The problem with cancer is not advertisements

#ICYMI the Wall Street Journal recently posted an opinion piece about the horribleness of cancer center advertising:

Yes, there is a relationship between cancer center volume and outcome in leukemia. The discussion we had on this topic was started by a recent paper from England on this association. I agree the piece was overly cynical and missed the mark several ways.

Outcomes are better for many diagnoses in large treatment centers, but those benefits are not shared equally among our population, with low income patients having less access to care. Health care disparity is a much more pressing issue than advertising, I think.

Does Steve Salerno have a point? Kinda. The article’s subheading, “The multi-billion dollar treatment industry appeals to emotion in misleading ads,” is true but isn’t that the nature of the advertising business? Does the automobile industry appeal to emotion to sell cars? Sure. Did you notice there’s never any traffic in those ads? Neither do they mention climate change or traffic fatalities.

Cancer patients are different in class from car buyers because patients are at a vulnerable time in their lives, but Salerno fails to make this argument.

“Predatory advertising?” These cancer centers lure people into their clutches, and….what? Give them state-of-the-art diagnosis and treatments?

By focusing on “truth in advertising,” Salerno also sails right past the unsettling fact that treating cancer is a multi-billion dollar industry. Should cancer treatment be this profitable? That’s a separate, complex discussion, with good arguments on different sides.

The relentlessness of the Oprah-initiated positivity industry and it’s effect on cancer patients has was better addressed by Barbara Ehrenreich.

The closing sentences of the piece completely torpedoed it for me. The internal inconsistency of the the following sentence is ridiculous: “But the war on cancer is not the place for pep talks or poetic license.” What the heck is “the war on cancer” but poetic license?? I agree with many who feel that the “war on cancer” metaphor is itself misleading and unhelpful. Do I give pep talks? All the time.

In my experience, pessimism is simply unhelpful. A great clinician once told me, “it’s not your job to take away anyone’s hope.” I’m also brutally honest with my patients, but one can do both. One can be honest with facts, and still approach a tough situation with optimism.

“Hope” is the thing with feathers –
That perches in the soul –
And sings the tune without the words –
And never stops – at all –
And sweetest – in the Gale – is heard –
And sore must be the storm –
That could abash the little Bird
That kept so many warm –
I’ve heard it in the chillest land –
And on the strangest Sea –
Yet – never – in Extremity,
It asked a crumb – of me.
– Emily Dickenson

Full disclosure: I work as interim Director of the Hematologic Malignancy Section at a large academic hospital a

Russia in the news, remembering my grandparents

With the Russia imbroglio in the news, I’ve been thinking about my grandparents. My father was orphaned when a child, so I only ever knew my mother’s parents. As an only child raised by a single mother, my grandparents were a big chunk of my tiny family.  Phil and Sally were life long New Yorkers, and starting when I was 10, when my mother moved us out of Manhattan, I would take the MetroNorth train, by myself, in to the city to spend weekends with them. I remember my favorite meal being fried flounder with mashed potatoes, and peas, and falling asleep to the radio in their dark bedroom, and my grandfather carrying me half asleep to my bed in the TV room. My grandfather taught me to play chess, “no mercy,” he would say at the beginning of every game. And we’d play cards and practice music. We’d watch ships coming up the Hudson River from the bay window of our co-op apartment on the 16th floor.My grandfather played the cello and the mandolin. My grandma would say, “if people ask me what instrument I play, I tell them, ‘I applaud.'”

Until I was a young adult, if I would bring a friend to meet my grandparents I’d have to prepare them a little. they did not fit the Hallmark stereotype of older cookie baking and gardening retirees.  My grandfather was a fiery, argumentative intellect, a civil engineer, and my grandmother a self-employed stenographer and accountant. They were literally card-carrying communists and staunch atheists. They lived through the Depression and my own views about money and debt were influenced by their caution and spend thriftiness. When my grandfather said that he bought something in his “favorite store,” it meant he found it in the trash. My grandfather was never out of work, but had to travel the country for his job and saw the devastation all over. They viewed the United States as having failed its potential by embracing and celebrating capitalism since then. They were not liberals. They felt the dream of a workers world hard, and I remember them saying often in response to something in the news that no person is worth a million times more than another. They would have thought Bernie Sanders socialism weak tea indeed.

As a rebellious kid, I remember thinking, “I’m worth a million times more than a lot of people.” By the time I got to my teenage years, I identified a little with Alex Keaton of family ties, the oddly conservative teenager in a liberal family, but shifted: I was a centrist among real leftists.

