Saturday, January 30, 2010

The dark side of "cancer awareness"

The American Cancer Society has designated this weekend "Suits and Sneakers Awareness Weekend," as part of the annual Coaches vs. Cancer program that will feature well-dressed basketball coaches wearing "sneakers instead of dress shoes with their usual game attire during weekend games to demonstrate their support for the Society and the fight against cancer." The idea is to encourage people to exercise and eat a healthy diet to reduce their risk of cancer. Of all of the ACS's cancer prevention initiatives, this is probably one of the best.

I'm suspicious of other "cancer awareness" efforts, though - in particular, the increasing fad of designating particular months or weeks of the year as times for heightened awareness of individual cancer types. According to the 2009 ACS calendar, the fall months are particularly crowded: September was for ovarian cancer, childhood cancer, leukemia and lymphoma, and prostate cancer Month; October was for breast cancer (with a "National Mammography Day" on the 16th); and November was for lung and pancreatic cancer. And this month saw Facebook virtually consumed for a few days by a "breast cancer awareness campaign" with female users posting the colors of their bras in status updates. While advocacy groups such as Susan G. Komen for the Cure denied any involvement, they also professed to be pleased with the attention that breast cancer was getting.

Yet I wonder if breast cancer really needs any more attention in a country where the recent release of painstakingly crafted recommendations to individualize mammography decisions for women in their 40s caused weeks of public furor and threatened to derail health reform legislation over the make-believe issue of "rationing." And from a public health standpoint, focusing on this single cancer to the exclusion of all other threats to women's health makes little sense. Among the causes of death in women, breast cancer doesn't even make the top five. It ranks 7th overall, and according to statistics from the Centers for Disease Control and Prevention, it isn't even the number one cancer cause of death. (That would be lung cancer, by a nearly two to one margin.) Even if breast cancer is detected and appropriately treated, there is scientific consensus that up to 1 in 3 women receiving treatment gain nothing from it, because the cancer was either slow growing or the patient was destined to die of some other cause (such as a heart attack or stroke) before the cancer would have caused any symptoms.

Finally, well-intentioned cancer awareness efforts can backfire by encouraging unnecessary or unproven screening for cancers. During the Facebook campaign, I was dismayed to see some of my former high school classmates discussing how a similar strategy might be used to persuade men to get testicular and prostate screenings (brief or boxer color?) or women to get checked for ovarian cancer (you've got me on that one). Unfortunately, there is no evidence that detecting any of these cancers with existing tests saves lives, and doing so could lead to cause emotional or physical harm from false positive testing.

I'm all for cancer awareness when the goal is to reduce the risk of developing cancer, or to deploy proven screening tests for early-stage cancers in age and risk groups that are supported by good scientific evidence. But naive "awareness" - that is, high doses of enthusiasm combined with misinformation - may actually harm as many people as it helps.

Thursday, January 28, 2010

Guest Blog: Cure

Veneta Masson is a registered nurse and poet living in Washington, DC. She has written three books of essays and poems, drawing on her experiences over twenty years as a family nurse practitioner and director of an inner-city clinic. Information about her poetry collection Clinician's Guide to the Soul is available at The following poem from that collection was originally published online in Pulse: Voices from the Heart of Medicine.



In Latin it means care,
conjures priests and temples
the laying on of hands
sacred pilgrimage
the sickbed
invalid and
solemn attendants.

How far we have come.
Today's English
has neatly expunged
those purely human elements.
Cure is impersonal, consequential
unequivocal, sometimes violent -
the annihilation
of the thing that ails.

This nurse
approaching the patient
has discarded temple garb
for practical scrubs.
His gloved hands
unsheathe the magic bullet,
shoot it through the central line
where it locks onto the target cells.

For the not-yet-cured,
there is still sacred pilgrimage -
that dogged slog
to the high tech shrine,
the health food store,
the finish line of the annual race
where, etched on each undaunted face,
is a gritty tale of survival.

