Saturday, October 8, 2011

How Do You Get Patients To E-Consent? - Healthcare - The Patient - Informationweek

The Office of the National Coordinator for Health Information Technology's (ONC's) Office of the Chief Privacy Officer has awarded a $1.2 million contract to APP Design to support its e-Consent initiative, which seeks to find ways to educate patients about their options for sharing their health information.

Under the contract, awarded September 29, APP Design, based in Itasca, Ill., is required to develop innovative ways to educate and inform patients of their options to share their health information electronically in a clinical setting. The vendor has also been tasked with helping patients understand the consequences of those choices.

By utilizing APP Design'sRHIOnet and Story Engine tools as a platform for the pilot, the project will involve educational features and provide feedback for future applications though a survey.

However, developing an e-consent system won't be an easy task, according to Sharon Canner, senior director of Advocacy at the College of Healthcare Information Management Executives (CHIME).

"E-Consent is an extremely important, yet difficult, effort. This will be a very difficult task for both patients and clinicians. Patient data can be used in a multitude of ways across the continuum of care," Canner told InformationWeek Healthcare. "If the e-Consent model is too granular, you end up disrupting the clinician's workflow and you run the risk of confusing the patient. If it's not granular enough, a patient may unknowingly choose to deny important data that providers need to improve care."

According to a statement from APP Design, the e-Consent pilot program will be conducted at four provider sites within Western New York's Health Information Exchange, HEALTHeLINK. Utilizing HEALTHeLINK's companion administrative transaction network, HEALTHeNET, APP Design will develop a graphical user interface that will allow patients to access information regarding their options to share their medical data as well as encourage patients to engage in follow-up questions. The system will also provide a method to capture and record the patient's choice about sharing health information. HEALTHeNET uses RHIOnet, a secure, Web-based, healthcare information exchange system that delivers healthcare data to caregivers in different locations.

"Being awarded this contract will allow us to further demonstrate how our solutions, specifically RHIOnet, can enable HIEs to successfully deliver more complete and comprehensive patient information," Robert Quinn, president of APP Design, said in a statement.

As healthcare delivery organizations move toward Meaningful Use Stages 2 and 3 and connect to health information exchange networks, a patient's ability to understand whether and when their healthcare provider can share their health information electronically will be critical.

"Categorizing use cases into well thought-out 'buckets' so the patient understands where and under what circumstance their data is being shared is important. Equally important is enabling providers the ability to have the needed data at the right point in time to make an informed clinical decision," Canner said. "As we move towards more robust and ubiquitous exchange of health information, I hope this process focuses heavily on balancing what patients want with what the providers need. If this can be done correctly, patient safety will not come at the expense of patient privacy. And patient privacy will not hinder patient safety."

Friday, October 7, 2011

'50/50' strikes a chord with cancer patients, survivors -

In the new film "50/50," there is a scene where cancer patient Adam, played by Joseph Gordon-Levitt, is on a gurney being wheeled into the operating room with his parents by his side. As the nurses take the 27-year-old away, he calls out for his mom like he's a little boy. It's an affecting moment, but for Matthew Zachary, it was particularly personal.

"That's exactly what happened to me," said the 37-year-old father of twins from New York City who was diagnosed with brain cancer at age 21. "Literally I'm with my parents and they are wheeling me off to the operating room and I lost it. It was a horrible, horrible experience."

For Heidi Adams, it was the scene at the dinner table between Gordon-Levitt's character and his mother, played by Anjelica Huston, who wants to move in to help care for him.

"I remember that conversation with my mother, that struggle at that time in your life when you are discovering your independence, fighting for your independence and you are thrown back into this position where you need to rely on people, where you need your mom. It's very disorienting," said Adams, 44, from Austin, Texas, who lived with her parents for 2 1/2 years when she was 26 and undergoing chemotherapy and radiation for bone cancer.

Making a film about a deadly disease, then adding in strong comedic elements as "50/50" does, would seem to be a recipe either to offend with its audacity or insult with a sappy portrayal. A few other recent films about illness, such as Judd Apatow's "Funny People" and the Anne Hathaway movie "Love and Other Drugs," have tried to walk the line between drama and comedy, but reactions were mixed. Yet the reception among those who might be most sensitive about "50/50" — cancer patients and survivors, particularly young adults — has been surprisingly positive.

"The first thing we had to do was to make sure the cancer community was going to embrace the movie. You don't want to put a movie out there that they are uncomfortable with," said Nancy Kirkpatrick, president of marketing for Summit Entertainment, the studio behind the film. "We did a really broad screening program so I was expecting to get the emails saying, 'How can you be so insensitive?' But we didn't get any of those."

"50/50" is based on the screenwriter Will Reiser's fight against spinal cancer at age 25, and the story is resonating with those who are too old to be considered pediatric oncology patients but too young to share much in common with older adult cancer patients.

While there is a slew of resources targeted at child and older adult cancer patients, those who fall in between, like Reiser, say they're often at a loss. The medical establishment, they say, is only beginning to recognize their specific needs. This group tends to be the most transient, and the most uninsured. They have specific psychological, physical and financial issues unique to their age.

"Will's story is the archetype for the story of how much it [stinks] to be sick in your 20s and treated as if you're in your 60s," said Zachary, who founded the I'm Too Young for This! Cancer Foundation as a resource for young adults affected by cancer. " '50/50' was torn from the pages of my life and I've heard that quote from hundreds of other young adults who have seen the film. Whether it's the doctor who doesn't make eye contact or the overbearing mom who wants to help, or the girlfriend who abandons you, or the manic hysteric fits of rage, all of it is so accurate."

Reiser said he never intended to become the poster child for young people with cancer but he is very gratified that his retelling of his experience has connected with so many others in similar situations.

"We were just trying to tell a story that was personal to us and to tell a good story," said Reiser, who produced the movie with his longtime friend Seth Rogen, who co-stars in the film and was an active part of Reiser's support group during his treatment. "The fact that it's starting a broader conversation, and is helping people who are going through a similar situation, that is really validating."

Summit initially instituted a series of word-of-mouth screenings with Stand Up to Cancer and Lance Armstrong's LiveStrong foundation more as a defensive measure than anything geared toward advocacy.

But they were pleasantly surprised when they heard from people like Adams, who started her own young-adult cancer foundation and co-wrote a guidebook for young adults with cancer before merging her efforts with LiveStrong, where she now serves as the foundation's senior director of engagement.

"I walked out of the screening and wrote an email to Jonathan [Levine, the film's director] thanking him for finally representing my experience in a way that was real, didn't pull any punches or dissolve into something soft and politically correct."

