CancerDoc

2012

2012-01-12T15:15:00.000-05:00

The last couple years were pretty difficult. Personal problems, professional problems, existential problems.

But, rather than view 2012 as some kind of "new" year, I'm starting to accept that all pain is simply the flip side of happiness.

As I see countless cancer patients struggle with their lives and deaths, I start to see it all as the grand cosmic cycle of life and death, birth and creation.

Ecclesiastes. The Tao. Samsara.

We are all just cycling through, brief ripples on the cosmic ocean of life.

I have tried so hard over the years to insulate myself from pain. Exercising, studying, saving money, trimming negativity from my life, cultivating spirituality and on and on.

Yet, no matter how much free range, grassfed, fair trade, organic, local food I eat... no matter how caloric restricted my diet is or Zen-like my demeanor is, the truth is that I will get age, get sick and die some day soon.

Just like everyone else.

I was reading something about this concept of big self, little self.

Often, when faced with something good or bad, we operate in the little self.

Why me? I am feeling well. I feel anxiety. My sadness is unique. What am I going to do about this?

But, we can just change our thinking to say things like: I am touching the feeling of wellness. I feel the emotion of anxiety or sadness. What do others do in this same situation? Why not me?

If we do this small step, we can tap into the larger mind, the larger more common existence and emotion and feeling of others and the universe.

We are not alone, even in our death. We are not the first to die. Not the first to have joy or sorrow.

Indeed, if you believe the Gita and perhaps modern physics, we were never born and will never die in the first place.

Our energy, our matter, is constantly recycling over and over again, just manifesting in different life forms and cosmic energy and star stuff.

My molecules are the same as those that existed in the Big Bang. I share some with the Buddha, or Jesus, or Hitler... or Mount Vesuvius or Halley's comet.

I hope this year, 2012, is an insightful and spiritual one. I hope I become closer to God and to my loved ones. To truly feeling a connection with the universe and my own place in the cosmos.

I know that's a little far out, but I finished 2011 with a whole spate of self-help/spiritual books... :)

Cancer Love

2011-12-13T03:49:00.000-05:00

L.D. was one of those patients that I sometimes get a crush on. Not in a teenage, pimply, excited kinda crush, but a chemotherapy, bald-person, gaunt, I-wonder-why-that-person-has-such-equanimity kinda crush.

Like, how is a 49 year old single female chiropractor with metastatic colon cancer and liver and omental metastases so cheerful coming into the clinic? So appropriate and mentally balanced despite being totally shafted by nature, biology, God and country?

Why does she smile and laugh after vomiting? Or pull clumps of hair cheerfully out of her scalp? Or gently respond patiently that she drove here alone for the umpteenth time? Or that she might check out acupuncture or Reike or craniofacial therapy or any host of things that are really cool, except if you have a fucking bowel obstruction.

Nasogastric tube placement. Now that's a good first date.

That's the kind of patient I go for.

Just so pretty on the inside. A supermodel of personality. The sexiness of humility and kindness.

I find myself wandering the infusion center just to chat with her. Maybe get a glimpse of what Victorian novel she's reading or just preening for a jaundiced smile or laugh at one of my canned cancer jokes. Hell, she sometimes looks at my Eeyore face and asked ME if I'm okay... sheesh. You had me at hello.

Her bloated stomach needing a paracentesis is something horrifyingly beautiful to me. Maybe it's the way she bears it, accepting in a yogic way that this is just the natural end of her life. What was it supposed to be? Why NOT me who gets cancer, she asks?

Children used to die in droves young, mothers in childbirth, men by some wayward industrial accident. It's not so abnormal for a young healthy vegetarian athlete to get huge goombas in her liver, is it?

Do you believe in God? No.

Do you have much other family? No.

Are you depressed? I don't think so.

Denial? Definitely not.

Bitter? No, I've had a wonderful life.

Are you an angel? (No answer)

Can you teach me how to accept my own life? (Just a smile and a squeeze of my hand)

L.D. died a few months ago. She elected not to get any more chemotherapy. She wanted to spend her remaining months with friends and traveling a bit.

She didn't travel much. Maybe a couple miles up and down I-95.

But, she traveled deeply into my mind and that strange, sensitive, underdeveloped place in the center of my chest, between my lungs, under my ribcage... that thing that seems so deadened sometimes by hospice talks and vomit and shit and bleeding and crying and mourning and loss.

The Tin Man would have had it bad for her.

Hair gray from stress and meds, gaunt, ascitic, bloated... but, still smiling. Still laughing. Never questioning why. Never blaming or lashing out.

I'm not the first person who ever was born, lived and died... it's just my time.

I still find myself sometimes looking for her in her favorite chair, my heartbeat quickening, my hands reaching to straighten my tie, trying to think of something funny and wise to say.

Quite a lady, that one. I'll miss you, L.D.

The Buddha didn't have goddamn a thing on you.

Phoenix Rising

2011-12-13T02:42:00.000-05:00

There is something about insomnia that makes one want to express thoughts for anyone on Earth to read. Banal, predictable, but personal and sometimes pithy thoughts.

I've passed nearly the 6 (or is it 7) year mark in practice. G-d, it's hard to believe.

What are some of the highlights?

Engagement broken
Lawsuit
Cynicism and Depression (they need capital letters)
Failed romance
Nearly quitting my practice out of burnout/ethical disgust/boredom/emotional impairment
Hating my job
Selling the practice and becoming financially secure
Buying a lot of crap
Giving said crap away
Buying more crap
Taking a lot of trips
Feeling the escapism of said trips
Therapy
More therapy
Kung Fu
Yoga
Meditation
Friendships
Parents divorce saga
Parents individual healing
Lots of vacations with same parents (individually)
Broken relationships
Celibacy (hopefully not permanent)
Kindness of strangers
Letting go of perfectionism
Learning from so many patients and their struggles
Crying
More crying
Vulnerability
Actually feeling some emotions
Helping so, so many people die
Maybe curing a couple of folks
Being amazed at people's fortitude and love and perseverance
Coming to love my job
Being loved
Feeling human
Grace
God (or Brahman, take your pick)
Feeling honored again to be not just a doc, but a human being

It's funny. When you start medical school, there are these "soft" classes amidst the daily grind of anatomy, histology, pathophysiology and the like.

Classes like "Doctoring" and "Compassion" and "The Impaired Physician"

You meet older docs talking about their travails, their burnout, their personal relationships, their addictions, their frailties.

As a twenty something year old, it all just seems so foreign, so narcissistically weak and alien.

But, six (or seven) years into full bore clinical oncology practice, I see it. Not just in us, but in the other docs, in other specialties.

In me.

Physician, heal thyself.

It ain't that easy.

The perfectionism that works so abundantly well in calculating chemo doses or clipping through 25 patients a day really doesn't work so hot in your personal life.

Who are we when no one is looking?

Am I moral? Ingmar Bergman, you ain't got nothing.

I remember PBS having a long term documentary chronicling Harvard medical students as they go from their first days, through training and later decades of being attending physicians. The divorces and emotions, the idealism and despair, the physical and mental toll. The glimmer of youthful passion and idealism still there, peeking out shyly amidst the money and status and time demands and stress and oncoming aging of the once bushy-tailed participants.

Francis Weld Peabody once wrote that "the secret of the care of the patient is IN CARING FOR the patient."

And how can we care for someone if we cannot care for ourselves?

I see now the beauty of medicine, the holiness of it. I once talked of A.J. Cronin's "The Citadel" and how medicine was something to be cherished. How easy it is, as in the book, to slowly slip into something that you don't want to do or be. To lose that gentle naiveté, that openness to ideals and love of fellow man. That purpose that makes healing and palliating so wonderful.

It's so easy to crumble your dreams in the face of lawyers and accountants and diagnosis codes and RVUs and bonuses and mortgages and alimony.

It is easy to get caught up in narcissism and self-pity, self-gratification and banal materialism.

I know. I have been there in such a short time, despite my protestations.

But, there is a way, a more human way forward, I believe. Not the youthful blush of innocence, nor the jaded, self-absorbed path of pride.

But, in realizing that we are human. We caregivers are every bit as broken and in need of healing as our patients. My MD and my white coat are no shield against my own demons and diseases, real or imagined.

The care we give is the care someday we hope to receive.

If I can just serve another dying cancer patient in the dignified and humble way that I hope to someday be cared for myself, then perhaps I can rise again to the Citadel.

Accept myself and pick myself up and I will try not to forget to hold my patient's hand and cry for them as I will someday cry for my parents, my lovers, my children, myself.

The phoenix rises, older and different, less perfect. Less, but more.

That is the beauty of oncology. I am blessed to even touch this for my brief time on earth.

Thank you for waking me up, cancer.

Clean my body and soul my Guru, you bring light to the darkness.

It's Time To Hang It Up

2010-10-28T19:08:00.003-04:00

This is my last entry. This blog has served its useful purpose in my life. It's allowed me to explore many emotions and thoughts during this transition point in my life, from student to physician and maybe to the beginning of healer.

But, it's a vanity in a way. A service to ego and it's time to face life without a crutch.

Time to turn inwards as we still fight to grip with all that is outwards.

I am grateful for the responses over the years. The many insights. The love. And, sometimes lack of love.

Time to unplug and whip out the old pen and paper...

Grief

2010-10-07T12:35:00.003-04:00

Lunchtime. I don't each lunch, really. Maybe tea time. Or downtime. Or depressed time.

This morning was a bear. The sounds of crying. Not ostentatious crying. Just sobbing.

I'm sorry. There is nothing more I can do...

I must say that to people ten times a week.

Most of the time it's just a stunned silence, then a polite thank you.

Every now and then, it's anger.

Sometimes, histrionics.

But, then there is just the solitude of grief.

It doesn't matter how many family or friends are in the room. When the realization dawns on the patient that life is over, there is this retraction of space, this contraction of feeling.

Alone, facing your death.

This morning was one of those.

I feel washed out. I have to gather myself for the afternoon panel of patients.

Two Steps Forward...

2010-09-17T10:47:00.002-04:00

The "no consumption" thing is terrifically difficult.

Coffee and other beverages are being phased out.

My canvas bag travels with me to the fruit and vegetable aisle.

Takeout, carryout, order out, etc. has been crushed.

Books from Amazon have slowed to a trickle and will soon dry up.

And yet, there is still a small amount of recycling that I had to put out this morning...

I liken this attempt to my yoga practice. Or my meditation practice. Or my practice of medicine for that matter.

You keep trying. Despite some injuries here, or boredom. A setback. A steak dinner. A piece of styrofoam.

But, hopefully, with practice, you become the person you want to be.

I was listening to an audiobook about Confucius and his philosophy. Like all religious teachers before and after, like the Buddha or Jesus, Confucius emphasized behavior and attitude. Part of the emphasis on propriety and politeness is a recognition that as we perform the outer trappings of humility and compassion, eventually, they become part of our personality.

Our minds, like our bodies, are modifiable.

Habit. Samskara. Patterns of behavior. Patterns of thought.

Just like when we meditate and our mind is racing. We come back to our breath and begin anew. Eventually, it becomes natural and easier. But, there is always awareness that, without constant vigilance, the thoughts arise forcefully.

So, I begin again. And again.

Trash one day.

The odyssey of life another.

The Fatman

2010-09-13T20:58:00.003-04:00

I don't know why I always think of this patient as the "Fatman".

Well, other than the obvious fact that he is quite overweight, tipping over 300 lbs on a 5-10 frame.

Maybe it's his lack of self-consciousness about it. His laughter and cheer and egolessness, if that is even a word.

Which spellchecker tells me it isn't.

A wonderful guy, a healer. A therapist. Not just any therapist, but an uber-therapist. Well regarded nationally, urbane, published, graceful, the Fatman is a mensch in every way, except in regards to himself.

I first met him more than 3 years ago. He came to me ostensibly for thrombocytopenia, or a low platelet count. After ruling out the various bad actors, I got an ultrasound of his liver.

Lo and behold, he had cirrhosis, probably from "fatty" liver, a growing problem in our society.

I explained the dietary things he needed to do, the lifestyle changes, the exercise, the low fat, the diabetic control, etc., etc.

He proceeded to gain 60 more pounds, develop congestive heart failure, eat like a pig and get horribly depressed.

All the while, he continued to counsel patients and even other therapists, serve on national committees, hob nob with rich and famous people and generally just carry on.

Every time I saw him, I would berate him. He would look at me patiently, full of remorse, with sad Eeyore, droopy eyes and promise to do better.

I admitted him to the hospital. Had him see multiple cardiologists. Got him a liver specialist at Johns Hopkins. Transfused him when he bled from an ulcer and then bled again from esophageal varices.

Just trying to die.

I couldn't understand it.

His IQ exceeds mine easily.

His EQ in theory is off the charts as well.

He lacks for not. His wife and family are sophisticated and supportive.

Why?

Today I finally understand why, after nearly 4 years.

I guess, in retrospect, predictably so... he, like most of us, is in a whole lot of pain.

A lifetime of helping others is only a mask for being unable to help himself. Of being masochistic.

Today we talked of his broken family.

His schizophrenic mother who tried to kill him more than once.

Of being beaten and starved.

Of viewing food as a safe place and a refuge emotionally.

Of abuse.

Of self-loathing despite brilliance academically.

Of his own depression and low self-worth.

Of a family genetic tendency towards mood disorder.

Manifesting in his only son as schizoaffective disorder.

Of him offhandedly turning down an offer to accompany his son to Montreal for a conference and then being called 24 hours later that his son had killed himself, blaming the father for leaving him.

Of 20 years of guilt and self-abnegation. Self-loathing.

Of wanting to die.

All the while, collecting accolades and wealth and the trappings of success.

I haven't cried in front of a patient in an exam room in a while.

And he doesn't even have cancer like most of my patients.

What a waste...

In all these years, he himself has NEVER seen a therapist.

It never ceases to amaze me how troubled we all are underneath the veneer of a placid home life. How the banal collides with the absurd and existential in all of us.

All the Fatman needed was someone to just listen to him and let him sit with the pain of his past life and just be okay with it.

No pushing. No pulling. Just letting it wash over him and recede. Again and again, until he learned to just sit with it.

Instead, he's going to die of liver failure. Yellow. A miserable death, slow, tortuous and painful.

I know he thinks he probably deserves it for failing his son and doing something to make his mother hate him so much.

But, I don't think so.

Why do some war veterans survive near death experiences, none the worse for wear?

And others are crippled mentally forever, victims of post traumatic stress disorder?

The more I do this job, the more I realize that we are all carrying some hidden shame inside of us.

That we all fear how our loved ones or society would reject us if our true selves emerged?

We are not free, for the most part. Not free to be truthful. Not free from fear.

It's not just the cancer that kills. It's the guilt or shame or anger or ignorance.

Physician, heal thyself, Hippocrates once admonished.

Heal thyself.

Heal.

Fatman, I pray you find some peace before you die. You've helped a lot of people in your life. Given a lot of love.

I hope you pour yourself some one of these days.

Heal yourself.

If you can, maybe I can too.

This Is a Lot Harder Than I Thought

2010-09-06T18:29:00.002-04:00

My list of violations so far:

1. forgetting my steel mug when i sometimes get coffee or tea (even though i'm trying to get rid of the habit altogether anyway)
2. forgetting to bring my reusable plastic bags to the health food store and then needing another bag
3. driving when i could easily walk or bike to my local coffee house/drug store/grocery
4. getting tired of composting, especially since i don't grow anything
5. forgetting to use my drying rack (better today, though)
6. having a constant urge to buy another lawnmower (my old-school push bladecutter just does a terrible job; i feel like i'm lowering my neighbor's property values with my inability to make the lawn look even semi-presentable)

this is challenging.

granted, i'm a lot more aware of consumption. it's like a constant reminder to stop getting things.

it's mind boggling when you think of the zero-sum nature of our planet. commodities get used up, like oil, gems, precious metals... they get turned into non-degradable and rarely recycled things like plastic-everything, rings and other jewelry, cans, toiletries, etc.

it's not even conspicuous consumption that's the problem.

it's consumption in general.

at our medical conferences, i've become very aware of the catered-food, and all the plastic cups and plastic utensils. the cans of soda. the plastic containers for the food... all of which is NOT recycled, just trashed.

all the paper that we use.

like, i said, it's mind-boggling.

i just saw this documentary, the "Age of Stupid".

A British tongue-in-cheek imaginary scenario set in the year 2055 or thereabouts.

the planet is in ruins. twelve feet or rising seas have engulfed the planet. warming is real. countries are destabilized. nations destroyed. famine, ruin.

an archivist or the sum total of world knowledge looks back to the beginning of the 21st century with real stories of people struggling with the reality of climate change.

an aging mountaineer near Mont Blanc. A British wind farm activist. an ironic retiring oil geologist for Shell/ecologist whose home is destroyed by Katrina. An aspiring medical student in Africa.

All real stories. Their struggles to survive, all the while confronting the day-to-day choices, the mundane, banal choices that we all face... that seem so insignificant, yet have huge, lasting impacts on our environment and ultimately, our very existence.

It is like that famous butterfly in chaos theory that gives rise to the hurricane.

It is so hard for each of us to be mindful of our daily impact, when we are just trying to make a living, find some love and happiness, have good time.

Yet, if we are not mindful, the consequences eventually will imperil us all.

I wish I weren't so damn addicted to Starbucks feta wraps...

Blue Gold

2010-09-03T13:04:00.003-04:00

I was watching a documentary yesterday. "Blue Gold".

It was about water resources around the world and how competition for water will be a main battleground of this century.

So much focus has been on global warming and declining hydrocarbon resources.

Yet, one of the main consequences of both problems will be a decline in the amount of available freshwater in the world.

Some contributing factors:
1. contamination of available sources of groundwater and rivers by agricultural pollution.
2. growing worldwide population
3. a warming planet
4. privatization of water in the hands of multinational companies who have no incentive to maintain clean supply or to diminish pollution.
5. globalization of agriculture and other products resulting in production of non-native food that is potentially water intensive and depleting to the natural water cycle of a country (e.g. producing mega-flower farms in central Africa, or moving most US apple production to China)

The result is that there is increasing potential for military conflict over these resources.

Needless to say, I had to try hard not to slit my wrists after the show ended.

This documentary, as well as other wonderful modern facts like the Great Pacific Garbage Patch, just makes me want to veg out on the couch, eat Pringles and watch some PGA golf like the rest of society, blissfully chomping away as we careen towards the Apocalypse.

But, then, of course, the documentary has some positive ending notes.

Maybe we can find a way to reclaim water as a public good, a public right, instead of a commodity.

Maybe we can eat more sustainably and locally.

Maybe we can have fairer trade agreements with Third World countries, where our standard of life is not predicated on their living in squalor.

Maybe we can rise above petty commercial or religious or patriotic disputes and think more broadly about our planet as a whole, as something to cherish, now and forever.

Water. The stuff of life.

Gladiators and the Forgetting

2010-08-31T21:35:00.003-04:00

Buy Nothing Year???

Barely Buy Nothing Day... I managed to use my steel cup for a Starbucks coffee a couple of times, but I blocked out my conscious thought as I bought a bagel on my way to work (30 minutes after morning meditation no less).

Hypocrisy starts at home, I suppose.

This is going to be a whole lot harder than I thought.

So, tonight.

I'm feeling the jitters of someone who is a few weeks into trying to be VERY strictly vegetarian... Well, maybe one week of KINDA vegetarian.

So, I'm craving something. A week of getting up at five in the morning and praying to Shiva or Narayana can do the darndest thing... like make you want to drink beer or read People magazine or masturbate...

But, I let that pass. Exhale.

Well, I get some beer and order a sandwich from my local eatery. Yes, in packaging no less.

As I flip the TV on, lo and behold, what is the first thing that I spy on?

A documentary on the NFL...

I never watch sports.

But, since I'm on the sixth ring of hell, I might as well drop down to the final level.

But, it's not about money or sex or bling or even spectacular plays.

It's about postconcussive issues from the collisions in the NFL and early onset dementia.

And, it's moving.

It's karma, right there on the screen. Cause and effect.

Young, strapping men, at the peak of their physical prowess, their power, their glory.

Flash forward 20 years and you see crippled, broken, depressed men. Families. Their wives.

And a League that treats them as we treat all older people... with benign neglect on one hand and contempt on the other.

It is a Faustian bargain that these players make.

The star that burns twice as bright burns half as long, so says the maker in the movie, Blade Runner.

But, enveloped in the darkness that is dementia, the evil forbidden land of confusion, these former giants, former gladiators must feel some sense of regret. Some sense of sadness at a life destroyed by a moment of fame.

There was one very moving piece about a 58 yo former linebacker. Now a successful partner in a law firm. Smart and able, he and his wife planned for a life after football. But, tests show that his memory is slowly, inexorably slipping away.

He is just intelligent enough to clearly see his future. His drift into the "long goodbye". And, all he can think about is whether he will someday have the courage to take his own life.

We are all dying. Every day.

We do things unknowingly to expedite this. By the time we realize that we've smoked or drank too much, slept with the wrong person, worked in the wrong, unsatisfying job or just generally lived the life that we've come to regret... well, it's too late and we regret.

I hope the NFL can find a way to take care of these men. And their future players in need.

What happens to all of us, someday, when we are no longer young and good looking? No longer powerful and rich? When the lights are off and we are left alone, facing our end?

Is there compassion? A hand to hold? Someone to listen to our cries, our fears, our aches?

I hope so.

We will be there soon enough.

Buy Nothing Day... or Year?

2010-08-28T18:13:00.002-04:00

I was reading some of my Walden today. Simplify, Thoreau entreats us. Live near the margin. In your mind more so than geographically, isolation/solitude/aloneness is a cleansing experience to him.

Unorthodox even in his own time. Ridiculed even. But, timeless in its apprehension that what is essential in life is often not seen or understood until we strip away most of the veneer of "happiness".

The clothes. The nights out carousing with people you don't even like. The pomp of titles and accomplishments.

Who are you, without the externals? Without the signals that are sent to others that signify your status, your importance, your role in the hierarchy of life?

What if you step outside the hierarchy?

What do they see?

More importantly, what do you see in yourself?

The magazine Adbusters advocates a "Buy Nothing Day" in the hopes of trying to turn this perspective on in the general population.

One of their main premises is that we are constantly inundated with advertisements, enveloped in messaging and commercialism and useless technology.

Our thoughts are rarely original, even if we think they are.

Right now, I'm channeling Thoreau, who was transmitting Hindu scriptures, which were expressing some age-old, preexisting thought no doubt itself.

The difference is not that originality is difficult.

But, rather, we are so swamped by external influences that it is exponentially harder and harder to identify anything true and resonant within our psyche.

The Internet, text messaging, the I-whatever of the month, group vacations, Monday Night Football, the war in Iraq, antiterrorism, even self-help and yoga...

Commercialization of everything rots our sense of the "commons". Our community itself.

Even our "communities", our prefabricated suburbs of uninspired, crappily manufactured, industrially toxic McHomes, with the pool and the community center and the geometrically proportioned lawns that shouldn't be there in the first place... even our communities are "sold" to us with packaging and mental manipulation.

Hence, "Buy Nothing Day".

But, how about buying nothing for a month or a year? Or forever?

I guess I have to qualify what constitutes something that is "bought".

I'm talking about discretionary purchases that are unnecessary to live, that don't factor into your day to day needs and are not essential in any way.

I was just at the Recycle Center this morning. Just seeing all the stuff that we get rid of. The sofas, the TVs, the plastic lawn chairs, the children's toys. All that stuff going into landfill.

Multiply that by the populations of China and India and I just felt despair.

We destroy our planet so we can buy some gadget that we'll only throw away in a year or two?

So...

I'm going to try.

I've been paring my possessions down quite a bit over the past year. Getting rid of as much stuff as I can.

If I don't wear it once a week, it's gone. If it's a duplicate of something that I already have that works well, it's gone.

But, perhaps I need to stop the influx of stuff in the first place.

So...

I'm going to try not to buy anything for a year... Yikes!

Let's have some caveats here.

These things don't count (I'm backsliding already):

1. Soap and other toiletries (toothbrush, toothpaste, etc.)
2. Food, although I'm committed to not buying anything that results in artificial packaging being needed. That means no takeout or delivery. Minimizing eating out altogether. No cups of coffee unless I use my own container. No little plastic caps. You get the picture.
3. Travel. No souvenirs or other trinkets, but the cost of the tickets themselves, etc.
4. Electronic music and books. Sorry, I'd die if I couldn't download books on tape.

The main thing that will pain me is not buying books.

But, I just better hope the public library has a good selection.

I've thought of buying a Kindle, but forget it. It would probably end up in landfill.

So, we'll see. I might mess up a bunch. I'm sure I will this week.

But, that is my commitment. I'm going to try to simplify, simplify, simplify.

I don't want to live that life of quiet desperation.

Moksha Redux

2010-08-25T13:41:00.005-04:00

What is liberation? Moksha. This ancient Hindu concept.

It is translated as liberation or release. Likened to Nirvana, the "extinguishing out" to which the Buddha awakened.

I have been reading over and over these various concepts from Yoga and ancient Indian thought. They are described in various texts. You can get easy definitions from the Internet, various popular authors, a Sanskrit dictionary.

But, what is it? The feeling of it?

I have no idea. I'm not even close to it.

There are various stories from the early sutras of the Pali Canon that characterize the Buddha after he achieves Nirvana. They are illustrative.

I think of him as a humanistic, agnostic/atheist, fully-realized yogi.

He achieves the mastery of his body and mind early on through yoga. Studying with two renowned teachers shortly after leaving home, he quickly reaches the final, fourth stage of samadhi. That state of bliss and equanimity that is the final path of Raja Yoga.

And, yet, as he comes out of his state, each time, he faces the same reality. The same emotion. Transcendence is temporary. Bliss itself is constantly changing. There is an ebb and flow to all things, including liberation.

And, so he pursues tapas, austerities. The same kind of bed-of-nails, walking on hot coals, starvation-type activity that can be seen in India today.

Can you purify yourself by pain?

Can you, in effect, burn impurities out of you, like you would burn an alloy to reach the elemental metal?

His answer is an affirmative no.

Self-abnegation is a form of ego in itself.

And, so he sits down, remembers a state of blissful meditation from his childhood and sits under the Bodhi tree.

He confronts his demons. His alter ego. Mara. The demon is within. But, this time, rather than pushing him away or appeasing him or running towards purity or love... he simply watches.

Without engaging. Without reacting.

Without grasping towards or pushing against... Mara, his darker nature of both pleasure and pain... simply disappears and dissolves.

He is "liberated".

But, from what?

There is a great story of him walking past the first person he sees after achieving Nirvana... another yogi mystic. A fellow traveler.

He exclaims in joy that he is liberated.

The response.

A shrug of doubt and a "good luck" for the road.

I find that one of the most telling stories about the Buddha and the very goal he taught us to aspire towards.

The ultimate change is not external at all. You cannot "see" it.

Liberation has more to do with your internal state of mind and view than any outward appearance.

There are several other stories of young monks not recognizing him when he is under their nose, mistaking him for some wayward older monk. Stories of his frailty, even complaints of his back hurting as he approaches old age and death.

Moksha is within.

There is another famous story of the Buddha going before a crowd of other yogis, explaining the Dharma, his truth and path to liberation.

They scoff at him, seeing this ordinary yogi like themselves, if anything, a failure at tapas and divergent from their path.

Behold, to stun and silence them, he displays his siddhis, his yogic powers. He flys in the air, he hovers above, he is radiant and powerful.

Only after seeing this display of mastery of their own skill will they accept him and listen to the Dharma. Shortly after hearing his deep and humanistic understanding of life and death and the impermanence of things, they are quickly converted to the Sangha.

There are lessons from this story.

Having mastered yoga, the Buddha explored the limits of its power and technique, yet discarded some of its most sought after powers.

Liberation requires a certain discipline, but taken to extreme, the powers that are mastered through yoga are a diversion at best and destructive and illusory at worst.

Siddhis, yogic powers... I suppose this is metaphorical in the story for all kinds of byproduct, bystander, misleading accomplishments that are superficial but very powerful... Powerful, yet unnecessary and perhaps even an impediment to internal awareness.

That which can be seen by others or spoken about... they are by definition arousing of the ego. The ego solidifies a feeling of uniqueness in each of us, of specialness and of permanence...

This is illusory and drives us to deny the reality of our own decay and ultimate death. We pursue love and sex, money and objects, family and false spirituality, even intellectualism and excessive rationality. All in the hopes of assuaging our inner discontent and disappointment at the end that will inexorably approach us.

A beautiful body, being able to jump into a handstand, outwardly displaying a calm demeanor, seeming more progressive and Earth-friendly and "holistic", getting a better sex life, enhancing my relationship with my spouse or family... and on and on.

These are the modern day siddhis that we strive to achieve through hatha yoga in most places in the West and perhaps now throughout the world.

What will yoga do for me? How will I look? How will I feel?

Will I be more happy? Or attractive? Conquer my addictions? Be free from pain and suffering?

These are our modern aspirations.

But, like the the story of the Buddha, are they just for show, good to look at but unhelpful on the ultimate path to self-knowledge and understanding?

Anicca. Dukha. Anatta.

Impermanence. Suffering. Non-self.

I don't know much about moksha or nirvana... except it ain't gonna be easy.

Atha Yoganusasanam

2010-08-19T18:20:00.002-04:00

The moment is here.

It's always here.

It's so hard to not get caught up with the failures and regrets of the past or the fears and loathings of the future.

Our minds are constantly swirling about. We are forever moving from one idea, one thought, one emotion to the next.

Can we silence this?

Should we silence this?

The second, more famous line of the Yoga Sutras of Patanjali is "yoga citta vritti nirodah".

One translation of this is that "yoga is the cessation of the fluctuations of consciousness".

By slowing the mind, quieting the turbulence, we then get a glimpse of our "real self" or Self. We see who we really are, naked, alone, after removing all of the external forces that swirl around our body and mind and soul.

But, the first line is key.

Atha Yoganusasanam.

Now, with divine blessing, the exposition of yoga begins.

NOW.

As in the here and NOW.

The present.

Without staying in the moment, we will never grasp our inner self. We will always be slaves to our prior misfortune or exhilaration or fawns awaiting doom or bliss.

We must grasp what our body, our mind, our consciousness, our good, our bad, our essence is right at this moment, realizing, as the Buddha, one of the greatest of all yogis, realized... that the moment always changes.

Our fear of the change. Our fear of not being how we were yesterday or a year ago... or of not becoming or attaining what we wish. Of a future that we fail to realize.

We grasp for pleasure and shy from pain.

Never really understanding that all of life encompasses both of these and that pleasure and pain are always intertwined. They always follow one another. You cannot have one without the other.

So, now. Now. NOW. NOW!!!

We begin.

2010 has been the beginning of my life.

The Fire Next Time

2010-08-15T11:34:00.004-04:00

Inner Russia.

A place that more often than not is temperate to cool to plain frozen for most of the year.

