Alternative

This article “What Do Doctors Say To ‘Alternative Therapists’ When a Patient Dies?” by Ranjana Srivastava appeared on my Facebook newsfeed yesterday.  I couldn’t resist reading it.  I think you should read it too.

First of all, it is clear I am a big nerd when this is the most eye catching thing I saw on Facebook.

But, the big reason it is eye catching is because I was curious what it would say.  And it said what I thought it would.  We say nothing.  We don’t talk about it with others.  We talk about it amongst ourselves.

It also echoed a lot of feelings I would describe having around alternative therapies.

I am probably one of the more “loosey-goosey” of the people in my department when it comes to alternative therapies.  I am touchy feely, I inherently trust people and I do believe that there is value in a lot of things we can’t or haven’t necessarily studied.  I’m that kid who did a presentation on medical marijuana in research rounds and concluded that it isn’t all bad and we really need to look into the stuff more because people are using it whether or not we think they are or should.

I ask people what they take over the counter or with supplements.  I explain why I ask.  You see, some products, although “natural” act in ways that counteract the actions of chemotherapies or radiation or other drugs.  Sometimes in terribly harmful ways.  Ways that make cancers not respond to treatments.  Or ways that make side effects worse.  I ask because I care.  Not because I want to judge you or make you feel foolish.

Actually, some of the drugs that we give people are “natural.”  Some chemotherapies are plant derived.  They are natural and very toxic, but when used appropriately can treat cancers.

I see nothing wrong with trying something different when nothing is working.  I see nothing wrong with adding things that have low risks of harms that may help.  I see nothing wrong with doing things that are healthy for you.

I do see something wrong with people who are encouraged to spend their life savings on a “miracle drug.”  When people risk their lives to procure enough cannabis to make the oil they were told online was a “cure.”  When people entrust their health to internet “doctors” and people who make a profit from preying on the sick and the scared.

Many of the “miracle” agents on the internet are anecdotes.  Sure, everything starts as an anecdote.  But, that is why things are tested, because we are often wrong and they are one-off events.

There is some laboratory in anecdotal data about cannabinoids.  I’m not refuting it.  I’ve read it.  But, there is no cold hard evidence for it as a cure for cancer in humans beyond the odd case.  Could it be coming?  Maybe… But that day isn’t today.  And there is cold hard evidence for other treatments in some cancers.

It scares me that some people believe the person that will make a fortune off of them buying their concoctions is more trustworthy than the person who makes the same amount of money whether or not they take the treatment.   It upsets me that people think I am the one brainwashed because I am offering medicine with evidence behind it, with the experience of time, the monitoring of governing bodies and the backup of provincial funding.

It terrifies me to know that supplements and some complementary therapies (not all) are not regulated at all.  In fact, often they aren’t even containing what they claim or have contaminants that can be harmful.    And people die from complications from these therapies.  Just like conventional medicine.  But in a lot of cases we don’t even know some of the risks.

When something claims to work almost all of the time or have no side effects… It probably isn’t for real.  Too good to be true is something I see a lot.  But people want it to be true.  And why not?  Some people have nothing left to lose.  But really, everyone has something to lose.

It also makes me sad that some of my colleagues think all complementary or alternative therapies are bad or dangerous.  It is scary to see people doing things we don’t understand, so I get it.  And it is hard to trust when people you cared for and gave your all for die, sometimes because they gave it all up for the wrong choice.

Miracles happen.  There are things we don’t understand how they work, but they do.  There are things we know do work and they scare some people because of misinformation or lies spread through all kinds of media.

When people forgo conventional treatments or risk counteracting treatments for something advertised on the internet or sold by an alternative provider, it makes me uncomfortable.  I’ll be honest.  When people die doing this, it makes me sad.

Complimentary and alternative therapies can be many things… I send people for massages, acupuncture, reiki and I think chiropractors do good work. I encourage spirituality and  and exercise.  I preach good diets and appropriate vitamin supplementation depending on need.   I think cannabis can be an option for some people for symptom control.  I am okay with you doing something else so long as it isn’t putting you or your treatment at risk.  I can’t stop you from doing something I don’t agree with or trust because you are your own person.  But, I can be honest and tell you why it is concerning.  I can review the evidence.  I can help you interpret it because I have a background in reading that kind of stuff when many people don’t.   I’d rather know than not know in any case because your health is important to me.  And I make no gains or losses by having someone take “my treatments.”

I just want people to be healthy and safe.

