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Me: Ms G, you have atrial fibrilliation and a lot of other medical problems. That means that your heart can form blood clots that go to your brain It is REALLY important that you take the blood thinner the cardiologist put you on.

Ms G: I know but he gave me this Elliquis and I just can’t afford it. My Blue Cross charges me $140 a month for the medication and that’s just too much

Me: There are much cheaper alternatives. Warfarin, for example, can be used very safely and keep you from getting a stroke.

Ms G: He never even mentioned that to me. Can you talk to him?

When this happened this past week, I was a little irritated. Ms G is not the easiest patient to care for and now I was having to deal with a problem not of my making. After making several phone calls we switched the Elliquis ($275 a month, $140 out of pocket to my patient) to warfarin ($6.50 a month plus $24 in monitoring costs, less than $10 a month to my patient) and everybody left happy (and late). Eliquis and other expensive blood thinners offer only a marginal improvement over warfarin and they do it in a very expensive manner. They reduce of the risk of stroke over 3 years from 16 stokes per 1000 people treated with warfarin to 12 stokes for people taking the newer medications. Of those 1000 patients, an extra one (2 vs 3) on warfarin will have a major bleeding problem. While an advantage, my patient chose not to trade $1200 in food money to do this and instead made the decision on her own to triple her risk of stroke (10 strokes per 1000 annually in those untreated with atrial fibrillation and her other conditions) by not taking anything. My patient is now on warfarin and presumably much better protected from having a stroke. Why was my patient not offered the opportunity to make a choice between the new improved method OR the tried and true method?

May have had something to do with marketing. As was pointed out last night, Americans have an expensive ($330 billion) prescription drug habit. The habit not only pays for the pills (a very small part of the cost) but also the payments to doctors who do the “education” of their colleagues. In 2013 this education cost Americans $24 billion, with marketing accounting for more than research in 9 of 10 companies. In the words of John Oliver “Drug companies are like high school boyfriends: they are more interested in getting inside you than in being effective once they are there.” Bristol Meyer Squibb spent an estimated $20 million in 2013 to “educate” physicians regarding the advantages of Elliquis over warfarin in stroke prevention, with about $15 million going to physicians to extol its virtues to other physicians. I don’t know if that was the reason for the oversight. To be honest I suspect in my patient’s case it was mostly ignorance of my patient’s social situation by the cardiologist that caused my long day.

At least my patient didn’t die from an overzealous sales force. Every day, 46 people die of prescription narcotic overdoses in the US. In Alabama in 2012 there were 140 narcotic prescriptions written for every 100 people. We really don’t need folks selling doctors on selling more narcotics. However, in 2012 a potent narcotic (Fentanyl) was introduced in a sublingual spray to compete with others similar preparations (Fentora and Actiq). These medications typically have, as their very specific indication (the reason to give to a patient), cancer pain not responding to around the clock narcotics. Insys, the company that makes Subsys, spent an estimated $6 million to educate physicians about this drug in 2013. I have to admit, until I read the Propublica article, I had not heard of it. As I don’t treat many patients with intractable cancer pain, that did not particularly surprise me. They only spent $44 a meal to educate 5,000 physicians. They did pay for 775 educational events (paying a physician $2,500 to talk about the drug every time) and hired 189 consultant physicians at $2,370 each. I guess they had to get the word out. Problem is they were and are getting the word out to the wrong people. Less than 1% of the prescriptions were written by oncologists. The product was a high potency narcotic of which there were already others on the market (a “me too” drug):

The former sales employees said that while the company targeted some oncologists, it placed more focus on high prescribers of competing products like Actiq and Fentora, regardless of whether those doctors treated cancer patients. They also said they were trained to mention the restriction to cancer pain at the beginning of the sales pitch and then to move on to a more general discussion of “breakthrough pain” in the doctors’ other patients.

Not only did Insys not worry about its drug getting into the wrong hands, it kind of counted on it:

Comments from a Wall Street analyst underscore that view. “As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”

The company used physicians who had problems with the DEA as their speakers and unorthodox methods to motivate its sales force. A cursory review of the Opiophiile forum reveals that their product is a success, with many addicted individuals enjoying the convenience and simplicity of the medication, with some even ingeniously discovering they can use it intravenously…just like heroin. Also the boards attest to the effectiveness of the marketing strategy.

Shelley, my doctor recommended it to me pretty much as soon as it came out. He said that the company that makes them wanted him to be a representative for them or something like that.

