wife who’s drunk, speak so crudely about her husband’s sexual skills to a patient. I’m sure it’s happened, but not very often.

And if the show’s directors are so comfortable covering sex, and tampons (last episode), and urine (pee in the pool, did they really have to include that?) and death (there’s a bit of a morbid thread emerging), they could talk about THE BIG C, i.e. Cathy’s melanoma.

If you cover all of the above, why not some jaundice, emesis (med-speak for throwing up), leukopenia (low white cells) or fatigue, or something having to do with cancer, treatments and side effects, or informed decision-making?

This program is a lost opportunity to, in a light-hearted and well-acted way, help people (1) understand what it’s like to go on a clinical trial, (2) live with advanced cancer, and (3) deal with a family during cancer treatments. It’s struck out.

(first sports metaphor on ML; probably the last -)

I’ll follow until the end of the season. Maybe it’ll turn around, but I doubt it.

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Maybe We Should Teach Medical Students About Healthy Living

By |September 14th, 2011

Last week I wrote a simple post on eating yogurt with fresh fruit for lunch. It wasn’t until later that I realized why it’s a medical lesson.

It happens that yesterday morning I was up and out early. I saw a former colleague walking along the street. He’d gained weight, and walked slowly. I thought about how hard he works, and what a good doctor I know him to be. And yet any citizen or patient might size him up as heavy, maybe even unhealthy.

The problem is not that he’s uneducated or can’t afford nutritious foods. He knows fully about the health benefits of losing weight and exercise. The problem is the stress and long hours of a busy, conscientious physician’s lifestyle.

When I worked as a practicing doctor and researcher at the hospital, I rarely ate a nutritious breakfast or lunch. My morning meal, too often, consisted of a gobbled muffin and coffee. A weekly lunch conference provided faculty, fellows and students with Domino’s pizza and soda. (To the best of my knowledge, these were not pharma-sponsored; otherwise the food would have been better quality.) On other days, we’d get take-out sandwiches from a nearby deli.

There was a salad bar in the hospital cafeteria. I took from it occasionally, but that involved time (long lines) and risk: You never knew who’d coughed over the lettuce, or swiped her hand too close to the chick peas.

Dinner was usually at home with my family, but I didn’t have much time for cooking then. Sometimes my husband prepared dinner, which was a huge help. Still, we sometimes ordered in Chinese (American-style), from diners, and other local sources of high-fat, low-vitamin, low-fiber “junk” meals.

It wasn’t until I stopped working at the hospital that I learned to eat three healthy meals on most days. Preparing meals with fresh foods takes time and effort, besides access to ingredients and a kitchen.

Med school can be stressful and involves long hours and late nights of study. The same goes for residency, and then for clinical practice in some specialties. Grabbing a slice or an over-sized sandwich is satisfying, and easier than packing lunch.

Maybe part of the curriculum for first-year students, even just a session, should focus on staying healthy as a busy doctor – on maintaining a good diet, keeping physically active and getting sufficient rest.

Perhaps this seems patronizing: Students in med school typically learn what to tell their patients about exercise, stress and weight control; it’s assumed they know how to take care of themselves. But maybe we shouldn’t wait until there’s a problem (a student with an alcohol overdose, or an overweight doctor with a heart attack) to take note and address the fallout of long workdays and stress in physicians’ lives.

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The Big C Continues: on Family Life and Friendship, Season 2, Episode 10

By |September 12th, 2011

A Labor Day break in broadcasting afforded some respite from the Big C. The latest episode continues with its focus on normal and not-so-normal life among Cathy’s family and friends.

On the family front, her teenage son “Adam” goes with the woman he met on-line in a cancer kids’ support forum to her high school reunion and has a good time there, despite a strange blip in which she calls from the ladies’ room and asks him to buy her tampons. Cathy’s brother, said to have manic depression but to this doctor-TV-critic seeming more like a schizophrenic, continues to deteriorate off his meds. Cathy’s overweight husband buys a fancy scale with a computerized voice that tells him his “metabolic age” is too high.

About cancer, there’s little on screen: Lee, Cathy’s “cancer friend” and clinical trial companion, is coughing, but that detail goes unmentioned. He mentions that Dr. Sherman, the clinical trials oncologist, wants to see him because he has “more tumors.”

“My tumors are shrinking,” Cathy reports.

And that’s about as much detail as we get about her treatment and evaluation for advanced melanoma.

Château Lafite Rothschild

Toward the end of this episode, Cathy appears at Lee’s apartment with a bottle of wine, not quite the 1982 Lafite Rothchild on his bucket list, but enough for them to drink again and share secrets. She says she feels “buzzed” as he opens another bottle, which may be as revealing about how some people cope with illness as is anything else on this show, so far.

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Should You Tell Your Employer When a Loved One Is Ill?

By |September 12th, 2011

An article caught my attention in the September AARP Bulletin:

The Caregiver’s Dilemma considers the 61.6 million people in the U.S. who care for older relatives or friends. People with jobs are, understandably, unsure if they should let their boss or supervisor know they’re caring for someone who’s sick. This indirect cost of illness and aging in America is said to tally $33.6 billion each year.