Conventional medicine can’t save everyone.  Neither can alternative medicine.

It is scary, but things go wrong.  Alternative therapies (namely the various supplements and drugs and cleanses) can cause a lot of problems.  But, we don’t talk about it when things go right.  We also don’t talk about it when things go wrong.

Talking would be a good start. Regulations would be wonderful.

There will always be people out there trying to make money and preying on the sick and vulnerable. Sadly, these people give everyone a bad reputation and are the source of my distrust and skepticism.  I know there are practitioners out there who think they are doing good and maybe are not.  That is where better regulations and research could make a change.  And I know there are practitioners out there doing amazing work with the best interest of the patient at heart.

An open mind is good.  Educated professionals are better.  But, I think that opening up the lines of communication between professionals but also with patients could make a movement towards making a difference.  At least in some cases.

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A Haunting Encounter

Today, I had a class on incorporating the humanities in medical education.  We were asked to write a short piece of prose or poetry on a patient encounter that haunts us.  Hearing what others wrote was way to much for my hormonal psyche.  I didn’t share mine because I was too busy trying not to let anyone see me cry about the ones that were shared.

I am not a poet, but it kind of has a poetic feel, I think… Here it is…

You did your best.  You knew something was wrong.  You were low risk, they said.  But, now, you are sit in clinic and don’t know how bad it really is.

You are angry and scared.  You cry when I review what is happening within your body.  I am gentle, but I am up front.  Medicine is so advanced, but so limited.  

Together, we bring you down off that ledge.  We have a plan.  You know what is likely to happen.  Then, I point out you need to meet my staff.  To keep in mind that a chance for second opinion isn’t gone.  

Gruff and curt, he approaches.  The plan changes and you are confused.  There is no explanation.  Just a closed door.

I try to help you understand.  I feel a sense of loss.  Like I am free falling in a place outside of my control.  It can’t compare to what you feel.

You don’t want another opinion.  You trust him.  Because you trust me.

In that moment, I don’t trust me.

I go home and review the literature.  I think and think.  I talk to another staff person.  I am right.  There may be more.  But, how does that get approached?  Who is willing to speak up?  

Everybody talks, but nobody deals.  That seems to be the way sometimes.  The questions are brought up, but I wonder if they were truly dealt with.  They get swept under rugs that some of us can’t help but look under.

This time, someone did say something.  This time, something did change.  Somehow, the suggestions were accepted.

I was relieved.  I want the best for you.  I want the best for all of you.  But still, the whole thing is unsettling.

In the long run, will it be enough?  Will you continue to get the care you deserve? 

If I hadn’t been there, if you didn’t trust me, would it be different?  Would you have made a different choice?

Maybe it is enough.  But, I wonder if we could do better.  I wonder if it is my fault.  That my being nice, that we “clicked” made you not question, not request that second opinion.

I won’t know.  I can’t help but wonder it is my fault.  And I’m not even sure what “it” is.

My Study Buddy

I’m studying.  Again.

You see, I have another sporadically scheduled treatment planning exam this Tuesday.  I had one last Tuesday (which got cancelled… And has yet to be rescheduled… UGH).  It seems that I have a “get me to do something” sign taped to my face.  This week’s topic is Rectal Cancer.  Last week’s was Small Cell Lung Cancer.  We can’t get much further apart.

I spent my morning picking up a few things at the grocery store and cleaning (ah, I do love a clean house (just don’t look in the guest/to-be-baby room or our room)).  I have mac and cheese in the slow cooker and the oven preheating to make some veggie crisps (looked like a good idea on the internet).  Patrick is playing Wii with his little brother with Big Brothers Big Sisters (great organization, by the way).

I decided to hole up finally and get some studying done.

I can’t study on my own anymore.  I have these two study buddies.  One goes everywhere with me, thanks to a little thing I call the placenta.  The other is the feline that can only travel as far as the confines of the apartment (hypothetically).

Jeter has a strange obsession with sticking nearby.  Today, he passed out on my textbooks.  Including the one I wanted to read. 10325749_10153286555099316_5885870976480320603_n

Silly cat.

Plus, the placenta attached study buddy is having a small dance party in my uterus.

Clearly these folks are not the best study partners.  They did not get the memo.

So, I’m updating my phone and my laptop and writing a blog post.  With a textbook open in front of me.  If it is open, it at least half counts, right?

Turning Tables – Treating Physicians

Today, one of the other residents and I had an interesting conversation.

Somehow, the topic of treating physicians came up.  And it is something that terrifies us both.  And not just for the reasons you might think.