Well, this year, there are such devastating droughts and heat waves there that there have been significant California-esque wild fires and scorched earth. So much so that they have had to limit wheat exports, thus resulting in rising wheat and grain prices throughout the world.

A third of Pakistan is now flooded, a la the usual scenario in Bangladesh.

Are these just part of the normal variation in the climate or is this evidence that "climate change" is affecting us sooner rather than later?

I'm unsure, although I am a firm believer that the planet is being warmed due to the actions of mankind.

It is grey outside. Rainy. Dreary. But, not in a charming, English sort of way. It is gloomy, dark rain amidst a gentrifying blue-collar postindustrial town.

My thoughts turn to the future. My future. But, also the future of our species. Other species on the planet and our world itself

If anything in recent history has proven, it is that we simply cannot predict the unforeseen consequences of our actions.

Iraq, Afghanistan, the deficiit, the economic collapse, the worry about the influenza pandemic to come that never came... and on and on.

As applied from a conservative standpoint to climate change, this leads one to be skeptical that it will really be as bad as they say.

But, from another perspective, I can't help but think that maybe, just maybe, we've UNDERestimated the impact of warming. That there are unmeasurable changes yet to come which will accelerate this process. That we maybe will face a catastrophe of epic proportions.

Perhaps not in my lifetime. I will likely be dead by the middle to end of this century. But, will the next generation or the one after have the same planet that we have now?

Doubtful.

The fire next time will affect more than just the cost of my morning bagel.

Turning the Wheel

2010-07-15T12:53:00.002-04:00

Greed. Anger. Delusion.

Minimizing these three states was a primary focus of the teachings of the Buddha.

In not understanding that all things are dependent or "conditionally arising" as some choose to translate, we humans grasp on to that which is impermanent.

Trying to maintain a permanent hold on that which is by nature constantly changing is the source of dukha, or suffering.

Our lack of understanding propels us to desire more... more sex, more money, more objects, more stuff, more experiences.

Our disappointment with this never ending, escalating need for fulfillment results in anger and resentment...

The source of all of this is our delusion and ignorance of the nature of reality.

This helps me sometimes as I meditate on all the things that I see every day in the clinic.

Sometimes, it doesn't help at all.

M

2010-04-27T22:56:00.003-04:00

M is my friend. Lover. Ex-lover. Inspiration. Source of a lot of joy, some occasional pain, and a whole lot of thinking.

M has helped me understand myself. Helped me to accept myself.

Not be afraid of life. Not be afraid to be alone.

M is the only other person I've ever met who matched all my crazy interests and enthusiasms for things.

She has similar belief structure.

She is crazy. In a good way. But, crazy nonetheless.

She excites me. Frustrates me. Titillates me. Challenges me. Saddens me. Breaks me. And makes me whole again.

Every cliche you can think of... well, you get the point.

It is funny in life how you can know some people for a long, long time and never feel close, like that sibling that you never really connect with.

And then there are these people that cross through your life for who-knows-how-long, like a comet flashing its tail through your atmosphere... it is brilliant and striking. And then gone.

I know I drive you crazy even as I call you crazy, M.

Forgive me.

Even Siddhartha wasn't so great at the romance thing.

I love you still.

Om

2010-04-22T22:17:00.002-04:00

How on earth did anyone figure out that the three-syllabic A-U-M sound has cosmic overtones?

Or at least that it was pretty cool.

I wonder this sometimes, like tonight, when I lay down after yoga.

Yoga, derived from the Sanskrit root, yuj...

To yoke, as in yoke a team of animals. Or join. As in your body to your inner consciousness.

The Buddha used yoga to strengthen his body and mind to gain insight into the deep realities of life.

In America, we use it to get "buns of steel" and look good in spandex.

I'm not sure where it's standing for me so far. Probably more the "deep reality" type stuff, but let's not discount the superficial just yet.

A lot of emotions turn over in your mind as you sit there about to collapse in your headstand.

Your day flashes by. Love. Anxiety. Your fears.

Then, nothing. Nothing.

A big peaceful clearing of your mind.

Om

Om

Om

Om shanti shanti shanti

It's the only time I ever forget about cancer.

Denmark

2010-03-20T18:02:00.003-04:00

R.N. just died.

She was my first breast cancer patient out of fellowship and training. My first breast cancer patient where I was the "doctor". No backup. Nobody to turn to for advice. I write the orders, I explain the side effects. I hold the hands.

She was only 33 years old when she was diagnosed 4 years ago.

She and her husband had just moved from Denmark only months before for his company. Something with maritime equipment that brought him to the mid-Atlantic.

Then she found the lump. A small, 1 cm mass in her breast.

So young.

Triple-negative. A bad prognosis.

But, still stage I.

She got chemo, lots of chemo. bilateral mastectomies. We took her ovaries out when we saw that she had a genetic predisposition to breast and ovarian cancer.

All the while, I learned a little bit about Scandinavian stoicism.

She and her husband and their three children were amazing. Gentle, intelligent, kind. So loving and so close.

Well, you know the deal.

She relapsed only 7 months after therapy.

We tossed the book at her. More chemo. Even salvage radiation to the arm and neck.

Another remission.

Maintenance chemo.

And then, home.

She went back 18 months ago.

She died two weeks ago.

During her course, she became very philosophical, as we all do during illness. She started to read about diet and about this woman, Jane Plant, a British scientist who advocated dietary changes to combat cancer. Who felt that much of breast and prostate cancer is related to meat and dairy products and that we need a radical way of overhauling our diet to better suit what we were evolved to eat.

She gave me a book, "Your Life In Your Hands", by Dr. Plant.

I was rummaging around, rearranging my bookshelf today, and I came across it. My patients know I love to read, so I have a little section with gifts from them and here was R.N.'s book.

In it, she inscribed that she hoped that I could learn something from this. That she wished she had learned something about diet and lifestyle growing up, if only to give her a slightly better chance of surviving.

That she knew she might die. But, that she hoped that I would learn from this book. That maybe I would incorporate some of the insights into my own health.

But, mostly, that maybe I would spread this gospel to others. That we CAN do something about our health. That our toxic lifestyle and food supply is at the root of many of our medical problems, both physiologic and psychologic.

I have striven to live up to this for the past couple years. I preach health to patients and friends. I have tried to change my own behavior, to live with less. To eat and live consciously, for health, but also for animal rights and for ecological reasons.

I have tried.

Rikke, I hope you are at peace. You were one of my most memorable patients.

You have changed my life forever.

The Snow That Heals

2010-02-08T18:53:00.003-05:00

A curious thing happened to me today. I had several really wonderful interactions, all due to shoveling snow!

How strange.

I live in a nice, family oriented community in Baltimore, rowhomes mainly, populated by 30ish and 40ish couples with young children.

Having no children myself, I often smile a lot to everyone playing outside, but rarely interact. Other than to grunt as I come home late and can't find a parking spot or laugh when a neighbor's dog jumps the fence into my yard or look curiously when children play endlessly on a patch of grass and stones in my front yard.

But, yesterday and today... during "Snowmageddon" here in the Mid-Atlantic, I've been shoveling like a you-know-what. And, so have all my neighbors. And their kids. And their dogs. And mothers. And husbands and wives.

And, you know what? They are really nice.

People helping each other dig out. Making friendly conversation. Refreshments.

Like a community of Eskimos... sorry, Inuit (that's the new PC term)... meeting out amongst the igloos and seals and whale blubber.

So, one of my neighbors, with whom I'd had a really bad interaction a few years ago over a barking and threatening dog, made some friendly comment about this not happening in California (where I'm from), so I took my headphones from my Ipod off and said hi... then, I remembered the incident where we had been yelling at each other years ago (I totally blocked it out since then) and asked him about it... he said, "yes, I remember".

And, so I said those magic words... "I'm sorry". Which I am and was and am again. I was a bit of a prick, after a long call night during training and his young dog came barking at me, so I freaked and he told me to chill, that it was just a puppy, so I flipped at 2AM on a Tuesday...

But, now, magically, nearly a decade later, during this snow hell... well, we MADE UP. And it was really nice. And he remembered that I was a doctor. And he apologized also. And we talked about his dad, who is now sick and his kids and my buried car and well, IT WAS PRETTY COOL.

The second interaction was equally neat. My next door neighbor, with whom I'm friendly, came out with his young daughter and we were shoveling side by side. We started yapping about this and that, when I realized that he was shoveling MY car out, having already finished with his car. It took about 30 minutes for me to realize that he was just helping me along, tidying up my part.

Now, this isn't just some miniscule amount of snow we're talking about. This is like almost 3 feet in the Maryland/Baltimore area.

Without a word, just helping me along. Daughter playing. Dogs running around, pooping and whatever they do.

It was kind of Beaver-Cleaver in a way. As much as an Asian guy from California knows anything about Beaver or Cleaver...

Finally, I went to shovel my kung fu school out of misery as well this afternoon. A massive amount of snow. Kind of a Zen experience.

Well, a block down, this guy is shoveling out in front of his business. No one else is doing anything on the street. That whole commercial area is just buried.

Well, this guy sees me toiling away, sort of in a trance, in a daze, just mindfully shoveling to save my life.

He motions behind him, to something/someone I can't see.

And BOOM, out comes this SNOWBLOWER!

He is like a 100 feet from me. Not close, with a whole lot of snow.

So, he waves and then just starts approaching me, blowing away the whole sidewalk, until he gets to where I am.

And, he helps clear out my area as well as the rest of the block.

For nothing. Barely a smile and a nod from me.

I just yelled, "thank you" as he snowblowed away from me back towards his shop.

It's funny. I'm usually kind of cynical about people.

But, yesterday and today... well, it was pretty neat.

I'm almost glad it's going to snow again tomorrow...

Avoidance

2010-02-03T14:52:00.002-05:00

I feel so withdrawn.

Empty.

Attached.

The Buddha teaches that life is suffering. Dukkha. The root of that suffering is in our desire, our attachment to our wants.

The more we desire, the more suffering we feel when that thing, that person, that feeling is lost. As it inevitably will be lost.

We all decay and die.

Life is an illusion.

I hurt someone very dear to me today. Someone I care for deeply. Who I love.

I feel it as a result.

I know it will pass. As all things do.

But I feel it nonetheless.

Death and the Maiden

2010-02-01T13:41:00.002-05:00

My partner's sister just died.

28 years old, pregnant with twins.

A complication in the third trimester. The liver enzymes go up, the blood counts go down.

Babies come out of Mom.

Dead.

Mom goes into organ failure. Dialysis. Ventilator. Bleeding.

Dead as well.

I don't know this women. Or rather, I didn't know her.

We forget sometimes how dangerous pregnancy can be. In times past, many children never survived to adulthood. Maternal complications were so frequent and severe.

But, we live in such a different world now. We all expect pregnancy and childbirth and the first years of life to be so wonderful.

We are just stunned when it goes wrong.

I'm stunned.

I can't imagine what her husband is feeling. Life, about to be realized fully with the birth of the first children... now, destroyed. No children, no wife. No life.

Hug your children and your loved ones.

Our brief dalliance with this life will soon end.

Health Care Debacle

2010-01-26T13:41:00.003-05:00

I have to say, if this is "Change You Can Believe In", I might need to drag GWB back into office. I'm about as progressive as they come, but there is something real to this whole Scott Brown/Massachusetts backlash/potential collapse of the health care bill.

Leave it to Congress to produce something no one has read, understands or cares about. To produce something that does little to control entitlement cost and growth. Something that does little to help tort reform. Almost nothing to deal with the perverse incentives for physicians and hospitals that underlies the cost and poor quality of our system.

Rather, it's a bit of a grab bag of giveaways to various lobbying groups, from Pharma, to Hospitals, to Docs to Insurance.

It lacks VISION.

Obama has not done a good job communicating a VISION of what health care in this country should look like. What "health" is. What our collective responsibilities are as a nation.

It's just ripping on insurance companies and Pharma and the usual suspects while defending lawyers and poor physician behavior.

There is an amazing documentary from PBS, called "Sick Around the World", where several health systems in other countries are profiled and analyzed for their strengths and weaknesses vis-à-vis the U.S.

There has been so little discussion in this debate about what we can learn from other nations about 1) why they have as good or better health outcomes and 2) why it's so much cheaper there.

Whether Obama rams some bill through at this point or not, it ceases to matter to me. The essential poor incentives of our capitalistic health delivery system will remain. We will all adapt and try to change our behavior to maximize revenue while only distantly caring about the health of real people. There will be little incentive for individuals to take their own health care choices seriously. The system will continue to teeter on the edge of financial insolvency.

Until it all collapses, that is.

Then we'll all really believe that there is "change".

Nurse C.

2010-01-18T09:38:00.002-05:00

Caring for cancer patients is hard enough. Caring for someone that you work with is that much harder. I suppose caring for a loved one that you work with would be the ultimate in emotional pain, but thankfully, I have yet to experience that one.

K.C. is... or, as of this morning, was a 50 year old patient of mine with metastatic ovarian cancer. She worked as a floor nurse in Oncology at the hospital where I attend. A wonderful woman. Just a positive ray of sunshine for anyone who knew her. A family woman. Kind and loving husband. Wonderful teenage children. Loving.

Just the kind of person who dies.

Diagnosed in 2007 with stage III ovarian cancer (the most common presentation), she had the usual surgery and chemotherapy. Like so many woman with her condition, she recurred within a year or so.

Not a good sign.

Since she was young, we switched into "aggressive" mode. Even though she and I both knew that this was not curable, we seemed to dance around the issue during our visits. She was upbeat, I tried to be.

What was most disturbing was running into her on the floor at work while she was on chemo.

Do we talk about HER cancer? What about our common patients? Everyone on the floor of this community hospital is pretty tight.

Oh, and did I mention that I take care of two or three other cancer patients on the same floor?

Anyway.

She died this morning. It's a long story. Multiple rounds of chemo, blah, blah.

A salvage "second look" surgery.

Wound dehiscence. Infection. Progression. Sepsis. Multiorgan failure. Withdrawal.

She came back to our floor from a tertiary center where she had the surgery in order to die.

She wanted to be cared for by her own nurse colleagues and to die where she worked for so many years.

Thank you K.C. for reminding me that we are all frail and mortal. That we can face our fate with dignity and courage and love.

You were a very special person and I was honored to be your physician.

Godspeed.

The Fear That Kills

2010-01-13T12:34:00.004-05:00

I just saw a 50 year old woman with a large 7 cm right breast mass and a scan that shows her liver and bones to be riddled with tumor.

Breast cancer. Metastatic.

She's very intelligent. Pretty. Educated.

Oh, did I mention that she's a nurse?

WTF?

Divorced, living alone, she knew that this was cancer. She knew she should have it examined and biopsied. But, she was afraid.

She noticed it a year ago... that's right. ONE YEAR AGO.

It was small then. It was probably curable and early stage. Just like so many other women. Just one of the "1 in 9" that get it.

I can't tell you how many times I've seen this in patients. Not just the subtle weight loss or a nagging ache in the spot of an old injury.

No.

I'm talking about large mass coming out of the breast or skin or neck or leg.

I'm talking about bleeding, ulcerating, fungating wounds that any child could tell are wrong.

Denial.

I am so averse to the excessively nervous segment of the world, the worryworts, that I sometimes forget about the other end of the spectrum.

The deniers. The minimizers. The people who fail to accept their illness, their sickness, their cancer.

And, it kills them.

I'm not sure anything could have been done in this case. She is an intelligent person in health care. She should have known better.

But, she, despite being very functional and successful on the surface, must have had some feelings of loneliness and desperation that she was unable to communicate. She must not have had anyone to trust or rely upon to tell her fears to.

She was afraid of the diagnosis.

Now, the diagnosis will kill her.

Love

2010-01-11T21:21:00.003-05:00

Love is an ephemeral thing. It swoops in, takes charge of your existence, turns on a form of madness in your brain and then often leaves you exhausted.

Love is passion, heat and whispers, mumbling and smooth textures. It burns.

Love is hot. That is, before it goes cold and unfeeling.

Love is nurturing. Maturing. Snuggling. Cuddling.

Love is nursing. Touching the neck. Sweeping the hair back.

Love is loyal. Sometimes. Sometimes it is deceitful.

Love is gain.

Love is loss.

Love is what we all aspire to have.

Love is what makes us all miserable.

Love is dedication. It is pure. It is good.

Love is betrayal. It is base. It is evil.

I have been fortunate in life to have loved deeply, to have lost love, to have spurned and been spurned by love. I have run away from it as much as towards it. I fear it.

Is love all there is to hope for?

Or is it something that we will never fully feel or attain? I don't know sometimes.

I don't know.

The Ties That Bind

2009-12-23T12:23:00.003-05:00

Home. As I stare out of my window at the office, looking at the people try to navigate the snows here in Maryland, milling about, hats on heads, gloves, wool coats flapping in the wind, I think about the concept of "home".

I grew up in Los Angeles. Well, part of the time there. Bronx, to Westchester County, to Oklahoma, then California. But, West L.A. was my home from middle school to high school and was formative. Sunny, wealthy, diverse. There were 10-20% Iranians in my high school. It was predominantly Jewish otherwise. 99% of the people went on to college. Every Ivy League school was represented on my block, both in the parents and in their children.

It was privileged to say the least.

But, strangely, it never felt like home to me. There was an artificial quality to it. Maybe it was because I wasn't born there and came as an observer. Maybe I just romanticize my supposed individuality from the materialism.

So, here I am in Baltimore, Maryland.

10 years now and running.

Not a whole lot of Asians, few Iranians. Mainly Christians, white and black.

Most of my patients have a very different background than I do. I practice at one hospital that borders the city and another amidst pure suburbia.

Remnants of blue-collar industrial Baltimore inform my existence. Bethlehem Steel. Sparrows Point. The Aberdeen Proving Grounds military base. Domino Sugar.

Smoking. Heavy metal exposure. Lead paint. Heroin.

When friends from elsewhere ask me if HBO's "The Wire" is really true about its depiction of Baltimore... they are a bit stunned when I say that it is 100% accurate and real.

I've been spit on by patients. Stuck myself with an HIV needle a couple times. Learned more about drug terminology than I ever thought possible. Seen very creative hand tattoos that I never thought could be done in the confines of a person's home.

We travel in life. Sometimes it's tourism to some cruise through the Mediterranean. Camping. Going to a museum or a monument.

Sometimes, though, the traveling is mental. We move somewhere in our minds, we transform as we accumulate each new experience. Our ethics, our worldview change as we grow, age, fall in love, feel loss.

Why the hell do I live here? They always ask me. My friends from home.

Why do I live here?

Because it's my home.

What Does A Cure Mean?

2009-12-23T10:41:00.005-05:00

"I'm cured, right?"

"Yes."

"So, why can't I walk?"

"Well, it's not as simple as that."

"The cancer was in my back, right? You said it was in my back? Now, it's not. Now, it's CURED..."

It's been 2 months since K.S. finished her chemotherapy for lymphoma. She had had some low back pain for a couple months. She saw her primary doc who had ordered an initial set of spine films and started some physical therapy.

I mean, she's only 40-something, busy in life with kids, family, etc.

Moving boxes, bending to get a casserole, having sex... there are a million reasons why a woman her age can get a little back ache.

Who would have thought it was an aggressive lymphoma eating into her vertebra and eventually compressing her spinal cord?

Well, that is until she one day just started urinating on herself, slipped and a big CRACK let out in her lower back... boom, no feeling and little movement below the belly button.

A spine MRI showed a massive lesion eroding one of her lumbar vertebrae and causing the dreaded "cord compression" and "pathologic fracture".

She had an emergent spine operation, then radiation and chemotherapy... steroids, pain meds, rehab, physical therapy, months of treatment.

A repeat PET/CT scan showed no cancer. A complete remission. Maybe even a cure.

But, she can barely wiggle her toes, has no control over her bowels, has a chronic indwelling catheter in her bladder and has a bed sore.

Is that a cure?

She likely will never make a neurological recovery. Her cord was partially transected during the fracture and it's been months now with little functional improvement.

The prognosis, as we say, is poor.

But, she's alive.

"Maybe I should have just died."

"Don't say that. You are alive. Don't give up."

"Do you ever really think I will walk again?"

"Maybe."

"Tell me the truth."

"Maybe. Don't lose hope."

"Please don't lie to me. Be honest with me."

"No, K.S., I don't think you will ever walk again."

What does it mean to be cured? The cancer is gone, but the patient is destroyed. The life that was once known is no longer and will never come again. No matter what, she can never be made whole again.

Entropy. The 2nd law of thermodynamics says that entropy can never decrease. It can only increase. We all decay. It is the natural order of things.

We age, we wrinkle. Our joints hurt, our minds falter. Our bodies fail us.

I try to think of this as the natural cycle of life. To meditate. To think of the teachings of the Buddha and Taoism to guide me.

But, it's hard. K.S. will never have the moments of joy that she once had before her illness. She will always be a paraplegic. Broken, even if repaired. Always broken.

But... CURED.

Whatever that means.

I'm Focused On Living

2009-12-21T11:41:00.002-05:00

"I'm focused on living right now, ON THIS...", she said, pointing to her maimed left breast, as I asked her about loneliness and dating. Then she smiled... "but next year, when my reconstruction is done, watch out."

I'm focused on you, S.G. It's hard to see someone sick at any age. I don't deal with pediatrics so that is often abstract to me.

Honestly, for the patients that are 70 years old and older, part of me thinks that their suffering is a tragedy, but that this is part of the cycle of aging and life. Maybe I'll feel differently when I'm that age.

But, for the 30 and 40 year olds like S.G., struck down with the lymphomas and leukemias and breast cancers and testicular cancers... it's different. They are "young", my age and can articulate their loss and their potential loss so well. They are often smack-dab in the middle of marriage and child rearing and career, so the losses are, some ways, if you can even quantify them, more.

S.G. is in her late 30s. Unmarried. Very sweet. She was diagnosed with node positive breast cancer, stage IIIA a year ago. After surgery and chemo and radiation, a year of Herceptin monoclonal antibody treatment and now anticipating a TRAM reconstruction, she has four more years of hormone treatment, at least.

She's gone into early menopause, can no longer have children, has a disfigured left breast and a distorted body image. Her libido, if there even is such a thing after all of that, is gone. Oh, and her hair thinned prematurely as a result, so she still has to wear a wig.

And, yet she has time to joke with me about all the "action" she's gonna get in 2010. Hell, I can't even think about that.

I hope to face my own death and the death of loved ones with courage and humor and dignity.

There was a massive snowstorm this weekend. As I struggled to get from hospital to hospital amidst the blizzard, I cursed my fate at drawing this crappy weekend call.

But, like all things, today, the sun came out, the streets were cleared and there is a freshness to the air.

Taking care of cancer patients is the same. It's chilling, lonely, fraught with fear and despair. But, there is an end to it. And a beginning again.

What you lose and what you gain is sometimes largely dependent on your mind and spirit.

Like S.G., I'm hoping for a good 2010.

Ode To The Gas Passer

2009-12-17T18:45:00.002-05:00

I just heard that a colleague of mine killed himself two days ago. An anesthesiologist. Trained at the same hospital that I came from. Wife. Family. The whole shebang. I don't know the whole story, but apparently, he had been depressed for some time. He had tried once before.

All of this was triggered a year ago by a complication involving a pregnant young woman. First child. 27 years old. Supposed to go well.

It didn't.

She died.

He was involved. He thought he did it. An epidural gone wrong or some crap like that. Just some horrible unforeseen shit went down and he happened to be involved.

So, it ate at him.

Maybe there was some prior depression. But, this doesn't help. So, he finally killed himself.

I never even suspected a thing.

I would talk with him about common patients in the hallway, about his new position coming up, about our time at Hopkins, blah, blah.

I just saw him two fucking weeks ago...

2 weeks.

Two weeks.

When I was in med school at UCLA, 4 classmates killed themselves by the time I graduated.

Four!!!

Problems with boyfriends, with parents, with drugs, with grades, with self-esteem...

We would have some crap lecture every year about the "impaired physician"... something so abstract when you are just trying to use the stethoscope from the right direction or trying to get laid with some nursing student that you met in the library.

Who the hell knows about life and sadness and all that B.S.?

We all carry such pain inside of us. From our lives, our jobs, our families... maybe just from the despair of living on this blue dot, circling this crazy galaxy in this infinite universe.

But, we feel it. It. Sadness? Blah? Something. Despair. Sometimes, we don't even know the unsettled feeling that we feel.

Underneath the veneer of perfection and the titles and the money and the house and the 2.5 kids and the dog, there is a real feeling inside of us that sometimes remains hidden...

I'm sorry for you and your family, C.G. I can't imagine what you felt to think that you caused that young woman's death. I'm so, so sorry that you had to die to make yourself feel less pain.

If there is a heaven, I hope you are in it.

P

Christmas

2009-12-14T22:02:00.004-05:00

Another holiday approaches. I am not Christian, as anyone who reads my blog would surmise. But, the message of Jesus is one that resonates strongly with me. I suppose it is universal in its appeal.

I try to think of Jesus as a historical figure. An itinerant preacher amongst the Jewish poor, preaching a message of faith, charity and love. This, despite Roman oppression. Despite poverty and sickness and despair. Despite venality and sensuality.

How this message of hope for a better, more just afterlife must have provided such comfort for those who were the most downtrodden in life.

I would hope that we all would reflect some time, amidst the crass materialism of the "holidays" and think of how we can, in our own way, in this singular life of ours, strive for more justice and generosity in our day to day existence. How we can provide hope and help for others less fortunate. How we can lift ourselves up from despair.

The new year approaches. Renewal in the middle of wintertime. Turning towards the spring to come.

Physician, go forward and heal others.

Most of all, heal thyself.

Camus

2009-12-13T23:03:00.004-05:00

I've been listening to my books on tape quite a bit recently. Actually, more of a lectures on tape. Albert Camus. That is the latest fascination. I've finished the piece on "The Stranger" and they've moved to the "Myth of Sisyphus". It's not light reading, to say the least. A bedrock of Existential thought, Camus provided some core principles that later philosophers such as Sartre expanded and modified.

The nutshell of his thinking is that life is fundamentally absurd. Devoid of intrinsic meaning. That there is no God. And that we are deluding ourselves by thinking that there is a rhyme or reason to the nature of the universe. There is only life and then death. Nothing more. And that simple fact makes each of our finite lives difficult and ultimately doomed. One solution is suicide. Terminate as soon as possible, since you will one day die anyway. Why wait? The other solution is to delude yourself with fixation on the supernatural. God, mysticism, the unexplainable. To dream or hope or even truly believe that there is a Watchmaker behind all of this, blind or otherwise. The third is to actively embrace your life and its absurdities. To accept the inevitable decline and destruction of life and to revel in it.

I think a lot about Camus lately. The holidays. Cancer. Getting older. My brother turned 40 this year. Our lives are AT LEAST half over. It's ironic that I'm only just starting to really enjoy life and find meaning in it, but it is speeding ever more quickly by. I guess that is the very nature of life.

I wonder sometimes if I would ponder all of this as much if I didn't deal with death on a daily basis. I wonder sometimes if people NEVER think about this. If they blissfully pass through life without much worry or useless thinking. At least until the end.

But, this is my lot. My job makes me think endlessly about death. Even as I relax with a girlfriend or vacation with parents or have drinks with friends. As I exercise. Or read. Or sleep.

And I think of Camus.

Can I embrace life?

The Holidays

2009-12-12T19:05:00.002-05:00

I find the holidays somewhat depressing. Maybe it's the juxtaposition of cancer opposite the Hallmark messages that surround me. Maybe I'm just a curmudgeon. I saw four people yesterday with new cancer diagnoses. All under the age of 50. Young. I'd like to think that I've become more toughened to the nature of suffering, but I'm not sure that is the case. If anything, I feel more sensitive as I get older. I'm not sure why. Maybe it's my own mortality. Maybe I've just come to recognize that there is no judgment of the value of a life. That it is essentially absurd and intrinsically meaningless. But, to each of us, there is some existential meaning that we construct for ourselves. And, after being a doctor now for more than a decade, I accept that our lives are precious, if only for the fact that they are OURS. But, seeing these four kinda got me down.

I am grateful for my job, my occupation, my calling, if you will. It is unique to step outside of our own sphere and see how other lives unfold. To see the movie that plays for each person's hopes and dreams, loves and losses. I reminisce of people that have come and gone. Patients, colleagues. Friends, lovers. Family. And, I feel blessed to have experienced so much in my life.

It's just that cancer sucks a lot. Especially during this time of year.

Goodbye, Mr. B

2009-10-26T20:33:00.005-04:00

Today was a somewhat bad day. I mean, I've had quite a few bad days in my years on this planet. But, this one was up there in terms of pure badness.

It started as the usual. Not too busy. Rounds. Paperwork. Returning some calls. Waving to some of my chemo patients.

Mr. B. A wonderful man. A wonderful family. A "country boy", as his daughter calls him. Tough. Salt of the earth. Decent.

You name the cliche, he fits the bill. Truly a good guy.

But a smoker. Big time smoker. Did I mention how much I fucking hate smoking?

I met him a couple months ago... well, "met" isn't quite the description, since he was intubated and sedated. He had just been diagnosed with a new lung cancer. A huge tumor sitting right near his pulmonary artery, filling his right mainstem bronchus. He couldn't breathe. So, in went the plastic into his lungs.

Some scraping, roto-rootering, some lasering and a lot of antibiotics later, we had a diagnosis of squamous cell cancer and a lung that started to aerate.

I didn't expect him to make it. Didn't give it a thought.

Then I met his daughter, S. S is a special person. Young. Married. Pretty. But, there are so many people like that. Caring. Nice. Loving. Also commonplace.

But, there was something different. An innocence. Something in her face, a gentleness when she and her husband looked at me as I explained his condition. Something that made me want to give my right arm to do something for Mr. B.

Patients don't realize sometimes that we play favorites. I try to be objective. But, in the end, we (I) do favor some people. It's hard to know why. It's like falling in love. Who knows?

I fell in love with this family. With her look of hope, her tears, her husband's caring and tenderness.

My project.

Well, today, he died.

Sitting in a chemo chair, he started to cough blood, then vomit blood, then POUR out blood... in a span of 5 minutes, he "bled out". His tumor ate into the pulmonary artery that so tenuously sat near. With each heartbeat, jets of blood poured out into his lungs and then out of his mouth and onto the floor.

In the middle of the infusion room.

I've seen chaos. Many times.

This was one of the worst.

Between his daughter's sobbing, the other patients' horror and the look on his face as his life literally poured out of him... well, I don't know what to say except that it was horrible.

Horrible.

Is there justice in the world?

God?

I don't know sometimes.

I hate fucking smoking.

Dying is one thing.

Cancer is one thing.

But, this, in front of others, the fear in all of us. His daughter, S.

I'll never forget her crying if I live a hundred years.

And, in the midst of primal screaming, grief, pandemonium, the crashing of the paramedics, the blood everywhere... she had the decency to turn to us, to me and thank me for everything we did.... THANK US?!

All we did was watch him die.

