Oliver Sacks learns he has terminal cancer

Oliver Sacks, in his moving NYTimes op-ed about learning that his ocular melanoma has metastasized to his liver:

I have to live in the richest, deepest, most productive way I can.

This will involve audacity, clarity and plain speaking; trying to straighten my accounts with the world. But there will be time, too, for some fun (and even some silliness, as well).

I feel a sudden clear focus and perspective. There is no time for anything inessential. I must focus on myself, my work and my friends. I shall no longer look at “NewsHour” every night.

Sacks’ version of “live like you were dying” is exactly what you’d hope/expect, showing his depth and ability to turn his careful consideration and clinical acumen internally, just as he did in his New Yorker essay about prosopagnosia (face blindness). Read the whole op-ed (and the essay too).

“Sudden clear focus and perspective” seem harder and harder to come by in the contemporary era, but I’m adding tacking it on late to the resolution list this year. I still remember first reading and being inspired by Sacks’ An Anthropologist on Mars and The Man Who Mistook His Wife for a Hat in high school, probably the two books which most shaped my early interest in neuroscience and medicine. He’ll leave a tremendous legacy.


Last day for 60% off Game Set Matched

Back in November I wrote about residency consultants, the folks who generally purport to help you polish yourself, your CV, your ERAS essay, and your residency application in general, as well help you prepare for interviews. Most readers of this site have no intention of ever utilizing these types of services, and I think that’s fine.

But for those considering in investing in some professional help (e.g. IMG/FMGs, US grads with a tight fight ahead), today is the last day left to get Game Set Matched‘s complete package for $399 (normally $999) by using BW399 when you create your free account (you don’t have to pay until you’re ready to actually use the service). Signing up now nets you the package for the 2015-16 application cycle, and the promo code will work through February 25th, the day rank lists are due this year. So if there’s any chance you might want to use their service, sign up now to lock in the discount.

Preliminary Medicine vs Transitional Year Internships

I’ve noticed a trend when I talk to applicants on the trail: a significant number of faculty advisors are giving some questionable advice, such as recommending that their students applying to advanced specialties (e.g. derm, ophtho, rads) only apply to preliminary medicine programs because transitional year (TY) programs are too competitive. That, combined with a lot of mystery about internship programs and the fact that most TYs are not at recognizable university based hospitals, means that applicants are at a disadvantage when it comes to making an informed decision about where to fulfill their internship requirement. I talk with applicants at dinners and lunches who already regret treating their internships like an afterthought and wish they had put more time into researching their options. I’ll address some myths below: Continue reading

What I read in 2014

2014 wasn’t a particularly big year for my library, but it is the first year I kept track of all of the books I read for pleasure, reproduced here in the order I consumed them:

  1. Steelheart by Brandon Sanderson (Reckoners #1)
  2. Divergent by Veronica Roth (Divergent #1)
  3. The Calling by Robert Swartwood
  4. Insurgent by Veronica Roth (Divergent #2)
  5. Allegient by Veronica (Divergent #3, finished the same day)
  6. Steps by Jerzy Kosinski (National book award-winner…in 1969)
  7. Cloud Atlas by David Mitchell
  8. Canticle by Ken Scholes (Psalms of Isaak #2)
  9. Gilead by Marilynne Robinson (a completely epistolary novel, rare form)
  10. Antiphon by Ken Scholes (Psalms of Isaak #3)
  11. The White Coat Investor by James Dahle MD (Basic financial literacy for physicians)
  12. Legion by Robert Swartwood
  13. The Dishonored Dead by Robert Swartwood (a highly unusual Zombie thriller)
  14. The Name of the Wind by Patrick Rothfuss (The Kingkiller Chronicle: Day 1)
  15. Requiem by Ken Scholes (Psalms of Isaak #4)
  16. The Wise Man’s Fear by Patrick Rothfuss (The Kingkiller Chronicle: Day 2)
  17. A Dance with Dragons (A Song of Fire and Ice #5)
  18. Maze Runner by James Dashner (Maze Runner #1)
  19. Cod by Mark Kurlansky (the spiritual prequel to Salt; that’s right, history through fish!)
  20. The Scorch Trials by James Dashner (Maze Runner #2)
  21. The Death Cure by James Dashner (Maze Runner #3)
  22. The Kill Order by James Dashner (Maze Runner Prequel)
  23. The Slow Regard of Silent Things by Patrick Rothfuss (Kingkiller side-novella)
  24. Light Boxes by Shane Jones
  25. Stiff by Mary Roach (cadavers do more than just get dissected, though that happens too)

