T-cell/histiocyte-rich large B-cell lymphoma

Another month, another tumor board talk. The slides aren’t self-sufficient, I’m afraid, but the references might be a good starting point for learning more about TCHRLBCL[^wtf], or diffuse large B-cell lymphoma in general. I’d start with [this excellent review article on DLBCL treatment][ccr], written by several NCI attendings[^attnd].

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History of advance care planning in the US

Here is a slide show I had to make during my [pain and palliative rotation][ppc], which ended up being an updated rehash of [a review article I wrote for Cancer Journal on the history of end-of-life care][eolreview]. The article itself is behind a paywall, but you can find the PDF on [ResearchGate][rgate].

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Stem cell transplants, a slide show

As first-year fellows, we have to present a case at the Medical Oncology Service tumor board every four weeks. Obviously, I can’t share the details of those talks here. But I can post a sanitized version of my slides, with all identifying information removed.

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Pain. And Palliation.

I am not spiritual, or religious. Living in an atheist country that suddenly takes a turn towards militant Christian fundamentalism does that to you. I don’t believe in woo. I do believe that American doctors are overtreating their patients’ pain, and that American patients are too sensitized to it. Yes, the understaffed orthopedic VA surgery wards where post-op patients were screaming for their morphine may have led to the Kabuki of a nurse coming in every couple of hours to ask you about where your pain is, and what is the QUALITY of the pain, and howbadisitfromonetoten? But a cancer center is no VA. The ritual only reminds those with chronic cancer pain that yes, it is still there, and yes, it hurts more than it did 3 hours ago, and now they can’t finish reading their book because there is a twinge every couple of minutes while they are thinking about it.

Which is all a longwinded way of saying that I should not have enjoyed the pain and pallitavie rotation that much. There is spirituality, there is woo, there is a lot of pain. And yet I did.

These people know what they are doing. They have plenty of resources available to do it. And yes, they may “do Reiki”—nothing more than elaborate Kabuki for patients with advanced diseases—but there are times when that is exactly what the patients need. When 4am vital signs and checking for hepatomegaly every day just aren’t enough.

Some useful questions to ask your patients with any serious chronic disease, if and when you have some extra time in clinic:

  • Are you the same person now as you were before the diagnosis? How did you change?
  • What do you fear the most?
  • What do you hope for?
  • Who(m) do you rely on for support?1

The patients’ answers may surprise you.

  1. Whom” is gramaticaly correct, but interrpreted as pretentious by most patients. Use it judiciously. Yes, I realize that what I have written here is just as bad. 

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It’s well-known that most common knowledge is false

Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

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How to spend a Monday morning train ride

The GTD weekly review does a good of job keeping my task list managable, but not all tasks and projects are equal. It’s good to have a sense of when you might have time for deep thinking versus mindless task processing—-something GTD doesn’t trully account for. I had been doing a variant of weekly planning since high school, until internship destroyed any hope of having a daily, let alone weekly plan. It’s time to start again.

And if you are not following Cal Newport’s blog already, you should. The man is a machine.

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No, there’s nothing wrong with your attention span

After skimming through the fifth long-form article about the increase in bite-sized consumable writing made for the short-attention-span—-dare I say “millennial”—-crowd, I became scared for my own tenacity. Would the 15-year-old me, the one who had read the LotR cover to cover, be horrified by this balding humunculus with twice the age and—-if you’d believe the articles—-half the attention span?

No, he would not. I can write that with confidence of a man who has just burned through the first two Dark Tower books exclusively while riding the subway. Get in at Union Station, actually sit down to read at Gallery Place, blink and I’m done with a chapter or two and arriving at Bethesda.

Stephen King is a hell of a writer, you see, and most of what you can find online—-this blog post included—-is derivative crap at worst, well-written nonsense at best. My brain jumping from text to text was its way of saying Dude, why are you punishing me with this drivel? Just get us a good book. So I did, and the percieved length of my metro commute has decreased by two orders of magnitude. Which is a convoluted way of saying that time flies when you’re having fun1.

But if you’ve never read a book in your life and are now devouring Buzzfeed like a horsefly in a manure factory—-sorry, there is no help. It is you.

