It is not that doctors have fallen from the one true path.  It is not that they have lost focus or forgotten important theory.  It is not that physicians heal without altruism, passion, or perfection.  It is more basic.  Art is to medicine as blacksmiths are to airplanes, flat earth is to astronomy, or prayer to the atheist.  It is an idea relegated to the past.  The doctor, as artist, lies in the grave.

This “art” of medicine is not communication, empathy, or drive.  Rather, the art of medicine is how, for millennia, doctors have made decisions in complex situations when there was risk to the patient, with a significant element of the unknown: A life or death “educated guess.”  The unknown may be insufficient knowledge about the disease, an incomplete understanding of a patient’s health, lack of foresight of potential complications or an absence of definitive knowledge of the correct, best treatment.  It has often been all of the above.  The “art of medicine” has been about judgement, experience and action, when the “right way” was not clear.

We have long depended on the artists of medicine to make decisions which affect human lives, without really knowing what is happening or what that intervention would do.  We have been without an understanding of biochemistry, physiology or pathology, had few active therapies, and had little ability to predict an individual’s future.  There were no tests beyond those caught with the eye and the touch of a hand, and very little “objective” data.  There was art because there was no optimal path, no “indicated” treatment.  Just the need to make a decision. To act.  To care.

Which is now dead.  We can no longer say we do not understand pathophysiology and do not have revolutionary ways with which to measure it. We are not without a broad range of treatment answers for most medical conditions.  Research tells us what the probable benefits and side effects will be.  We are no longer in caves painting pictures on the wall, or serve in massive putrid wards without a basic concept of what is happening in front of us.  For almost all health decisions, there is now a right and a wrong, an optimal, a most probable action.  The practice of medicine will never again be based on a clinician’s experience, observation or gut.  It will be based on hard-fought scientific reality.

Shoveling dirt on the casket is that most solemn of pallbearers … the clinical pathway or guideline.  No feeling.  No passion.  No caring.  Just metrics, research and statistics.  Physicians once trained to make decisions on their own, to be responsible not only for patient care, but for interpreting primitive science, conflicting superstition and their instinctual observations of medical events, now feel cast aside.  Indeed, if all has been decided, if all paths are clear, one might ask: Is the medical profession at its end?

This is an absurd question which fails to understand the nature of what is means to be a modern doctor.  It is like asking if we need carpenters, because we have power saws, cooks, because we have microwaves or orators, because we have microphones.  Yes, having clear pathways and data massively changes medicine.  Nonetheless, in not the slightest degree does it decrease the vitality or need for the medical profession.  Quite the opposite, it makes us much better at our job.

We are called to heal.  With clear answers and understanding we can connect and empower each patient, giving them a place to turn when they are sick and frightened. We can collect and process extremely complex information which makes possible medical analysis and we can make diagnoses more accurate than ever.  This becomes better treatment and, in our most critical skill, we can teach, direct and apply healing. Revolutionary cures give doctors the ability to confidently enable each patient to journey toward health.  Knowing that there is an optimal way, a more perfect result, does not in some bizarre way make doctors obsolete.   Rather we are reaching toward the pinnacle of our profession.

The doctor of today and tomorrow is the ultimate compassionate healer.  We convey our patients through and beyond illness.  We guide our patients back to lives of meaning.  We have so much opportunity, such a burden of possibility to be personal practitioners, to guide each patient so they may return to life.  It is a rebirth of medicine, moving beyond primitive confusion, suffering and loss, to empowerment, strength and real hope.  The art of medicine is dead.  Long live the art of medicine.

The post Rest in Peace: The Art of Medicine appeared first on Sunrise Rounds.

It is printed on my card and I emphasize it during office visits. “If you need me, call.” I remind them that when you are lying on the floor with crushing chest pain, the correct number is 911.  PLEASE, do not leave life and death messages on my voice mail.  Call the office.  Call the rescue squad.  Call another doctor.  Nonetheless, in general, my job is to help, so feel free to reach out and touch me.

Not that I am warm and fuzzy with out-of-the-blue calls from patients I have not seen in years, with a new, non-urgent message. “I saw in the Times today, that coffee prevents liver cancer … what about decaf?” Or the elderly spinster who calls, every couple of days, to review bowel, bladder and bunion.  Admittedly, I do not get much pleasure reviewing vitamin recommendations at 11:18 on a Saturday eve. “Can you combine B12, biotin and grapefruit? All at once?  Really?”

