Reflections

Beneath the Surface

Mon, 06 May 2013 16:59:31 GMT

Could a greater miracle take place than for us to look through each other’s eyes for an instant?
-Henry David Thoreau

It is almost 7:00 a.m. and I carry my briefcase and lunch bag from the car to my office. I nod to some of the night shift employees heading home. Another day has begun.

I type my password and check the computer, reminding myself of the twenty patients I am scheduled to see today in the cancer clinic. A few new consults with untreated or recurrent cancers occupy the longer appointment slots. Follow-up and post-operative patients will be seen more quickly. It will be a full day but, hopefully, I will grab a few minutes around noon to eat my sandwich.

I print out some office notes and carry them with me to our weekly 7:15 a.m. Tumor Conference. Several physicians present cases for discussion. We review the scans and the pathology, making recommendations for treatment. We determine who is eligible for a clinical trial. We look at recent research results. Usually, a brief discussion will mean better news for the patient; we have something to offer. A longer discussion can reflect the lack of good options.

Clinic gets going. First is a 64-year-old man with a tongue cancer. Symptoms have been present for about six months. The scans are helpful. The cancer has not caused much damage. Only one lymph node is involved. Everything else looks fine. I run through the surgical risks, benefits, and alternatives. I prepare the consent form and look at the schedule. Any questions?

He drops his head, hands gripping his knees. “My wife would have known what to ask,” he tells me. “She died six weeks ago. That’s why I waited to come in. I was caring for her.”

I pause. There is a story pressing in on us from all sides. It floods the room.

“I am so sorry,” I reply. “I am glad you are here. Your cancer is still very curable. Tell me about her.”

We spend some time. I am soon behind on my schedule. There will be more stories that need to be shared before the day is through.

A recent You-Tube video from the Cleveland Clinic is a spot-on rendering of what happens every day in a hospital. See what you think. No matter where we are, stories surround us, but they are closest to the surface when we are most vulnerable. Recognizing this reality should be part of the repertoire of every physician. We teach this to our students and residents. Even still, how easily we all forget.

The day in clinic draws to an end and everyone has gone home. At 6:00 p.m., my charts are half-complete. I pick up my briefcase and lunch bag. I find my car and head home.

Tomorrow will be here soon enough.

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The following is feedback received for this blog:

Dr Campbell, Your Reflections are always so moving including this one. The You-Tube Video from the Cleveland Clinic was excellent.

- Mary Ann, an RN

Recurrence

Thu, 11 Apr 2013 13:37:05 GMT

She grips my hand. Hard.

“Doctor, what does this mean?”

She is looking at the CT scan. Her furrowed brow demands honesty. In the ten years I have been her physician, she has shaken off cancer twice, first with radiation, then with surgery. Now, it returns.

“Doctor, my grandchildren are just now growing up.”

She is looking to the future. Despite being in excellent health deep into her seventies, she knows there are challenges ahead.

"Doctor, I want to go back home to visit my sister.”“

She is looking at the present. Her far-distant sibling is not well. She has pledged to reunite before it is too late for each of them.

“Doctor, you have always helped me.”

She is looking to the past. Good fortune and technology have been effective. Maybe they will sustain her once again.

“Doctor, please.”

She is looking at me intently without smiling. She grips my hand. Hard.

Previous version published in 2007. Thanks to my writing roundtable at Red Bird - Red Oak.

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Signs of Obsolescence

Thu, 21 Mar 2013 13:34:07 GMT

Tell me to what you pay attention and I will tell you who you are.
-Jose Ortega y Gasset

The senior resident hauled our little band of medical students down to the radiology file room. As he dug through the heavy manila x-ray jacket searching for films, he told us the patient’s story. “This 63-year-old lady was really sick when she came in. Heart attack a couple of years ago. New trouble breathing. Swollen ankles. She was miserable. She was in the ICU for over a week.”

He slid one x-ray after another from the jacket, searching for the chest x-rays that had been taken with a machine rolled to her bedside in the intensive care unit each morning.

“Aha! Here they are!” He snapped the films up onto a series of light boxes and pointed to the one on the left. “Okay, students. This is the chest x-ray from the emergency room the day she was admitted. What do you see?”

We were on our first hospital rotations. We had a pretty decent understanding of anatomy, biochemistry, and pathology, but knew little about clinical medicine. We stared at the x-ray and said nothing.

“Okay, people. Look closely. Describe what you see.”

“Well,” said the bravest among us, “the lungs are here. Here are the ribs and the spine. Here is the heart and the blood vessels. Oh, the diaphragm is down here.”

“Good, good. That’s a start. So what do you see that is different from a normal x-ray?”

This was tougher because we had so little experience with either normal or abnormal images. We stared blankly.

“C’mon. The radiologist has left you some clues. What do you see?”

We leaned in close. At the edge of the lungs near the diaphragm, someone had drawn red pencil marks on the film, pointing out several short parallel lung markings. “Those red wax marks, my friends, point to some Kerley B lines, named after the Irish radiologist Sir Peter Kerley. The lines are seen most commonly in congestive heart failure. They disappear as the failure clears up.”

We looked at the series of chest x-rays and, indeed, the lines resolved as she improved. The resident spent a few minutes describing the radiologic signs of heart failure.

“Okay, students, what lessons did you learn here?”

We repeated back what he had taught us about the x-ray findings in heart failure. We reached into our lab coat pockets for our notebooks and wrote “Kerley B lines = CHF.”

“I learned something else,” said one of the other students.

We all looked at her.

“ALWAYS look for the red pencil marks. If the radiologist was interested in a finding on the film, I should be, as well.”

The chief resident smiled. “Very good! Those marks on an x-ray are a sign of disease as certainly as any clinical finding at the bedside. We call the marks “The Wax Pencil Sign.” Always look for them. They can save your butt in the middle of the night.”

Over the years, light boxes have all but disappeared from hospitals. Voice-recognition software and electronic medical records have made radiology reports available almost instantaneously. Information passes from the radiologist to the treating physicians quickly.

For a generation of physicians, though, The Wax Pencil Sign was a reliable means of communication. It said, “Look right here for the secret.” It helped us when we needed to discern the critical findings in an x-ray.

Not long ago, I ran across a long-forgotten wax pencil in a drawer. Few people remember its use and importance. It makes me wonder about all of the Wax Pencil Signs we depend on today that will be obsolete when our current students finish their careers.

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The following is feedback received for this blog:

I came across your blog post about wax pencils and a rush of memories came flooding back to me. I am a third generation radiologist. My grandfather became one in 1953, my father in 1972, and I did in 2000. I experienced the change from films to PACS (Picture Archiving and Communication Systems) during my residency. I fondly remember using my father's wax pencils for school projects and even rolling up the paper shavings that were used to expose the tip and using them for wheels on army vehicles I built out of cardboard. I can still smell the wax! So, thank you for bringing back those memories! Oh and we radiologists refer to those marks as the "positive radiology sign" and you are right, pay attention to them.

- Peter Bream

Thanks for you note. The other things I miss in Radiology are the sound of films being slapped up onto a light box and those enormous motorized rotating machines that held dozens of films waiting to be read. The file room clerks were always forces with which to be reckoned, as well.

- Bruce

A Positive Attitude and Cancer Survival

Tue, 05 Mar 2013 07:34:06 GMT

“God helps those who help themselves.”
-Something that sounds like Truth but fortunately isn’t mentioned in any religious text

“I’m gonna beat this thing again, Doc! I just know it!”

Over the course of several years, I helped care for a man with a very rare cancer that recurred over-and-over. With each new tumor, he became more focused on beating the disease and despite the repeated setbacks, he remained eternally positive. He spent hours researching every available experimental treatment. He trekked from center to center for therapy. His determination was inspirational. Despite the intensity of his effort, he eventually lost his battle and died. His well-attended visitation and funeral were testimonies to his remarkable life, his outgoing personality and the respect everyone had for his determination.

My super-positive patient told me more than once that his attitude was helpful. “It’s why I’m still alive,” he said. His intensity prompted me to ask: How does attitude affect survival? If a patient tries “hard enough,” can cancer be controlled?

It’s a difficult issue. It is wonderful being with people who are optimistic. As a physician, patients who are positive in the face of terrible adversity are inspirational. Of course, many patients dealing with cancer are devastated both physically and emotionally. With the tobacco-related cancers for which I care, many of my patients carry an extra burden of guilt.

Memorial Sloan-Kettering Cancer Center Psychiatrist Jimmie Holland, MD works with many patients who carry this burden. She refers to a patient or family’s insistence that he or she maintain a positive attitude at all times as “The Tyranny of Positive Thinking.”

What does research tell us? A positive attitude in cancer patients does not prolong life. In a study of over 1000 head and neck cancer patients, there was no association between the scores of Emotional Well-Being and cancer survival. (Coyne, Cancer 2007, 110:2568-2575.) Similarly, a study of Canadian women with metastatic breast cancer randomized to receive group psychosocial support did not survive any longer than women who were not in a support group, although they had an improved mood and some experienced less perceived pain (Goodwin, NEJM 2001 345:1719-1726).

So, is this good news or bad? It depends on your interpretation. From my vantage point, the finding that there is no correlation between attitude and survival serves as a gift for our patients and for us. Allowing people to accept their condition and honestly question their fate, no matter how they handle the challenge, might be enormously helpful for some. They don’t need to fear honest discussions.

“No, you don’t have to be upbeat all the time.”

“Yes, you can talk about your sense of loss.”

“You can’t cause any harm by facing the difficult topics.”

Patients do not risk disaster if they react appropriately to stress.

Cancer Centers like ours provide resources for patients and families who are dealing with stress, and I commonly suggest people explore the resources in our Quality of Life Center. The goal is not to regain a positive attitude, though. It might be to improve a relationship or understand and manage their lives at a stressful time. The small victories come, not always with cure, but at the moments of healing.

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The following is feedback received for this blog:

Please edit to add the "s" to "he' when referring to the wonderful woman author, Jimmie Holland.

- Liz McMillan

Sorry for the oversight. My apologies.

- Bruce

Having personnely survived head & neck cancer (base of tongue squamous, stage 4 with bilateral metastisis of lymph nodes) 17 years ago, thanks to the recommended treatment from Sloan-Ketterling of co-combatent chemo and radiation, I have a few thoughts on a positive attitude. To me, it's what helped me stay focused on beating the cancer. It made me feel like I had a chance, which in turn reduced the stress of negative possibilities and the debilitating treatments. A positive attitude gives you the needed push to keep trying anything and everything to beat the disease and keeps you from sitting around going "woe is me", or "why me"!

I looked at it as if it were a journey. Another diversion on the path of life. I didn't have a choice of going down the path (never a smoker or heavy drinker) so I took it as any other diversion, stay positive, focus on what can be done, let your care givers do their best, and pray--alot!

I've always said that the medical community tried their best to kill me (after my second week of 5FU, I understood what the FU stood for), and prayers and a positive attitude saved me.

17 years later, I still believe this! I've been blessed to work as a Professor for the past 15 years, retired from the Air Force Reserves after 35 years and still exercise and play racketball 3 days a week, thanks to the "new" treatment recommended by Sloan-Ketterling in 1996.

- Al Smith

Out-of-Pocket

Thu, 07 Feb 2013 13:29:33 GMT

You know you're getting old when all the names in your black book have “M. D.” after them.
-Harrison Ford

The sun streamed through the windows and the trees were in bloom. The coffee was flowing and the retirees sat in a circle at the senior apartments. Kathi and I stopped by to greet my mother and some of her friends. The circle widened to admit us. We found a spot to share a moment.

“What are you talking about today?” I asked.

“Same as always,” someone said.

“Yeah. Yesterday’s Brewers game, the weather, the people who didn’t show up this morning…you know,” added another.

They all nodded in agreement. “Oh, yeah. One other thing,” added Harold.

“What’s that?”

“The cost of health care. Whenever we get together, our one common theme is how much we spend out of our pockets for medical care. At our age, we spend as much time at hospitals as we do at home!”

There was some truth to that. As our own parents and relatives aged, they accumulated doctor appointments, hospital admissions, therapy visits, prescriptions, and piles of paper. My dad had several bulging files jammed with incomprehensible Medicare forms.

“Doctors!” Harold said. “They suck us dry!” Then, apparently remembering what I do for a living, he added, “Of course, it’s not your fault, personally.”

It was quiet for a moment before the conversation switched to another topic. Yet, I realized this is the table talk that occupies many of my own patients and will, no doubt, occupy us if we are fortunate enough to live that long.

I remember a moment many years ago when I was working as a nurse’s aide in a Chicago-area emergency room. An elderly woman was violently pushed to the ground and her wallet, containing $2, was stolen. She ended up in the ER, had an exam, stitches, and x-rays. The hospital visit cost a lot more than the $2 she had lost to the mugger. When she started to realize how much the emergency room visit would cost her, she cried.

Harold and his wife eventually moved to another city to be closer to their family. Before he left, he told everyone it was due to their depleted finances. “We’re going broke here,” he said.

The coffee group still gathers every morning, although the participants have changed. We still stop once in a while. These are the people those of us in middle age hope to be. These people took good care of themselves and their families. They live simply and quietly. They enjoy talking about the Brewers, the weather, and each other. And, as I am certain, they will continue to worry whether the health care system upon which they depend will eventually make it impossible for them to feel safe and secure as they approach the end of their lives..

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Half of What We Teach You

Wed, 23 Jan 2013 14:48:21 GMT

Half of what we teach you is wrong. We just don’t know which half.
-Anonymous

My most vivid memory of medical school is the pressure we felt to learn everything that was set before us.

There was pressure to learn and pressure to understand. We gorged ourselves on facts, concepts, diagrams, flashcards, lecture notes and mnemonics. Even as we drank facts and data from a proverbial fire hose, however, we realized entire disciplines were evolving.

For example, much of the Immunology we struggled to memorize in medical school was soon proven incorrect. We searched for information in older textbooks with trepidation, fearing encounters with long-discarded details and theories. We marveled that previous generations of physicians had never been taught tobacco and cancer were somehow linked to each other. How could they have not known?

And then there were changes we encountered in surgery.

When I was just beginning my training, a volunteer faculty member offered to let me assist in a procedure to remove the tumor from a patient’s parotid gland – one of the major salivary glands in the cheek. I was anxious to work with this teacher because he had trained forty years before at one of the most prestigious residency programs in the country.

As we scrubbed, the faculty member carefully explained the operation to me. These operations are tricky because the nerve that controls the facial muscles runs through the gland. The initial step in performing parotid surgery involves identifying and protecting this nerve.

He crafted an incision hidden in the patient’s skin folds and from this created a narrow one-inch deep tunnel in front of the ear that ran from the skin down to where he expected to find the main trunk of the nerve. I looked in. It was hard to see anything at all. Blood and fluid repeatedly obscured the view.

“Here,” he said. “Watch carefully how I do this. This is the most critical step.”

And so I watched. He pushed and prodded, opening a space between the tissues with a small spreading device. Things did not go well. There was more bleeding than usual, he noted. The patient was large and the tunnel needed to be longer than expected. His angle of approach was apparently a bit off. He repositioned the spreading device over and over – first aiming more superiorly and then more inferiorly. I could sense that he was not happy.

Finally, after a long period of anxious searching, retracting, stretching, and straining, there it was: the trunk of the facial nerve. He poked it gently with a nerve stimulator and the patient’s cheek
twitched.

“There you have it.” he announced. “That’s how you find the nerve!”

I dutifully noted what he had just shown me. That night, I wrote down the steps of the procedure for later reference. The approach I had witnessed seemed perfectly logical. I worried, however, that the initial steps had been so difficult and the risk to the nerve so high that I might never be able to duplicate what I had just been shown.

A few months later, I scrubbed with a different surgeon on a parotidectomy. He too told me that the critical first step involves finding and protecting the nerve.

I looked for the spreading device I had seen used to create the narrow, dark tunnel during the first procedure, but there was none. Before I had a chance to ask the surgeon whether he would need the spreader, he created the same incision but then took a long and wide approach to the nerve, carrying the dissection down to the trunk with a broad front rather than the narrow tunnel I had seen the first time. Before long, he had safely found the nerve and the procedure was off and running. Suddenly, I could see myself being able to someday master this operation.

“Why did the other surgeon use such a limited approach to the nerve?” I asked.

“Perhaps,” the surgeon replied, “that was the way he was taught and he never learned a newer way.”

Innovation and technology are constantly pounding on the surgeon’s door; there is always some new medication, approach or technology. Many of these “latest and greatest” things will disappear with time, but each of them will influence how we think and what we teach. No one consistently picks the winners, but my experience years ago with two parotid surgeons taught me to try to stay open to innovation.

I love the opportunity to teach surgery to the next generation of surgeons, but I am certain there are many, perhaps half, of the things I teach today that will be sources of laughter and wonderment in a couple of generations. I only wish I knew which half. I hope they will be gentle with me.

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"No Residents!"

Wed, 12 Dec 2012 15:29:24 GMT

Skill to do comes of doing.
-Ralph Waldo Emerson

We are in the last steps of getting surgery arranged; the counseling is complete and the consent is on the clipboard. Just as the patient is putting pen to paper, she asks, “When I’m asleep, you’re not going to let some trainee practice on me, are you? I mean, I wouldn’t let the brand new stylist cut my hair, right? I don’t want any residents involved!”

The patient sets down the pen and eyes me carefully. These can be uncomfortable conversations. I think back on the times my own family members have needed surgery. We all want “the best” for our loved ones.

I begin. “The operation requires two people to perform. I am right there for every part of the surgery. The resident does nothing without my direct involvement.” These statements are true, but she is not satisfied.

“Not good enough. How will I know for certain? I insist that there be no students or residents scrubbed in at all.” At this point, I need to decide if the proposed operation is one I can do by myself. If so, I might still proceed. The patient has put me in a box but she has the perfect right to make such a demand.

I start again. “I can’t know for certain,” I say, “but changing my usual routine for a complex procedure like yours might place you at some unnecessary risk.” She looks at me skeptically. “In any case,” I add, “I am certain that having a resident involved in your surgery is safe.” Despite having made this claim many times over the years, I have never really known if it is true.

Fortunately, a new research paper confirms that having residents participate in surgery is, indeed, safe.

A study of over 60,000 major operations (40,474 with residents and 20,237 without residents) performed between 2005 and 2007 did find that the resident cases took slightly longer (122 v. 97 minutes) and did show a slightly higher rate of “mild” complications such as superficial wound infections (3% v. 2.2%). Happily, there were no differences in postoperative deaths or major complications such as bleeding, re-operation, heart attack, blood clots, or postoperative length of stay. The resident group had slightly FEWER postoperative strokes. The authors conclude that “resident involvement in surgical procedures is safe.”

One of the things I love most about my career is that I have the opportunity to teach head and neck surgery to the next generation of young physicians. I love seeing the spark of recognition when a young physician finds and hones skills that she or he never knew they possessed. I enjoy watching them find real-world ways to connect theory to technique. I am humbled that there are people all around the country whose lives have been touched by one of the 80 ENT physicians who I have helped train over the past 25 years. I am very proud of our graduates.

My patient thinks for a moment then signs the surgical consent. “Just keep an eye on them.”

“Absolutely,” I assure her. Had she persisted with her objection, I would have had to decide whether to proceed. Over the years, there have been a few situations where I have refused to perform an operation. That has not happened often.

Knowing that our system safely trains young surgeons is comforting. Someday in the not too distant future, the odds are that I will probably need surgery myself. It is great to know that the students and residents training today will be ready to safely help me when that day arrives.

____
Ref: Kiran RP, et al, Impact of Resident Participation in Surgical Operations on Postoperative Outcomes: National Surgical Quality Improvement Program, Annals of Surgery (Sept) 2012; 256:469-475.

doi: 10.1097/SLA.0b013e318265812a

A subscription might be required to read the article.

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The World Needs More People like Charlie Runge

Thu, 08 Nov 2012 07:00:53 GMT

“Hey, how ya doin’?” Charlie Runge greeted everyone with a smile, genuine attention, and a real interest in knowing the answer to his question. He really wanted to know how we were doing.

I first met Charlie in about 1991 when he was a young administrator at the Milwaukee County Medical Complex and I was a young physician on the hospital Cancer Committee. It was a time of great transition and a particularly tough time for the County Hospital. The institution was hemorrhaging money and county government was looking for a way to get out of the health care business. Charlie was a young junior-level administrator thrown into the midst of upheaval.

He was almost too good to be true. Charlie apparently never took the class in graduate school where he should have learned that hospital administrators and physicians are natural-born enemies. He was level-headed, pleasant, and a great listener. He was opinionated and honest, yet he knew how to convey his opinions in ways that always respected his listeners.

No one was surprised when he joined the team as Froedtert purchased the County Hospital in 1995. He helped blend diverse sets of programs, facilities and staff. Although I observed the process from a distance, Charlie was part of a strong, dedicated group that made many, many innovative and difficult decisions. The hospital in which we work today is partly his legacy.

Over the years, Charlie always took time to chat when our paths crossed. Despite his growing stature in the organization, he gave the impression he had plenty of time. Although he picked up a hint of gray over the years, his hair and his suit remained impeccable.

At all points in his career, Charlie was a person of character who lived his values. He was a friend, a husband, a parent, and a role model, fulfilling all of his roles with understated brilliance.

As poet Bessie Stanley wrote:
To laugh often and much;
To win the respect of intelligent people and the affection of children;
To earn the appreciation of honest critics and endure the betrayal of false friends;
To appreciate beauty, to find the best in others;
To leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition;
To know even one life has breathed easier because you have lived.
This is to have succeeded.

Needless to say, Charlie was a success in every way. He weathered some difficult transitions over the years. I will miss knowing that he is helping to guide us through the transitions yet to come. And I will miss those moments in the hallway where he listened and nodded as we spoke about our lives in the community.

If you would like to make a donation in Charlie's memory, click here for the Froedtert Foundation or here for the AIDS Resource Center of Wisconsin where Charlie was a board member.

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The following is feedback received for this blog:

Beautifully written, perfectly said.

- Kathy Myers

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.

Please Hang Up and Dial 9-1-1

Fri, 05 Oct 2012 16:44:15 GMT

How we spend our days is, of course, how we spend our lives.
-Annie Dillard

I wish I could add up all of the moments I spend waiting for things to happen.

I wait for computers to boot up. I wait for computer screens to load. I wait for programs to ask for and accept my user name and password for the umpteenth time so I can view a CT scan and then re-enter a different user name and password to retrieve the patient's phone number. I stay near phones and wait for people to return pages.

I know, I know ... not everything can be instantaneous. There are millions of electronic baby steps and digital binary calculations that need to be repeated each time I complete typing in my password and hit “Enter.” Maybe someday, my son, the computer engineer, will solve that one.

However, there are things that make me wait that seem completely unnecessary.

Consider the phrases below that each of us hears dozens of time each year:

“Thank you for calling Dr. Bob’s office.”

That phrase is probably okay. It's nice to know I reached the correct number.

"Our regular business hours are 8:00 to 4:30 Monday through Friday."

Not surprising. I check my watch. It is 10:00 a.m. on Thursday.

"If you are hearing this message during business hours, it means we can’t get to the phone right now."

Duh.

"Please stay on the line because our menu options have recently changed."

Although I heard this same message approximately two years ago.

“If this is a medical emergency, please hang up and dial 9-1-1."

How stupid do they think I am? “Hey! I’m bleeding to death here!!! Any quick advice??? Can you squeeze me in today and sew my arm back on??? Gawd, I hope you are taking these calls in the order they were received!!!”

“If you know your party’s extension, you can enter it at any time.”

If I knew their extension, whether they are at a party or in their office, I wouldn’t still be listening to the recording.

