Gone fishing!

But we love you, C. O.!

Does the Cheerful Oncologist need some cheering up?

I guess it is a sign of vulnerability but I have never become inured to being fired by a patient. It bothers me that someone would prefer another doctor’s wisdom, another doctor’s beside manner, another doctor’s eyes for the future. After all the time I had spent counseling him, why did this new patient abruptly want to leave me? As I stood over my desk, re-reading the request to send records to a rival oncologist I made a mental list of possible reasons, wallowing in what the psychiatrists call projection as I steamed over this incident. I considered a few causes:

1. The patient was in such profound denial about the diagnosis that he was exhibiting what the headshrinkers call displacement - that is, instead of becoming angry at the disease cancer he was angry at me for being the bearer of bad news about the ugly details of treatment and prognosis. This is known in businesses far and wide as “Kill the messenger.”

2. The patient found my personality shall we say unappealing, and thinking it would clash with his own, decided to switch rather than fight (cf. Bernard Law Montgomery vs. George Smith Patton, Jr.).

3. I’m an abject failure as an oncologist and should be summarily executed cometh the dawn..."

I won't spoil the ending. Please read the whole, wonderful post. Dear C. O., it's terrible to be fired by a patient, but sometimes it's all for the best!

Inhabitants of the world of pain

In The Observer: Memoirs of a survivor.
Robert McCrum tells us about his stroke.

Ten years on it seems like a dream, a hallucination, or a nightmare. Occasionally, in the morning, I will wake and wonder, "Did it really happen?" But of course it did; I have what doctors call the 'deficits' to prove it. For me, amid all the late-Nineties talk of the millennium, the apocalypse came early.

This defining moment caught me unawares. I went to bed on the night of 28 July fit, 42 and fully articulate. I woke up next morning semi-paralysed, prematurely aged and scarcely able to speak. In medical jargon, I'd suffered 'an insult to the brain', a right-hemisphere haemorrhagic infarct.

The brain is only 1.4kg of grey matter. You could hold it in the palm of your hand. But it's you and it's me - my command post, my HQ, my language, my movement, and my window on the world. Oscar Wilde once wrote: 'It is in the brain that everything takes place... It is in the brain that the poppy is red, that the apple is odorous, that the skylark sings.'

So 'the insult to the brain' is not any old affront. It's a colossal four-letter word, the ultimate Expletive Deleted, a cataclysm at the centre of who we are...

Uh-oh

Times Online: Is the global housing bubble set to burst?

"From Alaska to Zanzibar, rich westerners are snapping up what they hope will be bargains in bricks and mortar as local markets have taken off.

In three years house prices have rocketed in South Africa by 95%, in China by 68%, in Australia by 56% and in America and Thailand by 29%. In Britain they rose 50%. The world has never seen a boom of such breadth and scale.

“Eighteen months ago you could have bought a studio in the Jumeirah Beach residence for 40,000 pounds,” said Paul Taylor of Dubai Select, a property marketing company. “Now you could sell it for 150,000 pounds.”

According to estimates by The Economist this week, residential property in developed economies has leapt in value by more than 16,500 billion pounds to more than 38,000 billion pounds, in just five years. That sum is the equivalent to the entire GDP of all the countries in question. Only in Germany and Japan have prices failed to jump over the last decade.

To doubters — who are predicting prices will fall by 20% or more in many countries — it is the gigantic bubble that swallowed the world, bigger than the stock market boom of the 1990s and almost twice the size of the Wall Street bubble of the roaring 1920s.

I've blogged about our dizzying experience with local real estate. I didn't know that the boom is global! What will happen when this bubble bursts? Here's more:

Experience so far suggests that house prices are more likely to stagnate than crash. That is what has already happened in Australia, where a boom has been followed by stable prices for 18 months, although in hotspots such as Sydney double digit falls have been recorded.

As Milan Khatri, head of economics at Rics, summed it up: “It looks like stagnation so long as interest rates don’t rise sharply and we don’t go into recession.”

That, however, is a fine balance since in the Netherlands the stagnation in house prices led to a fall in consumer spending, driving the economy into recession.

Let’s hope the doomsayers, though, are wrong, since the prospect of a meltdown is scary. In Japan, where property was once the most valuable in the world, prices have been falling for 14 years and are now down 40% on their 1991 peak.