- Veneta Masson

Sunday, January 24, 2010

Guest Blog: Facts and Lies

David Watts’ second book of stories, The Orange Wire Problem, along with Bedside Manners, forms a body of work which explores the complexities of the art of medicine. He has published four books of poetry and a CD of “word-jazz.” Dr. Watts is an NPR commentator, a producer of the PBS program Healing Words: Poetry and Medicine, a gastroenterologist at the University of California-San Francisco, and a classically trained musician. He has been an on-camera television host and a medical columnist for the San Francisco Chronicle. The following excerpt is from a piece originally published in the Bellevue Literary Review.



Well, your pulse is great.

The emergency room nurse is bending over my foot, his tattooed deltoid rippling with fine movements of support for the hand that reaches to feel my ankle. His words, the last to come from the ER staff after a six-hour visit, are, I assume, intended to reassure, which they do, arriving like carriers of some thread of connection between us, a fellowship perhaps, a gesture both well intended and well received. And I do feel better, better able to face the tremors in my muscles, fatigued by hours of clenching a tight protection for the red-hot joint, now diminishing after the long needle's nip, the suckout of orange reticulated fluids and the push of Novocain and steroids to soothe the singe. I am in the aftermath, in the place where the body luffs in its wheelchair like sails in a dying wind. And here, in this place, his words do mean something to me, even though I know he's lying.

You see, the problem is he palpated the wrong place, not behind the inside of my ankle, where the posterior tibial artery runs like a river of renewal, but - a common mistake - behind the outside, where it does not. That he chose to tell me the pulse was great even though he didn't feel it - couldn't possibly have felt it - let me know he meant to say something grander, maybe something that sounds more like best wishes or you're going to be all right.

What puzzles me is that even though I knew his mistake as he was making it, that contrary knowledge did not prevent the good deed from happening or being well received. ... His report on the status of my pulse floated in like a gesture, only part of a larger gesture that signaled something to me - maybe only that I was being cared for. For although skill and accuracy were missing, intention was there. And somehow intention was enough.

So here I sit not minding the chill of my body so much, not minding the wait so much, sustained at least partly by the effort, though flawed, the nurse had made to try and make me feel better.

And for whatever the hell reason, I do.

- David Watts

Thursday, January 21, 2010

Life, death, and organ transplantation - Part 2 of 2

In health care, rationing occurs when resources (doctors, nurses, hospitals, imaging devices, drugs, and, of course, dollars) are inadequate to meet the real or perceived medical needs of the population. One area of health care in which rationing is absolutely essential is organ transplantation, since the supply of organs is never enough to meet the demand. In my previous post, I described how I felt while presiding over the choreographed death of a potential organ donor several years ago. This memory came back to me after I read a New York Times Magazine article by pediatric cardiologist Darshak Sanghavi that described the ethical challenges of obtaining vital organs, such as the heart, for critically ill patients who would not survive without a transplant. In addition to "brain dead" donors (who are, contrary to what you might see on soap operas or prime time TV, quite rare), there is another option for donors who do not meet the critieria for diagnosing brain death - donation after cardiac death, or D.C.D.

If someone's heart has "died," how can it be transplanted to save the life of another person? In 1997, the Institute of Medicine declared that the passage of five minutes without a heartbeat to be consistent with death, and some hospitals created organ donation protocols for brain-damaged (but not brain-dead) patients similar to the one that I participated in to retrieve organs such as the liver and kidneys. Unfortunately, the lack of oxygen delivery to the heart during this 5-minute waiting period causes the destruction of enough heart muscle to make it impossible to transplant successfully.

Since the supply of brain-dead donors is not enough to meet the need for new hearts of infants born with inoperable heart defects, up to 50 infants in the U.S. each year die while on the waiting list for a heart transplant. So in 2008, pediatric cardiologist Mark Boucek published a controversial paper in the New England Journal of Medicine that detailed 3 case reports of successful infant heart transplanation via a new D.C.D. protocol that shortened the waiting period from 5 minutes to 75 seconds after the donors' hearts stopped, based on the rationale that the longest reported interval of a heart spontaneously re-starting was 65 seconds.

Predictably, many readers reacted unfavorably to the paper, feeling that it had crossed an ethical boundary. Critics of Dr. Boucek and colleagues feared that transplanting a heart so soon after it stopped beating would lead to a public outcry and loss of confidence in the organ donation system. Supporters pointed out that 3 infants were still alive who would most certainly not have been if not for this protocol. As theologians and philosophers have long debated when a human life begins, the transplantation debate revolves around the question of when we can safely say that someone has died, and amid inevitable disagreement, where a line can be drawn that most of us can live with ... no pun intended.