  1. See above re: quality of online writing. 

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Which opioids are safe in kidney and liver failure?

Many times during residency I looked for a table like this online. There weren’t any, so I decided to create one.

Ye’r welcome.

Source: Induru RR, et al. Managing Cancer Pain: Frequently Asked Questions. Cleveland Clinic Journal Of Medicine. 2011;78(7).

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What I learned and unlearned on bone marrow transplants

The average heme/onc fellowship program doesn’t have many “tough” rotations. The one that is universally feared is the erroneously named Bone marrow transplant service2. After spending six weeks on such rotation fresh out of (Chief) residency, I think I can understand—-though not agree with—-the reasons why.

It is not easy. The patients are either already, or about to become, extraordinarily sick, with little outward signs or symptoms to show it. Having cancer while not having an immune system is not a good combination, even if it is temporary. The ones who are months or years out from a successful transplant and still need to be hospitalized are usually miserable from longstanding severe graft versus host disease1. It makes for a tough bunch of humans to deal with day-to-day.

Then again, being on transplant service in an academic center can be the apex of your inpatient career. Months of residency spent on acute care floors and in intensive care units should have given you all the skills you need to do well. These are, in no particular order:

  • Clarifying ambiguity: The rounds are over, attendings and consultants have dispersed, and you have just heard more facts about T-cell activation than you realized existed. But—-do you know if that febrile-but-not-neutropenic patient should get an antibiotic? What’s that other patient’s target Tacro level? Send CSF for flow, or just give intrathecal Methotrexate? If those aren’t clear, you should have asked more questions, and not of the “Which cells have IL-6 receptors?” kind.
  • Identify attending priority: This is often the biggest cause of ambiguity. Between the floor attending, the study PI, staff ID consultant, and various other consulting services, whose advice do you heed? Not always the same person’s, and not even in the same order. Not much you can do, except be aware of it, and not follow everyone’s advice as soon as you hear it.
  • Asserting your autonomy: With all this asking and following, you may rightly ask if you were anything more than a glorified intern. In the field of hematology, oncology, and infections that affect this population, you most certainly are—-you are, after all, still in training. Not so for most other matters of internal medicine. Blood pressures, fingerstick, TSH levels—-if you are comfortable managing them, let the team know.
  • Being there early: An important trait often forgotten by senior IM residents. Just getting there an hour earlier than anyone else to get the work done makes you look like a superstar. One hour in the early morning save three in the late afternoon.
  • Dictating right away: Like, pronto. The answer to “How many pending dictations do you have” should always be “Zero”. It’s easier for you, and is just good patient care. No excuses.
  • Writing everything down: This is How to be an intern 101, but being at least two years removed from internship can make you stupid. Carry the patient list and a good pen with you at all times. Yes, that includes the restroom.

Nothing here is particular to transplants—-it is just good inpatient medicine. Which may be why so many oncology fellows loathe it—-it is, after all, an outpatient specialty. Then again, stem cell transplants are one of the few therapies we have that can cure cancer.

  1. Which is not to say that everyone who had a stem cell transplant is miserable—-a mistaken belief many oncology fellows have after the rotation, and a clear example of selection bias. 

  2. Most stem cells used for transplants are now harvested from the peripheral blood, not the bone marrow. 

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What is the evidence for that?

This has become the mantra of every medical student, intern, and resident wanting to appear smart on rounds and conferences, of every attending intent on shooting down a team member’s suggestion. Five, ten years ago it might have have signaled genuine interest. Now it means, usually, “I don’t know anything about the subject, but I’m still calling you out on (what I think is) your BS. Here, look at me! I am evidence-based!”

No, nobody has posed me that question in quite a while, and I don’t remember ever asking it in any context1. But, honestly, except for a few very well-known examples listed in this excellent post, you can find “evidence” in the medical literature to back up any claim. Off-the-cuff conversations during lectures and rounds are not the best place to dissect them, especially when one side has seniority.

  1. Although I understand asking questions means showing interest, I’ve always preferred looking things up myself. This would make me appear either very smart or very dumb, depending on whatever subcontious impression I made on the person in the first few minutes of us meeting. Try to use the halo effect to your advantage. 

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