On April 17th, 81-year-old Warren Buffett told investors that he had very early prostate cancer. The Washington Post headline read: “Warren Buffett Has Prostate Cancer that is Not Remotely Life Threatening.’” Within hours, news accounts said that the story unfolded after discovering a high PSA in a routine appointment. Next, he had a prostate biopsy. A few hours later, news accounts said that Buffett decided to get radiation therapy for prostate cancer. What’s wrong with this picture?
10. He’s an icon who other men will follow, and there is limited (or no) evidence of benefit of aggressive treatment in men as old as Buffett. At 81, his life expectancy is 7.41 years, shy of the 10-year life expectancy mark doctors look for when they recommend aggressive treatment for prostate cancer.
9. Although Buffett can afford whatever care he so desires, it would cost a fortune if tons of men in his age group went for active treatment and there would be little yield and plenty of side effects.
Recently a patient with advanced lung cancer was admitted to a local hospital. Pain in his abdomen was diagnosed as a gallbladder infection.
Because he had metastatic cancer, in addition to the new problem, the patient and family decided that if things deteriorated he should not be given CPR or put on a respirator. A Do Not Resuscitate (DNR) order was entered in his chart. Treatment for the gallbladder was continued, but it was decided that there was a line that the doctors would not cross.
This made sense to me.
Try conventional therapy, but if he was too weak to recover, then do not continue treatment which could cause more suffering than benefit. Give him the opportunity to survive the gallbladder problem, but respect the terminal nature of the greater disease. We were all gratified when his pain and fever went away, and he recovered from the emergency.
When we were discharging him from the hospital, a surprising thing occurred.
The patient and family requested that since he had survived the infection, that the DNR be reversed. They decided that when a sudden new major medical complication occurred, that CPR be performed and he would be placed on a respirator. The clear protective line vanished.
In difficult lengthy discussions with the patient and family, it became clear that they were riding tides of emotion. When things looked better, they focused on life and “cure.” When things grew worse, they were ready to withdraw. They became defensive and angry at the suggestion that this decision might cause suffering. We were not able to redefine limits to his care.
When first diagnosed with cancer, I felt as if my body had not only let me down, but actually turned on me. Some of my own DNA had gone rogue, grabbed some prime real estate in my lungs, and set up headquarters. Even when forcibly evicted, the rebel cells kept returning. Their numbers grew, and soon recruits were colonizing new neighborhoods.
Attempting to slow the spread of cancer has required unyielding vigilance. Emotionally and spiritually, I believe this has resulted in an unforeseen benefit; a chance for personal growth.
Physically, it has taken quite a toll. My body has been a battleground and I am scarred inside and out. This could potentially be distressing, as we live in a beauty and youth oriented society where great measures are taken to avoid the imperfections associated with aging and disease.
I am not afraid of getting old. I hope to hell I do. And I made peace with myself some time ago. Not only is all forgiven (the whole cancer thing), I have an abiding affection for this body of mine. We’ve been through a lot together, and somehow, some way, we both just keep on going.
Must be love.
I must start out with a confession: When it comes to technology, I’m what you might call a troglodyte. I don’t own a Kindle or an iPad or an iPhone or a Blackberry. I don’t have an avatar or even voicemail. I don’t text.
I don’t reject technology altogether: I do have a typewriter—an electric one, with a ball. But I do think that technology can be a dangerous thing because it changes the way we do things and the way we think about things; and sometimes it changes our own perception of who we are and what we’re about. And by the time we realize it, we find we’re living in a different world with different assumptions about such fundamental things as property and privacy and dignity. And by then, it’s too late to turn back the clock.
When I think of new frontiers on the internet I’m reminded of a science fiction story I read in college by my favorite SciFi author, Isaac Asimov. It’s called “The Dead Past,” and it goes something like this: Scientists have invented a machine called a chronoscope that can be used to view any time in the past, anywhere in the world, but this technology is strictly regulated by the government. Historians try to get licenses to view ancient Carthage or Rome, but government bureaucrats churlishly deny most requests based on mundane considerations of cost and convenience. So a frustrated historian teams up with a frustrated physicist and a frustrated journalist and together they reverse-engineer the chronoscope. They are eventually apprehended, but by that time the journalist had sent the plans to half a dozen of his news outlets; the secret is out and can never be retrieved.
