Celebrating Thanksgiving, Appreciating Life

Dear Readers,

Ten years ago, we had a special Thanksgiving at my home. It was less than a month after my breast cancer surgery, and I was scheduled for chemotherapy to begin the following week. We decided to hold the family gathering at my place, despite all that, because I love to cook and wanted to celebrate the holiday as fully as I might.

My husband’s mom, who helped me in that year in more ways than I can count, came over at 8AM. We started with stuffing. I’m a purist, and we made the stuffing by toasting bread and cutting croutons, and then sautéing thyme and sage with shallots in olive oil, and then adding in various fresh-cut mushrooms, and white wine, and tossing it. Being ambitious, we made a second kind of stuffing, this one sweet – with bits of onion, pear and roasted hazelnuts mixed in. I cut no corners. We put the giant turkey in the oven early, at 325 degrees, for slow-roasting with basting, over 6 leisurely hours.

Everyone delivered. My husband’s sister made everyone’s favorite potatoes. My mom and my sister baked desserts. The guys carried chairs, helped with the table and poured drinks. We played music and, for one day, forgot about my medical stuff.  I had bandages tucked in under a flannel shirt, but I was OK. Glad to be there, here, as I am now, today.

This week hasn’t been easy for your author. I had a flare of my diverticulitis. Then yesterday, after I came home from teaching a class, I fell backwards on a washed floor. Slammed down. Fortunately, nothing’s broken that wasn’t before. I just need to take it easy – always a challenge for an ambitious person – and can’t swim for just a few days.

Medical Lesson – a reminder – for me: Remember to be careful; don’t ignore your health. #Balance.

Meanwhile, some of my loved ones need care now. What can I say, except that I am appreciative for all the doctors, nurses and others who are working today at the hospital, helping them and others to heal.

I wish a happy Thanksgiving to everyone.

Peace,

ES

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Cyberchondria Rising – What is the Term’s Meaning and History?

Yesterday the AMA news informed me that cyberchondria is on the rise. So it’s a good moment to consider the term’s meaning and history.

Cyberchondria is an unfounded health concern that develops upon searching the Internet for information about symptoms or a disease. A cyberchondriac is someone who surfs the Web about a medical problem and worries about it unduly.

Through Wikipedia, I located what might be the first reference to cyberchondria in a medical journal: a 2003 article in the Journal of Neurology, Neurosurgery, and Psychiatry. A section on the new diagnosis starts like this: “Although not yet in the Oxford English Dictionary, the word ‘cyberchondria’ has been coined to describe the excessive use of internet health sites to fuel health anxiety.” That academic report links back to a 2001 story in the Independent, “Are you a Cyberchondriac?”

Two Microsoft researchers, Ryen White and Eric Horvitz, authored a “classic” paper: Cyberchondria: Studies of the Escalation of Medical Concerns in Web Search. This academic paper, published in 2009, reviews the history of cyberchondria and results of a survey on Internet searches and anxiety.

Interesting that the term – coined in a newspaper story and evaluated largely by IT experts – has entered the medical lexicon. I wonder how the American Psychiatry Association will handle cyberchondria in the upcoming DSM-5.

 

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On Deaths in the New York City Triathlon, and Pushing Ourselves to Limits

Yesterday some 3900 people swam, biked and ran in New York City’s 11th annual triathlon in what might be a celebratory event of human strength and perseverance.

According to this morning’s paper, a 40-year-old woman suffered a heart attack during the 1500 meter swim in the Hudson. She was hospitalized and said to be in stable condition. A man, aged 64, became unconscious mid-way through the swim and was pronounced dead. The man’s death was the second in the history of NYC’s triathlon; three years ago someone else didn’t make it through the water segment.

In March, 2009, the LA Times ran a piece on Death by Triathlon. Most who died in triathlons were men between the ages of 35 and 55 years. Most of the deaths occurred during the swimming portion of the race.

Triathlon (Wikimedia Commons image)

At the pool where I swim, I see people training for the triathlon, and I admire them.

Still, you have to wonder, do people not know their own limits? Or do they choose to ignore them?

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MyFoodAPedia, A Government-Sponsored Resource For Nutritional Facts

The other day I came upon MyFoodAPedia.gov, sponsored by the U.S. Department of Agriculture. I love the site’s name and logo:

The site allows you to look up a food and see how cooking it in different ways, or adding sauce or a condiment, affects the calories and nutritional components. Try looking up what’s in a half cup of broccoli florets, raw, cooked, or cooked with some butter. Or an English muffin, with or without butter, with or without jam.

The biggest limitation is the site’s lack of information on vitamins and minerals for most foods. And holes in what’s covered, especially in terms of cooking preparation. For example, you can find out about the fat content and calories in spinach and most other vegetables served raw or cooked with butter, margarine (is this 1975?) or “tub margarine” (yuck). But what about vegetables roasted or sautéed with olive oil, as most cardiologists and this homemaker would suggest to her readers?

I like MyFoodAPedia, but mainly for its potential so far. Hopefully, like Wikipedia it will become more informative over time. Still, it’s a handy, probably objective resource for cooks and others who care about what they’re ingesting.

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The Transportation Safety Authority Screens Travelers Inside and Out

I’ll be staying near my home in Manhattan this week. But if I did have plans to travel by airplane for the holiday, I think I’d be apprehensive about the new screening procedures implemented by the Transportation Safety Authority (TSA).

My concern is not so much with the scanners. (For a detailed review of these machines, I recommend this article in Popular Mechanics.) There are two types of scanners in current use: millimeter wave machines, which use radio-frequency waves to generate 3-D images, and back-scatter units which, by design, use low doses of x-rays to visualize what’s inside a person being scanned.

Rather, I’m worried about screening errors – false positive and false negative results, and about harms – physical and/or emotional, that patients and people with disability may experience during the screening process.

In the context of travelers’ screening, a false positive occurs when an examiner thinks he or she sees or feels something abnormal – say a weird expression on a passenger’s face or when an initial, low-threshold alarm goes off somewhere in the system – but the person isn’t carrying any dangerous or contraband items. That early, false positive signal puts the traveler through extra procedures, possible embarrassment and/or stress.