While these are easy, social and efficient, they can raise doubt regarding my open-phone policy. Fortunately, they are rare and well balanced by the positive intervention of rapid direct contact.  Truth be told, patients and families are respectful and perceive my number as a life-line privilege.

There are several types of calls which have great value. There is the patient six days into chemo with the fever of 102.8, or the gentleman with maroon stool or the woman with breast cancer who notes a suddenly swollen leg and dyspnea. Easy.  Do not pass go; Do not collect $200; Do go to the ER. We will see you there.

Then there are the “I left an urgent message with the office, but you didn’t call back,” or the “can you repeat the plan to my sister,” or “I have a “_____” (fill in as indicated), what should I do?”  I rarely get the dreaded “refill my medication” call and truthfully it is often a screen for a deeper question and conversation. “Can you order oxycodone” may equal “is hospice appropriate?”

The call which has the most value is the one which says, in effect, “Doc, I am really scared, can you help me?” Why is this call so important? Because, fighting fear and danger is why I went into medicine in the first place… The opportunity and honor to be there when “s**t” really hits the fan.  That is what it means to be a healer.

Tony called me this morning, while I was waiting for a plane at Logan. He had a CT scan on Friday to restage his disease.  At home, alone even with family by his side, seconds were minutes were hours and, in many ways, felt like a lifetime. So, after rethinking a dozen times, “Do I bother Dr. Salwitz, I am just being silly,” he called.  I viewed the images on my IPad and reassured him the cancer was melting away.  Is that incredibly cool, or what?

Now, some will say that I can replace this sort of direct, personal connection, with a high quality, compassionate front desk, triage nurse and answering service. A “screening” team would allow me to organize and focus on the task in front of me, without interruption.  I am fortunate enough to also have that support.  Despite best intentions I should not and cannot answer every call.  I depend heavily on great teamwork, especially when I am seeing other patients.

However, when push comes to shove, when a patient really needs a doctor, really needs me, the cell phone contact fills a critical need. No delay.  Instant answers.  Rapid resolution. Dial, ring, answer, discuss, act.  The patient gets great service.  Disease and fear are on the run. I get closure and can move on.  Wait a minute.  I do my job quickly, easily and well, and do not have to deal with an infinite list of unanswered ”call backs?”  Perhaps, it is all about me.

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That is one of the problems about perceiving the horrendous destruction caused by human action; we think of it as a planetary problem.  It is not even someone else … it is something else … the third rock… the earth.  It is something gigantic over which we have no control and barely even understand.  It is not about us.  It is bigger than we comprehend, let alone affect.  It is not personal.

But, it is.  It is very personal.  We are drowning in oil.  The black foul grease flows into our mouths, floods nose, eyes and ears, and stains every inch of our skin.  We soak in it and, glutinous we swallow, choking it goes down, penetrating every inch of our bodies until it saturates our brain.  Then, in hunger, in desperation, we dive deeper into the massive tank and consume ever more.

The ridiculous ramblings of an environmental kook, frustrated by the failure of mankind to slow its planetary digestion?  No.  The diagnosis of a doctor who has spent a career watching thousands of lives destroyed by the overwhelming and deadly choice, variety and abundance which oil, natural gas and coal present to kill us each day.

The CDC estimates that 50% of cancers, and most cardiovascular disease, are caused by lifestyle decisions. Much of it is not smoking. Most heart disease is caused by diet and lack of exercise.  Countless new and increasing cancers and rheumatologic illness are caused by chemicals and additives, either obvious in the foods we eat, or subtle in the water we consume.   We only have to open the back door and inhale to get lung disease.  The morbid epidemic of obesity leads to diabetes and cancer at accelerating proportions, so much so that endocrinologists are swamped and oncologists are paid extra to take care of fat patients.

Once mankind survived by consuming foods which were the current and direct products of sunlight.  A plant grew, building itself from soil, water and solar radiation.  We ate that plant or the animal which it fed.  We used our bodies to survive, to hunt, gather and farm.  This was a short, clean, empowering, healthy, rejuvenating, non-polluting cycle.  It was how life evolved and man came to be.  It is how we were designed thru millions of years of genetic experimentation.  It is what our bodies expect.  But, driven to consume and conquer, we found a “better” way.

Fossil fuels are the detritus left by trillions of plants and animals which lived millions of years ago.  Thru time and pressure their bodies produced a high caloric soup.  Oil is the ultimate civilization feeding, mountain moving, empire building, energy drink.  It is global surgarized cocaine. Its massive easy power fuels a lazy hypersonic society where men and women do not need to use their bodies, are wilted by intense societal stress, live separated, fragmented, overwhelmed, sleepless existence, and consume more food than is needed by an Olympic marathon runner.

