Time to Recharge

I have a trip planned next week. Camping alone in the desert of New Mexico and parts of southern Colorado. I forget sometimes that my problems are small within the grand scope of life on this planet. Sometimes, the majesty of the West reminds me of the long view of nature and of the smallness of my own life.

This past week was difficult. One of our practice's long time patients was sent to hospice with refractory lymphoma after years of battling her disease. In the stress of it, her husband of 30 years had a massive subarachnoid hemorrhage the evening after our hospice discussion. He was otherwise totally healthy. Within a week, their daughter lost both parents.

A colleague of mine was diagnosed with melanoma. Early stage. She's only 33 years old. I think it will be fine. She's a triathlete, smart, beautiful. Has a great attitude. But, it reminds me that it is so fragile... this life of ours.

Being a cancer doctor has been a gift to me. I could never imagine being anything else. Lost in all the health care debate is the emphasis on the sacred relationship between patients and their healers. I say healers in that it is not just doctors but nurses and techs and holistic treaters, nutritionists, PAs, NPs, etc., who can "heal".

We forget sometimes, amidst the data and the money and the overhead and the cramp schedule, that helping people is truly what it is all about.

That, ultimately, we are all small in this world. That there are timeless truths that exist beyond our finite life, be it God or "god" or nature or the cosmos or whatever. But, that these transient connections with friends, colleagues, patients, loved ones... these things, though not unique, are always special... eternal, in their own unique way.

Controlling the Deficit

I'm an Obama supporter. Let's just get that out of the way right off the bat.

But, like many others, I'm a bit frustrated and confused by the "health-care reform" discussion that is going on in this country right now. It is complex, perhaps too far reaching and opaque. Although I support a single payer system, I'm a little skeptical about the government's ability to do anything correctly.

Hopefully, with all of this rancor in these town meetings, there is now some increasing emphasis on the core problem at the heart of entitlement reform: that our country is doomed in the future if we don't control costs.

Honestly, we need to reign in the cost of Medicare. That is just the number one priority for the fiscal solvency of this country. That is where Obama seems to have taken his eye off the ball. Granted, I support insurance for all. But, not if it only jeopardizes the economic stability of our government even more than now.

Unfortunately, I foresee only two solutions, both of which are needed. Benefits for Medicare must be restrained, i.e., the cost of doctors, hospitals, insurance and tests/services of patients... all of these must be cut back, even as the population ages and there is greater demand.

Two, taxes must rise. Yep. On all of us.

Pay more, get less. They'll never tell us that, but it's the truth. We need to get used to it.

Pay more, get less.

Say it with me. Pay more, get less.

In some ways, this whole red herring Republican, Palinesque distraction of an attempt to claim that Obama wants to enact euthanasia is actually an important issue that needs scrutiny.

Much of the cost of Medicare is spent at the end of a person's life. The public lacks the desire or sometimes the ability to wrap its mind around this fact. Because it brings in the whole issue of: what is a life worth?

I would argue that we DO need a discussion about end-of-life care, euthanasia, self-determination of our deaths and the responsibility of all individuals to NOT drain society's resources with an expense and purposeless over utilization of resources in the waning days of life.

We need to accept death, take control of it and, quite frankly, save money in the process.

Memory of An Elephant

My thoughts drift back to my friend from prior posts, Elephant Number 5. That was her family's way of referring to her as the 5th daughter in their close knit family. She died three?, maybe four, five years ago now. It's funny how the time goes so fast. Sometimes, after seeing so many people pass into the hereafter, day after day, it is easy to get somewhat distanced from the pain, the personal journey of each patient. There really isn't time to mourn. The next person, the next chart, the next consult is a tragedy all on its own and requires your laser-like focus.

That is often when Numero Cinco comes back in my mind. Because she was my own friend, who faced cancer early in life, beat it back for a couple years, was on the verge of cure, only to die of a complication of a bronchoscopy in one of the premier cancer centers in the land. I'll never forget her last email to me, wondering why I hadn't responded in a couple days. She had all sorts of interesting observations on aerosol masks, diarrhea and the wonders of graft versus host disease. She had no idea she was going to die the next day. It all just can change in an instant. So cliche. So true.

I think the first time I really grew up, really became a man, as well as an oncologist, was when I looked into the face of a patient and saw the pain and shock that comes with the knowledge that your cancer has returned and now it is incurable. If I was naive or Pollyannish ever, now it was over. I saw life for what it is and will always be. Finite.

