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?

While 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.


Unmoored and learning to drift

red_buoyNow this is a bit of a surprise.

Sam is two weeks into our Gap Year and apparently enjoying his freedom. He has the normal worries (logistics of packing and travel) but he doesn’t seem particularly anxious about his yet-to-be-made-up future.

I, on the other hand, am feeling confused and discombobulated, set adrift. I seem to have lost my bearings.

This doesn’t make any sense.

Nothing about my work life has changed. I’ve been a creative entrepreneur, making up my own story as a writer, speaker and Web consultant, for a decade. My work and professional identity are location independent. It doesn’t matter if I am in Washington DC or Stonington, ME.

And in fact I have spent a good chunk of the past five summers working from Stonington while Sam has mostly remained in DC, taking care of patients.

So what’s up?

I’ve spent much of our 13-hour drive from DC to Maine sifting through my anxious brain for an answer. It finally came to me.

For the past three decades, Sam has been tied to his medical practice, the hospital and his patients. He had a permanent mooring while I bobbed around him doing different things at different times. Thirty years ago that meant being the hands-on parent for our three young children. After getting a late-in-life MBA and enduring a brief corporate career, I struck out on my own and have been an entrepreneur ever since, relishing – among other things – business travel on my own to China, Australia, Dubai, Canada and Europe.

In fact I railed against Sam’s inflexible career. We couldn’t take a three-month trip through Asia. We couldn’t take a six or 12-month break to live and work in another country. Sam was tethered. We could not leave.

But it turns out Sam’s being tied down provided stability for me to come back to while I wandered through the Interwebs and foreign airports. I depended on it as a way to define my life.

And now we are both untethered and it feels… different. It is a little scary.

I know the freedom of our Gap Year will make adventure possible. I wanted this. Sam’s stepping back from medicine to pursue a second act was as much my idea as his.

Now I must learn to be comfortable with a flood tide of freedom.

The luxury of time; the challenge of structuring it

Time For ChangeI am one week into my Gap Year. One friend emailed to ask how it goes.

Of course a gap year in the usual sense is for a young adult to gain perspective on life, blow off the initial energy of post high school freedom, explore the world and return to university with a more mature focus.

A gap year after 60 is quite different. It is not about focusing but about refocusing.

It is not about blowing off energy but about marshaling energy anew.

It is not about looking forward but about looking back, analyzing, then looking forward again – but with a less distant horizon.

Without a daily load of patient appointments and hospital visits, the first challenge for me is to structure my days.

I was a slave to punctuality

One of the rewards of medicine is the knowledge that your work is valued and valuable. Even if unable to heal, a physician can guide and comfort a patient. To replace that structure of appointments and procedures (and I was a slave to punctuality) I plan to impose a schedule of blocks of time to allow for more free reading, some exercise, writing, studying, and whatever errands and projects need to be done.

From the point of view of restructuring my day, Milwaukee might not have been the best first choice. To visit a 92-year-old man for the sake of catching up and reminiscing is to be a slave to his schedule. Meals, naps, treatments, etc. dictate the general rhythm of the day but the idiosyncrasies of the nonagenarian supply plenty of unexpected interruptions.

Of course, the point of the trip was to maximize face time so when he called I responded, dropping whatever mini-project I was working on. It was well worth the time. I hope to get back soon.

Time, what a luxury

Today is one of the first when I can set the schedule I have outlined above. Write, clear my desk, read, exercise, study, do errands and leave the evening free. Repeat tomorrow.

Clearly, if I were an exceptional person and physician I could have done this over the last few decades, but I didn’t have the energy or bandwidth. I never found the time. My work expanded to fill the gaps and I never blocked out enough time to grow in other areas.

Time, what a luxury for me.

