The Complex World of Cancer Treatment

Cancer. With such variation in its form, cause, and effect, with fundraisers of every kind—from walks for breast cancer to Humans of New York posts—millions of dollars a year are dedicated to researching these diseases  and how to cure them. But when it comes to treatment, what are the obstacles in the way?  From the scientific mystery to the side-effects and dangers, the issues around cancer treatments are just as complex as what they try to cure.

When shadowing Dr. X* this week, I saw almost exclusively cancer patients. Most of them came in with choroid nevuses, freckles that had to be watched in case they became tumorous, or else they came in with the cancer behind them, for post-surgery check-ups. Despite the serious tone of the appointments, there was no lingering pressure in the air. The threat either had not arrived, or it was past. The last patient was different.

Patient John Doe came in at 9AM for tests and didn’t leave until after 1PM. The nevus in his eye had become eye melanoma. Dr. X sat down with him and his daughter, showed him the images, answered their questions, and of course, discussed treatment. She gave two options—the standard treatment, which involved radiation to the general area in a patch sewn directly on the eye, or an experimental new treatment found only in Boston and San Francisco, which targeted radiation on the tumor itself. Up until now, most of the questions came from John Doe’s daughter. His first question: “So this will save my sight?”

The answer was no. The radiation from the standard treatment would likely leave him with only shadows and light (with luck, he may be able to read large print) and while the experimental treatment was likely to leave him with more, he still would lose many of his everyday abilities, such as driving. But if left untreated, he would lose vision in that eye and face the possibility of the cancer spreading to other parts of his body. His indecision was palpable, for whichever way he turned, he wasn’t coming out unharmed.

This incident reminded me of Sadie Winthrop. In eighth grade, Sadie Winthrop and Sam Smith were two Mason students who were diagnosed with leukemia at the same time. “For Sadie and Sam” was emblazoned on every in Mason for two years, eventually, both when into remission. Last spring semester, however, the community learned that Sadie had been diagnosed with cancer once again: this time, it was an inoperable brain tumor (glioblastoma)—caused by the radiation treatment from her leukemia days.

As cancer treatments continue to advance, I wonder whether or not it is possible to create a treatment that won’t hurt the body it tries to heal. After all, a cancer cell is still a cell, and anything that can kill it can kills your healthy cells as well. So, always there is a search for new genes and new techniques. These can lead to targeted therapies, focused on attacking only the affected cells or focusing treatment specifically on the affected area alone. Ideally, this seems to be our best path of action, and such treatments are being created constantly. For example, Dr. Souwedaine, whose efforts on DIPG were recently told by Humans of New York, has created a therapy that works to administer drugs in brain tumors directly to the site itself. Many of these treatments, however, are still experimental and unavailable to the widespread public (either due to cost, FDA approval, or other factors). Such research also enquires innovation, which can be a tricky line in treatment. To be creative, you often have to make various models that won’t work to find the one that does. But for doctors, every failure is a life, and thus they “must invent without being too imaginative” (Humans of New York 2016). Additionally, many of the more common treatments are not as precise, which can kill the cancer, but also negatively affect the patient’s health in other ways.

Cancer treatment can also become a political and ethical minefield. The hot-button topic of universal healthcare envelops cancer care as well and, on the private healthcare side, access to more effective, but more expensive treatments can be vetoed by insurance companies. Certain types of cancer, like pediatric cancer, receive little public funding, and thus is reliant on private donations, with fundraisers often set up by the parents of the affected children themselves. There are high profile cases of individuals with cancer who refuse treatment—sometimes they are celebrated and other times, vilified, but the “right to live/right to die” always remains a controversial topic. In journal club as well, we touched on the lesser-discussed right-to-try. On the state level, some laws are passing to allow terminally-ill patients to use drugs or treatments that are not yet FDA-approved in the hopes of extending or saving their lives. These laws raise questions around morality and ethics, questions which are only set to become more complicated as time goes on. Take a hypothetical example: since cancer arises from malignant mutations in the genes, the only way to rid the world of cancer, as many want to do, is to rid humans of mutations. On one hand, the elimination of cancer would surely be a benefit to the world. On the other hand, stopping mutations, which are often helpful, would stop evolution as well, a subject which would cause even more discussion and controversy.