Dr. Stuart Siegel, associate director for pediatric oncology at the USC Norris Comprehensive Cancer Center, has partnered with Dr. Debu Tripathy to start an adolescent/young adult program at the facility. It's a burgeoning area of research, practice and training that he says came to the forefront in 2005 when the national tumor registry published data indicating that this group of patients was not showing much improvement in survival rates, compared with children and older adults.

Siegel, who moderated a post-screening panel with Reiser, Rogen and co-star Anna Kendrick at USC last month, said the film could serve as a useful tool.

"All of the medical students and faculty I talked to after the screening thought it was a wonderful training film, which is unusual for a Hollywood movie. But it really did hit virtually all of the key issues," said Siegel, referring specifically to how the film addresses interpersonal relationships, sexuality, the pain associated with treatment, and losing friends made during chemo sessions, among other topics.

"The only issue Will didn't hit was the financial issue, which I asked Will about," added Siegel. "He told me he had to write his script to pay all his medical debts.",1,583952.story

Trying Out New Ways to Deliver Health Care -

PLANO, Tex. — At Village Health Partners, patients receive a year's worth of wellness exams in a single visit; get their e-mails answered 24 hours a day, 7 days a week; and have their mammogram and M.R.I. results logged into their electronic medical records by the time they pull out of the parking lot.

Kelsey-Seybold in Houston is the galleria of health clinics: it has storefronts for every imaginable specialty; online, same-day, no-referral-necessary appointment scheduling; an on-site pharmacy; and even free valet parking.

As the United States grapples with rising health care costs and a system that rewards doctors and hospitals for how sick their patients get, not how healthy they become, Texas health care providers are increasingly experimenting with new payment and care delivery models — joining forces to emphasize efficiency and outcomes.

These new models present a culture shift for the state's physicians. But they have provided an intriguing benefit for patients, drawn to the convenience and comfort of a system financially motivated to keep them as well as possible.

"Doctors in Texas traditionally haven't wanted to share resources, to share financial risk, to share clinical information," said Tom Banning, chief executive of the Texas Academy of Family Physicians. "But there are pioneering groups here that are putting an emphasis on quality and cost efficiency. They're innovative nationally, and they're moving the ball."

The nation faces an undeniable crisis in health spending. By 2020, the country's health expenditures are expected to reach $4.6 trillion a year, almost 20 percent of the gross domestic product. Roughly half of this spending comes in government programs, a potentially catastrophic hit to state and federal budgets.

Health care experts say the leading contributor to escalating costs is the dominant fee-for-service payment system, in which doctors and hospitals are paid per treatment or procedure and make more when patients get infections or complications. But they fear returning to the health maintenance organization model that limited patient choice and gave doctors a financial incentive to ration care.

The solution, health care providers including Village Health Partners and Kelsey-Seybold believe, is clinical integration — in which groups of family physicians and specialists share electronic patient information, the costs of case management and care coordination, and the latest research on best practices, all with the symbiotic goal of keeping costs low and patients well.

Texas is not blazing a brand-new trail. Nationally, health systems like the Mayo Clinic in Minnesota, the Geisinger Health System in Pennsylvania and Intermountain Healthcare in Utah have long taken this value-over-volume approach. Scott & White Healthcare, with its 12 system hospitals and more than 60 clinics, has led the integrated-care charge in Central Texas.

But with the rollout of the federal health overhaul, and new Texas legislation tended to pay for performance, not procedures, more Texas providers may join the movement. Last month, the United States Department of Health and Human Services started a pilot program to pay primary care practices a monthly fee if they provide better chronic-care management, give patients 24-hour access to care and health information, and collaborate with specialists to better coordinate care.

The Kelsey-Seybold clinic has been a gold standard for the multispecialty group practice since it opened in 1949. Today it employs 373 physicians across 55 specialties in 20 different facilities — all of them with in-house labs and X-rays, and wired for the same electronic medical record. Its flagship clinic, which opened in 1999, looks like a gleaming shopping mall, with storefronts for a multitude of services, from pediatrics to women's health to day surgery. But its most innovative approach may be KelseyCare, a four-year-old so-called accountable-care plan offered through Cigna in which patients, via their employers, have all their health care for a single year provided at a fixed, customized rate.

"The real focus ought to be on how much it costs to care for a group of patients over a period of time and achieve desirable outcomes," said Dr. Spencer R. Berthelsen, Kelsey-Seybold's chairman and managing director. "There's way too much attention on unit cost — what is the cost of an office visit or a laboratory test or a day in the hospital."

To make KelseyCare work outside the fee-for-service model, the clinic relies heavily on electronic medical records to prevent duplication in tests run or treatments provided. It has automated best-practice alerts, to make sure patients get regular immunizations or mammograms that could prevent costly ailments down the line. And it has made it convenient for its patients — including three-quarters of the City of Houston's employees — to get the preventative care they need to stay well, from offering same-day online appointments to housing specialists mere feet from their primary care partners.

At Village Health Partners, the anchor tenant for the 100,000-square-foot Legacy Medical Village in Plano, the payment model has not shifted from fee-for-service yet. The various physician practices at Legacy remain independent, and their doctors self-employed. But Dr. Christopher Crow, the founder of Village Health, has a similar idea: attract patients by making care accessible, convenient and high quality, and reinvest the profits into measuring what works.

As a family medicine physician fresh out of medical school, Dr. Crow watched, frustrated, as his patients waited days for lab results and weeks to get in to see specialists, while their health suffered. "It was like going to McDonald's and being told to come back in four days," Dr. Crow said. "I wanted to build a place where everything was built around access and convenience."

So he did, opening Legacy Medical Village, a sprawling health complex that four years later is now home to 14 primary care physicians and 30 different services and specialty practices that provide comprehensive treatment, from oncology and bariatric surgery to physical therapy.

Legacy Medical Village has a wide range of tenants: a workers' compensation program, behavioral and weight loss therapy, a sleep study center and a headache department. It runs research trials and has an in-house dentist.

But care is centered on the family medicine linchpin, Village Health Partners, which coordinates the care of its 45,000 patients with electronic records technology, case managers, around-the-clock e-mail responses and a guarantee that phones will be answered within 60 seconds.

Dr. Crow said the model could be reproduced virtually anywhere, once Texas doctors get past their fierce independent streak.

"Anywhere there's a population of patients who need health care, these synergies can be stuck together," he said. "The individual models foster zero coordination of care. The physician-led organization is the solution."

PubMed Health

PubMed Health specializes in reviews of clinical effectiveness research, with easy-to-read summaries for consumers as well as full technical reports. Clinical effectiveness research finds answers to the question "What works?" in medical and health care.
PubMed Health is a service provided by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM).

The Search Principle blog

Dean Giustini is the biomedical librarian at UBC's Biomedical Branch Library at the Vancouver General Hospital (VGH). He blogs at The Search Principle.