Monday, January 18, 2010

Life, death, and organ transplantation - Part 1 of 2

Several years ago, when I was a family medicine resident taking overnight call at Lancaster General Hospital in Pennsylvania, I was called to preside over my first - and so far, only - organ donation. A young woman had suffered an irreversible traumatic brain injury in a car accident, and although her heart continued to beat, her breathing was supported entirely by a mechanical respirator. Informed of their daughter's condition, her parents had decided to turn off life support and, in accordance with her previous wishes, donate her heart and other healthy organs for transplanation.

What complicated this decision, from an ethical point of view, was that this woman wasn't brain-dead, by the legal and medical standard prevailing in 2003 and today. Since it is illegal to retrieve a heart from a person who is technically alive, transplant surgeons were prohibited from acting immediately after the respirator was turned off. Instead, they were required to wait until an independent physician pronounced the patient dead based on the absence of a heartbeat, for however long it took for her heart to stop beating. Which is where I came in.

I remember feeing vaguely uncomfortable. Told that I had the option to pronounced death either when I was unable to feel a carotid pulse or when the patient's EKG monitor showed no heart rhythm, I decided on the latter as the more conservative course. I took a position at the head of the bed and a respiratory technician turned off the respirator, then gently extracted the breathing tube. The patient's pulse, which had been about 100 beats per minute, gradually slowed. Five minutes passed, then ten. The crisp upstrokes on the EKG monitor became flatter and more wobbly. The pulse rate fell to 40 beats per minute - well under the normal resting heart rate for all but the fittest of endurance athletes - then stabilized.

The gazes of everyone in the room, including mine, were fixed either on the second hand of the clock on the wall or the pulse rate on the EKG monitor. Fifteen minutes passed, then twenty. The patient's grief-stricken parents, and a young man whom I decided was either her brother or boyfriend, began fidgeting quietly. Doubtless they had not expected the process to take nearly this long. Although the EKG tracing was barely discernible, the monitor was still showing a fluctuating pulse rate between 35 and 39 beats per minute.

I knew that surgeons in the operating room next door were scrubbed, gowned, and ready to operate, and that an ambulance was waiting outside to carry the organs to other dying patients who desperately needed them. Every passing minute deprived of oxygen made those organs less likely to survive a transplant. Thinking about this, and looking at the ashen patient in front of me, I made a decision. I reached down and felt the patient's neck for a carotid pulse. There was none. With one last glance up at the still stubbornly-pulsing monitor, I turned my eyes to the clock on the wall, intoned, "Time of Death: ..." and read the time.

In the next post in this 2-part series, I'll explain why a recent New York Times magazine article brought up this memory of mine.

Saturday, January 16, 2010

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from November and December:

1) Ignore health reform scare stories (12/11/09)

2) Food for thought on health care reform (12/27/09)

3) Doctors' conflicts of interest can harm your health (11/4/09)

4) Healthy skepticism and improving health communication (12/3/09)

5) Airport security and hamster wheels: analogies for American primary care (11/30/09)

If you have a personal favorite that isn't on this list, please let me know. Also, if you care to nominate my blog for the "Best New Medical Weblog of 2009" award, please do so at Thanks for reading!

Thursday, January 14, 2010

The 50 yard-line perspective on health care

I have, without a doubt, the best brother-in-law ever, and his wife's parents are also, without a doubt, two of the best in-laws ever, as well as the owners of season tickets to the newest, biggest stadium in the National Football League. So it was that I found myself sitting in a front-row seat at the 50 yard-line of Cowboys Stadium on January 3rd, to watch my favorite football team shut out their division rival Philadelphia Eagles in the final regular game of the 2009-10 season.

The next weekend, I again watched the Cowboys rout the Eagles by 20 points in the first round of the playoffs, only this time on television. The stakes, the tactics, the players, and the outcome of this game were all very similar to those of the week before ... but the difference in perspective was dramatic. Whereas the week before I was able to see up close the sideline coaching, impromptu strategy discussions, and players going through their mental and physical warmups, the TV perspective focused almost exclusively on the action on the field.

