A Spoonful of Sugar

I don't think I'm unique in having a family that discusses medical issues at the dinner table. But in a family with a doctor, sometimes discussions – to the dismay of my children – are more colorful than they would like. I have learned (mostly) to keep discussions from veering off track. For my family’s part, they know there is a cardinal rule that must be obeyed: you are not allowed to mention Google or Reader’s Digest when discussing medical facts. That rule was recently broken by my wife, Catherine, but in an interesting and forgivable way. Here's the story.

My wife takes a potassium pill – a common supplement – once a day. As anyone who takes this pill knows, it is a big tablet. A horse pill, some would say. And because of that, she wasn't taking it reliably. Some days she could swallow it without too much difficulty, and other days she just couldn't get it down. If she tried a couple of times without success, she just let it go. That’s where Google comes in. In a worthy attempt to educate herself, she went online, researched the medicine, and found out why she needed it. Now, she is much more compliant... to a point. She won't take it if she is alone, because she doesn't want to choke on it.

When she told this story at the dinner table, she concluded, "Isn't that interesting?" To which I replied, "What is interesting is that you didn't trust that because the doctor prescribed it for you, you needed to take it." My daughter then remarked, "That's because a lot of doctors are quacks." So much for respecting the medical profession these days.

Of course, as a doctor's wife, Catherine very much respects the profession of medicine, and I had a twinkle in my eye when I "accused" her otherwise. My daughter's sarcastic analysis, however, did sting a little. Long gone is the era of paternalistic medicine, where TV doctor Marcus Welby, MD simply told his patients what was best and they complied without question. Now patients come to our offices telling us what is best and expecting us to comply. And front line primary care doctors are so strapped for time and paid so little for each office visit that sometimes it is easier just to acquiesce. 

Physicians must resist that temptation. Historically, perhaps it was appropriate for the family doctor to be paternalistic when he knew his patient so well – both inside and outside the office – and when he took care of the medical needs of the entire family. Too often today, the primary care physician is seen simply as the source of a referral to a specialist. The gatekeeper moniker was a kind way of referring to the physician whose true role was (as far as the insurance companies were concerned) to prevent specialist referrals rather than facilitate them. That is a far cry from the position of a genuine coordinator of care who manages the various specialists’ recommendations and knows all the medications that have been prescribed. Such coordination takes a great deal of communication not only among healthcare professionals but between the primary physician and the patient as well.

All physicians – not just primary care physicians – must work harder to earn the respect and trust of their patients. We must take the time to explain the interventions we recommend and the medicines we prescribe. Those horse pills will go down a lot easier with a little sweet talk and education along the way. And our patients will be happier and healthier as a result. Now, that's good medicine!

Cancer is a Global Problem

Tomorrow is World Cancer Day. We think we have a cancer problem in the US, and we do. But other countries, especially the poorer ones, are truly suffering. Two publications by the American Cancer Society - Cancer Atlas and The Global Economic Cost of Cancer (which I quote extensively) - soberingly detail the scope of the problem.

For example, 6 out of 10 cancer patients would benefit from radiation therapy (my specialty) in the course of their cancer treatment. However, about 20 countries in Africa do not have a single radiation treatment facility. And even when radiation facilities are available, as is the case in several countries in Africa and Asia, coverage is woefully inadequate. Ethiopia, a country of around 90 million people, is served by a single radiation treatment center located in the capital city.

Similarly, although morphine to treat cancer pain is plentiful, safe, and easy to use, millions of terminally ill cancer patients in Africa and Asia die in pain because of regulatory restrictions, cultural misperceptions about pain, and concerns about addiction. Eighty-five percent of the global population lives in low- and middle-income countries, but consumes just 7% of the medicinal opioids, like morphine.          

For the first time, research has shown that cancer has the most devastating economic impact of any disease in the world. The total economic impact of premature death and disability from cancer worldwide was $895 billion in 2008, nearly 19 percent higher than heart disease. And, that figure does not include direct medical costs.

