Looking for the best

I was asked to see a patient for a second opinion the other afternoon. A fortyish Malaysian Chinese gentleman, he presented with a recent and unexplained loss of weight, and had been evaluated quite thoroughly elsewhere. After a lack of a conclusive diagnosis, he had decided to seek further care at my centre.

Reviewing his medical history, I was convinced that there was an issue with his gastrointestinal system. Although the abdominal CT scan of my patient had been given the all-clear by a consultant radiologist from another hospital. Something still felt wrong to me, and I decided to amble down to the basement to look for a trusted colleague and a subspecialist in gastrointestinal radiology. In between smacks of coffee, the radiologist swept through the scans with a practised eye, but he stopped at one particular image, and his eyes narrowed. It was a subtle, and yet distinct lesion in the duodenum, that had eluded the first radiologist.

Skill matters, and one is more likely to find subspecialized skill in a large academic medical centre, than in small private practices. This is particularly critical in a world where this much desired subspecialization has also fragmented care, where a patient’s care may depend on doctors from a variety of disciplines such as diagnostic radiology, anaesthesia and pathology, without the patient even realizing it.

Unfortunately, it is usually very difficult for patients to recognize quality among their physicians – this is knowledge restricted to gossip and drinks over breakfast at the Houseman’s Canteen and the tea rooms of Mount Elizabeth and Gleneagles Hospitals.

The New York Times reviewed this lack of transparency recently with regards to the widely varying quality of MRI scans, and their reporting, in the United States. In this case, it is not just difficult for patients to know whether their MRI scans are optimal, but even the referring doctor may not recognize that not all MRI scans are equal. Think high definition TV versus black and white as an analogy of the differences in image quality. Further, it is seldom known to any whether the radiologist reporting the scan is a generalist or a specialist in the field.

What then for the patient who seeks the best care? In all honesty, just as knowing the right people can let one into the best clubs, it really helps to know some people in the field. Otherwise, the odds are that on average, a large academic medical centre is likely to provide better care than smaller fragmented practices, although there are always exceptions of course.

What or who is behind “Prime Oncology”?

The organization “Prime Oncology” has surfaced recently, purporting to provide professional education to oncologists.

With offices in the USA and in Europe and a surfeit of conferences, it is obviously well funded, but strangely very little can be found on the Internet about just <i>how</i>. Interestingly, the company is able to secure leading members of the profession to speak in its seminars and conferences. It claims to be “independent”, but independent of just what is unclear.

I have written to both offices to seek more information, but to date, there has been no reply forthcoming.

It is likely that Prime Oncology is funded by pharmaceutical companies. The lack of disclosure is worrying.

Be wary.

The drug industry has no choice but to creep towards transparency in the United States, with Eli Lilly and Merck planning to declare the payments it makes to doctors and consultants, but it’s a uphill battle all the way.

To please no one

Marc Weide reflects in the Guardian on the run-up to his mother’s (Mdm. Weide-Boelkes) scheduled appointment for assisted suicide, or voluntary euthanasia (the former term is preferred by myself). The article is poignant and mixed with black humour.

‘I’m going to die on Monday at 6.15pm’

5.30pm: Dad is bent over the toilet bowl with a brush in his hand and a scowl on his face. I walk up to him. “Shall I give you a hand?” Dad begins to snigger, abandoning any attempt to make sense of the situation. We stand shoulder to shoulder with our backs to Mum, who paces around the landing with a newly fitted catheter in her hand. The catheter has been put in by nurse Marianne to enable our GP, who will be with us in half an hour, to give Mum a lethal injection. But instead of having a moment of peace with us, as Marianne suggested, Mum demands that we clean the toilets. Both upstairs and downstairs.

My brother, Maarten, is sitting on the edge of the bath, staring out of the bathroom window.

“Imagine,” he mutters. “Her last hour, spent like this.”

This is the Netherlands, where voluntary euthanasia is permitted, as well as physician-assisted suicide. This is the day my mother has chosen to die, and the toilets need to be spotless.

Mr. Weide proceeds to describe the surreal weeks between the diagnosis and Mdm. Weide-Boelkes’s death. I wonder whether the behaviour that Mr. Weide found so troubling in his mother was the result of brain metastases, rather than merely dysfunctional coping mechanisms. This could explain the nocturnal vacuuming, which is incidentally a common presentation of mania. Palliative cranial irradiation may have gone some way in alleviating the nausea, vomiting and seizures that troubled and robbed her of her sense of security.

