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Demystifying Medicine One Week at a Time

ObiTrio

When I was young, I avoided reading obituaries out of superstition that I or a family member might fall ill or die.

When I was pursuing a medical education, my fear lessened and I became fascinated by obituaries–especially the 2nd paragraph, in which the cause of death is mentioned (or speculated upon).

As I’ve matured, I now read them because they are a distinct form of writing–succinct, and in telling about the decedent’s life, amazing true stories of our time here on earth.

OBIT | Theatrical Trailer Exclusive from Green Fuse Films on Vimeo.


Three recent NYT obits caught my eye, because each one had an interesting connection to health care. In chronological order of when they died, here they are:

John Sarno was a physical medicine and rehab specialist at NYU for almost 50 years. He was adored by his patients, particularly those for whom he helped achieve relief from back pain. He authored several books on the topic, suggesting that most if not all of it was caused by unresolved anxiety and rage. He coined the term “tension myositis syndrome” as a catch-all for the most common form of back pain–muscular pain that in most cases is episodic or short-lived. The obituary discusses how his ideas were never accepted into the medical mainstream, despite the facts that his books sold millions of copies just by word-of-mouth, and his own skeptical physician colleagues turned to him for help.

Spencer Johnson started his career as a medical doctor, but decided against a career in clinical medicine. As the obituary states, “…while working in a hospital, he grew frustrated at seeing the same patients return with the same ailments, as if they were not trying to better their lives…” He went to work for a medical device company, becoming its director of communication. Learning how to write succinctly for lay audiences led him to his ultimate success–co-authoring the massive bestseller “Who Moved My Cheese,” a parable about pushing ourselves out of our comfort zones. It has since sold nearly 30 million copies worldwide and has been translated into 44 languages.

I love the quote he gave to a newspaper writer: “Most writers write the book they want to write. You’re much wiser if you write the book people want to read.”

Keith Conners was a psychologist most known for his work in the world of defining and diagnosing Attention Deficit Hyperactivity Disorder (A.D.H.D.). In the first half of the 20th century, hyperactive children with difficulty focusing were said to suffer from “hyperkinesis,” or the lovely moniker “minimal brain disorder.” Conners brought rigor to the field, and created the Conners Rating Scale, a 39-item questionnaire that became the gold standard for diagnosing A.D.H.D. Conners went on to become a critic of what has become a big industry, stating that A.D.H.D. is now diagnosed about three times as much as its actual prevalence. [If you are interested further in this topic, you can hear a podcast of my interview with author Alan Schwarz of “A.D.H.D. Nation” here.]

These doctor/writers all lived interesting and varied lives–I was simply struck by the proximity of their deaths and the loveliness of their obituaries.

How Treating Cancer is All About Playing the Odds

The following is a guest post by Dr. Andrew Howard:

Like many Americans, I was sad to hear about Senator John McCain’s recent cancer diagnosis. Though I don’t always agree with his political stances, I greatly admire many things about him, including his service during the Vietnam war.

Senator McCain has a type of malignant brain tumor called a glioblastoma multiforme (also called a GBM). This is the same sort of tumor that Ted Kennedy, Beau Biden, and Ethel Merman had. Since the news about the senator’s diagnosis came out, a lot has been written about the fact that GBMs are associated with a poor prognosis. This has made me think about the term “prognosis.” In my experience, patients and their families often misunderstand how doctors think about that term.

Prognosis is all about trying to answer the question, “What’s going to happen to this person?” It’s not always easy to tell. However, early in my training, my mentors taught me that all cancer patients can be divided into two groups, which they called “curative” and “palliative.”

If a patient was palliative, that meant that there was no real chance for curing their cancer. Treatments may still be helpful for slowing the cancer’s growth and reducing symptoms. But we knew from the beginning that the cancer would eventually cause the patient’s death.