A false negative happens when a screener misses an explosive device or other harmful material. A good example is the so-called Christmas bomber, who last year got through airport security and boarded a plane with explosives effectively hidden in his underwear. In that December 2009 instance, the examiners failed to identify a passenger who carried a potentially lethal weapon. The TSA’s goal should be to minimize the number of false negative screening tests. That’s because we wouldn’t want someone to get through screening and board a plane while carrying a weapon.

The problem is that it’s easy to imagine an imperfectly-trained, inexperienced or just plain tired screener missing an irregularity in someone’s 3-D or other kind of whole-body image, especially in the context of a steady stream of passengers rushing to catch flights. The operators might miss weapons despite the visual “information” available, right in front of their eyes.

So I don’t object to the new technology, which should increase the accuracy of the screeners’ function. Ultimately, though, we can’t get around the fact that TSA employees are human and some will be nearing the end of their shift; the scanners can reduce but not eliminate these kinds of errors.

My second concern is with the potential harm to patients and people with disabilities. People may be harmed physically if, for example, a screener mishandles a pump or other device. There’s been a lot of attention to one recent report, that of a 61 year old man with a history of bladder cancer whose urostomy bag ruptured during an airport pat-down. The man described his urine spilling, and his feeling humiliated.

This is a very understandable reaction; as someone who has implants after mastectomies, and who carries a lot of internal metal hardware in her spine and elsewhere, with scars galore, I know how damaging can be a stranger’s scrutiny. Unlike doctors and nurses, most TSA employees are not accustomed to seeing colostomy bags, stumps and other disfigurements usually hidden under a person’s clothing. Even an accidental, unkind expression in a look-over, or an insensitive pat-down, could make a person feel pretty bad about their ailment.

Of course we don’t have to travel on airplanes. I don’t see this as a civil rights issue; I don’t think there’s a right to board a public vehicle without full screening if the TSA deems it’s necessary for public safety. Rather, I accept that an aspect of having illnesses is that sometimes you have to put up with things other people don’t experience.

What would help, clearly, is better sensitivity and training of TSA staff, as was considered in response to the urostomy incident. But given the huge volume of travelers and enormousness of our complicated transportation system, it seems unlikely we’ll get a satisfactory solution among all staff at all airports, at least not in time for Thanksgiving.

From the patient’s perspective, there are some practical points that might help. Amy Tenderich, at Diabetes Mine, offers tips for individuals with insulin pumps. Trisha Torrey has an interesting piece on her Patient Empowerment blog (where she argues that this is not an empowerment issue) and recommends a simple, common-sense approach, which is to arrive early at the airport. As for me, I carry cards indicating the dates of my surgeries and the nature of my hardware. Now, I’ll add to those a note from my doctor.

Meanwhile I hope the screeners will use their new equipment to do a better job at detecting people carrying weapons. And that those individuals who plan to boycott the scanners with a National Opt-Out Day tomorrow, will change their minds. The TSA employees have enough on their hands already, without a demonstration; it’s in everyone’s interest that the screening be effective, hopefully 100 percent, in this holiday season.

minor rev: 11/23, 2PM

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Stepping Back, and Thinking Forward to October

Before jumping into the raring-to-go, already re-sparked debate on the value of breast cancer screening, or not, I thought I’d step back today and consider the background of what I won’t call the “mammography wars.”

So here’s the first point on this subject: happily, it’s not a war. This is about medical progress, or lack of progress, and what may or may not spare women morbidity (what doctors and stats types call illness) and mortality (death). This is not a battle by any sane measure.

The discussion should be civil and fair, ideally without assumptions and bias. (Of course it’s impossible for me to be unbiased on this subject – I am a trained oncologist, I’ve treated women with breast cancer who responded to chemotherapy drugs and witnessed their subsequent well-being, and I’ve seen women with metastatic breast cancer who died with disease eating through their bones and brains. And I had breast cancer, and was lucky that mine was found in an early stage. So far am well in that respect, eight years ago next month and counting -)

So I have bias, yes, but my second point is that we all do. Every journalist does, whether or not they’re up front about their life-experiences and community background, and so does every medical researcher and public health official who authors a paper and is not a robot. We delineate stories, analyze and represent data based on points we want to make and, in some medical journals – even for some trials that aren’t funded by drug companies – publish to serve academic, career or even what we think are idealistic, cost-saving, pain or procedure-sparing often high-minded goals.

Data can be very tricky to sort out and among.

The problems with mammography studies, as partly-detailed in the current NEJM paper, is that it’s considered impossible to do a controlled, randomized trial in which half of the women undergo screening and half don’t. (I might argue this assumption; now, that so many women and doctors are questioning the merit of mammography, maybe we could do a truly randomized trial involving a few thousand women in the U.S.) This issue relates to the important topic of ethics and real-life dilemmas oncologists face when they set up studies for evaluation or treatment of humans some of whom are likely to die.

But before we delve into the details of this study, and next month (October), what I hope is that we’ll keep some facts in mind:

The National Cancer Institute estimates that 40,000 women will die of breast cancer this year in the U.S. There’s been dramatic progress in how we manage this once-dreaded condition: prior to 1926, fewer than 20 percent of women survived for 5 years after diagnosis. By 1950, the overall 5-year survival rate among Caucasian women with breast cancer was 60 percent. Now, the overall 5-year survival rate is around 91 percent.

A question central to today’s discussion – which does at least acknowledge the decline in breast cancer mortality – is the extent to which mammography is responsible for this trend, as opposed to other factors such as increased awareness about cancer, better cancer treatments and other variables.

What concerns me is the tone of the debate on mammography, that it shouldn’t subtly or not-so-subtly, denigrate women’s valid concerns about their health. The quote with which today’s front-page story ends is this: “I think we have to respect what women want to do.” The way the story is framed insinuates that a decision to undergo mammography is based on something other than reason.