I've never felt so helpless as a physician.

As I sit here, I am a bit numb, writing this. It is a bit unreal.

Goodbye, Mr. B. I'm so, so sorry. I'm sorry we failed you and your family. I'm sorry that this disease is so cruel and merciless and swift in its decisions.

I don't know if there is anything after this short life of ours... I wish sometimes. But, if there is, I hope you are there and I hope someday you and your daughter meet again.

I was honored to be your doctor.

Love, Dr. P

Medical Wealth Transfer

2009-09-24T21:29:00.003-04:00

Something like 50% of Medicare health dollars are spent in the final two years of a person's life. What no one is really talking about is that, in order for the system not to become bankrupt, there must ultimately be a diversion of resources from the elderly to the young.

Unfortunately, this is in stark contrast to the trends of the past several decades, where debt is increasingly being transferred to future generations. Not only have we overspent at the cost of our progeny in things like defense, our trade deficit and our overconsumption of material goods, but we have essentially placed our current health debt burden on subsequent generations.

Unless something is done now, this will undoubtedly worsen as the Baby Boomers age. That generation, unfortunately, has shown some of the least propensity for self-sacrifice of any American generation.

As we watch the health care debate currently going on in Congress, pay close attention to this idea of generational wealth transfer. Currently, in the Senate, there is a proposal to cut some $500 billion from Medicare over 10 years. Despite what Democrats argue, this is ultimately the first phase in cuts to benefits for seniors.

They just can't be honest about that because the elderly vote far more than the young and they almost always vote in their own economic interests.

If, in the final legislation, the Medicare cuts remain, then there is hope for cost control in the future as that will finally set some precedent for further reductions. If, however, the final bill lacks Medicare restraint, then prepare for an even larger economic disaster in the future as the costs of health care will skyrocket even further as our population ages.

A Family Undertaking: POV

2009-09-06T00:16:00.002-04:00

I just saw one of the most riveting documentaries in my life. It is called "A Family Undertaking: POV". It is all about dying and the industry of death in this country. It follows a growing movement in this country that emphasizes "home deaths" and "home burials" as opposed to the usual affair that occurs in a funeral home.

A brief history is given of the evolution of embalming and modern funeral procedures that started during the Civil War. Apparently, prior to this, as would be expected, when people died, their families at home often took care of the burial, providing whatever ceremony was consistent with the family's beliefs. Burials often occurred on family property. There was no embalming or embellished caskets and other funeral rites. Rather, it was more of a personal affair. Where families were much more intimate with the death process and the deceased.

I highly recommend this for anyone who has ever given thought to the absurd and often frightening rituals that occur when a loved one dies.

I think we, in this country, need to become more accepting of death. We need less denial. I think one negative byproduct of our modern technical advances in medicine is that physicians, Pharma, hospitals, everyone involved in health care in the US have promoted the idea that life can be extended indefinitely. That we really can push the boundary of aging and death and suffering.

Yes, life expectancy can and should improve.

But, we still will all die. And, being in denial of this does no one any good.

I'm often stunned by how many of my patients, in their 80s and 90s, with chronic illnesses and cancer, often seem shocked that they might die soon. That so many have made little preparation for their death.

We spend so much time and effort thinking about birth. About our jobs and the acquisition of material goods throughout our lives.

It's time we thought a little about the fate that we all share.

Death.

Watch the documentary. It's amazing.

Recharged

2009-09-05T18:03:00.002-04:00

It was difficult to return. I suppose this is what most people face as they get older. You get wrapped up in your job, your parenting, your social and religious roles in your community. You "become" someone. You have a persona. There are responsibilities and expectations. Much of this is a really good thing.

But, in some ways, it can be oppressive.

For the past few years, I have fully evolved into the role of an oncologist. I know. After 18 years of schooling/training, you would think that it was about time. But, after all of those years, learning side by side with other fledgling docs, there is a bit of groupthink and herd mentality that occurs.

Only when you are thrust into the "real world", where your day to day is essentially similar to what it will be for the rest of your life that you start to understand the role of your job as the doctor. This is undoubtedly the same in other professions. But medicine is all I know.

I am "Dr. So-and-So". And, although, I eat dinner sometimes in my underwear and caterwaul terrible songs in the shower just like others, my persona at work lends a certain air of responsibility and gravitas to my life, especially in the face of the daily existential crises of my patients.

I love it.

I do.

But, sometimes, I am so immersed in being a physician that I forget that I am no different from anyone else in life. I forget some of the other aspects of my persona. I like to write. I like to loaf around. I like NOT being responsible sometimes. I like to meander for hours in the woods or sit by a body of water.

There is something else to my life then caring for the sick.

For the last week, I was backcountry camping throughout New Mexico and Colorado. For much of it, I beheld ancient Ancestral Puebloan sites. Anasazi sites, they were once referred to.

Often, I was alone. No shower. No cell phone. Just walking, seeing, quietly observing. When I met someone or chatted along the way, my job rarely came up.

I was just "So-and-So". No doctor.

It is humbling and refreshing to see that much, if not most or even all of the world functions so very well WITHOUT you. That you are a very small part of this world and a mere blip on the face of humanity, much less the universe.

It is freeing. It is wonderful.

I forgot that I was a physician so much that, when I came back to work, I realized how lucky I am to do what I do.

Recharged. At least for a moment.

Time to Recharge

2009-08-20T13:04:00.003-04:00

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

2009-08-13T21:16:00.002-04:00

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

2009-08-13T16:12:00.006-04:00

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?

2009-08-07T21:24:00.002-04:00

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

2009-08-05T14:04:00.006-04:00

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

2009-08-02T21:24:00.003-04:00

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.

What's It All About?

2009-07-31T00:02:00.002-04:00

There is a creeping bias towards agnosticism, if not outright atheism, throughout most of modern science and medicine. I can say for a fact that most of my mentors in college, medical school and training were, for the most part, nonreligious, and sometimes, quite hostile to belief.

I, myself, a child of physicians, grew up in a household where atheism was viewed through the prism of truth and science and religion in the realm of voodoo and blind faith. I must say that to this day, I remain deeply skeptical of faith, at least as it is promulgated by the Judeo-Christian-Muslim triumvirate.

What the hell are we doing here then? It plagues me, torments me, affects every aspect of my being. I know that that sounds awfully melodramatic, but it's the truth. Maybe it's the daily existential crises that I see going on in the minds and hearts of my patients. Maybe it's getting a bit older myself. Maybe it's just being down. But, I can't shake, in the dark quiet of the evening, this essential, age-old, unanswerable, but extremely difficult question of our existence.

I tend to subscribe to the Carl Sagan-ish approach to our existence in that: many say that the origin of the universe traces to "God"... when asked "who created God?", the answer is often that it is beyond our comprehension. Sagan's rejoinder to the this was that he preferred to remove the middleman and just say that the very nature of our existence and the universe is beyond our comprehension. Period.

If, then, we are all just "star stuff", and our molecules decay back into the nothingness of entropy, what is our brief time on this planet about?

Christians often say the communion with God's love. Muslims speak of obedience. Buddhists talk of dharma. Taoists talk of , well, the indescribable Tao. Existentialists talk of our own whims and desires.

I read and read and read and yet, as I think of how so many people I see have confronted illness and death, I still have no answer.

I would like to believe that we are all children of a loving creator. That there is something eternal to our souls. That a soul even exists.

But, I don't believe and I won't believe.

I simply cannot accept that the suffering of the world is justifiably caused by a knowing being. If it is, then I reject such a being.

I suppose I take more comfort from the idea that we are all together in this absurdity of life. That we all exist in the same short window of years. That, although, as Ecclesiastes says, there is nothing new under the sun, that there is something holy and mystical about each of our own individual journeys through life. However mundane, however painful, however comedic.

We all face the same fate. We are all humbled eventually by illness and death. Life is a treasure, despite its lack of purpose per se. It is simply about living itself. And respecting how others choose to live.

And having a few laughs along the way.

The Hurt That Never Leaves

2009-07-29T10:18:00.005-04:00

It's been a pretty crappy week. Three years into full-time practice and it still gets to me when a patient dies. I know to the lay person that that seems appropriate, but there is a certain amount of detachment/PTSD/burnout/self-survival that occurs when you're knee deep in trauma of some kind, be it cancer care, war, police work, or any number of personally demanding jobs that are wonderful and horrible simultaneously.

But, it's still gets me. Maybe too much. I've laid off the blogging for nearly two years to kind of get my bearings in full time practice. It's never pretty when idealism collides with reality, but I guess that's what "growing up" really means. It's not chronological, it's psychological.

My last 10 days... a colleague, 32 years old, another doctor, was diagnosed with node-positive breast cancer. she's 32 years old...! granted, I've treated a fair number of young breast cancer patients, but that sucks. oh, and it was diagnosed shortly after the birth of her second child.

i just found out that a woman, 37 years old, 2 years ahead of me in training... she was my senior resident in the ICU for Christ's sake, 2 kids, the usual... she has metastatic breast cancer that is progressive through 3-4 regimens. She probably won't live another year. Her last email talked about the "end of the tunnel" which she knows is coming, but can't quite see around the bend. I cry when I even think of her and all my countless patients, young and old, who lose so much freshness in their lives during these battles.

One of my all-time favorite patients (i know, we're not supposed to have favorites, but we do), 50 year old man, with chronic lymphocytic leukemia diagnosed 3 years ago. He had a complete remission to his chemotherapy at the time, but a few months ago, his white cells came back, but they were a little different. This time, he had a different leukemia, something called acute myeloid leukemia, a completely ominous and often fatal diagnosis. Likely, it was a known complication of the original chemotherapy he received, a side effect of the DNA damage from those drugs... he died last week. Hearing his wife sob on the phone sends chills down my spine as I write this.

Last night, I had an end-of-life discussion with a 49 year old with metastatic prostate cancer that I treated for 2 years. In one year, his PSA was normal, the next year it was in the 100s. I had to sit there as this guy, a state trooper, salt of the earth, broke down crying at the thought of not seeing his daughters get married some day.

And on and on...

I sometimes wonder what being exposed to suffering constantly will do to me in the long run. I'd like to say that I've achieved wisdom and compassion and the full range of emotion and life, but sometimes, I just feel a bit fried.

I often think, in the quiet of my evenings, about some of my patients and their families. You get to know them so well as an oncologist. Where they went to school. Their pets. Children. Hopes, dreams. The things they are fighting so hard to keep. Love.

Sometimes, I just sit there and cry.

Weakness at Work

2008-02-15T22:34:00.003-05:00

The day is long. Stressful. So-and-so has a lytic lesion at T1. Mrs. X just got intubated and is in the ICU. Mr. Y has called 10 times in the last hour about his upcoming prostate surgery. It's stressful. It's wonderful. It sucks. It's amazing.

My job is so diverse. A million different decisions occur every day. Affects so many people. Being a doctor is being a lifelong student of people. And, God, sometimes, I just want to curl up in a ball and cry. But, I keep coming back. I love it. I hate it. I need the money. Screw the money. I should have been a dermatologist.

And then it happens. A flirtation. An intimacy. You work with someone. You're getting crushed in the hospital. The job is killing you. You're there all the time. Hey, there's that nurse smiling at you. That married pulmonologist complaining about her accountant husband. The secretary with the deadbeat dad/husband.

The Weakness. It hits us all. You justify it, saying you're stressed. You say you're overworked. That no one understands you. But it's not true. I've seen it before so many times. I see it all the time now. A dalliance. A brightness to the day. A smile. A shared story.

I used to wonder how people had affairs. It seemed so abstract to me. I don't wonder any more. I see it all around me. It pulls me. It probably pulls my partner. The combined beauty and curse of our Internet modern life is that we have endless choice. Endless exposure to anything. Not just my city or even my state. Europe, the world, anonymous.

Maybe it's just the natural hormonal infidelity that grips all people in any line of work. But, I see the cliche doctor's affairs all the time. I see it. I understand it now. I've just got to avoid it all and just go home and work out or something.... just meditate. But, I see it.

The chemo part is easy. It's the living that's tough sometimes.

Does You Really Think They Look Okay?

2008-02-08T22:48:00.000-05:00

"Hmm, I don't know..."

"C'mon, Dr. ________, my husband noticed the other day. I think he's right"

"Well, uh, there's definitely a slight shift to the right and, hmm, let me see again... yes, maybe..."

"Oww!"

"Sorry" (sheepishly)

"How about the other breast?"

"That one is okay, symmetric. No problems"

"Do you feel any lymph nodes?"

"No"

"Why does the implant shift like that?"

"Well, sometimes the healing process takes months, you know... scar tissue, etc."

"I have another question..." (as she puts her bra on)

"Okay, go ahead, shoot"

"What about vaginal dryness?"

"Are you experiencing pain during intercourse?"

"Yes, it hurts when we... you know.."

"Have you tried K-Y or Astroglide?"

"Yes, but, it's not always ready... not always spontaneous. Why is that?"

"It's the tamoxifen"

"Really? Will it get better?"

"Maybe... but, the drugs basically put you into early menopause..."

"But, I'm only 32"

"Yes, I know. How about your libido?"

"It's low. Sometimes, I just don't feel like doing it. I don't feel attractive. I mean, something seems strange. And my husband just doesn't understand. He tries, but he gets frustrated."

(Pause. Silence.)

"Tell me more"

"I just don't feel whole. I know the odds are okay. But, I'm 32 for Christsakes. THIRTY-TWO. I'll never have children. My body feels disfigured. I hate this goddamn breast! I mean, look at them. They look so strange.

(More silence)

"Do you really think they look okay?"

Consumption

2008-01-10T20:25:00.000-05:00

I get it. I do now. For years, after hours, days, years, even decades of studying, then student loans, 100-hour workweeks, I always told myself that I do/did what I do/did because of love, passion, honor and so on. For the love of it. That was true, no doubt. But, now that I make a decent salary for the first time EVER and I have started paying my student loans, I understand what it is to consume, to want, to spend, quite frankly.

I don't know where it comes from. But, it comes. Like this vile force rising out of my bosom, this desire to spend, to consume, to purchase, to attain, it overwhelms me. I usually think of myself as progressive. I drive a respectable car (a Honda), I have energy-efficient lightbulbs. I give to the Sierra club and PBS. Blah, blah.

But, when I come home, when I sit in the quiet of my home, I waver between various emotions. Sadness at my day. Fatigue. Joy. I exercise. I eat. I read. I make love. I do the things that we all do. But, whether it's the new-found salary or my position or the impending burnout of my job, or a combination of all... I feel this urge to buy things, to drown my sorrows in possessions.

I'm trying to fight it. I know that it is pathetic. That it is transitory. But the cashmere sweater, the silk tie, the new suit... it somehow makes me feel better, makes me forget my problems, if only for a moment.

Yet it's dismal. Empty as the cliche goes. Money for money's sake. Mix boredom or depression, misery, etc. and you have the generic human experience. I fight it. I do. But, sometimes you just want a sweater that feels nice....

Bhutto

2007-12-28T21:17:00.000-05:00

Sad. It's sad. Why would the death of someone somewhere in Pakistan make me so sad? She wasn't a saint, despite the hagiography that CNN would promulgate on you. She had scandals, controversy, drama. Not a saint. Not by a long shot. It's not the Islam-thing. The 9/11 B.S. It's the death of someone, some-thing, something that had the potential to "turn the page". Like the end of a marriage or an affair, or recovering from a loss or graduation, there is something about moving on, about moving forward. For a person, for a country. The death of Benazir Bhutto was like ice water splashed on my chest.

Makes me fear for our future. Not for the future in little old Baltimore. I doubt someone wants to blow up Towson, Maryland. But, it just feels like we in the US need some chance to move on... from Bush, from Iraq, from "terror". Just to freakin' move on, or move back to an America that we once loved and cherished.

Bhutto's death makes that return more fragile. Sad. Real sad.

Why care about the other end of the Earth?

Because it will be at our doorstep before we know it...

Our little America. This country that I truly love.

Making Money and Slogging Chemo

2007-12-20T21:11:00.000-05:00

It's been a while since I wrote anything. I'm not sure why. I suppose I could feed some bullshit about the "emotional toll of being an oncologist"... the reality is I probably am just a combination of fried and lazy. I'm sitting here in my living room, days before yet another Yuletide moment and another New Year and there is just a whole lot to absorb about the WWI-like year I've had. I'm shellshocked, PTSD'd, thrashed.... I don't know the words for it.

Private practice oncology is a mixture of compassion, death, science, love, business, you name it. Nothing in my fellowship prepared me for it. I got a figurine from one of my patients today. This wonderful 50 year old woman with lung cancer who finds time in her day to thank me for cranking up some chemo in her veins and praying that she is a survivor. This wonderful woman, no kids, husband a fireman, trying to make the most out of limited funds and a lot of drugs, pain, wheezing, whatever. And, yet, she has time to think of me, to give me a figurine of a doctor, a "healer", as if that is the most appropriate appellation for yours truly.

Death. Lots of it. Some of my favorite patients. Some people that just struck me so hard and so fast. Struck them so hard and fast. Mary, with her lung cancer and her children and her husband with whom she was supposed to spend the "golden" years. Irma, matriarch of the family, that blessed family from Highlandtown, that nurtured her children to dream big and rise above working-class Baltimore.... Irma always asked if "you are eating well". How about Jaswinder? Can't speak much English. Shitty insurance. 3 kids. 38 years old. Breast cancer disaster. How's that for a Christmas? Makes you believe in the G-d, doesn't it?

People ask my why I've stopped writing. It's not because I lack things to say. I just feel burnt. Burnt already.

All those fucking tests. The little tests, the labs, the scans.

Oh, and the money... don't forget the money...

Yellow Week

2007-05-29T10:37:00.000-04:00

I'll call him Jack. Eighty-four years old, 57 years married to the same woman, WWII vet, all-around nice guy. Shows up one day to his primary care physician YELLOW. Eyes, skin, urine, I'm sure his tears are yellow if we checked. Pancreatic cancer. In retrospect, that's what that nagging backache was after finishing the back nine last weekend. That's why he had success for the first time in years shedding that tire around his waist. That's why he's a little more tired.

Bradley. Fifty-four, schoolteacher, 3 kids. Christian man, as if that matters (I'm Buddhist) somehow. YELLOW. Just sitting around one day, on a Sunday, kids in tow, when his wife notices a strange tinge in his eyes. Never seen it before. More pronounced in the natural sunlight of the outdoors. Hmm. Maybe it's nothing. The next day it's worse. Did you eat something weird? Nausea, anything? Nah, just yellow. Imagine the shock on those five faces when I tell them that he's got bile duct cancer. Say what? What the f-ck is bile duct cancer? Well... sir... blah, blah, blah... it sucks.

Sally. Fifty-one, mother of one, divorced, two sisters. Very, very funny woman. Coarse, crass, was once probably a really good-looking woman, but a few too many six-packs and a couple decades of Camel Lights really show themselves. But, there is something just "illuminating" about her. Call it personality. Call it spunk. She's funny. Bitingly funny. Oh, yep, and she's yellow as all get out. Some right upper quadrant abdominal pain for weeks. Liver cancer. Oh and a little cirrhosis to boot. Yikes. Double yikes...

Then there is the 74 year old woman with relapsed breast cancer and a belly swollen as all get out... the ninety year old with metastatic lung cancer... he was yellow, but the roto-rooter GI specialists took care of that blockage... well, at least for the next few weeks. then there is... on and on...

Things always seem to come in bunches. Kind of like when you just can't seem to buy a date and then other times, when you're in a great relationship and it seems like everyone and her mother is giving you the "come on" sign. Well, sometimes it seems like symptoms come in bunches.

This week is Yellow Week. Stent here, ERCP there, chemo, radiation, Whipple, unblock, reblock, percutaneous. Jaundice (as being yellow is termed officially) is never a good thing. It's downright disturbing and scary. For doctor as well as patient. There is something so profoundly upsetting as such a change in appearance as COLOR. Something that just screams of illness, that dehumanizes and debilitates and changes forever our perception of ourselves and others. Jaundice. Even the word stinks.

When to Be the Doctor, When to Be the Patient

2007-05-17T09:19:00.000-04:00

This past week has been surreal for me. Cast for the first time in my life on the receiving end of bad news rather than the delivering end, it's opened my eyes again on the nature of the "doctor-patient" relationship and the boundaries, emotional and physical, of our knowledge and our profession.

Someone really special and dear to me learned this past week that her mother, a healthy, health-conscious, vivacious 64 year old woman with no medical problems had a potentially fatal disease: hepatocellular liver cancer. This is usually something that occurs in patients with known liver disease, hepatitis or cirrhosis.

Devastating. You know, as many times as I've given bad news, I've never sat with someone I knew and loved and received some bad news, or, for that matter, received my own bad news. I've seen the hollow devastated looks on patients' faces. Seeing it on my friend was something totally different.

When my friend, Elephant Number 5, died last year, it was different. She was in the "fighting" phase. I wasn't there for the diagnosis. She was already pushing forward, had battled the disease for years when I met her, and was resigned to this being the end of her life.

This is different. Shock. Flabbergasted. Compounded by the fact that my friend is ALSO an oncologist. A doc. She knows the score. She knows that this is probably fatal. I don't think I'll ever get the sound of her sobs and crying out of my head. I've always thought that things would be easier because I'm a doctor, but that's just a pile of crap.

What's more painful is watching someone you care about run around like crazy, just crushed and frantic, and you just don't know what to do. You just listen and cry and hold hands and listen more and buy food and listen. I've had to try to put away my "medical" hat and just be a friend. There are enough experts working on this case. We're trying not to be that stereotype of the doctor who is a nightmare patient or family member, just torching the medical staff with questions and second-guessing. But it's hard... sometimes, the medical staff sucks...

For months, my friend's mom had nausea. We kept telling her that maybe she needed a scan. Hell, we're oncologists. All we ever see is cancer. We kept wondering why a scan hadn't been performed. And now that it shows this, we just keep wondering and banging our heads and second-guessing everything.

I know that this is what we all go through in our lives as we face illness and death. It's scary. No amount of education or status or training takes that fear away. We all have this one precious life on earth and it is sacred. And it hurts. It really does.

I don't think I'll forget that the next time I talk to a patient. I'll look for that fear and hope in their eyes. Hopefully, they won't see it in mine also.

Thailand and Medical Tourism

2007-05-14T13:16:00.000-04:00

I just got back from several weeks of vacation in Thailand, the homeland of my parents, also where my brother lives and works. See the family, tour the countryside, a temple here, beaches there, easy smiles and many drinks with pink umbrellas. Overall, a wonderful trip. Much has changed about this Third World country since I was a child.

Bangkok is filled with state-of-the-art shopping centers, high tech freeways, savvy urban dwellers and an ultramodern, brand spanking new airport. In some ways, the whole place was almost MORE modern than where I live in the US. The people so forward looking, so tech-focused.

Another thing caught my eye as I appreciated how far Thailand has come from its poverty of the last century. ALL OF THE SUPER-NEW HOSPITALS EVERYWHERE...

I asked my brother, "what's going on with all of these mega-hospitals?" He answered, "medical tourism". Thailand, like India, has become a destination for medical tourism from around the world. Many of the physicians, like my father, are US trained, having come to America during the Vietnam War. Now, fully trained, many have returned to a booming Thailand to work in the private, for-profit hospitals. These are opportunities that didn't exist when they were growing up.

Thailand is extremely friendly to tourism and foreigners. It is stable politically, or at least, it has been until this past year or so (with some ethnic/religious tension in the South). And, while parts are developed, it is still Third World by many standards and remains quite inexpensive in Western eyes (and pocketbooks).

So, you have had an explosion in the development of for-profit healthcare, that caters to the West. Indeed, 60 Minutes, the American news show, did a profile on medical tourism and cited Bumrungrad Hospital, a prominent private hospital in Bangkok. Some insurers on the West Coast of the US will pay for patients to go to Thailand rather than get care in the US. A total knee replacement or a coronary bypass procedure are probably a third as expensive in these countries as they are in the US. Indeed, my sister-in-law's father had his bypass done in Bangkok by a Thai surgeon who had spent decades at the Cleveland Clinic in Ohio.

So, is anything wrong with this? It's cheap for the US people. It redistributes wealth to a poorer country like Thailand. The care is good. I'm not sure how I feel about this.

One problem in my mind is that this takes something that is already a problem in the US and transplants it to another country. Namely, the proliferation of highly expensive, boutique medical care at the expense of preventive care. Also, it provides yet another service for the wealthy and insured at the expense of the indigent and unconnected. As hospitals in Thailand and/or India make a dash for the dollars and euros from Western countries, as they tailor their services to meet the needs of the more lucrative foreign market, what is to happen to their own people, the majority of whom are quite poor and lack basic medical care?

Indeed, funding for HIV prevention and other basic health services in Thailand have been recently cut, even as these for-profit skin centers and plastic surgery units have proliferated.

One of the major problems with the US health care system, as I've delineated elsewhere, is the stratification of health care based on wealth and insurance status. Some people get gold-plated, very expensive, often unnecessary health care, while others get nothing. Both get care that is focused on end complications, rather than preventive medicine. It is simply more lucrative and sexy to "treat" disease than prevent it.

I hope that this medical tourism will be a passing fad. It is just a symptom of the greater pathology within the American medical system. It threatens the viability of the health care delivery system in Thailand and other Third World nations.

It's one export from the US that the world can do without.

Impaired

2007-04-08T22:40:00.000-04:00

I remember when I was growing up, myself the son of a cardiologist, growing up amidst a community of physicians and lawyers and successful businessmen... I remember every now and then, at the annual Christmas party hearing the whispers of so-and-so's divorce... of Dr. You-Know-Who's affair and sex addiction, of little Johnny having to sign up for the military for medical school because Uncle Blah gambled the family fortune away in Vegas.

Whispers. Knowing looks. Disapproval in a sort of Scarlet Letter kinda way. That tsk-tsk sentiment of pity mixed with schadenfraude and disgust. "So-and-so is impaired... (whisper), he's at Betty Ford... he's getting sued by his secretary for sexual harassment."

It seemed so juicy, so carnal yet entirely remote from my otherwise unremarkable suburban adolescence. The kind of thing that you just love to hear about but can never in your wildest dreams imagine happening to you. Why do people become impaired? Addicted? Self-destructive? Why?

Is it the circumstances of a life or something innate? Nature versus nurture. I guess I always used to think of addiction or self-destruction as a human frailty that was entirely under self-control. A form of personal weakness to which I was immune. Yet another form of hubris.

Now, looking back, facing my depressing Fridays, feeling this urge to drown my tough days sometimes with a swig of Jack Daniels, I'm no longer so judgmental about all those poor souls that I witnessed growing up. Now, sitting through friends' and friends' parents' divorces and mix-ups, experiencing my own losses and pitfalls, just growing up and experiencing life a little bit, I wonder how any of us avoids a mid-life or late-life crisis, physically or mentally.

Judgment is so easy when you are young. It is so easy when life is green and fresh and filled with endless blue sky. How different after a wound or two.

Physician, heal thyself. I understand now what Hippocrates was talking about. I'll put the glass down now and go for a walk.

It's a Good Friday

2007-04-06T22:26:00.000-04:00

As a non-Christian, I sometimes wonder why this day is called "Good Friday"? What could have been "good" about the death of Jesus Christ? It seems like a strange name to me. Always has. It's weird. Although I am not religious, for some reason, Good Friday and Easter have always gotten me thinking about religion and life, more so than any other holiday on the calendar. More than Christmas, more than Thanksgiving, Passover, Kwanzaa, etc. There is something about the story, the history of Jesus that just gets me thinking this time of year.

I suppose it's the story of compassion throughout the New Testament that registers with me so profoundly. Forgiveness. Turning the other cheek. Love of our neighbor. These are important concepts to anyone. Perhaps more so for a physician. Even more for an oncologist.

Today was an amazing day. It's been just over a year since my friend, Elephant Number 5, as I refer to her in a prior post, died of complications from a bone marrow transplant. One year. Sadly, I've been so busy, I haven't thought of her that much. Someone so sweet, so gentle, so important to my life, yet forgotten amidst the business and daily trauma of my life.

One year ago. She would have wanted me to drink a beer for her on this day or watch a sunset or drink a beer AND watch a sunset. She was lyrical like that. Spiritual. Funny. Fun.

What is life, except a string of seemingly unconnected experiences that add up to a tapestry of a life? We are all alone in the end. All alone in this absurd life, filled alternately with tragedy and happiness. Alone in our search for meaning in a short stint of breathing.

I'm not sure if being an oncologist has helped or hurt me spiritually.

I miss naivete sometimes.

I miss that nervousness I used to feel in college before a date with a girl.

I strangely reminisce randomly on the past even though I'm only 34.

I digress.

Good Friday.

I guess it is a Good Friday.

A Friday to think, to feel.

Brain tumor, pathologic leg fracture, leukemic blasts, swollen spleen, intubation, dialysis, DO NOT RESUSCITATE, FULL CODE, lung biopsy, hand holding, crying, living, dying...

It's all just a normal Friday. Random... very human.

The Hurting

2007-03-16T20:45:00.000-04:00

"It hurts"

"He's my life, I can't let him go"

"Is it really that bad?"

"I don't know what to do... should I put him in the nursing home? I just can't take it anymore..."

"I'm ready to die... really, I'm ready"

"Forget it. No way. No hospice. He's going to go out fighting."

"I'm too young to die"

"Phew... thank God, thank God!!! Remission!!!"

"Why did this happen to us?"

Just a sampling from my week. A small sampling. One week. Just another week in the life of an oncologist. My first impulse is to reach for a drink. Seriously. I just want to numb it. I can't bullshit and say that I feel everything for every patient, but man, oh man, it just hurts sometimes.

Cancer is brutal. It robs our dignity. It sucks our lifeblood. It dehumanizes. Yet, it's just amazing how people are sometimes. So funny, so noble, so ironic. Sometimes so angry, so bitter, so vitriolic... yet, all of it, just so, so human.

I feel like crying every Friday. I hang on for the week, just holding on to my sanity and emotions until the cathartic drive home every Friday at around 6 PM. Just reviewing all the sadness of the week.

The woman who survived breast cancer for 10 years only to get a new diagnosis of metastatic esophageal cancer. The 50 year old nonsmoker with Dana Reeve-like metastatic lung cancer. The guy cured from lymphoma who develops leukemia from the prior chemotherapy. The young married guy with myeloma and now the elimination of ever having children. The blood clots, the ulcers, the pneumonias, the kidney failures... the montage of character actor illnesses that accompany every cancer diagnosis.

I hate it. I love this job. I'm depressed. I'm fulfilled. Fuck this shit. Yet, I show up every Monday. Cancer is a bitch, as many of my patients have told me. Damn straight, man. Damn straight.

The Status Syndrome

2007-02-24T13:09:00.000-05:00

For a number of years, a British physician and epidemiologist, Michael Marmot, has been studying health disparities throughout the United Kingdom and the world. In a book published a couple of years ago,The Status Syndrome, and in a recent article in JAMA, he outlines a phenomenon that he names the "Status Syndrome."

