Over Easter weekend, I read an article in Newsweek about the waning of Christianity in the
There is an old army adage that there are no atheists in foxholes and maybe the diagnosis of cancer brings patients to re-examine their lives and re-examine whether they in fact have faith. I also feel that in today's world, being a Christian or someone who believes in God is maybe not seen as "cool." I think it is en vogue to deny a faith in God. On so many different levels, I feel that this is a mistake and I believe that in many cases it is just an act and that when push comes to shove, it is our human nature to turn to a higher being and seek help in times of stress. I wonder what would happen if Newsweek had polled 1000 cancer patients. I would suspect that the results might have been different.
My son and I visited two universities over the last several days. We looked at Belmont University in Nashville and Loyola University in New Orleans. It was a fun and interesting trip. Hours on the plane and many hours in a car gave us a chance to talk like we haven’t had in years. It has been an amazing transformation to watch him mature into a young man. We don’t agree on everything in life (music, politics’ etc.) but his thoughtfulness shows a level of maturity that I respect. As parents we hope and pray that our children “turn out right”. I think that is more important that they find their own way and develop a sense of themselves. If there is one thing that I hope I can give all my children is the idea that developing that sense of oneself is a lifelong process. It is one of the most fulfilling parts of life.
To be diagnosed with best cancer at the age of 25 must be one of the most difficult things a human can go through and endure. At twenty five people still feels invincible, with their whole life ahead of them. A patient of mine went through this almost five years ago. Chemotherapy, radiation therapy and nearly 5 years of antiestrogen therapy put many of her dreams on hold. She had wanted a family with her new husband and looked forward to the possibility of having a child after her 5 years of antiestrogen therapy was completed. Over the last 5 years she has become one of my closest patients. I looked forward to her visits, as did all my staff. She is kind and always smiling.
Tragedy struck this week. After being only ill with the “flu” for one week she went to her home town doctor and was found to have a white blood cell count of 150 thousand (100 times normal). The work up included a bone marrow biopsy which revealed the diagnosis of acute leukemia. She is now in the second fight of her life. This leukemia is almost certainly related to her previous treatment for her breast cancer. How can this happen? It is a known complication of certain kinds of chemotherapy. The chemotherapy damages the bone marrow in some way that eventually allows the development of this kind of “secondary” cancer. This is a very rare but feared complication of the treatment of many kinds of cancers.
Treatment of her leukemia will require aggressive chemotherapy and eventually possible a bone marrow transplant. If she survives the first couple weeks of her treatment, which is in no way certain, she will face years of potential treatments and side effects. Her ability to have children has been lost. The amazing thing is her attitude has not changed. Despite the pain, fatigue, difficulty breathing, and the prospect of a long hospitalization her spirit and smile hasn’t dimmed. These are the characteristics that give her a fighting chance….. Everyone’s payers would help also.
I was in Austin Texas recently for the American academy of Hospice and Palliative Care Medicine (AAHPM) meetings. This was my first trip to this organizations meeting. This specialty takes care of chronically ill and dying patients. It was a very different sort of meeting for me. Many of the national meetings that I have attended over the years have been so focused on the molecular basis of cancer. Don’t get me wrong, this is important and interesting but it also seems to sometimes forget the patients. The care of patients on a day to day basis has very little to do with the biochemical pathways of the medicines we use. Yes, these pathways ultimately determine the actions, responses and the side effects of the medicines but the individual response of patients is personal. It is unique to each patient. These pathways don’t even come close to determining the reaction of the patient both mentally, spiritually or emotionally.
The AAHPM meetings were different because the majority of the talks, lectures and meetings were focus directly on the patient. There were sessions on how to listen and talk to patients. There were studies on pain control, insomnia, and shortness of breath. The research that is going on in palliative medicine is in its infancy. Palliative medicine is a new medical specialty and the people who work in this field of medicine are on the “cutting edge and uncharted water “. There is an excitement and a passion that is difficult to describe. Talk of spirituality was freely overheard. The emotions, stresses and thoughts of patients, their care givers, and the professionals that care for them were the highest priority.
I think that the doctors, nurses, social workers and ministers that work in this new and expending field of medicine understand the finality of life. They are not so concerned with the statistical difference in survival between two chemotherapy drugs. They understand that we have a finite amount of time on the world and how we live is much more important than how long we live. I can’t wait for next year’s meeting in Boston.
