Wednesday, May 16, 2012

Choices

In the last hour, I suddenly became overwhelmed with just how many choices we make in a day. We choose whether or not to wake up in the morning to drag ourselves to school [some might argue that this isn't a choice ... but let's just go with it].

We choose what to eat when we're hungry. We choose which lane to drive in. We choose how we spend our time [such as right now, I am actively choosing not to study].

In life, we make a lot of choices that we don't think twice about because for the most part, they are trivial.

But if you really think about it, some everyday choices we make affect those around us. Something as simple as smiling at a stranger as you hold the door open could be the highlight of someone's day. Cutting someone off as you merge into another lane could ruin the rest of that person's day. Sometimes, I think we forget just how interconnected we all are; most of the time I think I am just minding my own business and living in my own little world, but there's no such thing. We all end up influencing another human's life at some point in time, whether we acknowledge it or not.

In medicine, our choices hold even more weight. This thought is exciting and chilling all at once; our choices can lead to bringing a new life into this world or ending one prematurely. Our words can tear a family apart or bring tears of joy to a patient. Our actions truly impact the life of our patient, whether we like it or not.

This is the path we chose. We want to help people. We want to heal people. But in the end, there is no escaping the reality that we won't always be right. Most of the time, there is no such thing as black and white; there is just an expanse of gray that will only morph into clarity retrospectively.

Amanda Xi is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Ann Arbor, Mich. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

Labels: Amanda Xi, And Thus It Begins, guest post, medical education, work-life balance

The outlier's message, and evolutionary science in breast cancer

This past week I read several attitude-altering articles about breast cancer.

The first lesson, if I might call it that, in the way an oncologist can learn from variations in her patients' pathology and clinical outcomes comes from the case of Katherine Russell Rich, who died last week at the age of 56. As reported by Katherine O'Brien in the I Hate Breast Cancer Blog, Rich lived with metastatic breast cancer for 18 years. That's phenomenal, was my first reaction to this news. The prognosis for metastatic breast cancer is said to be around 3 years, and Rich lived for 18 years beyond her tumor's recurrence with stage IV disease.

As sad and unsatisfactory as this outcome may seem, and it is, Rich's story offers hope for life beyond the 3 or 4 or 5 years some women with metastatic breast cancer pray, "ask" or otherwise bargain for, fingers-crossed.

As she detailed in an O article, Rich's initial diagnosis came when she was 32 years old, in 1988. The New York Times, in an obituary, tells of her lumpectomy, chemo and radiation. In 1993 her cancer came back in bones including her spine. She had a bone marrow transplant, but the disease progressed. Ultimately, she coursed through various and some archaic hormone treatments.

Along the way, she lost or quit a job in publishing, or both, and traveled to India, and authored two books . In a 2010 first-person story about her case, she told of updating her status--of being alive--at Breastcancer.org each year. She wrote: "... I tell the women how deeply I believe there's no such thing as false hope: all hope is valid, even for people like us, even when hope would no longer appear to be sensible."

Life itself isn't sensible, I say. No one can say with ultimate authority what will happen--with cancer, with a job that appears shaky, with all reversed fortunes--so you may as well seize all glimmers that appear.

My take, as an oncologist and former clinician, is that patients sometimes surprise you. Hard to know which woman will respond to a non-targeted treatment, or even a drug like an estrogen modulator, without trying. And I wonder--and this is speculative, but maybe, likely, the two together, doctor and patient, worked together to see what worked in Rich's case over nearly 2 decades, and what didn't work.

If a drug helps, keep it going; if it hurts, stop. There are so many algorithms in medicine, and molecular tools, but maybe the bottom line is how the, one, your patient is doing.

Which leads me to another post, by Dr. David Gorski, a breast cancer surgeon and researcher who blogs as Orac--what once was imagined as a fabulously capable information processor, at Respectful Insolence. He describes how tough it can be to define, and thereby target or destroy, any individual patient's breast tumor because the cancer cells are constantly changing. Within each woman's tumor, an evolution-like process is ongoing, leading to selection of treatment-resistant cells. This is not news in oncology; the concept has been understood for years as it applies to "liquid" tumors like leukemia, as he points out.

