Sunday, November 16, 2003

Time = Medicine

I went into work today, even though the clinic is closed. This is a time when I can go in undisturbed and call patients back ("I didn't expect you to be calling on a Sunday, doc"), take care of abnormal test results, catch up on all my charting. But today I spent about 3 hours trying to help someone who isn't even my patient.

The parents of one of my daughter's classmates have a brother-in-law who was diagnosed a month and a half ago with a tumor, and it wasn't until a couple of weeks ago that a 2nd biopsy showed that it was metastatic pancreatic cancer. I got involved because he has Kaiser insurance, and his relatives were hoping that, as a Kaiser physician, I could help him figure out the best way to get action. I guess they felt like they weren't getting enough communication from his doctors.

I've never met Charlie. The only time I spoke with him about a month ago, he sounded pretty normal and he was grateful that I could answer some questions for him. My wife is a pathologist and she also reviewed his biopsy slides as a favor, but she could only confirm his diagnosis. When she saw him he appeared strong and healthy. Today he requires an oxygen tank because he gets short of breath with even mild exertion. Such is the nature of pancreatic cancer, one of the deadliest cancers because it is so hard to identify. Most of the time, by the time it is diagnosed, it is too late to treat because it has already spread to other parts of the body. In medical school, we were taught that most patients with pancreatic cancer have less than 6 months to live.

In his case, I think Charlie would be grateful if he could last another 6 months. His doctors told him that they didn't think chemotherapy could help him at this stage, plus he is already weak and short of breath. His wife told me today that he doesn't want to spend his remaining time suffering from the effects of chemotherapy, especially when it is unlikely to help him anyways.

This is so unfair. Charlie is only 49 years old. As his wife said, they know there is a reason for everything, but right now they can't understand why this is happening. I don't think anyone can.

I remembered one of my patients who was diagnosed with liver cancer a few years ago. Probably because he is Chinese, he also consulted with a traditional Chinese medicine doctor who treated him with herbs and acupuncture. His cancer regressed and has not shown any signs of return ever since. His hepatologists and oncologists can't explain it, and have used his remarkable case as a topic of discussion at their conferences. I called him up so I could get the name and phone number of his Chinese medicine doctor. Charlie's wife was grateful to take the information. At this point, what did they have to lose?

I also remembered reading about a small study from a few years ago. A doctor treated 11 patients with inoperable pancreatic cancer with high dose pancreatic enzymes. The average survival time was 17 months, or three times the usual survival time. The longest survival time was 4 years. It was intriguing enough to warrant further study, so now there is an NIH study looking at the use of nutritional therapy to treat pancreatic cancer. I left a message with the principal investigator to see if they were still enrolling patients.

I dug deeper on Google and located a website that claimed to have the exact same formula as the enzymes used in above study, and was selling them for $275 for a bottle of 360 pills. The "ideal regimen" requires 6 bottles a month. I also sent this info to Charlie's wife today and told her that there was no way to know if this enzyme therapy really works, or if the pills being sold were the same ones used in the study. But because doing nothing is equivalent to accepting death, I told her that if it were me, I would try it.

This reminds me of Laetrile, a controversial anti-cancer treatment that we used to discuss in a medical ethics class in college. What can you do when modern medicine has no answer? Is it right to recommend treatments that are unproven, yet expensive, for a terminal condition? Are they just taking advantage of the desperate? Perhaps.

And yet, this is also about hope, a necessary part of medicine and healing. If I hadn't been able to spend 3 hours researching this stuff, I would've had to shrug my shoulders and say, "I'm sorry, but there's nothing more that can be done." I like to give people choices. I want to be able to spend this much time finding those choices for all my patients, not just the sickest. I want time to think, to look up evidence-based answers to clinical problems. Time is what is in short supply in my practice now.

This is another reason why I want to start a solo practice. To have the time to practice better medicine, to know that I've tried my best. Because everybody deserves the best. Especially Charlie.

And now, there is only one other investigational medical treatment I can do for Charlie, and that is to pray.

Countdown: 50 days until target start date