What is it, exactly? It is a disparity in health that relates to discrepancies in social standing, money, power, influence and level of self-esteem. Apparently, Academy Award winners live a few years longer on average than nominees. Independent of salary, higher educated individuals live longer than less educated people. However, money is not the only issue. There is something else, something intangible yet familiar to all of us that is embodied in the idea of "status" or social worth. The JAMA study showed that class for class, individuals in the UK had better health outcomes than their socioeconomic peers in the US despite our spending TRILLIONS more per year on health care. Countries with much, much lower GDPs per capita such as Greece or Israel have higher life expectancies than we do. Furthermore, the point has been made by Marmot and others that countries with little income disparity, such as Canada, Japan and Sweden, have better overall health than countries with wide and gaping disparities in income.

What is behind this phenomenon? Well, no one knows, quite honestly. But, science and pop culture have merged a bit in the past decade on the concept of stress. Since time immemorial, humans have noticed that less anxious, more socially integrated, happier people who feel good about themselves and their lives seem to do well. People under dramatic stress or trauma or who have suffered a loss often seem to have more medical problems or die sooner. Almost any of us can point to a friend or a family or an urban legend about so-and-so dying after his or her spouse died or of someone who "aged so quickly in a year" and on and on.

Well, research is catching up with this. There are studies that look at telomeres, the endings on chromosomes, which shorten with each replication of DNA. Some of these studies have shown correlation between more rapid telomere shortening and a history of stress or trauma. We are learning more about "inflammation" and its role in heart disease, cancer and other medical problems. Inflammation is driven by diet and activity but also hormones and our own bodies’ reactions to events. Some of our most effective medications, such as aspirin, decrease inflammation and it's thought that this may underlie the role of anti-inflammatory drugs in prevention and treatment of illness.

What's the bottom line? Well, I suppose there are really two bottom lines, at least. One is a personal bottom line. Namely, that we as individuals, in wanting to promote our own health and longevity and quality of life, should seek out behaviors that reduce stress, provide meaning to our lives and give us a sense of direction and autonomy. We should promote the usual healthful behaviors of diet, exercise and social interaction. Also, that money alone and the accumulation of wealth is not the answer. At least on a personal level. Rather, it is the satisfaction that comes with self-esteem, purpose and usefulness that may improve both our psychological and medical well-being.

From a societal standpoint, we have only to look at countries such as Sweden or Canada or Japan. Granted, they are more homogeneous populations than the US, but philosophically, there is something different between those countries and US. One aspect, in my opinion, is LESS of an emphasis on self-importance. Whether it is Canada's universal health system, Sweden's social safety net or Japan's stereotyped philosophy of "the nail that sticks out gets hammered down", there is on many levels more of an emphasis on community and group responsibility in those countries than in the US. While this allows for dynamite corporations and fabulously wealthy and entrepreneurial individuals in our country, it also accepts and allows for a much larger population of downtrodden and dispossessed people.

As a nation, I suppose we should aim to promote policies that reward innovation but at the same time attempt to reduce broad income and social disparities. Whether it's universal health or balancing our budget or providing for a social safety net, I think that our government at every level can enact policies that not only save money and provide services but also can actually save lives and help us live longer and healthier. I believe the data is becoming clearer and clearer in that, although the US allows for enormous success personally, our American way of life fractures us socially and widens both our financial as well as our physical health. In social policy as well as in science, it is not enough to simply look at single variables and outcomes. Humans are complex organisms and societies multiply that complexity many-fold. By focusing on the overall goal of longer life, better well-being and more equality in our health care delivery as well as being honest in looking at our neighbor countries and peers for what they are "doing right", maybe our government and ourselves (we make our government) can actually wake up and realize that there are better ways to live. It will probably save a few bucks also.

This is Why People Distrust Research and Turn to Alternative Medicine...

2007-02-15T21:55:00.000-05:00

A recent Washington Post article described a recent article in the medical literature challenging the long held notion and recommendation that pregnant women should limit their fish consumption. The recommendations from a variety of agencies, including the Environmental Protection Agency and the Food and Drug Administration, that pregnant women limit fish intake comes from a long history of calculations based on the presence of methylmercury and PCBs and their purported effect on neurological function. These recommendations are very well meaning, based on sound science and logic.

So, imagine the surprise when a longitudinal study observing a large cohort of women who consumed a variety of fish showed that the highest consumers had children with the highest neurological function. Granted, there are a variety of biases that are associated from such studies and this is far from a gold-standard randomized controlled study of fish consumption in this population, but the findings are thought-provoking on the one hand and confusing to the public on the other.

Whether it is hormone replacement therapy, fish oil, garlic, multivitamins, and Celebrex or fish consumption during pregnancy, there are just so many conflicting studies on a variety of topics that are near and dear to the public. This is natural. This is science. There is nothing wrong with this and, ultimately, the beauty of science and research is that the truth eventually emerges.

The problem is that, in this day and age of the Internet and the need to publish quickly, there is just a complete flood of information that reaches the public, often via the pages of the New York Times or CNN, and that these studies are taken as the word of God. The public then stands confused when a conflicting headline is showcased months or years later.

I think that, in some ways, this constant conflict of thoughts and ideas that are aired constantly in public only serves to undermine medicine and our confidence in medical science. It drives, in my view, the increasing confidence of patients in "alternative" medicine or anecdotal therapies. I can't tell you how many times patients come to me on all kinds of pills and therapies that I know nothing about. Drugs that they read about on the Internet. Attitudes from extremely intelligent people that "doctors just don't know everything.."

I agree. We don't know everything. Often, we know nothing. I'm not sure what the solution is. Maybe it is limiting what gets published and released in the media. Maybe it's better science education and background for the common layperson. Maybe it's more nuance in our discussion of health. Maybe it's just waiting and thinking and just not sensationalizing every little new discovery that confuses patients and doctors alike. Alright, I'm taking my multivitamin and fish oil now. Oh, and my baby aspirin.

Cost, Quality and Access

2007-02-01T23:22:00.000-05:00

"Cost, Quality, Access..." I can still hear it now. My college professor of Social Medicine speaking about the tradeoffs between these three aspects health care. "You can emphasize low cost, high quality OR universal access, but it's nearly impossible to have all three." This was in the heyday of Hillary Clinton's attempt to revise the health care system. She was trying to educate a young student in the perils of American health care. It seemed so abstract, our class sitting there debating the pros and cons of the Oregon Health Care plan, the Canadian health care system, universal vaccination, the rights of citizens, the rights of corporations to make profit, the responsibilities of government for people's welfare and on and on. So abstract.

Well, it ain't so abstract anymore. Every day, I seem to confront the realities and limitations of our health care system. And I'm as perplexed as anyone else as to what the answer is. I'll give you my examples from this past month alone... I one guy who is deciding whether to take a pill for chemo that Medicare covers but is clearly inferior or have to put up 20% of the cost of intravenous chemo that would put him easily into remission but would amount to probably $10,000. He's a machinist and his wife is sick and he has no kids and his insurance sucks. What do you say to this kind of thing? Go broke or take shitty treatment. Or take another patient of mine. He has private insurance, but it only covers labs drawn at a particular university system. The nearest blood drawing area is dozens of miles from where he lives. He's 76, can't see, lives alone and, yes, has a blood disorder that just happens to require very, very frequent blood draws. So, I see him, wait for the labs to be faxed from this other place, try to make some decision in some timely fashion and then enact it. Usually requires a form of injection growth factor that isn't covered by his program to be given in the office unless he wants to cough up that 20%. Oh, but it covers it being "self-injected", but he has bad arthritis, and, yes, did I mention he couldn't see?... well, that's life. Never mind that he fought in the Korean and Vietnam wars and worked as a civil servant for a number of years. Or the Mexican illegal immigrant who rolled into the hospital with a cough and left with the diagnosis of metastatic kidney cancer. Can't get medicines, can't get surgery, can't even get an office visit paid for, can't go home to Mexico. He just waits. And waits. He's a nice guy and so respectful, but I just sit there impotent to do anything. I can't take a huge financial loss to treat him. I can't stop thinking about him. No one wants him, even the university hospitals in our city. Yep. Stinks.

Cost. Quality. Access. Currently, we have the worst of all worlds. We have the most expensive health care on Earth, some 14-17% of GDP going towards health care. We have spotty quality. Yep, you heard it. Yes, we have more MRIs in Maryland than in all of Canada and you have people lined up around the corner to install high tech stents, pacemakers, dialysis, catheters, etc. We've got high tech alright. But, how about infant mortality, or vaccination strategies or public health or just plain lifespan. Based on everything we know about science and public health measures, we do a crappy job of implementing care that would help millions of people. We pay through the nose for a cardiac bypass, but pay primary care docs 10 bucks to spend an hour trying to help us stop smoking or lose weight. We don't go for the most quality for the MOST PEOPLE. We go for the absolute PREMIUM care for a chosen few, adequate care for the majority and severely, disastrously poor care for the chosen slobs. Finally, access. Well, everyone knows about the 30-40 million uninsured. But, the grim fact is that the uninsured utilize even more care sometimes than the insured. They lack primary services and therefore utilize emergency care more frequently. Emergency rooms are packed to the hilt with uninsured patients who use the ER for their primary care, driving up costs enormously, overwhelming docs and resulting in often-disastrous outcomes.

What's the solution? I have no freaking idea. All I know is that people need to be aware of the tradeoffs between these issues. In my opinion, the only way to improve things is to accept that dreaded, hush-hush outcome that has rarely been mentioned for nearly a decade... RATIONING. Yep. Rationing. Any system that provides universal health care for the entire population and doesn't completely bankrupt the Treasury is going to require rationing. It simply has to. But, rationing isn't what you think. It isn't the managed care kind of rationing where some phone tree or technician either argues with you or ignores you in order to minimize your use of the system.

No, rationing is maybe something different. It means taking what we ALREADY know about effective treatments and implementing as many of those as possible FIRST, before turning to more expensive treatments that benefit fewer people. Something akin to the Oregon Health Plan that came about in the 90's. What that plan basically tried to do was to come up with a list of treatements... a list of treatements of all the known medical conditions, bone marrow transplants, diphtheria vaccines, gallbladder surgery, hair removal, etc. Take a panel of medical experts, ethicists, business people, lawyers, government agencies and other stakeholders and come up with a list from 1 to whatever, listing the treatments from most effective to least effective. Most effective might be something like the polio vaccine. Helps everyone, costs pennies. The least effective might be some totally rare experimental bone marrow transplantation for a super rare disease like aplastic anemia. Take that list, take your state budget and find some point on the list where below that point, you just can't pay for the treatments solely by government, because the benefit is outweighed by the cost. Everything above the list is covered by the government. Everything below, well, you're on your own. There is, in effect, "rationing" of care.

Yes, it is fraught with problems. Wealthy people could find ways to circumvent the list. There would be bias in favor of the rich. But, honestly, there already is a many-tiered system of care in this country based on wealth. It's just more opaque and more fraudulent. I've always liked the Oregon Health Plan. Somehow, it just seemed logical and fair and would control cost while providing broad care to the most people with the most beneficial treatments.

But, alas, I don't think we'll get there. Too many stakeholders, too many powerful interests. The states, however, are experimenting with different things in the absence of national leadership. Who knows? Maybe something will happen before the Baby Boomers impoverish the government. I can dream, though. I can dream of a day when I close up my oncology shop, because most cancers have now been prevented by public health measures curbing smoking, excessive drinking and obesity. How people will prevent heart disease and when there will be no more disfiguring breast cancer surgeries or big scars on peoples' chests where their lung cancers have whacked out. Ain't gonna happen. I know that. But I can daydream. Gives me something to think about while I'm pushing more chemo.

Six Months Under My Belt and I'm Coming Up for Air

2007-01-19T13:07:00.000-05:00

It's been quite a six month stretch. No blogging, just working. These first few months of practice have been both entirely predictable in many ways and totally surprising in others. First, the predictable: sometimes long stressful hours fraught with uncertainty about knowledge, compassion, talent and/or any number of other attributes that a competent oncologist is supposed to have. Lack of experience leading to frantic running back and forth to Google and PubMed and UpToDate in an attempt to understand what I'm supposed to be doing (all this after already 4 years of med school and 7 years of training). Some politics with dealing with referring physicians, competing groups, academic centers. And so on and on.

Now for the less anticipated things. Well, first of all, commuting sucks. It's better now that I have books on tape, but after not having to commute much for most of my life, even the 30 minute drive to my outer office is somewhat painful. I can't imagine how people drive for hours and hours when they live far out in the suburbs or exurbs or whatever it's called. I guess I should have known about commuting, but, hey, I've been locked up in one hospital for the last 7 years. Give a brother a break.

Two, I kind of like the "business" side of things. Yes, for all my railing against the system, for all my complaints about the inefficiencies of things (and there are still many, many inefficiencies), the fact is that running a private practice is like running a corporation. Whether it's ethical and meaningful and trustworthy has less to do with the inherent nature of the "industry" and more to the individuals. Enron versus Google for instance. Both money-making giants, one a lot more corrupt than the other. But, being involved in the design, structure, development and delivery of medical care under the control of your own hands is, after years under the yoke of hierarchical and sometimes nonsensical training, quite, well... refreshing. There is just something to being part of an organic process, a growing organism that you can shape so directly with your input, your attitude, your know-how. When I mean the "business", I'm not talking about money. I'm talking about the "ownership" aspect, as in "taking ownership of our own lives" kind of thing, or "ownership society" a la the hated Dubya. It's just plain nice to talk with partners about how and what we want to do in the future and just go out and do it. No grants, no blah-blahing, no kowtowing to superiors... just a small, nimble organization hoping to develop a good way of helping people and a culture of success and caring.

That brings me to number three. The money. After a month, the money becomes meaningless. Seriously. Money is kind of the thing that matters a ton when you don't have it. When I was making the $35,000/year resident salary while working 110 hours a week, I would think sometimes how it must be so nice to make a bigger salary, all the freedom, the satisfaction. How in some ways my disgruntlement at times was related to feeling underappreciated. Don't get me wrong, you make peanuts as a medical trainee, after spending your whole life studying and accumulating $150,000 in debt to go to school. It can be daunting at times. But once you make a little more money, unless you have a ton of other financial needs, the luster of it fades quickly. Honestly, my lifestyle hasn't changed a bit. I just have finally started paying off some loans and saving for the first time. It's just a little security but it really doesn't make me any happier and it certainly isn't a driving force to continue my work. The bottom line is that no amount of money makes working so hard worthwhile if you don't love it.

Number four. I LOVE IT 80% of the time, loathe it 10% and am somewhat numb 10% of the time. I thought those percentages would be different when I started. I won't tell you how different. Anyway, being a doctor is great. It is the most challenging and interesting thing ever. Far more challenging than my training. Medical training is stressful in terms of the hours spent and the insecurity of learning while taking care of generally sick inpatients. However, there was usually a "superior", someone who had both the final say and the final responsibility. Now, I am that person. It's nice to sort of know what to do, but sometimes the burden of the responsibility, especially in cancer care, is a bit heavy. Also, the paperwork... yuck. The paperwork truly is burdensome. When it's just me and a patient in an exam room, I'm in heaven. When it's this form or that, or dictate this or sign that, it's torture. Administrative issues are really painful.

Five. Politics. Not the Iraq war kind, but the medical-industrial complex kind. The there-is-a-lot-of-dinero-on-the-line kind. There is this palpable tension between doctors and the hospitals and the insurers. A strange love triangle that is unsurprisingly devoid of love and affection. I assumed there was more politics in the academic center. In a way, there is more in practice. And, it's somewhat less transparent. In academics, you have smart and not-so-smart professors pushing for glory, publications, promotions, lab space, etc. It's predictable and you can sort of understand the game that is afoot. In practice, it is a little more opaque. Yes, money is at the center, but it is sometimes hard to assess other doctors, patients, insurers and hospitals in terms of their motivations, maneuvers and manipulations. Not to get all Machiavellian, but with a lot of money on the line in medical care, a shrinking pie and some greedy folks, sometimes it's hard to know how much you have to fight to "get patients". After all, a doctor who sees no patients has no practice, and therefore has nothing. It's complicated. I'll allude to it in future blogs.

Lastly, dealing with the dreaded Pharma reps. Painful. Very. Unbearable. Yet... yet, there is some use SOMETIMES. Most of the time, you feel like you're dealing with total charlatans who sneak around plying some snake oil. But, every now and then, someone is actually helpful. They sometimes provide useful (and often biased) information on a drug or a side effect or a way of getting a drug to an uninsured patient. Yes, there is ultimately something in it for them and yes, I've had reps offer me chances to "speak on the lecture circuit" and make cash, but every now and then you have a relatively decent rep who is reasonably intelligent who is also helpful... okay, I confessed it.

So, I finished half of a year in practice. I had to go underground for a while. Overwhelmed, just processing, mentally fried. Hopefully, I'm back. Passed my boards. Taking my first vacation tomorrow. Just felt like my old blogging self. 2007 is hopefully going to be a good year. CancerDoc is hopefully coming back. There is just too much out there to talk about.

Obamamania

2006-10-22T22:40:00.000-04:00

I seem to have seen Barack Obama everywhere lately. NY Times, on the cover of various magazines, on "Meet the Press" this morning. Caught up in the swirl of life, Iraq looming somewhere remotely in my consciousness, vaguely aware of the possible changing of power in Congress coming up (like, who cares?), I'm somewhat distantly cognizant of politics and our civic discourse lately. No matter where I turn, it all seems the same. I read the paper daily... I skip it a couple of days, I come back to it in a week or so. It's all the same. Scandal there, something pornographic in either pop culture or our politicians daily. A murder somewhere, a school shooting. Deaths in Iraq. Nuclear weapons. I swear. It's like Groundhog Day, every day, all year. Politicians seem to babble about the same thing. Abortion. Minimum wage. Terror. Medicare. Welfare. Immigration. The same stuff that was being debated in my college dorms ten years ago.

So, there was something kind of refreshing in listening to Mr. Obama on TV these last couple days or reading a bit about him in the papers or leafing through his new book, "The Audacity of Hope" in the book store. Dunno quite what it is. It's not because I believe in the same stuff he does. Actually, I'm not really sure what this two-year senator from Illinois even believes in. It's not that he's multiracial or younger or from Harvard. It's not even that he's articulate.

I think what struck me most was an observation that he relayed first in the pages of his book and more recently illuminated in interviews on TV. Namely, and I paraphrase, that so many of our current debates... the debates between the Clintons and the Bushes, the liberals and conservatives, the right-to-lifers and pro-choicers... so many of these debates seem like replays of the 60s. So many of the theoretical constructs seem mired in the well-trodden logic of four decades ago. Very little of that logic resonates with my generation, "Generation X". So much of it centers around the "Baby Boomers". Like much of everything that goes on in this country, be it Social Security or the war, at the heart of the demographic appeal is the Baby Boomer generation.

Yet, I believe that so many in the country, young and old alike, seek something past the ideology of prior years. So many of us I think are "post-ideological". Globalization, trade, outsourcing, China, terror, global warming... these issues seem outside of the tired and worn-out roles of Democratic, Republican and Green Party hacks. Obama stated that he felt people nowadays were not just searching for the "center", but in reality, were searching for "pragmatism". Whether it's the market economy or government regulation, entrepreneurs or social workers solving problems or whatever, what we need in this century is a more practical, problem-oriented approach to the huge issues of the world. Climate Change, Terror, the Role of Big Government, Trade, Religious Fervor, Population Growth, Health Care... and on and on. There are so many big problems facing this country and the world. With the growth and dissemination of knowledge and power on the Internet and globally, it just isn't up for a chosen few individuals or nations to solve the problems of our day.

I don't know if Barack Obama would make a good leader. I hope so. His rhetoric is pretty good so far. But, we've been down these paths before. Rather, I think what appeals to me is the sense I get from listening to him that maybe, just maybe, a new generation is on the cusp of taking power. A generation that is focused more on finding real solutions to problems, across ideology. A generation that grew up in the shadow of our somewhat self-indulgent Baby Boomer parents and our selfless "Greatest Generation" grandparents. A generation that is maybe a little less ideological. That is respectful of marriage as well as homosexuality and "alternative lifestyles", that is religious, but also tolerant. That is socially conscious, but entrepreneurial and trusting of capitalism to a certain extent. A generation that is willing to consider all possible solutions to all imaginable problems.

Maybe that's just the dreaming Progressive in me.

I'm Just a Rookie

2006-10-18T20:49:00.000-04:00

It's set in. Insidiously. Gradually. Inexorably. As some of you have commented in the past weeks, I've been a little absent from the blogosphere lately. I wish I had some pithy comment as to WHY or some good reason. I guess I've just been getting busy with the beginnings of my long journey down this road called "private practice". I think I'm a little shellshocked at finally being the person ultimately responsible for so many sick people with life-threatening illnesses. Dude, this is scary.

You know, it's funny. I make all these somewhat self-congratulatory observations on issues that come across my eye in the New York Times or Washington Post. I feel educated, just finishing my training at one of the top institutions of this country. I felt like I was "on top of my game" coming out of fellowship. Yikes. I think the Greeks had a term for this... HUBRIS.

My first months in practice have been a lot of things. Exhilarating, exhausting, frightening, funny, sad, predictable in many ways, completely horrifying in others. I'm still getting used to the feeling of moving from one room where a young patient is gurgling on their own vomit, dying from metastatic breast cancer, three kids in tow, husband, picket fence, to the next room, joking with the "cured" early stage colon cancer patient to the nurses' station where I have some yucks about my weekend to my house where I have this ever present urge lately to throw back a couple of beers nightly (I don't, mind you... well, sometimes I do).

It's almost comical... almost. I saw so many patients in my seven years of training. I pretty much saw everything medical that I could imagine. Or so I thought. I guess you get used to hearing about how you're a hot shot so many times that you start to believe it a little bit. But, being out in the "real world" is something very different.

You know, behind the verneer of confidence in your doctor's eyes lies just a little bit of terror. Trust me. Just that little feeling like "I'm an imposter". I really don't know what the hell is going on but I'll fake it or punt until the next visit or step out of the room and look it up on the Internet. It's crazy. It's one thing if I'm dealing with coughs and colds or sprains and bunions. But, this is chemo and death and tumors and horrors.

Sometimes it seems like there is no break. Like I just gasp in relief when I look at the next patient on the list and it's someone with chronic leukemia or a run of the mill blood disorder. What a break. It's getting a little easier, though. I'm not staying up all nights reading furiously. I'm relaxing a bit more on the weekends. I don't need to get up at 6AM every day now. I'm sleeping okay for the most part.

But, it's there. Just that little panic, that obsession, that fear that I'll completely screw up someone's life, mess up their wedding, their Bar Mitzvah, their vacation, their kids, their opportunity to have kids, their life.

Honestly, sometimes being an oncologist is tough, draining. But, in truth, I love it. It's like crack cocaine in a way. Sometimes, when the day seems long, when I just dread one more conversation about death or hospice or the future, I look into the eyes of my patient and see THEIR compassion for me. I feel human. I feel humbled. I feel like a doc. That's the only way I can explain it.

It's a nice feeling.

Perils and Promise of Monopolization

2006-09-21T12:20:00.000-04:00

Two recent developments in the news have made me think about the growing consolidation of corporations and their impacts on our lives, both for good and bad. Take the spinach crisis that emerged a week ago or so in the US. It appears that at least one and maybe more industrial farms are implicated as sources of the E. coli-laden spinach that affected more than a dozen states across America, resulting in numerous hospitalizations and a nationwide recall on all spinach products.

How does this come about? How is it that our FDA gets the point where it says that NO ONE in the US can eat any spinach "until further notified?" Consolidation, that's why. With modern large-scale industrial farming, something like 70% of all spinach consumed in the US comes from California. Why is this so? Well, these large corporations enjoy economies of scale; can provide low-cost, relatively high quality products with quick distribution. By the way, this was a large-scale organic farm, if I remember correctly. So, many of our "organic" or "natural" products are being produced at large industrial farms. Whole Foods and Trader Joe's both buy from such companies.

The downside is obvious. With less diversification of our food resources, we are prone to health breakdowns like the one that occurred this past week. Furthermore, some argue, such as in Michael Pollan's "The Omnivore's Dilemma", that increasing homogenization of the food that we eat is in itself detrimental to our health. Rather than eating locally grown, seasonal foods like our forebears did, we are all stuck with the same diets, whether they are McDonald's, organic or vegan. The sources are the same. This is 1) potentially a health risk during contamination episodes like the E.coli problem or Avian flu, 2) limits biodiversity and impacts other plant and animal species and 3) potentially promotes unhealthful farming techniques, like feeding cattle corn instead of their traditional, evolutionarily-developed grass.

A second article in the NY Times got me thinking of the impact of monopolization from a different perspective. Wal-Mart, in a bid to assert more influence in the competitive health care market, has begun to offer generic prescription drugs. This will place a large amount of pressure on other pharmacies and insurance plans to keep up with Wal-Mart's demands. Wal-Mart is such an enormous player economically in the world that this action alone may have substantial effects on the health care industry in this country.

Although I have some problems with Wal-Mart's health care policies, I have to agree that this decision to support generic drugs is an important and positive development. Many generics are quite cheaper than their brand name competitors but equally effective. Pharmaceutical companies fight tooth and nail to maintain individual patents or suppress generic drug makers. In the end, costs skyrocket but health benefits are not necessarily improved.

In other ways, I often wonder to myself if the global dominance of Wal-Mart is a good or bad thing. I enjoy getting cheap products all in one spot from a Target or Wal-Mart. Deep down, I realize they are pressuring small vendors around the world with their purchasing power. Yet, at the same time, I think they provide real service and cost-benefit to us, the consumer.

I guess my point is that there are plusses and minuses to consolidation of resources and economies of scale. No kidding. I guess I've steered away from my prior knee-jerk reaction to "corporate" influences. Sometimes, business and the "invisible hand" of Adam Smith are the most efficient ways to stimulate progress and development. I think my main beef is not with companies or marketers or business people. Rather, it is with our own government. Our own watchdog institutions such as the EPA or FDA or Justice Department.

Whether it's our own Department of the Interior interfering with its internal auditors or Congressmen who move back and forth from government to the Lobby de jour or our academicians and scientists who have stock options or honoraria from the very companies whose products and drugs they are supposed to evaluate "objectively", it is the growing conflicts of interest in all aspects of our society that is most disturbing to me.

We must not forget that the FDA and USDA emerged shortly after Upton Sinclair's "The Jungle" shed light on the dismaying practices of the meatpacking industry. That the SEC gained strength after the stock market crash of 1929. That we needed antitrust litigation to break the power of Standard Oil. That perhaps humans are meant to simply repeat our mistakes over and over again. That the endless cycle of progressivism alternating with conservatism is simply the way of life.

I just hope we don't all have to get the E.coli runs to bring back Teddy Roosevelt.

Utopia, USA

2006-08-05T18:23:00.000-04:00

One of the comments on my last blog was about how "idealistic" my suggestions sound in relation to being a good health care consumer. I think that that attitude is part and parcel of why we have such a fractured system. People expect a fair, equitable, well-meaning, beneficent health system to just be available to them at a low cost and for little responsibility on the part of patients and consumers.

My point of the last couple blogs and indeed this entire blog is to illustrate some of the realities in the system and to let people understand the larger forces at work in our system and how they affect the delivery of care. There are so many economic and political undercurrents to the simple office or hospital visit that is entirely opaque to the average person. I think it's clear that patients are unhappy with many of the problems in the system. Our health care industrial complex is expensive, unwieldy, has poor outcomes and limited access. It's great for the wealthy few and frustrating for the average many. But, quite honestly, only the patients, only the populace, once informed, can effect change by voting with their wills and their wallets.

You can't expect companies and insurance organizations and pharmaceuticals to not pursue their own interests. That is the nature of a corporation. Government and governmental policy are mere reflections of the voters. My sincerest hope is that, by providing some of this insight, people become motivated to push for change at their local and state level. That people learn to take responsibility for their own health, to make positive lifestyle choices and to be good consumers of health care.

If that's living in Utopia, USA as one of the last commentators opined, then call me Citizen Numero Uno of Utopialand. Peace.

The Drug Lunch

2006-08-05T07:41:00.000-04:00

One of the most insidious and pernicious practices that exists in the medical marketplace is the "drug lunch". Hovering out there, somewhere between the largesse of the "consulting fee" and the banality of the penlight is the pharmaceutical-sponsored lunches that occur in private practices and academic institutions throughout the country and world, every day of the week.

What is it, exactly? A company, under the approval of the physicians and/or administrators, is allowed to provide lunch to any number of people, ranging from under a dozen to hundreds. Why would any company spend up to thousands of dollars a day on a limited group of doctors, you ask? Access. Marketing. Influencing of prescribing practices.

Take my field, for example. Oncology. Some blockbuster drugs, like Avastin (bevacizumab) or Tarceva (erlotinib) cost thousands of dollars a month when prescribed. Granted, they are amazing drugs for certain conditions and are welcome additions to the oncologist's armamentarium against that scourge that is cancer. But, if a drug rep can influence just a couple doctors to prescribe a bit more of these drugs, even just a couple times a month, it MORE than makes up for the cost of a piddly lunch. If you can influence several physicians or, better yet, influence a "thought leader" whose recommendations then affect hundreds or thousands of other doctors, then, well, you can do the math...

Drug companies spend BILLIONS of dollars per year on marketing. Some estimate that the total expenditures of Pharma on marketing rival their expenditures on research and development. Once again, I'm not down on marketing in general as a means of promoting a business. There is a reason Betamax lost to the inferior VHS or why Windows crushed the Mac. Spreading the gospel through marketing is a time-honored and critical way of selling a product.

The problem lies in the unique nature of medicine and the supposed "objective" stance that we expect our physicians to have when looking at our case, our medical problem, our illness. Let's face it. Drug companies wouldn't be spending so much time and money on pens, lunches, consulting fees, commercials, advertisements, etc. if they didn't work, if they didn't add to the bottom line.

There has been increasing scrutiny from outside groups regarding these practices. This is a good thing. I wish our government and physician groups like the AMA would take principled stands and attempt to ban these practices. It's hard and allowing "self-policing" is often a slippery slope. Take my own practice, for example. I just joined a group. Love the people. Love the staff. There has been a long history of drug lunches there. The staff gets a free lunch every day of the week and for those that make under $40,000 or $50,000 per year, a free lunch every day of your work life adds up. Hell, it adds up for anyone, regardless of income. So, as the new guy of the docs, do I try to "ban" these lunches? Of course not. I need to fit in the culture. The staff's opinion and loyalty is critical to my own success. Does the practice really want to spend thousands per year to feed the staff daily? No. Do I want to piss off any of my new partners? Of course not. You don't sign up for the US Army one day and then the next start telling the top brass how you're anti-war...