I will confess, treating other health care people is always nerve wracking because you worry even more about saying something wrong or stupid because you always wonder if they are secretly judging your skills.

But the bigger thing is that when we see them, they are being faced with a cancer diagnosis.  And for some reason, most physicians and nurses get the bad ones and all the complications.   And that is horrible for anyone.

The issue is, they know too much.  Sometimes, having some uncertainty is a good thing.  But, when you have cared for people with the same thing.  When you understand the odds and get the treatments, it is a whole other level.  You know the worst case scenarios.  All of them. Sometimes the unknown bits of the known are the worst.  Especially when your whole world gets turned upside down.

That is the hard part.  The anxiety, the sadness, the anger and guilt.  The fact that sometimes, the person who knows too much coming in can’t be easily comforted.  That the numbers that scare everyone have too much meaning.

It also forces us to face our own mortality.

We both agreed that given we work in Oncology and given the odds in the world today, we will both one day have cancer.  And we will probably die from it.   Those are simply real odds.  And the “comedy” that is life.

And we know this and accept it.  In fact, we laugh about it in an uncomfortable kind of way.  Sure, I might have a heart attack or an accident, but it is more likely I get dementia or die of cancer… Or both.

Really, it is something I accept.  But, it is still something that is terrifying. And maybe that won’t happen.  Maybe I’ll just die in my sleep in old age.

Either way the reality of seeing people who dedicate their lives to healing others broken, afraid and unwell is terrifying.  They are “one of us” who became “one of them.  It is just too real sometimes.  Too close to home.

I just want to fix the hurt.  I want to prevent the hurt.  I want to be out of a job (kind of).

But I can’t.  So, we do the best we can.  With every person.  Because one day the tables will turn in one way or another.

The last few weeks in a nutshell.

When it comes to regular blogging, I have been an epic fail lately. Sometimes life is just plain busy and my priorties have been such that sitting down to write has not been a priority.

So, for those of you who care… Some updates on my last couple weeks in a nutshell.

The treatment planning exam I wrote about went decently. It was challenging. I got through it and my score was not good, but was good for a first exam. Plus, that means I met the milestone of doing my first treatment planning exam.

The Child and I started going to Body Pump classes. Once a week. But every week. For those of you who are regular Pump attenders, this may not seem like much, but it is a huge stretch for us to commit to going every week and getting stronger (even if it would be better to go more than once a week, I’d rather set a realistic goal). As a result of attending these classes, we have turned into bigger gym rat-like people, not only discussing our run times at times, but now also plotting out how we could go up on our weights or do a certain move better.

I went wedding dress shopping in a real wedding dress store for the first time ever last week with my sister-in-law. True story. I am married, but I bought my dress online from Sears. I lived away, so I didn’t go dress shopping with any of the friends that I know who got married. It was an experience. I feel okay with never having to do it again.

I am very excited to go see Gone Girl later today. The book freaked the heck out of me (once I got past the first ¼).   I expect the movie could do the same.

Patrick and I went to a produce store yesterday that is known for its ridiculous deals. We have had friends from church recommending the place for ages, but had yet to go. We now understand the beauty that it truly is.

My program changed our academic half days to Friday afternoons. It is a form of torture to sit through 4 hours of lecture on a Friday afternoon. Especially when you have a busy review clinic all morning and no time to see your inpatients until after all the teaching. I discovered caffeine and cookies help, but don’t cure the Friday half-day blues.

I had a post-call day last week because I was stuck in hospital until 2am with a spinal cord compression who, after we treated, started having “new” chest pain (that in retrospect wasn’t new) and then was called several times overnight. I was so excited to have a post call day. And didn’t even feel that guilty for taking it because the night was that kind of ridiculous. Then I remembered, post call days suck when you were actually up most of the night because you need to sleep. Silly.

I love treating head and neck cancers. Even though they tend to get so sick from treatment. And even though some of the patients are tough drinkers/smokers who don’t want to do anything they should. I like a challenge. And I really want to help. And we can cure people with this type of cancer, which is always cool.

My computer at work was giving me the blue screen of death and shutting down intermittently. It got to the point that I couldn’t get any work done and had to use someone else’s computer. The helpdesk person had no real explaination as to why my computer blew up in my face like it did. He had to reload everything back on it from scratch (and I lost everything that was saved on the computer itself (not much)). In retrostpect, I like to rest my feet on the computer console thing under my desk and twice in the last few weeks I accidentally kicked it over. That might be related. Whoops.

