A Medical Career

A talk on Medicine as a Career was recently requested.  Feeling stumped by my own thoughts, I begged off.  One always wants to ask WHY? when a young person plans for a life in this job.  Too many times, I'm made to feel old by their frank response.  A talk from someone like myself may scare them away.

Its not that the personal costs are too high in Medicine.  Careers are like all other things in life– best when in moderation.  The Greek concept of hubris applies.

Wondering if what doctors do seems difficult to most outsiders…  I thought I had a pretty good idea of this life as a student but, as it turns out, its a role assumed like most others- adult status, married life, parenthood.  After years of training, experience, & discipline, the most complex clinical situations take on the properties of a time-delimited puzzle, a "best fit" challenge to a prepared mind.

One simply does what one has to do, and the modifier is how well we do it.

Grief

I think that I'm tired and my defenses are down because of it.

Just lost 4 patients in 10 days.  None of these deaths came as a surprise, but they happened to people I've known for a few years.  Long, drawn-out declines in fairly young people with advanced disease.  That they all went in what feels like one fell swoop seems intolerable to me just now. 

Surprise, surprise…after all these years, this job can still deliver a shock of grief after all.

New Cancer Treatment Options

Archimedes having his best bath.

Its an ambivalent relief when they confirm the significant activity of targeted therapy for a specific cancer. A lot of publicity is involved, and that's only right. The companies have a flurry of educational seminars and lunches to pound in what you already know, if you had half a brain. That's appropriate too, given the multimillion dollar investments involved.

What's horrid is the small number of patients who can actually afford these new treatments. My ulcers act up each time that unguarded look of despair flashes from across the table when costs are discussed (in my gentlest tones).  Although it always elicits my own guilt, budget must be nailed at the first encounter with a patient, especially where no corporate insurance is involved.   When a quick size-up hints that budget may be severely limited, I zip through the expensive options anyway in the hopes that I'm mistaken, but confine myself to 2-3 loaded sentences.  Thereafter, the minutiae of costly treatments are presented on a computer screen only when specifically requested.   As in, 

• "Your breast surgery has taken out all visible cancer but you are at risk for relapse & require chemotherapy at about 10 thou per dose given every 21 days for 6 times– and you must have at least that." – said slowly in ALL CAPS fashion.  Then, almost as a brisk aside, "Newer chemo drugs can give you better control and less risk of relapse at an additional 45 thou per dose, with another 30 thou held in reserve for supportive medications. Moreover, your specific breast tumor profile shows that you can potentially reduce relapse rates by half with targeted therapy, each dose to be given intravenously every 3 weeks for 1 year (later, maybe two, depending upon current trial results) at an approximate cost of 70-120 thou per dose depending upon your size — this, in addition to chemo and, perhaps, further hormonal therapy later on, if it applies."  

Whew.   A long pause follows, after which, this particular patient population usually tries to bid down the original 10 thou quote for 1 cancer treatment. 

In a third world country, what is the optimal way to bring down costs of cancer care?  Prevention and early diagnosis, one suspects.   Education, of course!  I wish the government would step up their programs.

 

Mysterious East



Chinese Opera Mask

A reader noted that the US embassy in Beijing has looked into the rumors about the Sujiatun facility and found no hard evidence of wrongdoing.  The Falun Gong had been claiming that they were kept there for their organs.  On my part, I do hope that it was little more than a would-be plot for a B-grade movie.

One wonders how such horror stories are investigated, what it takes to get a good study going, and just how much caution about conclusions is appropriate.  Its not as though the investigation details are always fully open to the public at the pertinent time.  Besides, throughout our known history, when a minority population group is despised, the ensuing possibilities can sometimes be too terrible to contemplate.  The Jewish persecution (from the age of the earliest Pharaonic dynasties to Mengele), the African slave trade, Rwanda 1994. The Inquisition-- how I'd love to browse the Vatican archives. The 1950's McCarthy hearings.  Then there's the recent Saddam/Iraq "over-reporting"/misinformation (?disinformation) fiasco that cost certain agencies a lot of trust & credibility.  Hmm.  What will history uncover about that strange business?

Kinda depressing how consistently these persecutions have turned up over time.  Part of the human condition?  Homo sapiens of Kingdom Animalia.

Don't mind me.  I question, therefore I am.  Still, here's hoping that the reader's info signals the true end of that issue.  Thanks for your comment.

If you have cancer…(Cancer Tips)

…see a CERTIFIED oncologist.   The real ones tend to work in teams, with specifically-trained surgeons, radiation oncologists, medical oncologists, & allied services.  Ultimately, you may not need all specialties, but these guys serve as each others' check & balance.  Its best to go to a cancer treatment center with multidisciplinary guidelines but, short of that, get several opinions.