Well, 5, needless to say, she had a lot to give. Much to live for. There was always something a little flirty between us. The emails were banter, always an allusion to a future meeting, a time when her hair would grow back, the color would be back in her cheeks and we might spend a few moments in person.

It's funny. I didn't even really know her that well. We met at a wedding. She knew the bride, I, the groom. Paired together in the bridal party, traded at the last minute, she turned what was otherwise a tepid, classically excessive Boston Brahmin's wedding into something magical and free.

A week. That's it.

Then the writing begins. And continues. More. Emily Dickinson on the page. You can really get to know someone through their words. Their dreams. With no tension in the air, no awkward silences, only the thoughts that careen off the page into your brain and down into your heart.

Her death, like that of so many patients that I have seen, was both protean and unique. Death comes to all of us. But, not everyone lives a vibrant life like she did.

She reminds me that all of my patients have loved and lost and lived and now died. They had their one unique time on earth and hopefully, their memory persists for the brief moments of another generation.

You did it to me again, E5.

Who Am I?

I think a lot of my blogging lately is centered around some existential questions that have popped up lately. When I first embarked on this, I was confronted by so many issues centered around the nature of my future career/profession and all of the choices within.

Now, I've chosen my life. It's been three years. I've settled into the meat of it. Like a marriage, the honeymoon is over. I'm beginning the cusp of the phase of it where I start to think about the rest of my life in this role.

The oncologist.

A lot of people died on me this past month.

Two friends were diagnosed with breast cancer in their 30s.

My relationship has foundered.

My beliefs are shaken.

Am I where I want to be? Am I going where I want to go?

Who am I, when you strip away the accolades and the white coat and the test scores?

Do I want a family?

If this is my one life, my only life, then what is it all about?

I suppose these are the questions that we all pose in life. We get busy with jobs, with children, marriage, parents, sickness, etc.

I guess I've thought about this a lot lately as 1. I'm single, 2. I have no children and 3. I'm constantly bathed in existential questions as I try to navigate life and death with my patients.

I have no answers.

Only questions.

Jesus says this. Mohammed that. Confucius, Lao Tzu, Buddha... and on and on.

But, in the end, we face our life alone. In the quiet of the night, when things are still. After the children are asleep. The lovemaking is over. We think about it all.

I'll let you know if I get any insights.

Our Water Footprint

I've been thinking a lot about water lately, after I read in a magazine about the "water footprint", somewhat analagous to the carbon footprint that has become widely popularized as the population becomes more eco-conscious. We think about eating vegetables instead of beef, as the the carbon footprint of beef is much, much higher than fruits and vegetables... less fossil fuel needed to make the feed to give to the animals... less methane production from the animals... less issues with transport of product and refrigeration, etc. Therefore, beef is a bit less environmentally friendly than fruits and vegetables.

Likewise, everything has a measurable water input. However, it is much less clear and less publicized. For instance, an apple may require several gallons of water to be produced. A pair of blue jeans requires thousands of gallons, if you factor in the growth of the cotton, the transport, the cleaning, the dye process, etc.

I've thought about this more and more, as I've faced patients' questions about the relationship between the environment and their cancers. The story is far from clear, but what is known so far is that there are diminishing numbers of watersheds and aquifers that are free of industrial pollutants, pesticides and other toxins that are known or potential carcinogens. There is increasing evidence that our drinking water is contaminated with pharmaceutical agents that get into our sewer systems. There is a question of so-called "endocrine disruptors", agents that mimic endogenous hormones like estrogen or testosterone, having biologic effects on wildlife. Increased feminization of amphibians. Male fish that lay eggs in the Potomac river watershed.

Patients always ask me if cancer is getting more common than in the past. And, if so, then why? I usually think of smoking or the fact that we are living longer and dying less of pneumonia and heart attacks. After all, we need to die of something.

But, with or without data, I'm becoming more convinced that the progressive contamination of our water and food supply with man-made chemicals is at the root of many diseases. Outside of cancer, there is some epidemiologic evidence for pesticide exposure and risks of Parkinson's disease, autism and Lou Gehrig's disease. There is a decline in sperm counts in boys throughout the industrialized world. Girls seem to be getting menses sooner and sooner. Cryptorchidism, or undescended testes, is occurring in up to 6% of boys in the US. It later descends in most cases, but still, this is a hormonally driven process.

Certainly, within oncology, there are clear associations between some substances like benzene or Agent Orange (a herbicide) and lindane on cancer risk. There is epidemiological data that associates people in farming communities with the risk of some cancers like lymphoma or leukemia.