Apart from that detached clinical observation, I have nothing but sympathy for Mr. Weide and Mdm. Weide-Boelkes. As an oncologist who cares for patients with terminal cancer, I can appreciate how difficult the situation can be. Each person must face his or her own inevitable mortality eventually, and this process can be very stressful for families. Not all families are equipped or have evolved a dynamic to cope.

Finally, that the obsessive house-cleaning was a diversionary tactic to turn attention to the external, material world rather than the self is obvious. Who really was the target?

“To please no one will I prescribe a deadly drug nor give advice which may cause his death..”

An anachronism today, but Hippocrates has never been faulted with lack of clarity.

A prison of our own making

I remember the last time I met Mdm Lee clearly. She was crying in my clinic, but refusing admission for her paroxysmal vomiting and headaches. I knew her symptoms were due to brain metastases arising from her breast cancer. This malignancy had already eaten away one breast, leaving behind raw and weeping chest wall.

Expert witnesses

“We are easily shocked by crimes which appear at once in their full magnitude, but the gradual growth of our own wickedness, endeared by interest, and palliated by all the artifices of self- deceit, gives us time to form distinctions in our own favour, and reason by degrees submits to absurdity, as the eye is in time accommodated to darkness.”
Samuel Johnson: Rambler #8 (April 14, 1750)

Kathy approached me at a conference about a week ago*. She was a drug company representative whom I was familiar with, having seen her around the hospital over several years, rain or shine. An unfailing smile always at the ready, you could be assured that Kathy would be bearing food from Maxwell Road Hawker Centre, or little gifts for less hostile medical oncologists than myself. Nevertheless, we always had a civil relationship, even though I constantly declined all pharmaceutical largesse, from pillows emblazoned with logos all the way to including free business class flights to Prague (yes, Prague).

East versus West

“Youth cannot know how age thinks and feels. But old men are guilty if they forget what it was to be young” – JK Rowling, Harry Potter and the Order of the Phoenix

I like to keep in contact with young doctors; it keeps the mind agile, and less prone to the ossification that afflicts the worldly and experienced. Today, I heard from a junior colleague involved in the Internal Medicine Basic Specialty Training that the Specialist Training Committee had decided to link the Singapore training system to the American College of Physicians annual exams which all US residents in the Internal Medicine sit.

Feet of clay

As a medical oncologist, one rapidly becomes accustomed to the seemingly endless spin generated around new drugs. These drugs are hailed as ‘breakthroughs’, ‘potential cures’ and more. The buzzword in the last ten years has been ‘targeted therapy’, where new monoclonal antibodies and small molecule inhibitors are breathlessly rolled out at each year’s ASCO (American Society of Clinical Oncology) meeting.

There are no secrets between us

“Don’t tell her.”

The old widow with incurable cancer had been hustled out of the room by her other children, leaving her eldest daughter, whose eyes were hard and flat. The next few minutes are usually quite easy to anticipate: ‘The patient is a very pessimistic person’; ‘I want her to keep her fighting spirit’; ‘I don’t want her to know, she will think of suicide’; ‘Her third brother’s son, a nephew now working as a doctor in the USA, doesn’t want her to be told till he is back in three months time’.

The above patient is composite and fictional, in the interests of the sanctity of medical confidentiality. Nonetheless, the actual scenario does play itself out quite regularly in the hospitals of Singapore. How does a physician manage a request from a family member not to disclose a diagnosis to the patient involved?

Little joys

Oncologists are often incurable optimists. I suspect that most of us have rather sunny dispositions, contrary to what many colleagues outside this discipline might think. It is true that many of our patients have terminal disease, but certainly the proportion is not as high as one might think. In some oncology outpatient clinics, perhaps over 70% of patients have curable or cured disease. At the same time, even when cure is not be an option, we optimists are able to assign value to a wide variety of little triumphs. Here are some of these little triumphs that I have imagined – if you think these stories are based on real events and characters, you think wrongly.

The red pill or the blue one?

I break for chemotherapy, and so can you.

It may surprise some, but there is often no definitive standard of care for those individual patients who vary from the Olympian athlete profile of the typical clinical trial participant. This is true of all fields of medicine, from anaesthesiology to trauma care. To therefore discuss the varied options requires a Sisyphean mental effort to make sense of all available data in the light of individual circumstances.

Many situations demand some improvisation. Consensus guidelines may be idols with feet of clay. There really is little purpose in recommending a cocktail of six different medications, if the little old lady staying alone is having problems with her eyeglasses, and thus prone to mixing up the red and the blue pills. Given inevitable modifications of best practice, a discussion of options is usually required for most patients.