Today’s project is to select our first load of furniture for the new rooms on the coast of Maine. It will be a test of my new relationship with Debbie, vis-a-vis time, space, and each other. [Editor’s note: ha! the new relationship is going well. Yet I fear that Sam is so organized… and I am not. – Debbie]

Parking permits, moving trucks and the D.C. government

Yesterday we went to the local police station to obtain a parking restriction permit for the moving truck, which is scheduled for later this week. What a farce. In years gone by the desk officer would simply handwrite the request and advise you to give your neighbors 72 hours advance warning.

Now the police station houses a terminal for the DDT (District Dept. of Transportation) that prints out the red parking restriction signs – for a hefty fee of course. You pay by credit card. The police have nothing to do with the new process and the desk officer is quite happy to tell the petitioner that she can’t help at all.

It took two college grads (with three post grad degrees between them and 31 years of experience with the D.C. government) an hour to work through the program. We came out with the wrong request (a moving container instead of a moving truck) and the wrong dates (five days of restrictions versus the intended two days).

If we hand modify the sign we are threatened with a fine. So goes it in DC.

You can see I like to get things done.  Doctors tend to be that way.  We see the patient, institute therapy, push for a cure and move on to the next.  More about that later.

Why it’s OK to have a (non)plan for a Gap Year

ImageIt’s here! Our Gap Year officially starts today, June 1, 2013.

Sam and I haven’t gotten very far with planning. (Except for two things, see below). The truth is that we’ve been so busy the past few weeks, we haven’t had time to sit down and articulate every dream that will come to fruition in the next 12 months.

And yes, we each have a list of dreams and Wanna Do’s.

This reminds me of the conversations I had many years ago with our three children. We encouraged each of them to take a Gap Year at age 18 before starting college. They were clear they wanted to take “time off” after a rigorous high school experience. But none of the three had a clear idea, initially, of what they would do.

As the “organizing parent,” I was a bit disconcerted by this. But I chalked their indecision up to being vague and adolescent.

Now it seems Sam and I are equally vague at age 61.

We’re 19 in the photo above. Cute, huh?!

Surprisingly, we’re feeling rather comfortable with our non-plan.

In fact, having a non-plan is part of our plan for this next year.

Instead, we’ve set a few ground rules:

  • We want to learn to live on a much smaller budget
  • We want to travel to places we haven’t been
  • We want to try new ways of working

A little bit about what we do: Sam is a physician and he just completed (yesterday!) 31 years of medical practice as a gastroenterologist in Washington DC. He’s highly knowledgeable and he’s passionate about health care reform. He’s not a blogger – yet. But you’ll be hearing much more from Sam soon. As soon as I can coax him into publishing his first blog post. Whoa… here’s his first post!

vm_logo_SMALL copy 2I’m the author of THE CORPORATE BLOGGING BOOK. I’m a speaker, a book coach and an eBook publisher helping up-and-coming business authors take advantage of the publishing revolution. My company, Voxie Media, is starting to take off. As a location-independent enterprise, Voxie Media will continue during this Gap Year. Oh and I’m working on a new eBook, How to Write a Short, Business eBook: The Remarkable Guide.

In addition to a non-plan, we have some shared values.

We really do want to make the world a better place – for our children, our grandchildren and many others.

ile de la citeWe believe that less… can be more. That means a smaller house, a much smaller budget and living in a less expensive city. And we believe that a guiding principle should be “Yes, and… ”

So, no, we don’t have a perfect plan laid out for the next 12 months. We’ll figure it out as we go along. Finances will dictate some of what we can or can’t do. We will disagree about a whole bunch of stuff. That’s the “No, but… ” part.

But we’re confident that “Yes, and… ” will help us to THINK BIGGER and have the adventure of a lifetime.

World Domination Summit and Paris!

First up, we’re both going to Chris Guillebeau‘s World Domination Summit in Portland, OR so we can learn to hack travel and other useful skills for a low-budget Gap Year.

Then Paris for five weeks in November and December. w00t!  We’ll be living in an apartment on the Ile de la Cité. Deets to come.