Cancers of the lung, bronchus, and trachea account for the largest drain - nearly $180 billion - on the global economy. That's not surprising, given that smokers die an average of 15 years earlier than nonsmokers. Tobacco is predicted to kill seven million people annually by 2020 and eight million per year by 2030, with more than 80 percent of the deaths taking place in low- to middle-income countries. One-third of those deaths are the result of cancers. This is almost entirely preventable.

And it isn't just lung cancer. Despite the fact that most cases of cervical cancer can be prevented or treated effectively, 274,000 women die from the disease yearly. Approximately 241,000 of these deaths are among women in low- and middle-income nations. And then there's breast cancer, colorectal cancer, and on and on.

It seems like all we hear about on the global stage is HIV/AIDS and malaria (and, more recently, Ebola) - the so-called communicable diseases. But the economic loss from HIV/AIDS ($193.3 billion) TB (45.4 $billion) and malaria ($24.8 billion) combined is not even 30 percent of the economic loss of cancer.

Why should you care?

Put simply, the global cancer epidemic is huge and is set to rise, according to World Cancer Day planners. Cancer treatment and pain management for those dying of cancer are not political issues. They are global health issues which we in the United States, with our expertise and yes, wealth, can tackle better than any other country. They are also the type of moral issues which donors and politicians of every stripe can come together to address. 

This will require effort on the part of organizations like the American Cancer Society and other NGOs, but it will to an even larger degree depend on the leadership of the United States in organizations like the United Nations and the World Health Organization, whatever you think of them. And it will depend on you. Support the American Cancer Society and ACS CAN - the American Cancer Society Cancer Action Network - so that we can create a world with less cancer and more birthdays.

Recognizing Stages of Grief

My father recently passed away from pancreatic cancer at age 81. What a devastating disease! He lasted a mere two months. Thanks to attentive physicians and great hospice care, he was comfortable and at peace when he died.

For my mom, who was married to my father for nearly 60 years, grieving will be a process. In the medical field, we are taught to think about grief in five stages first described by Elisabeth Kübler-Ross in 1969: denial, anger, bargaining, depression, and acceptance. Watching my mom walk through my father’s diagnosis and death, I caught glimpses of many of these stages in her emotions and responses. It is important to note that these stages were never meant to be all-inclusive or rigidly ordered. Depending on circumstances, certain stages may be more prominent than others, or not experienced at all.

Denial is indeed often the initial response to hearing that you have (or a loved one has) a terminal disease. We just can’t believe it is happening, especially when the one with the diagnosis looks so well on the outside or doesn’t feel that bad. Unfortunately, denial can result in poor judgment. Luckily for my parents, any flashes of denial were tempered by solid medical advice and faith in their doctors.

Anger is one of those ugly emotions that can pop up at any time. But, it is one that is not difficult to understand. I typically see anger as a reaction because of dreams that will go unfulfilled. My mom was humorously a little miffed that my father didn’t make it to their 60^th anniversary in April. But anyone familiar with my mother knows she is too strong a Christian to be truly angry. Significant, unresolved anger can signal deeper emotional or spiritual needs that can affect everything from pain management to dying a peaceful death.

Bargaining is the most interesting stage to me. There is a deep desire in us to bargain as Faust did with the devil for something unattainable… in this case, a cure. Sometimes we bargain with God: “If only you would spare him, I promise I would do anything!” In the terminal cancer arena, this bargaining often takes the guise of a search for alternative, unproven “snake oil” treatments. (Mexico, anyone?) To my parents’ credit, they did not pursue futile, expensive elixirs or elusive cures.

Depression and acceptance tend to wrestle with one another, with melancholy eventually fading and acceptance gaining the upper hand. At least that is what we expect with typical grief.

