Wednesday, August 4, 2010
Tuesday, August 3, 2010
There are places where Ebert exists as the Ebert he remembers. In 2008, when he was in the middle of his worst battles and wouldn't be able to make the trip to Champaign-Urbana for Ebertfest — really, his annual spring festival of films he just plain likes — he began writing an online journal. Reading it from its beginning is like watching an Aztec pyramid being built. At first, it's just a vessel for him to apologize to his fans for not being downstate. The original entries are short updates about his life and health and a few of his heart's wishes. Postcards and pebbles. They're followed by a smattering of Welcomes to Cyberspace. But slowly the journal picks up steam, as Ebert's strength and confidence and audience grow. You are the readers I have dreamed of, he writes. He is emboldened. He begins to write about more than movies; in fact, it sometimes seems as though he'd rather write about anything other than movies. The existence of an afterlife, the beauty of a full bookshelf, his liberalism and atheism and alcoholism, the health-care debate, Darwin, memories of departed friends and fights won and lost — more than five hundred thousand words of inner monologue have poured out of him, five hundred thousand words that probably wouldn't exist had he kept his other voice. Now some of his entries have thousands of comments, each of which he vets personally and to which he will often respond. It has become his life's work, building and maintaining this massive monument to written debate — argument is encouraged, so long as it's civil — and he spends several hours each night reclined in his chair, tending to his online oasis by lamplight. Out there, his voice is still his voice — not a reasonable facsimile of it, but his.
"It is saving me," he says through his speakers.
He calls up a journal entry to elaborate, because it's more efficient and time is precious:
When I am writing my problems become invisible and I am the same person I always was. All is well. I am as I should be.
Monday, August 2, 2010
Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die. It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid. A sample of the fluid was drawn off with a long needle and sent for testing. Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest. Her pregnancy was thirty-nine weeks along, and the obstetrician who had ordered the test broke the news to her as she sat with her husband and her parents. The obstetrician didn't get into the prognosis—she would bring in an oncologist for that—but Sara was stunned. Her mother, who had lost her best friend to lung cancer, began crying.
The doctors wanted to start treatment right away, and that meant inducing labor to get the baby out. For the moment, though, Sara and her husband, Rich, sat by themselves on a quiet terrace off the labor floor. It was a warm Monday in June, 2007. She took Rich's hands, and they tried to absorb what they had heard. Monopoli was thirty-four. She had never smoked, or lived with anyone who had. She exercised. She ate well. The diagnosis was bewildering. "This is going to be O.K.," Rich told her. "We're going to work through this. It's going to be hard, yes. But we'll figure it out. We can find the right treatment." For the moment, though, they had a baby to think about.
"So Sara and I looked at each other," Rich recalled, "and we said, 'We don't have cancer on Tuesday. It's a cancer-free day. We're having a baby. It's exciting. And we're going to enjoy our baby.' " On Tuesday, at 8:55 P.M., Vivian Monopoli, seven pounds nine ounces, was born. She had wavy brown hair, like her mom, and she was perfectly healthy.
The next day, Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancers—more than people realize—occur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, "some of these responses can be long-term."
Words like "respond" and "long-term" provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on "aggressively managing" this diagnosis.
Sara was started on the Tarceva, which produced an itchy, acne-like facial rash and numbing tiredness. She also underwent a surgical procedure to drain the fluid around her lung; when the fluid kept coming back, a thoracic surgeon eventually placed a small, permanent tube in her chest, which she could drain whenever fluid accumulated and interfered with her breathing. Three weeks after the delivery, she was admitted to the hospital with severe shortness of breath from a pulmonary embolism—a blood clot in an artery to the lungs, which is dangerous but not uncommon in cancer patients. She was started on a blood thinner. Then test results showed that her tumor cells did not have the mutation that Tarceva targets. When Marcoux told Sara that the drug wasn't going to work, she had an almost violent physical reaction to the news, bolting to the bathroom in mid-discussion with a sudden bout of diarrhea.
