Breaking The Bad News

On the TV show House, House’s oncologist pal Wilson was reputed to be so humane and caring when giving patients bad news about their condition that, when he was done, patients actually thanked him.  Studies indicate, however, that there aren’t a lot of Wilsons out there in the medical profession.  Instead, many doctors botch one of the most important parts of their job — giving patients truthful information about their medical condition when the diagnosis is grim.

Telling patients that they have untreatable cancer, or some other fatal disease, clearly is one of the toughest parts of a doctor’s job — and research indicates that doctors just aren’t very good at it.  Some doctors will break the bad news indirectly or use medical jargon that leaves the patient confused, others will do it with brutal directness, and still others will sugarcoat the news with treatment options.  As a result, many cancer patients aren’t well informed about their actual condition, and their prospects. A 2016 study found that only five percent of cancer patients understood their prognoses well enough to make informed decisions about their care.

Why are doctors so inept at giving patients bad news about their condition?  Of course, it’s incredibly hard to be the bearer of bad tidings, especially when the bad news is about a fatal illness, but there’s more to it than that.  Communications skills apparently aren’t emphasized at medical schools, and many doctors see a diagnosis of an incurable disease as a kind of personal failure on their part.

It’s interesting that, in a profession so associated with the phrase “bedside manner,” so many doctors regularly mishandle what is arguably the most important part of their job and so few medical schools make sure that their graduates are equipped to handle that task in a genuine, caring, and understandable way.  I hope I never receive a devastating diagnosis, but if I do I hope it comes from a doctor who knows how to break the bad news.

A Good Man Down

We lost another friend yesterday.  A colleague from work, Tom passed away after a short but valiant battle with pancreatic cancer.  He was only 60.

We met 31 years ago when I joined the law firm and was assigned to an office next to his.  We shared the same curse, both being diehard fans of Cleveland sports teams, and became workplace friends.  Because I had worked for a few years between college and law school, he was already a seasoned associate when I was a raw rookie, and he happily served as a sounding board for the kinds of questions that inevitably arise when you start working at a new place.  It quickly became apparent that he was extremely smart, a very talented lawyer, and somebody who was viewed by firm partners as a rising star.  He invited me to join a group of older associates who went out for lunch from time to time and swapped stories about the firm at a place that specialized in apple dumplings, and it made me feel included, and a little bit more like a part of the firm.  He didn’t have to do it, but he was just that kind of person.

After a few years in neighboring offices he exercised his seniority and moved to a better office, and we saw less of each other.  He got married and we both focused on our families and things like trying to build our law practices, but he remained the kind of guy who would send along an article and funny observation about the latest crushing Cleveland sports disappointment or email a wry comment about national politics or a development at the firm.  Since his death yesterday, several people have said that he had no enemies — and that’s true.  He was a person who was happy with his wife, happy with his life, and happy in his work, content with his circumstances and satisfied with how things worked out.

And that’s one of the things that made the news about his discovery, only a few months ago, that he had already advanced pancreatic cancer so difficult to accept.  It simply doesn’t seem fair that such a friendly, mild-mannered, fundamentally decent person could be taken so cruelly and never given the opportunity to retire and enjoy the fruits of his years of very hard work.  But after you’ve seen untimely death take a number of good people, you realize that fairness really has nothing to do with it and stop trying to make sense of it.  The key thing is to live a life that, when the time comes, hopefully leaves those who must move on with fond memories of a good person who will be missed.

Tom Ruby accomplished that.

Going Out Your Own Way

There’s a reason — aside from getting helpful birthday reminders — to endure the political stuff and the paid ads and still participate on Facebook:  sometimes you’ll see a story that you missed the first time around.

I saw this article about Norma Jean Bauerschmidt on my Facebook news feed today, thanks to a posting by Dr. Golden Bear.  It’s old news, dating from last year, but the underlying message is timeless and bears repeating.