To be clear: this is not about what women want. It’s not about emotional turmoil, comfort, stress or people’s feelings. It’s about the efficacy of state-of-the art mammograms and whether or not those, when taken by skilled, well-trained radiologists in carefully-regulated modern facilities save women’s lives, at a reasonable cost (however we might calculate that) and reduce illness by detecting breast cancer in its early stages.

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Wednesday Web Sightings

(Snakes on the Net, and OR games!)

Today ML read in the WSJ that a 3-foot long yellow corn snake popped up in a 19th floor Bronx apartment yesterday. It seems the resident was so surprised to find the snake in his toilet, and shaken, that he dialed 911 more than once.

a corn snake (Wikimedia)

Medical tidbit: according to the Journal, corn snakes are not usually harmful to humans.

The above would have been the most curious Internet medical finding of the day, except for an ad I found on a blog for a short adventure called OR Games. (The video is sponsored by Kimberly-Clark, a medical supply company.)

Serious stuff tomorrow!

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Big Implications of Blog-Bickering About What Doctors Should Be Doing

Yesterday in class my students learned, incidentally, just a bit about the vital signs that doctors sometimes measure as part of the physical exam. It turns out this is the subject of a recent med-blog debate:

The discussion started on db’s Medrants, with a Sept 9 admonition that if orthostatic vital sign measurements are needed to evaluate someone – presumably in a hospital setting – the intern and resident doctors should take those measurements themselves rather than writing an order for someone else, such as a nurse, to do it instead.

The problematically anonymous Happy Hospitalist commented there, calling the task a “nursing function.” He posted his views on Sept 10 and took the trouble to provide his readers a fairly detailed explanation of what it means to take those sometimes crucial measurements of a patient’s pulse and blood pressure when they’re lying down, sitting and standing.

After some additional back-and-forth, on Sept. 13 the somewhat anonymous author of Musings of a Dinosaur summarized the matter:

There are two different issues being discussed that are being incorrectly conflated:

  1. The value of orthostatic vital sign measuresments, and
  2. Who should be doing them, nurses or doctors.

Her position, as I understand it, is that there’s no fundamental reason why an assistant can’t perform this kind of work but, as a practical matter there’s somtimes no one else to do it but the physician, who shouldn’t feel it’s beneath her to measure a patient’s vital signs.

My interest, as far as medical education goes, is this: I think it’s really important that doctors be trained in how to perform a complete physical exam including the basic vital signs – pulse, respiratory rate, blood pressure and temperature (for the latter 2, with a device that works!). Here are two reasons why this matters:

1. I’ve witnessed cardiac arrests and near-arrests when it wasn’t so easy for the doctors and nurses to discern if the patient had a pulse or a viable blood pressure. Doctors need to know what they’re doing, and practice makes it more likely they’ll know if there’s a pulse and what is the patient’s pressure during stressful, rushed situations like a code.

2. Subtle abnormalities in a patient’s respiratory rate and pulse can be signs of serious illnesses. If a doctor’s unaccustomed to measuring those while talking with the patient and critically thinking, he or she may not pick up on those “easy” clues about what’s wrong, i.e. the diagnosis.

(As far as taking orthostatic measurements, a more time-consuming and less-frequently needed procedure, I think doctors should learn how to measure those and have some experience in doing so, in part so they’ll be familiar with the method and its potential limitations.)

But – I don’t see how we can afford, routinely, for senior, seasoned physicians (such as hospitalists in hospitals and doctors in other large, bulk-care settings) spending their time taking patients’ blood pressure and other vital signs. As a society, we just don’t have sufficient health care resources to indulge this kind of medical practice.

I want my doctors to spend more of their time reading and thinking about their patients, besides sleeping and taking care of themselves.

So while this little debate might seem minor and technical, reflecting some pettiness and distinct personalities among the various physician-bloggers, it bears on a serious issue for medicine, which is not so easily resolved: what are the tasks that we really want doctors to do, and not to delegate.

This discussion relates to a recent editorial in the New York Times on whether we really need physicians to administer anesthesia. (For the record, I think the answer is “yes.”) It bears also on simpler matters – whether doctors should spend time calling patients themselves about routine test results, adjusting coumadin and other drug doses or performing other tasks. What will be critical is how well we train technicians, aides, nurses and others who we’ll need, and increasingly rely on, whether we like it or not, to assist physicians in the future.

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Perspective on Screening for Sickle Cell Trait in Student Athletes

Today I watched a video, The Student-Athlete with the Sickle Cell Trait, sponsored by the National Collegiate Athletic Association (NCAA) on its website. The 12-minute presentation provides some helpful background on what it means to have sickle cell trait and how awareness of that condition might influence a student’s (or coach’s?) behavior during rigorous conditioning and competitive sports.

“The more medical information we know about our student athletes, the better equipped we are to help keep them safe,” says Mark Richt, Head Coach at the University of Georgia, at around 3 minutes into the clip.

A new NCAA policy mandates screening all Division I college sports participants for sickle cell trait. Not coincidentally, the Sept 9 issue of the New England Journal of Medicine opens with a noteworthy perspective* on this topic. The screening recommendation, effective at the start of this academic year (i.e. now) directly affects more than a few young adults in the U.S.: among nearly 170,000 athletes who’ll be tested this year, it’s expected that several hundred “carriers” will be identified.

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Why Physicians Shouldn’t Tweet About Their Patients Or O.R. Cases

I fear this post may be a bit of a downer for some e-health enthusiasts, Internet addicts and others who might otherwise follow @medicallessons, but after nine months of “studying” medicine on Twitter, I’ve reached the conclusion that it’s probably not a good idea for most practicing physicians to use 140 character Web-broadcasted messages for communicating with or about their patients.

Sorry if I’m ruining a tweetchat, tweetup or doctors’ virtual party somewhere. I just don’t think these belong in the doctor’s office or, especially, in the O.R.

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On Patient Empowerment and Autonomy

Yesterday a Tweet crossed my screen that got me thinking. The source of was Gilles Frydman, founder of ACOR (Association of Cancer Online Resources) and a pioneer in the e-patient community:

@gfry: Participatory Medicine evangelists say “Engaged, empowered patients are better, healthier patients.” Where is the evidence?