This difference in perspective got me thinking about my goals for this blog, which I've now been writing for six months. I am not, by any stretch of the imagination, a health policy decision maker. Nor am I the typical family physician who labors for fifty-plus hours per week seeing a new patient every 12 to 15 minutes, catching up on paperwork over a nonexistent lunch break, and taking phone calls after hours. If you are looking for the 50,000 foot perspective or the view from the trenches of health care, Common Sense Family Doctor probably shouldn't be the first blog you read. Rather, I hope that my blog provides a 50-yard line perspective - a view of the critical intersection between health policy and clinical experience, where big ideas are tempered by the reality of everyday medical practice. Please feel free to let me know, publicly or privately, how well I'm succeeding.

Monday, January 11, 2010

No country for health care: rural medicine in America

Thanks to Dr. Fitzhugh Mullan and colleagues at the Medical Education Futures Study for letting me know about a terrific 4-part series of articles by Emily Ramshaw of the Texas Tribune. In "No Country for Health Care," Ramshaw documents the severe difficulties that residents of rural Texas have in accessing primary and specialty care services. While most of the national health reform debate has revolved around providing insurance coverage to more people, this series illustrates the profound challenges of obtaining medical care in these and other similar regions of the U.S., insured or not:

Many Texans live more than an hour from basic medical care. Some border communities have so little health care that U.S. citizens cross over into Mexico to get it. ... 63 Texas counties have no hospital. 27 counties have no primary care physicians, and 16 have only one.

Conventional solutions to this shortage of rural health providers - offering scholarships and loan repayment incentives to doctors who choose to practice in underserved areas and changing medical school curricula to increase exposure to rural medicine - have proved woefully inadequate to the task. As the urban population has increased relative to that in rural counties, fewer legislators are able to advocate for rural health needs, and recruitment of new doctors has become nearly impossible. (Cities, in contrast, usually have a glut of doctors - the District of Columbia, for example, has more nonfederal physicians per capita than any state in the U.S.)

Despite a recent infusion of federal stimulus funds, the National Health Service Corps is not, and probably never will, be enough to compensate for the tendency for physicians (and other types of clinicians) to gravitate toward urban and suburban lifestyles. Health care reformers need to come up with more creative solutions. Telemedicine may be part of the answer; old-fashioned house call practices might be another. No strategy can possibly succeed, however, in the absence of a coordinated and determined effort to train more family physicians.

Sunday, January 10, 2010

Guest Blog: Having an MRI/Waiting for Laundry

Jan Bottiglieri is a writer and editor, and a poetry student in the MFA program at Pacific University. She lives in Schaumberg, Illinois. The following piece was first published in the Bellevue Literary Review.



I am wondering how a childhood that seemed almost miserable at times can be looked back upon with such an aching love for even the smallest detail. Because the noise here inside the MRI machine is so common, so familiar, that within seconds I am leaning against the wall near the back door of my mother's house, circa 1975, listening to the green Maytag spin. The breeze does not circulate mechanically through a closed, bright tube; it wafts through the open door hung with flowered curtains my mother sewed herself in the room across from mine, and they are so lovely I am afraid to touch them. It is 1975, so my father is already dead but not my grandmother, and with my eyes closed I feel her moving through the house behind me, smoothing sheets, waiting. It is 1975, so my brother may already be smoking pot in some local basement but could then run up the steps and home for dinner, having still his childhood and all his limbs. It is 1975, so I have never been in love or made love to, never almost died from cancer, never married, never carried and bore my son, never had this MRI. It is 1975 and I am twelve in a house I know so well I can tell you - that cupboard? - left to right, bleach, silver polish, Bon Ami, a china dish filled with slivers of still-good soap. It is 1975, and I am just a girl waiting for laundry, trying to help her mother. Then the nurse cuts in over the speaker to tell me I am finished just in time: because I tell you, I am certain, that in a few more seconds that bell would have rung, as clear as the sunlight through the open door, telling me the cycle was over - and that sound, circa 1975, would surely have stopped my heart.

