Trying to Put a Value on the Doctor-Patient Relationship

This is an important article in the NY Times Sunday Magazine (May 20, 2018).

In its push for profits, the U.S. health care system has made it difficult for patients to get personal attention from doctors. But what if hands-on medicine actually saves money — and lives?

The question of what the role of a primary-care physician should be, and how it should be valued, has perhaps never been more urgent. That figure, typically a general practitioner, family doctor or internist, is a patient’s first and often most personal connection to the rest of the health care system. But well-known corporations are betting that Americans would prefer to have health care 'delivered' by a trusted brand rather than a trusted physician."

Kim Tingley's  thoughtful piece is a "keeper' worthy of study.

Photos from a famous 1948 Life magazine article on the life of a country doctor.

Body Ritual among the Nacirema

The anthropologist Clyde Kluckhohn has pointed out that man is distinguished from other living organisms by three characteristics of human activity: the systematic making of tools; the use of abstract language; and religion. Religion is a broad term, embodying not only belief in a supernatural power but also an elaborate web of myth, theology and ritual. Most people like religion in their hearts and in their houses of worship, and they are delighted that modern science has largely emancipated them from irrational ritual and ceremony in medical habits. It is both disturbing and instructive, therefore, to learn that right in the midst of Western civilization there is a tribe of natives that practices daily elaborate rituals filled with mysterious and magical elements designed to sustain the health and well-being of the body. Another distinguished anthropologist, Horace Miner, was able to gain the confidence of these natives, and he has reported on his scientific investigations in an illuminating essay entitled, "Body Ritual among the Nacirema."

See “Miner, “Body Ritual among the Nacirema” The American Anthropologist 1956

Miner’s essay was cited in Barbara Ehrenreich’s book, Natural Causes (2018)

Dermatological PUVA Ritual

High Energy Proton Beam Ritual

Norwegian High Priestess performs Skin Screening Ritual

Sentinel Lymph Node (SLN) Biopsy Decision Aid

The question of whether to undergo a SLN biopsy for melanoma is a difficult one.  It is clear that some experts recommend it while others don't.  Where does that leave a patient?  In England the National Institute for Clinical Excellence provides decision aids for many conditions. Here is a link to the SLN Decision Aid.  Please give it thought and discuss it with your dermatologist or surgeon.  The decision is really up to you.

The Problem With Miracle Cancer Cures

by Robert M. Wachter

April 22, 2018, NY Times

Robert Wachter is Professor and Chairmen of Department of Medicine at UCSF.  His book, “The Digital Doctor,” (2015) is a great trove of information presented in a palatable, non-geeky manner.

A new generation of cancer treatments have become available in recent years.  The medical literature now fairly gushes with terms like “revolutionary” and “cure.”  Oncologists are seeing patients whose cases they once would have pronounced hopeless experience Lazarus-like responses to these new therapies.

If these new treatments worked most of the time, this would be an unambiguously happy story. But they don’t. A recent analysis estimated that about 15 percent of patients with advanced cancer might benefit from immunotherapy — and it’s all but impossible to determine which patients will be the lucky ones.

What can we do to alleviate the hype?

·      First, it turns out that many patients can benefit from palliative approaches even as they continue aggressive treatment for their cancer.

·      Second, doctors need more training in how to have these hard conversations with patients in light of the new cancer treatments. Doctors will need to become more at ease with the prognostic ambiguity.

·      Finally, through the federal Cancer Moonshot program, the government is spending hundreds of millions of dollars to study immunotherapy and other emerging treatment options for cancer. The sooner we can work out which patients will — and just as important, won’t — benefit from these approaches, the better.

Let’s be sure that we don’t rob dying patients of a smaller, more subtle miracle: a death with dignity and grace, relatively free from pain and discomfort.

Throw Deep

The NFL Hall of Fame quarterback Ken Stabler was once being interviewed by Sports Illustrated when the journalist recited a quote from the author, Jack London that was near to London’s statue in Oakland:

“I would rather be ashes than dust!

I would rather that my spark should burn out in a brilliant blaze than it should be stifled by dry-rot.

I would rather be a superb meteor, every atom of me in magnificent glow, than a sleepy and permanent planet.

The function of man is to live, not to exist.

I shall not waste my days trying to prolong them.

I shall use my time.”

When sked what these words meant to him personally, Stabler replied with the gritty confidence of a veteran, “Throw deep.”

The Hypothetical Rabbit

Michael W. Kattan,

Front Oncol. 2016; 6: 123.

Published online

This common analogy for describing newly diagnosed prostate cancer patients appears to be attributable to Hinman,* who borrowed from Crile when applied to breast cancer.

·      Turtles are patients with very slow growing disease. Their disease grows so slowly that they need not be diagnosed, for the disease will never spread to the point of causing problems within the patient’s lifetime. A turtle will die of another cause, not prostate cancer.

·      The bird has been diagnosed too late to have impact on the disease. It has already spread and cannot be meaningfully slowed down, to the point where the patient is likely to die of his prostate cancer. The bird is similarly not helped much by a diagnosis of prostate cancer since it is already too late to stop the disease.

·      The rabbit sits in the sweet spot. The rabbit is the man with prostate cancer who needs to be diagnosed (his disease spreads faster than that of the turtle and indeed poses a threat to his life), yet the disease is still curable (unlike the disease borne of the bird).

This model holds for many other cancers, perhaps most. It can be helpful when patients or physicians think about screening and treatment.

*The value of screening for prostatic carcinoma: a commentary.

Hinman F Jr.  Urol Int. 1991;46(3):275-8.

Abstract

Can routine digital rectal examinations, transrectal ultrasound studies, and prostate-specific antigen determinations reduce deaths from prostatic carcinoma? The evidence is that the benefits of early diagnosis and treatment are at least neutralized by the limited reliability and high monetary and human costs of the test and by the lack of proof that treatment is effective for those tumors detected. One must conclude that universal screening is not now warranted and will await demonstration of effectiveness by controlled studies.

Out of the Straightjacket

Michael S. Weinstein, M.D., M.B.E.

N Engl J Med 2018; 378:793-795

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This is the narrative of a trauma surgeon who has a history of major depressive illness.  He tells it as it was; including his psychiatric hospitalization, electroconvulsive therapy, and recovery.  In some ways, this is a restitution story.

Dr. Weinstein addresses important areas we’d rather not face.

“We often make decisions in the face of uncertainty that deeply affect our patients’ lives. When things went wrong, I frequently blamed myself. I learned that doubt, ignorance, and lack of confidence were my own failings.”

“Though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a “nervous breakdown.” I joked about it, said he was weak. Now it was my turn.”

“I wanted out, out of work and out of life. I wished I would get hit by a car, and sometimes took steps to increase my risk. I felt trapped in my work and worried that I would expose my shortcomings if I sought a leave or disclosed my feelings. I’ve subsequently learned that my colleagues were quite concerned about me but found me unreceptive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.”

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This is an important topic.  We’d rather not acknowledge it.  The best-selling author, Sherwin Nuland, was a surgeon who similarly was hospitalized for major depression.  He chronicled that in his autobiography, “Lost in America.”