Tuesday, July 22, 2014
There seems to be an intense public fascination with emergency room medicine. Television shows like Scrubs, and ER presented humorous or sanitized versions of the subject. A documentary series on Vancouver General Hospital on the Knowledge Network (Emergency Room: Life and Death at VGH) won several awards this year. Books abound: Emergency! True from the Nation's ERs by Mark Brown, MD; Angels in the ER: Inspiring True Stories from an Emergency Room Doctor by Robert Lesslie, MD; and Something for the Pain: Compassion and Burnout in the ER by Paul Austin, MD, all present a more distilled and abridged version of the reality experienced in the trenches.
This is not so with On the Edge of Life. Mikkael Sekeres, MD, MS, rotated through the ER of Mass General where a journal had been started by Theodore Stern, MD, allowing house staff to jot down their thoughts about the experience. Now, 20 years later, the journal has grown to seven volumes of unabridged observations recorded in real time. The editors have used these thoughts and distilled them into separate chapters on humor, life and death, patients and families, and doctors.
The result is a candid, realistic, no-holds-barred, even at times harsh, collection, which will unfortunately ring true to all who have rotated through an MICU. It must be said that the information is also disturbing and in many ways disheartening. As one house officer said, “I’m scared, sad, incompetent, weak, pressured, lonely, isolated, bitter, dumb, inefficient, and nobody else could feel as I do.”
House staff are plunged into this fray and have to act immediately to care for the sickest of the sick. One house officer captured the feeling of inadequacy perfectly: “I wrote my first order as a physician (to give the patient potassium). Actually the nurse told me the patient needed potassium, taught me how to write the order, what to give, where and when. But I was able to write my name without any help!”
Humor somewhat paradoxically is a common part of the MICU experience. Dr. Stern emphasizes that “Humor bonds staff. Sleep, food, and shared laughter are powerful medicines and great pacifiers. Displays of humor insulate staff from the misery around them. To outsiders, the gallows humor may seem inappropriate, sophomoric, and ill timed. It probably is. Humor can facilitate coping but it comes at a price. Doctors use humor because at times it is easier to laugh than to cry.”
Female physicians struggle with career building and child-bearing during training years. This makes for some unique physician-related humorous circumstances. Consider this interaction: “JAR [junior assistant resident] on the .road to matrimony plans for the future. Let’s see, if I get pregnant right now, I wouldn’t have the baby until August.” SAR [senior assistant resident]: “It would make rounds a little uncomfortable for the rest of us.”
Humor often comes from patients who misunderstand our “medspeak.” Here is an example: Patient who had an inferior wall MI while walking his pit bull. SAR: He needs bypass surgery. Patient: Can’t I just get rid of the dog and take it easy?
One of the grimmest messages in the book is the struggle doctors have to come to grips with the realities of desperately ill patients. Twenty-five percent of patients will not leave the MICU alive, and even fewer will leave the hospital and return to functional lives. The ideal candidate for the MICU is a patient with a short-term serious curable illness. Yet the editors point out that “most [MICU patients] are frail, elderly, and destined to die of chronic disease but are kept alive by the use of advanced technology.” As one house officer explains;” Plenty of people have come through the MICU this month. Yet it strikes me that in the saves column, after 59 admissions and only 12 deaths, we have only two.” As another house officer wrote; “just because we have the capacity to prolong life in elderly people doesn’t mean we have to, but we do; everyday in this place we prolong suffering at little benefit.”
The editors explain; “We manage to learn a great deal about the mechanics of medical care for desperately sick patients, but caring for patients in the ICU raises issues about aggressive and expensive health care; it is often ambivalent and disturbing. A lack of definitive answers, guidance, and policies contributes to the distress experienced by house officers.”
Because these unvarnished thoughts from these young physicians are all too familiar to most doctors, it’s hard to know whether re-reading these first-hand experiences will be of sufficient interest to a broad spectrum of doctors or oncologists. It certainly left me with the view that many of the serious and stressful issues of complex care of the chronically ill in MICU’s have not been addressed since I was a house officer.