Can Cancer Ever Be Ignored? -

As chief medical and scientific officer of the American Cancer Society, Otis Webb Brawley — who is also a professor of oncology and epidemiology at Emory University — is the public face of the cancer establishment. He operates in a world of similarly high-achieving, multiple-credentialed, respectable professionals, where insults tend to be delivered, stiletto-style, in scientific language that lay people aren't meant to understand. So it can be more than a little jarring to hear, for example, James Mohler, chairman of the urology department and associate director of the Roswell Park Cancer Institute in Buffalo, say of his friend: "I have known Otis for over 20 years. He doesn't come off as being ignorant or stupid, but when it comes to prostate-cancer screening, he must not be as intelligent as he seems." Or Skip Lockwood, the head of Zero, a prostate-cancer patient advocacy group, charge that Brawley is more concerned about saving men's sex lives than about saving the men themselves.

Brawley has become the target of these attacks because of his blunt and very public skepticism about the routine use of the prostate-specific antigen, or P.S.A., test to screen men for early prostate cancer. "I'm not against prostate-cancer screening," Brawley says. "I'm against lying to men. I'm against exaggerating the evidence to get men to get screened. We should tell people what we know, what we don't know and what we simply believe."

The P.S.A. test, which was approved by the U.S. Food and Drug Administration in 1986, has become an annual ritual for millions of middle-aged men who assume that finding prostate cancer early will prevent death. By 2008, nearly half of men over 50 reported that they were screened in the previous 12 months. Despite the seeming logic of the P.S.A. test, the evidence that it saves lives is far from conclusive, and Brawley is not the only one questioning it. A growing cadre of doctors, epidemiologists, patients and cancer biologists are rethinking its value. And the most recent studies, while not ending the debate, indicate that routine P.S.A. testing appears not to reduce the number of deaths, and if it does, the benefit is exceedingly modest.

Patients and their doctors are now faced with radically polarized views about the logic of routine testing. On one side are physicians like Mohler, who argue that the test can reduce a man's chances of dying of prostate cancer, plain and simple. This side of the debate is passionate, backed by the persuasive conviction of men who have survived prostate cancer and well financed by the multibillion-dollar industry that has grown up around the testing and treatment of the disease.

The other camp makes a less emotionally satisfying argument: on balance, scientific studies do not support the claim that screening healthy men saves lives. Screening, Brawley and others argue, can lead healthy men into a cascade of further testing and treatments that end up injuring or even killing them. As Richard Ablin, who discovered a prostate-specific antigen, put it in an Op-Ed in The New York Times, using the P.S.A. test to screen for cancer has been "a public health disaster."

So what should a man do when his doctor suggests a routine P.S.A. test? The U.S. Preventive Services Task Force, a panel of independent experts that evaluates the latest scientific evidence on preventive tests and treatments, is charged with making recommendations in just such situations. It already recommends against routine screening for men over 75. According to an internal document, in 2009 the task force conducted an in-depth analysis of data and seemed poised to give routine P.S.A. testing a "D" rating — "D" as in don't do it — for any man of any age. But this was around the time that the task force stated that routine mammography for women ages 40 to 50 was not necessary for every woman. That recommendation caused a public uproar, and Ned Calonge, the task-force chairman at the time, sent the P.S.A. recommendation back for review. One year later, in November 2010, just before midterm elections, the task force was again set to review its recommendation when Calonge canceled the meeting. He says that word leaked out that if the November meeting was held, it could jeopardize the task force's financing. Kenneth Lin, the researcher who led the review, quit his job in protest, and now, nearly two years after its initial finding, it remains uncertain when the task force will release its rating for P.S.A. screening.

Cancer screening is a growing field; existing tests are becoming more sensitive, and new tests are constantly developed. We now have CT scanning for lung cancer, and there is also a blood test marketed by Johnson & Johnson known as a "liquid biopsy," which searches for stray cancer cells in the bloodstream. More testing inevitably brings more treatment, because the urge to correct every cellular anomaly, no matter how small or potentially harmless, is practically irresistible. But if there is one lesson from the P.S.A. test, it is that more information and intervention do not always lead to less suffering.

The popularity of the P.S.A. test as the main weapon against prostate cancer is due in large measure to the earnest and passionate advocacy of William Catalona, a urologist from Northwestern University Feinberg School of Medicine. During his residency training at Johns Hopkins Hospital in the mid-1970s, Catalona set up a clinic for late-stage prostate-cancer patients. Back then, the only tool for finding prostate cancer was a digital rectal exam — actually feeling the prostate through the rectal wall. By the time many tumors could be detected, the cancer was already advanced, and removing the prostate surgically did not offer a reliable cure.

Catalona grew close to many of the men he treated, as well as to their families. "Prostate cancer is a terrible death," he said. "They developed bone fractures, they had a lot of pain, they lost weight. They required heavy doses of narcotics."

Catalona wanted to catch these cancers early, when they might be curable. He noticed that men with more advanced cancers at the time of surgery tended to have the highest P.S.A. levels. Could there be a bright line, a "safe" level of P.S.A. that could distinguish healthy men from those with prostate cancer? After reviewing his own patient records, he decided the cutoff level should be 4 nanograms of P.S.A. per milliliter of blood. He followed up with a study of 1,653 patients. The results, published in 1991 in The New England Journal of Medicine, showed that P.S.A. testing could detect prostate cancer several years earlier than a digital rectal exam.

The test quickly gained powerful support: Gerald Murphy, who held the position at the American Cancer Society now held by Brawley, pushed the society to endorse the test. In 1996, Gen. H. Norman Schwarzkopf, a prostate-cancer survivor, appeared on the cover of Time magazine over the statement "There's a simple blood test everyone should know about."

By then, doctors were using the test for routine screening. "P.S.A. testing was so easy," says H. Gilbert Welch, a professor of medicine at the Dartmouth Institute (full disclosure: one author of this article is an instructor at Dartmouth). Doctors were predisposed to use the test for several reasons. First and foremost, there was the perception that early detection could save lives. It was also easy to administer. "It was a blood test," Welch says. "You didn't need equipment. . . . You didn't need to put any scopes up any part of the body. Heck, you didn't even need to ask the patient if he wanted it; you could just check off the box on a list of tests, like cholesterol, when you did a blood draw." Today it's common for doctors to order the P.S.A. test and patients to take it without talking about what it might really mean.

At one time, Otis Brawley, too, assumed that routine screening was the best medical practice. Sitting in his living room in an Atlanta suburb, Brawley recounted his transformation from believer to skeptic. In 1988, after medical school at the University of Chicago, Brawley landed a prestigious fellowship at the National Cancer Institute in Bethesda, Md. There he came under the tutelage of Barnett Kramer, an oncologist and epidemiologist who went on to become the associate director of the institute's early detection and community oncology program. Kramer walked Brawley through a short history of screening, beginning with the Pap smear, which has been an unqualified success, significantly cutting cervical-cancer deaths.