My mother is a strong, confident woman. She held her head high at my father’s funeral and presided over the reception and luncheon with poise and grace. She so appreciated having her sons and relatives with her! I feared she might not do well by herself after everyone left, but she firmly informed me that she needed some time alone to grieve. For her, that was the right decision. She will cry; she will remember. But she will go on, I have no doubt.

Grief shouldn’t be buried. Tears are OK, even desired. However, debilitating, ongoing depression is not healthy. A minority of people experience a complicated grief that requires significant emotional, psychosocial, even medical support. Hospices are obligated to offer bereavement services for families of patients. What most don’t know is that you don’t have to have lost someone on hospice to join a hospice bereavement group! If you are grieving a recent loss and want to talk to someone or participate in a support group, contact your local hospice for help. You don’t have to grieve alone.

Living Between the Dates

As a cancer physician, reading obituaries is, unfortunately, part of my job description. I don't mean to be morbid about it. Not everyone who gets cancer dies from it - far from it. We cure two-thirds of cancer today. But we still have a long way to go.

I recently read my father's obituary. Oh, he hasn't died yet. My mother, you see, is nothing if not organized. So both of my parents' obituaries have pretty much been written for some time now.

Obituaries are fairly emotionless documents. They also don't often convey the true sense of who a person is. Usually, an obituary is a simple compendium of facts - dates - such as when a person was born and when they died. Others before me have said that what is important is not the date of birth or death, but the "dash" in between. That dash is what symbolizes who a person is, how they lived, what they accomplished.

My father just had his 81st birthday on Sunday. He has been working full time as a financial consultant at the same firm in Midland, Texas (RBC Wealth Management) for more than 48 years. That is a remarkable accomplishment in a field where jumping between firms is not uncommon. But loyalty was important to my dad, and to his clients. They knew they could trust him. His honesty and integrity were natural, unspoken expressions of his Christian faith. But that won't be in his obituary.

My parents love to travel, and they have taken quite a few overseas trips since he reached retirement age, even though he didn't retire! In September, my wife and I were able to go with them to Ireland on a fantastic trip. At 80, their vigor and stamina was amazing. Those two weeks together were so precious, even more so now in retrospect.

Just weeks after we got home, my father was diagnosed with pancreatic cancer. He had the usual tests and meetings with specialists to determine what, if anything to do. His liver is involved and his prognosis is quite poor.

I consult often with patients who are bombarded by well-meaning friends and relatives who think they know what is best and are, frankly, a bit too vocal with their opinions. Thus, seeing my father have to deal with the "You ARE going to MD Anderson, aren't you?" pretentiousness was particularly difficult. Those of you who want to comfort someone dealing with a cancer diagnosis need to learn simply to listen. Don't give advice, because 1) your story or experience is almost always irrelevant, and 2) you unknowingly aggravate the situation by making the patient feel guilty or second guess their decision. Please remember: It's not about you!

Ultimately, after much deliberation, my father opted for comfort care only. I am incredibly proud of the strength it took to make that brave decision. His cancer is not curable and his prognosis is less than six months under the best of circumstances. He chose instead to share quality time with friends and colleagues, with each of his three sons' families, and with his wife of nearly 60 years. What a blessing that time has been!

The apostle Paul wrote that he has fought the good fight and finished the race well. Thank you, Dad, for finishing strong. For demonstrating integrity and commitment in your work for more than 50 years. For your quiet faith, service, and generosity. For your love of family. For filling that "dash" between birth and death with a life well lived and memories we will cherish. Maybe we can insert that into your obituary!

Tips for Success in Any Office Environment

My wife, Catherine, starting working for St. Cyprian's Episcopal Church as Parish Administrator about four and a half years ago. We were close to empty nesting at the time, and she felt she wanted to get back in the workforce in a meaningful, purposeful way. St. Cyprian's has been a blessing for her, and she for them.