In breast cancer, understanding the complexity of each case is more recent. Dr. Gorski considers a genetic analysis of 104 triple negative breast cancer (TNBC) cases presented at the recent AACR meeting and published last week in Nature: "... The 59 scientists involved in this study expected to see similar gene profiles when they mapped on computer the genomes of 100 tumours.

"But to their amazement they found no two genomes were similar, never mind the same. 'Seeing these tumours at a molecular level has taught us we're dealing with a continuum of different types of breast cancer here, not just one,' explains Steven Jones, co-author of this study.

"... TNBC is not a single disease. In fact, even an individual TNBC tumor is not a single disease. Tumor cells evolve as they proliferate, so that the cells in them are genetically heterogeneous. The cells growing in one area of a tumor can and often do harbor markedly different genetic mutations from the cells growing in another part of the tumor ...

"The team found that each tumor displayed multiple 'clonal genotypes,' suggesting that the cancer would have to be treated as multiple diseases, rather than a single entity."

So besides that there are distinct subtypes of breast cancer, those labeled as TNBC are diverse and contain variation within; each patient harbors sub-clones of malignant cells that, in principle, respond differently to treatment.

Putting these links together ...

The message from Katherine O'Brien, who lives with metastatic breast cancer and blogs about it, is that one outlier, like Katherine Russell Rich, can provide hope to other patients and, maybe, clues for scientists about why she lived for so long with metastatic breast cancer. The message from Orac, a physician-scientist blogger, is how hard it is to pinpoint an individual breast tumor's molecular aspects, because the disease is so mutable and diverse.

The problem, and this reflects evolution in my thinking over a long while, is that published data--the gold standard, what supports EBM--are largely limited to findings based on trials of groups. We understand now, better than we did 10 or 20 years ago, that each patient's tumor is unique and can evolve over time, naturally or in response to therapy. Clinical trials, though rigorously planned and elaborately structured, are incredibly expensive and flip-floppy, disappointing overall.

What I'm thinking

Algorithms, except in the broadest sense, may not offer the optimal approach to cancer treatment. Maybe the median doesn't matter so much as we'd thought.

Here's a retro idea: In 2012, maybe the ideal and most cost-effective oncology practice would blend low-tech observations, like findings on physical examination and how the patient's feeling, with occasional, high-tech analyses, like markers for genetic drift within a tumor. If doctors are well-trained and non-robotic, in either the literal or figurative sense, and if they lack conflict of interests regarding treatment decisions, they'd provide better, more effective and personalized treatments than what's typically offered based on evidence reached through elaborate, costly clinical trials of many patients with similar but non-identical cancers.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

Labels: breast cancer, Elaine Schattner, evidence-based medicine, guest post, Medical Lessons, research

QD: News Every Day--Six in 10 doctors using digital tablets

Six out of 10 doctors are using digital tablets for work, mostly iPads, and half use them at the point of care, according to a survey from health care market research and advisory firm Manhattan Research.

But is it a good thing?

The online study surveyed 3,015 U.S. practicing physicians in more than 25 specialties.

Tablet use for professional purposes almost doubled since 2011, reaching 62% this year.

Physicians using tablets, smartphones and desktops/laptops spend more time online on each device and go online more often during the workday than physicians with one or two screens.

Adoption of physician-only social networks remained flat between 2011 and 2012.

Physicians reach out more frequently to and are more influenced by colleagues they formed relationships with at school or at work than peers who they first connected with online.

More than two-thirds of physicians use video to learn and keep up-to-date with clinical information.

Is this a good thing? How can doctors manage three computing platforms and still connect with patients? ACP Internist addressed this topic in its April cover story.

