The Hopeful Cancer Doc https://thehopefulcancerdoc.com Jennifer Lycette MD. -- an oncologist's blog on maintaining hope in medicine, work-life balance, and related musings Mon, 22 Jan 2018 07:12:19 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.2 https://i2.wp.com/thehopefulcancerdoc.com/wp-content/uploads/2017/03/cropped-kite-icon.jpg?fit=32%2C32&ssl=1 The Hopeful Cancer Doc https://thehopefulcancerdoc.com 32 32 125993226 Why you might need chemotherapy after surgery: the basics of adjuvant chemotherapy https://thehopefulcancerdoc.com/why-you-might-need-chemotherapy-after-surgery-the-basics-of-adjuvant-chemotherapy/ https://thehopefulcancerdoc.com/why-you-might-need-chemotherapy-after-surgery-the-basics-of-adjuvant-chemotherapy/#respond Mon, 22 Jan 2018 07:12:19 +0000 https://thehopefulcancerdoc.com/?p=508 What is adjuvant therapy? One of the most common questions I hear at an initial visit, as a medical oncologist, is: “My surgeon told me she got all the cancer.  So why am I here?” One of the jobs of the medical oncologist is teaching our patients that cancer is a systemic disease. That means ... Read moreWhy you might need chemotherapy after surgery: the basics of adjuvant chemotherapy

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What is adjuvant therapy?

One of the most common questions I hear at an initial visit, as a medical oncologist, is:

“My surgeon told me she got all the cancer.  So why am I here?”

One of the jobs of the medical oncologist is teaching our patients that cancer is a systemic disease.

That means even though it started in one part of the body, there can be cancer cells in other places of the body.  That can go undetected for months or even years before they cause a problem.

There are therapies that we can offer, called adjuvant therapies, that can decrease the chance that those cells can grow into new tumors months, and yes, even years, later, what is called metastatic disease.

First, some definitions.

  • “Adjuvant” = any therapy given after surgery to increase the chance of being cured after surgery.  This can include chemotherapy, radiation therapy, endocrine (hormonal) therapy, and immunotherapy.
  • “Cure” = living out the rest of one’s life cancer-free and dying of something other than cancer.  (You will note that this definition means we cannot say whether one is “cured” at any timepoint prior to death from another cause.  Rather, we can estimate the likelihood one is cured.)
  • “Metastases” = sites of cancer that have grown outside of the initial origin of the cancer.  This can be confusing.  I like to explain to my patients that cancer is always “named” for the site of origin.  One example is breast cancer.  If breast cancer metastasizes, (or travels, spreads), to the bone, it is not “bone cancer.”  It is breast cancer, metastatic to bone.  How do we know this?  Because if we did a biopsy, and the pathologist identifies the cells under the microscope, they are breast cancer cells, not bone cancer cells.
  • “Cancer-free” = the assumption that there is no remaining or active cancer in the body.
  • “Remission” = the best evidence suggests no evidence of remaining or active cancer in the body.

Confused yet?  Let’s use a (hypothetical) example to try to make it more clear.

Ms. Smith is a 55 year old woman who went in for her yearly mammogram and an abnormality was found in her left breast.  Fortunately, it was small, but a biopsy showed it was cancerous.  She was referred to a surgeon who sat down with her and explained her two options for surgery, mastectomy (removal of the entire breast tissue), or breast-conserving surgery, also called “lumpectomy” (removal of only the tumor and a small portion of the breast surrounding it).  Mrs. Smith would like to preserve her breast, but she is afraid that if she does not have mastectomy, she will have a lesser chance of cure.

Her surgeon explains that if she chooses lumpectomy, it will be recommended to have adjuvant radiation therapy afterward, and that if she completes this, she has the same chance of cure as someone in the same situation who chooses mastectomy.  Huh?  Ms. Smith is confused.  Let’s break it down to explain why:

  1. Over several decades, it was proven that more and more aggressive, extensive, and disfiguring breast surgeries, did not impact the long-term cure rates for breast cancer.  i.e., even women who had extensive removal of tissue under and around the breast, including muscle –“radical” mastectomy — still had metastatic recurrences of breast cancer months to years later, to the surgeons’ dismay.  Ultimately, surgeons realized that breast cancer is not just a disease of the breast. If breast cancer cells have metastasized, or ‘escaped’, into the body, BEFORE the surgery, it does not matter how extensive the mastectomy is, the cancer can recur months to years later, because those cells can hide in other tissues (such as bone, bone marrow, liver), and grow new tumors months to years later.  (For an elegant in-depth discussion of the history and evolution of breast cancer surgeries, I highly recommend the book “The Emperor of All Maladies,” by Siddhartha Mukherjee.  Don’t be put off by the size of the book, it is highly readable.  It was also made into a documentary series by PBS).
  2. Once this reality gained widespread acceptance, surgeons instead turned to doing SMALLER surgeries. To summarize many decades of research, the current standard of care is that a lumpectomy need only remove enough tissue to show (to the pathologist, under the microscope), that there are no cancer cells at the margin (the edge of the tissue that has been removed), and that if then paired with adjuvant radiation therapy, will have equal long-term survival rates as mastectomy.  Please note, this is key, PAIRED WITH RADIATION.  I sometimes meet patients who choose a lumpectomy, but then tell me afterward they are not going to choose the radiation.  Unfortunately, that is not how it works.  I tell my patients, IF YOU CHOOSE LUMPECTOMY, THAT MEANS YOU ARE CHOOSING ADJUVANT RADIATION.  They go together, we do not consider it optional.  (one possible exception would be a woman over age 70 with a small tumor with no high-risk features, but again that is a discussion that needs to happen between the woman and her surgeon, radiation oncologist, and medical oncologist).
  3. Whether Mrs. Smith chooses mastectomy, or lumpectomy with radiation, she will need to meet with a medical oncologist after surgery, to review her risk of future recurrence, and whether she needs adjuvant medical therapies. Let’s continue the story to illustrate this better:

Ms. Smith is relieved by the information and chooses lumpectomy with adjuvant radiation therapy.  (As an aside, I should mention that not all breast cancer qualifies for lumpectomy – this should always be a discussion between a woman and her surgeon – but some factors that can disqualify a woman from being a candidate from lumpectomy can include (and are not limited to) a very large tumor and/or more than one tumor in the breast).