What makes this question so ripe, in my oncologist-patient-teacher-blogger’s way of thinking, is that we may never, even if formal studies do provide data on this issue 10 years ahead, reach an objective conclusion on this matter.

The problem is this: To prove that empowered patients are “better and healthier,” how would we design a trial? If we were to compare those engaged – who almost by definition are more educated or at least have Internet access, or who are one way or another are linked to people who can help them find needed information – they’d likely do better than the disconnected patients. But the outcome might be a function of confounding variables: their education, economic status, on-line connectivity, etc.

I think the answer is inherent in the goal of being engaged, and this has to do with the concept of patient autonomy – what’s essentially the capacity of a person to live and make decisions according to one’s own set of knowledge, goals and values.

Autonomy in medicine, which borders on the empowerment idea, can be an aim in itself, and therefore valuable regardless of any measured outcome. For autonomy, or patient empowerment, to be meaningful and maybe even “better” in the strictly medical sense, as measured by outcomes like survival or quality of life, there needs be stronger public education in the U.S. and everywhere.

You can read all you want on stem cells, gene therapy or rare forms of chronic leukemia that are driven by a turned-on oncogene, but if you don’t know the basics of science and math, or don’t have sufficient language skills to read and absorb new knowledge or at least ask pertinent questions, it’s easy to get lost in that information, overwhelmed or – worse – suckered by those who’d try to persuade you of something that’s not true, cloaked in pseudoscience, that’s abundant and available on-line and, occasionally, in some doctors’ offices.

This is why public education matters, so much.

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Cooking With Universal Precautions

A half-billion or so eggs were speedily pulled off semi-cooled supermarket shelves this week. The concern is that bacteria-laced eggs can cause serious and even deadly illness. The companies that produced and disseminated those marked eggs fear more lawsuits. Some people who usually enjoy their eggs in the morning, sunny-side up, are thinking twice.

The greatest egg recall ever set off alarms on CNN (Paging Dr. Gupta), on the front page of my newspaper’s business section, on some health blogs and in some homes. I’m concerned and saddened by this, about the cost of all this – the frank wastefulness of it. Our food supply is not infinite.

But I’m not particularly worried about getting sick from eating eggs at this time. Rather, I’ve been aware of this potential problem at least since 1984, when I took classes in microbiology. That raw or undercooked, runny eggs can effectively deliver salmonella to the digestive tract is something doctors learn in medical school. (And, maybe, the rest of the population should be taught in what used to be called home economics?)

In my home we don’t eat a lot of eggs, mainly because of my personal aversion and fear of cholesterol-lowering drugs. We go through perhaps a dozen eggs in most months. But when I do cook with eggs, whether that’s in baking a quiche, vegetable soufflé or cake, or rarely, for breakfast in omelet or scrambled form, I cook them thoroughly, applying heat through-and-through, and keep any utensils that have touched raw egg apart from anything else in the sink or on the kitchen counter.

Shifting gears, just a bit – this story reminds me of a gradual change in how we practiced medicine in the years after the start of the AIDS epidemic. In 1983, when I entered medical school, few doctors wore gloves except when they were performing surgery. At Bellevue Hospital in 1985 and 1986, my classmates and I helped to deliver babies with our bare hands.

Gradually, and as fear caught on, some doctors started to discriminate – they’d wear gloves while drawing blood from a patient with obvious risk factors for HIV, such as a promiscuous homosexual man or an intravenous drug user. But I always thought to myself, you never know who’s got what virus, we should be careful more often.

A few years later, when I was a resident physician and pregnant fellow, the concept of universal precautions came into widespread practice.  Doctors and nurses learned – had to be instructed – to don gloves whenever they drew blood or potentially came into contact with any patient’s body fluids because, the idea emerged, anyone might have HIV. Better to be careful in general, without prejudice.

These practices annoyed some at first. For doctors, they cost us time and the value of touch. Among other problems, it became suddenly more difficult to insert an IV catheter in one shot because feeling a patient’s vein is a lot harder when there’s a layer of material between your fingers and the patient’s skin. I suspect, also, that some hospital administrators must have resisted, too, because of all the money needed to buy all those gloves and new-fangled needle-dispenser boxes.

Some food-minded folks and editorialists suggest that risk might be reduced by buying less-travelled eggs from local producers. But regardless of where you live and shop for food, local farmers vary in their practices and habits. As for organic farms, there’s no real evidence that those are cleaner than other agricultural sources. (Some may be, but which? It could go either way.)

This situation bears some analogy to the reason why doctors implemented universal precautions in medicine. Some of us harbor prejudice (and maybe even some anger or resentment…) against efficient, industrial-sized food-growers and may be, accordingly, biased and even lenient in attitudes on standards and regulations for local farmers’ markets. And so the danger is, we may be less careful with eggs from a small-scale farm down the road. Those eggs seem OK, or at least we feel better about their purchase.

My point is, it’s generally better to behave without bias.

I think it would be smart for cooks to use universal precautions when handling eggs. There’s always some risk of contamination by salmonella and other disease-causing bacteria. I cook eggs well, regardless of their source or what’s picked up in today’s news.

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Another Take On An Ordinary Day

A few weeks ago, on August 1, I threw out the concept of living life every day as if it’s Shark Week. The line, delivered by 30 Rock‘s Tracy Morgan in that show’s first season, has stuck with and puzzled me for years.

Then I came upon a striking post called Live Each Day Like There’s a Lot of Them Left, dated August 2. Jen Singer, a blogger with two sons and a history of lymphoma, expresses the considered notion that maybe the best thing to do after cancer is to live, essentially, as you would do otherwise, except with a bit of added balance.

