- What is my blood pressure? Is it OK?
- Have I been checked for diabetes?
- How is my cholesterol? Is that OK?
- Am I due for any vaccinations?
- Do I need any cancer screening, such as PSA, colonoscopy, mammogram, pap smear?
- How is my weight? What is my body mass index (BMI)?
- Here is my medication list–does it match yours?
- What is my overall cardiac risk? (e.g. see this link).
- How do I quit smoking?
Category: Medicine
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Questions you should ask your doctor
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Cancer 201—treatment basics
Once a cancer has been diagnosed, we must use our knowledge of biology, medicine, and clinical trials to plan treatment. Treatment can be curative or palliative (that is, with a goal of reducing symptoms or extending life, rather than effecting a cure).
Understanding cancer treatment requires a little bit of basic biology, and as with all of my more “science-y” posts, please forgive any oversimplification (but please also note that this complexity stands in stark contrast to the simplistic altmed cancer “cures”), or for overtopping the head of the hapless non-scientist.
As you recall from Cancer 101, cancer is a proliferation of abnormal cells. This fact alone, that the cells are actively dividing, gives us a target for therapy.
Cells go through particular phases in their lifetimes, but these phases aren’t as simple as “birth, growth, death”. The life of a cell is roughly divided into the cell cycle, during which the cell is preparing for and conducting cell division, and the G0 (G sub zero, or G-naught) phase, where the cell simply goes about all of it’s non-reproductive business, such as structural support and protein production. Normal tissue has a fairly balanced growth fraction, that is the number of cells dividing is roughly equal to the number of cells being lost (to normal programmed cell death and other normal attrition). Cancerous tumors have a higher growth fraction than normal tissue, that is the number of cells in cycle is higher than the number of cells being lost (to programmed cell death, etc.).
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I've been (not) workin' on the railroad
This story is disturbing for a host of reasons, but there’s a medical ethics issue hiding in here.
Apparently, if you work for the Long Island Railroad, you can retire at 50, then claim disability for a job you no longer have, and collect both a disability check and a pension. I shit you not. But it gets better. According to the Times, “Virtually every career employee — as many as 97 percent in one recent year — applies for and gets disability payments soon after retirement….”
I strongly encourage you to read the whole article, but let’s focus on a particular point.
Dr. Melhorn, who has studied disabilities, said the numbers alone were a cause for concern, “in particular if there seems to be a limited number of physicians who are providing this disability impairment.”
[…]
L.I.R.R. employees favor certain doctors, and their disability applications are sometimes so similar as to be almost interchangeable, said one Long Island resident who has seen dozens of those applications. That person said that M.R.I.’s merely document physiological changes that commonly affect people over the age of 50.
(empasis mine)In my practice, I often have to fill out temporary disability forms. It’s pretty standard—when a patient has a knee replacement or a heart attack their work requires them to file certain papers.
There is a separate subset of patients who believe themselves to be completely disabled, and want me to fill out forms from the state to help them get disability payments. Very few of my patients are so disabled as to be unable to work at all, ever. But many of them think they are. Who wouldn’t want to collect a check for doing nothing? I usually tell them that if I answer the questions on the form truthfully, they are unlikely to ever get disability. I let them decide at that point whether they really want me filling them out (which may, of course, be passing the buck, and ducking a responsibility, but since the state can assign doctors for disability exams, I don’t feel I’m shirking).
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Who's your hospitalist?
Me: Hi, I’m Dr. Pal and I’ll be taking care of you here in the hospital.
Patient: Where the hell is my real doctor?
Me: He’s at the office seeing patients. He doesn’t come to the hospital anymore.
Patient: Why the hell not?
Me: Well, it’s complicated, but it’s getting harder and harder for doctors to pay their overhead. They have to see more and more patients, and in the time it takes to come to the hospital and see one patient, he can see 5 or 6 in the office.
Patient: What’s wrong with him just getting up earlier?OK, time for a brief lesson on modern medical practice. First of all, I’m an internist. In the old model, an internist sees patients both in the office and in the hospital. Over the last decade or so, there has been a shift in practice. Fewer and fewer outpatient primary care doctors see their own patients in the hospital. Most now use “hospitalists”, internists who specialize in taking care of hospitalized patients.
There are several reasons for this.
First, hospitalized patients are much sicker than they used to be. To meet the “severity of illness”, and “intensity of service” requirements, you have to be pretty darn sick. This means that hospital care is more complex and specialized. Still, it’s not impossible to keep up with both outpatient and inpatient medicine.
Second, there are the financial pressures. Margins are very thin in small practices. Medicare pays me perhaps seventy bucks to see a patient. In the time it would take me to go to the hospital, I could have seen a whole lot of patients, and seeing a hospital patient doesn’t pay all that much more. Not only that, but to pay the bills, you have to see lots and lots and lots of patients, which leaves even less time for other things, such as family, eating, urinating.
I’m in a unique situation, in that I need to be at the hospital every day to teach, so seeing my own patients is no big deal. But for most internists, it’s becoming impossible. Taking care of hospital patients is not just the 10 or 15 minutes at the bedside; it’s the paperwork, phone calls, and pages; the discharge planning, the specialists. Each hospital patient is more work than any 5 office patients, for the same pay.
Where does that leave patients?
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Cancer 102
In Cancer 101, I gave some basics to understanding cancer. A commenter asked a good question, and our next lesson will attempt a simple answer.