No wonder sales have increased 400% in the most recent quarter over last year and people are bullish on Insys’s prospects. in fact, investors only got skittish when a physician in Michigan who accounted for 20% of the drug sales lost his license. Fortunately for investors, their “medical marijuana” product is about to come to market to broaden the Insys portfolio and the market cap is back up.

Don’t get me wrong, I am by no means anti-medication. In fact, only 30% of people who would benefit from warfarin or related blood thinners receive them in the correct dosage and we need to work to use this inexpensive drug more effectively. I would personally prefer to find a different way to get the Opiophile readers their fix (with entries such as “Fentenyl patch, shootable” I am concerned their might be a lot of misuse in that community). Most importantly, as a profession, let’s stop shilling for Wall Street. I’m sure they’ll do fine without us.

df940103In 1987, during my internship, there was a cautionary tale making the rounds about violating patient privacy and the consequences.  I was in Norfolk but a friend swore he had heard it from a friend who was working in an emergency room in Philadelphia. It seems that a local newscaster showed up after a night of fun with friends with a little problem…a gerbil had “wormed” its way up the newscasters exit hole and had to be extracted. Oh, it was very true, I was assured, the newscaster even had to go to surgery (gerbils are unable to survive the passage through the large bowel no matter how entered). What’s worse, the health care workers who provided the public service of notifying the inquiring public were not only left unrewarded but FIRED.  Can you believe??

These were the days before internet and to be honest, since I didn’t know anyone in Philly the story meant very little to me. I will say I had a friend who happened to be gay that I did tell the story to and he proclaimed it BS. He, as it turns out, was correct. No one, not even Richard Gere, has ever been x-rayed with gerbil remains “up there.”

Doctors see a lot of stuff. For those of us who collect stories, it is a really neat job. People pay money, sit down, look me in the eye, and after I say “How are you today” they say “Fine, except for this gerbil…” Okay, there are no gerbils, but they do tell me a lot of stuff. One of the key classes in medical school is the one where the student is reminded to keep a straight face and show no emotion no matter what comes out of the patient’s mouth. As a physician, your job is to problem-solve, educate, and  instruct, but not to judge.

Doctors have the bond of “guess what silly thing my patient did” in common. The number of people who come in with a Coke bottle where it shouldn’t be and a lame story such as  “I slipped in the shower while drinking a Coke” is actually quite high. Doctors’ lounges used to be places away from the average citizen where these stories could be recounted in a private, safe, environment. Now much health care occurs outside of the hospital, many doctors have little time to lounge, and (at least in the lounges around here) docs hollering, “Say it, Brother Sean” at the TV blaring Fox tend to drown out other conversation. So who can blame doctors for moving this conversation to social media?

Dr Milton Wolf is one such doctor. A Kansan and distant relative of Barack Obama, he graduated about 10 years ago and is a practicing radiologist in Kansas. He is one of 20 some-odd physicians running this year. The odd part, for some, is Dr Wolf’s use of Facebook to “educate.” Turns out that prior to deciding that a career in politics was in order, Dr Wolf found humor in radiographic images of people who suffered tragically, mostly from trauma. He collected these images and posted them, with comment, on a blog and to a Facebook account. One such exchange:

Wolf launched a Facebook chat about the 3D image by explaining it was taken from a postmortem examination. A Facebook friend, Melissa Ring-Pessen, responded that she performed the scan on Jan. 22, 2010, and was admonished for improperly positioning the man’s head.

“Seriously?” she wrote.

“Sheesh Melissa,” Wolf replied, “it’s not like the patient was going to complain.”

There is a video of the reporter confronting Dr Wolf about this post and it is worth watching. Apparently this particular image and discussion was posted before the patient’s funeral.

The Federation of Boards of Medical Examiners has suggested some guidelines for physicians when using social media that include using candor regarding possible personal gain, respecting the privacy of patients, and maintaining professional integrity. For anyone who is in the medical profession and uses social media, this is a must read.

The Doctors’ lounge had a couple of things. It had a door that separated “us” from “them.” The conversations were evanescent; if something untrue or hurtful was said, it didn’t sit on the Internet for years. If someone was too much of a jerk, they wouldn’t get patients sent their way. Lastly, when someone was a persistent problem, the medical staff president was always there to threaten a loss of privileges. Unfortunately no one seems to police the virtual Facebook lounge. Notice that the cautionary tale about the misplaced gerbil ends in a firing. The real story about the real patient (Google search “homicide victim” “Johnson County” Kansas on that date and I bet you can find the decedent’s name) ended in the guy getting on Fox and Friends and running for Senate. Go figure.