Dr. Marcoux recommended a different, more standard chemotherapy, with two drugs called carboplatin and paclitaxel. But the paclitaxel triggered an extreme, nearly overwhelming allergic response, so he switched her to a regimen of carboplatin plus gemcitabine. Response rates, he said, were still very good for patients on this therapy.
She spent the remainder of the summer at home, with Vivian and her husband and her parents, who had moved in to help. She loved being a mother. Between chemotherapy cycles, she began trying to get her life back.
Then, in October, a CT scan showed that the tumor deposits in her left lung and chest and lymph nodes had grown substantially. The chemotherapy had failed. She was switched to a drug called pemetrexed. Studies found that it could produce markedly longer survival in some patients. In reality, however, only a small percentage of patients gained very much. On average, the drug extended survival by only two months—from eleven months to thirteen months—and that was in patients who, unlike Sara, had responded to first-line chemotherapy.
She worked hard to take the setbacks and side effects in stride. She was upbeat by nature, and she managed to maintain her optimism. Little by little, however, she grew sicker—increasingly exhausted and short of breath. By November, she didn't have the wind to walk the length of the hallway from the parking garage to Marcoux's office; Rich had to push her in a wheelchair.
A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexed—her third drug regimen—wasn't working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out.More ...
Sunday, August 1, 2010
For generations of pre-med students, three things have been as certain as death and taxes: organic chemistry, physics and the Medical College Admission Test, known by its dread-inducing acronym, the MCAT.
So it came as a total shock to Elizabeth Adler when she discovered, through a singer in her favorite a cappella group at Brown University, that one of the nation's top medical schools admits a small number of students every year who have skipped all three requirements.
Until then, despite being the daughter of a physician, she said, "I was kind of thinking medical school was not the right track for me."
Ms. Adler became one of the lucky few in one of the best kept secrets in the cutthroat world of medical school admissions, the Humanities and Medicine Program at the Mount Sinai medical schoolon the Upper East Side of Manhattan.
The program promises slots to about 35 undergraduates a year if they study humanities or social sciences instead of the traditional pre-medical school curriculum and maintain a 3.5 grade-point average.
For decades, the medical profession has debated whether pre-med courses and admission tests produce doctors who know their alkyl halides but lack the sense of mission and interpersonal skills to become well-rounded, caring, inquisitive healers.
That debate is being rekindled by a study published on Thursday in Academic Medicine, the journal of the Association of American Medical Colleges. Conducted by the Mount Sinai program's founder, Dr. Nathan Kase, and the medical school's dean for medical education, Dr. David Muller, the peer-reviewed study compared outcomes for 85 students in the Humanities and Medicine Program with those of 606 traditionally prepared classmates from the graduating classes of 2004 through 2009, and found that their academic performance in medical school was equivalent.
"There's no question," Dr. Kase said. "The default pathway is: Well, how did they do on the MCAT? How did they do on organic chemistry? What was their grade-point average?"
"That excludes a lot of kids," said Dr. Kase, who founded the Mount Sinai program in 1987 when he was dean of the medical school, and who is now dean emeritus and a professor of obstetrics and gynecology. "But it also diminishes; it makes science into an obstacle rather than something that is an insight into the biology of human disease."
Whether the study's findings will inspire other medical schools to change admissions requirements remains to be seen.
Because MCAT scores are used by U.S. News and World Report and others to rank schools, the most competitive ones fear dropping the test, admissions officials said. And at least two recent studies found that MCAT scores were better than grade-point averages at predicting performance in medical school and on the series of licensing exams that medical students and doctors must take.
"You have to have the proper amount of moral courage to say 'O.K., we're going to skip over a lot of the huge barriers to a lot of our students,' " said Dr. David Battinelli, senior associate dean for education at Hofstra University School of Medicine.
But, Dr. Battinelli added, "Now let's see how they're doing 5 and 10 years down the road." The Mount Sinai study did not answer the question.