After you finish medical school classes, the night before graduation, they take you to a dark, quiet room.  There, among leather bound tomes 300 years old, diseased skeleton trophies swinging behind glass, as you sip 50-year-old port in ancient crystal, they tell you the secrets. This is the wisdom passed not in lectures, rounds or at the operating table; it is the hallowed legacy of thousands of healers over the millennia; ...

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One of the first things I teach medical students is to be aware that they have arrived in a bizarre land.  The strange things they see, the disturbed experiences they have, the weird stories they hear, are like noting else in life.  I advise students to stay in touch with their feelings, to note what shocks, frightens, or embarrasses them.  Remember those emotions now, because as doctors learn their craft ...

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Recently I met the husband of a patient with a diagnosis of advanced lung cancer. Even though she was young and had been healthy, the disease spread to her bones.  I outlined treatment for this incurable illness: choices, goals and side effects. This was a very tough meeting, because by the end we had to discuss time as measured by dollars. The particular challenge was that this family had health insurance ...

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You are taking care of a patient with metastatic pancreatic cancer.  The disease has spread, surgery is not an option and second line chemotherapy has failed.  He is in pain, but is poorly compliant with narcotic directions.  He keeps falling down the stairs.  His wife cries all the time.  The family is desperate for help. The patient is in the office with loved ones, looking for guidance. “What do we do ...

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Recently, I continued my crusade to make end-of-life care a basic skill, as I gave the "Introduction to Dying" lecture to third year medical students, for the twentieth time.  For me it is not just about pain control, family meetings and hospice care, but rather convincing physicians that they must change the medicine practiced for the last 100 years.  That medicine says that a doctor can fight all disease, give any treatment, ...

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I do not argue with my patients.  Rather, I teach, outline options and explain my point of view, as each person must choose their path.  However, the other day, Audrey and I got in a tiff when she was in the office to discuss her breast cancer.  We had an enthusiastic discussion not of chemotherapy, x-rays or surgical options.  Nope, we disagreed about what is wrong with healthcare. It seems to ...

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How long do you continue to fight when death is certain? Not long from now, the last cancer will be defeated, and even today most with the dread disease survive.  However, many still fall.  This leaves us with one of the toughest questions of life.  How long do you continue to fight, when death is certain?  When does striving become vain hope which drains quality and creates only suffering?  What makes struggle worth the ...

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When donated blood is wasted This week my toughest case involved futile care.  We admitted a patient with very advanced cancer, dying naturally at home on hospice. Because of last minute family intervention, the patient ended up spending 48 hours on super-max support, dying quite horribly with tubes and lines in every natural and unnatural orifice.  Liver failure, lung failure, kidney failure, bleeding, blood clots and ...

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It occurs to me there are several keys to being an excellent physician.  One must love science, enjoy hard work, have the courage to make tough decisions, carry a modicum of intelligence and suffer angst at receiving 94% on an organic chemistry test.  In addition, the very best physicians, those we admire and to whom we flock, have a secret weapon.  They do not care. I do not mean that they ...

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If you had cancer, how good would a treatment have to be, how much would it have to help, for you to use it?  How about if it gave you a 5% better chance of cure?  A 10% chance?  How about a 20% chance to be beat the disease using a treatment without side effects that is free?  “Sign me up,” you say?  Nonetheless, only 8% of breast cancer patients ...

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