I recently learned that a cousin has been diagnosed with brain cancer. He is a few years younger than I am. It was a stunning revelation. My response to all things medical is generally muted. I have given bad news to hundreds of patients and been the first physician to recommend hospice care to dozens. Still, when cancer strikes within the family it reverberates.
I found myself telling family members, “Well, he will be cared for at the World Famous Medical Center (insert the WFMC of your choice: Dana Farber, Sloan-Kettering, MD Anderson) and that is the best we can hope for.”
And then I ask myself, how does one know? How does one know they have the right doctor or facility?
The simple answer is that one doesn’t know, but one can hope. It starts with trust in your primary care physician. It moves on from there.
WFMC and other acronyms
WFMC is an acronym used in the admission notes of interns and residents where, understandably, abbreviations abound. “This is the first WFMCA for this 75yo W LOL in NAD” is the initial line in scores of hand-written notes at tertiary medical centers across the country. Translated it says, “This is the first admission to this hospital for this 75-year-old white Little Old Lady in No Acute Distress.”
It means, with a tone that is at once self-mocking and disparaging, that this woman has mild symptoms, probably evaluated elsewhere on several occasions and now she has been referred to the “Mecca” (a WFMC) for final assessment.
As an aside, I wonder how these abbreviations fare in the world of Electronic Medical Records. Although free texting exists in EMRs there are also a lot of check boxes, pre-populated phrases, and cut/paste opportunities. I digress.
The point is there is an appropriate suggestion of cynicism in the use of WFMC as well as a little pride.
Keep in mind that WFMCs are giant institutions with giant PR machines that promise hope and brag about their US News & World Report rankings.
What you can expect from a WFMC
I have had plenty of experience with WFMCs. In my opinion the physicians are generally not exceptional and the care is less than extraordinary. The physicians tend to be very intellectually engaged and offer wild diagnostic possibilities. But their diagnoses are no more accurate, nor does their treatment offer better results.
My opinion has been formed over decades, however, and currently the national movements to monitor patient satisfaction, quality and outcomes as mandated by the Joint Commission and the CMS, are making these institutions perform as well as their PR machines have claimed in the past.
I have frequently used WFMCs to supply a third opinion about a patient who has a symptom that is not diagnosable. When a group of MDs at the Mecca fails to find a cause for the complaint, it reinforces to the patient that their care has been adequate to date. Sometimes I have sent the patient with a cynical agenda on my part because I believe he or she is malingering, and sometimes because I am truly worried that I could not find the answer to a real problem.
Even in the hallowed halls of a WFMC you should remain alert and skeptical. There are many stories to tell but here is one that is most informative.
When a WFMC surgeon was wrong
Years ago, one of my favorite elderly relatives called with an intermittent and severe GI symptom. Her primary care physician started standard treatment for diagnosis X. After our phone interview it was clear that simple X was not the diagnosis and Y was quite likely. If the tests I outlined were conclusive and Y was confirmed then surgery would be the treatment.
Y was confirmed and after consulting with several surgeons my relative sought the opinion of the chief of surgery at a WFMC a few hours from home. The surgeon outlined the surgical options and described the risks and benefits of doing it laparoscopically versus by open surgery. He opined that the procedure MUST be done open and that ONLY he could get the promised results.
My relative called to report. It became clear that the surgeon was self-important, older, uncomfortable with the new laparoscopic technology and unable to admit it. His advice was unconscionable and at a minimum he should have brought a laparoscopical surgeon into the room to present their results.
I advised my relative never to see him again. Another surgeon performed the procedure laparoscopically and the results were immediately effective. Long term I have heard no complaints.
Questions to ask a WFMC
This experience highlights some issues with WFMCs. They are institutions with the associated inertia. Here is an older, past-his-prime, physician. He is “revered” by some and his reputation masks his current failings. The other surgeons know that his laparoscopic skills are inadequate and that his recommendations are old-fashioned but they are unable to unseat him.
Inertia can be good or bad. Do not put yourself on the “bleeding” edge of new technology without deep thought. Equally important, do not ignore advances in technology. Finally, examine the ego of the physician and the collective self-importance of the institution. If the physician says, “Only I can do this well,” then you are probably in the wrong office. If the institution’s PR machine makes promises that sound too good, they probably are.
So what about my cousin, his brain cancer, and the WFMC? Most of what I have written pertains but hard-to-treat cancer is a special case. A team of physicians will be involved here so no single ego is likely to pull them off course. The early phases of brain cancer therapy are fairly well regimented across large institutions so “pie in the sky” promises will not be made. Yet, because of the WFMC research, clinical trials will be available to consider at some point in the future.
For my cousin the WFMC is the place to start. My hopes are with him.
[Ed. note: when I chose the MD Anderson logo to illustrate this post, Sam pointed out that “eradicating” cancer is what the WFMCs and their PR machines promise – and it is a promise they cannot keep. That makes him angry. – Debbie]