Unfortunately, patients and lay readers will likely be confused by the medical jargon and probably frightened by the candid expressions of ambivalence toward end-stage medical care expressed in such blunt fashion.
However, progress in making the MICU a more inviting and compassionate place is being made. In the June 26 issue of the New England Journal of Medicine (NEJM 2014;370:2506-2514), a review article, “Dying with Dignity in the Intensive Care Unit” by Deborah Cook, MD, and Graeme Rocker, MD, explores in detail the coexistence of palliative care and critical care in the MICU. They discuss the need for palliative care, the importance of eliciting the values of patients, the critical need for communication about patients’ perceptions about what matters most for high-quality end-of-life care. They call for providing clear prognostic information, recommendations to forgo the use of life- support technology, and the need to provide holistic care. They advocate for patient and family-centered decision making, communication, continuity of care; emotional, spiritual, and practical support; symptom management; and importantly, organizational support for ICU clinicians. The article is a comprehensive and encouraging blueprint for improving MICU care. However, it will be a challenge to accomplish in this era of restricted health care budgets, manpower shortages, and clinicians’ time constraints.
In the same issue of the journal, a Perspective article, “Where We Die” by David Rothman, MD (2014;370:2457-2470), notes that throughout history until the mid-20th century, the appropriate place to die was at home surrounded by family and friends. Now in the 21st, we are returning to more deaths at home and fewer in hospitals, but greater ICU use.
The test for the future will be to create an ICU culture that utilizes increasingly complex treatments but also helps patients and their families make wise decisions about managing the end of life.
Monday, May 19, 2014
BY MIKKAEL A. SEKERES, MD, MS
We followed the highway, its boundaries occasionally buttressed by cement walls to block sniper fire, past checkpoints in and out of Area C of the West Bank until we arrived finally in Jerusalem. The four of us--an Italian, a Brit, a South African, and an American--specialists in lymphoid and myeloid malignancies, packed tightly behind our 84-year-old tour guide like ducklings following their mother as we left the safety of our small shuttle for the Old City.
After traveling thousands of miles to attend the annual hematology conference organized by Aaron Polliack in Israel, we would have one day to explore this ancient town.
We passed through the Zion Gate, the walls forming the arched entrance pocked with bullet holes from the most recent attempt to overtake this conflicted area. Inside, more walls--this time surrounding the Armenian church, a barrier thwarting those who would try to complete their genocide. We stopped after walking a few hundred meters as our tour guide described life in the different quarters--Jewish, Muslim, Armenian, and Christian. As he talked, we noticed that in one small view we could see the remains of an ancient Roman thoroughfare, a Chabad temple, and a Mosque, and we heard the call to prayer.
Hawkers in stalls selling textiles, menorahs, hookahs, jewelry, rugs, scenes of Christ and the apostles. “I give you a good price!” We heard over and over as people jostled into one another through the narrow, crowded path. We stopped for lunch, falafels and chicken shwarma, the table and chairs appearing as if out of nowhere. Nearby sat some Chassidic Jews, with black hats and long beards; a tour group of Christians from Holland, we guessed; Jordanians smoking cigarettes. We finished and pressed on.
Throngs of people were entering and leaving the Church of the Holy Sepulchre. Inside, we followed the flow upstairs, to Calvary where Christ is believed to have been crucified. People dropped to their knees almost helplessly to pray. Scenes from the old and new testament on the walls, originally depicted to instruct illiterate parishioners. Downstairs, people pressing hats, scarves, shirts to the Stone of Anointing, where Christ was laid before being transferred to his burial tomb, which was itself encased in a wooden supporting structure donated by England, which in turn was encased by more crowds waiting to enter. A group from Thailand kneeled in an enclave, praying. We heard another tour guide speaking in German. about the multiple iterations of the church’s destruction and construction. “Babylonian stone…Greeks erected a wall dividing the church…Crusades came through and killed everyone…” Their distinct crosses etched in the stone.