I have been attempting to read The Maze Runner for two weeks. Much like my blogging, life has gotten in the way of my fun reading. Silly.

I have been obsessed with listening to Needtobreathe lately. Not sure why, but their mellow has been drawing me in. Like this song:

What is new with you? Anything exciting?

Head and Neck

I got an email with the topic for my very first treatment planning exam.

Aside… A treatment planning exam is an oral exam where we get grilled on our management of patients from presentation to treatment and follow-up to help us practice for our licensing exams at the end of residency.  It can include basic questions right up to referencing why we do treatment in a certain schedule and where a target its. They start in third year, which is where I am now.  They are supposed to start off easier and get harder as time goes by.  At least in theory.

The site is “Head and Neck.”

Agh!

My issue with this?

Head and neck is probably one of the most difficult sites to treat and master.

I mean, we don’t do much head and neck related stuff in med school or even the first two years of residency and then, bam!  I’m treating cancers there.

At least, I have for the last two and a half weeks of this rotation.

I like head and neck.  I have said it is likely a site I’ll want to treat.  That doesn’t mean I feel anywhere near confident in it.

And it is my first exam.

When I opened the email, I just cracked up laughing.

Apparently most people get something like bone metastases from another primary.  Nope, not me.

Maybe it will be more simple than it sounds.

But, I don’t feel optimistic.

It is going to force me to read more.  But, I really was hoping for a relaxing weekend home.

That is how life works.  And how residency works.

Learning is good.  Looking stupid is part of learning.  I just need to embrace that.

Thank goodness Dr. Bond gave me some notes and tips.

I just hope my examiners remember I’m just in third year.

How Did That Happen?: How I Survive Breaking Bad News

It is due time for another How Did That Happen? post. This one is How I Survive Breaking Bad News. Not how to break bad news. That gets covered all over the place. I’m talking about the facing people later, living the rest of your life kind of survival.stethoscopes1

This one is a result of my week of breaking bad news. I know, I am an oncology resident. More days than not, I break bad news. I tell people about pathology reports they don’t want to hear about. I tell them they have cancer (not always for the first time, but sometimes for the first time they really process it). I tell them their cancer is back. That it isn’t curable. That they need treatments they didn’t want. That they are going to die… Soon.

Breaking bad news is tough. So tough it is its own section in many med school communication classes. So tough most people do a crappy job of it because they are scared.

I’m a weirdo. I don’t love breaking bad news, but I like to do it. Because I believe people have the right to know the truth. And to hear it in such a way it is understood and compassionate.

This week has been especially bad newsy. From clinic to call to pediatric brain tumor clinic, I have delivered or been in on delivering all kinds of crumminess. It wears on a person.

  • It is okay to cry. Seriously. Sometimes, stuff is really tough and you just have to let it out. I’m not saying sob on the shoulder of the person you are talking to, but it is okay to shed some tears then or later.
  • It is okay to be angry or disappointed or relieved. Emotions are good.
  • I’m going to sound cliché, but reflect on it. Sometimes, you say stuff that is stupid or comes off the wrong way and other times it goes well. Actually think back on it, even if it is tough and then learn from it and move on. I tend to really stew on things, so this is something I’m working on.
  • Find the rays of hope. This is also helpful when delivering and discussing the news, but I really mean it is important for me too.   Sometimes, I start to feel like I am the grim reaper or that life is a miserable existence. It is good to find the bright sides, like how fortunate I am, how that person will have a good outcome or good days or whatever. Just something positive.
  • Count your own blessings. If I get really discouraged, I find it helpful to think of how fortunate I am despite the bad in the world.
  • Talk about it. Confidentiality is important to maintain, but there is nothing wrong with discussing it with co-workers involved in the case, or even just your thoughts around it without disclosing details with a friend or family member.
  • Have an outlet. I sing and dance like a fool. Or exercise. Or write. Just something not work that helps get some of that badness out.
  • Do something happy. I like ice cream. Or spending time with friends. Or music. Or books.
  • Mix it up. This isn’t always an option. But, I love that my job involves lots of time on the computer doing technical stuff or research, not just difficult conversations. I also love that there are really good positive things mixed with the difficult in clinics.
  • My faith is super helpful to me at those times too.

What are your bad news survival tips?

My Kind of Husband

I have the kind of husband who let’s me play in the waves at the beach for hours. Even if he’s cold.

He is also the kind who celebrates anniversaries a week early because Im on call on the real one.