"Cancer Surgeon" on a card is no indication of experience or formal training.  Ask your favorite radiation & medical oncologists who the best surgeons are for you– then look them up & check them out!

If you are a competent adult, you are responsible for your own health to a very large degree.  Do the research & exercise great caution.  Be critical when you're given an opinion, and doctors who know their stuff will appreciate it.

You must get your cancer treated optimally that first time, especially if you're talking (however remotely) about a cure.  Should relapse set in, subsequent "salvage"  programs may not be as successful, and they're usually tougher.  So, play it smart:  invest your resources at the start.  Ultimately, its cheaper that way too.

Oncology in the community setting (vs trial setting) is evidence-based.  There are statistics on response (tumor control) rates, adverse effects, etcetera.  Confused?  How do you know if the info you're given is accurate?

What every patient should browse…

• NCCN  http://www.nccn.org/
• NCI  http://www.cancer.gov/

Sample: "What is the current standard of care?"; "What are the other options?"

• "Expensive" or "new" does not always mean "better".   That's true in more instances than you'd think.  Like any investment, seek to justify costs.
• Complete disappearance of a tumor does not always mean cure or a longer survival time.  Ask about the goals & endpoints of your cancer treatment.  ?Cure  ?Palliation
• When planning the budget for a chemotherapy series, consider that receiving just a few costly "best" treatments may not be as beneficial as completing the set of an "acceptable" alternative at tenable costs.

Sujiatun Harvest

There was this patient with a stage IV liver cancer who'd gone to China-- and came back in almost no time with a new liver. I thought to myself then: who in his right mind would give away a presumably healthy liver to someone with incurable disease? Bad medicine. Well, that patient soon died, as expected. Who knows-- maybe that cocktail of immunosuppressants got his tired organs overly excited?  Whatever... that was that.

Then now I stumble upon this National Review article about the "possible" harvesting of organs from live patients at a Sujiatun "concentration camp".  I feel sick because, on the surface, it figures.

Why they leave...?

Ah, this job.  What difference would it have made if I'd taken on that university position instead of coming home after training?  Professionally, I mean...as the personal costs would have been too high to contemplate.

Apart from the obvious financial advantages, that PhD would be in my pocket by now.  Research grants medical school work...yummy.  Rare patient calls on my mobile, and none of those pesky text messages clogging up the gadget's memory every single day.  (Why do they think you can make informed decisions via text?)  Free weekends, for sure, and some version of El Nido to escape to.  A treat-as-you-see-fit ethic, with much less of the bargaining / budget straining that the lack of adequate insurance mandates.  Doctors would be compelled to ask multidisciplinary opinions by the high level of patient information.  Surgeons would compete according to the level of operative skills instead of competing with medical oncologists for patients.  Fixed fees for medical oncologists, with no direct sales of drugs to patients.

Ahh...the contravida there would largely be government regulation, and this blog would be venting personal ire against it.

No Fiestas

Holy Thursday-- working, as usual.  Don't know how one can get things done efficiently when most everybody else is out for the next 4 days.  Pity the patient for poorly justified delays & add-on expenses.

I wonder if I'm the only one who feels that there should be no holidays for key hospital personnel.  Why charge a premium to get things done then-- when people would never have themselves confined on those days unless absolutely necessary?  No Fiestas for patients.

This Job

Van Gogh

Sometimes, one just gets so tired of this job. Its interesting, yes!, but oh so taxing.

My subspecialty selection process could bear a re-do, but only so I can make the same choice for the right reasons. Attracted to neurology & nephrology as a trainee, these lazy bones were born just too darned toxic. Duty night was The Signal for ARF's & subarachnoid bleeds to surface. While everyone else was sleeping in the duty room, I ran around with small pieces of paper in my pockets, the beeper yelping "Memory Full", chain-smoking & snacking on deeesgusting leftovers, smelling all the while like vile dialysate. So I asked myself... what's the job with few emergencies, a decent patient load, that still allows for some degree of gratification? Diagnostic radiology scored 2 of 3 but, like dermatology, its such a snore. Reconstructive surgery sounded suitably challenging, but with my toxic track record, the burn cases would just keep rolling in. So, OK, let's do oncology. Almost totally brain work, I thought. Such profound ignorance never goes unpunished.

Years ago, cancer was a pitifully manned area of medicine. Too few of my peers were interested in the specialty back then, maybe because treatment options were so few. Depressing, they'd said. One then figured that the job would be primarily focused on symptom alleviation. OK!, I'd thought. Let the laws of supply & demand rule.

What can you expect from an overgrown kid who'd wished only for adequate & undisturbed sleep? Yes, it was simplistic & selfish thinking. Theorem: Professional students are stuck in adolescence-- but that's another topic.