For those who missed the story, Miss Norma was 90 years old when she received the news that she had uterine cancer.  Her only treatment option, which wasn’t likely to produce much in the way of positive long-term results, was surgery, radiation, and chemotherapy.  Miss Norma decided to chuck the treatment and live her remaining days traveling the United States.  She ended up on the road with her son, daughter-in-law, and their dog Ringo for about a year, visiting multiple states and national parks, taking her first hot air balloon ride (where the photo accompanying this post was taken), and trying her first taste of oysters, before the disease forced her into hospice and eventually led to her death.  Thousands of people followed her exploits on a Facebook page called “Driving Miss Norma.”  She died on September 30, 2016, and you can see her obituary here.

It’s a great story, and it made me wish that I had the opportunity to meet Norma Jean Bauerschmidt.  When people are faced with such end-of-life decisions, there is no right or wrong answer — you just have to be true to yourself.  Miss Norma chose the path that was right for her, and thousands of people were made a little bit better thanks to her decision.

One part of the story linked above particularly touched me.  During her year of travels, Miss Norma was often asked which spot was her favorite.  She always responded:  “Right here!”  It’s a good reminder about the importance of living in the present.

In The Grand Scheme Of Things

Yesterday I received word that a friend and long-time colleague had died.  Even though I knew it was coming, the news still was difficult to take.

It had been about a year since my friend was first diagnosed with cancer.  He had one of those “bad cancers,” where the survival rates are low and the prospects are grim and there just haven’t been many treatment advances that can give the afflicted some encouragement.  Nevertheless, my friend was unfazed.  He’s always been one of those happy warrior types, the kind who approach everything, even a terrible personal illness, with optimism and enthusiasm and curiosity.   He learned what he could about his condition and his treatment, engaged in spirited and intelligent discussions with his doctors about his options, and could give you detailed, knowledgeable descriptions of what was happening, and why.  It told you a lot about his true nature.

There was something inspiring, too, in how he dealt with his condition.  He may have had private moments when he cursed his luck and the dread disease that had befallen him, but his public face inevitably was hopeful and confident.  He came to work when he could, and spoke of days in the future when he could take an even greater role, because he loved being a lawyer.  It was an amazing display of spirit and fortitude.  He unfailingly projected the positive mental attitude and willingness to battle, undeterred, that doctors often say can make a significant difference in a patient’s prognosis.

Unfortunately, this wasn’t an instance where the mental could control the physical.  When my friend got the news that the treatments weren’t working, he accepted it with a kind of awesome grace.  He would speak of how his illness had opened up new channels of communication, made his talks with his friends and family more meaningful, and brought his already close family even closer.  He actually seemed to feel that, in certain ways, the bad news had nevertheless provided some important benefits.

The last time I saw him, Kish and I visited my friend and his wife at their home.  The cancer was taking its physical toll, but his mental outlook remained bright.  We talked and tried to say the things that need to be said without making it seem like we considered this to be the Last Time Ever, and as our visit drew to a close he mentioned that we should see his “trophy room” — which turns out to be his dining room, filled with pictures of his family.  As the inevitable end neared, he realized that that was what was important, and the pride he obviously took in his family left us moist-eyed and with lumps in our throat as we left his house and walked to our car.

I’ve always liked the phrase “in the grand scheme of things,” because it captures the sense of perspective that we should all strive to maintain.  In the vast spectrum of possibilities that we may encounter during our lives, some are important but most truly aren’t, even though they might seem to be at the time.  My friend fought his cancer with courage, faced his prospects with dignity and grace, and could find positives even in circumstances that many people would find unendurable.  He was able to see the grand scheme of things and distinguish the crucial points from the petty reversals and the minor annoyances.  We should all hope that we can do the same.

Happiness And Health

Studies show that happy people — or, at least, people who self-identify as happy — are likely to live longer.  So, does that mean being happy is the key to living to a ripe old age?