Through metal detectors as we ended at the Wailing Wall. Our small group splintered now as we walked to the men’s or women’s sides. The Wall was almost blinding as the mid-afternoon sun reflected off of it, but soft to the touch from generations of people wearing its surface down in prayer. A man quietly davined next to me, scraps of paper with prayers written on them stuffed into the Wall’s crevices. As we left, we walked past kids newly enlisted into the Israeli Army, not yet assigned to a unit, still carrying their guns awkwardly. Our shuttle was waiting, and we said goodbye to each other, until ASCO, or ASH.
I can’t pretend to even start to understand the history, politics, and religions of the Middle East, the conflicts that have arisen there, or their resolutions. It seemed to me, though, that there are lessons we can take away in how we approach cancer research and treatment.
We frequently do research in isolation, trying to develop theories within our narrow disease focus, when those theories may already have been tested and expanded elsewhere. We’d learn a lot more, faster, if we packed a group of people from different disciplines in a shuttle, or at adjoining tables over lunch, and forced them to spend a day together.
Too often, we compete against each other, and spend an inordinate amount of time trying to tear down each other’s research in favor of our own. It would be an interesting exercise to assess how many letters to the editor in academic journals are truly about open public debate to test scientific rigor, as opposed to needless self-aggrandizement. We should spend more time building, less time destroying.
Oncologists across the world often will not change their practice until trials have been replicated in their own country. There are examples in every cancer. As is the case with many religions, where much of the fundamental moral structure is similar, our fundamental motivation is the same: We want to cure cancer, and we want to treat our patients with the best available drugs. We should trust each other more, and be quicker to adopt the findings of well-done clinical trials conducted elsewhere, so we can improve what we consider standard therapy for our patients, and move more quickly to the next clinical question.
Finally, we shouldn’t give our hematology/oncology fellows their “guns” too soon. In other words, we need to devote real time to teaching clinical skills, sound research principles, critical appraisal, and writing tools, and to developing communication prowess before we nudge them out of the nest to enter their own practices, and conduct their own research.
Anyway, that’s my religion.
MIKKAEL A. SEKERES, MD, MS,
OT’S Clinical Advisory Editor for Hematology/Oncology and a member of the FDA's Oncologic Drugs Advisory Committee, is Director of the Leukemia Program at the Cleveland Clinic Taussig Cancer Institute and Chair of the Hematology/Oncology Pharmacy & Therapeutics Committee. He is a staff member in the Department of Hematologic Oncology and Blood Disorders and holds a joint appointment in the Departments of Translational Hematology and Oncology Research.
Sunday, April 27, 2014
BY LARRY MAXWELL, MD
Department Chair of Obstetrics and Gynecology
Inova Fairfax Hospital
Advisory Board Chair, Globe-athon
As doctors, we have an incredible ability to touch patients’ lives, often when they are going through the most vulnerable moments. In the safety of our offices, we provide consultation and facts to help with a patient’s short- and long-term outcomes. However, as soon as patients walk out of our doors, they are bombarded with myriad messages from non-medical sources about their conditions, some that are true and some that are false, but few we have control over.
It is also our responsibility to help engage patients in the dialogue regarding cancer education outside of the office to help dispel myths and keep them focused on potential treatment outcomes. Some cancer campaigns to date have been unifying, increasing public awareness and adding fundraising dollars to cancer research. But there is more we need to do as physicians.
From a health care perspective, there is a great need for educational efforts, especially for lesser-known cancers. Lack of information causes significant problems in prevention and early detection, especially in the case of gynecological (GYN) cancers. Research from the American Cancer Society reveals that only 15 percent of ovarian cancer cases are caught before the cancer has spread. Due to late diagnosis, GYN cancers are harder and more expensive to treat and the survival rates are lower. Yet, ACS research also shows that when ovarian cancer is detected and treated early, the five-year survival rate is 92 percent.