Binge-reading young adult mega-hits over the course of a weekend off seemed to predominate interspersed with lengthy epic fantasy. For the record, the Maze Runner series isn’t as strong as either Hunger Games or Divergent. And truthfully, the weak third book in each of those trilogies almost ruins those series as well. Still can’t wait for Rothfuss to finish the Kingkiller trilogy; I almost wish I hadn’t already read the first entry so that I wouldn’t need to wait for the final/third book to come out!

Should your radiologist tell you the results of your scan?

Probably not. But some interesting lines from Gina Kolata’s article in the NYTimes:

Dr. Christopher Beaulieu, chief of musculoskeletal imaging at Stanford:

At that point the radiologist may be capable of transmitting the information but the obvious next question for the patient is, ‘What do I do now?’ which, as nontreating physicians, radiologists are not trained to answer.”

This issue here is not that radiologists aren’t “trained” in what happens next (in many cases, of course they are!)—it’s that radiologists don’t actually do what happens next. If you aren’t going to provide treatment, you probably don’t need to be offering patients their options, particularly if you aren’t privy to their history.

For now — with one big exception — how quickly a patient gets the results of a scan, including M.R.I.s, PETs, CTs or ultrasounds, can be idiosyncratic and depend on the particular doctor and the particular patient.

Yet patients want to hear from radiologists, the groups say. One admittedly unscientific indicator was patients’ comments to the American College of Radiology on Twitter. They said they did not want to wait for results and could not understand why a radiologist would tell a doctor their results but not them, said Dr. Geraldine McGinty, chairwoman of the group’s commission on economics.

Realistically, patients want their results quickly and probably don’t care who tells them. The main issue here is patient scheduling. It’s not fair to patients to have an MRI one day and then have an appointment with the ordering provider two weeks later. Many physician schedules are fully booked with routine follow-ups, leaving no room for add-ons when unexpected scan results come up. In some thoughtfully scheduled clinics, patients have a scan in the morning and are seen that afternoon. That’s ideal.

If a patient then still wanted to speak to a radiologist (leaving aside the issue of the non-reimbursable time spent), I think both the radiologists and the referring clinicians would be much happier having that happen in a context in which the definitive management discussion would happen immediately afterward and not in some yet-to-be-determined future appointment. If the patient finds out before the referring provider, then the system breaks down. And learning you have cancer only to be told you won’t be seen by the oncologist until three weeks later is also not therapeutic. We need to be more thoughtful in how patients are scheduled for follow-up—that’s the crux.

“The chance of your actually seeing a radiologist is almost zero,” said Steve Burrin, a physicist and retired vice president of The Aerospace Corporation. Mr. Burrin, 70, who has lung cancer and lives in Los Angeles, has so many scans — CT, M.R.I., PET — that he decided to take matters into his own hands. Now, he immediately asks for a copy of his scan and tries to understand it himself.

I do though think the current state of patient accessible information is problematic. More and more patients have access to their raw reports, which are written for a physician reader. 1 The information, terminology, and certain turns of phrase can be bewildering and frankly misleading to patients. If a patient report states there several “indeterminate renal hypodense lesions” which are “too small to characterize,” that sounds super mysterious. But they’re really just (essentially always) tiny cysts of no clinical consequence.

If the future is centered on more transparency and patient empowerment, it would probably be better if a patient-centered report was incorporated into the medical record with the salient points written in accessible language. This is similar to the approach used by WebMD and Medscape, which are owned by the same company, where there are pages on the same topic with one set of data shown to patients and another set to physicians.

  1. In many cases, the body of the report is actually geared for other radiologists and specialists and is confusing to most other physicians (which isn’t necessarily a good thing either)