Fossil fuel’s victims will do anything, go anywhere, sacrifice anything for its high.  More perfect than any narcotic, whose addicts might try to fight their disease, even as lumps of coal shatter teeth, gas displaces oxygen and cholesterol blocks arteries, mankind revels in that glory to the grave.  My patients are drowning in oil.

Fat, weak, and out of control, pickling our brains with alcohol, smoking tobacco and abusing each other, we slave for petrodollars.  Then, in a terminal irony that would astonish Kafka, as blood vessels clog, bones decay, hearts falter and cancers spread, we turn to organic chemistry derived science to heal our contaminated bodies.  Personalized medicine’s bizarre promise is to fix genes built with elegant evolutionary care, which have been mutated by oil fed lives.  We are killing ourselves by feeding off the planet’s past, even as we destroy the planet’s future, and we have the hubris to beg biochemical innovation to save us.

We live in a world, of choice and creation, which is trying to kill us.  Even if we ignore what we are doing to the planet, we cannot ignore what the products of fossil fuel are doing to each of us.   We cannot say that what happens to our bodies is someone else’s problem.  How we live each day, the foods we eat, the activities we do, how we handle stress, how we treat each other, how much we sleep, what poisons we consume, it is all personal, all about us.  We may not feel that we own the world.  That is “someone else’s problem.”   We certainly can feel and act as if we own ourselves.  As if in a horror film, we are drowning in the addictive, rotten carbon debris of lives ended long ago.  It is time we take responsibility for ourselves.

The post Diagnosis: Drowning in oil appeared first on Sunrise Rounds.

A few days ago, Dr. Ghazali A. Chaudry, M.D., FACS, Lieutenant-Colonel and surgeon, United States Army, shipped out to Iraq.  There he will work to save the lives of our injured warriors, as well as those of our allies and even, at times, those against whom we struggle.  He will take months away from his practice and career.  He will leave behind his community.  He will risk his life for our country … for each of us.

Dr. Chaudry has young children, family and friends, entrusted to us, his nation.  Every soldier should have the comfort and confidence that that those they leave behind will be safe and supported.  However, in a cynical twist of national attitude, in a swelling of ignorant bias and nationalistic fear, we accept without hesitation his sacrifice, his willingness to go in harm’s way to protect our values, our way of life, but we hesitate to express those values of openness, acceptance and justice toward the community he leaves behind.

The Association of Physicians of Pakistani Descent of North American, New Jersey Chapter (APPNA), gave a send-off dinner for Dr. Chaudry, honoring his willingness to serve their country.  Most who attended are first and second generation immigrants, now citizens who have built lives in the United States.  They have businesses, families and vital communities. They are philanthropic and have a culture of volunteer support for their towns.  They feed the poor, heal the sick, build toward new tomorrows. They, like all immigrants before them, represent the future of America.

Nonetheless, despite the sacrifices they have made, the gifts of blood and sweat to build here, they are anxious and confused.  Powerful examples of the successful American Dream, they sacrifice, work hard, create, and worry we are abandoning them.

The talk that night spoke of anxiety and fear.  They are stunned by a national conversation that is attacking them for how they pray, the god they hold.  Suddenly, this Nation doubts their loyalty, commitment and cannot seem to tell the difference between men and women who love America, and those who would tear it down.  They are confused how a polyglot country which was been built almost completely by immigrants, cannot tell friend from foe.  They are stunned the definition seems to come to a single word:  Islam.

In every religion, through all time, there have been those who twist faith toward violent, bigoted and nationalistic ends. When people are in pain, hungry and frightened, when they are impoverished, angry and ignorant, religion, god himself, may become a false flag under which demagogues gather their flock.  It is not the religion which truly calls, it is fear, disconnection and twisted sociopathic vision.  Religions of peace which build community and justice, which bring communities together, become tools of power, dominance and war.

If any nation in the history of the world should know this lesson, it is the United States.  We have intentionally built a country of many religions, of many communities.  We balance and celebrate the critical need for individual freedom, local community, and a unified national vision.  This diversity is our greatest strength, as it brings an extraordinary wealth of ideas, belief and vision.  It makes us passionate, curious, fluid and is a deep well of knowledge.  We are strong because we salute being many.