Catherine was recently asked to provide her job description for other churches in the diocese. She wisely commented that the key to being a successful admin is understanding that your calling is to make someone else successful. A well-written job description is a great starting place, but a smart admin thinks beyond the dry description. What follows are her guiding principles, in her own words:

Smile. Every parishioner deserves to be welcomed into the office with a cheerful attitude. Not because they pay your wage, or you might need them to do something for you, or simply because you regard them as a friend beyond the walls of the church, but because this is God’s house and we are a very small reflection of Him and the joy He has in His people.

Menial Work. Every job has tasks that seem menial. When I’m feeling a little weighted down by such chores, I remember that Martin Luther once said that a dairy maid could milk cows to the glory of God. So I milk the cows and am surprised by how the more enjoyable aspects of my job pop up unexpectedly in the middle of the humdrum.

Don’t bring troubles to work. Don’t come to work thinking that you are coming to therapy or your own counseling session. Yes, be open and honest with your co-workers, but remember how much emotional baggage they are expected to carry for others already.

Wear multiple hats. Learn how to compartmentalize within your work relationships. That sounds bad, but think about the different roles that are necessary to function smoothly in an office. With my former rector, I would put on my Employee/Employer hat to discuss things like salary or vacation or working conditions. The Friendship hat I wore outside the office when I would invite him and his wife to events or would socialize with them away from the office. The Big Sister hat was worn when I needed to try and teach him something about parenting or life (I am 15 years older).

Listen closely. As you gain trust and credibility, people will begin to solicit your opinion. Note that sometimes they are simply practicing or working out their own thoughts and ideas by talking them through. You can be a valuable asset by listening closely, reflecting back what they have said, and helping them think through the implications of what they are discussing. Sometimes you will be able to contribute an original idea, but what the ministerial staff really need is a safe ear to listen. The freedom to think out loud in confidence is a gift you can give them. Most of them are very verbal people who talk things out and sometimes don’t want to just talk to themselves.

Finally, try to say yes more than you say no. This job is full of the humdrum, the interesting, and the surprising. Be flexible and enthusiastic. It is a valuable ministry. Every day I am blessed to further God’s kingdom in some small manner by helping his shepherds and their sheep to follow him better.

What Catherine has written is great advice for all of us, regardless of our position or job or ministry. Thanks, Catherine!

One Teacher's Story of Cancer and Community Support

I have had the privilege over the last few months of speaking at Lions and Rotary Club lunches about cancer and the work of the American Cancer Society. My tag team partner in these presentations has been the lovely Jean Ann Keen, a two-time cancer survivor and mother/teacher extraordinaire.

Jean Ann has had the misfortune to be diagnosed with two different cancers decades apart. When she had her first cancer while pregnant with her now 25 year-old daughter, Kylie, there were no local support resources to speak of. Thankfully, surgery alone was curative for that cancer.

However, when Jean Ann was diagnosed with breast cancer last year, she learned her treatment course was going to be more complicated this time, involving both surgery and multiple cycles of chemotherapy. She felt a bit lost and overwhelmed. Luckily, someone told her about the American Cancer Society and the wonderful office we have in Lufkin.

In our Lions and Rotary Club presentations, Jean Ann tells a wonderful story of driving back from Waco one night. She decided to pull out a GPS unit for the first time, as she was unfamiliar with the dark roads and wanted some extra assistance. She plugged it in, turned it on, input her home address, and - lo and behold! - a map appeared with directions to her destination! She was fascinated to be able to see ahead what was coming – every turn, every intersection – with a voice telling her when to change course and how long it would take to get to where she was going.

Jean Ann goes on to explain that the American Cancer Society was like that GPS for her when it came to dealing with breast cancer. It was unfamiliar territory, and she needed that guidance to help her see ahead what was coming, where the intersections were, what roads to take. There were questions that she didn’t even know to ask that she had answers to right from the beginning.

Why am I telling her story?