- Jan Bottiglieri

Thursday, January 7, 2010

Hospitalists: complicating continuity of care

Whom would you rather take care of you if you need to be hospitalized? Your family physician who has managed your health issues for years? Or a complete stranger with specific training and expertise in caring for hospitalized patients? My medical school years (1997 - 2001) saw the rise of the "hospitalist" movement, a new physician specialty that defined itself as doctors who only cared for patients admitted to the hospital. This specialty has grown dramatically over the past decade, and is now represented by its own organizations, such as the Society of Hospital Medicine.

As a result, many primary care physicians have restricted their practices to office care only, which has financial (seeing extra patients in the time previously needed to travel back and forth from office to hospital) as well as lifestyle benefits (no more trudging in to the emergency room in the middle of the night to admit patients). A 2007 study found that patients cared for by hospitalists had a slightly shorter length of stay than patients cared for by general internists and family physicians, though costs of care were comparable between hospitalists and family physicians.

For the most part, this is a win-win situation for doctors and patients. But many office-based family physicians, including me (I stopped hospital work in 2008), feel that something valuable has also been lost in the transition - namely, continuity of care, the knowledge about a patient attained over years that can't be easily summarized in a brief admission note or even an electronic personal health record. In a recent piece in the Annals of Internal Medicine, Howard Beckman, MD, a former chief of medicine who subsequently stopped providing hospital care, relates the story of having a longtime patient hospitalized for breathing difficulty without his knowledge, until the patient's husband called him personally. When Dr. Beckman contacted the hospitalist on call to ask why a head CT scan had been ordered, rather than providing an answer, the hospitalist challenged him about the rationale for one of his patient's anti-anxiety medications:

The CT scan question was lost in my sense that I was viewed as the local medical doctor from whom the patient needed to be protected. At that moment, the lack of continuity in the patient's care seemed stark and disappointing.

Dr. Beckman goes on to describe how this lack of continuity, rather than being an isolated case, is in fact "the norm":

I am notified by fax of a patient's hospitalization. I am seldom informed of a patient's arrival in the emergency department or consulted to discuss their impressions and integrate my knowledge of the patient's ambulatory course into the decision-making process. Most of the time, I find out about patients in the emergency department because they or their families call me. Patients erroneously assume that I have been part of the admission conversations.

Although the American Academy of Family Physicians has established guidelines for communication between hospitalists and primary care doctors, there is much anecdotal evidence that hospitalists often fail to consult a patient's personal physician to the extent they should. This is a tragedy that will likely worsen with health reform, as more patients who would otherwise end up in hospital emergency rooms are able to routinely access outpatient primary care services. There is no reason that physicians can't work together better to improve a patient's hospital experience and quality of care.

Monday, January 4, 2010

Guest Blog: Found in Translation?

Danielle Ofri is a writer and practicing internist at New York City’s Bellevue Hospital and editor-in-chief of the Bellevue Literary Review. The following piece is an excerpt from her newest book, Medicine in Translation: Journeys with my Patients (©Beacon Press, 2010, reprinted with permission). In addition to following Danielle on Twitter, Facebook, or her homepage, you can also meet her this month at readings in New York and Washington, DC (including Barnes and Noble in Bethesda on Jan. 20 and Politics and Prose on Jan. 21).


“Je m’a…,” I stuttered to Aristede Mezondes, the serious young man in a grey wool overcoat, standing before me with ramrod posture. “Je m’appelle Dr. Ofri.”

There. I’d gotten it out.

The language of Descartes, Voltaire, and Balzac had clearly vacated my cortex. Despite those years of French classes and one brief visit to Paris, “Je m’appelle” was the best I could come up with. And even that was a struggle. Pushed aside by the overwhelming necessity for Spanish in our clinic, further dilapidated by decades of disuse, I could not conjure up a single word in French beyond stating my name. I was appalled at my brain’s porosity.

Mr. Mezondes smiled politely. No doubt he was accustomed, and perhaps resigned, to the challenges of communication here in America. I gestured for him to sit down, and tried to signal a polite, “just a moment,” as I started down the list of options. First was calling the office of our volunteer interpreters. I asked around in the waiting room, but nobody spoke French. I surveyed the clinic staff—only Spanish and Chinese to be found. Back at my office, I resorted to the final option and called AT&T. When a French-accented voice graced my ear, I exhaled a sigh of relief.