But other cancer screening tests had not worked out so well. For example, researchers at the Mayo Lung Project conducted a study between 1971 and 1983 to determine whether frequent chest X-rays could help reduce deaths from lung cancer. Chest X-rays detected lots of suspicious spots and shadows on the lungs and probably led to some cures of early lung cancers, but the study ultimately found no difference in death rates between the patients who were screened and those who were not. Kramer suggested one probable explanation: diagnosing the spots picked up by X-ray often requires surgery, which carries a small but definite risk. Brawley knew that many spots seen on X-rays are simply old scars or minor abnormalities commonly seen in healthy people. With so many innocent blips detected, complications from lung biopsies and other invasive tests, along with treatment complications, could kill enough patients to negate any benefit from early detection.

Prostate cancer is the second-leading cause of cancer death among men, after lung cancer. In 2009, it was diagnosed in approximately 192,000 men. A small number of tumors are very aggressive, but the majority of prostate tumors are not likely to cause death. They grow very slowly, and only a fraction break out of the prostate, seed new tumors in other parts of the body and kill the patient. The current thinking is that about 30 percent of men in their 40s have prostate cancer, 40 percent of men in their 50s and so on, right up to 70 percent of men in their 80s. Yet only 3 percent of all men die from the disease. In other words, far more men die with prostate cancer thanfrom it, and only a tiny fraction of prostate cancers ever cause symptoms, much less death.

But here is the tricky part: Unless there are symptoms or a finding on a physical exam, doctors generally cannot accurately predict which cancers are destined to be indolent, to sit around for years growing slowly, if at all, and those that will ultimately prove lethal.

In his discussions with Kramer, Brawley saw that these two pieces of information — the fact that a certain number of prostate cancers will never cause harm, and that doctors can't reliably predict which cancers will be dangerous — had powerful and potentially devastating consequences for men. The first implication was that using the P.S.A. test to screen men who had no symptoms would uncover a huge reservoir of indolent cancers. Most of those cancers that men previously died with — and not from — would now theoretically be detectable. And once detected, the majority of those cancers would be treated.

The most frequent treatment then, as it is now, was the surgical removal of the entire prostate gland. The prostate sits at the base of the penis, wrapped around the urethra, which is the tube that carries urine and semen out of the penis. Trying to separate gland from urethra is a difficult job, and even the best of surgeons can damage the urethra or the bundle of nerves that initiate erections. About half of men who undergo radiation or surgery will have permanent side effects like impotence and incontinence. Up to 1 in 200 men die within 30 days from complications related to the surgery.

"You didn't have to be brilliant to see that history was repeating itself," Brawley says. "Doctors were just substituting a blood test for chest X-rays."

More ...

U.S. Panel Advises Against Routine Prostate Test -

Healthy men should no longer receive a P.S.A. blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.

The draft recommendation, by the United States Preventive Services Task Force and due for official release next week, is based on the results of five well-controlled clinical trials and could substantially change the care given to men 50 and older. There are 44 million such men in the United States, and 33 million of them have already had a P.S.A. test — sometimes without their knowledge — during routine physicals.

The task force's recommendations are followed by most medical groups. Two years ago the task force recommended that women in their 40s should no longer get routine mammogramssetting off a firestorm of controversy. The recommendation to avoid the P.S.A. test is even more forceful and applies to healthy men of all ages.

"Unfortunately, the evidence now shows that this test does not save men's lives," said Dr. Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chairwoman of the task force. "This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does."

But advocates for those with prostate cancer promised to fight the recommendation. Baseball's Joe Torre, the financier Michael Milken and Rudolph W. Giuliani, the former New York City mayor, are among tens of thousands of men who believe a P.S.A. test saved their lives.

The task force can also expect resistance from some drug makers and doctors. Treating men with high P.S.A. levels has become a lucrative business. Some in Congress have criticized previous decisions by the task force as akin to rationing, although the task force does not consider cost in its recommendations.

"We're disappointed," said Thomas Kirk, of Us TOO, the nation's largest advocacy group for prostate cancer survivors. "The bottom line is that this is the best test we have, and the answer can't be, 'Don't get tested.' "

But that is exactly what the task force is recommending. There is no evidence that a digital rectal exam or ultrasound are effective, either. "There are no reliable signs or symptoms of prostate cancer," said Dr. Timothy J. Wilt, a member of the task force and a professor of medicine at the University of Minnesota. Frequency and urgency of urinating are poor indicators of disease, since the cause is often benign.

The P.S.A. test, routinely given to men 50 and older, measures a protein — prostate-specific antigen — that is released by prostate cells, and there is little doubt that it helps identify the presence of cancerous cells in the prostate. But a vast majority of men with such cells never suffer ill effects because their cancer is usually slow-growing. Even for men who do have fast-growing cancer, the P.S.A. test may not save them since there is no proven benefit to earlier treatment of such invasive disease.

As the P.S.A. test has grown in popularity, the devastating consequences of the biopsies and treatments that often flow from the test have become increasingly apparent. From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, the man who developed the test, Dr. Richard J. Ablin, has called its widespread use a "public health disaster."

One in six men in the United States will eventually be found to have prostate cancer, making it the second most common form of cancer in men after skin cancer. An estimated 32,050 men died of prostate cancer last year and 217,730 men received the diagnosis. The disease is rare before age 50, and most deaths occur after age 75.

Not knowing what is going on with one's prostate may be the best course, since few men live happily with the knowledge that one of their organs is cancerous. Autopsy studies show that a third of men ages 40 to 60 have prostate cancer, a share that grows to three-fourths after age 85.

P.S.A. testing is most common in men over 70, and it is in that group that it is the most dangerous since such men usually have cancerous prostate cells but benefit the least from surgery and radiation. Some doctors treat patients who have high P.S.A. levels with drugs that block male hormones, although there is no convincing evidence that these drugs are helpful in localized prostate cancer and they often result in impotence, breast enlargement and hot flashes.

Of the trials conducted to assess the value of P.S.A. testing, the two largest were conducted in Europe and the United States. Both "demonstrate that if any benefit does exist, it is very small after 10 years," according to the task force's draft recommendation statement.

The European trial had 182,000 men from seven countries who either got P.S.A. testing or did not. When measured across all of the men in the study, P.S.A. testing did not cut death rates in nine years of follow-up. But in men ages 55 to 69, there was a very slight improvement in mortality. The American trial, with 76,693 men, found that P.S.A. testing did not cut death rates after 10 years.

Dr. Eric Klein of the Cleveland Clinic, an expert in prostate cancer, said he disagreed with the task force's recommendations. Citing the European trial, he said "I think there's a substantial amount of evidence from randomized clinical trials that show that among younger men, under 65, screening saves lives."

