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Day 85

September 29, 2012
I was reading a blog of an acquaintance who mention she had met a fellow cancer victim at UCSF who felt he had received poor medical care given by his local doctors back home.  They are both receiving treatment and will subsequently get a transplant.   As both a physician and post transplant patient, now day 85, I was struck by the story and some of the questions that were brought up concerning his experience.
Everything we read both in the lay press and hear on the media are large population studies.  By that I mean they include enough people so the conclusions reached have statistical significance and are not just chance.  So, if a treatment is 95% effective, that means it fails 5%.  But what always bothered me while in my own practice as a general internist in Santa Cruz was that when it came to the individual it was a 50/50 chance.  You either got it or you don’t.  Now I’m not saying we should throw out what is now called “evidence based medicine” with its double blinded cross over studies or meta analysis but as physicians, we’re more than number crunchers, we must combine the science of medicine with the art of medicine.
We are in a paradigm shift in both the economics and practice of medicine.  When I was doing my rotation in Pediatrics at Children’s Hospital in LA in 1980, Acute Lymphocytic Leukemia was 95% fatal and now it’s 5%.  Why?  Because of the incredible scientific breakthroughs in treatment and supportive care.  These advances are not without a price.  The number one reason for the explosion in medical cost is due to technology in diagnosis and supportive care i.e, MRI, ICU equipment, etc…  I for one, spent 35 days in the hospital last July at City of Hope in LA and it was incredible.  Thank God for what we can do in the name of healing and good medical care.
The blogger alluded to the recent US preventative Task Force position on prostate screening (PSA) and their conclusion that screening should be discontinued.  I won’t bore people with the specifics of the studies but it did stimulate a passionate debate among physicians.  Many experts disagree with the conclusions.  I think a physician needs to explain all the pros and cons of doing a PSA or any test or procedure with a patient and come to a mutual decision.  There is only one problem.  That takes time and trust and modern medicine has limited room for that.
I’ll put in my 2 cents.  My approach is what is common or statistically likely is what should be looked for initially.  In other words, when I hear hoof beats, I think horses (unless I’m in Africa then I think Zebras).  But if things don’t go the way they “should”,  then I expand my search and if necessary either do more testing or refer to another doctor.  When to do that is just one manifestation of “the art of medicine” and that requires experience, concern, and an open mind.  As a patient, I must be comfortable with my doctor and have trust.  But that does not mean I’m passive.  I ask questions and try to be proactive in my own health care.  For myself, I have my wife present to act as my advocate and help reflect back to me what was discussed.
I hope this isn’t overly pedantic and coming off as “sage on stage”.
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7 Comments
  1. Lee & Gwynn permalink

    Very insightful, Doc. From a patient’s point of view I have an enormous amount of trust in your perspective. Quite a bit more now that you’ve been “blessed” with your present circumstances. Now if the government would get out of the way and the trail lawyers would stop chasing ambulances the wonders of modern medicine will get more attainable by more sufferers. At least we can hope. God Bless….Lee & Gwynn

  2. laura maslon permalink

    lee and Gwynn i agree. my niece’s husband has been in this catch 22 of not getting into medical trials because he’s “too sick” and they want to have “positive” results. but then if every hospital and doctor acted that way..what would happen to our medical system? one hospital, in la jolla and one doctor stuck his neck out and fought for him because my niece is such a nudge and he’s alive today. so,bravo for compassionate doctors!!

    and shana tovah! to you and your family, jim.

  3. Chip Goldeen permalink

    Jim,

    Sounds like you are feeling better. Thinking about your job again! Sweet!
    The Giants are playing right now in San Diego and leading 3-2 in the first inning. Hang in there.

    Chip

  4. marc yellin permalink

    You said it so very well…completely agree!

  5. Randy Danto permalink

    Jim, I think the analysis of science based medicine vs. the art of medicine is extremely interesting. It offers the lay person a totally different insight into medicine. Your experiences are going to be invaluable. I think you should consider writing a BOOK!!! You’re a great writer and your insight is fabulous! I also think it’d be something you’d enjoy very much. “A Dr’s experience from the other side of the bed” or something catchy like that!!!

  6. Howard Eddy permalink

    Very well expressed Dr. Jim. Spike

    Sent from my iPad

  7. Jim Melendy permalink

    A dozen days to go, as I write this. I’m looking forward to your return!

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