Another year

I will have recently had my five year anniversary. So far, everything is looking good. Markers low, CT/MRI good. I'm working more. Life is more normal in that sense, too. In one way, I can put this disease behind me. But, the experience has permanently changed me and my family.

The experience of cancer, or any life threatening disease, changes how one approaches life. Time with family becomes more important. My children are teens and wanting to develop their own identities. I now know I will likely see them into adulthood. It now seems likely that I may even experience being a grandparent.

My cancer has also affected work. I was limited by my health during treatment by the disease, and now am being limited by the perception of others that I cannot work as much as before. I, too, have changed my perception. Being a workaholic makes less sense, since I feel relationships are far more important. But, now, having spent part of my retirement savings on my time off due to illness, I know I will need to keep working for several more years.

Cancer also affects my sense that I need to continue to have good insurance, as I know I am not invincible. As I see the ACA protections being taken down, I worry not only how this will affect my patients, but how it will affect me. I am still too young for Medicare, and that, too, seems in jeopardy. None of us will get out of this life without the clouds of illness or injury. Unless our society does not value its people, we need to think about this. We need to have a system to care for all of our people. I have seen far too many people whose lives are destroyed, not by the disease, but by the economic disaster that accompanies it.

Triage and the R-word

Recently, I retook Advanced Trauma Life Support. I had been an instructor in the past, but lapsed during my own medical treatment. But, now, back in the trenches, I needed to redo my certification. Since it is geared toward standardizing trauma care, the issue of mass casualties is addressed.  Even with a modern trauma center, a natural or man-made disaster could overwhelm the locally available resources. Traditionally, this was more of a problem for the military, and it was in that setting, during the Napoleonic wars, that the term "triage" originated.

Triage consists in dividing patients into three categories--those with unsalvageable injuries, who will die regardless of care; those for whom treatment will make the difference; and those with minor injuries who will survive regardless of care. Clearly, in the mass casualty setting, attention is directed toward the middle group, with minimal resources directed toward the other two. 

Modern healthcare has become so costly, that a society must decide how to allocate resources. Clearly, an extremely old and debilitated patient will not have a long survival with an aggressive cancer. So, perhaps care should be directed to palliation rather than attempt at cure. This might be kindest, as well as most cost effective.

Similarly, those with minor self-limited issues might be best treated with "watchful waiting" and reassurance. Again, what is best for society is also best for the patient.

The middle group is where the resources should be directed. These are the patients for whom more aggressive treatment will make a difference in outcome. Most infectious diseases have a low cost to benefit ratio, and their treatment is also beneficial for society. Cancer treatment is often costly, but is valuable to the patient and to society if there will be a reasonable length of survival with good quality of life. Recently, I reflected on the dozen or so of my friends who are back working full time after cancer treatment. For us, it was definitely worth it. But, I don't know if I would have wanted to go through it at age 90.

This sort of allocation is gradually becoming more accepted, as people are not wanting heroics as much near the end of life. But, still, nearly half of our health care expenditures are in the last month of life. If we, physicians, could do better at prognosticating which of the groups a patient would fall into, we would be better able to discuss potential outcomes, and guide patients and their families through end of life decisions. I am convinced that this lead to better outcomes for both the individual and society.