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An Inspiring Story

The first two years of medical school are traditionally when students learn the scientific knowledge that serves as the basis of medical practice and research. Most students are more motivated to acquire this knowledge when they see how it connects to human health. Accordingly, many medical schools now teach at least some of their basic scientific concepts through illustrative clinical cases.

As part of a team helping to create the curriculum for the new UT Dell Medical School in Austin, I was recently given the assignment of writing about retinoblastoma. Since this is a cancer that occurs in childhood and I see exclusively adults in my practice, I do not have experience treating patients with retinoblastoma. When I set about researching actual cases of the disease, I came across the story of Ben Underwood. When Ben was two years old, his mother Aquanetta noticed that his right eye had a peculiar glow. After an examination by an ophthalmologist, Aquanetta was informed that Ben had a tumor called retinoblastoma in both of his eyes.

If left untreated, retinoblastoma will spread backward from the eye socket into the optic nerve, and then into the brain. Ben began chemotherapy, but after two months his right eye was consumed with cancer that it was removed. This was followed by an additional eight months of chemotherapy and then six weeks of radiation in attempt to save the left eye. When this treatment did not work, Aquanetta made the agonizing decision to have his left removed in order to save his life.

When Ben awoke from his second surgery, he said, “Mom, I can’t see anymore. Oh, Mom, I can’t see.” Aquanetta writes that “after praying for strength, I said, ‘Ben, Yes you can see’ and I took his little hands and put them on my face and said, ‘See me, you can see me with your hands,’ next, I put my hand to his nose and said, ‘Smell me, you can see me with your nose,’ then I said, ‘Hear me, you can see me with your ears, you can’t use your eyes anymore, but you have your hands, your nose, and your ears.’”

Ben’s mother and siblings worked hard to help him adjust to life without vision. Around age six, Ben began making clicking sounds with his tongue that enabled him to make sense of his surroundings by listening to the echoes bouncing off of objects. This process, known as human echolocation, is similar in principle to the sonar and animal echolocation employed by bats, dolphins, and toothed whales. Over time, Ben became so skilled at echolocation that he could accomplish such feats as playing basketball, riding a bicycle, rollerblading, and skateboarding. He was featured on the Ellen DeGeneres and Oprah Winfrey shows and was the subject of a program called The Boy Who Sees Without Eyes aired on the Discovery Channel.

I encourage you to watch the video I’m linking here. It’s a beautiful story of love, courage, hope, resilience, and faith.

Sadly, in 2007, a tumor developed in Ben’s sinus cavity and despite intensive treatment, he died two years later at age 16. This year, his mother Aquanetta released a book she wrote about Ben called Echoes of an Angel. It just arrived in the mail and I look forward to reading it.

 
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Posted by on November 29, 2014 in Uncategorized

 

Cholesterol and Heart Disease

I’m enjoying a brief lull between a number of demanding projects. So I thought I’d dust off the old blog and share some articles on medicine and health I find interesting. Here’s one on cholesterol and heart disease.

Back in 1995, a study was published showing the benefit of a cholesterol lowering-medication called pravastatin. Over a period of 5 years, 6,595 men aged 45-64 with high cholesterol who were either given a placebo or pravastatin. The study showed that treatment with 40 mg of pravastatin for 5 years significantly reduced the risk of having a heart attack or dying from cardiovascular causes by 31% compared with placebo. After the study was published, researchers followed the men for another 20 years. And at this year’s American Heart Association’s Scientific Meeting the results of that additional 20 years of study were presented. They showed that the risk of heart-related deaths was 27 percent lower among the men who took pravastatin for those first five years rather than dummy pills. They also found a 31 percent lower risk of heart failure and a 13% lower incidence of death in the group initially assigned to take pravastatin. Furthermore, no adverse effects from taking pravastatin, such as cancer, were detected. What’s interesting is that once the initial 5 year study ended, the men went back to their regular doctors, and about one-third of both groups kept or started taking a statin such as pravastatin. So any differences seen 20 years later were probably is due to whether the men took pravastatin during the initial five-year study.

Coronary heart disease is the leading cause of death in the U.S. and the world as a whole. So a study showing such an effective means of preventing and treating this condition is very good news. Yes, yes, I’m aware of the possible side-effects of statins like pravastatin. About 1 in 10 people get muscle aches. But these usually resolve quickly once the medication is stopped and may not occur at a lower dose or on an alternative statin. Statins tend to cause a slight increase in a person’s glucose level, but that is far outweighed by the decreased risk in heart disease these medications cause. There have been rare reports of people feeling less mentally sharp after taking a statin. But in these cases, such side effects quickly resolved upon discontinuing the medication. Furthermore, this kind of neuro-cognitive side effect seems to be quite rare. I’ve never observed it in my practice and a recent, comprehensive review of multiple studies failed to find evidence that statins cause memory loss. In fact, some studies suggest that statins may even have memory-protective effects. By the way, the medication pravastatin used in the study I’m citing is generic and very inexpensive.

