Allow me to describe a recent case and ask your opinion. Today, you are the intake nurse at hospice and you are asked to evaluate Stan. This gentleman has incurable cancer, but treatment would probably prolong his survival. However, Stan has refused that treatment and been referred to you. It is your job to decide if he is “hospice appropriate.”
Why has Stan refused therapy? It is not that he denies …
Would you admit this patient into hospice?
I was working side-by-side with a Kenyan ENT doctor at his hospital in Eldoret, Kenya. My wife, Kathi, and I were part of a team of head and neck surgeons organized by Indiana University spending two weeks working with Kenyan ENT surgeons to help them build confidence to perform operations independently. In rapid sequence, we were seeing dozens of patients who had signed up to be examined and hoping to …
Powerless to treat a complicated cancer case in Kenya
I was recently sent a link to this article entitled “Smile! You’ve Got Cancer” written by Barbara Ehrenreich. I encourage everyone to read it. The article lives up to its striking title and more. And I couldn’t help but respond with my perspective. So that you know where I’m coming from, my most personal encounter with cancer is that my grandmother died from cancer. I also treat people with acute …
The dreadful cost of denying how you really feel
“I’m so sorry, but it looks like the cancer has spread.”
As I heard these words come out of my mouth, I knew that in a split second, a new reality was created in the mind of the patient that I was talking to. I looked at his face and saw that he was trying to remain strong, but in his demeanor, it was apparent that dreams were crushed and that …
Unexpected lessons from an unexpected patient
For years internationalists have being trying to make the argument to ordinary Americans that foreign policy matters — that we must contend with complex issues overseas like countering terrorism while also focusing resources and energies on economic issues at home. We have posed it as a trade-off.
We are making the foreign affairs case the wrong way. Rather than argue the positive merits of trade or the negative repercussions of unchecked …
Cancer is an international war and peace issue
“I walked in a person, and out a cancer patient,” my dad said as we filed home. Crossing this threshold, we found ourselves on the other side of medicine — the side on the exam table or gurney, as opposed to the one standing over it. As a physician I was used to the latter. This is my family’s story in our new position, and how the cost of medical care has impacted …
A struggle against cancer becomes a financial worry
Have you ever had a conversation that rattles around in your head for days? Maybe, it changed what you thought you knew about the world. Perhaps the ideas or comments did not make any sense. I had a discussion last week and it seemed that logic stood on its head. The means was defined by the end, with no connection to the beginning, or more exactly, the tail wagged the …
When insurers dictate medical decisions
When I meet a new patient, I’m frequently astounded by the health care he has received. I’ve met patients with absolutely no cardiac symptoms who have been receiving EKGs every six months for years. I’ve had patients brag to me about their annual executive physicals in which myriad tests including treadmill stress tests and chest x-rays were routinely performed. Patients get head-to-toe CT scans under the mistaken hope that they …
Perverse incentives push physicians to order ineffective tests
While it is unusual for gastroenterologists to see colorectal tumors in patients under the age of 50, and even more uncommon before the age of 40, it does happen, so patients need to be aware of their risks. Colorectal tumors in young people are often detected either through symptom evaluation or because of a colonoscopy performed for an underlying risk factor, most commonly a family history of colorectal cancer (CRC).
During …
Young patients with adenomas: Who should get genetic testing?
Supporters of the most recent paper from the Canadian National Breast Screening Study (CNBSS) falsely contend that only radiologists are criticizing this study. This simply is not true. The Canadian study flaws have been well documented for decades.
Robert E. Tarone at the National Cancer Institute (who isn’t a radiologist) wrote in 1995 that there was a statistically significant excess of advanced cancers that were allocated to the mammography …
Radiologists aren’t the only ones criticizing the new mammogram study
I went to see my oncologist for my six-month checkup yesterday. All was routine, other than my blood pressure being 131 over something when it’s usually in the 115 range, even when I see my family doctor. No anxiety there.
When he asked what had changed in the last six months, I told him about the endoscopy I had in December, which turned out to be normal. But what prompted it …
Residual fear after a cancer diagnosis
I still remember being taken aback by how young she was. “She” was Mary — a 28-year-old woman who had completed chemotherapy for stage II breast cancer. She was treated elsewhere and had moved cities when her husband got a promotion.
“I’m still getting used to this area, but I am happy my hair came back before we had to move. I …
When patients ignore the evidence: Try to understand their values
News reports covering a prostate cancer study recently in the New England Journal of Medicine have all pretty much come out with the same message: men diagnosed with prostate cancer who had radical surgery did much better than men who were assigned to “watchful waiting” after they were diagnosed.
But guess what? There’s a critical fact that seemed to be missing in much of the coverage I saw. And that fact …
Watchful waiting for prostate cancer: Implications of a new study
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It was probably the most awkward question I had been asked before, and I did not have an answer.
He was a middle-aged gentleman, neatly dressed — very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED. He was clearly what we call a “frequent flyer,” but …
I still remember when my phone rang with an eerie sound, early in December 2013. The oncologist I had seen a couple of days earlier was on the other end asking me to return to the hospital ASAP because my bone marrow biopsy results was consistent with acute leukemia and I was at risk of bleeding.
That was the first time I knew about my diagnosis while he merely broke the …
Sympathy is the missing art in medicine
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 43-year-old man is evaluated in the hospital for severe abdominal pain of 2 days’ duration. He is otherwise healthy except for the recent finding of pancytopenia. Family history is noncontributory. His only medication is a daily multivitamin. Following a physical exam and lab results, what test is most likely to establish …
MKSAP: 43-year-old man with severe abdominal pain
It happens, now and then; not as often as one would wish, but occasionally. In other professions, a perfect day is when you make that super sale, finish a protracted project, win an important race or craft a special, remarkable piece of art. An oncology perfect day can be without bells, whistles, pats on the back, nor cash register’s whirr. Some of the best days lack pizzazz, vibrant emotion or …
A perfect day in the cancer clinic
We’re all waiting for something.
As kids, we waited for the time that we could do it ourselves, go it alone, tie our own shoelaces, order our own food off the menu, take our baths by ourselves, and walk up and down the street or around the mall without parental supervision. We were kids. We didn’t yet have enough life experience or enough insight to realize that the time we occupied, …
We will be waiting for something until the day we die
Mrs. Sandra Jackson knew that she was no Warren Buffet. She knew that she was no Bill Gates. Instead, Mrs. Jackson knew that she worked two jobs, 7 days a week to support her family. So, she hid her breast condition for a better time, another day. She would ask herself, which was more important: going to a doctor or buying her children dinner? For a true mother, the answer …
The costs of care was far beyond her means
When first introduced four decades ago, breast cancer screening with mammography was widely regarded as an important tool in the fight against this terrible disease. It seemed obvious that the earlier it could be diagnosed the more lives could be saved. Aggressive treatment, it was thought, would prevent the cancer from spreading through the body. A huge amount of research evidence since then has slowly and painfully led to a …
The benefits of screening mammography have been greatly exaggerated
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