Scientists now say . . . not so fast.  They found that although the happy people in the studied population of a million women were less likely to die during the ten-year study period than people who described themselves as unhappy, when researchers looked into the health of those groups they found that happy people also tended to be objectively healthier than the sad contingent — and healthier people by definition are likely to live longer.  In short, happiness might be correlated with longevity, but being happy, by itself, doesn’t cause long life. The study bluntly concluded:  “Our large prospective study shows no robust evidence that happiness itself reduces cardiac, cancer, or overall mortality.”

No surprise there, really.  Only the most ardent happiness advocate might think that the simple act of being happy could, say, prevent the formation and spread of cancerous cells in your body or allow you to escape a genetic predisposition to heart attack.  But that obvious conclusion still begs a significant question — why does the correlation exist in the first place?  Why do happy people tend to be healthier than unhappy people?

I think the answer is clear — and the key is not happiness, but the state of unhappiness.  If you are in pain or feeling sick or otherwise are suffering from poor health, it’s difficult to maintain a happy attitude.  On the flip side, if you’re down in the dumps, it’s harder to get motivated to do the things that help to keep you healthy, like getting a decent amount of exercise and watching your diet and your weight.  How many unhappy people overeat to compensate for their depression, for example, and end up dealing with obesity, the health problems associated with it, and the poor self-image issues that tend to accompany it?

Happiness therefore might not be the cause of good health, but unhappiness and poor health seem to be part of a cycle, with one reinforcing and contributing to the other.  Happiness therefore might not be the cause of a long life, strictly speaking, but if you can develop and keep a positive attitude it sure seems to help.

Cancer, And Bad Luck

Cancer, in all of its many forms, is a terrible disease, and when you are part of a family where cancer has taken its grim toll you come to dread the very word.  It is not surprising that many people — whether cancer sufferers or survivors and their family members, cancer charities, doctors, or researchers — have passionate views about the disease.

This was illustrated earlier this month when Cristian Tomasetti and Bert Vogelstein of Johns Hopkins University published an article in the journal Science that attempted to quantify the role of random chance — what we might call “bad luck” — in the process that causes normal cells to mutate and become deadly agents.  They found that while there were clear causes for certain forms of cancer, such as smoking and lung cancer and exposure to sunlight and skin cancer, more than half of many cancers appear to be the product of random mutation.

The notion that random mutation plays a role in the development of cancer is not a new idea; our bodies have 50 trillion individual cells, and in a number that enormous there are bound to be anomalies.  Nevertheless, the Science article provoked a huge outcry.  Some people accused the researchers of being shills for industry and overlooking or excusing the possibility that foods, chemicals, and other products and substances that we are exposed to are the cause of the cancers.  Others depict the article as socially irresponsible, because the quantification of the significant role of simple “bad luck” may cause people to throw up their hands and forsake steps that can reduce the occurrence of cancer.  And still others — such as parents of children who have battled cancer — were grateful for the suggestion that the cancers that have affected them and their families wasn’t their fault.

It’s an arbitrary world out there, and bad things happen for reasons, but also for no reason at all.  We would like to think that we can control everything that might affect us, but obviously we can’t.  When it comes to cancer, that reality doesn’t mean we should rush off to buy a pack of cigarettes, but it does mean that we should accept that bad luck plays a role and not reflexively blame the victim, their lifestyles, and their genes.  Avoiding cancer-causing agents remains important — but the unfortunate reality of random mutation and bad luck means that early detection is crucially important, too.

Dope And Hope

The politics of marijuana are changing.

As exhibit number one, consider Michelle Malkin, a reliably conservative political commentator. Yesterday she wrote about her visit to a marijuana shop in Colorado — not to rip the legalization movement, as you might expect, but rather to describe the positive impact marijuana use has had for her mother-in-law, who is dealing with cancer and has experienced problems with loss of appetite. By using the legal marijuana in Colorado, her mother-in-law’s food intake has improved, leading to hope that she will get stronger and weather the ravages of cancer treatment. And, as a bottom line, Malkin notes that the operators of the shops carefully run neat businesses, pay taxes, employ people, and provide goods and services that people like her mother-in-law want and need.

