Demystifying Medicine One Month at a Time

Tag: the Atlantic

Age is Just a Number, Right?

In case you missed them, a couple of lay press articles hammered home the idea of our lifespans being finite.

ezekiel_emanuel_0First there was Zeke Emanuel’s provocatively titled “Why I Hope to Die at 75” in the Atlantic.

The title was unnecessarily inflammatory. A lot of people saw that and thought “Health Care Rationing…” and “what a jerk!

One of the core points of his article is well-taken: when we hit a certain age (75? 80? 85?), it no longer makes sense to “look for disease.”

Health care must continue improving and striving to reflect and honor the wishes of patients, but in addition, we should be more rational about whom we screen for disease and how often. It makes no sense to perform colonscopies in octogenarians to “screen” for colon cancer. Even if they have it, the colonoscopy  is unlikely to extend their life or improve its quality.

I think readers are right to quibble with Emanuel’s contention that at 75 creativity takes a nose dive. He was using that opinion, and the statistical evidence of age-related slowdown, in support of his point about the cutoff age for aggressive medical care. I hope sensible debate is not lost because of his tone and the fact that he’s seen as too political. He did work for the administration during President Obama’s first term, after all.

cohen-01-by_david_boswell

Cohen in younger days.

That same week, the New York Times published an opinion piece by Jason Karlawash of Penn, who wrote about musician Leonard Cohen’s decision to resume smoking (something he’d quit) upon turning 80. Titled “Too Young to Die, Too Old to Worry,” Karlawash examined how the 80+ population has grown from a half of one percent of the population to more than 3.5%. Doesn’t seem like a huge percentage, but it is certainly a significant increase and a huge demographic shift.

As Karlawash writes in the key paragraph of his piece

…Mr. Cohen’s plan presents a provocative question: When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?

Mailbag

Dear Glass:

I loved your recent piece on unnecessary screening tests in the Atlantic.

“Letters! We’ve got letters!”

You explain things so simply and clearly. Kudos!

One question, though. I understand when you say in general that CT scans for lung cancer screening can be dangerous. Excess radiation exposure, incidentalomas, cost, etc. I get it. But for those occasions when someone gets a lung tumor discovered early, don’t you think the screening is actually worth it? I mean, how can finding cancer earlier NOT prolong life?

Sincerely,

Paula from Paducah

Good question. Two related answers.

The first is the concept of lead-time bias. [Look at figure 2 in the article linked here.]

Simply defined, lead-time bias gives a the false impression of prolonged life, because the time of diagnosis occurs earlier. But in diseases for which the treatment we have doesn’t alter the course of the illness (like lung cancer), we do not actually prolong life. So the “early” diagnosis is in fact an artifact.

Reason 2 is that lung cancer discovered on screening CTs is usually too far advanced to make early treatment meaningful in terms of survival benefit. Put another way, even if you know earlier that you have the illness, it doesn’t make a difference (in aggregate) for people with the disease.

This stuff is hard because if you’re the one (or you have a family member or friend) with the disease, it seems logical that it HAS to make a difference to find the information sooner rather than later.

Sadly, at this point, it’s just not true.

Lamentation

I had an article published on the Atlantic’s website.

I’ve been struck over the last few years by how many graduates in my field of internal medicine choose NOT to work as ‘traditional’ internists.

Some good readin’.

Call us what you like:

  • traditional internists
  • general internists
  • primary care internists
  • outpatient internists
  • just plain old internists

You can see we’ve always had a problem with what we’re called. What is an ‘internist’ anyway? No one has any problem understanding what a cardiologist is. It’s right there in the name.

Subspecialties have always been a good career path for Internal Medicine graduates. But those of us that didn’t want to do the additional training (three to four more years) to become certified in a specific body part could always be internists.

But now our graduates are choosing hospital work as the path of least resistance. And for good reasons:

  • Better pay
  • Flexible scheduling
  • No ‘on-call’ (i.e. after hour) duties
  • Feeling better trained for the work

Part of me is jealous that this opportunity did not exist as such when I graduated twelve years ago. Part of me is sad that our trainees don’t want to take the job that I willingly signed up for.

The hospital has excellent systems in place to provide good care for patients. The doctors that work there are part of a well-oiled (well, at least greasy) machine that caters to them as much (if not more) than it does for patients.

Not true in the office world, where there is less support. More of the administrative, financial and organizational burdens fall on the doctors. That isn’t inherently bad, but it’s not what we are trained to do. And by comparison, it makes the practice of outpatient (office) medicine that much harder.

More importantly, there’s the relationship aspect: I chose to work in primary care because my relationship with patients would evolve over decades. I believed (and still do) that by getting to know patients more thoroughly over time, I can provide better, more informed, value-conscious care. The relationship between a hospitalist and a patient lasts days. Then it’s over. For an ER doc, it’s hours or even minutes. I’m not passing judgement; it’s just a different type of thing altogether.

I think about my patients at night. On the weekends. In the shower. Wherever and whenever.

In site-based care, like the hospital or the ER, when your shift is over, you go home. Without your work. [I know, of course doctors in these settings think about their patients when they go home. It’s just the idea of this ‘freedom’ that rankles.]

I could jump ship and become a hospitalist. As I reported in the article, a colleague left her office practice after twenty-three years. Her patients are upset, confused, wistful. Grateful for her care over the many years. Happy for her personally on an intellectual level. But emotionally distraught.

When I started researching the article, I identified with Dr. Fingold (read the article for context). To some degree, I looked at Dr. Wachter as someone who had unleashed a profession-altering (destroying?) force into the world.

By the time I was finished, I realized that things are not that simple. Dr. Wachter took me on a whirlwind tour of the history of hospitalists and their impact in American medicine–and it’s quite a story. He certainly didn’t unleash the disruptive force as much as he understood it, rode it, catalogued it, and helped develop it.

“I invented the term ‘hospitalist’ like Al Gore invented the Internet,” is only one of his well-crafted interview lines.

The work I did for the article is helping me to radically re-think both how we practice and deliver health care, including how we teach it to our future doctors, regardless of where they end up practicing.

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