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Volume 4, Number 1

VIEWPOINTS
A Death in the Family

MYCHAEL GLEESON, PH D

Death ends a life, but it does not end a relationship, which struggles on in the survivor's mind toward some resolution, which it may never find.
Robert Anderson, I Never Sang For My Father (1970)

On September 8, 1980, a suicide touched my life and that of my family. It was the beginning of a journey that was to demand a strength and an honesty that, at that time, we did not know we had.

That Thursday, before my day had begun, the telephone rang. The police were calling to tell me that they had found my best friend dead at his vacation ranch, some 200 miles from my home. They had little other information. My life with David had been special. For 10 years we had smiled, lunched, fought, memoed, laughed, and cried together. We had fought all the big battles, won a few and lost a few, but we always knew that there was someone who cared, waiting for us at the end of the day. The years had been good to both of us, though certainly not easy, but we had survived, grown, and come to mean a great deal to each other. The best thing we shared was our common feeling of being comfortable with each other.

David was 49 the year of his death; he was an accomplished teacher, writer, philosopher, and academic. He loved cars, books, Bach, science fiction, and me. That was the part I liked best. He was gentle, determined, articulate, and aware. He had an understanding of the world in which he lived that was rare and seldom found in men at 49. He had a kindness and a warmth about his presence and a need to care for his family and friends. He trusted and accepted his students, and he was vocal about the rights and responsibilities of the human beings and other creatures that share this planet. He was a complex man, a loving and creative soul; agnostic and determined; playful and courageous.

His death left to mourn a small group of people who gathered to try to cope with an afternoon memorial that would be, for some, forgotten within a few hours. A group gathered that would remember David forever.

As we watched each other, each trying not to be the first to cry out loud, there was a silence that was harsh and sterile. A few people said comforting things, but the best things said were the unrehearsed stories, which brought back the days when David was doing all the things that only David could, or would, or might, do. It was a long afternoon. Public grief is an invasion of the relationship that exists between the mourners and the dead. For its survivors, a suicide means a long battle with bereavement, because they never had an opportunity to say that last good night. There has been no good-bye or time to watch together over those special last moments.

David's death, 200 miles away from our home, terrified me; it was a nightmare, a sudden and cutting separation that felt like it would last forever. I would have to live with the David I had known, rich in the memories left me, bitter about the time taken from me.

I entered a time of denial, a time of waking up at night thinking that the phone had rung when it had not. There was a time for anger, and a longing to be dead. There was a time for acceptance and trying to find a life for myself that would be mine and that could accommodate one dead friend.

There were all the legal battles and entanglements. There were decisions that had to be made, and people who had to be told; a story to be repeated countless times. There was the first night I spent living in David's house - alone, cold, empty, having lost the one person who had made it a home. They call it "coming to terms with a loss." But in November 1980, just two months after the suicide of my best friend, I still felt empty and alone. My energy was gone, my self-confidence lost; terror came at night, daydreaming suddenly turned to horrific scenes of pain, I heard screams in the silence of the afternoon. I relived it time and time again. I would meet someone I knew on the street and they might ask "How is David?"; I would cry inside while telling, yet one more time, the story I had rehearsed for public release.

A suicide is not a crime; it is not a cry for help; it is not a punishment for parents or loved ones who didn't understand or react or care; it is not a momentary flight into insanity. A suicide is a planned, determined act. It is the act of taking one's own life with one's own hand. Those who become candidates are people who feel that they can no longer survive the struggle and feel the hopelessness of living the life that they are experiencing. If a suicide is any one statement, it is an assertion about a planned end to the living hell of hopelessness.

I am a counsellor. I counsel people each and every day. I talk about plans and fears; I talk about growing and risking; and I talk about death and suicide. I have to respect the rights of the people who come to me to talk about their emptiness, their sadness, their anger, their loneliness. I have to remember the terror of some years ago when I was faced with having to carry on without David.

