The Map of Reality is Not Reality: Guidelines and Melanoma

How often do you use GPS to get somewhere? I use it all the time. Whether it be going to the hospital, dropping off my son at daycare, and even going back home, I have GPS on. Using GPS is useful. If there is traffic on the route, GPS will reroute me to a better route. If I am lost, I can easily get home with a few touches on my phone.

Relying on a map can lead to a variety of problems. The map can be wrong, missing information, or can be interpreted incorrectly. Maps should be treated as a guide, not the rule.

Map is not the territory

In 1931, mathematician Alfred Korzybski popularized the idea that the map is not the territory. Basically, the description of something is not something itself. Abstraction is not reality.

Alfred Korzybski poses three downfalls to using maps.

  1. Maps can be incorrect without our realization.
  2. Maps are a reduction of reality by necessity, and this reduction can lose viable information.
  3. Maps require interpretation, which in turn can generate errors through misinterpretation.

A map is a representation of a territory. We use maps all the time. Whether it be physical maps or Google maps, maps are useful in getting from point A to point B. However, maps are not perfect representations of reality. Maps should be served as a guide, but if something in reality does not appear on the map, we should trust reality. With this mental model in mind, I successfully treated and continue to treat one of my longest living patients with active cancer.

Beyond the guidelines: Treating melanoma in a Jehovah’s Witness

An elderly male with past medical history of advanced melanoma presented as a follow-up in my clinic. He is a known patient of mine who was initially found to have melanoma of his right axilla (armpit) several years ago. At the time he had no sites of metastatic disease. The standard treatment for him would have been surgery followed by immunotherapy. However, his melanoma was almost 10cm in size which would have been a big surgery. Further, he was a Jehovah’s Witness. Jehovah’s Witnesses believe that Christians should not receive blood transfusions, even from themselves.

Since the surgery would have been extensive requiring blood transfusions, I presented the case to our multidisciplinary tumor board. We reviewed the guidelines and decided to treat with radiation first followed by immunotherapy. With radiation, he would not require blood transfusions. Immunotherapy was successfully given to patients with melanoma after surgery, but there is a paucity of data on radiation only. There are no guidelines to support this approach, however based on clinical experience and reasoning, this approach was the best option.

At the follow-up, he is doing well. He has been on immunotherapy ever since his radiation treatment with no sites of recurrence. In fact, the melanoma has been stable and decreasing in size. His quality of life returned back to baseline and is enjoying life.

Guidelines are like maps. Every patient is different so there is no one size fits all type of treatments. Religion is not a factor mentioned in the guidelines for treating melanoma, however it is a huge factor for patients in real life. If the guidelines contained nuances for every religion and personal belief out there, the guidelines would be too large for any clinical benefit.

Better decision making requires a firm grasp on reality

By remembering that the map is not the territory, we can make better decisions. Maps don’t strictly apply to geographic areas but to guidelines for life as well. By staying footed in reality, we will make better decisions. If reality and the map contain a discordance, follow reality. Remember who created the map as their perspective may not necessarily coincide with ours. And there is plenty in reality not seen in the map.

If I strictly followed guidelines for my patient, I would have likely recommended no treatment. He would have passed a long time ago. Instead, by following reality, he is alive today.

A Swollen Arm, Radical Mastectomy, And Becoming A Doctor: How To Overcome Failure

Holly, a 68-year-old woman, came in with a red, hot, and swollen left arm. On presentation, her left arm was at least twice the size of her right arm. She’s a thin lady, so the contrast was remarkable. She told me that the arm blew up 2 days ago. Her left arm felt extremely hot. She chronically gets arm swelling because she had a mastectomy of her left breast about 5 years ago. This type of swelling is a common side effect of the surgery. Lymphatic ducts in the arm cannot drain the fluid correctly, thus congesting and blowing up the arm like a water balloon. Ever since the surgery, Holly tells me that her arm keeps on swelling up, but never this big. Normally she goes through her physical therapy very religiously; she never misses a session. She’s frustrated that her arm is infected, but she states she’s not going to let this stop her.

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Crohn’s Disease, Poop In The Urine, And The Reclining Buddha: How To Sell Yourself To Yourself

The nurse comes into my office with a grim look on her face.  She tells me that my next patient threw up in the exam room. The nurse adds that the patient has severe abdominal pain. I save my note, get up from my desk, and briskly walk to see the patient. In the room, I see a light-skinned African-American 29-year-old female embracing her stomach and crouched over. Her name is Rae.

Rae’s afro was bobbing up and down due to the pain. She’s crying and wincing while clutching her stomach. I ask her what’s wrong. Rae tells me for the past month she’s noticed increasing amount of feces in the urine. I ask her how does she know it’s feces. She tells me that it’s brown and it smells.