She does well with surgery, and at her post-op visit, her surgeon explains that she “got it all” and the “lymph nodes are clear.”  Ms. Smith is relieved and prepares herself for the next step of her post-lumpectomy radiation, but then she is alarmed and confused when her surgeon recommends, and sets up a consultation with, a medical oncologist.

The first thing she says to the medical oncologist is, “My surgeon said she got it all, so I don’t even know why I’m here.”

Here’s what I tell my patients:

Breast cancer, like most all cancers, is tricky.  It can be sneaky.  Even small tumors, not in the lymph nodes, (stage I), have a small risk of recurrence over time.  For hormonally sensitive breast cancer (often referred to as “ER – positive”, ER = estrogen receptor), this risk persists for life.  (A recent NEJM meta-analysis of over 60,000 women with breast cancer sheds more evidence on this).  I tell my patients that I do not tell them this to frighten them, but to empower them to make the best medical decisions for themselves.

I would explain to Ms. Smith that taking a pill medication with overall low rate of side effects once per day for the next 5 years would lower her risk of the breast cancer coming back by about 50%, and lower the risk of dying from breast cancer by 30%.  I would also explain that it is not a guarantee; unfortunately a small number of women could still relapse, and even die from breast cancer, despite taking the anti-estrogen pill.  Our job as medical oncologists is to advise our patients when they are in a high enough risk group of that happening, that taking several months of chemotherapy after surgery (adjuvant chemotherapy) would be “worth it” to lower their risk. (i.e. the potential life-saving benefits outweigh the potential risks of treatment).

Historically, the main predictors of risk of relapse and metastases were anatomic – the size of the tumor and whether or not there are cancer cells in the lymph nodes.  More and more however we are learning that the risk is not always tied to anatomic features – sometimes cancers can be small in size, but aggressive in behaviour – and again, it is our job as medical oncologists to analyze and interpret the findings of the pathology report to advise our patients.

Ms. Smith is relieved to learn her risk of recurrence is overall low, but upset to hear that the risk is not zero.  She wants to know why there isn’t a scan or blood test that could be done to determine if she needs chemotherapy.

This is a great question, and there is quite a bit of research working on a blood test, but that is likely still years away.  In the meantime we do have some risk-stratifying tests that can be run on the tumor tissue (beyond the scope of this post – I think I’ll have to devote another post just to this topic), and we, as medical oncologists, will advise our patients when we think those tests should be done.

But as for scans, they will not help us, as we are talking about treating microscopic cancer cells — not possible to see on CT scans or PET scans. (or MRI, or ultrasound, or any other imaging test).

So to conclude the story:  Ms. Smith and her medical oncologist decide together that her breast cancer is in a low enough risk group that she would not necessarily benefit from chemotherapy.  She proceeds to her radiation therapy treatments, and when they are completed, she will return to her medical oncologist to start her endocrine adjuvant therapy (the anti-estrogen pill).

While this example focused on breast cancer, we have these same discussions every day with patients with almost all other types of cancer after surgery.  For each person, we use all the available clinical data to make a risk assessment, but we also take into account each person’s age, health, level of function, living situation, goals, and support system, before making a recommendation.  This is what we mean when we say we individualize the cancer care.  Expect this visit to last 45-60 minutes (or even longer), and believe that your oncologist has spent already that same amount of time, or more, analyzing your case, and talking with your surgeon.

If you are reticent to meet with a medical oncologist, I hope this article will help change your mind.  At the least, try to go into the appointment with an open mind.  Even if it is not the news you want to hear, if your medical oncologist recommends adjuvant treatments, they are doing so with your best long-term interests in mind, which is to give you the best chance of cure.

Disclaimer:  This is by no means an exhaustive coverage of this topic (which would be impossible to do in under1800 words), nor is this meant in any way to be used as medical advice.  Please see full site disclaimers on the about me page.

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Episode 2: The Prior Authorization Games: Where the Odds are Never in Your Favor https://thehopefulcancerdoc.com/episode-2-prior-authorization-games-odds-never-favor/ https://thehopefulcancerdoc.com/episode-2-prior-authorization-games-odds-never-favor/#comments Sun, 12 Nov 2017 21:28:56 +0000 https://thehopefulcancerdoc.com/?p=476 Greetings Readers.  I thought I would try something new and start somewhat of a series.  If you didn’t see my original post on prior authorizations, this link will take you right to it. Last week I found myself on the phone, yet again arguing on behalf of a patient, to overturn the denial of the ... Read moreEpisode 2: The Prior Authorization Games: Where the Odds are Never in Your Favor

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Greetings Readers.  I thought I would try something new and start somewhat of a series.  If you didn’t see my original post on prior authorizations, this link will take you right to it.

Last week I found myself on the phone, yet again arguing on behalf of a patient, to overturn the denial of the insurance company to pre-authorize a PET/CT scan.

The conversation was as usual, frustrating and, a waste of 15 minutes of my clinic time where I had to keep another patient waiting in the exam room.  (Because the insurance physician is only available during clinic hours, I cannot wait until after 5 PM when I am finished with my patients, but must sacrifice my schedule and keep other patients waiting in order to complete the phone call).  While in the end I obtained the approval for my patient, I was frustrated with the usual ridiculousness of the “peer-to-peer” discussion.

Here, is a summary of the conversation:

Insurance physician (IP):  “So, I see here this request is for a PET/CT scan?”

Me:  “Yes.   Let me tell you about the patient.  But first, I want you to know, I’ve been kept waiting on hold for 13 minutes, waiting to speak to you.”

IP:  “Uh, Ok.”

Me:  “Mrs. X. has a metastatic cancer of unknown primary.  As part of our work-up to find the origin of the cancer, I need for her to have a PET/CT scan.”

IP:  “So, what is the primary site of her cancer?”

