Live Long and Prosper!

I’m gonna live forever…

…I’m gonna learn how to fly

Fame-1980

Barb and I have been lying. To ourselves and to each other. To friends and family too. Ever since we turned the big “LX” along with some of our buddies, we have been telling the world that 60 is the new 40. It turns out we were wrong. According to an article in the New York Times, 60 is still 60. Our bodies have changed, our brains have changed and we are in the “anteroom of the aged.” How’s that for a spring awakening?

The Times article, written by Gerald Marzorati, suggests that all the workouts, all the dieting, all the brain games we play won’t really do a thing to keep us from aging, gracefully or otherwise. The author’s prescription for possibly adding a few years of life, and keeping memory intact, is to choose and master a new task. And not to go about it casually, but to find a coach in whatever it is you want to master, and strive for the 10,000 hour mark that makes an expert. Talk about digging in!

The task Mr. Marzorati has undertaken is to become a decent tennis player. He has trained in at a tennis academy and improved his game. Now Barb and I have been playing tennis for the last 10 or 15 years, sometimes with coaches, sometimes without. I regret to say that if becoming a good tennis player is what it will take for either of us to add a decade or so, we might as well have the Grim Reaper as the line judge.

So what are the new tasks we can choose to master? Who knew that Barb would become a juggler? She is currently juggling building a house and selling one, doing hand therapy here and hand therapy there, planning a wedding for one of our kids and baby sitting for the other, and oh yeah tennis. She may not have coaching for most of it, but I see no problem with her getting in her 10,000 hours of juggling. She must be lengthening her lifeline with every faucet she chooses and diaper she changes.

As for me, to master a sport, any sport, is a non-starter. I have given up golf, frequently feel like giving up tennis, and haven’t bowled in years. I do a bit of running, but my time for last weeks 5K race indicated I won’t be winning any trophies, even in my senior(ish) age group. I guess short form writing, such as this blog, has become my new passion. 10,000 hours = 10,000 posts? I don’t think anyone would want to sit through that! Now a novel on the other hand…that would add years to my life!

Any suggestions for new skills to master, comment below, or send ’em along to les.raff@post.com.

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Running Mates and Other Mates: Fighting Trump, Fighting Cancer

Girl, I heard you’re getting married,

Heard your getting married,

This time you’re really sure.

Brooklyn Bridge-1969

Ted Cruz keeps looking for a partner. First we have the sort of/maybe/not really deal with John Kasich, trying to not cut each others throats in the remaining primaries. Quickly followed by yesterday’s announcement of Carly Fiorina as his Vice Presidential running mate, and vocal coach as well. All of this, of course, in an effort to stymie Donald Trump in his march to the Republican Presidential nomination. It appears that Cruz’s philosophy is that if you can’t win on your own, grab your partner or partners and do-si-do.

I don’t know how well the pairing technique is going to work in politics, but a new study reported in the journal Cancer and summarized in the Chicago Tribune suggests that married patients do better in their fight against cancer than comparable single people. The advantage is greater for men than women, and is not associated with socio-economic status. It seems that hand holding, cooking, chaffeuring and all around loving can help survival. No surprises there, right? But it brings to mind a former colleague of mine, one of the most talented men that I have had the pleasure to have known and work with. Let’s call him John, and his wife Mary About 18 months ago John was given the diagnosis of advanced lung cancer. He has undergone surgery, traditional chemotherapy, and novel treatments as a patient in advanced clinical trials. During all this John has maintained his active lifestyle and achieved new professional goals and accomplishments. He has documented his battle in a wonderful blog (the blog is not public, I cannot share a link) that both faces the difficult realities and celebrates all the wonderful triumphs. And as he freely admits, it is the love, care and support of the magnificent Mary, now aptly nicknamed Chemo-sa-babe, that makes it all possible. I know that as I experience John’s life on his blog, Mary is there holding his hand for every battle won and for every set-back. And as the study in Cancer suggests, that hand holding may be the reason the wins so greatly outnumber the backslides.

Cancer has also visited our family; fortunately it did not stay. I hope I did enough to support Barb four years ago, though I think it may have been the prospect of Michael and Becca’s wedding that hastened her recovery. I hope neither one of us becomes the supporter or the supportee in the future.