Curative patients, on the other hand, had cancers that were potentially…well, curable. The goal of their treatment was to entirely eliminate their cancer. I often imagined those patients finishing their cancer therapy and going on to live long and healthy life. Eventually, I hoped, the cancer would just be a faded, bad memory in their past.

Even in cases where the goal is curative, there is still no guarantee that treatments will cure the cancer. Instead, treatments are intended to make it as likely as possible that the patient will be cured. Curative treatments are all about playing the odds. It’s like we’re at a casino in Las Vegas, and we’re trying to maximize our chances of winning at the blackjack table. With curative treatments, we’re doing everything we can to stack the deck in our favor.

Here’s another analogy: Imagine you’re out for a walk, and your goal is to cross a busy street. You could just step blindly out into traffic, but your risk of not making it to the other side would be high. There are some simple things you can take to make it more likely that you will make it across. You could:

  • Look to your left before you start to cross
  • Look to your right before you start to cross
  • Cross at a crosswalk
  • Wait for a walk signal from a traffic light

Doing any one of those alone would increase your odds of making it across the street alive. Doing two of them would improve your odds even more. Doing all four would give you the best shot. However, even if you do all four of them, your likelihood of making it still isn’t 100 percent. A speeding truck could come out of nowhere, or you could be hit by lightning, or you could have a heart attack when you’re halfway across. Also, even if you don’t do any of them, there’s still a chance you could, by pure luck, make it across the street alive. However, no one would ever recommend you try that!

Your cancer treatments are like these things you do to improve your likelihood of making it across the street. They are each intended to improve your chances of achieving a cure. They can’t make it absolutely certain you’ll be cured. What they do is shift the odds in your favor.

I’m sure Senator McCain’s doctors will do all that they can to stack the deck in his favor. Glioblastoma is usually treated with a combination of surgery, radiation, and chemotherapy. Though the odds aren’t great, a small minority of patients do achieve full cure, and go on to live years and years after their diagnosis. I certainly hope that for Senator McCain.

Andrew Howard, MD, is an Assistant Professor of Radiation & Cellular Oncology at the University of Chicago. He has written a new book for cancer patients and their families titled So You’ve Got Cancer: A Super Patient’s Guide to Diagnosis, Treatment, and Beyond. You can find it here.

Triage

The following is a guest post from Dr. Sarah Fraser:

During my surgery rotation as a third year medical student, my resident sends me to the Emergency Department to assess a new consult. She tells me to “make it quick” and I hustle down to meet my patient.

Mr. Jones is a 64-year-old male who rarely goes to the doctor. He has been vomiting for two days and has a fever. His heart rate is up and his blood pressure is low; his belly is swollen up like a beach ball. When I examine his abdomen, he winces in pain with even the lightest touch. The x-ray shows a bowel obstruction and free air in the belly, a sign of intestinal perforation. I know he needs surgery.

Stat.

I text my resident who tells me I have five minutes to get the paperwork in order before transporting him to the operating room. As I am about to start writing my note, a frail, elderly woman emerges from a different room with a troubled expression on her face.

“I need help. My husband’s IV is beeping and we need to shut it off.” There is fear in her voice.

I quickly decide that her problem is not an urgent one. The IV is probably beeping because the fluid is done dripping in, or maybe the line is kinked. But the man with the busted bowels–that is urgent. I need to devote every ounce of my attention toward finishing my note and getting that man into surgery.

“I’m dealing with an emergency right now, but your nurse should be back shortly.”

“We need to stop the beeping!” She is on the verge of tears.

“It’s probably nothing serious. I’m really sorry but I can’t help you right now.” I put my head down and continue writing.

“The help here is awful,” she says, returning to her room with her sick husband and his beepy IV.

A knot forms in my stomach as I continue with my note.

Was there time to have helped her? Maybe, but I had a short deadline and was feeling the pressure. Relieving the concerns of this elderly lady would have taken away from the care I was providing for a the very sick Mr. Jones. So I prioritized, and in doing so, I failed to address her request, leaving her disappointed and probably scared.

