Taking care of oneself is a very personal notion.  Each person would have a different definition of what “taking care of” means.  Some cancer patients would say it’s taking a nap to fight the fatigue of chemotherapy or spending extra time with loved ones in order to feel more connected.  Some patients would say it’s taking a vacation to a place that they have always longed see. For healthcare providers, many of the same things would be also true.  Taking a vacation, taking an opportunity to rest, and taking time to exercise are all things that might important.  For me, “taking care of me” means mostly being with family, spending time with my children and being part of their lives.  It also means exercising.  Rarely do I feel better than just after exercising hard on the treadmill.

I think another thing that the patients and healthcare providers can do to take care of themselves is to set realistic goals. Understanding that regardless of their situation in life that one can make goals in order to make their lives better is so important.  I have a young, single mother who was treated in the past for non-Hodgkin's lymphoma.  Prior to her treatment, she was employed in a challenging job.  She was able to take care of her children and keep all of the” many balls that she juggled in the air at the same time”.  Then her diagnosis and subsequent treatment with chemotherapy and radiation therapy cut much of her energy. Much of her ability to keep those many juggling balls in the air is now gone. We had a long discussion recently about her not being the same as what she was before her treatment. I stressed to her that she may not be able to be the same as she was before her diagnosis but she is now something even more remarkable. She is now cancer survivor.  Unfortunately, the likelihood is that her body, her energy level and her memory will never be the same as before her diagnosis and treatment.  She may never get back to the point where she can return to her previous job. She still can take pride in reaching new goals. She still can strive to be the best mother for her children and set some new goals that may in fact lead her to somewhere that she cannot yet imagine.  In other words, she needs to take care of herself.  She needs to understand that her diagnosis of cancer has likely changed her permanently. Accepting this and at the same time moving on from the grief and disappointment is vital.

One of the wonderful things that inspires me and makes me love my job as much as I do is seeing patients adapt and overcoming their diseases. Many find unique ways of taking care of themselves that ultimately inspire me to take care of myself.

 Pomegranate Juice May Slow Prostate Cancer

April 26, 2009 -- Drinking 8 ounces of pomegranate juice daily may slow the progression of localized prostate cancer ( prostate cancer that hasn't spread), a new study shows.

The study included 48 men who had surgery or radiation therapy to treat localized prostate cancer.

When the study started in 2003, the men's PSA levels were doubling every 15 months. In prostate cancer patients, PSA (prostate specific antigen) is used to monitor their cancer.

All of the men drank 8 ounces of pomegranate juice daily, and that slowed down the time it took for their PSA levels to double, as the researchers reported in 2006.

After that, the researchers -- who included Stanford University urologist Allan Pantuck, MD -- kept following the patients every three months. Fifteen of the patients stayed with the study for up to 64 months (a little more than five years), and it typically took four times longer for their PSA levels to double when they were drinking pomegranate juice, compared to their PSA doubling time at the study's start.

The results were presented at the American Urological Association's 104th annual scientific meeting in Chicago.

Five of the six researchers who conducted the study disclose ties to POM Wonderful, which makes the pomegranate juice used in the study.

In 2007, another team of researchers bought pomegranates, made their own pomegranate juice, and tested it against human prostate cancer cells grafted into mice. Those tumors grew slower than other tumors treated with a placebo solution.

Last night, however, one exchange angered me. When President Obama said that the physicians make decisions to take out children's tonsils based on economics.  I believe that the vast majority of physicians do their job and make the decisions for their patients based on what they believe is best for the patient.  It is true in oncology that part of my income is derived from giving patients chemotherapy, giving them radiation therapy, and following their disease on CT scans, but I would like to assure the president that I would give everything that I own, all my retirement if cancer would just disappear.  I would be more than happy to be put out of business if cancer no longer existed.  I am truly saddened that The President of The United States would characterize the profession that I have been a part of and have been proud to be a part of in such a demeaning, dark and ugly way.

The human condition is one of endless production of these fluids.  Our bone marrow with its ability to produce a near endless supply of blood, our stomachs producing gastric acids, and our livers producing bile to help in our digestion are examples. Our sweat glands produce sweat in an effort to cool our bodies during exercise and in the heat of the summer. Our kidneys produce an ever continuing supply of urine to dispose of endless amounts of wastes that must be processed and removed from our body.

So much of what we worry about in many diseases today is based on the transmission of these secretions.  Hospitals wipe down rooms to prevent coming in contact with aerosolized respiratory secretions. We wear rubber gloves to prevent the touching of skin to decrease the transmission of Staph infections. We do not enter a patient’s room without spraying out hands full of antimicrobial foam.  We are seemingly in a constant battle to rid our patients and ourselves of the various secretions that are vital and really honestly make us human.  The human condition can never ever be a sterile condition.  We will never ever be rid the waste products that are produced by life.  I find it amazing how this complex organism that we call the human body can make such an almost seemingly endless number of secretions and how our mind has spent hundreds of years trying to come up with ways to cover up, remove, and suppress these secretions.

I would never call myself an environmentalist, so much of my professional life has been dedicated to taking care of humans. The environment around me has always been seemingly second place in my heart.  I do realize how important this planet that we live on. If we are not good stewards of this planet we run the risk of destroying its ability to sustain life.  I do believe as we deplete our planet and utilize its resources that illness and specifically cancer will become more likely and more prevalent.  I know the answers to the problems of green house gases and pollution are difficult; they are complex and the solutions may be costly. As a warrior of a different battle; the battle against cancer, I believe this other battle needs to be waged.  Ultimately, I think that the final triumph over cancer or pollution is a battle that will be well worth the cost.

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.

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. 

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.

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 Boulder, Colorado where it has been met with great success.  He has presented the results and outcomes of this program at The Society for Integrative Oncology meeting and also at M.D. Anderson.  We are so excited to be a practice that will be participating in this unique effort to help our patient's deal with the sometimes overwhelming problems that they face as they struggle to comprehend and fight their diagnosis of cancer.  Our staff is also fired up about this program and its potential benefits for their own growth and the growth of our patients.

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.

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.

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.

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.  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 partners that we have partnered with in our palliative care program is the Center for Practical Bioethics, which is here in Kansas City.  This is a wonderful unique “think tank” that explores ethical issues around healthcare.  Their help, I believe, will be invaluable in helping us to develop and sustain a vigorous palliative care program within our practice.  I would encourage everyone who reads this blog to visit their website (www.practicalbioethics.org) and support their effort in bringing to light the ethical issues that we commonly see in healthcare.