I had a patient this week that really screwed up his medical care when he experienced a predicted side effect of curative chemotherapy. Despite clear instructions and access to every number my partners, my staff and I have, including office, triage, cell, and answering service, he did not reach out. Day-by-day he lay in bed, as he grew weaker and multiple systems failed. No one contacted me. Finally, he sent an email to a doctor 3000 miles away, in California. That doc forwarded the email to me. I sent the patient to the hospital.
Did we rush to the emergency room, to salvage his life? Of course. Were there innumerable tests, complex treatments, multiple consults and an ICU admission? You bet. Did I patiently explain to him what was happening? Yes. Did I look him in the eye and tell him that I was upset, that he had neglected his own care by not reaching out and in doing so he violated the basic tenants of a relationship which said that he was the patient and I was the doctor? Did I remind him what I expect from him and what he can expect from me? You better believe it, I was really pissed!
The practice of medicine for most doctors is fueled by a passion to help our fellowman. This is not a vague, misty, group hug sort of passion. This is a tear-down-the-walls and go-to-war passion. We do not do this for money, fame, power or babes; we do this because we care. Without an overwhelming desire to treat, cure and alleviate suffering, it would not be possible to walk into an oncology practice each morning. Therefore, just as we expect a lot of ourselves, we darn well expect a lot out of our patients.
Continue reading “Why Is the Doctor Angry?”
Filed Under: Physicians, THCB, The Insider's Guide To Health Care
Tagged: Cancer, doctor/ patient relationship, James Salwitz, noncompliance, Oncology, patient engagement, practice of medicine
Jun 1, 2013
Dear Ms. Jolie,
Thank you for your bravery and leadership in the battle against breast cancer. In a small way, through my patients, I understand the challenge and pain it took not only to undergo prophylactic mastectomies, because you carry the BRCA1 cancer gene, but also to reveal this deeply personal part of your life to the world (NYT, 5/14/13; My Medical Choice). You had no obligation to open your soul; your selfless act leaves those of us that treat the dread disease, in awe.
Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years. By opening up the conversation, by educating and by boldly stating that beauty, strength and health are possible, even when radical choices are made, you open up life saving opportunities for many. Mastectomies may not be the answer for all women, but the very idea that cancer can be prevented, instead of simply waiting in fear, is earth shattering.
Women and men will now better understand the genetic risks for cancer, be exposed to the different options which are available in the prevention of cancer and know that it is possible, whatever path is taken, to continue with full lives. You have made it easier for patients, their families and physicians to have vital discussions.
The announcement of your surgery coincides with a critical legal battle, the deliberations of the United States Supreme Court regarding BRCA genetic testing. You have put pressure on the Court to find against Myriad Genetics Corporation in the company’s attempt to protect their expensive monopoly of the breast cancer genetic assay. Thus, the Court will have the opportunity to reduce the cost of testing, which as you note, can run thousands of dollars per patient.
Your action changes the war against breast cancer. You have prevented the suffering of thousands and given them the opportunity to go on with life and be part of what is truly important, families and communities.
Thank you for your remarkable sacrifice.
James C. Salwitz, MD
James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.
Filed Under: OP-ED
Tagged: Angelina Jolie, BRCA1, Breast cancer, Cancer, James Salwitz, Screening
May 14, 2013
A woman’s mother dies at age 56. A blood test is done. The woman finds out she has a genetic pre-disposition to cancer. She takes what action she thinks she needs to take. A familiar story repeated over and over again every day. I’ve met many women who have made this choice. While not “normal”, it is a familiar situation. These women’s difficult choices go unheralded. But not Angelina. She has a voice and she’s not afraid to use it.
I am of two minds about Ms. Jolie’s announcement. Unlike double mastectomies for ductal carcinoma in situ (DCIS), which isn’t necessarily a cancer and can be treated with a lumpectomy, BRCA1 gene mutations can’t be treated any other way. Unless I hear differently from my breast surgeon friends, I’d say she probably did the right thing. Her decision to talk about it is probably encouraging to women who have or will have to make that choice. It raises awareness of the gene mutation. It puts breast cancer on the front page of the New York Times. Again.