I had the opportunity this month to host a remarkable guest into our practice, Dr. Jeremy Geffen. Dr. Jeremy Geffen is a board-certified medical oncologist who has become a nationally and internationally recognized expert in integrative oncology. Integrative medicine is the practice and study of alternative and complimentary therapies. He came to Kansas City to present to our practice the possibility of bringing his incredibly unique and powerful program, The Seven Levels of Healing to our practice. The Seven Levels of Healing is best described as a systematic journey that a newly diagnosed cancer patient takes under the direction of Dr. Geffen and highly trained coordinators to learn the best way in which to deal with their diagnosis. Below is the general outline of his remarkable program.
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Lasting 7 weeks this Program is a unique education and support class that gives patients the needed resources to deal with the diagnosis of cancer. We are working hard to bring this program to our practice and are hoping to start the first classes this summer.
Dr. Geffen originated this program in
I would strongly encourage anyone who is battling cancer to seek out Dr. Geffen's website and read his book. The book is a wonderful and powerful statement on the concept that the patients are whole beings. Treatment of patients must be at every level of their being, including their mind, soul, body, and spirit, not just focused on chemotherapy, radiation therapy and other “traditional “therapies.
In my life, I have lost several people that have been close to me. The person that had the greatest impact on my life was my grandmother. When I was a senior in the high school, my grandmother died. She was an extraordinary woman and after my parents, she probably played the biggest role in shaping the man and doctor that I have became. Losing her was a terrible blow.
Although the loss of the grandmother certainly is very difficult, I cannot image losing a young child to violence. I recently finished reading a book called "The Shack" where a man loses his young daughter to a serial killer. This book is one of the most unique pieces of literature that I have ever read. This book struck me in so many ways and on many levels. It made me cry as I imagined the feeling that I would have if my own daughter was lost. It then gave me great hope as it talked of an extremely personal relationship with God and how that personal relationship with God can heal all wounds. I have picked up the book several times since I have finished it the first time to re-read chapters.
As written in this book, I firmly believe that there can be no healing in this world without faith, hope and a strong belief in God. I have witnessed many a time in my practice where the faith that a patient had has carried them well beyond what they should have survived. Although I do not believe that death is a failure, I have seen patients that I believe have been cured not so much from the chemotherapy, or radiation therapy, but from the strength of character, will to survive and their great faith in God.
I would encourage everyone to read "The Shack." It is a wonderful book with great, great insight.
Facing the diagnosis of cancer can be the most challenging time in a person’s entire lifetime. It takes great courage to face the diagnosis and treatment of cancer.
Cancer of the gallbladder is a devastating disease. It is a rare disease most commonly found late in its course and usually discovered only after it has spread widely throughout the abdomen. Currently, I am treating a young lady with gallbladder cancer. She is struggling with this diagnosis and is dealing with a great deal of pain. I am amazed at her perseverance and strength despite things not going well. She has spent the last several weeks in the hospital trying to get her pain under controlled. She has approached her diagnosis with strength, resolve and I certainly admire her for these characteristics. I am not sure I would be as strong.
We have talked about her family and her youth in Tennessee. I have met her father and have seen the caring and worry on his face. She is in a loving long term relationship with another woman. The dedication and love for each other is readily apparent. Her sense of peace is amazing. I love her smile and her Tennessee ascent. I pray that the therapy she is receiving will be successful.
I think we can all take a lesson from these wonderful patients who are battling against insurmountable odds. As we go through our day, struggle with the present economic crises, and struggle with difficulties in our personal life I think we should realize things could be a great deal worse. We should be thankful for our health, and all the blessings we have in our lives.
Sarah died this week. She died of her breast cancer way to soon. Nothing really went right with her case.
She was diagnosed so very young. She struggled through her adjuvant chemotherapy. Nausea, fatigue, and pain were a constant for months as she took Adriamycin, Cytoxan, and Taxol. She finished therapy only to lose her insurance. Not feeling she could aford care she canceled apointments and was "lost to follow up".
Four months ago she returned to my practice after finally getting a new job and the insurance that came with it. Her first blood tests revealed signs of possible reoccurrence. This was quickly confirmed by CT scan and PET scan. Her disease was in her lungs, bones, and liver. She quickly developed severe pain and fractured her hip stepping over the threshold to her home. Hip surgery lead to post-op infections which made it difficult to give her additional chemotherapy. She had to have her hip prosthesis removed because of the infection. She struggled with the anesthesia with each surgery. She struggled with more nausea with her pain medication. She struggled to stay positive in the face of one set back after another.
She leaves behind a 10 year-old daughter, a devoted and loving husband and a family that I sure will miss her dearly.
We have made such great progress in the treatment of breast cancer in the last 10 years. Many women are cured and even when faced with metastatic disease many women live long lives. But it is CANCER that we fight, it is a terrible disease and it sometimes takes an awful toll.