A number of states have changed their marijuana laws in recent years, but Colorado appears to be the focus of attention. In states like Ohio, where there doesn’t seem to be an significant movement toward either approval of medical marijuana or decriminalization on a state level, I expect that legislators are taking a hard look at the Colorado experience. Are significant additional tax revenues are being produced? Is there any appreciable effect on crime? Are people like Michelle Malkin’s mother-in-law benefiting? Is the legal sale of marijuana having any impact on tourism? The answers to those questions will tell us whether states like Ohio, which tends to be a follower rather than an innovator, may change its marijuana policies.

The Genetic Snare

Recently a friend survived a heart attack.  He didn’t smoke, kept his weight down, ate the right things, and got exercise.  But his father had had a heart attack, and when my friend reached his mid-50s, so did he.

When something like that happens to a person you know, it shakes you.  You think about your own family medical history and wonder how many of those health problems were due to lifestyle and how many to awesome genetic forces lurking deep within our cells, like tiny time bombs that could explode with devastating consequences at any moment, irrespective of how much lettuce you eat?  Did my father, uncle, and grandfather die of cancer because they were heavy smokers, or because of some squamous anomaly in their mitochondria that was triggered by strands of DNA without regard to intake of tar and nicotine?

And, probing even deeper into the levels of introspection, what would you prefer the answers to these questions to be?  Are you a fatalist who is more comfortable thinking you’ve already been dealt all the cards and just have to play the hand as well as you can?  If you could take a test and determine, conclusively, that the raging fires of cancer were going to consume your body no matter what you did, would you want to know so you could adjust your lifestyle accordingly and move down the spectrum to enjoy the delightful but unhealthy things you’ve avoided?  Or would you rather hope that your good behavior and healthy lifestyle could win you a reprieve from the otherwise inevitable genetic snare?

I’m in the latter category.  I’d like to think that my decisions make a difference to the equation and might have an impact on whether I keel over in the near future.  My friend’s situation makes me think, however:  “Am I just kidding myself?”

“Reports Of My Death Are Greatly Exaggerated”

Somewhere, Mark Twain — who coined the classic phrase appearing above, upon learning that his death had been mistakenly reported — must be smiling.

Today Hugo Chavez, the thuggish Venezuelan dictator who is undergoing ongoing treatment for cancer, had to call a state-run TV station to try to dispel rumors that he was already dead.  Chavez said that he is in Cuba getting radiation treatment for a pelvic tumor and contended that the rumors were part of a psychological war against him.

I’m sure it’s not easy being a loud-mouthed dictator under any circumstances, and it’s probably even harder to be a successful autocrat when you have to interrupt the normal propaganda programming on national TV to deny rumors of your own death.  It’s undoubtedly tough to rule by bullying and intimidation when those you are trying to bully and intimidate think you might already be toes up.

50/50

If you’ve lost a family member or close friend to cancer, as most Americans have, you’re probably not eager to watch a movie about someone struggling with the dread disease — even if it is billed as a comedy of sorts.  Kish and I decided to take the chance, however, and went to see 50/50.

We’ve enjoyed the prior work of Joseph Gordon-Levitt and Seth Rogen, the two principal stars, and they were as good as we expected.  Gordon-Levitt plays Adam, a risk-averse neat freak who learns he has cancer, parts ways with his overwhelmed, self-absorbed girlfriend, goes through chemotherapy, and struggles with the 50-50 possibility that he might not survive.  Rogen is Kyle, a crass, stoner friend who provides crucial moral support — and, Adam learns, is approaching his friend’s disease with care and thoughtfulness.  Their interaction is hilarious and touching.  Along the way Adam learns important lessons about himself, the men in his chemotherapy group, and his domineering, yet deeply caring, mother.  The relationship that develops between Adam and his emotional counselor seemed like a plot contrivance to me, but it didn’t detract from what was otherwise an enjoyable, emotionally satisfying film.

It’s hard to imagine a movie about a young person dealing with cancer and potential death could be funny and positive, but 50/50 pulls it off.