Reflections

Familiarity

Sun, 25 Jul 2010 07:55:30 GMT

We say we exchange words when we meet. What we exchange is souls.
-Minot J. Savage

It was Monday evening. The shelves in the electronics department overflowed with different styles, prices, and brands of headphones, all displayed in sealed plastic cases. I was in the mood to buy but was baffled by the array of options in front of me. This was not going to be as simple as I had thought.

A young salesperson broke off his conversation and sauntered casually to where I was struggling. Grinning impishly, he leaned on the display. “Hey,” he wanted to know, “how was your weekend?”

“How was my weekend?” I repeated silently to myself. I neither looked up nor answered. What kind of question was that? Was this some new technique he had learned guaranteed to increase the likelihood of a sale? I’m here looking at headphones and he wants to know about my weekend?

I put down the package I was examining and glanced up at him. “It was busy but I doubt anything that happened would be of much interest to you.” My desire to spend money at that store had evaporated. As I headed toward the door, he called after me to wish me a nice day. I can only imagine his facial expression as he did so.

The next morning, I was in the office seeing a newly diagnosed cancer patient. Each question about her cancer and its symptoms elicited more anxiety. She nearly shook as she related the problems she had experienced: worsening pain, trouble swallowing, difficulty talking. Her unease only grew as I probed her smoking and dietary habits. Her family tried to reassure her.

I crossed the room to begin the examination. As I checked her skin, I noticed that she had a faint sunburn. Maybe there was a story there. “So tell me,” I asked with a smile, “how was your weekend?”

Her face lit up. As I continued the examination, she told me about how Saturday had been spent outdoors watching her grandchildren play soccer, taking them both to the park, and then stopping for ice cream. Sunday had started with church and then a quiet afternoon with an old and dear friend. By the time she finished, she had visibly relaxed and I had a context through which to understand how her upcoming treatment would affect her, her family, and her close friends.

I suppose it was presumptuous of me to ask about my patient’s weekend. I had, after all, bristled at the notion that the young salesperson considered it his right to ask about mine. Occasionally, a patient will let me know that I have crossed a boundary when I steer the discussion toward the more personal.

Most of the time, though, my patients are very willing to share their stories. From my perspective, there are practical reasons to understand social contexts and relationships; what they choose to share often points to the people and things that are most important to them.

Months from now, when the fear of the disease has been mastered and she finally sees her life as pre-cancer and post-cancer, it is very possible that my patient will turn to me with a smile and ask about my weekend. As I happily summarize my time away from work, maybe I will throw in the tale about how I was so rude to the young salesperson. I suspect we will laugh at both his ingratiating tactic and my overly sensitive reaction. After all, when I tell it correctly, it really does make for a great story.

In Memory of My Father-In-Law

Tue, 22 Jun 2010 19:10:46 GMT

All would live long, but none would be old.
-Benjamin Franklin

When I first met him three decades ago, he was a clever, accomplished 60-year-old. He was self-aware, well-versed, well-read, and well-travelled. He was rigorously honest, selfless in his actions, and generous with his time. He was engaged with friends and colleagues from around the world. His self-deprecating humor was well-known to everyone who knew him. At the time, he was about to retire from a career combining his gifts as a beloved teacher, a respected leader, and a deeply spiritual intellect.

One thing really annoyed me, though: It seemed that whenever a conversation had reached a stopping point and I had taken a couple of steps toward the door, he would invariably call out one more question. It happened all the time. With each new query, I would turn back, finish the conversation again, and retreat. Sometimes, this happened two or three times before I would finally escape.

Over the years, I became accustomed to this propensity of his. Sometimes, I found ways to distract him as I snuck out. (“Look! A huge bird! Right behind you!”) Too many times, I mumbled an answer or pretended that I had missed his final question. I did not like being rude. Sometimes, though, it seemed the easiest way out.

During the final years of his life, Alzheimer’s Disease tightened its grip. His eyes still sparkled when he got a hug from his grandchildren. He remained pleasant and attentive, playing card games with help. He could answer simple questions appropriately when they allowed for an automatic response and was able to maintain a social veneer long after the ability to reason had abandoned him.

Somewhere along the way, though, he stopped calling me back for just one more question. I never noticed when the habit vanished.

Who would have thought that his loss of spontaneity would be manifest by no longer needing to prolong a conversation? Who would have thought that he would still be able to process and answer simple questions but no longer be able to create his own?

As he neared the end of his life, I was not surprised to find that I missed those moments every time we concluded one of our simple conversations and he sat quietly, watching me walk away.

The following is feedback received for this blog:

Sorry for your family's loss.

- rlbates
http://rlbatesmd.blogspot.com/

Your blog just beautifully summarized what my family is experiencing with my father-in-law. Thank you for putting it into words.

- Nora Sale

Nicely done, Dr. Campbell. I wonder how many times this pattern has been replicated? That which was so annoying becomes that which we miss...

- richard holloway

Dr. Campbell- isn't it interesting that the things that often irk us most about family are the things we miss the most when they are gone! Sorry for your loss.

- karen rudzinski

What a beautiful tribute to your father-in-law! Your honesty allows us to identify with our own situations and recognize how we might strive to make the best of our relationships. Thanks for being so open, and so caring. My best to your family.

- Susan L

Real Survivors

Thu, 10 Jun 2010 20:17:43 GMT

If you have to ask what jazz is, you will never know.
- Louis Armstrong

The stillness in the meeting room was electric.

First, one panelist addressed the audience members who have never experienced a malignancy. She described the unique and powerful bond that exists between cancer survivors. She described how the brush with mortality forces each survivor to renegotiate terms with Life itself. She reminded everyone that the cancer care system too often lets down both cancer patients and survivors.

Then she addressed the cancer survivors. “As a fellow survivor, even if you and I have never met before, I would bet that we would find common ground within fifteen seconds.” Other survivors in the room agreed with her immediately.

This was not a typical cancer conference. The Cancer Survivorship Forum was part of the recent Wisconsin Comprehensive Cancer Control Summit. An eye-opening presentation on the value of physical activity for cancer patients and survivors was followed by a panel of articulate survivors and their significant others (co-survivors) reflecting on which policy initiatives will have the biggest impact on future cancer patients. Everyone in the audience was engaged from start to finish.

What did the survivors want? Patients and survivors expect appropriate, user-friendly, and balanced information about their treatment. They expect compassion from every person with whom they have contact. They demand quality, timely care that does not leave them financially devastated. They deserve a network of support for themselves and their families. They expect more resources that work and fewer things that do not.

The survivors were not shy about describing their experiences or how they felt about the care that they had received. With each comment from the panel or from a survivor in the audience, there was applause. Survivors craned their necks to see who was speaking and later made contact.

At most scientific meetings, I sit in rooms full of fellow clinicians, hear about the latest research, and jot down ideas for new projects. The following year, I realize that I never quite got around to initiating many of the project ideas I had explored. Oh, well, I think. Maybe next year. I shrug my shoulders and make excuses. Cancer will still be there.

At the Survivorship Forum, though, surrounded on all sides by people who have experienced cancer treatment, it is much harder to pass off our lack of progress. In the stillness of the conference room, the survivors listen intently to the presenters who articulately speak for them. They look at the clinicians and researchers expectantly. It is clear that cancer survivors can hold our feet to the fire in ways that petri dishes of cancer cells cannot. If we fail to act, the survivors will be at the next meeting. They are the real people to whom we will answer.

The following is feedback received for this blog:

I've been reading your blog for a few years now and just caught up with your survivors' expectations post. I have to say that Froedtert more than met those expectations for us. If I can sit here four years later and still think of the experience as positive, well, you must be doing something right over there.

My husband is just completing 7 months of apparently successful obliteration of a gastric adenocarcinoma that was incidentally discovered during treatment planning for an acoustic neuroma. Our initial all-consuming terror at this diagnosis crumbled by infitesimal degrees over time, and has been replaced by a genuine sense of hope not only for a future, but for one that provides an acceptable quality of life. Despite having worked at Froedtert & Medical College of WI with lung and esophageal cancer patients for 22 years, I was and continue to be stunned by the array of caregivers that immediately entered our lives to support us both during this journey. Your statement that cancer survivors (and co-survivors) in the audience bonded within 15 seconds of realizing each other's shared stigma is profoundly correct. While I always felt that I had a gift for my role as our patients' first phone contact for a thoracic surgeon - helping our patients face what they must - my ears are now intimately more attuned to the subtleties of each individual's needs as expressed "between the lines" of their communications. I feel more confident than ever that what we are offering people here goes far beyond the physiologic aspects of cancer care. We are presenting them with a community of teachers that provide the skills to go on.

Raw Milk

Tue, 11 May 2010 14:18:54 GMT

All change is not growth; as all movement is not forward.
- Ellen Glasgow

Pity the poor Public Health research scientists! They just do not get any respect. An essay in the New England Journal of Medicine points to four reasons why Public Health research is rarely celebrated with outpourings of enthusiasm:

Reason #1: The benefits of Public Health tend to lie far in the future. We need to invest resources now in order for our children to reap the rewards later. Not a popular concept these days.

Reason #2: The names and faces of the people who will benefit are not known. The entire population might be healthier, but there is no way to know who, exactly, will remain healthy.

Reason #3: The people behind the initiatives are often unknown. Since the benefits are widespread and diffuse, there are only a few well-known heroes like Jonas Salk or John Snow.

Reason #4: People often resist altering the status quo. We do not like change even when it might be to our benefit.

Solid science often runs headlong into strongly held beliefs. This conflict came to mind recently as the Wisconsin legislature passed a bill to legalize direct-to-consumer sales of raw, unpasteurized milk.

The backers of the legislation hope to return raw milk to the societal acceptance it had in the 1920s, claiming that raw milk tastes better, is more natural, and has health benefits. Raw milk supporters also believe that pasteurized milk is less healthy than raw milk and might cause "everything from allergies to heart disease to cancer, but when Americans could buy Real Milk, these diseases were rare." Unfortunately for this particular argument, the leading causes of death in 1920 did include heart disease and cancer, as well as influenza/pneumonia, tuberculosis, stroke, kidney disease, accidents, diarrhea/enteritis, premature birth, and childbirth related conditions. The diarrheal diseases and infant deaths associated with contaminated raw milk consumption led to the pasteurization of all milk sold commercially in the United States.

So, what is the Public Health perspective? The CDC reports that raw milk can be contaminated with pathogenic bacteria including Brucella, Campylobacter, Listeria, Mycobacterium bovis, Salmonella, Shiga toxin-producing E. coli, Shigella, Streptococcus pyogenes, and Yersinia enterocolitica. At least 45 known outbreaks were reported to the CDC which resulted in over 1,000 illnesses and at least two deaths over a recent seven year period.

We all take risks every day. None of us is obligated to minimize our own personal exposure to things that might kill us. There are those who are well aware of the risks and still continue to smoke, sleep in the same bed with their infants, refuse to use seatbelts, drink and drive, decline vaccinations, forego exercise, abuse drugs, and eat poor quality diets.

I suspect, though, that the underappreciated Public Health scientists will continue to plug away, hoping to find ways of breaking through our resistance to living better, longer — and safer — lives.

__
Hemenway D, New Engl J Med 2010 (May 6); 362:1657-1658.

The following is feedback received for this blog:

Interesting observation you have concerning raw milk. There are a lot of factors that I believe you may have overlooked to reach the conclusions you made. Raw milk advocates have research on their side as well, it is just being ignored. If you would take the time to research it a bit more thoroughly, I believe you would come to a much different conclusion than your current one.

- Karoline Rehm

Karoline - Can you share references to the research you mentioned?

- Ron Stubbers

Can Cancer Be Overdiagnosed?

Wed, 05 May 2010 00:57:35 GMT

The heresy of one age becomes the orthodoxy of the next.
-Helen Keller

The patient returned to my clinic several years after her original thyroid cancer surgery. “The cancer blood test never went completely back to zero,” she told me. “We knew there was cancer in there somewhere. Finally, the new ultrasound machine found it! I guess it is time for more surgery!”

I guess. In my patient’s situation, the latest high resolution diagnostic test had identified a slowly growing, small cancer. However, there are no studies to show that taking out these small cancers has any significant, long-term impact. At two national meetings I attended in the past few weeks, surgeons from all around the world scratched their heads and debated the merits of aggressive surgery versus careful observation without coming to any conclusions.

Two recent papers help point to why this is such a difficult topic.

The first study, titled “Overdiagnosis in Cancer” published in the Journal of the National Cancer Institute, makes a very convincing argument that screening and very early detection can often identify cancers that would otherwise have never caused any problems. As evidence, the investigators demonstrate that the number of people who develop some types of cancer (prostate, thyroid, breast, kidney, and melanoma) has doubled since 1975 with no increase in the number of people dying from these types of cancer. Further, they cite autopsy studies of people dying of non-cancer diagnoses that have detected tiny, harmless cancers in as many as one-third of people. Chasing down and treating these “overdiagnosed” cancers carries both risk and cost. An accompanying editorial notes that policies must “reduce the burden of cancer death AND cancer diagnosis.”

The second study looks at the rapid growth in the use of follow-up scans in older cancer patients (mean age = 76). The paper, published in the Journal of the American Medical Association, found that the use of PET scans grew 36% to 54% each year between 1999 and 2006 for Medicare patients with cancers of the prostate, breast, colorectum, lung, as well as leukemias and non-Hodgkin’s lymphomas. For the lung cancer patients, there was a 14-fold increase in the use of PET scans over the seven years! Other tests grew at a slower rate. The overall cost of imaging grew at 5% to 10% each year.

So, what does this mean? Despite the continuing good news that fewer Americans are dying of cancer each year, there are more and more people being treated, thanks to sophisticated screening procedures capable of detecting smaller and smaller abnormalities. At least some of these smaller cancers would have been harmless. At the same time, spending on scans and other imaging studies is growing much faster than inflation. The growth rate in expenses contributes to the spiraling costs of medical care.

Some things that we always felt were “true” about cancer deserve another look. We were all raised to believe that cancer, left untreated, was uniformly fatal. We always knew that small cancers are more curable. For many people, these statements are certainly true.

For other people, though, it is equally true that cancer is more of a chronic disease, like hypertension or diabetes. It is also true that many of us have cancer and will never, ever know it. The data call for changes in how physicians and people with cancer understand what the diagnosis means.

Change might be great for society, but what about each individual? Will we tolerate having less care? Witness the recent upheaval over the evolving recommendations for mammography in younger women. What patient, knowing that he or she might have a cancer inside, would ever agree to just let it be?

When the door to the examination room closes, we sit with our patients and make decisions. Do we operate? Do we watch? Do we order a scan or don’t we? Do we try something else? As much as we love certainty, there are times when we proceed based on the available research and our best guesses.

My patient elected to have surgery to remove the tiny recurrence knowing that there were real risks to the surgery and that there might be no benefits. I was never convinced that what we did made a difference in her long-term prognosis, but I certainly hope it was money well spent.

The following is feedback received for this blog:

And, we surgeons are not in this alone. Our non-surgical colleagues eagerly participate with us in the quest to find the "biochemical recurrence". Stimulated thyroglobulin high, thyroid scan negative, PET scan positive in the neck, tell the patient, then call the surgeon. . .the dye is cast before that exam room conversation can take place. (Just attended an endocrine TPC yesterday with this scenario). Our hardest work is often not the operation, but NOT carrying out the operation. . .

- Merry Sebelik

good provocative piece. i wonder how many of us would elect not to have the surgery, knowing there was "something" in there?

- RICHARD HOLLOWAY

From a holistic patient perspective, is neglecting a proactive approach toward diagnosis of disease appropriate? Is the failure to follow through or complete treatment truly caring for the whole patient? Is our goal, as health care providers, to simply treat disease or provide holistic care for our patients? Should we being doing so in a non-discriminatory fashion and is it ever appropriate to take those privileges away? I wonder how many patients could sleep at night and continue to live a "normal life" knowing they have cancer residing inside of them. I agree we must reduce health care expenditure, but at what cost? Interesting, thought provoking article! Thank you Dr. Campbell.

- Pam P

Ironic, Hellen Keller was an anarchist

The Odor

Tue, 27 Apr 2010 21:19:59 GMT

Things that were hard to bear are sweet to remember.
-Seneca

Thoughts of my first job rushed back into me as I pulled open the front door of the veterinary clinic. My son carried his sick cat past me and headed to the receptionist’s desk. I took a breath. “Oh my goodness,” I thought. “This place smells just like the animal hospital back home.”

And it really did. When I was sixteen and thought someday I might want to be a veterinarian, I worked part-time at the local animal hospital. It was not glorious employment. I bathed dogs and clipped their nails. When I worked weekends, I spent my days completely alone taking the dogs out to the run one at a time, cleaning the runs and cages, refilling food and water dishes, and just trying to keep my furry friends calm. I did an awful lot of shoveling. My mother did not let me carry my T-shirts or shoes into the house until I had rinsed them thoroughly with the garden hose.

One day, a family brought in their old basset hound. The vet gently led the limping old animal back to the kennel area where I was working. “Here,” he said. “Hold her while I give her a shot.”

I put down my broom and came over to the table where the dog was sitting. Her eyes were cloudy and her tail wagged weakly.

I looped one arm under her neck and held her close. I comforted her as I would have comforted my own dog, patting her side while the veterinarian pulled some medication up in a glass syringe. He shaved some hair from the top of her front leg to better expose the large vein there. The dog barely flinched when he inserted the needle and emptied the contents of the syringe.

“There we go, old girl,” he said.

The thumping of the dog’s tail slowed and then stopped. A few seconds later, her body softened and her head drooped. In a minute, she crumpled. I had not realized until that moment that our task was to put the dog to sleep.

“Use one of those bags over there and put it by the door. The service will pick it up tomorrow.” The vet left.

What had just happened? I was completely confused by the experience. Over the next few months, the scene was often repeated. To make some sense of my role, I always tried to remember that I was the very last person that would comfort these animals before they died.

That summer, I figured out that I could tolerate some extraordinary things. When the opportunity arose to change jobs, though, I went to work as an orderly at the local hospital. The “people hospital” had a unique aroma as well, but it was nowhere as pungent or as distinctive as the one at the animal hospital.

Fortunately, my son’s cat was fine. While we sat together in the waiting room, my nostrils and my memories continued to fill with that distinctive and melancholy smell.

The following is feedback received for this blog:

I know the smell. I have had the great pain and responsibility of saying goodbye to a number of my canine and feline family members. Each time I have held them and said my goodbyes to each of these friends and companions I am the last person they see. I am fortunate that my vet is caring and understands the importance of saying goodbye in a quiet room.

- Judith Moudry

What Every Medical Student Should Know …

Thu, 18 Mar 2010 14:38:36 GMT

The aim of education is the knowledge not of fact, but of values.
- William R. Inge

“If there was one thing I would have every medical student learn, it would be this …” The woman was talking to her companion while moving down the clinic hallway. I passed her going the opposite direction and strained to listen for the end of her sentence. Unfortunately, by the time she reached the punch line, she was around the corner and out of earshot.

Still, it got me started thinking. What should every medical student learn? What are the most important lessons – both inside and outside of the curriculum?

Here is my attempt at a few things I would hope every medical student learns before graduation:

That they will help their patients heal by simply being attentive, empathetic listeners.

That not doing something is much harder than doing something.

That they really can and should help their patients quit smoking.

That they should always ask themselves, “What else might it be?” before settling on a diagnosis. (Borrowed from Jerome Groopman’s book, How Doctors Think)

That procedures and tests don’t always help, are sometimes painful, and are usually more expensive that they could ever imagine.

That they should never be satisfied with how much they know about either the science or the art of Medicine.

I will never know how the woman in the hallway finished her sentence, but I would bet that a lot of you have a thought about this topic. You have seen my quick list. Hit the “Feedback” link below and share what you think are the most important lessons every medical student should learn. I will try to print many of the responses.

The following is feedback received for this blog:

I am a nurse here are a couple of things I would suggest:

If the student was in that hospital bed how would they want to be treated/spoken to or touched?

Please wite your orders and sign your name so it can be read. None of us learned how to read squiggley lines in school!

When you become a resident and we have to call you for orders/pt updates or changes be nice. We all have long days/nights when we havent had alot of sleep or nothing seems to be going as planned.(not just medical students or Drs., nurses get tired and crabby to at timees)

How ever good or bad the situation it will change.

Laugh or cry with someone. It's more healing than doing it alone.

Be confident in what you say and do even though if you don't feel like you are.

Every person who works in the medical profession needs to know what the patients needs are this includes: mental, physical, social, financial, present, past and future needs. If they are seeing a doctor they should be treated by that doctor. We all have more than one need in our lives.

B w

Nurses know the patients. Listen to their opinions and yes...even their suggestions.

i particularly respond to the one about tests. i certainly understand the need to reduce uncertainty, and that's good, but there have been so many times with our son when we've felt like we were a part of someone's "fascinating experiment" that never went anywhere. thanks for raising this important and [somewhat] risky issue.

- Richard Holloway

I am a radiographer/CT Tech/educator. I once had a med student ask me for general advice. This is what I told him. "Before you order a diagnostic test, ask yourself if the information you get from the test will enable you to improve the patient's outcome or quality of life. If the answer is no, don't order the test.

- Mary Hood

Two Worlds Collide

Tue, 20 Apr 2010 21:00:37 GMT

All the world is a stage,
And all the men and women merely players.
They have their exits and entrances;
Each man in his time plays many parts.
-Shakespeare

“There’s a consult downstairs, Campbell. Go check it out and I’ll catch up with you later.”

“Sure, OK.” I was a third-year medical student fumbling through my first clinical rotations. The resident headed off to whatever he needed to accomplish and I trotted down the back stairwell. I glanced at the consultation slip and found the patient’s room number.

56-year-old man with progressive medical problems. Please evaluate for central line placement.

Not much information. The man was on the General Medicine ward and needed a more permanent intravenous line to avoid having to put a new IV in his hand every day or two. Arranging for the new line would be our job.

I reached the ward and found the chart that matched the room number. As I started flipping through the chart, I froze. “I might know him,” I realized.

Finally, I worked up the courage to push open the door. “Mr. Anderson?" I called. My medical school was only twelve miles from my childhood home, yet as I peeked into the room, I was still hopeful that I would find a different person with the same name lying in the bed.

He looked up and smiled. “Bruce! Look at you with your white coat! Very impressive. C’mon in!” He looked thinner and a bit yellow but was as enthusiastic as ever.

I had been very busy over the previous two years with medical school and had not seen him recently. Thomas Anderson [not his real name] had been a family friend throughout my childhood — one of those people that kids love, teenagers respect and adults seek out at a party. He was always a big, gregarious man with an easy lope and a ready smile. He was never in a hurry. He was active all over the community and had had been one of my scout leaders during my childhood. I realized later that he had volunteered to be a scoutmaster well before his own son had been old enough to join.

As I sat in his hospital room, I remembered a weekend camping trip in seventh grade. After we had finished the evening routine, Mr. Anderson made certain that all of the kids were tucked in for the night. Not long afterwards, I peeked out to see why the adults were all laughing. There were all of the dads sitting around the table drinking beer, smoking cigarettes and playing pinochle. They were clearly having a wonderful time in a 1960s-kind-of-way. The game broke up late, yet Mr. Anderson was the first one up in the morning getting breakfast prepared and setting us to our tasks for the day.

We sat and talked for a while, and he invited me to look at the criss-crossing surgical scars on his abdomen. “Did you see the admission number on my chart?” he asked. I had. The number told me that this was the 24th time he had been in the hospital. “These days, I spend more time here than at home.”

I finished up my examination and turned to leave. I would spend the next half-hour writing up my report for his chart and would return later with the rest of the team to make arrangements for the IV. I stopped in the doorway to say goodbye. He looked at me.

“Bruce, tell me something. Is this the first time you have cared for someone from your world outside of the hospital?”

“Yes, Mr. Anderson, it is.”

He paused then smiled. “Well, I suppose that you had better get used to it.”

“Thanks, Mr. Anderson. I am certain that I will.”

Thirty years later, though, I realize that I never have.

The following is feedback received for this blog:

great post, really captures the bittersweet changing of the guard between generations. I take care of my former track coach as a patient now. It does ground you.

-dr. charles
http://www.theexaminingroom.com

Time

Tue, 13 Apr 2010 06:52:15 GMT

People like us, who believe in physics, know that the distinction between past, present, and future is only a stubbornly persistent illusion.
- Albert Einstein

The surgical case is delayed for ten minutes and I am getting restless. I anticipate a very difficult dissection. The cancer has returned after extensive prior treatment with surgery, chemotherapy and radiation. I have enlisted additional help to make certain that everything goes as smoothly as possible. Now we wait as the final preparations take place. Time passes very slowly.

Waiting is a part of surgery. Patients wait to see the physician. Surgeons wait until a day is available on the operating schedule. Families wait in the family center during the operation. Everyone waits while the patient recovers from the procedure.

As a medical student and intern, I remember scrubbing in on surgical cases for the first time. There were clocks by the scrub sinks that reminded us to vigorously wash our hands and forearms for ten minutes. The first days in the OR were scary. We did not know what we could and could not touch. I am tall, so I was constantly bumping my head into — and contaminating — the overhead sterile light handles as I looked around at the unfamiliar sights. Being in the operating room was such an unusual experience that time always seemed to stand still. I soaked up every little detail.

A few months later, after I had grown accustomed to the privilege of being in the operating room, the passage of time changed. I remember one day when my resident referred to me as “a hook." “Here, Campbell,” he said. “Your entire purpose for the next two hours is to think of yourself as being a hook that was screwed into the wall as an anchor for this retractor. Hold it like this. Don’t move.” I did not do a very good job at standing still, and he reminded me of that several times. I could see nothing of what was happening. Those were the longest two hours of my life and I remember them like yesterday.

Back to the present. The delay is eventually resolved, and we begin the operation. The dissection is, indeed, challenging, and my colleagues and I call on all of our prior experience and training to remove the large cancer. We stop to discuss the best way to proceed. We trade places for a while to get different perspectives. We quiz the trainees about the anatomy and their reading. We overcome several obstacles, changing course as needed. The cancer finally yields and is removed from the field. Soon, we are closing the wound.

I look up at the clock. It seems like only a few minutes have passed since I had anxiously waited to begin the case. Five hours have disappeared like an instant.

I realize that time spent truly engaged in a challenging experience follows no rules. For the residents, maybe the case might seemed like an all-day event. For the nursing staff, the clock likely slowed as the end of their shift approached. For the family, I imagine the day seemed like an absolute eternity.

Einstein famously said that “reality is merely an illusion, albeit a very persistent one.” I do not pretend to understand the mathematical or existential implications of his statement. I do know, however, that the mysterious slowing and speeding of time really does occur, and I sense the shift most intensely while working in the operating room.

The following is feedback received for this blog:

Hi Bruce - wonderful post! I agree with you about time. It's a matter of perspective. I just wrote about it (briefly) when describing my last night with Mom.

You are so blessed to love your work as you do. You've been given a gift. And no doubt have given your patients the gift of healing ..of life .. the gift of ...more time.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

The Delay

Mon, 15 Mar 2010 18:53:20 GMT

Whatever begins, also ends.
-Seneca

One final story from our visit to El Salvador …

Our return trip to Milwaukee included a two-hour layover between flights. Five of us who had made the journey together sat in the waiting area at Houston’s Intercontinental Airport sharing photos and telling stories, anticipating a scheduled arrival back at Mitchell Field about 10:00 pm.

In some ways, our experiences in El Salvador had differed. A woman from Sheboygan had served as a translator; because she is a native Spanish speaker, she easily befriended many of the Salvadorans and always had a crowd of giggling kids swirling around her. A woman from Milwaukee had led empowerment workshops for the Salvadoran women, developing deep friendships in the process. A woman from West Bend had been involved in the non-traditional and spiritual therapies, finding herself touched by the number of ways people experienced healing. My wife, Kathi, and I had worked as a nurse and a physician, seeing the physical challenges and sensing the joy of the people we met despite the frustrations of the language barrier.

In other ways, our experiences were shared. Despite the disturbing levels of violence throughout the country, the people we met, from government health ministry officials to San Salvador’s homeless, were friendly and thoughtful. Despite the dust and mud, the people were clean and dressed as nicely as they could afford. Despite the clinic’s long lines and protracted wait times, the Salvadorans were, to a person, patient and grateful.

As we waited at the airport, two hours turned into four then into six. A major storm on the East Coast had caused a chain-reaction of delayed flights all over the country. Later, after our plane had finally arrived at the gate, there were no flight attendants available. The Houston ground crew worked overtime trying to get us home.

Our little group continued sharing stories. One of our friends had been outside of the clinic building late in the afternoon on the last day. The local organizers had shut off the line so we could pack up our things and get back to the guest house. Some of the Salvadorans who had been waiting all day to see one of the doctors or dentists were now being told that the clinic was over until next year. Despite this setback, some of the people had hugged and thanked the clinic volunteers. “Thank you for coming,” they told one of the staff. “We will see you when you return.”

The story seemed almost unbelievable, especially as I watched three American tourists returning from vacations in Cozumel tear into the airline employees about the delays and how important it was for them to get home. They exploded again with each delay announcement storming around and pointedly shouting into their cellular phones.

Of course, I knew why they were upset and maybe I have been that upset at some point in my life. But, for the moment, the extra time in that airport offered me both the opportunity to hear some more stories and the possibility to be grateful for a bit more of the healing that is best experienced by, sometimes, just living in the present.

The following is feedback received for this blog:

So nice to read a bit about your trip! Thanks for keeping up with this blog, it remains inspiring to me.

- Mary Buckler

Turning Away

Tue, 30 Mar 2010 21:14:28 GMT

The capacity to give one's attention to a sufferer is a very rare and difficult thing.
-Simone Weil

The e-mail message about my long-term patient was disturbing.

In retrospect, her initial cancer treatment had been nothing short of a miracle. A large tumor of the mouth was completely controlled with a limited surgery and radiation therapy. When her cancer recurred again a few years later, treatment again came to the rescue. She did well for a long time.

Eventually, though, treatment side effects developed. Over the years, the problems caused by the aggressive cancer were replaced by problems caused by the aggressive therapy. She suffered.

In the months before I received the e-mail message, several physicians, nurses, and therapists had been involved in her care. Her weekly schedule was jammed with medical appointments.

One day, I received an e-mail from one of her friends telling me that she was dying and that the family was struggling. “The family is under the impression you didn't want to see her anymore.”

I was stunned. I am a surgeon and it is true that I had nothing to offer her surgically. From my perspective, though, each office visit had involved extra time to review her options and discuss what was happening. I thought I had always tried to answer her questions. I was always careful to remind her that she could come and see me anytime.

However, I knew that our scheduled return appointments had gone from every few weeks to every few months to an open invitation to call if she wanted to return.

From her perspective, apparently, it was clear that I had given up on her.

As I re-read the message I wondered: Would she have felt differently if our office visits had become more frequent instead of less frequent as things became more difficult? Is it possible that an office visit is a sign of hope or an expression of caring?

I thought of my experience with this patient as I read Dr. Pauline Chen’s book, Final Exam: A Surgeon’s Reflections on Mortality. Writing about her dying patients, Dr. Chen laments, “I want to sit and linger with my patients but know that such inefficiency would never work in a clinical world. I want to soothe my patients’ suffering without the burden of knowing the inexorable future courses of their diseases.”

I am certain that I have the same anxieties as Dr. Chen. In addition, I struggle with the knowledge that each office visit generates a bill for which the patient is partially responsible. Medical care is expensive and I do not like charging people when I have little to offer. On top of that, there are only so many appointments available in my weekly clinic schedule. How do I see everyone who might benefit from an appointment?

No one should ever feel abandoned. My patient died a few days after I received the e-mail message. Her legacy is that I will somehow find new ways to accompany my patients as they approach the end of their journeys.

The following is feedback received for this blog:

Very nice essay.

Maybe that is why patients love the newsletters, patient receptions and your blog. It keeps that connection.

Could survivorship clinics possibly serve this need in a meaningful way?

- Kathy

Very thoughtfully written. It is a struggle to find a good solution. The visits may offer hope, but they can be costly not only in money but the time and effort it takes as the patient weakens. No easy solution.

- rlbates
http://rlbatesmd.blogspot.com/

Thoughtful article. As a psychiatry resident, I find that some 'stable' patients subconsciously take fewer visits as a sign of abandonment and some of them might even become sicker. My solution is simply to ask them, 'When do you want to come back?', and most of the time I'm able to go along with what they want.

On the other hand, it is worth considering how we as doctors bring much more than just medical treatment to the table. Yet, this 'other care' is often undervalued, (certainly by insurance companies) and we feel unable to help a patient when faced with an untreatable disease. This may not always be true.

- En Jay

Medical school, residency and our early years in practice imbued us with lots of technical expertise but our patients (and by extension their family and friends) teach us so much beyond that, we just have to make sure we keep listening to their message.

- Deborah Benzil
http://womenneurosurgeons.blogspot.com/

The Small Things

Tue, 02 Mar 2010 00:10:58 GMT

The elderly man came to the San Salvador Lutheran Medical Clinic nearly blind and almost completely deaf. Our interpreter helped me figure out what he wanted.

“How can I help you?”  we shouted.

"I have a cough and get headaches sometimes. Can I get some medicines?”

“Sure,” I said. “Let me take a look.” The interpreter moved to another of our physicians while I performed an examination.

The patient had undergone cataract surgery at some point which had improved his vision a bit. I peered in his nose and focused my headlight in his mouth. His last few teeth were in pretty bad shape. Otherwise things looked pretty good. No obvious infection and nothing worrisome. The neck was okay. His lungs were clear and his heart was steady. His belly was soft and there was no swelling of the ankles.

I peeked in his ears. Both were full of wax.

“Would you like me to clean your ears?” I peeked at my cheat sheet with a few Spanish words. “¿Limpio los oídos?”

I’m not at all certain he understood my question, and I wondered if I had chosen the correct word for “ears.” Nevertheless, he turned his head and let me dig in his ear canal.

The wax was very adherent to the canal wall. I continued to work and the man was clearly uncomfortable.

Just as I was about to give up, the plug of wax moved. I reset my instrument and slowly worked the solid mass of wax from deep in the canal to the opening. Suddenly, I triumphantly pulled out one of the biggest plugs of ear wax I had ever seen. Clearly, he had been working on this masterpiece for all of his 85 years. Now it was out.