From Michigan via the Detroit Free Press:

Patients who didn’t have cancer were diagnosed as such. Sick patients were given too-high doses of powerful drugs. Some in remission were sent for unneeded chemotherapy. End-of-life patients were pumped full of drugs that couldn’t help them anymore.

These millions of dollars of medical treatments and tests were billed to Medicare in a pricey health care scheme run by metro Detroit hematologist oncologist Farid Fata, according to a federal criminal complaint filed Tuesday. The complaint says Fata intentionally misdiagnosed patients “as having cancer to justify unnecessary cancer treatment.”

So is this an example of government over reach? The invasion of ObamaCare into the doctor-patient relationship?

In one case, the federal complaint outlines, Fata prescribed 56 doses of rituximab to a non-Hodgkin’s lymphoma patient over two years, when the norm would be a dozen in two years. In another instance cited in the complaint, Fata allegedly forced a sick man who’d fallen down and hit his head when he came to the center to get his chemo before he could be taken to the emergency room — and the man later died as a result of the head injury.

OK, maybe not.

However, it is an example of our patients’ difficulty in judging quality. He was highly qualified based on the measures doctors use:

According to the Michigan Hematology Oncology Centers’ website, Fata did his his hematology oncology fellowship at the world-renown Memorial Sloan-Kettering Cancer Center in New York. He was voted one of the “Top Docs” in hematology or oncology in 2008, 2009, 2011 and 2012 by Hour Detroit Magazine.

as well as based no society’s measures

Fata founded the Swan for Life Cancer Foundation, which offers support to cancer patients and their loved ones in southeast Michigan, according to the oncology centers’ website.

From a follow-up article, he was qualified based on patient criteria as well:

“I always liked Dr. Fata. He had kind eyes,” she said Wednesday, a day after Fata’s arrest.

The real problem I have with the whole, sordid, alleged affair is that we are being told perhaps we should not  expect any better:

“The trust that a professional is acting as a professional becomes a matter of survival,” said Ann Mongoven, assistant professor at Michigan State University’s Center for Ethics and Humanities in the Life Sciences. “ That’s why some might argue physicians have a special kind of obligation.”

And I guess some might argue otherwise??

 

images (1)Last night I was at a local pub listening to a band when suddenly everyone’s eyes were drawn to the television over my head. Straining to look around and see what had happened (another airplane crash, Lance Armstrong caught doping as a spectator in the Tour de France?) I read that a verdict was in regarding the death of Trayvon Martin. As the “Not Guilty” verdict was read, the crowd seemed relieved that the shooter would walk away (though civil proceedings will almost certainly follow). I must admit, I have not been following the trial. To me the entire episode was a tragedy.

As we were walking home, we ran into a neighbor and fell into conversation about the events. My wife, who followed the story, pointed out that the shooter was not participating in a neighborhood watch event but was going to the local “big box” to purchase groceries with HIS GUN IN HIS POCKET when he stopped to follow a “suspicious character.” Made me wonder how many of my neighbors are packing heat and why would they feel compelled to do so.

In my home town of Baton Rouge, Louisiana in 1992, Japanese exchange student Yoshihiro Hattori was going to a party and knocked on the wrong door. Mistaken for a burglar intent on home invasion (he was dressed in a tuxedo recreating John Travolta’s look in Saturday Night Fever) and not understanding the meaning of the word “Freeze” in the context of potential victim-of-gun-violence lingo he was shot and killed by the home owner. The home owner was charged with manslaughter and later acquitted with the court identifying that the shooter had a right to use lethal force to “protect himself.”.  In 2005 there were 30694 people who died of gun violence. When a gun is pointed at a person and the trigger is pulled, about 1 in 3 people with die prior to reaching  the hospital. Since the death of Yoshihiro, laws have been changed. in 35 states anyone requesting a concealed carry permit must be given a permit. In 2 states, no permit is needed. In my home state of Louisiana, where the gun laws were “liberalized” after this shooting, about one in every 10000 people can expect to die from a gun shot. Half of these from their own hand.

So, what should my response as a medical educator be? Gun violence is a serious public health issue. It costs about $2 billion in direct costs, and because it overwhelmingly affects young people, there are about $100 billion in indirect costs (loss of future productivity, health care costs for the rest of their lives, etc.). How should we as physicians and educators be involved in the prevention of this often needless tragedy?