So, I elect to limit my own exposure to the reps. I don't eat their food, ever. That way, I won't feel obligated. I refuse their entreaties, their trinkets, their "CME" or continuing medical education (Pharma sponsors up to 80% of all educational activities for physicians in this country). I try to maintain my own code of ethics. Hopefully, it will slowly inspire the staff, as I get to know people and gain their trust. Already, I sense the frustration by the drug reps that can't have access to me. Many of them just barge into my office and start yapping away or leave their info on my desk. It's annoying. Oh, and don't even get me started on how they're all 1) good looking, 2) well-dressed and 3) quite slick. Don't get me wrong. They're nice and are just doing their job. But, the fact that there are nearly 100,000 reps in this country is just absurd. And, my profession is the major catalyst for the perpetuation of this absurdity.

So, in keeping with my last couple blogs, here is some advice to patients and consumers out there:

1) Try to get some idea of any conflicts of interest in your physician or in the academic center or facility that you use. If it's a private practice, try to see if the doctors own the same lab or imaging center that they refer to. It's hard and not transparent, but if it ever feels to you like your doctor is ordering too many tests or overprescribing needless medicines to you, that's a danger sign.

2) Try to get a feel for any clinical trial investigators that you may encounter if you enter an academic institution. Do you think they have conflicts of interest? Many of these are now being reported as part of institutional policies. For example, faculty as part of the American Society of Clinical Oncology have to report "conflicts of interest", stock, honoraria, etc. in the beginning of some talks and papers. You can sometimes look for recent papers by oncology faculty in the Journal of Clinical Oncology (JCO) and at the end of articles, you'll see a listing of their conflicts.

3) Look for the reps swarming in offices and institutions. Are they in the clinic? Are they there at times other than lunch or trafficking heavily in patient areas? This is inappropriate, distracting and just plain rude. Complain about it or demand something different.

Here is some reading on this subject:

A NY Times Article on the entire practice of drug lunches and some recent movements to ban their presence.

A Baltimore Sun Article along the same lines...

An article in the New England Journal of Medicine on another topic: pharmaceutical tracking of physician prescribing habits. Drug reps use this to pressure docs with data on their prescribing history. When you feel a bit guilty about eating free lunches for years, and the rep starts barking at you about how you never prescribe "X" drug, well, you get the picture...

For physicians reading this, here is the AMA website where you can ask to block the use and access of your prescribing data. Remember, it's the AMA that often sells our damn data to drug companies in the first place!! Oh, also, historically, they also blocked Truman's initial attempt to create a national health care system.

This other NY Times Article is on how many drug reps come from the ranks of cheerleaders and how that upbeat personality is very helpful in marketing.

So, just to finish. I'm not saying that drug reps are bad people. They are just doing their jobs. We, as physicians, bear the responsibility to regulate ourselves and practice a high level of ethical conduct. It's critical. The drug lunch is just a symbol of the increasing corporatization of health care and medical delivery. The marketplace has always been a part of medicine, from the times of the snake oil salesmen and the bloodletters. But, now, I and many of my colleagues feel that any resistance at all on the part of academia or watchdog groups has been brushed aside in the pursuit of ever-vanishing health care dollars. This endangers all of us. It endangers our health. It endangers our souls.

Some Early Challenges

2006-07-25T12:27:00.000-04:00

So, as I'm wrapping up my first week in private practice, I've noticed some important features of community care that are important to think about for both patients and providers alike. One, care is quite fractured in the US. The people we refer patients to and who refer patients to us... this is an arbitrary process that relies on personal whim, business relationships and reputation for quality care. I suppose it's no different in any other sector of the economy, but is quite interesting when juxtaposed against the backdrop of illness, particularly cancer. Two, lack of efficient and universal medical records is a huge detriment to care. I thought the clumsy, cumbersome system of my former university was a pain, but the multiple systems in the different hospitals I now go to and the myriad, incongruent, non-user friendly electronic record systems that are in place just complicate care. They create gaps for mistakes to be made. Third, there is broad discrepancy in community standards of care. Quality control and continuing education are variable and therefore quality varies. Granted, I'm already becoming exponentially out-of-date the farther I am from my training, but I've already observed some practices that fall a bit outside the cutting edge of the university system.

So, what to do? What are some important things that patients should ask of their physicians and hospitals when you get sick?

1. How does your doctor keep up with the pace of medical change? Does he go to meetings and read on the Internet or is he/she still reading age-old textbooks and quoting out of date literature? This is CRITICAL. Medicine changes so, so rapidly and it is easy to get out of your element. The only way to maintain even a semblence of quality is to use technology to keep up with the rapid dissemination of information. For example, the way we treat certain types of breast cancer or lung cancer has dramatically changed in just the last 3-5 years. If you've been resting on your laurels a bit, you might give suboptimal advice. Patients focus so much on a doctors "medical school" or maybe their residency. But, as any doc worth his or her salt will admit, the best physicians are the ones to keep up to date. Resting on a prestigious past is the first way to become a hack.

2. What are the financial incentives involved? It's a touchy subject, no doubt. I'm not sure the best way to ask or inquire. But, is there some type of quid pro quo between referring docs? Are needless consults called to people whose role in your care is unclear? Is there any self-referral bias going on? As the medical system faces more financial constraints, it becomes easier to step over the line. All of us as patients have to be aware.

3. What is a doctor's experience with your disease? Ask honestly how many times he or she has seen "your case" or done your procedure or operation or whatever. Brains are important. Judgment is key. But, repetition is also critical. Someone who has just seen a lot of your case is important. So, if it's rare, then clearly the academic center is the place to be, because there are often certain doctors who just treat one type of disease. However, if something is more "bread and butter", the converse might be true. Sometimes, someone who does high volume in the community might be better.

Just more ideas as I try to muddle through this thing called doctoring.

Week One Under the Belt

2006-07-07T12:56:00.000-04:00

I'm wrapping up my first week in private practice. To reiterate, I've joined a small five-man hematology/oncology group in Maryland. As I searched for a future job, I agreed in my mind to a few key principles. One, I wanted direct patient care. I'm a doctor after all. Two, I wanted some "control of my own destiny", so to speak. After years of training, debt and taking orders from superiors far and wide, I wanted some autonomy, some sense of dexterity in making decisions about my future and my patients' care. Three, I wanted a large enough group where I could enjoy some regularity in my quality of life. Four, I wanted a small enough group where I wouldn't feel like another cog in a machine. Five, I wanted a nice working environment where nurses, doctors, patients and staff treated each other with mutual respect.

So, I've settled here. After one week, I can already appreciate the vast differences between private practice and the academic environment. There are positives and negatives to everything in life and this is no different. First the positive. It is much, MUCH more efficient. Seeing patients quicker, in a more friendly, more personal way is just plain easier when the staff and docs are committed to such care. Granted, we have a financial incentive to give good care, but I think also that the focus is on more humanistic treatment also. Two, there is less ego in this setting. We're all on the same team and all pulling for the same goal. In the academic environment, there is almost a disincentive sometimes to do patient care. It distracts from research and grant writing. Also, there is always a battle between individuals and departments. For us, we sink or swim together. Doctors, staff and patients all have to be on the same page. Three, people are happy to do their jobs. When I ask a nurse or another doc or a consultant to see someone, they do it with a smile. In the academic world, because often there is no financial incentive to see people, people are just plain resistant or angry to do more work than necessary. They "block" or "turf" as we call it.

The negatives are predictable. We lack the resources to provide certain high end care. There aren't as many minds together working on the same problem. There aren't as many layers of residents, fellows and other trainees to pick up mistakes sometimes. Then, there is the flip side of the whole financial thing. We are unable to provide care unless we are sure someone can pay for it. That is an unfortunate reality. And, truthfully, I can imagine how some unethical individuals might "overutilize" or just plain bilk the system to make money.

So far, nothing has surprised me. I think I would apply these priniciples to all my patients and even my own mother.

1. If you have a routine, "standard" medical problem and want a more personalized treatment setting, I think private practice or a small group offers a more individualized experience and doesn't sacrifice care.

2. If you have some rare disease or need a complicated procedure or diagnosis, you might be better off in a tertiary care, academic center where all the resources can be brought to bear on your problem. It might be impersonal, but there are more minds available to figure out a strange thing.

3. Experimental therapy is of course more available in a university setting, but the caveat is that it is in the direct interest of the faculty to "put you on study" and so you must be aware of the biases.

4. Pharma is EVERYWHERE. They crawl all around the university, trying to enlist "thought leaders" so as to have their products promulgated throughout the world. They are all over private practices, providing lunches and "education", in the hopes of increasing prescribing patterns of the doctors. Some of these drugs nowadays can cost $60,000 for 6 months of FOLFOX therapy for colon cancer or even $7000-8000 for 30 pills for Sutent for kidney cancer. Is it worth it? Perhaps. But, someone has to foot the bill and our government can't decide what steps to take to prevent going broke.

5. The bottom line is that we, in all aspects of life, not just medicine, have to be aware of the incentives involved. Money is always an incentive. Prestige and fame are others. When you go to a stockbroker, realize what their commission will be. When you come to a doctor, understand if they have some heavy financial stake in their own recommendations or if they have to make tenure by publishing studies requiring your entry into their trials. I've come to think that only by creating the right combination of incentives can we design a system ultimately that combines patient personal responsibility with compassionate universal care.

6. I alone am responsible for my own ethics, my own care of people, my own interaction with colleagues.

Let's see what next week brings.

The Commons

2006-06-29T05:34:00.000-04:00

I saw a very disturbing documentary last night, "The Future of Food". Produced in 2004, it chronicles the consolidation of the food industry by giant agribusinesses, such as Monsanto or ConAgra or ADM, and the implications of such consolidation for our future "food security". Genetic modification (GM) or genetic engineering (GE) of food staples like corn and wheat and soybeans is a major international issue. A couple of key issues came up as the discussion of plant biotechnology was elucidated. Giant multinational corporations, in the hopes of capturing large markets, produce genetically modified strains of food in the hopes that certain traits, like pest resistance or drought resistance, will result in dominance of their product in the marketplace. There isn't anything inherently wrong with this, except that during this process, the genetically modified foodstuffs are patented and legally controlled. This has a couple of ramifications. The biodiversity of our food resources narrows and while, in the short term, this allows perhaps for greater crop yields, in the long term, this can expose us to greater threats of crop failure due to genetic monotony. Another ramification is that it is very difficult to prevent contamination of non-GM food from GM food. In many sites around the world, including Canada, Spain and Mexico, it has been documented that there has been cross-contamination of non-GM crops by GM crops. This is important also because there isn't necessarily longitudinal data that indicates the longterm safety of GM crops. Who knows if any of these Frankenstein foods are harmful to us? We just don't know. I'm not saying that some of these products aren't beneficial. But, just like the idea of global warming, is it really smart to experiment with our very lives without perhaps a little more caution?

I think this issue gets to a critical issue that is dear to me, which is the concept of the "Commons". The whole concept of genetically modifying our food and subsequently patenting it, indeed, effectively attempting to OWN nature itself, strikes me as abhorrent. As the biomedical industry has raced to patent our very DNA, charging fees for the study and use of our own biology, as people attempt to own more and more of our natural resources, I wonder if the very concept of common resources is intact. By the "commons", I mean things that most any human can agree are essential to our survival. Perhaps not sufficient alone, but certainly essential and basic. Water for example is a "common" and its privatization around the world in the next decades will be a source of strife, for sure. Just read "Water Wars" by Vandana Shiva and your eyes will open to the challenges Third World countries face as their natural resources are plundered internally and externally. Another would be something like public lands, parks, rivers, landmarks, etc. Another would be the biodiversity of our agriculture. Another would be the preservation of the global climate for future generations. Things like our own genetic code and that of the other species on the planet. These are all things that we as humans must strive together to preserve and protect. That we can never own, but rather that are shared and treasured by all people for all time. Things that are essential to life and from which we draw our very sustenance.

To me, this isn't a Republican or Democrat issue. This is simply an issue of what is available for "ownership" in the first place. How do we "own" a cancer causing gene or a type of wheat or a ten thousand year old river? When does this sort of thing become ridiculous? Consolidation, in my opinion, whether in medicine or agriculture or media or energy, is a very important issue. Is Wal-Mart good or bad for us in the end? Is ExxonMobil? There is nothing inherently wrong with the consolidation of business interests. That is, by definition almost, what businesses are meant to do, they are meant to grow and expand and dominate their markets. Any investor knows that. The problem is that such growth ultimately is amoral. Not immoral, but simply amoral. The pursuit of profit and growth can be a good or bad thing. It is for our society and populace to try to decide the limits on such activity.

http://www.southendpress.org/2004/items/WaterWars
http://www.centerforfoodsafety.org/
http://www.thefutureoffood.com/

Friendship, Love and Health

2006-06-16T11:57:00.000-04:00

This past week, perhaps this entire past month, for me personally has been filled with incredible moments of emotion and self-reflection and feeling. I've thought long and deeply about the role of love and feeling in our lives, in the whole tapestry of our lives, not just in the romantic, familiar sense that we all are accustomed to seeking. I've thought about the connection between love, friendship, happiness and our own health. Our own physical as well as mental health. I've had just a tremendous succession of roller-coaster like ups and downs emotionally in the past months, but the central building theme has been the power of my own emotions to so dramatically affect they way I see and feel about life in general. It helps that I have amazing friends, the kind that aren't just good when you're in revelry mode, but who are there in the clutch and who, quite frankly, just completely call your bullshit.

It seems that everywhere I turn, there is some treatise, or TV show or conversation being had about love and feelings. Not the Dr. Phil variety of schmaltzy experience tailor-made of TV, but of a richer, more nuanced and more scientific variety. National Geographic had an article on the biology of "love", describing our modern scientific or quasi-scientific understanding of the chemistry of attraction, attachment and sex as well as the impact of certain feelings on our own health and welfare. Another favorite magazine of mine, The Atlantic, had a similar article on love, this time including the rise of modern electronic love, on the Internet and how that is changing our society and the rules of human interaction. Finally, this past week, I watched a PBS special by Andrew Weil, the Arizona physician who specializes in "alternative" medicine and a more natural, holistic approach to health. He focused on traditional medicine and some of its virtues, but then shifted toward natural remedies and finally focused on the importance of our psychology, our mental fitness in this singular existence that we all face.

Now don't get me wrong. I believe traditional medicine is invaluable. You don't cure polio by just thinking peaceful thoughts. A bypass surgery is a bypass surgery. All of these things have their extremely important roles in our modern health care system. But, when I think of our modern culture and modern stresses, I can't help but wonder about how big a role emotion has in the rise of certain problems.

Take for instance the role of simple touch in our lives. We know that people who have pets or who are married live longer than single people. We know that having a dog or other animal comfort us during recovery from open-heart surgery can sometimes speed rehabilitation. We know that at the turn of the 20th century, "eating" disorders were uncommon, that for instance, in Argentina, anorexia and bulimia were rare, but with the rise of the modern expectation of thinness in women, those rates in South America and in the world have just completely skyrocketed. We know that there are two populations in the world, Okinawa and Sardinia, with the largest numbers of very healthy centenarians (100 year olds). Not only do they have vigorous lifestyles filled with exercise and healthful eating, but they also have cultures that respect the elderly and the process of aging and that the psychological expectation of eternal youth is simply nonexistent. We are all very familiar with the concept of spouses who die within very short time frames from each other. And on and on.

We know that feelings of warmth and love and friendship enhance our lives. But, they enhance our health and welfare also. There is a physiology to human interaction, to the basics of human touch in its simplest form. Laughter clubs and National Hugging Day are organic grassroots movements that simply express our most basic desire for human interaction. Unfortunately, in this advanced society of ours, as we spend more time in our own climate-controlled cars, looking at our self-directed TiVO and Netflix, as we stare into the breadth but isolation of the Internet, we distance ourselves from basic human contact.

I think that the incredible interest by the public in alternative medicine and holistic approaches to health care is fueled by a conscious and/or unconscious dissatisfaction on the part of all of us with some of the failings of our health care. It is impersonal, cold, analytical and unfriendly. Gone are many of the days when the physician was a pillar in the community, when he or she knew and cared for a wide spectrum of society and was fully integrated into the social fabric of a community. Today, we are lucky to know even a few of our neighbors much less get the same doctor on each visit to the clinic.

Once again, I'm not saying that choice is a bad thing. It is fantastic that we can do so many things nowadays that were unthinkable even when I was a child. But, with everything, there is a tradeoff. And, fundamentally, humans have evolved as social beings. We require one another and have relied on each other throughout our societal growth over the last few thousand years. Only in the last century or so has it become so easy and natural to remain isolated in our own lives. I believe that this isolation, this lack of interaction, love, friendship, and romance ultimately is detrimental to our health and the health of society as a whole.

After the last few months, I've been lucky to connect and reconnect with so many important facets of my life. The decades can go by and you can go for a long time without coming up for air, coming up to see the people that really touch your life, both personally and professionally. For this moment in time, I have a few wonderful, inspiring, healing friends and family that have touched me, grounded me and energized me in ways that are indescribable. This has made me think, just think so much about the importance of our connections in our lives and how easy it is to lose those connections, to withdraw into a solitary life. For the rare person, solitude is gratifying and comforting. But for most of us, we simply need others. Just need those simple conversations, those hugs, those kisses, those laughs in order to get the most of our brief lives.

Physician, heal thyself, Hippocrates once wrote. It's easier when you have the right people in your corner.

For more information, check out:

http://www.laughteryoga.org
http://www.nationalhuggingday.com
http://www.drweil.com/u/Home/index.html
http://www7.nationalgeographic.com/ngm/0602/feature2/index.html
http://www.theatlantic.com/doc/prem/200603/online-love
http://okinawaprogram.com/
http://www7.nationalgeographic.com/ngm/0511/feature1/

Looking Back On My Medical Training

2006-06-06T16:05:00.000-04:00

So, some recent comments by readers on my last blog got me thinking about what has changed in me personally, good and bad, over the past 12 years or so since I started medical school. Questions like "Did you get hardened?" or "Did you get jaded?" are both easy and very difficult to answer. It is like looking at the soldier who comes back from a war like Iraq or Vietnam. Has he or she become hardened or more worldly or more realistic or more cynical or just older and wiser? All of these words are charged in their own ways. There impact on us has as much to do with our own perceptions and personal feelings as it does with the people we observe and try to understand.

Medical school, like marriage or buying a car, is somewhat of a leap of faith. You spend a lot of time preparing and testing just to have the chance to embark on a career as a physician. As you study and sacrifice various things along the way, certain mindsets start to predominate. For the most part, physicians are a relatively high-achieving, hardworking, self-disciplined lot. This can make for tremendously dedicated people, but can also make for somewhat entitled and self-important people. Like any group of "successful", high prestige occupations, it is often populated by people who have confidence and sometimes overconfidence in their beliefs and/or abilities.

As we hit medical school, filled with heroic TV exploits of shows like "ER" and buoyed by the hopes and dreams of friends and families, it is all but impossible not to get swept up in the drama, the self-importance, the idealism and the beauty of medicine. Getting your first white coat, often in a formal ceremony, is a moment of pride and fear and hope and triumph as we embark for the first time on this very noble calling. However, like soldiers who just finish basic training and land for the first time in the "shit", new med students show up on the chaos/battlefield of the hospital wards as complete newbies, unprepared for the clash of reality with their idealism.

Gone are the textbook cases and neat summaries that you learn on in the first couple years. There are conditions that border on the absurd, the foul smells, the gaps in our system, the indigent patients that sometimes seem so alien culturally, the complete lack of glory at times in the mundane things you do to keep a hospital afloat. There is hierarchy, endless hierarchy. Sleepless nights and strange orders. All of this combines to change the initial viewpoint. Is this good? Bad? I don't know. It simply is.

Sir William Osler, a oft-quoted and well-respected physician, once said (and I paraphrase), "To take care of patients and never read is like sailing the ocean without a compass, but to read alone and study but never care for people is as if you never set out to sea in the first place." I believe this to be true. As in almost any endeavor, like the Iraq war, or Medicare reform, or affirmative action or the budget deficit, there is a stark difference between theory and reality, between the dreams of politicians and analysts and pundits and the truth on the ground or in the average home or in the peoples' hearts.

In medicine, it is simply not possible to practice without really immersing yourself in the day to day care of people, in their imperfect diseases and suffering and emotions. For many young doctors, this is an embittering, brutal, exhausting process, one that leaves you "toxic" and spent, anxious only to leave the hospital. Often, personal lives are damaged, personalities can change and there is a marked transformation until one day, you no longer think of yourself as a student at all. You are finally the physician, decisive, seasoned and experienced.

However, as training finishes, you can go one of a couple ways. Some, unable to recover from their experiences, can calcify their frustrations and become crusty, judgmental and prideful. Others, anxious to forget their experiences, can leave clinical medicine, preferring research or industry or business or whatever. But, some, hopefully many, can reflect on their experiences, can look on the moments of hardness, the tears, the complexity of the system, the absurdity of medicine sometimes and can come out the other end a more whole person. Still in touch with the idealism that once started the whole shebang, but tempered by the practicalities of care for real everyday people.

Much of who a physician ends up being depends on their own background, their own expectations and their own hopes for the future. Like a friend has told me over and over again, "if we want the world around us to change or our relationships to change, we must start with ourselves." That is certainly true for doctors and other health care professionals. It is very easy to gripe about this and that. I have done it numerous times in this blog and will do so in the future. But, like any good citizen of this country or any member of a family, we've always got to look inward to see how we can become better, more effective, more humble, more helpful.

So, in the last decade or so, have I become more jaded? Yes, at times. At times more cynical. Perhaps smarter, certainly I've been humbled by both my patients, my colleagues and just time itself. But, I'm still hopeful. Very hopeful. Not in a Pollyannish way that everything will just work out on its own, but rather in a practical, determined way that involves my working every day to create the environment around me that lives up to my ideals in medicine. And being a doctor is one of the biggest privileges in the world. There is no other job where you can meet so many different people whom you would otherwise never meet in your life.

Talk to me in another 10 years. We'll see how I feel then. :) CancerDoc

P.S. If you ever want to read a humorous and only slightly dated book on the life of medical residents and the "changes" that occur in the first year of internship, read Samuel Shem's "House of God"... very hilarious, very accurate in terms of emotions and even the way we sometimes talk in the hospital and very poignant.

Memorial Day

2006-05-28T20:02:00.000-04:00

As I sit here, PBS starting its National Memorial Day concert to honor the long history of "American heroes", I have to wonder about the near total disconnect between the individuals who are currently fighting our conflicts around the globe in the US military and the vast majority of the populace who have no engagement at all in the trials and tribulations of the average American soldier.

Granted, as a physician in the Mid-Atlantic, I am not exactly engaged in the conflict in Iraq or Afghanistan. I know no friends who are soldiers. I have no patients who are active duty serviceman. Perhaps a few veterans of WWII, Korea or Vietnam, but no one from the first Gulf War and certainly not the "War on Terror".

How do I see this day, this memorial day? In times past, when many in this country knew a neighbor or friend or had a relative or loved one in the military, this day must have had tremendous impact. It was a tangible, real, painful reminder of loss and sacrifice for communities near and far throughout this country. Now, as our military has become all-volunteer and totally professional and careerist, soldiers come predominantly from lower and middle income ethnic and white families. Very few upper middle class or upper class families would dream of sending a child even to West Point or Annapolis to start a career. That just doesn't seem like the right, safe or appropriate thing to do.

Hence, as thousands of people have been injured and devastated in this recent conflict, most Americans are consumed with their daily lives, feel no connection or loss from the conflict and simply view Memorial Day as another day to barbecue and relax.

I don't propose we should all act somber and contrite or that we should fly American flags everywhere or leave no tree unribboned. No, that doesn't express anything. Rather, I wonder if "Memorial Day", while aptly named as a day to commemorate the dead from past wars and conflicts, really should be more of a "Peace Day", a day where we use the pain of war, the devastation of humanity destroying itself, to think, ruminate, dream of alternatives to this most basic of human interactions. A day where we honor the dead in the best way I can think of: we find a way so other people in the future will not have to die in the same manner or for the same reasons as they did. I think that would be the best possible memorial any of us could ever think or dream of.

Okay, I Think I Get It

2006-05-25T11:11:00.000-04:00

Okay, so a few posts ago, I wrote about denial of our own mortality, about the confusion that I've observed as people confront illness and death. A lot of easy words from someone in a privileged, protected position. Well, I think I get it finally and I retract any odious, arrogant, pseudo-lofty statements I've made in this blog.

This past week, my best friend, the one who got married (see last blog), had one of the biggest scares of his and my lives. For a period of months, he was having this muscle twitching and slight muscle loss in this limbs and torso. For a variety of reasons that are unimportant to detail, he had relatively good evidence that he was developing Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig's disease, its more common eponym.

People don't usually know too much about ALS except that it is a terrible, fatal, progressive neurodegenerative disease. It is currently untreatable and like many neurologic diseases, the slow undulating dance with decline and death is what is most heartbreaking.

Imagine, just before your wedding, before your life is about to begin in some ways, you are hit with devastating news. This was the first time I have witnessed someone truly close to me experience a real shock in life, the kind I've talked about many times in this blog as an observer. This is someone I've known for years, we've been through a lot, I have a sense for the rhythms of his emotions and the unsaid things that pass over his face when he is worried about something.

I saw the unpreparedness, the shock, the confusion, the uncertainty up close and personal. I FELT it. We lived it. Honeymoon cancelled, immediate flight home to see a specialist, family heartbreak, never before heard discussions about death and anger and loss and children.

Well, thankfully, the testing was okay and it looks like he has some strange benign twitching disorder and the muscle loss might be congenital. It's not ALS, that's all we know. Breathe... colors start to be seen again, we feel hungry, life emerges.

I apologize to all my patients who I may have misunderstood over the years. I know now why we are unprepared for our own mortality. We just are. We may ruminate over it, witness it in others, try to heal it or cure it, but until we ourselves live with sickness and death, we simply cannot know. There is no preparation to be had. There just is and then there isn't and we all will face our lives and deaths in our own unique, human, individual ways.

My Best Friend's Wedding

2006-05-24T10:41:00.000-04:00

My best friend got married this past weekend. A sumptuous, vibrant, kaleidoscopically beautiful affair that combined his South Indian with her Vietnamese Catholic heritage amidst the backdrop of the bright blue sky of the Museum of Latin American Art. Only in Los Angeles is such a thing possible. Well, maybe not only in LA, but that is our hometown, the place where whole communities have signs only in their native languages, where cultures and traditions from all over the planet are smashed together. It is the modern Ellis Island of this country and the results, despite what you might hear about in the news on immigration or see on episodes of the "OC" are usually wonderful, challenging and speak to a bright future for all of us.

As I thought about my friend and his wife-to-be this past week, I had a chance to reflect on our friendship of nearly 12 years and on the true beauty of marriage. As has been so much the case in the past decade, I have received so much more from my best friend than I have perhaps given. Never mind the parties, the laughs, the trips, the conversations, the "events" that occur between ourselves and the myriad people who come and go in the course of a full life.

What is it that makes a person "stick" in our minds and in our hearts? What sets a person apart from all the countless wonderful, beautiful, interesting, sexy, dynamic people we meet in our lives? There are people we've known for a long time who always remain at a distance in our hearts. Likewise, there are people we meet for a very short moment who speak to us for the rest of our lives.

I believe that our closest friends, our cherished loves of our lives, our inspirations show us something special in OURSELVES, they bring out an openness and wonder and childlike love that is difficult to capture with each advancing year. Through our touchstones, we inch just a fraction closer to the people we truly wish to be in life. They bring out that intangible, vanishingly rare feeling in ourselves that is so difficult to describe yet so recognizable and so wonderful.

In the Catholic ceremony, the priest talked about "symbols", about how the ceremony itself is just an event, a movement of people and words. Yet, what makes it so special are the people involved and their FEELINGS toward one another. "What makes a gift a gift?", he asked. "Why is it not just an object?" It is because of the feelings between the giver and the recipient that make it a symbol of a gift. The same is true in marriage. No certificate or validation or holy words can replace the genuine, sincere feelings of love and respect between two people, yet when the movement is combined with the feeling, it is an awesome thing to behold. As I watched Arun and Cindy say their marriage vows, I felt the power of this symbol, this recognition of love and faith among friends and under God. It was both humbling and beautiful.

My parents always told me that I would be lucky to find one true friend in my whole life, someone who spanned not just the years of our lives, but also the emotional and physical vicissitudes of life itself. Someone from whom I could learn something and find my true nature. Arun, you have been and always will be that person for me. I love you and no words will ever describe my true joy at our friendship and at watching you find someone who truly matches you, who brings out the very best in you.

Congratulations to Arun and Cindy. I love you both.

P.S. Now that you're married, I ain't picking you up from the airport anymore...

The Year of Magical Thinking

2006-05-14T16:00:00.000-04:00

I just finished Joan Didion's most recent book, "The Year of Magical Thinking", an autobiographical account of her grief and near pseudodementia following her husband's death after nearly forty years of marriage. Similar to, yet following a more modern, literary and less spiritual approach than C.S. Lewis' account of his wife Joy Gresham's death, Didion vividly portrays the multitude of thoughts and feelings that sometimes follow the death of a loved one.

Life changes in an instant. One day you're sitting at the kitchen table and the next... One of the key themes in her book. Somehow, this is both simultaneously prosaic and profound. I don't know how we've become conditioned in our contemporary lives to feel that change must be so unexpected or dramatic, that it must be "processed", planned, emoted over and memorialized. I wonder if, in the days of the nineteenth century, before much of modern medicine, when you could be stricken with polio or smallpox or die of a simple skin wound or get a bone sawed off by the "barber"... I wonder if in those days, people had less of an expectation of perfection about their lives. Life, even for the privileged was difficult. Our daily sustenance connected to the rhythms of farming and the land, transportation over natural resources of lakes, streams and rivers...

Somehow, as convenience has replaced everyday hardship, as we have so much at our fingertips, indeed, as life has "improved" by most every measure that we can imagine in our industrialized countries, an insidious mentality of expectation has naturally developed. At least in our modern American life. Not that that isn't the right thing to happen. But, I imagine that if you grow up in Sudan, or Armenia or Turkmenistan in this early 21st century, your thoughts, feelings, expectations, desires are similar to but more tempered than that of the average Westerner or even denizen of East Asia.

And so, the "Year of Magical Thinking" takes us through the different stages of grief and mourning. A year of strange thought, magical thoughts that stand in contrast to facts, juxtaposed against an admittedly lucky, charmed life. Beliefs that the person who died is still there, the "vortex" chain of memories that get triggered whenever something familiar to the both of you is seen by the surviving member, the tears, the forgetfulness, the daydreaming, the nightmares, the freedom, and the fear. And the guilt. Guilt over past failures. Guilt over moving on. Guilt over forgetting.