The immigrant experience in the United States has never been easy.  Each of us, each of our families, earned the opportunity to be here.  Dr. Chaudrey’s sacrifice and service are part of that tradition.  But, there are two parts to that social contract.  He gives, struggles and makes all of us a little safer, a little stronger.  In return, we support him and his family.  Therefore, we must be concerned when we attack that bond, that national commitment, by any conversation which threatens the communities we leave behind, especially when that talk is based on manipulation by prejudice.  Those that would attack our diversity, would tear us down.

American Muslims are part of who we are.  They are threads in our national fabric. We must support every one of them, as we would support any other citizen who strives to make this a better nation.  The faiths we hold, Christian, Jew, Hindu, atheist, Muslim, is what makes each of us strong.  Our belief in protecting every faith, is what makes the United States of America remarkable, exceptional and powerful.  Together we are all Americans.

I wish Lieutenant –Colonel Chaudry a successful journey and deployment.  We salute and need him.  We will hold his family dear and, together, pray for his safe return.

Picture copied from USNews.com

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Medicine is paradox.  To save, we cut with sharp knives.  We ignore pain, so that it will light the path to diagnosis. We give toxins to destroy toxic disease. We scold our neighbors when they neglect their health, even as we work ourselves to exhaustion, eat too much and evade exercise. We comfort the families of our patients, while ignoring our own.

There is one contradiction, which by its very nature defines what it means to be a doctor.  It is a foundational value on which the profession rests.  We must care deeply about each person, while not caring about them at all. 

Doctors must be without judgement or prejudice, and must treat every person without regard to what they believe, what they have done or who they are.  Murderer, mother or monster, saint, slum lord or sex offender, nurse, noble or Nazi, the physician is tasked to treat each as human and patient.  This creed is not only every doctor’s calling; it is the utopian vision which Medicine offers the world.

I am concerned that this fundamental value may be in danger.  It is not just the suddenly angry, callous, in-your-face society into which we have spun.  Nor is it vicious Facebook assaults, or the increase in public acceptance of ostracizing, biased, fear-laden rhetoric.  Rather it is a change, perhaps the result of this furious flood of disrespectful national communication, which I sense in myself.

I recently took care of a patient with advanced cancer … the type is not relevant, but the pain, loss and terminal nature is core.  He grew increasingly terrified, as his life, part by body part, was stripped away.  He desperately needed my help.  The problem is that, frankly, I cared.

I cared that he was an evil man.  His life had been spent bringing abuse and hurt to others, and even though he was very sick, he continued to reap misery upon his family.  He was manipulative, condescending, hubristic and usurious.  I found myself thinking that there was justice in his fear.  It was hard to see any benefit or reason, let alone “good,” in helping him live even a little longer.

The real horror, is that I had come to see him as “evil.”  Such judgements may be rendered by family, courts, society or god.  They are never the place of a physician.  None-the-less, every time we met I could feel, in me, the bile of anger, frustration and sanctimonious judgement.  I was sliding close to that line where prejudice would change my care, so that he might suffer more, as he so “deserved.”

I am deeply disturbed by this case, because it is a gross deviation from how I have seen my patients and profession for so many years.  I have learned to see, and without out judgement accept, human frailties and deviation as part of the constellation of each individual and to use those traits, even when other forums might judge, to guide and help each patient.  I found myself feeling as if I might punish this man for his life, instead of returning him to it.

The peril is that the shift in tolerance, diversity and compassion of our society may penetrate so deeply that it will poison even the healers.  The national tumult may have affected my ability to treat this man because it gave me license to find righteous justification in anger. This is a frightening result.  If this pathological societal conversation continues and spreads, if blame and hate grows, like a disease it may infect the whole of us.  If its virulence is not stopped, the consequences may be catastrophic.

While it is the role of all to be open, fair, accepting, and to recognize the sanctity of each person, this burden rests most heavily on the shoulders of the medical profession.  It is our calling not only to care for the sick without judgement, but to teach the value of life.  The altruistic voice of physicians must remind us of the beauty and potential of all persons, and we must help others see through fear in order to accept that while we may be different, we are more deeply the same.  Any society which holds as less by anger, bigotry or hubris any person or people, has within it a spreading disease.  Doctors must heal. They must guide and remind us that in the end, we are, one and all, human.

The post Prejudice: first do no harm appeared first on Sunrise Rounds.

The doctor’s failures concerned length of stay (far too long), sloppy medical records (incomplete, loaded with cut-and-paste) and a temper, which while not directly abusive of staff, made the work environment tense, perhaps even hostile.  After months of trying to coral the doc into the straight-and-narrow, the administrator was maxed out. “For god’s sake,” he said, “Can’t we just throw him off the staff?”