First, as with any complex illness we need to be aware who is really at risk and target those people. The belief in our society is that personal risk of violence at the hands of a stranger is great and mitigated by the presence of a gun. Unfortunately, research on gun violence is sketchy at best. Recently, the Robert Wood Johnson foundation published the findings of Andrew Papachristos on their website. He found that a lot of the potential victims (41%) come from a very small circle of people at risk (about 4% ) in a given community. Many of our Academic Health Centers sit in these at risk neighborhoods (and have benefited from caring for trauma victims). Based on this, those of us interested in teaching prevention should be promoting our Academic Health Center’s involvement in these high risk communities through partnering with community organizations.

Second, we need to teach our learners how to preach gun safety. A gun in the home is associated with violence to the people living in the home. About 25% of households report having a handgun (and there are guns enough for almost every citizen already in circulation in this country). These guns should be locked up, especially when there are children in the house. In one of the few studies done of trauma center workers (in Birmingham in 1994) 33% of those with children (who presumably knew better) did not keep the weapons properly stored.

Third, we need to understand and teach risk assessment. Our well child form has a question regarding guns in the home which we ask all parents. If the answer is “yes, there are guns in the home” there is then a prompt that directs us to ask about storage and safety methods. This is because, though patients perceive the societal risk to be great, we need to understand and preach that societal risk is small and localized. The greater risk when a gun is present is to a family member or a stranger that happens to get in the way. For us to convince our patients of that we need to understand and believe it ourselves.

Fourth, we need to fight against willful ignorance. In Florida, where the Trayvon Martin was shot, a law was passed (later blocked) barring physicians from asking about weapons in the home. It is important for health care professionals to be clear and of one voice, the opportunity for gun violence is lessened greatly when there are NO guns in the home and lessened when the guns that are there are stored safely.

w-b-park-sure-we-doctors-make-a-lot-of-money-but-don-t-forget-we-spend-a-heck-new-yorker-cartoonI just finished reading The Celestial Society, a biography of George Burch written by his daughter Vivian. I knew him as an older attending who seemed oddly out of touch with students. I now know that he was a beaten, sick man at the time I had contact with him. I also found out that he never deviated from his core belief that what medical schools needed to do was train good generalist physicians and develop tools to allow these generalists to become better doctors. He was Chairman of Medicine at Tulane for 30 years, forced out in the 1970s when he opposed the creation of a practice plan to capture faculty patient care revenues. The dean and the chancellor both felt that without the ability to harness this revenue source, Tulane would be forced to shut down.

It is amazing how much medicine changed in the 40 years of Dr Burch’s career. Dr Burch’s entire career was at Tulane and spanned from the 1920s to the mid 1980s. When he started the EKG “machine” was a string galvanometer and was only done on selected patients. He was instrumental in describing variants of EKGs, wrote the first book on interpretation which made the technology available to all clinicians and developed the circuitry which allowed all 12 leads to be measured simultaneously. All the while he was on faculty at Tulane, making very little money when compared to his private practice colleagues and caring for poor patients at Charity Hospital. To him the academic “life of the mind” and the noble activity of caring for the poor sick should have been rewarded by society. The building of a University Hospital with the corresponding contractually obligated faculty sounded the death knell for this type of medical practice.

The conflict at Tulane was the result of Dr Burch’s stature in the world of Cardiology and the perception that his belief regarding cardiac surgery were holding up progress. He believed that outcomes were terrible. His perception was that patients were more likely to die from the surgery than the disease, a belief grounded in observation but since surgeons kept no data not measurable. He believed that surgeons were uneven at best (again, unmeasurable) and in reality it was the post-surgical care that mattered the most. He abhorred the “chance to cut is a chance to cure” mentality and in his clinical experience many people would be better served to have nothing done than to subject themselves to angioplasty or surgery. Tulane wanted him to refer his patients exclusively to Tulane surgeons and likely expected a larger number of patients to be referred, conditions to which he was unwilling to agree. Medicine was moving into an entrepreneurial direction and Dr Burch was being left behind.

Dr Burch died in 1986. Tulane continues to thrive (at least according to the alumni magazine) despite not being in Charity Hospital at all. Many of his beliefs regarding invasive cardiology have been affirmed. Meanwhile, the article on colonoscopy in today’s New York Times, illustrates the cost we have paid for dismissing Dr Burch’s warnings regarding our abandonment of the generalist physician model and embrace of the entrepreneurial model of medicine.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees….