My husband is also the kind who gives me cancer for our anniversary (the giant microbe kind) and is okay with the fact it is probably my favourite part of the gift.

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1 week to five years and we’re still alive!!

How Did That Happen?: How to overwhelm the pulp out of a new resident

I have been off my blogging game.

I blame starting core Rad Onc.  I keep staying late and studying at night and all of that stuff.  Funny how when you are doing something you actually love you tend to work more.

I also blame summer.  The nice weather nights have us out and about meeting up with friends.  Last night, we had a hymn sing at the nursing home we volunteer at with our small group and then went out for ice cream.  Tonight was coffee with a couple we know from back home who recently moved here.  So awesome.

I am a week overdue on a How Did That Happen? post.  So, that is what you shall receive.  stethoscopes1

I have been spending my last week orienting and mentoring our new, delightful R1.  My How Did That Happen? is how to overwhelm the pulp out of a new resident (in case you didn’t already know).

**Note: This is kind of sarcastic and based on things that really do happen.  There are some things I think administration and faculty can do better with.  There are some things that I can’t see solutions to… Just facts of starting new jobs.

  • First of all… DON’T OVERWHELM THEM.  This is my for real advice.  This will fail.  Starting residency at baseline is kind of overwhelming.  But, bits of information at a time and having someone available as help and back-up is better than just slamming it all in a book or presentation at once.
  • Have multiple giant orientation sessions for the incoming residents from the university, the hospital.  Fill them with tons of information that is both useful and useless intermixed with facts about failures, crying and patients dying.  Make sure that it is unclear what is useful or useless and make it seem like terrible things will happen.
  • Make sure to start them on call the first day or so of residency.  Nothing is better than really starting out with a bang.
  • Send out various passwords and user IDs to different email accounts and expect the person to sort them out themselves.
  • Have a very not user friendly computer system with a million different log-ons, passwords and variations.  Review these in orientations, but don’t do any practical training, that would be too helpful.
  • Use four digit paging in a hospital where you have to dial 7 numbers that can differ between sites.  Expect new person to call you back promptly.
  • Let new people loose in the hospital without giving a tour. 
  • Take the new person a tour on a hot day after a full day of orientation to show them everything.  Realize that they will remember very little of this.  Do it anyway.
  • Leave them to figure out everything on their own.
  • Tell them all of your call horror stories.
  • Take them to visit the ward.  Show them where everything is.  Show them the charts.  Talk about writing notes, finding computers and how the rooms are organized.  Introduce them to the all of the staff on the ward who promptly start asking who they are looking after. 
  • Go to a session about how to use an EMR only for the radiation oncology patients and for radiation planning.  Use technical terms just to really keep them on their toes.
  • Give them the sickest patients. 
  • Ask them to read around everything they saw that day.  The list of topics totals a page.  Oh, and review the clinic charts for tomorrow too.  Hope you can work the disconnected computer systems!
  • Talk to them about booking vacation.  That is months away.  On rotations that “you just need to take vacation from.”
  • Tell them you are so glad to be done intern year, it really does get better (this can be good… it can also instil fear of what is yet to come).
  • Try to tell them everything they need to know ever in one day.  Or at least make them think that is what is happening.

 

What things happened to you that overwhelmed you as a new resident or med student or employee in general?

 

Happy Belated Canada Day and Residency New Year!

Yesterday was Canada Day.

That also means it was start of the new residency year day.

I am officially a PGY3  (well, I am still missing a few evaluations from PGY2, but barring surprise failure, I am a PGY3) and today is my first day of doing actual Radiation Oncology for the rest of residency (minus my medical education elective).  I’m a happy girl.

I started off my first day as an R3 on call.  I’m just festive like that.

It was a sunny, beautiful day.  Everyone and their dog was out for celebrations dressed in red and white and I was off to the hospital (also in red because for some odd reason, having to work made me festive).  I waded through seas of people coming and going to various festivities, dodged a parade route that they were closing strangely early and all of that good stuff before even 9 in the morning.  Getting coffee was a challenge because the first two places I tried were closed.  I had to settle for the very Canadian, but not festive enough to close Tim Horton’s (ugh).

The fact that it is home call, however, was good.  It meant I got to spend some of the afternoon sitting out on the deck with the husband and the cat watching the crazies and waiting for a page.  I even got a little bit of work reading done.  A little bit.  Oh, and we took a M family selfie.10480582_10152674222399316_5582227936371051593_o

Happy day late Canada Day and residency New Years!