She writes:

… I — the one who has been so close to the end of life – am supposed to tell you to treat each day as though it’s your last. Except, if it were my last, I certainly wouldn’t be tanking up my mini-van for the rest of the week’s carpools…

Rather, I suggest that you treat every day as though you’ve got a whole lot of them left, precisely because you don’t really know if you do. Go about the everyday, do the drop-offs, get out the knots. Clean the house. Go ahead and get through the stuff that fills your To-Do list…Slog, if you must, because that’s perfectly okay…

Still, every now and then, don’t forget to turn up the radio and listen…

Her point, I think, is that we all have to move on with our lives if we can. It’s the nitty-gritty, mundane activities that keep families on track may also keep us sane, safe and sound. Cancer can be liberating, but that doesn’t necessarily mean we should exploit that as license to escape from responsibilities.

The pressure to “treasure each moment” can be counterproductive. To live life as usual is a challenge of another sort, important for the normal development of our kids and ourselves.

I like this perspective.

Like Jen, I take pleasure in the ordinary stuff – cooking, helping my family and yes, checking off items on the list of things I’ve been meaning to do for years. It’s a long list, and I’ve lots to take care of.

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Eye Care

On Friday I had a slightly, subtly dehumanizing experience at the eye doctor. It’s no big deal, really, almost not worth mentioning -

It was an entirely ordinary set of events that triggered this near-rant from this determinately positive blogger. But maybe the commonality of it – the blandness of what happened when I visited the doctor the other day – typifies what’s as a tragedy in modern health care: the loss of caring.

eyeglasses on a table (Wikimedia Commons)

How it went was like this:

That morning I raced (or, rather, walked quickly – but dangerously quickly for a woman with poor balance and limited gait) to catch the bus to take the train to reach the optometrist’s office on time. And I did.

The office was crowded but not full. A receptionist sat behind a partly glass-enclosed counter with desks, fax machines and filing cabinets and other workers.

“Name, please” she asked me.

I told the woman my name.

She nodded. “Take a seat, someone will be right with you.”

I waited just over half an hour, during which time I had the opportunity to look around and listen.  A man, who said he’d undergone Lasik surgery the day prior was “seeing great” as he chatted enthusiastically with a couple to my left, one half of which was contemplating the procedure.

“It’s a miracle,” he said. “I’m having each done separately, one at a time.”

After a while I returned to the receptionist’s window and noticed a sign having to do with Botox injections and information on a doctor who might provide those.

My mind wandered… I never knew that eye doctors do Botox. Then again, maybe they don’t…Perhaps this office maintains a reciprocal relationship with an office that provides those, where the staff posts notices about Lasik surgery. Either way, the sign is nothing more than a business strategy, which is fair enough if you believe that health care can or should be run as a money-making enterprise. (I don’t.)

Back to my optometrist, who was running late (OK, usually forgivable, human):

How I first met this capable woman was through the long-ago care of my semi-retired ophthalmologist, a medical doctor (MD) who provided start-to-finish eye examinations and might, if you ever needed it, perform eye surgery. I trusted him and always felt good about visiting his office.

Some time ago he expanded his practice, taking in some less-established doctors and optometrists. The idea, I imagine, was to have a doctor of optometry (DO) carefully perform the initial eye exams, patiently fit vision-impaired people with just the right prescriptions for their lenses and, finally, refer any questions or concerns to the ophthalmologist in the same office. In this sort of setting, he could spend more of his time helping, and doing procedures, for patients with serious eye problems like glaucoma.

I was happy with the system for most of 10 years. I genuinely liked the optometrist, and still do – she did a terrific job evaluating my vision and optimizing my lenses. Around the time I had breast cancer, bald and walking with a needed cane, she looked into my eyes with extra care. She was sympathetic and spent an unusual amount of time making sure that my glasses would be all right, if nothing else.

The problem – what I’d diagnose as a change in the practice’s character – manifest a few years ago after the group moved to a new office space where there seems to be a lot more traffic. The carpeting on the floors, once fresh-appearing, is no longer. The waiting area, formerly quiet, has a TV broadcasting CNN. But I don’t care much about the floors or media selection.

What bugs me is that the office has expanded and become so systematized that when I go there I don’t feel like I’m visiting a doctor, the kind of professional who sincerely cares about my health. Instead I feel like a commodity, which I suppose I am.

Back to the visit:

As has happened before, a technician called my name  and asked me to come with him, so I did. He was young and unfamiliar. He told me his first name and, without further explanation, indicated where I should sit while he used a machine to take pictures of each retina, the light-receiving membranous surface at the back of the eyes. Next, he asked me to follow him into a small room where he proceeded to open my chart and question me, sketchily, about my recent medical history.

I wasn’t thrilled about sharing, but went along up until a point. Then, when he began to perform my eye evaluation – the exact sort of work that the optometrist used to spend her time with me doing, I asked him what was going on. Where was she?

“She doesn’t do this part any more. It’s been like that for a while. Now please, can you read the letters in the first row…”

So now the optometrist, who had for years assisted the ophthalmologist, has an assistant who would evaluate my vision instead. This saddened me, first and selfishly because I’d spent the better part of my morning going to see her so that she could check my eyes and write another ideal prescription I could rely on, and now I couldn’t count on that small part of my health care going smoothly ever again.

What’s more – and the bigger picture – is that she no longer has time for me and my eye glasses. I see this simultaneously as good and bad:

Good – I suppose, because we don’t really need people with MDs, and probably not even with DOs, for routine examinations and procedures that could be handled by someone with less training and who is, therefore, less valuable in our limited health care system.

Bad – It happens that the particular technician who started to check my eyesight did a poor job until I stopped him at that. The machine he used to project letters into a mirror shook so much that the small blurry letters in the lowest row wobbled clearly.

More generally – it’s bad because the time I once valued with my optometrist, as previously with the ophthalmologist, is gone. I guess it wasn’t sufficiently worthwhile for them to keep the relationship going as it was. No more annual, while they’re flipping the glass circles, questions like “how are your kids?” or “how’s your summer going” or a generous, once-credible “how are you feeling?”

My visit was almost reduced to a series of standard interactions with a technician of unknown credentials who I don’t expect to ever see again. I intercepted that, this time, but this scenario will surely recur, overwhelmingly, as health care delivery becomes more checklist-based and efficiency-minded.