I was so mad at the nurse I could hardly see straight. Mr. Jones had just received chemotherapy for non-Hodgkin's lymphoma. Unfortunately, a mistake was made and the nurse gave him another patient's treatment that was for lung cancer. I could not believe that she had made such an error. How was I going to tell the patient that he had just received the wrong chemotherapy? Sure the chemotherapy that he received may have some activity in his disease, but how could he ever again trust me, my office, or the nurse again. What would his side effects be? I didn’t talk to the nurse the rest of the day.
I was so mad. The nurse called me at 3 a.m. in the morning. I awoke out of a sound sleep as I answered the phone. Trying to get some bearing on where I was I heard the nurse tell me that the patient in room 520 had not had a bowel movement for three days. The patient was wondering if he could have something orally to help him have the bowel movement. I exclaimed in my sleepiness that this was certainly something that would be best handled on morning rounds. I slammed the phone down. The next morning I complained to the charge nurse.
I was so mad. I had just gotten the word from a insurance company that they had denied my patient her treatment for the third time. I had spent hours writing letters, faxing records, talking to the Medical Director of the insurance company only to receive the "final review" that the therapy that I felt was best for my patient was not going to be covered. I slammed my office door shut and began to throw pencils out of pencil drawer at the wall. One stuck in the wall.
I was so mad. I had come to the hospital to see a patient who had been dying of breast cancer for the last three months. She had wound up in the hospital because of shortness of breath. I had specifically made her "no code blue," however, during the night, her respiratory failure had gotten worse. Despite my orders and despite the fact that she had a living will indicating that she wanted no life-support, her family had demanded that she be intubated. She was now on the ventilator. I felt like the patient's trust in me had been somehow broken. As I stood there watching her as she struggled on the ventilator, it just broke my heart. I left the hospital avoiding the patient’s family.
I was so mad. The consultant physician I had called had not shown up to see my patient. The patient was irritated that she had sat in the hospital for the last 24 hours without having the consultant see her and make his recommendations. I could not understand why he had not yet been by to see my patient. I had to sit and hear to the patient complain for a half hour. I cussed under my breath as I left the room knowing that I was now late to the office.
Thinking back I am so angry that I had allowed by emotions to affect my patient’s care. All the above instances were situations where my anger ultimately got in the way of taking care of my patient the best way possible. In a healthcare system that is made up by hundreds of thousands of people, mistakes, delays, and miscommunication are going to occur. One thing that I have learned as time has gone on is that it is best to control my anger , to be more approachable and less quick to let my emotions flare when things don’t exactly go right.
In January, a new leadership standard from The Joint Commission (the body, which certifies the operations of hospitals) was developed to define physician and healthcare workers behaviors. This standard develops procedures to discipline inappropriate conduct by individuals working at all levels of an organization including management, clinical, and administrative staff members. Anger and intimidation only stifles communication. The hope is that this new standard will foster the free flow of communication between all members of the treatment team. Anything that impedes communication between members of the treatment team potentially produces a barrier to safety and good patient care. I think this new standard is long overdue and it is something that I myself need to be careful to follow.
One of the initiatives that I have been working on for my practice over the last six months is to develop an ongoing palliative care program. I am really excited about some of the things that we are putting in place for our patients. Palliative care is the treatment of patients who are having symptoms due to a terminal illness. My hope is that through these new initiatives in our practice that we will begin the process of palliative care much earlier in our patients. The patients who are diagnosed with advanced lung cancer, metastatic breast cancer or other ultimately terminal cancers probably should see a palliative care specialist early in their treatment. This is what our program is striving for. By bringing palliative care specialists into our practice to see our patients, I am hopeful that a transition between active treatment and palliative care and hospice will be made smoother. The stopping of treatment for advanced cancer is a very scary thing for the patients. Many physicians have difficulty discussing the subject of stopping therapy. One concern that I have today is the high degree of patients who received chemotherapy within two weeks of their lives. In many studies this was 10-20%. These patients are obviously not benefitting from this chemotherapy as their condition is such that the chemotherapy is likely doing more harm than good. It is our duty as medical oncologists to do a better job explaining to our patients the risks and the benefits from our therapies. As the patient's disease progress and they go on second and third-line therapies, a patient should know that the benefit or the chances of benefit from our chemotherapy become very, very small. The risks of increased side effects become increasingly large. I am hopeful that the new palliative care initiative that is going on in our practice will make this transition both smoother and hopefully earlier in a patient's disease course.
One of the partners that we have partnered with in our palliative care program is the Center for Practical Bioethics, which is here in
