Saturday, March 4, 2017

NYTimes: Whom Do You Tell When You’re Sick? Maybe Everyone You Know

Last year, my mother, a few weeks before a milestone birthday, learned she needed major surgery. The circumstances were not life-threatening. She would not be in the hospital long. But the recovery would still be protracted and restrict her ability to care for my father, who has Parkinson's.

No worries. Her three grown children, all of whom live in distant cities, snapped into action. We would fly in for the surgery, call in extra help, telephone a few of her friends and ask them to check in, drop off some food, otherwise be on call. We congratulated ourselves for a well-designed plan. There was only one problem.

My mother insisted we not tell a soul.

"I don't want to inconvenience my friends," she said. "Also, I don't want people to feel sorry for me, and I absolutely don't want to listen to all their medical stories. It's just so wearying."

How people decide whether to go public with their medical conditions has long been highly sensitive and deeply personal. Certain situations, like broken limbs and cancers that require chemotherapy, are virtually impossible to keep secret. Others, like H.I.V. and mental illness, are easier to keep under wraps, at least for a time. Older people, in my experience, lean more toward secrecy; younger toward disclosure.

These days, all of the old rules have been thrown out. With more and more people used to sharing even the most minute details of their daily lives on social media, centuries of customs have been upended. If you post photos of yourself emptying your cat litter, filing your taxes or getting your cavity filled, you can't as easily come out later and say, "Oh, I've had muscular dystrophy all these years and didn't want to tell you."

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When doctors know that they don’t know - The Boston Globe

Imagine that you are a medical doctor. You need to tell one of your patients that he has advanced-stage pancreatic cancer, an almost incurable condition. You learn that your patient's only daughter is getting married five months from now. Without treatment, your patient has about a year left to live. Chemotherapy would increase his chances of being alive in five years by about 20 percent but would also double his chances of dying before his daughter's wedding. What do you tell him? Of course, the choice is by no means easy or clear-cut.

Doctors are scientists who operate in a world of statistics, odds, and probability. Yet they've long been taught that when dealing with patients they should convey a reassuring level of confidence and certainty. As a result, patients expect their doctors to give them a clear diagnosis and a straightforward course of treatment.

But now that information about every medical condition imaginable is just a few clicks away, experts are asking whether doctors' apparent certainty when communicating with their patients actually does more harm than good. With the information overload brought by the progress of medicine and technology, answers are rarely black or white. Medical schools are only just starting to teach doctors how to deal with this, and patients' expectations haven't adjusted, either.

The fact is that medicine has long been steeped in uncertainty and has arguably even thrived on it. To avoid bias when testing a new drug, researchers must have no preconceived notions of which treatment, the new one, the old one, or even a placebo, is the best option. This principle, called equipoise, protects patients, doctors, and researchers alike from making assumptions before scientific proof of efficacy has been gathered.

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Tuesday, February 28, 2017

Colon and Rectal Cancers Rising in Young People - The New York Times

Cancers of the colon and rectum have been declining in older adults in recent decades and have always been considered rare in young people. But scientists are reporting a sharp rise in colorectal cancers in adults as young as their 20s and 30s, an ominous trend.

The vast majority of colorectal cancers are still found in older people, with nearly 90 percent of all cases diagnosed in people over 50. But a new study from the American Cancer Society that analyzed cancer incidence by birth year found that colorectal cancer rates, which had dropped steadily for people born between 1890 and 1950, have been increasing for every generation born since 1950. Experts aren't sure why.

Rectal cancers are rising particularly sharply, far faster than cancers in other parts of the large intestine or colon. The American Cancer Society estimates about 13,500 new cases of colon and rectal cancers will be diagnosed in Americans under 50 this year, with more than 95,500 cases of colon cancer and nearly 40,000 cases of rectal cancer in all age groups.

"People born in 1990, like my son, have double the risk of colon cancer and quadruple the risk of rectal cancer" compared to the risk someone born in 1950 faced at a comparable age, said Rebecca Siegel, an epidemiologist with the American Cancer Society and the lead author of the new report, published in the Journal of the National Cancer Institute on Tuesday. And though the absolute risk is still small in younger people, she said, "They carry the risk forward with them as they age."

It is the upward trend that is worrisome: The risk of colon cancer for individuals who were born in 1990 was five per million people in that birth group, up from three per million at the same stage of life for those born in 1950. And the risk of rectal cancer for those born in 1990 was four per million, up from 0.9 per million for those born in 1950.

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Sunday, February 26, 2017

Netflix’s new documentary Extremis shows the tension of end-of-life care.

Documentaries often deal in sadness and Netflix's new short Extremis is no exception. A film on end-of-life care that is shot entirely in an Intensive Care Unit at Highland Hospital in Oakland, California, the piece centers on Dr. Jessica Zitter, a palliative care specialist who leads a team in helping terminal patients prepare to die. Zitter treats or oversees patients who have no hope of recovery—for example there's Selena, who stopped breathing on the way to the ER and suffered severe brain damage, and Donna, a woman with severe myotonic muscular dystrophy that has severely compromised her existence. Her family is tormented with the knowledge that the breathing tube is likely all that's keeping her alive. A third patient is a woman on a respirator who is unsuccessfully trying to write her intentions on paper. Many of these patients are chained to supportive equipment with no hope to ever get off.

The main tension in the film is Zitter's efforts to help guide her patients and their families toward the ultimate realization that there is often no realistic chance of recovery. She comes across as compassionate and supportive if rational to the point of dogma. There are disturbing points in the film where families such as Selena's try to resist, clinging to a sliver of hope, which Zitter cuts through with reasoning and calm resolve. In this way, the documentary highlights the main tension of end-of-life care: Doctors often have different priorities than the patients and family members they're treating. That's because doctors are often able to see the stark reality of a situation before the patients and family can. "I'm always looking for another miracle," Selena's daughter Tama says, adding that pulling her mother's tube "feels like murder."

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