Cancer Doesn't Care

Cancer does not care what you think or what you feel. It does whatever it wants.

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Several months ago a young man came into our office with a strange looking lesion on his scalp. I was not sure what it was but I knew it wasn’t normal. It was big enough and weird enough that I referred him on to a specialist for the biopsy. My worst fears were confirmed when the pathology report came back as a very rare type of melanoma, the most deadly type of skin cancer. I referred the patient to a cancer specialist for ongoing treatment.

The cancer doctor immediately recommended that he see a plastic surgeon for a wider excision to make sure that none of the cancer was missed and to also biopsy a lymph node in the area to make sure the cancer had not started to spread. The patient didn’t want to go. He didn’t want the scar, didn’t want to deal with the recovery, didn't want to believe it was serious. He refused to listen to the oncologist’s warnings not to trust that all of the cancer had been removed in the initial incision. The patient refused the doctor's advise and decided to instead try herbs and holistic medicines.

The cancer wasn’t impressed with the patient’s interest in natural remedies, nor did it care that the patient believed he was cured. It spread anyway, and it spread everywhere. Lungs, liver, and bones all had tumors within a matter of months. The patient is in his early twenties and is too young to die. The cancer does not care. The odds for long term survival are not good. 

Cancer never cares what we want or think. It is a heartless killer. Colon cancer does not care that you are afraid of having a colonoscopy, is not moved by your embarrassment about having someone insert something into your rectum, or worry that you can't take the time off of work. It ignores all of our concerns and attacks who it wants when it wants. It will attack 1 in 20 Americans and do what cancer does. If not caught in time it will spread and it will kill.

Breast cancer does not care that mammograms can be uncomfortable or that you have sensitive breasts. It does not care that no one else in your family has had cancer, or how big or small your breasts are. It will attack 1 in 11 American women and do what cancer does.

Cancer can not be wished away or ignored into oblivion. It does not care how positive your thoughts are. It does not care how many children you have or about your retirement plans. It moves at its own pace on its own timetable. It does not discriminate. It does not care about the color of your skin, your religious faith or what you do for a living. For many cancers it does not care whether you or male or female. It does not care whether you or rich or poor. It can attack anyone and when it does it will try to do what cancer does. It will spread and it will kill.

So what can we do? Like any enemy it is best to attack when the opponent is weak and small. While early detection does not always guarantee victory there are cancers for which it truly matters, such as breast and colon cancer. Smart people get colonoscopies and mammograms done when they turn 50. Smokers can stop smoking, and those who have smoked too long and too much can get CT scans to look for cancer after age 50 as well. When diagnosed with cancer we can listen to our doctors and pursue aggressive treatments, and trust their opinions more than our feelings. We deny denial a chance to harm us. We can do these things because we care about ourselves and our families, even when cancer doesn’t.

- Bart

Thanks for reading and sharing. More importantly, thanks for getting your colonoscopies and mammograms!

Where Have All the Patients Gone

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It was time to get rid of some old charts. The garage attached to the converted home that is my office had reached the maximum allowable clutter and we needed to clear some space. Charts for former patients that had not been seen in more than 7 years could be shredded, charts for active patients needed to be saved. I hired a college student for the task, to painstakingly check computer records to see which of the several thousand charts were which.

It became clear early on that it was going to take dozens of hours for the student to complete the task so I decided to help with the job. I realized that I could recognize the names of active patients immediately, and set them aside so the student did not need to deal with them. To that end I spent the afternoon of the fourth of July separating out these charts I recognized. It was an unexpectedly depressing task for I came across many familiar charts that bore the names of former patients I had not seen in years.

I saw the names of babies I had delivered whose families had moved away as well as other patients I had cared for who had gone home to family or followed job assignments out of state. I read the names of several people who had passed away, their names bringing memories of the sorrow of their last days. Some names brought smiles as they were associated with a patient who was quick with a joke or a story.

Some names brought stabs of pain bringing to mind patients who had left my practice in anger, including a vivid memory a patient who was angry that my chart notes had impacted an insurance purchase.  He had once given me an engraved gift for the care I provided his family. This was forgotten when the insurance denied his application. For him, all of the care I had provided meant nothing compared to an elevated premium.  He called into question my character and competence. I never saw him again. Other names, of parents who had left over my position on vaccines or antibiotics, also brought sadness. There were many other patients who had simply disappeared from the practice for reasons unknown.