“If you don't know your party's extension or if you have a rotary phone, please stay on the line. We will be with you shortly.”

Rotary phone??? Are they kidding? Who has a rotary phone? And what if it’s an emergency? Am I supposed to both hang up AND dial 9-1-1 on my rotary phone? While my arm is hanging from its socket? While I'm bleeding to death??? I’m so confused …

“Otherwise leave a message after the tone and we will get back to you at our earliest convenience ...”

You will call me at YOUR earliest convenience?! That’s probably true, but is it wise to TELL ME THAT?!

I wish I could live a whole week where I never had to wait for a computer to boot up, for a password to clear, for a page to load, or for a recorded message to finally get to the beep.

Then again, maybe someday I will achieve a level of serenity that allows me to enjoy those empty spaces in my day. Only then will I understand that the quiet moments are, in fact, a precious and rarely appreciated gift.

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Too Much Fun

Fri, 21 Sep 2012 11:56:20 GMT

Not everything that is faced can be changed. But nothing can be changed until it is faced.
- James Baldwin

She sits in the examination chair reeking of cigarette smoke. “I had a new sore under my tongue last week,” she tells me. “It was bad.”

A year ago, she finally developed a large throat cancer from her years of smoking and drinking. The cancer had spread to the neck lymph nodes and had grown large and hard. The outlook had not been good.

Yet, things went surprisingly well. Her family's wonderful support had helped her make it through the chemotherapy and seven weeks of radiation. Though it was not easy for her, the cancer responded nicely and the throat and neck look fine now. A scan confirmed the good news.

So, when she developed a new sore on the tongue, everyone was worried. Her daughter brought her in to see the primary doctor who started her on antibiotics. Within a few days, the tongue was better. Now she is in my office.

“You must have bumped it. Maybe you bit the tongue, I can’t tell. In any case, things look fine now. No cancer.”

She smiles. “I do feel better, Doctor.”

“Let’s talk about your smoking, though.” She frowns. She has had this discussion with her family, her friends, and her care providers many, many times. “If you continue to smoke, your risk of another cancer goes way up,” I tell her. “How can we help you quit?”

“Mom, listen to what the doctor is saying.”

“I already know all that,” she replies. “I just enjoy smoking too much! I don't want to quit.”

As a society, we have made great strides helping people quit and preventing a new generation from starting. Smoking peaked in the mid-1960s when about 42 percent of adults smoked. Now, it’s less than 20 percent. In the mid-1990s, about 36 percent of 12th graders smoked at least once per month. Now, it’s 19 percent. That’s good news.

Things are not perfect, though. We have not helped our most vulnerable. Half of cigarettes smoked in the United States are consumed by people with substance abuse or psychiatric disorders. The poor are more likely to smoke and have greater difficulty quitting. A recent study of smokers earning less than $30,000 per year in New York (the state with the highest cigarette excise taxes) found that they spend up to 23.6 percent of their total income on cigarettes, double what they spent in 2003. Unfortunately, very little of the revenue generated from cigarettes sales is designated to fund tobacco prevention and cessation programs.

My patient fits into all of the high-risk categories and I doubt she will quit until she is too ill to physically smoke or when she can simply not afford to buy cigarettes.

So, we will talk about her smoking again. And again. And again.

___
Ref: Farrelly MC et al., The Consequences of High Cigarette Excise Taxes for Low-Income Smokers (2012), PLoS ONE 7(9): e10.1371/journal.pone.0043838

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Preparation

Thu, 30 Aug 2012 09:54:20 GMT

Chains do not hold a marriage together. It is threads, hundreds of tiny threads which sew people together through the years.
- Simone Signoret

Allen’s cancer has continued to grow quickly. He raises his chin so I can see. I check my notes from a month ago and pull out my ruler and make new measurements. I jot down my findings and turn to look him in the eye. We both know this cannot go on much longer.

When he had first come to see me about his newly diagnosed cancer, Allen had been a vigorous, active, enthusiastic man in the prime of life. He was a regular at the gym. He had always been very accomplished, maintaining a wide circle of loyal friends. Despite his failing health, he still keeps his weekends full of activities. His delightful family continues to be his bedrock.

We have known each other for several years now – through his initial cancer treatment and the increasingly aggressive recurrences. His typical reaction at each juncture has been a smile, a shrug, and a "Let’s get going!" Now, things are deteriorating. Treatment options have been exhausted. Active cancer treatment has given way to comfort measures. He is ready to die.

Today, he is weak and, although he insists that he does not really need the wheelchair, he acknowledges that using it makes the visits easier for Therese.

Therese heads out to the waiting room for a moment and Allen looks at me. "Doc, I realize I won’t be here much longer and haven't finished making all of my preparations yet. It’s just hard."

I am surprised by Allen’s remark. He has always been completely organized and I assumed that he already had all of his ducks in a row. Everything all set and ready. Color-coded files with instructions. He’s that type of person.

I look at him. "Do you want me to help find someone who can set up your Power of Attorney? Have you worked with a lawyer to get things prepared for after you have died?" "

Nah. I took care of that years ago. My will and all of the financial planning is complete. I updated it just a couple of weeks ago. No problems there. Doc, It’s the OTHER stuff." He smiles.

"My Harley, for instance. I love my bike but I know I won’t ride it again. It just sits in the garage looking great. And my sports car. It’s got a touchy clutch and Therese never liked the stick shift. She won’t want either of them after I am gone. They will be a burden to her and I know I should get rid of them. I just haven’t gotten around to it yet."

He smiles again.

"Doc, I’m sorry. There was no need to burden you with our problems."

Therese returns and catches the end of the conversation. She shakes her head. "Allen, honey, I’ll take care of it. Don’t worry."

"I know you will. Just in case, though, I have a list of places in the green file cabinet where you might want to list the car."

The visit ends and we set up the next appointment, not knowing if he will still be alive. Allen waves as Therese pushes the wheelchair down the hall toward the elevator.

[Allen and Therese are not their real names.]

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Barriers

Wed, 15 Aug 2012 12:50:11 GMT

Language barriers are a contributing factor in health care disparities.
-Donald J. Hernandez, PhD 　

Years ago, I sat in clinic with a new patient, her family, and a Hmong translator. I studied the biopsy report from another doctor’s office. This would be difficult. I asked about her symptoms.

The mass had been there for a while, I learned. She had pain but they were trying some medicines from their traditional healer. She hoped that I could help her.

Then I discussed the report. "She has cancer," I told the daughter. The daughter nodded and turned to tell her mother, speaking at length and re-working my three-word phrase into something much, much longer. The translator helped, as well.

The mother sat quietly, searching her daughter’s face, hearing the words but saying nothing. I tried to learn more about her life. She had been born in Laos. She had never seen a Western physician before developing the mass.

"Do your siblings have any health problems?" I asked.

"We don’t know," her daughter replied. "They were all killed during the war. We haven’t seen most of our relatives since we came to this country."

The woman’s facial expression did not vary. Gradually, the questions came out. "What will this mean?" "Will the treatments make the sore go away?" "Can this wait?"

I did my best to answer. Then I asked, "What other questions does she have?"

"Doctor, it is hard to ask questions," her daughter told me. I waited. "You see, in our language, there is no word for ‘cancer.’ She does not know what that means. It is very hard to explain."

Indeed. 　

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The following is feedback received for this blog:

Thank you for this touching post. I've never thought about what it would be like to try and explain cancer to a patient who comes from a part of the world where it is a foreign idea.
- Theodore Diktaban, MD

Junking

Mon, 09 Jul 2012 06:41:06 GMT

All happy families are alike; each unhappy family is unhappy in its own way.
-Leo Tolstoy

“He’s out junking.”

This term is unfamiliar to me. My patient did not come to his clinic visit today because he’s “junking?”

His sister has arrived alone to what-was-supposed-to-be my patient’s follow-up appointment. There is nothing else she can do. Her brother’s mouth has been sore for months and the pain is worsening. He can no longer eat solid foods, a couple of his remaining teeth have fallen out, and his lower lip is now numb. Lumps have developed under his chin.

A couple of weeks ago, he had called the one sibling he thought might help.

And she did. A few days later, he was in my office and she was there with him, attentively taking notes and asking questions. He chuckled as he acknowledged that he has “a few” other issues. He talked about his drug use. He smokes whenever he can afford cigarettes. He drinks all day long. Cancer has destroyed part of his tongue, lower jaw, and lip. He has big lymph nodes under his chin. He is skin-and-bones – nutritionally, a wreck.

At that first appointment, we had scheduled testing. He failed to show up for some of the scans. Before today’s office visit, I had looked at the available results; the treatment guidelines told me that his best chance for cancer cure would involve surgery, chemotherapy, and radiation. I wondered how he would get through the rugged treatment and months of supportive care.

Today, his sister sits alone in the office, near tears. She tells us that her brother rents mattress space in the basement of a house. Yesterday, he refused to come to the door when she had stopped in to remind him of today’s appointment. Today, when she arrived to pick him up, he was gone. His mattress was empty. One of the other men told her that he was out.

She knows what he is doing. He spends his days digging through garbage and wandering through empty lots looking for cans and bottles that he can sell. “He uses the money to buy alcohol,” she says. “He says he has to keep junking. It’s the only way he can keep on living. I tried to be firm with him and told him he needs to see the doctor. He wouldn’t listen to me.”

She wrings her hands. “What am I supposed to do?”

There are no easy answers. We offer support to her, we talk about social service agency referrals. We spend an hour together. She is devastated.

Before she leaves, we assure her we will care for him when he decides to return. We all realize, however, that he will not come back until he finds he needs cancer treatment more than he needs his junking.

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Typing Class

Thu, 21 Jun 2012 10:37:19 GMT

In teaching you cannot see the fruit of a day's work. It is invisible and remains so, maybe for years.
- Jacques Barzun

As a sixth grader, I trembled in fear. Seventh grade was, to me, a looming, terrifying, child-eating giant.

Seventh grade would mean a new school. Junior High kids were so cool! It was the late-1960’s. Would I be allowed to wear bell-bottoms and denim shirts? Would Mom let me grow my hair? I wanted to be like the “big kids” in the worst way.

Anticipating Junior High classes, though, was also frightening. I had heard from the older kids about History class. I would have to memorize “The Gettysburg Address” and the Preamble to the Constitution. Math would have impossible tests and pop quizzes. Science would involve a fill-in-the-blank Periodic Table and dissecting a giant worm. The English teacher would make me write my first “term paper.” I was scared.

Nothing, though, loomed as frighteningly as Typing class. Mrs. Locker was the classic “stickler.” “Posture, boys and girls!” She demanded perfectly aligned margins, accuracy, precision, no eraser marks, and clean technique. Type too quickly and the keys would jam. Type too slowly, and Mrs. Locker would be over your shoulder, keeping you rattled. There was no slacking off. EVERYONE was held to the highest standards. “The quick brown fox jumps over the lazy dog! Again! Again!!!”

Once I was in Junior High, all of my worst fears were confirmed.

In Typing class, Mrs. Locker made us work hard. She waxed poetic about the speed and accuracy of great students from the past. I knew that I would never live up to her expectations and worked to stay beneath her radar. Some of the students, of course, had perfect scores on every quiz and won every typing contest.

As I despaired at my Typing test results, I remember thinking, “Why does it matter, anyway?” I did not know any adults other than secretaries who needed typing skills. I knew typing would come in handy writing papers in high school and college, but I could not imagine I would ever need to type anything after that. My dad owned a Ben Franklin Store; he had an old manual typewriter which he rarely used. Even if I had known that I would someday become a doctor, it would not have mattered. Doctors were known for their handwriting, not their typing.

Oh, my, how things have changed.

I started typing again when I first worked with Radio Shack computers during residency in 1983. My first work computer, in 1989, was an IBM 286. At the time, faculty computers were used to prepare academic papers and write letters; it was just a fancy typewriter with some memory. Medical charts were still paper. Clinic notes were two handwritten sentences and a line drawing. Mail came in stacks with rubber bands and paper clips. Email came much later, as did the internet.

During my professional lifetime, American medicine has become completely dependent on computers and the information that is indiscriminately poured into them. Medical billing – and the Electronic Medical Record upon which it depends – prizes lots of detail and, hence, lots of words.

These days, the cynic in me sees a room full of doctors pounding away on keyboards as a room full of people providing great patient care.

Everything depends, in the final analysis, on typing.

In seventh grade, I was not the best typist nor was I the worst. When typing hyphens or numbers, I still have to look at the keyboard and then hunt-and-peck.

Pearl Buck once said, “One faces the future with one's past.” My socially-inept, seventh-grade experiences are all a part of who I am as a person and as a physician many, many years down the road. As a physician, my Science class helped me explore nature and biology. My English class helped me listen to and record patients’ stories.

But, Mrs. Locker’s Typing class turned out to be one of the most important experiences from that period of my life. Fortunately, I paid enough attention to make me functional as a physician.

And, somehow, that is kind of sad.

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The following is feedback received for this blog:

My only B in all of high school was typing class in 1974. I should have taken it more seriously, since it became an essential skill in my journalism career. Now, as an accountant, I have (somehow, finally) become comfortable with the number keypad. But I would surely fail a "texting" class.
- John

White Coat to Commencement

Tue, 15 May 2012 07:17:27 GMT

In August 2008, I was honored to be the speaker at the White Coat Ceremony that welcomed the Medical College of Wisconsin class of 2012 . Here is a link to my talk. My suggestions to them at the time were to:

Remember where you came from
Listen to your friends and family
Find a mentor
Keep your white coat thin by letting patients' stories affect you and letting patients feel your compassion

Now, four years later, those students are graduating. Most of them forgot my talk long ago. It has been great to meet many of them during their time at MCW and I am proud that a few have chosen careers in otolaryngology! The world is in good hands.

This week, I reflected on the differences between college commencement and medical school commencement on WUWM's Lake Effect.

Congratulations, Class of 2012!

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Thank YOU, Dr. Campbell! I hope that other students in the future will be as inspired by you as I was.
- Appreciative

The Moment

Mon, 23 Apr 2012 14:40:31 GMT

There is always a way to be honest without being brutal.
-Arthur Dobrin

“The oncologist mentioned the possibility of some newer treatments,” his wife tells me.

I look at him doubtfully. Placebo-light? I think to myself. Pretend-imab?

“Oh,” I say.

He slumps in the exam chair, listing sideways, searching for an imaginary support that is not there. He occupies only a fraction of the space he filled four years ago when he first came to my office – before his first surgery, before radiation therapy, before the last round of salvage chemotherapy, before the latest frightening scans.

He looks up, staring at me from the depths of his being. “Doc,” he whispers, “is this thing curable?”

I move closer and rest my hand on his fragile arm. I have known him for a long time. “No.” I search their faces. “You will die with this cancer.”

His eyebrows rise momentarily but there is a smile at the corner of his mouth. “Doc," he says, "Thank you.”

I look at his wife. She shifts. “No one has told us that before.” She pauses then continues. “We talked about it ahead of time and we knew you would be straight with us.”

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The following is feedback received for this blog:

Your kindness to them required courage and integrity. Thank you for sharing this tender "moment".

Professionalism v. Humanism

Mon, 26 Mar 2012 16:30:56 GMT

We are already one. But we imagine that we are not. And what we have to recover is our original unity.
-Thomas Merton

I recently sat with a group of residents and students to discuss two fictional short stories that are classics in the Medical Humanities: “The Use of Force,” by William Carlos Williams (1938) and “Brute,” by Richard Selzer (1982). Both stories are difficult and violent.

In “The Use of Force,” Williams tells the story of a home visit to see a sick child. The doctor must examine the child’s throat because he fears the child has diphtheria. Things do not go well. He tries to cajole the child and to enlist the help of the parents. The child resists and the parents are reluctant to force the child to cooperate. The doctor’s thoughts are transparent to the reader: he despises the parents for their weakness, admires the child for her strength and tenacity, and eventually loses his temper. “In a final unreasoning assault, I overpowered the child’s neck and jaws.” The doctor sees the tell-tale membranous discharge in the throat, thus sealing the diagnosis.

In “Brute,” Selzer tells the story of a man brought to the emergency room in the middle of the night, roaring drunk and handcuffed. He has a deep gash across his forehead. The man is powerful and fights the doctor’s attempts to repair the cut. The doctor and patient are alone in the room, and the reader is privy to the doctor’s anger and exhaustion. In frustration, he finally grabs two large sutures and sews the man’s earlobes to the mattress. “I have sewn your ears to the stretcher,” I tell him. “Move, and you’ll rip ‘em off.” Along the way, the doctor-narrator tells us of his rage.

My discussion group reflected on the stories in ways I did not expect. They took the narrative conflicts personally. These residents and students have experienced long and difficult on-call nights and times of great frustration in patient-care settings. They have certainly had moments when interacting with patients was difficult and exhausting.

Yet, some were very critical and unforgiving of the way the doctors in the stories reacted. “That’s just wrong!” they declared. “No one should ever treat patients that way!”

The stories ARE difficult. The doctors get their tasks accomplished, but they are angry and sometimes profane in the process.

It was an opening for me to talk about the difference between “Professionalism” and “Humanism.” We work to train professionals – people who have certain sets of attributes, skills and demeanors with which they will practice high-quality medicine with integrity and empathy. This is a good goal. “Humanism,” on the other hand, is broader than professionalism. These are qualities we hope every physician brings to the table from childhood. Humanism refers to a deep respect of humans individually and collectively, and concern for their general welfare and flourishing.

In the examples we looked at, both doctors were, strictly speaking, professional. The child’s throat was examined and the man’s laceration was repaired. The spoken dialogue is, by and large, “professional” and focused on the medical issue at hand.

But, “humanism,” that is another story. Williams speaks of the doctor’s “fury” while Selzer speaks of his doctor’s “rage.” Both doctors overpower their patients. The inner dialogue is the focus.

Both essays close with the doctor-narrator expressing shame and regret. A physician can be perfectly professional but lack humanism, depending on how he or she see patients and co-workers. Being attentive to our "inner dialogue" can tip us off to when we are in danger of losing our humanism.

The discussion helped me see the difference. Great writing and great colleagues can do that.

___

References:
Williams WW, The Doctor Stories, New Directions, New York, 1984. MCW Library WZ 350 W728d

Selzer R, The Doctor Stories, Picador, New York, 1998. MCW Library WZ 350 S469d

A wonderful discussion of the topic can be found at: Goldberg JL, Humanism or Professionalism? The White Coat Ceremony and Medical Education, Academic Medicine 2008; 83:715-722.

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Opening the Senses

Fri, 27 Jan 2012 16:20:37 GMT

The hardest hit, as everywhere, are those who have no choice.
- Theodor Adorno

During my recent mission trip to East Africa through Kenya Relief, all of the surgeons took turns seeing walk-in patients. The lines were long, but the people were incredibly patient and grateful. A 4-year-old boy had waited for hours with his mother. I sat down and asked her to tell me his story.

Kamau (not his real name) sat quietly, looking back-and-forth from his mother’s face to mine. He appeared very healthy and attentive. Like most of the Kenyan children, he was thin. These kids walk everywhere and have very simple diets.

“How can I help?” I asked.

The translator spoke. “Kamau does not talk and never responds when he is spoken to. At first we thought he was distracted. One time, though, when a motorbike backfired, he didn’t react. We decided he might be deaf.”

Kamau looked around the room and smiled at me. “Have you taken him to see anyone?” I asked, knowing that there were few resources available.

“Oh, yes. We saw a local doctor once, but he couldn’t help. We had hoped you American doctors could do something to make him hear.”

I looked at Kamau, hoping to find something I could fix or recommend. He reached up and touched my ears after I looked in his. Unfortunately, it appeared that he had profound nerve deafness.

In the United States, as soon as a child is found to have hearing loss (often detected in the newborn nursery), a series of events begins and support services begin to take charge. Hearing aids are fitted for appropriate children by the time they are a few months old. Children who need cochlear implants get started with evaluations early and are soon seen by an otologist, audiologist, speech/language pathologist and psychologist. Surgery and the early follow-up including device programming and training can easily cost $50,000 to $100,000.

Sub-Saharan Africa bears 24% of the world’s disease burden but has only 3% of the global health workforce. Health insurance is all but nonexistent. Infrastructure is poorly maintained. Whatever resources exist tend to be aimed at diseases like AIDS, tuberculosis and malaria.

There are no cochlear implant programs in Kenya. Hearing aids, even if available, require batteries, something this family would not be able to afford. I tried in vain to think of something I could offer other than suggesting a trip to the capital city of Nairobi, an insurmountable 240 miles away. “What is possible, doctor? What can you do for Kamau?”

He was deaf, but I was speechless.

“I am sorry, Ma’am. I have nothing to offer Kamau, other than to tell you he is a very handsome boy.”  The mother smiled weakly but thanked me profusely. She picked up her son and started the long walk home.

The following is feedback received for this blog:

Nice post, keep going

- prakash j

Gone Missing

Fri, 10 Feb 2012 15:31:21 GMT

“I will never forget that day.”

She smiled broadly.

“It was about a week after my cancer surgery and I had finally worked up the courage to look in the mirror. I knew you had rearranged things a bit, okay. Moved stuff around. Taken things apart and jammed them all back together, right?”

I probably would not have said it quite like that, but she was correct that her surgery had involved removing part of her tongue, a ridge of bone from the jaw, and some of the lymph nodes in her neck. She had been a bit swollen after the procedure but no more than expected, as I recalled. Things had gone well.

“So, I am standing in the bathroom and look up at myself in the mirror. Well, the face peering back WAS NOT ME! It just wasn’t me! I just kept staring. I wanted to know what had happened! Finally, I found something that looked familiar.”

“What was that?” I wanted to know.

“Finally, I recognized my left eye. I knew that face in the mirror was mine because it had my left eye! But that was the only thing I recognized! Only my left eye.”

Of course, at the time, I knew nothing of what she had discovered in the bathroom mirror. My daily rounds probably consisted of telling her she was recovering nicely and the cancer was gone. We would have talked about nutrition and what she would need to do once she was discharged from the hospital. I would have reminded her that her swelling would disappear gradually over a few weeks. I might have shared that the scars would fade steadily and would be almost invisible someday. I have had hundreds of similar discussions over the years.

She, on the other hand, must have been wondering, What the heck did this surgeon do to me?

I pressed her to go on. “So, what happened?” I asked.

“Well, gradually, I recognized more and more of my own face. After a while, I realized the unrecognizable person in the mirror had my nose, for instance. Then, over the course of a few days, I found my other eye, then my forehead, then my mouth. Finally, I recognized myself entirely. It was really weird, though! Now I know what it must be like to lose your memory or forget your childhood.”

“That must have been a scary experience,” I said.

She laughed. “I guess so. It all turned out fine. I’m doing
great now.”

I tried to imagine what else had run through her head at the time. Will I get better? Does this happen to everyone? Why didn’t the doctor warn me about this? What if it gets worse?

Now, several years of cancer-free existence later, she still tells the story with great enthusiasm. Those days when her memory did not work remain very fresh in her mind.

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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

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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

I was just reflecting back on my liver Transplant. I celebrated 5 years on 9/15/2011. I owe that to Dr. Adams and the Froedtert Transplant Team. I thank them deeply for what they have done for me.

The first time I met Dr. Adams was for my interview to get onto the transplant list. He was very intimidating, I was SO nervous. I later find out that he is not so intimidating and that he has this face he puts on just so the paitients know he means business. I also found out he was quite a practical joker. I never knew that side but I heard a few stories.

In the days after the transplant he would come to my room with his little entourage of students and examine me and ask a few questions. By the 7th day I was asking him timidly if I could go home. "Sorry, not today". By the tenth day I was not so timid and just wanted to get out of there. This time I begged, "Please, please, please can I go home. He said Yes and I let out a howl and wanted to hug him right there and thank him for all that he had done. I guess that would have been a little awkward in front of his students.

