James Salwitz

marijuana cancer patientsMy wife calls them “hand-me-ups”…  things we inherit from our kids.  My ex-fashionable shirt that my son wore in college.Our semi-vegetarian diet my daughter adopted in high school. The dog at my feet that came visiting for the weekend, three years ago.

Our lives are enhanced and modified by the most unexpected of teachers, our children. The mentoring of our progeny keeps those of graying years at least partially youthful.  Still, I was astonished to hear this week, the words, “Dad, you need to starting doing drugs.”

The “dad” being addressed is 93 years old and has advancing cancer. He is tired, nauseas, anxious and sleeps poorly.  Though he likely has a number of months to live, he has become withdrawn.  Despite my usual medical brew, his incapacitating symptoms are without palliation.

Dad is miserable.  Enter his daughter with the solution.  The “drug” she is talking about is the treatment de jour, marijuana.

How did this happen?  We raise our kids to be good, honest, mature citizens; we drive them to soccer, suffer through years of homework (do you remember dioramas?), and do the whole college obsessive-compulsive tour thing.  In addition, above all, we beg our offspring to stay away from pot, pills and addictive mind-altering potions.

Now they turn on us, pushing ganja in our time of need. How did we go wrong?  Actually, it is we that missed a great opportunity.

50% of Americans have inhaled marijuana at some point in their lives.  More than 25 million of our neighbors have used it within the last year.  Those that imbibe are of a decidedly younger demographic.  The oldest citizens, especially those of the Greatest Generation, are much less likely to have experience with cannabis.

Fortunately, once again, youth presents the solution.

Continue reading “Dad, You Have to Inhale”

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Medical students frequently see patients with us in our office.   Their presence is welcome, if for no other reason than it makes us think young.

A second year student has been coming to our office for over a year and is excited about a future taking care of cancer patients.  She just completed the Hematology and Oncology section of lectures at the med school.  I asked her how it went.  “Frankly, “ she said, in the articulate way of the highly educated, “it sucked.”

I was astonished. How could such an exciting, complex and rapidly evolving field, yield teaching that would cause a motivated student to take such umbrage?   Too much information?  Too complex a topic?  Too much difficulty in the exams?  “No,” she said, it lacked “too” of anything.

It was not organized, not at the appropriate level, rambling and incomplete.  Without reviewing the critical information in texts and online, she would have learned little and the entire class would have failed the subsequent tests.

In a huff, wanting to assure that we not lose a crop of budding oncologists, I swore to find the cause of this didactic discord.  Surely, it must be possible to put together a set of clear, complete, cancer and blood lectures, so that the students were not only taught, but inspired.   Somehow, we would fix those lagging lectures.  But, then it occurred to me, why?

There are 141 medical schools in the United States, 2372 in the world. They teach 20,055 students in North America and hundreds of thousands around the globe.  In every school, every state, and country, they all teach about cancer.  In every school, cancer is the exact same disease.  On every continent, the possible treatments are the same. 

Therefore, why in the world do students listen to different lectures by different teachers on the exact same subject?

Why use the lecture hall format in medical school?  Why not find a few super-experts to write one perfect lecture, and then record that lecture one perfect time, given by a brilliant, inspiring, articulate educator (with translations)?

Continue reading “Med School: Can the Lecture!”

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Once-upon-a-time, when a patient said they were taking a vitamin, most doctors would simply shrug their shoulders and say, “well, I guess its OK, it couldn’t hurt.”   There was little research to judge the affect of vitamin supplements, so there was no reason to take a stand.  That is no longer true.

Now we have published data on many vitamins and we can say that for most people they do not work.  More importantly, there is increasing research that says manufactured, chemically synthesized nutriment compounds in a pill, can be deadly.

For this reason, I am likely to ask my patients if they are taking a vitamin and, if so, which fabricated additive and how much.  Therefore, I asked Bill, while he was in the office receiving chemotherapy for Hodgkin’s disease, what alternative therapies he was using.