My grandfather died in Vancouver when I was in high school. My grandparents were spending more and more time there in retirement, and after his death, my grandmother returned to their co-0p apartment in Chelsea on the lower West Side. After I graduated from college, I moved in with her for a year and a half as I worked in a laboratory at Columbia P&S, Physician & Surgeons, the medical school, a 20 minute #1 red line ride uptown. It was a fun time in my life, but I won’t lie, we fought like cats and dogs. She was highly intelligent, but emotionally distant. When I came home one day devastated from an argument I’d had with my unreasonable boss, she said, “you must have done something wrong.” She also refused understand why a young man living in New York City might want to venture out of the apartment after dark.

She died before the Berlin Wall fell, and I remember thinking that she was rolling over in her grave. She and her husband so hoped that the USSR would win the cold war.

And now? A former KGB agent turned kleptocrat has taken over Russia and appears to have taken over our current administration as well. My grandparents, the inveterate political arguers, I think would be speechless. Heartbroken that greed, selfishness, and exploitation are ascendant in our age. They were an odd couple, Sally and Phil, but they were fiercely loyal to one another, and had a profound sense of social justice. I think if they were alive today, I would show them the young people on social media who share their desire for social justice and a skepticism of capitalism. It turns out that the Cold War hasn’t ended, but it has mutated.


The Affordable Care Act gets support from where? Are we still in Kansas?

I don’t live there, but I’ve been watching what’s going on in Kansas because there’s a fascinating battle between ideology and reality going on there.My wife and I have gone ketotic, and after a refreshing cup of “bulletproof coffee“, I have a lot of energy to write about it!!

Sam Brownback has been governor of Kansas since 2010, made it his explicit mission in his state to demonstrate the magic of supply-side economics. That is simply, if they made massive tax cuts, the benefits to the economy would be so great, that not only would businesses thrive, but the budget would actually improve and life would be better for everyone because of all the growth. Never mind that economists who have looked at this hypothesis have found no evidence to support it. It’s a firm belief of some conservatives. And so Brownback and the Kansas legislature did it. In 2012 they passed a massive tax cut bill. And then they sat back and waited for the free market to work her magic. And they waited. And the budget got redder and redder and their fairy godmother refused to show. Brownback said that the experiment just needed more time, there were reasons. He was narrowly reelected.

Now, the Kansas economy has lagged significantly behind the nation as a whole for years. Private businesses have benefited from tax cuts, as have the wealthy, but the public sector budget, schools and roads, have been hemorrhaging money–through 2019 the deficit is project at over $1 billion.

Republicans in the Kansas legislature are starting to revolt. Yesterday, they narrowly failed to overturn Brownback’s veto of a tax increase that was designed to end the experiment in huge tax cuts that never seem to pay for themselves as advertised. The great thing about an experiment is that if you’re paying attention, you learn something. Brownback hasn’t learned yet, but more and more Kansans appear to be.

This story gets more fascinating when the Affordable Care Act (ACA) gets factored in. Because the deep red state of Kansas has of course refused on principle to take advantage of the ACA to expand Medicaid. Conservative philosophy is the only reason I can think of for refusing  to accept federal dollars to pay for the health care of the poorest in your state. Then, seemingly out of nowhere, Kansas lawmakers have reopened the issue of  Medicaid expansion with the House voting overwhelmingly to expand and sending the bill to the Senate. Mike Pence referred to the ACA as a national nightmare, but apparently, Kansas is looking to the law to help them out of the nightmare budget hole they have created. Interesting to see where this goes.

Also interesting to see how long we drink the butter coffee. Not going to lie, it was pretty tasty!


Narcissists and narratives

Binge watched and listened to Marc Maron and WTF the past few weeks. I didn’t know who he was until I heard him on Fresh Air a few weeks ago.  A comedian, he was one of the original godfathers of the podcast medium. He has had EVERYONE on his podcast. So respect, and jealousy.

“You really have to stop listening to Marc Maron.” – M


One thing I learned from Maron: Isis was right. Her advice was that I needed to keep writing consistently. Maron keeps to a rigorous posting schedule despite a chaotic artistic life. One of the secrets to being a productive neurotic is to be dependable. Let’s see if I can post every week.

Recently heard a podcast with the Robert Shiller explaining narrative economics and it sparked a connection with narcissists. Shiller believes that for economics to evolve, they must transcend raw mathematics and borrow from the humanities the art of narrative. I’ve been thinking a lot about narcissists, both the one in Washington, and ones in my life, and it dawned on me that narcissists are narrative ninja warriors.

The entire nation is learning about narcissistic personality disorder, but I had a head start — I have more than one malignant narcissist in my family. A signature feature is if you suggest to a narcissist that they are doing something wrong, causing someone pain for example, they respond with angry counterattack.  They can’t hear it. You are a bad person if you suggest to a narcissist that they are a bad person. Trying to explain my feelings and find compromise in these relationships has caused me a lot of suffering that I’m just now getting past. The narcissist is the Golden Child of their story and their psyche absolutely refuses this principle to be challenged. With a malignant narcissist, you’re either on the bus or off the bus. Facts and discussion won’t help. I’ve needed to move on from that, and so will opponents of the current administration.

