Saturday, November 28, 2009

NEJM -- On Mammography -- More Agreement Than Disagreement

NEJM -- On Mammography -- More Agreement Than Disagreement   


This week’s blog is serious. Please take a few minutes and click on the link above to read the New England Journal article on mammography in women between 40 and 50. Before you start reading, take a moment to recognize and acknowledge your biases. After you have read the article I’d like to discuss some of these issues with you. The issues that come to mind for me are breast cancer, cancer screening, women’s health, health care rationing, the health care crisis, the government’s role in health care decision making, technology and its limitations….there’s a lot to talk about.


In order for an online discussion to take place, you have to use the comments area at the bottom of the blog. You can use your name or be anonymous. If this format works, we can use it to discuss other issues in upcoming weeks. If not, it was worth a try.

Some food for thought:

• In 2009, some 192,370 American women will be diagnosed with breast cancer, accounting for more than one in four cancers diagnosed.

• In 2009, an estimated 40,170 women will die from breast cancer; only lung cancer kills more women. This corresponds to 25 deaths per 100,000 women, down from 35 in 1989.

• Data from 2006 -- the most recent statistics available -- showed that about 2.5 million American women have a history of breast cancer. Most of these women were cancer-free. Others were still undergoing treatment.

• From 2002 to 2003, there was sharp decline in breast cancer rates, particularly for women aged 50 to 69. This reflects the drop in hormone replacement therapy by menopausal and postmenopausal women that began in 2002. Breast cancer rates have remained about the same since 2003.

• Since 1990, breast cancer death rates have dropped steadily. The decline has been greater among women under 50 (3.2 percent per year) than among women over 50 (2 percent per year).

• From 1997 to 2006, breast cancer deaths dropped by 1.9 percent a year among white and Hispanic women, 1.6 percent a year among black women, and 0.6 percent annually among Asian-American and Pacific Islander women. Death rates have stayed the same for American Indians and Alaska Natives.


“The choice is not between health care rationing and some undefined alternative, since there is no alternative. Rather, the choice concerns what principles we will use to ration health care. In the United States, we have traditionally rationed health care in the same way we ration expensive cars: those who can afford to pay for them are those who can have them. The alternative currently being considered in health care reform would involve a shift to other principles, such as those rooted in considerations of fairness, efficiency, and efficacy.” Robert D. Truog, M.D. From the same NEJM issue as the article above.

17% of Congress are women.

The Republican National Committee’s health plan covered abortion for its employees beginning in 1991. When feminists pointed this out this year, the Committee Chairman withdrew the coverage.

Among uninsured women, only 30 percent had a mammogram during the past two years, compared with about 70 percent of insured women.



I am interested in what you have to say!

Sunday, November 15, 2009

Cay-ent Get They-uh From He-uh

Dr. PETER AMES GOODHUE, M.D.

Announces His Retirement from

THE PRACTICE OF GYNECOLOGY

Effective January 1, 2010

So reads an announcement on page 7 in Sunday’s Stamford Advocate. An announcement, paid for by the doctor himself. It seems sad, and wrong. In another era this would be front page news with a two inch banner headline. There would be a feature story and additional commentary with testimonials from his thousands of patients, not to mention from the thousands of children he delivered over the past 50 years. But Stamford is no longer a small town and the Advocate is no longer locally owned or beholden to the community. Stamford is a far cry from the back country Maine that Peter loved and brought to the rest of us with his storytelling.

When I began my medical practice in 1987, Peter Goodhue was the President of the Stamford Medical Society. The Society was an organization that met four times a year in local restaurants. There was a brief business meeting, an occasional outside speaker and then a dinner. If there was a speaker, the presentation was always short, sometimes educational, sometimes political but never so intrusive as to distract from the primary purpose of the Society, doctor sociability. Before Christmas there would be a silly card game where winners got free turkeys. Once a year there would be a dinner dance with spouses invited. That era, along with the Society, has passed. Doctors are too busy or ill-tempered to want to socialize with each other. The rubber chicken dinners can’t compete with ritzy drug company seductions at the best restaurants. We have too many other responsibilities and too large a community to relax or be collegial. Peter, however, remains to this day the epitome of collegiality.

He is handsome with a full head of silver hair, a ruddy complexion and an easy smile that brings a sparkle to his Paul Newman blue eyes. He is always well dressed with a trademark bowtie, usually bright colored and flowered. And he speaks slowly in that Maine sort of way. As President of the Medical Society, he would begin his meetings with a story. If you have never heard a Mainer story I encourage you to do so. They are unique regional Americana at its best. They are told slowly with the distinctive “they-uh, he-uh” Maine accent and a Bob Newhart deadpan. Think the opposite of Henny Youngman with his one liners and you have Bert and I—the comedy team that brought Maine humor to the mainstream.