I wish I would have known more about him when he was alive. Thanks to him, I"M ALIVE. I'm sure there are many more patients out there that feel the same way. God Bless Him and I'm priviledged to have known him.

- Wendy Childers

I was a young teenage boy when I first met Dr. Adams. I had had a kidney transplant performed by another doctor. several years before (1987) and at that time, I was one of the first children to receive a kidney transplant at Children's Hospital of Wisconsin. At that time a lot of things were very new and experimental. I went through a couple rejection episodes which were treated with experimental drugs at that time. These caused some very unpleasant side effects. Day after day doctors would tell me "You can go home tomorrow." Well, tomorrow would come and numbers in my labs wouldn't cooperate, so I'd have to stay. After 49 days in the hospital, I finally was able to go home. Well, that transplant lasted four and a half years when it failed not because of rejection, but because of an obstruction. It was making urine, but it would "backup" and not make it into the bladder. I was on dialysis from 1992-1995. Remembering the events that took place during my transplant, I did not want to go on the waiting list for a new one. I waited about a year or so and my mother really wanted me on that list. We set up a meeting to talk to Dr. Adams for talk to him about going on the list. I was very vocal about not wanting to be on the list. My mother expressed to him that she wanted me on the list. Being that I was a minor, she pulled rank. but Dr. Adams told her that he was hesitant in putting me on the list because of my attitude on the subject. This frustrated my mother because she was the parent and my decision was being considered and not hers. She understood the doctor's position though. She explained to him that my decisions was based on fear from the last transplant and that once he had another one, it would be worth it and not a waste (he thought I would care enough take care of it properly if I did get one.) After some arm twisting, I decided to tell the doctor that I wanted to go on the list. I was on that list for a very long time. A nurse told me that one day she was in church and had a prayer said for me to receive a transplant soon due to many complications I was having with the dialysis. She was the one that received the call on Good Friday of 1995. The kidney was from a young lady who was killed in a car accident. The kidney was severely bruised and would normally not be used for transplant. Dr. Adams didn't pass this opportunity up for me because he said this kidney is a very good match me and it will probably heal in my body. That was in 1995. This April (God willing) I will have had this kidney for 17 years and if it wasn't for Dr. Adams, it would have gone unused in fear it was no good. It's been pretty useful for me. Thank you Dr. Adams. I am proud to be one of your success stories. You truly made a difference in many peoples lives. I'm glad mine was one of them..

- Bryon (B.J.) Nelson

My Mom had a kidney transplant back in 1984. This kidney has lasted her 27+ years. Thank you Dr. Adams for giving life back to my Mom.

- Cindy Burg

Cancer at the Holidays

Mon, 19 Dec 2011 14:07:28 GMT

"Do any human beings ever realize life while they live it? ---Every, every minute?"
-Thornton Wilder

His cancer was growing and his symptoms were progressing alarmingly. As holiday music played in the background, I searched the calendar to see how rapidly his surgery could be scheduled. The young man and his wife first looked relieved when we found a surgical opening in the coming week, but their faces fell as they realized that he would spend December 25th in the hospital. Family plans were to be put on hold that year. The future was uncertain.

It has always seemed to me that "cancer" causes more life disruption during this time of year. The quickened pace of life and the family expectations, particularly when small children are involved, push people to their limits.

On the other hand, it has been my experience that the holidays bring out the best of the people who work in hospitals. This is especially true of those who provide cancer care. While some clinics might slow down a bit, the Cancer Center clinics seem to be open and busy.

During my days working as a hospital nursing assistant and then later in medical school and residency, I always enjoyed being in the hospital on the actual holidays. Maybe it was because everyone was resigned to being at work instead of at home with families, but the interactions with even the crankiest staff members seemed unfailingly positive. Everyone was more cheerful. And, of course, as we went about our duties, we kept on the lookout for leftover treats and plates of cookies.

As cancer care providers, we are privileged to work with patients and families at the most stressful moments in their lives. Cancer can bring incredible focus, just as the holidays can prompt us to remember what is truly important in our lives and in our relationships. Maybe our calling to be "healers" is reawakened most effectively in December.

Happily, my patient recovered from his holiday cancer surgery. Over the following years, we reminisced about the first few days after his cancer diagnosis. It was a Christmas week that he and his family would never forget.

Happy holidays to one and all!

Shortages

Sun, 04 Dec 2011 01:26:06 GMT

Neither fear the problem – nor trust the solution – too
much.
-Paul Ramsey

The headline was clear: the United States is headed for a worsening physician shortage. The Wisconsin Hospital Association and the Association of American Medical Colleges both confirm that Wisconsin and the United States have a shortage of doctors and they predict a deepening hole, particularly in primary care specialties. The solution is not at all obvious; although medical schools can increase class sizes (and UW-Madison has recently done just that), much of the bottleneck is at the level of Medicare-funded residency training positions. The realities of the federal deficit and the looming Medicare crisis make additional funding for training slots very unlikely. Things look bleak.

As I was mulling over this predicament, I heard a story on National Public Radio describing a self-sustaining mission hospital at the southern tip of India devoted to eye diseases and to sight restoration. The reporter interviewed an ophthalmologist about the logistics of her operating room. All day long, the staff readies the next patient for her while she is performing surgery. As soon as one operation is finished (each taking about 10 minutes), she turns her chair, adjusts the microscope, and proceeds with the next. She continues moving back and forth, one after the other, completing as many as 40 cases each day. Each ophthalmologist at the hospital performs as many as 2,000 cataract surgeries yearly. By comparison, a busy U.S. ophthalmologist performs 125 cataract operations each year. The report did not discuss it, but I assume that the Indian doctor does not stay up all night completing her dictations, filling out insurance forms, and electronically signing her charts.

I am frequently amazed by the amount of time my U.S. colleagues and I spend on tasks that drag us away from providing direct patient care. For example, in response to fraudulent Medicare claims, every home-care form and prescription now requires, by law, a physician’s handwritten signature and date. The threat of billing audits obliges me to include long, irrelevant, never-read passages and specific wordings in already cluttered medical record progress notes. In the name of privacy, electronic records time-out every few minutes and I spend many hours each year simply waiting for double-password-protected medical records and images to pop up on computer screens. In the name of patient safety, hospital charting requires every signature to be accompanied by both a handwritten date and time.

Each little delay, log-in, new requirement, interruption, signature, authorization phone call, form, and re-typed password consumes just a few seconds, but, of course, these moments add up. When combined with all of the moments spent by physicians and health care workers across the country each day, the amount of time consumed is not trivial.

Having recently glimpsed inside several hospitals in East Africa, I believe that the overwhelmed doctors there would love to have "shortages" like ours. There are, of course, no simple solutions to the challenges facing the African health care systems, but consider: There is one physician for every 360 Americans. By contrast, Kenya has one physician for every 7,600 people, and Tanzania has only one physician for every 24,000 people.

Disturbing, too, is the news that "[a]bout one-fourth of the primary care physicians now practicing [in the United States] are graduates of foreign medical schools." Our shortage in primary care is siphoning off the best and brightest from some of the countries that can least afford to see their young doctors depart.

So, can an eye hospital in India that routinely screens 2,000 patients each day tell us a thing or two about efficiency? Is it possible that the East African non-physician Assistant Medical Officers can share some insights into how to take better care of our expanding population of elderly with chronic, stable conditions? What can we do to help the developing countries improve their health care outcomes without plundering their talent?

The problems — First World vs. Third World — are very, very different. At the very least, we should be able to discern better ways to help them cope with their overwhelming needs. We, on the other hand, must find ways to better utilize people who now spend their days typing notes, signing forms, constantly logging back into computerized record systems, and waiting for the opportunity to get back to seeing patients.

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Hi Bruce - I can appreciate your frustration and hate to see medical professionals hindered from providing all the hands on medical care they trained to do and prefer ...versus handling the sea of paperwork, etc., they are continually inundated with. And speaking from the patient perspective ...I think it is both sad and frustrating that the patient-physician relationship is compromised due to time constraints because of regulations, insurance requirements, technology, etc.

I miss being able to chat with my former pcp. He had to close his practice last March (still in prime) because of expensive overhead and low insurance reimbursements. :(

It would be interesting to hear how these other countries are able to see/treat so many patients. And would be great if all countries could incorporate the best ideas from other countries into their health care systems/practices.

- SeaSpray

Boxes and Hyenas

Wed, 02 Nov 2011 14:24:52 GMT

My humanity is bound up in yours, for we can only be human together.
-Desmond Tutu

Death is more palpable in this place. We make rounds in the large open wards of a District Hospital in western Kenya. Each bed often holds two people. The sheets are thin. The room is warm despite the open windows and the flies come and go. Mosquito nets hang in tight balls above each bed.

We are "wazungu" — white people — even though some of our team is African-American. The Kenyans often believe naively that we are somehow better able to cure their illnesses. I know essentially nothing about the medical management of untreated malaria, tuberculosis, typhoid, or HIV/AIDS and everyone here has one, two, or three of these diagnoses.

One man does not look up when we our group passes.

The man’s vacant eyes do not focus. He is gaunt yet his skin is taut — perhaps he is young. He is dead — no — wait — he breathes, but barely. The woman sitting next to him on his bed looks up at us but says nothing.

The nurses are friendly but they lack the most basic supplies. The patients here are relatively fortunate because they — or someone they know — can afford the dollar per day charge for the bed or the cost of IVs and antibiotics. Most Kenyans never come at all.

As our vehicle leaves the hospital compound, I scan the businesses that line the road. Young men sit next to huge piles of shoes and T-shirts. Battered shipping containers have been converted into small shops and restaurants — called “hotels” here — but they all appear forbidding.

A furniture store catches my eye. There are a few tables out front but, as I look more closely, I see that the tables are actually handmade coffins. These are ribbon-bedecked, freshly-constructed coffins that wait for the young man we just saw up the road. Small boxes wait for the child nearing death we met on the Pediatric Ward. As we travel, I notice other coffin stores and I believe they are clustered near the hospitals. The small cemeteries we see in the cities and rural zones are all well-tended.

I think back to our time on safari driving across the Maasai Mara — the vast expanse of grassland in Africa’s Rift Valley that supports the giant migration of animals each year. Predator and prey, Life and Death – “The Circle of Life” of which we taught our children as they sat transfixed by The Lion King. “Animals die and that is sad,” we told them, “but in death, life is sustained.” They nodded in apparent understanding.

The Maasai Mara often stretches to the horizon. I ask our guide, who is not Maasai, about the people who live there. They are nomadic, I recall, so what do they do with their dead?

His eyes narrow and he stares at me. “Did you see any cemeteries all the time we were out on safari? Did you?” I try to recall. No, I don’t think so. The Maasai live exposed and difficult lives. They don’t survive long and 40 is “old” for the people of western Kenya. No, I saw no cemeteries.

“The Maasai – they carry their dead outside of the compound at night and leave them in the bush for the scavengers.” I catch my breath. “The ancestors of the Maasai,” he tells me, “they are in the belly of the hyena.” He lets that sink in. “The hyena,” he repeats. Then he falls silent.

This is not the "Circle of Life" image I shared with my children when they were young. I spot another row of coffins back in town. They are beautiful despite their ultimate purpose.

We return to the place where we are staying. The sky glows bright orange. Back at the District Hospital, the lights are, no doubt, flickering as the power fails yet again. A man  whispers “asante sana” — thank you — as a nurse tucks the mosquito net neatly beneath his mattress.

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Haunting. Thank you for finding the ironic and hidden beauty in this place of seeming deprivation.

- Merry Sebelik

You are a gifted healer and author, how important it is to recognize that each circle of life is related to the other circles we are privileged to be a part of.

Asante sana Bruce,

- Aleta Chossek

Dear Aleta,

Thanks so much. I feel fortunate to have had the exposure to the health care issues in Tanzania and Kenya. It put our "first-world problems" into perspective.

-Bruce

The Comfort Zone

Mon, 24 Oct 2011 08:08:31 GMT

Traveling makes one modest – you see what a tiny place you occupy in the world.
-Gustave Flaubert

We have come to Kenya, expecting to work outside of our “comfort zones.”

Our patient has arrived from miles away, riding on the back of her husband’s bicycle. She has an enlarging, bleeding mass growing off of the side of her neck. There are no pathologists available, so we are uncertain what kind of tumor it is, although it appears to be a cancer. She has been wearing a scarf to hide the mass for the past year; her head covering is speckled with blood.

We are anxious. Unexpected things can happen in an operating room this far from home. We expect the local power will fail several times each day. The OR team members come from different hospitals and we barely know each other. The operating room will be sticky and warm despite the air conditioner. None of us has ever worked in an OR that has two operating tables in the same room. Some of our favorite technologies are missing. And like many Kenyans, the patient has had no access to regular medical care, and there are things we do not know about her medical history.

Surgery is a complicated, dynamic, choreographed variety of chaos, and this unfamiliar environment magnifies the potential for catastrophe. The circumstances here are starkly unfamiliar. Back home, it takes months for team members to learn each other’s routines. We do not have the luxury of time. We introduce ourselves.

The patient is moved to the operating bed and is soon asleep. Our surgical team starts slowly but picks up steam. We build up confidence and the case develops a flow. When things become difficult or unfamiliar, our routines are cast aside and we work around the obstacles. The lights flicker off, but the battery powered headlights work just fine, and the anesthetist squeezes the bag until the ventilator again has power. Before long, things feel familiar and safe. The tumor is removed, the stitches are placed, and the patient moves to the recovery room.

Like all of the Kenyans we encountered, she is grateful and gracious. I, too, am grateful for the team that is here. Our surgeons, anesthetists, and nurses perform 25 operations and see 1000 clinic patients over three days. This place has turned out to be a comfort zone after all.

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May God bless you for what you're doing Dr. Campbell!

- TGWisconsingirl

Thank you for bringing this story "back home" so we can all learn a bit of what you learned. Your writing takes me there in a small way. I can only imagine.

- Kathy Myers

When it Clicks

Wed, 31 Aug 2011 15:51:26 GMT

We do not remember days, we remember moments.
-Cesare Pavese

One of our children recently started medical school. The realization that my son has taken the first steps down the same path I began long ago has yet to fully settle in me.

Most people immediately exclaim, “You must be so proud!” and, of course, we are. We are enormously proud. He has worked hard to arrive at this point. He has been dedicated. He truly understands the concept of delayed gratification. Having grown up in a medical family, it is still quite remarkable that he applied to medical school in the first place.

Some physicians have been less encouraging. “What was he thinking? I would never let my child be a doctor!” The unhappy ones cite how the practice of Medicine has changed, be it Medicare, declining reimbursements, HIPAA, politics, commercialization, interference with “the doctor-patient relationship,” or the burgeoning documentation requirements.

As physicians, we are often reminded that our profession is partly to blame for our country’s unsustainable growth in the cost of medical care, and we are painfully aware that many of our patients are one serious illness away from being homeless. We have spent our careers at the front lines of this mess and now the next generation, including my own son, will be thrown into the fray.

So, it makes me pause and wonder: Why are people still attracted to our profession? And why do I still love it?

Medical school aspirants often declare that they dream of “having a real impact on people,” or “making a difference every day.” Those sentiments reflect the narrative we continuously tell ourselves. Some days, I doubt the dream. Nevertheless, I still find it remarkable that even basic medical encounters can offer intense person-to-person interactions that do not exist in other vocations.

Of course, there are times when clinical interactions leave either the doctor or the patient disappointed. No one is happy.

“He missed my cancer for months, despite what I told him about my symptoms.”

“She would feel better if she would quit smoking and lose weight, but has made no meaningful attempt to change her old habits.”

“I have spent a small fortune on tests and treatments and feel worse than ever.”

"She never even filled the prescription.”

“The doctor didn’t look at me, never examined my sore leg, and spent the entire visit typing on her computer.”

"He missed half of his appointments and never called to reschedule.”

“He interrupted me before I could even tell him where I was hurting.”

“He never let me help him.”

Despite it all, though, there are moments when everything clicks. Not long ago, in the middle of a busy morning clinic, a once-terrified cancer patient returned for a five-year check-up and gushed about how great she felt. I remember several times where I experienced a rush of satisfaction in the operating room as a cancer was finally freed up and successfully removed. I was once overwhelmed while reading a letter from a family member offering heartfelt thanks for the care I had provided to her dying sister. These are the moments that have kept me coming back for more.

Other professions, of course, have their own special moments. The satisfaction a baseball slugger feels when he connects on a 450-foot home run probably makes up for years in the minor leagues. The pleasure a pro golfer feels when she realizes the 40-foot downhill putt is going to drop into the center of the cup certainly makes the hours on the practice green worthwhile. The growing chant for an encore ringing through the auditorium makes life-on-the-road bearable for the rock musician. My moments, by comparison, are small and private, yet, I would never trade them.

So, to the MCW Class of 2015 (my up-and-coming colleagues), I hope you keep your senses constantly on alert for those fleeting glimpses into why Medicine is still a thrilling calling. Congratulations, David, and welcome.

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As your direct descendant, I imagine he will be an AMAZING doctor. (No pressure, David!) Congratulations!

- Lucia

Separating Primary Care from Cancer Care

Tue, 05 Jul 2011 15:33:52 GMT

Over the past few months, my cancer patient and I have spent much time together. At the first visit, we discussed her new, frightening diagnosis. Subsequent visits involved reviewing tests and scheduling surgery. I saw her daily during her time in the hospital and a couple of times during her difficult weeks of radiation therapy. Her life has been turned upside-down, but she is a survivor. She is starting to look, once again, toward the future.

“I will keep sending copies of my progress notes to your primary doctor,” I say, checking the computer screen and reminding myself who she sees for her general medical needs. “Dr. Johnson has been getting reports since we first met.”

“Oh, I haven’t seen Dr. Johnson in months!” she tells me. “I have been so busy with my cancer doctors that I just haven’t had time. By the way, would you be able to refill my hypertension medications?”

Now, I am getting uncomfortable. My knowledge of hypertension medications is outdated and I am convinced that the loss of regular contact with the family physician or internist is a frequent and unfortunate side effect of cancer treatment.

This impression was recently confirmed for me at the Wisconsin Cancer Survivorship Forum. The survivors shared their reasons for this:

First, cancer patients are busy. Active treatment involves frequent hospital visits and people’s lives are busy. One more trip to the hospital or clinic is often out-of-the-question.

Second, cancer patients are focused. Who has time (or money) to worry about cholesterol or health maintenance when she is battling cancer? The other problems can wait!

Third, we tend to separate PRIMARY care from CANCER care. Elaborate buildings are designed to be self-contained and specialized cancer center spaces. Marketing efforts attract new patients. Referring physicians are educated to send patients with worrisome symptoms or new findings for evaluation — and “the cancer center” will take care of the rest.

Fourth, primary physicians no longer feel comfortable caring for cancer as they might have done decades ago. While we do not expect our personal doctor to refer “routine” diabetic or hypertensive patients to specialists, we would never expect our family doctor to oversee a course of breast or prostate cancer treatment.

I worry about the separation of primary care from cancer care. Primary physicians really do take better total care of patients.

The ultimate goal of successful cancer care should be to transition survivors back to their primary doctors — a process that requires education of both the patients and their doctors. These are responsibilities that not every primary physician will want to assume and not every patient will want to assign.

Cancer survivors are best served when they continue to see doctors dedicated to caring for every aspect of their health, whether that happens during treatment or later. To me, it just makes sense.

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Your post is right on the mark! I have been bringing my lifelong friend to her treatments and other appointments for lung cancer. Everything else does fall by the wayside.

And pcp's do get to know their patients and are familiar with so many aspects of their medical needs vs specializing.

As a uro patient who has been on a roller coaster ride of ups and downs because of how it all turned my life upside down, etc ..I have sometimes thought to myself that I don't even think of the rest of my body. You forget you have other organs and things that should followed with a pcp. I am good about it, but just don't have the same focus as the *hangnail that hurts at the time*.

I wonder if she *possibly* has grown attached to you (since I know from your writing how compassionate you are) and because she looked to you for so much during this life threatening time ...it may be a way to stay connected to you? or not. :)

Sadly, my dear pcp had to close his practice (still in his prime), because he couldn't keep it going as a solo practice with expensive overhead and reduced ins premiums. :( I do have a new one and believe he will be excellent for us, but no one can replace my first one.

Sorry so long - your post touched me on many levels.

- SeaSpray
http://seaspray-itsawonderfullife.blogspot.com/

I really enjoyed this entry as I do all of them, although as someone with a lot of health problems my primary doctor told me she would actually rather have my specialists take care of everything. It seems like she's afraid to touch me with a 10 foot pole. It's a good thing I have such great specialists at Froedtert!

- youngwisconsingirl

Hi Bruce! I just came across your blog, courtesy of KevinMD. You are right, of course, about cancer care sucking patients into an orbit that excludes the PCP. And, you're right that it impairs the overall quality of the healthcare the patient receives. If consultants in cancer centers worked to prevent such happening it likely wouldn't. But, it would require sharing simple cancer care regimens with PCP's who might not want to do it. Solutions are always harder than identifying problems, aren't they?

- Bob Condon

A Report from Ground Zero in Joplin

Thu, 02 Jun 2011 11:51:15 GMT

My father grew up in southwestern Missouri about 25 miles east of Joplin, the site of the devastating tornado on Sunday, May 22, 2011. We visited the region every year to see family and spend time with people my dad had known and loved.

Over the past two weeks, I have thought many times of the gentle people I met in the communities near Joplin.

This essay, written by an Emergency physician who was on duty when the hospital was destroyed, is a remarkable piece of writing that reflects the character of the people who live and work there and whose lives have been forever changed.

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Disruption

Wed, 01 Jun 2011 09:23:09 GMT

Make it a rule never to be angry at anything a sick man says or does to you.
-Benjamin Rush, MD (1809)

Thirty years ago, I heard dozens of stories about a memorable doctor. His daily outbursts in the hospital were legendary. No one wanted to get in his crosshairs, so people scattered when he was spotted coming down the hall. As soon as he burst into the ICU, it was chaos. Minor bedside procedures always included an extended rant directed at his assistant. He threw instruments, clipboards or charts across the room when answers came too slowly or were not what he wanted. The overworked nurses and young students with whom he interacted were usually close to tears when he finally stormed out. For all of the time I worked in that hospital, his behavior was tolerated. He was a big shot, after all.

Why would any adult treat other people this way? Why didn’t someone do something?

I suspect the doctor justified his behavior by claiming he was only trying to protect his patients from incompetent and lazy help. He probably had been trained by someone who behaved in exactly the same manner. I suspect the hospital leadership had few tools to deal with an otherwise invaluable staff member who had a knack for regularly throwing everything into upheaval.

Many years have passed, and the problem of disruptive doctors has not disappeared. A recent survey of a very small sample of medical leaders indicates badly behaving physicians still exist in hospitals of every size and locale. The most common types of disruptive behavior still include degrading comments, insults, refusal to cooperate with other providers, refusal to follow established protocols, yelling, profanity, inappropriate jokes and incompetence. Throwing objects and physical assaults are rare, but are reported.

Interestingly, about a quarter of the physicians who responded to the survey admitted they had been disruptive at one point in their careers. The most common justifications the physicians cited for their own disruptive behaviors included workload issues and falling back on behaviors learned years before from role models. They also blamed other health care workers, non-work related pressures, hospital policies, the patients or reimbursement issues.

The list of "justifications" is telling — the physicians were routinely able to identify another person or an external source for their behaviors. As my kids sometimes told me years ago, it just wasn’t their fault.