Even if we’ve never had it, cancer touches everyone’s lives. Society continually works harder on preventative care and education, but once diagnosed, we have a responsibility to give patients the best treatments that we can. Sometimes, our treatments might seem lacking, as they may have to John Doe, who must now decide which treatment to gamble his sight on, or to the Winthrop family, whose child’s cancer treatment lead to another cancer. Sometimes the research is stymied by practicality or funding, and sometime treatment in and of itself can become tangled in political and moral questions. None of this, however, means that we don’t continue to try. Cures are being found month after month, with patients coming home with positive prognosis due to the treatments and research being done. A treatment, even a flawed one, gives hope for the future, and a way to fight back when faced with the impossible. So, we continue in our search for the cure to cancer, all the while being mindful of that finding the cure isn’t the only obstacle facing cancer treatment in the future.

*All names, except that of Dr. Souwedaine, have been changed for privacy purposes

The Effect of Words in the Medical Field

Over our radio, on our television, in our newspapers. Language, and its effects, are grabbing more and more headlines as people begin to understand the power of words. Arguments arise over the historical vs. current implications of racially-named sports teams (ex. Redskins); mainstream media devotes full articles to the implications of college students wanting safe spaces and inclusive language. Politically, words have become statements, lines in the sand to showcase your positions. Do you say ISIS or ISIL? Are you pro-life or anti-abortion? In the light of words’ power, I decided to look at the various effects of word choice in the medical field.

One intriguing factor I noticed the use of traditionally business-associated terms in the clinics. Throughout this week, especially in Dr. X’s* clinic, I heard various business-like concepts, such as patients being referred to as “clientele” and decisions being motivated by “reducing overhead costs.” Dr. X prides himself on “efficiency” and “streamlining the process.” He asserts that his lack of technician is due to his attempt to “keep costs down” and mentioned that one of his dislikes about  patients cancelling late because they can’t fill up that spot with another patient, which he comments is a loss of revenue, especially as they don’t charge a no-show fee. He had an appointment with a patient who was also a doctor, and interestingly, their conversation (about another practice) revolved largely around the cost of service. When describing the establishment, they would mention cost first, and care second (ex. “It’s definitely on the higher end price-wise, but you really get what you pay for”). They used phrases like “getting your bang for your buck” and emphasized “free advertising.”

The proliferation and use of business-associated terms can influence the thinking/practices of medicine and lead to the creation of healthcare as business, which I would argue, is detrimental to healthcare overall. This is not to say, however, that business models do not have important and replicable values that the health system could benefit from. The efficiency and stream-lined process prized in business, and focused on by Dr. X, should be strived for in healthcare, so that patients can receive quick and accurate diagnoses and treatments. Likewise, the concept of good customer service can cause doctors to be cognizant of their patient interaction.

The issue with this mentality, however, is that it was designed with companies in mind, which operate on a system that puts revenue first. A mentality great for capitalism, but unfitting for health. When medicine is treated like a business and profit comes before patients, various pitfalls appear. For example, appointments may be rushed in order to fit in as many paying customers as possible, leading to lower quality visits and misdiagnoses. Doctors can also feel the need to prescribe unneeded drugs/prescriptions in order to satisfy the client and ensure repeat visits. For example, I also shadowed ophthalmologist Dr. Y this week, who saw a case of blepharitis. This clears up on its own, but can also be assisted with manual means like warm compresses. Instead of suggesting these treatments to the patient, however, she prescribed a set of steroidal drops and antibiotics. When asked, she responded that one of the reasons she did so is because “people just want a drop,” showing how doctors can, and do, change their treatments plans to satisfy the client, despite knowing that other, less costly, options exist, and that the problem will resolve itself without intervention.