Here’s my problem: double mastectomy is not a benign procedure. Ms. Jolie seems to have had a remarkably easy time of it. Yes, she says she was right back to her normal life soon after, but since Jolie’s life is not normal that’s hard to generalize. The truth is there is significant pain involved, a long period of waiting while the tissue expanders do their work, then there’s further procedures for the implants, which can develop capsules around them, or rupture, or get infected. If Angelina had chosen breast reconstructive surgery there would be the risk of the flap losing blood flow, multiple drains, overnight stays in recovery rooms or ICUs, and many many surgeries for revision, nipple creation, etc. And the results are not always beautiful. I understand that it is not Ms. Jolie’s role to scare people, but to encourage them. I would just warn against falsely rosy expectations.
I am not trying to discourage double mastectomy. Sometimes it is necessary. I do think that people who have extraordinary access to public attention must pay extraordinary attention to what they say. I wish Angelina all the best for a complete, and beautiful, recovery.
Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real.
Filed Under: OP-ED
Tagged: Angelina Jolie, Breast cancer, Cancer, prevention, Screening, Shirie Leng
May 14, 2013
The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.
It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.
Except when it doesn’t — and harms employees instead, which happens altogether too often.
Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.
Continue reading “Caution: Wellness Programs May Be Hazardous to Your Health”
Filed Under: OP-ED, THCB, The Business of Health Care
Tagged: Al Lewis, Cancer, CDC, Costs, Employers, Health Risk Appraisal (HRA), NCQA, Obesity, overdiagnosis, prevention, Screening, The Affordable Care Act, WebMD, Wellness, workplace medicalization
Apr 26, 2013
Jennifer Stinson was a nurse at The Hospital for Sick Children (SickKids) in Toronto who enjoyed brainstorming new ideas for improving care, especially for the kids with cancer she treats. But even as she gained status by getting her PhD and becoming a clinician scientist, she came up against persistent bureaucratic and organizational barriers to innovation.
Stinson’s challenge is common at big organizations, but overcoming bureaucracy and breaking down silos is especially critical in healthcare. To tackle these obstacles at SickKids, CEO Mary Jo Haddad in 2010 elevated innovation to a “strategic direction,” and engaged Innosight to help devise a full system needed to spur innovation. The resulting system has three major components:
- An Innovation blueprint detailing the types of innovations the organization wants to encourage. SickKids prioritized encouraging doctors, nurses and clinicians to look for unmet needs they could address, rather than wait for solutions from IT or top management. That required creating a focus group with 25 front-line healthcare workers to discover and catalog key “jobs to be done” (like reducing the length of hospital visits), surveying all 5,000 employees, and training most of them on how to integrate the innovation system into their daily practices.
- An innovation pipeline to reliably take ideas from concept to reality. This involved establishing a new 18-member Central Innovation Group of leaders from different areas of the hospital, a team that was tasked with prioritizing and advancing ideas and projects through various stages. The team helped innovators test prototypes, make adjustments, and then scale to a wider population.
- An innovation culture that features the right people, in the right roles, speaking a common language of innovation. A key enabler of this culture was the establishment of a $250,000 Innovation Fund to provide seed money for promising ideas. Now, instead of being stalled by permission hurdles that suppress initiative, promising new ideas could be funded, fast-tracked and prototyped.
Consider how the new system helped Stinson bring a transformative innovation to life. Every year at SickKids, thousands of children are battling various forms of cancer. It’s vital that they keep accurate diaries tracking their pain, but if it’s not done daily the data are virtually worthless. Typically these diaries must be filled out by hand, an annoying task that children with cancer aren’t motivated to do. The result is poor reporting and suboptimal pain management.
Continue reading “Driving Front Line Innovation In Health Care”
Filed Under: The Business of Health Care
Tagged: Apps, Canada, Cancer, David Duncan, Innosight, Innovation, SickKids, The Hospital for Sick Kids, The Pain Squad
Apr 19, 2013
True to his proudly claimed Chicago newspaperman roots, famed movie critic Roger Ebert remained a writer literally up until the moment he died.
