Reflections in a Head Mirror

The gas station has lots of signs. “We card!” reads one. At the same time, other signs read: “Alive with pleasure!”  “Buy one pack, get one free!” ”Lowest legal cigarette prices!”

The signs drive me nuts.

Why do cigarette makers advertise? Well, because it works, of course. Teens began smoking Camels in unprecedented numbers after the cartoon character, Joe Camel, was introduced in 1988. The campaign was so effective that Congress banned the use of cartoon characters, cigarette brand clothing, and several other marketing practices in 1997.

Can you guess how the cigarette companies spend their money now? The tobacco manufacturers now put 94% of their advertising budgets into point-of-sale marketing; examples include in-store and window displays, price promotions, on-pack coupons, and value-added gift offers.

Marketing has a direct impact on whether kids will begin or increase tobacco use. A study by Dr. Sandy Slater and others in the May 2007 Archives of Pediatrics and Adolescent Medicine concludes that initiating smoking was associated with increased advertsing in non-smoking teens. Lower cigarette prices were associated with progression to regular smoking in teens who were light smokers.  

Federal Trade Commission data show that the tobacco industry spent $14.2 billion for advertising in 2003. Compare that with the entire 2003 National Cancer Institute budget of just under $4.6 billion! Does it make sense that three times more money is spent to encourage teen smoking as to provide federal support for cancer research?

Our campus is going smoke-free in November. Our state legislature is considering making all Wisconsin businesses smoke-free. Whenever I walk into a gas station and look at the signs, I realize that going smoke-free can’t happen soon enough for this cancer surgeon.

In the years before I went to medical school, I worked as a nurse’s aide. Early one morning, one of the surgeons dropped by the Emergency Room in a particularly good mood. The ER doctor asked him why he was so happy.

“It was the first night in a week that I did not get a 2:30 a.m. phone call from Mrs. Swanson,” he replied. I pretended to work but kept listening.

“Really? Why does she call you at night?”

“Well, it seems that since being discharged from the hospital, she hasn’t been sleeping well at all. I prescribed medication, relaxation, exercise, dietary change … anything I could think of … but she could not sleep! She was spending hours each night roaming throughout her house.”

“And ...?”

“And so, when she couldn’t sleep, she would call me at home at 2:30 a.m. and tell me how miserable she was! Every night, the phone would ring and there she would be!”

“What would she say?”

“Not much. Same thing every night. ‘Doctor, are you asleep? I can’t sleep, Doctor! Can’t you give me something? I feel so tired, Doctor! When will I sleep?’ I was running out of ideas.”

The ER doctor thought for a second. “Why didn’t you tell her to call in the morning?”

“I DID tell her that, of course. It just didn’t make any difference.”

They stood silently for a while. I'm not certain what the surgeon was thinking, but I'm certain the ER doctor was trying to come up with other treatment options. The absurdity of the situation percolated for a few moments; they both pictured the bleary-eyed woman forlornly padding around in robe and slippers repeatedly checking the clock and finally picking up the phone to make her nightly call.  

The ER doctor spoke: “But you said you slept through the night last night …”

“No, I didn’t say that. What I said was, ‘I didn’t get a call at 2:30 a.m ...'"

The ER doctor was confused. “What do you mean?”

“I mean she didn’t call ME.”

“Oh, no! You didn’t …”

“Of course I did! At 3:00 a.m., my alarm went off. I picked up the phone and called HER! ‘Were you sleeping, Mrs. Swanson? You were? Oh, that's wonderful! I'm so happy for you! I just wanted to make sure you were doing okay! Uninterrupted sleep is so refreshing, don't you think? Well, good night!’  She mumbled something in return. I'm pretty confident that will be our last nighttime phone conversation!”

The ER doctor shook his head. The surgeon grinned and pushed the metal plate on the wall and the ER doors slid apart. He was humming as he headed down the corridor towards the elevator that would take him to the operating room where he would start his day.

“Mourning has become unfashionable in the United States. The bereaved are supposed to pull themselves together as quickly as possible and to reweave the torn fabric of life.” -Margaret Mead    

For many years, I have attempted to write a personal note to the family whenever one of my patients dies. The task runs in streaks; a few weeks ago, I wrote cards to three separate families. Several times each year, I attend a visitation.

Writing notes and saying goodbye to families was not easy at first. I selfishly worried that they would “blame” me.

Instead, I have been overwhelmed by the warmth, gratitude, and caring that the families express. They often single me out for family introductions and to share wonderful stories that open new windows for me. Many times, we all realize that we have shared some truly unique experiences.  

The value of these gestures came into focus as I recently re-read “The Doctor’s Letter of Condolence” (Bedell SE, Cadenhead K, Graboys TB, NEJM 2001; 344:1162-1164). The writers describe the physician’s historically important role in mourning. They provide guidance on how a letter should be written. They point out that “failure to communicate with the family members conveys a lack of concern about their loss…particularly when we share with them some of the most profound moments of life and death.”  

When my father died a couple of years ago, my mother and I spent some time looking over the cards we had received. Among the messages from friends and family was a note from my dad’s internist. It was warm and personal. It showed thought. I had a renewed sense of appreciation for both the physician and the gestures of sympathy.  

I recently ordered a new box of note cards. I wonder what stories I will accumulate before it is time to order another.      