I rush the history and physical. I tell the nurse to give her some pain medication and to straight catheterize her. When the nurse catheterized the patient, 100 millilitres of brown, fecal matter mixed with urine came out. I call the hospital and admit the patient. She had surgery the same day. The patient had an acute flare up of Crohn’s disease.

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A Flood and Fiesta For The Common Good: How Family Might Save U.S. Healthcare And You

Over the past three weeks I have been traveling throughout Asia including Vietnam and Philippines. I don’t speak any of the languages, but it didn’t take much to see the culture of community and family.

On one particular day in Biên Hòa, a suburban area one hour away from Saigon, a storm flooded the street. As I stood at the doorstep of the place I was staying at, I watched cars and motorcycles trudging across the high water. I looked at the stores around my area and saw people helping each other put their belongings away, move their scooters inside, and even push cars through the torrent. There was hardly any hesitation in any of their actions – a firsthand example of working for the common good.

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Flood one hour away from Saigon, Vietnam. 5/12/16

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Paralyzed Breathing and 2 Simple Steps To Be Happy Now

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Kari’s feet on a kayak in Halong Bay, Vietnam. Photo taken 5/16/16.

Several months ago, Gary came to my hospital complaining of weakness. Gary was 72 years old, so weakness was a pretty common complaint in his age population. While lying in bed, Gary told me that this morning he could not move his feet. Since then, the weakness has gotten progressively worse and traveled up both his legs. At presentation, Gary said that he could not even lift either of his arms or legs. I lifted up one of his legs, and let it go. The leg dropped like a dead weight. In addition, Gary said he recently got over a cold. Gary also told me he had a similar illness over ten years ago. He said at the time he was hospitalized for 3 weeks with over 10 days connected to a breathing machine. Essentially, what he had ten years ago was the same as what he had at presentation.

Gary had Guillain-Barré Syndrome.

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The Body Destroying Itself And Creating Your Own Luck

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In the emergency department, I saw a 52-year-old female that was here for a flare up of her systemic lupus erythematosis (SLE). Let’s call her “Lupe.” So Lupe has been in and out of the hospital for the past several years for different reasons. One time it was for severe back pain. Another time was low energy from anemia. The most recent time was for acute lupus nephritis (kidney failure) which required for her to start hemodialysis every other day (hemodialysis is a method of purifying the blood when the kidneys aren’t working properly).

Lupe was here this time for a lot of critical lab values found on her blood work – a poor sign for those with kidney failure.  SLE is a devastating disease, and it can affect almost everything in the body. If kidney failure is one of them, it’s usually a poor prognosis. I felt sorry for Lupe because she was so crippled from this menacing illness.

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Ventricular Tachycardia, Bomber Planes, And Checklists: How To Decrease Cognitive Load To Be More Productive

On my last day on the ICU rotation block, one of the patients went into an irregular heart rhythm called ventricular tachycardia. He was a 60-something year old guy with multiple medical problems and connected to a breathing machine. All of a sudden, he became unresponsive and hypotensive and had a heart rate of 150+ beats per minute. As we all rushed into the room, we systematically ran through the ACLS algorithm. We initially evaluated him, checked for pulses, started CPR, established the  airway, monitored blood pressure, identified the rhythm, and gave a dose of treatment. We repeated the process until the patient was stable. It was efficient, it was effective, and most importantly it was routine. It was a checklist that was used around the world and saved many lives.

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Goals Of Care, Family Meetings, And The 80/20 Rule

Surprisingly, in my past month in the intensive care unit (ICU), I spent more than half the time talking to family members about goals of care. In a previous post, my attending had a great quote about survival in the ICU. If one-third of your patients survive the ICU stay, you’re doing hall of fame work. So if only one-third of patients are surviving on a good day, then why am I spending most of my time speaking to families about goals of care? Shouldn’t I be spending more time treating the patients?

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“20% of our efforts leads to 80% of our results.”

 

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Look Down A Trachea And Succeed With A Growth Mindset

In the ICU, we had to perform a bronchoscopy on a patient to rule out excessive bleeding in the lung. It might have been my attending who was in a good mood or the fact that I was just sitting at the computer responding to WordPress comments, but whatever it was, he asked me to do the bronchoscopy. For those of you who don’t know, a bronchoscopy is a procedure where you take this thin tube with a camera at the end of it to visualize the inside of someone’s airways. The procedure looks like this. Gross, I know. I’m not much of a procedure person, but as I was standing there holding the scope in my hand and looking down this guy’s trachea, I came to a realization. Bronchoscopy is a type of endoscopy, and endoscopy means to look inside.

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Bronchoscopy (Courtesy of WebMD)

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