Crying helps for about an hour; running away, distraction, or overwork get you through a month - but the reality of a life lost hits hard late at night when there is no one to talk to, and so much to talk about. It is still perhaps the silence that is hardest to take. It is the empty house that waits for me every night after work, or the garage where he used to park his car. It might be the coffee mug with "D" on it, which sits on the shelf unused. Perhaps the one group of people who should be identified as our "at-risk" population are the philosophers, psychologists, counsellors and physicians who understand, accept and respect suicide. Depression and anger are normal. These are natural emotions and reactions that people experience.

Suicide should and must be examined. A discussion of suicide has to be part of the education of our society - in our schools, our universities, our churches and our courts. We cannot hide suicide as if it were the shameful act of lunatics and misfits.

Doctors, teachers, counsellors and parents have to show a concern and a trust when dealing with patients who come into care talking about their deaths. They have to be treated, not threatened; they have a right to talk about their deaths in terms of their dreams, their hopes and their struggles. They have a right to be heard.

Suicides are not impulsive. They do not happen when Friday-night dates don't arrive on time, or law-school grades are below 68 per cent. Suicides are a product of a sense that the hopelessness will never end, that there are no alternatives to the pain, suffering, and sometimes emotionless hours spent living a daily life filled with meaningless tasks and disruptions, and empty of joy.

If we are to do anything productive for our patients who talk about suicide, we must talk with them; we must take the time to listen beyond what they are saying, and to be there. We must open the doors of our offices and allow our homes to shelter a few of the nightmares. We, as counsellors, have a mandate to learn about suicide; and to understand and experience our patients' need to reach out. Our at-risk patients will hide in the shadows and hide from us until they know for certain that their feelings will be safe in our hands - that we will not betray their trust, belittle their fears and frustrations, punish or restrain them. We have to reach out and allow these frail souls to explore other worlds and other places. We have a responsibility to care for our patients and trust them to tell us what they need, because the path away from their death by suicide is hidden in the very nightmares and terrors that haunt them.

We cannot allow suicide to be a silent threat every time we deal with a disturbed patient. We cannot try to "fix" our patients' problems; we can only try to discover with them a walk that will lead them to a life that is healthier, more rewarding, more complete, and a little less scary.

David's death in 1980 was not my first experience with suicide. It was the first suicide in my family - and not the last. There will never be a resolution for the emptiness that I feel when I remember David; but day by day I feel a little stronger, a little less alone, and each day I thank David for the 10 years we had together. I think I understand David's suicide. I know that I accept his suicide. I forgave him a long time ago. What remains now is the pain and the cries in the night, but those too will eventually find some resolution. I do not have the fears I once had about suicide. Maybe it is because of David's death, because I have been forced to learn about what leads once loving, productive and creative people to such desperate hopelessness.

Every year on the anniversary of David's death I light a lamp that hangs in a tree in the yard of our house. It is to welcome home David's soul, to signal the way home for him. One day the lamp will not appear in the tree and David will be home forever. I suspect that the night terrors will have stopped and the emptiness will have softened. I suspect as well that it will be the time in my life when I have completed all that once was unfinished.

Mychael Gleeson, PH D
Mychael Company
P.O. Box 2212
New Westminster, British Columbia V3L 5A5


"To Hell with Seat belts": Changing Confrontation to Collaboration*

CHARLES F. MARGOLIS, MD
THEODOR T. HERWIG, MD
ELLIN L. BLOCH, PH D
JOHN R. KUES, PH D
TERRY M. PERLIN, PH U

Many states are enacting laws requiring the use of automobile seatbelts by everyone except those exempted by their doctor. The following dialogue explores the interaction between a medical student working in a physician's office and a patient who was seeking a seatbelt exemption.