The task force's recommendations apply only to healthy men without symptoms. The group did not consider whether the test is appropriate in men who already have suspicious symptoms or those who have already been treated for the disease. The recommendations will be open to public comment next week before they are finalized.

Recommendations of the task force often determine whether federal health programs like Medicare and private health plans envisioned under the health reform law pay fully for a test. But legislation already requires Medicare to pay for P.S.A. testing no matter what the task force recommends.

Still, the recommendations will most likely be greeted with trepidation by the Obama administration, which has faced charges from Republicans that it supports rationing of health care services, which have been politically effective, regardless of the facts.

After the task force's recommendation against routine mammograms for women under 50, Health and Human Services Secretary Kathleen Sibelius announced that the government would continue to pay for the test for women in their 40s. On Thursday, the administration announced with great fanfare that as a result of the health reform law, more people with Medicare were getting free preventive services like mammograms.

Dr. Michael Rawlins, chairman of the National Institute for Health and Clinical Excellence in Britain, said he was given a P.S.A. test several years ago without his knowledge. He then had a biopsy, which turned out to be negative. But if cancer had been detected, he would have faced an awful choice, he said: "Would I want to have it removed, or would I have gone for watchful waiting with all the anxieties of that?" He said he no longer gets the test.

But Dan Zenka, a spokesman for the Prostate Cancer Foundation, said a high P.S.A. test result eventually led him to have his prostate removed, a procedure that led to the discovery that cancer had spread to his lymph nodes. His organization supports widespread P.S.A. testing. "I can tell you it saved my life," he said.

Thursday, October 6, 2011

Jobs’s Unorthodox Treatment - The Daily Beast

Steve Jobs was right to be optimistic when, in 2004, he announced that he had cancer in his pancreas. Although cancer of the pancreas has a terrible prognosis—half of all patients with locally advanced pancreatic cancer diewithin 10 months of the diagnosis; half of those in whom it has metastasized die within six months—cancer in the pancreas is not necessarily a death sentence.

The difference is that pancreatic cancers arise from the pancreatic cells themselves; this is the kind that killed actor Patrick Swayze in 2009. But cancers in the pancreas, called neuroendocrine tumors, arise from islands of hormone-producing cells that happen to be in that organ. Jobs learned in 2003 that he had an extremely rare form of this cancer, an islet-cell neuroendocrine tumor. As the name implies, it arises from islet cells, the specialized factories within the pancreas that produce and secrete insulin, which cells need in order to take in glucose from the food we eat. Unlike pancreatic cancer, with neuroendocrine cancer "if you catch it early, there is a real potential for cure," says cancer surgeon Joseph Kim of City of Hope, a comprehensive cancer center in Duarte, Calif.

But although neither Apple nor those close to Jobs were willing to discuss the treatments he elected or the course of his disease, interviews with experts on neuroendocrine tumors suggest that some of the choices he made did not extend his life and may have shortened it.

The cancer was detected during an abdominal scan in October 2003, asFortune magazine reported in a 2008 cover story. It was 7:30 in the morning, Jobs said in his 2005 commencement address at Stanford University. He reportedly had the scan—which is seldom done, much less advised, as a routine part of a physical—because he had a history of gastrointestinal problems, but he also may have been experiencing symptoms, most likely gastrointestinal ones. Those tend to arise from the hormone that the particular neuroendocrine tumor produces, explains medical oncologist Matthew Kulke of Dana-Farber Cancer Institute in Boston. In Jobs's case, that was insulin. (Other neuroendocrine tumors produce gastrin, glucagon, and other digestive hormones.) The main effect of high insulin levels is a profound drop in blood sugar, says surgeon John Chabot of Columbia University Medical center, which can lead to shakiness, cold sweats, nausea, vomiting, blackouts, and neurological changes such as impaired judgment, moodiness, irritability, apathy, and confusion.

There is virtually no debate about the best treatment. "It has long been held that surgery can lead to very long-term survival," says Kim. In a 2010 analysis of cancer registries, he and colleagues found that patients with neuroendocrine cancer who were eligible for surgery (the cancer has not spread beyond the pancreas) "can have outstanding outcomes," living for many more years. In part, that is because neuroendocrine cancers tend to be quite slow growing, or indolent. Even those that have been present for years, and in some cases decades, often stay safely confined to the pancreas. This kind of cancer can be so indolent that patients often die with it than from it. Although an estimated 2,000 to 3,000 people in the U.S. are diagnosed every year with neuroendocrine tumors of the pancreas, autopsies find the disease in hundreds more—people who were apparently not harmed by this very slow-growing cancer.

Despite the expert consensus on the value of surgery, Jobs did not elect it right away. He reportedly spent nine months on "alternative therapies," including what Fortune called "a special diet." But when a scan showed that the original tumor had grown, he finally had it removed on July 31, 2004, at Stanford University Medical Clinic. In emails to Apple employees immediately after, Jobs said his form of cancer "can be cured by surgical removal if diagnosed in time (mine was)," and told his colleagues, "I will be recuperating during the month of August, and expect to return to work in September." Despite the delay in having the surgery, Jobs's upbeat report was not unrealistic: most patients diagnosed with neuroendocrine tumors in the pancreas live at least another 10 years.

Not that the surgery was a walk in the park. In many cases, says Kim, "you can just remove the tumor with a little of the surrounding [pancreatic] tissue." But Jobs's was not such a simple case. He underwent an operation called a modified Whipple procedure, or a pancreatoduodenectomy, Fortune reported. The surgery removes the right side of the pancreas, the gallbladder, and parts of the stomach, bile duct, and small intestine. The fact that so much more than the pancreas itself had to be removed suggests that Jobs's cancer had spread beyond the pancreas. The cancer might have already spread by the time it was discovered in 2003, though Jobs's sanguine description of his prognosis suggests that if that were the case, the metastasis might have been so small— "micrometastases"—as to be undetectable. Alternatively, the cancer could have spread during the nine months that Jobs was experimenting with nonstandard therapies.

Within five years, it was clear that Jobs was not cured. He underwent a liver transplant at Methodist University Hospital in Memphis in 2009. That strongly suggests the cancer had spread beyond the digestive system that was the focus of the surgery and into the organ that is one of the most common sites of metastasis. Liver transplants are a well-established treatment for tumors that originate in that organ, such as hepatocellular cancer, says City of Hope's Kim. But removing the liver because it has become riddled with tumors that originated elsewhere is rare. For one thing, liver metastases probably mean the cancer is elsewhere, too, such as in the bones or brain. Swapping out a cancer-ridden liver for a new one may therefore buy some time, but not much.