Me:  (deep breath) “That’s what I’m telling you, we don’t know.  It is a cancer of unknown primary.  That’s why I am ordering the PET/CT scan — to try to help us find the site of the primary, in order to best recommend treatment options.”

IP:  “Why can’t she have a CT scan?”

Me:  “She did have a CT scan.  It showed some possible thickening in the lower esophagus, and no other site of possible primary.  But she had a negative endoscopy.  The PET/CT scan will help us see if there is metabolic activity in the esophagus, or anywhere else.”

IP:  “Oh, she had a CT scan already?”

Me: (another deep breath, count to 10)  “Yes.”

IP:  silence

Me:  “I assure you, as a board certified oncologist, this is well within the standards of care of oncology.”

IP: (after a few more seconds of silence).  “Ok, I’ll give you an approval number…”

 

Do you have a good story on prior authorizations?  Reply in the comments field.

For resources on prior authorizations, see my original post , and here also are a few more I have found since my first posting:

Dear insurance doctor: You are not my peer

An insurance company denies a test. Here’s what physicians should do next.

Stay tuned, for episode 3.  (While I would hope for no more episodes, my practice experience unfortunately tells me there will be more…)

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My Mom is a Doctor, My Dad is a Dad. https://thehopefulcancerdoc.com/mom-is-doctor-dad-stays-home/ https://thehopefulcancerdoc.com/mom-is-doctor-dad-stays-home/#respond Mon, 23 Oct 2017 05:42:50 +0000 https://thehopefulcancerdoc.com/?p=466 “My mom is a doctor, my dad is a Dad.” So stated one of our children in their autobiography assignment for school.  I kept reading, curious what would come next. “My dad usually stays home and cleans up, and takes care of the pets.” I thought for a moment.  “That’s very good, honey, but do ... Read moreMy Mom is a Doctor, My Dad is a Dad.

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“My mom is a doctor, my dad is a Dad.”

So stated one of our children in their autobiography assignment for school.  I kept reading, curious what would come next.

“My dad usually stays home and cleans up, and takes care of the pets.”

I thought for a moment.  “That’s very good, honey, but do you think you could write something else about Dad?” I suggested.  “He does other stuff too, add some more nice things.”

“Ok, how about … ‘And he takes care of us, because my mom works all the time.’”

Ugh, not exactly what I was going for.  I tried not to show any hurt feelings on my face.  “Honey, I don’t work all the time, do I?”

He thought hard and then responded, “Oh, I know, I know!  How about this – ‘He takes care of us because our mom works most of the time.’”  His face was beaming with pride at his adaptation of the sentence.

And so that is how it reads in the final draft he turned in to his teacher.  I can’t wait to see it up in the hallway at parent-teacher conference night.

I have been thinking a lot lately about the parenting role-reversal that exists when the woman is the full-time bread-winner and the man is the stay-at-home-parent.

The following are a few examples from our lives.

One of my favorites is from about 10 years ago, when our oldest was in preschool.  It was a weekend and we were both home.  The phone rang and my husband answered. (yes, back then we used an actual landline).  It was the preschool teacher calling to tell us about a change in schedule.   A few moments later he handed the phone to me with a frustrated look on his face.  “She insists to talk to ‘my wife.’”

I took the phone and listened as she went into detail about the schedule change.  After the call I relayed the information back to my husband, who was the one who really needed to know it, as he brought our child to and from the preschool.

“Strange, she absolutely insisted to talk to you,” my husband said.

We then burst out laughing as we realized it was because the teacher held to the stereotype that the father wouldn’t be involved in school schedules, and couldn’t possibly be trusted with the new information.  With us, she had definitely gotten it backwards.  Although we laughed about it, I could tell my husband was irked.

That was approximately 2007.  Around 2009, during the time of the financial crisis, I started to notice that my husband was no longer the only stay-at-home dad in our children’s schools.  An interesting thing happened–with the economic slow-down, many couples with children were making the choice for the woman to keep her job while the man stayed at home.  It was a welcome change to no longer be the only ones we knew in this situation.

As our three children have advanced in school, and society seems to have adapted a bit more over the past 10 years, a situation like above with the teacher hasn’t repeated itself.  Now he gets all the texts from teachers and coaches, and I rely on him 100% to keep track of our kids’ schedules.  To be honest, at times I am downright envious to be the parent least in touch with the classrooms.

I have been subjected countless times to the comment, from both teachers and other parents, “So, you’re the mom!”  As in, “so, you really do exist.”  They say it with a grin but I don’t understand why, as it is not funny, it is hurtful, and, dare I say, sexist.  I don’t think working fathers are subjected to this type of commentary when they come to a parent-teacher conference, even if it is the first time the teacher has ever met them.  But for a working mother, others can’t seem to wait to rub the salt in the wounds of guilt.

Similarly, I don’t think it is likely that a mother has ever been told by a teacher on the phone, “I can’t talk to you — let me talk to your husband so I can tell him about the school schedule change.”

Another example of being stereotyped by other parents:  some years ago, in picking my daughter up from kindergarten, the only one day a week I could do this with my schedule, another parent eventually admitted to me that she and the other moms had thought for the whole first quarter that I was the nanny, since they hadn’t seen me at any other activities.  Outwardly I laughed along, but inside my heart was bleeding.  Ouch.

My husband and I never sat down and planned that he would become a stay-at-home-dad, it just evolved as our family grew.  We realized life was a teeny bit less chaotic, and we could keep up with all the homework and extracurricular activities better, with one parent at home full-time.  I am very grateful that I have a job and career that can support my family on a one-parent income.  I know many women who work not because it’s a choice, but because their families would not survive without dual income.

Do I sometimes wish the stay-at-home parent was me?  Absolutely.  Do my children seem to mind that they have their dad instead of their mom as the stay-at-home parent?  Absolutely not.  As my son concluded in his essay, “My parents are of course just parents.”

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The Puzzle Table https://thehopefulcancerdoc.com/the-puzzle-table/ https://thehopefulcancerdoc.com/the-puzzle-table/#respond Tue, 03 Oct 2017 05:04:50 +0000 https://thehopefulcancerdoc.com/?p=453 I am pleased to share the link to my newest published narrative essay, entitled The Puzzle Table, published online 10/2/17 in the Art of Oncology section of the Journal of Clinical Oncology.  