Physicians and other medical professionals have an opportunity to share their expertise with individuals so that they can be aware of the prevention and early-detection measures they can take every day. For this to occur, physicians need to use their expertise to support initiatives that help disseminate the right information and bring awareness to the issues.
Patients, survivors and caregivers are having the conversations at home and online, and we need to continue to support these conversations to ensure information accuracy and awareness.
Movement for One Dedicated Mission
In the case of GYN cancers, there are five primary cancers -- cervical, ovarian, uterine, vaginal, and vulvar -- and multiple education and advocacy organizations involved in a variety of complementary, yet separate, initiatives. Only those diagnosed know to turn to these organizations for support.
To help unify and use our collective voice, GYN cancer organizations across the globe are organizing around one goal – ending women’s below-the-belt cancers. While each organization has its own mission and goals, we all agree that awareness is the most important component of our efforts. Globe-athon to End Women’s Cancers is a global movement to raise awareness about GYN cancers, while also serving as a catalyst for unprecedented bridge building and collaboration beyond regional and international borders.
As part of the effort last year, more than 60 countries and 130 cities hosted events to raise awareness and encourage participation in Globe-athon. During the second annual effort this year, Globe-athon will occur during four weeks in September with hundreds of events and educational seminars throughout the world to raise awareness for, and ultimately increase, early detection and prevention of GYN cancers.
With Globe-athon we are working to create a global communications grid through our multi-lingual website (globeathon.com) and social media platforms, including Facebook and Twitter, to facilitate dissemination of information to patients and the general public, foster discussion amongst survivors around the world, and ultimately enable retrieval of survivor information to support research efforts.
The real impact, over the long run, is a global network talking about the issue and sharing solutions. With this kind of attention on below-the-belt cancers, we have the opportunity to save a generation of women.
National and international health initiatives like Globe-athon are opportunities to raise awareness about major health issues like GYN cancers in a way that help improve doctor-patient conversations, and call attention to the need for more education and research. The vast health information available is daunting for many people who are trying to take charge of their health.
When physicians and other medical professionals team up for specific health initiatives, it is a unique opportunity that brings credible and trusted resources together for one dedicated mission. Oncologists have the credible voice to inspire and inform educational campaigns to raise awareness, increase detection, and pursue prevention. Now is the time to lend your voice to the organizations and movements that need it most.
Sunday, April 13, 2014
BY CAROLYN B. HENDRICKS, MD
Center for Breast Health
I have been in a small or solo suburban medical oncology practice since 2001. My practice is breast cancer dedicated. I have terrific staff and phenomenal patients. I love it.
But right now, I am seriously considering closing my practice.
Why? Over the past several years, the increasing cost of chemotherapy drugs has risen and the reimbursement for chemotherapy has fallen to the point where my practice is at the tipping point. In addition to the high drug costs, giving chemotherapy is complex and expensive. In my practice, it requires two highly trained nurses, a nurse practitioner, and a really top notch biller. Because chemotherapy drug prices are tied directly to how much chemotherapy is purchased, small practices like mine -- whether urban, suburban, or rural -- pay more for the same chemotherapy drugs than larger practices do. But we still have the same safety and staffing requirements.
In 2013, I purchased $3.4 million in chemotherapy, about average for oncologists, but in my case that high cost is due to a handful of very expensive drugs for breast cancer.
I have worked hard to increase my practice efficiency including a complete transition to an electronic health record, but quality oncology care is time intensive, so it isn’t possible to dramatically increase the number of new patients that I see. I won’t compromise on quality.
For the past two years, my practice has lost a significant amount of revenue. Oncologists like me purchase chemotherapy on credit and then scramble to get reimbursed. I have assumed a significant amount of debt (too much to not publicly) and had a significant reduction in my own income down to the same amount I took home 10 years ago.
Since it went into effect in April 2013, the sequester has resulted in a loss of $12,000 in Medicare revenue for my practice -- that amounts to one payroll or one month’s rent.
I experienced a significant staff shortage last year because of overlapping staff maternity leaves, and ended up sending my patients to my local hospital for three months. They received good care but were very distressed to receive much higher bills for their out-of-pocket expenses than for the exact same chemotherapy administered in my office.
