January 25, 2008
Category: Science Bloggers
Farewell! a long farewell, to all my greatness!
This is the state of man: to-day he puts forth
The tender leaves of hopes; to-morrow blossoms,
And bears his blushing honours thick upon him;
The third day comes a frost, a killing frost,
And, when he thinks, good easy man, full surely
His greatness is a-ripening, nips his root,
And then he falls, as I do.
-Henry VIII, Act III, Scene ii
It is time for The Cheerful Oncologist to sign out. I have decided to take a holiday from writing and therefore am cutting the cord from ScienceBlogs. I send thanks to those readers who put up with my malarkey over the past three years. If the fair maiden Blogorrhea, the muse of web logging, returns to bewitch me at some point I may start again, but until then I place my pen down and say to all, "God Bless."
Be wise in the way you act toward outsiders; make the most of every opportunity. Let your conversation be always full of grace, seasoned with salt, so that you may know how to answer everyone.
-Colossians 4:5-6
Posted by Craig Hildreth at 9:08 AM •
January 24, 2008
Category: Patient Advocacy
Dr. Scott Berry, a medical oncologist at the University of Toronto, has written an interesting essay in this month's Journal of Clinical Oncology entitled "Just Say Die." His point is that doctors are hesitant to use the words "die" or "death" when counselling patients who are in the process of doing exactly that - dying:
Die is a short, simple word. The problem is that I rarely use it when I speak to my dying patients, and I don't think I'm alone.
According to Dr. Berry, one of the reasons why we eschew the "D" word when talking to patients about their prognosis is to avoid upsetting them with the use of such blunt terms since they are already in distress as it is. Another explanation is that we doctors find it awkward or unpleasant to bring up such bad news, which the author believes is a reflection on the perverted way our society identifies death as a distasteful subject, one that is almost taboo and should be identified with euphemisms. He remarks on other possible explanations:
It is not hard to see why physicians might have trouble talking about death and using the word death; we live in a culture where many physicians and patients may see death as an admission of failure or of giving up.
For the patients we have known for many years and with whom we have developed deep bonds, we may not want to use the word "death" because we are starting to feel our own sense of loss and the beginning our own grieving.
I understand where Dr. Berry is coming from with his request to speak more clearly about dying when counseling the dying, but I have a twist on his advice. First, here is his approach:
It's time to take the next step in opening up the discussions we have with our dying patients. The next time you must let someone know they are dying, the best way of doing this may be to say, "You are dying." It's more than just semantics. Using the word "die" will clarify our conversations with patients and let them know that death doesn't need to be considered unnatural or a failure.
Telling every patient "You are dying" seems too formulated to me. It pays no respect to the tremendous amount of hard work the patient has put into the mind, into developing and maintaining a hopeful and courageous attitude during his or her illness, an outlook that reduces anguish and perhaps even steels the body to fight on longer than it was meant to. I have seen the power of the mind and heart, and what it can do to support a body infested with cancer, and the results are impressive. I therefore respect the unique spirit that resides within each of us, and when I see this power still shining in a failing host who wants the truth I might just say this:
"Your body is dying, but not your spirit. The fire that blazes within you, that has allowed you to carry on so long with this disease, is still bright. It will not vanish until your body reaches its final breath, and on that day, on the day of your death, the person that inhabited your body will indeed disappear, yet it will live on - in the memories of those who knew and loved you. Such is the power of the human spirit."
Posted by Craig Hildreth at 12:59 PM • 27 Comments
January 22, 2008
Category: Commentary
If you have an important point to make, don't try to be subtle or clever. Use a pile driver. Hit the point once. Then come back and hit it again. Then hit it a third time-a tremendous whack.
-Winston Churchill
Point number one: "Work-related stress can kill, study finds"
Point number one again: "The team conducted seven surveys over a 12-year period and found chronically stressed workers -- people determined to be under severe pressure in the first two of the surveys -- had a 68 percent higher risk of developing heart disease."
Point number one a third time: "Stressed workers eat unhealthy food, smoke, drink and skip exercise -- all behaviors linked to heart disease...stressed workers also had lowered heart rate variability -- a sign of a poorly-functioning weak heart -- and higher-than-normal levels of cortisol, a "stress" hormone that provides a burst of energy for a fight-or-flight response. Too much cortisol circulating in the blood stream can damage blood vessels and the heart."
If you are stressed out at work, please keep in mind the fact that you may be increasing your chances of a heart attack. How you reduce the effects of stress on your body is up to you, but if you're so inclined, try this piece of advice from Peter Kokkinos, director of the Exercise Testing and Research Lab at the Veterans Affairs Medical Center in Washington:
Older men who were classified as "highly fit" died at half the rate of those who were not fit in a major long-term study, U.S. researchers said on Tuesday. The study of more than 15,000 U.S. military veterans is one of the largest yet to show that exercise extends lives regardless of race or income.