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I am pleased to share the link to my newest published narrative essay, entitled The Puzzle Table, published online 10/2/17 in the Art of Oncology section of the Journal of Clinical Oncology.

 

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Guilt and the Physician Mom: Doing Enough; not Perfection https://thehopefulcancerdoc.com/guilt-physician-mom-doing-enough-not-perfection/ https://thehopefulcancerdoc.com/guilt-physician-mom-doing-enough-not-perfection/#comments Tue, 05 Sep 2017 07:49:05 +0000 https://thehopefulcancerdoc.com/?p=438 Recently I was enjoying a “mom day” running errands with the kids, you know, the usual essentials — groceries, school supplies, and espresso coffee drive-through. At this last stop, the barista made small talk and, seeing the kids in the back seat,  joked about school starting soon and how I must be looking forward to ... Read moreGuilt and the Physician Mom: Doing Enough; not Perfection

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Recently I was enjoying a “mom day” running errands with the kids, you know, the usual essentials — groceries, school supplies, and espresso coffee drive-through. At this last stop, the barista made small talk and, seeing the kids in the back seat,  joked about school starting soon and how I must be looking forward to that — “You’ll get your Mom time back!” To which I laughed and relished the rare moment of just being a Mom. Until one of my kids yelled up, “But, Mom, you work all the time!” 

The previous week, sitting around the dinner table, this same child decided he wanted to give his take on what everyone did that day. We were enjoying his version of how everyone spent the day – my husband — “mowed the lawn and did Dad stuff;” his siblings – “played with the dog, played with the iPad;” until it was my turn – he pointed an accusatory finger at me and yelled “Work, work, work!”  Not destined to be one of my cherished family memories.

These episodes, and others, make me wonder how my kids are going to view me, and their childhood, when they are grown. In the best moments, I envision them grateful for two progressive parents who defied conventions and stereotypes by Mom working full-time as the bread-winner, and Dad staying at home full-time to make sure they were cared for, supported in school, and kept from actually building that zipline they drew that would take them from the top floor window to the bus stop across the street.
In my worst moments, I envision them remembering me as that caffeine-addicted woman always at work, always in a rush, and too busy to notice that zipline under construction.

I know from discussions with colleagues I am not alone. Whether we have a spouse that stays at-home, a nanny, an au-pair, grandparents that watch the kids, utilize day-care, or some combination of the above, we constantly question our parenting decisions and life choices.  Are we doing the right thing?

As Erma Bombeck wrote, “Guilt: the gift that keeps on giving.” 

I don’t necessarily have any answers, but I do have another moment to share that helped make up for the others, and gave me hope that maybe, just maybe, my kids will one day view me more along the lines of option #1 above.

The same child who made the comments above has decided he, too, will grow up to be a doctor. “But, Mom,” he said, “I might feel kind of lonely.” I braced myself for what he was going to say next — and to get hit with the next load of guilt.

He went on to say, “Because I might be the only boy – you know, since doctors are mostly all girls.”

So to my fellow physician-moms-in-guilt, I write: maybe we aren’t perfect, but maybe, just maybe, we are doing enough right after all.

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The Prior Authorization Games: Where the Odds are Never in Your Favor https://thehopefulcancerdoc.com/prior-authorization-games-where-odds-are-never-in-your-favor/ https://thehopefulcancerdoc.com/prior-authorization-games-where-odds-are-never-in-your-favor/#respond Fri, 04 Aug 2017 14:26:34 +0000 https://thehopefulcancerdoc.com/?p=421 I am not the first physician blogger to write about the difficulties of prior authorizations, denials, and appeals, but recent occurrences in my own practice have been so convoluted that I feel they must be shared. The nonsensical denials would almost cause one to laugh, if not for the reality that each denial represents potential ... Read moreThe Prior Authorization Games: Where the Odds are Never in Your Favor

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I am not the first physician blogger to write about the difficulties of prior authorizations, denials, and appeals, but recent occurrences in my own practice have been so convoluted that I feel they must be shared.

The nonsensical denials would almost cause one to laugh, if not for the reality that each denial represents potential delay in care for the patient and redundant work for the physician — work that expands exponentially from the initial time taken to submit a carefully-worded request (in the futile hope that one might receive an approval on the first try).  The incredulous laughter at the absurdity of the denials turns quickly to lamentation as my inbox fills each week with more and more denials of prior authorization for reimbursement, which must be appealed.

Case #1.

I requested an MRI of the brain for a patient with a history of malignancy, now with new concerning neurological symptoms.  The insurance company approved the MRI, but only WITHOUT gadolinium contrast.  I had requested the MRI to be done WITH gadolinium contrast.  Some nameless, faceless, person at the insurance company, who has never met my patient, and I am certain does not have a medical degree, dictated what kind of MRI that I could order.  It seemed they were willing to concede the patient needed the MRI, but they wouldn’t approve it the way I, the physician, a board-certified medical oncologist, had ordered it.  This degree of attempt at micromanagement of my medical care of my patient was jaw-dropping.

The letter indicated I could appeal the decision in writing.  I was so upset at the ridiculous nature of the denial that I wrote a more forceful letter than is my typical approach.  Here is an excerpt:

… I have ordered an MRI of the brain WITH contrast in order to evaluate the brain and meninges for any evidence of malignant involvement of the CNS.  This is according to current standards of practice in oncology.  For reasons that are entirely unclear and inexplicable to me, your company has approved only an MRI WITHOUT contrast.  Without the use of contrast, the radiologist cannot adequately evaluate the brain and meninges.  Please approve the MRI of brain WITH contrast ASAP so that we can properly take care of our patient.

Less than 24 hours after I faxed the appeal letter, a response letter of approval was on my desk; for MRI — WITH contrast.

While I was grateful for the patient’s sake that the approval turned around so quickly (not always the case — sometimes these appeals drag on for weeks), I couldn’t help but reflect on the situation, that what it really comes down to is a deep lack of trust.  The insurance company does not trust that I, as a physician board-certified in my specialty, know the best test to order for my patient.  Why is that?