And there, in the closing pages of the story, Asimov explains why the government had been so secretive about this invention:
“Why aren’t you taking your cholesterol medication?” I asked the woman.
With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.
“It made me tired,” she replied matter-of-factly. ”And besides, the cardiologist said the stress test was negative, so my heart is fine!”
I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis. She totally misunderstood the results, and I needed to fix that problem. So I pulled out my secret weapon: a good analogy.
“The purpose of the calcium score test was to see if you had termites in your home” I explained. ”I found them. The negative stress test just said that the termites hadn’t eaten through your walls. It’s good news that your walls aren’t falling down, but they will if we don’t stop the termites.”
Her eyes opened wide comprehension: the termites were eating her walls. She was living on borrowed time.
“Would you take a medication if it didn’t have side effects?” I asked.
She quickly nodded. Of course she would. From now on she would be a compliant patient.
Compliance is good. Noncompliance is bad. It’s something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don’t follow instructions are noncompliant (bad). If you are lucky as a doctor, you have compliant patients. They are the best kind. They obey their doctors. They are submissive. Noncompliant patients are bad; they are a bunch of deadbeats.
Please hold your nasty comments; I don’t really believe my patients should obey or submit to me.*
Imagine for a moment you are suffering from an illness that makes you feel like your soul has been run over by an angry defensive lineman, a disease that interferes with your desire to sleep, eat and make love. Oh, and this illness will continue to make you feel this way for the rest of your life. How much would you be willing to pay for a treatment makes you feel normal again?
My colleagues and I posed that question to a nationally representative sample of more than 700 Americans and we discovered something troubling—people’s willingness to pay for medical interventions depends in large part on whether the illness in question is “physical” or “mental.” People are much less willing to part with money to treat mental illnesses, even after accounting for the perceived severity of those same illnesses. Our article—“What’s It Worth?”—is available online at the Journal of Psychiatric Services.
Let me tell you a bit more about our study. We described a handful of illnesses to people and asked them to tell us, in effect, how bad each one would be to experience. For instance, we describe type 2 diabetes to people, and told them that it was uncomplicated by any other medical problems. People thought that would be pretty hard on their quality of life. We also described below-the-knee amputation, and they thought that would be even worse than diabetes. We described severe blindness, which only leaves one able to distinguish shadows. People thought that one was worse than either of the first two problems.
We also described a case of moderately severe depression to people, a level bad enough to cause the victims to “feel sad and downhearted a lot of the time.” The description went on to explain that it would make people “feel like a failure” and lose interest in food and sex. Trust me, it was a thorough and devastating picture of how depression can affect people’s lives. Indeed, people thought it was horrendous, at least as bad as any of the physical illnesses we described.
“I should have gotten cancer last month,” she told me.
That was the first thought from my patient after she’d heard the news: her ovarian cancer would remain untreated for weeks, due to a critical shortage of the chemotherapy agent doxorubicin. Like her, several thousand patients have been affected by critical shortages of chemotherapy agents like doxorubicin (Doxil) and methotrexate—common medicines that are essential backbones of cancer chemotherapy. But hundreds of other people have also been affected by critical shortages of pills around the country—limiting the supply of critical ICU medications like intravenous versed, or tuberculosis drugs like isoniazid.
Why are these shortages happening, and what can be done about them?
The state of the problem
Doxil and methotrexate are among 287 drugs in “critical shortage” in the United States, according to the University of Utah’s Drug Information Service, which has been tracking the problem. Shortages have been mounting in recent years, up from about 74 in 2005.
At present, the US Food and Drug Administration and independent researchers have tracked the status of major drug shortages occurring throughout the country. The FDA keeps an online catalog of these shortages. What this catalog reveals is that among 178 drugs that were in shortage during the year 2010, a vast majority (132) were sterile injectable drugs. These are generally cancer drugs, anesthetics used for patients undergoing surgery, as well as drugs needed for emergency medicine, and electrolytes needed for patients on IV feeding.
Yes, I am going to talk about…autism. The last time I did so I was inundated with people trying to convince me of the dangers of immunizations and their causal link to autism. I really, really, really don’t want to go anywhere near that one.
No, I am not going to talk about the cause of autism; I am going to talk about my observation of the rise of the diagnosis of autism, and a plausible explanation for part, if not most of this fact. The thing that spurs me to write this post is a study by the CDC which was quoted in the NY Times:
The new report estimates that in 2008 one child in 88 received one of these diagnoses, known as autism spectrum disorders, by age 8, compared with about one in 110 two years earlier. The estimated rate in 2002 was about one in 155.