MR. HERWIG: I encountered Mr. C. during my family practice clerkship in a small Ohio town. He was a 70-year-old farmer with controlled hypertension and mild osteoarthritis who came in for a routine blood-pressure check. He had a thick chart, having made many visits for arthritis pain control and hypertension, and the office staff were glad to have me see him.

A fit, young-appearing man, Mr. C. rose as I entered the room, angrily cutting my introduction short as he waved a newspaper under my nose. Jabbing at me with a finger, he said: "It says here that everyone must wear seatbelts, but a doctor can give an affidavit so people don't have to wear them." Mr. C. believed that arthritis in his hands and shoulder prevented him from fastening the seatbelt. He also wanted his blood pressure checked and medication refilled, and he wanted a handicapped parking sticker, "so I don't have to walk so far with my groceries when people with hardly nothing wrong with them can park up close."

I dealt with the parking sticker first, by referring him to the proper state agency. As I concluded my brief examination, he again demanded an affidavit. I replied that, as a student, I could not sign the affidavit and that I would ask the preceptor to come in. "No, I've already taken enough of your time," he said, and walked out muttering, "To hell with seatbelts!"

Afterwards, I was irritated and frustrated. I had felt assaulted when he interrupted me and thrust a rolled-up newspaper and his finger at me. He seemed unreasonable, and I felt I was "taking the heat" for a law I did not legislate. It was frustrating to have only two sentences in a newspaper clipping to guide my decision-making. Furthermore, I was not impartial: in an accident that had occurred four years before, a seatbelt had saved my life. Also, my work in emergency rooms, seeing severe injuries in people who did not wear seatbelts, left me opposed to his request. Neither of us came out of the office happy. Mr. C. did not get his affidavit and my preceptor and I were denied the pleasure of helping the patient.

DR. MARGOLIS: As a practicing physician, I would have felt irritated and frustrated with this patient, in part because of the matter of malpractice liability. The doctor might be held responsible if a patient who had been granted a seatbelt exemption were to have an accident and sustain more severe injuries because a seatbelt was not worn. On the other hand, there is a risk that if the exemption were denied, the patient might claim that subsequent injuries were caused by a seatbelt (1).

This patient was demanding and threatening, and exhibited behavior that is characteristic of the "entitled demander" - a type of "hateful patient" Groves describes (2). Such a patient challenges authority, and provokes family doctors into negative responses (3). Doctors are socialized to play by the rules and their training emphasizes conformity to law and societal obligations (4). Here Mr. C. has asked you to collude in circumventing the rules.

DR. KUES: Physicians often have to enforce rules created by others - in this case, legislators. Even if the doctor is familiar with the details, this particular law is vague, stating only that a doctor can given an exemption where the wearing of seatbelts is "impossible or impractical." These terms do not indicate what might satisfy the law's requirements. In this case you feel caught in the middle, between the legislature's intent and the patient's desires. Did other patients request seatbelt affidavits? How did you handle their requests?

MR. HERWIG: I saw a pleasant couple in their seventies. The woman wanted an exemption because of pressure sores on her shoulder, although she had previously adapted by padding the seatbelt. We talked about it and she decided she could do without the exemption. Her husband wanted an exemption because he was blind and had some arthritis. I agree that being blind and having an impaired range of motion would make it diffult to use a seatbelt. However, I didn't consider the consequences of a blind man traveling without a seatbelt. I agreed to an exemption.

The couple were more social and showed an interest in me. Also, they were flexible; because the wife was willing to do without the exemption, I was more inclined to grant one to her husband. However, now I am having second thoughts and am embarrassed about granting an exemption to a blind man. In a crash he might be thrown free, because he would have no advance visual warning. A disabled passenger can be strapped in by the driver, and someone who is able to drive should be able to fasten seatbelts. With regard to my decision about Mr. C., I wish he had agreed with me, and had withdrawn his request.