I can't emphasize enough the salutary effects of regular exercise. Now get out there and boogie!
Posted by Craig Hildreth at 8:56 PM • 4 Comments
January 21, 2008
Category: Commentary
The New York Times has a story published last Friday about American men traveling to Mexico to receive a treatment for prostate cancer that is not approved in the United States. The article implies that this treatment is an unproven entity and may be unethical. I'm not so certain about this, so let's take a look.
The treatment is called High-Intensity Focused Ultrasound, or HIFU. The title of the story is:
"Despite Doubts, Cancer Therapy Draws Patients"
Doubts? Who's doubting the treatment - the doctors who perform it? The company who makes the product? The patients themselves? Of course - it is physicians in America who don't have access to the treatment who are skeptical. Such attitudes are not necessarily detrimental to the advancement of prostate cancer care; most oncologists prefer to see at least a modicum of sound clinical evidence for a new treatment before recommending it. In the matter of HIFU, however, I believe that some caveats need to be given to both sides before anyone jumps to conclusions about it being the latest example of quackery.
HIFU for prostate cancer involves sedating the patient and then using a transrectal ultrasound to destroy prostate cancer cells with temperatures in excess of 80 degrees centigrade. The controversies surrounding this procedure have been clearly listed by experts in prostate care. Here are some of them:
Read on »
Posted by Craig Hildreth at 1:39 PM • 1 Comments
January 18, 2008
Category: Literary
When used deftly, words can be incisive tools of communication. Finding the best word to describe an emotion or idea tumbling around inside of one's brain should be an exciting and rewarding experience. Such mental exercises keep one's wits sharp while relaying information in a vivid, often memorable manner, such as when Winston Churchill described the expected role of the Allies in World War II: "In War: Resolution. In Defeat: Defiance. In Victory: Magnanimity. In Peace: Good Will." Notice how he distilled the essence of these powerful concepts down to just a few words.
We all enjoy wielding certain favorite words in our conversation or in writing, and as a fierce proponent of increasing one's vocabulary I'd like to share some of mine. (Disclaimer: I don't use them as often as I should, but that's only because I'm shy).
adduce: to bring forward in argument or as evidence; cite as pertinent or conclusive. "Papa interrupted John before he could adduce any more reasons why he should be allowed to stay out late."
omphaloskepsis: literally, the contemplation of one's navel, which is an idiom usually meaning complacent self-absorption. "After an hour of listening to her tedious exercise in omphaloskepsis I quietly signaled our waiter for the check."
unctuous: characterized by excessive piousness or moralistic fervor, esp. in an affected manner; excessively smooth, suave, or smug. "The senior oncologist on the panel annoyed us all with his unctuous presentation of the case history."
lickspittle: a contemptible, fawning person; a servile flatterer or toady . "The Führer slammed his fist into the map, sending lickspittles hovering nearby into a frenzy of apologies."
hebdomadal: taking place, coming together, or published once every seven days; weekly:. "Mark rang off, grabbed his briefcase and headed for the elevator, anticipating a hebdomadal date with a dry martini."
See how much fun it is to use colorful words? I'll add some more later if I can find the time in between my uxorious propensities.
Posted by Craig Hildreth at 10:21 AM • 2 Comments
January 16, 2008
Category: Commentary
The following is a hypothetical advertisement seen on a community sign, let's say by a bus stop.
ARE YOU EXPERIENCING ANY OF THESE SYMPTOMS?
*chest pain, pressure, discomfort, tightness or squeezing, with or without nausea / sweating
*inability to breathe
*loss of consciousness
*worst headache of your life including at least the past six incarnations
*uncontrollable vomiting, or vomiting up blood
*hemorrhage from the rectum, with or without light-headedness
*traumatic injury
*abdominal pain that is severe enough to interfere with your ability to remain upright, not to mention remain calm, cool and collected
*sudden loss of sensation or muscle strength
*altered mental status
IF YOU ANSWERED YES, PLEASE GO TO THE NEAREST EMERGENCY ROOM.
IF YOUR SYMPTOMS ARE NOT SEVERE NOR MENTIONED ABOVE, PLEASE CALL YOUR PERSONAL PHYSICIAN AND LEAVE US THE HELL ALONE - WE'RE SWAMPED!
Patients seeking urgent care in U.S. emergency rooms are waiting longer than in the 1990s, especially people with heart attacks, U.S. researchers reported on Tuesday.
According to the experts, more and more hospitals are closing their E.R.s because, as study author Dr. Andrew Wilper states, "...in our current payment system, emergency patients are money-losers for hospitals."