It can even be counterproductive. Transplant patients need massive doses of immune-suppressing drugs to keep their bodies from rejecting the foreign organ. Although experts differ on how big a role the immune system plays in keeping cancer, especially micrometastases, in check, there is a consensus that it provides some benefit. "Immune-suppressing drugs after a liver transplant for hepatocellular cancer are therefore a major concern," says Kim. "They may increase the risk of recurrence." A more standard treatment is to remove only those parts of the liver that contain malignant cells. "If there are a limited number of such spots, we recommend surgeons go in and take them out," says Kulke. Since the liver regenerates, "that can be curative—or at least it can let patients do a lot better." Presumably, Jobs was being carefully monitored by his physicians, so it is odd that the liver would suddenly be so riddled with metastases—especially given that neuroendocrine tumors are usually indolent—that more limited, targeted surgery was rejected in favor of a full, and risky, transplant.

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Steve Jobs' Commencement address, Stanford University (2005)


My third story is about death.

When I was 17, I read a quote that went something like: "If you live each day as if it was your last, someday you'll most certainly be right." It made an impression on me, and since then, for the past 33 years, I have looked in the mirror every morning and asked myself: "If today were the last day of my life, would I want to do what I am about to do today?" And whenever the answer has been "No" for too many days in a row, I know I need to change something.

Remembering that I'll be dead soon is the most important tool I've ever encountered to help me make the big choices in life. Because almost everything — all external expectations, all pride, all fear of embarrassment or failure - these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart.

About a year ago I was diagnosed with cancer. I had a scan at 7:30 in the morning, and it clearly showed a tumor on my pancreas. I didn't even know what a pancreas was. The doctors told me this was almost certainly a type of cancer that is incurable, and that I should expect to live no longer than three to six months. My doctor advised me to go home and get my affairs in order, which is doctor's code for prepare to die. It means to try to tell your kids everything you thought you'd have the next 10 years to tell them in just a few months. It means to make sure everything is buttoned up so that it will be as easy as possible for your family. It means to say your goodbyes.

I lived with that diagnosis all day. Later that evening I had a biopsy, where they stuck an endoscope down my throat, through my stomach and into my intestines, put a needle into my pancreas and got a few cells from the tumor. I was sedated, but my wife, who was there, told me that when they viewed the cells under a microscope the doctors started crying because it turned out to be a very rare form of pancreatic cancer that is curable with surgery. I had the surgery and I'm fine now.

This was the closest I've been to facing death, and I hope it's the closest I get for a few more decades. Having lived through it, I can now say this to you with a bit more certainty than when death was a useful but purely intellectual concept:

No one wants to die. Even people who want to go to heaven don't want to die to get there. And yet death is the destination we all share. No one has ever escaped it. And that is as it should be, because Death is very likely the single best invention of Life. It is Life's change agent. It clears out the old to make way for the new. Right now the new is you, but someday not too long from now, you will gradually become the old and be cleared away. Sorry to be so dramatic, but it is quite true.

Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.

Wednesday, October 5, 2011

Lancet Report Cites Rate of Late-in-Life Surgery -

Surgery is surprisingly common in older people during the last year, month and even week of life, researchers reported Wednesday, a finding that is likely to stoke, but not resolve, the debate over whether medical care is overused and needlessly driving up medical costs.

The most comprehensive examination of operations performed on Medicare recipients in the final year of life found that nationally in 2008, nearly one recipient in three had surgery in the last year of life. Nearly one in five had surgery in the last month of life. Nearly one in 10 had surgery in the last week of life.

The very oldest patients were less likely to have surgery. Those who were 65 had a 38.4 percent chance of having surgery in the last year of life. For 80-year-olds, the chance was 35.3 percent, but the rates fell off more sharply from there, declining by a third by age 90.

But such analyses are controversial. By looking only at people who died, researchers can get a skewed picture of what is taking place, critics say.

"Because the patient died, you can't assume that the treatment and therapies were not of value," said Dr. Peter B. Bach of Memorial Sloan-Kettering Cancer Center. "Although in that individual, things may not have worked out, you have no insight into whether the decision to operate was appropriate." Nor is it known how many similar patients who had that same surgery did not die.

But the sheer number of operations at the end of life was unexpected, said the researchers, at Harvard School of Public Health. They added that they did not know why the operations had been done. Some undoubtedly were necessary to relieve pain and suffering or to prolong life. But, they said, they know from experience that doctors often operate to repair something that can be fixed but that will not save a dying patient, avoiding the difficult discussions with patients about their prognosis and whether the surgery will improve or compromise their quality of life.

In their study, published Wednesday in The Lancet, the investigators analyzed data for all the 1,802,029 Medicare recipients 65 and older who died in 2008. In addition to the number of operations nationally, they reported marked regional variations in the use of surgery at the end of life. For example, the rate of surgery in Honolulu was a third of that in Gary, Ind.

"Honolulu and Gary, Ind., can't both be doing it right," said Dr. Ashish Jha, an associate professor of health policy at Harvard and the lead author of the study.

But regional variations in health care have been controversial because it is not clear whether they reflect true differences in patient needs or in health care practices or regional differences in health care payment rules, Dr. Bach said.

Dr. Scott Ramsey, an economist and a physician who is director of cancer outcomes research at the Fred Hutchinson Cancer Research Center in Seattle, faulted the researchers for citing regional differences but then suggesting a long list of factors that might be causing them, including the health of the population, the patterns of medical practice, and the availability of hospice care and other end-of-life services.

Their list of potential explanations "covers about everything and says absolutely nothing," Dr. Ramsey said.

But the researchers said their study — done from public records and with no financing — probably pointed to a real problem in American medicine: surgery, which can be painful, expensive and debilitating, is tempting for doctors and patients alike.

"I will admit to being guilty of this," Dr. Jha said. "Often we say, 'If you have this intervention, we will be able to fix that problem. You have an intestinal blockage. Surgery will fix it.' But will it let you walk out of the hospital alive? Will it let you return to your old life?"

Dr. Mark McClellan, a former commissioner of the Centers for Medicare and Medicaid Services, who directs the Engelberg Center for Health Care Reform at the Brookings Institution, said, "Evidence like this — and a lot of previous evidence, directly from patients and their families — shows that we need much better support for patients and their families when they have serious illnesses and may need intensive treatments."

Dr. Jha said he and his colleagues were continuing to study the causes and consequences of surgery at the end of life, adding, "It is hard to take these data and make clear policy recommendations about what is appropriate and what is not."

But he said he had no doubt that the difficult conversations that should precede a decision to operate all too often never occurred.

"As clinicians, we often end up focusing on something narrow and small that we think we can fix," Dr. Jha said. "That leads us down the path of surgical intervention. But what the patient cares about is not going to get fixed."

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

"No one had talked to him about how close he was to death," Dr. Jha said. "It's the worst kind of conversation to have."

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. "We did all of this because we were trying desperately to find something we could fix," Dr. Jha said.