R. PERLIN: In other words, you wish Mr. C. had accepted your concept of his best interest. This attitude is paternalistic - that is, it involves "a refusal to accept or to acquiesce in another person's wishes, choices, and action for that person's own benefit" (5). What were his best interests? You were concerned about his health and safety. Were you also concerned about his emotional response?

MR. HERWIG: I knew he was going to be angry, but I believed that his physical well-being was of greater importance. I wanted to protect him and avoid unnecessary health-care costs to society.

DR. PERLIN: In affirming society's needs, you aligned yourself with the authority that the patient held in contempt. There is a related ethical issue: in order to grant his exemption, from your perspective, you would have had to lie, exaggerate, or be duplicitous. Many doctors, when pressed, would agree that sometimes "lying" may be in the best interests of the patient - for example, expressing hope and optimism to a seriously ill patient when it is not fully warranted by clinical evidence. If, on occasion, doctors act duplicitously to patients, what is wrong with acting duplicitously on behalf of patients?

Another issue is that of personal freedom, which includes the liberty to say or do something contrary. When an older patient has to ask permission, especially from a youthful medical student, it is demeaning and derogates that freedom. This man may be upset because you can either extend or limit his freedom.

DR. KUES: This may be particularly difficult for an older independent farmer, who was raised in an era of respect for the elderly. However, every day Mr. C. probably deals with people who give him little respect. Legitimately parking in the special space and driving without a seatbelt may be perceived as surrogates for the respect he is not getting elsewhere. In addition, he may be chafing under some recent loss of independence.

DR. BLOCH: At this age, people suffer a number of losses: of job, of financial security, of physical mobility, and of spouse. Friends and neighbors may die or move away. The seatbelt is a vivid symbol: in resisting it, he says "I want my freedom." It's a protest against getting old.

Did you wonder if Mr. C. 's anger was a clue to something else that he wanted to discuss? Why did he make that particular demand? Did he want you to perceive him as a fragile and handicapped individual?

DR. PERLIN: It appears that Mr. C. was trying to gain control. He seems to have a different concept of the doctor-patient relationship than the usual model. In the predominant form, which Robert Veatch calls "the priestly model," a supplicant patient comes to a medical expert for direction and, perhaps, absolution (6). Veatch also describes a "collegial model," in which the doctor listens to the patient and collaborates in devising a plan to benefit him or her. This requires flexibility on both sides. In the cases described here, the couple were flexible, but Mr. C. was not.

DR. BLOCH: Negotiation is easier in a well-established doctor-patient relationship, especially if each has empathy for the other. What made Mr. C. difficult was his inability to put himself in your place. Mr. C. pressured you and prevented you from playing a helping role. The encounter moved outside the typical doctor -patient model and became adversarial. The couple wanted to be "patients" and they wanted you to be their doctor. It is much easier to work where roles are clearly defined and each is adhered to.

Finally, subjectivity is important. Doctors tend to favor patients who are attractive, interesting, intelligent, or of the right class or social background. The couple appealed to you; perhaps you felt pity because one of them was blind.

DR. MARGOLIS: In avoiding confrontation, it helps to avoid saying "No" directly. For example, one might agree that no one likes being told what to do. Then one might explain, "I understand your difficulty with the seatbelt, but if I sign that paper, it makes me legally responsible and could get me in trouble. If you feel that strongly, you can drive without seatbelts, but I would rather not be involved." Telling an anecdote supporting or explaining your viewpoint may help - for example, "I just read the book about Iacocca, the man who is so successful selling cars. You know, he believes everyone should wear seatbelts, because they save lives" (7). Sharing personal experiences may help create empathy and increase the patient's trust in the doctor (8). For example, you might have told Mr. C. that a seatbelt once saved you from a paralyzing injury. Another approach is, "I am sorry that I cannot do this for you. Is there anything else I can do for you? If you come back, I won't always be so hard to get along with ... .": make a joke of it. Humor, or a smile, usually helps to defuse a confrontation.