When he informed me that he swallowed a multivitamin (MVI), large doses of Vitamins C and E, as well as a B complex preparation, I advised him to stop.

To my astonishment he responded, “Well, you only want me to do that because you make a lot of money on chemotherapy, and vitamins might put you out of business.”

Bill’s response, he lack of trust in my advice, disturbs me at several levels.  He fails to understand and does not wish to learn the present state of science regarding nutrition. In addition, there is a major problem regarding his perception of my motivations and therefore the veracity of my guidance.

Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin.  They do not prevent or fix anything.  Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.

More importantly, there is increasing data that people taking a multivitamin may become less healthy.

Continue reading “That Vitamin There Could Kill You”

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One of the spinoffs of being an oncologist is that you do not to take the world for granted.  Each morning, I walk around the yard and smell the morning breeze. I am thankful for my children, my wife and my own health.  I am thrilled, if occasionally skeptical, to have the opportunity to pay taxes in a Country that I love.

So, who would believe I would take our Electronic Medical Record (EMR) for granted?

I know, shocking, isn’t it?  How could I overlook a key factor in the success of our practice, ever since we ditched paper records, 13 years ago? Nevertheless, it is true. Day-by-day, the keyboard and screen became just another device, like a stapler, paintbrush or pocket comb.   I began to use it out of simple necessity, and neglected to sit in awe of its power and glory. I ask the geeks of Silicon Valley to forgive me.

We have been binary in our office for a long time, but not in our main hospital.  In the office, everything flows by electron, but at the hospital we have been using a kind of EMR-light, call it E-decaf.  Maybe we turn on the machine to check a few labs, order the occasional test, and perhaps send an email.  Thus, even though the docs of our practice spend more than a hundred-fifty hours a week on the wards taking care of 60 patients a day, we were still paper-binder-chart-bound.

But, last week it happened … we crossed the Rubicon … in a blinding flash of bits and bytes, clicks and clacks, copy and paste, we went full-on-no-holds-barred, every-piece-of –data-for-itself electronic and converted to the EMR.  It was glorious!

In the hospital, I had long gotten used to the appalling inefficiencies of the crayon and papyrus world.  First,  find the chart ( good luck… I am sure I have lost a year of my life hunting ). Then, read the prior notes ( which for many doctors, including yours truly, is impossible ).  Find the labs.  Find the X-ray reports.  Check the images.  Call the lab and radiology for the labs for the results that you could not find.  Seek and then check the vital sign clipboard.  Read the I&O record (different clipboard).

Now, there’s time, barely, to see the patient.

Then, painfully, ridiculously, illegibly, write down what you just found, repeating everything you also wrote yesterday (except what you forget or can’t read, which is probably critical) and then put the chart back in the rack (maybe), so that the next doctor can start this whole process over again.

You think I am kidding? Exaggerating? Not the tiniest bit. What I described is what every doctor using chisel-stone-tablet records does every day with every patient and if you have a lot of patients in the hospital it takes a very long wasteful time and is guaranteed to result in error.  Ask any doctor to pull any binder at random from any chart rack anywhere and read it carefully and there is an almost 100% chance you will find a mistake in that record.

Continue reading “Actually, I Love My EMR …”

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What do Louis Pasteur, Jonas Salk, Sigmund Freud and Barack Obama have in common?  They all championed controversial medical revolutions and if not for their bravery in the face of conflict, billions would have died.

Sterilize instruments to kill invisible bugs? Inject disease particles to build immunity?  Look into our subconscious to explain everyday behavior?  Give basic healthcare to everyone?  Ludicrous.  That is why we named these advances after these men.

As an oncologist who has seen the fatal cost of our patchy, imbalanced and unfair healthcare system, I have to be at very least hopeful about ObamaCare; AKA the Affordable Care Act (ACA).  The list of benefits is so vast that whatever glitches happen along the way, I know that cancer patients will be helped:

-No pre-existing condition exclusion: So the 31-year-old programmer with Stage 1 breast cancer can change jobs without losing insurance.