The man died of a complication from the surgery.

"The tragedy is what we should have done for him but didn't," Dr. Jha said. "We should have given him time to have the conversation he wanted to have with his family. You can't do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea."

Instead, Dr. Jha said, "we sent him to the O.R."

Tuesday, October 4, 2011

Selflessness Gone Awry, and the Damage It Can Cause -

Some years ago, Dr. Robert A. Burton was the neurologist on call at a San Francisco hospital when a high-profile colleague from the oncology department asked him to perform a spinal tap on an elderly patient with advanced metastatic cancer. The patient had seemed a little fuzzy-headed that morning, and the oncologist wanted to check for meningitis or another infection that might be treatable with antibiotics.

Dr. Burton hesitated. Spinal taps are painful. The patient's overall prognosis was beyond dire. Why go after an ancillary infection? But the oncologist, known for his uncompromising and aggressive approach to treatment, insisted.

"For him, there was no such thing as excessive," Dr. Burton said in a telephone interview. "For him, there was always hope."

On entering the patient's room with spinal tap tray portentously agleam, Dr. Burton encountered the patient's family members. They begged him not to proceed. The frail, bedridden patient begged him not to proceed. Dr. Burton conveyed their pleas to the oncologist, but the oncologist continued to lobby for a spinal tap, and the exhausted family finally gave in.

As Dr. Burton had feared, the procedure proved painful and difficult to administer. It revealed nothing of diagnostic importance. And it left the patient with a grinding spinal-tap headache that lasted for days, until the man fell into a coma and died of his malignancy.

Dr. Burton had admired his oncology colleague (now deceased), yet he also saw how the doctor's zeal to heal could border on fanaticism, and how his determination to help his patients at all costs could perversely end up hurting them.

"If you're supremely confident of your skills, and if you're certain that what you're doing is for the good of your patients," he said, "it can be very difficult to know on your own when you're veering into dangerous territory."

The author of "On Being Certain" and the coming "A Skeptic's Guide to the Mind," Dr. Burton is a contributor to a scholarly yet surprisingly sprightly volume called "Pathological Altruism," to be published this fall by Oxford University Press. And he says his colleague's behavior is a good example of that catchily contradictory term, just beginning to make the rounds through the psychological sciences.

As the new book makes clear, pathological altruism is not limited to showcase acts of self-sacrifice, like donating a kidney or a part of one's liver to a total stranger. The book is the first comprehensive treatment of the idea that when ostensibly generous "how can I help you?" behavior is taken to extremes, misapplied or stridently rhapsodized, it can become unhelpful, unproductive and even destructive.

Selflessness gone awry may play a role in a broad variety of disorders, including anorexia and animal hoarding, women who put up with abusive partners and men who abide alcoholic ones.

Because a certain degree of selfless behavior is essential to the smooth performance of any human group, selflessness run amok can crop up in political contexts. It fosters the exhilarating sensation of righteous indignation, the belief in the purity of your team and your cause and the perfidiousness of all competing teams and causes.

David Brin, a physicist and science fiction writer, argues in one chapter that sanctimony can be as physically addictive as any recreational drug, and as destabilizing. "A relentless addiction to indignation may be one of the chief drivers of obstinate dogmatism," he writes. "It may be the ultimate propellant behind the current 'culture war.' " Not to mention an epidemic of blogorrhea, newspaper-induced hypertension and the use of a hot, steeped beverage as one's political mascot.

Barbara Oakley, an associate professor of engineering at Oakland University in Michigan and an editor of the new volume, said in an interview that when she first began talking about its theme at medical or social science conferences, "people looked at me as though I'd just grown goat horns. They said, 'But altruism by definition can never be pathological.' "

To Dr. Oakley, the resistance was telling. "It epitomized the idea 'I know how to do the right thing, and when I decide to do the right thing it can never be called pathological,' " she said.

Indeed, the study of altruism, generosity and other affiliative behaviors has lately been quite fashionable in academia, partly as a counterweight to the harsher, selfish-gene renderings of Darwinism, and partly on the financing bounty of organizations like the John Templeton Foundation. Many researchers point out that human beings are a spectacularly cooperative species, far surpassing other animals in the willingness to work closely and amicably with non-kin. Our altruistic impulse, they say, is no mere crown jewel of humanity; it is the bedrock on which we stand.

Yet given her professional background, Dr. Oakley couldn't help doubting altruism's exalted reputation. "I'm not looking at altruism as a sacred thing from on high," she said. "I'm looking at it as an engineer."

And by the first rule of engineering, she said, "there is no such thing as a free lunch; there are always trade-offs." If you increase order in one place, you must decrease it somewhere else.

Moreover, the laws of thermodynamics dictate that the transfer of energy will itself exact a tax, which means that the overall disorder churned up by the transaction will be slightly greater than the new orderliness created. None of which is to argue against good deeds, Dr. Oakley said, but rather to adopt a bit of an engineer's mind-set, and be prepared for energy losses and your own limitations.

Train nurses to be highly empathetic and, yes, their patients will love them. But studies show that empathetic nurses burn out and leave the profession more quickly than do their peers who remain aloof. Give generously to Child A, and Child B will immediately howl foul, while quiet Child C will grow up and write nasty novels about you. "Pathologies of altruism," as Dr. Oakley put it, "are bound to arise."

Rachel Bachner-Melman, a clinical psychologist at Hadassah University Medical Center in Jerusalem who specializes in eating disorders, has seen the impact of extreme selflessness on the anorexic young women who populate her ward.

"They are terribly sensitive to the needs of those around them," she said in an interview. "They know who needs to be pushed in a wheelchair, who needs a word of encouragement, who needs to be fed."

Yet the spectral empaths will express no desires of their own. "They try to hide their needs or deny their needs or pretend their needs don't exist," Dr. Bachner-Melman went on. "They barely feel they have the right to exist themselves." They apologize for themselves, for the hated, hollow self, by giving, ceaselessly giving.

In therapy they are reminded that to give requires that first one must have. "It's like in an airplane," Dr. Bachner-Melman said. "The parents must put on the oxygen mask first, not because they're more important, but if the parents can't breathe, they can't help the child."

Denial and mental compartmentalization also characterize people who stay in abusive relationships, who persuade themselves that with enough self-sacrifice and fluttering indulgence their beloved batterer or drunken spouse will reform. Extreme sensory denial defines the practice of animal hoarding, in which people keep far more pets than they can care for — dozens, scores, hundreds of cats, rodents, ferrets, turtles.

The hoarders may otherwise be high-functioning individuals, says Dr. Gary J. Patronek, a clinical assistant professor at the veterinary school of Tufts University and founder of the Hoarding of Animals Research Consortium. "We've seen teachers, nurses, public officials, even veterinarians," he said in an interview. "They live a double life."