—–

Some definitions – for those of you who aren’t completely confident in your knowledge of the distinctions among eye care specialists:

An ophthalmologist is a medical doctor (MD) who specializes in eye diseases and might perform eye surgery.

An optometrist is a professional who’s earned a doctor of optometry (DO). Usually this requires four years of post-graduate education that covers eye diseases, pharmacology, anatomy and more. Optometrists are trained, extensively, to examine the eyes, give prescriptions and perform certain procedures.

An optician is someone, typically a licensed professional, who helps people get the eye care they need and may prescribe eye glasses or contact lenses.

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First Take On the Big C

Laura Linney as Cathy in The Big C

Last night I stayed up to watch the first episode of Laura Linney portraying a middle-aged woman in a new series called The Big C. The story is that she’s got a teenage son and a recently estranged, overweight husband who loves her. She lives in a suburban house that could use some work.  She teaches in a high school. She has a brother who’s deliberately homeless.

Her name’s Cathy – how ordinary can you get? Well, Cathy recently found out she has a terminal case of melanoma. In a change of pace, she expresses herself freely and does pretty much whatever she feels like doing.

For me, this TV situation has some big draws:

Laura Linney‘s a fine, not uninteresting actress. A few years ago she played a charming Abigail Adams in a history-minded miniseries. But I couldn’t bear to watch her miscast counterpart, Paul Giamatti, pretending to be President John Adams, so I didn’t. As in the storyline of the Big C, here’s an opportunity for Linney to shine.

Gabourey Sidibe, a young obese woman who stars in the movie Precious, may or may not be a fantastic figure on film or TV. She’s yet to be established beyond her debut and after watching last night’s episode I’m concerned already that she’s being “used” as an object for the protagonist’s preterminal beneficence. Still, she’s a definite plus.

The Big C‘s plot includes at least two “atypical” and potentially complex features. First, Cathy chooses not to take chemotherapy or other treatment. This intrigues me, and may be the show’s most essential component – that she doesn’t just follow her doctor’s advice. Second, she doesn’t go ahead and inform her husband, brother or son about the condition, at least not so far.

We’ve seen this non-communication before in movies (Susan Sarandon in Stepmom, for instance) and in real life, for most of human history. It’s too-easy for a blogger-patient-oncologist to forget that not long before our Facebook era, most people didn’t talk much about having cancer and even today, many patients prefer not to do so. Norms change.

If the point of the Big C is to broaden the dialog on cancer and talking about cancer, that’s worth a lot, still.

What’s wrong with the program? I think the doctor has some brushing-up to do about his image. He’s 31 and Cathy’s his first “case” – all of which is credible, but with the exception of an x-ray briefly revealed on the wall-mounted light-box, it’s not clear if he’s an oncologist or a dermatologist somehow offering her chemotherapy and pamphlets. His white coat is too short, in the style of a medical student’s. He uses few polysyllabic words. He looks well-rested and neat. In one strange scene, the patient and doctor meet for lunch at a pleasant outdoor restaurant. That’s not how oncology’s practiced, at least as I know it.

But I’m learning, too. And I’m wondering about the informational content of the doctor’s slick handouts, about which the protagonist, Cathy, has a vision.

—-

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The Physical Exam’s Value is Not Just Emotional

Lately there’s been some talk about the value of the physical examination. It’s my sense that this discussion was sparked by a lovely piece by Danielle Ofri published two weeks ago in the New York Times. In that, Dr. Ofri describes a patient’s visit in which, toward the end and almost as an afterthought, she pulled out her stethoscope and performed a physical exam in a perhaps cursory but essential, thoughtful manner.

Or is it so cursory? There’s little scientific evidence to support the physical exam in practicing medicine but, as she writes:

…Touch is inherently humanizing, and for a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust — on both ends. As has been proved in newborn nurseries, and intuited by most doctors, nurses and patients, one of the most basic ways to establish trust is to touch…

KevinMD picked up on the story, essentially echoing the idea in a post called “Touch Humanizes the Doctor-Patient Relationship.” In that, he considers that some doctors (including him, previously) dismiss the physical exam obsolete – “like staying with a horse and buggy when cars are rapidly becoming available.”

It happens I know something about physical exams. Early in my years as a junior faculty member at Cornell’s medical school, around 1994, I was assigned to teach physical examination to second-year students during each of two consecutive spring semesters. To prepare for teaching, I carefully reread my copy of Bates’ Guide to Physical Examination.

my old copy of Bates' Guide to Physical Examination, on my desk now

Together, my students and I listened to normal and abnormal heart sounds. We looked in each others eyes with ophthalmoscopes. We visited some of my patients with lymphadenopathy (swollen glands), big livers and palpable spleens who were willing to let us learn from their pathological physical findings. We listened and described course and fine rales on some pneumatics’ lung exams, and checked arthritic joints for swan-like deformities characteristic of rheumatoid arthritis. We examined patients’ petechiae, purpura, ecchymoses and more, and discussed the differences among those findings and what they might signify. All of this we did without CT scans or echos.

I know also, as a patient, that physical examination can be life-saving. Once, when I was in the hospital as a child and had unexplained fevers after surgery, it seemed for a while that no one could figure out what was wrong. I was terrified. The surgical team consulted with an infectious disease specialist, who as I recall ordered a whole bunch of unpleasant tests, and then my dad – a physician – noticed that one of my legs was more swollen than the other. He realized, based on my physical exam, that I might have a blood clot. It turned out that he was right.

So I agree that the physical exam is humanizing. So much so that, later in my career when I routinely donned space suit-like gowns and masks on rounds for the leukemia and bone marrow transplant services, I became frustrated by those barriers, and by the very lack of touch which, I think, can help patients heal.

But what’s also true, in a practical and bottom-line sort of way, is that a good physical exam can help doctors figure out what’s wrong with patients. If physicians were more confident – better trained, and practiced – in their capacity to make diagnoses by physical exam, we could skip the costs and toxicity of countless x-rays, CT scans and other tests.

