Friday, October 27, 2017

ATTITUDE ADJUSTER COFFEE BREAK

New in town, I sulked my way thru a huge grocery market.  Why don't they have the food I always bought at home in L.A.  You know, regular food!

Then, out of the corner of my eye, I noticed a pair of silver shoes - not your ordinary silver shoes. Not silver sneakers.  Glittering, new, company-for-dinner-flatware, blingding, fairy-tale movie, smooth leather slides.  I wanted to laugh, sneaked a look at the wearer to see if I might get slapped. We both smiled, then laughed.

The gorgeous young woman said "I was almost afraid to wear them." 

I assured her it was the perfect decision, and insisted:  There are times when it takes such a completely unlikely, unimagined, fun perspective to blast away a clunky, who-needs-this kind of a morning.

I wish you smiles.

Tuesday, October 17, 2017

MAYBE WE WON'T GET THE DOCTOR WE NEED




  Writing the Surgery post, I got a short reprieve from the real picture. I thought those steps and sources and questions would help us get the doctor we want.  Then a 5 yr old NY article re-issued re  Twitter, from one of our most famous doctors, threw cold water on my hopes.

Dr. Atul  Gawande sees our chances of getting an excellent doctor as definitely not guaranteed.  The article, THE HEALTHCARE BELL CURVE is subtitled "What happens when patients find out how good their doctors really are/"  And as I read on, it seemed to I had to face ..or how good they aren't.  Dr. Gawande, as he makes clear in his book, BEING MORTAL does not sit in an ivory tower and tell us what to think.  He travels to the places where medicine is or is not practiced in excellence.

He draws us in with the first chapter of a story of  a sick little girl, Annie; who we find has been taken to the famous hospital that is the very wrong one for her. 

Then we learn why it's so tough to find a find doctor:  The Bell Curve--how does it look?  "What you tend to find is a bell curve: a handful of teams with disturbingly poor outcomes for their patients, a handful with remarkably good results, and a great undistinguished middle."
 He doesn't expect complete perfection nor movie miracles in impossible situations.
  "What one really wants to know is how we perform in typical circumstances.   After I’ve taken out a thyroid cancer, how often do my patients have serious avoidable complications? How do my results compare with those of other surgeons?"


How can we stay away from the poor or worse ones?  He tells us it's not easy to get the facts: 
The results of their treatments is hard to get - in some cases hospitals and specific illness groups don''t always keep track.  And keeping track is hard to do, in part because of privacy laws.

Attempts to keep score by number of deaths also doesn't impress him--there are emergencies and uncommon variances.  But sometimes differences by hospital, for example, are unexpectedly dramatic.  "A Scottish study of patients with treatable colon cancer found that the ten-year survival rate ranged from a high of sixty-three per cent to a low of twenty per cent, depending on the surgeon."  And that's not the only disease with scary differences.


Maybe the doctor we're considering doesn't even know where he is on the curve - so what will we get when we ask? 

WHAT TO DO WHEN WE SEE HOW FEW MAY HAVE RIGHT ANSWERS?

If you don't want to read the whole story of records & and improvements in CF, Annie's disease, at least you might like the story of how a CF doctor in Gawande's "good" example, deals with a very young patient who's been backsliding, and how he makes a deal with her, and gets her back to safe self-care.

It's a happy ending.  Shows us in an action what can be done.  But where does such care fit into  our  fifteen-minute MD visits?

Of course, we want good hospitals,and good doctors who have the best knowledge, and who can think. 

We can't just hold on, live with that cancer or whatever we suffer from, until our medical schools turn out more greats, and the answers:  my brother died while doctors admitted they were keeping him alive until a better cure became available.  We want more hospitals that let the best doctors do what they need to do, when they need to do it.  

Please. 

Sunday, September 24, 2017

SURGERY? WHO YOU GONNA CALL? Real help



Surgery!     .  You may already be a surgeon's office.  You called  because something is very wrong. .   The surgeon who is talking to you now may already have a plan.     .He (or she) starts talking about what will happen.  This can make us think it's decided. But we must ask our questions, answer some of his, and be prepared

 To say that's all we can handle for today
 To tell him we will want a second opinion.  
To stand up, thank him and 
Walk out.

Surgery for most is permanent and risky.  Do-Overs do not fix what's been done, and we won't get 0ur money back. If you don't read all this, please at least read the last section.

A recent AARP  article "PICK THE RIGHT SURGEON subtitled Act as if your you choice is a life or death decision--because often, it is."  convinced me to work on this.  The writer, Linda Marsa emphasizes that any thing with knives can have "life-threatening complications."

Some state medical groups police their doctors.  My state medical board has punished some.  But doctors don't always police themselves.   A pub-med article lately said some doctors don't reveal bad doctors because they think... nothing would be done about it, or there's a "fear of retribution." https://www.ncbi.nlm.nih.gov/pubmed/20628132

The good news: her quote from ProPublica:

  "One group of 756 highly active surgeons
 didn't have a single complication over five years."

Later Marsa suggests such great results should happen oftener, quotes a study for one kind of surgery, death rates 4xhigher for those who performed fewest of a certain surgery compared to those who performed the most.  (Doctors have even tweeted that doing a certain number of times counts.)

Also she ssays MBJ finds that specializing in one demanding complex surgery type "significantly cut the risk of complications and mortality."  So we ask a lot of questions like: how often, and is it your specialty?

She also has other places to search:

For credentials, the Federation of State Medical Boards has fsmb.org.  Click Consumer Resources
     For reprimands -for $9 they will give you disciplinary history
     Some state med boards have doctor profiles fsmb.org/policy/contacts
For  surgical board certification, certification matters.org, or call: 866-ASK-ASMS.
For specific errors, Consumers Checkbook or Pro Publica.  Remember some doctors take on very difficult patients which may affect their success numbers, while others take the easy ones. 