It is a sobering thought that in the decade before that peak, the boom in Japan was smaller than the one now happening in America, Britain and elsewhere round the world.

(Sigh) There oughta be a law

Three Sisters Over Eugene, originally uploaded by L. A. Price.

Yes, this is our town. As urban development spreads through our valley, will we see more scenes like this one? Horrors...

Father-blogging at Medmusings

Dr. Enoch Choi is the latest medblogger to catch the eye of mainstream media. A reporter asked for his thoughts about being a dad:

...i have something of the following to say, lets see how much they garble it:

- many dads nowadays are more involved, diapering, bathing, feeding, putting to bed, to try to be as helpful as possible
- this is something they do out of love for their kids, and thru it become more intimate with them -- recompense enough! kids, they're so sweet...
- many dads take time off, or reduced schedules to do more with kids
- moms may not appreciate it since they're so overwhelmed with the care needs that a little help is not that big a reduction in their workload
- dads can feel underappreciated for their efforts

More thoughts for Father's Day, and some incredibly cute photos of Dr. Choi's kids, at medmusings.

Meet the CancerDoc

This "budding oncologist" is live-blogging his first job search. He also has thoughts about residency work hours:

...in the process of restricting hours, the new rules have altered the work ethic of most trainees. Whereas in times only a couple years ago, residents would work incredibly long hours and stay at work "until the job was done", now doctors go home at precise hours, regardless of whether the patient is unstable or needs something. They simply hand them off to the next shift, like in the emergency room. This "shift" mentality, I believe, contributes to an erosion of work ethic that will eventually rear its head later in a trainee's life when they are the attending physician. It is hard to strike the balance. While patient safety is paramount, the fact of the matter is that you will never train tomorrow's physicians without exposing them intensely to today's patients. That is the difficult reality that most laypeople do not understand...

Stop by his new blog and say hi!

In other news, Cheerful Oncologist's office practice is inspiring some anxiety, as well as fine writing...

"Boxer now in fight of her life"

She's fifty years old. She's 5' 2", 125 lbs. It was her first professional match. Why was she in the ring with a much taller, much younger opponent?

After lasting 2 1/2 rounds in the fight at Seven Feathers Hotel & Casino Resort in Canyonville on Thursday night, "Sweet Shampang," as she likes to be called, was still unconscious Friday night at Sacred Heart Medical Center in Eugene after collapsing and then undergoing emergency surgery to relieve swelling in her brain about 1 a.m...

Shampang had suffered a hematoma, a clotting of the brain's blood vessels in the front of her brain, Angel said.

The article mentions that when Shampang started boxing two years ago, no one said she was "crazy." (Why isn't there another term for tragically poor judgment that leads to needless endangerment?) Women's boxing is surging in popularity, says the article, but there are problems:

Boxing commissions have made it easier for women with no professional experience to get licensed than for men who have fought amateur bouts for years, Triplett said in a Register-Guard article on Shampang earlier this year...

Miele and Dr. Julian Bailes, a professor and chairman of the department of neurological surgery at WVU's School of Medicine, wrote an article for The New York Times in May titled "Fatal Attraction for the Ring?" in which they described the increased risk women boxers face and how they are being rushed into professional bouts because of the novelty of it all...

Several factors contribute to boxing being far more dangerous for women than men, said Miele, including the smaller size of their necks, less muscle mass, lighter weights, less training and medical attention, and mismatches.

Because of their smaller numbers, it's more difficult to match female boxers, Miele said.

A doctor works though pain

At Medviews:

Well, I must say, the most humbling of experiences for me as a practicing physician is to see patients while in pain. I hobbled along today with my acute Achilles tendonitis, feeling myself to be in full middle aged bloom. A younger person would have a great story to tell of their daring athletic exploits, proudly describing their injury as a great war story. I, of course, have no such exploit to describe. I think I injured myself walking up the stairs at Dulles airport. Pretty sexy, huh?


Being in pain lets me know that I am not apart from my patients; that I just as vulnerable as they are. I have the same semi-rational fears (will my Achilles tendon rupture, causing me to go straight to the operating room?) and concerns ( will I be able to enjoy my upcoming trip to California) as any one of my patients would have. Suddenly, anecdotes of how other people handled such injuries become very important to me. And, of course, I want to get better immediately...