The pressure on workers is tough, writes Sally Abrahms:

Many employees are in that elder care-giving boat, yet workers with work-family conflicts are often reluctant to raise the issue with superiors. They fear they’ll be viewed as not committed enough, or receive bad year-end reviews. They may also think that discussing their personal life is unprofessional or sense resentment from colleagues and the boss, who may have to pick up the slack during their absences…

The article reminded me of the dilemma faced by cancer patients, and by the parents or children of anyone who’s got a serious diagnosis and needs help. How much to tell the boss?

It’s a tough economy.

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Contemplating the List of Names

By |September 11th, 2011

—-

Hard to live in Manhattan and not note the fact that it’s 9/11/11.

Here we are, a decade later: some progress, and some opposite-of-progress.

Watching the family members, in pairs, reading the names. So many Smiths, among all I never knew.

Each hurts.

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By |September 11th, 2011|Categories: Life, Life in NYC, poetry|Tags: , , |0 Comments

Lunch with Yogurt, Honey, Crumbled Cereal and Cut Fruit

By |September 9th, 2011

For today I thought I’d skip writing a formal post and try a picture, instead, of yesterday’s lunch – fruit with yogurt, honey and crumbled cereal:

Ingredients:

Plain, low-fat yogurt (I use Fage brand, 2% fat, 1/4 – 1/3 cup)

Honey, less than 1/2 teaspoon

Cereal (a fistful of your preference – I like “Smart Start,” roughly 1/4 – 1/3 cup)

Fruit – whatever’s ripe and in the ‘fridge: in this case I included cut honeydew melon and a nectarine, grapes cut in halves and some blueberries

Easy to prepare:

1. Transfer yogurt to a cereal or soup bowl. I usually use a tablespoon to take 3-4 dollops.

2. Add the honey and use a teaspoon to swirl it through the yogurt.

3. Crumble the cereal in your fist, above the bowl – so that the small pieces fall into the yogurt. Mix everything with the spoons.

(You may prefer granola, but I found that by breaking the cereal into bits I can get more crunchiness into the yogurt per calorie added.)

4. Add the cut fruit, stir it in, and you’ve got a nutritious, fresh and filling lunch!

 

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Medical Aspects of ‘The Help': The Plight of a Woman with Recurrent Miscarriages

By |September 8th, 2011

the character Celia, in "The Help"

Last weekend I saw The Help, a movie on race relations in Jackson, Mississippi 50 years ago with lingering implications for people who hire “help” to take care of their children and tend to their personal business anywhere in the world, including now. It’s a heavy-handed, simple-message and nonetheless very enjoyable film, with fine acting and imagery, based on the book of the same title by Katherine Stockett.

One element of the narrative interested me from the medical perspective, having to do with the plight of a pale, thin and sexy young woman who’s marginalized by the white Jackson social elite. The character Celia, portrayed with flair by Jessica Chastain, lives, isolated, on an out-of-town plantation. She spends her days alone while her husband’s at work. The nominally proper women in town, while playing bridge and otherwise gathering, call her “white trash,” and she sometimes lives up to their prejudices by drinking too much and behaving erratically.

It turns out the young woman’s having a hard time because she’s unable to bear children. She feels inadequate and fears her husband might leave her if he found out. Her history of recurrent miscarriages is discovered by the African American maid, Minny, who comes to work with her. In a revealing scene Minny finds Celia locked in the bathroom, severely bleeding from a miscarriage and crying. The maid, played with conviction by Octavia Spencer, helps her to recover, clean up, and bury the fetus in a shoebox in the yard, nearby three other small burial sites. With this, the young woman’s odd behavior becomes comprehensible.

I couldn’t help but think of countless women of earlier eras, and friends I’ve known in my adulthood, and women I’ve treated as a physician, who felt really bad about their inability to bear children. These days, with fertility treatments and work-ups for miscarriages so prevalent in communities like mine, we don’t see so many cases like Celia’s. It used to be a common problem, and it still is in many regions in the U.S and certainly in other parts of the world, for women who have difficulty conceiving or carrying babies to term, not just to not have children, but to become sad, and feel inadequate about themselves as women.

The Help is a worthwhile film at many levels, with fine acting, a good, PC message and story. I hope movie-goers will take special note of Celia’s predicament.

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September is Busy, National Health Awareness Observance Calendar

By |September 7th, 2011

A tweet last week led me to look up the fact that September is indeed National Prostate Cancer Awareness month. It turns out the U.S. Department of Health and Human Services sponsors a website listing official National Health Observances (NHO).

You can see the YEAR 2011 AT A GLANCE, chock full of disease dates. What’s curious is that some and possibly all of the campaigns are sponsored by private foundations. Some examples listed for this month, September 2011 (except for the proclamation, all links by the NHO):

ITP Awareness Month

Childhood Cancer Awareness Month (and a related Presidential Proclamation)

Leukemia & Lymphoma Awareness Month (Link to the LLS.org yields no ready details on September.)