Amazingly, neither Bert nor I, Marshall Dodge and Bob Bryan, were from Maine. They were Yale undergrads with connections to Maine from summer vacations, great ears for dialect and a talent for low rent sound effects. Their original album, recorded for family and friends, went on to sell more than a million copies. They inspired the storytelling of Garrison Keillor (Lake Wobegon Days) and were forerunners to other styles of regional American humor such as southern redneck, as perfected by Jeff Foxworthy.

Excuse the digression, but what native New England story would be complete without one. Peter’s stories went on and on and, if there was a punch line, he never got to it in the first fifteen minutes. The audience of doctors would groan, and then try to hurry him up, and finally shout and heckle to get him to stop so we could eat our dinner. It was of no use. Peter would finish when he was good and ready. Now, after 50+ years of practicing Obstetrics and Gynecology I guess he is good and ready. He is retiring. One story ends and the next one, hopefully just as long and rich with that same Mainer spirit, begins. Q: Have you lived in Maine all your life? A: Not yet.

Sample Maine storytelling at:

http://www.islandportpress.com/BIwhichway.html

Tuesday, November 10, 2009

A Thing and Two

The sun sure did shine, and I wanted to play,
Still we sat and we sat on that beautiful day.
I sat there with Barbara, we sat there we two
We were waiting for Himes, our new congressman who
Was to talk to us doctors about a new bill
Being bandied about up on Capitol Hill.

We doctors grew restless, we bided our times,
Just who does he think that he is this Jim Himes!
We heard he’d been talking to town halls of late
He was dealing with folks spewing venom and hate.
Though he was a freshman, of little import
Fear mongers set out free discourse to abort.

I cut him a break as I sat and I waited
He just tried to listen and ended up hated.
A bit late and flustered he entered the hall
He looked like an intern who’d just come off call.
He said he was sorry, yes friends, fancy that
A humble young man, not no Cat in the Hat.

He was a bit slim with an oversized collar
He was poised, I believe he had been a Rhodes Scholar.
Retired real young, he said those were the facts.
He made all his millions at Goldman and Sachs.

Now some would not trust one so young and so wealthy
To keep us in health and to make health care healthy.
But me, I believe that a man who’s patrician
Is less apt to be a corrupt politician.
Our own Constitution was drafted you’ll note:
A Pres’dent gets in by Electoral vote.

So back to Jim Himes, what did he then do?
He pulled out of his tall hat Thing One and Thing Two.

No kidding, he said it. He said that Thing One
Was though smoking and drinking and eating were fun
They were bad for us one and thus bad for us all.
And in order to get healthcare spending to fall
It was up to us doctors to somehow arrange
To institute effective life style change.

Thing Two then chimed in with a screech and a shout
Saying docs, pretty soon all our money runs out.
If we don’t all spend less getting sick people cured
We’ll be unemployed and we’ll be uninsured.
Great Britain’s care’s cheaper, Canucks they pay less
It’s spending and costs got us into this mess.

I listened to Himes going on with offenses
And sat on the fence not yet come to my senses.
Did he think that changes in base human nature
Could come from a bill he and his legislature
Would magically cook up and somehow then pass?
Was he bold and enlightened or foolish and crass?

My friends, I’ve no knowledge of mirrors and smoke.
I’m a doctor and sometimes I tell a good joke.
But big steps, they scare me. Small steps they seem wiser
And if to Obama I was an advisor
I’d say be more cautious. Don’t go risking it all.
Take it small step by small step or you and we fall.

Friday, November 6, 2009

MRB 1924-1994

Eulogy delivered to the Stamford Medical Society on December 13, 1994.  For his Yahrzeit November, 2009.


Martin Robert Benjamin loved medicine. From Brooklyn, N.Y., the son of a clothes manufacturer and a housewife with a heart condition, and from the University of North Carolina, he went to Flower Fifth Avenue, the New York Medical College, where he got his MD. From there he went to Bellevue where           The elusive blue breasted seersucker   he completed his training in Internal Medicine. Bellevue, my father told me, was a lively place even back then. As often happens when working in the trenches,a camaraderie developed among the residents. Marty got to know an attractive female resident who happened to be married, but told him that she had a sister at home just like her. She introduced him to her identical twin, Vicki, and Marty and Vicki soon married.

