November-December Book Club - No Apparent Distress

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Froggy88
Regular Member


Date Joined Mar 2017
Total Posts : 62
   Posted 11/4/2017 9:46 AM (GMT -6)   
Welcome, readers. For November and December, the book for reading and discussion will be Rachel Pearson's "No Apparent Distress: A Doctor's Coming-of-Age on the Front Lines of American Medicine," which was released earlier this year. Most of the book involves the author's experiences as a medical student, caring for mainly indigent patients in the Galveston area.

As far as the applicability for here, several of the cases involve cancer, with misdiagnoses, as well as undertreatment and nontreatment that I found shocking. There will be certainly a lot to discuss in terms of the different experience levels of medical personnel and how that impacts treatment, the callousness that our medical system (and society) engages in in refusing treatment to the uninsured, and how people (doctors and patients) react in the face of such a system.

As usual, the first month (November) is for reading/listening, and the following month (December) is for discussion.

Please respond if you're joining in this time around.
11/16 DRE+ PSA 3.66
Dx 03/17 (Age 56), 1/14 positive, G6 (5%), T2a
05/17 PSA 1.38
Currently on AS

81GyGuy
Veteran Member


Date Joined Oct 2012
Total Posts : 2194
   Posted 11/4/2017 1:30 PM (GMT -6)   
Yes, I'll participate.
Age: 71
Chronic prostatitis (age 60 on)
BPH w/ urinary obstruction, 6/2011
TURP, 7/2011
Ongoing high PSA, 7/2011-12/2011
Biopsy, 12/2011: positive 3/12 (90%, 70%, 5%)
Gleason 6(3+3), T1c
No mets, PCa likely still organ contained
IMRT w/ HT (Lupron), 4/2012-6/2012
PSAs (since post-IMRT): 0.1 or lower

Froggy88
Regular Member


Date Joined Mar 2017
Total Posts : 62
   Posted 11/11/2017 10:14 AM (GMT -6)   
Just a reminder that this book is on the agenda for discussion next month. Hopefully we can get a few more to join in.

As encouragement, I'll blurb from a review:
"Dr. Pearson relates a number of ... instances of hesitation, error, awkwardness, and confusion as she progresses through medical school. As I noted earlier, these are all standard student responses, as are the array of hostile, difficult, engaging, and grateful patients. What makes No Apparent Distress stand out is the author’s ability to bring her feelings and these characters to life. She also has a distinctive voice, an attractive mixture of naiveté, passion, sharpness, and common sense that hooks the reader and makes him keep turning pages."

This ties in with something worth keeping in mind for reading, the various relationships between doctors and patients. There is some tendency on both sides of the relationship to devolve (or default) to an interaction on a surface level, with the doctor as a mere provider of medical services and the patient merely a consumer of such services -- what Martin Buber termed an I-It mode of existence. What keeps doctors and patients from more often engaging on a personal level? To what extent is it desirable to overcome these barriers?

Anyway, those questions (and more) are on the agenda for next month. Please chime in if you'll be participating.
11/16 DRE+ PSA 3.66
Dx 03/17 (Age 56), 1/14 positive, G6 (5%), T2a
05/17 PSA 1.38; 09/17 PSA 1.47
Currently on AS

Froggy88
Regular Member


Date Joined Mar 2017
Total Posts : 62
   Posted 12/3/2017 10:18 AM (GMT -6)   
Well, the response so far has been underwhelming, but I'll take a stab at trying to start a discussion, and see if anyone responds.

One theme of the book is how inexperienced medical students, with some supervision, are thrown into the breach to take care of the uninsured and indigent patients that no one else is willing to help. In the prologue the author discusses her failure to diagnose stomach cancer because of an incomplete examination, and later she relates her neglect of a detail that indicated kidney cancer in another patient.

Mistakes are a part of any profession, but when it comes to health care no one wants the mistakes inflicted on them, at least not when anything significant is on the line. For prostate procedures people understandably want the best and most experienced doctors in charge, recognizing that there is a significant difference in outcomes. Locally, I've read about a series of lawsuits against the Cleveland Clinic that lasted for several years, where a patient alleged that the robotic surgery that left him incontinent and impotent was not actually performed by the surgeon he had engaged, but rather by two doctors in training. (The Clinic denied the allegation, and eventually won the cases on technical grounds.)

But where are medical personnel to get the experience that makes them the top providers in their fields, and who is to be left to be treated by those doctors who are not the elite? What should or could be done to improve care in general, so that care of the highest quality is not just reserved for the well-informed, the well-connected, and the well-insured?