Recently I wrote a piece on medical education and going back to basics. The physical exam should be included, for sure.

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Today’s Calls

This is an easy post with a simple message. Maybe it’ll even help some people.

Earlier today, in the midst of a deep water exercise class, I remembered that I needed to  call my eye doctor before the weekend. You see, I’ve been meaning to get a new pair of glasses and it doesn’t make sense to get those without a current prescription. Then I realized that I hadn’t been to see her in two years. Time flies -

Like many people, I’ve been carrying around a mental stack of offices I’ve been meaning to call. So instead of taking care of some serious writing for a book proposal, that I really need to do, I ran the list:

  • internist
  • ophthalmologist
  • dermatologist
  • physical therapist
  • gynecologist
  • oncologist
  • orthopedist
  • other appointments (for your kids, spouse?, partner, whoever depends on you …)

Done!

It turns out that late summer is a great time to call medical offices for routine appointments. (Sorry secretaries, I know the doctor’s vacation is when you tidy up, even electronic paperwork and filing.) But seriously, someone answered the phone promptly or readily returned my call today. What’s more, I beat the post-Labor Day rush for adult doctors’ visits.

Calling is, unfortunately, too often an obstacle. But it’s no excuse.

(Not having insurance is another story, of course.)

Just do it!

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Shutting Off Nurse Jackie

A few months ago I wrote that I’d take another look at Nurse Jackie, a ShowTime series about a drug-addicted ER nurse and mother. The posters, featuring Edie Falco as the program’s heroine, caught my eye; she’d charmed me in her previous role, as Carmela Soprano. Besides, this story’s set in NYC. The hospital is vaguely-modeled upon St. Vincent’s Medical Center, a recently-shuttered Catholic Hospital in Greenwich Village.

Out of some sense of compulsion, wanting to provide careful follow-up to my readers, I forced myself to watch each episode before completing this review. Unfortunately I found the series so unpleasant, besides uninteresting, that it took me months to plod through my assignment.

Jackie is supposed to be a crackerjack nurse who has some serious problems including drug addiction. That premise might be fair enough, in a House-like way, if her life-saving skills had unique value. But they don’t: the underlying problem with this show is that Jackie has no exceptional or redeeming qualities as a nurse. Sure, she cares about some of her patients, but that’s nothing extraordinary. Rather, she stands out by lying, making up results and, not infrequently, cutting out when and where she’s needed.

The emergency department where Jackie works is supervised by a not-quite indifferent administrator portrayed disappointingly by Anna Deavere Smith, whose real talents reach far beyond the realm of the petty disputes and not-unusual life issues that plague this TV hospital’s staff.

As a physician-blogger who’s trying to understand the potential value of Twitter in health care, I thought perhaps I might learn from the show’s ER doc Cooper’s social media skills: he tweets while working, nominally as a physician. But he’s presented as such a vain, stupid twit that he’s just not credible as a doctor of any kind. Even his Tourette’s tics are adolescent – he grabs women’s breasts when stressed, a curious behavior that seems, if anything, to suit the show’s shallow drama more than any real patient’s disease.

Plenty of TV shows have offered insights on health care delivery by quirky, self-absorbed and sometimes-deluded workers with interpersonal issues and stress (think M*A*S*H, for starters). But this series doesn’t make that grade. There’s no adult humor, no attempt at medical mystery-solving or even a good, old-fashioned medical ethics quandary. Unlike the Sopranos‘ story, here most of the characters bear little depth. Jackie’s multiple psychopathologies are a vile, exaggerated example of a woman juggling too many things, badly.

So I was surprised to find out that Jackie’s contract was renewed. Even more, I wish that the real St. Vincent’s Hospital, which once provided care to me and, over the years, helped countless other real New Yorkers, were still open.

I won’t revisit this show. But I’m looking forward to The Big C, which starts on Monday. Hopefully that will deliver better entertainment, or at least some fresh ideas.

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Doctors Not Using Email Like It’s 2010

There’s been a recent barrage of med-blog posts on the unhappy relationship between doctors and electronic communications. The first, a mainly reasonable rant by Dr. Wes* dated August 7, When The Doctor’s Always In, considers email in the context of unbounded pressure on physicians to avail themselves to their patients 24/7. That piece triggered at least two prompt reactions: Distractible Dr. Rob’s** essay on Why I Don’t Accept eMail From Patients and 33 Charts‘ Dr. V on The Boundaries of Physicians Availability.

Perhaps the most astonishing aspect of these three guys’ essays is that, in 2010, there’s still a question about whether doctors should use email to communicate with patients. It’s hard for me to imagine physicians – including bloggers – so disconnected. But many are.

Last year, I had the opportunity to speak with Professor Nathan Ensmenger, a historian of technology at the University of Pennsylvania who’s studied physicians’ use of the Internet and email. Physicians aren’t luddites,” he told me. “On the whole, they’re a computer-savvy group, among the first to use the Internet in research and for professional development.”

Ensmenger contrasted doctors’ hesitation to take on email with patients with their early espousal of the telephone, which facilitated their practices and care in the early 20th Century. Doctors might want to work on-line, he suggests, even out of self-interest: the asynchronous nature of email, by contrast to telephone calls, affords more flexibility and workload control. Published studies, including an early 2004 report in the British Medical Journal, cite evidence  that an overwhelming majority of patients would welcome the chance to communicate with doctors by email. Nonetheless, many medical providers refuse to email patients.

Here’s a partial list of reasons why some doctors are reluctant to get on board with this (1990s) program:

1. Physicians don’t get compensated for time spent emailing patients.

2. Any written communication with a patient, or about a patient, is a potential liability that might be used in a malpractice suit against them.

3. There might be a breach of patient’s privacy if the email is not sufficiently secure, encrypted, or is accidentally sent to the wrong person.