When popularized in the 1980s, outpatient surgical centers were hailed as a cost-saving innovation because they cut down on expensive hospital stays for minor operations likeknee arthroscopy. But the cost savings have been offset as procedures once done in a doctor’s office have filled up the centers, and bills have multiplied.

It is a lucrative migration. The Long Island center was set up with the help of a company based in Pennsylvania called Physicians Endoscopy. On its Web site, the business tells prospective physician partners that they can look forward to “distributions averaging over $1.4 million a year to all owners,” “typically 100 percent return on capital investment within 18 months” and “a return on investment of 500 percent to 2,000 percent over the initial seven years.”

To quote Chairman George, “I’m not antisurgery, I’m pro-patient.”

I was sent an e-mail regarding one of my previous posts and included was a copy of an address given by one of my former professors, Dr Charles Dunlap, at Tulane’s Ivy Day in 1975. While the scientific knowledge changes, much remains the same. For example:

Among the standards required of a physician few are more basic than integrity and simple honesty. In ordinary business dealings, each purchaser of goods or services is assumed to have sufficient knowledge of the game to safeguard his own interests. In medicine, the rules are different. Each patient puts himself, naked, alone, and helpless, into the hands of the physician. In this transaction, the sole security the patient has is simple faith in the integrity and competence of the physician.

In another part of the essay he points out that rituals are a large part of what we do. As you participate in the ritual of Thanksgiving, consider this quote Edmund Burke, also found in the essay:

Human beings participate in the accumulated experiences of their innumerable forefathers; very little is totally forgotten. Only a small part is formalized in literature and deliberate instruction; the greater part remains embedded in instinct, common custom, and ancient usage.

Happy Thanksgiving

We have gone from a lecture based format to a team learning format in our medical school. In the previous format, I was assigned the “Don’t be a bad doctor” talk to give to the students. I would point out that of the doctors who lose their license, very few lose it for delivering bad care. More commonly, the physician lose their license as a consequence of illicit drug use, writing prescriptions of controlled substances for folks not their patients, having sexual relations with their patients, or a combination of the above. The students were informed that 3% to 10% of physicians reported having had a sexual relationship with their patient. The students, most of whom are young enough to be my children, could not see themselves in a compromising situation such as this so I was seen (or so it seemed to me) as a prudish nag. OK, maybe not but I was introduced to the parents as “The professor who told us not to have sex with our patients.”

This brings us to another one of our physician congressmen, Dr Scott DesJarlais (R-Tennessee).

Rep. Scott DesJarlais, a physician who opposes abortion rights, said in a letter that he was “deeply sorry” that supporters had to find out about the relationship with a patient that occurred while DesJarlais was separated from his first wife. But he said he used stark language about traveling to Atlanta to get an abortion try to get the woman to acknowledge that she wasn’t pregnant.

A group of Tennesseans are trying to hold him accountable. In their words:

“Tennessee law is crystal clear: Doctors are prohibited from engaging in sexual relationships with patients,” Melanie Sloan, the group’s executive director, said in a release. “The only question remaining is, now that Tennessee authorities are aware of Rep. DesJarlais’ blatantly unethical and scurrilous conduct, what are they going to do about it?”

If only he had taken my class. Or read the words of the Hippocratic Oath he recited:

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

Some people suffer from back pain, others SUFFER from back pain. Almost 1 in every 33 office visits is for back pain meaning that for an average primary care doctor there will be a person complaining about back pain in the office almost every day. When I was in medical school I was taught that 80% of low back pain would resolve no matter what the medical approach so the best approach was “Do nothing, Doctor” followed by “Say… I know your back hurts but…” Since then, health care costs have skyrocketed in part because of back pain and it turns out that, though pain may not be lethal, the treatment of back pain has tragically been lethal recently for seven people.

How has the strategy changed since I was in medical school? This paper does a nice job of outlining the problem. First, folks want to know “Why is my back hurting.” Docs, not wanting to stand in the way of self knowledge, have obliged by ordering imaging studies…lots and lots of them. In the last 12 years, the number of MRIs (a test done using a strong magnet) done for low back pain and paid for by Medicare has quadrupled. Why is this a problem? Turns out that one picture is not only worth a thousand words but often a procedure as well. Why is this?

Positive findings, such as herniated disks, are common in asymptomatic people.20–22 In a randomized trial23 there was a trend toward more surgery and higher costs among patients receiving early spinal MRI than those receiving plain films, but no better clinical outcomes. Six other randomized trials, involving a total of 1804 patients from primary care without features suggesting a serious underlying disease, compared some form of lumbar spine imaging with none.24–29 In these studies, imaging was not associated with an advantage in subsequent pain, function, quality of life, or overall improvement.