He blinked and stared at me with his softened gaze. I suspected he was hearing from that ear for the first time in 20 years.

“The other?” I attempted in Spanish.

He grinned and turned his head to present the other side. Soon, despite some discomfort, I had delivered another plug of wax as large as the first. He stared at the plugs of wax on the gauze. He wrung my hand enthusiastically. “¡Muchas gracias!” he said.

“De nada. You are welcome. Thank you for coming!” Pretty soon, he had received a flu shot and was heading home with his small bags of vitamins, calcium, and acetaminophen.

I’m not altogether certain how many patients I helped while visiting El Salvador, but I am pretty sure there is one 85-year-old nearly blind man who is very glad that I was there.

The following is feedback received for this blog:

Very nice story. As always, thanks for sharing!

- Jen

Awww ... that's such a neat story. You made his day. I'm glad I read this.

- Leigh Ann Otte
http://thedoctorwriter.wordpress.com/

Just the small things can make a world of difference for everyone. Thank you for sharing.

- Scot

Go figure, all the years of training and skills acquisition and removing ear wax is still one of the most gratifying thing we do. . .enjoyed the story.

- Merry Sebelik

I *hear* the biggest difference we often make, is often one we don't realise

- Jabulani

Awww.... I loved this story! I'm so glad you took the risk to visit this memorable place.

- Penny

Just had to add this. I am a physician, a radiologist, but somehow keeping the wax out of my ears has always been a problem, I mean really, getting somebody to dig around in my ears, nobody seemed interested, maybe the ENT guy's nurse if I was lucky. I didn't see anybody interested in going after that awful stuff. Even the nurses never seemed to get it all. At least in my own clinical days I used to soak that stuff with drops of soap held in with some cotton balls for about 30 minutes which allowed me to blast it out with the little water gun we had in the back office. Yes I really enjoyed doing that!! But good luck when it came to my issues!!

Finally I picked up on just soaking that wax with hydrogen peroxide. Only takes about 20-30 minutes per side and after awhile all that bubbling is pretty pleasant and one has to be careful not to fall asleep which might possibly lead to H2O2 burns. When all the wax is gone the bubbling stops, it's that simple.

Cheers.

- Steve D.

What a great story. In pediatrics - we use a liquid stool softner (Colace). Fill the canal with the nice pink stuff and flush in about 10 minutes. Somestimes we have to repeat the process. We flush with warm water in a 10 cc syringe connected to a cut-off butterfly tube. The one inch or so of tubing slips into the canal nicely.

Works every time - then you can see to China or through to the other side as we tell the kids. Thanks for the story and for your trip to help those people.

Outside the Comfort Zone

Mon, 08 Feb 2010 16:35:36 GMT

A life spent making mistakes is not only more honorable but more useful than a life spent in doing nothing.
-GB Shaw

After over twenty years working as a head and neck cancer surgeon, much of what I do has become routine. Even the operations that once kept me awake at night or the procedures that required a trip to the library are just part of a day’s work.

I am certain that most vocations have the same experience. The commercial airliner pilot plans her weekend while she is constantly scanning the displays and switches arrayed around her. The construction engineer carries on unrelated conversations while aligning girders that will support giant buildings. The bus driver listens to the radio as he guides his vehicle for the hundredth time through the switchbacks and the mountain passes. Things that used to command every bit of attention no longer require that degree of intensity.

Every once in a while, though, something comes along that brings everything back into a sharp-edged focus:

I had  performed dozens of procedures on patients with voice box cancer over the years. My experience told me that this operation would be difficult because of this particular patient’s previous radiation, but otherwise should be straightforward.

What I found, though, was anything but routine. Nests of cancer cells were scattered throughout the tissues and a new separate cancer was identified. The original plan was quickly abandoned, and, while the patient lay on the table, I went to the family center to have a detailed discussion with her husband and children. I returned to the operating room and continued to work. Over the course of the day, there was another change of plans, another trip to the family center, and phone consultations with colleagues. I ended up performing a procedure about which I had only read. I re-checked everything. Several hours later than originally anticipated, we were finally finished.

Sitting in the recovery room waiting for her to wake up, I realized that I was in need of some recovery as well. I had spent much of the day outside of my “comfort zone” in a place requiring my full attention, all of the insight I could muster, a bit of creativity, and reliance on others. Now, I could return to the routine of postoperative care and paperwork. Although drained, I was energized and alert. I felt alive.

Happily, she did just fine, thanks to the good advice I received from my colleagues. I slept very soundly that evening.

The following is feedback received for this blog:

Wish I could work with you. I know I'd learn so much.

- rlbates
http://rlbatesmd.blogspot.com/

I work in Law Enforcement and I read your post, nodding yep....yep...yep...

Mostly, after 21 years, I am comfortable where I am. Due to a tragedy at another station in our troop, I volunteered to work the desk for them on a Sunday, midnight shift. I was brought way out of my comfort zone, not knowing the area, not knowing the troopers I would be working with and not used to that shift. At the end of a quiet night, I was glad I had done it. It not only helped the members of that station, but it also helped me to realize, and appreciate, how comfortable I am at the job I do at my home station.

- Holly Wood

Touch

Wed, 17 Feb 2010 22:59:41 GMT

We have to believe that even the briefest of human connections can heal. Otherwise, life is unbearable.
-Agate Nesaule

The patient arrived at the rural clinic near Guazapa, El Salvador, in his mother’s arms with a mouth gag tied in place and his hands wrapped in bandages. As his mother put him gently onto the examination table, his muscles twitched hard, tearing the paper bed cover and forcing the gag out of his mouth. “Be calm,” his mother whispered to him in Spanish. He remained contorted but visibly quieted as our pediatrician, Dr. Mike, held him.

Oh, oh, I thought. We are miles from a hospital and a three-hour plane flight from anything familiar. We have a very sick kid on our hands. How will we handle this?

While I watched from my exam station across the room, the mother shared her story. What I initially assumed was an emergency turned out to be just another day in the life of this family. The patient had been born in the final years of the Salvadoran civil war in a poor, rural community with no functioning infrastructure. Severe oxygen deprivation during his birth caused significant brain damage. It is safe to assume that he received almost no medical care as an infant; only the love and care of his family had allowed him to survive at all. Now, 21 years later, his mother was bringing him to a medical mission clinic staffed by volunteer North American physicians, nurses, pharmacists and healers.

During his childhood, his family had found that cloth gags and hand wraps could keep him from inadvertently biting and scratching himself. The mother calmly related the joys and challenges of his life. Dr. Mike had helped care for patients with this same diagnosis back home and I am certain that he was mentally cataloguing all of the potential treatments and support options that would be offered to this family back in the States. What did we have to offer here that would make a difference?

Julia interpreted. Nurses Kathi and Jean helped. Nurse Practitioner Gail brought her experience. Dr. Mike supported the patient while performing a gentle, thorough examination. He peered in the ears and throat, listened to his heart and felt his abdomen. He pressed the muscles of the arms and legs. He warmly complimented the mother on the exceptional care she had provided for her son.

The mother smiled. Despite the challenges, this child was the biggest joy in her life. But, she wanted to know, can you help him? His biggest problem is sleep. Can you help him to sleep?

We had arrived in El Salvador with only the most basic medications; we had things like vitamins, calcium, iron, anti-parasite pills, mild pain medications, and basic treatment for coughs and colds. Well, Dr. Mike said, we could try giving him one of the cold medications at bedtime to make him a bit drowsy. That might help.

Thank you, the mother said. Suddenly, the patient’s arm flew up around Dr. Mike’s neck, surprising everyone. What was wrong?

He is giving you a hug, his mother told Julia. He wants to thank all of you, too. Dr. Mike held the young man in his arms for several seconds before passing him to my wife, Kathi.

Most of the patients we saw during our days in El Salvador came to us with routine concerns: coughs, headaches, and sore throats. Watching this family, though, reminded me powerfully that, no matter how severe the problem, there is power in touch and value in just being there. As the examination wrapped up, the mother repositioned the mouth gag. After hugs, good wishes and thanks to everyone in the room, the mother and her son were soon on their way back home.

Two Questions

Mon, 01 Feb 2010 13:25:13 GMT

Insanity: Doing the same thing over and over and expecting different results.
- Albert Einstein


As medical students rotating through the wards, we spent a significant portion of each day ordering laboratory tests and then chasing down the results. We wanted to investigate our patients’ illnesses and, just as importantly, we wanted to be prepared for any question with which our professors might surprise us during Attending Rounds.

One day, as I was hurriedly checking boxes on a laboratory order form, my resident challenged me to justify one of the blood tests I was requesting. “You can order that test after you answer these two simple questions ...” His eyes narrowed. “First of all, what exactly are you going to do with the results? And, second, who is going to pay for it?”

He became increasingly impatient while quizzing me about all of the potential outcomes. Clearly, I would need to spend my afternoon reading in the library. I also admitted that I had no idea how much the test would cost or whether the patient’s insurance would provide coverage. It turned out that this was, indeed, a very expensive blood test that was only performed in an out-of-state laboratory. The results would not be available for several days. Checking that box would have cost the patient several hundred dollars; by the time the result was available, it would have been all but meaningless. “Aha!” my resident chided me triumphantly, “Do you still want that test? You need to make an effort to understand the impact and cost of everything you order.” I had learned a lesson and sheepishly tore up the slip.

My memorable medical school incident came back to me last week while reading an editorial in the New England Journal of Medicine. Dr. Howard Brody reminds us that high-cost care is not necessarily better care and that a study of regional variation recently showed that “nearly one third of health care costs could be saved without depriving any patient of beneficial care.” Cost-effective care is possible.

Since physicians order tests, Brody suggests physicians need to be at the forefront to curb healthcare expenses. As a start, he proposes that each medical specialty create a “Top Five" list of its most commonly ordered, expensive tests and treatments for which there is little evidence of any meaningful benefit. The specialty would then be charged with educating its own members. In “In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” In the best of worlds, this approach represents utilization oversight driven by providers rather than insurers or government.

Resource consumption — be it money, time, supplies, or energy — is a real-life dilemma in every medical center; in medical care, there are just so many places where simple decisions carry a fiscal wallop. Three quick examples: Technology is routinely touted as providing improved safety and efficiency, but, sometimes, it adds cost without any proven benefit whatsoever. Adding one more test or ordering one more consultation at the end of a clinic visit “just to be certain” quickly adds up when repeated hundreds of times each month. And, of course, any provider who can spell “PET Scan” can order one.

We can all play a role in cutting costs. I tend to avoid technology unless I can show that it is truly going to benefit a particular patient. For example, I recently saw a patient for a second opinion. His community physician had recommended an extremely expensive test. After reviewing his records, I told him that there was no reason to have the test performed. He was understandably skeptical. “Why did the other doctor think I needed it?” He frowned. “She said it would be very useful. Shouldn’t you order it anyway?” We had a long conversation. Deciding not to “do something” can be a hard sell.

Even now as we engage in a national discussion about health care, it seems that the questions still come down to these two: What exactly are you going to do with the results? Who is going to pay for it? On both an individual level and as a society where we all depend on each other, these two questions are just as relevant — and difficult — today as they were when my resident made me stop and think about a box that I had checked on a laboratory slip so many years ago.
___
Reference: Brody H, “Medicine’s Ethical Responsibility for Health Care Reform – The Top Five List,” N Engl J Med 2010 (Jan 28); 362:283-285
(NEJM.org 10.1056/NEJMp0911423).

The Doctor Will Friend You Now ...

Thu, 07 Jan 2010 11:20:21 GMT

The argument that you need the "laying on of hands" to practice medicine is an old and tired argument that simply has no credibility …
- Rashid Bashshur, PhD, Director of the University of Michigan Telemedicine Center

The family legend goes like this: When my grandfather’s tonsils became infected yet again, the doctor rode out to the farm in his horse-drawn carriage toting his surgical instrument set. While he was there, the doctor supposedly looked at my dad, who was about 7 years old.

"Does Ray complain of sore throats, too?" the doctor wanted to know.

"Sometimes."

"Well, put him up here on the dining room table. Let’s take his tonsils out right now, too!" And so they did.

In the days of my dad’s childhood, medical care was routinely delivered in the home.

For better or worse, the focus of medicine may well return to the home. Consider this scenario: Bob has a headache, sore throat, and a runny nose. He walks into his kitchen and sits down at his computer.

Type, type, type, type. Click. Enter. [wait] Fill in name and personal information. [wait] Enter credit card information. Enter. [wait] Screen pops up. Smiling doctor appears.

"This is Dr. Johnson! Are you Bob? How can I help you?"

Bob pulls his bathrobe tighter around his shoulders and concentrates on his keyboard. The blue light next to the camera on his laptop blinks on. "I’m sick, Dr. Johnson. I hope you can give me something to make me feel better."

Dr. Johnson peers at the image of Bob on his monitor and sets to work trying to figure out if the symptoms represent a cold or something more ominous. Over the next few minutes, Dr. Johnson makes a diagnosis, comes up with a treatment plan, and generates a bill. They both sign off. A few minutes later, Dr. Johnson opens a video chat with a different patient. The two of them could be in the same town or separated by a thousand miles.

Quick and efficient! Germ-free! No parking hassles!

A recent article describes the future of telemedicine and how, in Texas, it is already a reality. For $40, an internet company offers Texans 10-minute live video medical evaluations. The company’s Web site notes that "while sometimes there is no substitute for an in-person visit, [the clinic] offers you a convenient complement to a traditional practice." I suspect that, for a lot of ailments, a quick discussion with a prescription might be perfectly suited to a live video chat.

Where could this all lead? Perhaps, new iPhone applications will take vital signs, peer into eyes, check blood sugars, and buzz disapprovingly when we walk into fast food restaurants. Guitar Hero will spin off Surgery Hero. Digital cameras will tour our intestines in the privacy of our own homes. On-screen instructions will tell us where to place the Wii controller while we bend over and cough. Web-based interface systems will control common kitchen appliances and power tools that allow surgeons to remotely perform delicate operations.

Traditional face-to-face office visits — flesh-on-flesh — are challenging enough. They are fraught with the nightmare of overlooked signs of disease, delayed diagnoses, incomplete evaluations, and misunderstood instructions. Sometimes, words spoken in the hallway after the visit are as important to making a diagnosis as what transpires in the room. To my old-school thinking, I have enough trouble coming up with treatment plans when I have the opportunity to sit side-by-side with my patients and touch them physically. It would seem that the benefits and risks of the office visit would only be magnified in a virtual clinic.

Medical care during my dad’s childhood days was not perfect. Did he need his tonsils out? Probably not! However, there was inherent value in receiving all of his health care on the farm from the family doctor.

Perhaps the day of that "in home" approach is returning. It seems so odd to me, though, that in an era when we value both "high tech" and "high touch" medical care, that our physician-patient interactions might actually be receding to a place where we see each other only behind a computer screen and feel each other only through a keyboard. Somehow, I think, Bob and all of our future patients deserve better.

The following is feedback received for this blog:

I agree patients deserve better! And you deliver!

- Marilyn Hagerman

right on, scribbler b! nicely written argument for the importance of in-person healing. my psychological training supervisor, back in the day, told the story of a home visit by his g.p. (in ireland!) who walked into the ill child's bedroom and announced "it smells of rheumatic fever here!" i don't think you can do that via telemedicine.

- RICHARD HOLLOWAY
www.theemptysuits.com

Another Auld Lang Syne

Thu, 31 Dec 2009 13:02:49 GMT

And there's a hand my trusty friend!
And give us a hand o' thine!
And we'll take a right good-will draught,
for auld lang syne.
-Robert Burns

It was the very last night of a difficult two-month rotation early in my residency. I was On Call. Exhausted. Burned out. Going-through-the-motions. Not having a good time.

I was sitting at the intensive care unit console writing notes in the charts of two of the patients I was following.

One young woman had taken a fistful of pills and then hanged herself. Her beleaguered family had tried very hard to help her over the years and now they were spending their holidays in the hospital standing vigil at her bedside. After this one final attempt to kill herself, the family hoped she might bring light to someone else’s life with an organ donation. My task was to keep her alive long enough for her body to clear the toxic levels of the medications she had ingested. I flipped through her chart and wrote my note. Family members walked numbly past me.

In another bed lay a young mother who had been getting ready to go out for a New Year’s Eve dinner party. Her husband found her unconscious in the bathroom after having heard her collapse. After being rushed to the hospital, the scans confirmed that she had experienced a massive, certainly fatal brain hemorrhage. She was completely unresponsive and spiraling downhill rapidly. The family, dressed for an evening out, sat disconsolately at her bedside. I dutifully recorded my findings in her chart.

As I sat writing, a song came on a radio nearby. I never really knew the lyrics but I recognized Dan Fogelberg’s voice. The song is a first-person account of running into an old friend.

We drank a toast to innocence
We drank a toast to now
And tried to reach beyond the emptiness
But neither one knew how.

We drank a toast to innocence
We drank a toast to time
Reliving in our eloquence
Another 'auld lang syne'...

Then the strains of “Auld Lang Syne” filled the air. I checked my watch. It was midnight. I put down my pen and called home, wanting to talk to Kathi.

“Hi, sweetie,” I said. “Did I wake you?”

She had been dozing. “Guess so. Hi, yourself. How are things going?”

I scanned the patients in front of me. I looked at the family members moving in and out of the rooms. I looked down at the chart notes I had written. I thought for a second.

“Not well. It has been quite a day. I love you.”

“Love you, too. See you in a few hours?”

“Yeah. Can’t wait to get home. Happy New Year.”

The following is feedback received for this blog:

As always, a well-written post. Thanks again for sharing!

- Jen

This story really hit home as I am dating someone who works in an ICU. There have recently been a couple rough nights after which he has had to emotionally unload in order to get past things.

I have had the unfortunate experience of having to sit two torturous nights in the same ICU prior to losing my (late) husband. I am proud to call him an organ donor.

Luckily, even though my sweetheart worked this past new years eve, it was a quiet night and was able to leave at 3:00am instead of 7:00am.

We appreciated the cherished time together. I know the value of quality time.

- Karen Farra

Sorting Things Out

Wed, 23 Dec 2009 16:55:32 GMT

If you can't explain it simply, you don't understand it well enough.
-Albert Einstein

Holiday music plays in the background as I scan my Cancer Center clinic schedule for the day. Most of the names are familiar. There will be three or four new patients that I have never met, a few that are coming to the office for postoperative wound checks, a few that are returning for routine cancer survivor visits, and a few that have noticed alarming new symptoms. Over the course of the day, about 20 people will pass through the office. Their medical problems will vary but each one hopes to hear good news.

Preparing for the day, I review scans and laboratory tests. Indeed, some of the reports will allow me to share happy moments with patients.

"The biopsy showed only scar tissue; there is no cancer!"

"The new scan shows that everything has gone completely back to normal."

"Surgery was completely successful; we removed all of the cancer and you need no more treatment"

"You have been cancer-free long enough that we do not need to schedule any more appointments."

These are wonderful moments!

Other reports, however, carry ominous warnings. I anticipate these discussions. Although there is no one "right" way to share bad news, I try to remember: Be honest. Be gentle. Preserve hope. Listen. Answer questions. Don't hurry.

"There are new findings on the scan that explain your pain."

"We found more cancer in the operating room than we expected."

"The treatments did not control all of the cancer."

"There are options for care."

"Even though we cannot cure the cancer, we will do all we can to help you and your family."

"We will not abandon you."

"I am so sorry."

During the day, I move from exam room to exam room. Good news here, bad news there. In one room, there is a sense of pure delight and celebration. The holidays will be merry! In the next, there are tears and a gradual realization that the world has been turned on its head. What will we tell everyone? By the end of the day, I will have fallen woefully behind during the complicated visits and then caught up a bit during the routine ones.

As the last patient heads to the parking lot, I move on to the next task. Clinic is not truly complete until I have prepared a computerized report for each visit — a note succinctly distilling the history, examination, reports, diagnoses, and plans. My task is to translate moments of joy and horror into a written form that will become part of the medical record.

Notes for the "good news" visits are a pleasure to write. I work on these first.

Preparing the notes for the bad news visits, though, is often very difficult. There are many things that I cannot understand and for which I know no words. At the moments when I find myself struggling with a note, I often realize that I am incapable of comprehending the issues with which the patient and family are dealing.

Medical records have a variety of purposes. They record what has happened. They document what needs to be billed. They help caregivers communicate. And, sometimes, while I am trying to capture a critical moment in writing, they can even be a means of healing all by themselves.

Impact

Wed, 16 Dec 2009 10:59:17 GMT

"Perhaps the most important thing we ever give each other is our attention."
-Rachel Naomi Remen

You have been cancer free for two years now. Congratulations!

That was a terrible time. The whole time I was getting treatment, things were absolutely terrible! Just terrible!

What do you mean? In what way?

On top of everything else, we lost all of our friends! We were totally alone through all of the treatment.

Your friends abandoned you? All of them?

Every one of them! When people learned I had cancer, they stopped coming around. Later, a couple of them even told us, “I didn’t know what to say.” They really told us that!

That’s common, I think. People sometimes don’t know what to say.

Yeah, but it was terrible! There are several people we have never heard from again. We ended up with mostly new friends as a result. And that wasn’t the worst part.

What was worse?

My son told us that he couldn’t stand seeing me so sick so even he stopped coming over to visit me.

Completely?

I didn’t see him for over a year! Not at all. Just now, he’s starting to stop by again.

Wow.

You know — my wife and I — we went through this completely alone. Just the two of us. Well, we were alone except for the people who work here. They were great. Some of the people really made a difference for us. Otherwise, we were alone.

[Pause]

You people don’t realize how much impact you might have on someone while you are just doing your jobs.

[Pause]

Anyhow, things are going okay now.

Thanks for telling me this. See you in six months?

Yeah, six months. I can’t wait.

Essays on Milwaukee Public Radio's Lake Effect

Fri, 04 Dec 2009 20:04:47 GMT

Periodically, Milwaukee Public Radio will air one of my essays on its locally-produced magazine program, Lake Effect, The first essay, entitled "The Christmas Letter," aired last week. An earlier version of the essay appeared in the blog on 1-2-2009.

Thanks, WUWM!

Leaving it Behind

Mon, 09 Nov 2009 10:00:10 GMT

It is not enough to be busy; so are the ants. The question is: what are we busy about?
-Henry David Thoreau

The man staring intently at a newspaper vending machine grabbed my attention. He was bent over, reading through the plastic door. As I guided my shopping cart around him, he barely shifted his stance. Clearly, he was very interested in whatever was on the front page of the Wall Street Journal.

We were staying on the Florida panhandle for spring break and I had just finished the week’s final run to the grocery store. A few final items, a trip through the express lane, and then back to the beach. In a day or two, we would be home again and back to work and school.

The man at the vending machine must have just arrived in Florida for his own family vacation. His shorts were still pressed. His T-shirt was clean. His skin was still pale and his shopping basket held large containers of sunscreen and some inflatable toys. The little girl yanking on his arm still had price tags on her new sunglasses and plastic pail. Daddy, she ordered, Let’s go! Now! Please!

Buddy, I know your pain, I thought to myself.

Here was another person having trouble leaving work behind. In the run-up to being out of town, I had spent many extra hours seeing patients in clinic, adding urgent surgical cases onto the schedule, and hammering through the pile of paperwork that had accumulated on my desk. By the time we had gotten in the car to drive from Wisconsin to Florida, I had been frazzled. It had taken me a few days to reset.

As I watched the man, I realized that I was not alone.

I drove back to the place we were staying and unpacked the groceries. The beach beckoned but so did the computer.

I reached for the laptop power switch just as the cell phone rang. Daddy, where are you? Did you get everything? We’re waiting for you on the beach!

I froze for a second. Then, remembering the poor guy at the grocery store, I grabbed the cooler and headed out the door.

The following is feedback received for this blog:

Hi Bruce -I know exactly what you mean. It is difficult to disengage in things we throw ourselves into..even when we want to because we've been in *the mode* and it's the pace we've acclimated to.

Electronics also have a way of pulling us in... insidiously so at times. The next thing we know..we are involved in things (work/recreation) that aren't cultivating our personal relationships..

They are wonderful ..but I think easily become substitutes distracting us from what is most important ..the people right in front of us.

Maybe I am discussing apples and oranges here ..but I identified with the girls requesting their dad's presence.

- SeaSpray

seaspray-itsawonderfullife.blogspot.com

Some Conversations are Easier Than Others

Mon, 23 Nov 2009 21:46:46 GMT

Dear Blog-Reading Friends...

Once again this year, I am participating in a Thanksgiving weekend "blog rally" for "Engage with Grace," an effort to get families to talk to one another about end-of-life issues. I hope you find the information below to be useful.

Happy Holidays!

Bruce Campbell

From "Engage with Grace:"

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes. It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations — our closest friends and family.

Our original mission — to get more and more people talking about their end of life wishes — hasn’t changed.

At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them on the slide above. They’re not easy questions, but they are important.

Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation. One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

What if...

Thu, 22 Oct 2009 23:50:19 GMT

I wanted a perfect ending. Now I've learned, the hard way, that some poems don't rhyme, and some stories don't have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what's going to happen next. Delicious Ambiguity.
-Gilda Radner

Several years ago, we attended Milwaukee Irish Fest, the annual musical and cultural experience of everything even remotely Irish. While wandering the grounds, we discovered the band, Schooner Fare, a trio of singer-songwriters from Maine that captivated us with their tight harmonies, their musicianship and their enthusiasm. It was a great show.

After the performance, we bought a CD and made our way to the tables outside of the stage where the singers were signing autographs. We reached the front of the line.

As we greeted the performers, I was appalled. Two of the three were smoking cigarettes. “You depend on your voices to make your livings!” I heard myself saying. “I take care of people with throat cancer. What are you thinking?”

I do not remember their responses, although they acknowledged that they knew the habit was bad. I quickly wondered if I had overstepped my bounds. I thanked them and left.

For a few years after that, Schooner Fare continued to perform at Irish Fest and we continued to sit in the audience and cheer. Then, suddenly, they were no longer on the schedule. It turned out that bass player and singer Tom Rowe had developed throat cancer and died while receiving chemotherapy at age 53.

I still think of him as a talented songwriter, a confident and energetic performer, and a crowd-pleasing musician. He had a versatile and expressive voice. For me, it remains eerie that this person, whose talents I truly enjoyed, was taken by the kind of cancer I have spent my career battling. The day he died, the outside world crowded close to my professional world in a new and uncomfortable way.

Tom Rowe’s death still saddens me whenever I listen to one of his rollicking bass lines or hear him harmonize on one of the band’s albums. I still wish that there had been something I might have said to him on that day, long ago, that would have made a difference.

The following are comments received for this blog:

I work at Ft. Detrick in Fredrick Maryland, half of the base is used by the National Cancer Research Institute. As I go across the base I see little knots of cancer researchers puffing away. Every one of them thinks they will stop one cigarette short of cancer.

- Mark A.

The folks at Milwaukee Irish Fest have told me that Schooner Fare (without Tom Rowe) will appear again this coming year. See you there the weekend of August 20, 2010!

- Bruce Campbell

Missing the Airport

Mon, 02 Nov 2009 08:21:33 GMT

... [Former Delta pilot] Bill Mazzone, who flew jet airliners for 23 years, said it’s just as possible they got caught napping. "It’s kind of like being in an operating room. You know the physicians and the nurses…are listening to music, telling jokes, they’re doing what keeps them alert," he said. "Things are happening that if the public knew about it, they wouldn’t understand it, but it’s done. They’ve got the same thing in the cockpit."
- Associated Press story, "Could Letting Pilots Take a Nap Make Flying Safer?" which appeared after a Northwest Airlines flight missed Minneapolis. (Published 10-24-2009)

When I was in medical school many years ago, I was assigned to a surgical service that also had two first-year surgical residents known as "the interns." As a medical student, I was required to stay in the hospital every few nights to help one of them.

Internship was very demanding. The young, newly minted physicians were exhausted from being on-call every other night. Much of the night work was of no educational benefit. Each lab and X-ray report needed to be tracked down from a different corner of the building. All night long, they walked all over the hospital preparing for morning rounds. Just when the interns thought their work was completed, they would get called by the Emergency Room or the floor to see a patient, start an IV, replace a urinary catheter, draw blood, or disimpact a rectum (don’t ask). As the interns stumbled through their assigned tasks the next day, one of the senior physicians would invariably tell them how much easier things had gotten over the years. At the time, I remember dreading my own upcoming internship.

One day after a particularly difficult night of call, one of our interns was standing across the operating room table from me. We were both holding retractors as one of the attending surgeons worked deep in the abdomen. I held a long, curved metal retractor that pulled the liver up and out of the way; the intern held a broad, flat metal instrument to retract the stomach. No talking or extraneous noise was tolerated so we stood silently, leaning slightly backwards — still as posts — hoping to avoid attracting attention. Neither of us could see what the surgeon was doing.

The case dragged on for a long time. I glanced up at the intern and noticed that his eyelids were getting very heavy. Suddenly, he fell over backwards, crashing into a rolling table full of instruments as he headed to the floor. The retractor in his hands flew up and landed with a clang clear across the room. Total chaos ensued.

Within moments, the intern was sent to the lounge. I don’t think he ever scrubbed in with that particular surgeon again, and I am pretty certain he ended up in ophthalmology.

When I ran across the pilot’s comments comparing airliner cockpits to operating rooms, I paused for a moment. Yes, both pilots and OR personnel review checklists before we begin. Yes, we do best work when we are relaxed, careful, and attentive. Yes, there is often conversation and music while we work.

But, naps? Um, I don’t think so. Not a good idea.

The following is feedback received for this blog:

I agree with the analysis and I always objected to this comparison of the Operating room to aviation for the following reasons; Many air planes are a like but no 2 patients are When the pilot is tired a flight is canceled but when nurses have to work a double shift due to a sick call we do not cancel the shift, we go on. An air plane is a mechanical device our patients are not. In a flight events are most of the time predictable but in the operating room they seldom are.
So what is similar?
thanks

- Gaby Cohen

I have been a Surgical Tech for 16 years, yes you get tired, but you do everthing you can to keep yourself alert. Granted when you are "just holding retractors" it is difficult. That's when you try to make eye contact with your Circulator to say, "Help, this is very tiring!" Usually they pick up on what you need and start up a small, quiet conversation. To help keep everyone going!!!!!! They may even ask the Doctor if they can turn on some music. Most of the time the Doctor will say sure!

The comparison between aviation and operating room work is valid NOT because patients are comparable to airplanes but because the WORK of being vigilant over human life - and the fact that human lives are involved should that responsibility for vigilance be betryed - contains many parallels.

Isabel

The Unbelievable Dr. Adams

Tue, 29 May 2007 08:56:32 GMT

I ran into a colleague at the grocery store. “Can you believe it?” he kept asking. “Can you believe Mark is gone? I mean, he’s really gone! Can you believe it?”

Our medical community is reeling from the untimely death of Mark Adams, MD, the Chair of Surgery. Mark was an unbelievably gifted surgeon. Twenty years ago, I watched one of our most respected senior surgeons shake his head and tell a room full of people that Mark was far and away the best surgeon he had ever seen. Mark’s talents remained evident to all of us; one of the operating room employees with a special gift for nicknames once dubbed him “Edward Scissorhands” in recognition of his speed, efficiency, and focus. It was the perfect nickname and it stuck.

What a life he lived! He worked hard, wasted no words, and was a model of integrity. I did not know him well, but even I was aware of his passionate intensity for hunting, fly fishing, furniture and boat building, single malt beverages, and motorcycles. Whatever tasks toward which he directed his unbelievably intense gaze, he mastered.

The events of the past few days are truly unbelievable. I keep recalling Mark’s unique gifts, interests, skills, and passions. And, in answer to my colleague's repeated question, no, I cannot believe he is gone. It remains profoundly unbelievable.

Do you have a personal reaction to Mark’s life? If so, click on the Feedback link below. We will post your comments

The following is feedback received for this blog:

My wife called me today to tell me about the passing of Dr. Mark Adams. My wife heard it from her mother who was seeing her primary care physician who new of Dr. Adam's reputation. Dr. Adams was one of the many fine physicians and surgeons who has touched my family's life as I was a kidney transplant recipient in 2000 at Froedtert. Although Dr. Adams did not perform my transplant my wife and I saw Dr. Adams for subsequent post-transplant visits and he was always direct and to the point with us which we always appreciated. You could just tell he was a great surgeon and human being by how he treated you as a person and as a patient, with respect.
- Mike Dahlke

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I had a KP transplant on Oct 23, 1998 after living with diabetes for over 37 years. I had the typical post-operative lab visits but had not seen Dr. Adams in the clinic for over 5 years. I did run into him a few times around the hospital and at the transplant picnic and he had the ability to remember me and the details of my condition. I'm sure he did the same with all of his patients, which had to number in the thousands. Aside from being a top notch surgeon and instructor, he made me feel like a friend. The compassion that he showed for his clientele and his craft will be genuinely missed.
- Daryl Manka

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Dr Adams gave me my life back more than once in my 38 years ofliving. After receiving my kidney transplant in January of 2005 ( which heperformed) I had some internal bleeding and Dr Adams fixed the bleeding and I believe saved my life. I will always remember joking around with him at my post operative visits. He was a very talented surgeon.
- Erin Decker

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Dr Adams performed my first and then second Kidney transplant in 1984 when I was only 16. I started out being afraid until I met Dr Adams. I can't really explain it, but he just had a way that projected everything would be ok and that I could rely on him. I've known and read about all the accomplishments and accolades he's received over the years and they are a testament to the passion and dedication that dwelled inside him. I have to add that in addition, it's mind boggling to know the numerous lives that are also changed and have been affected to this day because of him. I could hardly believe the news of his passing. I'm still in shock. What has always stayed ingrained in me about Dr. Adams is the way he pin pointed the exact thing that needed to be pin pointed. He just had a knowing, always, on how to solve what ever needed solving. He was respectful and kind and has impacted my life beyond words. My heart is heavy and my prayers go out to his family.
- Mary Wind

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Dr Adam not only used the skill of his hands, but the Skills that Really made him stands out. His Heart.