What is it to remember a life lost? To look back on decades of combined memories? We grieve for the dying, we remember them. Yet, in many ways, it is the survivor who suffers the most. In that rare thing that we call a "happy marriage", especially one that spans decades, that is full of vibrant, challenging, heartfelt memories... how can a surviving spouse "move on"? Obviously, they can, but as Buddha described over two millennia ago, our suffering is tied directly to our attachment to things and people. The price of loving, coveting, desiring, cherishing is the feeling of loss when things, persons, possessions, even thoughts and emotions are gone. In a way, Joan Didion has articulated this age-old observation through the prism of her own feeling and loss.

I loved this book, but not just in the knee-jerk way you love a National Book Award winner or that you love a tearjerker or a pop culture no-brainer. No, the book is sensitive and poignant, but hardly cliché. There is the predictable vulnerability but only rare self-pity. My one major issue is that her perspective on death is coming from that of a wealthy, famous Caucasian, raised-Christian author who calls upon the elite in life as a form of personal therapy and catharsis. We can all write diaries about our losses. How many of us can publish bestsellers? How many can take solace in friendship with David Halberstam or simultaneously reminisce about trips to Indonesia, Bogotá, Greece and Malibu? How many people can get elite medical care at Cornell, Columbia, UCLA... can call upon experts in the medical field at anytime? This is a unique and uncommon perspective.

As in most history and literature, we often see things only through the eyes of the educated, the literary, the wealthy or the privileged. In effect, the poor, disenfranchised, uneducated, and downtrodden either cannot, do not or will not express themselves in words. In fact, much of our knowledge about such masses even in recent literature or history comes only from the perspective of brief visitors to such populations.

But, that caveat and criticism aside, the "Year of Magical Thinking" is an amazing book. One that I think will strike people of all ages and all backgrounds. A book that must be read and reread as we pass through our own journeys in life. That speaks to loss and feeling and emotion in all of our lives. That speaks to the wisdom and humility that comes with age and experience. And hope, hope that we must all have as we continue to live as others die. The hope that simply must be if there is to be any point of continuing on our individual, finite, absurd, wonderful, painful journeys through life, love and eventually sickness and death. We mourn for Ms. Didion's loss because we mourn for our own. Because, even though we act as external and dispassionate observer to her own pain, we know deep down that the same tragedy, devastation and hopefully perserverance and awareness will befall all of us in due time, but that that is what makes our existence so amazing, universal and so human.

I'm The One Who's Deaf And Blind

2006-05-12T14:14:00.000-04:00

I just saw the most amazing patient yesterday as a consult. She was referred by her neurologist for some abnormalities in her hematology labs. So, as I'm sitting there, leafing through the faxes and pages, a "whoosh" sounds out above my right ear, that sound of another patient chart slipping in the slot. Hmmm, it's Ms. G... I'll go out and get her...

So, on these consults, I've generally reviewed all the info and in something like Hematology, you almost don't need to talk with the patients that much... it's so based on objective data like labs or the blood smear under the microscope... In her case, I have the main lab abnormality, and all the "objective" data, but no notes from the referring doctors. Just a blind case, I guess.

So, as I walk out to see her, I quickly scan the room as I've done thousands of times, calling out her name. As my eyes fixate on an attractive, middle-aged woman in the left corner of the room, I hear out of the corner of the right side, "it's us". My gaze sweeps over towards the sound, settling on two white-haired, slightly pudgy women. One, short-haired, bespectacled, holding the hands of the other one as she quickly enfolds fingers, hands, face in movements, gestures and sensations. The bland white cane at the second person's feet is the sure tip off of what is becoming slowly obvious to me: the patient is both deaf AND blind.

My mind sort of has one of those brain, freak-out moments... one of those the doctor has endlessly almost daily that is totally imperceptible to anyone other than a close friend, spouse or other similarly feeling physician. That feeling of "shit, there goes the afternoon" or "this is gonna be challenging" or "this just put me an hour behind schedule." I imagine many physicians have nothing but positive feelings when confronted with challenges... I seem to meet, greet and hang out with the whiny ones. Maybe it's just me.

So, resorting to that annoying behavior that people do when they are either 1) confused, 2) with an old person or 3) with a sick person or 4) with someone they don't know how to interact with, I start to talk REALLY LOUDLY, as if I alone possess the voice that will cure both two of the major senses of the body. As I am not a figure in the Bible, this has no effect except to make me seem ridiculous and amateurish to the interpreter for the patient. "I'M DR. SO AND SO! NICE TO MEET YOU!" A minute or so of signing, translating and touching hands before a response makes my stomach sink and my schedule seem hopelessly behind.

I walk her back to the room, assuming that someone with this disability must be slow or inept or... something. I assume that her minor hematologic problem is really just a harbinger of some disaster, something that her disabilities will make impossible to treat, something that will tie me to her in a frustrating, disastrous slow dance with sickness and maybe death.

"Hi, I'm Mrs. So and So, I'm here because of the protein level in my body, the numbness in my fingers and the fact I've been reading about Raynaud's phenomenon. I think I have that, but this neurologist wanted me to see you, Doctor." "Oh, and the interpreter says you're cute, in a youngish way..."

Yep. That's what emerged out of this modern day Oracle of Delphi. No signing. No touching. Just a blind person LOOKING me dead in the face (after touching my arm to find which direction I'm at) and speaking CLEARLY to me. My voice ratchets down an octave in simple respect and we proceed to have one of the most enjoyable hour-long consults I've ever had in my brief (and apparently amateur) existence.

Man, what assumptions we (I) make based on looks, initial impressions, stereotypes!? I've been appropriately prepped to be cognizant of racial and ethnic appropriateness, of class distinctions, certain gender and even age discrimination. But, "disability"...?

When I hear "Down syndrome" or "blind" or "deaf" or "amputation", I make tremendous assumptions. I suppose they are solely my own, but I suspect other medical practitioners make a whole host of negative assumptions about intelligence, quality of life, way of being.

This woman was one of the most articulate women I've met as a patient. She teaches COMPUTER CLASSES to the blind. She has advanced degrees. Three kids, married, has traveled quite a bit, and even FLIRTS a little bit... and best of all, she radiated that unmistakable and utterly unpretentious feeling of hope and positivity and wonder at the world that sometimes only people who have faced real challenges in life can express. Time truly is the best teacher... not just of knowledge, but also of humility, of respect, of patience.

I can't say I won't make absurd assumptions and buy into stereotypes in the future. I suppose I'm only human. But, this one was a doozy. She and I had a laugh about the whole thing, as I confessed my ignorance and ultimately agreed with her own self-diagnosis. She confessed to me that she was also a bit surprised at me... she said she thought I'd "look" older... Touché...

Health Outcomes

2006-05-11T15:31:00.000-04:00

Okay, so I'm never mentioning either Latvia or Finland in another blog... their respective lobbying organizations have spoken. Seriously, here is some info to back up my assertions about our health care and the dollars we spend versus how other countries do.

Here is an old paper from the journal, Health Affairs You can download the PDF by clicking on 'reprint'.

Here is a comparison in JAMA of the US and UK. You might have to sign up for JAMA to get the PDF reprint. JAMA article

The thinktank RAND corporation put out its first 'report card' on health outcomes in the US. Some important points: 1. quality varies dramatically by region (not standardized) 2. almost half of the people don't get their recommended routine screening or preventive care, resulting in more expensive acute care. Check it out.

Please keep your comments coming. Debate each other, write your congressman. Whatever your belief, it doesn't matter. Despite my own personal leanings, this blog is about ideas and communication. Not just one way from me, but about creating dialogue. That's what we need. We need to keep discussing with each other, with our politicians, with our families, with our employers... our society, in my opinion, sort of anesthetizes itself with mindless entertainment. Our media is complicit in bringing 24 hour coverage of Who-Murdered-Who, the endless life and times of Brad and Jen and Angelina and the ever fascinating American Idol. It keeps us all revved up and stimulated like a drug, distracts us from unsavory things like the Iraq War or our aging population or immigration reform.

We cede control of the debate on abortion and the death penalty and any number of other issues to the crazies on both the left and the right because in some ways, they are a form of bloodsport entertainment for us as well. So, I'll agree to stop dissing Latvia or painting the lowly lighted Finland as a vacation destination if we all agree to write our Congressmen and Senators from time to time... Cancerdoc

At Least My Kids Won't Be Born In Latvia

2006-05-09T18:08:00.000-04:00

A CNN article about infant mortality rates in modern industrialized countries sheds yet more light on the disparity between the amount of specialist care and true hard statistics on health outcomes like neonatal mortality. We're basically in the toilet in this issue, above only, get this, LATVIA?!?

Holy Cow! You've got to be joking. Latvia? What the hell is in Latvia? You mean other former Soviet satellites beat us in infant health outcomes. How is this possible? With all of our specialized care, with the amount we spend per person of our GDP on health care?

Once again, it's about priorities. It's about where the dollars get allocated. Even factoring the racial disparities and the heterogeneity of our population and the administrative and legal costs of our system, it is STILL preposterous that we have one of the worst health care systems in the industrialized world. Things like prenatal care and "family planning" are, next to vaccinations and mammograms, prototypes of preventive health initiatives. Things that aren't sexy or particularly intellectual or even that interesting. But, that matter. No one is that excited about pushing your prenatal vitamins or making your glucose checks during pregnancy or getting good counseling or understanding the home environment of the mother. Yet, it is clear what helps lower both maternal and infant morbidity and mortality.

What are the barriers if money clearly isn't the limiting factor? It's education. It's the politics of health in the US, with the blurring of science and religion. It's the lack of standardization of health measurements. It's the decentralization of care and the corporatization of care. If anything, it is the financial incentives that promote super-supersubspecialized care and not routine things like midwifery.

I was just talking with my parents last night. They just turned 65 and are trying to navigate this whole Medicare Part D. It's crazy. My parents are intelligent, sophisticated, financially secure people and they're just confused by the whole thing. There is just so much complexity in the American health care system. I'm not asking for socialized care per se. But, in line with my prior criticisms of various aspects of our medical-industrial complex, we simply need leadership, leadership at a governmental level. Yes, let's keep the high end stuff. Yes let's have botox and boob jobs and baboon transplants and stem cells for hair growth if we want it, but we need some baseline structure of care for ALL people.

Unfortunately, I'm becoming more and more skeptical about whether we'll ever get there. As I sat in clinic today, in the semiprivate offices of our university, out in the richer part of this city, I still marveled at how woefully inefficient the movement of patients, tests, labs, exams were. Why is this place so much less efficient that even the most basic private practice? It's all about incentives. We all work by some form of incentive. Money, success, glory, fame, comfort, ease, whatever.

How do we design a system where there are incentives to innovate and work hard, yet also to provide standards of ethical and available quality care? I think that is the essential question for our government and our society. How do we create the checks and balances, a la our Constitution, that allow for a give-and-take between capitalistic and socialistic motives? If we ever figure just some of the basic tenets to what we all can agree on in a system, then I think we'll be on our way to somewhere. Otherwise, I'm going to Finland...

Mr. V.

2006-05-07T17:34:00.000-04:00

One of my longtime patients, Mr. V. has surgery tomorrow. A soft spoken Puerto Rican man in his late 50s, he has had the proverbial 'nine lives'. Diagnosed with a rare form of sarcoma almost a decade ago, he has had to date four surgeries, radiation twice, chemotherapy three times, outlasted an oncologist or two, and generally trained a whole host of nurses, technicians and doctors on himself by virtue of his disease and, more importantly, his wonderfully insightful personality.

His surgery tomorrow is going to be brutal. For the last couple months, just a year or so from his last round of bone marrow destroying therapy, he started to feel some abdominal discomfort. A CT scan showed some small masses around both his left kidney and his stomach. Having not tolerated his last set of therapy so well, knowing the likelihood of recurrence, somehow having faith in a Creator, his family, his heritage and his slightly overwhelmed oncologist (me), he sat tight. He was feeling great and honestly, there weren't that many options out there. His surgeon wasn't excited about operating again, given the month long recovery required from the last hatchet job.

So, we wait. And wait. I get an email here or there. I'm in Puerto Rico. Now I'm in Florida. Here's a photo of my family. The surgeon and I both pretend it's all kosher. We just sort of do that thing doctors do sometimes, pretend everything is okay, smile and just pray that, despite your disease, the fact that you look so good will buy some "quality of life". So what happens?

Of course, it looks like he's progressing. Weight loss, fatigue, depression. The good times have stopped rolling. The masses are bigger. He's losing blood. Has a blood clot in the leg. Something is bleeding. He's vomiting. His wife looks more haggard than he does, shuffling all over the state trying to take care of him.

So, as I sit by his bedside, I can only imagine what is going through his mind. I can't imagine my face looked too happy. Usually, it's a bit of pep here or there, a joke, some comment on the family, whatever. This time, I'm at a loss. When you see someone continuously for three years, they become more than your patient. Not really a friend or family but something very distinct. Not the impersonal feeling of a brand new patient, but something akin to a comrade in arms. A fellow soldier. Someone you've humped through the bush, the desert, the bullshit for a couple years and now he's hit the goddamn landmine. Most of the time you just have talked shop, but that and the emotions involved are enough to bond you forever. Call it doctor-patient relationship. Whatever you want to call it. It's brutal.

"Why the sad look, Doc?" "You know, I imagine how hard it must be for you doctors to have to talk to sick people all day, one after the next... to try to give hope and comfort to strangers all day, every day. Thank you for taking care of me. My wife thanks you, too." Man, you don't hear that from patients that often... just hits the nail on the head, hits you in such a way that the air is just sucked from your lungs and the tears start to well up.

At that moment, I had to wonder who was the doctor and who was the patient. He'd been sick so long, he'd long since come to grips with his death. He'd found peace with his God and his family and his disease. I was the one who wasn't ready to face my own impotence, my own failings.

I have a terrible feeling deep down about this surgery. It is undoubtedly going to be a lot of tumor. It probably won't be fully resectable. I don't have many options for him for chemotherapy. We've talked in the past about hospice. We've talked about death... he has told me that he is at peace with this. But, as I hit this brick wall of therapuetic ineptitude, I try to think over and over again about the truth, the veracity of Mr. V's words, "Doctor, I know you've tried your best." No, Mr. V., you've tried YOUR best.

Mr. V., I pray your surgery goes well tomorrow. Godspeed. You've always said you loved to being a professor back in the day. That you liked to see the eyes of your students when they finally got it. You've certainly taught me a whole helluva lot about life. I think I might be getting it. Thank you.

Big Brother is Watching and Making a Profit

2006-05-04T10:36:00.000-04:00

Read this NY Times article to understand yet another pharmaceutical practice that is well known throughout medicine but little known amongst the public. There is precise monitoring and data mining of all prescription practices of physicians. Pharmacies keep records obviously of prescriptions given out by doctors. Companies devote resources to mining this data, compiling it and then selling it to drug companies that then use it to pressure individual physicians to push the various Lipitors, Procrits and Levitras of the world. That way, Pharma doesn't have to devote its resources to docs that already push their pet drugs in good amounts. Rather, they can strong arm other less compliant physicians.

Sounds crazy? I've learned over time that if money is on the line, there will always be more creative ways to push products. I saw once on the PBS show, Frontline, that marketing companies, in order to promote teen-oriented products to little girls, generate 'buzz' by identifying 'alpha' females, the dominant girls within a peer group, and get them to adopt and promote certain products which then disseminate through the rest of a peer group, school or environment, etc. I know, it's insane, but it makes money. Didn't we once think that infomercials were insane just a decade ago or so? Now they're everywhere.

So, not only do companies do manipulative things to coerce both patient and physician to prescribe their drugs, they basically act as Big Brother on all of our consumption habits. The biggest problem is that our own AMA (American Medical Association) colludes with these companies to prevent legislation from Congress against this practice. It just makes me ashamed sometimes to know that our own lobbying organizations, whether for oncology alone or all of medicine, just act like typical money-grabbing, power-protecting, corrupted political machines like Big Tobacco or the oil companies. With so many dollars involved, everyone is just trying to protect their income. It sucks and it drives costs up and makes care awful. Pharma promotes their much more expensive new drugs (with protected patents) over often equally effective generic alternatives.

If you care about this issue, write your Congressman. Believe me, this is exactly the kind of thing that drives the cost of care up and erodes any doctor-patient trust.

Why Do We Deny Our Own Mortality?

2006-04-27T23:07:00.000-04:00

As I sit here on one of my few remaining (hopefully) "moonlighting" shifts before I depart into private practice, I find myself wondering why it is the human condition to live in a state of subtle denial of our own impending deaths. Finishing my fourth "hit" for the night, two brand new leukemia patients, a patient with awful pancreatitis secondary to his chemotherapy treatments, and another of my patients admitted for a recurrence of his sarcoma, I am struck by the shock of illness, to the patients, but also to the nurses, doctors and staff. Old or young (particularly young) patients who are sick just surprise us, horrify us, give us pause at the sad shocking nature of a life cut short, out of the blue, incidentally, "not like they did anything to DESERVE it", as we often say. As if anyone 'deserves' pain, illness or suffering of any sort.

Are there any societies that confront death in a 'better' way? I don't know. I am not a religious person. An afterlife or eternal bliss does not comfort me. Neither am I living in fear of damnation. I don't particularly dwell on my mortality. Yet I sometimes wonder if I'll face it with grace and strength or fear and desolation. I hope for the former, dread the latter. The mere fact that we in the medical profession are often so shocked and pleased when a patient and/or his or her family has thought deeply about their illness and possible death, made plans, advanced directives... made peace. It is rare, even in a field like oncology.

I hear that the inevitabilities of life and death are met with more equanimity in Europe or Canada or in Third World countries. I wonder though. Yes, there is something to the native, sunny, Pollyannaish optimism of the American people, the desire to be young, fit and strong forever that is powerful and inspiring, yet somewhat scary and disappointing.

I've touched on this before in prior blogs, but I wish we as a society were more open about sickness and death. That we realize that there is something to cherish and celebrate in this phase of life as well as fear and loath. That no matter how many push-ups we do or pounds we lose or Botox shots we get, someday we'll face our lives. Why not face it in an affirmative way? As a choice and an active decision if possible?

Maybe I'm just saying all of this to convince myself. I have no desire to become ill now, in the "prime" of my life, whatever that means. In truth, I'm every bit the hypochondriac as the next person. A little knowledge in my case about medicine is all the more dangerous. But, as I see more and more patients, friends, colleagues get sick, as I start to enter a different phase of life, I start to observe that a little thought, comfort and equanimity about our mortality can go a long way. At least I hope and pray that's the case.

Elephant Number Five

2006-04-25T12:48:00.000-04:00

My friend, Michelle, died nearly a month ago from Hodgkin's disease. It's funny. Sometimes, you know someone for a lifetime and never feel that close. Other times, you meet for a few moments and the bond seems forever. She fits into the latter category.

I met her at one of my closest friend's wedding. She, a longtime friend of the bride, was the bridesmaid paired up with me, one of the groomsman. "Hi, I'm Michelle, sorry I'm late." I turned around to see this pretty Asian woman smiling at me somewhat sheepishly. Her full head of hair, rosy cheeks and energy seemed in sharp contrast to my expectations. "Hey, we're gonna change the pairings of the bridesmaids", my buddy had told me two days before the ceremony, before most of the people had arrived. "Er, well, you see..." Never having been to one of these things before in this capacity, I of course retreated to my inner brat... "Don't tell me, she's not pretty... or, she thinks I'm ugly... or stupid... or..." "Don't be an idiot, she's got cancer and we figured that you'd be mature enough to deal with her." I felt like an idiot.

So, the festivities began. The other bridesmaids and groomsmen started pouring in. Family, smiles abounding, a compendium of upwardly mobile, overly educated and somewhat snobby guestlist was shaping up rapidly. I hate functions like this. Ones where your education and profession and hence, your net worth, comes out within minutes. This is usually when the "oh, and what do you do?" question quickly deflates when I mention that "I'm an oncologist, I take care of cancer patients..." "Oh... how noble, that must be depressing, though... excuse me, I need to be over near that spinach dip.." Zoom away.

She was late a day. Stuck in New York getting a treatment for her 2nd relapse of Hodgkin's disease. I just didn't know what to expect. Bandana on head, pale, feeling self conscious, scared. I committed myself to being a gentleman and being the pillar of calm. Little did I know that I was probably the one feeling most self-conscious, as if I was some bedrock for this person I didn't even know. How pathetic and presumptious on my part. No better than the narcissistic banker at the other end of the room.

So, when I saw that smile and the hair and the healthy tan, I was taken aback, just thinking that I, the doctor, make as many assumptions as anyone else. The hundreds of thousands spent on my education and the years of study didn't make me any more wise or human than anyone else. I felt immediately at ease with her. We talked about the to-be-married couple, the sweet digs, the expense, the pompousness of the crowd, our lives, families, friends, you know, the whole shebang. And, finally, we talked a bit about the cancer.

We talked about being 26 and spending the better part of the last four years in and out of hospitals. The failed relationships, the career angst, family stress. The tears, the strength, the acceptance and release of fear. God. Charming doesn't even begin to describe the evening. Not necessarily in a romantic way, either. It was just one of those moments when the room feels silent, although there are hundreds around, and you just feel so connected to another person. Cancer or no, she became my friend instantly. You can imagine my pleasure when, as the night started to end, and she started to feel tired, she touched me gently on my forearm and told me, "I'm really glad I made it here tonight. I was just going to stay in, but you've made it so easy to be here. I'm glad they switched groomsmen. At first, I thought maybe I got the 'alternate'..." Quite a funny one, she was.

So, we spent the next couple days in the festivities. I sort of chaperoned her around, we got to know each other and in a way, it was the best pairing. I wasn't shocked by her disease. She didn't feel like she had to censor anything with me.

So, fast forward a few months, we've emailed a bit. We're both busy with life. She is preparing for a bone marrow transplant. I'm having some of my own personal crises. I wonder what has happened with her. An LO AND BEHOLD, I get an email from New York. It's her. She's going into the hospital the next day for her transplant. A risky, high morbidity procedure, but she'll certainly die without it, has about a 30% chance of dying from it. But, screw it, you gotta live your life, as she would say. I've come this far. I'm not afraid. The person in me cheered. The oncologist in me just cried.

This is where our friendship truly began. Sometimes, you or someone close to you faces a moment of struggle. And, it's funny. In those most difficult of times, sometimes it's hardest to deal with those who've known you for so long. Sometimes, a stranger or newcomer reinvigorates you, gives you a fresh sounding board, just does something different for you. If you are reading this and thinking 'that's crazy', then you've never felt this way, but if you know what I'm talking about, then you know how powerful this experience can be.

Well, Michelle was going through the fight of her life and I was having some major problems in my personal and professional life and we just totally bonded forever. There is something about a 'penpal' that is so liberating, so engulfing, so amazing. Just pouring your thoughts into the void, expecting no judgment, requiring no apologies or justifications, having no prior history. Just experiencing. We must have each written 20 or 30 emails or letters to one another over the next month. As much as you can get to know someone by thought alone, I got to know her. To see her. To feel her life.

I'm starting to get upset just writing this. I don't really have the words to say what is in my heart. I am forever honored to have known you. Losing you has truly been painful. I just want to thank you for giving me hope and inspiration to live my life with no regrets, no fear and no excuses. "Do you know that elephants mate for life? Or that they are one of the most loyal animals on Earth? Or that they grieve for their dead?" No, Elephant5, before I met you, I didn't know those goofy, random things. I didn't know a lot of things about my life. Thank you, Michelle. Love, -P

More FDA Info and Other Things

2006-04-25T09:08:00.000-04:00

Some more articles about the FDA. A recent report by the GAO on the FDA offers a scathing report on the impotence at the agency in terms of enforcement of postmarketing trials by drug companies (CNN article).

Here is the actual GAO report.

Just to give other perspectives, albeit slightly older, look at this Forbes magazine article on FDA conflicts of interest (Forbes article).

Check out this website by Public Citizen, www.worstpills.org. Some interesting info. I don't always agree with their perspectives, but in terms of medications and health issues, I'm always for more regulation than less. It takes years to understand the long term health consequences of many drugs and with a lack of postmarketing enforced studies to determine safety, we end up discovering the Vioxxs of the world the hard way.

A USA today article on the whole Plan B disaster (USA Today).

Anyway, just another sampling of some of the recent press on the FDA. There are a few critical things that I think are key to all of our health:

1. We need some type of universal health care. No one should be impoverished by medical bills.
2. That being said, we ALL need to take some responsibility for our health, either via some type of financial or other incentive to stay fit, exercise, lose weight and stop smoking. We can't mistreat our bodies our whole lives and then expect someone else to pay for the whole thing when the shit hits the fan.
3. Again, that being said, our government needs to devise incentives to promote such preventive measures (e.g. tax breaks for making health targets or screening tests, financially support/reimburse preventive care, not just expensive high tech care that treats final symptoms/disasters like angioplasties and bypass operations and big cancer chemo)
4. We need a strong FDA!!! An independent and nonpoliticized body that is properly empowered to actually PROTECT us. That has the resources and the teeth to go after pharmaceuticals and the tobacco industry. That has the resources to do Phase IV trials and safety. That is independent of financial incentives. That doesn't just serve as a breeding ground for industry and biotech.

We spend more of our GDP on health care than any other country in the world and get such crappy results. Americans think we have the best health in the world. That's a bit of a farce. Somehow, we've either come to hate our system (if we're uninsured or impoverished) or think it's the cat's meow (if we have tons of insurance and want the latest gizmo). As a culture, we think nothing of blowing thousands on facelifts and Botox and skin peels, but bitch and moan when we have to lose 10 pounds or stop smoking.

Life is about incentives and inducements. Right now, we have a system that rewards doctors, companies and patients by focusing on expensive pills and devices, rather than time-tested lifestyle changes. Losing weight, eating an apple and walking up the stairs doesn't put money in anyone's coffers, not politicians, greedy docs or Pharma execs. It isn't sexy or easy to consumers/patients. But, such things work, despite their lack of a constituency. When I reach old age, I want the world to look at Americans much in the same way as my immigrant parents and grandparents used to: a hard-working, no-nonsense, honest, up-by-the-bootstraps, no excuses kind of people. Leaders of the world in both action and ideals. Automobiles, porn and McMansions aside, improved health would be one helluva place to start up again.

FDA and Marijuana

2006-04-23T08:32:00.000-04:00

Yet more evidence that the FDA is completely overrun by politics, not sound science or public interest. In a direct contradiction to an Institute of Medicine report on the potential health usages of medical marijuana, the FDA issued a statement (CNN article) coming out against any sound use of the drug. This not only stands in contrast to scientific analyses, but against the common sense experience of many patients and physcians alike. That marijuana has roles as an anti-nausea drug for cancer or AIDS patients, there can be no debate. It is just a shame that in this case, like in the Plan B contraceptive debate, there is an inability of our federal agencies to maintain an "objective" on judicious stance. Granted, we're all human beings and there is always "politics", but the FDA for years stood as a bastion of defence against the ravages of business, Pharma and medical malfeasance.

Now, they are just completely politicized by incompetent government appointees and infiltrated by corporate and pharmaceutical interests. Whether it's in the regulation of so-called Phase IV studies (postmarketing) of drugs like Vioxx or antidepressants, debates of hot-button drugs like RU486, the sometimes too-rapid approval of fast-track, high-cost drugs for AIDS or cancer, the failed response to pacemaker or other medical device errors or now issues like medical marijuana, the FDA has increasingly shown its lack of quality as a public watchdog. In fact, IT now needs its own watchdogs, like Public Citizen. It doesn't help that the Republican administration has politicized it to the umpteenth degree or that many FDA employees use the experience there to springboard into a drug or biotech company, using the experience in regulatory issues to usher new drugs or devices through the approval process.

If there is a resounding theme in many of my blogs, it is that there needs to be more transparency in all of our systems. Strict conflict of interest regulations need to be in place. It must be absolutely transparent when our government or university or NIH leaders have financial ties to industry. We must use the Internet and the wider dissemination of knowledge to demand full disclosure of any issues of impropriety, whether financial or relating to how certain officials obtain their appointments by government cronyism. There is something wrong in our society when Congressmen like Billy Tauzin (Louisiana) go from being a Health services committee chairman to the head of the Pharmaceutical lobbying effort or when the former head of the Veterans Affairs system, Anthony Principi, turns around and gets a huge contract as a private consulting firm (LA Times Article). Or when university professors turn around and form biotech companies based on publicly financed research. Or when private doctors get kickbacks or junkets from pharmaceutical reps. Or when the Continuing Medical Education (CME) that all doctors rely on is nearly 100% reliant on drug company money. Or when drug companies ghostwrite articles for investigators. And on and on.

The public doesn't know most of this and yet, it hurts them, financially, medically and I dare say, spiritually. Society fails when our institutions corrupt so insidiously that we fail to even realize that they are corrupt. Now, I'm not saying that patients should get marijuana or that I have some key opinion in the abortion debate or that doctors or scientists or patients have some unique and therefore holy perspective that "objectivity" will allow to shine through. No. These are difficult issues and difficult debates for our society.

I just feel that discussion, debate, knowledge, whatever you want to call it... it is being squashed before rational people can understand and talk about the issues. We are being dominated by the extremes of debate in our society. Business interests are infiltrating every aspect of our public "Commons". It is a loss in the long run for all of us.

Thank You

2006-04-23T07:11:00.000-04:00

I've received more comments and emails in the last week than for most of the life span of this blog. To a one, they were so compassionate, full of life, personal and gentle. I've always felt that being a physician is a unique privilege. What other job is there where you get paid to meet people from all walks of life? Where you get to help others and learn so much about your own life and journey? Being an oncologist is just the ultimate in this. I suppose, like so many other physicians, my frustrations sometimes are a result mainly of my own feelings of impotence, my inability to heal my patients. But, as I've read through the emails, understood the stories of friends, patients and families, I am reminded yet again and again of the power of simple caring. Cure if we can, if we're lucky to be able to. But, always care and try to heal, physically and emotionally. Thank you to all the friends, patients, strangers for helping to heal me.

Damaged

2006-04-18T08:06:00.000-04:00

What do they call it? Burnout? Physician impairment? Some other type of euphemism so people won't look at you funny at parties. "Once promising physician now huddling in corner by himself, divorced, fetid alcohol breath, self-absorbed and morose". It all seemed so abstract a few years ago, when I first donned the white coat, a brand spanking new doc. Idealistic, out to help, heal, save, discover. It's still there, somewhere in the recess of my brain, but increasingly, there is a whole lot of other shit piled up on top of it.

Maybe it's the endless "end-of-life" talks. The hollow look in a person's eyes when they know it's over. After first meeting them in the office, the inspiration and hope of the first treatment, the puking, bodily excretions, anger, frustration, sexual dysfunction, emotional terror, relationship pain. Then the relapse talk. No one really tells you about the relapse talk until you have to give it. There just isn't any way to articulate powerlessness in a nice way. Then it's the slow (or sometimes rapid) wasting goodbye. Not like Alzheimers, with a sort of benign neglect, but often a combative, take-no-prisoners, I'm going out swinging kind of goodbye. Full of rage, sadness, hopefully compassion and friendship, often loneliness and isolation. And then the death. The family. Tears, funerals. Repeat. Oh, and do it in a 15 minute visit, please. Oh, 10 times a day, also.