In 1954 Marty, Vicki and their one year old son, Dan, made the adventurous move to the suburbs. Marty put out his first shingle on Summer St. at the Mayflower Gardens, with the
young family living upstairs. Those early days were a struggle, but Marty did what he had to do. He covered for many of the            well established doctors in town, taking their night and weekend
call, and through their kindness received referrals as well. Marty wrote a story about his first New Years Eve in Stamford. It was 3 AM, cold and raining, when he got a call from one of the busiest doctors in town, someone who had never called him before, a real SOB to those who knew him, but, of course, the doctor to his patients. Marty was told to see an immigrant tailor with CHF who was short of breath. Before long, Marty was climbing up to the third floor of this tailor's tenement. He was let in by two policemen and stared down by a tiny man in obvious heart failure. The man said nothing, but took Marty's coat lapels and ran the material between his fingers. He then turned the lapels over to examine the stitching. Now, Marty always prided himself in his dress. He took to heart the advice of Polonius, "In thy dress be rich but not gaudy," paraphrased in Brooklynese, "Dress British, think Yiddish". Even after his stroke, when it would take him 45 minutes to dress, he would walk out to the family room to have us check his ensemble. He called himself a public figure and always had to maintain that professional appearance.

But how was that little tailor to know that this was the only winter jacket Marty owned. When he got through fingering the material, he told Marty, between coughs, "Big shot, vat do you know". He just couldn't trust such a young doctor with such a well made jacket.

Mayflower Gardens soon got crowded with the practice downstairs and the family, now expecting a second child, upstairs. Marty moved the office south on Summer St. where he rented space from Dr. Leo Heimovitch. His first break, an ironic one, came soon when Dr. Heimovitch had a heart attack. Marty took care of the older physician’s practice and from there his own practice took off. I don’t have many vivid memories of my father in those days. I know I was busy with school and football and baseball. He was busy with the practice. That seemed okay to me…except when my friends’ fathers would throw a baseball with us or take us swimming, or just be around the house. I guess I was so used to not seeing him that I didn’t really notice when, in 1961, at the age of 38, he had a heart attack. My older brother and I visited him once in the hospital. The two younger brothers, there were four boys then, never did. As soon as his doctor would allow, Marty went back to work. He was in Hanover Hall on Bedford St. then. Dr. Michael Browne had the office to the left and Dave Widrow the one on the right. Dave’s consultation room was through a thin wall from Marty’s. That, Dave tells me, is how he learned all of his dirty jokes. Marty would call them stories, “true stories”. He’d tell them and then laugh louder that any of us.

Marty loved his patients. He was a kid from Brooklyn. They were mostly blue collar workers, West Side immigrants, cops. He just hit it off with them. He’s listen to them, they’d confide in him. We were never hurting for cookies, cakes, sweaters, wine; you name it at Christmas time. We couldn’t walk down the street in Stamford without someone stopping us to say hello. They wouldn’t even let us pay the 25 cents at the Greenwich tolls. The toll taker would take my father’s quarter and return 25 cents in nickels to the kids in the back seat. I remember one call at night at home. My parents were out and my father had signed out to another doctor. The man was calling about his wife. She was sick, but not the kind of sick that a covering doctor could help. He told me this, and then told me, a kid, maybe ten years old, that my father was a special man. That he listened and cared and meant more to people than just a doctor. My brother Fred tells of another middle of the night call, on the kid’s telephone. My father, head on hand, elbow on knee, listening and listening, and finally putting the phone down. Fred said, apologizing for getting dad out of bed, “The man told me it was important”. Marty replied, “To him it was, and that’s enough”.

In 1967, at the age of 44, Marty had his second MI. This time his doctors told him he couldn’t continue to practice medicine. Marty had Vicki, now five boys, the youngest just one, and the practice. He became depressed. After he recovered from the MI he spent six months in a Westchester psychiatric institute. I was twelve. I remember this very well. I hated seeing him sedated, moving slowly, smiling slowly, walking among the splendid trees and the green grass of this institution. I saw him only twice in that six months, but when he came home he looked normal, walked normal…smiled and told jokes…and went back to work. He said he had to work half time. But we all knew what that meant.

I noticed a real change after that. Marty did spend more time at home. He was home for dinner with the family. And I liked that. Dinners at home with the family were great. Every time my mother got up to go to the kitchen he’d tell us another dirty joke or “true story”. We were turning into teenagers and he wanted to be a part of it. “Did you get lucky last night?” he’d ask me. At sixteen I was pretty tight lipped in my replies. But by eighteen, after my freshman year in college, I knew I could go to him when I needed some penicillin. And I’m sure to this day he never told Vicki.

Marty practiced another 15 years. He put a lawyer, a doctor, a rabbi, an MBA, and a young Hollywood exec through college. A lot of pressure, a lot of worries. Vicki tells me that he started to voice a lifelong conflict. “I’m sicker than most of them,” he’d tell her. He resented when, after praising him, deifying him, they left him after his illness. But there was a good side to this. The practice became almost like work and his important relationships grew with us. He became co-owner of Ben-Paul Stables so he could sit in the owner’s box at Belmont. He travelled, read, gardened. He was the life of the party with his violin on birthdays and holidays.

