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

Free Full Text

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.”

Free Full Text

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.”

Doctors, Revolt!

The 96 year old patient lamented that today's hospital is more like a factory.   He told his intern that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.” 

This is a moving article by Dr. Rich Joseph, a resident at the Brigham and Women’s Hospital in Boston.  His Op-Ed piece, Doctors Revolt!, published in the Sunday Review of the NY Times is a moving introduction to Lown’s fine book, The Art of healing.  It also chronicles a refresher course in humanistic medicine for Dr. Joseph at a crucial point in his career..

Here are notes from The Lost Art of Healing.

Medical Hysteria

Inappropriate medical activity is directly proportional to the gravity of the patient’s illness, and inversely proportional to the likelihood of real or lasting therapeutic benefit. This inappropriate medical activity can be called medical hysteria.  JM Naish, Lancet 1970

For a link to Full Text PDF.

How To Swim With Sharks: A Primer

by Voltaire Cousteau

In 1973, the hematologist Richard Johns, using the pseudonym Voltaire Cousteau, published an iconic essay on how one survives in academic medicine.  It has inspired many colleagues many of us for decades.  Strangely, an appreciation of Johns’ essay has been recently published by F. Shanahan in the Quarterly Journal of Medicine.

Forward

 Actually, nobody wants to swim with sharks. It is not an acknowledged sport and it is neither enjoyable nor exhilarating. These instructions are written primarily for the benefit of those, who, by virtue of their occupation, find they must swim and find that the water is infested with sharks.

It is of obvious importance to learn that the waters are shark infested before commencing to swim. It is safe to say that this initial determination has already been made. If the waters were infested, the naïve swimmer is by now probably beyond help; at the very least, he has doubtless lost any interest in learning how to swim with sharks.

Finally, swimming with sharks is like any other skill: It cannot be learned from books alone; the novice must practice in order to develop the skill. The following rules simply set forth the fundamental principles which, if followed will make it possible to survive while becoming expert through practice.

For Links:

References:

1. How to swim with sharks: a primer. Cousteau V. Perspect Biol Med. 1973;16(4):525-8. doi: 10.1353/pbm.1973.0039. Download How To Swim With Sharks (this is a reprint of the original)

2. How to swim with sharks: a perspective on Voltaire Cousteau's primer. Shanahan F. QJM. 2018 Feb 5. Full Text Link.
   

Functional Somatic Syndromes

This article is a classic reference on this common but poorly understood group of disorders.  It is well worth studying if you are interested in this topic.  The large group of illnesses that fall under the rubric of Medically Unexplained Symptoms are functional somatic syndromes.  

Functional somatic syndromes.
Barsky AJ, Borus JF. 
Ann Intern Med. 1999 Jun 1;130(11):910-21 

Link to download of Full Text of article.

The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms.

The Medical-Industrial Complex

This is the classic first article about the medical-industrial complex.  It first appeared in the New England Journal of Medicine in 1980.   It is an imporant article, maybe needing to be updated.  My own feeling is that the concept of the Medical-Industrial-Academic Complex is more important -- but academics control what gets into our journals.  The most prestigious journals tend to benefit greatly from advertising dollars (can skew content) and the authors of scholarly articles are academics.  That focuses the literature on what academics feel is important.  Thus they report on diseases much more than illnesses.

The Medical-Industrial Complex
Arnold Relman
NEJM 1980; 303:963-970

ABSTRACT: The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to $40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also excercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interests of the public before those of its stockholders

The private health-care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need, i.e., services that are likely to be helpful and are relatively safe.

In the health-care marketplace the interests of patients and of society must be represented by the physician, who alone has the expertise and the authority to decide which services and procedures should be used in any given circumstance.

We should not allow the medical-industrial complex to distort our health-care system to its own entrepreneurial ends.