And as for Ted Cruz, does it matter how many partners he takes? He will continue to be Ted Cruz, and that doesn’t seem to be the man the rest of America wants to marry!

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Doctor, Doctor, Give Me the News

Affordable Care Act or Obamacare, no matter which one you call it, it has probably had some effect on you or your family. As a “bleeding heart liberal,” I applaud the expansion of some sort of insurance coverage to millions of Americans. As a physician, employer and provider of health care insurance for the two of us, I have my reservations about the cost-benefit ratio. I have been hit by higher premiums, higher deductibles, changing provider networks and complex pharmacy rules. I understand that even without the ACA, health insurance premiums would rise pretty steadily every year, but some of the other perturbations in the health care system seem to be a direct result of the Act. And don’t ask Barb about the phone calls she gets from our insurance carrier offering to make her primary care appointments for her, probably as a result of the carrier trying to meet some new quality regulation. As she points out to the caller regularly, she is quite able to make an appointment, and money spent on calling her is money wasted.

When I look for data about the effectiveness of the Act, I can find statistics about the number of new insurance enrollees and Medicaid enrollees, but nothing much telling me if the health of the nation has improved and if people are satisfied with their coverage. So I am taking an informal poll. Its just a few questions, and won’t be scientifically significant, but if you have a few moments, click on the link below. If we have enough results, I will publish them at a later time. To that end, please feel free to pass this post around!

Click here to take the poll.
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When Cancer is no Longer Cancer

Things change. A recently published study discusses re-evaluation of a certain type of thyroid lesion–Encapsulated Follicular Variant of Papillary Carcinoma of the Thyroid (EFVPTC). Follow up on over 100 patients who had the lesion surgically removed showed no evidence of spread or recurrence. The findings imply that EFPVTC is benign, with no need for further treatment, and tumors with this particular microscopic appearance will henceforth be given a rather lengthy name, shortened to NIFTP . Don’t call it cancer! The appearance of the tumor hasn’t changed, just our understanding of its behavior*. This is big and important news for patients with a lump in their throat. Similar re-evaluations have arisen or may arise in dealing with lesions in the bladder, prostate and breast.

I learned about the study in an article in the New York Times. The article is interesting reading, but what I spent more of my time examining was the Reader Comments section of the Times. I am amazed at the varying opinions, observations and hostility that this article provoked. A major thread is that Cancer-Industrial Complex (CIC) of physicians, hospitals, and Big Pharma are in the business of over-diagnosing and over-treating cancer in the interest of increasing revenue. These readers are amazed that the CIC would ever allow a study to be published that would decrease the number of cancer patients. After all, fewer cancer patients equals fewer dollars in the hands of greedy docs, hospital administrators and pharma execs. Then there are the readers who believe a study such as this one must be supported by the government and insurance industry. Medicare, Blue Cross, Humana and others stand to save millions of dollars if there are fewer thyroid cancer patients making claims.

My view? Designations change. One way is through the use of long term follow up studies such as the one on EFVPTC. Molecular studies on the genes in tumor cells may soon do an even better job at differentiating benign tumors from malignant ones. In the meantime, I report what I see under my microscope, the “names” I use based on our current knowledge and agreed upon terminology. My goal is neither to enrich our “industry” or save the insurance company some bucks. The people whose biopsies I look at may not know my name or where my office is, but they are still my patients, and I want only the best for them.

*A reinforcement. The findings in the published article refer to only one very specific type of thyroid cancer.

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Kitten Power Can Get Things Done

And I’ll be takin’ care of business, every day…

…takin’ care of business, every way.

Bachman-Turner Overdrive-1973

The mighty Colorado River carved the Grand Canyon over millions of years. The immense pressure of the earth’s mantle creates the environment for the creation of diamonds. Small aquatic plants and animals crushed under the weight of sea beds leads to petroleum. So eons and eons and tons and tons can lead to massive changes. But what can the weight of a seven pound cat accomplish in the span of just a few years?

We have talked about our kitten and my problems with her before. The two of us are on improved terms these days, though her objections to visiting the veterinarian did lead to several scratches, puncture wounds and a cancelled appointment. She remains tiny, even more apparent now that she has lost her warm winter coat. But this skinny, demure creature has made an indelible impression on our house (for sale! for sale!) , or at least on our furniture.