Labels: health information technology, new technology, QD

Frivolous medical malpractice lawsuits targeted by medical justice

Whistleblower readers know my views on the perverse and dysfunctional medical liability system. I have read numerous plaintiff lawyers' blogs, and those of other tort reform opponents, to better understand the issue from other perspective. As a physician, I bring bias to the issue, as do all the players in the game. After 20 years of thought, and some legal brushfires, I am persuaded that the medical profession has the better argument.

I also do not believe that we physicians are as strident and ideological as the other side is, but perhaps this is simply because this gastroenterologist has a jaundiced view of the issue. For example, most physicians readily admitted that our health care system, before Obama and the Democrats cured it, had serious deficiencies that demanded reform. In contrast, rarely do I hear or read plaintiffs' attorneys remarking that the medical liability system needs some healing. What I read in their columns and postings is a spirited defense of the status quo.

When a physician like me points out flaws in medicine, as I have done throughout this blog, this is an attempt to improve our profession and public health. Indeed, physicians on blogs and in medical journals write openly and often about where our profession is falling short. Reflection and self-criticism are ingrained in the culture of the medical profession. If a plaintiff's lawyer were to publicly advocate medical malpractice reform, then I suspect he would be shunned for his blasphemous utterance, or banished to the gulag for some re-education.

In my tort reform meanderings through the blogosphere, I stumbled upon Medical Justice (MJ), a company that is devoted to protecting physicians against the abuses of the medical liability regime. This organization aims to:
--prevent frivolous litigation from being filed against a member physician
--attack internet defamation of physicians' reputations
--hold medical "expert" witnesses accountable

I was intrigued and reached out to them to learn more about their enterprise. When a member physician is unfairly sued, MJ gets into the other side's face to alert them that their national organization is squarely behind the doctor. This puts the plaintiff and the opposing medical experts on notice that their actions will be scrutinized and held accountable. There is a yearly charge for membership, which depends upon the amount of protective service the practitioner desires.

Some of MJ's services require the physician and the patient to sign certain agreements, which I think would be problematic for doctors to implement. While I understand why a physician would desire a signed agreement that would protect his interest, I am less certain why a patient would do so. In addition, such a discussion might erode the doctor-patient relationship.

Thus far, they have over 2,000 physician members and are in a strong growth phase. I think their fees are reasonable, a fraction of what I pay each year for my medical malpractice insurance. If even one lawsuit is prevented, it would be worth a decade or two of MJ membership charges. I wish them well and encourage Whistleblower readers to visit their site and their very fine blog.

In fairness, I should disclose my relationship with this organization. Admit it; you already think I'm an MJ shill, right? You suspect that I have a pay-for-click arrangement with them. I must get a kickback for every Whistleblower reader who signs up. Here is the arrangement I have with them, which I disclose publicly.

I am not an MJ physician member and they pay me nothing. They didn't ask for this blog post and the only reward they might offer me is gratitude for having done so. Keep reading, because I now must confess a potentially corrupt act as my conscience is torturing me. I did have lunch with their Cleveland rep months ago who rejected my offer to grab the tab and paid for my meal, which cost about 10 bucks. Readers must now weigh and decide if my integrity can be compromised for a free meal.

MJ added me to their blogroll for the usual reasons; they liked my Whistleblower tort reform content. I am plugging them for free because they are the only folks I've discovered who want to put a few arrows in our quiver so our unfair fight will be a little less unfair.

I expect that MJ's services will grow and become more refined as the company matures. If they are successful, then medical malpractice carriers might be willing to subsidize physicians' membership costs.

With so many out there stabbing us in the back, it's refreshing to have an organization that's watching our back.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Labels: guest post, malpractice, MD Whistleblower, Michael Kirsch

Older Posts

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

CasesBlog
Ves Dimov, MD, ACP Member, is an allergist/immunologist and Assistant Professor of Medicine and Pediatrics at the University of Chicago, where he evaluates and treats both pediatric and adult patients.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Musing of an Internist
Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident.

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

RSS feed

American College of Physicians: Internal Medicine — Doctors for Adults ®

Related ACP Resources:

ACP Internist