Charismatic narcissists have honed to perfection the art of the narrative — the spinning of a compelling story. We all crave a narrative and don’t feel satisfied with data alone until we have one. As scientists, we are counseled to tell a story. The internal life of the narcissist has been replaced with unceasing  narrative construction, so they are masters of this very powerful tool. Distrust and fear are quick participants in their process, and they can draw many people in to a story of heroes and villains that feels so true. I want to shake my friends that don’t understand that these dynamics are utterly unshakable. They seem to believe that more facts and more calling out of sins, the narcissist will be shamed or convinced. They can’t. To a narcissist, you are a prop, and props don’t participate in the writing of the story. Engaging a narcissist doesn’t work, the only way to transcend is to adopt a different narrative. This takes discipline and consistency. I’m scared for my country these days, but in my home life, I’m fortunate to have a partner who listens and loves me and with whom I can co-write our story together.

Disclaimer: if you’re reading this and are mortified that I’m talking about you…I’m not talking about you!! You’re amazing!! I’m talking about the other one!!


Obamacare is dead! Long live Obamacare?

Donald Trump’s first executive order as president appears to be aimed at fulfilling his promise of weakening the Affordable Care Act (ACA). The order is confusing, though, because it doesn’t really do anything immediately.  It emphasizes that the next Health and Human Services (HHS) secretary will be in charge of implementing the law as s/he sees fit, which is that job description anyway. The primary content of the order is the framing of the ACA as a burden on many groups of people and the intent is to reduce that burden. Okaaay, but…

The emphasis on giving more control to the states and reducing the financial burden on states is striking. This appears to show belief in disinformation about the law rather than the reality that the ACA has a been a boon to some states. The role of the states in ACA centers around Medicaid expansion. The reality is that the ACA for states that expanded Medicaid has been a windfall. In fact, governors are worried about ACA repeal because of the huge hole repeal will put in their budgets. Giving an order that the ACA must be implemented to reduce the burden on states could be interpreted as encouraging states that haven’t done so already to expand Medicaid. No?

A constant refrain about the ACA is that it is oppressive federal intrusion on the states, but calling it oppressive has always been disingenuous because the federal government has shown great willingness to grant wavers and flexibility to the states in how to implement Medicaid expansion. Trump’s first executive order seems to be encouraging efforts already underway to help craft expansion in a way that the states agree to.

Similarly, the ACA has provided subsidies to reduce the burden of the law on individuals, and the order could be interpreted to make sure these subsidies are maintained. Others have interpreted the order as an attack on the individual mandate. But the mandate is intended to reduce the burden of health costs on more people.

This order does nothing to repeal the law. That is up to congress. Tom Price, or whoever is chosen to lead HHS, will have huge discretion in how to implement the law as it stands now – just as Sylvia Burwell did. To my eyes, the order says, “Obamacare is dead! Long live Obamacare!” It underscores that the title of the law is despised, but the content is not. If I were a Democrat right now, I would see this as an opening for a win-win effort to improve upon the ACA by emphasizing the intent to reduce hardships. Yes, maintaining the framework of the ACA is at odds with the substance of plans GOP lawmakers have floated, but this order seems to suggest that Trump is not yet on their page.

Tom Price for HHS wants patients to receive the best care they can afford.

Dr. Price was on Capitol Hill testifying to Congress to be chairperson of the Department of Health and Human Services. Price is an opponent of the Affordable Care Act (ACA) and believes that the attempt to provide uniform health insurance was misguided. By focusing on “options,” he intentionally blurs the difference between healthcare (e.g. doctors and nurses) and health insurance (how we pay for them).

Price wants healthcare to be accessible and affordable. He wants more options. I agree with Tom Price on those goals. But I applauded the ACA’s attempt to first and foremost to provide comprehensive coverage for people. When the rubber meets the road, we don’t need many options on insurance. More insurance options may not be a good thing. What the ACA demanded was that insurance provide deep coverage, and that is what Price opposes. I agree with him that diverse healthCARE choices are good for patients. We agree that costs will come down for many people if we renege on our commitment providing deep insurance coverage. He’s got an essentially free market approach and wants the government out of the business of regulating health insurance, which will reduce costs for many people. But when people get sick many patients with cheap insurance will be in deep trouble. Price is not concerned about that because he believes marketplace magic will make cheap wonderful care available. The healthcare reform Price wants is to occur in the doctor’s office. The pain will no longer be asking healthy people to ask for insurance they don’t feel they need..the pain will be when patients will be unable to afford options that they want. Some patients will be able to afford some options and other patients who will be unable to afford those options. That is the “improved choices” that we are heading for.