Taking it one step further, if insurance companies can dictate what kinds of tests that we, as physicians, can order, why do we have a board-certification process to begin with?

I re-certified for both medical oncology and hematology within the past 1 year.  It was a good opportunity to review changes in practice and provided the reassurance that I was up-to-date in my fields of specialty, and I have the certificates again to prove it (at least for the next 10 years).  It was also a lot of work, expense, and time away from my practice.  And for what?  What good is being board certified in one’s specialty if someone without a medical degree is deciding what kind of tests will be reimbursed by insurance?  If insurance companies trusted the board certification system (for medical specialties, the ABIM — American Board of Internal Medicine), they wouldn’t second-guess our every radiology order, and make us submit “proof” of why we are ordering them on our patients.  Isn’t the “proof” in our medical degree, and our board certification?  The only conclusion that can be drawn is that insurance companies do not trust that being licensed and board-certified in one’s specialty means a physician knows what s/he is doing.

The irony is, I try to put the information I know they will ask for in the original order and the clinic note that accompanies the order.  I don’t think anyone with any medical knowledge reads it.  The result being that I have to double my work and write a letter with the same information and submit an appeal to finally reach someone, we presume, with some medical knowledge, to “authorize” the test that the board-certified physician has already determined to be indicated.  Like every physician I know, I am not given extra time in my clinic day to take care of these administrative tasks, so I am often doing them after clinic hours, on my “own” time.

Case #2

A patient with an upper extremity DVT (deep venous thrombosis) associated with an implanted portacath had completed a course of definitive chemotherapy, and we thus wanted to allow the surgeon to remove the portacath.  I recommended a repeat ultrasound to make sure the anticoagulation (blood thinner) treatment had been effective against the blood clot, before the surgeon removed the portacath.

We received a notification of denial of prior authorization.  The reason:  this insurance company only authorizes repeat ultrasounds for lower extremity DVT for ONLY the following 2 criteria:  (1) one week after diagnosis of the DVT, or (2) up to three times in the first 2 weeks if a DVT in the calf is not being treated.

My immediate thoughts on this as a board-certified hematologist were:

  • These criteria make no clinical sense for any DVT patient
  • They don’t even apply to my patient as the DVT is not even in his calf.

So again, I wrote the obligatory appeal letter.  I explained in great detail where the blood clot was, what a portacath is, and the potential dangers of the surgeon removing the portacath if there was still a large blood clot at the tip of it.  Based on the above success, I decided to take again a direct and forceful approach.  Here is an excerpt:

…it would be most prudent to repeat the ultrasound BEFORE we remove the portacath, so that we make sure the DVT is resolved (so that we do not risk dislodging a piece of blood clot that could go to the lungs).

Your company, however, has decided to deny coverage of a repeat ultrasound.

I would ask that you please reconsider this most expeditiously.

And reconsider it most expeditiously they did.  Again, within 24 hours, I had a letter of approval on my desk.  It seems that pointing out that their denial of the test could result in a potentially life-threatening consequence worked wonders in getting approval from the insurance company.

But again, I wished I didn’t have to go through this ludicrous process to get a clinically justifiable test approved.

Case #3

A tumor removed at surgery turned out to be a much higher stage than the preoperative testing had indicated.  I recommended adjuvant chemotherapy.  (Adjuvant chemotherapy is chemotherapy given after surgery, to decrease the chance of cancer relapse in the future).  However, to make sure we will not be exposing the patient to the risks of intensive chemotherapy inappropriately, I recommend a CT scan to make sure there is not already metastatic disease. (If there is metastatic disease, the chemotherapy cannot change that, and we would instead recommend chemotherapy treatments with less risk of toxicities, to palliate the metastatic disease, but balance side effects with quality of life).

The surgeon had ordered a CT scan prior to the surgery, but the insurance company had denied it.  We re-ordered the scan urgently, with the hope to have results quickly, and scheduled the start of chemotherapy in one week.

We received a denial of reimbursement for the CT scan.  This particular insurance company told us that they subcontracted this patient’s care to a subsidiary company.  We contacted that company.  They told us that, no, the parent insurance company is responsible for the decision on authorization.  After one week of repeated calls to both companies, we still did not have an answer.  We had to delay the start of chemotherapy.  After 2 more days, we finally received an authorization.

If I did not have a medical assistant whose primary responsibility is to help obtain these prior authorizations, I would never have been able to take care of the numerous back and forth phone calls that were necessary to finally obtain the approval.  No physician could do it alone.  (note to self – remember to bring coffee tomorrow for my prior authorization specialist MA).

Is there any hope for the future?

I think so.  I think physicians are starting to be heard.   A workgroup led by the AMA recently released a statement of Prior Authorization and Utilization Management Reform Principles.  I found an excellent summary on this blog post on medaxiom.com.

On their website, the AMA states:

The inefficiency and lack of transparency associated with prior authorization cost physician practices time and money. The lengthy processes may also have negative consequences for patient outcomes when treatment is delayed.

The AMA believes that prior authorization is overused and that existing processes are too difficult. … the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients.

Here are some more blog posts that I found to be good reads:

https://www.nytimes.com/2014/08/04/opinion/adventures-in-prior-authorization.html

http://gomerblog.com/2017/02/prior-authorization-eternity/

http://www.fiercehealthcare.com/practices/physicians-frustration-prior-authorizations-only-grows

http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/insurance-companies/prior-authorization-predicament?page=0,0

http://www.physicianspractice.com/blog/obtaining-prior-authorization-three-success-strategies

http://drmintz.blogspot.com/2012/05/prior-authorizations-suck.html

Epilogue:

Case #1:  No CNS metastases

Case #2:  Portacath removed successfully

Case #3:  Patient able to start chemotherapy

These are just 3 examples of the 50+ patients I see in a week.  Next time your doctor is running late, think about the last test you had — now you have a glimpse into what happened behind the scenes to make that happen.