He not only changed my life but the lives of my three children as well. His bed side manner was impeccable He was truly a blessing the first day I walked in his office at Froedtert Hospital in Milwaukee. He gave me back Life on March 03, 2006 with a Kidney. I not only lost a beautiful Doctor. More importantly I lost a Great Friend that will be Heart Felt & Deeply Missed

Much Luv 4 Dr Mark Adam
Broken Hearted,
Kimberly M. Young & Family
Kenosha, WI

----------

THE MAGIC OF DR. ADAMS
I consider myself blessed to have known Dr.Adams for so many years. As nephrologist in Kenosha, Medical Director of the St. Catherine's Kidney Center, I referred innumerable patients to Him for transplant evaluation. He has given life to so many, touched their lifes and the ones of the families in a special way so that all of them came back with new kidney, a pancreas, but, most of all, with a new friend. His caring, integrity, devotion are legendary. He was always available and willing, he went the extra step for all. Indeed he gave our patients kidneys and pancreas but he stole pieces of our hearts , instilling in its place the sparkle of His eyes and warmth of His smile. We shall never be without Him. That is the magic only Dr. Adams could perform and He gave so gallantly ... He was my colleague, my friend, my mentor and inspiration. He was humble and pure at heart. I am saddened by the immense loss and would like to extend my warm condolances to his family, to Dr. Chris Johnson and the entire transplant team, to the girls of his office and to the entire Froedttert Community.

- Rosanna Ranieri MD

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I first met Dr Mark Adams in 1978 at which time he told me to ignore the charts and graphs others were creating to plot out the expected failure date of my kidneys. He was the first to allow me to peek through the dark cloud hanging over my head. His comments had an immediate and life-changing effect on me for which I will be forever grateful.

On Thanksgiving Day 1978 Dr. Adams spent the afternoon crafting a fistula for a very young (25) scared, six-month pregnant woman whose kidneys were failing and who couldn't undergo anesthesia. I had the audacity to vomit all over his nice sterile operating room, yet he simply stopped surgery and then, in his own inimitable way, calmly and quietly assured me that it wasn't a problem and that he'd get back to surgery whenever I was ready.

Later, on March 30, 1981, Dr. Adams performed my kidney transplant surgery. My fondest memories of my time in the hospital were the tales of his children, and I will never forget the beautiful sunny April day he checked in on me and then announced he was leaving the hospital to take his children to the park to fly kites. A dedicated surgeon who had his priorities straight.

As a direct result of his skill and dedication, and of others, as well I recently celebrated the 26th anniversary of my transplant, the 28th birthday of my older daughter (the "dialysis baby"), the 20th birthday of my younger daughter, born after the tranplant,and will soon celebrate my 32nd wedding anniversary.

I am only one of many. The enormous, postive impact Mark Adams had on the lives around him will be felt for generations to come.

He will be missed. May we all aspire to be more like him.

- Ann Pendergast Christman

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I was so distressed to belatedly hear of the death of Dr. Mark Adams. He was my partner, colleague, compatriot, and friend through my years at MCOW (1977-1989). For those years he was in fantastic physical condition and skied the Birkebeiner. I remember vividly his going through the windshield of a car that hit him while he was bicycling to work on Bluemound.

Mark was a terrific terrific surgeon and certainly got me out of trouble on numerous occasions though I never seemed to get the chance to reciprocate.

I cut down a huge tree in my Elm Grove yard and Mark sawed it up into planks and handmade a beautiful bench of it. I always think of him when I see it. It seems to stand for his dedication to work, care, and friends.

He will be deeply missed.

- Stephen C. Jacobs, MD

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I met Dr. Mark Adams in the 80's. I was covering a story of a child named Virgil whose kidney transplant hopes had all but vanished. We had accompanied Virgil on a last wish trip to Disneyland. Imagine the shock when we got the call that the impossible kidney match had been found. Time was of the essence. We got Virgil back to Milwaukee and into an operating room. Dr. Adams was amazing it was remarkable to witness that operation so many years ago..

Today....the day after the tragic plane crash in Milwaukee that claimed the lives of the University of Michigan doctors and others dedicated to life saving transplants....I suggested we call one of the finest advocates of organ donation I've know...to get some valuable perspective on that element of the story. A quick google search led to this website and a tremendously sad discovery.

I got the chance to see how much he adored his family. A couple years ago, I ran into Dr. Adams at the hardware store. He told me how he was delighting in the prospect of building his family a kayak.

Reading this blog, I find that adoration spread to his extended family too...all the people who were given a second chance at life thanks to his skills in the operating room.

- Kathy Mykleby

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Dr. Mark Adams along with Dr. Chris Johnson performed the kidney transplant between my brother, Greg Key and I. We were the 100th transplant at Froedtert. Doctor Adams was a great man, he helped us feel calm and re-assured about the procedure. I was deeply saddened to hear the news of his death. The medical community will suffer a great loss.

- Loretta Sue Meinel

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I came to the Medical College of Wisconsin in 1985, as an intern in General Surgery. One memory that stands out is being the intern on the transplant service in December. Early in the month Dr. Adams asked me if I was married. When I said I was, he turned to my senior resident and said, "Mike, you take call on Christmas--this intern needs to be with his wife." Later, after I switched specialties to anesthesiology, doing residency and fellowship at MCW, I always enjoyed doing cases with Mark, as he was quite simply the best surgeon I'd ever seen. (Although if something didn't go well, his withering laser beam stare could be quite intimidating!) Eventually, after being on the anesthesiology staff at MCW for a couple years, an opportunity presented itself at the Mayo Clinic in Arizona. I asked Mark to write a letter of recommendation for me. The letter included the line "I could not recommend him to you more highly, although I hope he stays here with us in Milwaukee."

When I told him that I got the job and I was leaving, he smiled and said, "I hope you get sunburned!"

Nearly 10 years later, here I am doing a transplant case, when my surgical colleague says to me, "Say, Karl, did you know that surgeon in Wisconsin who just died of an arrhythmia, Mark . . . ." I didn't want him to say the last name, because right then I knew.

I could go on with anecdotes, but suffice it to say I'm honored to have had the opportunity to know and work with Mark Adams. It has been said that we all die, but not everyone lives. Mark clearly lived, and I like to think that maybe I lived a little bit more having had a chance to know him.

- Karl Poterack

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I decided to look at the news at Froedtert Hospital today and found such a sad heading that Dr. Adams had passed away. I worked at FMLH for 20 years, but have been gone for 6 years now, but I do remember his wonderful demeanor and of course his good looking manner and enjoyed knowing him. I am so sorry for all of his family, friends and co-workers. I know you will all miss him.

- Brenda Holfert

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I gave my husband a kidney in 1998. Dr. Adams was the surgeon who put my kidney into my husband. Dr. Adams was a very professional, caring, dedicated doctor who obviously had an enormous talent for what he did for others. He has been taken away far too soon, but his work on this earth will live on in others for many years. Dr. Adams saved many lives and because of that, his legacay will live on. There is no answer why such a person leaves us so soon when he can do so much to help others here, but my husband and I are greatful with our lives, that Dr. Adams came into our lives when he did. We will never forget him and our sympathies go out to his family, colleages, and patients, whom he has touched over the years. We are very saddened. How ironic that Dr. Adams saved my husband's life, only to be outlived by him in the end.

- Cindy Fredericksen

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Well, it has been 4 almost 5 months now and I think I can finally sit down and write this. I worked with Dr. Adams as his assistant for the last 9 years. As you do when you work closely with someone we shared many family stories, happy times and stressful times. That morning when I came in and his door was still closed I could not be prepared for what I was told. I thought his flight from New Orleans came in late and he was resting.

Indeed, he was resting. The essence of ones being is a strong thing, and as I intently listened to what I was being told I could see him walk from his office through mine and smile as he always did. He walked right behind Jon and went around the corner. Surely Jon was wrong. His brown shoes were neatly tucked away under his desk and his lab coat hung quietly in the closet. Surely, this moment was an awful mistake and he would be walking back through that door with his helmet in hand, smiling and asking what was on his calendar for the morning. I sat for a moment in anticipation of that happening, but it did not.

I quietly went to his desk and sat in his chair. I watched his dream catcher gently swaying in the corner, right where we hung it when we moved down here. I heard him laughing as he teased me about climbing up into his bookcase to dust and strategically place every item which had its own story and purpose. He was quite sure that worker's comp would not cover "secretary falling out of bookcase". His computer screen was dark and his desk was in its usual state of organized mayhem. I took the letters for signature out of his in-box and I took his "blue" pen and placed it in my pocket. He was lost without that pen, and I was going to be lost without him.

I still see him in the halls, every so often, when I come around a corner or get off the elevator and head towards the office. There he is at the end of the hall in his blue shirt and Khaki's, coffee in hand, smiling. One blink and he is gone, but the warmth of that moment is still there and it is that moment that starts that work day.

Everything that Dr. Adams is, was, and always will be is enveloped in this office, the halls and the College/Hospital itself. You can see him, hear him and feel him everywhere because in one way or another he touched everyone.

Until the next time I see you Dr. Adams........

- Trudy Becker

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I was a recipient of a kidney transplant on May 29, 1984. Dr. Adams was such a wonderful doctor and so nice. I saw him about year ago and I will always remember what he told me. He told me that I would live to 100 years old and based on that, I really, really take care of my kidney. I will not ruin the wonderful work he did for me. He was a wonderful man.

- Mary Kuether

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My first transplant was 3-22-88, which Dr. Adams performed. He was great doctor no two ways about it. Like people said in comments before mine, he would always remember you. He would always stop and say hi, eventhough you wouldn't be seeing him that day. I remember once I was sitting in the hallway no where near the transplant floor, he stopped sat down and asked how everything was going. That really impressed my family. He was a great guy and doctor. Thanks for being you. Thanks for the many years you added onto my life.

- Tom Park

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Dr. Adams i met in the spring of 1982 i had previously had a transplant at uww of madison,

Dr. Hauns Solinger preformed my first TX.

Dr. Adams took me on a personal tour of the transplant unit at that time. I was looking to put my name on the transplant list at Froedtert &at the UWW. after my first transplant had failed.Little did i know that i would recieve my 2nd 3rd & 4th at the hands of dr.Adams, among the many other surgeries preformed by Dr. Adams if it were not for the skills of him i would not be here today. Thanks to Dr. Adams & the nurses and staff of 4se.

- Michael W. West

PS. i will never forget Mark B. adams

I just recently found out about Dr. Adams and was deeply saddened. He explained the whole transplant process to my family and I since having a liver transplant was my only major surgery i ever had. I had a liver transplant15 years ago him and he was the best. He took away the questions and any fears from us. As I look towards the possibilty of another transplant, his wisdom and advice will give me comfort.

- Greta Melcher

The Save

Tue, 15 Sep 2009 10:15:13 GMT

A woman has the age she deserves.
-Coco Chanel


She sweeps into the office with a flourish, filling the place with her commanding personality. Because she can be curt, some of the staff members avoid her. She usually refuses to step on the scale to have her weight checked and reveals her septagenarian status only with reluctance.

Long ago, I recognized her as being “old school” since I have known other women of a certain vintage who were outspoken and uncommonly crusty. She reminds me of a few of my parents’ friends who engaged confidently and forcefully in every social interaction. She remains stylish, if a bit dated, and is fond of expensive perfume.

Her office visits have never been complicated. Her cancer was successfully removed with a surgical procedure over five years before and, except for some scar tissue and dryness, she has no other problems. She has no difficulty talking and she remains cancer free. Everything, from my point of view, is perfect. She is one of my “saves,” someone who had been cured of cancer with one of my surgical procedures.

“Everything looks fine, Mrs. Anderson,” I told her at one of her visits. “You are doing great! No sign of the cancer. There is nothing worrisome.”

She glares at me. “Nothing, eh? I would NEVER have another surgery! Never!” She continues. “This life is terrible! Why can’t you do something about the dryness? Why does my tongue feel so tight all of the time?”

“Oh,” I think.

“And another thing! Why does my tongue burn so much when I eat Mexican food? I used to love spicy foods, but I can barely tolerate them anymore! Oh, this is terrible!”

So it goes. I try to explain the mucosal changes. Scar tissue is less flexible. The linings are thin and sensitive. Things are never the same.

She is not satisfied.

As she gets up to leave, I find myself apologizing. “I wish things were different,” I say. "See you next year?"

“I'll call when I'm ready to come back," She turns as she reaches the door and tosses me a patronizing look. “Oh, it’s OK, I suppose,” she decides. "I know you did your best.” Then she gathers herself up and heads down the hall.

The following is feedback received for this blog:

I love older people; one day I want to be one ... in fact, one day I want to be one just like this!

- Jabulani

Congrats on the save. That must feel so good.

sounds like she enjoys complaining... but underneath it all appreciates that you saved her life.

It must be frustrating to have some of her concerns.

I'm the polar opposite of that. My Mother spoke what she thought and could come across hard. when she really was not that way inside.

years a go when my firstborn was a baby, I decided to sell cosmetics for Mary Kay so I could make my own hours, have an income but choose the time I could be with my baby.

They had a saying in reference to having a skin care program... that I still abide by today..although now with a different company.

At 20...you have the skin you've inherited.

At 40... you have the skin you've made.

And at 60... you have the skin you deserve.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

Surgeons and Empathy

Mon, 31 Aug 2009 11:36:18 GMT

Insight, I believe, refers to the depth of understanding that comes by setting experiences, yours and mine, familiar and exotic, new and old, side by side, learning by letting them speak to one another.
-Mary Catherine Bateson

Last week, a group of third-year medical students completed their first rotations through Surgery. They spent eight weeks doing things that no normal person would ever be asked to do. Many days, these students arrived at the hospital at 5:30 a.m. to begin 30-hour shifts seeing patients, checking laboratory reports, making rounds, and observing surgery.

In the operating room, these students saw, heard, and experienced many unthinkable things for the first time. They held retractors for hours. They felt the warmth of another person’s intestines envelop their hand and forearm as they listened to the surgeon describe findings deep in the belly. They watched as a heart resumed beating after bypass or transplant surgery.

The students also spent time talking to patients and learning their stories. Many of the students were present as a person that they had gotten to know died.

When I was in medical school, the end of the surgical rotation meant merely that it was time to move on to the next, certainly less intense, clinical experience.

For this group of students, though, their teachers planned something different.

These students were offered the opportunity to prepare a creative piece to reflect on what they had just experienced. Almost half chose to write a poem, create an essay, or paint a picture.

This was not your standard bookshop reading! There were poems about bowel movements and horrific odors. There were pieces about cardiac arrests. There were appreciations of patients’ stories. There were evocative poems about sick children. Some of the pieces were very funny, some displayed great tenderness. Many of the students admitted that this was their first attempt at reflective writing or verse, yet all of the pieces reflected their shared immersion in a rich, vast, and powerful experience.

When the session ended, all of the participants and their classmates sat stunned. As one later shared, “I've experienced many emotional moments throughout the past two months and it wasn't until this hour did I finally have time to realize and reflect on my personal experiences and their impact on my life.” Importantly, one student wrote, “I learned that perhaps I do need to put some effort into maintaining empathy.”

Medical school involves thousands of hours of instruction. This was unique. This was a single, planned, intentional hour of reflection.

Perhaps none of these particular students will go into a surgical field, and that is just fine, yet I hope that one of them becomes my own physician when the time comes. Having heard them read and reflect, I know that I will be in good hands.

The following is feedback received for this blog:

Interesting post. It takes a special person to want to go through all that. Has to be a calling! certainly... most people could not withstand the rigors of a medical education.

I never realized how empathetic doctors are toward their patients until I joined the med blogosphere. I'm glad to know they are. :)

I thought surgeons weren't supposed to have feelings though. ? That they were supposed to be the non-feeling specialty? generally speaking.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

Thanks for the comment! "Surgeons weren't supposed to have feelings"!?! Ouch! Occasionally, a little empathy slips out!

Actually, a research study a few years ago confirmed that medical students that have higher empathy scores are more likely to go into primary care specialties, so I guess you are on the right track.

-Bruce

It's not that we don't have emotions, or are not caring; its that we have learned to suppress our emotions in order to perform the incredible tasks that are required of us. If a surgeons hand slips, or his concentration wavers, even for a second, while performing a routine operation, loss of life can ensue. Procedures tends to be much more routine and methodical when you have the distance separating you from what you are actually doing. It is this ability that makes us successful as surgeons. I would hate to have an overly emotional, frantic surgeon's hands in my abdomen while I was bleeding out.

- Steven Savage

Dear Dr. Savage,

Thanks for your comments. What you say strikes at the heart of one argument I have heard about the ACGME's core competencies for residents. A resident can excel in all of the competencies and still be technically dangerous surgeon.

Still, I don't think that a side effect of including reflective or narrative experiences in a Surgery clerkship is to make surgeons more caring or less capable of making hard, rational, dispassionate choices. There is value in having a person whose hands hold my life in the balance being a person capable of insight and compassion. Think of Richard Selzer, Sherwin Nuland, Pauline Chen, Atul Gawande, and Loyal Davis...all renowned surgeons, accomplished writers and keen observers of their own motivations and their patients' dilemmas. These people, at least in their writing, did anything BUT suppress their emotions.

Thanks again.
-Bruce

Both...very interesting comments! :)

"technically dangerous surgeon. " Scary thought... that someone could have a surgeon like that. God Forbid!

I'd take a competent surgeon over a sensitive one... but if I can have both..then that's just icing on the cake.

If you haven't read this..one of my favorite surgical posts is Dr Schwab's "Taking Trust". I believe he wrote it in October, 2006. A moving post. :)

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

Smoking is Good for Business

Tue, 25 Aug 2009 23:06:10 GMT

"I have every sympathy with the American who was so horrified by what he had read of the effects of smoking that he gave up reading."
- Henry G. Strauss

I have worked in hospitals long enough to remember when there were few smoking restrictions. The air in the emergency room where I had my first hospital job as an 18-year-old nursing assistant was thick with smoke from the nurses and physicians. As a medical student, I recall conferences where the slides were projected through a haze of smoke. I remember one of the most prominent surgeons at my medical school smoking cigars while making hospital rounds. One of my deans kept his pipe half-lit in the pocket of his lab coat, pulling it out between patients.

During my residency, there was a smoking lounge adjacent to the operating room where some of the surgeons gathered between cases. Across town, the VA had the cheapest cigarettes anywhere and patients would leave after their appointments with shopping bags full of low-cost smokes. Because the VA did not allow the veterans to smoke in their rooms, we residents would often head first to the smoking lounge when we needed to find one of our patients. Even at the cancer hospital where I did my fellowship training, patients smoked on the hospital floors and several of the doctors smoked in their offices.

My, how things have changed! A recent report confirms that 45 percent of hospital campuses nationwide are, like our own, completely smoke free including the buildings and surrounding open spaces. In 1992, only 3 percent of hospital campuses were smoke-free.

Despite the declining number of smokers, though, some hospital employees and patients continue to struggle with tobacco addiction. Every day, I watch people duck out though the garages to go for walks around the grounds and then catch the odor of smoke on them as they return from the out-of-doors.

A while back, I spotted an employee with whom I work heading out for a walk. “Where are you going?” I asked. “Isn’t it time to quit?”

“Y’know, Doc, I’d love to,” he responded.

“Talk to me when you get back.”

Later that day, I reviewed smoking cessation strategies with him and confirmed that he was truly motivated to quit. I handed him a prescription. “I think you can do it!” I said.

“Me, too,” he replied and he meant it. He has been smoke-free for a year.

To be honest, when it was first proposed, I was not certain that a smoke-free campus would work. Certainly, there are those who continue to break the rules. On the other hand, I know several employees who have cut down or even quit smoking because of the policy.

Over 15 percent of lifelong smokers will develop cancer. The average smoker loses decades off of his or her life. Having someone quit smoking before they become a patient of mine is a real pleasure for me. As much as I love my work, I love my friends and colleagues even more.

SurgeXperiences 303 - The Dog Days of Summer Edition

Sun, 09 Aug 2009 07:54:53 GMT

Welcome to the Aug. 9, 2009 edition of surgeXperiences! I'm happy to be hosting again. Here in the Northern Hemisphere, these are the "Dog Days of Summer," so in honor of dogs everywhere, lets chew into the best of the surgical blogosphere. Along the way, we will sniff around a few categories and search for the "Best of Show."

Candidates for the "THAT'S REALLY AMAZING" Trophy:

MedGadget posts about a remarkable chain of kidney transplants. Sixteen people in four states received organs! The chain was started at Johns Hopkins where one of their administrators donated her kidney for a co-worker. She has kept a blog about the experience including a nice post on the therapeutic benefit of staying in your pajamas. Amazing!

Dr. Wes has a post that links to a video of a 34-year-old man who was born with his heart outside of his ribcage.

In a post entitled weighty issues, South African surgeon and blogger bongi tells about treating a substantial woman who was mauled by a hippopotamus.

Candidates for the "I NEED A BREAK IN THE ROUTINE" Trophy:

T., who crafts the blog Notes of an Anesthesioboist, reflects on the healing moments. In a post entitled Detour, she writes "Sometimes it's the moments between procedures, the tucked-away opportunities to participate in healing (even if it can't be completely achieved), that remind us why were called to medicine in the first place..."

Here's a post by someone who needs a different kind of break. Gizabeth Shyder, a pathologist, in her blog Methodical Madness tells how the odor of Tuna Salad affected her day.

Candidates for "THE LIFE OF A SURGEON" Trophy:

Ramona Bates at Suture for a Living provides some great links this week! Here's a discussion and photo of macrodactyly that would set any hand surgeon to planning a series of procedures. She also provided a link to a patient blog with photos of his ulnar nerve transposition. And here she provides a link to a blog with a photo of a cute young man showing off his Colles Fracture.

Kevin, MD, in a post entitled, Are Female Surgeons Happier than their Male Counterparts? provides a link to a MedPage Today report. Happiness is hard to quantify, but female surgeons are significantly more enthusiastic in recommending surgery as a specialty to students. The study also confirms the huge impact that specialty choice has on lifestyle and family.

The New York Times Health Blog, Well, has a post and a link to a wonderful essay by surgeon Pauline Chen, MD. Dr. Chen tells the story of a woman who pursued alternative breast cancer treatment for two years before presenting with a large, painful mass. She writes, "I find myself wondering when it comes to patients like Marla or others whose diagnoses are delayed for various personal, social and economic reasons, how responsible am I as the physician and are they as the patients?" I have had several similar experiences.

Dr. Jon at Unbounded Medicine presents some amazing (and a bit disturbing) photos of Rectal Prolapse. Thank goodness for colorectal surgeons!

In my own blog, Reflections in a Head Mirror, I describe how, in the operating room, not everything the patient tries to hide stays hidden.

Sometimes, the life of the surgeon has unpleasant challenges. Jeffrey Leow provided a link to a story about plastic surgeons in Australasia being stalked by unhappy customers.

A medical student, MedZag, writes a moving post about the loss of a patient in The Bee Gees, Storage Closets, and Medical Education. It is another essay that resonated with me. (His current post is about his initiation on the surgical service. Hang in there!)

Candidates for the "THIS MAKES IT ALL WORTHWHILE" Trophy:

QuietusLeo, an Israeli anesthesiologist who writes The Sandman, has a beautiful essay entitled The Gift where he reflects on the gratitude of a young patient and his family. "He who saves one soul - saves an entire world."

Sid Schwab at Surgeonsblog writes about how a patient and a gift had a long-term effect on him in a post entitled Kung Fu Surgeon.

South African surgeon and blogger b ongi writes about his surprise when he learns that Americans are not all the same in a post entitled "gracious."

In a post entitled "difficulties," bongi writes about how hard, yet rewarding, it is to keep visiting patients for which we have little to offer. He remarks, "i just kept on visiting her, usually just to say hello so that she would know she was not totally alone."

In another great piece, bongi reflects on the concept that "Only the Good Die Young" in a post entitled, "who actually wants to live forever?"

SeaSpray, an eloquent patient-blogger, writes about the final moments before surgery. She writes, "I do believe it ... but there is always that ... last glance around the room or up to the ceiling, knowing that I am right then ... at that moment in time ... surrendering my mind and body to them." Powerful stuff.

Candidate for the "BAD DOG!" Trophy:

In a story entitled Plastic Surgeon Botches 28 Operations, we learn that there is value in checking to see if your physician is board-certified. Tragic outcome.

Candidates for the "GET READY FOR THE FUTURE" Trophy:

Surgery in the future will have new tools. MedGadget tells of research at MIT that will lead to the development of tissue-specific adhesives.

Is social networking coming the the operating room? Kevin, MD reviews some of the potential uses for Twitter in medical practice. Two of our local hospitals recently used social networking for surgical procedures. One live-twittered a bilateral knee replacement with 250 tweets. (Can you sterilize your BlackBerry???) Another local hospital used Twitter, Facebook, and YouTube to follow a patient through prostate surgery. A bioethicist and colleague, Art Derse, MD, JD was interviewed on our local NPR affiliate about the Twittering Dilemma in the operating room. (Spoiler: Social networking has potential pitfalls, but is not inherently unethical.)

Can we afford the future? Buckeye Surgeon discusses the future of medical innovation in the midst of healthcare and world financial crises. He notes, "At some point in time (like when health care in America isn't in full crisis mode) it may be advisable, even desirable, to see innovation...gather momentum as acceptable alternatives to the standard of care. But we aren't there yet." MedGadget includes a post with a photo of President Obama at the controls of a DaVinci Surgical Robot, one of the world's most expensive medical innovations at $1.75 million apiece. Paul Levy, at Running a Hospital explains why every medical center feels pressured to spend the millions of dollars the devices cost just to stay competitive.

AND FINALLY ...

The winner of the "BEST IN SHOW" Trophy:

Rusty, who lives at Suture for a Living, is one of the medical blogosphere's beloved mascots (along with a certain lobster and some llamas). Rusty is a contestant in the Top Dog in Arkansas Contest! You can vote for him (registration required) at the Arkansas Democrat-Gazette's website from now until August 26. Go, Rusty!

Thanks for visiting! If you would like to host a future edition of SurgeXperiences, contact Jeffrey (our fearless leader) here. Be sure to submit for SurgeXperience #304 using the carnival submission form. Past posts and future hosts can be found on our SurgeXperiences index page.

Technorati tags: SurgeXperiences, blog carnival.

The following is feedback received for this blog:

I think it is terrific the way in which you used the opportunity to teach additional non textbook info.

Also..that you are nonjudgmental and compassionate.

Having lost Mom this past April.. I sincerely appreciate this comment from your previous commentator "Previous family deaths have taught me that the intense pain does diminish but it never diminishes the love for your loved one. As time progresses, memories will come in stages as painful, then bittersweet, then as soothing and delightful. "

If it is alright with her I may quote her. Certainly I am putting it in my drafts. :)

- SeaSpray

seaspray-itsawonderfullife.blogspot.com

Thank you for allowing my submission and your kind words Dr Campbell.

You did a great job with Surgxperiences! Quite clever using the *dog* days of summer and loved seeing Rusty in the pics. :)

I am going to borrow son's lap top so I can kick back and do some reading in comfort. Lots of good reads here!

Now I shall link. :)

- Seaspray

Great edition! Thanks for the vote for Rusty!

- rlbates
http://rlbatesmd.blogspot.com/

SurgeXperiences Call for Entries

Tue, 04 Aug 2009 11:42:28 GMT

SurgeXperiences 303 (Aug. 9) will be hosted right here! The deadline for submissions is midnight on Friday, Aug. 7.

SurgeXperiences is a blog carnival of surgical blogs. It is open to all (surgeons, nurses, CRNA's, anesthesiologists, ORT's, patients, etc.) who have a surgical blog or article to submit.

The last time I hosted, I waxed poetic. I can’t predict what will happen this time.

If you are a blogger, be sure to submit your post via this form. If you would like to be the host in the future, please contact Jeffrey who runs the show here. To view the catalog of past SurgeXperiences editions, click here.

Come back next Monday and read the best of the surgical blogosphere for and by people who spend time in the operating room!

Hidden

Mon, 27 Jul 2009 09:34:55 GMT

In the fields of observation chance favors only the prepared mind.
-Louis Pasteur

“Do you drink much alcohol, wine, or beer?” He was a patient with a newly diagnosed mouth cancer. I was working through my checklist while we became acquainted.

“I have a beer most nights before dinner. Maybe I’ll have a couple more on weekends.”

The questions continued. The patient’s teenage granddaughter was clearly taken by my young, handsome resident. “How long does it take to be a doctor?” she asked him. He went through the litany of four years each of college and medical school, followed by five years of otolaryngology residency. She counted the years up in her head. “You’ll be 30-years-old when you finish! Why does it take so long?” she exclaimed.

He smiled and shook his head. “It takes a long time to learn everything you need to know to be a safe surgeon.” he replied. “Dr. Campbell even added two more years onto his training after residency.”

She looked at me in disbelief. “Slow learner,” I explained.

The focus returned to her grandfather and we completed the other questions about his health. The examination and scans confirmed what we already knew. His cancer was treatable but he would need an operation. He appeared to be in good shape and, before he left the office, we arranged a surgical date.

A few days later, he was asleep on the operating table. I made the incision. As the resident and I lifted the skin off the underlying neck fat and lymph nodes, a familiar feeling washed over me. “Look at these tissues,” I said. “What do you notice?”

The resident examined the fat intently.

“Why, the tissues are too flimsy, too soft, too yellow, don’t you agree? They don’t handle the way you would expect. Why is that?”

“I have seen tissues look like this in alcoholic patients. He didn’t tell us about any problems, but we will have to watch him carefully after surgery.”

I have never found a textbook that describes the subtle phenomenon we identified that day during surgery — the boggy, yellow fat that some alcoholics hide in their neck tissues — but this rare, subjective finding is something that I have noticed several times during my career. I spend time pointing out and discussing the condition whenever I see it. On top of everything else that our residents are expected to learn, we spend a lot of time sharing the non-textbook lessons. It is a long process.

Indeed, two days later, we were ready when our patient started spiraling into the alcohol withdrawal his tissues had predicted. Later that week, his family discovered a stash of liquor bottles in the basement.

Happily, my patient made a full recovery. In the process, though, he had helped prepare one more resident for the next patient who thought he had something to hide.

The following is feedback received for this blog:

Dr Campbell,

You recently were involved with treatment for my brother who has tongue cancer. Now that I have seen your comments in this blog I feel he more than likely received some good, direct and caring advice from you. Myself and other of his siblings have been with him 24 hr's/day for the last 9 days. And he has finally agreed to Hospice care. But we allowed him to make all his own decisions, as hard as it was for himself and for us. After 46 young years, his death is coming soon. He too was an alcoholic and a smoker.. Some people refer to the previous bad habits he had as the reasons for this cancer. I prefer to look at what is occurring today and forgive and forget his past. Even a person who did not lead a good life in lifestyle and/or relationships does not deserve to suffer in the manner in which cancer imposes. I look forward to his death for peace for himself but will relish many memories. Previous family deaths have taught me that the intense pain does diminish but it never diminishes the love for your loved one. As time progresses, memories will come in stages as painful, then bittersweet, then as soothing and delightful. Thank you for all the caring and humanity given by yourself by all the staff at Froedtert.

- Lori C.

Dear Ms. C.,

Thank you for your comments. It has been an honor to be involved in your brother's medical care.

One of your statements struck me. I agree that people tend to "blame" patients for the things that happen. We know that people who smoke and drink are more likely to get these cancers, and that knowledge can be very difficult for both the patients and their family members.

Still, developing cancer was not his fault. In light of that, your understanding words are so important. I truly hope that your spirit that focuses forgiveness and love on him can bring healing both to your brother and to your entire family.

Thanks again for writing.

Sincerely,
Bruce H. Campbell, MD

Numb

Sat, 04 Jul 2009 14:13:09 GMT

The capacity to give one's attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle.
-Simone Weil

I walked numbly down the steps of the funeral home, squinting as I reached the bright afternoon sun. People moved all around me, pushing strollers, walking dogs, searching pockets for car keys, talking on cell phones, looking into store windows, laughing. They were completely oblivious.

My mother and I had just spent the past hour at the mortuary, making arrangements for my father’s remains. The funeral director had worked steadily though his list: What should be in the obituary? Should the paper run the listing for two days or three? Here are several forms we need to complete. Could you please sign here? And here? Would you like to pick up the ashes or should we deliver them to the church? Do you want the clothes he was wearing? Because he was a veteran, he is eligible for a flag. We are so sorry for your loss! Will you be paying with a check or credit card?

Many memories remain from that afternoon. Most of all, as I left the funeral home, I wondered how all of these people could be going about their business as though nothing had happened. Doesn’t everyone feel this numbness – this incredible weight – just as I do? How can they be rushing about at such a time?

There is value, writers tell us, in these intense, shared experiences. Eventually, each of us is temporarily overwhelmed, however briefly, by personal or shared loss. Like most people, I slowly returned to “normal,” shaking loose the shroud that had pressed down on me. Occasionally, the sensation revisits me, stopping me in my tracks for just a moment.

Not long ago, I was walking down the hallway on one of our hospital inpatient units when I felt the old twinge.

Behind some of these doors, I realized, there are people having cataclysmic experiences. It is possible that the man in this room has been given terrible news. A woman in that room might suddenly have realized that her husband is never coming home. Just down the hall, a young family could be coming to terms with a series of difficult and life-altering treatments. Next to the nursing station, a young child is being led to a bedside, perhaps to say goodbye.

At the same moment, out in the hallway, I am having a trivial conversation with a colleague, smiling as I hear laughter around the corner. I plan out the rest of my day, trying to save enough time to grab lunch and complete my operative notes before I head to clinic. Later, I will head home after I have finally checked everything off my list.

On this day, I am one of the oblivious ones.

The following is feedback received for this blog:

This post reminded me of when I lost my father just two years ago. It seemed the whole world was asleep as we left the ICU at St. Luke's in Milwaukee at about 3:20 a.m. Only a couple of stoic nurses were stationed at computers and everything was dark, with the exception of blinking lights and monitors. Heads down, we were a sobbing mass of humanity making our way through the abandoned hallways. When we emerged outside after so many hours at vigil with him, it seemed the rest of the world was completely oblivious to our loss. (Call the funeral home, contact a priest, do this, do that.)

My father was a very sensitive guy. I recall him admonishing us kids when we visited him in the hospital many years ago, for making way too much noise. "Quiet," he said. "The people in the next room just got some bad news." We all experience the highs and lows of life, but a little empathy goes a long way.

- Steve B.