Spotlight on Codeblog

BlogWatch: June 12 Issue - Newsweek Technology - MSNBC.com. A weekly mainstream media snapshot of what's hot (and what's not) in the ever-widening world of weblogs:

..."ER" not gritty enough? Try codeblog.com, where medics share blood-spattered and bittersweet stories of life on the wards.

Another medblogging milestone. Geena's mom is thrilled, and so are we!

Geena has assembled some "gritty" posts for Newsweek readers. Don't miss them!

"Such patience for patients is amazing"

In the Telegraph: Trust me, I'm a junior doctor.

"Mr Berridge suffers from Korsakoff's, which sounds, ironically, like a cheap Russian vodka but is a syndrome of irreversible brain damage caused by alcohol excess. It is characterised by short-term memory loss and confabulation, where the sufferer fills in the gaps in his memory with fictional explanations.

Mr Berridge was found confused and wandering the streets a few months ago, and was brought into hospital. He remembers that he has savings, but not that his social worker opened a bank account for him, and that his money is safe. Because he can't remember, his mind becomes creative and he imagines that it's been stolen. And no matter how many times you explain, within a few minutes he's forgotten again.

Anyone needing a reminder of the evils of drink should spend a day on my ward, having to explain, repeatedly, to Mr Berridge what has happened to his money. I can last only a few minutes, and so I have the greatest admiration for the nursing staff.

Psychiatric nurses are a special breed. While they might not have the technical expertise of nurses working on the medical and surgical wards, their skills are equally specialist. Regardless of the form of mental illness, nothing seems to faze them. They are calm in the most extreme situations. They make sure that everyone is comfortable, they offer support and help, and have awe-inspiring patience.

With Mr Berridge, whose short-term memory is only two or three minutes, this means non-stop work, all day, every day. I honestly don't know how they do it...

Betcha didn't know

From the Oregonian:

"According to languagemonitor.com, as of 11:40 a.m. Tuesday, there were 870,007 words in the English language.

You are more likely to be attacked by a hamster than by a shark.

According to researchers studying how late is late, 10 minutes, 17 seconds is the threshold at which people feel it necessary to telephone and admit they are going to be late.

Sneezes travel at 40 mph on average. The fastest recorded sneeze clocked in at 100 mph.

The average person will inhale 75 million gallons of air in their lifetime.

When you're asleep, your brain is more active than when you're watching TV.

Your hair will grow almost 600 inches during your lifetime.

Cockroaches can run up to 3 mph.

A 10-gallon hat holds only 3/4 of a gallon.

The brain activity of people in love is nearly identical to the brain activity of someone with mental illness.

Flies taste with their feet."

(excerpted from the Edge.)

The woman who invented Viagra

In the Telegraph:

History should rate Samuels as one of the most significant female scientists of her generation. She has worked on a number of drugs, and rose through the ranks of Pfizer, one of the world's biggest drug companies, to become executive director for science policy in Europe...

"I have never personally been aware of a glass ceiling," she says. She couldn't come from anywhere but the North of England. She's both erudite and plain speaking and doesn't believe that being a woman need stop career progress.

She does, however, feel that lots of women step off the career ladder voluntarily in their thirties and forties, typically for family reasons. (Though she has no children of her own, she helped raise step-children.)

Something must be done about this "leaky pipeline", she says. She has been personally involved in formulating Pfizer's equality and diversity programmes. She has helped ensure that women can take breaks after having babies, go part time or work from home as they wish, but believes there are more subtle reasons for women's arrested progress in science.

Working in all-male teams means being thick-skinned: "Men josh each other. I've worked mainly with men and it doesn't bother me. Some women don't find it easy to take certain kinds of banter - not necessarily sexist banter.

"In the North, when you meet someone new, you insult them and they insult you back. It's how you get each other's measure. Generally, though, men are more used to this sort of thing. I don't think our brains are that different... we're socialised differently."

Mr. Sun's advice

An open letter to the psychiatric community.

Shrinkette wants to know when it is appropriate for psychiatrists to use humor with patients. I'm thinking that I might be an expert here, because I am funny and also possibly mentally ill (references available upon request).