David Brooks, in a recent essay entitled The New Humanism, reminds us we all benefit when we develop characteristics that help us work better in groups. We are our best as human beings when we strive to be closely attuned to each other, see the "big picture" patterns in our worlds, and find ways to work effectively and sympathetically with others. Individuals thrive when we are able to “serenely monitor the movements of one's own mind and correct for biases and shortcomings.” A tall order, but critical in the hospital and clinic, where other people’s lives are in the balance.

As we prepare the next generation of physicians, we pass along medical knowledge and procedural skills, but we must also seek to develop each young doctor's ability to be insightful and compassionate. None of us wants to be remembered like the old, cranky, profane physician I witnessed many years ago who put his patients at risk, all the while thinking he was helping them. It was just plain wrong. We can do better.

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The following is feedback received for this blog:

Great article Dr. Campbell! Having worked with you years back I can honestly say you are one of the true Humanitarians yourself! You're time and willingness to "hear" patients sets you apart. You are compassionate and kind. It has been a gift to have had the opportunity to work with you and I'm so proud to know that physicians like you are out there!

- Jane Leuzinger

Bumps in the Road

Tue, 17 May 2011 08:25:46 GMT

The best laid plans of mice and men often go awry.
-Robert Burns

Her eyes were lowered, and she would not meet my gaze. I was certain I knew why.

I skimmed her chart and reviewed my notes. “How have you been doing since your last clinic visit?” I asked. She finished her cancer treatment about a year ago and was doing fairly well. Her recovery was slow but steady. Her swallowing was gradually improving. Her weight was stable. She reported no new problems at the last few check-up visits. Everything was going fine except for one issue. Even after being treated for cancer, she had never been able to quit smoking.

Last time, she declared she was finally ready to quit. She decided she didn’t want to try any of the medications to help with smoking cessation. She didn’t need the Quit Line phone number (by the way, it is 1-800-QUITNOW). She knew smoking caused her cancer and was bad for her — no need for another lecture. She would just quit. She had a timetable all mapped out and made a solemn promise to quit later that month.

Now, about four months later, she was back for her next visit. I could smell the tobacco smoke on her clothes as I examined her.

“Still smoking?” I asked. “Ready to talk again about quitting?”

I was expecting the usual litany of excuses. Sometimes, people blame their families for leaving cigarettes around the house even when they are trying to quit. Sometimes, they say they were doing just fine until they went out with a friend for a drink or two. Most times, though, they never quite got around to quitting in the first place.

“I’m sorry, Doctor. I really am. I did quit for a few weeks but then started again.”

She paused and then continued.

“Remember the big guy with the Green Bay Packers jacket that always came to my appointments? My husband? Remember him? Well, he dropped dead of a heart attack about a month after I quit smoking. It has been a hard time; real hard. I went out and bought a pack of smokes the day of the funeral. Maybe I will quit again. I don’t know.”

We sat quietly for a while. My prepared speech was on hold. I had assumed she was not meeting my eyes because of her continued smoking. I had been wrong.

We talked about her husband and her family. I reassured her there was no sign of cancer. Encouraging her to quit smoking will have to wait for another day.

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Being "Oprah-ed"

Thu, 12 May 2011 08:48:55 GMT

I'm just trying like everybody else. I try to take every conflict, every experience, and learn from it. Life is never dull.
-Oprah Winfrey

She sits in the exam chair with a list of questions, her gray hair falling out from beneath her hat. I remember her from last year. At the time, I had spent time reassuring her that everything was fine and that she was at no risk for oral cavity cancer. "I just feel so much better when I hear you say that!" she tells me again. "You just never know. I’m certain that Michael Douglas never suspected he would get cancer, either!"

Each May, we host a Head and Neck Cancer Screening event along with dozens of other hospitals and cancer centers around the country. In the early days, our nurse, Kathy, and I would set up our equipment in the corner of the sales floor at the former Small Stones store near the campus. The first year, we screened about 20 people. It was always fun (seeing healthy people always is), but we never identified anyone with cancer. The events are really a moment of community. Mostly, we answered questions about related (and very unrelated) topics.

That is not surprising, actually. Head and neck cancer is rare, with only 40,000 cases per year in the US. In addition, people who attend free public screenings tend to that take pretty good care of themselves and are not in the demographic most at risk for these cancers.

Interest in our head and neck cancer screening event exploded this year. Michael Douglas, the most famous recent survivor of head and neck cancer was on Oprah two weeks ago and spread the word about the need for people to undergo screening, telling people to go to the website and call for an appointment at their local screening site.

Before the Oprah show, we had about 10 people registered for the event. Within two hours, there were 96. By noon the next day, we had 90 more on the waiting list. We cut off the list after that. It was, as they say, crazy. Our people whose phone numbers were linked to the event can confirm that the potential impact of the media is remarkable. Oprah’s support for this cause has, for the moment, raised awareness all over the country.

Of the 100 registered, about 75 actually showed up to undergo screening, learn about dental issues, talk with experts about hearing loss, and discover a bit more about head and neck cancer. I do not think we identified any new cancers but more than a few people smiled when they were assured that everything looked fine. And almost everyone told us that it was all because of Oprah.

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The Survivor Center

Sun, 24 Apr 2011 15:06:28 GMT

My new patient and his wife have entered the “cancer world,” a place where nothing is familiar. He clutches a self-help book but mostly sits in stunned silence.

“We never even thought about cancer before!” his wife tells me. “Never! We knew nothing about it until last week when the doctor gave him the diagnosis!” She pauses and looks protectively at her husband. “We have been reading nonstop ever since then. It is all so overwhelming!”

She has a pile of internet downloads and a notepad crammed with carefully numbered questions. Why did this happen? Shouldn’t the cancer have been discovered sooner? Are the kids at risk? These two internet sites have completely opposite recommendations! What about lasers and robots? What clinical trials are available? What tests can be performed today? Can he have treatment closer to our home? Our daughter is getting married in three months! The side effects described on this site are terrifying! Can we start treatment tomorrow?

Initial office visits were very different when I first started caring for cancer patients in the 1980’s. In those days, people often arrived with no information and, sometimes, had not even been told they had cancer. Most people could, however, recall a family story about a distant relative who had suffered through treatment years before. “She developed a terrible burn and then died,” they would recall. “There is no way I will take any radiation!” Thanks to the internet, my task has shifted from providing very basic information to sorting out the competing information already encountered.

Cancer survivorship has also changed. Twenty years ago, survivors often felt completely alone, lamenting that they had no one with whom to share their concerns. Back in those days, a regular group of my patients met weekly just to talk. The group disbanded as survivors turned increasingly to the internet. Social media allow a 24/7 connection to survivorship sites, blogs, discussion boards, reflective writing and even survivor-created artwork.

What has not changed? The statement, “You have cancer,” still brings pain and fear. The reassurance, “You no longer have cancer,” can sometimes bring doubt and uncertainty. Patients are overwhelmed by the diagnosis, the well-meaning advice, the tests, the treatments, the appointments and the information overload.

Not long ago, I realized that I see about four times as many people for follow-up visits as I do for initial visits. In other words, I see many more people who have been cured of cancer than I see people who have cancer. For every patient who needs a plan of cancer care, four will need a recheck and encouragement. For every patient needing teaching about what is to happen next, four will need reassurance the things they are experiencing are common for other survivors as well. For every patient scheduled for surgery, I will try to help at least four leave behind their fears.

My new, anxious, overwhelmed patient will complete his cancer treatment in several weeks. He and his wife will struggle through the ordeal and, once the treatment is complete, they will enter the “survivor world,” full of its own mysteries and overwhelming experiences. Our “Cancer Center” will become, for them, a “Survivor Center.” It will be a good place for us to meet once again.

_____
This post is reprinted from the Froedtert & Medical College of Wisconsin 2011 Clinical Cancer Center Special Report.

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Far From Home

Tue, 12 Apr 2011 11:17:26 GMT

When I hear somebody sigh, "Life is hard," I am always tempted to ask, "Compared to what?"
- Sydney J. Harris

I recently was privileged to hear Dr. Claire Wendland describe two groups of medical trainees.

The first was a group of medical students from the United States spending time in the sub-Saharan African country of Malawi. Each day, the students learned from their American professors and African colleagues. The students were surrounded by patients with diseases that they had previously encountered only in textbooks and lectures — malaria, untreated HIV/AIDS, the late stages of tuberculosis. Many patients had very advanced disease or long-neglected illness. The students were immersed in a medical system that relied heavily on improvisation. The medical facilities had inconsistent electricity, limited imaging studies and bare-bones laboratory testing. The students also noted that the Malawi hospital had none of the American obsessions with billing and record keeping.

The second group she described was the Malawi interns working at the institution the American students were visiting. The interns were very bright and, compared with their African peers, most fortunate. Because of the lack of technology, they had very well-developed physical examination skills. Their hard work and long hours were rewarded with a salary of $11 per day.

The next phase in the lives of the American students would include residency interviews to prepare for their careers. Many hoped they would eventually be able to pay off their burgeoning educational debts, some of which approached $200,000.

The next phase in the lives of the Malawi interns would include assignments in rural health clinics and a slim possibility of obtaining a residency. Many would be willing to accept any opportunity to train and work in America or Europe.

The students from America envied the Malawi doctors their finely honed skills and their chance to practice medicine “closer to its roots,” free of bureaucracy and paperwork.

The doctors from Malawi envied the American students their unlimited opportunities and the chance to practice medicine with the latest in technology, devices about which the Malawi doctors had read but had never actually seen.

Both the American students and the Malawi doctors thought that the other group was very fortunate. You see, each group wished that they could spend their working lives in an environment where they would always be able to have the “real doctor experience.”

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The Doctors' Dining Room

Wed, 06 Apr 2011 11:08:26 GMT

What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others. (attributed)
- Pericles

Before I went to medical school, I worked as an orderly in a private hospital. It was not glamorous work, but I loved the people. It was there that I had my first glimpses into the joys and sorrows of Medicine.

Like most hospitals in the early 1970’s, ours invested few resources on amenities, technology, or marketing. Patients stayed many days or even weeks for relatively minor illnesses. The X-Ray Department’s new, painfully slow CT scanner could only study the brain and was frequently out-of-order. The doctors, particularly the surgeons, were supremely confident in their skills, having been steeled by service in military hospitals in Europe and the South Pacific during World War II. The last remaining general practitioners finally gave up delivering babies, but they still set broken wrists, lanced boils, performed minor surgery, and made house calls.

In those days, each patient’s own personal physician managed his or her care whenever they were hospitalized; I remember seeing the internists and family doctors arriving early in the morning to make rounds before heading to the office. If they had six or seven people in the hospital, rounds would take a while. The physicians returned to the hospital before they went home in the evening, as well. On their days off, they made rounds only once unless someone was particularly ill.

The hospital’s cafeteria was nothing special. A single, long serving line ended as the cash register. The families and employees spilled from there into the large seating area with rows of Formica tables and plastic chairs. Long lines and crowds were normal at lunchtime.

A doorway off of the seating area led to the “Doctors' Dining Room.” Although I never actually entered, I often peeked in to see what was happening. Their dining room was less crowded than ours. Sometimes, there would be a lecture and, on those days, a table would hold free sandwiches, chips, and sodas. Other times, the doctors would be seated in small groups, talking and laughing. Some would have pushed their trays aside and, in those days, would be smoking cigarettes, using their dessert plates as ash trays.

I am a child of the 1960’s, and freely admit that the very idea of a “Doctors’ Dining Room” seemed elitist. Why did they get their own room? Why did they get a free lunch? It seemed wrong! We spent our lunchtimes plotting to crash their room and sit at their tables. We never did, of course.

Perhaps, in retrospect, the “Doctors' Dining Room” was elitist. However in those days before HIPAA, the room provided a safe place for doctors to discuss patients without risk of being overheard. Before the Internet, it was the only place besides the ancient hospital library where a physician could gather information or pick a colleague’s brain about a difficult case. Before the pharmaceutical companies allocated astronomical budgets for marketing to doctors and the public, the room was the only place where a busy, solo practitioner might learn about new medications.

I returned to the old hospital a few years ago to visit an old family friend. After the visit, I stopped by the cafeteria. The serving line had been broken up and rearranged a bit, and there was now a short-order grill, a Grab-and-Go counter, and a salad bar. After paying for my meal, I stepped into the dining area and was transported back in time. I immediately noticed, however, that the wall between the seating area and the “Doctors’ Dining Room” had been removed.

The cafeteria was not crowded and I intentionally found a table in the area that had once been off-limits. As I looked around, I reflected on my journey since my days working at that hospital. I gratefully remembered stories of many of the old physicians who had once gathered in that space. Thanks to them, I am still learning each day of Medicine’s joys and sorrows.

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The Tattoo

Wed, 23 Mar 2011 14:25:28 GMT

Regret for the things we did can be tempered by time; it is regret for the things we did not do that is inconsolable.
-Sydney J. Harris

The images were dramatic. I spent a moment studying the skull, the loops of barbed wire, and the tapestry of violent illustrations that were visible on the young man’s chest and shoulders. This must have sent a message to anyone who saw them. More pictures disappeared underneath the hospital gown that had been draped over him.

Over the years, my patients' tattoos have definitely become more elaborate. When I was in training, older men often carried blurred, fading World War II-era souvenir images of sailing vessels, pin-up girls and birds. Somewhat younger men had blue daggers and women’s names etched on their arms.

As the culture changed, more and more patients displayed an ever expanding range of detailed and colorful images, phrases and symbols. I have also spotted spelling errors and some images that have probably served as permanent reminders of world-class lapses in judgment.

I rarely ask my patients about their body art. In my experience, tattoos are rarely conversation-starters like, say, a logo jacket or a carried book. If your favorite team proves to be a disappointment, you can change sweatshirts. Not so with body art. A sexy woman in a 1940s swimsuit looks somewhat incongruous on the bicep of an 85-year-old man. Since I can never know if the person regrets or celebrates the decision to get the tattoo, I usually leave the discussion alone.

Nevertheless, the artwork often makes me stop and wonder. What was she thinking? What does that particular image mean to him? Does that picture say something special about this person? Is there one image or statement that I would ever want to define me for the rest of my life? Wow! Didn’t that hurt?

The tattooed young man in his early 20s was brought to the operating room and we gingerly transferred him onto the table. His gown was unsnapped and folded down before we cautiously removed the hard plastic collar encircling his neck. The nursing staff carefully washed the skin of his neck and upper chest with sterilizing solution. There were several abrasions from the motorcycle accident that had recently broken his neck.

We started placing the sterile drapes before performing his tracheotomy. As we did so, I noticed that many of the images were only barely outlined and most of the colors were only partially filled-in. Much of the artwork had been left unfinished, apparently with plans to return to the artist another day.

I pulled the last of the surgical drapes into position. I wondered if he would ever see the images completed. His was a work in progress.

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What She Taught Me

Tue, 18 Jan 2011 21:58:32 GMT

Truth, and goodness, and beauty are but different faces of the same all.
-Ralph Waldo Emerson

A smile filled her face eternally and she seemed incapable of ever being self-conscious. Despite that, the first time she arrived at my office for an appointment, my eyes were drawn — not to her smile or the twinkle in her eye, nor to the stark whiteness of her upper denture — but to the surgical scars crisscrossing her lower face and cheek. Each crevice darkened and became more distinct whenever she worked the few remaining muscles into a laugh. The lines glowed. “Here we go again!” she would chuckle. “Heading down that cancer road once more!” She would shake her head and close her eyes but keep on smiling.

After that first office visit, I plowed into the paper medical records that she had assembled. Reviewing her old chart was an archeological expedition marked by the hieroglyphics of an earlier era. Many of the doctors listed had long since retired or died.

The story slowly emerged. A tiny but slowly growing mass had first appeared in her cheek while Eisenhower was still president. When it finally became noticeable several years later, she had seen a surgeon. In his effort to remove the mass as completely as possible, he had rearranged her cheek skin and lips dramatically. “Thank goodness I was already married when I needed that surgery,” she chortled. “I was certainly a mess after that!”

Her cancer stayed quiescent for ten more years before she developed more swelling and discomfort. Surgery was followed by radiation therapy. She told me that it had been rough but had not slowed her for long.

Her life was a cancer life. She lived in an uneasy but cheerful balance with the disease — talking about it openly, knowing a bit too much about it, and realizing that it could reappear at any time.

My contributions to her cancer care did not diminish her deformities. Despite her appearance and challenges, she volunteered regularly at two museums. She distributed chocolates to everyone she knew each Valentine’s Day. She read books to children. She traveled. She kept busy. She moved about her world with purpose and pleasure, her face be damned.

Years later, after more surgery, another round of radiation therapy, and some futile attempts at chemotherapy, she announced with a smile, “I am finished now, Doctor. Don’t be mad, but I think it is time to let it go.”

A few weeks later, as I sat at her bedside in the hospice, she opened her eyes for just a moment. A glimmer of a smile escaped and washed over the fading wounds. Before my eyes, I noticed — not the scars — but the marks of her grace-filled and gracious life.

The following is feedback received for this blog:

Really, really touching tribute. Beautifully penned (as always)!

- Lucia

Yet another great entry Dr. Campbell. This one brought to tears to my eyes, just beautiful!

*Her life was a cancer life. She lived in an uneasy but cheerful balance with the disease - talking about it openly, knowing a bit too much about it, and realizing that it could reappear at any time.*

This hit me because it happens after years of dealing with cancer as a patient.

There are often times I think *cancer be damned* as well as face be *damned.* All the head and neck issues. I just make it point to move on and live life. Whats the point of surviving if you sit in the house and waste the time your given. Purpose grounds you and keeps you moving daily.

Thank you Bruce for writing such a beautiful tribute. It made me smile,cry and cherish the gifts and the hardships.

- Kerry
http://iftheresonethingiknow.blogspot.com/

Thanks, Dr. Campbell. You continue to help David and I to be better than we thought possible. You completely embody our ideals ; to provide compassionate, excellent care, in a 'real' person, to a patient we treat as a person, not a number. What an amazing mentor, even years later. Thank you. Our patients thank you as well...

- Lori Book
http://www.frendo.us

OK...you made me cry. I needed it. Thanks.

The Sign

Tue, 22 Feb 2011 07:55:04 GMT

“Give, give, give — what is the point of having experience, knowledge, or talent if I don’t give it away? Of having stories if I don’t tell them to others? … It is in giving that I connect with others, with the world, and with the divine.”
- Isabel Allende

My office is not unusual. Amid the clutter there are several special mementos and gifts received from patients and families over the years. Each one holds a story, brought back to life when I touch it again.  Several years ago, the sister of a long-term patient stopped by with a framed picture. We talked about her brother and his long battle with his cancer.

As her brother suffered through treatment and the effects of his relentless disease, the family sought to make sense of his impending death. He was, from my perspective, optimistic and unflappable. He understood what was happening to him and seemed to accept what was coming. We often discussed his situation as though it was happening to someone else. Everything was “rational” and “logical.”

His sister viewed life and its transitions differently. Shortly before his death, she told him to send a “sign” when he was safely “on the other side.” He smiled, but didn’t respond right away.

Sometime later, he came to her with an answer.

“Remember when you asked for a sign?” he asked.

“Of course,” she replied.

“A white butterfly.” She was confused. It was the middle of winter. She thought about the response and sought meaning.

Not many days later, he died. When she returned from the visitation, a magazine had arrived at her home; she flipped it open and there was an article illustrated with dozens of white butterflies. You can imagine her response.

She stopped by to give me a framed copy of the image from the magazine. I don’t know what to think of the story, but I know that I am filled with memories of the patient, his courage, and his family whenever I pick up the gift and study it once again.

Non-Frail

Wed, 12 Jan 2011 16:04:24 GMT

"If I’d known I was going to live this long, I would have taken better care of myself."
-Eubie Blake

He leaned forward, energetically listening to my conversation with his daughter. There was more than one cancer treatment option. We reviewed everything and she asked what he could expect with either a major surgery or seven weeks of daily radiation treatments. Soon, both the father and daughter were peppering me with questions about timing, quality of life, side effects, and expectations.

The conversation continued for several minutes while I did my best to answer each concern.

Finally, the big question emerged. The daughter took a breath. “Do you really think he could survive a big surgery, Doctor? After all, Dad is 90.”

Their eyes swung toward me. Here was a man who looked a lot younger than the calendar would predict. He still gets outside and walks every day and is fully engaged with his world. But, true enough, he has lived a very long time.

When I was first in training in the early 1980’s, we rarely operated on anyone who was over 70, thinking that "the elderly" were too likely to get very sick or die. Over the decades, as technology expanded and the population aged, the “ceiling” age climbed. Given the proper precautions, we found that we could safely operate on older and older individuals. We recognized that some of our patients were the “young old,” and some were the “old old.” It wasn’t very scientific, but it helped us make recommendations.

A recent article takes a step forward in assessing the risks of performing surgery on older patients. In a paper entitled “Frailty as a Predictor of Surgical Outcomes in Older Patients,” Makary measured “frailty” in almost 600 people over 65-years-old who were preparing to have surgery. What constitutes “frail?” The researchers looked at five factors:

More than 10 pounds of unintentional weight loss
Decreased measured grip strength
Exhaustion as shown by the patient’s agreeing that “everything I did was an effort” or “I could not get going”
Reported very low leisure-time physical activity
Very slow walking speed (for example, 6 seconds to go 15 feet)

Patients who had four or five of these characteristics were “very frail,” while patients who had two or three were “intermediately frail,” and patients with none or one were “non-frail.” The higher the preoperative frailty score, the more likely the patient would suffer a surgical complication, require a longer hospital stay, or be discharged to a facility of some kind.

Fortunately, my patient was in excellent health and remained very active. Despite his age, he appeared to be a great candidate for surgery. Soon, he had signed the surgical consent and picked a date for his procedure. Everyone seemed satisfied.

As I opened the door to leave, he stopped me. “Doctor, I realize that I can have the surgery. Thanks for that. I trust you. But, Doctor,” he paused, “should I have the surgery? I am 90-years-old, after all!”

That, of course, is a completely different question. “I am quite certain you will do well,” I told him. “Would you like to think about this for a few days?”

He and his daughter went home and discussed things with the rest of the family. When he returned for the surgery a few weeks later, he was relaxed, ready, and as “non-frail” as they come. It was a good day.

The following is feedback received for this blog:

That was a very touching story. Thank you as always Dr. Campbell, it's always a joy to read your blog.

Hi Dr Campbell - beautiful post.

I learned some things too.

Glad you both had a good day in the OR. :)

- SeaSpray
http://seaspray-itsawonderfullife.blogspot.com/

The Reminder

Wed, 15 Dec 2010 06:09:14 GMT

People are never more insecure than when they become obsessed with their fears at the expense of their dreams.
-Norman Cousins

Even many years later, my dad could still recall how his mother had hovered over him and wept. When he was 6 years old, one of the horses had pulled a hay wagon over his toes while he was helping in the fields. A nail had become loose and his foot had swelled. For the next few days, his mother soaked his foot regularly, applied poultices, changed dressings, and checked his foot for signs of infection. My dad recalled how they had both cried through the entire episode.

“She had me convinced that I would die just like the President's son.”

Her fear was real. In the summer of 1924, 16-year-old Calvin Coolidge, Jr., had developed a blister on his foot while playing tennis with his older brother, John. Over the next couple of days, his swollen foot had become infected. Despite the best efforts of the doctors, he developed a systemic infection and died a week later at Walter Reed Army Hospital. The entire country followed the family's ordeal and then mourned the death. Historians believe that the grief in the aftermath of young Cal, Jr.’s death was the main reason for the decline of his father’s presidential career.

