By Rob Lamberts, MD

I saw a gentleman in my office recently.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight.  I know that this would just get better if I lost the weight.”  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don’t like to lecture people on things they already know.  I don’t like to say the obvious: “You need to lose weight.”  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

Continue reading “Shame”

By Rob Lamberts, MD

Don’t assume anything.

Assumptions can kill.  Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you.  Here’s my list of potentially harmful assumptions:

1.  No news is good news

If you have a test done and don’t hear anything about the result, do not assume it is fine.  This assumption kills people.  I have too many patients with too much information flying at me every day for me to catch every important detail.  Sometimes things are missed, but sometimes the results don’t come to our office.   We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in.  I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.

Always know what tests are being run, and always get the results of those tests (in writing, if possible).

2.  The doctor will think I am stupid

I often have patients apologizing to me.  They apologize when they have a “weird” symptom, when they “ask too many questions,” when they stop taking a medication due to side-effects, and when they are really, really worried about something.  They seem afraid that I am going to roll my eyes and think of them as “one of those patients” – the kind that I complain about to my office staff.

I hate it when people apologize.  Apologies assume there is some standard or expectation that a person is not meeting, and the only expectations that I have of my patients is:
a. they have or want to prevent medical problems
b. They want my help.

Why should I get mad at people for either of these things, as it is the job of a doctor to help people who need them.  I know there are doctors out there who treat patients like bad kids or like they are morons, but those doctors are out of step with reality.  They are the morons.  I don’t apologize to the barber that my hair grew.  I don’t apologize to my accountant for having tax questions.  Understand your position as the paying customer; get what you paid for.

Continue reading “Zen and the Art of Not Thinking Magically”

By Danielle Ofri

I can’t tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren’t sure of the difference between the two, then “God’s Hotel” is the book for you. It’s an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco’s Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, “slow medicine,” as Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Continue reading “Slow Medicine”

By John Halamka, MD

Kathy heads to surgery tomorrow at 7am.   She’ll be NPO (nothing by mouth) after midnight.  She’ll wake at 5am, shower with Hibiclens (a antibacterial prep), and I’ll drive her to surgical check in.  Prior to surgery, the radiology department will insert a wire adjacent to the titanium markers that were placed in her tumor at first diagnosis.   Her surgeon will use this wire to guide the lumpectomy.

Her left breast will become smaller than her right.  She jokes that her career in exotic dancing will come to an end.

The operating room will call me at the end of her procedure and I’ll pick her up.   Since she’ll not have had general anesthesia, we’re presuming she’ll feel good enough for a bit of an extended ride home.   The last of our chickens arrives on Friday (Buff Orpington’s) and we’ll pick them up as we drive back to our new farm.

We’ll anxiously await the results of pathology.   If the margins on the lumpectomy tissue are clear, Kathy will start Radiation Therapy 1-2 months after surgery, likely late June or early July.

By Labor Day, if all goes well, this phase of our cancer  journey will end, although our continued vigilance for reoccurrence will be lifelong.

Continue reading “Our Cancer Journey”

By Allen Frances

Sigh of relief. The DSM 5 website announced recently that two of its most controversial proposals have finally been dropped. We have dodged bullets on Psychosis Risk and Mixed Anxiety Depression. Both are now definitively rejected as official DSM 5 diagnoses and instead are being exiled to the appendix. And one other piece of good news-the criteria set for Attention Deficit/Hyperactivity Disorder has been tightened (not enough, but every little bit helps).

The world is a safer place now that ‘Psychosis Risk’ will not be in DSM 5. Its rejection saves our kids from the risk of unnecessary exposure to antipsychotic drugs (with their side effects of obesity, diabetes, cardiovascular problems, and shortened life expectancy). ‘Psychosis Risk’ was the single worst DSM 5 proposal—we should all be grateful that DSM 5 has finally come to its senses in dropping it.

For the first time in its history, DSM 5 has shown some flexibility and capacity to correct itself. Hopefully, this is just the beginning of what will turn out to be a number of other necessary DSM 5 retreats. Today’s revisions should be just the first step in a systematic program of reform—a prelude to all the other changes needed before DSM 5 can become a safe and scientifically sound document.

Continue reading “DSM 5 Finally Begins Its Belated and Necessary Retreat”

By Joan Wickersham

First, a confession: I like to watch reality TV. Not all reality TV, not often. (I wish I could say, as I would about a junky magazine, “I saw it at the hairdresser” or “ . . . while I was waiting in line at the supermarket.” But no — I sit in my living room, turn on the TV, and choose the station. I take full responsibility. Though I do also use the time to fold laundry.)

The show I’ve gotten hooked on lately is called “Giuliana and Bill.” Giuliana and Bill are on TV because they are famous for being on TV — she as a host of E! News and he as a winner of “The Apprentice.” Their eponymous reality show, about the ups and downs of their marriage, is a marvel of glitzy minutiae. Giuliana and Bill are just like us, only with a lot more Hermès accessories. They bicker; they smooch; they argue about what to have for dinner; they host New Year’s Eve in Times Square. It’s “reality” — life’s big and little moments, carefully staged to seem breezy and spontaneous. But what has hooked me on the show this year is that “reality” has suddenly collided with reality: Giuliana’s diagnosis of breast cancer.