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Relay for Life 2017: Who is your superhero? https://thehopefulcancerdoc.com/relay-for-life-2017-who-is-your-superhero/ Mon, 10 Jul 2017 06:43:18 +0000 https://thehopefulcancerdoc.com/?p=401 The following post is an edited transcript of my speech given on 7/8/17 at the Relay for Life 2017, Clatsop County, OR.  I am very excited by this year’s Relay for Life theme, “Who is your superhero?” I am excited because I get to work with real-life superheroes every day.  And this morning I get ... Read moreRelay for Life 2017: Who is your superhero?

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The following post is an edited transcript of my speech given on 7/8/17 at the Relay for Life 2017, Clatsop County, OR. 

Logo
American Cancer Society Relay For Life Logo

I am very excited by this year’s Relay for Life theme, “Who is your superhero?”

I am excited because I get to work with real-life superheroes every day.  And this morning I get to tell you about some of them.

If I had to pick just one group of people who are my superheroes, there is no question, it would be my patients.

A hero is an ordinary individual who finds the strength to persevere and endure in spite of overwhelming obstacles.  — Christopher Reeve

If there was ever a real-life example about the creation of a superhero, it was Christopher Reeve.  The actor who became famous for portraying “Superman”, later paralyzed in a random accident, rose above his injuries to become an advocate and real-life superhero to the world.

My patients inspire me every day with their own strength and perseverance.

In fact, I am in awe of them.  All of you out there today, who are either in treatment or have finished your treatments, whether last week or years ago, you are my heroes.  It is my privilege to guide you through your journey of treatment and survivorship.  You DID endure.  You DID overcome those obstacles.

But I can’t pick just one group of people that I consider superheroes.  The families and caregivers are my next group of heroes.

A hero is somebody who voluntarily walks into the unknown. — Tom Hanks

One of the first things I say to my patients at the initial consultation visit, is that you cannot do this alone; no one can do this alone.  Who is going to walk by your side through this?  Most family and caregivers have no experience with cancer.  It is all an unknown.  It is scary.  They are scared for their loved one.  They are worried they don’t know the right things to do.  But they learn, and they attend, and they administer, and they care.  They don’t walk away when the going gets tough.  And for that, they are heroes.

My next shout-out to heroes is to the oncology nurses.

A hero is no braver than an ordinary man [or woman], but he [or she] is brave five minutes longer. —Ralph Waldo Emerson

The nurse is the one I unfailingly see taking the extra 5 minutes (or often much longer) — providing comfort, reassurance, teaching, and a listening ear.  In actuality, the nurse spends much longer time than the doctor, often hours as the treatments are given, whereas the doctor might get 15-30 minutes.  There would be no cancer care without oncology nurses.

In addition to the nurses, we have a whole team of heroes who make up our clinic staff.  Oncology pharmacists, social workers, medical assistants, customer service representatives, to name a few.

I like to say that oncology is a team sport.

The ordinary man [or woman] is involved in action, the hero acts. An immense difference. —Henry Miller (writer)

There are innumerable acts our staff perform to enable the care of our patients.  Just like in a team sport, the individual player is not always recognized, but every play is what leads up to the goal.  These unsung heroes of our clinic provide all the essential services that lead to successful treatment.

I also want to recognize the heroes of the hospice care team.

Heroes are like angels, they’re all around us… we just don’t always stop to notice … —Nanette L. Avery (writer)

The hospice nurses and care team are truly angels and heroes.

Shifting gears, my list would not be complete without recognizing my former and current mentors.

I wouldn’t be in my position today without them.

A hero has faced it all: he need not be undefeated, but he must be undaunted. —Andrew Bernstein (philosopher)

I would especially like to recognize Dr. Steve Chandler, my colleague who has joined me for the past 9 months here to care for patients.  He has practiced oncology for over 40 years, yet faces each day truly undaunted and brings his wise and kind spirit to the clinic that has benefited us all.

Another often unsung hero is the oncology researcher.

A hero is someone who has given his or her life to something bigger than oneself. —Joseph Campbell (writer)

It is these tireless brilliant people who work “behind the scenes” so to speak, whose scientific advances have led to our current breakthroughs in cancer treatment, most especially in the past 2 years including the immunotherapies.  Molecular analysis of tumor DNA is letting us strategize targeted therapies for many more cancers than in the past.

Personally, I also want to recognize my family.

Whatever you want to do, if you want to be great at it, you have to love it and be able to make sacrifices for it. —Maya Angelou

Without the support of my family, I couldn’t be an oncologist.  They have to share me with my job, and I know it’s not always easy.  They are my heroes for the sacrifices they have made, and understanding the sacrifices I have made.

So in closing,

in keeping with the superhero theme, if you will permit me to indulge my inner geek, and to quote from popular culture, the latest superhero movie, Wonder Woman,

YOU ARE STRONGER THAN YOU BELIEVE.

YOU HAVE GREATER POWERS THAN YOU KNOW.

 

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The Doctor is In; The Mrs. is Out: forms of address toward female physicians. https://thehopefulcancerdoc.com/the-doctor-is-in-the-mrs-is-out-forms-of-address-female-physicians/ https://thehopefulcancerdoc.com/the-doctor-is-in-the-mrs-is-out-forms-of-address-female-physicians/#comments Mon, 26 Jun 2017 06:32:17 +0000 https://thehopefulcancerdoc.com/?p=391 My smile freezes on my face as my patient says to me, “I’m so glad you’re back – that I get to see Mrs. Lycette today!” He has been my patient for several years, and I am perplexed to hear him address me as “Mrs.” rather than “Doctor.”   At the same time, I really do ... Read moreThe Doctor is In; The Mrs. is Out: forms of address toward female physicians.

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My smile freezes on my face as my patient says to me, “I’m so glad you’re back – that I get to see Mrs. Lycette today!”

He has been my patient for several years, and I am perplexed to hear him address me as “Mrs.” rather than “Doctor.”   At the same time, I really do not think he means an intentional insult, so I keep my face neutral and continue with the visit, without saying anything to correct him.  But it sticks in my mind.  It is not the first time one of my patients has referred to me as “Mrs.”

I know my patients know that I am their doctor.  They allow me to treat them — for cancer.  But some of them are apparently unsure of, or perhaps incapable of, addressing a female physician as “Doctor.”