Ovarian Cancer Awareness Month

Prostate Cancer Awareness Month(Link to zerocancer.org gives no front-page info on September.)

There are plenty of other conditions and treatments listed, but some of the linked-to sites don’t provide details on the month’s specialness (e.g. the a-fib and sickle cell organizations). For some reason, September has been designated as National Yoga Awareness month.

I haven’t included all the month’s activities, so you might want to look over the complete list.

Finally, some moms and dads might want to keep in mind that September is National Pediculosis (Head Lice) Prevention Month, and the third Wednesday of the month is National Backpack Awareness Day.

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Reducing Cancer Care Costs by Comparative and Cost-Effectiveness Research (CER)

By |September 6th, 2011

Well, it’s the day after Labor Day, time to resume our discussion of Bending the Cost Curve in Cancer Care.

We’ve reached the end of the list, on ideas to reduce oncology costs put forth by Drs. Smith and Hillner in the May 25 issue of the NEJM. Really this 10th and final point intended for oncologists is two-in-one: “The need for cost-effectiveness analysis and for some limits of care must be accepted,” they chart. So doctors should embrace studies of comparative effectiveness and cost effectiveness.

Hard to argue with reason – they’re correct, of course. They write:

… The national imperative is to empower a transparent, acceptable, equitable, politically independent agency for guidance in making tough choices in the public interest so that doctors do not have to make them at the bedside.60 Ultimately, we will have to make decisions based on some criteria, and comparative-effectiveness61 and cost-effectiveness62 analyses are good ways to align resource use with the greatest health benefit.

This sounds great, and is probably right, but I don’t think it’s realistic.

A more detailed consideration on the issue of cost-effectiveness, IMO, came out a few weeks later, also in NEJM: Comparative Effectiveness Research and Patients with Multiple Chronic Conditions. This piece, by Drs. Mary Tinetti and Stephanie Studenski, considers the problematic application of CER in the real world.

The problem with CER, these authors emphasize, is that most medical patients have more than one condition and many are elderly; clinical trials tend to include, exclusively, patients who don’t have more than one major illness are relatively young. This limits the physicians’ abilities to apply data to their patients.

What’s more, reported results tend to focus on central results, but most patients fall elsewhere on measured curves:

The heterogeneity of treatment effects will further complicate CER. Although studies typically report average effects, most participants experience more or less benefit and harm than average. Such heterogeneity results from variability in patients’ initial level of risk for a given outcome, in their responsiveness to treatment, and in their vulnerability to adverse effects — issues with particular relevance to patients receiving treatment for multiple coexisting conditions.

The authors, who recognize the need for better research to support treatment decisions, write that “CER will probably accelerate the movement toward outcome-driven decision making, reimbursement, and quality assessment. As this shift occurs, we must move toward a focus on cross-disease, “universal” outcomes in research and clinical care.” Their thesis gets more abstract (which I admire), but meets a wall or two: the lack of consensus on a set of universal health outcomes, different parameters measured by the likes of the VA administration, CMS, the FDA, NIH and other huge agencies.

They make a practical suggestion, about the need for head-to-head comparisons in CER:

… interventions such as exercise that affect multiple conditions simultaneously should be a high priority…Studies should include assessment of the burden of treatments for patients and families. Another CER priority should be the examination of treatments for common pairs of diseases in which treatment of one may exacerbate the other. For example, when hypertension and osteoporosis coexist, what treatment best minimizes the risk of adverse cardiovascular outcomes without increasing the risk of falls and fractures?

All of this sounds reasonable to this patient-doctor, but it’ll take a lot of time and money to accomplish effective CER that encompasses the needs and conditions of sufficient numbers of patients in disease and age combinations to power any meaningful studies. You have to wonder at some point, as I have been lately, is all this clinical research worth the effort?

That said, I respect this paper‘s conclusions on CER:

Researchers have largely shied away from the complexity of multiple chronic conditions — avoidance that results in expensive, potentially harmful care of unclear benefit. We cannot improve health care’s quality, effectiveness, and efficiency without addressing its greatest consumers. Development and testing of innovative approaches to care for patients with multiple chronic conditions could prove the most lasting legacy…

My bottom line: CER, and consideration of treatment costs, should underlie reduction of cancer care costs in the near and long-term future. As to how we accomplish sufficiently careful research, and avoid inappropriate cutting of helpful treatments – especially those that prove beneficial for some younger and otherwise healthy cancer patients – is one of the two main challenges ahead.

(The other big challenge, mainly a moral one, is the subject of rationing, to which Smith and Hillner allude but don’t detail, and which subject I won’t address in this post.)

Meanwhile: thorough, apolitical, nuanced and transparent reporting of trial results would help doctors, patients and the general public understand what information is available.

Finally, in the next month or so I will look back over the full, provocative and generally excellent list by Drs. Smith and Hillner, and see what holds hope for the future of cancer medicine. What’s clear is that the path ahead mandates clear thinking through some very tough clinical decisions.

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