What are my options? Purchase, merge, sell, or close?
I negotiated with an academic medical center for a year and a half for purchase, merger, or sale of my practice. Last month, they withdrew from the negotiations explaining that the economic climate for outpatient oncology is too precarious in Maryland.
I am considering attempting merger with other oncology groups, locally and regionally. It is a daunting task. I am also seriously considering closing my practice. Both of those decisions would have a very significant impact on my staff and patients. I really want to preserve the small, nurturing, and high-quality practice environment that I have cultivated.
I sincerely hope that the changes outlined in ASCO’s State of Cancer Care in America report will be enacted. Small practices like mine would benefit directly from:
- lifting the sequester;
- introduction of new payment models that don’t rely on buying and billing for expensive chemotherapy drugs, and
- an eventual transition to payment for quality and not quantity or location of care be it urban, suburban or rural.
These changes would go a long way towards alleviating the workforce issues I have described -- that is, early retirement, burnout, increasing scarcity of oncologists in rural areas, and the steep decline in the number of small practices. Hopefully, these changes will occur rapidly enough that I won’t have to close my practice doors in the near future.
Adapted from remarks delivered at a Capitol Hill briefing in March where the American Society of Clinical Oncology released its comprehensive report on the state of cancer care in the U.S., “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis” (OT 4/10/14 issue)
Monday, January 13, 2014
I reviewed with great interest the recent article on the AACR’s 2013 Cancer Progress Report highlighting advances in immunotherapy (OT, 10/25/13 issue). As a clinician who closely follows this area of research, I share the AACR’s concern about the current oncology research funding crisis, and I echo AACR’s call for greater patient participation in cancer clinical trials. Such participation is crucial to the continued advancement and adoption of immunotherapy, a treatment modality that has been shown to produce meaningful and durable responses in a subset of patients, and which is “beginning to revolutionize the treatment of certain cancers,” in the words of AACR President Charles L. Sawyers, MD.
Whereas immunotherapeutic agents such as ipilimumab and interleukin-2 (IL-2) are thought to modulate “natural immunity,” the nature of their clinical effector process is not well understood. When we have therapies capable of durable response but such benefits are limited to a select group of patients, greater effort needs to be applied to identifying the predictive and prognostic markers of response. Understanding such biomarkers will enhance response rates (i.e., by enabling selection of appropriate patients) and limit toxicity (i.e., by facilitating appropriate dosing). In addition, biomarker studies tied to clinical trials will provide a basis for rational combinations.
Registration databases have been established for ipilimumab and IL-2, and clinical trials such as the ongoing PROCLIVITY program are advancing understanding of combination immunotherapy. However, the lack of significant funding outside of industry has limited understanding of biomarkers. While the registration databases are collecting valuable clinical information, they lack annotated tissue samples needed for biomarker studies. Ideally, every patient undergoing immunotherapy should receive immunologic assessments just as they have CT scans and other blood tests. Yet we lack the basic understanding that would allow immunologic assessments. Consequently, we are administering costly therapies to patients who may only experience toxicity.
Policymakers should increase support for translational research focused on understanding the expanding number of tools available to the treating clinician. One such tool is the immune score, a proposed classification system that quantifies the density and location of immune cells within a tumor, and which purportedly has a prognostic value exceeding that of the AJCC/UICC TNM-classification.1 The immune score is emblematic of the huge strides we have made in translational research, and may eventually be regarded as the immunotherapeutic equivalent of molecular targeting, which has led the way to personalized cancer care. Indeed, enhanced understanding of these potentially valuable tools may someday lead us to the era of personalized immunotherapy.
Gregory A. Daniels, MD, PhD
Moores UCSD Cancer Center
La Jolla, CA
1. Galon J, Pages F, Marincola FM, et al. The immune score as a new possible approach for the classification of cancer. J Transl Med. 2012;10:1. http://www.translational-medicine.com/content/10/1/1