Not long ago, a very polite older man that I had been treating for over a year said to me at the end of the visit, in a hesitant voice, “What do I call you — I’ve been wondering?”

I replied that he could call me “Dr. Lycette,”  “Dr. Jennifer,” or simply “Doc”.  He seemed relieved to have the choices and know what was appropriate.  I appreciated that he asked the question, but I wondered as to why he was unsure what to call me, after one year as my patient, as I highly doubted he would have been unsure what to call his male physician — “Doctor”.  

As with the first patient, I do not think the insult was intentional, but regardless of intent, an insult is felt.

To attempt to explain why, let me first review a short history of the “Mrs.” title.

“Mrs.” was originally short for “Mistress,” the female version of “Master.”  Prior to the mid-18th century, it was a title associated with the property-owning class.  It was only sometime in the mid-18th to mid-19th century that “Mrs.” became associated with marital status. “Mrs.” referred to a married woman, and “Miss” referred to an unmarried woman.  In the 20th century, the term “Ms.” was first proposed as a tactful way to refer to a woman without inadvertently breaching etiquette if her marital status was not known.  It only later became associated with the Feminist movement, and gained traction in the early 1970s to disassociate a woman’s title from her marital status. (The New York Times did not officially recognize Ms. as a title until 1986).

To address a female physician as “Mrs.”, even if she is married, is to imply that despite all her professional accomplishments, her worth is reduced to her marital status.  It ignores all the hard work that went into earning the title of “Doctor,” and denotes, whether intentional or not, that a female physician is somehow less deserving of the title than a male physician.

It turns out even among physician peers, female physicians are not accorded the title of “Doctor” as often as male physicians.

In a study published in the Journal of Women’s Health, the authors — some of whom had personally experienced having their professional title omitted repeatedly when introduced as speakers — conducted a study to compare gender differences in introductions at medical grand rounds.

Dr. Files et al analyzed data from 6 months of videotaped introductions, and found that male doctors introduced a male speaker as “Doctor” 72% of the time, but introduced female speakers as “Doctor” less than 50% of the time.  (Women introducing any grand rounds speaker used “Doctor” 96% of the time — regardless of the speaker’s gender).  The authors explain:

The reinforcement of gender hierarchy that occurs by not acknowledging the professional title of female speakers further reinforces the social norm that men are of higher status than women … Word choice and selective use of forms of address may reflect conscious or unconscious assumptions about gender roles.

This study has in the past few months been reported on by multiple media publications and blogs, including The Standard-Examiner, Newsweek, The Huffington Post, NPRGenderAvenger, and KevinMD.

In a comment from The Standard Examiner article for the Washington Post,

Kim Templeton, a professor of orthopedic surgery at the University of Kansas in Kansas City, said she cringed every time she heard female doctors introduced by their first names and had experienced it plenty of times herself.

“Women don’t tend to be thought of as leaders. They’re thought of as worker bees and the people who work well together,” said Templeton, immediate past president of the American Medical Women’s Association. “Talking to us is no different than talking to their wives or daughters at home.”

“They just assume, somehow, that they don’t warrant the same respect as the men do,” she said.

The following are two instances I have personally experienced:

  1.  I wrote in an earlier post about being cropped out of a press photo when I was the only woman at the table.
  2.  Earlier this year when I did a live radio interview, my husband (a non-physician) told me immediately afterward that he was offended on my behalf that the (male) host did not refer to me as “Doctor” during the entire interview.  (I hadn’t noticed as I was too busy worrying about being on live radio).  I didn’t think much more about it until later that day when my brother (also a non-physician) texted me in sibling solidarity outrage — “he never once addressed you as Doctor, what is up with that!”

So I checked the website for the radio station.  I was identified for the segment as the medical director, which is correct, but not as a physician or doctor, and there were no M.D. initials after my name.  I couldn’t help but wonder if the host was in fact aware that I was a physician or not.

However, I am chagrined to admit I have made the same mistake.

Several years ago a woman was introduced to me at a social event as a director of a department, without using her title, and I made an assumption that she was a non-physician administrator.  I later felt incredibly foolish when I realized in another context that she was a physician.  But the misunderstanding could have been easily avoided if she had been introduced to me as “Doctor” so-and-so, but our introducer had left out her title.

I struggle with my title outside of the workplace as well.  Most male physicians in our society are referred to as “Doctor” in all aspects of their lives.  Why shouldn’t female physicians be as well?

Recently, while participating in a career fair for grade-schoolers, a 4th grade girl addressed me as “Mrs.”   The boy next to her then called me by my first name, with no title at all.   I wondered why children in our society, in 2017, would not think to address the female doctor standing in front of them as “Doctor,” and whether the boy would have addressed a male physician in front of him in a school setting by his first name (“Hey Joe!” for example).

However, upon pondering this, I realized it could be at least partially my own fault.  When I have spent time volunteering in my children’s school classrooms, the teachers at times have referred to me in front of the class as “Mrs.”, and I have not corrected them.  I worried to do so would come across as arrogant, and I told myself that it was not so important – since in the classroom my role is that of a parent volunteer, not a doctor.

But when the young girl called me “Mrs.” at the career fair, it made me realize that we still owe more to the next generation.  If we do not point out to others, as Dr. Files et al have done laudably in their study and publication, that the omission of a woman’s professional title, even when inadvertent, has real consequences for that woman, and greater society, then we are silently aiding the misconception in our society that female physicians do not need to be, or care to be, addressed as “Doctor”.

When in actuality – we really do.

Lone tree

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In cancer, there is no place for blame. https://thehopefulcancerdoc.com/in-cancer-no-place-for-blame/ Tue, 13 Jun 2017 06:50:10 +0000 https://thehopefulcancerdoc.com/?p=379 I recently read a post by oncologist Dr. Stephanie Graff on the experience of blame, from self and others, that people with cancer are subjected to. The talk about risk factors and early detection makes us think we can achieve perfection, and that cancer is somehow a personal fault…let us stop making accusations and blaming persons ... Read moreIn cancer, there is no place for blame.