-Healthcare coverage by parents until their child is 26: So families will not lose their homes paying for Hodgkin’ s disease in a 22-year-old.

-Guaranteed payment by insurers for patients entering experimental trials: So patients with any insurance can be involved in research, and everyone benefits from the latest advances.

-Free healthcare screening: So that my 58-year-old neighbor with a family history of colon cancer gets routine exams and life saving colonoscopies.

-Uniform healthcare insurance standards: So that the 45-year-old man with stomach lymphoma I saw last week, does not have to suffer and die because his employer brought a health policy, which excluded chemotherapy.

Continue reading “The Next Great Cure? A Cancer Doctor Explains Why He Supports the Affordable Care Act”

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The general practice of oncology seems to come in waves of disease.  One week every breast cancer patient is in trouble, another sees multiple new cases of lymphoma or leukemia, the next it as if someone is giving away lung cancer (or perhaps cigarettes) and then three patients with pancreatic cancer end up in the ICU.  This week a portion of the 240,000 yearly USA cases of prostate cancer walked in our door. The rush of cases served as a reminder that when it comes to this illness, we have a long way to go.

First, Allen. He is 73 years old and has prostate cancer in one out of twelve biopsies. The cancer has a Gleason’s Score of 6 (a measure of aggressiveness of the cancer tissue: more then 7 is particularly bad), which means it is not fast growing.  We recommended that given the small amount of slow growing cancer, Allen should be watched without treatment (“Active Surveillance”).  What Allen found so difficult about this recommendation is that his son was diagnosed with prostate cancer just one month ago and his son, who is 49, has a Gleason’s 8 Prostate Cancer on both sides of the prostate, and is scheduled for robotic surgery.  More than having cancer, Allen is hurt by the feeling it should have been him.

Then there was Robert and Mike. Robert was in the office at 10:00am for evaluation of his newly diagnosed prostate cancer, PSA blood test 32 (high), Gleason’s 7, with evidence of invasion through the capsule of the prostate gland.  Fortunately, because prostate cancer likes to spread to bone, his bone scan is normal.  Despite Robert’s relatively young age (66), the surgeon recommends external beam radiation therapy (RT) instead of operating.  What is bizarre and makes my head spin, was that at1:00pm, in the same exam room, in the same chair, I saw Mike.  He has recurrence of prostate cancer, previously treated with surgery.  Now Mike needs RT.  Although Robert and Mike do not know that the other has cancer, they have worked together in the same small company for 28 years, and consider each other friends.
Continue reading “Prostate Cancer: Not a Good Week”

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May 30-8:12pm: 27 yo teacher, Pam S., is out for her evening run. The delicious evening air fills her nose and lungs. She feels strong, healthy, and alive.

May 30-8:13pm: Pam pushes up a gentle hill. She feels sudden and severe pain, as if stabbed deep by a flaming splinter.  Pam stops, almost falling.  She struggles the mile home. The searing throb begins to fade. A long hot shower gives some relief.

June 3-5:45am: The torment progressed through the weekend and curled around pillows, drenched in sweat, she has not slept all night.  As traces of sunrise light frame her bedroom window, she decides to get medical care.

June 3-9:22am: Pam tells her story to her Primary Medical Doctor (PMD) and is examined.  Her pain is intense with any movement and he is worried. He orders blood work, pain medication and calls an orthopedic surgeon. The PMD completes his history and physical report, as well as his differential, in his Electronic Medical Record (EMR).  The note is transmitted instantly to the surgeon.

June 3-9:59am: STAT blood work is drawn at a lab down the street.

June 3-10:37am: Pam picks up the pain medication.

June 3-11:25am: The orthopedic surgeon reads the PMD’s note, listens to Pam’s story and examines her.  He orders an emergency MRI.

Continue reading “From the Case Files of the Robert Wood Johnson University Hospital, Dec 2015″

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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?”

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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.

Humbly,

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.

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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”

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