Finding structure without patients and hourly appointments; proton beam therapy and more

Time For ChangeSix weeks into my gap year I continue to enjoy my freedom and I feel significantly less stressed. I do have, however, a persistent inability to apply structure to my day. I get distracted and am unable to follow through with my more important projects.

The structure of office visits and colonoscopies was a special luxury for helping with time management. During a procedure there could be no interruptions. During an office visit only a few things rose to the level of importance to allow for an interruption. The result was that everything non-medical, in terms of daily activities, had to be squeezed into a narrow window. This promoted both efficiency and stress.

Less stress means less efficiency

Now, with all the time in the world, there is less of both. I lament the fact that I have been unable to assert enough self control to carve out a block of time for reading, another for studying, a third for exercise, etc. Perhaps this will improve when the distractions of our construction project end. Perhaps I simply have to do better.

The euphoria of the World Domination Summit is waning. I really enjoyed the sympathetic qualities of the participants. I was inspired to develop my own writing project as a result. I hope it will become a short book. I cannot discuss the subject matter now because it could be seen as relating to a family member with whom I have not yet conferred. I am further inspired to maintain my disgust with the “market forces” in American health care.

When does unethical behavior become a crime?

Overdiagnosed_WelchWhile at the WDS I missed a New York Times Op-Ed piece by H. Gilbert Welch, M.D. who is trying to rally moral outrage against the high cost of medical care and the unethical, immoral (?), and to use his term “criminal” practices behind it.

Curiously, I was involved in two of the problems he cited: colonoscopies and proton beam therapy for special radiation treatment needs in Washington, D.C.

I have written about the excessive use of anesthesiologists during routine colonoscopies and how it has become the standard of care in well-to-do communities because doctors can leverage a higher income per procedure – not because it improves outcomes.

Because this practice runs counter to the recommendations of our professional gastrointestinal societies it is highly unethical. Because it is spreading based purely on medical mammonism, it is disgraceful. When does a professionally disgraceful and unethical behavior become a crime?

What you need to know about proton beam therapy

Proton beam therapy is slightly more nuanced and highlights a new set of issues. Specifically, we as a population are underwriting the expense of these unnecessary costs. But first, let me describe the benefits of proton therapy in laymen’s terms.

External beam radiation therapy is an important therapy for certain cancers. It has been refined over the decades to improve the focus and minimize the side effects, particularly the collateral damage to other tissue. Standard external beam therapy has an entrance beam and an exit beam and normal tissue in this pathway can be altered significantly. Some normal tissue will become cancerous at a later date.

If the heart is in the pathway, the risk of myocardial infarction is increased over time. Finally, surgical tissue planes will become fused by radiation and complicate surgery if indicated in the future. Therefore, standard external beam therapy is fine for palliative care where the long-term prognosis is limited but not ideal for curative treatments, especially in young patients.

Tomotherapy and Cyberknife therapy combine to improve the focus and to use multiple beams that overlap at the disease site so that the dose of radiation is appropriately lethal but the surrounding tissue is exposed to less damage.

The advantage (and higher cost) of proton beam therapy

Finally, proton beam therapy has special characteristics in this regard. It can be more precisely focused, it has a reduced entrance beam effect, and there is no exit beam. You will have to speak with a nuclear physicist for further explanation. It can be argued that this is very important for the treatment of children, especially with brain and spinal cord disease. However, it is very expensive and there are comparatively few cases of child hood cancers.

The total number of proton beam accelerators in the U.S. is currently small. They cost tens of millions of dollars to build and require a lot of space, much more than a standard radiation facility. Somewhere between 15 and 20 centers exist, mostly at university centers. Plans for many more are in the works but no one knows how many more are needed.

The backstory of proton therapy in D.C. begins in Baltimore where the University of Maryland obtained a CON (certificate of need) from the local authorities. Johns Hopkins Health System determined that it needed a proton therapy center to remain competitive and maintain its “brand.” Recognizing there was no conceivable way it would also get a CON in Baltimore, it looked to its affiliated hospital, Sibley Memorial Hospital, with lots of property in Washington, D.C.

Sibley is a community hospital in an affluent neighborhood. It is licensed for about 250 beds but does not run at full capacity because of local demographics and competition from several other nearby hospitals. Its budget is tight. The added income from proton therapy was very appealing to the hospital administration. I practiced at Sibley for thirty-one years and served on its board of trustees for ten years. When the proposed financing package to build the $130million Sibley/Hopkins facility looked doable, it was my fiscal responsibility to vote for the project and protect Sibley’s future.

But at what cost to society?

Immediately upon hearing the news of the Sibley/Hopkins plan, Georgetown University Hospital filed for a CON to protect its Lombardi Cancer Center brand. And that is how three facilities are in the pipeline in the mid-Atlantic region. Fortunately, no ground will break in D.C. for sometime and sanity might prevail.

But the point for all working Americans is this. If we over build proton beam facilities we will ultimately use them for patients without special needs, men with prostate cancer, for example. Of unproven benefit beyond the benefits of standard radiation, the cost of proton beam therapy is exponentially more expensive and the trade off is simply convenience for the patient.

Although the following numbers are very rough estimates, the order of magnitude is accurate. Standard radiation therapy for prostate cancer is 28 sessions and Medicare reimburses $25,000.

Cyberknife therapy is only five sessions and Medicare reimburses $125,000.

Proton therapy is done in a single session and Medicare probably reimburses the facility over $200,000.

Why would I want my tax dollars spent on the treatment of a cancer that is probably diagnosed too frequently, probably would not kill the patient, and which costs society eight times the standard therapy? So that the patient suffers less inconvenience?

Well, I don’t want to do that but I see ads for proton therapy for prostate cancer and I am outraged. It suggests there are already too many underused proton gantries.

As an aside, I believe some doctors are underpaid

As an aside, let me say that I think doctors are underpaid. This does not apply to overpaid specialists who exclusively cherry pick and treat the walking well. This does apply to treating doctors who care for the sickest of the sick in the trenches of the ER, the ICU, the OR emergencies, etc.

Doctors are the most highly educated and extensively trained professionals in our society. Good doctors deserve compensation consistent with the sacrifices they made and the professionalism they continue to exhibit. If we did not waste money on unnecessary and costly treatments such as proton therapy for prostate cancer (not to mention the hundreds of billions of dollars overcompensating the pharmaceutical industry, health care administrators, insurance company executives, etc.) there would be plenty of money to compensate providers for doing the right thing.

Start getting outraged, dear reader

Stop being satisfied with your personal health care system. Stop overcompensating unnecessary care, unnecessary executives, and unprofessional providers. Get outraged with the national health care dysfunction and lend your voice to the fray.


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