The effects of the business model of medicine also have political and public health effects. Many doctors are refusing to accept Medicaid because they feel that the revenue is not enough for their services, leading to problems in healthcare access for those on government assistance. Drug companies practice “price gouging,” which can lead to individuals going without needed medication. A high-profile example would Martin Shkreli, a CEO of a pharmaceutical company, skyrocketing the price on an HIV/AIDs drug price by 5000% ($13.50-$750). The prescribing of unneeded antibiotics contributes to the creation of more resistant disease strains. In terms, politics affects healthcare as well. Congress has barred Medicare from negotiating with drug companies, depriving many of its members the ability gain their drugs for a fair price. Budget cuts in federal spending and in hospitals can lead medical personnel to increase focus on the bottom line, leading to the uprise of business terms in medicine. This contributes back to the adoption of the business model, leading to a cycle of action creating language, which creates action again.

Intriguing, the “business model” focus in language was heard most prevalently in the Optometry rotation. Dr. X also seemed hyper-aware of this situation, prefacing many of his comments with “it sounds like I’m talking about money . . .”One technician I spoke to specifically pinpointed towards this specialization as having issues, quoting that she “didn’t like the direction that field was going in,” and “didn’t like the high-pressure-to-sell environment where it disregarded what was best for the patient.” Following discussion at Journal Club, I discovered that there is often a rift between optometrists and opthalmologists based on these different models. So perhaps this specialization particularly lends itself to such practices but, as seen above, the effects of the business model can be felt throughout the health field.

The other point that jumped out at me was the use of language in the doctors’ medical notes. When denoting information about the appointment, examination, etc., the inclusion of race was sporadic—sometimes noted, sometimes absent. After watching appointment after appointment, I found the pattern–race was only included when the patient was non-white. When I asked the doctor how they decided whether or not to include this, the answer was usually some variation of risk factor. Different races may have different incident rates of a disease, and thus, the doctor would note the race to coincide with this information. (For example, African-Americans may have a 8% incidence rate, Caucasians 4%, Asians 6%, etc.).

At first, this method seems completely logical, useful and efficient. Yet, I still felt dissatisfied with this system and, after some time, discovered why. First of all, the ethnicity of the patient is already in each record, next to name, gender, age, etc., so any repetition is technically unnecessary. Secondly, the inconsistency of information creates ambiguity. When the information is absent, is it because the patient is Caucasian, or because the doctor forgot? But, lastly, while risk/incidence factor is a perfectly valid reason for calling attention to this information, risk factors come with other markers besides race. Age and sex also create different incidence rates, and in every record I saw, the doctors recorded both in their notes. We do not only mention gender if the patient is female/male. We do not only mention age if the patient is out of a certain range. So why only mention race if the patient is non-white? This creates a situation where “white” is considered the default, where minorities are singled out, marked, or set aside as “other.” In a world where racial bias is still prevalent, where some doctors still hold the belief that different races have different pain thresholds, leading to differences in pain medication and treatment, only harm can come creating “default races” and deeper distinctions between majority and minority.

Words are, technically, just words. Collections of sounds, arrangements of letters that we assign meaning to in order to communicate. But that assignment of meaning tells all and gives words, not only power, but political clout. Language has the ability to affect the reality around us. Denoting race in patient records only when it is not Caucasian perpetuates a system that places “white” as default, which engenders troublesome situations and complications. Adopting the language used in business can influence healthcare into adopting a similar model, which comes with benefits, but also negatives that we must be aware of. The creation of the business-model style is further supported through budget cuts, which also foster business-like language, creating a cycle that feeds into itself.