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A previous version of this essay appeared in the MCW Cancer Center News.

"Hey, Doc! How ya doin'? Look at how great this scar healed up! You did a fantastic job! Man, I LOVE this place! You look great! What are your kids up to these days? Did you lose some weight? Give me some more good news!"

I laugh and hold up my hand, but he is irrepressible. Had we initially met socially rather than because of his cancer, I realize that we would have quickly become friends. During his office visits, I can expect stimulating conversation, new stories about his family, and a shared confidence or two. I really enjoy his appointments.

And that worries me.

There are a couple of reasons for my concern. First of all, despite the fact that physicians should care deeply about the health and well being of all of their patients, the therapeutic relationship is not based on “friendship.” Physicians must be vigilant and objective in ways that friendly relationships can disturb.

Second, physicians need to provide care with Justice. All patients who come to us, whether they look like us or not, deserve the same quality of care. Physicians must be scrupulously fair in the equitable distribution of their time and attention. It is clearly unethical to spend more time with a patient simply because they remind us of ourselves.

Medical blogger, Kevin, MD, has a link to a New York Magazine article that interviews several anonymous physicians. These doctors provide blunt, sometimes disturbing observations on everything from picking a doctor to medical mishaps. In response to a question on how patients can get doctors to pay attention to them, a gynecologist responds, “The truth is, we’ll spend more time with patients we like. We’ll joke with them, we’ll laugh with them. You have fun with patients you like." He implies that being charming pays benefits. Interestingly, neither the interviewer nor the other physicians challenges him.

Someone once told me, “It often seems that the worst medical care is given to VIPs and to doctors’ families.” It certainly seems to be true at times. Corners get cut. Potentially embarrassing critical questions are left unasked. Treatment is too hesitant or too aggressive. In an effort to be both a physician and “something more,” things can happen. 

My easygoing, friendly patient sits grinning at me. I truly am happy to see him, but the alarm bells go off in my head. I keep a "safe" distance, keep to my checklist, and try, once again, to overlook how much fun it is to see him. 

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The following is feedback received for this blog:

I agree with you. I find it harder to be objective if I become too "close" to a patient. And I regret often that I can not be a friend to that person, because some of them would be great to have as friends. - Ramona Bates ------------------- I agree with you that care varies depending on the interpersonal relationship between physician and patient. It's a complex interaction - and the patient's personality and treatment preferences (do they want "everything done" or want to try the "wait and see" route?) can (and sometimes should) influence management. It's ok if you spend more time chatting with one patient more than another - but we need to make sure that the full range of treatment options are explained to all patients as we help them navigate to the choice that's right for them. - Val Jones ------------------- This was an interesting post. I realize that the original intent was to encourage physicians to be fair in how they allocate their time between patients. However, there are lessons to be learned for us patients as well. After all, how often do we hear from people who feel they don't get the attention they deserve from healthcare providers? Maybe the answer is... if you want more attention from your doctor, try being a better patient. (I feel a blog post coming on...) Great blog, btw. Keep up the good work. - Dean Moyer ------------------- just wanted to say thanks for a great post... usually don't see this amount of ethical consideration of these matters (time and objectivity) ... these are same issues i myself wrestle with in own life in different contexts... same principles can be carried over into other situations. - w mersy

Cancer fatigue is a long-lasting and vexing problem for many survivors. Any breakthroughs will be welcome.

Although exercise remains the most effective treatment, a placebo-controlled study presented at last week’s American Society of Clinical Oncology meeting demonstrated a benefit to patients taking American ginseng. Debra L. Barton, RN, PhD, (Associate Professor of Oncology at the Mayo Clinic Cancer Center) presented the data. Some of the findings reported in the pre-meeting abstract include:

• Had better scores on the Brief Fatigue Index
• Were more likely to report their fatigue levels were “very much better” (25% v. 10%).
• Were more likely to report that they were satisfied with the medication (33% v. 13%).

This was a pilot study, and Dr. Barton was quoted in the Milwaukee Journal Sentinel as saying, “we’re not recommending this.” She added that more studies will be needed to reach sound conclusions.

Fatigue is a real problem for my cancer survivors and we talk about it frequently. Although ginseng is not for everyone, I am certain that I will be getting lots of questions over the coming weeks and months.

Recently, I saw a middle-aged ex-smoker with throat pain. The standard Medical History carefully characterized the pain’s location, duration and character. He thoughtfully answered all of the questions. Soon, I understood where and when he hurt and what he needed to do to make the pain go away. He allowed that as long as he spoke quietly, he felt fine and could stay pain-free.  

That did not alleviate his concerns, however.  

To do that, he had to tell me about his calling as a Pentecostal minister. He expressed some of the joy he had experienced from years spent shouting, singing, imploring, cajoling and inspiring. The pain, he said, made it impossible for him to continue. He could still teach and counsel, but his days at the pulpit appeared to be over.  

I do not know if we can solve the problem, but we set a plan in motion that addresses not only the pain, but the context in which the pain occurs. Perhaps, someday, he will return to the pulpit.  

A wonderful essay by The Cheerful Oncologist explores the importance of eliciting the patient’s Social History; he shares his insights into how hearing patients’ stories can be both a delightful and a critical exercise. Spending the moments needed to gather the Social History gives the care provider new insights, clues, and treatment options.