Some of the negative interactions I recalled caused me to stop and ponder the changes that had occurred in me over the years. I realized that modern day Bart would have handled many of the situations differently. There were times I could have been kinder, could have listened better, could have explained better, and could have been more gracious. I realized that if I had been better, done better,  some of the lost patients might still be a part of my practice.

I sifted through thousands of charts that day, overwhelmed by the reality that so many people had passed through my office doors and humbled by the fact that I had been privileged to care for so many.

Out of the multitude of memories and emotions I confronted that day arose a sense of purpose. I realized that there is never a guarantee that any relationship is going to endure. Each patient encounter my be my final opportunity to love and serve someone. With this in mind it is my goal to practice medicine in a way that honors that reality, to never waste a chance to be kind and gracious. It is my prayer that in so doing I will have a positive and lasting impact, to leave each person with an enduring positive memory, that the sight of my name will one day bring a smile.

- Bart

Thanks for reading and sharing. I greatly appreciate comments and questions and those who subscribe regularly to the blog. 

The Stranger in the Wedding Pictures

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It was intended to be a quick dinner at a casual local restaurant, the kind where you order at the counter and they bring food to your table. We ordered pizza, salad and tri-tip and found a place to sit. Shortly after we sat I realized I did not have my phone, meaning the answering service could not reach me. I got up to walk to the car and see if I had left it there. As I headed for the door a party of about 12 people caught my eye.

They caught everyone’s eyes, for they were a wedding party. A very young bride in a wedding gown, her new soldier husband in his dress uniform, a few bridesmaids and what I assumed were their parents were seated in the middle of the dining area. In the center of their table was a small two tiered wedding cake, with red trim and bride and groom figurines perched perfectly on the top.

Thoughts about them filled my mind as I went to my car. I thought of how young they looked, and remembered how excited I was when Lisa and I were married at nearly the same age. I thought of him in the military and wondered if they would soon be separated. I reflected on the modesty of their celebration. It seemed to me that their choice of venue meant that they must not have had much in the way of material wealth.

They were strangers to me but I felt a strong desire to bless them and encourage them. I knew it would be strange and perhaps awkward, but I decided to give them a gift. I took a few bills out of my wallet and folded them tightly so as to be discrete. As walked by their stable I stopped across the table from the bride and groom. I reached out my hand as I said, “Congratulations!” and combined a handshake with the handing of the gift. I walked quickly away, not wanting to intrude any further.

A few moments after I rejoined my family I heard a voice over my shoulder saying “Excuse me.” It was the bride and groom. In her hands she held a few slices of their wedding cake. “That was so nice of you, we wanted to say thank you!” I was overwhelmed at the kindness of their response, blessed that they had included us, strangers, in their celebration. I was also excited at the prospect of cake for dessert. (It was delicious, confirming my decision to hurry through the healthy portion of my meal.)

The cake was so good that my wife and daughter wanted to know where it was made. Somewhat embarrassed at the additional intrusion I made my way back to their table. “Sorry to intrude, but the cake was so good, my family wanted to know where you got it.”

The bride smiled, and asked if we wanted more! I politely declined, and she said she would write down the number of the bakery. I turned to go but before I could walk away a woman who appeared to be her mom said to her, “Wait! Don’t you want a picture?”

Before I knew what was happening I was posing for a picture with the bride and groom. I was both touched and embarrassed, and said, “Wedding pictures with a complete stranger!” We exchanged names (They are Siria and Damion) and shook hands, and I again congratulated them before returning to my table, unable to repress a smile.

It was one of the best dinners I have ever had. The few dollars I had given them as a gift were more than worth it. How often does one get to share wedding cake with strangers? I doubt I will ever forget their smiles, their grace and their kindness. I know they will never forget me, for I will forever be the stranger in their wedding photos!

Bart

Please join me in praying for this couple as they start their lives together. Her life as a young army bride will almost certainly be challenging. Pray for his safety and their happiness and for many years of joy together. 

Sleeping Pills for a Sick Dog

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He had never had a sleep problem before, not when his girlfriend had died, nor with either one of his knee replacements. Nevertheless, by the time he came to my office he had not slept well for over a week. He told my PA that he did not feel that he had slept at all and asked if there was anything she could do. As he was over 80 years old she proceeded with caution, giving him a low dose of a short acting sleep aid. She gave him 5 pills, hoping that it would be enough for him to get back on schedule.