The rise in numbers is cited as one of the main evidences for some external source – a new thing in our environment – that is causing this rise. The article, however, gives another clue:
The frequency of autism spectrum diagnoses has been increasing for decades, but researchers cannot agree on whether the trend is a result of heightened awareness, an expanding definition of the spectrum, an actual increase in incidence or some combination of those factors. Diagnosing the condition is not an exact science. Children “on the spectrum” vary widely in their abilities and symptoms, from mute and intellectually limited at one extreme to socially awkward at the other.
Children with such diagnoses often receive extensive state-financed support services — which some experts believe may have contributed to an increase in numbers.
That last sentence holds the golden ticket. What would make me think this? My experience.
Two years ago, I put myself in hot water by making the simple (admittedly somewhat hyperbolic) claim:
Because it is so easy to find bad reporting and public stupidity, it is easy to overlook something. Press coverage of health care reform was the most careful, most thorough, and most effective reporting of any major story, ever.
This column appeared on April Fools’ Day. Some readers didn’t quite believe that I was serious. I was. Others were simply horrified. Allison Kilkenny, writing in the Huffington Post, typified the reaction among frustrated left-of-center commentators who had just witnessed the “death panels” debacle, the demise of the public option, and similar depressing episodes: “Harold Pollack went out on a limb, and unfortunately fell off the edge.” Andrew Sullivan said something similar.
The Columbia Journalism Review’s Trudy Lieberman was more brutal:
Last week, The New Republic turned over its health care blog “The Treatment” to an odd commenter on media coverage—University of Chicago professor Harold Pollack, who runs the university’s Center for Health Administration Studies. I thought I knew most of those who dabble in these waters, but Pollack’s name took me by surprise. Pollack, a special correspondent for The Treatment, may know something about welfare programs and substance abuse, but we on Campaign Desk take issue with his credentials as a press critic and dispute his central point….
Better coverage than the Vietnam War; the civil rights movement; the consumer movement? Really? In the case of the civil rights struggle, the press helped change the discourse; Americans began to view race in a new way, which led to the eventual passage of the Civil Rights Act. During the Vietnam War, the media effectively changed the public dialogue from a war we couldn’t lose to one we could not win. In the early days of the consumer movement, media coverage of Ralph Nader led Congress to enact significant consumer protections. Coverage of health reform has hardly risen to that level.
Losing one’s credentials as a “press critic” is a particularly low blow. The only thing worse would be to lose the moniker “Democratic strategist” on the cable talk circuit. I appreciate where Lieberman is coming from, but I think she missed my point, which was actually intended to be sobering.
One of the most common ideas in the whole healthcare financing discussion is a moral one. Why, people say, should my taxes and my healthcare premiums go to take care of the huge medical problems of people who don’t take care of themselves? As one commenter on THCB put it: “…self inflicted injuries to not be covered at all, ideally. If someone drinks their liver away I don’t think we should all have to buy them a new one. Same for smoking.”
This is a common idea, one that seems logical and right on the surface. But there are four assumptions built into it, all four of which have problems:
1) That the “self-inflicted injuries” that people commonly identify (smoking, drinking, other addictions, obesity) actually are major predictors of cost.
2) That we can clearly differentiate “self-inflicted injuries” from other medical problems
3) That to the extent that they are actually “self-inflicted,” the patient could just stop doing them if they just had enough gumption, or enough something.
4) That if our goal is to cut unnecessary medical costs, refusing medical coverage would cut costs.
But each of these four is problematic.
1) The best predictors of medical costs are not smoking, drinking, or obesity, but depression and stress. (“Association Between Health Risks and Medical Expenditures“) So trying to dis-insure “self-inflicted injuries” might miss the target of lowering healthcare costs.
2) Trying to decide what is “self-inflicted” and what is not presents a major problem. A friend has a lifelong condition that gives him excruciating pain. He has struggled manfully (and successfully) against addiction to booze and painkillers to ameliorate his pain. He has always felt bitter toward his father because his father was addicted to booze and painkillers. He recently realized that his condition is genetic, and guessing from some symptoms he observed, realized that his father was fighting the same excruciating pain. His attitude toward his late father changed instantly.