With water as an example, I think that so much of the health care debate dovetails with greater issues in our society such as overconsumption, too much development, contamination and destruction of our environment and overpopulation.

Our decline in drinkable, safe water is related directly to our rise in population and industrial capacity.

In my last blog, I talked about specifics related to the US health system. But, as we all fight about "winners and losers" in the health care system and as physicians, patients, hospitals and insurers all try to maximize personal gain and minimize loss, I think there needs to be a greater discussion and awareness about the pathologic nature of our way of life in general.

What is the nature of "growth"? Does the Gross Domestic Product, which measures total economic productivity, really factor in well the costs of environmental damage, sprawl, overwork, population density and "quality of life"? Or is it merely a numerical game that sets the world on a path of trying to achieve ever increasing "wealth", while sacrificing many of the core things that truly make up happiness and health.

Our usage of water and its subsequent contamination is a function of excesses in our consumptive modern lifestyle. The earth has an amazing capacity to heal itself, if left to its own devices. Even over time, deforestation, soil erosion, habitat destruction... these things can all come back.

Water is life. We ruin it at our own peril. If we fail to understand the connection between the overall structure of our modern Western society and its impact on health, then any attempt at reform of the health care system is ultimately flawed.

Getting electronic medical records, insuring more people and eliminating preexisting conditions are noble goals. But, they are mere peripheral band-aids compared to the larger issues of our society and the impact on health.

Water. Inactive lifestyles. Meaningless consumption. Broken families and communities. Overpopulation. Social inequality. Pollution. Sprawl.

These are at the core of our problems in health care. All the technology and money and rah-rah enthusiasm about increased access or the "Mayo model" or Congressional Budget office estimates miss the point.

If we don't eventually accept deep in our hearts and minds that we must live within our WORLD'S ecological capacity, all the chemotherapy in the world ain't gonna do it.

Just ramble in my mind on a warm Maryland day...

Health Care Reform

Congress is on break for a month, the so-called summer recess. As if they work particularly hard when they are there... anyway, this next month marks a very important point in the "health care reform" legislation that is going through both houses of Congress right now.

From what I see and read of the proposals and the surrounding media coverage, it is not really clear to me that the American people really understand what is being proposed or what real reform requires.

Let us briefly go over the acknowledged problem in the first place:

1. America spends something like 15-17% of the Gross Domestic Product on health care
2. Yet, despite this, our health outcomes are no better and, in some cases, worse than our industrialized counterparts in Europe and Asia.
3. There are a lot of uninsured
4. Entitlement spending on Medicare and Medicaid, if left unchecked, will balloon to disastrous proportions in the next several decades (as the population ages), to the point of bankrupting our already debt-laden government.
5. If we wait until the bubble finally pops, as a result of our national debt and unfunded governmental liabilities, then we'll face a steep rise in interest rates and a sharp devaluation of the dollar, resulting in a catastrophe for our standard of living and basically the entire American economy/society.
6. So, we need to reign in our debt, and health care, as the largest portion of this, is a huge part of that effort.
7. Oh, and we have a totally inequitable system that has many uninsured and a large number of "underinsured".

Now, amidst all the pandering and bickering in Washington, I think that there is a total lack of honesty on the part of the politicians as to what is really required (from my viewpoint) to "fix" health care. If they were actually straight with us, they would express what most physicians already know.

That our current system does too much for too many with no clear benefit. Getting the system on firm financial standing requires several things to happen altogether.