Fabulous post. Thank you. I'm so sorry for your loss. My grandmother slipped away in February. When I got that phone call to tell me, I simply said thank you. I asked when they wanted me to clear her room. They said there was no rush. I called my husband. I told my children their Great-Nan had gone. I called my father in South Africa (I'm in UK) to tell him. I called my other grandmother and several other family members.I called her lawyer who held her Power of Attorney. He told me to clear the room the next day! I remember looking back and thinking I worked through a process, step-by-step. You see, for me, the death had been coming on for 10 years as slowly as the Alzheimer's had been consuming her. I'd had to say goodbye to her 5 years earlier when she forgot who I was. In the remaining 5 years, she basically fell apart ending up bed-ridden and a mess. So when I did get the call, I was so relieved that she'd finally been released from all that misery and anguish. But then the processes begin. There's a certain groove you slot into to deal with phone calls, funeral directors, ministers, catering arrangements, florists, etc. etc. And once the whole shabang is over, then you realise that you did all that in a kind of haze. And gradually the numbness wears off and life resumes. It's a very strange experience.

- Jabulani

Beautiful post. I could complete relate when you said: Most of all, as I left the funeral home, I wondered how all of these people could be going about their business as though nothing had happened. Doesn't everyone feel this numbness - this incredible weight - just as I do? How can they be rushing about at such a time? I felt the same way at the loss of a loved one a few years ago. I always think I'm the only one thinking or feeling a certain way and it's nice to see that I'm not alone. Thank you for sharing!

- Jen

I am sorry about the loss of your Dad. I know you are a man of faith and so have the hope/expectation of seeing him again... but it hurts on this side because we miss them.

My mother died back in April and I am still in disbelief sometimes... even though elderly and declining in health.

You said you feel the sensation of losing him and I think of it as it comes in waves.

I have lost and cried over people I love... but nothing prepared me for losing my mother. Oh sure..intellectually you know it will hurt... but it is a profound sense of loss.

I consider myself empathetic and have been supportive of friends who've lost parents... but now having gone through it... I really know how much it hurts and think I should've done even more.

That 1st week was like I was in a timeless tunnel. now a thought will hit me out of the blue... and the pain of it washes over me like a wave and falls back again.

I understand your feelings. Those moments are surreal.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

So very true.

Strangely enough,we as human beings [social creatures] must still grieve at a very personal level,and all the rituals and procedures that follow may lessen the loss of a loved one,BUT amidst the deafening roar of life,we must grieve in equally deafening silence and in isolation.

- shantu patel

Transience

Mon, 15 Jun 2009 22:40:58 GMT

Hospitals are a little like the beach. The next wave comes in, and the footprints of your pain and suffering, your delivery and recovery, are obliterated; the sheets are changed.
-Anna Quindlan, “One True Thing”

When a patient spends more than a few days in the hospital, the room often takes on his or her personality. For a while, the patient and family have a space — four walls, a bathroom, a window — that becomes their own. Frequently, I feel like a visitor as I enter such a room. When I walk the halls, my memory stirs as I link specific rooms with particular patients and their stories.

When I was first in practice, I was asked to see a woman who had been hospitalized for several weeks. She was holding her own but, in those days before hospice, she had nowhere else to go. As I opened the door, my nose filled with the aroma of flowers. There was soft music playing, The bedraggled bulletin board was covered with family photos and get well cards. A “We Miss You!” banner hung from the ceiling. Board games were stacked on the ledge.

The place felt like someone’s home or maybe their summer cottage. Family and friends had taken a few square feet of hospital and planted their own personal healing garden.

“The flowers are beautiful!” I commented, approaching the bed rail.

“It’s like a funeral parlor, don’t you think?” she responded. I looked to see if she was serious. Her eyes gave her away.

“A very classy funeral parlor,” I agreed.

Over the next few weeks, she deteriorated. Her family kept vigil, personalizing and rearranging the photos, cards and mementos. Every few days, I looked to see what was new.

One day, I knocked on the door and peeked in. The flower fragrance had dissipated and the room was empty. The bed was raised to its highest setting and the sheets were crisply made. I blinked. The personality had been swept away.

The cocoon had opened. She was gone.

___
Thanks to Courtney S. for the quote from Anna Quindlan.

The following is feedback received for this blog:

Thanks for painting a beautiful picture of a person not only a patient.

- Kerry
http://clubsammichcafe.spaces.live.com/

Dr Campbell...what a moving post!

I can relate to your patient.

My dear friend Pat... brought some of her personal items from her apartment when she entered into a hospice -palliative care facility.

Her room reminded me of her various homes and apartments. One of her beautiful oil paintings was hanging on the wall, her dried flower arrangements, books, and other things. She had a picture window with a gorgeous view. The room reflected her. There was always a peace that surrounded her and that was felt in any of her homes... and I felt it there as well.

She outlived the hospice time frame but fortunately was able to retain her room until she died.

There was a fold out sofa in the room and I stayed over a couple of times. Her room was like grand central station in that *staff* seemed to like to come in for a respite. She had been a counselor and also in ministry as well as teaching regarding death and dying.

Needless to say... she ministered to anyone in need around her. I did worry it may have been a bit much toward the end as she tired easily... but she had a gift for helping others... and enjoyed it. They seemed to love to hang out in her room.

No doubt...had she been your patient... you would've felt it too. I am sure she was missed by the staff.

I miss her too.

It's nice to know that physicians feel/care about their patients as you do.

I am moved... by the depth of feeling you have for your patients and the connected experiences. Not only do they live on in the hearts of others... but in the heart of their doctor as well... and it would warm my heart to know my docs cared as you do.

- SeaSpray

seaspray-itsawonderfullife.blogspot.com

Health Care, House Building and Ethics

Mon, 08 Jun 2009 21:34:42 GMT

Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.
-Atul Gawande, MD

In response to my last blog entry, a colleague who returned recently from six months working in hospitals and clinics in Rwanda and Cameroon asked for resources on “different perspectives on the current politics and changes in health-care.” I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me.

But, what is the heart of the matter? What fundamentally needs to change in order to reform health care?

In a recent article in the The New Yorker, surgeon-writer Atul Gawande, MD helped me understand the issues in a fresh way. Here is an analogy that he uses to describe the current healthcare situation in much of the country:

"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem."

So what does Dr. Gawande seem to suggest?

First, we need to develop a team approach to medical care. He details the differences between market-driven, free-wheeling healthcare communities like McAllen, Texas, integrated systems like the Mayo Clinic and smaller, partially integrated communities like Grand Junction, Colo. Team care is less expensive and built around evidence.

Second, we need to understand culturally that more health care does not translate to better health care. Some communities seem to value quality medical care and some seem to reward "quantity" care — more tests, more bills, more frequent exams, more procedures. The people who control the number and types of tests (the doctors) don't usually see the impact of their prescribing patterns on the bigger picture. For example, McAllen, Texas, has no better and, in many ways, even worse outcomes than much-lower cost towns. Interestingly, the McAllen physicians with whom Dr. Gawande spoke had no idea that that their community’s health care was extraordinarily expensive nor did the physicians know why that was the case.

Third, in many places, no one, neither the government, the insurers, the physicians, nor the patients has any role in overseeing the entire system of care for the community of patients. As he says, "Someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes."

Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation.

I still don’t know much about policy, but Dr. Gawande’s house-building analogy makes sense to me. I have seen medical care that concentrates on the fancy decorative embellishments and ignores the foundation. We have a lot of work ahead of us.

Controlling Healthcare Costs - 1929

Thu, 14 May 2009 13:28:02 GMT

Common sense ain't common.
-Will Rogers

I have been sorting out family memorabilia lately. Here is an excerpt from my great-grandfather’s obituary from March 7, 1929:

“Frank Briggle, 63 years old and a widely known farmer, died suddenly this morning at his home on Joplin Street, death following an attack of heart disease. He had been in poor health for three weeks but was considered improving. He came to town this morning with his son, Will, and was at the Dawson Motor Company’s office when he was seized with heart failure. He was rushed to his home in the ambulance and died there soon afterwards…Mr. Briggle is survived by his wife and three children: two boys, George and Will, and a daughter, Mabel.”

Did you read that? Were you as surprised as I am? “He was rushed to his home in the ambulance.” In fact, my great-grandfather’s town had a very well-respected, up-to-date hospital. Apparently, though, when my great-grandfather was close to death, the place to send him — via ambulance, no less — was home. That would never happen today.

This dusty family episode came into perspective for me when I ran across the following numbers: we each spend, on average, over $300,000 on health care during the course of our lifetimes. Of this, over $188,000 is spent after we reach age 65. Studies show that we spend an average of $30,000 on health care in the very last year before we die. People who eventually die from cancer spend even more. The costs can be devastating.

I would like to think that my frugal Presbyterian great-grandfather completed his life controlling his own healthcare costs and maintaining his dignity. Maybe he was on to something when he persuaded the ambulance driver that the place he needed to be in his final moments was not at the local hospital, but at home with his wife, his two boys, and the sweet young woman who would eventually become my grandmother. May they all rest in peace.

________
References:

Joyce GF, et al. The Lifetime Burden Of Chronic Disease Among The Elderly, Health Affairs 2005 Sept; 24 Suppl 2:W5R18-29

Alemayehu B, Warner K, The Lifetime Distribution of Health Care Costs, Health Serv Res. 2004 June; 39(3): 627 - 642.

The following is feedback received for this blog:

Thanks for the personal-anecdote from your family's past - certainly helps to add perspective to an otherwise seemingly polarized political-topic. If you have any recommendations for resources as far as how I can learn the different perspectives on the current politics and changes in health-care, I'd love to hear them! Thanks!

- Mary B.

The Pre-op Visit

Sun, 22 Feb 2009 22:08:58 GMT

Minor surgery is surgery someone else is having.
-J. Carl Cook

In a couple of minutes, I will knock gently on the door of the examination room and meet the new patient and her husband.

The young woman visited a doctor in the community because she had found a mass in her thyroid gland. She and her husband had been shocked when a needle biopsy had suggested that the mass might be cancer. Now, a couple of days later, she sits behind the door knowing that her life will never be the same.

I can barely imagine what the patient and her husband are thinking right now. Perhaps they are wondering how this cancer will change their lives. Possibly, they are worried about what to tell their children. Maybe they are too scared and preoccupied to think about much of anything at all. Their minds are, no doubt, alternating between terror and a desire for everything to be back to the way it was last week.

Her medical records, though, tell me that her case is relatively straightforward.

Even before I meet her, I am quite certain that I will advise her to undergo the complete removal of the thyroid and an evaluation of the lymph nodes in preparation for radioactive iodine treatments. The surgical procedure is tailored for each individual but the overall plan remains the same. Happily, the long-term outlook is bright. The vast majority of young women with early stage thyroid cancer do extremely well and the patient behind the door should be no different.

I knock and enter. The woman and her husband freeze in mid-sentence as they look up at me; she relaxes only a bit as we greet each other. On her lap is a notepad with a series of handwritten, numbered questions. Her husband shakes my hand as he sets aside the stack of articles and Web pages.

Between now and when they leave, they will need to understand the cancer treatment. They will want to know what to expect over the next few weeks and what to expect in the future. Hopefully, they will grow to trust me when I promise that our team will do its best to help them.

First, however, I will have to address their anxiety.

I tell them, “I am going to jump to the end. Is that okay?”

They nod.

“I promise that I will come back and fill in all of the gaps, but I want you to know that there is every reason to believe that you are going to be just fine.” I mean it. “I will be proposing a surgery that will be the first step toward completely curing this cancer forever.”

They look at each other as I repeat, “Our goal is to cure this cancer completely!” They look visibly relieved.

Over the next few minutes, I will carefully examine her and prepare them both for the surgery. There will be arrangements for consultations, surgical and research consent forms, handouts, appointments, teaching, questions, and scheduling. There is a lot of material to cover and much to think about.

Whenever I can, though, I start these conversations by "jumping to the end.” This approach removes the suspense. The patient is better able to hear the rest of the discussion and participate in the decision-making. And, hopefully, nothing beats a renewed sense of hope to make a bad situation just a bit more bearable.

The following is feedback received for this blog:

Nipping things in the bud can often be painful, but ultimately less hurtful. Great post. Thanks.

- Jabulani

Lovely story. Do you also "jump to the end" when the outcome is less clear, or when it is grim? As a palliative care provider, I find that physician's reluctance to walk patients through the bigger picture results in piecemeal optimism and contributes enormously to difficult end of life experiences.

-Risa Denenberg
http://risaden.blogspot.com/

When my mother was diagnosed with lung cancer (of which she died 7 months later), the doctor jumped to the end immediately with me (my mother had dementia, as well, so I was the first person with whom he talked) and I was never so grateful. It was the first time, in many years, that a physician had done this with me, with us. I hope lots of physicians read this.

- Gail Hudson
http://themomandmejournalsdotnet.net/

That jumping to the end was indeed what we wanted to hear and so very, very comforting. We cling to it. We barely hear anything else but "You will be cured!" We go for a second opinion. The next physician doesn't jump to the end, nor reassure, no stilling qualms. He too has expertise and an entirely different treatment plan. If one doctor is reassuring and the other merely scientific, should this play into whom you trust with your life? When you're scared and ignorant, as we are in relation to cancer, it is so easy, so preferable, to go with the comforting story. It is too hard to take in the science and decide the better course. Yet the rational mind, not the fearful newly diagnosed cancer patient, knows this is an important decision between two treatment plans. This decision should not be based on the comforting bedside manner, but rather on the best statistical chance for a good outcome. This decision needs a rational analysis not a needy fear-based reaction. When we are so afraid the comfort overtakes the science.

- Jane Boylan

Who Owns the Story?

Tue, 28 Apr 2009 10:00:30 GMT

Question: What do you call physicians who write?
Answer: Physicians.
- Jay Baruch, MD

I sit in the office and listen as she tells me her story. Her cancer treatment had impacted her family in nearly unimaginable ways. Personal demons are everywhere. Just as she recovered from surgery, her marriage disintegrated. Her life has been and would always be completely different from my own. I am riveted.

As I sit transfixed, my mind starts working … is this a story I can turn into an essay?

In a piece entitled, “Thin Walls,” Jay Baruch writes about a woman who leaves college and lives with her grandparents, becoming part of their lives in the months before her grandfather succumbs to a slow and debilitating death from cirrhosis. The story careens dangerously through drug dealing to child neglect to the physical effects of liver failure to suicide to death. We watch proud, angry, and stubborn people collapse. We wonder at the effect on the young woman — a character created by Dr. Baruch, an emergency physician and bioethicist at Brown University. The narrative is breathtaking and is only one of the remarkable fictional essays in his book, Fourteen Stories.

As an accomplished physician-writer, Dr. Baruch has chosen to work in fiction and he does so for a reason: the stories really belong to the patients. In an essay entitled, The Story Always Comes First, he confesses that “[w]riting about ‘real events’ and ‘real people’ from my roles as a physician makes me feel like a thief … [because] [t]he physician-patient relationship is tender and complex, charged with issues of vulnerability and power.”

As I listen to my patient run through the latest disasters, I wonder how I could share her story, honestly and reflectively, in a way that betrays nothing of the patient’s private experience. Like Dr. Baruch, I write to “understand particular human behavior and to effectively communicate that which surprises and disturbs me.”

I decide to pass on turning this woman's difficult struggles into an essay. Maybe a small piece of it will end up in a work of fiction someday. In the meantime, I will continue to admire writers like Jay Baruch.

Oral, Head and Neck Cancer Screening on April 28

Mon, 20 Apr 2009 21:48:43 GMT

Froedtert & The Medical College of Wisconsin will participate in the 2009 Oral, Head and Neck Cancer Awareness Week (OHANCAW) by hosting free screenings, an information fair, and some brief talks. Screenings will be performed next Tuesday, April 28 from 4:00 pm to 6:00 pm. Screening requires an appointment; the exams can be scheduled at (414) 805-3666. Even after the screening schedule is full, everyone is invited to come and learn more about head and neck cancer. More information can be obtained in the media release.

Several of us have performed the screenings over the past several years. We rarely find anything worrisome, but it is always great to answer some questions and put someone’s mind at ease.

This year’s event is much more ambitious than usual! We will have speakers including cancer survivor and blogger Jay Walt. We will also be featured on Fox 6 Wake Up News on Tuesday morning, April 28!

If we can ease just one person’s mind or catch just one early cancer, it will have been worth the effort. We will post some photos after the event. Special thanks to Kathy Myers, RN, who is coordinating the event and to all of our wonderful volunteers.

The Role Model

Tue, 14 Apr 2009 10:05:15 GMT

Children have never been very good at listening to their elders, but they have never failed to imitate them.
-James Baldwin

I calculated backwards and figured that her granddaughter must have been about 10-years-old when my patient first developed cancer. Few of my patients have had such a difficult run.

Nothing has come easily. Her cancer was difficult to control and she required radiation and then extensive surgery and more radiation. The side effects led to additional treatments, a feeding tube, and expensive pain medications. She had battles with both her employer and her insurance company. She cannot gain weight. I suspect she has lost friends because of her difficulty with communication. Many of her old friends no longer spend time with her since she quit smoking and does not like to be around smoke.

Of course, to hear her tell the story, she is doing fine. She feels well and has adjusted reasonably well. She celebrates her freedom from cancer every single day.

I was worried, therefore, when she arrived for a follow-up visit. She looked distracted. I moved into position to perform the examination.

“What’s this?” I blurted out. “Have you started smoking again?”

“Oh, no!” She was adamant. “Quitting was the best thing I ever did!” She looked quizzically and then realized that I had smelled tobacco smoke on her clothing. “Doctor, my family still smokes in front of me. They know how I feel but they smoke anyway.”

She paused.

“Even my 17-year-old granddaughter! She just started smoking. Despite growing up watching what I have been through, she smokes.”

My patient sat silently and shook her head.

“Doctor, it is just absolutely unbelievable.”

Of course, raising kids is tough. When my own children were very small and my oldest son was acting up, a favorite teacher once told me, “Remember: your sons will wreck your cars, but your daughters will break your heart.” My teacher’s half-joking comment came to mind again as my patient struggled to land on an argument that would induce her granddaughter to see what smoking could potentially mean for her own future. Was there something that the girl had somehow missed watching her grandmother’s ordeal over that last seven years? We came to no conclusions and both suspected that getting through to the girl would be neither quick nor easy.

The following is feedback received for this blog:

My husband was forced to give up smoking in late Nov 2006 because of a severe sore throat. Some 7 weeks later when it had practically improved, he'd "gone off" smoking, much to my delight. Recently, I've discovered that he's taken it back up again. He tells me that it's only 1 a day, but I know it's more ... Sadly there is just no telling some folk. And even more sadly, nothing we can do to stop them.

- Jabulani

"The Code" Published in JAMA's "A Piece of My Mind" This Week

Tue, 07 Apr 2009 23:06:21 GMT

I was delighted to have an essay accepted for this week’s “A Piece of My Mind” section of the Journal of the American Medical Association (JAMA). For those of you with access to JAMA online, you can find the essay here.

The editors of JAMA have been kind enough to publish three of my essays (10-10-2007, 2-27-2008, 4-8-2009). Before they would accept this essay, however, Associate Senior Editor Roxanne Young gave me a tough assignment. The journal wanted the family’s permission. After all, if the family happened to see the article, might they not recognize themselves?

At first, I was resistant to calling the family. Couldn’t we just change a few of the details of the story? Maybe we could change the patient’s gender. I worried: what if the family refused to grant permission to publish?

Most of all, though, I realize that contacting the family would be uncomfortable for me. The essay was about a failed resuscitation attempt. The experience was traumatic to the staff, the residents, and the nurses; I could not begin to imagine the potential effect it had on the family. Furthermore, it had been a long time since the events chronicled in the essay had occured.

I realized, of course, that the editors were correct. I worked up the courage and called the family member who I had known best. It was a wonderful conversation.

We talked about the patient and about how each of the family members had coped with the events and his death. She was surprised to learn how much the physicians had been affected. We talked about how much all of us missed him. Permission was granted and soon the essay was accepted.

I had a similar experience with a previous essay. When I called the patient, a man whose religious beliefs affected his medical care, he was delighted to share his thoughts and provide additional resources. After the contact, I realized how much I had enjoyed talking to him again.

In both cases, the conversations had offered each of us a moment to remember an event that had been very important to us.

Medical bloggers like me often write stories about their patients. As bloggers, we do not routinely obtain written consents like the one required to publish in JAMA. Some bloggers change identifying details. Others leave out important data. Sometimes, however, people spot themselves in the essay and, occasionally, this lack of formal permission has gotten bloggers into hot water.

For me, these moments of contact have been wonderful experiences. In each case, they have allowed me to better understand the patients, the families, and, of course, the final chapter of the stories I am trying so hard to tell.

The Choices We Make

Thu, 02 Apr 2009 23:35:48 GMT

To choose what is difficult all one's days, as if it were easy, that is faith.
-W. H. Auden

"They want to operate on your grandmother."

Dad was shook. I shuddered. This was one of those dreaded moments when my family looked to me for medical advice.

“What should we do? What should I tell them?”

I was still in training. I tried as best I could to think objectively.

“Who wants to operate?” I asked. “What did they tell you?”

My dad had received a phone call. My grandmother was in her 90s and confined to a healthcare facility six hundred miles away. For years, she had adamantly insisted that her boys never put her in “one of those places.” However, after a rapid deterioration in mental and physical status, she had passively allowed herself to be moved to the local nursing home. For two years, she had shared a room with a woman who had spent her entire life on a neighboring farm. Although they had known each other for decades, my grandmother no longer recognized her old friend.

“What surgery are they suggesting?” I asked.

“Her foot is turning black. They say she needs an amputation soon.”

We had visited the family farm just a few months before. When we spent time at the nursing home, my grandmother had not recognized us even once. She had smiled pleasantly when we spoke to her but the vigorous farmer’s wife of the past had long since faded away. This remarkable woman who had weathered the Great Depression saving pennies, selling eggs, worrying about rain, raising cattle, and butchering chickens no longer knew who anyone was. Her eyes were empty.

“Why do they want to operate? Will it make her better?”

“No. They said the foot is getting infected. They said surgery might help her live longer.”

Dad and I talked about our visits to the farm. In my memory, I could taste the home-cooked meals around the kitchen table, gaze at the sunsets from the front porch, smell the fresh-plowed Ozark soil, and feel the clean sheets of the upstairs bedroom. I could hear the boards creak beneath my feet and touch the bare plaster as I climbed the stairs.

“I don’t think surgery will make her feel better, Dad.”

There was a long pause. “Could you talk to the doctor?”

“Sure.”

A few minutes later, as I hung up the phone after talking to my grandmother’s physician, I felt an unfamiliar heaviness in my chest. To this day, that heaviness returns whenever one of my patients presents me with a choice that I would rather not have to make.

Cancer Control and Humor

Tue, 31 Mar 2009 12:58:03 GMT

“Life is too important to be taken seriously.”
– Oscar Wilde

I noticed recently that April has been designated both as “Cancer Control Month” and “Humor Month.” Is that a coincidence? Patients often find that humor is important, even essential, to recovery after cancer treatment. Cancer survivor newsletters, support activities, and Web sites often contain references to the value of laughter and a positive attitude.

Has this been studied in detail? Maybe not in the depth that serious-minded scientists would require, but the value is re-discovered daily by cancer patients and their families.

For many years, I had a delightful patient in my practice who lived with an indolent cancer in one manifestation or another for over 30 years. Over the years, her treatment required several operations and two courses of radiation. She knew more about side effects than all of her doctors put together.

Despite everything, though, she spent countless hours as a community volunteer. She brought joy (and hugs) to the office whenever she visited. She made sure that we always had plenty of chocolate after each appointment. She never forgot Valentine’s Day. She was an inspiration to each person who met her. Even as a hospice patient, she smiled and joked, trying to cajole her friends and family into being happy with her just one more time.

Cancer is not a laughing matter. It alters and threatens people’s lives and relationships. For some, though, it brings strength, focus, and renewal. Sometimes, “Cancer Control” and “Humor” do belong together.

___
A previous version was originally published in the MCW Cancer Center News.

The following is feedback received for this blog:

There is truth in the adage "Laughter is the best medicine".

- Jabulani

A Spring in Her Step

Wed, 04 Feb 2009 23:13:08 GMT

Beautiful young people are accidents of nature, but beautiful old people are works of art.
-Eleanor Roosevelt

My 88-year-old friend was very excited.

First of all, her beloved doctor had just confirmed that she is in excellent health. The doctor had gone out of his was to reassure her that, despite her challenges, things are going very, very well.

Second, and just as importantly, she had found some real bargains while shopping.

“Tell me what you found," I wanted to know.

She was beaming. “I just love the post-holiday sales! I found a half-off price on all of their boxed Christmas cards. Just look at these! Now I am all set for next year! Look how much I saved!”

I checked the receipt. Indeed, she had hit the jackpot.

My friend’s happiness reflected much more than the remnants of her Depression-era childhood. Her enthusiasm reminded me of a recent JAMA editorial written by Dr. James Harris and Dr. Catherine DeAngelis.

Drs. Harris and DeAngelis remind physicians that a sincere emotional engagement between the patient and the doctor is a powerful tool for adressing fears and restoring hope. A “confiding relationship” — one that provides the patient with the support needed to deal with illness — can keep people out of the hospital and improve outcomes.

My friend’s physician had clearly provided her with a renewed vigor with just his words. He had fulfilled Drs. Harris' and DeAngelis' admonition that “… no patient should ever leave a visit with a physician without a sense of hope.”

As I congratulated my friend on the purchases, I realized that her physician had given her a remarkable gift. What reflects optimism more clearly than an 88-year-old woman who is fearlessly making plans for her holidays eleven months in advance? Despite everything she faces, thanks to the physician's simple words, she is able to approach her year with confidence and hope.
___
Harris J, DeAngelis, C, The Power of Hope, JAMA 2008 (Dec 24/31) ; 300:2919-2920

The following is feedback received for this blog:

Hi Dr Campbell -what a beautiful post. She has a terrific doctor. Sounds like a neat lady herself. :)

I was struck by her planning for next Christmas too.

I read the article too and could very much relate. I have a couple of docs that are terrific with me and they make all the difference. Particularly, my urologist..because I have been through so much over the last few years and still not sure where it is all ending up. He and his staff make it all bearable. Knowing how well he takes care of me has caused me to feel safer... even though my condition has been chronic and there are concerns.

I keep hoping for the miracle. :)

You docs are very special to us patients and I thank God for the good ones. :)

If it is alright with you ..I may do a post about this and link back here and to that article..

Thanks for sharing it.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

A Momentary Pause

Fri, 23 Jan 2009 14:14:07 GMT

What do we mean by patriotism in the context of our times? I venture to suggest that what we mean is a sense of national responsibility ... a patriotism which is not short, frenzied outbursts of emotion, but the tranquil and steady dedication of a lifetime.
-Adlai Stevenson

Late, as usual, I rushed from the Operating Room to the Cancer Center clinic, mentally going through the checklist of tasks needing attention. I pushed open a hallway door and ducked between the chairs in one of the Center’s waiting rooms, heading toward another door that would bring me to the work area.

Suddenly, I stopped short.

Instead of the usual groupings of patients reading, talking, or resting, I realized that everyone — patients, family members, nurses, clinic staff, and physicians — was looking upward, focusing on the waiting room televisions. Some of the people nodded or commented quietly to their companions, but they never took their eyes from the screens mounted high on the walls above them.

For there, on the televisions throughout the hospital and the rest of the world, a new President of the United States was being inaugurated.

As I stood with my hand on the door, I reflected on how rarely events in the outside world are able to bring things in a hospital to a near-standstill. A couple of previous moments have come close:

During my fellowship in Houston, I was working on an experiment in a research lab the morning of Jan. 28, 1986, the day the space shuttle Challenger was lost. I can vividly recall the anxiety and profound sadness felt throughout the institution. It was days before the pace of work recovered.

Years later, I was in the middle of performing a neck dissection the morning of Sept. 11, 2001 when the attacks occurred on the Pentagon and the World Trade Center. As the events unfolded, I finally had to ask the helpful anesthesiologist who kept charging in every few minutes with updates to leave us alone so we could concentrate on our task at hand. When the case was finally completed, I was overwhelmed with the palpable sense of uncertainty that pervaded the building.

Last week, though, the mood in the hospital was quiet but optimistic. I sensed that we all slowed down for a while — maybe so we would be able to someday recall where we were at that moment in history.

Each of the clinics in our new Clinical Cancer Center has a solid, uplifting name like “Courage,” “Life,” or “Faith.” It was with no small sense of satisfaction, therefore, that I pushed through the doorway to go see my waiting patients, on this day of Mr. Obama’s inauguration, in the clinic called “Hope.”

The following is feedback received for this blog:

I had an similarly profound morning during President Obama's inaguration. Or clinic was slow, as Tuesday mornings are. On a chance, I brought in my laptop, knowing that my doctor was not holding clinic. I was also hoping that my supervisor would allow me to set up my mac in his dictation area, allowing us girls a chance to catch some of the events while keeping atop of phones and patients. She took a little pursuading, but I knew whe really wanted the oppertunity also. I recieved a yes. I had a really unusual experience, getting quite caught up in the moment with a few coworkers that I do not usually see eye-to-eye with. They shared a couple "hallaujah's" with me that day, and even a few tears. I was allowed to"break the rules" and the resulting effect was somehow very satisfying. For me on that day, I had already experienced a little change and hope.

- Karen

Finalist for "Best Literary Medical Weblog"

Fri, 23 Jan 2009 13:14:11 GMT

Reflections in a Head Mirror was a finalist for "The Best Literary Medical Weblog" of 2008! I did not win, but was tremendously honored to be included among blogging peers like Notes of an Anesthesioboist, On The Clock, other things amanzi, and Running for My Life: Fighting cancer one step at a time. The top vote-getter in my category was Ronni Gordon at Running for My Life.

The finalists are listed here and the winners in all of the categories are listed here. Congratulations to all of the winners, especially Ronni!

The Christmas Letter

Fri, 02 Jan 2009 14:13:53 GMT

The natural flights of the human mind are not from pleasure to pleasure but from hope to hope.
-Samuel Johnson

The Christmas letter we fear each year finally arrived.

The family that sends this letter includes a friend from school — one of those friends that we were close to decades ago but haven’t seen in years and only connect with at the holidays. She sends a card each year describing the family progress in a newsy letter. At the bottom, she always includes a couple of neatly penned sentences telling us “How nice it would be to get together again” and “Please stop by if you are ever in our part of the country.” The picture shows the family, the dog, and all of the kids, now nearly grown up. Usually, there is a mountain in the background and the whole family is arm-in-arm, smiling. They are a handsome, active, and accomplished bunch.

Despite this, as soon as the letter arrives, we scan down the page with trepidation. You see, the woman in the family, our friend, was diagnosed several years ago with breast cancer. We know none of the details, but, each year, amidst the reports of children’s accomplishments and family trips, there is always some brief glimpse of the specter that walks with them. Here or there, we spot things like: “Despite the treatments, I was able to keep up with all of my volunteer activities,” or “A few cells were discovered on a new biopsy a few months ago,” or “The small tumors apparently are enlarging.” Despite this, each letter contains a list of upcoming events and goals. Those few words overwhelm the page.

When the envelope arrives, our thoughts fill with a mixture of relief that she lives and anxiety that she continues to struggle. Her smiling face looks up at us from the family photo.

It has been years — a generation, really — since we spoke or spent any time together, yet we are touched and renewed each year by her message of hope and resilience. We look forward, anxiously, to next year.

The following is feedback received for this blog:

Dr. Campbell,

I found your blog through WhiteCoat & Seaspray & I must say you write exceptionally well. I sincerely look forward to reading your posts.

- Mottsapplesauce
http://dmefile13.wordpress.com

This post reminds me of 2 situations:

I have a similar letter which hits my doormat every year from a buddy in Wisconsin. In the past 18 years, Christmas was the only time we corresponded. Fortunately, a few months ago, I discovered him on facebook. We now correspond more frequently! The second occurrence was a card I received some years ago, where the name of the husband was not shown. Since the card had no return address and I knew the "friend" had moved on, address unknown, I had no way of finding out what had happened. It was very disconcerting. This year's card had an email address on it. I'm back in touch ... hurrah.

- Jabulani

I'm glad your friend is alright this year. She sounds like an amazing lady. :)

Beautiful post.

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

Anatomy Lab

Mon, 19 Jan 2009 13:30:57 GMT

"Men fear death as children fear to go in the dark; and as that natural fear in children is increased by tales, so is the other."
-Sir Francis Bacon

Anatomy Lab is a rite of passage that no physician ever forgets. Human dissection begins during the first days of medical school. Unspoken questions well up. What does a cadaver look like? How will I react? How will I ever remember everything? What if I can’t deal with working on a dead body?

A cadaver feels more like cold, moist, heavy fabric than a person. The color is all wrong and the tissues are firm and unyielding. As the dissection continues, many of the features that we recognize as being "human" are lost, although the contours and the scaffolding remain. Three decades later, I have vivid memories of the intricate anatomy of "our" cadaver.

Each year, I try to spend a few afternoons helping students perform Head and Neck dissections while demonstrating surgical procedures and discussing clinical illnesses. The questions are earnest and the students stump me regularly. As we all ignore the fact that a dead person lies on a table between us, we discuss everything from cancer to cosmetic surgery.

Over the years, I had learned to disconnect the cadaver from the person. That attitude changed abruptly when one of my cancer patients announced that he had donated his body to Science. He hoped fervently that he would "end up in a cadaver lab teaching medical students." I congratulated him, and hoped, fervently, that he would not. I marveled at his gift and thought of him often after he died just a few weeks later.

When classes began the following August, I approached the lab with dread. How would his presence change my ability to teach in this most unnatural of environments? I made the rounds through all of the dissection stations, stopping at each but always looking to see who was on the next table. It was eerie and a bit unnerving.

My patient was not one of the cadavers and I suspect his prior surgery made him unsuitable for a place on one of the tables. Nevertheless, I have approached the Anatomy Lab with a different attitude ever since.

The following is feedback received for this blog:

I'm a first-year medical student and we're well into our cadaver. I'll admit that during dissection I don't really connect to the cadaver as a person, although ironically we do get closer to them, physically, than any spouse of 50 years ever could. We are the only ones ever to run a finger down their spinal cord or azygous system of veins.

Inevitably though, hours after the dissection when the books are closed for the day, I feel grateful for the people who have donated their bodies for our education. It's a privilege to see the content of an anatomy text as the real content of a chest cavity, and their gift is not taken for granted.