I would have to say the answer is no.

* Psychiatrists: unless you have a strong fifteen minutes that you've tried out in the clubs, then stick to exploring my your patient's domineering mother.
* Patients: you are in serious trouble if your therapist opens your appointment with, "How about that airplane food, have you ever tasted this stuff? But seriously, how long have the voices been speaking to you and what do they tell you to do?"

He also asks why we won't do something about "the Rasputin in our midst." Psych resident Maria addresses this at Intueri. She's quite brave to do so.

Psychiatrists and humor

Dr. Maurice Bernstein has been posting about the use of humor in the doctor-patient relationship. He sends this e-mail:

What I am interested in is whether, in your opinion, psych patients should be treated differently when either giving or receiving humor compared with patients who are not in a psychiatrist's office. Is there a similar role for humor in a psychiatrist's office as in the office of an internist? Your views would be valuable in my thinking out my presentation to the students. ...Maurice.

What a difficult question! Both patients and psychiatrists can find benefits in humor, but there are risks. Humor can be constructive or destructive, as Dr. Bernstein points out. Humor can be used to approach or avoid difficult topics. The wrong tone can humiliate a patient (or a doctor), and sabotage treatment.

So I am posting this little poll (scroll down, please):

Free polls from Pollhost.com

How should psychiatrists use humor with their patients?

They shouldn't.  Patients' problems are not funny. Very carefully and very selectively. When a joke might be instructive or illustrate a point. When a joke might defuse tension or show compassion. Is humor being used as a defense?  What's causing the anxiety? Try not to laugh so hard that you disturb patients in the waiting area.

Comments welcome!

Update: here's Dr. Howard J. Bennett, MD, on Humor in Medicine, via Medscape.

When a child has cancer

Sad news, via NYT:
Hodgkin's Returns To Girl Whose Parents Fought State

A bitter standoff between the parents of a 12-year-old and Texas social workers and doctors over radiation treatment ended on Friday on a somber note with a medical report that the girl's Hodgkin's disease, which had seemed in remission, had reappeared.

Katie Wernecke was taken into custody last week.

The parents, Michele and Edward Wernecke, lost custody of their daughter Katie a week ago, after opposing radiation therapy as unnecessary. When the new test results were announced at a hearing in juvenile court, the parents quickly complied and agreed through their lawyers to let doctors set the course of treatment, which could resume in days.

Who can imagine the anguish that this family has felt? They've (apparently) been blogging about their experiences, detailing their disputes with doctors and the state. Their love for their daughter is obvious. But, if said blog is trustworthy (a big "if"), they clearly interpret their daughter's tests in their own way, and trust their own judgment far more than that of their oncologist. They also talk about a referral to a psychiatrist. Did they go? The blog doesn't say...

Here's the blogging pediatric oncologist at Q Daily News:

Whatever their arguments turn out to be, as a pediatric oncologist, there are two truths that guide most of what I do in the clinic: first, the achievement of remission doesn’t mean that the treatment so far is enough to prevent relapse, and second, there is a stark difference between what we know to be true and what we suspect may be true...

He explains the rationale for continuing treatment when remission is achieved. He adds,

...here’s where there is a kernel of truth to what the Wernecke family is saying — there is currently a study being run by a national pediatric oncology consortium to examine whether there is a select group of Hodgkins lymphoma patients in whom radiation can be omitted from their therapy. But here’s why it’s just a kernel of truth, and not the whole truth: the hypothesis of the study contends that it’s only the truly lowest of the low-risk patients who could be cured without radiation, and in fact, an intermediate-risk arm of the study had to be closed because it was clear that the patients were doing worse (read: more early relapses). And thus, while pediatric oncologists believe to be true the fact that there’s a subset of lower-stage Hodgkin’s patients who don’t need radiation to cure them of their disease, we also know to be true that with the chemo medicines we have today, higher-stage patients require radiation in order to give them any chance of a cure.

Again, this is sad, mostly because the family and the oncologists weren’t able to come to a consensus that acknowledged the sometimes-bad side effects of treatment for a cancer that is certainly lethal without effective therapy...