Now, I get the point.  With all the complexities of running a modern healthcare organization, it is frustrating and wasteful when the best educated, best paid and most committed individuals, cannot carry out the most menial tasks.  Hand-holding physicians and correcting paperwork 101 is annoying, and can be expensive.  Isn’t time that docs step-it-up, put on their big-boy-pants and do their part? To get good, let alone great, we better get tough.

I mused on this and came to a revelation.  One may sympathize with that administrator wanting the best and blaming recalcitrant docs for low-hanging-fruit failures.  None-the-less, if we are going to build world-class systems, then the question is wrong.  Instead of asking how soon we can throw the flawed doc out the door, we should ask, “What can we do so that we never have to throw another doctor off our staff or take a physician out back for a talking-to?  How can we protect, encourage and support our doctors, so that they are not drowning in a torrent of e-paper, regulation and consumptive confusion?”  The doctor is the product and we should be lending support, not increasing her misery.

There are days when I would like to blame doctors for all the ills of healthcare.  Physicians have always had final control, deciding on the patterns and specifics of care, directing and implementing innovation, and whispering into the patient’s ear.  It is doctors who over-order, duplicate, overspend and run sloppy organizations without metrics or any obvious collaborative structure.  They could have maintained professional, fiduciary control of medicine for the past 50 years, and left nothing for CMS or the insurance industry to pre-certify, no gaps in quality or efficiency, no corrosive cost overruns and no sloppy vulnerabilities upon which politicians and malpractice sharks feed.  However, doctors failed. We did not maintain control, so it is being done to us.

The truth is that we cannot really blame the doctors.  Frankly, they did not know better.  Med schools selected students who cared about science and human service, not bookkeeping or the bottom line.  Then students, interns, and residents were promised that if they worked hard … really hard …. That all good things would follow.  Not a word about how to lead, structure or manage the system.

Med schools teach that a doc’s only responsibility is that one patient in front of you. That must be your entire focus.  You are the ultimate decision maker and completely responsible for each patient’s treatment.  Give great care, one soul at a time, and everything good will follow. Fail and everything will descend upon your head.  Ignore the rest. Ignore the realities of the real world.

Med schools taught medical ethics, not business ethics.  They taught how to balance blood pressure, not budgets.  They taught how to talk to patients about life and death, but not how to talk or guide an employee or co-worker.  It was never explained or even suggested that other professions have real value, and what that value might be or how to use it.  Lawyers are bad.  Insurance companies all greed.  Hospital administrators wanna-be B+ healers.  And the most the most corrosive lesson?  There is no “I” in team… you are alone.  God and Hippocrates have willed it.

So the doc “strays” because he does not understand his role in a modern, integrated, automated, politically correct, monitored, complex medical system. He or she was raised to believe that the system is strange and perhaps anti-patient … evil.  How can we assign blame when doctors were chosen and channeled for the role of lone hero and then, we attack, isolate, insult and underappreciate their decades of just trying to do the right thing?

Healthcare, and therefore the daily practice of medicine, are going through a cyclone of change.  No one feels this more than the physician who still needs to touch, understand and treat one patient at a time, even while they flap, grasp and flounder in the systemic storm.  While we might want to blame each doc for being a stubborn, archaic relic, the truth is each is motivated, caring, intelligent and deeply passionate about not only the patient in front of them, but the entire community around.

Physicians have not failed us.  We have failed them.  The possibility, the opportunity, the need, is that we must work together to teach and learn the requirements of integrated, global, team-based healthcare and the value each of us can bring.  We must build systems that support, not subjugate. We must not only direct, but listen. We must treasure the value and sacrifice of each clinician, each healer.  If we do not, then we will burnout passionate and skilled doctors, and it is patients who will pay the ultimate price.

The post Fixing the doctor appeared first on Sunrise Rounds.

Fall brings school buses, a freshening breeze and an avalanche of meetings.  There are seasonal sales, myriad projects and the splendor of colored leaves.  The season is also announced, again and again, by a particular peculiar and perilous decision, which, no matter how much I try, I do not fully understand. Frankly, I just don’t get it.

“Jane, it is time to start chemotherapy.”

 “What are the side effects?”

 “Well, this is powerful chemotherapy.  It is necessary to cure your cancer.  It will cause hair loss. It will cause a drop in your blood counts.  It might cause severe diarrhea.  There might be numbness of your hands and feet… that can be permanent.  It can damage the muscle of your heart.  You could be allergic.  You may require blood transfusions or be hospitalized.  When we finish the chemo, we will start radiation.  Do you want to hear about the radiation?”