At work, they behave responsibly and know the importance of good hygiene. They go home and enter another world, one of squalor and chaos, of overwhelming stench and undernourished animals, of pets that have died for lack of care.

Yet the hoarders notice none of this. "You walk in, you can't breathe, there are dead and dying animals present, but the person is unable to see it," Dr. Patronek said. Cat carcasses may alternate with food in the refrigerator, "but in the person's mind it's happy and wonderful, it's a peaceable kingdom."

Hoarders may think of themselves as animal saviors, rescuing pets from the jaws of the pound; yet they are not remotely capable of caring for the animal throngs, and they soon give up trying. "It's a very focal, delusional behavior," Dr. Patronek said. And it can be all the more difficult to treat for wearing the trappings of selflessness and love.

Coaching a Surgeon: What Makes Top Performers Better? : Atul Gawande, The New Yorker

I've been a surgeon for eight years. For the past couple of them, my performance in the operating room has reached a plateau. I'd like to think it's a good thing—I've arrived at my professional peak. But mainly it seems as if I've just stopped getting better.

During the first two or three years in practice, your skills seem to improve almost daily. It's not about hand-eye coördination—you have that down halfway through your residency. As one of my professors once explained, doing surgery is no more physically difficult than writing in cursive. Surgical mastery is about familiarity and judgment. You learn the problems that can occur during a particular procedure or with a particular condition, and you learn how to either prevent or respond to those problems.

Say you've got a patient who needs surgery for appendicitis. These days, surgeons will typically do a laparoscopic appendectomy. You slide a small camera—a laparoscope—into the abdomen through a quarter-inch incision near the belly button, insert a long grasper through an incision beneath the waistline, and push a device for stapling and cutting through an incision in the left lower abdomen. Use the grasper to pick up the finger-size appendix, fire the stapler across its base and across the vessels feeding it, drop the severed organ into a plastic bag, and pull it out. Close up, and you're done. That's how you like it to go, anyway. But often it doesn't.

Even before you start, you need to make some judgments. Unusual anatomy, severe obesity, or internal scars from previous abdominal surgery could make it difficult to get the camera in safely; you don't want to poke it into a loop of intestine. You have to decide which camera-insertion method to use—there's a range of options—or whether to abandon the high-tech approach and do the operation the traditional way, with a wide-open incision that lets you see everything directly. If you do get your camera and instruments inside, you may have trouble grasping the appendix. Infection turns it into a fat, bloody, inflamed worm that sticks to everything around it—bowel, blood vessels, an ovary, the pelvic sidewall—and to free it you have to choose from a variety of tools and techniques. You can use a long cotton-tipped instrument to try to push the surrounding attachments away. You can use electrocautery, a hook, a pair of scissors, a sharp-tip dissector, a blunt-tip dissector, a right-angle dissector, or a suction device. You can adjust the operating table so that the patient's head is down and his feet are up, allowing gravity to pull the viscera in the right direction. Or you can just grab whatever part of the appendix is visible and pull really hard.

Once you have the little organ in view, you may find that appendicitis was the wrong diagnosis. It might be a tumor of the appendix, Crohn's disease, or an ovarian condition that happened to have inflamed the nearby appendix. Then you'd have to decide whether you need additional equipment or personnel—maybe it's time to enlist another surgeon.

Over time, you learn how to head off problems, and, when you can't, you arrive at solutions with less fumbling and more assurance. After eight years, I've performed more than two thousand operations. Three-quarters have involved my specialty, endocrine surgery—surgery for endocrine organs such as the thyroid, the parathyroid, and the adrenal glands. The rest have involved everything from simple biopsies to colon cancer. For my specialized cases, I've come to know most of the serious difficulties that could arise, and have worked out solutions. For the others, I've gained confidence in my ability to handle a wide range of situations, and to improvise when necessary.

As I went along, I compared my results against national data, and I began beating the averages. My rates of complications moved steadily lower and lower. And then, a couple of years ago, they didn't. It started to seem that the only direction things could go from here was the wrong one.

Maybe this is what happens when you turn forty-five. Surgery is, at least, a relatively late-peaking career. It's not like mathematics or baseball or pop music, where your best work is often behind you by the time you're thirty. Jobs that involve the complexities of people or nature seem to take the longest to master: the average age at which S. & P. 500 chief executive officers are hired is fifty-two, and the age of maximum productivity for geologists, one study estimated, is around fifty-four. Surgeons apparently fall somewhere between the extremes, requiring both physical stamina and the judgment that comes with experience. Apparently, I'd arrived at that middle point.

It wouldn't have been the first time I'd hit a plateau. I grew up in Ohio, and when I was in high school I hoped to become a serious tennis player. But I peaked at seventeen. That was the year that Danny Trevas and I climbed to the top tier for doubles in the Ohio Valley. I qualified to play singles in a couple of national tournaments, only to be smothered in the first round both times. The kids at that level were playing a different game than I was. At Stanford, where I went to college, the tennis team ranked No. 1 in the nation, and I had no chance of being picked. That meant spending the past twenty-five years trying to slow the steady decline of my game.

I still love getting out on the court on a warm summer day, swinging a racquet strung to fifty-six pounds of tension at a two-ounce felt-covered sphere, and trying for those increasingly elusive moments when my racquet feels like an extension of my arm, and my legs are putting me exactly where the ball is going to be. But I came to accept that I'd never be remotely as good as I was when I was seventeen. In the hope of not losing my game altogether, I play when I can. I often bring my racquet on trips, for instance, and look for time to squeeze in a match.

One July day a couple of years ago, when I was at a medical meeting in Nantucket, I had an afternoon free and went looking for someone to hit with. I found a local tennis club and asked if there was anyone who wanted to play. There wasn't. I saw that there was a ball machine, and I asked the club pro if I could use it to practice ground strokes. He told me that it was for members only. But I could pay for a lesson and hit with him.

He was in his early twenties, a recent graduate who'd played on his college team. We hit back and forth for a while. He went easy on me at first, and then started running me around. I served a few points, and the tennis coach in him came out. You know, he said, you could get more power from your serve.

I was dubious. My serve had always been the best part of my game. But I listened. He had me pay attention to my feet as I served, and I gradually recognized that my legs weren't really underneath me when I swung my racquet up into the air. My right leg dragged a few inches behind my body, reducing my power. With a few minutes of tinkering, he'd added at least ten miles an hour to my serve. I was serving harder than I ever had in my life.

Not long afterward, I watched Rafael Nadal play a tournament match on the Tennis Channel. The camera flashed to his coach, and the obvious struck me as interesting: even Rafael Nadal has a coach. Nearly every élite tennis player in the world does. Professional athletes use coaches to make sure they are as good as they can be.

But doctors don't. I'd paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?

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