In my grandmother’s era, there was a pervasive fear of infection. In fact, until the 1940s, Americans worried intensely about infections, epidemics, and tuberculosis, as well as sudden devastating illnesses like strokes and heart attacks. It is only in recent decades that cancer has joined the other conditions in our collective list of fearsome ailments thanks to longer lifespans, effective antibiotics, new technology and an increased public awareness of cancer.

Living in the pre-antibiotic era on a farm in rural Missouri, my grandmother certainly must have seen animals die of infections, yet I am certain that she had successfully treated dozens of sores on her livestock over the years. In her world, though, she understood that any scratch might lead to death. My father’s foot injury and the simultaneous publicity surrounding Cal, Jr.’s death must have shaken my grandmother profoundly. This heightened anxiety kept her awake every night until my father recovered.

My dad joked about the distorted toenail that he carried for the rest of his life although I am certain that it always reminded him of the anxiety and tears of those terrifying days. Perhaps, in a similar way, my cancer patients and their family members are reminded of their own ordeals whenever they touch the scars and deal with the physical changes that they carry.

The following is feedback received for this blog:

I really enjoy reading your blog and I always look forward to the next post. Keep up the great work Dr. Campbell!

- wisgirl87

Very wonderful post.

We are very fortunate to be living in this era where antibiotics, pain killers and miracle drugs are accessible.

Keep them coming!

- Kristina Lo
http://www.facebook.com/oncallnurse

The Final Words

Sun, 05 Dec 2010 07:17:57 GMT

We are what we repeatedly do. Excellence, then, is not an act but a habit.
- Aristotle

For better or worse, all of my high school English teachers were memorable. Each held a precise, but completely unique, image of the perfectly crafted essay; therefore, every September I found myself adopting a brand new writing style. A paper that would have garnered an “A” at the end of one school year routinely received a “C-minus“ at the beginning of the next. For the next few months, then, I would master the new approach only to have it discarded and replaced again the following year. It was frustrating but I eventually discovered that my teachers were less cranky when I turned in work that was grammatically correct, unambiguous, and tightly crafted. That seemed to please each one of them.

As I labored over my editing, I wondered if my teachers were just as intense and unforgiving in their private lives. Did they keep a red pencil handy whenever they read a newspaper or magazine? Did they feel the urge to pick up the telephone whenever a radio announcer split an infinitive or a news anchor ended a sentence with a preposition? I suspected that that they were always on-duty even though I could not be certain.

Recently, my question was answered. One of my patients, who himself is a writer, shared a story about a retired high school English teacher to whom he was related. The old man had been a stickler both in and out of the classroom and his family was expected to treat the English language with respect, even in casual conversation.

The teacher had lived a long and productive life. As his death drew near, he was admitted to a hospice, and he was now spending his final days in bed, too weak to turn side-to-side.

Near the end, one of the nurses came to check on him. “Mr. Cooper,” she said, “you look uncomfortable. Would you like to lay on your other side for a while?”

Mr. Cooper groaned. He opened an eye just wide enough to peer at her. “It’s ‘lie,'" he whispered. “You must say, ’Would you like to 'lie' on your other side?’” The effort overwhelmed him and he closed his eye again.

The teacher’s calling, apparently, never ends. The family swears that those were his very last words.

The following is feedback received for this blog:

This made me smile.

- rlbates
http://rlbatesmd.blogspot.com

Very nice story! Well they should make sure his grave stone bears the proper grammar.

- Kristina Lo
http://www.oncallnurse.com/blog

The Artist and Cancer

Mon, 29 Nov 2010 11:30:46 GMT

“Write only if you cannot live without writing. Write only what you alone can write.”
-Elie Wiesel

My patient needed a way to deal with his loss. Between the loss of his lung function and my surgery to remove his voice box, his life had really changed. Two of his biggest pleasures, an energetic round of golf and a ride in the hills on his bicycle, were no longer possible. His health had progressively robbed him of his activity. He spent more time at home thinking about his life.

One day, he brought a portfolio with him for his clinic visit. From the bag, he pulled a self-portrait oil painting complete with scars, stoma, and artificial larynx. At later visits, he often brought new paintings of still life or landscapes. He happily announced that this new hobby had given him a way to interact with his world and understand his new equilibrium.

Others affected by cancer also react creatively. I recently paged through "The Cancer Poetry Project: Poems by Cancer Patients and Those Who Love Them," edited by Karin B. Miller (Fairview Press, Minneapolis, 2001). It contains over 200 poems by patients, family members and friends. The poems in this collection come from the heart, and many of the writers pointed to the healing they experienced through the process.

Gretchen Fletcher, a cancer patient’s co-worker, writes for all of us:

“How can I know
how it feels to lose a breast
and fight to save lungs,
bones, and brain
when all I have to battle
is the traffic?”

When our patients are at a loss for words, writing and other forms of expression can serve as rehearsals for later meaningful communication. My patient explained his struggle in a way that had never before been possible. His artwork became a delightful and insightful conduit to other discussions.

The following is feedback received for this blog:

Love your blog...and the creative outlet of your patients. I had a similar experience recently with a patient expressing his journey through painting as well.

It's hard to care for patients with cancer when they are losing so much. You try to give hope but sometimes I feel like an actor. However, the act of coping via creative expression provides healing to the soul...for the patient and physician.

I look forward to your next entry.

- Resident

Illness can have a huge impact on our life story, so much so that it changes the way we narrate it. But no matter what the medium (written word, paint, photography, etc), I've learned that part of the healing process is listening to their story.

Thank you for sharing this post!

www.d-o-ctor.blogspot.com

I so love this post. So much of it makes sense to me. I have survived cancer four times. Two types. If it was not for my art, photography and writing several blogs. I am not sure where I would be. It all keeps me productive. So like your patients I know how important it is. I love that you posted about it as well. Its awesome! You might remember me writing as the pen name of Hope at ClubSammichCafe© Thanks for sharing your insite.

- Kerry Allor
http://iftheresonethingiknow.blogspot.com/

Master Clinicians

Mon, 11 Oct 2010 14:46:50 GMT

No great artist ever sees things as they are. If he did, he would cease to be an artist.
-Oscar Wilde

The physical exam of the head and neck is both simple and challenging. Simple, in that even children are familiar with the shape of the face, the sheen of the eye, the curve of the ear, and the texture of the tongue. Challenging, because when complicated, interlacing structures malfunction, they send mixed and subtle messages.

Last month, over 200 second-year medical students descended on the ENT clinic for an afternoon. We supplied lights, ear specula and tongue depressors. They supplied the energy and curiosity as they practiced peeking in each other’s ears and throats. Some brought along their brand new $400 otoscopes. Most will never spend another minute working with me or my colleagues to learn the head and neck examination.

Is the physical exam even important anymore?

A recent story on National Public Radio confirms that some physicians skip the physical exam because they find that the quick 15 minutes allotted to an office visit is better spent engaged in conversation and reviewing test results. They also acknowledge that some of the parts of the examination are so difficult and subjective that an expensive test (for example, a $600 echocardiogram) might be more reliable than using a stethoscope to diagnose a murmur or extra sound.

The modern, technology-savvy doctors are probably correct, but, when it comes to a decent physical exam, I am painfully old-fashioned. I really enjoy the process of discovery that the exam provides by melding physical findings with the patient’s story to arrive at a diagnosis. It is far from a perfect science, but it is important work at which we can only improve with practice. The "laying on of hands" remains a big part of what I do in the office.

A friend of mine told me about returning to see a doctor that was caring for her broken ankle. "I saw the physician three times and he never actually touched my leg! My ankle healed up just fine, but it seemed odd that he examined me only by looking at my X-rays. Is that typical?"

I do not know what is typical anymore.

During my training, we flocked to learn from the gifted diagnosticians — the curious, thorough, patient, and perceptive teachers who could use their hands, ears and sense of smell to arrive at an obscure diagnosis. Even as technology pushes to every corner of Medicine, I am hopeful that we will always have those master clinicians among us.

The following is feedback received for this blog:

Nice Blog!!!
Thanks For Great Information .

- suvarna bhagwat

I recently saw a surgeon about my torn rotator cuff. He asked all sorts of questions, and I pointed out that I had had an MRI. He replied that looking at the MRI first was cheating. Sounded right to me.

- Bruce Small
http://brucesmallsurveys.typepad.com/

The Tanzanian ENT Clinic

Mon, 25 Oct 2010 09:52:55 GMT

I don't know what your destiny will be, but one thing I do know: the only ones among you who will be really happy are those who have sought and found how to serve.

- Albert Schweitzer

The middle-aged Tanzanian woman lived many hours away and had traveled to the academic medical center in Moshi. She had now waited all day to see the doctor. He would tell her why the neck mass was growing and if there was any treatment.

My host is a teacher at the Kilimanjaro Christian Medical Centre and the only fully trained otolaryngologist in Northern Tanzania. He is one of only six ENT physicians practicing in a country of 40 million people. He described her predicament. “She has had a growing neck mass for about one year,” he told me. “Look here! There is also a mass in her tongue. That is the source of the neck mass, don’t you agree?” I peered over his shoulder as he focused the dim light from his head mirror in the back of her throat. They had taken a piece of the neck mass out at some point and I pointed out the scar in her neck. “Oh, the report from the biopsy shows that the mass is a cancer but the description is unclear. We don’t have a pathologist here very often.”

I looked at the two-sentence pathology report that described a type of cancer that made little sense. Clearly, though, despite the fact that her diagnosis had been made in a way that was not consistent with our standard of care and the fact that I doubted the diagnosis on the pathology report, she had an advanced Stage IV cancer of the throat. Today, she would learn her diagnosis for the first time.

The Tanzanian doctor finished up his brief examination and then spent five minutes discussing her diagnosis and options in Kiswahili. I am quite certain that he shared that her cancer was best treated with radiation therapy.

I watched as they talked. Back home, she would be seen immediately by a medical oncologist and radiation oncologist and be scheduled for treatment. In Tanzania, though, the only radiation therapy was located in Dar es Salaam, 350 difficult miles away. Chemotherapy is rarely available. In addition to the difficulty getting to treatment, most Tanzanians must pay at least 50 percent of the cost of any medical care. As a result, most people put off seeing a doctor for as long as possible and most cancers present very advanced.

The discussion between the Tanzanian doctor and the patient was remarkably brief and I surmised that the doctor told her that she had cancer and that the only option for treatment would be both far away and expensive. She smiled weakly and spent a few moments shaking our hands (“Asante sana, Doctor”), and then left. The doctor jotted a few notes in her chart.

“What did she say?” I asked. “What will happen next?”

“Oh, she is lucky,” the doctor responded. “She has family near Dar es Salaam so she will have a place to stay during treatment. In addition, her family has some cows. They will sell two cows and she should be able to pay for some treatment. Still, without the cows, they might have trouble in the future.”

I had a hundred questions, but did not know where to start. No matter. We were late and it was time to visit the inpatient ward where we would soon find many more patients with very difficult problems, grinding poverty, and no easy solutions.

The following is feedback received for this blog:

Wow. 40 million people and only 6 ENT's. In honor of your work there a donation has been sent to KCMC. It is not much but perhaps it will help in some small way to those not as fortunate. May God continue to guide your hands and bring comfort to those in need.

- anonymous

A Well-Developed Sense of Denial

Tue, 05 Oct 2010 12:42:56 GMT

Inside every patient, there’s a poet trying to get out. My ideal doctor would ‘read’ my poetry. my literature.
– Anatole Broyard

"When did you first notice the sore?" I ask the newly diagnosed cancer patient. I was taught in medical school that a thorough history includes information on the "duration of symptoms." Over the years, I have been amazed how often the answer is: "Doc, I first noticed something about six weeks ago." Whether the cancer appeared large or small, completely confined or widely metastatic, barely symptomatic or agonizingly painful, the answer was frequently "six weeks."

Early in my career, I didn’t believe the "six weeks" response from patients with advanced disease, although it made sense when coming from patients with small cancers. However, after I noticed that the response was so common, I began to wonder why. Certainly, cancers can grow at different rates. Not every cancer behaves the same. Still, though, I suspected that denial was delaying evaluation and cancer care.

Danielle Ofri, MD, in her wonderful book of medical essays, Singular Intimacies: Becoming a Doctor at Bellevue (Beacon Press, Boston, 2003), tells the story of a prominent psychoanalyst with an unnamed cancer. Over the course of several months, the disease ravages his body and destroys his liver. Even with obvious signs of malignancy, he steadfastly refuses to admit even the possibility that he might have cancer. He is confident that he has a viral infection that will soon resolve. No need for a biopsy! No one can convince him otherwise.

Eventually, he becomes so debilitated that he has to be admitted, very reluctantly, to the hospital where he dies of the cancer and, perhaps, some of the zealous attempts to make a diagnosis. Suddenly, Dr. Ofri realizes that this intelligent psychiatrist had shrewdly used denial to his advantage. He had maintained control for as long as he possibly could. He had delayed the inevitable hospitalization and medical interventions until he was finally completely unable to resist.

There are a host of reasons that people deny things that seem perfectly obvious to others. Perhaps the person has a debilitating fear of medical care, a lack of insight, legitimate concerns about devastating medical costs, or a strongly held system of alternative beliefs.

Until reading Dr. Ofri’s story, though, I had not understood how powerfully denial could also allow the patient to maintain a sense of control over their situation for as long as possible.

For some, the decision to relinquish that control marks the end of denial. They finally admit that their symptoms — the pain, the mass, the bleeding — might represent something bad. They realize that it is time to reach out for help even if they would rather not. Now, six weeks later, they sit unhappily in my office getting ready to find out if their symptoms represent the very thing that they dread the most.

The following is feedback received for this blog:

having worked in ICU for 32 years, denial is huge. It is a good and bad thing. When an alcoholic denies, we know that ruins his life and others around him/her.

Denial does keep people from seeking help sooner, probably based in repressed fear and hope that "it will go away". It also does keep people in control and able to function, fight or carry on in difficult situations.

- Cheryl Scheuerman

Harder Than Doing Something

Wed, 15 Sep 2010 14:15:36 GMT

For everything, there is a season…
- Ecclesiastes

“Are you giving up on me?” My patient looks at me severely. “There must be other treatment options! Aren’t there some experimental drugs out there? I have beaten this cancer twice before. Are you saying that I can’t beat it again?”

No one can ever know with absolute certainty whether my patient's newly recurrent cancer might miraculously disappear with one more treatment. His recurrence, however, has developed very quickly and is growing very rapidly. New cancer nodules are developing weekly. I have never seen a patient with a cancer this aggressive have a meaningful, sustained response to further treatment. The research literature confirms my impression.

It is always difficult to know what to recommend. Although "no further treatment" is always an alternative, I routinely run through all of the options, reviewing whatever is available, and hoping that we land on the combination that offers that improbable, one-in-a-thousand cure. However unlikely, we sometimes set up appointments and hope for the best.

Today, though, my sense is that it is time to focus on new goals.

The decision not to pursue more studies and more treatment can be very, very difficult. Surgeon and journalist Atul Gawande in an essay in The New Yorker entitled “Letting Go,” writes about how difficult it can be for physicians and patients to halt cancer treatment as the end of life draws near. The dilemma, he concludes, “arises from a still unresolved argument about what the function of medicine really is — what, in other words, we should and should not be paying for doctors to do.” In Gawande’s view, the profession should equip and supply doctors and nurses “who are willing to have the hard discussions and say what they have seen …”

In most circumstances, this moment might be the first occasion that the patient hears a physician say clearly, “I do not think we should continue with the cancer treatment. It is time to stop focusing just on the cancer and spend more of our effort focusing on the rest of you.”

Those are very difficult words to say. On the other hand, I cannot begin to imagine what it must be like to hear your physician utter them.

At some point, the topic of stopping cancer treatment must be approached clearly and compassionately. An essay by Albert Lim, MD, sent to me by a patient, reminds us that physicians often avoid these difficult discussions. We push on with futile treatments and expensive tests because “it is difficult to say ‘no’ in today’s world.” Coupled with our own doubts, the patient and family sometimes want us “to do something, anything, everything.” There are situations where we need to learn to think through the choices and then choose to do nothing.

A recently published article might help me navigate these difficult discussions in the future. Dr. Jennifer Temel and other cancer physicians at Massachusetts General Hospital followed two groups of patients who were suffering from advanced, uniformly fatal lung cancer. One group received “standard” cancer care with chemotherapy and aggressive treatment. The other group was offered the “standard” care but also met very early on with the Palliative Care team. Overall, the Palliative Care group went on to have less intense treatment, less futile cancer treatment near the end of life, an overall better quality of life, and significantly less depression. They were more likely to have talked with their relatives about their end-of-life wishes.

Surprisingly, the Palliative Care group, despite receiving less intense cancer treatment, also lived a bit longer! For this group of incurable cancer patients, less aggressive care actually resulted in longer and higher quality survival.

As the conversation wraps up, my patient reviews all of his options. His previous therapy was difficult and he is not interested in spending any more time at the hospital than absolutely necessary. He and his family go back and forth. Finally, they all decide against any further cancer treatment. They will continue the conversation at home.

I am relieved. He has made what I consider to be a good choice and appears to be at peace with the decision. The most difficult decision he and his family have ever had to make had, in the end, been simple. The time had arrived.

The following is feedback received for this blog:

Salient topic and analysis, thanks for bringing these essays/studies into one place. It often feels likes my best "doctoring" is done after the patient and his/her family reach that fork in the road. Thanks once again for good thought-provocation!

- Merry Sebelik

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

Has any research been performed that explores the effectiveness of the HPV vaccine in preventing these oral/throat cancers?

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

An eloquent and succinct portrait, Uncle Bruce. Thanks for sharing.

At the time, I remember celebrating all of the little victories, the transient glimpses of his inner personality still coming through - whether he was participating in a lawn game, offering a prayer, or engaging in even the simplest of social exchanges.

Only now can I look back and realize how painful his silence was.

- Gabriel Andeen

Dr. Campbell, I was catching up on your blog entries and came across this one regarding your father-in-law. I am so sorry for your family's loss this summer. Your words thoughtfully conveyed how many of us feel when our parents start slipping away and then are gone, and the things we miss most sometimes drove us crazy during their lifetime. I hope everything else with you and your family is going well. Take Care.

- Michelle Wales

A Certain Age

Thu, 05 Aug 2010 13:10:11 GMT

For myself I am an optimist — it does not seem to be much use being anything else.
-Winston Churchill

Even before I met him, I could tell that his cancer was extensive. His problems had started several months before with a cough, a voice change, and some trouble swallowing. His primary doctor had not spotted anything but had kept an eye on him. Antibiotics and cough medicine had not helped. After he coughed up a little blood and developed a mass in his neck, he had seen a throat specialist. Sure enough, he had a cancer.

Before walking into the examination room, I reviewed the reports and scans. The cancer involved much of the throat and had spread to lymph nodes in the neck. This cancer is very dangerous, I realized. I prepared myself to meet someone who I assumed would be pretty miserable.

Instead, when I walked into the room, my new patient greeted me enthusiastically. As he energetically shared his life’s story, his wife shook her head and smiled. The doctors near his home had recommended chemotherapy and radiation. He had decided to get an opinion at our center. "You’re a surgeon," he reminded me. "If you recommend chemotherapy and radiation instead of surgery, then I will know that they are on the right track!" He laughed.

I completed the examination and told him that he had, indeed, received sound advice. If surgery would ever be necessary in the future, I would be glad to see him. "That’s great, Doc!" He smiled. "Hope I never see you again!" Pretty soon, he was shaking everyone’s hand, waving to folks down the hall, sharing more stories, and heading to the parking lot.

Later that night, as I was typing his progress note on the computer, I spotted something that I had overlooked during his appointment. In reviewing his family’s health history, almost everyone had died of some type of cancer. His own parents had died at ages 69 and 70.

I rechecked my patient’s birth date. He had just recently turned 70. He was exactly the same age at which both of his parents had died. Now he, too, was facing cancer treatment.

I wondered: was it possible that my irrepressible patient had not noticed the coincidence? That seemed very unlikely. Was there anxiety bubbling under his surface that I had overlooked? If so, he had hidden his worry well. Or was it possible, I wondered, that he was just not worried?

It left me amazed with the wide range of skills that some people have that allows them to cope with difficult and frightening circumstances. It also reminded me that, over the years, I have met some truly amazing patients.

The following is feedback received for this blog:

Once again, friend, a thoughtful and insightful piece. Look forward to the White Coat Ceremony!

- RICHARD HOLLOWAY

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.

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 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)

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 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/

Tasteful Cancer Treatment

Fri, 16 Nov 2007 11:29:52 GMT

“What do you do for a living?” I asked.

“I run all of the food services for a college.”

This was going to be a problem, I thought. His throat cancer was in the region of the tongue where his taste buds were most dense. I told him that there was a very real potential that his cancer treatment would forever lead to a loss of his sense of taste.

He was resolute, though. “Do what you have to do.”

Seven weeks of radiation therapy were difficult for him. Fortunately, his cancer disappeared completely and never came back. I still see him regularly.

“Tell me,” I ask, “how are things going?”

“At first, I could taste nothing! I worried if I would be able to continue working! Fortunately, my assistants helped immensely in the early days after treatment. I could taste next to nothing for a couple of years. Now, it seems that my taste is finally returning! Doc, do you think it will get all the way back to normal?”

There is no way to tell. Taste is a complicated sense that includes the integration of both his sense of smell and the interpretation of chemicals by the taste sensors in his tongue and throat. The treatments not only dulled his sensors but cause dryness which decreases the release of chemicals in his throat. Some of my patients tell me that foods they used to enjoy now bring them no pleasure. Sometimes, the opposite is true – foods they never liked are suddenly wonderful. There is no way to predict.

The dilemma of his loss of taste sensation in a professional that depends on his sense of taste came to mind when Dr. Val told me about a famous chef who is currently being treated for a large tongue cancer. His situation is unusual. He is only 33 years old (very young for tongue cancer). He has a very advanced (Stage IVB) tumor – cancers at this stage are rarely treated with surgery. Nevertheless, the articles about him make the point that he has opted to undergo non-surgical treatment hoping to better preserve his sense of taste.

I hope things go well for him. Based on my food services director’s experience, he might get his sense of taste back someday. Or maybe not. Or it might be altered. No one can predict.

The following is feedback received for this blog:

Another great post!
- rl bates
http://rlbatesmd.blogspot.com/

I hope that your patient's taste sensation comes back all the way. I guess it's hard to prognosticate - are there any positive signs that would sway you one way or the other? In spinal cord injury medicine we wait 3 months before discussing likely functional outcomes. Do you have any milestones that you look for - like return of taste sensation within X weeks - to help with prognosis? A curious colleague... :)
- Val Jones
www.revolutionhealth.com/blogs/valjonesmd

Thanks for the comment and the suggestion to write about this. ... The functional return after radiation and/or surgery is very unpredictable. Taste sensation and salivary flow are both affected permanently and some people get very little return while others have great recovery. I tell people not to give up since the time course can show improvement over a couple of years. I really do not know what leads to the improvement, though - it isn't really analogous to the resolution of nerve compression.
Thanks again!
-Bruce

The Drawing Part II

Fri, 08 Jun 2007 13:45:02 GMT

This is a follow-up to my post The Drawing. I've been asked for an example, so here it is. This is a drawing that I would use for an oropharynx cancer with neck metastases.

Signs

Fri, 29 Jun 2007 14:54:38 GMT

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

The signs drive me nuts.

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

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

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

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

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

How to Avoid Becoming Another Ionitch

Wed, 05 Sep 2007 09:29:30 GMT

“Will you be my doctor? The other doctor didn’t look me in the eye, kept checking his watch, and told me that I needed surgery. He didn’t answer my questions and never called me back. We just did not connect.”

I hear this occasionally (and I am certain that my former patients’ new doctors hear it, as well). Getting the elements of communication “right” between patient and physician is tricky, especially in the context of cancer surgery. The issues are not new.

