Wednesday, March 25, 2015
Miraculously, for many the disease went into remission, only to recur months later. But Dr. Farber's last-ditch attempt to save these children began an era of ultimately remarkable progress — decades of clinical trials of progressively complex treatments that now cure nearly 90 percent of children with leukemia.
Olivia Blair of Baltimore, who will be 3 in May, is showing the benefits of this progress. After her T-cell acute lymphocytic leukemia was diagnosed when she was 17 months old, Olivia has weathered more than a year of treatment at Johns Hopkins Kimmel Comprehensive Cancer Center with about 15 different drugs plus radiation to her brain and spine.
With her disease undetectable months later, she is now in a study of an experimental drug to help maintain the remission and is back to a near-normal childhood, a thriving, happy toddler who plays with other children, goes to day care and accompanies her mother grocery shopping.
Kelly Blair, Olivia's mother, said, "It was very hard for us to decide to participate in the new study, but we finally thought that even if it didn't help Olivia, it's going to help other kids."
The tortuous road to the kind of treatments now saving more than half of all cancer patients is graphically depicted in a six-hour series, "Cancer: The Emperor of All Maladies," produced by Ken Burns, to be broadcast on public television (PBS) March 30, March 31 and April 1.
Thursday, March 19, 2015
It was as if someone had taken a highlighter to the whites of her eyes and coated her skin with a layer of mustard. In actuality, the cancer in her colon had crept to her liver, where it blocked bile from taking its natural path out of the body, causing the ominous yellow chemical to spill into her blood and tissues. She had left the hospital two weeks ago, hoping to die at home, but came back with worsening pain and bloating in her belly — and because she couldn't stand to look at herself in the mirror.
"Doctor," she said softly — it was a title that still didn't feel quite comfortable to me, a newly minted doctor, especially coming from a patient several decades older than me. "You remind me of my nephew."
She asked me to sit for a few minutes and, shamefully, I hesitated. I had eight more patients to see before rounds and was already running behind. But I sat — listening to a dying woman's fondest family memories, my mind racing through a seemingly endless list of boxes I had to check that morning. When my pager went off five minutes later, I excused myself, promising to return in the afternoon to finish our conversation.
But I didn't.
There were new patient admissions. Emergencies on other floors. Notes to be written, consultants to be called, outside hospital medical records to be procured.
When I got home that night, I kicked myself for forgetting to stop back to see her. I briefly considered going back to the hospital but, exhausted, told myself she'd be asleep by now and vowed to arrive early the next morning to spend extra time with her.
She died that night.
The most draining aspect of medical training, it turns out, is not long hours, brash colleagues or steep learning curves — it's the feeling that you're often unable to be there with and for your patients in the way you want, in the way you'd always imagined you would be.
For hospitals to run efficiently, it is widely thought that they must operate like companies. There's a certain number of patients to be seen, doctors to see them, diseases to be managed, procedures to be performed, and hours in which all this must occur. For patients to feel cared for, we must treat them like family — with all the time, energy and compassion that entails
In studying why people opt to exercise or not, scientists often and understandably focus on individual psychology and situations. But increasingly, exercise scientists are also looking into broader factors that can have a bearing, including our social relationships and whether being single, married, childless or employed is likely to affect exercise behavior.
The results of past studies on this subject have been alternately predictable and startling. Single men and women, for instance, generally exercise far more than do married people, although divorce can change that. Men typically exercise more after a marriage ends; women in that situation frequently exercise less. Meanwhile, employed men, even those with desk jobs, usually exercise more than men who are unemployed.
Back in Ohio, shoppers at Marc's, a local discount grocer and pharmacy in Garfield Heights, can enter a kiosk equipped with a stethoscope, a blood pressure cuff and a two-way video screen that lets a patient talk directly to a doctor.
These disparate ventures bear the imprimatur of the renowned Cleveland Clinic, one of the most respected nonprofit health systems in the nation, as it tries to manage the extraordinary changes now transforming health care.
While it has traditionally relied on its ability to provide high-priced specialty care, the system, along with every stand-alone community hospital and large academic medical center, is being forced to remake itself. Patients are increasingly seeking care outside the hospital — in a family health center, a doctor's office, a drugstore or at home. Medicare and other insurers are moving away from volume-based payments to new models, to pay less for better care.
Dr. Delos M. Cosgrove, a 74-year-old former heart surgeon who took over as chief executive about a decade ago, likens what is happening in health care to the upheaval decades ago in the steel industry, where companies disappeared when they were unable to respond to change and new competition. "The disruption is going to happen," he said. As an inevitable shakeout takes place among health care institutions, a look at how the clinic is responding underscores the industry's challenges and the flurry of activity taking place as institutions try to adapt.
Wednesday, March 18, 2015
Tuesday, March 17, 2015
I hear that every time I write about a patient's often tortuous and usually prolonged journey through the medical system, featured each month in The Post's "Medical Mysteries" column.
I began writing the column in 2007 with twin goals: to explain the surprising complexity of medical diagnosis and to document the impact on patients and families when the process goes awry. Most stories are told from the perspective of a patient or close relative, while others reflect the viewpoint of the doctor or health-care worker who figured out what was wrong after others — sometimes many others — failed.
So how often does this desire to help others actually pan out? While there is obviously no way to measure the ripple effect, sometimes I learn about successes as dramatic as the original cases that served as the catalyst.
Saturday, March 14, 2015
Reading his chart, I have an ominous feeling that this visit won't be simple.
A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.
He suffers from both congestive heart failure and renal failure. It's a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.
Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can't blame him.
Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.
With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.
After 30 years of practice, I know that I can't possibly solve this man's medical conundrum.
A cardiologist and a nephrologist haven't been able to help him, I reflect, so how can I? I'm a family doctor, not a magician. I can send him back to the ER, and they'll admit him to the hospital. But that will just continue the cycle. . . .
Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it's useless to try.
Then I remember a visiting palliative-care physician's words about caring for the fragile elderly: "We forget to ask patients what they want from their care. What are their goals?"
I pause, then look this frail, dignified man in the eye.
"What are your goals for your care?" I ask. "How can I help you?"
Every Friday, Pulse--voices from the heart of medicine publishes and distributes a first-person story or poem, together with a visual image or haiku, about health care.
Launched in 2008, Pulse was created by members of the Department of Family and Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine in collaboration with colleagues and friends around the country.
At a time when the pioneering work of Rita Charon has established the value of narrative medicine--an approach that places a premium on personal perspectives within a healthcare encounter--Pulse makes narrative medicine available to all and accessible to anyone.
Pulse tells the story of health care through the personal experiences of those who live it--patients, health professionals, students and caregivers. While medical care is often rightly criticized for being cold and oblivious, Pulse highlights the humanity and vulnerability of all its actors. In doing so it promotes the humanistic practice of medicine and encourages advocacy for compassionate health care for all.