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.
Saturday, January 30, 2010
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 sagefemmepress.com. The following poem from that collection was originally published online in Pulse: Voices from the Heart of Medicine.
**
CURE
In Latin it means care,
conjures priests and temples
the laying on of hands
sacred pilgrimage
sacrifice
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
**
CURE
In Latin it means care,
conjures priests and temples
the laying on of hands
sacred pilgrimage
sacrifice
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.
**
FACTS AND LIES
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
**
FACTS AND LIES
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.
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.
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 Medgadget.com. Thanks for reading!
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 Medgadget.com. Thanks for reading!
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