It wasn’t. He was back in the office 6 days later. He saw me on this return visit and he told me that the medicine had done nothing for him, that he had not slept for a minute in almost two weeks. Given that he was alert enough to drive to the office and have a conversation I knew his report was not entirely accurate and that he had to be sleeping at least a few hours each night. Still, I was certain he was not sleeping well and was truly suffering.

I inquired into why he was not sleeping well and received the same explanation he had given my PA a few days earlier. He was worried about his dog. She had recently been diagnosed with a serious medical condition impacting her adrenal glands. She would need life-long hormone treatments which, at $100 a month, were beyond what he could afford. She was “just a dog” but she was his only companion and he did not know what he could do for her or how he would do without her. He was distraught and worried and had been lying awake at night wondering what to do.

It did not require a medical education to recognize that his problem was more social than medical and I began a search for solutions. It seemed to me that there had to be some way for him to get help paying the dog’s medical bills. I asked him if he had talked to the vet about any charities. He had, and the one charity that he had called told him they were unable to help. The charity only provided one-time grants and did not pay for ongoing treatment.

“Do you have children?” I asked, thinking that perhaps they could help.

“I have four,” he replied, going on to tell me that one of them, a son, lived nearby.

“Can they help?” I asked, “It would only be $25 a month for each of them to help.”

He seemed reluctant to ask for help so I offered encouragement. “You do not have a sleep problem,” I said, “You have a dog problem. You don’t need a sleeping medication, you need help paying for your dog’s medication. You should ask for help.” He remained hesitant.

An unexpected thought came to my mind. I do not know from whence it came, whether it was the Spirit of God or temporary insanity, but I went along with it. I reached into my wallet and removed a $50 bill. “Here is half of next month’s prescription for your dog. I want you to take it and go home and ask your son for the other half. Then call me next week and let me know how you are doing.”

A week later he called as I had asked. His son had agreed to pay for his dog’s medications, and he was sleeping well. The message brought a smile to my face and warmth to my heart. I had made a difference in the life of a lonely old man. The type of difference I had always hoped to achieve as a Family Doctor.

His story reminds me again that caring is the most important part of medical care, and that sometimes being a friend to someone is every bit as important as being their doctor.

Bart

PS- I was hesitant to share this post as some might think it self-serving, but his story was a great encouragement to me. It is a reminder of the importance of kindness and my need to be kind whenever I can, as well as a reason to reflect on the many times I was not kind or generous and instead rationalized my indifference. The Old Testament Proverb, "Do not withhold good from those to whom it is due, when it is in your power to act" should guide all of us. When someone we know needs help and we are in a place to give it, giving help should be the expected and not the exceptional response. A worthy goal for all of us.

Patient Suffering, Persistently Prolonged

His life was miserable and there was no hope for improvement. There never is for nonagenarians with terminal illness. His failing kidneys could be supported with dialysis, but they would never recover their function. His damaged lungs could be supported by a ventilator, but they would never be strong enough to support normal life. His damaged brain, crippled by dementia and recurrent strokes, would never again allow him to regain speech or understanding. His quality of life was below what any reasonable person would desire, below what he had previously told others he would want and yet the doctors continued to do everything they could to sustain him in his suffering state.

Day after day a steady stream of physicians entered his room in the ICU. They often did not speak to him, for he was unable to reply. They checked the readouts on the machines, briefly applied their stethoscopes, and reviewed the day’s lab and x-ray reports. They entered their “findings” in the medical record, using words such as “stable” to describe the patient’s poor condition, and then moved on. A few of them, aware of the futility of their actions, wrote faint words of protest, saying in the record that the patient would be a good “hospice candidate” or that there was “little benefit” or that “comfort care” would be reasonable.

The boldest among them addressed the patient’s daughter. She kept a near constant vigil at the patient’s bedside, questioning every action and every medication, every turn of a dial or push of a button and documenting every response in the notebook that never left her side. The bold ones tried to encourage the daughter to accept the gravity of her father’s condition, the lack of improvement, and the reality that 90-year-old men with disease this severe did not get better.