MD Referrals:  With the spine surgery - my primary doctor  knew everybody. I took his suggestion, and the spine has been great.  But another time I didn't take his first choice because I had met that surgeon and didn't like him. And my rule is:

Nobody I don't like is cutting me!  Period. 

 If you are new in town, you may not even have a doctor or a few friends to ask for recommendations.  If you're working, there might be someone you could cautiously ask.
A co-worker led me to  my beloved L.A. doctor.

 At the dentist, in the mammography place, in the drug store, keep your ears open:  I was lying on a gurney in the hospital hall once when a nurse saw the ticket on my gurney: Ooh!  You got Dr. G.  He does fancy!   Yes, Marsa admits - hospitals don't always kick out bad surgeons.

She suggests "Identify surgeons approved by your insurer."  I haven't tried that.

So it is possible to get a good one.  One more suggestion:

The hospital referred me to the solo lumpectomy surgeon. He did a good job, answered questions, told me I didn't have to do anything further, showed me my path report, gave me referrals including the oncologist I love.


Once you've got a name or three,  Do Not Skip This Section.  This is where we pin down the surgery facts way before our Yes or No.

 HOW TO INTERVIEW A SURGEON.    
Ask and persist until you get answers:

Can this be done with minimally invasive surgery - like laparoscopy or...?
What percentage of these involve open surgery?
What percentage of these have complications?
 Is hospitalization involved?
Do you specialize in this surgery? 
How many of these have you done?
What are my risks?  And above all...

DO I NEED THIS SURGERY AT ALL?  

Then as Dr. Cedrek McFadden's Tweeted:
"If no common ground or respect is found, move on." @cedrekmd


Sunday, September 17, 2017

A QUOTE I WILL KEEP - MIDNIGHT SPECIAL



Engineer, Air Force brigadier general, and surgeon: Michael Yaszemski, M.D., Ph.D., re time after last rites as he awaited surgery:

“I flipped a coin and it stayed up on the living side,”



 Mayo Clinic Discovory's Edge This week



Saturday, September 16, 2017

COLD MEDICINE - what's in it, good or not so good - COFFEE BREAK

On twitter this morning:  on a site Compound Interest

A picture chart (whatever they call them now) on what's in cold medicine and how does it work by Andy Brunning

You can see the picture on..... click this:







http://cen.acs.org/articles/93/i45/Periodic-Graphics-Chemistry-Cold-Medicines.html

I wish you health

Friday, September 8, 2017

TODAY'S COFFEE BREAK QUOTE:


"If you’re paid by the test, you’ll conduct more tests."

A little thought for our coloring books of what's wrong with our health system


https://www.forbes.com/sites/glennllopis/2017/09/06/value-based-healthcare-models-demand-inclusion-and-individuality/amp/

Thursday, September 7, 2017

NHS RATIONING TREATMENT THAT STALLS BREAST CANCER?

 A couple of women on Twitter drew attention the past week to this September 1 article in Telegraph by Laura Donnelly.

NHS rationing bodies refuse to fund treatment which stalls breast cancer 

According to the article, The National Institute of Health and Care Excellence said there was a lack of evidence to prove that the drug called fulvestrant extended lives.   

Studies that said fulvestrant "stalls the cancer’s growth by around three months" were seen as weak on research. 

Also NHS  feel it is too expensive compared to other available drugs. So over a thousand women will apparently not get the drug until it is studied further. 

The article says Fulvestrant is "licensed for women with oestrogen-receptor positive cancer, who have not already had other forms of hormonal treatment."  (my bolding)

Right there I began to find different takes on the drug as used in the states.

 Medline Plus for instance seems to find different rules on who is eligible here for the drug:  

"Fulvestrant is used to treat hormone receptor positive breast cancer (breast cancer that depends on hormones such as estrogen to grow) in women who have experienced menopause (change of life; end of monthly menstrual periods) " and whose breast cancer has worsened after they were treated with antiestrogen medications such as tamoxifen (Nolvadex). (Bolding mine.)
   
Fulvestrant is also used in combination with palbociclib (Ibrance®) to treat hormone receptor positive breast cancer in women whose breast cancer has worsened after they were treated with antiestrogen medications such as tamoxifen (Nolvadex)."

Also "Fulvestrant is in a class of medications called estrogen receptor antagonists. It works by blocking the action of estrogen on cancer cells. This can slow or stop the growth of some breast tumors that need estrogen to grow."

More specifics from cancer.gov:
https://www.cancer.gov/about-cancer/treatment/drugs/fulvestrant:
"Fulvestrant is approved to treat:  Breast cancer in postmenopausal women. It is used in patients with estrogen receptor positive breast cancer that has metastasized (spread to other parts of the body) after treatment with other antiestrogens."   There it is again!  Not for use here as a woman's first antiestrogen. 
So  who should get it as the first antiestrogen, and who should not.
Aside from who should get it, I found notes on what it does from   
https://www.cancer.gov/types/breast/breast-hormone-therapy-fact-sheet

On this site, Tamoxifen, which I take, is explained  as a SERM -  drugs that bind to estrogen receptors, keeping estrogen from binding with them.  Serms are also versatile, acting as estrogen agonists in other parts of the body.  
BUT Faslodex/fulvestrant is presented as a different substance entirely:  "However, unlike SERMs, fulvestrant has no estrogen agonist effects. It is a pure antiestrogen.
 In addition, when fulvestrant binds to the estrogen receptor, the receptor is targeted for destruction."    (my bolding)

Those last three powerful words from an American site might be interpreted as hope or ammunition for argument by the women who are protesting the refusal to use fulvestrant without more testing.  

Who is right?  How could we ever know?