Maybe it's the moments when you sit at a party of former college buddies and ex-girlfriends, listening to their babble about daycare and stock options and corporate partnerships and mergers and all you see is the Bethlehem Steel guy breathing out of his tracheostomy or the 21 year old student vomiting blood or your goddamn neighbor who you would have wine with in the evenings show up one day on your service with a big fucking liver tumor. It's hard to smile and nod and saunter through the wine party when you feel like Thanatos incarnate. Kind of kills the conversation sometimes. People either want to make you the specter of death and veer away or canonize you as some modern-day Mother Teresa. How can you burst anyone's bubble and talk about your own tears and rage and fear and sadness? Nobody wants their illusions broken, especially not at a wine tasting.

Maybe it's the hollowness you feel when you sit with family or your partner. You don't want to think it but yeah, sometimes their piddly complaints about their traffic tickets or relationship strife or sex life or whatever just seems so damn Mickey Mouse in comparison. "At least it's not a tumor" And least you don't have some freaking goomba in your brain. Just take the Viagra or go on online dating or do more yoga or whatever. I listen all day to dying people struggle with their very existence. Sometimes sitting in line at Rite Aid just pisses me off.

Maybe it's having a friend recently die of her Hodgkin's disease at the ripe age of 26. Chemo here, chemo there, two transplants, Stanford, Seattle, Sloan Kettering, all the wealth and education you can imagine. Doesn't matter. Death waits for no one. Being a friend sure as hell is different from wearing that white coat. Part of me wants to defend my profession, but as I listened to her talk about the "system", I realize how broken our "healing" is in this country. I hate that when I think of her death, the first thoughts are of statistics and odds and how she beat them by getting this far, instead of devastation and sadness and loss like any normal human would have.

All of it makes me want to numb myself sometimes. Just run away, get drunk, meet some strange women. I never used to understand how doctors would get "impaired". I mean, I love this job. I do. It's a calling for me. It's an honor. Being an oncologist is taking part in all the best parts of medicine and humanity. But, man, it's a beating sometimes. Emotionally, it just hurts. Good or bad, I take something from every patient... some little part is infused in my persona, my life. As I've finished my training these past few months, I realize something very subtle yet firm has happened over the past decade. I'm no longer just a person who studies medicine... I have finally become a physician, hopefully on my way to being a healer. As Hippocrates once quipped about the art of healing, "Life is short, the art long, opportunity fleeting, experiment treacherous, and judgment difficult..." This is not just a career, this is my life. This is the centerpiece of my being. I'll just have to follow it wherever it leads me.

Bali

2006-04-13T04:48:00.000-04:00

I just returned from a vacation in Bali. Yep. Bali... kind of conjures up exotic beaches, smiling natives, a palm tree here or there, scuba... oh, yeah, and then there is that whole bomb thing. I'm not sure what I expected when I first got a call from a friend of mine asking me to meet her there ten days ago. I actually had no idea what it would be like. So, like any good American tourist, I ran to my local Barnes and Noble, bought a Lonely Planet guide (no I'm not advertising for sites now) and promptly read for a day on the life, history, culture and art of this faraway Indonesian island.

So, as I meandered off the plane, face immediately flush with the tropical heat and humidity, dazed after nearly two days of transit, I gazed out at the bright blue sky, shining sun and palm trees and saw visions of Rama and Sita, Shiva, mask woodcarvings, snorkeling, sensual dancers swaying toward me in a sort of King-and-I courtly manner. Two days later, having settled into the nested, paradise-filled existence of the modern-day resort set in a Third World environment, complete with daily massage, morning meal, world-class pool and personalized canyon view, I started my search into something deeper in Balinese culture. Something beyond the tourist traps, the excursions, the well-traveled museums and shrines.

Luckily, my friend and I found a fluently English-speaking young 20-something Balinese man who worked at our resort to take us around. Spending some time with him and others, I learned of the impact of tourism, Westernization, "globalization", terrorism, modernization and other buzzwords on his homeland. Now, Bali has had many stereotypes over the centuries. Originally settled probably by an "Austronesian" migration (same one that originally resulted in Aborigines and likely Polynesians), Bali has served as a crossroads for multiple cultures. Indeed, all of Indonesia has had extensive exposure to Indian culture from traders likely in the 1st millennium A.D. Some of the islands took Indian mythology and religion and folded them into the native animist beliefs. As Islam took over the rest of Indonesia, somehow Bali retained a modified, mixed Bali-Hindu culture.

With the advent of colonial exposure, particularly Dutch from the 16th century or so on, there began yet more cultural admixture and exchange. Somehow, a culture originally described as warlike and militaristic by colonial powers morphed by the 20th century into a pleasant, peaceful, artistic and musical culture that was the embodiment of pleasure-filled tourism from the 1940s til now.

Traditional Balinese culture is quite religious. Temples and ceremonies dominate life. There are something like 20,000-30,000 temples on the island of only 3-4 million people. Oh, and each home is traditionally constructed in a set pattern, with a religious section facing the central mountains and the rest of the layout following a preset plan. At almost any point in the day, there is a ceremony going on Bali somewhere. Families are historically large, tight-knit and strong. College education is very limited and most people have enjoyed agricultural lifestyles, with the more privileged gravitating into the lucrative Western-focused tourism industry. Hence, there is Prada, Coach and a Duty Free mall in Kuta, the main tourist destination on the island and site of both beach and bomb.

So, as I sat and talked with locals as much as possible, I tried to glean a sense of the impression that modernization and introduction of Western goods, trade, lifestyle, etc. has had on Balinese culture. People seem to be having fewer kids as expense rises. Expectations of attaining and consuming a la Western people is gaining. There is rapid overdevelopment of beachfront regions with haphazard development of infrastructure. There is minimal cultivation of native industry other than tourism and an art/music culture that is tailored to exports. Most denizens of Bali make on average $500-600 dollars/month. You can eat on the street for about $1-2/day. A room at a nice resort is about $150-200/day.

As I talked to more people, I started to realize that, like everything, there are many sides to globalization. On the one hand, there is a chance that exposure to Western technology and lifestyle will elevate the quality of life on the island. More education may result from more money infused into the society, etc. However, it seemed, from my discussions with some of the people I met there, that there are growing rifts in the society. Traditional roles and structures break down. People have fewer children. There is growing income disparity between haves and have-nots. The decline in tourism after the bombs in 2002-2003 resulted in a disastrous toll on the economy, putting many out of jobs. Inflation is rampant. Overdevelopment, sprawl and pollution are becoming big issues. Not to mention the relationship with Muslim neighbors in the other islands. Some wonder if modernization and a tourist economy results in both a breakdown in "traditional values" and a permanent consignment of natives to a service/subservient role. Most of the investment and therefore profits on business ventures there come from the other islands or from abroad. Little of the wealth is redistributed amongst the population. Having only developed skills that pertain to serving a hotel, restaurant or tourist trap, the citizens may elevate their economic plight some, but not much in comparison to other countries that develop native "industries".

I guess, like in China or India or wherever else in the world, the embrace of American-style capitalism and "growth" must ultimately be tailored to fit a homegrown culture. As a citizen of the US, I benefit from the modernization of services abroad, especially with my high buying power. But, as a traveler and member of the world community, I have to wonder sometimes if globalization has potential negative impacts throughout the world. Economically, it may benefit everyone in the end. But, culturally, environmentally, socially, there are ramifications that may ultimately prove more destructive. Whether it's pollution and social upheaval in China, privatization of natural resources in India or Bolivia, oligarchy formation and mass corruption in Russia and the former Soviet countries, or civil war in Iraq, adoption of American style economic and political structures may have unforeseen effects.

Anyway, it was just a thought while I sat on a beach or two. Maybe just to assuage my guilt as I bought some woodcarvings, silver jewelry and lounged in a private villa. Maybe just a realization that my travel dollars, while benefiting me enormously in the short term, may contribute to a destruction of a society in the long term.

The Nurse's Perspective

2006-04-13T04:43:00.000-04:00

Check out this new blog (http://www.oncrn.blogspot.com), or OncRN as this person goes by. The perspective from the frontline "warriors" in medicine. Although the doc gets all the pseudo-glory in society and the financial remuneration, in reality, we all know that nurses are critical/essential/vital, whatever you want to call it, in the care/compassion/love/humanity of medicine. They are the ones in the trenches, seeing patients more constantly, up close and in a sometimes more brutally honest way. They take the first brunt of emotions oftentimes, the backlash, the disastrous crashing, the tears, the flailing that is part of every cancer death. Healing can be amazing, a total bitch, humbling, ego-boosting, a gift and sometimes a burden. Whatever it is, it's never boring.

Art Buchwald

2006-03-30T21:10:00.000-05:00

I just saw an interview on the "News Hour with Jim Lehrer" on PBS with Art Buchwald, the humorist, satirist and all-around funny guy who for years wrote amazing and observant columns on politics, society, nature and humanity. Suffering from diabetes, a prior stroke, an amputated leg and now kidney failure, he entered the Washington Hospice in DC in February and has decided to forgo dialysis in the name of dying on his own terms. The interview was about all of these things and much more.

I don't really have a particular point. Only that if anyone can ever see an interview with someone facing their own mortality, this is worth it. We in America seem to be in denial of death. We're exporting that view throughout the world. "Better living through chemistry" or extending the lifespan of humans or prolonging life appropriately or inappropriately... all of these things are acceptable and honorable dreams of modern day Americans. Plastic surgery, botox, Viagra, whatever. We want to be young forever. Fair enough. But death is a part of life and although I want a long, happy, wonderful life like anyone else, the truth is that we're all going to die.

Why not face our death as an affirmative decision, not a brutal, painful, expensive struggle? Why not choose to die on our own terms? I feel that, with modern advances and technology, we're so in tune with our "health", we fail to realize that part of our life, a big, sometimes powerful, even beautiful part of life is our own death. Really.

Anyway, if you can see the interview, great. If not, maybe just the transcript. If not that, maybe just a thought on our own lives and deaths. A transient moment where we consider how we want to live and how we want to be remembered. Maybe it's just an oncologist in me speaking. Maybe it's just my own fear. But maybe it's just a feeling that we are all united by this one common aspect of all of our lives and that if we, as humans, as people, found a way to honestly confront this fact, we'll all find a way towards our compassion, our humanity, our honesty. Maybe.

Some Interesting Readings

2006-03-25T11:18:00.000-05:00

I was looking on the Internet and I came across an article by a clinical researcher in England about conflicts of interest (Article). Check it out. It is nice to hear an opinion by someone much more senior who remains in academic medicine and has seen the full spectrum of Pharma-Academic relationships.

Another article talks about the future of academic medicine and some scenarios and challenges in the next century. It might be interesting for physicians and non-physicians alike to think about a more birdseye view of some of the challenges that we face.

Another article talks a bit about the concept of the "whistleblower" in academic institutions and how our cultural opinion needs to think of these individuals as ultimately doing a service, not just being "traitors" or "enemies". See Article.

Just a few thoughts from other sources that caught my eye. Obviously, I'm biased and these just attract me. But, food for thought...

The Personal Nature of Healing

2006-03-19T10:52:00.000-05:00

I just finished Sunday morning rounds in my hospital, seeing a variety of inpatients and consults in my academic medical center. As I wandered from room to room, talking with various family members and patients, it struck me yet again how fractured and uncoordinated our medical care system can be. With increasing pressure to shorten "length of stay" and to keep costs down, as well as regulations on resident work hours, there is isn't any time to talk or explain things to patients anymore. Large teams of fellows, residents, pharmacists, nutritionists, case managers and social workers round with and without attendings, yet it feels like the time actually spent with patients is very little. We "do" so much, yet communicate and empathize so little.

Don't get me wrong. It must all start with competence. The old mantra of "give me the surgeon who talks less but cuts straight" is important, but in the larger "quarterbacking" roles in medicine, I feel like that sense of a single person in charge of the care of a patient is declining. In our center, the "attending" physician often sees a patient very briefly during the day, filling out their billing sheets as they go back to their research. The day to day grunt operations are handled by teams of rotating residents and fellows, all of whom are running around like chickens with their heads cut off. Team numbers are mind boggling and often the primary care physician has little time to come to the hospital to engage in the day to day management of their patient, instead deferring the care to the inpatient team. Patients are frustrated, feel like they are treated like meat and satisfaction can be low. Doctors are frustrated, pummeled by competing forces of paperwork, litigation and financial pressure.

Private practice is no better. Large numbers of patients are needed in this age of declining reimbursement. Testing is defensive and often overutilized. All of this leads to a sense that no one really cares for a patient or really knows enough about a person to be their true advocate. We are so focused on supersubspecialization that there just isn't a sense of a single group of people totally committed to a person's care. So, we get duplication of effort and overtesting in the best case, negligence and malpractice in the worst case.

I don't know what the solution is in this day of so many powerful forces in healthcare. But, I think one thing that must be emphasized more than anything in medical education is the singular importance of the powerful, almost sacred relationship between doctor and patient. Like any relationship, it is trust that is the most critical, not all the bells and whistles. As we've abrogated our responsibility and trust by advertising Botox to patients and driving around in BMWs and Mercedes and fighting national health care reform and prioritizing experimentation and research in our medical schools over service and humanity... as we've embraced the capitalistic free market nature of medicine, we've created a depersonalized, cookie-cutter, overspecialized system that dehumanizes patients and demoralizes both patient and doctor alike.

In medical school, residency and fellowship, I have received many courses, lectures and personal talks about career, money, research, grant writing and success, but I've had scant attention ever paid to ethics, humanity, compassion, healing or trust. In our training, we are celebrated as "marines" or being "hardcore" or Oslerian or whatever, but not lionized for being compassionate or caring or personable. Once again, don't get me wrong. You must be smart, confident and decisive first. But, without compassion, communication and a feel for being a healer, the physician shortchanges himself, his patients and indeed all of society.

The Pharma Empire Strikes Back

2006-03-12T04:50:00.000-05:00

A NY Times article published recently sheds some light into pharmaceutical "pricing" or gouging as others might deem it. For years, industry critics have intimated that drug prices sometimes don't reflect the true cost of production of a drug. That Pharma often takes advantage of consumers and the government by 1) using NIH, publicly-funded research and then making a profit over it and 2) raising prices of drugs dependent on the market-driven nature of the "sector". Granted, Pharma is big business, so why should anyone give a hoot that it acts precisely like a big business? Shouldn't it have the right to make a whole hell of a lot of money?

Well, the answers to these questions are complicated and depend on a person's perspective. The article illuminates the arbitrary nature of health care pricing in terms of pharmaceuticals, the fastest growing part of health care cost in this country and probably the world. As medicine moves away from "invasive" procedures and relies more on pills, this issue expands in our consciousness. Medicare, part D is only the tip of the iceberg. Companies, realizing that cancer, like AIDS, and even more than heart disease, is a perfect "market" to realize their profit motives. Cancer tugs at the heartstrings. It is emotional, like HIV, and therefore demands political and social action and support. If cancer can be turned into a "chronic disease", then it will require continuous drug treatment for a good part of the life of a patient. At high cost.

Now, many of these diseases have few other treatments. Chronic myeloid leukemia, now treated with the pill, Gleevec, was in the past often started out with a bone marrow transplant. The whole paradigm of treatment has changed. However, Gleevec is increasingly looking like a temporizing medicine, not a cure. Yes, survival is probably improved, but at what cost? It is tens of thousands of dollars a year and CML only affects a few thousand people in the US yearly. Is that a really good use of resources for our government? Apparently, it is. As such, companies are able to identify effective molecular targets in cancer biology (often discovered in public labs) and design drugs to hit these targets. Since there isn't often a lot of "me too" drugs for these same targets and because there is so much patient emotion at stake, the companies have free rein to jack prices up to whatever they want.

My problem is this. Health, as I've always argued, is simply different from any other kind of business. The free market, in my opinion, isn't the best solution to forming an equitable health system. Yes, the capitalistic structure provides the incentives in the system that help us break ground in science and develop many drugs. But, the allocation of such resources is often based on market forces and NOT human needs. Smoking cessation, weight loss and water resources should have the most "bang for the buck" in terms of public health consequences and in an ideal health world, should command the majority of the focus and dollars of our government and society. But, because 1) it doesn't make a ton of money for anyone to focus on these issues and 2) it's not that sexy for scientists; there isn't a lot of emphasis. Yes, they'll spend billions researching drugs to stop your diet cravings, but we still have crap food in our middle schools and PE is getting nixed in children's educations all over the country. Pharma would rather make an expensive pill for our problems rather than encourage anyone to get on a treadmill.

But, once again, my bitching and moaning about this health stuff is rooted in the problems of our SOCIETY, not just the Pharma whipping boy. WE create the environment of easy expectation in the US that results in the situation. You can't expect a business like a drug company to NOT act profitable. It's just doing what it normally does. It's our society and our government that causes this problem and then we turn around and blame business. In Canada, where there is no private medical system and the government regulates the purchase and indications for any pharmaceuticals, the usage and cost of such treatments is much less than in the US. Moreover, the health outcomes across the board are better in Canada. Sure, people in the US will moan about how Canada is younger, more homogeneous, has a healthier population to start with, blah, blah... but the truth is that the lack of a market-driven system of health care there has taken a lot of the perverse incentives out of health care and that is a GOOD THING. There are no uninsured patients. There is less litigation against doctors. Likewise, doctors don't make millions of dollars in salaries. Pharma is forced to sell drugs there at lower cost and lower profit. Sure, there are some waits for MRIs and elective plastic surgery stuff, but that's a good thing.

Americans utilize health care in the most bizarre ways on earth. The uninsured have very little primary care and utilize emergency rooms and expensive late-stage care that ends up being passed to everyone else. The rich still get government entitlements like Medicare and are able to afford any care they want. Much of the Medicare budget is spent in the final 3-5 years of patients' lives. It's costly, illogical, and unjust.

If this seems like a steamy bitching session, it is. I've been busy on clinical services for the past month and while I haven't had time to write, I've had a lot of time to witness our system's patient care. And, it sucks. Drugs that are effective for patients that aren't covered by insurance because they're ridiculously expensive. Long waits for appointments because academic centers don't focus on efficient patient care. Loss of records between referring institutions because we lack standardized information technology between health systems that would reduce duplication of effort and minimize cost and paperwork. No rehab paid for a stroke patient because it's "not covered" in her benefits, so she stays in the hospital at an even higher cost. And on and on.

I'll leave with this. My brother lives in Thailand. He works as a journalist. The other day, he called me with a medical problem. He found some worrisome lesion in his groin. He is an avid cyclist so this sounded like a bicycling rash/nodule that comes from long hours on the bike. But, after hearing about it and his concerns, I recommended that he have a doctor see it and maybe ultrasound it if it was concerning. I told him to get back to me in a couple weeks, thinking that's how long things would probably take, given my experience in the US, the fact that he's in a "third world" country and also because he doesn't have a primary care doctor to begin with. So, THE NEXT DAY AT NOON, he calls me and tells me that he walked into the local clinic, saw someone within thirty minutes, had an exam, received his results, opinion, blood work, etc. by noon that day and could tell/fax/inform me of the results. All for a copay of about 10 bucks in US dollars. Don't tell me that we have best health care in the world. That's like saying we have the best cars or televisions in the world or the best cuisine. We could learn a lot from other countries. We better before we all go broke.

The Women's Health Initiative and Our Misconceptions

2006-02-16T10:20:00.000-05:00

The Women's Health Initiative (http://www.nhlbi.nih.gov/whi/background.htm) is a multimillion-dollar, multidecade study by the National Institutes of Health that was designed to test certain preventive health measures on a large population scale. It has had a huge role in debunking some of medicine's treasured preconceived notions and has generated a lot of controversy recently regarding its conclusions on low-fat preventive diets and the role of calcium supplementation in the prevention of osteoporosis.

So, let's start with a little background on how research gets to the public sphere and results in day to day recommendations by your average doctor. So, there are a couple ways to arrive at observations that result in changes in clinical care. The first is the more basic science, classical way. Either as a result of observing and analyzing select patients with certain diseases or as a byproduct of understanding 'normal' biological systems, scientists can develop hypotheses regarding the basic pathophysiology of disease. For example, you notice that a certain family in 'X' country has a high degree of heart disease. Testing the blood and their echocardiograms and what not shows that their cholesterol is really high. You do some genetic testing and you discover that there are certain genetic defects in this family that result in the high cholesterol. By teasing out the 'phenotype' in this family, you understand the 'genotype' that results in this problem and you then uncover perhaps some information on the basic mechanism of heart disease as it relates to cholesterol or 'you name the factor'. This results in efforts to develop animal models of this disease and then intervention studies to perturb the system and see if the natural history can be altered in select models. After a long time and a lot of money, then maybe medicines can be developed with the help of Pharma and trials can begin in select patients.

This scientific method is precise and clever and 'elegant'. However, it is difficult, requires select observations, and sometimes is not a good way to understand diseases that are multifactorial and combine large interactions between environmental and genetic causes. For instance, although there are some families with genetic tendencies where they'll all develop dramatic heart disease or cholesterol deposits, most people have a multifactorial risk of heart disease. There is an interaction between a patient's susceptibility and other environmental factors, such as smoking, weight gain, stress, diet, etc.

Oftentimes, because some relationships are subtle, epidemiology is required to look at large populations and tease out cause and effect. Such is the case when statements are made about colon cancer and dietary fiber, or hormone replacement and heart disease or exercise and longevity. 'Observational' studies are precisely that. You can take a bunch of patients who like to eat a lot of fiber and you can follow them for a period of time in comparison to low-fiber eaters and see if there are differences in cancer, heart disease or whatever. This isn't a true test of one versus the other, because the groups are not strictly randomized against each other and there are various biases in the interpretation of the results, but this type of analysis is often easier, less rigorous and can give a result sooner. If something looks promising in observational studies, then maybe, just maybe it will be tested in a randomized, controlled clinical trial, the purported gold standard of medicine.

Okay, so prior to the WHI, there were numerous small and large observational trials that noted a few things. One, that women who took estrogen replacement therapy seemed to have fewer heart attacks. Likewise, if you looked at women with heart attacks versus those who didn't, the 'didn't' category seemed to remember using HRT more. Likewise, nutritional experts noted that people who ate low-fat diets seemed to have better cancer or heart disease outcomes. Again, retrospectively, people who had less heart disease sometimes remembered diets lower in fats, etc.

So, obviously, you can imagine that there are so many confounding factors in these analyses. The same person who eats low fat might also be a big exerciser and overall just care about his/her health more. And so on. So, in response to the overwhelming evidence from observational studies, doctors decided to start recommending certain behaviors and Pharma started producing products to fit these niches. So, the NIH instituted the Women's Health Initiative to test some of these hypotheses.

When I was in medical school, hormone replacement therapy was all the rage. All the rage. Every postmenopausal woman that I could think of had recommendations to take HRT, to prevent osteoporosis, to help with their hearts. The only caveat was whether it would cause more breast cancer. So, lo and behold, imagine the utter shock when the results came out that HRT actually increased the risk of heart attack and death! Man, there went a few careers, a lot of money for some Pharma and the whole thing just went hush-hush. Now, very few people talk about HRT. Some women use it, but for the most part, doctors veer away from prescribing it.

Now, we've got two reports from the WHI in the past few weeks. One, showing, after nearly half a billion dollars, that low-fat diets are not better than regular diets in preventing colon cancer or heart disease. A bit surprising, but of course, the immediate rejoinder from the academic community is that 'we now know that some fats are actually good for you' so our knowledge now makes the assumptions when the WHI was started invalid. Hence, we need 'more studies'. Now, there is the recent report that calcium supplements don't help to prevent osteoporosis, despite recommendations that women take those supplements starting in their 20s and 30s.

Man, what to do? This kind of debunking of knowledge is totally shocking. It calls into question the millions of dollars that have been spent in the prior observational studies, the promotion of certain health behaviors and the cottage industry of diet fads and Pharma products that cater to these recommendations. In some ways, I start to wonder if we're all part of not just a medical-industrial complex, but also an academic-industrial complex. It's almost as if the whole point of doing studies is to generate complexity enough to create another round of expensive studies that are again inconclusive. It's a bit demoralizing sometimes, but I guess progress comes in fits and starts.

I think that the confusing nature of the public message is what makes so many people seek 'alternative' health care and ancillary medical services. We don't know what to believe from one day to the next, so we seek things that appeal to us. Hence, yoga, meditation, certain diets, vitamin supplements are pursued vigorously. I guess the final lesson is that we all need to take with a grain of salt some of the 'expertise' that experts spout out. We need to always understand what the biases are in any of the information that we hear. We need to remember that sometimes, modern medicine and society gives us too much information rather than helpful information. And, to think of the ancients, we should remember the Aristotles and Buddhas of the world who in general preached a goal of moderation, in our spiritual lives but also in our daily lives, whether it deals with eating or activities or sex and pleasure or work. I think deep down, we all know that if we try to find meaning in our lives, try not to overindulge in pleasure or asceticism, try to maintain meaningful relationships with those around us and live with a little humilty, we'll in general have more healthful lives. You don't always need to spend billions of dollars to tell you what your grandmother has always known.

What A Great Editorial!

2006-01-31T18:25:00.000-05:00

Read Nicholas Kristof's most recent editorial (NY Times article). In my humble opinion, it hits the nail right on the head. I've spent a lot of time on this blog talking about various aspects of our health care system, the various incentives and disincentives in the system that have resulted in the disastrous and expensive version of care that we currently have.

However, if you think about the most important and high impact changes in the past century or so that have improved our overall health outcomes, it is clear that public health is the way to go. Is it chemotherapy that makes the biggest difference in cancer care? How about angioplasty or bypass operations for heart disease? Antibiotics that save us from influenza or cholera or smallpox? If I think of the major achievements in health, I have to think of a few things that have really helped millions of people. One, sanitation and the improvement in our public water supply. An engineering feat as much as a medical one, this has completely changed our exposure to water-borne illnesses like cholera. Just ask any traveler to India or Africa or even Mexico and you'll understand quickly the impact of diarrheal illness and "fecal-oral" transmission of disease. This has mattered far more than antibiotics, that's for sure. Handwashing and general sanitation has done as much to save people during surgery as any new fancy technique or slick stitching.

Second, let's think vaccines. Polio, smallpox, malaria, tuberculosis... these are giants of history in terms of death and mayhem. Smallpox is eradicated and polio is very close to being eradicated as a result of vaccine research. Millions of lives have been saved. Millions more have been improved. Malaria and TB still devastate countless people, but their impact in the US has been improved in large part due to public health measures, better sanitation and living conditions and improved antibiotics. Third, how about nutritional supplementation and fortification in our diets. Rickets, scurvy, blindness from vitamin A deficiency, birth defects from folate deficiency, anemia from B12, and the list goes on. Many of these things are supplemented in our diets by our government and have improved the nutritional makeup of so many of our citizens, making many of these historic scourges a memory.

Sure, the basic and clinical research that resulted in these public health breakthroughs took a long time to develop. Now, the "low lying" fruit may be taken already and making big impacts on health may be harder... or is it? If Americans 1) quit smoking, 2) reduced obesity so that our body mass index was under 25 (BMI is a normative measure of weight in relation to height), 3) exercised, and 4) reduced fatty food intake, we would impact MILLIONS of Americans, save countless lives and reduce health spending by BILLIONS or even TRILLIONS of dollars... no joke!

Heart attacks are about 1 million/year in the US currently. Cancer, stroke, diabetes and emphysema round out the top five bad actors in our health today. Rates of all of these are rising in both the Western world and the Third World, particularly as other nations adopt the US' mode of sedentary and fast food culture. All of these are directly related to smoking, obesity, and diet. Lung cancer was quite rare in the nineteenth century. Japanese and Okinawans have traditionally had much less prostate cancer than the Americans, but their rates rise dramatically once they emigrate here, reflecting cultural and diet changes. Diabetes is skyrocketing in the US today, with some populations having kids with a 1 in 2 chance of getting diabetes by the time they reach adulthood. All of this is preventable. Really. I repeat. ALL OF THIS IS TOTALLY AND COMPLETELY PREVENTABLE!

But, where is the national constituency for this? Where is the corporate interest in prevention? Can you really have a sexy science career promoting public health? There are no big bucks or bigger glory in most of these jobs. I agree completely with Kristof. Since we can't wait around for our government to get its act together on national health care, since it's hard to just rely on people to take an active role in their own care, we need to incentivize people to promote their own fitness. Put more stairs in our buildings. Make elevators inconvenient. Reduce insurance rates for those who make a target BMI or diabetes goal. Give tax breaks for those who quit tobacco or meet a health goal. We all need a kick in the ass sometimes. That's what government is there for. It's there essentially to protect us. Not just from bombs or violence, but sometimes from our own behavior and self-destruction. Let's start early with our kids. Get the greasy pizza and Coke and ice cream out of our elementary schools. Make 'em do as much physical exercise as multiplication tables. Get off the Internet and on to the track oval. It will save us money in the long run. It will save our health system. The bottom line is it will save all of our lives.

Are We Interconnected?

2006-01-30T18:25:00.000-05:00

I just read a CNN article (CNN article) on global warming. Yet more evidence coming out of Europe that the planet is warming at a faster and more dangerous rate than previously predicted. It appears that the "experts", even conservative ones, are increasingly in agreement that industrial emissions throughout the world are the cause of climate change. Predictions of the future range from mild temperature elevations to apocalyptic descriptions of worldwide drought, famine and ecological devastation.

Whatever your politics or belief system, I think the issue of global warming, or "climate change" as some euphemists have politically chosen as an alternative label, is illustrative of a central problem with the nature of our modern society. Why is it that even many of the "progressive" people of our society feel detached from the direct impact of their actions on the environment? I know plenty of self-described liberals who drive SUVs and don't recycle and do other things that are somewhat contrary to their otherwise honest and consistent beliefs. Why is that it is so easy to sequester our convictions from our actions nowadays? Granted, hypocrisy, or to a lesser extent, inconsistency is a part of life. Most of us wish we could be "better" than we are. There is a reason why most major religions preach forgiveness and compassion. We are in essence very fallible as humans. Indeed, the human experience is almost defined by our fallibility. However, it is my belief that certain trends in modern society are serving to separate us even more from the consequences of our actions and detach us from a sense of connectedness with fellow humans around the globe.

In this day of the Internet, most of us live in urban or suburban or "exurban" dwellings, close in proximity to densely populated areas of our country. Our only encounters with the "land" include vacations to the countryside, apple picking excursions, trips to Whole Foods or the occasional friend from the "boondocks". Less than 5% of the American population is involved in any way with farming or an agricultural lifestyle. Despite our romantic notion of the American cowboy and Midwestern farmer, most of American agriculture is controlled by large multinational corporations that operate mega-farms. There is a distancing from our connection to vital elements in our lives. We get hydropower from faraway dams, irrigation from diverted water sources in neighboring states, imported food and energy from other countries and technology and manufactured goods from around the world. This is "globalization" and despite the anti-WTO movement, in my opinion, it is morally neutral and not necessarily a bad thing.