She was always forceful in her reply, “Do everything!” By everything she meant everything. She wanted CPR, electrical shocks and breathing machines if his heart stopped, dialysis for his kidneys and feeding tubes for nutrition. Her father was NOT going to die on her watch.

And so the dance continued. Nurses were demoralized. They had chosen their profession out of desire to provide comfort and care and now found themselves prolonging the suffering of a man who seemed to have no advocate, no one who cared enough to say “enough.” Physicians knew they should let the patient go, to put an end to his suffering by getting out of the way and allowing the natural course of life to occur but they felt powerless in the face of the angry daughter with the power-of-attorney form. Weeks went by, hundreds of thousands of dollars were spent achieving nothing, and despair and desperation mounted.

So they called me.

I am the chairman of the ethics committee at my hospital. Over the last two years my fellow committee members and I have worked to develop policies and procedures to deal with situations such as the one in which this poor old man had found himself, policies that address what doctors can do when there is nothing to be done.

I responded as I do every time I receive these calls. I reminded the physicians that they are not obligated to do things that do not work, that no one has the right to demand futile treatment. The truth of medicine and of life is that not every disease can be cured. The ultimate disease, old age, can never be defeated. I reminded them that there are times when the only thing left for us to do is to let a dying patient die in dignity and comfort. I guided them through the process of documenting this reality in the medical record and informing the family. Then I met with the family.

The family conferences usually fall on my shoulders. They are almost always intense encounters characterized by accusatory outbursts and rage. I have been accused of everything from neglect to euthanasia and murder. I do my best to let the angry words bounce off of me and to gently affirm their feelings and still confirm the realities of their loved one’s illness. Sometimes there is reluctant acceptance, many times there are further demands and I am forced to explain that their demands will no longer honored. It is a grueling and heartrending process. Regardless of the process, ultimately the patients dies in comfort and with as much dignity as we can provide.

With each case I find myself wondering, “How did we reach this point?” These circumstances are so devastating to all involved, one would think we would find a way to prevent the suffering and pain that patients and families endure. How is it that we don’t?

In my experience there are several factors.

1-      Patients and families do not prepare for death.

In spite of its certainty, many families live in denial. I have been told by families that their 94 year old parent wanted to live forever. The irrationality of the statement was lost on them. In spite of the efforts of physicians and the mandates of Medicare to discuss end of life issues a significant percentage of patients do not communicate their wishes in advance. Even when they do, they often assign decision making responsibility to family members who are ill-prepared for the task.

2-      Fear

Doctors are afraid. They are afraid of conflict, afraid of negative interactions and afraid of lawsuits. In every end of life consult in which I am involved this is the major issue of physician concern. The irrational fear of being sued causes physicians to do things they know are wrong, things they know are worthless and useless, in order to placate demanding families.

3-      Time

Doctors are busy and dealing with angry families can take several hours out of a doctor’s day. I recently consulted on a case for a physician who texted me that he was not sure when he could return my call because he had 28 hospital patients to see that day.

Every hour a physician spends dealing with an angry family is an hour that he cannot spend with sick patients who might actually benefit from his care and attention. It is easier to spend a few minutes a day continuing the status quo then it is spending hours fighting a family.

4-      Lack of training and support.

It is hard to stand alone against an angry family. Their words and accusations may be irrational and unreasonable but the accusations still hurt. Most physicians have no training in how to deal with these circumstances. Further, most of these patients have multiple physicians, and one weak-kneed physician and undo hours of relationship building and persuasion. It is a terrible feeling to summon up the courage to confront only to find yourself undermined by your colleagues. It is easier to not make the stand in the first place.

5-      Cultural inertia

This is perhaps the biggest challenge of all. Change is always difficult. Physicians and hospitals have been yielding to unreasonable demands for generations. Inaccurate beliefs about legal liability, decision making authority and allowing natural death are deeply ingrained in hospital culture. Convincing physicians that it is okay to do the right thing is a daunting task.

My colleagues on the Ethics Committee and I recognize these challenges. As difficult as they are, we are committed to overcoming them, one important patient at a time.

-          Bart

PS: The case above is real. Minor details have been changed to ensure confidentiality. It is typical of the cases for which I am asked to consult. If there is any important take away from this post, it is that we ALL need to make our wishes clearly known to our loved ones. It is a gift to them and ourselves.

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