-Bill Ragalie

Hi Dr Campbell - I am sorry about the loss of your patient. Being a doctor has to be a calling because I sure couldn't work on cadavers, but thank God for all the people that do.

It is admirable that people donate their bodies. Even that bothers me and I feel guilty for saying it.

It sounds like your patient and you had a good relationship and no doubt were mutually blessed with the encounters.

Speaking as a patient...it means a lot to have a caring and compassionate doctor. I have written about my doctors, how important they have been.

I could not imagine going through all the urological issues I have if it weren't for the wonderful care of my urodoc, partners and their staff.

I know it is shop talk and you get desensitized around things that would give most people pause.

It is interesting how life events can change our perceptions, continually teaching us a new lessons.

Your post was beautifully written

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

SurgeXperiences 214: Trees

Sun, 04 Jan 2009 18:24:19 GMT

I think that I shall never see
A list of posts so fun to read.
The writing’s sharp and never dull
Because the topic’s surgical!
The stories come from many lands
And emanate from surgeons’ hands.
So whether doctors cut or write
The anecdotes should bring delight.
So, with a basic theme of “trees,”
We’ll tour the world now, if you please.

In Africa, the baobab
Grow stout and old, but never drab.
Doc Bongi’s stories make us pause,
We read and often drop our jaws.

Bongi’s submissions this week provide an insight into how triage is done when too many people show up with stab wounds (hint: it has to do with whether the the puddle of blood on the floor is expanding), and why Africa is both exasperating and captivating. He also shows us a happy lioness (and why she is happy). Finally, he tells a story about breaking tragic news to a family after a drunk runs down two young boys.

Australian trees we might discuss
Include the famed eucalyptus
Med student Jeffrey gives us links
That show he reads, and writes, and thinks.

Monash Medical Student, Jeffrey Leow, provides great surgery-related reading this week! He links to blogs about an orthopedic surgeon in Kenya who needs to do a risky spine procedure which he has never before attempted, a comment on the impending shortage of surgeons, a gallery of REALLY dreadful celebrity cosmetic surgery outcomes, a nice discussion on the difference between plastic surgery and cosmetic surgery, and a quick summary of how to irritate a surgeon, written by an ophthalmologist’s family member.

Monash Medical Student also provides some links to recent surgery-related articles of interest. For example, he provides links to stories about an operating room fire in Taiwan, a donated cochlear implant procedure at UCSF for a young Iraqi boy who was deafened by a US missile strike, a spooky (if true) story about a plastic surgeon who apparently claimed to power his SUV with reprocessed human fat which taken from patients during liposuction, and a day in the near future when doctors will be able to reach any place in the GI tract either through the mouth or else, you know, the other end.

In Arkansas, the trees renew
Magnolia, dogwood, redwood, too.
It’s also where Ramona tucks
And quilts, and writes, all done deluxe.

Suture for a Living provides some great surgery-related posts! I never knew this definition for “bottoming out” before. She also tells of a polar-exploring Russian physician who did his own appendectomy! (Here is a link to other “self-surgeries” by physicians and non-physicians.) I loved the listing of the top surgically related posts that she provided in 2008.

Other posts which she submitted this week are remarkable. Here is a tribute to several U.S. military physicians who have been killed in Iraq. She provides a moving essay written by a physician in South Asia who struggles whether to operate on a patient with very advanced cancer and little support. She also provides a link to an essay by a junior surgical resident who diagnoses appendicitis and gets to do the surgical procedure … you can feel the young doctor’s excitement!

The patients’ blogs are strong as oaks.
Their stories brim with angst and jokes.
This week, they’re kind to all their docs
When surgery works, it really rocks!

Here are submissions from patient-bloggers. Karon Flinchum talks about her experiences with bariatric surgery. (Here’s a link to a patient-blogger who underwent bariatric surgery at our hospital, as well.) A satisfied Lasik surgery patient also leads discussion on his blog.

I live Up North where it is cold,
Each Fall, the trees are red and gold.
But now, the days are short, you know,
The leaves are gone, replaced by snow.

Even though these posts were not submitted, I enjoyed them very much and wanted to pass them along. Aggravated DocSurg hits the nail on the head in a recent post about getting “bumped” in the OR. Edwin Leap waxes both poetic and surgical in an essay on the joys of opening an abscess (among other things). Dr. T. also waxes poetic, this time about the beauty of the vocal cords (I would have to agree with her, by the way.) Dr. Val has a reflection on medical mistakes. I also include my own post on how Surgery is a form of Dance. Finally, I loved two non-surgical posts this week: DB's essay about why physician-teachers need to be thoughtful when they work with medical students, and Tony Miksanek's reflection on the Seven Reasons Why Doctors Write. All of the essays will give me much on which to reflect.

One last stanza:

So, now, the list of links is wrapped.
My poetry’s completely tapped.
And friends, I beg, PLEASE NEVER PRINT!
“But, why?” you ask. Well, here’s a hint:
I hope you’ll always read on-screen
Because that habit is quite Green,
'Cause blogs are made by fools like me
But only you can save a tree.

That's it! My apologies to Joyce Kilmer. Thanks to Dr. Rob for encouraging and inspiring medical bloggers to write in verse. Thanks for visiting!

SurgeXperiences is a blog carnival about surgical blogs, wherein surgical experiences are shared. It is open to all (surgeon, nurse, anesthesia, patient, radiologist, pathologist, etc) who have a surgical blog or article to submit. The next edition of SurgeXperiences (215) will be hosted by Jeffrey Leow at "Monash Medical Student" on Jan. 18, two weeks from now. Be sure to submit your post via this form.

The following is feedback received for this blog:

What a delight!
Thank you so much for this post. I will carry the memory of each of these stories (and that fabulous prose narrative) with me as I see my daughter through her surgery over the next couple of days. It will make my stay in hospital (my LEAST favourite place) more palatable as I remember these accounts :)
GBU

Wonderful poem / edition!

- rlbates
http://rlbatesmd.blogspot.com/

The Means of Grace

Tue, 23 Dec 2008 09:57:15 GMT

Warmest wishes for the holidays! Peace on Earth.
-BHC

________

God answers sharp and sudden on some prayers,
And thrusts the thing we have prayed for in our face,
A gauntlet with a gift in it.
-Elizabeth Barrett Browning

The bitterly cold Saturday morning temperatures are hovering just below zero as I search for street parking in downtown Chicago. I am anxious to get to a medical meeting and worry that I will be late.

After circling the block a couple of times, I spot an empty space near the corner. I pull in, turn off the car, bundle up, and open the door. The cold rips through my clothes. I tuck my head into my collar and walk stiffly to the middle of the block where the electronic parking meter will print the receipt I will need to prop on my dashboard. As I try to read the instructions, I pull off my gloves, fish several quarters from my pocket, and feed them into the machine. This approach is pointless as each quarter buys only five minutes of parking time and I am not carrying nearly enough change for my three-hour meeting. I pull out my wallet, balance it on top of my gloves, and fumble for my credit card in the frigid wind.

“Please.”

I hear a voice over my right shoulder. I look up only long enough to see an older man wearing a worn overcoat, a thin stocking cap, and a several-day growth of white beard. I focus intently on my challenge, trying to ignore him. He is quietly talking to me, but my cap is firmly clamped over my own ears as the wind whistles around us. I do not hear him.

“No!”

I speak firmly. Finally, I grasp the credit card between my fingers and extract it. I slide it through the magnetic reader in the machine. Nothing happens. I look at the diagram and realize I have inserted the card backwards. My wallet balances precariously and vulnerably in front of me. I redouble my effort.

I sense his presence as he waits patiently just out of my line of sight. It has been a long time since I have given money to a panhandler, and for all of the correct reasons. “Social service agencies are in place to help” … ”the money only goes for alcohol” … ”it does nothing to reverse the cycle of dependency” … ”our family contributes in many other ways.”

“How you doin’?”

My fingers are stiffening. As the electronic information on the credit card finally registers, my quarters drop and clatter in the coin return. The man stands patiently. He says nothing more. I actually know someone who carries a few coins specifically for use in these situations. What of grace? What of justice? The weather is brutal.

I fish the quarters out of the machine; it is about $2. I look at the change. I see my breath as I exhale. Spontaneously and without looking up, I extend my right hand towards the man.

“Will this help?”

“Oh, yes, sir. I’m hungry.”

He speaks without emotion. Out of the corner of my eye, I see that he is not wearing any gloves. My fingertips push the quarters into his bare hand, skin against skin. His palm is disturbingly thickened and hard. Why are his hands so heavily calloused? Does he have some skin disease? Is it a result of exposure? I press the gift into his grasp and then pull away.

“Thank you.”

“You’re welcome.”

He takes the money and moves on. I complete my task and finally retrieve my parking receipt. When I look up, he has disappeared.

The next morning, Sunday, I am back home and get pressed into service helping to distribute communion at church; my task today is to distribute the bread. For as long as I can remember, lay assistants were assigned the tray with wine; “This is the blood of Christ, shed for you.” This day, however, I have been asked to distribute the bread, a task for which I still feel somehow unqualified.

Standing in front of the line of waiting congregants, my left hand holds the bread partially wrapped in a linen napkin. I tear off a small piece as the first person approaches with hands cupped. I look up, trying to engage his eyes; I have been in his home, I know his family, I know some of the challenges he faces. I watch as our hands meet. “This is the body of Christ, broken for you.” I press the bread firmly into his palm — flesh against flesh — my fingertips into his soft, warm skin. His fingers close around the gift and I pull my hand away, preparing for the next in line.

“Thank you.” He moves on.

“You’re welcome,” I think to myself. I feel a twinge of recognition, and hours later, I realize why.

The following is feedback received for this blog:

You are one of the bloggers I hope to meet someday. We do think alike. Christ came for those people, and sees us as you saw him - I know you know that.

Thanks for the moving story.

- Rob
http://distractible.org

God bless you for this post, at this time of year. Earlier this year, our church and my children's school prepared shoe boxes to distribute to eastern European orphans at Christmas. Each box cost me £25 to fill with things they don't have and will love: a comb, hairbrush, face cloth, soap, sweets, etc. Other mothers at the school complained that £25 was a lot of money when you've got presents of your own to buy as well. I remember thinking at the time that £50 was a pale shadow compared with the money I was going to spend on my daughter's Wii and my son's Scalextric. And tonight I stood in the supermarket, among the throng of people hurtling their gargantuan trolleys of "need" up and down aisles, buying last minute bits I needed. Now I am reminded: how much stuff did Jesus "need" to be born? Thank you your story.

- Jabulani

Thank you for this moving story. Are you an elder in a church? If only every elder/deacon (session members) in my church knew each member of the congregation as well as you do. I feel this is important in dispensing the elements of Holy communion.

- Jeff
http://jeffreyleow.wordpress.com

I read your story several times.

I am like your friend- I carry money with me to give to people who ask. I also give my mittens or gloves to the person if they have none. A gift is just that- a gift. If someone spends the money I give them on something "inappropriate", it's not my money anymore, but theirs. Whatever they do with it is their decision. God bless us all our failings as human beings- as well as blessing our gifts.

Call for Submissions to SurgeXperiences 214!

Wed, 31 Dec 2008 11:11:54 GMT

I am honored to be the host of the next edition of SurgeXperiences!

This is a “Blog Carnival” of blog postings that are related, however tangentially, to surgery and the surgical experience. The post will go live on Jan. 4, 2009.

Every blogger is welcome to submit a favorite surgically related post, whether you are a physician, nurse, technologist, PA, PT, NP, pump tech, patient, caregiver, videographer, hospital administrator, quilter, llama lover, surgical groupie, or friend of any of the above.

I will try to be a clever host, but, given the holidays and the need to recover from all of the potential meals and celebration, we will just have to wait and see what happens. If you want to submit, click on this link to go to the submission page.

Submission deadline: Saturday, Jan. 3, 2009.

C'mon, bloggers! Dazzle us!

Surgery as a Form of Dance

Wed, 17 Dec 2008 09:28:51 GMT

What, exactly, is Surgery?

At its most basic, much of Surgery is a goal-oriented process by which something that is detrimental to the patient is removed in a way that will improve the patient’s well-being. The surgeon’s task is to accomplish the goal while carefully balancing the risks and benefits.

On a practical level, however, much of Surgery boils down to this: The surgeon must decide where to cut between something that is coming out and something that is staying in. The surgeon repeats this process until all of the tissues have been separated, whether it takes ten minutes or ten hours. Once the operation is under way, the surgeon and the assistants work hard delivering as much light as possible to a place where light might rarely penetrate. The surgical field must be dry, well-illuminated, and as accessible as possible. That’s it.

When all goes well, the procedure develops a momentum and moves along steadily. Once the problematic area is exposed, each movement has a purpose; each activity makes the next one possible. No matter how simple or complex the operation, the surgeon is always preparing a number of steps ahead.

When Surgery goes poorly, the surgeon is unable to smoothly complete the necessary tasks in a logical sequence. Using this definition, even “simple” surgical procedures can go poorly. My worst days in the operating room occur when each step of a procedure requires a specific instruction to the assistants: “Put a retractor there and pull that way,” “Get the suction and clear away the blood,” “Leave that area alone for a while and help me expose this,” “Move your hand so I can see better." Objectives that appear obvious to the surgeon can seem to be lost on the trainees.

During my best days in the operating room, my resident and I are in sync. We anticipate each others’ actions. While one of us is blotting the field, the other is adjusting the lights or the retractors. While one of us is dissecting a delicate structure, the other is carefully widening the exposure. Few direct technical instructions are needed; we might talk about the anatomy or the cancer, but there is rarely the need to say, “Retract this,” or “Put a clamp on that.”

Years ago, I realized that Surgery sometimes resembles Dance. Just like beginning students of the tango or the waltz, young physicians tend to focus on the “steps” needed to get from Start to Finish. But learning the “steps” is only the beginning of learning how to operate.

You see, Surgery, at its most glorious, is a form of choreography — a whole team that seems instinctively aware of each other’s movements and focus. When the “Dance” goes well, surgeon, assistant, and technician all drive the procedure forward.

Just like the action on a dance floor, Surgery can be exhausting and, at the same time, totally exhilarating. When things go well, the process is very special. When the Dance feels effortless, I cannot imagine any other line of work.

The following is feedback received for this blog:

Well "choreographed" surgery can also be beautiful to watch. Just like dance.

- http://sterileeye.com

Hi -I found you through Dr Rob's recent post.

Just want to say that I enjoyed this eloquently written post and the idea of surgery being analogous to synchronized dance.

Great blog and I am blogrolling you! :)

- SeaSpray
seaspray-itsawonderfullife.blogspot.com

Narrative Medicine

Mon, 08 Dec 2008 11:23:09 GMT

In the practice of our days, to listen is to lean in, softly, with a willingness to be changed by what we hear.
-Mark Nepo (Cancer survivor and poet)

My happiest times in the office are when patients tell me stories. Some people just can’t help themselves; they easily share their experiences of illness, children, lives, or struggles. More often, though, the stories need to be called out. These accounts, the hidden or subtle, are often even more interesting. When the office is slow, I might hear an elaborate tale. When things are hectic, I might have to survive on a vignette or an update. I have shared many of these stories through my blogs and essays.

This practice of intentionally listening to and recounting patient stories falls under the broad heading of “Narrative Medicine.” Medical schools around the country are modeling curriculum and seminars on the Program in Narrative Medicine developed by Rita Charon, MD, PhD, at Columbia University in New York. Every medical school hopes its graduates will be good listeners. Good listeners make better caregivers.

Over the past two years, the Medical Humanities Program at The Medical College of Wisconsin has developed a Humanities Track for first year medical students. Part of their experience involves shadowing practicing physicians during their office encounters. These students might not understand the intricacies of sub-specialty medical care, but they do understand people. During this first exposure to clinical medicine, the students start to build skills that will help them later listen to the story lying beneath their illness.

I ask my students to write, not about the disease, but about the person. With the students’ permission, below are two examples of what they have submitted.

I had a blind patient with recurrent cancer. Here are one student’s reflections about the office visit:

The human fight for survival and well being is incredible. People will go to the ends of the earth to live a happy full life. I was fortunate to meet an amazing patient that I will never forget.

The patient had been blind since a young age and had been diagnosed with cancer for many years. His cancer was [extensive and recurrent]. It is not his blindness and loss of voice that I will always remember, it is his fight and spirit that will never leave me. This patient would not give up his fight with cancer and would go to the ends of the earth to defeat it. Every punch that cancer threw at him, he countered with two or three punches of his own.

Sometimes we have bad days and let little things bother us. This patient did not know what a bad day was. This is a perfect example of living life to the fullest. To go through life without vision is amazing in itself; but to not be able to talk and battling cancer on top of the blindness is unimaginable.

Here is another submission. A man who had his voice box removed several years before came for an office visit. He could only talk using an electrolarynx (a vibrating device that he holds against his neck). Here is what the student remembered of the encounter:

Someone in the room curiously raised the topic of Mr. M’s age.

Before anyone could reveal his age, Mr. M quickly turned it into a quiz, “How old do you think I am?” he asked with an anticipatory smirk.

“77.” said the other student in the room. “69. 82.”

Finally Mrs. M answered with a roll of her eyes, “He will celebrate his 90th birthday during this month!”

Mr. M laughed. It was the kind the laugh where the shoulders bounce up and down with a big grin but no noise actually comes from the vocal folds.

If someone in Mr. M’s situation wanted to find a reason to complain and find misery, he could find several reasons to.

The fact: life is never going to be as easy as it once was. Did that mean the rest of his life had to be less fulfilling and enjoyable than it once was?

What made him different? Was it the fact that he had only minor complaints from an otherwise successful laryngectomy? Was it the fact that he made jokes using his artificial speaking mechanism? Was it the fact that his dear wife of many years was by his side at the appointment, asking questions and holding all of his prescription bottles? Was it the fact that he smiled a lot? Was it the fact that he held his hands up in triumph when none of the patient care staff could guess his age? Maybe.

All I know is when I have my 90th birthday, I want to be 90 years young!

The experience of having first-year medical students shadowing me in the office is interesting and, quite frankly, lots of fun. I sense that the early immersion into Narrative Medicine reinforces their understanding that the patient’s story is critical to understanding their illness. Hopefully, being a good listener now will prevent decent medical students from becoming miserable doctors later.

The following is feedback received for this blog:

Dr. Campbell: Thank you for your nice comment on my posting at the NYU lit med blog. I welcome the opportunity to talk with you about my project...and to visit you and your colleagues sometime to discuss it...all best,

Steve Langan

Where the Smoke Rarely Clears

Tue, 02 Dec 2008 11:25:10 GMT

Pick battles big enough to matter, small enough to win.
-Jonathan Kozol

She sits in the chair, rocking back and forth and talking very fast.

“Doctor, I have tried SO HARD to quit!” She is clearly troubled. “I had cut down from 23 cigarettes per day to 17 cigarettes per day, but yesterday was really hard and I smoked 27! I feel so awful! I know you hate me! I know I have to quit!”

The discussion varies only slightly each visit. She developed a tobacco-related tongue cancer many years ago that was successfully removed. Since then, she has had a couple of pre-cancerous spots, as well. She knows that smoking is dangerous; she probably realizes this more acutely than many other smokers.

Unfortunately, she also has a long history of psychiatric disease. She is meticulously compliant with her psychiatrist’s regimen of medications and therapy. As a result, she is able to function most of the time. Still, she cannot quit smoking.

The combination of tobacco use and Psychiatric Disorders and Substance Use Disorders (PD/SUD) is a bad one. Despite declines in tobacco use among the general population, the rates have shown little improvement among people with PD/SUD. While about 20 percent of the general population smokes, rates of smoking among these patients vary from 35 percent (for people with panic disorder) to 50 percent (depression) to 60 percent (PTSD) to 80 percent (alcohol dependence) to 88 percent (schizophrenia).

Medication use is more difficult with these people as well. The most effective medications are currently varenecline (Chantix®), bupropion (Zyban®), and nicotine replacement. Unfortunately, varenecline is not recommended in people with depression or suicidal tendencies. Many of these people already take bupropion as an antidepressant. Finally, nicotine products (gum, lozenges, or patches) can increase anxiety symptoms. Cessation can lead to exacerbation of manic depressive disorder.

So my tortured patient, and all smokers with psychiatric disease, has one more burden to bear. At each visit, I encourage her to quit smoking but know that she continues to fight many, many demons. Smoking is merely one of them.

Ritual

Thu, 06 Nov 2008 10:55:32 GMT

You've got to jump off cliffs all the time and build your wings on the way down.
-Annie Dillard

She stepped back to admire her handiwork. It was remarkable. Months before, during the first office visits, he had been resistant to her sympathy and she had clearly been uncomfortable with her new role as caregiver. There was no way she was going to take care of him and no way he was going to let her.

“Can’t someone come into the home and hook up the feeding tube three times each day?”

“It is something you can both learn very quickly,” I reassured them.

She was completely unconvinced. “Absolutely not! No way! What if some of the juices get on me? I can’t stand secretions! Just the thought of having to deal with mucus makes me sick!” He had made no attempt to change her mind.

They were adamant. Arrangements were made and schedules prepared. The jobs were accomplished.

As the cancer progressed, his resolve and his strength both weakened. She gradually began providing some of the care he needed. She learned to handle the tubing. She became more comfortable cleaning up after his accidents. She peeked under the dressings to assess how quickly his recurrent cancer was growing. She absorbed more and more of the daily duties — tasks she would have never dreamed of performing a few months before.

On this day, I carefully removed the dressing to examine the growing ulcer. The opening between the mouth and the cheek skin which had started as a pinhole was now large and weeping. Covering the defect had become a frequent necessity. The gauze needed changing after he tried to eat anything and whenever the dressings became soiled.

After I had finished examining and measuring the ulcer, I opened the drawer holding the supplies. I pulled out some gauze and a roll of tape and began by aligning the dressing with the edge of the wound. The first piece of tape gave way as soon as I placed the second piece.

“Here,” she offered. “Let me take care of that.”

And so this woman, who just a few months before could barely bring herself to look at his wound, carefully arranged the necessary supplies from the drawer on the countertop. Her husband relaxed and raised his chin, presenting to her the gaping defect in his cheek. As I watched, they performed a ritual of preparation, cleansing, and concealment. The outcome was perfect. Not a piece of gauze had been wasted. Not a strip of tape was out of place.

She stepped back and wiped her hands. “There!” she said.

He reached up and felt the edges of the dressing. “She’s become quite a nurse, don’t you think?”

Indeed, I thought. I admired the dressing. By comparison, my attempt to tape gauze to his face had been clumsy. I realized that I had been dressing a wound. She, on the other hand, had been dressing a person. The ceremony of his wound care reflected their transformation.

The following is feedback received for this blog:

I found this by way of GR's... A beautiful story and it reminds me of some folks I love very much. Thank you for sharing it. It's nice to know you see the beauty in all the other "stuff" you see daily.

- Robin
http://survivethejourney.blogspot.com

Engage With Grace

Wed, 26 Nov 2008 08:25:41 GMT

This Thanksgiving, medical bloggers around the world will all be posting the information below. It is well-written and powerful. I hope it is helpful to you and your family. I plan to share it with mine.

-BHC

We make choices throughout our lives — where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it.

This has real consequences. 73 percent of Americans would prefer to die at home, but up to 50 percent die in a hospital. More than 80 percent of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50 percent say they've talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide — wherever and whenever they can … at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide and share it at any opportunity — with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect ... and the incredibly positive impact we could have collectively. Help ensure that all of us — and the people we care for — can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to http://www.facebook.com/l.php?u=http://www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team)

Welcome to Two New Bloggers!

Mon, 24 Nov 2008 08:59:53 GMT

Two new blogs are up and running on the Froedtert & The Medical College of Wisconsin Healh Blog Web site.

First, Dr. Bob Gleeson has initiated the blog What Healthy People Do. Dr. Bob is an expert in motivating people to pursue healthy lifestyles and has spent years researching and lecturing about the topic. He is a new faculty member in the Department of Medicine and Director of the Executive Physical Program. I swear that I am only just a little jealous that Dr. Bob has already published a book.

The other blog, INERTIA, A Therapist's Thoughts, is written by Physical Therapist Jeff Wilkens, MPT. Jeff and I spent a lot of time together over the past couple of months when I needed some physical therapy. (To learn exactly WHY I needed therapy, click here.) I am almost back to what I call “normal,” and am certain that Jeff will be as great a writer as he has been a therapist.

Welcome to the blogosphere, Dr. Bob and Jeff!

One last note: please check back here on Wednesday for a special post that will appear on many medical blogs around the world focusing on the need to talk to your family about end-of-life decisions. For a preview of the topic, click here.

Reaching Across the Divide

Tue, 28 Oct 2008 13:45:43 GMT

They may forget what you said, but they will never forget how you made them feel.
-Carl W. Buechner

He was resting on a cart in the pre-operative area being prepared for his surgery. We had first met at the initial office visit, and I felt that we had made a connection. He looked up at me and smiled.

"Did you get a good night's sleep, Doc?"

I pretended that I was trying to control my shaking hand. "Not too bad. I was up most of the night reading about your surgical procedure and weeping uncontrollably."

He laughed. "You kill me, Doc!"

"We'll try not to," I promised. I stepped closer and laid a hand on his shoulder. "Do you have any questions for me?"

He shook his head and grinned. "Nah. I'm ready. Take good care of me, okay? And keep Betty posted, willya?" He reached up and patted my hand.

"Of course." Pretty soon, he was wheeled down the corridor to the operating room.

I always assume that patients must have come to some comfort level with me before they would allow me to perform surgery on them. Then I ran across some remarkable writing by poet, author, and farmer Wendell Berry.

In a lecture entitled "Health is Membership," Berry describes the giant chasm he sees between the healthcare system and its patients.

On the one side, the patientâs side, is the world of love. It is not a perfect world, but it depends on the interconnectedness of family, friends, and community.

On the other side, the healthcare side, is the world of efficiency, machinery, and statistical probability. The patient and the family are "amateurs." The healthcare workers are "professionals."

As Berry writes "... the amateur is divided from the professional by perhaps unbridgeable differences in knowledge and language." As his brother was undergoing heart surgery, Berry and his family made several observations. "We realized that under the circumstances, we could not be told the truth. We would not know, ever, the worries and surprises that came to the surgeon during his work. We would not know the critical moments or the fears. If the surgeon did any part of his work ineptly or made a mistake, we would not know it. We realized, moreover, that if we were told the truth, we would have no way of knowing that the truth was what it was."

He also notes: "That these two worlds [of patients and caregivers] are so radically divided does not mean that people cannot cross between them. I do not know how an amateur can cross over into the professional world; that does not seem very probable. But that professional people can cross back into the amateur world, I know from much evidence."

We caregivers were, after all, born on the "amateur" side of the chasm, so we should know how to journey back. As for me, I like to think that I am reaching across each time I greet and shake hands with family members and then spend time listening to the stories they share. I try to cross the divide as I wait until patients have exhausted all of their questions.

Still, Berry reminds us that, in a hospital, "the world of love meets the world of efficiency or, rather, these two worlds come together in the hospital but do not meet." The chasm exists even if we don't pay heed to it and it remains our responsibility, as caregivers, to reach across the divide whenever we can.

The following is feedback received for this blog:

A nice reminder.

- rlbates
http://rlbatesmd.blogspot.com/

These are some truly profound reflections. Both yours and Berry's.

I'm going to check up on his book.

- sterileeye
http://sterileeye.com

This is a good reminder to us teachers too; to treat our students as persons and not just impart theoretical knowledge to them.
- jan yen
http//simpleawareness.blogspot.com

Cure and Healing

Mon, 25 Aug 2008 11:36:41 GMT

“Be near me when my light is low ... And all the wheels of Being slow.”
- “In Memoriam” Alfred, Lord Tennyson

A friend asked, “What is the difference between Cure and Healing?” As a cancer surgeon, I was perplexed and challenged by the question. I eventually responded with two clinical vignettes.

The first story is of a talented Senior Executive Assistant for an important local businessman. Her years of smoking caught up with her and she developed a large tongue base and tonsil cancer. Her surgery and radiation therapy were completely successful and her cancer was controlled. Nevertheless, she was overwhelmed by depression. She continued to smoke and drink, refused to go out in public, quit her job, and rejected her friends. She agonized over her appearance and speech. She refused to return for follow-up visits or counseling. I eventually lost track of her.

The other story is of an immunocompromised woman I first met several years ago. Her first cancer took a portion of her mandible and tongue. She did well for several years, but developed a series of increasingly dangerous additional primary cancers and recurrences. All through the experience, I saw her regularly, and we suffered together. When she finally died of her cancer last year, I agonized. Until, that is, I received a letter that she had prepared in her own hand prior to her death. “Please don’t feel that you failed me,” she wrote. That message of comfort and gratitude was emotionally wrenching, but nevertheless, welcome and still treasured.

One person was cured but not healed. The other was healed but not cured. We aim for both Cure and Healing, but the difference, I believe, rests in the relationships.

______
Previously published in the MCW Cancer Center News

The following is feedback received for this blog:

both 4 letter words that I have used inner changeable.
After reading your article, I am moved to see a difference in perspective. I am a 13 yr breast cancer survivor who is launching a non-profit organization- "Creating 4 a Cure" (c4c) We especially want to define our purpose. Your article will help us. thank you for all your wisdom, your caring and blessings to you fo continued success.

-deb drager
www.ddrager.com

Clarity

Mon, 17 Nov 2008 11:50:53 GMT

Many attempts to communicate are nullified by saying too much.
-Robert Greenleaf

As a cancer surgeon, these are some of my favorite things I have the opportunity to tell cancer survivors during an office visit:

“Things look absolutely perfect!”
“Unless I knew where to look, I wouldn’t even be able to tell where your cancer used to be.”
“The cancer has completely disappeared … the entire area has healed.”
“I do not see or feel anything that worries me at all.”
“We don’t need to have you return for another cancer check-up for at least six more months.”
“I can tell that you are taking great care of yourself.”
“It is terrific that you have quit smoking!”

Physicians are not always the best communicators with either good news or bad news. When someone has cancer, I have learned to use the word “cancer,” and not words like “tumor,” “growth,” or “problem.”

Similarly, when things are going well, I have learned to tell people good news in the strongest possible, positive terms. Using the phrases listed above makes patients happy and lets them know that things are going well.

And, I have to tell you, it makes me happy, as well. I LOVE giving people good news.

The following is feedback received for this blog:

I love to be the bearer of good news and to receive good news as well.

Also, to be an encourager.

- jan yen
http://www.simpleawareness.blogspot.com

The Wind

Mon, 10 Nov 2008 10:52:28 GMT

Every day we are engaged in a miracle which we don't even recognize: a blue sky, white clouds, green leaves, the black, curious eyes of a child -- our own two eyes. All is a miracle.
-Thich Nhat Hanh

One of my early childhood memories takes place on a Sunday afternoon. I am sitting on the floor playing with some toys that we have brought along from my house. My parents are visiting a distant cousin in her home. In my mind, I can hear the adults talking.

Despite the passage of nearly fifty years, I still remember how their conversation sounded. My parents, sitting on the edges of their chairs, are speaking in happy, positive tones, talking about friends and relatives.

In my memory, I recall whenever the cousin spoke, it would take her a long time to say anything. After every few words, she would have to pause and wait until a noise like the wind had stopped before she could speak again. I can clearly recall the rhythmic sound of the wind.

When she spoke, she would get through a few words (a sound like the wind) then speak a few more words (a sound like the wind) and each time she spoke (a sound like the wind) her voice would trail off (a sound like the wind) then it would return (a sound like the wind) strong again but trailing off (a sound like the wind) and as she spoke (a sound like the wind) I could see her looking at me (a sound like the wind) smiling (a sound like the wind) and gazing into the mirror (a sound like the wind) above her head.

In my memory, I look up and watch the adults. My parents are smiling and talking. The woman, however, lies in a long metal and glass tube connected to a machine with gauges, hoses, and dials. In order to see us, she must look up into the mirror fixed above her face. She is the only person I ever encountered in my life who depended on an Iron Lung.

The woman had lost her husband suddenly while they were both young. When she had contracted polio, her family had eventually been able to take her home to care for her. Now, a few years later, she survived, still dependent on the total care of her family and caregivers, locked in her Iron Lung for most of the day.

Our family visited her regularly, and my memory of those encounters eventually melded into a single image. I will forever recall sitting on the living room floor, holding my toys, looking into the woman's upside-down face in the mirror, and listening to the sound of the wind interspersed between her short phrases.

Thinking back over the years, I cannot begin to imagine what would have been going through her mind as she lay in that machine gazing back at me.

Turning the Corner

Wed, 15 Aug 2007 05:51:21 GMT

"It was embarrassing," she declares, partly serious. "I could not believe he was doing it."

He grins. "I couldn't help myself."

Together they tell me the story. Before his cancer treatment, he had been a big man, weighing well over 200 pounds. The radiation for his throat cancer had robbed him of his saliva and his sense of taste and, therefore, he had all but lost any desire to eat. In the early days after the treatment, everything tasted like cardboard. Some things he had loved before — things like tomatoes and pineapple, for example — still burn whenever he tries them. He had all but stopped eating for pleasure and his weight dropped into the 150s. She had been very worried about him.

The seven weeks of radiation had been difficult for both of them and they hoped a few days in Las Vegas would serve as a time of retreat and reward. Indeed, they did relax and he began to feel more like his old self.

One afternoon, they stopped by the buffet at one of the hotels. He half-heartedly picked out a plate of food and headed back to his seat. As he ate, he realized that his taste buds were responding for the first time since treatment. This food is really good!, he thought. He finished the plate and headed back to the buffet line. She watched him in amazement.

The hotel staff was in the process of shutting down the buffet until dinnertime, but he kept going back. "Don't worry," said one of the waitresses. "Eat all you want." He took her at her word.

Again and again he returned to the buffet table. "They even had crab legs!" he marveled, realizing that he could taste them for the first time since before his cancer diagnosis. What other foods would taste good again? He became an eating machine. Back to the buffet line to find out.

He made several more roundtrips from his table to the buffet. After seven plates of food, he finally declared his eating experience complete. "Don't know where I put it all," he tells me wistfully, remembering the afternoon fondly.

Now, months later, he is at a perfect weight of 165 and estimates that 75 percent of his sense of taste has returned. She no longer worries about his eating and he makes a point of sticking to a healthy diet.

"So," I want to know, "did you eat so many things just to see if you could taste them?"