Ten years ago, Louise Maxwell and I co-chaired a highly successful campaign to raise support for a new office building for the American Cancer Society to manage a 54-county region in East Texas. This building was subsequently named in Louise and Harold Maxwell’s honor. Through the generous support of the TLL Temple Foundation, Memorial Health System of East Texas, the Polk family, the Lufkin Host Lions Club/Angelina Benefit Rodeo, Temple Inland Foundation, and many other individual, family, and foundation donors, the ACS regional office building was constructed. This office also houses the Susan R. Mathis Resource Center and the Louise Maxwell Patient Service Suite, where Jean Ann learned about hair loss, makeup, and tried on wigs through the Look Good Feel Better program.

You see, all those contributions ten years ago are still bearing much fruit today. Thousands of patients have benefited from these and other services, such as patient navigation, clinical trials information, help with finding transportation and lodging, the online Cancer Survivors Network, and I Can Cope support groups. Whether in person at the ACS office on Gene Samford Drive or through their 24/7 1-800-ACS-2345 phone number, the American Cancer Society is there to help.

I want to publicly thank once again all who contributed to the American Cancer Society ten years ago for this wonderful community resource. But the fight isn't over! Support Relay for Life by putting together a team, walking, or contributing in some way. Come to the Pineywoods Cattle Barons Gala on October 25th at Winston 8 Ranch! Call 936-634-2940 for more information about these events. And, thank you!

Being There for Those Who Suffer

Two articles appeared recently in major newspapers discussing how we can be more helpful to those who are suffering. The New York Times article by David Brooks (The Art of Presence) looks at helping those who are experiencing tragedy, while The Wall Street Journal column by Elizabeth Bernstein (To Be a Friend In a Time of Need, Talk Less, Listen More) specifically addresses helping those with depression. The lessons of each apply equally well to anyone who is grieving or suffering. To me, Brooks sums up our mission with one word: presence.

What does presence look like? Better yet, what does presence sound like?

First and foremost, silence. That means shut up. When I am sick or grieving, I don't want or need your advice unless I ask for it. Don't tell me I should go see XYZ doctor just because you or your Aunt Melba did. I can make my own decisions, thank you very much. But do let me vent sometimes, without thinking you have to fix it for me. Just be there for me; that is comfort. The Latin root of comfort means to come along side with strength. The Holy Spirit is also called the Comforter. Isn't that a beautiful image?

As friends, we don't feel very strong, though, so we try to overcompensate. Why do we always feel we have to solve someone's problems, rather than quietly comforting? Bernstein notes how we can comfort others with our notes and cards. Brooks agrees it is often simple non-verbal expressions like bringing soup that mean so much. Both emphasize: listen.

When I was in college, one of my best friends was very ill in the hospital from juvenile rheumatoid arthritis. She nearly died. She was a baby Christian, and I tried to "be there" for her. Unfortunately, there were others who told her that her faith was not strong enough or she wouldn't be sick. Not only is that terrible theology - Job, anyone? - it is devastating psychology.

Often, what presence boils down to is time. I remember conversation I had recently where I delivered some devastating news to a patient and her caregiver. It was near the end of a long day, and it would have been so easy to say some platitudes and "give hope" when what was really needed was simple truth delivered with compassion and grace. When the visit was over, the caregiver followed me out into the hall and said, "I know you are busy..." That's when I stopped in my tracks, paused, and replied, "You are the most important thing right now."

She asked some particular questions that made me realize we needed to have a much deeper conversation, and that the "truth" I delivered needed a little more "presence". So, we went back into the room and had the unrushed conversation we should have had all along. We talked much more about prognosis, treatment options, and whether or not to continue with plans to see another specialist and get more tests done.

Ultimately, I recommended hospice care - end of life care focused on comfort rather than prolongation of life. I wasn't sure if the patient would agree. But this lovely woman – who couldn't speak from a prior stroke, but who could understand fully the intricacies of the conversation – looked at me and gave me the most peaceful smile I have ever seen, along with her faltering, "Yes."

At the end of a busy day, that smile meant the world to me. The gift of presence, returned with a smile.