I was an intern in Philadelphia, doing my neurology rotation of all things, when I got a call. He had a stroke. Despite a dense hemiparesis, he felt he’d again return to work. He worked hard at the physical and occupational therapy. He learned to walk, to dress himself, to drive, but he never practiced medicine again.

Some have said over the years, that it was medicine that caused his heart attacks and strokes. But he never did. It was his family history, high cholesterol and hypertension that did it. It was medicine that kept him going. He never lost faith in medicine or in his fellow physicians. When he could no longer practice, he began writing, mostly about his days as a practitioner. He continued to go to medical conferences and, along with Monroe Coleman, developed the Physical Diagnosis course for second year medical students. He read and read about the history of medicine, and delighted students with the wisdom of Osler and Freud.

For his sons and many of his nephews, nieces and special friends, he remained a sounding board. He still wanted to listen. Something about the way he listened made others sure he cared, and this caring became addictive. In the end Marty was not ready to die. He still felt he had something to give.

This last year was a recurring nightmare for us. Marty didn’t remember what hit him, but we told him. I was angry at the indifference, incompetence, insensitivity of some fellow physicians, but not Marty. He was thankful. Among our community he had his heroes. He spoke of Mike Parry as a clinician, Noel Robin as a teacher. In his word processor I found a letter of congratulations to Bill Hines.

In the end, he wanted to come home. He never made it back to his study, his music, his gardens that he loved so. But he died where he labored…in Stamford.

If there is a message to us physicians from Marty’s life, it is his sons. We have all achieved some measure of professional success, but every day we go home to our families, and play with our children, bathe them, feed them, talk to them, listen to them, or just spend time around so they’ll know we’re there for them. Marty Benjamin loved his family, and we miss him very much.

Sunday, November 1, 2009

House and Holmes

I’d like to wrap up my Holmes series this week. It seems the history thing has not been too popular with my readers, at least judging by the lack of response to my recent columns. As for Sherlock, I won’t get into the upcoming Robert Downey Junior film, but will point out that the TV evening soap, House, is a cheap knockoff. The protagonist’s quirky personality, his drug habit, his musical instrument fixation, the detective bit…and just in case you didn’t get it, his apartment number 221b happens to be the same as that famous address on Baker Street. At least they got it right bringing him back to his archetypal state, physician.


Why does history bore us? I wanted to tell you how OWH Sr. started a monthly literary magazine that, of course he named, the Atlantic Monthly. His monthly column related conversations from the breakfast table at an inn of his creation. His persona, the Aristocrat one year, the Professor another, would talk with other guests at the inn. The conversations were witty, humorous, and were at times the same stand up routines he had given on his lecture hall tour years earlier. He was really not too different from George Carlin. He just came a century earlier. But who cares? No one, I think, unless you're a really old dude.
It took a most Excellent Adventure for Bill and Ted to get into history. It’s the same for me. I went through my years at Yale without ever taking a history class. I couldn’t read the stuff. History writers can’t write. Three weeks ago on a mountain in Great Barrington, MA I had my own most excellent adventure and discovered history. For me, it’s the same as learning medicine. The reason medical education takes place in the clinical setting is, in large part, that there it becomes alive, is understandable and is remembered. Once you see a case of say, subacute bacterial endocarditis, it becomes real for you and you want to go to the textbooks and read more. And when you read with interest, instead of laboring over the words, you become alert and absorb the material. Do medical writers write better than historians? Keats and Holmes aside, probably not.

I will never forget bacterial endocarditis because of a Delaware VA Hospital patient who came in with shoulder pain and chills. We talked. As it turns out, he lived next to a racetrack and every evening would walk his dog around the stables. Had I ever heard of Streptococcus equi? I’m sure it was in the books I read for cardiac pathology, but come on. After his blood cultures came back full of horse bacteria I went back to those books, learned about that obscure bug, yes, but also learned everything I could about SBE. I may be a gastroenterologist, but I still come across SBE, and get a big kick out of beating the interns, residents, medical attendings and cardiologists to the diagnosis. Our Infectious Disease guys, I admit, get there with or before me.

As Dean of Harvard Medical School, Holmes wanted to admit women. The overseers would not let him. He admitted three blacks, but withdrew the admissions, succumbing to pressure from students and administration. He resigned as Dean but continued to teach until the age of 73. “Life is a fatal complaint,” he said, “and an eminently contagious one.”

“It is a good thing to save a few lives, but it is better to infuse a new life into our language.” So said Holmes as he found new life and went on to worldwide fame as a poet and author. And that’s history. You can read about it, or better yet, do as I did…take a hike! Or do like my father and go birdwatching. (That translates to the racetrack.)

The crack-brained bobolink courts his crazy mate,
Poised on a bulrush tipsy with his weight.