"I suppose so," he replies, then adds with a grin, "but mostly because I was really hungry. Seven plates of food! Man, was that fun."

She pokes him. "I was so embarrassed," she repeats. Then she smiles.

The following is feedback received for this blog:

What a lovely story! I remember my taste buds being off just from Bell's Palsy. I can only image how it must have been for him.
- rlbates
http://rlbatesmd.blogspot.com/

What a great story! I was wondering what percent of folks lose their ability to taste after radiation therapy to the throat - and what percent get that ability back (and in what time frame)?
- Val Jones, MD

Dear Val,
Loss of sense of taste varies depending on the radiation field and the amount of residual dryness. Traditionally, most patients experienced severe dryness and loss of taste if they had full course radiation for oropharyngeal, hypopharyngeal, and oral cavity cancers. These changes were usually permanent.

With the newer radiation techniques, particularly Intensity Modulated Radiation Therapy (IMRT) and TomoTherapy, much of the uninvolved tissue can be spared; therefore, there is less permanent dryness. I don't have any "real" data, but most of my patients treated this way tell me that their sense of taste comes back 70% - 80%.
-Bruce

Thanks, Bruce! Very interesting - and great news for those who have IMRT. So this is largely about dryness? Hmmm... So perhaps the salivary glands (and not so much the taste buds) are being harmed? I hadn’t thought of that. :)
- Val

It is a real problem that the patients are worried about dying and longevity when we first meet them. When they are cured, though, often the biggest concerns they have revolve around dryness, taste, and swallowing.

A friend at the University of Chicago published a paper on the problem in 2000. I have a short commentary on her work in a local newsletter
here.
-Bruce

I completed treatment for base of tongue cancer in May of 2004. Within 2 months of treatment i was eating bland foods with some satisfaction coming from taste. Now 4 years out I would welcome a complete loss of taste. i am unable to eat a regular diet and depend on Nutren for all of my nutrition. My taste has become so preverted that I dread every feeding. Between feeding I have a taste in my mouth that can not be described. A good comparison might be salty wallpaper glue. In some other post you mention the relationship to saliva production and taste. In my case I have increased saliva production but my taste continues to get worst with time. I have trouble gaining weight or staying hydrated because even water has a terrible taste. I am debating possibly getting my peg back. There may be those that recover from treatment but I am the poster child for all that can go wrong from Chemo/radiation treatment.

- William J.

Real Money

Mon, 20 Oct 2008 17:43:44 GMT

A billion here and a billion there and pretty soon you’re talking real money.
-Everett Derksen

My new patient looked very discouraged. I studied the reports from his treating physicians at the outside hospital.

“Doctor, what happens next? They told me that the cancer didn’t go away! The doctor who sent me said you would have to do a big surgery!” The questions poured from him. “I am just now feeling better. I can swallow and the pain is almost gone.”

I reviewed the outside studies and reports. He had presented with a cancer of the throat about four months before and he had undergone radiation and chemotherapy. “Let’s see … you finished your radiation and chemotherapy about a month ago, correct?”

He nodded. I checked his mouth and throat carefully and felt for enlarged lymph nodes in his neck. Indeed, his examination was perfect. There was no visible cancer anywhere.

“But, Doctor, what about the cancer they saw on the scan last week?”

Ah, the scan. I pulled up the images of the most recent PET/CT, a sophisticated study that merges images of the anatomy (the CT portion) with a PET scan that shows abnormal uptake in areas cancer or inflammation. Each PET/CT takes over an hour to perform and costs several thousand dollars. The scans often yield very valuable information and have become important in the evaluation and follow-up care of cancer survivors.

His recent scan did, indeed, still show activity in his throat with only slight improvement from the scan performed a week before his treatment.

I looked at him. This was going to be a complex discussion.

“The new scan is not very helpful,” I told him. “Research has shown that PET/CT is often misleading in your situation when performed earlier than three months after completing treatment. Patients with head and neck cancer treated with radiation and chemotherapy almost always show continued activity while the body is healing. After three months, the healing activity goes away and the scans become more helpful. I am pretty certain that is what we are seeing here…your body is still recovering.”

He stared at me silently, not knowing whether to believe me or his other physicians.

“You mean the test was useless?” He paused, apparently remembering the out-of-pocket costs. “Are we going to have to do repeat it in a couple of months?”

“Not necessarily,” I responded. “When you come for another appointment in a few weeks we’ll decide what kind of tests to perform based on how things look.”

Why had his previous physicians ordered the PET/CT so quickly after finishing his treatment? No doubt, they had never run across the data and recommendations buried deep in the medical journals. In addition, there is no system in place that flags expensive and marginally helpful tests to ask if they are truly indicated.

There are also certain characteristics of “typical clinicians” that might help explain why we do not always practice the most appropriate and efficient care (see the JAMA editorial that is the source for the list):

(1) Physicians believe in what they are doing.
(2) Physicians prefer action, even with little chance of success, over no action at all.
(3) Physicians see apparent cause-and-effect relationships even when there are none.
(4) Physicians tend to rely on personal judgment more than evidence.
(5) When things go wrong, physicians tend to assign the bad outcome to chance.

I am no better than the next physician, especially in areas where I might not be expert. For people like me, we need to develop systems that block these types of errors. Although no one was hurt, plenty of money (both the patient's and the insurer's) was wasted.

Nationally, healthcare costs and health insurance costs are rising much faster than inflation. The combination of an aging population, complex and expensive healthcare technology, and limited success in promoting adherence to treatment guidelines will certainly drive costs even higher.

While the story here is an example of waste, it also provides a teaching moment that will improve medical care in the future. Too bad my patient had already undergone a very expensive and a very useless scan.

Where to Begin?

Mon, 13 Oct 2008 08:43:31 GMT

Let justice roll down like water…
- The prophet Amos

Today, I wander away from my usual themes because this is a problem that really bothers me.

Fifteen years ago, Milwaukee was the home to the most devastating water-borne illness outbreak in U.S. history. Over 400,000 people became ill and more than 100 died when cryptosporidium contaminated the city’s drinking water supply. Since then, the city has spent more than $90 million on ozone treatment, better filtration, improved monitoring, and a 4,200 foot extension of the intake pipe extending into Lake Michigan.  We are, again, safe.

At the time of the outbreak, I remember the sense of disbelief that anything like this could ever happen in a developed country. At the hospital, we used bottled water for several days. Beds were at a premium as more than 4,400 people were admitted to the area hospitals during the crisis. Soon, though, the contamination was controlled and everything went back to normal. The episode was quickly forgotten by those of us fortunate enough to have not been touched personally.

When I visited Tanzania earlier this year, I was struck by the number of women balancing brightly colored five gallon plastic buckets on their heads. Amidst a population with almost no personal possessions, the people treasured these pails. Like much of the developing world, such containers are indispensible in search by women and girls for water. Many spend two hours or more each day at the task.

The issue of water justice, particularly as a medical problem, was highlighted in a recent article in The New England Journal of Medicine. More than one-third of the world (2.6 billion people) has no reliable access to clean water for drinking and sanitation.

Many people in the developing world have access to only five liters of water each day; in the United States, we each use 50 liters each day merely for toilet flushing. We each consume approximately 350 liters each day for all of our activities combined.

In the developing world, the lack of clean water causes disease in several ways: by carrying pathogens, by permitting person-to-person transmission because of lack of hand washing, by carrying water-based hosts, by allowing breeding of water-based insect vectors, and by carrying toxins.

There are some problems where I, smugly, think I can make a difference. This problem, however, is an enormous, multi-faceted, overwhelming quandary that will take governments, education, and resources to remedy. The UN has challenged its membership to cut the number of people with no water access in half by 2015 and there are lots of good people working on the problem. What can each of us do to make a difference?

The Naked Truth about Tonsil Cancer

Tue, 07 Oct 2008 12:23:58 GMT

Most truths are so naked that people feel sorry for them and cover them up, at least a little bit.
-Edward R. Murrow

“Doctor, I should not have cancer! I never smoked! I am only 45 years old! It doesn’t make sense!” The patient and his wife sit stunned and frightened.

My new patient is absolutely correct … he does not fit the traditional profile of patients with cancer of the tonsil.

When I started training in the 1980s, the vast majority of our patients with these cancers were older men who had spent their lives smoking heavily and drinking hard. These were men that had out-lived many of their contemporaries despite wartime service, difficult lives, and chronic illness; now they were saddled with the burden of difficult, disfiguring, and often ineffective cancer treatment.

My patient today, though, fits the new profile as a younger, healthy, non-smoking person.

Recent research has confirmed the shift in the dominant demographic for tonsil cancers from older, smoking men to younger, non-smoking men. The cause for this shift is the Human Papilloma Virus (HPV), particularly HPV-16, HPV-18, and HPV-31.

A study in the Journal of Clinical Oncology compared 17,625 possibly HPV-related cancers to 28,144 possibly HPV-unrelated cancers. Since the 1970s, the incidence of HPV-related cancer has increased by 53 percent. The good news is that HPV-related cancers are much more responsive to radiation therapy and have better treatment outcomes.

“But, Doctor, why did I get the cancer?”

Although the answer is fairly clear, this question remains a difficult one for me. The most common cause for HPV infection is through sexual contact. A study in the New England Journal of Medicine found that the greater the number of vaginal sex partners and the greater the number of oral sex partners, the greater the likelihood of developing one of these cancers.

I look at my new patient and his wife. To me, this does not seem to be the right time to discuss epidemiology.

Or sex.

“The cancer is most likely from an HPV viral infection you picked up many years ago. We have a very good chance of curing your cancer.”

He looks relieved, then blurts out, “Do my kids have a higher likelihood of getting one of these cancers because I had one?”

I'm not certain. “I don’t know, but we hope that these kinds of infections and their associated cancers will be eliminated in future generations because of the HPV immunizations.”

I have to admit that I am still not comfortable knowing how and when to discuss this topic with my cancer patients. Clearly, though, we will be having more and more of these conversations in the future.

The following is feedback received for this blog:

Dear Doctor, usually it is the other way around, the patient is embarrassed to talk to the doctor. What we need is everyone feeling less embarrassed, and you certainly do not have to feel embarrassed online. I would like to have more specific information about this tonsil cancer and what exactly may cause it. I can read between the lines, but I would like to have this kind of info straight up....so to speak.

I presume you get this kind of cancer during oral sex, but is it oral sex with a female, a male or both? As a female I have always worried about passing on a yeast infection to the performing partner, although that never happend to me, it happened so a few people I knew when their husbands came down with a bad case of thrush. I could put two and two together and kind of figured out how it may have happened.

Also, for women, and this has been my experience, I would usually get a bladder infection, something I am prone too, after receiving oral sex. After avoiding oral sex, my incidence of bladder infection is way, way down. I really think there is a link, and women seem to have bladder infections a lot.

I will come out and say it, I think most people these days engage in oral sex, for some it is even a way to avoid pregnancy and other STDs, but I could be wrong, about the STDs that is.

We need an open to the point information about this subject. I would feel terrible if somehow I infected my sex partner with cancer! Darn...everything that is fun is either illegal or bad for you, or both!

- Carla

Carla,

I wish there was a simple explanation, but there is not. We do know from the New England Journal of Medicine article that people who have had >25 vaginal or >5 oral partners had 3X the risk of developing one of these cancers than people who had <6 vaginal or no oral partners. In addition, patients who had a positive blood test demonstrating the L1 antigen of HPV-16 (a very sensitive test for prior HPV-16 infection) were 32X more likely to have one of these cancers than people who did not test positive.

In patients who later develop these cancers, part of the virus’s genetic material becomes incorporated into the cells in the tonsil region in the same way it is incorporated in the cervix of women who develop cervical cancer. If a person is immunized before sexual exposure to HPV, the infection never happens and the genetic material is never incorporated.

I don’t think I am too embarrassed to talk about these issues with patients, but it certainly is not what most ENT doctors spend their days discussing with their patients! My concern is prying into the buried stories and potential land mines of a patient’s sexual history at a time when the biggest priority is developing a cancer treatment plan. On the other hand, the more information we gather, the better we might potentially be able to help people in the future. I applaud the researchers at Johns Hopkins who wrote the NEJM paper for their thoroughness in assembling sexual history data.

I appreciate all of your comments, but, for some of them, I would refer you to my fellow Froedtert & Medical College of Wisconsin blogger, Margarita Kressin, MD at Sexual Healing. I might try to tackle some of your other comments but that truly would be embarrassing!

-BC

The Interval Between the Biopsy and the Report

Tue, 30 Sep 2008 07:06:45 GMT

Words are, of course, the most powerful drug used by mankind.
-Rudyard Kipling

“But, Doctor, tell me! What do you think it is?”

We have finished the operation, catalogued and sent all of the specimens, closed up the wounds, and bundled the patient off to the Recovery Room. It will be a couple of hours before the patient is fully alert. And it will be a couple of days before the reports are back from the laboratory.

“You’ve seen other cases like this. You must have an opinion about what the pathologist will say.”

Of course I do. But, I think to myself, I have guessed wrong. What good would it do to raise hopes inappropriately or, on the other hand, dash hopes needlessly? I have, on more than one occasion told a family that I was pretty certain that the specimen would show no cancer, only to find out days later that I had been wrong. I want to avoid the sinking sensation that has accompanied that mistake.

“I wish I could tell you, but I’m just not certain. We will just have to wait for the reports.”

There is a time of limbo in Medicine that begins when the procedure is completed and ends when the patient learns the results. It occurs millions of times each year after everything from major surgeries to blood tests. Although it was not the point of her essay this week in The New York Times, Dr. Paula Chen touched on these moments as a friend's father waited for the results of a pancreatic biopsy.

From a relative’s perspective (yes, I’ve been there), waiting for the doctor to call or stop by after a procedure is akin to listening for the footsteps of the principal coming down the hall after you have been sent to the office. The wait is long and tense.

From the physician’s perspective, the time between the procedure and the report is a breather that allows a release of concentration from this patient because nothing more can be decided until the report is available. The physician can refocus on someone else during the interval. The wait can seem very short.

Finally, the report hits your desk. Or you call the lab. Or you are paged by the pathologist. Or you work your way through several passwords and computer screens and find the results.

At that moment, the physician has a piece of information that the pateint wants and needs to be shared. Sometimes the report will bring relief and joy; sometimes, just the opposite; sometimes, just a shrug.

But share, we must — clearly and promptly — even when it is hard and even when we don't know exactly how. People are waiting.

The following is feedback received for this blog:

Just to say I really enjoy reading all your posts..am slowly reading all previous posts.

- just me
http://simpleawareness.blogspot.com

Wrong Clinic

Mon, 22 Sep 2008 09:26:53 GMT

"We are healed of a suffering only by expressing it to the full."
-Proust

Years ago, in the ENT Clinic at the County Hospital, I was seeing a new patient. He had been sent to us from another physician with a hastily scribbled consultation note that read “Please evaluate for hearing change.” The patient was nervous but cooperative. His eyes darted around the room, but his gaze never met mine.

“Good afternoon, Mr. Evans! What can I do for you today?”

“My hearing has changed. Something is wrong with it.” His voice was flat.

We talked for a while about his ears. His answers were short. No exposure to loud noises, no drainage, no pain, no ringing, and no episodes of dizziness. He seemed able to hear me just fine as we talked.

“Let me take a look,” I said. I examined his ears. They both looked fine. Very little wax was in the canals, certainly no obstruction. The ear drums looked fine and there was no fluid behind them. I got out my tuning forks and did some basic testing of his hearing. Everything seemed pretty normal.

“Mr. Evans, when did you notice the hearing change?” I asked.

“When they increased my medicine!" he responded. This could be important since some drugs can be very toxic to the hearing and balance mechanisms.

“Which medicine?” I asked. “Who is prescribing it?”

“It’s one of the pills from my psychiatrist, but I don’t know its name!” he responded. As we talked, he was getting more and more agitated.

I couldn’t think of any of the standard psychiatric medications that affect the hearing. I paged through a book which listed common drugs and their side effects and came up empty. I was baffled.

One more try. “Mr. Evans, tell me in what way your hearing has changed since the medication was increased. What exactly is different?” I asked.

His eyes widened and his lip quivered. “I can’t hear the voices anymore!” He started crying uncontrollably. “I can’t hear them telling me what to do!”

We sat there. This was suddenly well outside of my area of expertise. I did my best to calm him and waited for him to regain some of his composure. Before long, I was on the phone, talking to one of my friends in Psychiatry. I later heard that things turned out well.

The following is feedback received for this blog:

Wrong place, but maybe right time/ right doctor. You got him to the right place. :)

- rlbates
http://rlbatesmd.blogspot.com/

Speechless

Mon, 15 Sep 2008 09:05:59 GMT

“The best way out is always through.”
-Robert Frost

“Mr. Williams, the mass we took out of your neck was cancer. The surgery went well and I feel that we were able to remove all of it.”

The surgery had, indeed, gone perfectly and I was feeling optimistic about his prognosis. Although his mass had been only mildly suspicious for cancer, we had been careful and had made certain that there were no other involved lymph nodes and no obvious sources for the tumor. Things were on-track.

“I’m going to die, aren’t I?”

I was stunned. I had just given him good news. He had responded as though I had signed his death warrant.

“Not at all! I expect you will do well! We will send you for a course of radiation therapy.”

His eyes widened and then closed tightly. He looked discouraged. Very discouraged. I was baffled. What could I say?

“Mr. Williams, tell me about people you know who have had cancer.” I thought I would get him to understand that there was hope. “Have any of your family members or friends been treated successfully for cancer?”

“No! Everyone I know who has had cancer has died!”

This was not going well. Then the story came out.

“Thirty years ago, my wife had breast cancer. It was pretty advanced. She had that radical surgery but the cancer came right back. When they did radiation, her skin turned red and then fell off. Her whole chest looked like raw steak. She was miserable! I’m certain that the radiation killed her.”

He stared a hole in the floor. We sat there silently.

“Mr. Williams, I’m sorry.” No response. “Would you be willing to meet with the radiation oncologist to hear about the possibility of treatment?”

He did not look up. “Yes.”

A few weeks later, he was undergoing radiation. What courage does one need to begin a course of treatment you are not certain will help and that you are convinced killed your spouse? I cannot pretend to understand.

What Would You Tell Them? (Part 2)

Thu, 14 Aug 2008 13:12:20 GMT

The Medical College of Wisconsin White Coat Ceremony is Friday, Aug. 15, 2008. I was honored to be invited to give a talk during the ceremony where the first-year medical students receive their white coats, symbols of their new profession.

I appreciated all of the comments that I received, both through the blog and in the hallways. I incorporated as many of the thoughts as possible.

My hope is that the students will learn to listen intently and intentionally to the stories that surround them. The ability to listen will clearly make them better physicians for their patients.

In addition, building on the writing of Rachel Naomi Remen, listening might even protect the students from becoming cynical and isolated from their patients. I tried to make this point with a couple of stories, some of which have appeared in this blog in the past and in other essays of mine.

Attached is the final draft of my talk. Thanks again for your input!

The following is feedback received for this blog:

Very nice. I really enjoyed reading your talk to the new students.

- rlbates
http://rlbatesmd.blogspot.com/

Our son David is an MCW M-1. Thus my wife Anna and I were fortunate enough to attend the MCW White Coat Ceremony on August 15 . Your talk was right on point as to the " big picture " in becoming an excellent clinician . Thanks for helping make the ceremony a very memorable part of a very important day.

- Lew Kaplan

Our son attended the cloaking ceremony five years ago and is now entering his second year of Residency. Your speech made me feel like it all happened just yesterday! Your words and encouragements were powerful and poignant. Thank you, for sharing your thoughts and for sharing your self with the students. Our son, and his finace', both from the same class, were deeply touched and influenced by your teaching, attention, interest and example. Thank you!

Paternalism

Mon, 08 Sep 2008 10:21:00 GMT

“If one is forever cautious, can one remain a human being?”
-Alexander Solzhenitsyn

I never leave my work behind completely. That is probably why I read the late Alexander Solzhenitsyn’s book, Cancer Ward while on vacation. (Thanks to Eileen who gave it to me!) Cancer Ward is a semi-autobiographical work about a group of men in a Soviet hospital undergoing surgery, radiation therapy, and hormone treatments in 1955. Solzhenitsyn uses “cancer” as a metaphor for the deteriorating Soviet system and its effect on the citizens. Still, much of what he describes of the physicians and patients holds true in every time and place.

The book highlights the paternalism of both Medicine and the Soviet system. In the story, the patients’ clothes and shoes are taken from them as soon as they are admitted. Treatments are rendered without consent. Patients are not told how long they will remain in the hospital. Casual comments dropped by the staff are routinely misinterpreted. Even the compassionate doctors routinely hide diagnoses, prognoses, and test results from the patients.

One patient, Oleg Filimonovich Kostoglotov, an exiled former political prisoner, is wily enough to befriend several of the physicians and staff members. By borrowing medical books (“Strictly forbidden to the patients!”) and slyly asking questions, he finally manages to understand his cancer and the potentially horrific effects of overtreatment. He cleverly talks his way out of the hospital before the treatments do more harm than good.

Oleg benefited only when he had plenty of good information and was able to hold someone’s attention long enough to get all of his questions addressed. Clearly, the more Oleg learned from the physicians, the more the physicians tended to see him, not as a patient, but as an equal. What a concept!

Solzhenitsyn is not alone in decrying paternalism in Medicine. As the literary critic Anatole Broyard wrote in the months before he died of cancer:

“Just as he orders blood tests and bone scans of my body, I’d like my doctor to scan me, to grope for my spirit as well as my prostate. While he inevitably feels superior to me because he is the doctor and I am the patient, I’d like him to know that I feel superior to him too, that he is my patient also and I have my diagnosis of him. There should be a place where our respective superiorities could meet and frolic together.”

When Medicine works, it becomes a partnership — a relationship of equals — that requires time, effort, and trust. Just as Oleg learned, and as patients and physicians continue to learn, forging this partnership can be a difficult, yet very rewarding, process.

The Follow-Up Visit

Fri, 29 Aug 2008 14:04:40 GMT

"Experience is simply the name we give our mistakes."
-Oscar Wilde

A long-term cancer survivor comes for a regularly scheduled follow-up clinic visit. These usually routine appointments focus on problem-solving. It is quickly apparent, however, that she is in significant pain and has lost weight.

"How long have you had this neck mass?" I asked.

"It appeared shortly after my last visit and has been growing ever since. It hurts."

My heart sinks. Her cancer has spread. We will order scans and probably schedule surgery. The outlook is not good. Why hadn't she called for an appointment when she first noticed the mass? She shrugs. "I'm not sure."

This scenario is all too common. Researchers at Ohio State University collected information on over 3,600 follow-up clinic encounters and found that a new or recurrent cancer was identified at 5 percent of the visits. Of these, the patients had already diagnosed themselves 79 percent of the time; the physicians rarely found non-symptomatic cancers. Oddly, the confirmation of the cancer occurred at a regularly scheduled visit 73 percent of the time; patients rarely called and scheduled an early encounter. (Agrawal A, Laryngoscope Feb 2004; 114:232)

Why don't patients with symptoms call immediately for an appointment? Maybe they don't believe that cancer can recur. Maybe the visits are too expensive or frightening. Maybe they don't want to deal with potential bad news and more treatment.

Somehow, we haven't found simple ways to encourage patients to return as soon as they are alerted by a symptom or sign. In my practice, a worried, symptomatic patient often apologizes for taking up my time after I tell them everything is fine. I, on the other hand, am delighted and relieved when the symptom has a non-cancer explanation. I reassure and congratulate them, schedule another visit, take a breath, and move down the hall to see the next patient.

This essay previously appeared in the MCW Cancer Center News

The New Pacemaker

Mon, 11 Aug 2008 11:05:39 GMT

"None are so old as those who have outlived enthusiasm."
-Thoreau

My mother, bless her over-90-year-old heart, received a pacemaker this week. The procedure went perfectly. She is fine and is recovering beautifully.

While sitting at her bedside in the hospital, we read the brochure that she received along with her pacemaker. My mother and I reviewed the warnings she must keep in mind with her new device. For example:

My mother should not hold a cell phone closer than six inches to her new pacemaker.

My mother should not stand closer than 12 inches to a slot machine.

These are good and reasonable suggestions. Although she rarely uses her cell phone, she does own one. The company suggests that she hold the phone on the ear opposite the device when she needs to make a call. We made a note of that. Since my mother never gambles, she doesn’t have to worry about slot machines. Again, the company appears to suggest that it is safe to play the slots but big winners should not hug the machines after hitting a jackpot. Now THAT restriction might make a difference to some of my patients.

We continued reading. My mother was also warned against the following activities:

My mother should stand no closer than 12 inches to a chain saw.
My mother should be no closer than 2 feet from an arc welder.
My mother should NEVER use either a stun gun or a jackhammer.

These are also very reasonable suggestions, but less likely to have a direct impact on her day-to-day existence. I questioned her closely and she repeatedly assured me that she had long ago given up her aspirations to become a lumberjack, welder, peace officer, or heavy construction worker.

Despite her claims, I am not totally certain that I can trust her. If any of you spot my mother heading off to either a job site or the casino, please let me know immediately. With the enhanced energy she is expecting from her new pacemaker, you never know.
_____
By the way, Mom gave me permission to share this story. -BHC

The following is feedback received for this blog:

Happy to hear your mother is doing well. I have a brother-in-law who did have to give up using a chain saw for cutting wood which with the increased energy was frustrating for him. The trade-offs that life hands us! :)

- rlbates
http://rlbatesmd.blogspot.com/

very entertaining-I'll keep my eyes open for her!!

Y N RN

I think this is the funniest blog you've written yet! In our litigious society it seems the practice of good medicine can be, at times, a bit inane, or even absurd! Thanks for sharing this anecdote. I also enjoyed your speech to the new M1s.

- Lisa Kodadek

The Answering Machine

Mon, 30 Jul 2007 12:54:49 GMT

“Hi, you have reached the voicemail of George and Sue. Sue and I are not available right now, but if you leave a message after the tone, we will get back to you as soon as possible. Have a great day!”

A tone warbles on the other end. I pause, dumbstruck, for more than a second. George is my patient, but he has not been doing well over the past six months. After a portion of his tongue was removed, he underwent a combination of chemotherapy and radiation. His cancer is controlled, but his health, poor to begin with, has deteriorated. For the time being, he communicates primarily with gestures, writing, and an occasional spoken word. After some time at home with Sue, they both decided that he needed more intensive therapy and she needed some rest. He was admitted to a local rehabilitation facility to regain his strength.

“Hello, Mrs. Jones. This is Dr. Campbell. I was just calling to check up on you and see how things are going …”

There is a sudden click and I hear some fumbling at the other end of the line. Suddenly, she is talking.

“Hello, Dr. Campbell. This is Sue. I just came back from visiting George. He is looking better.” She spends some time going over his situation. He is frustrated, but, overall, he is adjusting to his new life and the regimen. His communication skills need a lot of work. They both hope his stay there will be brief. She thinks he is resting better. It is clear that she is.

“That is great! By the way, it was very interesting to hear his voice on the answering machine when I called …” Since I first had met him, he has always had difficulty talking. The voice on the machine, on the other hand, was clear and strong with no hint of the coming tongue cancer problems.

She laughs. “I suppose I should change the message on the machine. He made that recording last year, long before he got sick.” She pauses. “You know, I don’t even notice it when it plays. That is the way I remember him always sounding. That is the voice I have listened to for 45 years.” She laughs again, ruefully this time. “Besides, no one would understand him if he made a new recording now.”

I emphatically tell her the message is just fine. I don’t tell her that hearing his message on the machine having perfect articulation is more than a little spooky – somewhat akin to getting an e-mail sent from a friend who has died (because the family hasn’t removed his name from the account), or like getting junk mail and magazines forwarded from a dead relative’s home. The voice is unique. While we might be able to flip though pages of yellowing, faded photographs of friends and family irretrievably gone from us, rarely do we have the opportunity to hear their voices.

“Thanks for calling, Dr. Campbell. Talk to you again soon.”

“Good to hear your voice. Take care, Mrs. Jones.”

The following is feedback received for this blog:

This is exactly the kind of vignette I enjoy. It puts a human face on science; thanks for sharing.
- cardiogirl

Thanks for sharing. its very inspiring

http://healthrecord.blogspot.com

What Would You Tell Them?

Tue, 29 Jul 2008 11:54:57 GMT

"The whole art of teaching is only the art of awakening the natural curiosity of young minds for the purpose of satisfying it afterwards."
-Anatole France

On Aug. 15, I will have the opportunity to speak to the incoming medical school class at the Medical College of Wisconsin. Two hundred men and women will be starting their first-year classes and I will have a few minutes to talk to them as part of the ceremony where they will receive their first white coat.

The “White Coat Ceremony” has been alternately praised and criticized in academic circles. It is praised because it emphasizes the role of compassion and an appreciation for the Humanities in Medicine. The ceremony reminds the students that they have a responsibility of "caring" in addition to "curing." The ceremonies have been criticized, though, because they sometimes seem self-congratulatory. Worse, some worry that the coat gives some students an irreversible sense of entitlement. Medical student bloggers tend to find the quality of the ceremonies inconsistent.

I have spoken to several medical students about their recollections of the White Coat Ceremony. By and large, the students are so animated about the entire process of starting medical school that any specifics about the speakers or the speeches quickly fade away. Maybe that’s a good thing.

Personally, I remember waiting with my classmates to be called up onto the stage where the University President helped us on with our coats and then the Dean shook our hands. If anyone made a speech, I certainly do not remember.

So, if you were in my position, what would you tell a roomful of first-year medical students? What do they need to hear just as they set out on their journey to become physicians? I look forward to your input. (Please select the Feedback link below.)

The following is feedback received for this blog:

Just tell stories. Tell the kind of things you write about. Don't tell them how to interpret them, just tell the stories. Usually the interpretation is plain enough.

- Rob Lamberts
http://distractible.org

Make mental health something you address with every patient. Please join consumers (those with mental illness that pay for doctors, couselors, day care centers, community support systems and medicines) in their quest to have ample insurance coverage to help them with their diseases of the brain.

- Anne Feyen

Why not encourage them all to start a blog? Explain to them that blogging is a valuable way to influence health policy and improve the healthcare system. Everyone has a voice - and even Secretary Leavitt is listening. Counsel them not to divulge private patient information, but to chronicle their growth as doctors, so that people can understand what medicine is all about (the good, the bad, and the ugly). And if any of them are particularly good writers - tell them Dr. Val would like to recruit them to post to (and maybe even host) Grand Rounds! :) My two cents...

- Val Jones
www.revolutionhealth.com/blogs/valjonesmd

When my mother came to Froedtert as a patient I thought this was the best hospital for her to be in. I don't know if I was right or wrong in my thinking. I have some mixed emotions on this while I waited for answers to questions and rarely got to see a faculty doctor. As a teaching hospital I know that having residents on call is how business is done. But I lament over the fact that faculty physicians are not visible. I think that being a good mentor means to be an example, and you need to be accessible and on hand to guide those students and residents. I know at an academic institution it is overwhelming for faculty physicians to teach, conduct research, practice, and sit on committees.

As my mother's daughter my expectation is that the doctor, nurse and any other medical staff treat my loved one as they would their own mother, father, sister, brother or child.

- Gail

Please remind them to treat the whole patient and not just the symptoms. I live with a chronic illness and I ask my doctors often "what else can I do to be well?" The doctors seem dumbfounded at times by the question.

Bruce, tell them that they are part of the healthcare team, the center of which is the patient and the family. Encourage them to always keep an interdisciplinary approach to caring for the whole person. But tell them in your own style, which embodies all of that. Good luck and enjoy the ceremony!

- Susan

Please tell them that there is a human being they are treating who has a disease. Treat each patient as you would want to be treated, with care and compassion.

- Mary Fiegel

There is only one thing I would tell young doctors:

ALWAYS LISTEN. Do not only hear, but LISTEN. !

- Priscilla Paliwoda

Boneheaded

Fri, 18 Jul 2008 09:38:17 GMT

"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.

At the Mall

Mon, 30 Jun 2008 09:14:05 GMT

“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.

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

Distractions

Thu, 10 Jul 2008 09:11:48 GMT

“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?

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

The New Finding

Tue, 17 Jun 2008 13:19:11 GMT

“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."

The Tongue Stud

Tue, 06 May 2008 09:12:25 GMT

“The most effective form of birth control I know is spending the day with my kids.”
-Jill Bensley

Cancer of the roof of the mouth rarely occurs in children. Several years ago, I took care of a young teenager whose orthodontist had noticed a slowly growing, painless mass on the hard palate. After determining that everything else was fine, we took her to the operating room and removed the tumor. Once she had healed up, she never had any more problems with her mouth. I saw her regularly for a while and then she stopped returning.

Several years later, her mother brought her back to the office for a check up. The patient sat glumly in the chair occasionally glaring at her mother. As I updated her medical history, she was having some trouble with forming words.

“I feel fine,” she said. “I’m only here ‘cause she made me come.”

“Okay, open up,” I said.

This was no longer the cute little kid I had cared for a few years before. As she leaned forward to let me examine her, I smelled tobacco smoke. When she opened her mouth, she clicked an enormous tongue stud against her teeth.

Her mother rose from her seat. “There! Doctor! Tell her that that thing is bad for her!” The girl rolled her eyes.

“When did you start smoking?” I asked. She shrugged and immediately delivered the same withering glance at me that she had just leveled at her mother.

We reviewed what I knew about tongue studs: they are interesting, they don’t help during job interviews, but they are not dangerous.

We also talked about smoking. As a survivor of cancer, she might be at an increased risk of additional malignancies, especially if she engages in high-risk behaviors like smoking. For the first time during the visit, she was engaged and was clearly listening, although she did not give me the satisfaction of saying she wanted help with quitting.

Mother and daughter left the office, both frustrated yet both vindicated, in a way. I'm pretty certain that the battle continued when they got home.

The following is feedback received for this blog:

Thought of you as we recently enjoyed a weekend in SMOKE-FREE CHICAGO. Not only is it safer inside - it's safer outside too. The streets are now monitored by smokers.

C'mon Milwaukee.

- Lucia

I read a cool article in the latest article about a chef in Chicago with tongue cancer..... thought it might be up your alley.
http://www.newyorker.com/reporting/2008/05/12/080512fa_fact_max/?yrail

- buckeye surgeon
www.ohiosurgery.blogspot.com

Great story! My experience with adolescents is that they don't get at all how risky smoking is (or maybe they like it for that), but your young patient at least knows what it is to have to have surgery for a tumor at least. And I bet she was more receptive because you okayed her tongue stud! Nice job!