81GyGuy
Veteran Member


Date Joined Oct 2012
Total Posts : 2194
   Posted 12/7/2017 9:04 AM (GMT -6)   
^^^BUMP^^^

(To remind everybody and invite them to join in).
Age: 71
Chronic prostatitis (age 60 on)
BPH w/ urinary obstruction, 6/2011
TURP, 7/2011
Ongoing high PSA, 7/2011-12/2011
Biopsy, 12/2011: positive 3/12 (90%, 70%, 5%)
Gleason 6(3+3), T1c
No mets, PCa likely still organ contained
IMRT w/ HT (Lupron), 4/2012-6/2012
PSAs (since post-IMRT): 0.1 or lower

snowboat
Regular Member


Date Joined Nov 2016
Total Posts : 25
   Posted 12/7/2017 9:12 AM (GMT -6)   
I will be getting the book from Amazon. I have enjoyed the last ones.
DX 63 years on 4/16, T1c Gleason 3+4=7, Prolaris intermediate risk.
PSA 3/12-3.6, 3/14-4.8, 3/15-5.6, during wellness checks.
Ultra sound biopsy 4/16, 5 0f 12 positive 5%-40%
Mayo Phoenix consult 8/1/16. Went with IMRT, 70 Gray, 6 months of Lupron ADT. 9/9/16 markers placed, prostate 62.9cc. 9/16/17 simulation and tattoos. 9/20/16 MRI. 28 rounds of IMRT 10/3/16-11/9/16. 4/12/17 PSA <.1

Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2291
   Posted 12/7/2017 11:35 PM (GMT -6)   
I have the book on order.

CuriousCharles
Regular Member


Date Joined May 2017
Total Posts : 240
   Posted 12/8/2017 1:30 AM (GMT -6)   
The whole area of the potential distrust between patients and their doctors can also be deeply rooted in linguistic habits. In the past, perhaps, there was more of a power relationship gulf between the "expert" doctor and the patient who was given all kinds of signals of how to behave and acquiesce to be a "good patient". In more recent times, doctors often put things in their patient Notes like "patient denies pain at such and such location", no so much because that's what the patient actually said, but sometimes because it will help cover someone's liability if something undiagnosed raises its ugly head at a later date.

There is a very nice related discussion in this paper about the language still used when doctors talk about a patient using the terms COMPLAINT, DENY, and FAIL. And the author makes a pretty good case for trying to abolish those terms from compassionate, healing communications and relationships between doctors and patients.

"There Is No Denying It, Our Medical Language Needs an Update"

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4507913/

Charles
Dx Nov 2013 Metastatic Prostate Cancer at Age 65
Numerous Bone Mets and Lymph Nodes, PSA 5,006
ADT Lupron + Zometa, PSA Nadir 1.0
Resistance after two years.
Short rechallenge Casodex.
Oct 2016 Provenge
Dec 2016 Start Xtandi, PSA 95
Sep 2017 Xtandi PSA Nadir 1.2
Nov 2017 PSA 1.7

cspivak
Regular Member


Date Joined Aug 2014
Total Posts : 207
   Posted 12/8/2017 7:15 AM (GMT -6)   
Mr. Curious,

Interesting - sounds like the nonviolent communications thing.
Dx 8/14, age 58, PSA 29, G9 (4+5), 11/12 cores, 3 bone mets
Lupron 9/14, Xgeva 10/14-12/14
10/14 PSA 2.0, 12/14 1.1, 6/15 6.87, 6/15 Provenge,9/15 0.8
9/15 osteonecrosis, 6 wk iv antibiotics
1/16 PSA 4.8, 3/16 2, 10/16-6/17 Xtandi, 12/16 IMRT
5/17 PSA 8.6, 6/17 PSA 13, 6/17 lymph node biopsy MSI-H
6/17 Keytruda(pembrolizumab), 7/17 PSA undetectable, 9/17 lymph nodes almost resolved

Froggy88
Regular Member


Date Joined Mar 2017
Total Posts : 62
   Posted 12/9/2017 7:19 AM (GMT -6)   
Charles,

That's an interesting little piece. I think more important than changing certain words is the need to move doctors off of the streamlined thinking that inevitably pushes its way into medical practice, an approach that is actively encouraged by the economic pressure brought on doctors.

Jerome Groopman, in his book "How Doctors Think," has some tips for how to get around this problem. First and foremost, he stresses the need for a fresh history to be taken when a doctor sees a new patient. Doctors tend to take the conclusions reached by other doctors as a starting point, and even patients often adopt doctors' conclusions and language about diagnoses. Especially where previous diagnoses and treatment approaches have been unsuccessful in addressing a problem, it often helps to start from the beginning, repeating tests if necessary.

He also recommends some questions to get doctors to stop and think, to avoid cognitive traps, and to expand their considerations: What else could it be? Is there anything that doesn't fit? Is it possible that I have more than one problem?
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