4. Email is a time sink, dragging physicians further down the slippery slope of doing more, undervalued work.

Each of these points has some merit, I admit. I am most persuaded by Dr. Wes:

…This is not a new trend. We saw a similar situation years ago with the advent of the digital beeper. Even the most basic of private bodily functions in the bathroom could be interrupted at a moment’s notice. The expectation that phone calls should be returned instantly grew from this – personal context be damned. Doctors were accepting of these intrusions, however; the feeling of being omni-present, omni-available, and omni-beneficent fit nicely with the Marcus Welby, MD psyche of the time…

So the problem is that doctors are human, i.e. we have limits. Which of course isn’t a problem, but a good thing. I don’t particularly care for robotic physicians.

I’m not sure how to resolve this, but here are my thoughts:

1. About the compensation issue – I think physicians should be salaried rather than paid per unit of work. Communication is an essential part of what physicians do, and so this type of task should be included in their designated workload – whether that’s part-time or full-time.

2. About liability – we need medical malpractice reform, sufficient such that physicians aren’t afraid to write messages to people who are their patients.

3. About privacy – this seems a relatively bogus excuse. Compared to faxing, email is far superior in regard to privacy. And, as many others considering this issue have pointed out, we’ve learned to trust internet-based communications for other critical matters such as bank accounts, credit cards, etc.

4. About physicians’ time – this is a critical issue that hits close to home. Unless the health care system evolves so that mature doctors can carry out expert, interesting and careful work with reasonable hours, few bright young people will choose careers in medicine, and more seasoned physicians will have to stop practicing to protect their own health and well-being. And then we’ll all lose out.

So I don’t think that physicians shouldn’t use email – they should. But the system needs adapt to the 21st Century.

*Westby G. Fisher, M.D. is a cardiologist who blogs as Dr. Wes;

**Robert Lamberts, M.D. is a primary care physician who blogs on Musings of a Distractible Mind;

***Bryan Vartabedian, M.D. is a pediatric gastroenterologist who supplies 33 Charts.

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Back to Basics – But Which Ones?

A front-page story on the Humanities and Medicine Program at the Mount Sinai School of Medicine, here in Manhattan, recently added to the discussion on what it takes to become a doctor in 2010. The school runs a special track for non-science majors who apply relatively early in their undergraduate years. Mount Sinai doesn’t require that they take MCATs or the usual set of premedical science courses – some college math, physics, biology, chemistry and organic chemistry – before admission.

The idea of the program is two-fold: first, that the traditional med school requirements are a turn-off, or barrier, to some young people who might, otherwise, go on to become fine doctors; second, that a liberal arts education makes for better, communicative physicians and, based on the numbers published in a new article, a greater proportion who choose primary care.

Today Orac, a popular but anonymous physician-scientist blogger, considers the issue in a very long post. His view, as I understand it, is that if doctors don’t know enough science they’ll be vulnerable to misinformation and even quackery.

On the side of the spectrum, perhaps, Dr. Pauline Chen, a surgeon who puts her name on her blog and essays. In a January column, “Do You Have the Right Stuff to Be a Doctor?” she challenged the relevance of most medical schools’ entry requirements.

I see merit on both sides:

It seems fine, even good, for some students to enter medical school with backgrounds in the humanities. Knowledge of history, literature, philosophy, art history, anthropology and pretty much any other field can enhance a doctor’s capability to relate to people coming from other backgrounds, to recognize and describe nonparametric patterns and, perhaps, deliver care. Strong writing and verbal skills can help a doctor be effective in teaching, get grants and publish papers and, first and foremost, communicate well with patients and colleagues.

Still, there’s value in a doctor’s having a demonstrated aptitude in math and science. Without the capacity to think critically in math and science, physicians may not really understand the potential benefits and limitations of new medical findings. What’s more, doctors should grasp numbers and speak statistics well enough so they can explain what often seems like jumbled jargon to a patient who’s about to make an important decision.

Thinking back on my years in medical school, residency, fellowship, research years and practice in hematology and oncology, I can’t honestly say that the general biology course I took – which included a semester’s worth of arcane plant and animal taxonomy – had much value in terms of my academic success or in being a good doctor. Chemistry and organic chemistry were probably necessary to some degree. Multivariable calculus and linear algebra turned out to be far less important than what I learned, later on my own, about statistics. As for physics and those unmappable s, p, d and f orbitals whereabout electrons zoom, I have no idea how those fit in.

What I do think is relevant was an advanced cell biology course I took during my senior year.  That, along with a tough, accompanying lab requirement, gave me what was a cutting-edge, 1981 view of gene transcription and the cell’s molecular machinery. Back then I took philosophy courses on ethical issues including autonomy – those, too, proved relevant in my med school years and later, as a practicing physician. If I could do it again, now, I’d prepare myself with courses (and labs) in molecular biology, modern genetics, and college-level statistics.

My (always-tentative) conclusions:

1. We need doctors who are well-educated, and gifted, in the humanities and sciences. But for more of the best and brightest college students to choose medicine, we (our society) should make the career path more attractive – in terms of lifestyle, and finances.

(To achieve this, we should have salaried physicians who do not incur debt while in school, ~European-style, and who work in a system with reasonable provisions for maternity leave, medical absences, vacation, etc. – but this is a large subject beyond the scope of this post.)

2. There may not be one cookie-cutter “best” when it comes to premedical education. Rather, the requirements for med school should be flexible and, perhaps, should depend on the student’s ultimate goals. It may be, for instance, that the ideal pre-med fund of knowledge of a would-be psychiatrist differs from that of a future orthopedist or oncologist.

3. We shouldn’t cut corners or standards in medical education to save money. As scientific knowledge has exploded so dramatically in the past 30 years or so, there’s more for students to learn, not less. Three years of med school isn’t sufficient, even and especially for training primary care physicians who need be familiar with many aspects of health care. If admission requirements are flexible, that’s fine, but they shouldn’t be lax.

Critical thinking is an essential skill for a good doctor in any field. But that kind of learning starts early and, ideally, long before a young person applies to college. To get that right, we need to go back to basics in elementary and high school education. If students enter college with “the right stuff,” they’ll have a better understanding of health-related topics whether they choose a career in medicine, or just go to visit the doctor with some reasonable questions in hand.

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