- Jane Geraci
http://janemariemd.blogspot.com/

Fear

Sat, 26 Apr 2008 00:02:23 GMT

“We make a living by what we get, but we make a life by what we give.”
- Winston Churchill

“Weren’t you scared?” my colleague asked a couple of days after we had returned from Tanzania. “Weren’t you scared? My God, there’s so much danger! It must be a very scary place!”

I was as startled by the unnamed questions as I was by the one she had asked. Maybe she was wondering if we were in danger because of the disparity between their poverty and our wealth. Maybe she was convinced that white people would be automatic victims of stereotyping and hatred. Maybe she thought the violence that has plagued so many nations on that continent over the past decades was present everywhere.

I pondered her question. “Yes, I was scared at first.” I went on to explain, “You see, everything was so unfamiliar. I am not accustomed to being in the minority. I did not know instinctively what situations to avoid. I was suddenly dependent on people I had not yet learned to trust. And, foolishly, I had read a disturbing book on the plane.”

“What book?” she asked.

On the flight to Tanzania, I had finished Left to Tell: Discovering God Amidst the Rwandan Holocaust by Immaculee Ilibagiza, a first-person account by a Tutsi who had survived three months during the 1994 genocide by hiding in a tiny bathroom with six other women. "It is a frightening description of the unbelievable atrocities that took place in a country that borders Tanzania. The book culminates in redemption, but the images of violent gangs wielding machetes and of the unspeakable, unthinking hatred haunted me. I could have picked a better book to read.”

She nodded, believing that she understood.

“As soon as we landed, though, I had the opportunity to interact with the Tanzanian people. They are soft-spoken, loving, and gentle. Most have very few material possessions. (Tanzania ranks in the bottom 10 percent of countries with a median income of $340 per year – less than one dollar per day.) They seemed oblivious to the deeply rutted roads and the near-complete lack of infrastructure. They didn’t seem to mind walking for miles in driving downpours. The few with access to electricity didn’t notice when the power went out yet again. I can’t recall any of them ever complaining.

“You see, their schedules and priorities seemed so different than ours. After a couple of days, I began to notice things. We saw almost no begging in the city of Arusha. We noticed how the people took pride in their small homes, carefully sweeping the dirt in front of their doorways. We heard stories of how they take care of each other and their extended families. We learned from their farmers, their pastors, their teachers, and their healthcare workers. We marveled at how they creatively carry on despite a near-complete lack of resources. I found myself envying their peace, serenity, and generosity in the face of seemingly insurmountable challenges, even though I barely understood their culture.”

She furrowed her brow. “But weren’t you ever scared?”

I laughed. “Yes. Without a doubt, the scariest night was the first time we heard lions roaring a few hundred meters from our tent camp in the Serengeti. That was a little unnerving.”

She shuddered and went back to work.

Later, that same day I was still thinking about my colleague’s question. Suddenly, my pager went off and I responded to the Trauma Operating Room. A young woman had been slashed with a knife by someone she knew. The trauma surgeons had saved her life and had asked us to repair some of the damage. The multiple wounds were deep and long. It had been a serious attempt to kill her.

As she lay asleep on the operating table, I explored the injuries. Here was a wound that could just as easily have occurred as a result of a machete attack during the time of the Rwandan genocide, from a brutal assault in Darfur, as a result of the recent unrest in Kenya, during ethnic cleansing in the Balkans, as a reprisal for a killing in Iraq, or in any of a hundred troubled lands in the world. Our patient was different only in that she would survive.

Silently, I thought to myself, “Weren’t you scared? My God, there’s so much danger!” I am scared that we will never learn the lessons that are just as evident in our own towns and cities as they are half a world away. I am repentant that our position of privilege has yet to teach us how to discern ways that make everyone safer and more secure. Mostly, though, I am grateful to our new friends in Tanzania for helping me realize that each of us, me included, is called to make a real difference whenever and wherever we are able.

The following is feedback received for this blog:

Wonderful story. Blessed are the poor... Seems counter intuitive but when all of life's material distractions are removed, character and kindness are the most valuable currency.
- Val Jones
www.revolutionhealth.com/blogs/valjonesmd

I read Left to Tell; it was heart-breaking. I think the thought of what human beings are capable of inflicting on one another is scarier than anything.

If you ever have a chance to hear Imaculee Ilibagiza speak, try and attend; she has such an incredible aura about her...truly moving.

- T.
http://anesthesioboist.blogspot.com

Back in Tune

Tue, 27 May 2008 18:05:01 GMT

[Music] makes practically everyone fonder of life than he or she would be without it.”
-Kurt Vonnegut

Had I possessed any musical talent at all, my life probably would have gone in a different direction.

Not that my parents didn’t try to make me a musician. They transported me to piano lessons, percussion lessons and voice lessons. They bought me a guitar. They pushed me to work hard in the middle school orchestra and the high school choir. They encouraged me to sign up for ensembles and high school musicals. In retrospect, each opportunity enhanced my appreciation for music but none of them made me into a musician.

My new patient, a talented jazz artist, agreed that he has known lots of kids like me — eager but musically inept — during his decades-long teaching and playing career. Now that he had retired, he still enjoyed performing regularly with a remarkable local big band. Playing his horn was as natural to him as breathing. Music was still a big part of his life.

When he had developed throat cancer, I silently worried that whatever treatment we proposed would finish his playing days. Surgery would change the shape of the pharyngeal cavity. Radiation would cause severe dryness. I shared my concerns with him and he shook his head. “Do what you have to do,” he told me. “I’ll be OK.”

We decided on a course of treatment. It was not easy. His mouth was changed. Each visit showed that the tissues were healing, but it was a slow process.

After a few weeks, he asked, “When can I start playing again?”

“Go ahead and see what happens,” I replied. He smiled in a way that betrayed the fact that he had already been practicing.

At each visit, he would announce, “I can play! I need to drink more water, but my chops are returning!” Before long, he was back performing with his friends. Without actively thinking about the process, he had not only recovered from our treatment but had learned to compensate for his new physical challenges in ways that no one could ever have predicted.

As I sat in the audience one night, I realized that he was playing much better after all that we had thrown at him than I would ever have played even if I had spent a lifetime practicing. Everyone was happy.

Still, I will always try to imagine what it is like to pick up an instrument and improvise as effortlessly as some of my naturally gifted friends. I guess my parents were correct when they stopped pushing me to take music lessons and suggested that I pursue a different line of work.

The following is feedback received for this blog:

Somehow I would guess your musician friend/patient finds you "gifted". I never had the chance to learn a musical instrument as a youngster, but am trying now. Maybe someday, I'll feel like I can play in front of someone. Not yet.

- rl bates
http://rlbatesmd.blogspot.com/

Bruce, you actually played guitar quite well, as I remember, but as always, you remain modest. However, your deep compassion for people and the skills you have acquired and shared to enhance the quality of life for those in need is a rare and blessed gift.

- Sue

As someone who practices medicine but also has musical longings - I've been playing the oboe for just a year now - this post meant a great deal to me. Thank you for sharing your patient's story, courage, and gifts with us - and your own.

-T.
http://anesthesioboist.blogspot.com

Just for Fun: The Six-Word Memoir

Tue, 06 May 2008 09:08:09 GMT

Bloggers often issue challenges to each other. This week I was "tagged" by Suture for a Living. The challenge was to create a six-word memoir. The other challenge is to tag other unsuspecting bloggers to do the same.

The challenge brings to mind a “Six Word Story” contest. To me, the best example of that genre is Hemmingway’s “For sale. Baby shoes. Never used.”   Another favorite (I can't find the author right now) is: ""I'm sorry.' 'For what?' 'Never mind.'"

So, my six word memoir reflects a continuing tongue-in-cheek battle that often surfaces in my office conversations with patients. I say it so often that it is a theme in my practice. When confronted with a cancer survivor who continues to smoke, I sometimes grin and say:

“No problem. Smoking’s good for business.”

Hmmm. Now that I have written that, is "smoking's" one word or two?

Anyone else want to try? Submit your Six-Word Memoir by hitting the "Feedback" button below.

The following is feedback received for this blog:

Sing. Ease burdens. Pass it on.

learned these things from my parents, Richard and Virginia and I am so grateful.

Sing in happiness and sadness, proclaim the Word of God, lift spirits (including my own) of those wearied by what happens on the journey of life.

Ease burdens of the dying, brokenhearted, those who have lost hope.

Pass it on - things, poems, food, skills, peace, anything that makes the world a better place.

- Deborah Ruck

Chronic disease. Shaped me. Bonsai tree
- Annette

Learning

Wed, 14 May 2008 07:52:16 GMT

“When we honestly ask ourselves which persons in our lives mean the most to us, we often find that it is those who, instead of giving much advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a gentle and tender hand.”
-Henri Nouwen

I have learned so much from this patient.

I have learned that, in some people, cancer can be a chronic disease. This particular woman first developed cancer symptoms 50 years ago and she still carries some of the same malignant cells to this day.

I have learned that small acts of kindness readily distinguish a decent person from an exceptional one; a lesson re-learned each year at Valentine’s Day when she drops off a bag of chocolate kisses wrapped in small bits of cloth.

I have learned that hearing a patient tell the story of her journey with cancer enhances my understanding of how others might face similar challenges.

I have learned that facial scars can affect how people might view a patient but they don’t have to affect how the patient views herself.

I have learned that a person can remain in control of her health care and her life despite two dozen operations, multiple courses of radiation, a myriad of medical conditions, and a steady stream of hospital visits.

I have learned that a life filled with community volunteering, raising children, being a friend, and staying active can co-exist with chronic illness and cancer.

I have learned that there are people who, when I give them bad news, have the gift of always making me feel better.

And today, as she smiled and told me that she is making plans to be admitted to an in-patient hospice unit, I learned that the terms “patient” and “friend” are sometimes inseparable.

The following is feedback received for this blog:

(She) is my aunt. She IS an amazing woman, and this word is almost inadequate to describe her. Despite the occupation of her body by illness and cancer, she has continued to own her life, to move forward, to continue to LIVE. She is able somehow to see-and feel-the positive which most of us, given her lot, would have lost sight of long ago. She has been able to take in the best of living and also to give with the same fullness of heart. I am, and will remain, in constant awe of her spirit. I will always feel grateful and lucky that her life and mine have been connected for almost fifty years. I hope, and somehow know, that she will continue to find joy in her continuing journey.
- Rebecca

I am not sure how I found this blog but I did and I have read most of it. Although I have lymphoma I had a parotidectomy in Sept of 97. I had a wonderful doctor that has changed my life in so many ways. When I read you post *Learning* Its very true after being a long time patient there is friendship as well. Its amazing to me how I count on his opinion just as much as I do the rest of my doctors. But his friendship equally as much as well.

You wrote so beautifully about a patients scars. I also think how my doctor handle my care was perfect. Yes I have scars but I walked outta of his office...with a confidence to handle whatever came my way. I always felt that he helped me every step of the way to get here.

I agree others might view me differently be it the scars or the cancer. But your so right I don't view myself any differently. Didn't then and don't know.

I just wanted to say thanks for writing on what you see as a Person and as a Doctor.

Heres to life and living it to the fullest.

Hope
http://clubsammichcafe.spaces.live.com/

The Phantom

Wed, 26 Mar 2008 11:05:58 GMT

"[J]ust as despair can come to one another only from other human beings, hope, too, can be given to one only by other human beings.
-Elie Wiesel

When her doctor told her that there was “nothing anyone could do,” and that she should “go home and get her affairs in order,” her life had changed. At 43 with a young family and a lifetime ahead of her, she now faced her own death for the first time. Suddenly, a Phantom accompanied her constantly, and every remark and experience filtered through this new presence. When I met her two weeks later, she was already accepting her sentence as inevitable. She was expecting more devastating news.

Without recognizing the presence of the Phantom, I entered the exam room. I knew only her original diagnosis and some of the details of her recently completed treatment. After a difficult course of therapy for an early stage oropharyngeal cancer, a follow-up CT scan had shown some residual lymph nodes. I reviewed the next steps … a biopsy, a neck dissection, and a review of the pathology. “We have a good chance of curing your cancer with this,” I told her. She had never allowed herself to consider the possibility of cancer cure before.

Unexpected cancer control happens.

For years, I followed a young man whose enormous pharyngeal cancer had completely evaporated with radiation therapy. Later, I cared for a woman whose recurrent oral cavity cancer disappeared after three cycles of a second-line chemotherapy. You just never know.

As the appointment ended, she wept and rushed out to call her daughter. Until then, there had been a Phantom in the room with us, but we had only become aware of its presence once it had fled. Hope had been restored.

___

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

The following is feedback received for this blog:

You just never know indeed. That's why I try to leave my patients with hope every time I see them.

- David Loeb
http://doctordavidsblog.blogspot.com/

The Smoking Parent

Tue, 01 Apr 2008 13:32:07 GMT

“The person I miss most is the one I could have been.”
–G. B. Shaw

The little boy ran circles around his mother as she stood outside of the restaurant smoking a cigarette. The young woman and a friend were engaged in an animated discussion and the smoke rolled from their mouths and drifted past their faces. Suddenly, the toddler stopped running and squeezed his mother’s hand. Once her gaze had focused on him, he smiled broadly. She grinned back at him and he resumed running laps. She took a drag on her cigarette and resumed her conversation. I remember being charmed and disturbed by the interaction.

A few days later, I stood at the bedside with the family of a delightful woman in her mid-fifties. Her smoking-related cancer had required removal of her voice box and a course of radiation therapy. Months later, her cancer had recurred and all of her treatment options had now been exhausted. She was at peace, slipping in and out of wakefulness, very near to death.

The whole family had tried to prepare for this day and her adult children gathered in a semicircle around the bed. One of her boys sat dejectedly in a chair gripping her hand. As I watched, she slowly opened her eyes. He brightened visibly and wordlessly returned her gaze. She closed her eyes, but they both continued to smile. This, too, was a powerful yet disturbing moment.

I was struck that the two scenes were essentially from the same drama, with the second following inexorably from the first. Within a few days, I had witnessed two points along the same arc.

____

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

The following is feedback received for this blog:

Once again you have captured the moment (or two in this case) so very clearly.
- rl bates
http://rlbatesmd.blogspot.com/

Great post, Bruce! I wish all the parents I used to see in the ER, smoking as they brought in their wheezing children, would read it.... and see themselves. Before it's too late.

- David Loeb
http://doctordavidsblog.blogspot.com/

Serenity

Fri, 14 Mar 2008 09:55:30 GMT

“Why love if losing hurts so much? We love to know that we are not alone.” -CS Lewis

I held the photograph of her gingerly and was surprised how clearly the image evoked a sense of peace. Such tranquility could only have sprung naturally from a depth of character; in her presence, everyone had felt warmth and a sense of stillness. As her cancer returned, each time more aggressively, she worried, not for herself, but for her husband and daughters. Her tears at recurrence were as much for them as for herself.

Her eventual death was not a surprise. For the visitation, her family had assembled photos and keepsakes of their collective time together. I stopped in front of each of the images, gazing at the smiling woman who would later become my patient. Photographs with bent, fingered edges recorded moments in her life when she held children, celebrated holidays, vacationed, and stood proudly at graduations.

Among all of the souvenirs, this one image had captured me. She sits in three-quarter profile on a screen porch surrounded by summer foliage. Her scars are not visible from this angle. It appears that she had been writing but has paused for a moment to read what she has just written, pen in hand and notebook on her knees. A coffee cup and a pair of binoculars rest on a table beside her while sunlight filters through the slats of the railings. The viewer is invited to listen to the birds, gaze at the lake through the trees, smell the pine forest and the stained clapboards of the old cabin, feel the familiar roughness of the wicker furniture, and then slip quietly away, attempting not to disturb her in her moment of solitude. The photograph captures the most peaceful place on the planet.

As I looked at the image, her husband unwrapped the story that accompanied it. “That photo was taken at a cottage in Maine that we first visited on our honeymoon. We returned many times over the years. The cabin is on a hillside near the shoreline so you get the feeling that you are up in the tops of the trees as you sit on the porch; they even call it 'The Crow’s Nest.' She absolutely loved to sit there and read. One day, I went looking for her and there she was. Later, when I showed her the photo, she was surprised. She never even knew I that had been there. It was her favorite spot on Earth.”

We stood and admired the image for a few moments, and then I set the photo back down carefully and took a step backwards. Two-and-a-half years later, she would be gone, but, for that one moment, she had been returned to the place that most embodied peace, both for her and for those whose lives she had graced.

Empathy

Tue, 11 Mar 2008 09:15:12 GMT

“We know what we are, but know not what we may be.”
- Shakespeare

Many years ago, I knew a resident whose only focus was himself. He studied alone, consistently begged off of or ignored teaching assignments, interacted poorly with faculty members, and received poor marks from those with whom he worked. Observing him examine patients was painful — he appeared to be completely unversed in basic social skills. When he finished training, memory of him quickly evaporated. It was as though he had never been part of our lives.

What had he lacked? Many things, I suppose, but even he agreed that he lacked any sense of empathy.

Some empathy (“imaginative” or “cognitive” empathy) can be learned and it allows us to assume the roles of others to predict their thoughts and feelings. Other forms of empathy (“vicarious” or “gut reaction” empathy) represent the spontaneous visceral response to another’s emotions. Vicarious empathy cannot be learned but it can be lost.

A recent article documents the disturbing association of medical education with decreases in vicarious empathy. Groups of medical students were tested yearly for four years for their emotional responses to fictional situations. Findings included:

Students entered medical school with vicarious empathy scores similar to the general public.
Vicarious empathy decreased over the four years of medical school, especially during the first and third years.
Students who eventually chose to enter specialties that focus on patient continuity (family medicine, pediatrics, internal medicine, OB/Gyn, and psychiatry) scored better on the empathy scale than students who eventually chose other specialties.
Separate research has found that idealism and empathy drop during internship.

The authors encourage medical schools to celebrate positive professional traits and focus on providing mentors who “can aid students in overcoming losses in empathy.” Not a simple task.

Consider the process by which physicians are trained: How can students not be dramatically changed by what they experience? They are locked into competitive, cloistered, expensive, and demanding curricula, often far from friends and family. During the initial clinical years, students are expected to witness and rapidly process a steady onslaught of sickness, death, suffering, injustice, loss, uncertainty and pain. Teachers, who are themselves products of the system, may not have the skills or insight to help the students understand what is happening to the patients or to themselves.

Not surprisingly, medical students are aware that the very process into which they have entered is capable of transforming naïve, altruistic, emotionally fragile college students into hardened, egocentric, cold physicians; I suspect that they all too often observe the disturbing results but do not discern the process. As they progress through the system, they declare, “That won’t happen to me!” But, of course, it can. Albert Einstein defined "insanity" as “doing the same thing over and over and expecting different results.” Something has to change.

Medical training is evolving. Work rules are in place and curricula are under constant evaluation. Our school’s Medical Humanities program brings interested students into contact with the works of poets, artists, healers, philosophers, theologians, and writers, attempting to spark new insights and to nurture coping skills. Will we create Empathy in those who possess none? Of course not. But, will we nurture Empathy in those students with the gift and the desire? Since this new cohort of physicians will be the ones caring for my generation as we approach the end of our lives, I, for one, am pinning my hopes on it.

___
Ref: Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P, Is There Hardening of the Heart During Medical School? Academic Medicine (March) 2008; 83:244-249.

Smokin' Slippers

Tue, 04 Mar 2008 09:59:00 GMT

Dr. David’s Blog (created by a pediatric oncologist at Johns Hopkins) posted a very impressive pair of socks that the good doctor spotted on rounds a few days ago.

His post reminded me of a remarkable pair of slippers that I noticed several years ago on one of our patients. She was actually in the hospital undergoing surgical treatment for a large cancer of the floor of the mouth. And, no, neither the patient nor her slippers quit smoking.

The following is feedback received for this blog:

hose slippers are awesome! And your timing... remarkable. Just today, the owner of the socks I posted gave me 2 pair as a gift! There must be something in the air today...

- David Loeb
http://doctordavidsblog.blogspot.com/

“Listening to Leviticus”

Wed, 27 Feb 2008 14:28:42 GMT

I am truly fortunate today … I had an essay published in JAMA entitled “Listening to Leviticus,” in which I wrote about the emotional turmoil I went through in the process of caring for a wonderful patient with a large goiter who was a member of the Jehovah’s Witnesses. Long story short: Everything turns out fine.

As if that wasn’t great enough, the article was picked up by the New York Times Health Blog and has generated a number of comments. I usually receive two or three comments for each blog post; I’m not used to this much attention.

For those who are interested, I had another essay published in JAMA a few weeks ago entitled, “The Book.”

Thanks for reading these entries! I appreciate your comments and suggestions.

The following is feedback received for this blog:

Congratulations on your multiple publications in JAMA. The Leviticus one was very well written. You have inspired me to submit to them as well. Got any tips to share?

I will probably link to this post and the JAMA article in a upcoming Pallimed post.

- Christian Sinclair
www.pallimed.org

I have to say, the praise is well-deserved. I very much enjoy reading everything you write.

- Rob Lamberts
http://distractible.org

Congratulations!

Both stories are thought-provoking and very well written (as all your writings).

"The Book" really left me puzzled.

- Oystein Horgmo
http://sterileeye.com

Congratulations, Bruce, on your fine work. Reminds us that there is a very real human side to our interactions with our patients. Many of us feel as you do but don't have the gift of expressing it so eloquently. Please continue your writing!

- Thomas Kidder, M.D.

I really enjoyed reading your JAMA essay entitled "Listening to Leviticus." Great piece of work!

- Wook Lee

Unhappy

Wed, 27 Feb 2008 10:27:35 GMT

“Always write angry letters to your enemies. Never mail them.”
-James Fallows

“He should never have agreed to treatment! It was the worst thing he could ever have done! I can’t believe you doctors did this to him!”

My patient’s cousin, whom I had never met before, was very angry and I was her target. Unfortunately, she chose his funeral as her opportunity to unload on me.

At one level, it was hard to disagree with her. He had been a gentle, hardworking, and quiet man. I had actually met him on occasion before he had developed cancer since his profession brought him into the hospital on a regular basis. In his mid-40s, a large cancer had developed in the sinuses that extend between his eyes. Despite aggressive surgery and radiation, the cancer had recurred just a few months after its initial treatment. Chemotherapy had been unhelpful, and, in the weeks before he died, he had been miserable. His vision had deteriorated, his cancer had a penetrating, noticeable odor, and it had been very difficult to find a balance between pain control and over-sedation. He told me more than once that he was ready to go.

Still, the cousin’s diatribe had taken me by surprise. I tried to think of a response, but could not. “I’m so sorry,” I said. “He was a wonderful person.”

She glared at me and said nothing.

I thought to myself …Would we have done anything differently had we known ahead of time that his tumor would be so unresponsive? I was uncertain. By searching the medical literature, we can predict how groups of similar patients will do, but there are wide differences in individual outcomes. He might just as easily have sailed through treatment and had a complete response.

One of his sisters, whom I had known well throughout his ordeal, saw what was happening and stepped in just as the angry cousin stormed off.

“We know you did all you could. Thank you, Doctor.”

“I’m so sorry,” I repeated.

She, too, said nothing at first. Then, “We all will need some more time to heal.”

The following is feedback received for this blog:

Another great post from you. It is hard all around when things go like this. You were good to go to the funeral. I feel sure you did your best. It's tough (and often hard to accept) when that is not good enough.

- rl bates
http://rlbatesmd.blogspot.com/

The Pediatrician’s Office

Tue, 12 Feb 2008 10:27:19 GMT

“Take care of all of your memories. For you cannot relive them.”
- Bob Dylan

For a 1958 Saturday Evening Post cover, Norman Rockwell created a painting of a young boy standing on a chair and facing the wall in the doctor’s office. The boy stares at the large diploma directly in front of him, his hands securely holding onto his unbuckled pants. While he waits, the distinguished, white-smocked doctor, working across the room, unhurriedly prepares an injection. The image, “The Doctor’s Office,” brings back vivid memories for me.

I grew up in the 1960’s. I can recall the tinge of anxiety as I held my mother’s hand in the lobby of the Medical Arts Building. I can remember anticipating the jolts as the operator clanked the internal metal cage shut before the elevator lurched into action. I can see the heavy dark varnish covering all of the woodwork in the corridors and hear the rattle of the frosted glass-paneled doors as they opened and closed down the hallway. I can smell the mercurochrome, taste the thermometer that had been soaked in disinfectant, feel the cotton ball soaked with alcohol on my arm, and taste the sugar cube impregnated with the polio vaccine. I can hear the crinkling paper sheet under my legs and feel my legs swinging as I sat waiting forever for the doctor to come into our room.

Mostly I remember the doctor exploding into the room, greeting my mother, and telling me how big I was getting. He smelled of cigarette smoke in a time when that was just fine. His stethoscope was cold but his hands were large and warm as he moved through the exam, felt my belly, checked my reflexes, and tousled my hair. I remember the relief if the doctor grinned at me and announced, “No shot today, Sonny Boy!”

Years later, I learned that my pediatrician had been on an academic faculty earlier in his career, publishing papers on the effects of war on children and authoring a book on normal pediatric growth and development. But as I was growing up, he was the unhurried, reassuring man in the white smock with the booming voice and ready smile who worked in a building with a really cool elevator.

The following is feedback received for this blog:

Hi! Loved your last Reflections. Do you know that Dr. [XXX] was your first pediatrician? He was awful. I was doing everything wrong; He bawled me out!

[My friend] got the same treatment. She brought little Mike in and when Dr. XXX stepped out for something, Mike asked "Has he gone to get a gun?" You can see why I switched pediatricians!

Keep Reflections coming!

Love, Mom

Dear Mom,
Thanks!
Love, Bruce

Rounds Together

Wed, 06 Feb 2008 08:54:22 GMT

“It is a wise father that knows his own child.”
-Shakespeare

Once upon a time, many years ago, my family was visiting for the holidays. On several occasions, I had tried, with only intermittent success, to explain to my father what I did for a living. On this day, I casually invited him to make rounds with me; he readily agreed.

When we got to the hospital, we headed to the inpatient floor. One of the patients that day was Mr. Johnson, a young man who had undergone cancer surgery to remove part of his cheekbone the day before. He had done well overnight and was recovering. I stuck my head into his room.

“Merry Christmas!” I said. “I have my father with me this morning to make rounds. He is not a doctor but he would like to meet you. Do you mind if he comes in with me?”

“That would be fine,” Mr. Johnson responded.

I returned to the hallway and retrieved my father. We entered and stood by the bed. If my father was surprised by my patient’s early post-operative appearance, he did not let on.

“Good morning, Mr. Johnson! How are you doing today?”

Despite his obvious swelling, Mr. Johnson replied, “I’m doing very well, thanks.” The young man was lying in bed with his one eye nearly shut and his cheek full of packing material. His fresh facial wounds were still healing and his skin graft donor site on his leg was tender. As I checked his surgical sites and looked at the chart, the patient spent a few minutes addressing my father and describing his initial symptoms, his treatment, and his recovery. My dad, a distinguished looking gentleman with graying temples, stood and listened, intermittently nodding and smiling, all the while absorbing the story.

“How long do you think I will be in the hospital?” asked my patient. My dad glanced at me.

“I think you are doing great,” I said. “I predict you will be home the day after tomorrow.”

“Thanks again, Doc. I’ll let my family know.”

Over the subsequent years, I didn’t remember many details of the visit, but my father certainly did. Several times during the remainder of his life, my dad reminded me about that day and inquired about the patients he had met. Those few minutes had given him insight into my life that I could never have provided by just telling him what I do.

Many years later, I received a Christmas card from Mr. Johnson, marking the anniversary of his hospitalization. “I remember you even came to see me on Christmas Day with your Dad. I will never forget that,” he wrote.

As I read the card, I was surprised how that brief encounter many years before had clearly impacted both my father and the patient. The shared experience of illness had affected both of them, sharpening their senses. Later, when I responded to Mr. Johnson’s card, I realized that I was grateful not only to have cared for the patient, but that I was particularly grateful to have shared that moment of insight, healing, and presence both with Mr. Johnson and with my father. It was a holiday gift I will always remember.

The following is feedback received for this blog:

This is one of my favorite posts of yours. Incredibly touching. Reminds me of how my mom used to send my surgeon a Christmas card each year, to let him know how I was progressing (he saved my life as an infant). And each year he'd write back a hand written card. Those little human touches mean a lot.

- Val Jones
www.revolutionhealth.com/blogs/valjonesmd

I love this one.
- selim firat

What a great post! I've had moments like these, and it never ceases to amaze me how much impact we have on the lives of our patients, and how things that seem so little to us can mean so much. And, conversely, how much of an impact our patients have on us.

- David Loeb
http://doctordavidsblog.blogspot.com/

Being Intentional

Tue, 15 Jan 2008 12:09:10 GMT

“The possible solutions to a given problem emerge as the leaves of a tree, each node representing a point of deliberation and decision.“
-Niklaus Wirth

His treatment had gone well and the large mass in his neck had completely receded during six weeks of radiation therapy. Now, I had recommended a CT scan to make certain that his cancerous lymph nodes had completely disappeared. I was surprised by his initial response.

“No way, Doctor! I don’t want a CT scan!”

“Really?” I asked. “Why?”

“I heard that CT scans CAUSE cancer. I don’t want one!”

Indeed, he had heard news reports of a study in The New England Journal of Medicine highlighting the explosive growth in CT usage and warning that the radiation exposure might have real, long term consequences. Over 60 million CT scans were done in the United States in 2006, up from 3 million in 1980. Although no long term studies of people undergoing CT scans have been done, atomic blast survivors and atomic industry workers who were exposed to similar dosages of radiation have an increased risk of cancer, and the younger the age of exposure, the greater the risk. The authors estimate that up to 2 percent of cancers might be caused by CT scans.

Having a patient refuse a CT scan was a new experience for me; usually, I am the one telling patients that they do not need a scan that they want. Unlike scheduled mammograms for breast cancer survivors, no studies have ever shown a benefit of routine CT scans for survivors of head and neck cancer. The financial costs, as well as the emotional toll chasing down inconsequential or equivocal findings, can be enormous. Adding to the confusion, some physicians now skip the “routine CT” and go right to the much more expensive PET/CT scans.

On the other hand, the studies DO occasionally identify findings that respond to early intervention; for example, the images of the neck CT scan might pick up a new cancer or non-symptomatic lung nodule. Not frequently, mind you.

After assuring my patient that, in his particular situation, the benefits of potentially identifying residual cancer outweighed the cancer risk from an additional scan, he decided to go ahead with the study. A few days later, we called to tell him that the scan looked great.

Follow-up testing for cancer survivors can pose real dilemmas. Patients and families crave good news, and, for some, that requires more certainty than I can provide with a physical examination. My patient who was worried about the risks of CT scans reminded me that each test requires thought and each result requires a deliberate reaction.

____

Ref: Brenner DJ, Hall EJ, Computed Tomography – An Increasing Source of Radiation Exposure, New Engl J Med 2007 (Nov 29); 357:2277-2284.

The following is feedback received for this blog:

Good post. I wondered how you and other cancer docs were having to deal with this.

- rlbates
http://rlbatesmd.blogspot.com/

I was just discussing this with a friend, who also happens to be my mom's oncologist. For us, the benefits outweigh the risks...as her latest followup CT found a cancer in her ureter. Part of the risk of being HNPCC+.

- angela marie

So Lucky

Wed, 30 Jan 2008 09:26:49 GMT

"Mishaps are like knives that either serve us or cut us, as we grasp them by the blade or the handle."
-James Russell Lowell

He looks sad, like the world weighs heavily on his shoulders. I mistakenly think I understand why.
“You look very down today. Am I right?”

“Yes. It has been rough lately. I have been going to the counselor and am making some progress.”

Before we first met two years ago, he had already been through a very difficult course of cancer treatment. Months of chemotherapy had been followed by a rocky course of radiation therapy. First, he had lost his hair then he lost his sense of taste, his saliva, and his desire to eat. Because his cancer had persisted despite his treatment, he had seen me for surgery. Now, two years later, he remains cancer free, yet the scars persist on both sides of his neck, he has little sense of taste, and he is fighting depression.

“Tell me about your days,” I ask.

“My family tries to get me to go out, but I spend most of the day in bed or sitting in a chair. I can’t seem to get motivated.”

“You went through a lot with your cancer treatment,” I mention, restating the obvious. “It was a difficult experience for you.” Then comes the surprise.

“That’s just it!” he exclaims. “I was so fortunate!”

I look at him.

“Right now, my cousin, who has always been really healthy and who was my rock throughout treatment, is sick. I don’t know what to say to him. I don’t know how to help him. I feel like I was so lucky and just breezed through treatment. I don’t deserve to be doing so well.”

I am startled and think back to how terribly sick he was in the days when he was just recovering from his therapy. “You don’t know what to say to him? What did people say to you when you were hurting?”

“Oh, a few were helpful just by staying with me and keeping me company. I got some cards. A few people said some really stupid things. Most people just stayed away from me. Some still avoid me, I think.”

He pauses.

“I think I am avoiding my cousin.” He pauses again. “That’s what I feel like I am doing.” He looks at the floor. “I feel so guilty. I don’t know what to say to him because I was I so lucky and he is sick.”

I sit and listen. It is clear that he has somehow found a way to blot out at least some of the memories of his very difficult treatment. Nevertheless, the scars, both internal and external, are still fresh. What are the real issues? Insight and healing are still a long ways off.

“I think I will go and visit my cousin this afternoon,” he decides. We talk for a few minutes and he rises to go to see the psycho-oncologist. He smiles briefly then I watch as he heads down the corridor to his other appointment.

The following is feedback received for this blog:

You manage tell a lot with only a few words!

This is another one of those great posts which instantly sucks the reader into the moment you describe.

- SterileEye
http://sterileeye.com/

Engaging with Patients: The Writing of David Watts, MD

Wed, 02 May 2007 09:13:21 GMT

David Watts, MD is an eloquent physician-writer and poet who illuminates the joys and trials of Medicine. His recent book, Bedside Manners: One Doctor’s Reflections on the Oddly Intimate Encounters between Patient and Healer, includes stories that reveal his insight, imperfections, humor and compassion. The essays capitalize on his special gift to describe encounters with the elderly and the disenfranchised.