Though I didn’t realize it at the time, when I ignored one person and prioritized a sicker patient, I was doing something called triaging. Every day in the Emergency Department, doctors and nurses are forced to choose who needs help and attention more critically.

Before entering the field of medicine, I remember sitting in the Emergency Department as a patient with a fever and chills, watching others who came in hours later being treated before me. Nobody likes to feel ignored. What the general public does not always realize is that there is a triaging system, where patients are given a score from one to five based on how sick they are. It is a system that helps us deal with the sickest first, though it can lead to long wait times for those with less serious issues.

Though I postponed dealing with the concern of the elderly woman that day, I also learned an important lesson. In medicine, you need to assess and assign degrees of urgency, and in doing so, you can’t please everyone all the time. And you have to be okay with that. What matters most is that you prioritize to the best of your ability, and do your part to keep everybody healthy, and most importantly, alive.

Dr. Sarah Fraser is an author, family physician and human rights activist in Nova Scotia, Canada. She is author of Humanity Emergency, a poetry collection about the need for more compassion in the field of medicine. Her work appears in the Canadian Family Physician, Ars Medica and the Journal of Academic Psychiatry, The Coast, Capital Xtra and on kevinmd.com

“Crowding,” and Other Items

The stock market is up. But the economy sputters along–it grows, but only slowly.

The health care sector has been an exception to the trend of slow growth. It continues to employ more Americans than ever before, without much sign of slowing down.

[Correction. Here’s a sign of some slowing.]

The health care industry has become so huge that it comprises nearly 1/5 of the economy. Now 1/9 American workers are somehow in health care (think medical coders, billing specialists, and various administrators). It’s astonishing. Whole cities (Hello Cleveland, Pittsburgh, etc., etc.) rely on health care as their #1 sources of jobs/income/investment.

[For a superb treatment of this phenomenon, read Chad Terhune’s piece here.]

A while back I read a great essay by a health care pundit who talked of health care spending “crowding out” other forms of public investment.

Think of it this way: a government collects taxes. If it spends an increasing amount on health care goods and services each year, there is less available for education, roads, infrastructure, etc.

It may not quite be a zero sum game, but it’s darn close.


Don’t You Just Love Those Drug Ads on TV?

I wrote new essay for NPR’s health blog, Shots, in honor of the 20th anniversary of drug ads appearing on TV in the U.S.

You can click on the box below to have a look. It ran with more great collage art by @KatStreeter.

How to Age Better: Live somewhere that combats Loneliness, Helplessness, and Boredom

At GlassHospital we strive to bring you interesting ideas about improving health and health care from places far and wide:

An article in the Saskatoon (Saskatchewan) StarPhoenix features Suellen Beatty, CEO of the Sherbrooke Community Centre in Canada.

Sherbrooke is a community centre, but it also is home to more than 250 residents — the kind of place we might call a ‘nursing home’ in the U.S. I love that in Canada they’re called Community Centres. That’s what any facility or neighborhood should strive for.

Suellen Beatty rejects the idea that nursing homes are places where people go to await death. Her team’s philosophy is to make old age more fun. Sherbrooke readily acknowledges the big three elements that compound the infirmities of aging: Loneliness, helplessness, and BOREDOM.

By loading up the day with activities, by listening to their residents and families, and by hosting hundreds of volunteers who see their job as providing fun and emotional sustenance to resident and day-visitor elders, Sherbrooke attracts visitors from all over the world who marvel at its success.

It reminds me a of a piece we ran a few years ago about a pretty special elder care facility in Arizona–one that put its residents’ happiness and comfort above all else — even when it means deviating from ‘standard’ protocols of elder care like eating bland food.

Take a look at what’s going on in Saskatchewan. We can all learn.

Marching for Science

Another piece I recommend: This time from Vox, in their First Person section.

It’s an essay by someone close to me who appreciates the scientific advancements which will help her survive the breast cancer she’s just been diagnosed with.

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