DR. BLOCH: Concern and curiosity can be powerful tools for the doctor. Saying "show me how this belt hurts or troubles you" allies you with the patient. It puts the patient in the position of teacher or expert, having information that you don't have. He or she is given more control, and is encouraged to form a collegial relationship.

DR. MARGOLIS: It was appropriate to refuse him an exemption from wearing a seatbelt, because it is an intervention of proven value. However, he may consult another doctor who, wishing to avoid conflict, will give him the affidavit.

DR. KUES: Also, you cannot assume that he will wear his seatbelt because you refused an exemption. I doubt if this man left the office intending ever to wear a seatbelt. While your decision was made "in his best interests," it probably had no impact on his behavior. This case caught your attention; what lessons have you learned from it?

MR. HERWIG: First, I will find it more difficult in future to grant an exemption, because I am more aware of the legal issues involved. Furthermore, I now cannot imagine a patient who is fit enough to drive and yet is not able to wear a seatbelt. In general, I am now more aware of how a patient's manner and language affects me. Things would have been different if Mr. C. and I could have agreed that the law is a nuisance and is an imposition for both of us. Allowing him to demonstrate his problem with seatbelt use might have defused the situation and showed him my concern and interest. I don't know if he would have been satisfied, but I would have been more comfortable and happier. It has been valuable to retain and discuss my experiences. I now understand how I reacted to Mr. C. 's hostility and to the elderly couple's warmth, and how much my decision was influenced by my subjective reaction. In addition, I have learned several techniques by which to convert confrontation to collaboration.

Charles F. Margolis, MD
Theodor T. Herwig, MD
Ellin L. Bloch, PH D
John R. Kues, PHD
Terry M. Perlin, PHD

University of Cincinnati
College of Medicine
Cincinnati, Ohio 45627-0582
*The authors are affiliated with the University of Cincinnati College of Medicine. Dr. Margolis is Associate Professor and a family physician, Mr. Herwig was a third-year medical student there at the time of writing, and is now a family medicine resident at the Duke-Watts Family Medicine Residency Program, Durham, NC. Dr. Bloch is Associate Professor and a clinical psychologist, Dr. Kues is Associate Professor and a social psychologist, and Dr. Perlin is Professor and ethics consultant.

REFERENCES

  1. New seat belt law raises liability questions. 0.5. M.A. Gram [newsletter of the Ohio State Medical Association], June 9, 1986.
  2. Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883.
  3. Klein D, Najman J, Kohrman AF, Munro C. Patient characteristics that elicit negative responses from family physicians. J Pam Pract 1982; 14: 881-88.
  4. Christie RJ, Hoffmaster CB. Ethical Issues in Family Medicine. New York: Oxford University Press, 1986.
  5. Childress JF. Who Should Decide: Paternalism in Health Care. New York: Oxford University Press, 1982, p. 13.
  6. Veatch RM. Models for ethical medicine in a revolutionary age, 1972. In: Arras J, Hunt R, eds. Ethical Issues in Modern Medicine. (2nd ed.) Palo Alto, CA: Mayfield, 1982.
  7. Iacocca L, Novak W. Iacocca: An Autobiography. New York: Bantam, 1986.
  8. Candib LM. What doctors tell about themselves to patients: Implications for intimacy and reciprocity in the relationship. Fam Med 1987; 19:23-30.

Are Medical Imaging Centers a Cause for Societal Concern?

A. EVERETTE JAMES, Jr., SCM, JD, MD
SEYMOUR PERRY, MD
RICHARD R. ZANER, PH D
JOHN E. CHAPMAN, MD

Medical practice is entering a phase of intense financial competition, which is illustrated by the appearance of medical imaging centers. These centers should flourish under the present mix of policies and regulations, including the application of Certificate of Need (CON) legislation, attitudes that make physician hospital privileges more difficult to obtain, and cost containment methods such as diagnosis-related groups (DRG5). The last will shift pretreatment diagnostic evaluation from an inpatient to an outpatient setting, and this method of prospective reimbursement will favor free-standing imaging centers. Now physicians will be forced to decide if these particular financial arrangements are beneficial to patients or necessary.