There is particular power in his story entitled “Evening in the Two Worlds.” An older gentleman is learning for the first time that he has widespread cancer. Dr. Watts does not pre-plan the speech with which he will break the bad news. He depends on his relationship with the man to guide the encounter. He writes:

My words will not form until they are spoken, reading the twitch of his face, the subtle motions of head and trunk, the silent conversation that will tell me how to deliver the news.

I am as good at this as anyone, and as bad. This conversation, like a blossoming, moved so slowly as to be imperceptible. Yet when remembered, remembered as lightning speed.

After he finishes the discussion, he reflects on the power of his words and the need to maintain hope:

The moment will tolerate only truth, but that truth has to contain promise. It’s about words, words and the weight they carry.

Dr. Watts’ example rings true with those of us who have the privilege of trying to use mere words to clearly, respectfully and compassionately tell a fellow human being that he or she has cancer.

The words we share can sting with their message and their power. Compassion and presence remain our overriding responsibility, and, at the final stages of disease might well be the best gift we can offer.

The following is feedback received for this blog:

We have always respected the power of words. Doctors must especially be aware of what and how they say things. Dr. Watts has proven to be sensitive to this need.

- Joyce Harvey

Don't Tell

Wed, 23 Jan 2008 12:31:12 GMT

“Always tell the truth. That way, you don't have to remember what you said.”
-Mark Twain

“She must not know she has cancer! Do not tell her!”

“I must tell her,” I respond. “How can we treat her cancer if she doesn’t know what she has?”

“Others in our family have had cancer and they died! It will cause her too much stress to hear that she has it, too. Tell her she has some sort of infection.” The son pauses. “Doctor, in our culture, the family makes the decisions in matters like this. We are only trying to protect our loved one. You must respect our values.”

I realize I am a Western-trained physician trying to negotiate my way with this non-Western family. How will we obtain informed consent? What about privacy regulations? Who will speak for the family? Does the patient truly want to assign this responsibility?

Until about 30 years ago, non-disclosure was the norm in our own society. When little could be done to change the course of many cancers, the paternalism of the times often led physicians to hide the diagnosis and prognosis from their patients.

Now, however, over 60 percent of newly diagnosed cancers will be cured. Many of these survivors will have gone through rigorous radiation regimens, extensive surgery, and side-effect-laden chemotherapy. How can we not honestly tell patients what to expect or why they can expect their hair to grow back when treatment is completed?

There is no one right answer. On a practical level, a recent article provides some guidelines for dealing with a family that insists on non-disclosure:

Do not overreact. Take a deep breath and avoid becoming emotional.
Attempt to understand the family’s viewpoint.
Be flexible. Work with the family on dealing with practical issues.
Respond empathically to the family’s distress. Remain open to the patient and the family.
Talk to the family about what the patient would want.
State your views as your views. Don’t be dogmatic.
Propose a negotiated approach.
Talk with the patient about his or her own desire for information.

Of course, not every person in a particular culture will feel the same way about relinquishing their care to the family. The physician also has to keep in mind that, in some cases, deference to a family’s request might actually lead to harm, inadequate care, or gross violations of Western autonomy-based ethics.

These situations make me sit up and pay attention because of the added stress of keeping everyone properly informed. Inevitably, there are miscues, but, if the relationships are established early, things can move forward. Whatever the family and I decide, I realize that each step of the process will be “interesting.” I am going to learn a lot.

___
Ref: Hallenbeck J, Arnold R, A Request for Nondisclosure: Don’t Tell Mother, Journal of Clinical Oncology 2007 (Nov 1); 25:5030-5034.

Ref: Macklin R, Ethical relativism in a multicultural society, Kennedy Institute of Ethics Journal 1998 (March); 8:1-22. (Excerpted in Biomedical Ethics. Mappes TA and DeGrazia D, eds. McGraw-Hill, NY, 6th ed. 2006. pp. 118-127.)

The Three Tasks of a Physician

Wed, 09 Jan 2008 11:18:52 GMT

“You don’t build a bond without being present.”
- James Earl Jones

“Will you follow me even after my cancer surgery?” the patient begs. I will continue to see you for as long as you are willing to return, I respond.

“Can we call you when we have questions?” the daughter asks. Of course, I answer.

“Why did she get cancer? What can we expect?” the husband wants to know. Soon, we are deep into a difficult discussion.

Tough questions keep physicians of every specialty busy. In order to evaluate and treat diseases, the demands of 21st century medicine require staying current with piles of journals and innumerable research studies. Office and hospital time is filled with performing procedures, prescribing medications, and administering treatments. The “softer” side of medicine — taking time to talk, provide explanations, and offer hope — takes a backseat whenever we view our main mission as providing intricate treatments for complex diseases. We all just get pulled along in the maelstrom.

In an earlier time, Lewis Thomas, MD — gifted physician, researcher, administrator, and essayist — described the primary tasks of a physician like this:

“First of all, the physician was expected to walk in and take over; he became responsible for the outcome whether he could affect it or not. Second, it was assumed that he would stand by, on call, until it was over. Third, and this was probably the most important of his duties, he would explain what had happened and what was likely to happen.”

How were physicians equipped to accomplish these tasks? Dr. Thomas amplified:

“The first two [taking over and standing by] needed a mixture of intense curiosity about people in general and an inborn capacity for affection, hard to come by but indispensible for a good doctor. The third, the art of prediction, needed education and was the sole contribution of the medical school.”

Thomas’s description comes from medicine at the time of his father’s medical school graduation — 1911. Thomas found medicine to be much the same when he started medical school in 1933.

Being accountable, being present, and making honest, informed predictions on behalf of our patients is never easy. Interestingly, despite the revolution in health care and explosion of information, these three tasks remain vital components of our profession. Things, it seems, haven’t changed all that much.

The following is feedback received for this blog:

Informed and to the point. Great post!

This article from NY Times adresses the value of emotional support from doctors:
http://www.nytimes.com/2008/01/08/health/08seco.html?ref=health

- sterileeye
http://sterileeye.com

Thanks for such an insightful post. I think the part about being there to explain and predict what happens is very critical to building trust with patients. In addition to this, knowing when to say, "I don't know" is a important way to build trust even though it somewhat violates the first rule, because then others know that despite seeming to have all the answers, you are smart enough to know when you don't have all the answers.

- Christian Sinclair
www.pallimed.org

A Suspicious Case

Thu, 03 Jan 2008 17:28:59 GMT

“Nothing is insignificant.”
-Samuel Taylor Coleridge

Winter reminds me of an incident from my internship …

I was six months out of medical school and on-call at a local hospital. One evening, I was called to the Emergency Room to evaluate a 3-year-old boy with a bruise on his forehead. Through her tears, his mother told me what had happened. The toddler had gotten cold playing outside in the snow and his mother had filled the bathtub with water intending to warm him up. When she wasn’t looking, he had tried to climb into the bath on his own, slipping as he did so and banging his head on the side of the tub. Although the boy was now playing happily with a toy, the mother was clearly upset. She sobbed as I took the boy’s history.

“Tell me what he did after he fell,” I asked.

“He started crying immediately! He was so upset! Is he going to be OK?”

“I’m sure he will be fine. Has he been healthy?”

“He has been very healthy, just clumsy. He falls a lot.”

I looked him over and, indeed, he seemed fine except for a small bruise on his forehead and a couple of scars. No other obvious injuries. “I’ll be back in a minute,” I said and slipped out to look at his old records.

I was surprised by what I saw in his old chart. This was his sixth visit to the Emergency Room over the past few months. Each trip had been for a traumatic injury of some sort: a bruised arm, a burn, a possible concussion, a fall, etc. His X-ray jacket contained at least four sets of skull films plus studies of a leg and his wrists. I was just starting out in my career, but it still seemed like a lot of injuries for someone so young.

I went back to the Emergency Room. “I need to talk to my attending,” I told her, “but I would like to have him admitted to the hospital overnight as a precaution.” The mother reluctantly agreed. A few minutes later, the toddler was settled into a bed on the pediatric ward.

I had other duties to complete overnight, but spent some time thinking about the little boy. Was I right to be concerned about a 3-year-old with multiple trips to the ER for trauma? Was he just clumsy, or was he being abused? I placed a consult and asked the hospital Social Service department to send someone by to evaluate his situation.

The next day, after being up all night, I was walking through the pediatric ward. As I looked in on the toddler, his mother immediately rose from her chair and walked directly toward me, glowering.

“You think I have been abusing my boy!” she hissed.

I was taken aback. “I didn’t know what to think, Ma’am,” I replied. “He has made a lot of visits to the ER this year, and I was just being careful.”

“The social worker came by and is having Protective Services come to my house! They are going to see if I am a fit mother!” She nearly spat in my face, she was so angry. “How could you accuse me of such a thing?”

“I’m sorry, Ma’am,” I mumbled, escaping as quickly as possible.

I still remember how I felt as she confronted me: I was tired, overwhelmed, and confused. I also remember feeling that I had done the right thing by admitting the child for a safety evaluation, trying not to take any chances and looking for patterns of injury that might indicate abuse. On the other hand, had I done the family a disservice if the child was clumsy or had a subclinical neurological disorder? What if the mother was merely incapable of discerning real emergencies from supposed ones?

Even now, years later, that uncomfortable confrontation still disturbs me. I never did learn what the investigation uncovered. Most of all, I hope that the little boy, who by now would be in his late 20s, survived his childhood intact.

The following is feedback received for this blog:

No child is that "clumsy" - instead of labeling my child as clumsy, I would wonder why he is falling so much at the age of three.

If he had a subclinical neuro disorder, the hospital was the place to be. If he was being abused, social service was the right one to call.

I hope the child grew up healthy and happy, but don't second guess yourself for one minute on this one.

You did the right thing; in fact, for someone so early in training, it was a great pick-up!

- Kim McAllister
http://www.emergiblog.com

Dear Kim,

Thanks for the feedback and for the reassurance. It would have been helpful to get some feedback at the time from the pediatrician or social worker.

It is funny how those formative experiences (especially the negative ones) stick with you for a long time. I spent high school and college summers and vacations as a nursing assistant ("orderly" in those days) in an ER and I probably remember more of those stories than from the last 10 years. They had an impact.

Thanks again. I enjoy your writing (and your images) very much. Keep up the good work!

-Bruce

You absolutely did the right thing. The fact that the mom was so vicious, and purposefully sought you out to shame you for asking for a social work consult, suggests to me that she is exactly the kind of person who could abuse a child. If you're still feeling the effects all these years later... I bet she was guilty. An innocent mom might have said, "Hey, I appreciate your concern for my child and I don't blame you for being surprised by all these recent falls. I'm happy to have someone come to my house - maybe they can help me figure out why he keeps falling?" You may have helped to get that child on a completely different path and maybe even saved his life. We physicians must learn to move beyond our comfort zones and investigate events that don't seem right - how many children remain in dangerous situations because their provider is passive or apathetic? ;)

- Val Jones
www.revolutionhealth.com/blogs/valjonesmd

Silent Night

Fri, 21 Dec 2007 10:29:14 GMT

Sometimes one creates a dynamic impression by saying something, and sometimes one creates as significant an impression by remaining silent.
-Dalai Lama

Once each year, she gets dressed up and goes to her annual follow-up clinic appointment. She has been cancer free for a long time, but she indicates that still enjoys these visits, especially the part when the surgeon tells her that everything looks great.

“How are you doing?” he asks her. “You look beautiful, as always! A vision of loveliness … that’s what you are!”

She smiles demurely and flutters her fingers at him, attempting to deflect the compliment just a little. She is 81, and she has been listening to his banter for a long time.

“Have you noticed anything that worries you?” She smiles again and shakes her head. Nothing new. She looks at him happily. She knows that “nothing new” is good news.

He runs through the physical exam. No new masses or ulcers. The tongue is soft. The pharynx is well-healed and open. The neck has no enlarged lymph nodes and the scars are all stable. The stoma — the opening where her windpipe is sewn directly to the lower neck skin — is open and clean. No changes since the last visit. He jots down a few notes.

“Tell me how you are doing,” he says. “Any trips? Has your family been up from the South for a visit?”

She gestures and tries to coax out some words. As always, he can only pick up a fraction of what she is trying to say. “Did you bring your electrolarynx today?” She shrugs and smiles sheepishly. She never brings along her speech device; the batteries likely died years ago. She digs in her purse for a pencil stub and a small spiral notebook.

She concentrates as she writes out her responses in large capital letters. Writing has been her only means of communicating since her voice box was removed. It has now been 24 years since she has spoken a word out loud to anyone. Over the intervening years, the hospital where the surgery was performed has closed. Many of her original caregivers are dead. Yet, here she is: silent and unchanged.

What if she had presented today instead of two decades ago? He skims her old, faded records and shakes his head. He knows that, today, her treatment would likely not include surgery at all. A few years after her voice box had already been removed, a large, randomized clinical trial demonstrated that treatment with chemotherapy and radiation was just as likely to cure larynx cancer as was the type of surgery she had undergone. Her physicians, acting on the best information available at the time, had removed her voice box.

She continues to write him notes on the lined paper. Despite his offers, she has refused other opportunities for restoring voice (“No more surgery! I'm not interested!"). She writes about spending time with family. She tells the surgeon she looks forward to the yearly visits. He tells her that he looks forward to seeing her, as well.

They finish their time together and she gestures toward her notebook where she has written in large block letters, “MERRY CHRISTMAS!”

“Have a wonderful year,” he tells her. She shakes his hand, smiles, and gestures enthusiastically. Then she slips on her coat and moves down the hall, silently disappearing around the corner.

The following is feedback received for this blog:

She sounds like a wonderful lady. I bet her doctor and his staff look forward to seeing her too. I know I would.

Timing is everything (much anyway). Yes, if medical therapy had been a little more advanced when she was diagnosised, etc. But she is happy (or seems so from you post). I sometimes have to remind myself and patients not to judge treatment from 20 years ago by today's standards. We knew what we knew, and we did the best we could.
- rl bates
http://rlbatesmd.blogspot.com/

Inside Out

Thu, 13 Dec 2007 11:53:38 GMT

“Life must be understood backwards; but ... it must be lived forward.”
-Soren Kierkegaard

He bumps the door open with his right hip and enters the operating room, water still dripping from his elbows. Toweling off his arms, he visually surveys the patient, the equipment, and the instruments. He is helped into his gown and gloves, and, while he waits for the rest of the team to get ready, he checks the lab reports and the CT scans one more time. The sounds in the room — the hum, the beeps, the ventilator, the chatter — are all familiar and correct. The patient has been positioned and the skin has been prepped. Everyone appears relaxed and ready.

The surgeon pauses and glances at a stack of papers on the table next to the door — one of the residents has evidently taken copious notes from textbooks about the type of surgical procedure they are going to perform today, creating a list of steps from incision to closure. The surgeon sets down the notes and steps to the operating table.

The sterile barriers are placed. The anesthesiologist adjusts the IV, re-checks the monitors, and clamps the drapes to poles. The nurse and the OR technologist pull the tables, stands, and trays into position. The cautery and suction are connected.

The residents and a medical student join him around the operating table. As he marks out the proposed incision, he assumes the familiar stance he will hold for the next two hours. He places his hand on the patent’s neck and assesses the enlarged masses below the surface.

"Here," he instructs the trainees. "Feel the tumors and how they sit below the muscles. Can you appreciate how they move in relationship with the other tissues?"

The trainees palpate the growths and nod. The surgeon remembers his own time as a resident. How he had loved learning all about this procedure! At the time, he, too, had carefully summarized and underlined all of the surgical descriptions he could find and had memorized step-by-step how-to lists. Later, he had carefully crafted his own description of the operation from start-to-finish, planning to use his notes as a set of imperatives to carry him safely through these intricate procedures when he was in practice on his own.

Now, he takes his turn palpating the neck. In his mind, the neck skin below his fingers has become translucent and all of the muscles, arteries, veins, nerves, bones, viscera, and the lymph nodes come into focus. He imagines how the structures are intertwining with each other and with the invasive tumors. As he stares at the neck, he visualizes how the dissection will look when the tumors have been removed and all of the structures explored.

At this point in his career, instead of working through the operation from beginning to end, he imagines the outcome first, realizing that there are hundreds of potential ways to achieve the final goal. Over the next two hours, he will attempt to discern the most efficient, safe, and effective route, all the while avoiding pitfalls, taking advantage of circumstances, and recalling prior experiences. He will dissect the diseased tissues, working from known to unknown, until the surgical field looks like the one he had visualized before the incision was made. The challenge remains thrilling and the anatomy remains elegant.

He releases his focus on the neck and the sounds in the room again reach his ears. The team is poised.

"Ready?" He has seen the final outcome. "Let's begin."

The following is feedback received for this blog:

Very nice.

- rl bates
http://rlbatesmd.blogspot.com/

Dr. Campbell -- Your latest post is a real gem. I've been thinking about it ever since reading it. It has applications in so many things that we do. I coach a men's sports team. I'm a big believer in envisioning exercises. Yet, envisioning is nothing without the repetition that we do at practice to hardwire actions. And, I'm a parent and your post had me thinking about that as well.

- Chris

Beautifully written, Bruce.

- Paul Levy
www.runningahospital.blogspot.com

This was truly a compelling read!

- sterileeye
http://sterileeye.com

Too Much Information

Tue, 04 Dec 2007 13:45:51 GMT

“You must trust and believe in people or life becomes impossible. “
-Anton Chekhov

“No, Doctor, I don’t have any questions. What do you recommend? I’ll do whatever you tell me to do.” She looked past me and smiled resignedly. Her adult daughter sat with pen hovering over a spiral-bound pad already overflowing with notes and questions. “When will you get started?”

This was a difficult case with no clear-cut treatment plan. She had an extensive cancer of the jaw. In younger, healthier individuals, this stage of disease is often treated with a complicated surgery, an intricate reconstruction, and then a combination of radiation and chemotherapy. Yet, at 77, she was not robust. My gut told me that she was a poor candidate for either the long surgery or a prolonged treatment course.

Recommending the standard treatment was, it seemed, out of the question — she would never get through it. On the other hand, recommending less intense treatment, although still very challenging, carried lower prospects of ultimate cancer control.

I tried to get her to react to the options. No luck. “I’m not certain, Doctor. What do you think?”

A recent journal article studied cancer-related decision-making and desire for prognostic information in older adults. A study of 73 recently diagnosed adults with colorectal cancer between 70 years old and 89 years old found that only 30 percent of women and 56 percent of men wanted information on their expected survival times. Over half of the patients adopted a "passive" role in treatment decisions; that is, they agreed with either “I prefer that my doctor make the final decision about treatment, but seriously consider my opinion,” or “I prefer to leave all decisions regarding treatment to my doctor.” A quarter of the patients adopted a "collaborative" decision-making posture and a quarter wanted to be "active" decision-makers. Physicians were not consistently able to predict their patients’ decision-making preferences.

This high proportion of passive decision-makers differs between age groups and cancer sites. The paper’s authors point out that cohorts of younger patients and patients with breast cancer have much higher proportions of “collaborative” decision-makers. They remind us to be sensitive to potential differences in the decision-making preferences in our older patients.

In the end, my patient opted for a compromise of a less extensive surgery and post-operative radiation therapy. Although it was, I felt, the best available option, it was a treatment plan that she never questioned. She just let it happen.

Ref: Eiken EB, et al., Desire for Information and Involvement in Treatment Decisions: Elderly Cancer Patients’ Preferences and Their Physicians’ Perceptions, Journal of Clinical Oncology 2007; 25:5275-5280

The following is feedback received for this blog:

I know I like it when patient's "work" with me in making the choices. Yet it must be overwhelming at times from the patient's point of view. I have often tried to imagine what it would be like, how can we not when patient's ask us what we would do in their place. But I truly hope I never have to find out.

- rl bates
http://rlbatesmd.blogspot.com/

What's My Line?

Tue, 27 Nov 2007 13:20:29 GMT

“A man's most open actions have a secret side to them.”
-Joseph Conrad

He was bright, friendly, and gregarious ... and had a hole in his neck. My new patient had undergone a laryngectomy elsewhere and had just moved to town. He needed a doctor to follow him.

“I would be happy to help,” I said. “Tell me about your treatment.”

“My surgery was last October. They took out my voice box. The doctor said they got all of the cancer out and there wasn’t any sign of spread. I didn’t need any radiation treatments. I feel back to normal, except for my mechanical voice.”

“You look great! Tell me where you had your surgery and I will ask the hospital to forward your records.”

“I can’t remember the doctor’s name." He shrugged and smiled. "I have it at home. I’ll bring it next time.”

And so it went for a number of visits. He would show up each time dressed in a great looking leather coat, shake my hand warmly, and sit and talk. Each time he would slap his knee, shake his head, and tell me that, once again, he had forgotten to bring the contact information for the doctor or the hospital where his treatment had been done. “Next time,” he promised at each visit.

One day, after a couple of years, he missed his visit. His girlfriend called. She was distraught.

“He can’t come in! They just arrested him! Oh, I’m so worried about him!”

Over the next several months, we followed his saga — first the arrest, then the trial, then the conviction. It turns out my gregarious, delightful, well-dressed cancer survivor was also a major drug distributor. The government took all of his assets, including, presumably, all those nice leather coats.

Now, I finally thought I understood why he had persistent memory loss about where his cancer treatment had been completed.

At the prison system’s request, I forwarded his medical information with suggestions on how to continue his cancer surveillance.

I usually see long-term survivors yearly. When will this man have his next follow-up appointment? Well, in about 15 years …10 with good behavior.

The following is feedback received for this blog:

Another great story!
- rl bates
http://rlbatesmd.blogspot.com/

The following is feedback received for this blog:
	My wife called me today to tell me about the passing of Dr. Mark Adams. My wife heard it from her mother who was seeing her primary care physician who new of Dr. Adam's reputation. Dr. Adams was one of the many fine physicians and surgeons who has touched my family's life as I was a kidney transplant recipient in 2000 at Froedtert. Although Dr. Adams did not perform my transplant my wife and I saw Dr. Adams for subsequent post-transplant visits and he was always direct and to the point with us which we always appreciated. You could just tell he was a great surgeon and human being by how he treated you as a person and as a patient, with respect. - Mike Dahlke ----------
	I had a KP transplant on Oct 23, 1998 after living with diabetes for over 37 years. I had the typical post-operative lab visits but had not seen Dr. Adams in the clinic for over 5 years. I did run into him a few times around the hospital and at the transplant picnic and he had the ability to remember me and the details of my condition. I'm sure he did the same with all of his patients, which had to number in the thousands. Aside from being a top notch surgeon and instructor, he made me feel like a friend. The compassion that he showed for his clientele and his craft will be genuinely missed. - Daryl Manka ---------- Dr Adams gave me my life back more than once in my 38 years ofliving. After receiving my kidney transplant in January of 2005 ( which heperformed) I had some internal bleeding and Dr Adams fixed the bleeding and I believe saved my life. I will always remember joking around with him at my post operative visits. He was a very talented surgeon. - Erin Decker ---------- Dr Adams performed my first and then second Kidney transplant in 1984 when I was only 16. I started out being afraid until I met Dr Adams. I can't really explain it, but he just had a way that projected everything would be ok and that I could rely on him. I've known and read about all the accomplishments and accolades he's received over the years and they are a testament to the passion and dedication that dwelled inside him. I have to add that in addition, it's mind boggling to know the numerous lives that are also changed and have been affected to this day because of him. I could hardly believe the news of his passing. I'm still in shock. What has always stayed ingrained in me about Dr. Adams is the way he pin pointed the exact thing that needed to be pin pointed. He just had a knowing, always, on how to solve what ever needed solving. He was respectful and kind and has impacted my life beyond words. My heart is heavy and my prayers go out to his family. - Mary Wind ---------- Dr Adam not only used the skill of his hands, but the Skills that Really made him stands out. His Heart. He not only changed my life but the lives of my three children as well. His bed side manner was impeccable He was truly a blessing the first day I walked in his office at Froedtert Hospital in Milwaukee. He gave me back Life on March 03, 2006 with a Kidney. I not only lost a beautiful Doctor. More importantly I lost a Great Friend that will be Heart Felt & Deeply Missed Much Luv 4 Dr Mark Adam Broken Hearted, Kimberly M. Young & Family Kenosha, WI ---------- THE MAGIC OF DR. ADAMS I consider myself blessed to have known Dr.Adams for so many years. As nephrologist in Kenosha, Medical Director of the St. Catherine's Kidney Center, I referred innumerable patients to Him for transplant evaluation. He has given life to so many, touched their lifes and the ones of the families in a special way so that all of them came back with new kidney, a pancreas, but, most of all, with a new friend. His caring, integrity, devotion are legendary. He was always available and willing, he went the extra step for all. Indeed he gave our patients kidneys and pancreas but he stole pieces of our hearts , instilling in its place the sparkle of His eyes and warmth of His smile. We shall never be without Him. That is the magic only Dr. Adams could perform and He gave so gallantly ... He was my colleague, my friend, my mentor and inspiration. He was humble and pure at heart. I am saddened by the immense loss and would like to extend my warm condolances to his family, to Dr. Chris Johnson and the entire transplant team, to the girls of his office and to the entire Froedttert Community. - Rosanna Ranieri MD ---------- I first met Dr Mark Adams in 1978 at which time he told me to ignore the charts and graphs others were creating to plot out the expected failure date of my kidneys. He was the first to allow me to peek through the dark cloud hanging over my head. His comments had an immediate and life-changing effect on me for which I will be forever grateful. On Thanksgiving Day 1978 Dr. Adams spent the afternoon crafting a fistula for a very young (25) scared, six-month pregnant woman whose kidneys were failing and who couldn't undergo anesthesia. I had the audacity to vomit all over his nice sterile operating room, yet he simply stopped surgery and then, in his own inimitable way, calmly and quietly assured me that it wasn't a problem and that he'd get back to surgery whenever I was ready. Later, on March 30, 1981, Dr. Adams performed my kidney transplant surgery. My fondest memories of my time in the hospital were the tales of his children, and I will never forget the beautiful sunny April day he checked in on me and then announced he was leaving the hospital to take his children to the park to fly kites. A dedicated surgeon who had his priorities straight. As a direct result of his skill and dedication, and of others, as well I recently celebrated the 26th anniversary of my transplant, the 28th birthday of my older daughter (the "dialysis baby"), the 20th birthday of my younger daughter, born after the tranplant,and will soon celebrate my 32nd wedding anniversary. I am only one of many. The enormous, postive impact Mark Adams had on the lives around him will be felt for generations to come. He will be missed. May we all aspire to be more like him. - Ann Pendergast Christman ---------- I was so distressed to belatedly hear of the death of Dr. Mark Adams. He was my partner, colleague, compatriot, and friend through my years at MCOW (1977-1989). For those years he was in fantastic physical condition and skied the Birkebeiner. I remember vividly his going through the windshield of a car that hit him while he was bicycling to work on Bluemound. Mark was a terrific terrific surgeon and certainly got me out of trouble on numerous occasions though I never seemed to get the chance to reciprocate. I cut down a huge tree in my Elm Grove yard and Mark sawed it up into planks and handmade a beautiful bench of it. I always think of him when I see it. It seems to stand for his dedication to work, care, and friends. He will be deeply missed. - Stephen C. Jacobs, MD ---------- I met Dr. Mark Adams in the 80's. I was covering a story of a child named Virgil whose kidney transplant hopes had all but vanished. We had accompanied Virgil on a last wish trip to Disneyland. Imagine the shock when we got the call that the impossible kidney match had been found. Time was of the essence. We got Virgil back to Milwaukee and into an operating room. Dr. Adams was amazing it was remarkable to witness that operation so many years ago.. Today....the day after the tragic plane crash in Milwaukee that claimed the lives of the University of Michigan doctors and others dedicated to life saving transplants....I suggested we call one of the finest advocates of organ donation I've know...to get some valuable perspective on that element of the story. A quick google search led to this website and a tremendously sad discovery. I got the chance to see how much he adored his family. A couple years ago, I ran into Dr. Adams at the hardware store. He told me how he was delighting in the prospect of building his family a kayak. Reading this blog, I find that adoration spread to his extended family too...all the people who were given a second chance at life thanks to his skills in the operating room. - Kathy Mykleby ---------- Dr. Mark Adams along with Dr. Chris Johnson performed the kidney transplant between my brother, Greg Key and I. We were the 100th transplant at Froedtert. Doctor Adams was a great man, he helped us feel calm and re-assured about the procedure. I was deeply saddened to hear the news of his death. The medical community will suffer a great loss. - Loretta Sue Meinel ---------- I came to the Medical College of Wisconsin in 1985, as an intern in General Surgery. One memory that stands out is being the intern on the transplant service in December. Early in the month Dr. Adams asked me if I was married. When I said I was, he turned to my senior resident and said, "Mike, you take call on Christmas--this intern needs to be with his wife." Later, after I switched specialties to anesthesiology, doing residency and fellowship at MCW, I always enjoyed doing cases with Mark, as he was quite simply the best surgeon I'd ever seen. (Although if something didn't go well, his withering laser beam stare could be quite intimidating!) Eventually, after being on the anesthesiology staff at MCW for a couple years, an opportunity presented itself at the Mayo Clinic in Arizona. I asked Mark to write a letter of recommendation for me. The letter included the line "I could not recommend him to you more highly, although I hope he stays here with us in Milwaukee." When I told him that I got the job and I was leaving, he smiled and said, "I hope you get sunburned!" Nearly 10 years later, here I am doing a transplant case, when my surgical colleague says to me, "Say, Karl, did you know that surgeon in Wisconsin who just died of an arrhythmia, Mark . . . ." I didn't want him to say the last name, because right then I knew. I could go on with anecdotes, but suffice it to say I'm honored to have had the opportunity to know and work with Mark Adams. It has been said that we all die, but not everyone lives. Mark clearly lived, and I like to think that maybe I lived a little bit more having had a chance to know him. - Karl Poterack ---------- I decided to look at the news at Froedtert Hospital today and found such a sad heading that Dr. Adams had passed away. I worked at FMLH for 20 years, but have been gone for 6 years now, but I do remember his wonderful demeanor and of course his good looking manner and enjoyed knowing him. I am so sorry for all of his family, friends and co-workers. I know you will all miss him. - Brenda Holfert ---------- I gave my husband a kidney in 1998. Dr. Adams was the surgeon who put my kidney into my husband. Dr. Adams was a very professional, caring, dedicated doctor who obviously had an enormous talent for what he did for others. He has been taken away far too soon, but his work on this earth will live on in others for many years. Dr. Adams saved many lives and because of that, his legacay will live on. There is no answer why such a person leaves us so soon when he can do so much to help others here, but my husband and I are greatful with our lives, that Dr. Adams came into our lives when he did. We will never forget him and our sympathies go out to his family, colleages, and patients, whom he has touched over the years. We are very saddened. How ironic that Dr. Adams saved my husband's life, only to be outlived by him in the end. - Cindy Fredericksen ---------- Well, it has been 4 almost 5 months now and I think I can finally sit down and write this. I worked with Dr. Adams as his assistant for the last 9 years. As you do when you work closely with someone we shared many family stories, happy times and stressful times. That morning when I came in and his door was still closed I could not be prepared for what I was told. I thought his flight from New Orleans came in late and he was resting. Indeed, he was resting. The essence of ones being is a strong thing, and as I intently listened to what I was being told I could see him walk from his office through mine and smile as he always did. He walked right behind Jon and went around the corner. Surely Jon was wrong. His brown shoes were neatly tucked away under his desk and his lab coat hung quietly in the closet. Surely, this moment was an awful mistake and he would be walking back through that door with his helmet in hand, smiling and asking what was on his calendar for the morning. I sat for a moment in anticipation of that happening, but it did not. I quietly went to his desk and sat in his chair. I watched his dream catcher gently swaying in the corner, right where we hung it when we moved down here. I heard him laughing as he teased me about climbing up into his bookcase to dust and strategically place every item which had its own story and purpose. He was quite sure that worker's comp would not cover "secretary falling out of bookcase". His computer screen was dark and his desk was in its usual state of organized mayhem. I took the letters for signature out of his in-box and I took his "blue" pen and placed it in my pocket. He was lost without that pen, and I was going to be lost without him. I still see him in the halls, every so often, when I come around a corner or get off the elevator and head towards the office. There he is at the end of the hall in his blue shirt and Khaki's, coffee in hand, smiling. One blink and he is gone, but the warmth of that moment is still there and it is that moment that starts that work day. Everything that Dr. Adams is, was, and always will be is enveloped in this office, the halls and the College/Hospital itself. You can see him, hear him and feel him everywhere because in one way or another he touched everyone. Until the next time I see you Dr. Adams........ - Trudy Becker ---------- I was a recipient of a kidney transplant on May 29, 1984. Dr. Adams was such a wonderful doctor and so nice. I saw him about year ago and I will always remember what he told me. He told me that I would live to 100 years old and based on that, I really, really take care of my kidney. I will not ruin the wonderful work he did for me. He was a wonderful man. - Mary Kuether ---------- My first transplant was 3-22-88, which Dr. Adams performed. He was great doctor no two ways about it. Like people said in comments before mine, he would always remember you. He would always stop and say hi, eventhough you wouldn't be seeing him that day. I remember once I was sitting in the hallway no where near the transplant floor, he stopped sat down and asked how everything was going. That really impressed my family. He was a great guy and doctor. Thanks for being you. Thanks for the many years you added onto my life. - Tom Park ---------- Dr. Adams i met in the spring of 1982 i had previously had a transplant at uww of madison, Dr. Hauns Solinger preformed my first TX. Dr. Adams took me on a personal tour of the transplant unit at that time. I was looking to put my name on the transplant list at Froedtert &at the UWW. after my first transplant had failed.Little did i know that i would recieve my 2nd 3rd & 4th at the hands of dr.Adams, among the many other surgeries preformed by Dr. Adams if it were not for the skills of him i would not be here today. Thanks to Dr. Adams & the nurses and staff of 4se. - Michael W. West PS. i will never forget Mark B. adams I just recently found out about Dr. Adams and was deeply saddened. He explained the whole transplant process to my family and I since having a liver transplant was my only major surgery i ever had. I had a liver transplant15 years ago him and he was the best. He took away the questions and any fears from us. As I look towards the possibilty of another transplant, his wisdom and advice will give me comfort. - Greta Melcher