I don’t have much in the way of eyebrows. They were victims of too much plucking back in the 1960’s and when you do that, sometimes they don’t grow back. There’s a very nice woman in Solana Beach who shapes and darkens what I have left, infrequently, when I bother to think about it which isn’t very often.
I was in there about a year ago when she told me, “I …
The cost of peace of mind: A case of unneeded bilateral mastectomy
10:11am Tuesday, June 5, 2006: This was the moment Marge was told the mammogram showed a mass, which was probably breast cancer. “But, don’t worry, the tumor is very small and with surgery and radiation, you will be fine.”
1:55pm Wednesday, March 25, 2009: This was the moment Marge was told that the breast cancer had spread to her ribs. “But, don’t worry, the tumors are small, and with hormones, you …
When does false hope become malpractice?
We’ve all been there. You’re in medical school, sitting in a lecture hall — maybe the course is pathology — and for the first time since starting your studies, you’re actually learning about real diseases, not just benzene rings and the Krebs cycle. You’re furiously note-taking, and you reach back to work out a kink in your neck. There it is! A palpable, enlarged lymph node. You have lymphoma. You …
Why are doctors the worst patients?
It’s been very interesting to read the range of responses to the recent FDA recent crackdown on the personal genetic service company 23andMe. Some have decried the FDA as too paternalisticwhile others have said the FDA is rightfully protecting the health of the public.
The evidence, I believe, shows the FDA is correct: 23andMe should not be doing genetic tests that have serious medical implications. Let’s look at an …
The problems with the BRCA test from 23andMe
Kerry was only 28-years-old. He showed up in the ER one night complaining of upper abdominal pain which started suddenly that day. The emergency physician did the usual workup and found two things which led to an urgent call: a large intrabdominal mass and free intraperitoneal air.
The large mass was not necessarily an emergency, but free air, that is, air outside its usual place inside the bowel, almost always represents …
The remarkable resiliency of the human body
Cancer screening is of little benefit in persons with dementia but can cause very serious harms. Older persons with dementia have limited life expectancies which makes any benefit from cancer screening very unlikely. This is because cancer screening works by identifying a cancer many years (generally at least 5-10 years) before it would threaten health.
But cancer screening tests cause lots of burdens when given to persons with dementia. The …
Stop cancer screening in patients with dementia
I used to think medicine would get easier over time. It makes sense, right? You see patterns, you learn how treatments work, and you just get to know stuff. Experience should make it easier to diagnose and treat.
That’s not been the case for me. In fact, it’s closer to the opposite. In the exam room, as I look up to the patient from my stool, and before I stand at …
The hubris of medicine has to end
Not long from now, the last cancer will be defeated, and even today most with the dread disease survive. However, many still fall. This leaves us with one of the toughest questions of life. How long do you continue to fight, when death is certain? When does striving become vain hope which drains quality and creates only suffering? What makes struggle worth the …
How long do you continue to fight when death is certain?
Patients are becoming more and more adept at taking control of their own health care, and this often involves seeking a second opinion of their presumptive diagnosis. However, in far too many cases in which cancer or precancerous conditions are diagnosed, the consultation is at the level of another treating physician, without confirmation that the patient’s pathologic diagnosis is correct. In cases where clinical management decisions and prognosis hinge on …
Why you should consider a second opinion from a pathologist
It occurs to me there are several keys to being an excellent physician. One must love science, enjoy hard work, have the courage to make tough decisions, carry a modicum of intelligence and suffer angst at receiving 94% on an organic chemistry test. In addition, the very best physicians, those we admire and to whom we flock, have a secret weapon. They do not care.
I do not mean that they …
The very best physicians do not judge their patients
The massive magnets of the MRI radiate fields through her brain, scanning veins, arteries and every millimeter of cortex. Grey and white matter, containing all she is and all she ever will be, identified, cataloged, mapped. Two centimeters under the front of her skull, just to the left of center, there is an abnormality; a one centimeter mass surrounded by swelling. The lung cancer has spread, metastasized. Really bad news.
A …
A guide to giving bad news to patients
There is nothing so horrifying as when your doctor is too nice to you. During my first mammogram at Kaiser Permanente, I knew I had cancer before they even told me because of the hushed voices, the pats on my shoulder, and the way, suddenly, no one cared how much time was being spent on my visit. When that happens to you before the diagnosis is official, there is nothing …
The problem with a negative BRCA test
For the first time in my career I asked myself that question. Over the years, I’ve had more than my share of difficult cases. I’ve had patients with life threatening conditions whom I wished I could offer more than to just shake my head and speak empty words of encouragement. They stare back at me and I see their eyes full of hope. How many times have been forced to …
What should a surgeon do with an impossible case?
Everyone is talking about health care costs these days. The presentations usually start with a chart of rising health care expenditures, the tip of the line pointing skywards. Next come exhaustive (and exhausting) tables, more charts, all punctuated with a final shrug of uncertainty from the speaker: What is the solution to rising costs? Of course, there is not just one.
But in the morass of data, we can lose the …
Address the financial burden of medical treatment
I am a physician, an anesthesiologist. I care for the sickest of the sick every day – struggling NICU babies born only hours earlier, victims of major traumatic accidents, and critically ill patients with life threatening illness. In this job, I must both connect with the patient, but also maintain a distance from them at the same time. Dealing with life threatening …
Being a caregiver has made me a better doctor
Radiologists care about their patients, even though most diagnostic radiologists don’t meet and greet their patients the same way direct-care clinicians do.
Some people have the erroneous perspective that radiologists and pathologists don’t care about the welfare of their patients. It is possible for us to understand that view if we look at radiologists and pathologists as isolated workers who work …
A radiologist reflects on indeterminate findings
Text message: “John, This cough and congestion is killing me. It’s turning thick and green. Can you write me a Z-pak? It always works for me.”
If you write a blog on medical decision-making and heart rhythm matters, it seems an incredible omission not to opine on the FDA warning concerning the commonly used antibiotic azithromycin (the drug in a Z-pak). Quoting directly from the FDA warning:
[Azithromycin] can cause …
Azithromycin and long QT syndrome: Facts from a cardiologist
Yesterday I had office hours: 26 patients at 15-minute intervals, followed by 3 new patients for one-hour visits, interspersed with 4 emergencies and 33 phone calls. An active normal day. However, the 1:30, 1:45, 2:00 patients all arrived at 2:15 and suddenly I was looking at an afternoon that would run deeply into eve. I really hate it when patients are late.
Now, I have to admit this is a unique …
As an oncologist, I hate running late
When I was young and foolish and just starting out in my career, I found it very hard to take “no” for an answer. If a patient needed radiation therapy, and he or she didn’t want to have it, I did my very best to talk that patient into it. I have always been a very persuasive person—if I didn’t get the go ahead on the first formal consultation, there …
Radiation therapy: Don’t let me talk you into it
I was very saddened to learn of the death of Roger Ebert. I, like so many around the world, was impressed and inspired at how he handled himself in the aftermath of his cancer surgery years ago that left him disabled and disfigured and unable to eat, drink or speak. And yet, despite his struggles he remained a dominant force in film …
Roger Ebert did not lose his battle with cancer
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