Butterfly in the Typewriter

Anyone with ties to New Orleans knows their Confederacy of Dunces, and it's Swiftian derivation. This new biography of John Kennedy Toole has me retreading it. Looking at the story as a manifestation of paranoid schizophrenia, reframes everything entirely, and refocuses our considerations of the causes of Toole's suicide. Worth plowing through the first chapter, which with it's irritating focus on the minutia of the Toole family structure and Toole's mother's predilections is difficult to push through. But do it anyway and you'll come away with new knowledge in what is the first non-fiction biography of Toole. Ignatius Rising was a alternative fiction attempt that was far too determined to push Toole's life into the boxes of the authors' own construction

Stuff is happening

New CT simulator on the horizon for the cancer center. Reviewed BC/BS of Alabama's policies on IMRT, much more reasonable than the national or Mississippi standards. Maybe we can get them to listen to reason if we can get a large enough voice.

Questions for Anyone Interested In Breast Cancer

I have a dilemma and I’ve asked everyone I know to ask, so I’ve decided perhaps I’ll just toss my questions out to the rest of you Americans and ask you to think about them.  First a little background: I am a Radiation Oncologist from Mississippi.  Mississippi has the distinction of being the fattest state in the union.  This isn’t an opinion we’ve got years of statistics to back that up. 

Obesity is a problem on many levels but the one which I’m concerned about in this is that it predisposes to the development of breast cancer and, because obese women have obese breasts, complicates the delivery of adequate therapy to combat the cancer once it develops.  In my practice I have a lot of patients with breast cancer and large breasts or breasts that do not really exhibit ideal geometry for radiotherapy.  Now, despite this fact Blue Cross/ Blue Shield at the national level has decided that this is something that they are entitled to ignore.  That’s my first question: How are they able to do that?  If they are providing coverage in my state, how can they ignore the specific needs of patients in my community?

            The issue at hand is Blue Cross Blue Shield Association Policy # 8.01.46, which is a national policy that states:

Intensity-modulated radiation therapy (IMRT) is considered not medically necessary as a technique to deliver whole breast irradiation in patients receiving treatment for breast cancer after breast-conserving surgery, because the clinical outcomes with this treatment have not been shown to be superior to other approaches such as 3D-conformal radiation therapy, yet IMRT is generally more costly than these alternatives.

The problem comes when after a conformal plan is attempted, and because of breast size or anatomy/geometry the plan fails to meet what are considered to be adequate standards for dose homogeneity.  Dose homogeneity means that all parts of the breast get the dose they’re supposed to get, without unacceptable hot spots or cold spots inside the treatment volume.  Hot spots are areas of overdosage, which result in things like fat necrosis, pain, and swollen large red tender breasts, which do not get better over time.  Cold spots are areas that leave the patient vulnerable to tumor recurrence, what’s bad about that is pretty obvious.  These issues can frequently be overcome by switching to utilizing a different algorithm for treatment planning and delivery, IMRT.

BC/BS would have you believe that IMRT is somehow different than other forms of radiotherapy, that the effects of the given calculated dose is somehow fundamentally different.  But in fact the difference is equivalent to the difference in a set shot and a jump shot in a basketball game.  Scott Serota, the President and CEO of the Blue Cross/ Blue Shield Association is like a basketball coach that forbids the players that are actually playing the game from taking anything but a set shot to get their two points.  So question number two is for him: How do you think that kind of plan would work out in the NBA play-offs?  Hell, in the NBA play-offs the only thing at stake is money and bragging rights.  In the game we’re playing the stakes are human lives, or do you understand that?  Maybe it’s only a decision about money and bragging rights for you too?  In February of this year the Seattle Times published an article claiming that several BC/BS subsidiaries in their area were stockpiling billions of dollars in cash reserves, the highest they’ve ever had, while at the same time raising rates they were charging their beneficiaries, AND THEY WERE OPERATING ON WHAT WAS SUPPOSED TO BE A NOT-FOR PROFIT STATUS in the state of Washington.  Those claims are still under investigation by the state’s insurance commissioner.

This is the unfortunate mindset that permeates the company at this time.  From their origin in 1939 to the Tax Reform Act of 1986 BC/BS was considered a self-funding social welfare program and therefore tax exempt up to that point. After 1986 it was considered not-for-profit until the national corporation became a for-profit entity in 1994, but many of the individual component companies remain not-for-profit at the state level at the present time. 

At every level they have become more predatory.  They are well aware of the steps that they are taking.  Originally they denied coverage for IMRT for breast and lung cancer because it was deemed investigational and unproven.  When the Federal Employee Program (FEP) dictated that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity, BC/BS changed their classification of IMRT from investigational to “not medically necessary.”  Not based on scientific studies, but because they wanted to continue to hoard money.