In addition, people want to have no pain. Prescriptions of narcotics have doubled for back pain in the last 12 years, with unclear benefit to the patient (but a clear increase in narcotic availability in the community). If the medicine is seen as ineffective, they think maybe surgery will fix it. The number of surgeries have  tripled, with the following result:

Higher spine surgery rates are sometimes associated with worse outcomes. In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest

In an effort to stave off surgery in these patients who want their pain to go away, many patients have turned to injections done by pain specialists directly into the spinal canal to try and eliminate the pain. Medicare payment for this procedure, too, has tripled in the last 12 years (although the Medicare population has only gone up by 10%) with the following result:

Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.57,58 This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates.59–62 Facet joint injections with corticosteroids seem no more effective than saline injections.

Which brings us to the deaths (covered here). They occurred during the application of steroids in the spinal canal for this purpose. The steroid used for these injections can be bought from standard supply houses. The folks who are dead (or are at risk of dying as they might be growing a fungus that will kill them and there is nothing that anyone can do) had steroids injected in them that were made under less than optimal conditions by a “compounding pharmacy.” Even though this pharmacy shipped 18,000 vials of this steroid, it is considered a “mom and pop” operation thus is not under the control of the FDA. No one is sure if this particular steroid was used because it was considered to be better or if it was cheaper for the physicians office (thus maximizing the doctor’s profit). What is certain is that without an injection, there would be no risk at all.

I have been installed as President of the Alabama Academy of Family Physicians. The work should not be too hard and on occasion should be rewarding (or at least ego-boosting). Such was the case the other day when the Executive Director asked me to recall a patient from “my early days” that had made an impact so he could publish my thoughts, thus officially making me an old geezer. I thought back, thinking of the the heavy snow drifts I walked through to get to the hospital (unusual weather in Portsmouth but it was before “climate change”), recalling the large hill that I had to walk up to get both there and back, and this was the patient’s story I chose:
In April of 1987 when I was an intern at Portsmouth Naval Hospital I saw a 54 year old male patient for fatigue and discovered a previous diagnosis of iron deficiency anemia. He was again anemic. He was subsequently found to have Stage 4 colorectal cancer for which he received treatment. About 6 months later I admitted him from the emergency department (where I was working after finishing internship while waiting for training in Undersea Medicine) with jaundice. The ward team provided aggressive care but he died anyway.
The sad part of the story is that this patient had been seen by one of my intern colleagues in July of 1986 (the first month of our internship) for a complaint of fatigue. An iron deficiency anemia was initially found at that time. He was placed on iron, felt better, came back for follow-up, and was discharged from care. No follow-up to identify the cause of the anemia was done at that time.
Though the snow is less in Mobile and the hills less steep, the lessons I took away from that patient are still indirectly shared with every resident and student I teach:
1) It is my belief that quality care should not be dependent on specialty or level of training. My colleague should have consulted with the attending physician who was sitting in an office on the unit (and may have). My colleague could have read about the work-up of anemia after the visit and called the patient back. Being young and inexperienced, he appropriately treated the symptom but did not look for the disease. Avoidable mistakes such as this are not acceptable. We try very hard to put systems in place in our practice so that when the patient receives care, regardless if delivered by a faculty member or from a trainee, it will be predictable and of high quality.
2) Colon cancer is not a pleasant way to die. This patient was diagnosed with a rigid sigmoidoscope (a firm, hollow, silver tube about 2 feet long). Though we knew that early detection of cervical cancer saved lives, we knew little about early detection of breast and colon cancer. We now know that through use of colonoscopy and home stool testing, lives can be spared. I would like to believe that this patient, who was of an age that screening is now indicated, would have potentially been spared this death as the result of a caring family physician facilitating this screening. In our practice we have made early detection of eminently treatable cancers such as this a priority. We all work to assure that our patients have access to these screening tests.
3) We are all going to die. Having a terminal illness makes this likely to happen sooner. There comes a time to move to comfort measures. I want my faculty, residents, and students to be advocates for our patients in disease prevention and treatment. We also need to be advocates for moving from cure to comfort when it is appropriate. In my patient’s case, the Naval Hospital was his “provider.” We did not make that transition easy for him. I am afraid to say we have not gotten much better at this in the last 25 years.

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