I once had a patient in whom I found a small breast lump. She was only thirty-two, and the lump was soft, non-tender, and mobile. But it was new. She examined her breasts monthly and was certain that she hadn’t felt it the month before. And she had a family history of breast cancer.
So, I asked myself, what to do? Her age—as well as the lump’s characteristics on exam—made the …
5 questions every patient needs to ask
When we love someone, we want for them the best. We fight for and with them. We push them to attack disease. Is it possible that our very love can cause suffering? Can we mistake our eternal love for each other with a futile fight for immortality? Does our caring crush the ones for whom we care?
In a fascinating article, the Wall Street Journal followed the terminal case of …
Does our caring crush the ones for whom we care?
In the summer of 2007, then-U.S. Preventive Services Task Force member Russ Harris, MD, MPH approached me about taking on what he suggested would be a fairly quick and straightforward project: summarizing the small amount of medical literature on the benefits and harms of the prostate-specific antigen (PSA) test that is commonly used to screen asymptomatic men for prostate cancer.
Little did I know that this research and its implications would …
Reaching the end of PSA screening
The New York Times recently published an article titled “A Life-Death Predictor Adds to a Cancer’s Strain” or, alternatively, “Genetic Test Changes Game in Cancer Prognosis.” The piece is interesting on several levels, but, to me, serves to highlight an increasingly common ethical conundrum: are physicians obligated to seek knowledge that is available but has no possible medical benefit?
Most of us are familiar with the Schrödinger’s cat thought experiment …
Are doctors obligated to seek knowledge that has no medical benefit?
Prostate cancer is in the news again, thanks to a recent study in the New England Journal of Medicine.
The study looked at surgery versus observation for localized prostate cancer. According to MedPage Today, “Neither overall mortality nor cancer-specific mortality differed significantly between men who had surgery and those who were prospectively followed. The absolute difference was less than 3% …
Localized prostate cancer treatment: Is surgery no longer an option?
I recently had the privilege of joining the Yale Cancer Center’s contingent on a visit to University College London in the U.K., where we share a number of scientific collaborations.
Between discussions of pathways, particles, and personalized medicine, some of the “tea time” conversation turned to policy and how uninsured patients with cancer in the U.S. get care. We talked about …
Stop searching for the health reform silver bullet
When President Obama turned 50 last year, he made an “informed patient request” for a PSA (prostate specific antigen) test. This is the blood test routinely used to screen men over 50 for possible prostate cancer. The President received his PSA test. But under ObamaCare, you may not be able to.
Now that ObamaCare has been upheld by the Supreme Court, all of its major provisions will be in force, …
How will ObamaCare affect prostate cancer screening?
Here is the setup. You’re working in the ICU. You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions. You sensitively state the facts: the patient has less than a 5% chance of survival. Or perhaps you say “he will definitely not survive.”
The family confers, and decides that they want to focus on keeping him alive as long as possible. …
Psychological factors influence how patients interpret information
I grew up with a harsh awareness of my own mortality. Though due in part to my drivers’ ed teacher, who spent most classes telling gruesome tales of the horrors that befall high schoolers who don’t pay attention while driving (you got your money’s worth, Mom and Dad!), I think the reality of cancer was what really struck me. It took my grandfather in his 70’s, and I miss him …
Life somehow leads us exactly to where we are supposed to be
A recent economic analysis concluded that patients with metastatic cancer value their treatments significantly more than regulators recognize, with many expensive new therapies looking like veritable bargains to most patients. Yet the study ignored the values really driving oncology spending—the warped incentives oncologists have to promote their own bottom line by prescribing expensive treatments.
Let’s start with the economic analysis, another in a series of studies by a USC team of …
Do oncologists have an incentive to prescribe expensive treatments?
“Everything must change, nothing stays the same. Everyone will change, no one stays the same.”
Technology is amazing. I love to download random songs on my iPhone and listen to the songs that populate. On one bright early morning, Oleta Adams came on. The song was “Everything must change.” It’s a beautiful and haunting, somewhat sad but at the same time hopeful, song. It stirred up memories, and I found myself …
Patients and doctors remain connected, even though distance
There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they …
Should personal anecdotes play a role in health policy?
“I will never forget that day.”
She smiled broadly.
“It was about a week after my cancer surgery and I had finally worked up the courage to look in the mirror. I knew you had rearranged things a bit, okay. Moved stuff around. Taken things apart and jammed them all back together, right?”
I probably would not have said it quite like that, but she was correct that her surgery had involved removing part of her …
Imagining what goes through a patient’s mind after surgery
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Today would have been easier if I did not give a damn. Easier if patients were clients. Easier if medical advice was causal suggestion. Easier if I believed that patients were solely responsible for their health. Easier if suffering was not real. Much easier, if I did not care.
However, despite the popular movement from “the doctor knows best” towards shared decision-making, I feel responsible for my patients. What happens to …
When patients make the decisions to harm themselves
I know a surgeon who, when consulted about a child with appendicitis, will insist that a CT scan of the abdomen be performed before he will see the patient. It doesn’t matter that the history and physical exam fit the diagnosis perfectly. It doesn’t matter that the child has already undergone an ultrasound of the appendix that shows it is dilated and inflamed. It doesn’t matter that the radiologist has …
Parents need to ask: Is this CT scan necessary?
My mom passed away last December to Stage V breast cancer metastasized to her liver. During this battle she developed ascites (an accumulation of fluid in the peritoneal cavity) as her liver failure progressed. This accumulation of fluid was not only extremely uncomfortable but painful as well. In an attempt to find symptomatic relief for the last months of my mom’s life, the oncologist presented us two options: we could …
The tragic outcome of a decision to minimize costs
The following column was published on June 5th, 2012 in USA Today.
I recently had the opportunity to try out a surgical robot, a medical device that has excited doctors, patients and hospital marketing departments. During the demonstration, I was able to precisely manipulate the robotic arms using joysticks. The experience felt right out of a Hollywood movie, as I was able …
Robots for surgery aren’t ready for widespread use in hospitals
In 2011 The National Cancer Institute published results from their study of low dose CT lung cancer screening of individuals identified as at risk for lung cancer. The investigators enrolled those between 55 to 74 years of age who had at least 30 pack years of smoking under their belt (number of packs per day multiplied by number of years smoked). These people were then randomly assigned to either a …
Is CT lung cancer screening worth it?
I was recently asked to speak at hematology-oncology Grand Rounds at Rhode Island Hospital. Instead of my usual topics on gynecologic cancers or sexual health, my colleague, MaryAnn Fenton, had asked me to speak to them about promotion in academics. I was both touched and taken aback that I was now in a position to give that kind of advice. …
Always remember why you are a doctor
“Cheers!” “To good health,” my girlfriend and I toasted in the living room of our apartment joined by my parents on speakerphone.
It had been 12 years since my last radiation treatment—my last treatment for Hodgkin’s Lymphoma. Tonight was the anniversary of my remission, and in the case of Hodgkin’s—a cancer with an exceedingly low relapse rate—tonight was my anniversary of being cured.
I kissed my girlfriend goodbye and tread the dark …
Long waits to access primary care are avoidable
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