Reflections in a Head Mirror

"Two things are infinite: the universe and human stupidity; and I'm not certain about the universe."
- Albert Einstein


Several years ago, with alarms sounding in the background, I answered an urgent page. “Dr. Campbell, please come to Mr. Pearson’s hospital room immediately.” I dropped what I had been working on and headed to the floor.    

Mr. Pearson was in his mid-50s but he looked much, much older. Like many patients with cancer of the throat, he had started smoking as a teenager. His first cancer had been treated several years before and, despite strong admonitions, he had continued to smoke and drink. When the second cancer appeared, we made a last-ditch effort to remove it surgically. Now, a few days after that procedure, he was languishing in a hospital bed, attached to tubes, and too weak to move around.    

I got to the room. “What’s wrong?” I asked. “Is he all right?”    

The staff alternated between anger and relief as they told me the story.

One of the nurses had been walking past his room and smelled something burning just as the alarms began. She pushed open the door to investigate and, sure enough, there was Mr. Pearson trying to put out a fire that had started in his bed. Apparently, he had decided to have a cigarette and had accidentally ignited the sheets. She quickly moved him into a chair and doused the blaze. The room smelled of smoke, burnt cloth, and ash as staff and firefighters slowly finished cleaning up and went back to work. Fortunately, my patient was unharmed. I was amazed by the entire scene.

“What were you thinking? You set your room on fire! Why didn’t you call for help?” I asked.      

He shrugged. Gesturing towards the nurses, "I knew they would be mad," he said. "By the way, is there is a smoking area nearby?” he asked.      

Duh, I thought. “No, there isn’t.”      

“Didn’t think so.” He slumped deeper into the chair.    

A couple of days later, an administrator contacted me because they were thinking of filing criminal charges against my patient. As Mr. Pearson's health deteriorated, they reconsidered. 

What an incredible addiction is nicotine! We were fortunate that there was no catastrophe. It was a memorable day.

“Difficulties increase the nearer we get to the goal.”
-Goethe    



Have you ever noticed this, as well?  

When the kids were little and we were driving cross-country, they would play and bicker pleasantly all day long in the back seat. Things were not exactly peaceful, but there was an acceptable level of uproar that allowed for happiness in the back of the car and conversation in the front. However, it never failed that when it was time to find a gas station, locate a campground, or figure out how to find an address in some unfamiliar city, the noise level always seemed to reach deafening and distracting proportions.  

“How come you always get out of control just before it is time to stop?” I would yell. They would look at me blankly and sulk the rest of the way to our destination. "Bad Daddy," I would think later.  

Interestingly, I was reminded of our car trips one day while working in the operating room. The bilateral neck dissections were proceeding smoothly. Our goal was to remove all of the cancer-containing lymph nodes in the neck, especially adjacent to both jugular veins.   

The dissection on the right side went well although the cancer had grown directly through the wall of that jugular vein. In order to clear the cancer, we removed the vein, a maneuver that has no long-term side effects. I reminded the residents that we would have to save the jugular vein on the left because removing both veins almost always leads to complications.  

As we lifted the nodes off of the left jugular vein, my heart sank. Once again, the cancer had invaded the vein. My mind flashed back to images of a patient for whom I had cared during my own residency who had lost both jugular veins — his head had swollen up dramatically, his eyes swollen shut and his lips massively enlarged. The swelling took weeks to resolve. I never wanted to see that problem again.  

Suddenly, the radio was too loud and the normal operating room chatter became oppressive. The distractions in the room became overwhelming.  

“Could you please turn down the music?!”  

The operating room stilled while I continued to attempt to free up the vein. I dissected the mass from every angle, working to see if I could discover a hidden plane between the cancer and the vein. It proved impossible. Finally, I conceded that the vein needed to be removed.  

I had not encountered this exact situation in the past. Just to see what options might exist, I asked a colleague from Vascular Surgery to take a look at the vein. The surgeon scrubbed in and grafted a leg vein into the neck to replace the portion of the jugular that I had removed. The graft went in perfectly and flow through the vein was re-established. I was relieved.  

The case suddenly became routine once again. As we closed the wound, I noticed that things were very quiet in the room.   “You can turn the radio up again.”  The chatter resumed. Things were back to normal.  


Who would have thought that a day in the operating room could have the same long, routine stretches and brief moments of intense concentration as a driving trip with the kids? And that my reaction would be exactly the same?