In other words, the fact that hospitals do not get adequately reimbursed to run an emergency room, combined with the hypothesis that increasing number of patients are using the E.R. as their family doctor, combined with the fact that emergency rooms need to be redesigned to allow for better access, treatment, transportation and coordination of care (plus given a larger space) means longer waits to see the E.R. doctor.
I can attest from personal experience that the emergency room is a lousy place to spend an evening. Are there any solutions? Dr. Wilper et. al. in the paper from Health Affairs have some ideas:
Read on »
Posted by Craig Hildreth at 3:26 PM • 6 Comments
January 14, 2008
Category: Footnotes
"You should think it over - you'd feel so much better if you took a transfusion."
My patient lay in her hospital bed, head at the proper thirty degrees of comfort, staring at some private point on the wall across the room. Her anemia had worsened and I couldn't tell if it was from the effects of cancer or of chemotherapy. It didn't really matter since the treatment was the same: two half-liter units of merlot-colored blood, courtesy of a pair of anonymous angels of mercy, also known as donors.
"I really don't want to do that."
"You don't have to, but getting two bags of blood will help your fatigue and tiredness."
"Yes, but how do I know I've got good blood?"
"How do you know you've got good blood? You mean is the blood safe?"
Her eyes met mine. "I mean, have I got the right kind of blood for this?"
I recalled what she had shared with me during our first visit, about how she had spent forty years working with school children while raising her daughters. She possessed an aura that reminded me of walking through summer meadows, but until today its source was unclear. As she fussed with her blanket I suddenly seemed to see behind her hardened voice. Here was a woman who had spent her life giving to others, who never showed up late nor petulant, a wife and a mother, an independent soul who now was forced to ask for mercy from a disease that harvested the living like a scythe. I still wasn't sure what she meant but answered her with a smile.
"You've got great blood - you worked your whole life to earn it. You know, you're my role model on how to live courageously. I can see the strength flowing through those veins.
"You've got the right kind of blood all right, and I'll remember that whenever I think that mine is faltering."
Posted by Craig Hildreth at 9:00 AM • 2 Comments
January 11, 2008
Category: Book Review
"Obesity now a 'lifestyle' choice for Americans, expert says"
"Waistline grows along with economy"
"Wealth and Waistlines - A new book explains how the obesity epidemic has been shaped by economics, and what we can do to reverse the trend"
The Fattening of America, by Eric A. Finkelstein and Laurie Zuckerman, is a fascinating new book proffering an economic explanation as to why more and more Americans are obese - I think. I haven't read it but that didn't stop me from perusing the news stories coming out on Dr. Finkelstein's analysis of obesity and its relationship to our modern economy.
If I may sum up his theses on why we're getting fatter:
Read on »
Posted by Craig Hildreth at 11:04 AM • 8 Comments
January 9, 2008
Category: Science Bloggers
That last post was my 300th since I joined the ScienceBlogs community in August of 2006. I usually don't comment about my personal life but I must confess to a certain feeling of satisfaction on reaching the 300 mark, as I never thought I'd last this long. Since creating my alter ego over three years ago I have enjoyed setting him loose on the unsuspecting blogosphere. Coincidentally, over this same time period my practice has become much busier, not to mention my family plus my snooty dog who requires more attention than Marc Antony gave the Queen of the Nile. This makes it hard to find the time to write. I wish I knew how these über-bloggers spew out fifteen posts a day.
Anyway, I am grateful for the chance to inform and entertain my readers - all four of you (just kidding). I hope to continue on as long as it can be determined that I have something worthwhile to say, which according to the International Web Log Rating Guide is a characteristic found in 0.000000000000001 % of all extant blogs.
Just kidding. Or am I?
Posted by Craig Hildreth at 7:46 PM •
January 8, 2008
Category: Patient Advocacy
A study from Duke University reveals that oncologists who hear an expression of emotional concern from their patients respond with an empathic statement only 22% of the time. In other words, patients who share feelings of distress such as anger, discouragement or fear with their doctors are likely to receive no recognition of their suffering nor any emotional support in return. As a medical oncologist I find this embarrassing.
By identifying how seldom oncologists provide empathic support to patients, the study illuminates the potential benefit of teaching such skills to doctors. Previous research has shown that patients who receive empathic responses (called "continuer statements," as opposed to "terminator statements") experience less anxiety. In one study cancer survivors who watched videotapes of physician-patient encounters, with and without just 40 seconds of compassion expressed by the physician, rated the empathic doctors as "warmer and more caring, sensitive, and compassionate." The study participants also reported less anxiety after watching the "enhanced compassion" tape. Listen to the introduction to the Duke study, published in the Journal of Clinical Oncology:
Read on »
Posted by Craig Hildreth at 7:04 PM • 6 Comments