*All names have been changed for privacy purposes

Contrasting Styles of Doctor-Patient Interaction

Patient interaction. This phrase features prominently in every pre-med class, lecture and discussion. Students are encouraged to volunteer so that they can get that interaction early; they’re given lessons on what they should and should not do. During a volunteer shift at the James, I recently found a book, written by and for doctors, advising them on how to take cultural background and beliefs into their interactions. During my first rotation (Glaucoma), the two doctors I shadowed had markedly different styles of interaction, which led to, arguably, different tones for the appointments.

The first doctor I shadowed, Dr. X*, functioned very much as the “authority figure” doctor. The moment she walks in the room, she takes command of the appointment. She usually begins with asking how the patient is, and then reviews the patients’ record, usually in silence. In my opinion, some patients seemed comfortable with these period of silence, while others seemed a little unease with it. During examinations, her actions were very business-like, with discussion focused purely on the appointment itself, rather than any small talk. At the end of the appointment, Dr. X would ask if the patient had any questions. Most patients would follow a similar format: a question, followed by a story either further explaining their concerns, or their day and its changes. Dr. X often interrupt this follow-up, going straight into answering the initial question, even when it was obvious that the patient wished to continue speaking/telling their story. In general, Dr. X’s visit times were shorter than her counterpart, Dr. Y.

Dr. Y was the second doctor I shadowed, whose approach was more oriented toward the “personal connection.” Small talk was much more prevalent, whether it was a comment or inquiry about family, school, etc. Often, he would be the first to offer this information as well, recalling information shared from past visits. This small talk usually occurred during examinations or before examinations, and was more bidirectional, with the patients contributing just as much, and were rarely interrupted. The patient record was reviewed outside of the room, leading to less periods of silence and larger percentage of time focused on the patient. Overall, these factors together made the appointments longer in length, but also gave them a friendly, casual tone.

Some of the differences, most likely, stemmed from logistics. For example, Dr. X’s access to a computer between appointments seemed much more restricted than Dr. Y. This, most likely, was the reason for the need to review records with the patient in the room, which sometimes resulted in patient unease. Other differences may have been attributable to personality differences, time restraints or numbers of patients.

Each style seems to have its pros and cons. I would argue that Dr. Y’s style appeals to those with a more patient-centered approach—it’s more personal, especially with the exchange of small talk and conversations outside the medical visit, and allows both doctor and patient to reveal a bit more of their personality. For many individuals, this can create more of a bond between the two, and lead to a better working relationship. Personally, this is the style that appeals to me. If I were the patient, I would enjoy the small talk and lack of interruptions, even if it lengthened the appointment, as it would make me feel like the doctor cares about me personally, rather than just as his 4:30PM patient. Others, however, may feel that this style is too familiar or casual. My father, for example, would much prefer Dr. X’s approach, due to its more clear-cut roles and expectations. The simplicity of the conversations—focusing largely on examinations, relay of information to patient, followed by treatment plan and future directions—makes it easy to follow and focus on the needed information. Dr. X’s style also clearly showcases her as a completely confident authority, which can assure patients of her competency and lead to better compliancy. Compared to Dr. Y’s patients, Dr. X’s patients were less likely to question or argue about the treatment. Dr. X’s methods also lead to shorter appointments, which would allow her to reach more patients in the same amount of time.

As a doctor, your job is to help your patient—to make them healthy and keep them as such. By these standards, the strength of a doctor should be focused entirely on the well-being of their patients. Yet, a doctor whose patients are healthy, but unhappy/hurt/insulted with how their doctor treats them, is not considered a good doctor. This shows the importance of patient-interaction. But should the patient’s feelings toward their doctor matter as much as if the doctor helps them recovery? I would argue yes. Having good patient-doctor repertoire is not only a good business model, as I’ve sometimes heard it described. It, more importantly, leads to better confidence in the physician, better compliancy, and a more at-ease patient. The Glaucoma rotation introduced me to two different, but effective, ways to achieve good patient-doctor rapport.

*All names have been changed for privacy purposes