For a family in crisis, with a frighteningly ill child, sorting through this data can be a nightmare:

In the initial period after diagnosis, parents sometimes doubt the accuracy of what they have been told...If a diagnosis is difficult to determine, they may wonder if the medical staff is as knowledgeable as they should be. They may decide to seek a second opinion. Initial disbelief or denial, like shock, can buffer very painful feelings. It is a way for parents to gain time to adjust to the disturbing reality of their child’s diagnosis and to confirm that their child will receive necessary and appropriate treatment. Only when parents’ denial delays timely treatment is there a problem...

Being anxious and fearful when events and their outcome are unfamiliar and beyond our control is a normal human reaction...Since physicians cannot guarantee the outcome of treatment for any particular patient, fear of the possible death of a child or adolescent is not unreasonable. Having to rely on the knowledge and skill of others to protect the life of a much-loved child is frightening. Facing major changes in daily life is upsetting and parents may worry that they will not be able to manage all that will be asked of them. They may also be concerned that their child will not be able to cope with the necessary treatment. They worry about the impact treatment will have on their child’s body and self-esteem. Fear of the intensive treatment, of an uncertain future, and of the unknown is very understandable...

More on children and cancer, at the American Cancer Society Website.

A father copes with multiple sclerosis

From the Guardian:

Just as my 12-month-old daughter is learning to take her first wobbly steps, I fear I am taking some of my last. As I watch her faltering progress across the kitchen floor, I know just how she feels. Like a toddler, I too need to hold on to the furniture and walls for support, and invariably I stumble and fall before I reach my objective.

Unlike her, I don't bounce quite so easily...

My eldest is beginning to suspect I am not quite like other dads. Information is on a need to know basis, and we have decided they will not really need to know details for some years yet. Daddy keeps them entertained by falling over and spilling things. If I don't hurt myself, it's not a big deal. The trick is to make it all matter of fact.

But that does not stop the questions. "Why are you wobbly? Why do you use a stick and wheelchair?" I explain my legs don't work sometimes as well as they should. And then it's swiftly on to the next thing.

Naturally, I want to protect my children and shield them from my MS. But I can't hide or cure the disease and we were never going to grant MS the status of becoming a big family secret. By not talking about something, you empower it and it becomes more threatening precisely because it is hushed up. The children would be vulnerable.

Their unspoken fears might include my premature death from MS or indeed their own deaths. MS is a very inclusive condition. Everyone in the family is affected...

A surgeon's poem

The Interview:

She remembers the interview. Appear earnest.
A pigtailed bobblehead.
I love science,
I love working with people,
and medicine
Running, she was running
A blue-collar upbringing complete with 2-carbon chain sucking parents
A vacuum.
Say community and rural, alot , and Smile
She wanted, no, needed a career.
A career to engulf her.
Too busy to cry.


And then she was engulfed.
Surgery.
The comfort of control.
And while she was away
Her children grew. What did happen to her husband anyway?
Is that genetic or was it his vacuum?


Her daughters were gone,
The shells were there – gutted, hollow.
For one it had gone on almost half a decade.
Where had she been, where had
the bobblehead been-
Cross-clamping somebody’s fuckin aorta.
Reveling in the glow of another save.


Now, left with the damages, the damaged
The justice system.
How do you fill a shell?
With newspapers? Like we do with an autopsied carcass.
What do you do with hollowed little souls
With innocence not ripped away but
coaxed and teased ?


Can we not tighten up this interview process?

-Hope Baluh, M.D., from Scope, SIU School of Medicine.

Excellent Grand Rounds

with pomp and circumstance, at MedGadget. Go there at once!

Star Wars on the couch

How can a med student get a much-needed break during psychiatry clerkship? ReaLspace finds that a movie may offer no relief:

Watching Star Wars 3 (much better than the first two), I couldn’t help the train of thoughts running through my mind: Paranoid delusions. Grandiosity. Impulsivity. Inflexibility in thinking. Black and white thinking. Anger management issues. Issues with authority figures. Tendency to aggression and violence. Ambivalence. Labile. Poor coping style. Difficulty with trust. Psychomotor agitation. Lack of insight. Query psychosis. Query antisocial personality disorder, possibly psychopathic. Query borderline personality disorder. At very high risk of PTSD, depression. Management? Likelihood of medication compliance? Need for involuntary treatment order? We’d need a lot of backup...