1. We need to raise taxes. There is no way around this. Seriously. Really. As someone who already pays 50% of my income to taxes, I HATE this, but it's true. Obama is trying to just tax the rich. Not too fair. The idiot Republicans don't ever want to tax anyone. It's asinine. We all need to pay a little bit more if we are going to insure the uninsured and pay for all the Baby Boomers to live to old age gracefully and with dignity.
2. We have to cut some benefits... I know. That sounds terrible. But, we need to ration health care. Granted, every lobby under the sun, from docs to insurance to pharma, is trying to scare the bejeezus out of us with "Canadian style health care", but the truth of the matter is that some rationing is needed. We can't pay for Viagra and stomach stapling and dialysis for every person over the age of 70. I often think of the failed attempt in Oregon to rationally apply health care dollars to the most cost-effective medical treatments. The Oregon Health Plan, as it was known, got together experts in medicine, public policy, public health and government and came up with a list of treatments, ranging from super cost effective, like the polio vaccine, to completely financially suicidal, like risky, experimental bone marrow transplants for ultra-rare diseases. In Solomonic fashion, they set a fixed level of money that was available in a given year and funded fully as much of the list as possible, starting from the most cost-effective side. Once they ran out of money, the treatments below the line were not funded by government money. I know, it sounds heartless, but think of Spock in Star Trek III, "the needs of the many outweigh the needs of the few, or the one."
3. Going along with number 2, we need to set a limit on the total yearly budget of Medicare or Medicaid. Simply letting them balloon is just stupid and eventually brings us all down.
4. We need to get away from fee-for-service medicine. I know, my colleagues will start lining me up to get shot or tarred, but it's true. Right now, I'm incentivized to give more chemo to anyone who walks in my door, regardless of need or age. The more I give, the more money I make. Granted, I like to think of myself as ethical, but when I see the monthly statements and our revenue is down and the staff are bitching for raises, I would be lying if I said I didn't think about "maximizing" the infusions or whatever... your physician should NEVER think about maximizing revenue, EVER. PERIOD. If we just found a way to pay for outcomes or bulk payments for certain diseases rather then per procedure, I think you would take some of the adverse incentives for doctors to overprescribe or overutilize services. Let's face it. We have similar cardiovascular outcomes to Canada and Britain, with similar demographics, but we spend a boatload more per capita than they do. Why, because cardiologists make more money putting in a stent than talking to you about stress and working out and fish oil.
5. There MUST be a public option for insurance. The current private insurance market is terrible. Inefficient with so much paperwork. Denials. Preexisting conditions. In an ideal world, medicine in the US would be publicly financed, but privately delivered. Meaning... the government is a single payer, but the doctors and hospitals compete to provide services. Therefore, you don't just have lazy, inefficient providers sitting there bored and waiting for a VA check. They are competing for patients and to provide good care. But, all the haggling and $600 billion waste in administration would be put to better use. In our own office, we pay tens of thousands of dollars to a billing company, whose whole purpose is to fight with private insurance. It's totally illogical.
6. Patients have to do their part. There has to be some built in tax breaks, incentives, whatever for better lifestyle choices. Losing a percentage of body mass index. Quitting smoking. More exercise incentives for work or schools. Some tax penalties for poor choices. I know that this sounds a bit draconian. But, society shouldn't be responsible for eating the cost of someone's really crappy life choices. I'm not saying we need some Orwellian state where you're being told what to do at every stage, but... well, let's just start with smoking. If smoking and obesity alone were addressed, that would affect the top 4 killers in this country: coronary artery disease, cancer, stroke and emphysema. There was a time when America was a "pull yourself up by the bootstraps" and personal responsibility type of nation. It's time to go back to that.
7. We need some tort reform. Yes, I know. This is age-old bitching by a doc, but it's true. Litigation has permeated all aspects of American life, but no place more than medicine. I think there should be a medical litigation board that quickly screens malpractice cases to determine their validity, before the costly process of litigation and then settlement begins. It is so NOT cost-effective for most insurances to fight claims that they usually just force the doc to settle, no matter who was at fault. The only winner is the lawyer. I think fear of litigation, combined with the perverse fee-for-service incentive system, help to drive up the bulk of overuse by docs. If I can both make more money and decrease my likelihood of getting sued, why not just order the same damn unnecessary MRI that I always do?
8. Lastly, I agree with Obama's attempt to set up a National Medical Board. It's important that an independent body evaluates and validates different treatments to see if they are truly effective and cost-efficient. Take early prostate treatment for example. Should you get surgery or radiation? If radiation, should it be something called IMRT, with or without radioactive seeds? To date, we still don't know which one, even though radiation, with all the bells and whistles, is much more expensive. That is, unless you do a robotic surgery. No one knows, but in places where they have a robot, you often get the robotic surgery. If the surgeon owns a radiation facility, you get the IMRT. Take some orthopedic procedures, like arthroscopy for some knee conditions. It took years to finally evaluate whether this is really needed for all cases of minor cartilage damage or whether conservative treatments like rest and physical therapy are as good. Well, the surgery is apparently WILDLY overused. Why? It makes money for doctors and hospitals, of course. Only if we get an independent body to do this will there be some impetus to reject payment for some expensive and unnecessary treatments.

Anyway, as you look into the debate over health care, try to think of these issues. Granted, this is all just coming from my perspective. But, I think we ALL need to chip in. Docs, health insurance, pharma need to make a little less money. The government needs to set standards and goals. Patients need to take more responsibility, pay a little more taxes and learn to live with less medicine. We all need to strive for the best evidence for the best outcome, at the lowest cost.

I'm telling you. Just think like Spock.