 “No, that’s OK.  I think I have heard enough.  That is really scary, but thank you for telling me.  How soon can we begin?  I want to start right away.”

 “We can start in a couple days. First, there are a few things to do. You need blood tests, a bone marrow biopsy, an MRI of your brain with intravenous contrast, a MUGA scan, a PET scan with radioactive dye and the placement of a Mediport.”

 “A Mediport?”

 “That is a catheter surgically implanted under your skin and the other end goes to the right side of your heart.  It is best way to give chemo.”

 “Oh, Ok…can we get all that done this week? I want to begin.”

 “Sure. No problem.”

 “Great.”

 “Oh, and one more thing.”

 “What’s that?”

 “Its fall. You need a flu shot.”

 “Absolutely not.  I do not believe in flu shots.  I never get them.”

Huh?  What did she say?  She won’t get a flu shot?  I am flabbergasted. Why?  Let us explore my bafflement.

My patients will allow complex, devastating, overwhelming, life changing surgery, radiation, immunotherapy, genetic therapy and chemotherapy.  They may get rashes, headaches, joint pain, swelling, fevers and risk heart failure, kidney failure, liver failure, and who knows what else failure.  However, they will, consistently, recurrently, refuse the simplest protection of all, a flu shot.

This is not a rational response.  What is the risk of a significant side effect of chemotherapy?  High.  Very high.  This is difficult treatment to kill a difficult enemy and almost all patients pay some price.  Occasionally a heavy price.

What is the risk of a significant side effect of routine flu vaccine compared to the danger of actually getting influenza, especially in immunocompromised patients?  Apparently, many of my patients think it is far too high.

The truth is the opposite.  The risk of a severe complication from taking the flu shot is literally, one in a million.  The risk of even a minor side effect, like a chill or slight fever, is small.

The reason that experts recommend the flu shot to essentially everyone, is that the flu is a deadly disease. Thousands of people die every year in the United States from the flu; the average deaths in the United States over the last decade were 32,743 per year.  Many of those people had weakened constitutions because of other medical problems … like, say, cancer and cancer therapy.

Several patients in any large oncology practice are killed each year by influenza.  Rare is the death or even the injury from receiving the flu shot.  I have given out tens of thousands of flu shots over the years and never seen a serious problem.  The biggest issue is that the vaccine is not perfect … it does not protect every patient.  However, you cannot “catch the flu” from the vaccine, because it is sterile … there are no intact viruses in the injection.

Cautions do exist; It is important to warn your doctor if you have an allergy to eggs or other component of the flu shot.  If you have had that very rare condition, Guillain-Barre (a paralysis from spinal cord inflammation), then talk with your doctor.

What perplexes me, is that these facts are common and obvious.  Chemotherapy and cancer care is tough and has serious risks.  Flu shots are easy and rarely cause problems…and they absolutely save lives.  So, why do patients refuse the obvious and easy, but consent to the complex and hard?

Part is a desire to maintain control over one’s body. Refusing the flu shot seems to be a minor choice, not a life or death decision.  On the other hand, cancer is a terrible frightening threat and seems almost beyond our ability to understand, let alone refuse recommended therapy.  Therefore, we accept aggressive, toxic, high-risk treatment.  Anything, if you will, to fight the dread disease and stay alive.

We fail to appreciate the danger.  “The flu” sounds like a couple of achy days curled up in bed with a fever.  Maybe we miss work for a week…not a big downside.   Therefore, we think that even the very slight chance of a vaccine side effect is “not worth the risk.”

We miss, that the flu shot is extremely benign, but influenza for many, especially those already frail, is a deadly disease.  We tend to neglect the whole idea of “herd immunity”; Even if the flu turns out to be just a few days on the couch for you, the person you in turn infect may be severely injured … or worse.  As part of a society, a community, a “herd,” if you will, we have a moral and personal responsibility to others.

In the end, of course, it is my role to advise and guide.  The patient is in control of their life and health.  I support whatever path they choose.  Still, some decisions baffle. From where I stand, some paths stray too close to a cliff.

The post OK, so I just don’t get it … the flu that is appeared first on Sunrise Rounds.

His wife, previously positive, happy and successful, never recovered. She quit work, drank heavily, and spun into a therapy-resistant depression.  12 months later, she used those same pills to take her life.

At the time of David’s death, his son was 17. The teenager found comfort in the kind of pharmaceutical intervention that come from bottle and needle.  A high school dropout, he was in jail by 20, and although paroled at 23, found the streets too much.  Back in prison by 26, his life dissolved to rubble.