“A lot of people have asked me how could Roger have [posted] that column one day and then die the next? Well, he didn’t know he was going to die the next day, and we didn’t expect him to. We expected him to have more time. We were going to go to home hospice. We thought we would take him home, let him enjoy that time, and let him get stabilized. I’ve got to tell you: I really thought he was just tired and that he was going to get better.”
“I want people to know that Roger was still vibrant right up to the end,” his wife, Chaz, told Ebert’s friend, TimeOut Chicago columnist Robert Feder, before an April 7 memorial service. “He was lucid – completely lucid – writing notes right up to before the moment of death,” she said. Only later did it occur to Chaz that Roger had begun signing his initials and dating many of the notes he wrote at the end. “Now I wish I had saved them all,” she said.
It was as if a man who had refused for years to be defined by illness refused to be defined even by death. Ebert spoke openly of being a recovering alcoholic (he stopped drinking in 1979), and when cancer cost him part of his lower jaw in 2006, cruelly taking away his ability to either talk or eat, he did not hide, wrote colleague Neil Steinberg in the Sun-Times, Ebert’s home newspaper. Instead, he forged “what became a new chapter in his career, an extraordinary chronicle of his devastating illness” written “with characteristic courage, candor and wit, a view that was never tinged with bitterness or self-pity.”
Ebert, wrote Roger Simon in tribute, was “a newspaperman’s newspaperman.” As a former Chicago newspaperman myself (at that other paper, across the street), I’m sure Roger Ebert continued to write even after his death.
It’s just that he hasn’t found a way, yet, to send out his copy.
As a long-time reporter for the Chicago Tribune, Michael L. Millenson learned the famous fact-checking fanaticism credo of Chicago journalism: “If your mother says she loves you, check it out.” He is currently president of Health Quality Advisors LLC of Highland Park, IL.
Filed Under: Uncategorized
Tagged: Cancer, End of Life Care, Michael Millenson, Roger Ebert
Apr 10, 2013
Most of us have spent some time thinking about our own deaths. We do it with a sense of dreadful curiosity, but then we push it aside with “well, we’ve all got to go sometime.”
Unlike most people, I probably know the how, the why, and maybe even the when of that event. It is profound information that turns the world upside down for us, our families, friends and caregivers.
I have cancer that is incurable, aggressive, and has negligiblesurvival odds. My chemotherapy is a long shot. I will leave a spouse, children, siblings and a life that I love and cherish. I cannot imagine existence without them.
I have read the books about stages of grief and end of life. But when all is said and done, truth is the great measure. The truth between doctor and patient when there is nothing else to be done. The truth between patient and family who want desperately to have a few more months or days and cannot. The truth between patient and friends who must accept and move on without bitterness. The truth between patient and spouse, partner, or caregiver who have waited for that moment and are helpless to change it.
Continue reading “Truth At the End of Life”
Filed Under: THCB
Tagged: Cancer, Caregiving, Elaine Waples, End of Life Care, Patients
Mar 21, 2013
After a terribly painful and debilitating illness, Steve died. He had been treated for Stage 2 Hodgkin’s Disease with a series of intense therapies including German enzymes, American antineoplastins, Mexican naturopathy and Chinese Herbs, complemented by focused meditation, innumerable vitamins, extreme diet modification and acupuncture for severe pain. He fought the cancer with every ounce of his being, doing everything to survive, except the one thing that had an 85% chance of cure; chemotherapy.
I was struck this week by a comment on my website, which bemoaned the highly disorganized state of “alternative medicine” in this Country and in particular the “paltry sums” for alternative research funding by the National Institutes of Health (NIH). The writer suggested that not only could the quality of health be improved with alternative medicine studies, but would go a long way towards saving health care dollars.
It seems to me that the idea that we need more Complementary and Alternative Medicine (CAM) research goes right to the core of the confusion between so called “conventional medicine” and CAM. There is a major difference between the medicine practiced by board certified, classically trained physicians and that of alternative practitioners. That difference is research and data.