Over Labor Day weekend, I immersed myself in several of the stories in the collection, Chekhov’s Doctors (Jack Coulehan, ed. The Kent State University Press, 2003). Anton Chekhov, the noted writer and playwright, was a practicing physician; doctors figure prominently in many of his wonderfully crafted, timeless, and very readable stories. He brings to life physicians who display mixtures of compassion, cruelty, tenderness, greed, sensitivity, saintliness, arrogance, depression, despair, immorality, and existential conflict — in short, his doctors are flawed. Doesn’t that sound familiar!

In a story entitled “Ionitch,” Chekhov’s physician protagonist begins as a poor energetic doctor who is welcomed to town by an artistic family; he soon falls in love with the beautiful daughter. Early in the story, she rebuffs his marriage proposal. He recovers, but the seeds of isolation and irritability have been planted.

Over the years, Ionitch focuses on working hard and making money. He becomes increasingly haughty, refusing all gestures of friendship. He grows rich.

By the end of the story, despite being a respected consultant, he is also corpulent and ill-tempered; when seeing patients, he raps his walking stick on the floor and shouts, “Be so good as to confine yourself to answering my questions! Don’t talk so much!” Chekhov’s doctor has become a success, but his quest for wealth has left him detached and bitter. Chekhov focuses more on the relationships between the doctor and others than on the medical care rendered and he cleverly leaves most interpretation to the reader.

Transformations from eager neophyte to bitter dinosaur still happen today, believe it or not. Can doctors be taught to be compassionate? Or at least MIMIC it? How do we pass these cautionary tales on to our next generation of physicians?

How do we get students to absorb the lessons they will need to avoid becoming The Someone they never intended to be?

Instructive examples are abundant in classic and modern literature. However, during medical school and residency, there are persistent demands from hard sciences and overwhelming clinical duties. When I examine our medical school library's collection of medical fiction, poetry, and reflective essays, I notice that some of the volumes haven’t been checked out for months or even years.

Medical schools, including ours (I am proud to say), are developing Medical Humanities programs to find other ways to expose students to this “softer” aspect of Medicine. It is critical that we find ways for physician-writers like Williams, Chekhov, Maugham, Percy, and Coles to teach students the following lesson: We, as doctors, are in danger of becoming complacent and arrogant when too many patients, parents, friends and acquaintances tell us that we are something special.

Because it just ain’t so.

That lesson won’t be on the final exam this year in medical school, but it might be important much, much later to our patients, our families, and ourselves.

The following is feedback received for this blog:

Thanks for this nice post.

- RL Bates
http://rlbatesmd.blogspot.com/

"Smiling Encouragement"

Wed, 07 Nov 2007 15:19:04 GMT

The Oncology Clinic waiting room chairs are full, the television replays yesterday’s events, and the conversation is quiet. Further down the hall, the laboratory draws blood samples from other cancer patients, guiding therapy and checking treatment progress.

Ambulatory patients and family members weave around me as I pass through the waiting room heading to my own clinic duties. The people, individually and in pairs, slow and turn at the reception area. A patient who has completed checking in drops heavily into an open seat. As I walk on, I am sensitive to the privacy of those assembled here, yet I glance up to see if I recognize any of my own patients’ faces.

The door to the clinic hallway opens and a staff member emerges. She scans the room and calls out. “Constance? Constance? Oh, there you are! You brought company today! Come on in. Bring everyone along!”

I pause as a wheelchair changes lanes in front of me. Constance looks up, smiles briefly, grits her teeth, and repositions her body — deliberately preparing to stand. She presses down firmly on the arms of the chair. Her companions, hands at her elbows, rise with her and together they move toward the doorway.

Poet Laureate and cancer survivor Ted Kooser, in a poem titled, “At the Cancer Clinic,” captures the moment cleanly. As those of us in the waiting room note the woman's measured steps…

“…There is no restlessness or impatience
or anger anywhere in sight. Grace
fills the clean mold of this moment
and all the shuffling magazines grow still.”

(from Delights & Shadows, Copper Canyon Press, Port Townsend, WA 2004)

We watch the patient and her companions move toward the door. We nervously scan the floor in front of them, looking for obstacles. We ache and hope and breathe along with them. We lean forward and care and dread, imagining their thoughts.

Constance disappears down the hallway where she will learn what she is to learn.

Chocolate and Liquor

Mon, 08 Oct 2007 12:40:52 GMT

His life revolved around his family, his traditions and his wheelchair. As a young man in Russia, he lost one leg during the Siege of Leningrad. As an older man, he lost the other to severe blood-vessel disease. Now, as an immigrant who spoke no English, he was dependent on his daughter to push him from place to place and to explain all of the inscrutable American customs along the way. I think he found us all to be very amusing.

Like many other Russians of his generation, he loved his vodka, his cigarettes and his traditional foods. In the months before I met him, his voice had changed from a joyous baritone to a coarse whisper. The growing cancer had taken away his voice and was affecting his swallowing. His eyes betrayed the universal sense that the things he loved deeply might soon be taken from him.

His treatment was difficult; he was not well and the recommended surgery and radiation therapy initially made things worse. For the first several weeks, he could neither talk nor eat. His dependence on his family grew, and he became very discouraged.

Gradually, though, he recovered. He brightened visibly as his voice returned – not to the rich tones of his youth, but to the point where he could sing the old folk songs to his grandchildren. His swallowing and sense of taste improved. He was able to eat many of the foods he remembered from his mother’s kitchen. Some of the touch points of his world had, at least in part, returned to him.

“You are doing very well,” I would tell him at his follow-up visits. “I see nothing that worries me at all. The cancer is completely controlled.” He eyes would move anxiously from my face to his daughter’s, waiting for her to translate my words into his mother tongue.

“The doctor says everything is fine,” she would say in Russian.

Sometimes, at this point in the encounter, he would smile broadly and reach into the bag he had kept poorly hidden by his side since rolling into the examining room. From within, he would pull a gift and press it into my hands with surprising force. “Spasiba!” he would exclaim. Thank you!

The first time this happened, I was very surprised. I looked at the gift, a small box of specialty chocolates and a bottle of liquor. “I can’t accept this!” I protested. “Please! This is not necessary!”

The daughter intervened. “Doctor, this is my father’s tradition! Good news is always celebrated with chocolate and alcohol. You have given us the best news possible today! My father wants to share his celebration with you. Please accept! He truly will not understand if you do not.”

I sputtered briefly as I reflected on the situation. Celebrate good news with European chocolates and a pint of Goldschläger? What a concept! It didn’t take long for things to come into focus. “Hmmm,” I thought to myself. “This seems like a remarkably fine tradition!”

I opened the box of chocolates and offered them to the others in the room. “Spasiba!” I repeated back to him.

He did not bring gifts every visit, but often enough, to be sure. The colleagues with whom I shared the gifts jokingly wondered whether or not we might ask him to return more frequently for check-ups.

Several years have passed since he died of heart disease, but I clearly recall his delight and how he used gift-giving to keep one of his traditions alive in a land far from home. The gesture deeply ingrained both his image and his graciousness on me. I have had several thousand patients pass through my practice over the years and, I admit, I remember some much better than others — some I do not remember at all. However, one of the most memorable was the wheelchair-bound Russian-speaking survivor of both war and cancer who celebrated good news with chocolate and a toast.

"Spasiba," I think again, and, sadly, "Dasvedanya."

The following is feedback received for this blog:

Great story. So much gratitude from someone with so many difficulties to overcome is inspiring. Makes me wonder what I can do to help my doctors remember me.
- Russ

What a great idea. I think celebrating good news is the best possible reaction.

- Chuck McKay
www.advancemypractice.com

another lesson in courteous behavior. Our culture will sometimes forget that to accept a gift graciously is to bless both the giver and the one who recieves it.
- Holly

Thanks so much for the response to the essay. I like your take on the interaction.
-Bruce
Bruce H. Campbell, MD

you're very welcome. I thought, as I read the eloquent way you phrased all that, how difficult it would be to be a "stranger in a strange land" and how I might feel if it were me. Feeling out of place in a different culture, trying to find a way to say thank you to someone who gave me such a great gift (of life).

As I have told my kids over and over, good manners (please and thank you) are never out of place, and this was a gracious way of saying both thank you and you're welcome.
- Holly

A Bad Example

Wed, 12 Sep 2007 11:56:37 GMT

During my first uncertain steps towards becoming a physician, I unconsciously searched for role models and mentors to emulate. First, as a nursing assistant and later, as a medical student and trainee, I had plenty of opportunities to observe doctors in their natural habitat. It was not always pretty.

Once, during my days as a nursing assistant, an older physician came to the hospital Outpatient Department accompanied by a woman with a small facial cyst. “Lie down!” he growled. She looked worried, but complied. I didn’t notice any attempt at informed consent.

He glowered at me, “Get me a set of instruments.” I got out what he would need and began to wash up her forehead. “Where’s the razor?” He shaved a wide swath well up into her hairline. “Gimme the local!” Without warning, he jabbed her several times, infiltrating the burning anesthetic into her forehead, completely oblivious to her discomfort.

He clumsily draped her head, leaving towels covering her mouth and nose. She tried to move the drapes so she could breathe. “Don’t touch that! It’s sterile!” he yelled. Her hand dropped submissively to her side.

As he made an incision, she withdrew. “Yeouch!” she cried. Blood dripped down the side of her scalp.

“Hold still!” he ordered. He made no attempt to add more anesthetic. Despite the small size of the cyst, the procedure took a painfully long while. After the cyst was removed, he placed a few thick, uneven sutures. “Don’t get it wet AT ALL for five days! Meet me here next week and I will take out the stitches!” I tried to clean up the blood, but she shot off of the bed and bolted for the door without saying a word. I doubt she came back.

Albert Schweitzer once noted, “Example is not the main thing in influencing others. It is the only thing.” I admit that at least a part of my career was heavily influenced by a cranky, old general practitioner on that day almost 35 years ago.

The following is feedback received for this blog:

Wow! I have always found talking to patients as a great way to distract them from the uncomfortable things we sometimes have to do to them (i.e. needle injections to place the local, etc).

- RL Bates
I encountered a doctor--and I use the word with a wince--who was like that, 20 years ago. Brought the needle tip to my eye, as I laid there, and fiercely demanded that I not blink. (I had a squamous-celled growth on the inside of my eyelid.) Thank you for learning from your own encounter not to ever be that kind of a doctor. Thank you for being a compassionate one.

- Alison Hyde
http://www.spindyeknit.com

“Gee, Mommy, you sure enjoy your Marlboro …”

Tue, 23 Oct 2007 14:41:18 GMT

“Doc, when I started smoking, EVERYONE was smoking. It was the thing to do. This,” – he says, pointing to the permanent hole in his neck – “proves it wasn’t the thing to do.”

My patient with the laryngectomy exaggerates a bit. In 1964, just over 50 percent of adult white males in the United States smoked cigarettes. That is down to a shade over 20 percent now. There is a lot of societal and legislative pressure to push that number further down.

Why did so many people smoke and what made it so acceptable? One clue is the advertising that was prevalent as smoking rates were climbing in the first half of the 20th century. Smoking was glamorous! It made you thin! Celebrities, movies stars, cute kids, teenagers, and athletes all appeared in the advertisements. “More doctors smoke Camels!” declared a series of ads. “Science proves they are milder!” It was a different time.

Want a glimpse into that era? The Lane Library at Stanford University has a remarkable collection of vintage advertisements collected by Dr. Robert Jackler.  (People with Flash 9 installed on their machines, including staff inside of Froedtert, might not be able to view the link.)

It makes me wonder, what advertisements from today will be collected and ridiculed in 50 more years? Fast food? Gas-guzzling cars? Coffee shops? Who knows?

The Head Bone’s Connected to the Neck Bone …

Wed, 31 Oct 2007 09:15:33 GMT

“Anatomy is destiny.”
-Sigmund Freud

The intricacies of Head and Neck anatomy fascinate me. As my schedule has permitted, I have spent a few afternoons every fall helping the first-year medical students explore this remarkable anatomy.

A recent article in the October 2007 issue of the Bulletin of the American College of Surgeons describes the participation of volunteer surgeons in the first-year anatomy course at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md. Having surgeons in the dissection lab helps students see how the anatomy relates to diseases. The Medical College of Wisconsin anatomy course also includes clinicians whenever possible.

Working with medical students in the anatomy lab is a humbling experience for me for several reasons:

First, the anatomy is wonderfully complex yet remarkably unwavering. Each time I enter the anatomy laboratory, I marvel again how each nerve, muscle, vessel, and structure courses above, below, behind, or around the others in dissection after dissection. Anomalies do occur, but they are rare and noteworthy.

Second, I learn each year how little I know. Despite spending my career performing surgery in the region, there are structures tucked away in corners that the surgeon never approaches or recognizes. My teaching time has improved my surgical insight, but I still carry my trusty 30-year-old atlas from table to table as I tackle the students’ questions.

Third, each year, I am reminded that human dissection is one of the watershed events of a medical career. Life can be broken down to “pre-cadaver” and “post-cadaver” years. Looking back, the privilege of probing, examining, learning from, and marveling at another person’s anatomic secrets remains almost incomprehensible. The students, to varying degrees, sense this already.

As the head and neck portion of the course draws to a close, the students review their lists, preparing for a rigorous exam and searching out tiny anatomic structures. I tie the anatomy we are exploring to real patients' problems about which the students will soon be learning. I am already looking forward to next fall.

Continuing to Mourn His Loss

Fri, 19 Oct 2007 16:11:40 GMT

Mark Adams, MD, the late Chair of the Department of Surgery, died unexpectedly on May 24, 2007. Those of us who knew him continue to mourn his loss.

Follow this link to read a beautiful, heartfelt reflection (in the feedback section at the bottom of the post) by one of the people in the Department of Surgery who knew him best.

Alive With Pleasure!

Wed, 17 Oct 2007 13:31:06 GMT

“There is much to support the view that it is clothes that wear us, and not we, them …” – Virginia Woolf

Although I do not pay much attention to how they are dressed, I realize that some patients have spent time struggling to decide what to wear to each clinic visit.

Some patients arrive wearing jeweled cufflinks and handsomely tailored Italian silk suits. Some wear handcuffs with their orange County Jail one-piece jumpsuits. I have seen everything in between.

Clothing choices often reflect the individual’s vocation, activities or passions. I have seen paint-splattered pants, work shirts with name badges, embroidered sweatshirts emblazoned with “World’s Greatest Grandma,” Harley-Davidson coordinated leathers, exercise outfits, steel-toed work boots, motor oil-impregnated shirt sleeves, carpenter’s suspenders, and lanyards with corporate ID badges.

Among my cancer patients, some women wear “guardian angel” pins. Survivors, both men and women, wear “Livestrong” bracelets. Some cancer survivors wear ribbons. These people are truly set apart.

Several years ago, a young woman came to my office for the first time with an untreated tongue cancer. We discussed the evaluation and management, settling on a surgery date. She was wearing a brand new T-shirt, the fabric still creased and the printing fresh; I realized later that it might have been the only clean thing she owned. There, sitting in front of me, was a young woman preparing for cancer treatment, wearing a shirt that read in large, glaring orange letters: “Newport. Alive with pleasure!”

What was my patient thinking when she chose to wear that shirt? Whenever I happen to spend a minute or two selecting my clothes, I suspect I want others to surmise that I am a little cleaner, a tad better pressed, and a bit more organized than I actually am. Maybe she went through that thought process, as well.

Initially, I didn't think she noticed the irony of appearing in a cancer surgeon’s office dressed in a shirt she obtained by sending in coupons from cigarette packs; however, she never wore it again.
____

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

The following is feedback received for this blog:

From your blog and the current essay in JAMA, I'd say you have the basis of a great book there.
- Mike McLellan
http://drmikem.blogspot.com/

What's in a Name?

Thu, 04 Oct 2007 11:29:15 GMT

Now that I have been writing this blog for six months, I wanted to take a moment and talk about the process.

The blog came into being because the Froedtert Hospital Marketing Department asked if I would take this on. I have a pathologic need to be liked so, of course, I agreed. I had already written monthly columns for the MCW Cancer Center News based on exploring what I felt were the attributes of a “good” physician. I intended to post an entry every four to five days; so far, so good.

Basically, I write because I see things that make me go, “Huh?” Writing allows me to process what I see, both the exhilarating and the devastating. I have kept a journal off-and-on since college (pretty much continuously for the past 10 years), accumulating stories and experiences; the blog allows me to re-think some of those moments.

I was a bit surprised to find out how much time would be involved. The shortest essays sometimes require the most effort; they are the most rewarding when finished. Annie Dillard once quoted Thorton Wilder describing the process of writing: one line drops from the ceiling, “and you tap in the others around it with a jeweler’s hammer.” That really rings true for me and keeps me coming back for more.

By the way, I appreciate readers’ reactions. The stuff I write about is not controversial, but I really enjoy hearing your insights about the topics. Feel free to hit the “Feedback” link below. Most people, however, choose to call, e-mail, or talk in the hall. I don’t need an audience, but, truth be told, it’s nice to know you are out there.

So, to recognize the six-month anniversary, we are re-christening this blog as “Reflections in a Head Mirror.” The head mirror, an almost archaic medical device, is the symbol of the doctor in cartoons everywhere. As an otolaryngologist, it is still one of my most cherished instruments.

Thanks for reading! Thanks especially to Christopher Sadler and Tamara Kroll who have made this all possible. If you have topics you think I should explore, please let me know.

The following is feedback received for this blog:

Thanks for writing. I really enjoy your essays.
- rlbates
http://rlbatesmd.blogspot.com/

you have answered one of my most enduring puzzlements. for the last thirty years, i have been asking my colleagues, what's that round mirror thing you guys wear (or used to wear). it's such a ubiquitous symbol that we used it on the cd cover for my band, dr. linda and the ultrasounds. even the great and wise dr. linda didn't know what it was! now i do, and i will lord it over everyone i know!!!

-dick

Oh, The Medical Things You Will See!

Tue, 02 Oct 2007 08:58:33 GMT

Every week, a medical blogger (yes, there is a whole community of such people) hosts "Grand Rounds," collecting interesting posts that are written by patients, students, residents, nurses, pharmacists, physicians, and anyone else interested in healthcare.

This week's Grand Rounds is particularly clever. It includes links to 40 posts on various topics and was created by Dr. Rob Lamberts, the host of "Musings of a Distractable Mind," one of my favorite sites. If you have a moment, check it out! One of my old posts is included ... see if you can find it. (Hint: it's part of the Frivolous Fun Finale Fling.)

A Good Example

Wed, 19 Sep 2007 11:16:12 GMT

When I was a medical student, I spent vacations working in a community hospital in the Chicago area. There were a few medical residents training there at the time, but, by and large, almost all of the care and teaching was provided by private practice physicians.

My favorite physician was a soft-spoken, warm internist. He actually carried a “little black bag” as he made his rounds; he also carried and had read the latest issue of The Annals of Internal Medicine. In addition to expertly balancing an inpatient load and busy solo practice, he actively participated in conferences. He taught students and residents on the spot whenever the opportunity arose at the bedside or in the hallway. His teaching style was Socratic but non-threatening. His explanations were crystal clear and organized. He appeared to think, and teach, in paragraph-form.

Interpersonally, he was an intent listener, humble, clever, and engaging. He always seemed unhurried for both patients and students.

I believe compassion and caring are, to a great extent, hardwired. Nevertheless, I gained new insight into my role model’s character development when I read a book he wrote after retiring several years ago. The too short volume chronicles his time serving as a medic near the front lines in New Guinea and Luzon during World War II. His writing style, like his personal style, was clear, organized, self-effacing, and often funny. For much of his deployment, he was attached to the 36th Evacuation Hospital, working hard to support a war effort that was just miles (and often less) away.

How might his military experience as a medic have made him a better physician later in life? He explains it in the book. While in New Guinea, he worked closely with the front-line combat troops and the experience moved him. He modestly writes:

“This exposure to the lowest soldier, the foot soldier, the grunt, the GI who was, and knew he was, expendable but willingly bore the brunt, deeply impressed me; I acquired an appreciation of and a compassion for such men which persisted and, I think, guided me a bit, sometimes, as I practiced medicine.”

As a student, I found him to be a remarkable, compassionate role model. To this day, I can hear his voice as I tease details from a patient, wait patiently for a family member to come to the point, or try to pass on a concept to a trainee.

There are some great teachers and role models in the big, academic medical centers. Fortunately, I met one such a physician in the halls of a community hospital in the very earliest days of my medical life and I have tried to emulate him ever since.

The Muscular Invocation

Tue, 25 Sep 2007 09:48:06 GMT

Recently, I have been helping guide the medical students’ dissections of the head and neck anatomy. The experience reminded me of a story I heard many years ago from one of my own teachers.

A famous anatomy professor, austere and distinguished, was invited to a formal dinner party. After the cocktails and hors d'ouvres had been completed, the guests were seated for the meal. The host, acknowledging the stature of the anatomist, turned and asked him to provide the blessing for the meal.

The anatomist, who remained calm on the outside, was inwardly apprehensive. He had not attended a religious service since his youth and had placidly led a long, solitary, and completely agnostic life. He had no idea how to properly return thanks in such a formal setting.

He stood slowly, bowed his head, and twitched his impressive moustache. The guests, in turn, quietly bowed their heads, anticipating his prayer. The anatomist, both sonorous and deliberate, slowly intoned:

“Levator labii superioris alaeque nasi.”

He raised his head, smiled gravely, and sat down. Several guests congratulated him on the perfectly chosen and powerfully delivered words. The remarkable incantation outlasted even the wonderful meal.

Art, Interrupted

Fri, 21 Sep 2007 15:53:23 GMT

She’s a painter … beautiful stuff. She has painted murals on walls for homes and restaurants. Shortly after her cancer surgery, she brought in a photo album full of images of intricate patterns and floral designs. The work was stunning. Now, more than a year later, I ask her about her art. “Have you painted recently?”

“Oh, yes. I still paint murals for clients.”

“I mean, have you painted expressively? Have you painted anything about your cancer?”

She looks at me quizzically.

“No. I never felt like doing that,” she tells me. “I have been busy. Lots of deadlines. Not much time for creative work.”

She pauses. “I don’t know.”

She pauses again.

“Do you think I should?”

“Some people are able to use art as a form of expression after cancer treatment. It can be a way of processing the experience, but everyone is different. What do you think?”

“Wow. I guess I hadn’t thought of it. I can’t believe it has been a year since the surgery!”

She pauses again.

“Maybe I’m ready to try painting about my cancer now. I’m not certain. If I do, you will be the first to know.”

The poet, James Russell Lowell, once said, “Creativity is not the finding of a thing, but the making something out of it after it is found.” Maybe that is what is in play in this situation.

"Thanks," I tell her. I am looking forward to seeing what she creates.

Re-Thinking the Battle

Wed, 29 Aug 2007 09:10:02 GMT

Cancer must be “fought.” Obituaries refer to a life lost “after a long and valiant battle against cancer.” We rely on the “cancer armamentarium,” and look for more and more “weapons.” The imagery of warfare against this disease is second-nature and, for many people, extremely helpful.

Recently, I encountered writings by a thoughtful and gifted cancer patient who rejects the battle metaphor. Walter Wangerin, writer, professor, theologian, and cancer patient, worries that those who see Cancer as an enemy miss an opportunity. He writes: "Are folks with cancer good fighters if they win? Bad fighters, failing falling foot soldiers, if they lose? Can they be heroic only in triumph? Listen: It never was an issue of defeat or victory … Sickness isn’t an enemy. It’s a rooster’s crow, calling me to the truth of myself and to the precise condition of my relationships …”

Dr. Wangerin, as a patient himself, believes that the warfare imagery constricts the range of the patient’s potential interpretations. “Rather than permitting the interruptions of our lives — like cancer — to enrich our lives, we impose old, familiar patterns of thought upon the experience, diminishing it.” In other writings, he notes how his cancer, in taking away his future, has allowed him to view the present with new clarity. “I don't look forward so much any more, dashing to grasp the future. I look left and right. I've the Time, you see, to scrutinize all that is.”