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The following is feedback received for this blog: Great post. OF course, I am reading this right before a 8 hour driving trip to Chicago with two year old twins. At least I can think I am not in the OR in any capacity! - Christian Sinclair www.pallimed.org Interesting parallels... :) - Val Jones www.revolutionhealth.com/blogs/valjonesmd

“Isn’t it a bit unnerving that doctors call what they do ‘practice?’”
-George Carlin  


My bad.  

A few months ago, on a day when I was already in a sour mood, I walked past the kiosks at the local mall trying to fend off the sales pitches — “No, I don’t need a phone;” “No, thanks, but I don’t need basement waterproofing;” “Thanks, but I already have a watch.” Suddenly, a pleasant, young woman with a lip piercing approached me.  

“Sir, would you like to learn how a scan can save your life?”  

Here, I was told, was an opportunity to use the very latest technology to check me for heart disease, screen me for many types of cancer, and make certain I was free of dangerous gall stones. The testing would be painless, I wouldn’t have to remove my clothes, and a package screening deal would allow for enormous discounts. My insurance company might even pay for some of the testing! She smiled and looked at me hopefully.  

I guess I snapped. “Are you aware that the screening tests that your company sells have never been shown to be effective?” She regarded me with surprise. With as much composure as I could muster, I tried to explain that neither the CT angiogram nor CT lung cancer screening had ever completed clinical trials testing. Over the next couple of minutes, I’m pretty certain I moved on to telling her what I thought of the company for which she worked. “You should think twice about this job,” I recall saying. She turned away and I mumbled an apology. Pretty soon, she had buttonholed another potential customer.  

I admit that I was embarrassed by my rant. The encounter resurfaced in my memory when I read an article entitled “Weighing the Costs of a CT Scan’s Look Inside the Heart” in The New York Times (June 29, 2008). The authors much more eloquently make the same case that I tried to make with that unfortunate saleswoman. Undoubtedly, doctors who have embraced the technology clearly disagree with doctors who have called for more research and evidence. Still, the article notes that a “faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques.”  

There are risks, of course. The article cites an expert who calculated that a CT angiogram uses the same amount of radiation as over a thousand conventional chest X-rays. On top of that, Americans spent over $100 million on 150,000 CT angiograms last year. Those volumes will only rise in the future.   

Whenever we are putting our patients at risk, either medically or financially, it seems to me that we should always try to act based on what we know is true rather than what we only wish was true. One of my medical school professors told our class many years ago, “Half of what we teach you in Medicine is wrong. The problem is this: We don’t know which half.” Some days, it seems like what we really, truly know is even less than that.  