The sky won’t fall with ACA repeal. But things will get worse for patients

These have been lonely years to be a supporter of the Affordable Care Act (ACA), in the face of sustained attacks from its enemies and neglect from its friends. I find dark humor now reading about plans to replace the ACA. For example, when I read, “lawmakers are working to forge a consensus on what form the ACA replacement will take” I hear, “congress has no clue how to pull this off.” Then there are those poor souls I have read about who are celebrating Obamacare’s repeal but hope they can keep the insurance they received through the ACA.

Democrats have suddenly found religion and are defending the law, claiming that repeal will bring catastrophe. Repeal alone would bring catastrophe, but that won’t happen. Lawmakers are smart enough to avoid ACA repeal doomsday scenarios that would hurt them in the next election. Repeal will bring many negative effects, but the replacement, whatever form it takes will mean it won’t unfold the way many ACA supporters think. I foresee a disaster unfolding more slowly, where many healthy people and people with means will be less affected. They may even the short term.

ACA supporters focusing on people losing health insurance when the ACA is repealed are forgetting something critical. The number of uninsured matters only when we all agree on what it means to have health insurance. And that agreement is about to unravel. Defining health insurance as a set of broad and deep benefits was something the ACA did. Without emphasizing that the ACA provided critical definitions for what being insured meant, ACA defenders are setting themselves up for failure when these definitions are destroyed upon repeal. The non partisan Congressional Budget Office (CBO) recognized the concern about counting people with cut-rate plans as “insured:”

The CBO is providing an important safeguard, but only by reminding lawmakers what is in the ACA. Lawmakers are doing their best to circumvent the CBO. Anticipate that repeal will dismantle the definitions of what being insured means, because dramatically loosening the definition is how to lower costs and maintain “coverage” at the same time, i.e. by slight of hand.

The dramatic decrease in the number of uninsured under the ACA was a spectacular achievement because the insurance they received was of high quality. Once the ACA is repealed, this number will become less meaningful. Supporters of the law have doomed themselves with this one dimensional focus. After repeal, maintaining the number of insured people will be simple: sell everyone health insurance for $10 a month that covers band-aids and crutches. This is how coverage will be “solved.”

ACA supporters are wrong to predict immediate catastrophe because lawmakers will “repeal” the ACA with a built in multi-year delay to cover their asses. The delay will allow lawmakers to  grab headlines and peacock their way around the talk shows, all the while spinelessly protecting themselves from immediate catastrophe. They repealed Obamacare and the sky didn’t fall!! Nothing will actually have happened yet. Lawmakers can and will say, “look, we repealed Obamacare, and no one lost their insurance like the scaremongers said!” Yeah, right. Not yet.

Ironically, another way the GOP is protecting people from losing their ACA-provided healthcare right away is by spending billions of dollars on the ACA that months ago they were dead set against. The time bomb will go off eventually. The hand wavy lip service to the magical effects ACA repeal will have is just that, and the only way congress will be able to lower costs and avoid a huge drop in the number of insured will be by defined payments or vouchers. If lawmakers give everyone in the US a coupon for $1000 for their health insurance (it will be more complicated than that, but) they can say, a) we gave everyone insurance! So much better than ACA!! and b) we did it with so much less money!! Look at the cost savings of our genius!! I am bracing myself for the fact that this will be seen as a good thing by many healthy Americans. It will be a problem at first mostly for the sick.

Focusing the pain on people with disease is part of the plan. Another way that cheaper insurance will become available for most people is with “high risk pools.” Which is a nice way of breaking the social contract of taking care of the sick among us. If we separate the healthy from the sick when dealing with healthcare insurance, then the healthy people will pay less. Lawmakers will put aside money for high risk people likely with defined contributions, i.e. a set amount. Only with time will it be revealed that in order to save money, voucher/defined contribution plans will be catastrophically insufficient for people with modest incomes who get sick.

I have one last prediction directed at thoughtful critics of the ACA like @avik and @mfcannon who earnestly believe, based on their free market principles, that ACA repeal will bring wonderful results: the lousy situation after ACA repeal won’t shake their beliefs. When costs go up, when sick people receive worse care, when job creation stalls, the free market folks will have a simple explanation: “sure, I said we should repeal the ACA..but not like *that!*” Their well-intentioned arguments will have been used as a smoke screen for political ends.

The repeal effort may yet stall, but I doubt it. Affordable Care Act RIP. It was ungainly and unloved. It should have been improved, not removed in a game of political football. The law wasn’t magic but nothing is, and it was clear to nonpartisan observers that it worked surprisingly well while it lasted. Now, patients and those that care for them need  to prepare for what’s coming next.