Notes & Links: September 26, 2013

Thoughts on diagnosis-Reflections of #SIDM2013
A thought provoking post at db’s Medical Rants who reflects on attending the 6th annual Diagnostic Error in Medicine Conference. First, this is new to me and second there were over 200 attendees. I am of that age when I remember ASCO was only a 1,000 attendees and the exhibit hall was primarily folding tables with drapes. Not sure the Society to Improve Diagnosis in Medicine will be where ASCO is today but we can hope because this is a critical area especially today with treatments being specific to a diagnosis and a patient. 

db captures this discussion clearly:

Back in the day (the 1970s and before), diagnosis was clearly job #1. Somehow focus shifted away from correct diagnosis to management strategies, performance measures and report cards. Wonks and politicians assume that we can make correct diagnoses. Unfortunately, the diagnostic process is difficult. We have problems of missed diagnoses, over diagnosis, and lack of diagnosis. One important policy influencing physician told us a story about a patient being treated aggressively without a diagnosis, a diagnosis that he (an internist) figured out with 2 questions. Having a correct diagnosis dramatically changed his relatives quality of life.

A Sick Stigma
Charlotte Huff writing in Slate addresses the question that haunted me when I would speak about Donna’s cancer, “Why are cancer patients blamed for their illness?”

I never really addressed the issue of smoking and Donna’s illness. In fact I got very angry when someone asked if she smoked because I knew, or thought I knew, that they would get all in my grill with their judgements. I never really got my head wrapped around it and what to do. Well the article written by Huff in Slate addresses the “hierarchy of the cancer blame game.” 

Judgments about behavior not only unsettle and stigmatize the patient, but reflect the interrogator’s own insecurities. Frequently, those disease detectives are attempting to regain a sense of control amid the inherently random and sometimes unjust world that we all reside in, according to researchers who have studied stigma. Psychologists refer to this as the “just-world hypothesis,” a bias in thinking and perception that was first described by psychologist Melvin Lerner and colleagues more than four decades ago, and which has since been documented in numerous books and articles.

I cannot agree more completely with this statement but what is really telling about this blame game is the following.

Stigma also can undercut research spending, as the National Lung Cancer Partnership details with a stark 2012 analysis. Each year, nearly 157,000 Americans die of lung cancer, compared with 49,380 from colon cancer and 39,970 from breast cancer. Yet, far fewer research dollars are spent per lung cancer death—$1,490 versus $6,339 for colon cancer and $21,641 for breast cancer.

The reasons for this do not solely rest on the fact we all hate smokers and wish them harm. Because lung cancer is inextricably linked in everyones mind getting patients and their families to organize around and for lung cancer is difficult. Unlike say breast cancer which has the great support nearly three times greater than colon cancer. And least we forget the incidence of lung cancer for nonsmoking men is four in 1,000. 

Huff shares with the reader that her mother was a smoker who was diagnosed with lung cancer survived for six years before it returned metastasized and untreatable.  She ends with this

Because she died at age 51, she was never able to enjoy my husband’s wry sense of humor or my son’s ebullience. Was her death just desserts, or just tragic? If people would just stop implying that this is an underlying question, I wouldn’t be forced to provide the answer.

Indeed why do we have to provide the answer to the question does someone who smokes got what they deserved?