He has become more aware of the present. Last year, when he built a planter in his garden, he had no idea if he would be alive to enjoy the strawberries it would hold. Now, he celebrates the outcome: “I am granted to close a cycle of life, intensely sensitive to the simplicity of its round, unvarnished shape — and to the grace of it. I have not died. My handiwork has become a food.”

I don’t know what to think. Many times, I have resented how Cancer has unfairly and capriciously stolen away a person that I had grown to admire and appreciate. How can I not feel anger? Many days, I feel locked in battle. For the moment, however, I will try to understand this new perspective and see how it might benefit my patients and, possibly, even me.

The following is feedback received for this blog:


Amen. This is not something to be taken lightly because you cannot turn from the tragedy that is really there, but there is always both good and bad in a situation. WW is one of the better, more thoughtful Christian writers out there. It does not surprise me his perspective is on target.

I just posted something on this track about Resilience on my blog.
-   Rob Lamberts
(Note: Dr. Lamberts' blog is listed in the blog roll at right and can be found at:
http://distractiblemind.ambulatorycomputing.com/)

Excellent post. I've had similar thoughts myself, especially about the "courageous battle" phrase so often seen in obits. I don't know what to think, either; but I've sometimes thought that if I knew I was dying of cancer, I'd write my own obit and say something like "after a pathetic and weak-willed battle..."
- Sid Schwab
(Note: Dr. Schwab's blog is listed in the blog roll at the right and can be found at: http://www.surgeonsblog.blogspot.com/)

I had to fight cancer, twice, but there was no anger in it. Cancer was not my enemy but a learning experience I would rather not have had to go through. I didn't pick up a sword but fought for the strength every day to do what I had to do to outlast the cancers. If it was war, it was a war of will and determination on a daily, even hourly, basis. I am a stronger person because of it and have gone on to perform tasks I never knew I was capable of. Perhaps I never would have tried, before cancer.

I went from a person ready to retire quietly 13 years ago to being the head of a non-profit online support group for education and rehabilitation of laryngectomees with a worldwide membership of 2,000, growing daily, 13% of whom are medical professionals. This is run by cancer patients (some under treatment and some clear for years), caregivers, vendors and medical volunteers. I am happy to be associated with them.

I had a good life before cancer but I have a better one now.

Pat W Sanders
President
WebWhispers.org

My Neighbor

Mon, 20 Aug 2007 09:55:43 GMT

The cancer surgery to remove part of his tongue, throat, and lower jaw, and the reconstruction took me about seven hours. Little did I realize that he was going to be a lot more challenging outside of the operating room than inside.

His first days after surgery were rocky. His prior drinking issues kept the Internal Medicine team busy finding the balance between alcohol withdrawal and over-sedation. After several days of careful, difficult medical care, he awoke.

His first comment to me the day he woke up was, “When I go home, I will need plenty of OxyContin.” Hmmm, I thought. Not a good sign.

A few days later, his stepson was admitted to the same hospital floor. My patient got out of bed, walked down the hall, and tried to get his son's friends to give him drugs.

A couple of days later, my patient’s wife announced that she was seeking a divorce. Her lawyer apparently pointed out, however, that the only reason she was able to stay in their home was his disability check, a source of income she would lose if they were no longer married. The relationship was miraculously salvaged.

As discharge approached, the family repeatedly refused to answer the door when the company providing the home health equipment tried to make deliveries. Only after the social worker called the police to investigate did the family finally open the door and accept the supplies.

The next day, one of the family’s friends stood in the hospital hallway and loudly berated the social worker for calling the police.

The morning of discharge, I made the final trip to my patient’s room to wish him well and take care of the final details. “Did you give me my prescription for OxyContin?” Ummm, No.

Follow-up appointments were rarely kept and, on the rare occasions when he did show up, his eyes were glazed and his questions focused on his narcotic prescriptions. My attempts at teaching him about his cancer and its care went unheeded.

__

Clearly, his world was not my world. I admit the entire experience of trying to care for him left me completely frustrated. He appeared to have neither interest in nor understanding of what we tried to do for him. I shake my head and remember that at one point in my teenage years, I truly wanted to be a veterinarian. At the times when I have had patients like this man, I feel as though my wish had been granted.

What was missing? We had no way to penetrate each other’s worlds. It is an old problem. William Carlos Williams, the talented poet, writer, and family physician who practiced medicine among the poorest immigrants of Patterson, N.J., in the early- and mid-20th century, had many patients with whom he had nothing in common and with whom he could barely communicate. Still, Dr. Williams, crusty as he was, found ways to discover the patients’ secrets that helped him cross the barriers. He took time to meet the families, discern the situations, and learn the stories, all the while sputtering about his patients’ seeming lack of care for themselves or their children. Dr. Williams was able to spot the surprising insight, the fleeting “thing” that underlay the story being played out before his eyes. Those moments of discovery fill his writing.

We still sputter. It is difficult! I am not proud of my interactions with and my reactions to this man; he was demanding, drug-seeking, and chronically unhappy. He was abusive to people whom I respect and admire.

I am no better or worse than the next person in dealing with the cultural chasms. Experience is a great teacher, however, and I am determined to do better next time. I think I will start by trying harder to understand the story before me.

The following is feedback received for this blog:

What a pleasure to read a blog that is thoughtful and content-full. To hear a respected physician and surgeon question decisions, motivations and meaning enriches all of us. And it reveals the physician to be the caring, insightful person he is. I particularly love the whimsy in "one slight problem." Great story. Keep it up!

- Richard Holloway

One Slight Problem

Fri, 24 Aug 2007 08:24:20 GMT

One day about twenty-five years ago, I was the resident on duty in the ENT Clinic at the County Hospital. Toward the end of this one particular day, I picked up a chart and stepped into the exam room.

A nicely dressed, very pleasant older gentleman stood to greet me. He had a neatly trimmed pure white beard and a distinct accent that confirmed that he had lived for decades in one of Milwaukee’s ethnic neighborhoods. I introduced myself and skimmed through his record. The appointment was a follow-up visit after a hearing test.

He leaned forward. “You will have to schpeak up, Doctor! I’m 84 years old and I have great trouble hearing!”

I loudly reviewed the audiogram with him. Indeed, his years of working in one of the city’s large manufacturing plants and his advancing years had taken their toll on his hearing. He had a severe bilateral nerve deafness.

He nodded in understanding. “Vat can I do, Doctor? Can you give me a hearing aid?”

We reviewed the different types of hearing aids and how they would help. He was stunned to learn how much they would cost. He was living on a fixed pension and Medicare would not cover hearing aids. His face fell.

“Too much, Doctor! Too much!”

There might be a way, I thought. I looked at his birth date again and calculated that he would have been in his late teens about the time World War I ended. “Are you a veteran?” I asked.

“Oh, yes!” he replied proudly. “Our unit walked and fought our way half-way across Europe. Oh, the stories I could tell you!”

His military service was, indeed, good news. While the VA insisted on documentation of a hearing loss sustained during active duty for later veterans, World War I vets automatically qualified for hearing aids. It was just a matter of completing the paperwork and he would be home free.

“I’ll help you set up a hearing aid evaluation at the VA in town. It might take a while, but they will get you a pair of aids that should make a world of difference!” I pulled out a pad to prepare instructions for him. It felt like a small victory.

He frowned. “Um, Doctor?” he asked tentatively.

“Yes, Mr. Schmidt?” I continued to write the information he would need when he made his appointment at the VA.

“Doctor?”

I looked up. “What is it?”

“This von’t work, Doctor. I am quite certain that they von’t give me the hearing aids.”

“Of course, they will, Mr. Schmidt! You served your country! All World War I vets are eligible.”

“Thank you, Doctor, but I vas on the wrong side during the war.”

I put down my pen. Good point, I thought. Back to square one.

Alarm Bells

Thu, 14 Jun 2007 11:07:58 GMT

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

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

And that worries me.

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

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

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

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

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

The following is feedback received for this blog:

I agree with you. I find it harder to be objective if I become too "close" to a patient. And I regret often that I can not be a friend to that person, because some of them would be great to have as friends.
- Ramona Bates

-------------------

I agree with you that care varies depending on the interpersonal relationship between physician and patient. It's a complex interaction - and the patient's personality and treatment preferences (do they want "everything done" or want to try the "wait and see" route?) can (and sometimes should) influence management. It's ok if you spend more time chatting with one patient more than another - but we need to make sure that the full range of treatment options are explained to all patients as we help them navigate to the choice that's right for them.
- Val Jones

-------------------

This was an interesting post. I realize that the original intent was to encourage physicians to be fair in how they allocate their time between patients.

However, there are lessons to be learned for us patients as well. After all, how often do we hear from people who feel they don't get the attention they deserve from healthcare providers?

Maybe the answer is... if you want more attention from your doctor, try being a better patient.

(I feel a blog post coming on...)

Great blog, btw. Keep up the good work.

- Dean Moyer

-------------------

just wanted to say thanks for a great post... usually don't see this amount of ethical consideration of these matters (time and objectivity) ... these are same issues i myself wrestle with in own life in different contexts... same principles can be carried over into other situations.
- w mersy

The Box of Slides

Fri, 10 Aug 2007 11:32:51 GMT

It was a big, dusty cardboard box and it sat along a corridor outside the departmental offices where I did my fellowship. The faculty members in my department were preparing to move to new offices. Boxes, files, and cabinets all sat in haphazard piles waiting to be moved or pitched. Among the items waiting to be sorted was this box, filled to the brim and labeled “SLIDES.” It, too, awaited its fate.

I lifted the flap and peered inside. My eyes widened as I saw a potential treasure trove of old slides, carousels, and movies. The slides had clearly been tossed in the box in no particular order. Some of the cardboard frames had fragments of old rubber bands stuck to their margins; others had deteriorated, partially releasing the slide film from their frames, but many of the images were still intact. The pictures ran from the mundane to the dramatic: small tumors, large tumors, extensive resections, major reconstructions, preoperative and postoperative pictures.

My curiosity aroused, I picked up a few of the loose slides and spent several minutes holding them up and letting the light from a nearby window shine through them. Some of the slides were labeled, but I did not recognize the handwriting.

“Whose slides are these?” I asked one of the nearby attending surgeons. “Some of these photos are amazing!”

He, too, dipped his hand into the box and shook his head in recognition. “These slides belonged to the former chairman. When he died suddenly a few years ago, someone apparently tossed all of his lectures and presentations into this box. I tried to go through them once, but could not. They aren’t of use to anyone anymore.”

What a thought! As surgeons, we sometimes gather images of patients for their records and for lectures, assemble them carefully, and keep them ready for presentations. Why wouldn’t these photos be of use?

I tried to imagine the process of putting them into some sort of order. I would have to go through the charts, record dates and treatments, sort and catalogue the images, and make some sense of the piles. For several minutes, I considered doing just that.

The one thing I would not have been able to retrieve, though, would be the stories that accompany each set of images. With no story, each picture would have lost some of its ability to reach beyond the screen to preserve and to teach.

Even still, I briefly debated setting the slides aside to consider spending some time with them. Maybe I could have made some sense of a few of them.

In the end, though, I decided that the stories and the teacher who had gathered the stories had been lost forever. I hesitated, closed the lid, and retreated down the corridor and back to work.

Briggs and Al's Run and Walk

Tue, 07 Aug 2007 11:10:06 GMT

The Medical College of Wisconsin Department of Urology has assembled a team for this year's Briggs and Al's Run and Walk for Children's Hospital, and, incredibly, they are letting me run with them.

If you would like to donate to support the programs and kids at Children's Hospital of Wisconsin, I would be honored to list some of my blog friends as sponsors. I promise you will get your money's worth ... I am a REALLY slow runner. Click here to go to the donation site.

I promise to post some photos after the run on September 15.

Thanks!

Gratitude

Thu, 02 Aug 2007 11:56:23 GMT

I’m sorry I had to break this to you today.

Thank you.

What for?

You guys gave me ten years. That’s a lot of time.

But we haven’t even started to treat your new cancer!

I know. But no matter what happens, I am grateful for the last ten years.

That’s great, but we just took the cancer out back then. You did all the rest. But … ummm … what are you saying? Do you want us to treat the new cancer?

I suppose so. What choice do I have? I really do not want to go through treatment again, but I will do whatever you recommend. Oh jeez, I hope I don’t have to have more radiation! That was rough.

Actually, radiation might be part of your treatment, although I can tell you that the technology has improved a lot since the last time. They can focus the radiation much more tightly than they could and spare most of the normal tissues.

Yeah, right. Easy for you to say, doc. It’s still gonna be rough, right?

No doubt.

Not surprised. No matter what happens, though, I’m still grateful.

Tell me more.

Before you treated me for my last cancer, I was a mess. I was drinking and smoking and living like there was no tomorrow. I got in trouble all the time. I was crazy. I’m amazed I was still alive. My family had given up on my ever being able to straighten out. I hadn’t seen them in months.

I remember you did have an attitude.

That’s one way of putting it. Yeah, I came to those first couple of appointments drunk. I didn’t know how else to face things.

So, what happened?

I woke up the morning after you guys took out my voice box and realized that I had to change or I was gonna die. It was that simple. Black and white. I realized that I was gonna die.

But you knew that even making those changes didn’t guarantee that everything would turn out fine, right?

I guess I knew that, but, at the time, I realized that I did have some things to live for – my kids, my family, mostly. I was scared.

It worked out?

Well, not completely, but for the most part, it did. Losing my voice box was my wakeup call. Watching my kids grow up and getting to see my grandkids has really given me unbelievable pleasure. I wouldn’t have missed that for the world.

A lot of people do miss that.

And that’s why I can say ‘Thank you’ even though you’re sitting here telling me I have cancer again.

Well, then, I guess you are very welcome.

The following is feedback received for this blog:

This is excellent. Thank YOU for sharing this with us.
- Rob Lamberts
http://distractiblemind.ambulatorycomputing.com/

Yes, thanks for sharing. I have been thanked many times when I didn't feel I deserved it. I try to be gracious, but often I just feel like I should be saying "I'm so sorry"
- rlbates
http://rlbatesmd.blogspot.com/

Left Field

Tue, 17 Jul 2007 09:43:03 GMT

For this task, I prepare but never rehearse.

Gathering my thoughts, I walk deliberately down the Day Surgery corridor. In a minute, I will walk through the door of my patient’s room and deliver the news that neither she nor her family ever wanted to hear again. The woman, who had been treated successfully a couple of years ago, has a new cancer. The biopsy today has confirmed the diagnosis.

As usual, I pause outside the door for a moment. Before I am finished with the imminent conversation, we will have confirmed the diagnosis, discussed the plan of attack, confirmed her upcoming appointments, and, possibly, explored some frightening topics. Experience tells me that she will remember few of the details.

In the moment before I slide open the glass partition and enter the room, I am flooded by the stories and faces of patients who have faced similar recurrences; they bang around in my head vying for attention. As I anticipate her thorny questions and concerns, I stock my memory bank with research information and words of encouragement as an archer might select arrows.

I walk into the room and sit down. Our eyes meet and I touch her hand. “What we found explains why you have had more pain recently,” I begin.

“Oh, my God!” Her voice trails off. Her husband, a husky, bearded man, reddens, stifling a sob. Their granddaughter, a quiet 10-year-old with a wide open expression, grasps her other hand. The woman struggles to clear her head and to pay attention.

The brief family discussion is familiar yet is still different from any other before or since. I remain as unambiguous and straightforward as possible. I intentionally maintain a sense of hope. I briefly cover the next steps and the treatment options. I encourage them to call anytime they need support. We will repeat this discussion almost word-for-word in a few days.

The dialogue is winding down. “What other questions do you have? What do you want to know?” The patient and her husband shake their heads; they have exhausted their lists for the time being.

I turn to the granddaughter. “And how about you, Brittany? Do you have any questions?”

She wrinkles her nose and regards me quizzically for a few seconds. Her mind had been far away. Finally, a question gels in her head and she wonders, “How long does it take to become a doctor?”

Her grandfather smiles and wipes his eyes. He shakes his large head. “You think you want to be a doctor?”

“Maybe.”

The mood has changed perceptibly. I reset my focus and spend a minute encouraging her to work hard in her classes. She nods and tells me how much she loves school. She understands.

“Other questions? None today? We are going to get you through this together! Call, okay? See you next week.”

I grip everyone’s hand and head back to the Operating Room for the next case.

The following is feedback received for this blog:

Wow, you are a very talented writer. I've only read a few posts, but I am intrigued and will be adding you as a bookmark. Keep writing!

- cardiogirl

cardiogirl.diaryland.com

“Kindling waiting for a match”

Tue, 24 Jul 2007 08:31:39 GMT

John R. Hogness, MD, was the first president of the Institute of Medicine. The IOM serves the country as an “aggressive, unbiased examiner of health care problems” within the National Academy of Sciences. It is an honest broker that tackles the biggest and most complex problems that medicine faces, proposes the difficult and rational solutions required to improve health care. By nurturing the IOM during its nascent days, Dr. Hogness likely shaped how we, as a country, will address health care public policy debates for years to come.

Dr. Hogness recently died; I loved the stories about him that were told and implied in his obituary. While serving as dean of the University of Washington Medical School, he spent two months showing, in a practical way, his belief in the value of rural medicine by substituting for a vacationing primary practice physician in Omak, WA. He saw patients, made house calls, and even completed an appendectomy when the surgeon became ill.

The article stressed that he believed that great physicians can be found both inside and outside of medical school practices. “There are turkeys everywhere, including academia,” he noted. I suspect he might have looked with disdain on the profusion of “Best Doctor” lists with their inherent biases against non-academic private practitioners.

After a professional career as a dean, provost, curriculum innovator, national leader, quality advocate, and visionary, he finished his calling where he began, as a physician. The article describes him as “a shy yet affable man … who used his sense of humor, a physician’s bedside manner, a diplomat’s skills, a flair for acting, and an administrator’s discipline.”

Pulitzer Prize winning author Wallace Stegner wrote in Crossing to Safety that “talent lies around us like kindling waiting for a match, but some people, just as gifted as others, are less lucky. Fate never drops a match on them.” As I read this short synopsis of his life, I was struck that not only were Dr. Hogness’s talents set on fire but that he nurtured his gifts and shared them willingly.

His life’s work will have an impact on all of our medical careers for generations to come; how remarkable that the vast majority of us will never know whose talents were ignited and fanned to bring us to where we are and could yet go in the future.

The New York Times obituary (NYT 07-10-2007 A21)

The following is feedback received for this blog:

Sounds like he might have been "the match" for many of those around him.
- rlbates

The Champ

Fri, 20 Jul 2007 12:50:43 GMT

My new patient had lost 30 pounds over the past couple of months because he could not swallow but was too proud to call his family. He had been growing progressively weaker and was only a shadow of what he had been; “He could walk through a harp,” we sometimes say. His breathing passage was getting tight. His family, who had not seen him for a few weeks, was alarmed. They finally reached him on the telephone and went to the house where he lived by himself. They all but dragged him to the local hospital.

A physician found a large cancer of the throat and immediately transferred him to us; we had gone to the operating room for a tracheotomy and placement of a feeding tube. Now he was stable.

It was time to discuss moving him back closer to his home for further care. As I walked into the room, I glanced at the two daughters, their husbands, and their kids. The scene was all too familiar: a concerned but estranged family with a lot of history and a dad who had absolutely no intention of getting any assistance from anyone.

He coughed. They scowled. I looked for a way to make a connection.

By chance, I glanced at the bulletin board in his hospital room where the family had tacked up an old photograph. I scanned through the faces of several smiling men wearing identical shirts and holding bowling balls. Their hairstyles and the faded image placed the picture in the mid 1980s – about 20 years ago.

“What’s this?” I asked. “Tell me the story.”

“Dad was in the National Bowling Championships in Las Vegas that year. His team did very well. He was one of their stars. That was one of the proudest moments of his life.”

I studied the image. I looked back-and-forth between the photograph and my patient. Sure enough, one of the smiling, well-muscled, healthy men had the same eyes as the man lying in the bed across the room. The years and the cancer had changed him. Now the bowling star had a gaunt face, wasted muscles, long gray hair, a scraggly beard, a new tracheotomy, and a disheveled appearance. It was clear that his days of controlling the spin on a 16-pound ball were behind him. I looked carefully at the photo and spotted packs of cigarettes in most of the bowling shirt pockets.

“That is absolutely terrific! Wow! What an accomplishment!”

My new patient beamed, his smile briefly lighting up the room. As he tried to say something, he coughed some more phlegm out of his tracheotomy tube.

He reached for a pen. In large letters, he wrote, “We were winners.”

As I studied the message he had written on the pad of paper, one of his daughters sighed and shook her head. “That was a long time ago, Dad.”

Honored to be in Grand Rounds

Tue, 17 Jul 2007 10:00:50 GMT

This blog, in particular The 5th of July post, was added to Grand Rounds, a weekly listing of the best of the medical blogosphere. The list is hosted on a rotating basis and thanks goes this week to Vitum Medicinus.

The following is feedback received for this blog:

Congratulations! This was much deserved. I enjoy your blog very much.
- KM

The Elvis Stamp

Mon, 09 Jul 2007 15:54:56 GMT

Headline: “Woman cured of throat cancer after licking Elvis stamp”

Many years ago, a colleague gave me a copy of an article from a tabloid. A woman with progressive swallowing and talking problems was, sadly, found to have throat cancer.

To boost her spirits, she listened to Elvis tapes and bought some of the brand new Elvis stamps. Shortly after paying some bills and using the new stamps, she noticed that she felt much better. "All of a sudden I could swallow again ... I couldn't believe it." A medical expert confirmed that her cancer had completely disappeared! He was quoted in the tabloid as saying, "Medically speaking, her sudden total recovery cannot be explained."

The patient gave credit to the King. "It was Elvis sending his love from the spirit world." It certainly was an inspiring story.

Unfortunately, these types of Elvis-related medical cures are not common. Perhaps, there are some reasons for this:

Elvis stamps are all but out of circulation now. The stamp pictured in the article sold for 29¢, which has not been the first class postage rate since 1995.
No one licks stamps anymore. What if someone could be cured of throat cancer by licking one of the current 41¢ self-adhesive Liberty Bell stamps? We would never know.
Possibly, the cure was possible only because the Elvis stamp got close to the cancer during the actual licking process. What if the person had cancer of a different part of the body? How would she have needed to moisten the Elvis stamp to have an effect on, say, a brain tumor?

Dr. Sherwin Nuland, in the epilogue of his book, The Mysteries Within, writes about two different approaches to understanding the “Truth.” Empiricism, which is embraced by “traditional” Western medicine, insists on data. In Empiricism, Truth can change when enough data show that a prevalent understanding is faulty. Rationalism, on the other hand, fits any available data to a preconceived image of what the Truth is. In this view, Truth is fixed and no amount of data can alter it. I suspect that most adherents to the “Elvis stamps can cure throat cancer theory” would tend to fall into the Rationalism camp.

The Elvis stamp story provides an extreme example, of course, but frequently I am handed printouts on various dietary supplements and “cancer cures” that have never been empirically tested yet have unshakably loyal supporters. The discussions I have had about these products satisfies no one. Sometimes, it appears that Empiricism and Rationalism are very, very far apart.