Medical cost analyses demonstrate that for comparable equipment use, physician involvement, and acquired information, outpatient imaging studies are more economical than inpatient procedures (1, 2, 3). Because hospital overhead, personnel requirements and equipment expenditures tend to remain fixed, it is also difficult to reduce charges for inpatient procedures (4).

While imaging centers offer the physician certain advantages, they have some inherent and potential hazards. The increased profitability of free-standing centers may lead to greater competition for ownership. As well, hospitals, venture capitalists, and physicians may compete to take advantage of the present freedom from regulation. Predictably, however, if profitable, these centers and their owners will become the objects of future regulation. While theoretical at present, these risks are significant.

One may finance an imaging center by including referring physicians as limited partners and having the imaging physician or nonphysician investors as general partners. Each partner incurs an initial financial risk in exchange for the opportunity to share in subsequent profits. The limited partners may be those physicians who are able to control patterns of patient referral. Investors could then select the most "profitable" equipment based upon anticipated diagnostic examinations (4-7). This arrangement could bias or at least influence the type of examinations requested in the center. To operate these centers profitably, seriously ill patients may be maintained outside hospitals longer so as to carry out preadmission tests in a less expensive setting. Also, more and more invasive procedures may be performed in these imaging centers. Thus, one may encounter complications from procedures more frequently in settings without ready access to fully trained advanced life-support teams, medical emergency equipment, or intensive-care units - thereby increasing the exposure of the owners to liability.

As described, these arrangements may raise significant legal and ethical concerns. Does this form of partnership constitute a "tying arrangement" or even a form of "fee-splitting"? These arrangements do not necessarily make the medical imaging centers illegal under antitrust legislation (1, 5). If the referring physician benefits financially as a return upon investment and the compensation is not related to the numbers or types of patients referred or by some scale or weighting factor for the examinations requested, the financial arrangement is a legal if not an ethical one (8). It is unlikely that a court case will develop on the basis of a "tying arrangement"; however, several states are enacting legislation that may make ownership by physicians who use these facilities unprofitable and subsequently illegal.

Another important antitrust consideration is "market capture." In smaller communities, medical imaging centers may represent the only diagnostic facility; even in larger towns or cities, because of the characteristics of the equipment, they may represent significant market "capture" or "penetration" (8, 9). Does the physician's ownership of the imaging center constitute control of a vital resource for the conduct of a particular business (the practice of medicine), which could affect patient choices adversely (5, 7)?

One could argue that such ownership, if nothing else, is a form of positive "gatekeeping," indirectly (and possibly even directly) controlling the nature and range of patient choices. In the framework of such economic arrangements, the physician may be constrained to increase rather than decrease access to services, or by directing them in certain ways - to limit such choices and access. Then services would be provided in response not so much to medical need but to market demand, thus compromising, in a basic way, the physician's traditional ethical position. This control, profitable and legal though it might be, raises serious ethical concerns about just distribution of goods and services. It can also introduce compromise and conflict into physicians' relationships with their patients, because it raises the question "To what extent can physicians simultaneously serve the needs of their patients, their own interests, and those of society?" Economics and ethics, individual rights and the social good, the physician's and the patient's interests need not be in conflict. Yet this form of "market capture," "tying arrangement," and perhaps even "fee-splitting" may encourage physicians to use their positions as gatekeepers to their own financial advantage or that of their co-owners (10, 11).

Medical imaging centers also have the potential to reduce access for those with low incomes (4, 12). "For-profit" imaging centers may tend to reduce care for patients with limited or no insurance or with -a catastrophic illness (12). Patients who are able to pay for their health care would be actively sought. Such market "skimming" might reduce the number of "reimbursable" patients cared for by community and "not-for-profit" programs that contend with significant financial constraints. Such initiatives would adversely affect delivery of adequate care to the underprivileged.