However, to me, this separation from the land is just one example of our lack of connection to our actions in our point-and-click society. As more things become commodified in society and our sense of regional difference lessens, we in some ways have less connection to our own impact on others. Clicking on Amazon.com for goods from around the world does a lot to minimize a sense of what we are buying, where it comes from and what cost, economic and otherwise, it has on the environment and other people. How are we to get a sense that our buying bottled water after a workout may in fact be promoting the hoarding of water resources from the impoverished in the Third World? When we want Salmonella-free chickens for our Sunday night family dinners, it is hard to connect that with antibiotic-resistant organisms that infect grandma after her heart bypass operation. Subconsciously, we are aware of some of our "interconnectedness", but on a day to day level, as our interactions with our fellow citizens become more impersonal, as we are isolated in our cubicles and megamarts and Best Buys and strip-malled, gated communities, we only interact with like-minded people and become more insensitive to other opinions and viewpoints. Hence, we get the partisanship of our government and the virulent nature of our local politics and coarseness of our entertainment.

I'm not sure what the solution is. Technology is neither good nor bad. It is simply progress. The ethics and morality of the Internet or genetically modified food or nuclear power plants are all debatable and open to varying opinion. My point is more that we are increasingly isolated from each other. Traveling in our climate controlled cars, listening to our personally directed radio stations, watching our lowest common denominator TV shows and socializing with our politically and economically like-minded friends and colleagues, the social discourse of our society has increasingly suffered. I think most people are aware of this. Loneliness, depression, addictive behavior and other psychological distresses are rising. There are so many movements to promote a sense of "belonging", whether it is to some nationalistic sense or religiosity or rampant and vulgar materialism. As we become more isolated from one another, we seek more and more to attach to some fervent belief system in the hope of feeling worth and self-esteem.

Maybe my psychobabble is just a bunch of garbage. Maybe our times are no different from the past. I just think that, unlike any other time in history, we live in an age where people can exist in a self-contained bubble, isolated from others and isolated from other types of thought. This, in my mind, is dangerous. Part of what Joseph Ratzinger referred to in his first papal encyclical dealt with the loss of true religious belief in modern society, particularly Europe and America. This disrupts the social fabric of society, unmooring most people from a sense of propriety of behavior and responsibility to the community. No matter what your belief system, I think it is inarguable that religion has played a huge role in stabilizing societies throughout history. Yes, this can be stifling and is frequently abused, but it also provides moral glue in some senses. With the secular nature of the West, particularly after the Enlightenment, the glue has weakened.

Part of the problem is also that America, which has promoted capitalism and individualism throughout the world, has exported our belief system for decades. I think that much of the world's resistance to America stems from a feeling that our way of life, while certainly economically the most successful and progressive, is not necessarily the best spiritually or emotionally. Whether it is France rejecting the Americanization of its culture and cuisine or Islamic fundamentalism or South America's recent socialist rejection of US intrusion into their affairs, the world is bristling a bit at the American way of life. While we are the most powerful and wealthy and "free", it isn't always clear that we are the most cohesive or happy or spiritual. Having cheap goods and a nice golf course and a huge McMansion doesn't necessarily appeal to the other 5.7 billion people in the world, particularly when our citizens seem to be unaware or insensitive to the fact that our wealth and "freedom" often come on the backs of other nations' suffering.

I think there are other forces that can rebuild a sense of community in our lives, our sense of community with other nations and peoples. Let's face it. For a couple centuries, America has stood as a beacon to other nations. Not because of our wealth, but because of our ideals and sense of moral high ground. Some of this is lost now. Not just from Iraq or Bush, as liberals will have everyone believe. Rather, I think is mainly from a sense that our naked pursuit of "progress" and success is not the best road to happiness and contentment.

I hope that America regains a sense of its connection with and obligation to the world and our own citizens. Perhaps a resurgence of a 19th century Transcendentalism might emerge. A feeling of the innate value of humanism and sense of shared responsibility to one another, particularly the downtrodden of society. When we talk of global warming, or entitlement reform, or the war in Iraq or whatever, I think sometimes we get bogged down in the details. These are obviously important. However, if we somehow are able to regain a sense of community, a sense of obligation to our fellow men and women, such that we all realize that we share a common bond by nature of our humanity and limited time on earth, I think many of the problems that we face both in the US and around the world will be dealt with more constructively. If there is any lesson of the past 2000-3000 years of human history, it is that while man's capacity for destruction and self-loathing is limitless, there is also an eternal desire in all of us to aspire to something that transcends our own small and short existence. Remembering that we are all going through the same absurd life might go a long way toward feeling more compassionate and generous towards one another. We might even give up the SUV and recycle more.

Hey, Hey, Have You Heard of PFOA?

2006-01-26T01:51:00.000-05:00

Every now and then, I discover something that totally takes me aback. Not something that I am sort of minorly surprised about but cynically deep down anticipating. But, rather, something that kind of blows me away and exposes something raw and humbling. So, I've heard a little bit in the past year about perfluorooctanoic acid (PFOA), a chemical that is critical to making such products as Teflon or Gore-Tex (Washington Post article). It has been linked to a number of adverse things, like cancer in a variety of animals. It is produced by a number of chemical companies, such as DuPont, and is in everything from Domino's pizza boxes to microwave popcorn bags. Well, little did I know that the chemical PFOA is found in the bloodstreams of over 90% of Americans... yes, 90%!!! It is fully within our entire ecological system, including Arctic polar bears, if you believe some of the literature out there and some of the newspaper articles.

I guess the ghost of Rachel Carson is alive and well in 2006. That we live, grow up, exist in whatever part of this country and perhaps world and have virtually NO choice but to be exposed to a potential carcinogen is, in my mind, just completely emblematic of everything that is wrong with modern life. In pursuit of unnatural youthful looks or tasty, ever crisp foodstuffs or conveinient, durable sporty clothing or whatever, we human beings push the boundaries of what is "natural" and unnatural. We seek to modify the basic molecular structure of our surrounding inanimate and animate world. We divert rivers and irrigate lands that should remain barren (think California's Central Valley), we overpopulate and pollute various environments, we ecologically tax everywhere around us, all in the hopes that some future technology will improve or reverse or stymie the progression of destruction of our ecosystem. Or at least delay the whole thing until we've lived our happy lives and just dumped the whole mess onto some other unfortunate generation. Then, we have the audacity to be shocked when our cancer rates skyrocket or we have mercury in our groundwater or we run around with PFOA in our pregnant wives, mothers, sisters, and daughters.

I have never in my life been much of a "treehugger" or environmentalist. Like most people, I sort of go with the flow, try to pay my taxes, get a safe and good job, meet loved ones and generally just pass the time. But, as I've gotten somewhat more cynical about the nature of big business and government, I've started to feel that action, individual and local, is where it's at. I've chosen to try to be vegetarian (with a few runs to Boston Market as a form of weakness thrown in), more out of respect for the life of animals and our environment than health reasons. I'm trying to conserve energy and be more conscious of waste and excess. I'm trying to invest in companies that I feel are socially responsible. Little things. Little things that are probably useless, probably just gestures that make me feel a tad less hypocritical. Probably just self-serving. But, somehow, I wonder that if we all start to learn more about the zillions of other PFOA-like stories out there, if we all start to make simple little local choices with regard to our environment and fellow man, well, maybe we'd start something that Rachel Carson could be proud of.

A Clarion Call to Action or Just Another Whimper?

2006-01-25T12:17:00.000-05:00

The Journal of the American Medical Association (JAMA) just published an article (NY Times article) calling for a ban on pharmaceutical gift-giving to physicians. As any doctor knows, this is one of the most pervasive, subversive and destructive forces that percolate throughout the medical system. When the lay public thinks of "gifts" to doctors, they shrug at the thought of pens, and hats and those cute little squeeze balls emblazoned with "Viagra" or "Cialis" or "Zocor". Who cares about a penlight or a clipboard? Surely, no intelligent, independent, self-respecting physician or scientist is swayed by mere trinkets.

However, the simple fact that large portions of total Pharma expenditures are spent on marketing and various enticements to physicians is a an indicator of the importance of these activities in the overall game plan of big drug companies. No, this is no "Constant Gardener" or "Syriana" type conspiracy plot. Rather, it is a decades-long slow, insidious, and therefore tacitly accepted practice that operates in a sort of ecological commensal arrangement. Doctors, not poor by any standards, but typically overworked and somewhat beaten down, feel that they deserve a free pen or nice meal or trip to a conference. After years of studying and sacrificing, dealing with demanding patients and burdened families, a little cush and comfort is felt to be deserved and expected. Especially for these folks who feel that, with their innate talents, they could have easily chosen professions that work less and are more lucrative. Pharmaceutical companies, for the small entry fee of these trinkets or junkets or "educational" activities, 1) get easy access to physicians and therefore physician prescribing patterns and 2) develop "relationships" with physicians that either push certain expensive drugs to practitioners or promote studies on particular drugs (e.g. Vioxx or Lipitor) that validate "research" supporting more widespread (read: expensive) use of these medications. For a $10,000 dinner taking out a host of hematology/oncology fellows to a swanky restaurant, a drug company can maybe get someone to prescribe a $3000/dose chemotherapy drug dozens of times. There is a reason why Pharma spends BILLIONS and BILLIONS (think Carl Sagan) on marketing and advertising. And that reason isn't altruism. It's MONEY.

There have been numerous calls for more accountability, greater transparency and more restriction on this type of corrupt behavior. I refer anyone interested to Marcia Angell's "The Truth About Drug Companies..." or George Halvorsan's "Epidemic of Care" or George Lundberg's "Severed Trust." Overprescribing of medications for "off-label" usage by physicians at the guidance of drug representatives is a major driving force in the cost of care. In Canada and parts of Europe, indications for certain procedures and medications are set by the government. You can only prescribe a medicine for its approved indications. In America, it is totally different. Once a drug is FDA approved, a physician can prescribe that drug "off-label". In nowhere is this more evident than in cancer care. I can give virtually any chemotherapy to any patient. Granted, this is decreasing a bit now that insurance companies have caught on and are tired of paying through the nose for unproven therapies. But, drug companies, despite some restrictions on their ability to talk about nonapproved indications, often allude to off-label usage in the hopes of getting people to overprescribe. It's cynical, pathetic and very effective. And costly.

Will doctors go along? Probably not. At least not willingly. Like politicians or pro athletes, we can't police ourselves. We need some external force to come in a help us find our ethical center. We really do. That isn't extreme. Trust me. If doctors don't step up, at some point the public will overreact and then put something more stringent over us. Either way, after so many years high on the hog, we deserve what we get.

Our Human Frailty

2006-01-21T19:34:00.000-05:00

When I think of Abraham Lincoln, I usually don't have episodes of introspection. Like most people, I'm inspired by the up-by-the-bootstraps story, the log cabin, candlelight self-study, the mental resolve, Emancipation, Gettysburg address, etc. But ruminating about the human experience or thinking deeply about my life isn't usually the result. But a new documentary, "Lincoln", on the History channel this past week has stimulated a different perspective for me. Drawing on a combination of more recent historical scholarship and the changing social mores of our society, "Lincoln" addresses the inner psychology of one of our national icons, delving into such touchy subjects as depression, madness and homosexuality.

Always known in his day as a melancholy individual, it appears increasingly clear that Lincoln suffered repeatedly throughout his life from episodes of severe depression, entertaining thoughts of suicide and death, even during the heady days of the Civil War. Arising from a troubled childhood and adolescence marked by the early death of his mother and sister, an abusive and unsupportive father and some difficult personal relationships, Lincoln was noted by his earliest contemporaries to be morbid, prone to black depressive episodes and given to tumultuous behavior. Indeed, at one point, he was on what would now be called a suicide watch by some friends. His writings and poetry rival Edgar Allen Poe in dark imagery.

Even more shocking are some suggestions that he may have had homosexual feelings. He maintained a very close correspondence with a Mr. Speed through a number of years. The letters are some of the most intimate of his life. The two shared the same bed for nearly four years. Granted, sharing a bed with a same sex individual in the nineteenth century was not unusual, but the intimacy of the correspondence raises some eyebrows from various historians. Also, it is clear that there were some rumors amongst the soldiers guarding him during his Presidency that he maintained a close relationship with some of his officers. Probably nothing, but the fact that it even raised some comment by the surrounding soldiers of the time makes one realize that it wasn't completely normal even for the times.

Then there are the visitations to prostitutes, the broken engagement to and then reconciliation with his future wife, Mary Todd, the story by a contemporary that Lincoln worried he had acquired syphilis, and other not-so-commonly-known stories. Pretty steamy stuff. Perhaps not shocking about most people who have lived a peripatetic and inquisitive life, but not the stuff of our usual textbooks on great figures. But, perhaps it is this kind of introspection, this kind of emotional difficulty and struggle that gives a person the inner strength to succeed, particularly in difficult times. Think of Roosevelt's polio or Churchill's troubled parents or other figures that suffer emotional difficulty throughout their lives.

So, who cares? It isn't the suggestion of depression or homosexuality or the very human frailty of Abraham Lincoln that makes me think. In our modern day cathartic environment of DNA on blue dresses, reporters poring over the most minute, ridiculous details of events decades in the past of an individual or the endless prurient, voyeuristic nature of the Internet, the fact that "what we see" isn't always what we get isn't all that surprising or interesting. Rather, as I get older, as I mature, as I learn more of others and myself through the humility of sickness and disease and healing, I increasingly wonder why we must elevate, lionize or mythologize leaders and other notables in our society. Why do we need to create legends of those who lead or inspire us, only to protest our shock and indignation at the very humanity of these people that likely makes them great?

Why not present our great figures in our schools as real human beings, prone to our own failings? When we learn of individuals in high school or on TV or in pop culture, we have this tendency to overemphasis the wonder, the drama, the soaring nature of a person. If it's Britney or Jessica Simpson, then we wait for the fall and rejoice. If it is Jesus or Thomas Jefferson or Bill Clinton or even George W. Bush, we act shocked and offended and dismayed. There is hypocrisy in this. Perhaps it is the dismal nature of our own failings that make us turn to a Jimmy Swaggert or a Jim Baker. Our shock at their falls from grace reflect our own horror at our own dark inner selves. We cannot accept our own passions and "sins" and misdeeds, so we must punish "others", the fallen stars, the downtrodden, the people who remind us of the distasteful in life.

One thing I liked most of all about Ang Lee's recent film, "Brokeback Mountain" is its "realness". It's not the portrayal of homosexuality in the film or its drama or its daring nature that most impresses me. Rather, it is the subtlety of it, the plausibility of it that is most powerful. Rather than some fire and brimstone, Schindler's List sort of ending (a great movie, mind you, just different) where there is almost a didactic element to it, "Brokeback", other than its topic of gay cowboys, is a story that could be true of millions of people in any relationship in the world. The reality of the tough choices we make in life, the reminiscence of middle and old age of zigs and zags in our past. The remorse, the guilt, the fear that accumulates as we get older and separates true adulthood from just the chronology of aging. Not living the life you dream of is a theme as old as time itself.

I wish we, as a society, would try to focus on "real" portrayals of our celebrities and famous figures. Not as a sort of blood sport or inquisition, but as an acknowledgment of the real failings and triumphs that are part of every person's kaleidoscopic life. I think if we can be more honest and forthright and accepting of the frailty in all of us, we will more naturally be compassionate towards those closest to us. Then we won't need some new government policy or catchy slogan or false and pretentious hope that sweeps across our psyche with each new election. Rather, if we accept that our leaders and celebrities and teachers and doctors and famous people are fallible, maybe we'll accept that our poor and drug addicts and immigrants are also human and fallible. We'll realize that the human experience is the same now as in Shakespeare's time, as in Buddha's time and that we can all strive to be better and kinder if we just accept our own humanity.

Sickness In the People We Know Part II

2006-01-10T00:29:00.000-05:00

A bone marrow transplant is a somewhat brutal thing. When you get cells from another person, "matched" to you genetically, there are still some subtle differences that remain and make for an immunologic response that is critical for the curative effect, but ironically, is also crucial in terms of side effects and mortality. I have observed countless patients on the transplant unit here at the hospital I'm working at. Many enter the process just "healthy" enough to tolerate the procedure. However, quite a few leave the process either permanently disabled or dead. Not that they have a choice. If they didn't opt for the procedure, they would 100% of the time be dead from their cancers, but the whole thing in some ways is a Faustian bargin. Sometimes improvement in your condition in the short term (months or years) can result in a long term disability or life of pain or a miserable death.

My friend with Hodgkin's disease is now nearly 2 weeks from her stem cell transplant. She is already getting quite ill. Another friend updated me. Rather, the line has gone silent. Visitors are firmly restricted to immediate family and there is an air now of sobriety and concern. Gone are the Pollyannish hopes and dreams that cancer patients share throughout the globe. Instead, there is a long slog ahead, filled with such things as graft versus host disease and venoocclusive disease and infections and nausea and other types of life-threatening illnesses.

All of this is the easy part for the doctor in me. But, when I sit alone in the quiet of my home, just thinking about this person, this friend, this friend of a friend, when I think of her as a human being... I feel scared. I feel sad. I feel frustrated. Life is fundamentally unfair. In fact, it is brutal and harsh. I suppose the 2-3 billion people around the globe who live in poverty and drink unclean water already know that. The victims of sex trafficking and violence and war and famine already know that. But, somehow, when it strikes personal, all of those larger issues seem impersonal and abstract.

The single life of the person you know, if only very peripherally, is what matters. When I muse as a physician on Medicare or the "medical-industrial complex", when I wax poetic or not so poetic on the state of the healer or some such lofty thing, I am speaking and thinking in the guise of the distant physician, the objective doc. All of the seems like a load of horseshit when I'm just a friend of a patient. The abstractness of the wasted healthcare dollars or the "priorities" of medicine seem ridiculous. I just hope and pray for my friend, this young person with so much to look forward to in life. I just pray that she gets the chance to live her life in the most fulfilling and meaningful way possible. To hell with the theories, the medicine, the intellectualism. I just want my friend to feel well.

Drive a Prius Here, Destroy an Ecosystem There

2005-12-27T20:30:00.000-05:00

Diverging from modern medicine for just a bit, I turn to yet another recent NY Times article (NY Times article) I've got to learn how to hotlink things more directly, but bear with me. In this article about one New Orleans-based company, Freeport, the NY Times exposes a disturbing web of corruption, power politics and environmental devastation that, in my mind, is somewhat representative of some of the "globalization" forces at work nowadays. Now, I'm not an opponent to globalization. And, for the most part, I lean conservative on most economic issues and liberal on most social issues. But, this article raises some important lessons on the nature of modern transnational corporations and their lack of any particular moral or ethical framework other than the pursuit of profit.

If you believe the story, and I suppose that's a big IF for some people out there (not me), then the multidecade long history of the gold mining company, Freeport, is one that should cause every American to think more carefully about the products we buy and produce in and from the "Third World". Let's face it. Industrialized nations, wealthy and developed, with populations that are predominantly service-based, make tremendous demands on the developing world. We have learned of this more and more with the past year's "outsourcing" political issue. It is simply more cost-effective and efficient to pursue labor for basic manufacturing in poorer countries. This is what gives us both cheap clothes and goods from the Walmarts and Targets of the world. In some ways, these companies benefit from development in these countries by providing infrastructure and investment. We get cheap products and some countries get our money. Hence, the negative current account deficits with much of Asia.

However, the dark side of this side of globalization in relation to manufacturing is abuse and poor labor policies. Whether it's the exploited kids of Kathy Lee Gifford's clothes line or Nike shoes in Southeast Asia, these economic pressures make for continuing abusive labor practices that exploit children and impoverished adults. Poor and weak governments allow for extensive corruption and "looking the other way."

The NY Times article profiles another facet of globalization, namely the pursuit of resources abroad to satisfy the demands of wealthier countries. Whether it's natural resources like oil or natural gas or luxury commodities like diamonds or, in this article, gold, there is a massive competition worldwide for resources. Part of the rise in fuel costs over the past summer has been a combination of natural disasters and ever-rising demand for resources from India and China. Likewise, gold, both for commercial and personal uses, is a highly demanded and profitable metal. In the pursuit of this resource, the company Freeport searches the globe for areas of extensive supply that are untapped. Mining is notoriously damaging to the environment with metal and chemical runoff from the process often destroying the surrounding soil and water supply. Just think about Montana and read Jared Diamond's "Collapse" where he profiles the historic destruction of much of Montana's ecosystem by prior mineral mining.

In Indonesia, there has been decades of mining in remote regions of the country where large gold deposits exist. In the process, tons of damaging byproducts, larger than the entire amount of displaced earth produced in the digging of the Panama Canal, have been deposited throughout large swaths of land and sea, resulting in widespread pollution of the system. How does this happen, when obviously, local residents and patrons have refused to just sit idly by as their habitat and homes are polluted for generations? Well, money, of course. Bribery and corruption and even the suggestion of theft, intimidation and murder.

This is nothing new. Think of millions of Africans who have been abused, maimed or terrorized by the diamond and gem industry. Think of all the destruction and strife in the Middle East. Would we really care so much if oil were not on the line? Think of conflict in Central Asia and the Caspian Sea region over oil and natural gas resources. Or in the North Sea region or with Japan regarding fishing and whaling? As more and more people compete for the scarce resources of the Earth, increasing strife will occur. What shames me about the Freeport relationship in Indonesia is that it is essentially about a luxury commodity. While I think our dependence on foreign oil and fossil fuels is ridiculous and a product of a greedy energy and automotive industry, even I can agree that protecting and defending our energy sources is of vital national interest. However, how can we justify the destruction and degradation of such large areas of the world over a shiny metal that is really just a superfluous trinket? It is only because America is a rich country and poorer, developing countries are unable to defend themselves against large corporate behemoths like Freeport or Bechtel.

In America, the richest country on earth, we have corruption in our politicians and the average citizen feels disempowered. How can we expect the average citizens of poorly governed and economically devastated countries to defend themselves against our greedy interests? They can't. And this is becoming increasing evident during this globalization of all industries. This globalization of luxury, of pornography, of prostitution. The globalization of sex trafficking and commercialization of water resources and public lands. The globalization of narcotics and cocaine.

When we think of globalization, we often think of a cheaper TV or nicer sneakers. But we should also think of the negatives. I don't often agree with all the protests at the WTO or the G-8 summits by antiglobalization activists, but I do believe that, like everything, money and development and corporations do not have an inherent moral or ethical compass. It is up to us to think about the ethics of our actions and realize that each purchase we make, each steak or chicken we eat, each piece of clothes we wear, each of these decisions has a serious effect on the world around us in this age of globalization. We really are all connected. As Americans, privileged to live in the richest and most free country in the world, touters of freedom and responsibility, it is critical that we LEAD the world with not just our words but with our deeds. We cannot expect our fellow nations to follow our idealistic proclamations about mankind when we continue to plunder and destroy the world under them.

It's All About Spin

2005-12-21T16:19:00.000-05:00

Take a recent NY Times article on cancer drug development (http://www.nytimes.com/2005/12/21/health/21cancer.html). In it, it quotes FDA members who cite frustration with some of the rules that govern clinical trials related to cancer. Cancer research comes across as something that is struggling along with little hope. In one section, there is commentary about the expense added to the cost of metastatic colon cancer treatment with only months added to the lifespan. This, by the way, is somewhat true. For most patients, the overall survival for stage IV colon cancer has increased from about one year to slightly over two years. The total cost added for that increase of one year is several hundred thousand dollars. Is this worth it? If you spin it a certain way, then it doesn't make sense in relation to the myriad other health and non-health related budgetary priorities of our government (think... vaccinations, preventive health, smoking cessation, etc.) However, I, and I'm sure many other oncologists can attest to a limited number of personal patient anecdotes where stage IV cancer treatment with modern methods and aggressive chemotherapy and surgery has resulted in "prolonged survival" as we call it, or several years. How much is a life worth? Serious questions over which our society can't seem to engage in a serious debate.

Contrast this with another article in the NY Times on cancer care and prevention (http://nytimes.com/2005/12/27/health/27canc.html?hp&ex=1135746000&en=4913abc62ba4d8a7&ei=5094&partner=homepage). In it, it profiles some of the amazing developments in the understanding of cancer biology, namely the many genetic abnormalities that underlie the pathophysiology of the various cancers. In it, a famous cancer researcher at Harvard says things like "we're close to being able to put our arms around the whole cancer problem." Is that true? Yes, it probably is. Over the past three decades, billions of dollars of funding have led to incredible discoveries concerning the molecular biology and genetics of various diseases. Much of this started with cancer research and has now spread to every aspect of medicine. Indeed, "molecular medicine" is the buzzword in every academic medical center, with discussions of "targeted" therapeutic approaches to an individual's disease a frequent topic of interest. The vision of the future touted to today's students and trainees is one of understanding the precise molecular differences amongst each individual and developing individualized drugs and devices that are accurately and safely designed to maximally affect that single person. Once again, how close to reality is this? How much will this cost? Does this necessarily supplant more cookie cutter preventive efforts? We know this is sexier but is it more cost-effective or even just plain effective?

The short answer is obviously that we don't know what all this will mean or how much it will be realized. Take for example the disease, CML, or chronic myelogenous leukemia. It is a disease characterized by a single translocation of DNA elements between two chromosomes. This results in an activation of blood stem cells that promotes a form of leukemia. Untreated, this is uniformly fatal. Prior to a few years ago, the main curative treatment was a bone marrow transplant. It cured the majority of patients. However it is costly, labor intensive and causes chronic debilitating problems in a good percentage of the cured individuals. Plus, the procedure itself can kill up to 30% of the patients in the first year due to toxicities from the therapy. On the whole, several hundred thousand dollars was the cost of therapy. CML affects under ten thousand or so individuals in the US yearly. Compare this to some 200,000 patients diagnosed with prostate cancer or several hundred thousand patients diagnosed with lung or breast cancer each year. Or the million or so heart attacks yearly.

More recently, CML treatment has been the poster child for the targeted revolution. Given that a single genetic defect is critical to the pathophysiology of the disease, alteration of this defect is a natural target for drug therapy. Gleevec or imatinib (its generic name) was developed by Novartis in conjunction by academic researchers at Oregon, UCLA and MD Anderson. Although it does not appear to be curative, it results in a remission in the majority of patients with CML. Plus, it's a pill taken a couple times daily. It has fewer side effects and appears to improve survival in a number of patients, particularly the ones who show an initial strong response. However, it can cost $15-20,000/year per person. Given that it's not curative, it must be taken indefinitely. It's a drug company's dream drug. An expensive medication that is critical for a serious disease and can never be stopped. Think of AIDS medications versus AIDS prevention (condoms or needle exchange or mandatory testing/reporting).

The incentives behind the push for focus on drug development for diseases versus prevention have been described multiple times in this blog. Don't get me wrong. These are serious diseases. If I had CML or leukemia or any cancer, I'd want all kinds of treatments, would want to fight tooth and nail to live and would have little interest in the cost, provided it didn't impoverish my family. But, what is good for any one individual is different from what is most beneficial to society as a whole. My fear is that, depending on the spin provided in the media or by academics or industry, the emphasis in this country is always on MORE and MORE for the individual. Little is emphasized on the global effect on health. Granted, we all see discussions of the "40 million uninsured" or the "baby boomer" costs briefly pass through the lips of politicians and pundits, but in reality, the current fear of the inadequacies of the health care system have only stimulated people to push for more individual benefits rather than think about the greater societal effect.

The questions that I would have all my patients, politicians, citizens, basically everyone.. ask themselves are these: 1) How much are we willing to pay, individually and as a society, for our health care, understanding that there are limited resources and that newer technology is expensive and the government alone cannot subsidize unlimited care and 2) How much are we willing to subsidize our fellow citizens who cannot pay for their own care? In other words, how much should we support the poor, the elderly, the infirm, essentially the entitlement system? What are the limits and how do we equitably decide them? Just pondering these two basic questions will go a long way towards each of us deciding how "free-market" or "socialized" we want our health care system to be. Do we want something like Europe or Canada, where catastrophic and most daily medical care is subsidized yet there are limitations on timely access to care? Do we accept that version of a multi-tier system where most get governmental care and the elite and rich have access to more private, quicker and sometimes better care? Let's not forget that the US system is already tiered. The wealthy can get the best care on the planet. the middle class and poor have more limited access and quality.

I'm not sure what the right answer is. I obviously have my own personal biases. They've been beaten to death in prior blogs. But, I at least want the public to start having the "broader" discussion. Not just about our own bills and Uncle Johnny's medications, but on establishing our own philosophies on what we think the roles of government versus the individual have in health care and delivery. Discussions at dinner tables and parties. Only then, when we generate a rational and well-thought out debate will this problem in the US improve. When we stop reacting to EPOGEN shots for grandma on TV commercials or giving into scare tactics by both political parties on how the Medicare drug plan will give or take benefits from us, then we'll have a rational debate. Or when we stop fluctuating between personally demanding every possible treatment to prolong the end of life by sometimes weeks or months and publicly complaining about the rising cost of health care entitlement programs like Medicare and Medicaid, only then can we have an honest debate. It might not make my job any easier, but I'd welcome it nonetheless.

Sickness in the People We Know

2005-12-18T23:12:00.000-05:00

For an oncologist, I have had very little personal experience with death (knock on wood). Sure, I deal with dying patients every day. I deal with the agonizing feelings that accompany the passing of a loved one all the time. But, I have had little exposure to death from friends or family members.

Today I received an email from a friend I know who is battling lymphoma. She has been heavily treated and is on the cusp of starting a bone marrow transplant. She is only in her 20s. What is odd is that I only met this person for a couple days at a friend's wedding. Nothing romantic, nothing mysterious. Just a young woman who I talked to for a little while at a wedding of one of my closest friends. I think we naturally hit it off in part because I was comfortable with her illness. I think that made her feel at ease and the conversation naturally flowed afterwards.

At the time, as she told me of her prior chemotherapy regimens and the status of her disease, I privately thought to myself that her future is a difficult one. A bone marrow transplant is a morbid thing and provided she got into remission, the transplant was no picnic. But, as weddings go, there were more festivities and all was forgotten. The months passed. I had no correspondence with her. Back to my daily life. Occasionally, I found myself thinking of her, wondering how she was doing, wanting to write. But, as these things go, the more time that passes, the harder it is to rekindle the relationship. Maybe I was just chicken and didn't want to deal with uncomfortable feelings. Being the doctor and somewhat in control is far different that being the friend and totally out of control.

Then, poof, here we are. She went ahead and emailed me out of the blue. I guess I wasn't the only one to sense the comfort of our last conversation. She is going for her allogeneic transplant next week. I don't know why it affects me. It is a mixture of sadness and resignation and hope. Maybe it is because she is so young. Maybe it is because she articulated so well the perils of her illness. I don't know. But, being someone's doctor is very different from being their friend or even acquaintance. I suppose I should have known that before. I'm learning it now.