Medicare, most other insurance providers, even poor little Mississippi’s Medicaid program all understand that IMRT is a tool in the fight against cancer.  It may be over-utilized by the unscrupulous if left totally uncontrolled and that is not what I’m asking for.  But using the appropriate tool, when needed, is what medicine is all about.  Sometimes you need a set shot, sometimes you need a jump shot, or a hook.  The person in the game needs to be the one to decide that.

Here are my last questions:  Who’s in charge of keeping an eye on stuff like this?   We need someone to keep an eye on any collection of companies, like BC/BS, which provides private health insurance to 99 million Americans and has already faced anti-trust litigation in several southern states, to be sure that they are acting in the interest of the patients they serve and not just their bottom line.

Where is the American Cancer Society? Where is the Susan G. Koeman Foundation?  Where are the celebrity breast cancer survivors?  Why aren’t all of you up in arms about this?  Is it because it’s only fat women from Mississippi?  Well, I’ve got a surprise for you, it’s not, it’s national, and it’s insidious.  You need to stand up.  You need to say something.

Mr. President and Mr. Romney this one’s for you:  What are you going to do about it?

Anybody got any answers?

Let me know.

Doctors and Magic

Doctors and Magic

Do you believe in magic?  Sure, no, yes, maybe, it depends on how you define magic are all acceptable answers.  But for the most part I think we, as physicians, tend to be skeptical.  It comes from a lifetime of requiring proof in making the decisions that affect our patient’s lives I suspect.  I wrote about my own personal loss of magic some time ago, and yes I believe in the magic of love.  I believe in the magic of innocence and beauty of the tenderness of Christmas mornings, and tooth fairy nights.  But I don’t much worry about wizards, or witches, or vampires, or evil magicians pitted in old feuds from Arthurian times.  Maybe I’m just obtuse.

I have a group of e-friends I enjoy very much.  I don’t know any one of them personally, but if I have the opportunity on M-W-F from 3-4 pm CST I log into #LitChat and share with other writers and readers from around the globe.   Last week we had begun discussing the book The Night Circus by Erin Morganstern and one of the participants allowed that in her book club, which was primarily composed of physicians, no one seemed to get it.  I felt bad.  I’d started the book when it was first published, and here it was three months later and I still hadn’t gotten a third of the way through it.  The problem was, I didn’t know why. 

Why had I stalled out?  It was beautifully written with luxurious description that creates a magical world straight out of a Tim Burton movie.  The plot revolves around two children selected as participants in an ancient feud and bound to one another in a battle to the death; no matter how long the contest takes.  They both receive different arcane training in the ways of magic until they are grown and then set on a collision course in the contest venue of the night circus, a magical circus that appears and disappears from place to place around the world.  That’s about as far as I got.  It was kind of like surgeons and internal medicine residents on night call appearing mysteriously in the various wards of the hospital to battle with one another over the true manner of healing.

I can hear the voices thundering through those cold gray green halls.

Zanziber, resplendent in his blue scrubs with contrasting Betadyne stains cascading down his thighs declares. “The only way to heal is with cold steel.  Surgery is the only way.  He has a perforated ulcer.”

And then Mortimer, rheumy eyes dull, places his stethoscope in the pocket of his yellowed white coat and responds to the challenge; “You wouldn’t know healing if it bit you on the ass.  It’s pancreatitis.  Look at his blood chemistries.”

Fire flies from Zanzibar’s eyes.  “Chemistries be damned, there is rebound, and where there is rebound is a surgical abdomen.”

And that was my problem with the book.  While it might have been magic for some, it was learned ritual for me, the IV or the blade.  You want arcane magic get a psychiatry resident involved in a case.  A life and death struggle that involves death by exhaustion is nothing to and old-school surgery resident.  The book didn’t take me anywhere that I hadn’t already been intellectually, but now that I had been called out I was damned and determined that I was going to finish it.  I will spare you any further plot details, to keep from ruining the plot for you, but suffice it to say that in the end it all returned to my own personal viewpoint on magic, that it exists in the relationships we pursue and the love we share with one another along the way.  All in all, it was worth the read.  It is a triumph of descriptive writing with a plot worthy of Shakespeare.  Perhaps a plot derived from Shakespeare, but that doesn’t detract from the writing.   

Bloggy Stuff

This isn't so much about as around,
A boat that doesn't float lies aground
Useless for what it's meant for
less than more then before

Take a walk, feed the dog
Neither spinning gear or whirring cog.
The world passes floating spin
And all I do is walk home again.


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