Only a few years ago, most physicians would have hesitated to participate in arrangements such as those that characterize medical imaging centers. Now, given the alternatives, they may choose to join the system so as to work for arrangements that will protect patient welfare. We appear to be at the threshold of regulatory intrusion and entrepreneurial initiatives by physicians. These phenomena will give rise to new legal and ethical issues and will force the physician to make decisions for which there are no historical precedents. The development of medical imaging centers seems to be an early initiative along a continuously complex pathway.

A. Everette James, Jr., SCM, JD, MD
Chairman, Department of Radiology and Radiological Sciences
Lecturer in Legal Medicine
Professor of Medical Administration
Senior Research Associate, Vanderbilt Institute for Public Policy Studies
Vanderbilt University Medical Center
Nashville, Tennessee USA 37232

Seymour Perry, MD
Deputy Director
Institute for Health Policy Analysis
Georgetown University Medical Center
Washington, DC

Richard R. Zaner, PHD
Stahlman Professor of Medical Ethics
Vanderbilt University School of Medicine

John E. Champan, MD
Dean
Vanderbilt University School of Medicine

REFERENCES

  1. James AE Jr. Hickey Lecture: Medical imaging technology in a societal context. AJR 1985;144:1109-16.
  2. James AE Jr, Greeson T, Price RR et al. Legal and ethical issues in a technologic discipline: new times, new choices. Investigative Radiology 1987;21 :673-77.
  3. Freedman GS, James AE Jr. Comparison of outpatient digital angiography and inpatient arteriography: some financial implications. In: Price RR et al., eds. Digital radio graphy: A focus on clinical utility. New York: Grune & Stratton, Inc., 1982.
  4. James AE Jr, Chapman J, Carroll F et al. Ethical choices in high-technology medicine: Current dilemmas in diagnostic imaging. Health Care Instrumentation 1986;1 :158-67.
  5. James AE, Partain CL, Hamilton RJ et al. A critique of the concept of MRI centers. Magnetic Resonance Imaging, February 1987.
  6. James AE Jr, ed. Medical/Legal Issues for Radiologists. Chicago: Precept Press, 1987.
  7. James AE Jr, Pendergrass HP, Robinson R et al. Exclusive physician contracts in hospitals: precedent cases for radiologic practice. Administrative Radiology, May 1987.
  8. Relman AS. Dealing with conflicts of interest. New Engl J Med 1985; 313 : 749-51.
  9. Hyde v. Jefferson Parish Hospital District No. 2, 686 F ed 286 (5th Cir. 1982), cert granted 51 U.S.L.W. 3649 (1983).
  10. Churchill LR. Rationing Health Care in America. Notre Dame, IN: University of Notre Dame Press, 1987.
  11. Pellegrino ED. Rationing health care: the ethics of medical gatekeeping. Jour Contemp Law and Policy 1986;2:23-45.
  12. Nutler DO. Access to care and the evaluation of corporate, for-profit medicine. New Engl I Med 1984;311:917-19.

Reflections on a Vocal-Cord Cancer

GIL SCHONNING, MA, PH D

It was a traumatic moment when I was told, "the nodule on your vocal cord is malignant." The news registered only superficially as if it were a foreign concept. The doctor might as well have told me I had leprosy. Presumably, I did not want to believe, and it took several days to fully accept the new reality. It takes time for the mind to adjust to any disaster and, in my case, I doubt it will until after the last checkup.

From my reading of articles about cancer, I gather that, apart from the aging process, which seems to weaken a person's immune system, and the self-induced trauma of cigarette smoking and similar toxins that activate malignant cells, cancer is no respecter of persons.