Here are links to a couple of articles on the study.

http://www.medscape.com/viewarticle/789649

http://hosted.ap.org/dynamic/stories/U/US_MED_CHOLESTEROL_DRUGS?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2014-11-19-15-20-07

 
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Posted by on November 27, 2014 in Uncategorized

 

Interesting Articles

The scientist Bert Vogelstein played an important role in understanding how cancer occurs. He is now working on developing what he calls a liquid biopsy. It is based on the fact that nearly every type of cancer sheds DNA into the bloodstream. By analyzing a sample of a person’s blood, a liquid biopsy would indicate whether a person has a cancer in his or her body. The hope would be that by detecting the cancer at an early stage, effective treatment could be started in time to result in a cure.

An article on the concept of a liquid biopsy explains that “making such screening a routine practice in medicine will be challenging. One difficulty is that while the test may detect the presence of cancer DNA in the body, physicians might not know where the tumor is, how dangerous it is, or even whether it is worth treating.”

You can read the entire article in MIT Technology Review here.

Robbin Williams’ tragic suicide has resulted in a proliferation of articles on depression and mental health in general. Last month’s Atlantic contained a fascinating article on the link between creativity and mood disorders such as anxiety and depression. The author Nancy C. Andreasen is a psychiatrist, neuroscientist, and a PhD in literature who has spent many years studying the brains and minds of creative people. Her study found that “80 percent of (the creative people she studied) had had some kind of mood disturbance at some time in their lives, compared with just 30 percent of the control group” she used. You can read the entire article here.

 
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Posted by on August 18, 2014 in Uncategorized

 

Listening

Doctors employ many means and methods in their effort to promote health and alleviate suffering. They ask questions and order tests to arrive at accurate diagnoses. They prescribe medications and perform surgeries. But I’ve sometimes found that the most healing thing I can do is simply listen to a person tell his or her story. The internist Rita Charon writes, that

Once, a young woman came to see me with severe and relentless abdominal pain. She was fidgety, spoke in fragmented speech, seemed clearly to be suffering. She had already seen a gastroenterologist, a gynecologist, and an expert in colitis, all of whom had found no abnormality to account for her symptoms. Since this was my first meeting with her, I asked as a matter of routine about the health of her family members. Her father, I learned, had died of liver failure. As she spoke of his horrible suffering—his abdomen swollen with fluid, his muscles spent, his mind clouded—she put both her hands, fingertips interlocked, almost protectively, over her own upper abdomen. I told her that she used the same gesture to discuss her own symptoms as she had to describe her father’s illness. For the first time in the interview, she became still. She looked down at her hands, now in her lap. We were both silent. And then she said, ‘I didn’t know this was about my father.’

 
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Posted by on August 11, 2014 in Uncategorized

 

The Tao

In A Little History of the World, art historian E.H. Gombrich attempts to provide an accessible, comprehensive history of the world for younger readers. It’s a delightful read that makes me want to see the places around the world where the stories he describes took place. Here is a beautiful passage about Lao-tzu.

A wise man lived in China at about the same time as Confucius. His name was Lao-tzu. He is said to have been an official who became tired of the way people lived at court. So he gave up his job and wondered into the lonely mountains at the frontier of China to be a hermit.

A simple border guard at a frontier pass asked him to set down his thoughts in writing, before leaving the world of men. And this Lao-tzu did. But whether the border guard could make head or tail of them I do not know, for they are very mysterious and hard to grasp. Their meaning is roughly this: in all the world–in wind and rain, in plants and animals, in the passage from day to night, in the movements of the stars–everything acts in accordance with one great law. This he calls the ‘Tao,’ which means the Way, or the Path. Only man in his restless striving, in his many plans and projects, even in his prayers and sacrifices, resists, as it were, this law, obstructs its path and prevents its fulfillment.

Therefore the one thing we must do, said Lao-Tzu, is: do nothing. Be still within ourselves. Neither look nor listen to anything around us, have no wishes or opinions. Only when a person has become like a tree or a flower, empty of all will or purpose, will he begin to feel the Tao–that great universal law which makes the heavens turn and brings the spring–begin to work within him. This teaching, as you see, is hard to grasp and harder still to follow. Perhaps, in the solitude of the distant mountains, Lao-tzu was able to take ‘doing nothing’ so far that the law began to work within him the way he described.

 
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Posted by on August 10, 2014 in Uncategorized

 

Prior Authorizations

So after a long hiatus, I’m attempting to get back into the swing of blogging. With everything else that I have going on in my life, writing something consistently became difficult. But what is doable is sharing articles I’ve recently enjoyed along with brief commentary.