Note chair “A”. See the nice straight line of the back cushion. That’s what our bedroom chairs looked like before Princess Kitten came along. Now lets take a look at Chair “B”, the cat’s favorite perch. On this chair, that back cushion is a deep “v”, a permanent, unreversable groove. I don’t have to tell you which chair has been the kitty’s favorite sunning spot for the last four years, do I?

So it doesn’t take a lot of weight, or even a lot of time, to make a dent in things. Look what this welterweight has done in just four years, the length of one Presidential term, or the length of time it might take to build our house. Is there a lesson to be learned? I guess you don’t have to have the power of the Colorado, or the weight of the earth’s crust to make a difference. Sometimes a little steady, gentle, pressure can get the job done. Sort of fits with my preferred management style. Of course, unlike our kitten, I try not to shed my fur as I go!

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What’s in Your Wallet? There’s a Little Aluminum Foil Package In Mine.

You can’t always get what you want

but if you try sometime you find

you get what you need.

The Rolling Stones-1969

I don’t leave it to chance anymore. There is always one in my wallet, sealed in its aluminum pouch. It was Barb’s idea. “You’re out and about and wish you had one, and then you get irritated when you try to buy one and can’t get the type you like.” After almost forty years of marriage, I have learned to listen to my wife on matters of such importance.

It wasn’t always a necessity. I used to be able to get them with ease. Every store had one of my favorites. Barb could buy them for me anywhere. We could share one, or I could grab one even if Barb wasn’t around.

It is a lot tougher to find what I want now. Last month we were headed for what promised to be an interesting evening at the home of friends. From past experience, I knew our hosts wouldn’t have any and it would be prudent to bring my own. Maybe I was distracted when we left our house, but I forgot to grab one or two from my stash. Realizing my slip-up, we stopped at a convenience store and I searched the shelves. I found plenty of exotic varieties. But where were my favorites? I unearthed a pile of them in the back of the store, unwrapped, unappealing, and not for sale. But I convinced the clerk I absolutely had to have one, and we negotiated a price. We closed the deal and the night was saved…I had my Lipton Tea Bag.

Yes, when it comes to my tea, I am a demanding purist. Give it to me black, without bergamot or orange rind. Load it with caffeine and make the water hot enough for a full, rich brew. No fancy blend is needed. Plain old English Breakfast will do nicely. But the supermarkets are crowded with frou-frou flavors, and restaurants are even worse. When I ask for tea at the trendy neighborhood trattoria, the waitress will flip open the polished rosewood box and tell me they “have Herbal Raspberry Zapper and Decaffeinated Green and of course Chamomile with Rose Hips.” Or the snooty waiter at the four star joint will tell turn up his nose and say “we have first blush, the finest tea in the world,” for a mere $25.00 a cup. I beg for Lipton. And if my favorites cannot be found? I whip the aluminum pouch from my wallet, rip it open, and ask for a pot of boiling water. Let them charge me a corkage fee, I am brewing my own! I was never a Boy Scout, but now I know. When it comes to my favorite drink, just like everything else in life, it pays to be prepared.

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Medicare Gets This One Right–For Now!

If you change your mind…

…I’m the first in line.

ABBA-1978

A few months ago I wrote a blog post about a Medicare proposal that was absolutely blowing my mind. CMS, the agency that runs Medicare, had it in it’s collective head that the prostate specific antigen (PSA) blood test, the test that checks men for prostate cancer, should get the boot, giving men a literal kick in the ass. The proposal apparently would have penalized the quality score of physicians who ordered the test to screen men for the disease. This prohibition even extended to men of an appropriate age for testing and in a high risk group such as being African American or having a strong family history of prostate cancer. Now I know the test isn’t perfect, but as a pathologist who sees about 30 cases of prostate cancer a week, and have also had my father die of the disease, I can tell you that any steps that help identify prostate cancer can’t be all bad.

I was not alone in my belief. CMS received 358 public comments about the proposed new policy. One of them came from me, maybe a few came from readers of my earlier blog post. The American Medical Association, The American Urological Association and The Large Urology Group Practice Association all chimed in. And CMS listened! Medicare has announced it has “temporarily suspended development of the draft measure.” That’s not exactly a strong endorsement for having a PSA test, but at least physicians who order it on their patients won’t face any penalties or sanctions. Thanks for coming to your senses, CMS!