Hitherto, although an expanding army of research workers has made progress toward understanding how the wide variety of cancer types come to be activated, as yet we have no sure way to prevent the activation of these cells. Once cancer has begun in a tissue, its grip is fierce and its growth is efficient and can be deadly unless treated. At present, the remedies are almost as violent as the disease. These are of two basic types: lengthy radiation treatments or the application of strong chemicals.

I have come to regard cancer as an alien force possessing many proclivities. Some breeds are far more virile than others. But whatever the breed, it has proven to be highly unpredictable. It may lurk about and be as sneaky and unreliable as a double agent. It is capable of metastasizing to another part of the body with devastating effects.

When the surgeon said I would need a series of radiation treatments, I selected the Ottawa Regional Cancer Center, a division of the Civic Hospital, to do the job. There the experts said I would need 30 radiation treatments of equal strength, 90 seconds on each side of the throat. At the conclusion, they informed me that there would also be monthly checkups lasting two or more years.

Like other similar clinics, the ORCC dispenses two kinds of treatment, radiation and chemotherapy. Most clients arrive, receive treatment, and go home; a small group are in-patients. Like other health-care institutions, it features multiple division of labor; its objective is to deploy all personnel so that all functions operate as an efficient whole. The ORCC would be unique indeed if it had no administrative problems. In my experience there are several interruptions in the routine of processing incoming patients; these include the doctor(s). While, of course, the doctor's diagnosis and prescribed cure should not be hurried, doctors are not always aware of the value of their patients' time. In any event, the process seemed inordinately slow in places, causing a bumpy flow. I stress this point because new patients are a most sensitive group. They come for treatment soon after they have been told that they have a fearsome disease. I know because I felt hypersensitive about any delays or apparent tardiness; often I was impatient to get out of the place.

Interruptions and delays are frequent in the treatment schedule. Because the schedule is designed to operate at a rate of so many minutes per patient, it seemed simple to draw up and follow. The cause for delay, I gathered, was the injection into the routine of one or more patients by those "higher in authority." No doubt, this occurred for good and sufficient reasons; however, the results were unfortunate for the many other patients, who grew increasingly impatient with often-lengthy delays. Watching the flow of patients through the operation, I got the impression that the demand for treatment services was rising and gradually exceeding the center's capacity; also, that the inertia may lie more with the equipment than with lack of space or with lack of human resources.

One aspect of the operation impressed me very much; namely, the friendly and obliging staff. The front-line group, the technologists, were an affable, pleasant and helpful bunch. Their cheerfulness did much to counter the demeaning and repetitive aspects of the treatments. In my state of mind, crawling onto the radiation table daily, harnessed with a mask, bolted to a table, seeing the other humans leave the room and being left to the deadly radiation beams streaming through my throat and escaping at the back of my neck did little to bolster morale; also, I saw no evidence that their bright presence impeded their efficiency. Those finer human touches helped to keep my mind off the sinister and capricious disease and the tiresome and ultimately miserable treatment. Good health is invaluable to counter the side effects (headache and nausea); it helps make the ordeal less intolerable.

Finally, the future looks anything but encouraging for an aging population and the institutions struggling to provide cancer services. It is estimated, for example, that while the Ontario population may increase 12 per cent between 1984 and 1994, the increase in the incidence of cancer may exceed 40 per cent. Aging of the population is the main contributing cause but, unless there is a dramatic cleanup of the environment, we may be drowned in carcinogens.

Naturally, as a patient I have been preoccupied with how the treatment period might be shortened, because if the incidence of cancer expands faster than the population growth, it will be essential to shorten treatment time if cancer-care institutions are to cope. The second step to reducing the treatment time will be upgrading existing technology, because not only is the cancer incidence increasing steadily but much of the existing treatment machines need replacement.

If these two steps could be accomplished, thousands of patients would be most grateful as their trips to the treatment room could be reduced by one-half or more.

Gil Schonning, MA, PH D
858 Echo Drive
Ottawa, Ontario K1S 5C5