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The following is feedback received for this blog: Thanks for this... my father, a non-smoker in great shape at 62, was diagnosed this month with stage 4 lung cancer. His prognosis is not good, and amongst all the other emotions comes the inevitable second-guessing about "could we have caught it sooner?" He was lamenting that while he's heard all those offers for "life saving scans" on the radio, he had always brushed them off as "life saving scams", but now found himself wondering if he should have had one. It may be reassuring for him to hear your viewpoint on these offers. I'll direct him to your blog. Good for you! I detest the whole-body scan vultures. What people don't understand is that you can pay for the scan, but you can't go to the mall to get the thought process a real doctor puts into the decision to order the scan. - Theresa www.ruraldoctoring.com Great post. A growing problem. And an uncomfortable one to face as a primary care doctor, especially when some local cardiologists are really pushing them. Patients come back to me asking why I never ordered it. It's hard not to snap and sputter like you did to the mall chick. - Dr. Smak www.drsmak.blogspot.com What struck me in The New York Times article "Weighing the Costs of a CT Scan Inside the Heart" was what the story omitted: peer-reviewed and emerging clinical trial data showing that CTA scans produce cost savings and improve patient outcomes. Also, for a story of this length to leave out any discussion of appropriateness criteria - even though cardiology and radiology medical societies already have programs in place, and both criteria are part of the current policy discussion - is curious. In my estimation, it fails to offer readers balanced information to help inform their decisions. There are numerous peer-reviewed studies demonstrating that CT scans detect heart disease and help patients avoid cardiac catheterization. For example, the article could have cited a 2007 study in the Journal of the American College of Cardiology, which found that multi-slice heart scans significantly reduced diagnostic time and produced cost savings. It could have also cited a recent study demonstrating how CT heart scans are an effective and cost-saving tool in selecting patients for cardiac catheterization. The selective catheterization resulted in average cost savings of $1,454 per patient. Proper utilization of any medical technology is important, and the majority of doctors do use medical imaging appropriately, without standing to realize any financial gain from doing so. In fact, according to 2005 Medicare claims data, an average of 94% of CT, MRI, PET and SPECT referrals are made to physicians who do not order the tests, and that percentage is even higher for cardiac imaging. To address the small minority of instances when imaging is improperly used, policymakers and medical societies are embracing appropriateness criteria and accreditation requirements as effective solutions that allow health decisions to remain in the domain of physicians and patients rather than insurance companies. Unfortunately, The Times story made no mention of this either. CT heart scans eliminate the need for an invasive and expensive procedure to diagnose coronary artery disease by providing precise and comprehensive information on heart ailments without surgery and within seconds. Yes, a CT heart scan may seem expensive when viewed in isolation, but compare the price tag of a one time scan to the cumulative, long-term costs that will come with its regrettable alternatives: repetitive consultation and progression of disease and inappropriate treatment. Talk about penny wise and pound foolish-especially considering that coronary artery disease is the most common type of heart disease, and the number one killer for both men and women. Thankfully, Medicare's recent heart CT scan coverage decision allowed continued patient access to these tremendously valuable scans, which have revolutionized the way doctors diagnose heart disease, and become the standard of care for cardiac disease throughout the country and the world. I am certain that patients across America are benefiting as a result, and in this vein, it is incumbent upon us and our healthcare system to ensure that physicians are continually armed with improved resources for diagnosing and treating disease more precisely, effectively and efficiently - not restricted in their ability to save lives. - Andrew Whitman Vice President, Medical Imaging & Technology Alliance http://www.medicalimaging.org/ Believe me, I am no expert, but the issue, of course, isn't whether new technology should be available to people when indicated to diagnose and treat disease. The issue is the direct-to-consumer marketing and the possibility that the people who own the devices might be tempted to overutilize the resource for whatever reason.   When people who directly profit from the use of the CT angiograms are quoted as saying, “It’s incumbent on the community to dispense with the need for evidence-based medicine,” the industry should be concerned.   Thanks for your comments. -Bruce Campbell, MD In this case, I don't think any expert can argue it appropriate to do mass screenings of the general public with CT scans. It seems the health insurance companies are not the only people hiring high school graduates to direct the rationing of healthcare. Direct marketing to consumers is highly frustrating to me - even with simple, evidence-based testing like lipid profiles that are done in malls or business settings by healthcare "companies." Patients end up getting fractured preventive care. Nothing beats a dedicated primary care physician who provides comprehensive preventive care services. - Jonathan Dee www.nzou.com

“Silence is more eloquent than words.”
-Thomas Carlyle  


He was a stoic guy who had spent his entire life on a farm. The skin draping over his lanky frame was weathered, but his clothes were clean and his boots were freshly polished. His feed cap hung on the hook behind the door.  

He had been free of cancer for a few years, begrudgingly returning for follow-up visits with the same enthusiasm that he probably reserved for trips to the dentist, the fabric store, or the shopping mall. As I entered the room, he tensed briefly like a cornered animal.  

“Good afternoon, Mr. Anderson. Anything new?”  

“Nope,” he answered. He looked at the floor just in front of his feet.  

I reviewed my last note, updating his history and trying to coax answers from him. He responded to each question with a barely perceptible gesture and “Nope,” “Yep,” or “Dunno.”  

Fortunately, everything appeared to be stable. I examined his throat, finding no new areas of concern. He shifted in the exam chair, sensing that the appointment would soon be finished. As he stood to leave, I glanced at the tooled leather belt and large buckle that he had worn to each appointment.  

“You’ve been out to your workbench, haven’t you?” I asked.  

He stared at me blankly. “Hmmm?”  

I pointed at his belt. “You got out your awl to make some new holes, I suspect.”  

He shrugged and sank back into his chair as though I had caught him pilfering cookies. “Yep.”  

“How much weight have you lost?”  

“Dunno.”  

I checked back in his record and found that he had dropped 20 pounds since the previous year. He allowed that he had been having increasing problems with swallowing for several months. I explained that patients who survived one cancer are at risk for side effects and even more tumors.  

“Cancer?” he asked.  

“We don’t know that yet. We’ll work on this together,” I said. I began the process of ordering tests and setting up visits. “We will find out what is going on, and do everything we can to solve this for you,” I promised.  

He stood, preparing to leave. He stared at the list of appointments that I had handed to him. As he retrieved his hat, he shook his head, gripped my hand, and said “Hmmm-hmmm." 

I looked at him. “I know." I said. "You’re welcome."