Dr. Danielle Ofri, a fellow internist, writes about her frustration with the tedious process of obtaining prior authorizations for some of her patients’ medications.  As Ofri writes, prior authorizations “are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, the doctor is required to provide a compelling clinical reason” through extensive documentation and sometimes phone calls.  I faced this issue recently when I treated a patient who was suffering from a severe infection of the colon. When the patient’s infection recurred after receiving a course of the first-line antibiotic, I prescribed a different antibiotic that is necessary in this situation. It nearly always works and there are no good alternatives. Unfortunately, rather than fill the prescription, the insurance company sent me a long form to fill out. Then, after immediately filling it out, the insurance company took their sweet time, before sending a fax to tell me they were would not fill the medication. I had to scramble to get the patient an appointment with a gastroenterologist, who, lo and behold, prescribed the same medication I did. But since it was a specialist prescribing it this time, the insurance company approved the medication. As soon as the patient started the pills, their problem resolved.

In Ofri’s similar story, she describes caring for a Mr. V, who

suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer-care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer-care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 asked me to list all the blood-pressure medications that Mr. V. had been on in the past, including dates of initiation and relevant lab values, a request of epic proportions in his case.

The representative went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

Ofri argues that

prior authorization clearly saves money for the insurance companies, at least up front. Many physicians simply give in, because the process is just too arduous.

But prior authorization ultimately ends up costing the health care system. The time and money that medical practices devote to prior authorizations could surely be put to better use for patient care. And it’s not even clear that insurance companies save money in the long run. One study examined the records of more than 4,000 patients with Type 2 diabetes who were prescribed medications requiring prior authorizations. Those who were denied the medications had higher overall medical costs during the following year; not getting the medications probably worsened their conditions. . .

I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.”

 
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Posted by on August 7, 2014 in Uncategorized

 

Illness and Reconciliation

In a previous blog post, I discussed the crucial role that relationships and community play in human flourishing. Indeed, our need to connect with each is so profound that conflict in our most important relationships can be a source of great distress. This is particularly true when we endure illness. As Daniel Sulmasy writes,

“As their bodies bend and break, dying patients are somehow reminded of the brokenness in their relationships with others and of their deep need for the healing of reconciliation.”[1]

In David Schenek’s book Healers, a physician tells the story of

“a mid-80s lady admitted to our inpatient unit with advanced GI cancer. There was no treatment, and she didn’t want it anyway. She progressed as expected, and she had stopped taking food or liquids. And then she lapsed into an actively dying phase.”

 

The physician explained that

“I had a very frank talk with the son and grandson, and they wanted to be at the bedside when she takes her last breath. So two, three days passed—four days come, five days passed. . . This went on a week, a week and a half, then two weeks. Defying physiology. We were at a month of not having so much as a drop of water, and yet her heart was beating, barely. No palpable blood pressure. But if watched, every fifteen seconds her chest rose. She was still breathing. . . . Then a friend of the family came in. She nudged me and said, ‘What’s going on?’ I said ‘I don’t know. She won’t die. Maybe you can help.’ She said, ‘You know she has a daughter. They parted 25 years ago. They’d had some disagreements, and then parted, and it wasn’t at all favorable.’ I wondered whether they could resolve it, even though they have not spoken to each other in 25 years, and I said. ‘Do you have any way of getting ahold of her?’ She replied, ‘I haven’t had any contact with her in maybe 10 years, but here is the number I have.’ So I walked in the room, and I called from the bedside phone. A lady answered the phone. I said, ‘This is the doctor from hospice. Is this so-and-so?’ ‘Yes.” ‘I am so glad to be able to get you. I just want you to know that I have been taking care of you mom. He developed cancer some months ago, and she has been declining every since. She is very close to the end of her life now. I just found out that you two had parted some years ago, perhaps not on the best of terms. I know in those circumstances some things can get left unsaid. Some things you might want to tell her and talk to her about.’ She said, ‘Well, yeah.’ I said, ‘You need to understand that she is very close to the end of life. She is not responsive at all. But I am going to put the phone up to her ear to give you a chance just to say whatever you think you might want to say to her. I don’t know if she can physically hear you. But I think she will know you are here.’ So I put the phone down by the patient’s ear. I can hear chattering—kind of wanted a speaker phone. What do you say to somebody after twenty-five years? . . After about five minutes, I see tears rolling down this lady’s face. It was a very powerful moment—because logically, where is the substrate for this? She has no water in her body. . . . So the tears were streaming down her face. I heard the chattering stop, and I took the phone back and described to her daughter what I just saw. ‘I want you to know that she heard what you said, and that her tears flowed. This is a very healing process for her. I thank you very much.’ I hung up the phone—and five minutes later she was dead.”[2]

The physician concluded that “clearly there something she needed to complete in her journey toward health. She was not going to die until that was done.”

 

[1] Sulmasy, D. Spiritual Issues in the Care of Dying Patients, JAMA, Sept. 20, 2006—Vol 296, No 11

[2] Schenek, David and Larry Churchill. (2012) Healers, Oxford University Press

 
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Posted by on June 20, 2014 in Uncategorized

 
 
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