As we have discussed before, PSA has its drawbacks. Many men with an increased PSA do not have prostate cancer. Some men who will be biopsied will have a cancer that does not require treatment. But as part of an all around health plan for men, and when the pros and cons are explained by a primary physician or urologist, the PSA test, definitely has a role. Maybe in the future we will have another test that is more reliable, equally available, and equally inexpensive. But right now, we don’t.

My dentist has a placard in his exam room reading “You only need to floss … the teeth you want to keep.” That is how I feel about PSA testing. I think I’ll hang a sign in MY office “You only need a PSA … for the men you want to keep.” Pass it on.

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Can Newman and Redford Paint Our Lab or Fund Our House?

Remember-one man’s ceiling…

…is another man’s floor.

Paul Simon–1973

How many of you remember the two great Paul Newman/Robert Redford buddy films from the late 60’s-early 70’s? Most people of our certain age can probably recall “Butch Cassidy and the Sundance Kid,” but my favorite was “The Sting.” The two played a pair of con men trying to work the ultimate grift on gangster Doyle Lonnegan, played by the appropriately fierce Robert Shaw. In one scene, the con men and their team, posing as house painters, fake a Western Union agent out of his office and paint a wall or two before vacating, leaving the unhappy agent to return to a half painted office and a big mess. And that’s what we have here at the lab. No con, just the big mess!

The lab has been operating for more than 10 years, and the walls, floors and ceilings are showing their age, not to mention wear and tear from exposure to formalin, paraffin, and other assorted chemicals and solvents. So working with building management, we agreed on new paint, carpeting and ceiling tiles, as well as refreshing our vinyl flooring which was deemed too difficult to replace. The problem was how to coordinate all that work with a lab that has some sections open seven days a week, and others that work on a pretty tight schedule to get our cases out on a daily basis. No way can we shut down for a week, or even a day or two. And oh yes, we have an unannounced accreditation inspection coming up. We have to look all in order for that, whatever day it may fall on.

After multiple walk-throughs with the building agent and several different contractors, we arrived at a work schedule. We were provided with a floor plan of the lab, highlighted with seven different colors, each representing a different work phase, each to be done on a different weekend. Doing our best to not interfere with the daily work flow except for those pesky Chemistry and Microbiology sections with their weekend hours. Now that was really tough to work around!

So the painters and ceiling guys are hitting those sections on the run, painting Chemistry on a quiet Monday, and Micro between plate reads from Friday night to Saturday morning. We have pleaded with the painting crew not to unplug any incubators, refrigerators, our temperamental tissue processors, and so far they have been gentle. On the downside, the non-toxic paint is giving everyone a headache and making us all cranky. Our Safety Officer is popping the respirator masks out. And the paint just keeps on rolling.

So with the ragtime theme music from “The Sting” (Marvin Hamlisch playing Scott Joplin’s “The Entertainer”) playing in the background, I ask how all of you have dealt with maintenance in the workplace. Any secrets to your success?

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On the home front, construction is moving along, though not as quickly as everyone had hoped. First floor walls are up, and with good weather we should make some progress this week. Barb and I (well, mostly Barb) are struggling through all the essential decorating decisions. So many choices. So many permutations and combinations. So much money! But I have the ultimate trust in Barb to get it right, and still leave a few dollars in the rainy day fund. And if we go broke, we can always try pulling a con. It worked for Newman and Redford!

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March Madness Bracketology-Presidential Style

I’m winning…

…and I don’t intend, on losing again.

Santana, 1981

March Madness! How have your brackets been doing? Michigan State? Kanas? Oh, no, I am not talking about THAT March Madness. I am talking about that other hardcourt, hardball challenge, the 2016 Presidential Campaign. Just as the the NCAA Men’s Basketball Season started long ago, so did the Campaign. Lets gaze into our backward crystal ball and take a look at how these brackets shaped up way back in the fall of 2015. Think it was tough then to pick the top college bball team? How about trying to seed the candidates?

Republican Region Tournament:

Last fall was a long time ago, but the rankings were something like this:

Governor Division-Because the State House can produce a Jimmy Carter, a Bill Clinton, or a George W. Bush.

Jeb Bush
Chris Christie
John Kasich
Mike Huckabee
George Pataki
Scott Walker
Rick Perry
Jim Gilmore

Congress Division-Because we all love how functional our US Congress has been.

