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”
Filed Under: OP-ED, THCB
Tagged: Cancer, James Salwitz, Oncology, Patients, Physicians, The Affordable Care Act
Oct 4, 2013
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”
Filed Under: OP-ED
Tagged: Cancer, Cancer Screening, James Salwitz, Oncology, prevention, Prostate Cancer
Aug 30, 2013
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″
Filed Under: Physicians, THCB
Tagged: EHR, James Salwitz, Oncology, Patients
Jun 7, 2013
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
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
At some point, this gets to be ridiculous. Online, I can buy any item from anywhere at any price, pay any bill, watch any movie, listen to any song, order dinner, schedule car repair or read about any subject on Wikipedia. I can determine the weather in Rio, sport scores of Barcelona, Parisian traffic or by GPS the location of my kids, just down the block. However, I absolutely cannot learn anything at all of the health history of the flesh and blood cancer patient sitting right in front of me.
Today, I am seeing long-term patient, Thomas R. Father of three and a really nice guy, Tom is a medical challenge.
He is immunocompromised and status post 20 years of complex chemotherapy, radiotherapy, a bone marrow transplant and several bizarre complications, we barely understand. In the last two months, since his last visit with me, he has seen an internist, a dermatologist, a podiatrist, a neurologist, a dentist and an infectious disease specialist. These doctors ordered X-rays, lab tests, blood cultures, an EMG, a skin biopsy and several new medicines.
These are confusing tests resulting in confusing diagnoses with confusing therapy in a confusing patient.
What records do I have of all this new complexity? Nada. None. Moreover, based on our files, all these other physicians have none of ours.
Continue reading “Can Facebook Save Us?”
Filed Under: THCB
Tagged: Care coordination, Facebook, James Salwitz, Medical Records, Silo Design, Stone Age, Universal Electronic Medical Record
Feb 6, 2013
Here is a little appreciated fact: Patients cannot order medical care; they can only accept or refuse it.
Only a doctor can order medical treatment. In an extreme medical situation, the doctor can offer CPR, but it is the patient’s job to accept or reject.
Any patient can refuse CPR. This refusal is known as Do Not Resuscitate or DNR, and for obvious reasons needs to be made ahead of time. The question is, when is making the decision to be DNR appropriate?
A further definition is needed. DNR (and its colleague, Do Not Intubate, DNI) is not the same as DNT, or Do Not Treat. A patient, at their discretion, may receive maximal medical care, including drugs, dialysis and surgery, and still be DNR. The DNR order in that situation is simply a line that the patient will not allow the doctors to cross. “Do everything you can to help me, but if it fails I do not want to end my life on a machine or with some gorilla pounding on my chest.”
On the other hand, a DNR can be a part of a hospice or palliative care program, so that all care is focused on comfort and not treatment. It is even possible, in very unusual circumstances, to receive hospice care without being DNR. A DNR order is like any medical decision, it can be changed if appropriate. DNR is not the same as “pulling the plug.”
How aggressive to be in receiving medical care is a personal decision. In order to make certain that our individual desires are followed it is critical that, as much as possible, these decisions be made ahead of time. This avoids panic, confusion, and guilt. In that spirit, let us review a few cases.
Ben is a 54-year-old gentleman with lung cancer, which has spread to bones and liver and is growing despite the third chemotherapy. His doctors inform him that a fourth chemotherapy has a 5% chance of helping him and a 20% chance of killing him. He wants to try the chemo. His physician says, “OK Ben, we will order the chemo but if things fall apart and your body starts to fail and we cannot fix it, do you want to be put on a machine?” Do you think Ben should make himself DNR?
Ben made himself DNR. He survived the chemo, but the cancer progressed and he died one month later.
Continue reading “To DNR or Not to DNR”
Filed Under: Uncategorized
Tagged: Cancer, Chemotherapy, CPR, DNR, End of life decisions, James Salwitz, Oncology
Dec 14, 2012
Terry is a particularly difficult patient. She is not hard because of her cancer, which is in remission, nor is there a problem with pain, of which she has little, and Terry is not particularly demanding for the nursing staff. No the real problem, the challenge, the thing that makes her so difficult is that Terry is married. Terry is married to Dr. P and he is a particularly difficult man.
Terry’s husband loves Terry very much. He wants her to have the very best care. Dr. P makes certain that all the doctors know everything that is going on, all the time; he makes sure the nurses are on top of every detail; he demands the best from the all the hospital staff. In fact, Dr. P works so hard to control Terry’s care, to stay on top of her case, to monitor every moment, it is nearly impossible to take care of Terry.
There are many challenges for doctors taking care of other doctors or their families, or, in reverse, there are many challenges for doctors when they seek care for themselves and their families. The result of this conflict is often inferior medical care. Therefore, wanting to honor and help doctors get good quality treatment let us take a moment to review the doctor verses doctor verses medical system dilemma.
First, it is hard for doctors to decide where to go for medical care. If you stay in the same community where you practice you lose some privacy and perhaps even respect in the physician community. Who do you chose and how do you avoid offending the other physicians you do not use? If you leave your own area, you lose the convenience and familiarity of getting care close to home.
Continue reading “The Doctor as Patient”
Filed Under: Uncategorized
Tagged: Cancer, caregivers, doctor versus doctor, Family, James Salwitz, layman
Nov 4, 2012
Now here is a novel idea to save lives and stop the cancer plague; stop trying! Sounds as crazy to me, as it does to you, but this idea actually may have merit. Some smart people are saying that we have spent too much money for little gain, thus it is time to give up and by retreating win more battles in the war on cancer, than by charging ahead.
The Cancer Prevention and Research Institute of Texas (CPRIT) is the second largest cancer research agency in the United States, after the National Cancer Institute, controlling a pot of $3 billion dollars, most of which funds basic science and clinical research. At recent hearings, university scientists and leaders in biotech proposed that CPRIT cut back on the money it is pouring into laboratories. As Professor John Hagan of the University of Texas proclaimed, “If people didn’t get cancer in the first place, CPRIT would accomplish much of its mission.”
This radical idea was echoed in a scary article in the September issue of Lancet Oncology, entitled “First do no harm: counting the cost of chasing drug efficacy.” This editorial reviewed data, which shows that between 2000 and 2010 many new cancer drugs produced marginal extensions in survival and simultaneously increased risk of treatment associated death and side effects. The Lancet authors emphasized the vital need as we develop new therapies to carefully measure both benefit and harm before FDA approval and for careful post-marketing follow up after drugs are released to the general population.
Now in reality no one is saying that we should shut down cancer research labs and simply hope for the best. Eventually we will completely cure this disease and basic science, as well as the development of new therapies, is key to that future. Perhaps what we should hear from these words is an idea about a different balance in health and healthcare.
Continue reading “Stop Cancer Research?”
Filed Under: THCB
Tagged: Cancer, Cancer Prevention and Research Institute of Texas, cancer research, chronic disease, health maintenance, James Salwitz, life span, prevention
Oct 22, 2012