The question regarded how a pathologist can tell if a cancer is “invasive” by looking at a specimen. Well, depending on the specimen, the answer changes, but let’s use the colon as an example. Most colon cancers start out as benign polyps. Eventually the cells in the polyp can become malignant, and after that, they can they can begin to grow through layers of normal cells.
Here is a diagram of a cancer of the colon at various stages. As you can see, at a certain point, the cancer begins to grow through each layer. The ability to grow through, or invade, other layers is one of the things that makes cancers behave in a nasty manner.
Here is a piece of colon cancer under the microscope. This could have been from a biopsy of a polyp, or from a tumor completely removed by a surgeon. The stripe of light purple cells labeled “normal muscle layer” should extend across uninterrupted. Instead, a glob of darker purple cells is growing through the muscle layer, destroying it. Once the cancer cells get to a blood vessel, they can go anywhere in the body (metastasize). That’s bad.I hope that’s helpful.
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Cancer 101
Cancer is the second leading cause of death in the U.S., and at any moment directly affects almost 4% of the population, or about 10.8 million Americans. A diagnosis of cancer can be one of the most frightening moments in someone’s life, and yet most people understand little about the disease. I hear the same questions about cancer over and over again, so it’s well past time to give a bit of an explanation of this set of diseases.
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A very confused pharmacist
I’ve written often about the ethics of doctors and pharmacists imposing their own morals on their patients and customers. Our Sb pharmacologist has as well. And even though all of our legitimate professional organizations recognize this line, Bush’s Department of Health and Human Services has jumped into the ring to join a fight that should never have started. And just to demonstrate how single-mindedly idiotic an evangelical (small “e”) mindset can be when applied to medicine, PZ Myers, uber-atheist, received an interesting solicitation (please, don’t quote-mine that).
To remind you of the issue at hand, there are a number of doctors and pharmacists out there who think that their own religious beliefs should trump the standards of good medical care and the needs of their patients. This is why I write of “evangelism”: professionals who are trying to teach the Good Word (any Good Word) to their patients have stepped very far over an ethical line.
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Medical professionalism, or WE ARE YOUR GODS, BOW BEFORE US
One of our sciblings, Dr. Signout, is learning the ropes as she struggles (and presumably excels) through her medical residency. As her writing has picked back up, she has brought up some important questions about medical education and medical professionalism. I’m a little further along in my career than she, and I have some thoughts that may flesh out her experiences, and shed some light on the medical profession as a whole.
Her latest posts brought up two particularly important issues, one about how doctors are treated “without the white coat” and the other on what it means to put others’ needs before one’s own. These, it turns out, are connected.
Even when we shed the white coat, we’re still doctors. If we are out to dinner, and we see someone in distress, we respond. If a family member or friend has a problem, they call us up, day or night. Being a doctor is uniquely tied into personal identity. This makes certain situations particularly awkward—being a patient in your own hospital is discomfiting to say the least, and visiting a loved one is often no better.
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How will the candidates fix American health care?
I don’t know. There was a pretty good piece in the New England Journal of Medicine, but it’s really not clear enough for most readers (including myself).
The McCain and Obama websites give fairly comprehensive looks at their health plans, but nothing useful for a lay reader.
The good news is that both campaigns have a plan. The bad news is that it is virtually impossible for anyone who cares to make heads or tails of the two and compare them effectively.
Well, gentle reader, I’m going to do you a favor. As an educated and knowledgeable professional, I am not going to try to parse through the various written statements, all of which leave me with more questions, in order to help you understand the issue.
I’ve left requests with both campaigns to ask to speak directly to other human beings, and if all goes well, to present to you an unbiased look at both plans and their implications.
Don’t hold your breath. Obama’s website has a pretty easy way to leave press inquiries. McCain’s not so much.
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Stossel gets it right
John Stossel of ABC’s 20/20 has never been one of my favorites. He’s one of those folks who often poses as a skeptic by using doubt and mockery indiscriminately. Tonight, though, he got it right. He discusses food obsessions and fads, pointing out the contradictions inherent in food cultists.
One of the worst of the food cult leaders is Viktoras Kulvinskas, a leader of the raw food movement. Stossel’s interview with this wacko is great…he actually calls him out on his bullshit.
Raw foodists believe cooking vegetables even a little destroys their nutritional value. And eating meat is even worse, Kulvinskas said, because you eat the animal’s fear.
“When they go through slaughter, they go through a lot of fear, and that fear is taken into the dietary habits of America.”[Stossel calls that ridiculous and ask him how he knows. Kulvinskas says he just knows.]
Everyone knows that eating too much meat can be a problem. But does Kulvinskas even make sense? All over the world, as people have gotten wealthier, they are eating more cooked food, more meat and life spans keep increasing.
“That’s correct,” Kulvinskas said, adding that people are “sicker than ever. Living longer doesn’t mean quality of life. It only says that you’re living longer under medical intervention. These are not natural, whole people.”
So living longer isn’t good if you’re not “natural and whole”. WTF does that mean? But maybe he really values quality of life over quantity and is filled with compassion for his fellow humans? Nope.
When questioned about a raw foodie who died from her obsession, he responded, “at least she got detoxified and clean and moved on to another incarnation.”
Do you get why I liken altmed gurus to cult leaders? This guy prefers that his followers die pure and organic than live against his rules. This is typical of cult and other alternative medicine. Irrational ideology trumps logic every time.
Kudos to Stossel for calling out the purveyors of food woo and their manipulation of their victims’ psychopathology (and thanks to Mrs. Pal for making me watch the show).