Mr. Mezondes and I took turns on the phone, and I learned that he was a 24 year-old man from Braazaville in Congo. He spent an extra cycle of translation ensuring that I understood that this was the Congo that used to be French Congo, not the Congo that used to be Zaire. He was generally healthy, but his main concern was a burning in his stomach, especially after he ate.

Even though we smiled gamely at each other as we handed the phone back and forth, it was hard to say that we were really having a conversation together. It was more like we were each having a conversation with the polite but business-like interpreter. And that’s what our conversation was: polite and business-like. I asked the questions, he supplied the answers. I kept my utterances brief, not wishing to overload the operator and I sensed Mr. Mezondes doing the same. I was also cognizant of the cost of the services, so I tried to be as efficient as possible. I even ventured to tell my patient his diagnosis and treatment during this initial conversation, something I normally would never do before the physical exam. But I didn’t want to have to call the operator back again, so I explained that he most likely had acid reflux, and—barring any information to the contrary that I might glean from the physical exam—that I would give him a medicine for acid and see him again in my clinic in one month.

We said goodbye to our AT&T friend and I gestured him up onto the exam table. As I palpated his abdomen and listened to his heart, Mr. Mezondes asked in halting English, “You speak little français?”

No.” I shook my head, regretting the years of study that had never succeeded in cementing my French. “Solamente español.”

“Español?” he said with a broad grin. “Yo hablo español.”

Spanish? He spoke Spanish?!?

For the rest of our visit, we chatted happily, if a bit awkwardly, in our mutual non-native languages. I learned that he’d studied Spanish at his university in Congo, and I told him that I’d studied on trips to Latin America. And then we were able to review his medical issues and treatment, and I could be confident that he understood.

It had never dawned on me that Mr. Mezondes would speak Spanish. I had assumed that, like most West Africans, Mr. Mezondes would only speak French in addition to his native language in Congo. It never dawned on Mr. Mezondes that I might speak Spanish. I guess he assumed that most white Americans didn’t speak anything but English.

“Hasta luego,” he said, shaking my hand.

“Ojalá que pasa un buen día,” I replied, with a small surge of pride that I’d nailed the subjunctive. I knew that Mr. Mezondes could appreciate the linguistic leap that grammatical construct entailed.

Mr. Mezondes left my office to make his appointment with the front-desk staff. Most of the Bellevue clerks were Hispanic, bilingual in Spanish and English. Mr. Mezondes—a native Congolese who spoke scant English—would have no trouble at all arranging his health care.

Friday, January 1, 2010

New Year's resolutions for physicians

The widening income gap between primary care and other types of physicians is one of many reasons that fewer medical students have been choosing careers in family medicine, general internal medicine, or general pediatrics. So it stands to reason that if any doctors will be paid less money in a reformed U.S. health care system, it ought to be the specialists. Up to this point, however, no physican organizations have offered to reduce their members' incomes in order to help control health care costs. In an editorial in last week's New England Journal of Medicine, medical ethicist Howard Brody points out the ethical problem with this uncompromising stance:

Early in 2009, insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration's health care reform efforts. ... Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests - including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Brody goes on to assert that physicians could lower health care costs simply by paying more attention to evidence-based care guidelines, since studies have shown that areas of the U.S. which use more health resources (e.g., diagnostic scans, surgical procedures) do not have better health outcomes. He then challenges each medical specialty society to draw up a "Top Five" list of expensive tests or treatments that provide little or no health benefit and to develop a plan to discourage its members from ordering items on this list.

Unfortunately, I would be shocked if any physician groups actually stepped up to the plate to do this. In our current health system, all of the incentives - financial and psychological (see my previous post on reform "scare stories") - are aligned so that physicians provide more wasteful care, not less. But just as we all make difficult-to-attain resolutions every New Year - "I'll start an exercise program" or "I'll lose ten pounds" or "I'll be nicer to people who get on my nerves" - all doctors, regardless of specialty, should resolve to set aside self-interest and order fewer tests, treatments, and procedures that are not supported by good evidence in 2010. And in 2011. And in every year after that, until it actually happens.