David’s suffering, poorly controlled during that precious last year of life, and the tragedy of his last days, were a direct result of the failure to plan for the inevitable and the inexcusable negligence of his caregivers to provide comfort. That misery transferred to those he loved.  David’s pain continued after death.

Ernest Becker taught that our malignant fear of death drives the pathology of all societies, and thereby man may be a diseased and doomed species.  In that light, David’s end-of-life journey amplified our universal injury.  The anger, fear, loss and confusion of David’s family sickened them, and the hundreds of other people they touched, spreading like cancer throughout humanity. Their pain is in all of us, augmented by the screams of the thousands of patients who die in similar agony, everyday.

Our failure to have open, meaningful and realistic conversations around our personal mortality, results in suffering not only of each patient and family, but of civilization itself.  While mega-atrocities dominate the front page of every paper and website, underlying that chaos is the banal pain of our lives

Of course, this is a cycle.  We do not talk about or plan for death, because we deny our mortality, and in doing so we make the pain of dying worse, which than ripples across society, to fan our subconscious horror.

Perhaps, therein lies an opportunity; a way to begin a universal conversation about dying.  Instead of an abstract struggle to recognize man’s psychoanalytic flaw, his status as a demi-god with which he cannot cope, start with a simple goal; what can be done to help one patient and one family.

The “core purpose” of the American Association of Hospice and Palliative Medicine (AAHPM) is to improve the care of patients with life-threatening or serious conditions through the advancement of hospice and palliative care.  Given what we know about inadequate pain control at the end-of-life, ubiquitous futile treatment for incurable illness, and poor final planning by millions of patients with terminal disease, this is a vital mission.

The AAHPM, the American Medical Association, CMS and countless other health leadership bodies, have seized on quality end-of-life care as a mandate to prevent individual suffering, a basic support to families and foundational to the distribution of scarce resources.  Palliative medicine improves clinical outcomes, quality of life and from a purely financial sense, makes solid business sense. These goals are noble and important.  What is missed in that focus on improving the care around dying is the most critical mission.  True holistic, open, honest conversations about the end-of-life, can save the world.

Seen this way, hospice care is a stealth grass-roots campaign to save the species; better end-of-life conversations may improve our understanding of the dominance of mortal fear in the decisions we make. This is kind-of-like recycling your newspaper, learning to drive 55 MPH or using low wattage bulbs. These do not individually make a difference, but they lay a foundation on which to build an entire system of environmental health and therefore address global warming.  A caveat applies to both the environment and death; one hopes we are not too late.

The growth of hospice, which reached America in the 1960s, but expanded logarithmically after the 1983 Medicare Hospice act, has gradually transformed healthcare. Nurses and doctors are trained to emphasize end-of-life discussions.  Hospice and Palliative Medicine has expanded as a formal specialty.  Even the choice of assisted suicide, has become a public conversation. In 1950, 85% of patients in America died in hospitals and nursing homes. By 2015, 45% of terminal patients received hospice care, most at home.

Two years ago, the American Society of Clinical Oncology (ASCO), in collaboration with AAHPM, held their first convention devoted solely to end-of-life care; a remarkable moment, given that most cancer patients during the 50 years that ASCO has existed, died.  This signals a new openness to conversation around dying, even among those that treat the dread disease.

By reducing the number of horrible experiences, like that of David, palliative medicine may decrease the ambient circulating pain in society. Even more critical, if we can accept that we are mortal, then perhaps we can begin to face that how we cope with death is the basis for all the decisions we will ever make, the foundation of our lives.  By empowering this vital introspection, we may achieve something greater.  A future for all of us.

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Human beings are meaning machines.  There has never been a society and rarely a person that did not seek answers to why we walk this planet.  For many the answer lies in a god and her love.  For others, the purpose of life is mankind, humanity itself, with our most important commandment to treat each other well and continue evolution’s path.  Some see man and womankind as the ears, eyes and memory of the universe itself, put here to revel and record its glory.

Just as important, in each of our lives we find meaning in daily events, in moments. The work we do.  The service and good deeds we perform.  The things we create.  What we learn.  What we teach. What we paint, mold or sculpt. What we sow and reap.  What we cook or even the pleasure of what we eat.  A sunrise.  A sunset.  Four birds against a pure blue ski, headed south in September.

Above all, there is meaning in what we share; A special meal, a dance, a song, a touch, a smile, knowledge, understanding, laughter. The joy and wonder of generations.