Ted Cruz
Marco Rubio
Rand Paul
Lindsey Graham
Rick Santorum

Outsider Division-Because if you can bankrupt a company you can run a country!

Ben Carson
Donald Trump
Carly Fiorina

So who was your money on way back then? Back before the debates, the name calling, the protests and the unholy alliances. If I were a betting man, which I rarely am, I would have put the short odds in the Governors Division on Jeb. So did most of the big money. So did the pollsters. But he never made much of a move, did he? Quite an upset. I am sure his lackluster performance busted a lot of brackets. Hard to predict that it would be Kasich coming out of that Governors Division on top. Who thought that last fall? Who outside of Ohio had even heard of him last fall? Just like a number 12 seed, some how slipping past higher rated rivals.

Oy, the Congress Division. Was there anyone in there that emanated “President?” Mean Ted is the division survivor, but I don’t see him getting out of the Final Four.

On to our Outsiders. In the NCAA Tournament everyone loves the Cinderella team. Everyone cheered Wichita State in 2013 as the Shockers made a run to the Final Four. Everyone loves an underdog. But who could have predicted that the Republican Cinderella, the one who could blindside all the guys and gals going for the glass slipper would be Donald Trump? The dude can hit from anywhere on the court, just like Stephen Curry. He plays a tenacious defense that hasn’t been seen since Scottie Pippen. This is NBA talent playing against college level ballers. He has clinched the Outsiders Division. But do we really want to see him win the Republican Region and advance to the Finals in November? Maybe it is time to call a few technical fouls and get him tossed from the tournament.

Democratic Regional Tournament:

Hillary Clinton
Bernie Sanders
Martin O’Malley

Not much of a bracket, is it? More like a long drawn out best of seven series. The Damn Yankees vs the Washington Senators. And Bernie Sanders isn’t getting secret help from the Lola or the Devil. Some excitement in the first couple of rounds, but I think we all know how this one will end up. Just wake me up before the final buzzer.

It’s been a long slog, and it has a long way to go until November. Just remember that if your candidate loses, there’s always another season. There is always 2020!

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FISH: A Little Known Lab Test for an Important Disease

And it’s one two three…

…what are we fighting for?

Country Joe McDonald and the Fish-1965

It is early morning, 6:30 a.m. I sit in a dark room, staticky music from WXRT playing on the beat up radio in the corner. The setting is ripe for meditating, but my meditation consists of peering through a large, clunky, microscope. I see glowing blobs of blue, shiny pairs of dots reds and yellows, greens and aquas. I make notes on a score sheet. I am without a rod and reel, there is no lake or river nearby, but I am on my morning FISHing trip.

I’ve talked about prostate cancer and looking at biopsies a few times here, but we actually process more specimens related to bladder cancer. Sometimes we get small biopsy samples, taken by the urologist during a cystoscopy procedure, but more often it’s the Yellow River that provides the material for us to analyze.

Most people don’t realize that urine contains a myriad of cells that drift off the inner lining of the bladder into your pee. Our job in the lab is to look at those cells and determine if any of them are suggestive of cancer in the bladder. How do we do it? We have a couple of different methods.

Our simplest test is called cytology. Our great lab team first centrifuges and then processes the urine specimen until a thin layer of cells covers a glass slide. Those cells are then stained with the Papanicolaou stain, and yes that is the same one used in a traditional Pap smear. Several pairs of eyes look at the stained cells, and any significantly abnormal ones are noted and reported. We do about 50 of those cases a day.

But my early mornings are spent in the dark room FISHing. FISH, which stands for Fluorescent In-Situ Hybridization, is a technique in which a glass slide covered with cells is stained with probes that mark specific chromosomes in each cell. Each probe is formulated to light up a different color when examined in the dark under ultraviolet light. Our special microscope is equipped with a UV light and four different wavelength filters. We examine each cell, and by switching filters are able to count four different chromosomes. Two of a kind is normal, when a cell has an increased number of chromosomes, we start to worry.

Our system is automated. It is linked to a computer that can do the initial screening of the cells and then take digital photographs for the pathologists to examine. But I like to get into the FISH room in the morning, turn off the lights, and look at those cells myself. Peacefully floating down the FISH river is a great way to start the day!

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