My training and convictions put me firmly in the Empiricism camp. Still, would it be okay to keep a few Elvis stamps around, just in case?

The following is feedback received for this blog:

Excellent post. Elvis has been credited with many wondrous things, but I have not heard of this throat cancer cure.

I think some of this comes down to the idea of "belief." We all believe things that are not scientifically shown. When we say "I believe the Colts will win the Super Bowl" (or perhaps the Packers, in your case), that is meant more as just "I feel that they will." This woman can very well believe that the stamp did it and not be irrational if she accepts other possibilities. The problem comes when people believe this stuff despite contrary data or other more plausible explanations. They believe the facts to be scientific, when in fact they are nothing more than opinion.

- Rob

Magical thinking is common, especially for those with diseases that have no known cure. It is understandable that patients do not want to accept their diagnosis and instead build false hopes on implausible "cures." I might also do this if I were terminally ill. However, it is dishonest to feed false hope, and it opens the door to snake oil and its salesmen. Some physicians feel that it's kinder not to disabuse people of their magic cures (that there is a psychological benefit to having hope in a placebo) - and I can respect that. However, if the patient is spending money (perhaps their life savings) on snake oil - or putting off getting their affairs in order or taking trips - all for a treatment that has no possible benefit - I would want to have a frank discussion with them. Many times we can talk through the feelings that are driving the patient towards Elvis stamps - and that discussion has more therapeutic value (in my opinion) than the stamps ever will.

- Val Jones

The 5th of July

Mon, 02 Jul 2007 10:10:29 GMT

It was the 5th of July in the Emergency Department many years ago. A 10-year-old boy was crying, embarrassed, and scared. He was hurt, but in the long run, everything was going to turn out fine. It was a moment I have not forgotten. I suspect he remembers it even better than I do.

At the time, fireworks were still allowed within city limits. Young kids, particularly boys, looked forward to the 4th of July by accumulating paper packs of Black Cat firecrackers. As kids, we would untangle the fuses and pull one of the firecrackers from the package. A friend would light the fuse and we would hold the firecracker as long as we dared. It was, of course, a completely stupid thing to do; occasionally, someone would wait too long and be rewarded with ringing ears and buzzing fingertips. All of our friends would think it was absolutely hilarious. If I had ever caught my own kids doing the same thing, I would have gone crazy.

So, back to our story … On this particular 5th of July, the 10-year-old boy had gone to the park the morning after a group of older kids had set off hundreds of the small firecrackers. The night had been dry and he found a couple of dozen that were intact but had no fuses. For some reason, he decided that it would be really cool to set them off all at once. Even better, he wanted to have them shoot up into the air. He looked around and found the metal pipe the older boys had used the night before to launch bottle rockets. Awesome! The pipe, he believed, would send the explosion high up into the sky.

He carefully jammed a piece of paper in one end of the pipe and then packed in all of the loose firecrackers he could find. He tried to figure out how best to steady the pipe. In his mind, he pictured an amazing, canon-like display of pyrotechnics.

He took a match, lit the paper, and decided which direction he wanted to aim the blast, steadying the pipe BETWEEN HIS LEGS! The firecrackers, obeying the laws of physics, sent hot gas, smoke, and flaming debris out both ends of the pipe simultaneously. His shorts caught fire. The results were not pretty, but he would eventually recover. He was fortunate.

Since that day, the image of the damage even those little firecrackers can inflict has been joined in my mind by images of the potential consequences of driving intoxicated, riding a motorcycle and smoking cigarettes. Being involved, even peripherally, in the care of patients who have made bad or unfortunate choices has made me risk averse.

It is more than just knowing that some things are dangerous ... I also have seen and remembered the outcomes. I have worked in the Emergency Department, followed patients in the Neuro Intensive Care Unit, and been present at the hospice bedside. I have watched the families. The lessons sting and they stick. The smell of scorched cotton shorts lingers.

St. Teresa of Avila pointed out: “It is extraordinary what a difference there is between understanding a thing and knowing it by experience.” Sometimes, the experiences we stumble across in a hospital can shake us to our very bones.

The following is feedback received for this blog:

I'm saving this blog for my unborn grandchild. It's never too early to assemble an arsenal of wisdom.
- Mary Brawley

The Phone Call

Mon, 25 Jun 2007 11:13:20 GMT

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

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

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

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

“And ...?”

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

“What would she say?”

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

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

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

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

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

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

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

“I mean she didn’t call ME.”

“Oh, no! You didn’t …”

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

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

The Condolence Note

Wed, 20 Jun 2007 09:55:19 GMT

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

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

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

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

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

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

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

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

Complementary Medicine

Sun, 10 Jun 2007 09:54:19 GMT

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

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

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

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

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

The Social History

Wed, 06 Jun 2007 09:41:50 GMT

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

That did not alleviate his concerns, however.

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

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

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

Commencement

Thu, 31 May 2007 15:09:20 GMT

Over the weekend, I attended two commencement exercises, one to celebrate my daughter’s college graduation, the other to celebrate our medical school's graduates. Both ceremonies were replete with pageantry, music, speeches, tears, promises, and unapologetic happiness; in fact, the rituals and emotions were so similar in appearance that it took me some time to identify the fundamental differences between the two events.

The college commencement truly marked a new beginning. These young men and women were now “commencing” their journeys into adulthood. Their lives will undergo seismic shifts; many will never again sit in a classroom desk or stay up all night to write a paper. "Yesterday" and "Tomorrow" are completely different, and the new college graduate’s friends and family members, many of whom have been down the same path, can guide and support them.

Although the external trappings are identical, the medical school ceremony is fundamentally different because these new graduates have experienced a thousand “commencements” already, including:

The first time a complete stranger unflinchingly trusted them with the most intimate details of life.

The first time another human being allowed them – expected them – to probe for liver, heart, lungs, spleen, hernia, or cancer.

The first time they repaired a cut, gave a shot, started an IV, plunged a knife, wrote a prescription, heard a murmur, or slid in a catheter.

The first time they sensed the pulsation of an aortic aneurysm, recoiled from the odor of an abscess, or felt their hand enveloped by the warmth of the abdominal contents.

The first time they watched another person die before their eyes.

Abraham Verghese has described the final two years of medical school — the clinical years — as the “cynical years” because students often dilute whatever sense of wonder, optimism, and unselfish compassion they originally possessed. It is no wonder, since, during this time, they have commenced becoming physicians without the benefit of a ceremony marking the accumulating moments that could have warned them of their imperceptible transformation.

I had the perfect seat at commencement to watch the medical students’ animated faces in the moments before they crossed the stage to receive their diplomas. Standing in cap and gown, waiting to hear the title, “Doctor,” and then their names tied together officially for the first time, they could anticipate a few short weeks off before beginning the process once again.

For the new medical school graduates, the "Commencement Ceremony" was merely one signpost in a long arc of commencement experiences that stretches far into the past and extends years into the future.

The Medical Resident’s Spelling Quiz

Thu, 24 May 2007 09:54:45 GMT

The medical resident had the perfect strategy to always get personalized service whenever he wanted. As new medical students rotating onto his service, he offered us a deal:

“Okay, rookies, I am going to give you a short spelling test of common medical terms. If you get all five words correct, I will do one of your history and physical exams for you. If you miss any, you will have to run and get me a cup of coffee whenever I want for the next two weeks. Deal?”

We were all pretty confident spellers, being college graduates and all. “Deal,” we replied.

He rubbed his hands together. “You first, Campbell. Here are the words and their usual pronunciations:

“Spell the name of the specialty that takes care of the eye (“Op-tha-mol-o-gy”).
“Spell the name of the bony plate that the olfactory nerve passes through in the skull base. (“crib-a-form”)
“Spell the name of the operation to fix a hernia. (“her-ne-or-a-fee”)
“Spell the name of the chemical that is used to check for blood in the stool. (“gui-ack”)
“Spell the name of the bony plates behind the maxilla (“ter-goid”)
“And for bonus points, tell me the difference between a regimen and a regime.”

None of us got more than a couple of them correct. He spent the rest of the month with a smile on his face and a cup of coffee in his hand.

Answers to the Medical Resident’s Spelling Quiz:
Ophthalmology (most leave out the first “h.”)
Cribriform (most leave out the second “r.”)
Herniorrhaphy (most give up.)
Guaiac (most leave out the first “a.”)
Pterygoid (most leave out either the “p” or the “y.”)

And for the bonus points, a “regimen” in medicine is a prescribed course of treatment. A “regime” is a government, although some authorities insist the words are synonyms.

If you did great on the Medical Resident’s Spelling Quiz, try this grammar quiz from the University of Iowa Carver College of Medicine!

Stereotypes of People With Cancer

Mon, 21 May 2007 08:31:32 GMT

The CT scan showed that her already incurable cancer had worsened. I walked into the examination room dreading what I might find. Despite the scan results, she smiled, stood up and grasped my hand in both of hers. I expected to see a woman in suffering; instead, here was a person glowing with contentment.

Don’t all patients with advanced cancer suffer? Is her situation unique? An article in the Journal of Clinical Oncology [JCO 2007 (May 1); 25:1691-97] reports a study of nearly 400 relatively functional people with advanced, incurable cancers. These people had been referred for hospice care and were not expected to live more than a few months. The study found that:

Half of the patients reported no suffering whatsoever, and one-quarter reported either minimal or mild suffering. One-tenth, however, reported severe or extreme suffering.
Greater suffering was associated with depression and anxiety.
Suffering was most closely associated with malaise, a sense of illness, weakness, and pain.
Suffering was more closely associated with physical symptoms than either psychological or existential concerns
A few of these terminally ill individuals worried about their own deaths, however, they were far more concerned about pain, stress, loss of function and control, and dependence on others.

I learned that my stereotypes of what "dying people" were supposed to feel and experience was wrong. As caregivers, we are charged with relieving pain and suffering when they occur, but we also provide support and a continuing presence when needed.

As frequently happens, my patient was also my teacher that day.

First-Name Basis

Thu, 17 May 2007 10:26:09 GMT

“Hello, Mr. Jones!” I reach to shake his hand as I enter the exam room. “You look great! How are things going?”

“I’m doing just fine,” he replies. “PLEASE call me Ken,” he adds.

“Um, okay,” I respond, but I will probably never call him by his first name.

Ever since I was in training, I have addressed patients by their last name: “Mrs. Thompson,” or “Mr. Silverman,” or “Ms. White.” Despite this, some patients insist at every opportunity that I address them by their first name. Occasionally, patients call me by my first name. I don’t protest when they do this, but I continue to call them by “Mr.” or “Mrs.”

Names are a funny thing in a professional setting. When I am getting an X-ray or lab test myself, the technologist usually calls me “Bruce.” Their training must assume that by adopting an unearned sense of intimacy, the patient is put at ease. When I was in medical school, however, most of my role models maintained professional distance and decorum whenever they addressed their patients. These mentors would never have dreamed of addressing a patient by his or her first name.

What does using a first name imply? In social settings, taking the step to using a first name implies intimacy and friendship. On the other hand, calling someone by his or her first name can also assume a sense of power over that individual. Even the ancients felt this.

So, I continue to address my patients the old-fashioned way. My philosophy of patient care seeks neither intimacy with my patients nor power over them. If I begin using a patient’s first name, I worry that the important relationship between patient and physician will be irreparably altered and also realize that, for some of my patients, a dreadful day will arrive when they will need a physician who is objective rather than one who is intimate.

The following is feedback received for this blog:

I agree with you - addressing patients by their last names (especially in your first encounter) is respectful and sets the tone for a professional H&P. As a general rule of thumb, I think of last names as an extension of the white coat - wherever you'd find it appropriate to wear the coat, you address your patients formally. So, in pediatrics you might not wear the coat... and perhaps not in psychiatry. Otherwise, it's a good idea.
By the way, LOVE your blog. Will add you to my blog roll. :)
- Val Jones

---

Thank you for treating your patients with dignity. Being addressed by my first name by a medical tech who is half my age does not put me at ease; it makes me uncomfortable and angry at the presumption. Having to wear one of those hospital gowns is bad enough!

Amazed

Mon, 14 May 2007 10:22:37 GMT

Years ago as a medical student, I worked as a nurse’s aide in a Chicago area emergency department. One weekend night, a middle-aged woman came in with leg pain after a relatively minor injury. An X-ray confirmed a femur fracture and the young resident physicians, who I admired very much, prepared her for admission to the hospital. They checked her labs, treated her pain and filled out forms. Soon, she was resting comfortably. I transported her to her hospital floor.

A short time later, the attending orthopaedic surgeon strode in from the parking lot and rummaged through her X-rays, which were still in a box in the ED. “Did anyone do a complete physical examination?” he barked. “Go up and do a breast exam!”

I wondered, How can he look at an X-ray of her leg and conclude that she had a problem in her breast? But, sure enough, there it was: a huge, ulcerated and long-neglected breast cancer stuck to the chest wall and growing out through the skin.

How could he have been so sure? His experience had taught him to recognize the bone metastasis and to know the most likely source. Now, years later, I realize that all physicians learn to make associations like this one through experience and training, but I distinctly remember how amazed I was at the time. I wondered, How will I ever be able to remember everything that I need to know as a physician? I’m still wondering.

Hearing the Stories Again

Fri, 11 May 2007 10:08:45 GMT

Two weeks ago at a national meeting, I stopped by the evening reception to renew friendships and find a friend with whom to go have dinner. Soon, I was sharing stories with former colleagues and their families.

As the reception broke up, several of us gathered in a circle with two outstanding retired surgeon-scientists, true giants and mentors, each of whom has influenced my career. From one, I had learned surgical technique, from the other, a philosophy of patient care. Both had modeled meticulous adherence to the precepts of cutting edge, evidence-based surgical management of head and neck cancer. At the same time, both had shared the stories that defined their approaches to patient care.

I had not expected to see either of these mentors at the meeting. One of them no longer lives in the United States.

Yet here they were, bursting with the tales that permeated my fellowship experience. As the evening progressed, I discerned the camaraderie in which I had been immersed twenty years before. I strained to hear every word, refreshing all of the true and not-quite-true legends. I ached with laughter and longing. It was a rare opportunity for which I was very grateful.

The evening ended and we each went our own ways. I finally understood that my mentors had taught me not only the techniques that permit cancer to be cured, but also the stories that allow patients to be healed. Rachel Naomi Remen, in her book, Kitchen Table Wisdom, writes that a story is the container for meaning. I am grateful that the stories have continued to unwrap and teach their own subtle lessons years after I tentatively ventured into practice on my own.

The Peanut Gallery

Mon, 07 May 2007 08:40:26 GMT

I was getting increasingly frustrated. Every time I tried to ask my patient a question, her husband would answer. And, even more annoying, he was sarcastic.

Are you having more trouble with your mouth lately?

From in front of me: Yes, there is quite a bit more pain.

From across the room: Of course she is, Doc! Otherwise why would we be here? Jeez, can’t you see that things are worse?

After a few minutes, I recommend scheduling some biopsies in the operating room.

From in front of me: I understand. I hope this will help get us some answers.

From across the room: C'mon, Doc! Why can’t you just take the samples right now? This will cost us more! Why do we have to keep coming back? Maybe we should go see an expert!

I kept my composure this time. Fortunately, I had recently read a quote from noted physician and writer William Carlos Williams who once observed: There’s nothing like a difficult patient to show us ourselves.

Amen. And I might add, not just the patients are difficult.

The following is feedback received for this blog:

This is a great blog/format. Too many patients know too little about their health and medical care, in part because they see MDs on a pedestal and are afraid to speak with them. I am a big fan of personalizing medical care, which helps patients "take ownership" of their health and better manage their lives.
Thanks,
Joan

The Gift

Fri, 04 May 2007 10:45:45 GMT

She was sitting in the examination chair with her arms tightly crossed. When the medical student had gone into see her, she had refused to allow him to check her pulse or blood pressure. She was disheveled and clearly agitated. As I entered the room, I greeted her and extended my hand.

“No! I can’t touch anyone! My boyfriend has an infection!” I have something on the top of my head and I think it might be from him! Just give me something!”

I carefully washed my hands in front of her and looked at the scalp. She had a small area of swelling on the top of her head, but it was merely a small cyst. Not a problem. No treatment required.

“Who told you that you couldn’t touch anyone?”

“I’m not sure. It has been weeks.”

Imagine going weeks with no human contact! What right is more basic? Surrounded by a sea of people, alone, unclean, and untouched.

After a discussion on the importance of hand washing, I gave her “permission” to again touch and be touched. She was a foot off the ground as she left. I did not give her much, but yet, what a difference that small gift made.

The Drawing

Sat, 21 Apr 2007 23:50:00 GMT

“Doctor, what did you need to take out during the surgery?”

“Let me show you.”

I pull out a dry-erase pen. During the post-operative discussion in the Family Center, I often draw out the procedure on a white board. I sketch the basic relationships between the structures and show what was removed and what was preserved.

“We removed this area and the lymph nodes from these areas of the neck." I erase the structures that were taken out. "When you see him he will have an incision here.”

The drawings serve as an additional communication technique. The families seem to appreciate and understand them and they are usually much simpler to interpret than photographs.

Early in my practice, I developed a series of quick line drawings that depict the regions where I spend my professional time: the oral cavity, the pharynx, the larynx, and the neck. I use the pictures in my office notes and in hospital charts and almost all of my notes have at least one drawing. They serve to remind me what I saw and what I need to check at the time of the return visit.

Believe me, I am no artist. Nevertheless, every few years, my residents ask for a demonstration of how I create my drawings. I am gratified when they discover this simple means of communication. I think some of them enjoy it as much as I do.

Who Will Take Care of the Boomers?

Thu, 19 Apr 2007 00:05:42 GMT

We baby boomers are in for a lot of shocks over the next years. One surprise might be too few cancer specialists to take care of us.

An article in the March 2007 issue of the Journal of Oncology Practice predicts that there will be between 2500 to 4000 too few medical oncologists by the year 2020. The problems swirl around the fact that training programs are not expanding, the U.S. population is aging, and older individuals develop most new cancers.

Another issue is the increasing number of cancer survivors. The United States currently has about 10 million cancer survivors, a number that is expected to double over the next 15 years.

What can be done? Oncology training programs could increase the number of new oncologists, but even that would not cover the expected demand. Nurse practitioners will see more and more patients. Many cancer survivors will get their follow-up from primary physicians.

Personally, I regularly encourage medical students to consider careers in cancer specialties. I tell them that cancer physicians assume demanding, rewarding and critically needed roles. Of course, knowing that the lifetime cancer risk is one-third for women and nearly one-half for men, there is a significant probability that I, too, will need a great cancer doctor myself someday.

Carry On

Wed, 18 Apr 2007 23:46:38 GMT

I finished surgery and found the family. The man’s wife was emerging from anesthesia and the tumor she had feared would be cancer was, happily, benign. He, however, was in obvious pain.

“Fantastic!” he exclaimed, but he added quietly, “I’m not sure I could have taken more bad news right now.”

When I asked him what he meant, he told me that his mother had died the week before, his sister had just died of cancer, and his own health problems might soon require surgery. He shook his head. “So many things to deal with all at once.”

The next day, I had bad news to share with a different family. This man’s aggressive cancer was back and rapidly growing despite treatment. Each day, he grew weaker. The patient’s wife had just lost her mother to cancer. Their sons were reeling from the ordeal. None of them was getting much sleep. His eyes contained an incredible sadness.

Each family was dealing with multiple simultaneous life-altering events, each of which would have been a powerful stressor. I marveled that, despite the assaults they were all enduring, they continued to find the strength to continue on.

Both times, I could do little but sit, listen, and promise to return.

Testimony

Mon, 09 Apr 2007 16:33:33 GMT

Several days each year, I teach high school health classes about smoking. The kids, no doubt, understand that a middle-aged physician is going to tell them that smoking is bad. As I begin, they are polite but disengaged. As I run through statistics about teen tobacco use, they look around, stifle yawns, and do their math homework. Then I show them videos I made of some of my patients.

One woman in her late 40’s had a recurrent cancer. She is lying in a hospital bed, gaunt, pale, and exhausted. She has a feeding tube in her nose. Her voice is hoarse and her movements deliberate. On the video, I ask her if she thinks her smoking had anything to do with her cancer. “Oh, definitely,” she responds. Then, spontaneously, she continues, “Every time I see someone smoking, I’d just like to tell them about me and how much I have suffered.” She takes a deep involuntary breath and begins to cry. I have watched the scene dozens of times and it still affects me.

As she wipes her eyes, the kids in the classroom are transfixed to the screen and absolutely silent. I honestly do not know if this woman, now long dead from her cancer, has had an impact on individual kids’ smoking behavior, but I like to think that her testimony has made a difference in at least a few of their lives.

Taking Cancer Screening to the Next Level

Mon, 09 Apr 2007 16:31:49 GMT

As physicians, we continually encourage our patients to undergo regular cancer screening and to pay attention to recommendations about diet and exercise. What if our patients actually listened to us?

The American Cancer Society recently issued recommendations for yearly MRI scans of the breast in addition to mammograms for high-risk women. These $1,000 to $2,000 tests are effective and increase detection of pre-clinical cancers.

However, as one of the co-authors of the report recently described, we currently do not have enough MRI capacity or radiologists to interpret the volume of tests that would be generated by complete compliance with the recommendations.

Quick reactions:

Why is screening recommended YEARLY? Cancer doesn’t recognize any calendar. Could studies be directed to better determine the most effective interval?

How can we address the disparities in cancer screening? Uninsured women already have lower mammography rates compared to all women (37 percent vs. 61 percent). An expensive, resource-intense study will increase this gap.

How about people with other types of cancer? What studies will determine whether this information can be translated to cancer of other parts of the body?

What happens when the next big study is released? What if it turns out that PET/CT is eventually proven to be more effective than MRI? That would quadruple the cost.

Early detection saves lives and money. We need to make sure the benefits reach all people.

The following is feedback received from this blog posting:

"How many hours is the MRI UNIT in operation at your facility.? Why not operate it 24/7. Wouldn't that bring the cost of these expensive machines down to the facility and therefore also the test cost to the patient. Maybe we need a certificate of need mandated by the state of Wisconsin to limit the amount of money spent. Its like having three cars in the garage for two people to use. Why is southeastern Wisconsin one of the most expensive medical areas in the U.S."

The Discussion after the Biopsy

Tue, 03 Apr 2007 22:54:32 GMT

She grips my hand. Hard.

“Doctor, what does this mean?”

She is looking for an honest answer. I have been her physician for ten years and she has fought off cancer twice, first with radiation and then surgery. Now her cancer has returned.

“Doctor, my grandchildren are just now growing up.”

She is looking to the future. She is in her seventies and in good health otherwise, but she senses the clouds gathering that threaten her future.

“Doctor, I want to go back home to visit my sister.”

She is looking at the present. She wants to spend time with her far-distant sibling before it is too late for each of them.

“Doctor, you have helped me before.”

She is looking to the past. She hopes that good fortune and technology can sustain her once again.

“Doctor, please.”

She looks intently at me. The harder she grips my hand the more I am humbled.

The following is feedback received for this blog:
	I agree with you - addressing patients by their last names (especially in your first encounter) is respectful and sets the tone for a professional H&P. As a general rule of thumb, I think of last names as an extension of the white coat - wherever you'd find it appropriate to wear the coat, you address your patients formally. So, in pediatrics you might not wear the coat... and perhaps not in psychiatry. Otherwise, it's a good idea. By the way, LOVE your blog. Will add you to my blog roll. :) - Val Jones ---
	Thank you for treating your patients with dignity. Being addressed by my first name by a medical tech who is half my age does not put me at ease; it makes me uncomfortable and angry at the presumption. Having to wear one of those hospital gowns is bad enough!