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I recently read a post by oncologist Dr. Stephanie Graff on the experience of blame, from self and others, that people with cancer are subjected to.

The talk about risk factors and early detection makes us think we can achieve perfection, and that cancer is somehow a personal fault…let us stop making accusations and blaming persons diagnosed with cancer. They are blameless.

Her post, The only perfect cancer statistic is an imperfect one, is a great resource for any of our patients who have experienced or are struggling with this.

Another type of blame we can see in oncology practice is when our patients’ families worry that they somehow did not do enough to save their loved one.  They blame themselves for not going to more or different doctors or a different hospital or cancer center.  They second-guess a decision to accept hospice care.

With the inundation of media advertisements and news stories on new cancer treatments, there is a misconception that there is a treatment success for every cancer and situation.  I hope one day that is the reality, but it is not yet.

Some time ago I wrote a metaphorical letter about cancer and hospice to someone, in the hope to find a way to reassure him that he, his family, and his loved one’s doctors, had truly done everything possible.  He told me it was helpful to him and so I thought I would use it as part of this post, in case it can be also helpful to others.  Here it is below (slightly altered from the original letter to protect privacy):

Dear Friend,
Once upon a time a wise and experienced colleague of mine shared with me that he often viewed the task of a medical oncologist as akin to a knight fighting a dragon.

We raise our swords and drive the dragon back for as long as we can, but too often, even from the onset of the battle, we know we will not win, and ultimately it is the dragon which will be victorious.

Most of the time, we do not know when or why the dragon attacks, or how it chooses its victim.  We have limited weapons to battle the dragon.  Sometimes, our weapons succeed at first to drive the dragon back, and the dragon may even retreat fully from view.  But with no warning, it can return.  And when it does, to our dismay, it has evolved, so that the initial weapons that seemed successful now fall useless to the wayside.   

We grab in desperation for another weapon.  A cadre of our knights toil steadily to invent and make new weapons.  We learn that different dragons have different vulnerabilities.  We stock our arsenals.  There are some dragons who are easily weakened, and we can drive them back with each new weapon.  But with one eye we watch the ever shrinking arsenal, as we are aware with each weapon used, we get closer to the day when the arsenal will be depleted.  The dragon is ruthless, and cares not who its victims are.

It is at this point where the knight must drop his or her sword.  If the dragon cannot be stopped, what can be done to shore up the village?

This is what hospice means.  It does not mean we are abandoning the village.

It means that we know from our experience that this kind of dragon is too powerful.  We have learned from our past battles, and those of our mentors before us, that no human power can turn it back.  Hospice is the shield we place over the village.

So why go to battle at all, one might ask?  Perhaps because sometimes, we find something unexpected, a chink in the dragon’s scales; a weapon that did not work before suddenly weakens the next dragon.  It gives us hope.  We study the dragons.  We learn that some dragons have features that make them especially vulnerable to certain weapons, but not others.  We start saving more villages.  Villages everywhere feel more secure.  But even so, certain types of dragons remain immensely powerful.  Our weapons bounce off their scales like harmless droplets of rain.  There is no rhyme or reason as to why one kind of dragon visits one village, and a different one goes elsewhere.

This cancer was one of those worst-of-all dragons.  I think your loved one, and all of you, were exceptionally brave and you had the best knights fighting on your side.  I want you to know that there was nothing overlooked — no better knight or secret weapon somewhere else that might have changed things.

We are but mortal.

 

(as Atul Gawande has written about in Being Mortal)

 

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A sense of purpose in a broken world. https://thehopefulcancerdoc.com/sense-of-purpose-in-broken-world/ Sat, 03 Jun 2017 07:49:11 +0000 https://thehopefulcancerdoc.com/?p=368 Recently I found myself sitting in my car in the parking lot of my clinic,  unable to will myself to open the door.  I didn’t want to head in to the clinic that morning.  Instead I was filled with despair; overwhelmed with the events of the world. How can I do it? I thought.  How ... Read moreA sense of purpose in a broken world.

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Recently I found myself sitting in my car in the parking lot of my clinic,  unable to will myself to open the door.  I didn’t want to head in to the clinic that morning.  Instead I was filled with despair; overwhelmed with the events of the world.

How can I do it? I thought.  How can I walk in there and summon the energy to see my patients?  

An even worse thought:  Why should I do it?  What is the point in trying to heal the sick, in a broken world?

In addition to world events, I had just found out that the loved one of someone I knew had been a victim of a brutal attack; a random act of violence.

I couldn’t fathom how I would be able to walk in to the clinic and face my sick, and in some cases dying, patients, and put forth to them the person they expected me to be — their doctor who believes in them, and who puts all else aside to be there for them.

As I sat there, I struggled to make some sense in my mind of recent events, but I realized, there was no sense to be made.  I still didn’t feel like I would be any use to my patients, but I decided I was no good to anyone sitting in my car either.

So I went inside.  I started my day and in moments I was too busy to think about anything else.  A few hours later it hit me — I was sitting with one of my patients listening to her concerns, and it was a few hours later.  Without conscious thought, I had automatically stepped into my role as a physician, to put all else aside except the person behind the exam room door.  And something else had happened too.  The sense of despair was gone.  I was filled with a sense of purpose again.  The one that usually gets me through the door each morning, but I had momentarily lost.

There are many forces that can make us lose our sense of purpose, both external and internal to the world of medicine.  It’s awfully hard to be a good doctor without that sense of purpose.  Some might call that burnout.

Some days, it feels like it would be easier to shut down, to just stop caring.  There’s too much bad out there.

But that’s exactly why we can’t stop caring.

I am often asked about my job as an oncologist, and most commonly I am asked whether it isn’t too “sad” or “depressing.”  I can never quite put into words how completely opposite it is.

That morning, it was only when I briefly lost my sense of purpose, that I felt a sense of despair.  The opportunity and privilege to help someone in a true time of need is about as far from despair as you can get.  And I get to do it every day.  As do thousands of other doctors.

It turned out, while I was sitting in my car afraid the world had filled me with despair, and I wouldn’t have enough to offer my patients, I needn’t have worried:  my patients are what restored me that day.

 

 

 

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