Giuliana and Bill started as a show about newlyweds who wanted to have a baby. But the couple wrestled with infertility, and an IVF pregnancy ended in miscarriage. Before proceeding with another round of fertility treatment their doctor insisted on a mammogram.

Breast cancer was diagnosed last October; and after Giuliana’s lumpectomies failed to produce cancer-free margins, she and Bill had to decide what to do next.

Continue reading “When Reality TV Collides with Reality”

By Peter Ubel, MD

Researchers at USC recently published a study designed to find out how much people are willing to pay for better drug coverage from their health insurance plan.  The question they posed to the general public was straightforward: How much extra money would you pay per month for a health insurance plan that would pay for “specialty drugs” if you need them?

Specialty drugs are expensive new treatments for diseases like leukemia, multiple sclerosis and rheumatoid arthritis.  These drugs often cost tens of thousands of dollars, and in some cases even run into six figures per patient.  But these high costs can be accompanied by significant benefit.  Gleevec for example can dramatically increase life expectancy for people with otherwise fatal leukemia.

Keep in mind that not only are specialty drugs expensive but they are being used with increasing frequency.  According to the USC team, 3 out of 100 people in the United States will use at least one specialty drug in the following year.

How much would you pay to make sure you aren’t responsible to pay for these drugs out of pocket?  Would you be willing to give your insurance company an extra $5 per month? $10?  Maybe even $20?

The USC team found that, on average, people were willing to spend around $13 extra per month to make sure their health insurance plans cover such specialty drugs. (The study was published in the April issue of Health Affairs, and was led by John Romney.)  To put that into perspective, the actuarial cost of such coverage—how much insurance companies would expect to spend per person if everyone obtained such coverage—is around $5 per month.

Continue reading “Is Health Insurance Too Cheap?”

By Merrill Goozner

It all began when Dr. Renee Hsia of the University of California at San Francisco received a simple request from a good friend who had checked into a local hospital for an emergency appendectomy. The fairly routine procedure took place 19,368 times during 2009 in California.

After he returned home, he received a bill from the hospital for $19,000, his co-payment for the parts of the $54,000 operation that his insurance company didn’t cover. “He wanted to know if this was the usual and customary charge for a one-day stay in the hospital,” she recalled.

And thus began her research into pricing variability in the state, which was published this week in the Archives of Internal Medicine. The prices ranged from $1,529 to $182,955 with the median hospital charge of $33,611, the study showed.

The prices not only varied between hospitals, they varied within hospitals. The largest spread occurred at one hospital, which Hsia wouldn’t reveal, where the cheapest appendectomy went for $7,504 while the most expensive charged was $171,696. There were numerous hospitals where the spread was $100,000 or more.

“They had the same diagnosis, but different things could have been done,” she said. For instance, one patient could have had multiple imaging tests and robotic laparoscopy, while the other received no imaging and a regular laparoscopy. There’s no evidence to suggest one set of alternatives had better outcomes than the other.

Continue reading “Anatomy of a Walletectomy”

By Laura Newman

On April 17th, 81-year-old Warren Buffett told investors that he had very early prostate cancer. The Washington Post headline read: “Warren Buffett Has Prostate Cancer that is Not Remotely Life Threatening.’” Within hours, news accounts said that the story unfolded after discovering a high PSA in a routine appointment. Next, he had a prostate biopsy. A few hours later, news accounts said that Buffett decided to get radiation therapy for prostate cancer. What’s wrong with this picture?

10. He’s an icon who other men will follow, and there is limited (or no) evidence of benefit of aggressive treatment in men as old as Buffett. At 81, his life expectancy is 7.41 years, shy of the 10-year life expectancy mark doctors look for when they recommend aggressive treatment for prostate cancer.

9. Although Buffett can afford whatever care he so desires, it would cost a fortune if tons of men in his age group went for active treatment and there would be little yield and plenty of side effects.

Continue reading “Top 10 Reasons Why Warren Buffett’s Decision to Treat Prostate Cancer Bugs Me”

By James Salwitz, MD

Recently a patient with advanced lung cancer was admitted to a local hospital.  Pain in his abdomen was diagnosed as a gallbladder infection.

Because he had metastatic cancer, in addition to the new problem, the patient and family decided that if things deteriorated he should not be given CPR or put on a respirator. A Do Not Resuscitate (DNR) order was entered in his chart. Treatment for the gallbladder was continued, but it was decided that there was a line that the doctors would not cross.

This made sense to me.

Try conventional therapy, but if he was too weak to recover, then do not continue treatment which could cause more suffering than benefit.  Give him the opportunity to survive the gallbladder problem, but respect the terminal nature of the greater disease.  We were all gratified when his pain and fever went away, and he recovered from the emergency.

When we were discharging him from the hospital, a surprising thing occurred.

The patient and family requested that since he had survived the infection, that the DNR be reversed.  They decided that when a sudden new major medical complication occurred, that CPR be performed and he would be placed on a respirator.  The clear protective line vanished.

In difficult lengthy discussions with the patient and family, it became clear that they were riding tides of emotion.  When things looked better, they focused on life and “cure.”  When things grew worse, they were ready to withdraw.  They became defensive and angry at the suggestion that this decision might cause suffering.  We were not able to redefine limits to his care.

Continue reading “Crossing the Line”