Hat tip to Rebel Doctor, who adds his own assessment of Darth Vader:

I think Realspace is on the right track when he mentions the cluster B personality disorder diagnoses of antisocial personality disorder and borderline personality disorder, though I would vote for a diagnosis of narcissistic personality disorder (he has a grandiose sense of self-importance, is preoccupied with fantasies of unlimited power, believes that he is special and should only associate with other high-status people, requires excessive admiration, has a sense of entitlement, shows arrogance, and is often envious of others or believes that others are envious of him. He also lacks empathy, at least at the end of the movie)....
Managment: he might have been a candidate for intensive psychodynamic therapy before he went to the dark side; after that he was essentially untreatable. Don't think any mediction would have helped. I don't think anyone is powerful enough to enforce an involuntary treatment order on Vader, and it can be hard to get an involuntary treatment order for an axis 2 diagnosis in many jurisdictions.

When our residents are sued

From Medical Economics: Malpractice Consult. Are you liable for a resident's mistake?

Q: I'm an attending physician who supervises residents at a big city hospital. If something goes wrong with one of the residents' patients, I'm afraid I could be held liable. My colleagues tell me not to worry. Are they right?

A: The short answer is "No." If a resident is sued while working at a hospital under your supervision, you and the hospital may both be held legally responsible for his actions. The resident may be sued initially, but plaintiffs will typically drop the resident and go after the attending and the hospital because they have "deeper pockets," and are therefore more lucrative targets.

Even if the resident is dropped from the suit, he may still be deposed, and may even have to testify at trial. If the case settles or results in a judgment, however, it's generally the attending whose name will be reported to the National Practitioner Data Bank, not the resident's...

One recent case involved a resident who worked at a nursing home under the supervision of an attending medical director who stopped by once a week. When a patient fell, the resident examined her and put her to bed without calling for an X-ray or consulting with the attending. Four days later, when the attending showed up and noticed the swelling, he diagnosed a fractured hip. In that case, the resident and the attending were both sued, but the plaintiff later dropped the resident from the suit, and proceeded against the attending only...

-excerpted from a column by John M. Fitzpatrick, JD. It's terrible for an attending to be sued for something that a resident has allegedly done (don't ask me how I know this...I might blog about it someday).

The temptation of the blogger

A late-night visitor greets Professor Batty at his laptop:

"Allow me to introduce myself," the apparition purred, "and please forgive my brash intrusion. I am Beezulbub, the Prince of Darkness, Satan, or he who some may call the Devil, and I am here to make you an offer that I think you will embrace willingly, once you comprehend it in its entirety."
The dubious professor thought: I simply must get that screen replaced...then spoke: "What do you want with me?"
"I notice that you're blogging, having a tough time of it tonight, aren't you? A little short on inspiration tonight?" -the hint of a sneer curled the nocturnal visitor's lip as he continued; "You realize, of course, that I could help you make your blog an overnight sensation...

-"Batty and the Devil," at Flippism Is The Key.

" Top Ten Pitfalls of Being a Psychotherapist"

From Jassy Timberlake's Other Side of the Couch:

Caution: Taking this seriously may be dangerous to your mental health!

1. You forget how to conduct small talk and can empty a room at a party in 30 seconds flat!

2. You’re constantly biting your tongue around friends and family (arm-chair therapizing of family is particularly de trop!)

3. ….and on the other end of the spectrum, running screaming from the room, after a 9 hour day in your therapy office, when your family wants to tell you about their marital challenges/office politics/boyfriend troubles/aches and pains/parenting dilemmas, etc.

4. Your hairdresser tells you all her problems. (Isn’t it usually the other way around?)

5. When you tell people you’re a therapist, they either (a) look scared and clam up or, (b) look grateful and unburden themselves or, (c) they ask if you can read minds and then test you, Verizon style, on your skill. (“Okay, can you read me now?”)

6. Your head is permanently tilted quizzically to one side.

7. You use the word “feel” so much it makes you want to slap yourself.

8. Having to hang out around other therapists.

9. Coming to the ghastly realization that your bottom is creeping out to the edges of your therapy office chair.

10. Comprehending with horrified astonishment that clients think you’re what passes for sane!

(hat tip: Dr. John Grohol's PsychCentral)