If an MD or DO is treating a cancer patient and that patient asks to see or understand the basic science and clinical studies which support the recommended therapy, that published data is readily available. Standard oncology treatment goes through 10-20 years of research, from the test tube, animal studies and through a series of supervised human multi-phase trials, until it is approved and offered to patients. Each step is refereed by competing and critical PhD and physician scientists and must be published in peer-edited journals for general review and criticism, all of which is public and transparent. Where it is not, and when people attempt to manipulate or falsify the system or data, massive blowback eventually occurs.
Continue reading “Choosing Alternative Medicine”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: alternative medicine, alternative research funding, CAM, Cancer, Chemotherapy, conventional medicine, Hodgkin’s Disease, James Salwitz, placebo
Feb 13, 2013
We need heroes. Heroes show us light in the darkness, the way to the miraculous and ignite a fire in our soul to survive. They prove what is truly possible, through the fog of the impossible. We mourn the disgrace of Lance Armstrong because he seems to have achieved Pyrrhic victory. Let us not doubt; whatever his frailty as a man, Armstrong vanquished a terrible foe; moreover the path blazed is not bare, for everywhere are cancer heroes.
- The 45 year old RN raising her children while she works full time in a pediatric intensive care unit, celebrates her eighth year in remission from pancreatic cancer, treated with surgery, chemotherapy and radiation.
- The grandmother who ignored a breast mass for two years so she could care for four disabled grandchildren, and when the tumor grew to be massive, continues to take care of the children while receiving chemotherapy.
- The hospital chaplain who has suffered from cancer, sits at the bedside holding a hand, sharing a smile, saying a prayer that is heard deep in the heart and to the heavens above.
- The 71 year old with four different cancers, treated with a bewildering mix of surgery, radiation and chemotherapy, whose primary worry is the cardiac care of her husband.
- The 64 year old rescue squad volunteer while receiving chemotherapy and radiation for extensive lung cancer, assists 150 people to flee from their homes and escape the wrath of Sandy.
- The national lymphoma expert, who could be wealthy in his own clinic, instead devotes his life to teaching and research, believing he can save more lives by consulting and advising oncologists in communities around the country.
Continue reading “Replacing Lance”
Filed Under: THCB
Tagged: Cancer, Desperately Needed Heros, Lance Armstrong, Livestrong foundation, Oncology
Jan 26, 2013
The Affordable Care Act contains a number of provisions intended to incent “personal responsibility,” or the notion that health care isn’t just a right — it’s an obligation. None of these measures is more prominent than the law’s individual mandate, designed to ensure that every American obtains health coverage or pays a fine for choosing to go uninsured.
But one provision that’s gotten much less attention — until recently — relates to smoking; specifically, the ACA allows payers to treat tobacco users very differently by opening the door to much higher premiums for this population.
That measure has some health policy analysts cheering, suggesting that higher premiums are necessary to raise revenue for the law and (hopefully) deter smokers’ bad habits. But other observers have warned that the ACA takes a heavy-handed stick to smokers who may be unhappily addicted to tobacco, rather than enticing them with a carrot to quit.
Under proposed rules, HHS would allow insurers to charge a smoker seeking health coverage in the individual market as much as 50% more in premiums than a non-smoker.
That difference in premiums may rapidly add up for smokers, given the expectation that Obamacare’s new medical-loss ratios already will lead to major cost hikes in the individual market. “For many people, in the years after the law, premiums aren’t just going to [go] up a little,” Peter Suderman predicts at Reason. “They’re going to rise a lot.”
Meanwhile, Ann Marie Marciarille, a law professor at the University of Missouri-Kansas City, adds that insurers have “considerable flexibility” in how to set up a potential surcharge for tobacco use. For example, insurers could apply a high surcharge for tobacco use in older smokers — perhaps several hundred dollars per month — further hitting a population that tends to be poorer.
Is this cost-shifting fair? The average American tends to think so.
Continue reading “About Time? Smokers Face Tough New Rules Under Obamacare”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Cancer, Dan Diamond, Insurers, Medicaid Expansion, MLR, Obamacare, Premiums, smoking, smoking cessation, The Affordable Care Act, tobacco
Jan 25, 2013