The end of our lives is about living and not about being dead. Therefore, the search for meaning never stops, as long as there is breath.  That being true and universal, what terrifies us most at life’s end is not physical loss and discomfort, but the possibility that such suffering may cause a greater agony … the loss of our search and connection to meaning.  The possibility of such a horrible existential and real loss, having to live empty without that which has given us purpose and direction, suggests being dead while walking.  A loss of everything we are and try to be.

Supportive, complete and empowering end-of-life care must focus not just on narcotics, dressing wounds, home supplies and complete communication.  It must understand that the goal is to help each person continue to be nourished by the search and enjoyment of life’s meaning.  This is absolutely personal, spiritual in the deepest sense.  This means never forgetting that the patient is the one on the journey and it is our responsibility to support their decisions and desires.  None of us exactly share their view of life and none of us understand what it means to them.

When we choose how our lives will end, or when we support and care for those with grave disease, we must remember that the great risk of modern aggressive interventional medical care is that it can strip us of everything we hold dear.  It is not just about preventing and treating physical pains. These losses are obvious, basic.   Life is about work, home, family, spirit, creation and discovery. The nightmare which threatens, as we rush from treatment to treatment, is that denial, futile hope and desperate action can rip from us that on which we have built a life.  Human beings must seek and find meaning.  Without, we are morbid shells.

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Warning: this piece is graphic and harsh.    jcs

Smoking and drinking caused the cancer, which Ed ignored for a long time. By the time a doctor looked at the hole in his neck, the mass had congealed the base of the tongue to the right side of the jaw and burst through the skin. A steady drip of pink tinged, foul saliva ran down the side of Ed’s neck.  Ed, not being able to chew for months, was wasted, and every bone of arm, chest, abdomen, hip, leg could be seen, as if a dried museum display.

Treatment was obvious.  Melt the cancer with toxic chemo, dissect and rebuild the side of Ed’s face, leaving a hole to breath, fry the whole thing with mega-voltage X-ray.  Straight forward, standard and ridiculous.  In his pre-coffin cachexia, Ed would not survive the first milligrams of cancer killing drug, would never heal a surgical wound and would cook in a photon beam.

Thus, the radiation therapist said to the surgeon,

and the surgeon said to the oncologist,

and the oncologist said to the wife,

and the wife said to the patient,

“Ed, it can’t be done.”

“Why,” Ed asked.

“Because, you are almost a skeleton. Your body is nearly gone. The cancer is too large.”

“Build me up. Feed me by tube. Feed me by IV.  Make me strong and plump, again,” said Ed, remembering a time when even he had to diet.

“If we feed you, we feed the cancer. Better nutrition, stronger cancer.”

“I have to try.”

“It is too late.”

“I have to try.”

“It will become more horrible.”

“You don’t know me. I am strong. I have to try.”

Thus, Ed said to his wife,

who said to the oncologist,

who said to the surgeon,

who said to the radiation doctor,

“I do not care what you say, I have to try.”

They put a tube in Ed’s stomach, which kept falling out and getting infected because his skin was thin-wet-torn-tissue.

They put an IV in the vein in Ed’s arm and threaded it to his heart and they poured in gallons of fluid, and 100 thousand calories, and kilograms of fat and protein, and an apothecary of vitamins.  And the IV kept getting infected and clotted and infection spread and Ed was very sick, for days and weeks.  Ed was in the hospital for two months.

Ed gained weight and puffed up.  But not muscle or fat or tissue.   Just fluid, lots of fluid. Ed was a sick sponge.  With bed sores.  And a growing hole in his neck.

Nonetheless, Ed was excited that he looked fuller, rounded and he was many pounds more.  And, the cancer too was happy, because it ate protein and calories and fat.  It came to be that the mass in Ed’s neck got bigger, and the pink, stinking drainage flowed fast.

Then, on the same day the Ed asked the oncologist if it was time to start the chemo, the cancer grew into Ed’s right carotid artery. And the artery, with all that precious blood pumping fast, had a hole filled with cancer.  And then, a cork from a bottle, the firehose pressure which had nourished Ed’s brain pushed out the cancer, and the artery burst.  The blood driven by Ed’s pounding, fighting, strong heart, sprayed past the cancer and out the hole and erupted across the sheets, floor and onto Ed’s wife as she rushed to his gurgling scream.  And, in three minutes, Ed was dead.

And the oncologist, and the surgeon, and the radiation therapist and his wife said, “But, he had to try.”  But, as she threw out the red blouse, she tried to remember why.

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