Monday, 3 November 2008

In which I'm left flabbergasted

I’m on the ward seeing patients before the morning’s general surgical list and the next patient is Mr Barnes, a 52-year-old man who’s come in to have his hernia repaired.

“…Mr Barnes, aside from the problem with the hernia, do you have any other medical problems?”

“Yes, I’ve had lung cancer.”

“Lung cancer?”

“That’s right doc.”

“Is it still a problem for you?”

“No doc, I’ve had it treated and they tell me it’s gone away.”

“Right… What treatment have you had?”

“I had radiotherapy and chemotherapy for a few months last year.”

“And do you still see the cancer doctors”

“Yes, I saw him about three months ago, but he said that it’s in remission and there’s no need to do anything else about it.”

A bit later on

“Do you smoke sir?”


“How much?”

“When I try to cut down, about ten a day, but I’m smoking about twenty a day at the moment.”


I really, really don’t understand some people. I’ve tried to get my head around it but I really can’t fathom where Mr Barnes is coming from.

I know that some people find giving up smoking really hard, but this is totally ridiculous. I could have understood Mr Barnes’ smoking more if he had terminal cancer and he’d said something like “I’m going to die anyway, so there’s no point in stopping now – it’s too late for that.” But he doesn’t have terminal cancer. His cancer is in remission.

Chemotherapy and radiotherapy is horrible ordeal to have to go through. It’s months of feeling awful, feeling weak, feeling sick, not to mention the emotional strain it puts on you and the people around. Why on earth would anybody put themselves through all that and then continue to smoke afterwards?!? So he can go through it all again in a couple of years’ time with his brand new cancer?

Mr Barnes is one of the lucky ones. He’s one of the few that actually get batter from their cancer and didn’t die along the way. He’s one of the people that we in the medical profession talk about when we say “To see Mr Barnes walk out of hospital for the last time after all those months of heartache, knowing that he’s actually got better, makes it all worthwhile you know. For all those that don’t make it, it makes it means so much to see somebody come through it.”

But Mr Barnes continues to smoke. He continues to spend his money on those little white sticks that gave him the cancer in the first place. In the not-too-distant-future, he’ll return to hospital either with a recurrence of his old cancer or with a new cancer and we’ll have to try and make him better again. What on earth is the point?

Sometimes I don’t know why we bother. This strikes particular chords at a time when there’s so much debate about top-up payments for cancer treatments because the NHS can’t afford to pay for everybody. If patients like Clive Stone really want to know why the NHS can’t afford to pay for their treatment, they should just pop in and have a word with people like Mr Barnes.

That’s where all the money’s gone.


H J said...

there is of course the argument that by the time people who smoke that much develop cancer the extra high tax on their cigarettes has almost paid for the treatment. but i think that's a pretty shit excuse. shouldn't there be some kind of law that says if you're taking a proven long-term detrimental substance and refuse to give it up after treatment has worked, further treatment can / will be denied to you?

similarly unfairly, why can you be prosecuted for wasting police time, but falsifying the reason for needing an ambulance (just because you know it will put you in a higher alert category) is not legally an issue?

some things are seriously fucked up. on a happier note for you, today a country decides the fate of the free world for the next 4 years ;)

Jo said...

This cuts very near to the bone for me - my grandmother died of a stroke (not directly smoking related as she was a Fabre's carrier as well, but the smoking exacerbated it), and my grandfather died of lung cancer which spread to his brain. Even after these object lessons, my aunt still smokes. :-(

I don't understand how anyone, knowing the well publicised dangers and the risks, can start smoking, nor why they then expect NHS treatment for their self-inflicted injuries.

Lily said...

It's really not up to doctors to judge whether or not people "deserve" treatment. Don't most people do something which actively damages their health? Drinking and smoking come to the front of most people's minds but what about people who have poor diets or wear their joints out exercising? Should all of these people be charged extra?

Although to non-smokers like myself it is unfathomable that someone could smoke, let alone after they've been diagnosed and treated for lung cancer but it is important to see things from the patient's point of view. He is of an age that when he was young smoking was acceptable. Teachers smoked while teaching, doctors smoked on the wards. Adverts even suggested smoking was good because it "cleaned the air". It can be hard to change these intrinsic views. He also may feel that as he was cured he'll be okay in the future. Not really true, but does he know that?

It really upsets me to see doctors openly judging patients. I just hope that this prejudice many doctors and medical students have doesn't become reflected in patient care. I hate to think that my mother might have died because she smoked so her doctors didn't see her as worthy as some other patients.

Dr Michael Anderson said...

You all make very good points and I’m grateful for your opinions. Mr Barnes got his operation, I anaesthetised him as well as I could and he had minimal post-op discomfort and he went home the next day. The point of my post was not that we should withhold treatment from smokers, but that I really don’t understand the mentality of someone who continues to smoke in his circumstances.

H J – you make a well worn point about smokers paying for their healthcare through tax. I delved a bit deeper into this and it turns out that this “commonly known fact” is actually a myth. I’m working all this out in today’s prices but follow me with this. If he smoked 20 fags a day since he was 15, he would have paid just over £54 000 in tax on his fags (£4.12 x 356days x 37 years). The data I found on lung cancer is from 1996 and it shows that for those who survive the first year of lung cancer like Mr Barnes, the average cost of treatment $107 167. Adjust for inflation and convert it to pounds and you get just shy of £85 000, much more than he’s ever paid. When I was working in respiratory medicine, one of my consultants told me that lung cancer is a relatively cheap disease to treat because people die quite quickly. Other smoking related diseases such as emphysema and strokes cost the NHS greatly more than cancer and is probably well into six figures, possibly up to £1million per person. There’s no way the tax they’ve paid on cigs is that much.

Jo - My uncle died of lung cancer because of his smoking just after the turn of the millennium – he was 66 and had just retired. I think the problem is that people just don’t see the effects of smoking until it’s too late. Because of this they don’t really believe the warning are true and think that it’s “just the government/busybodies telling me what to do.” I’ve seen it again and again and it saddens me every time.

Lily – I see your point and I agree that ideally, every single person should get the highest quality healthcare whenever they want it. You can appreciate that, unfortunately this is unrealistic. Top-up payment, postcode lotteries, waiting lists, transplant waits are all indicative that healthcare is limited, always has been and always will be. I’m not for one moment saying that smokers should be denied NHS treatment, merely that they should have some sort of concept of and show some sort of repentance for the people that their actions denies treatment to. You say that it’s not up to doctors to judge, so I’ll ask you, who should? Hospital managers? Politicians? People who have never spoken in depth to a real patient about their want and needs? Who do you think should decide? I’m not getting at you, I’m genuinely interested to know.
I agree with you that there are a myriad other self-inflicted medical conditions, but I do think that smokers are unique just because of the sheer amount of information out there about the harm it does. It’s on every single cigarette packet in the western world and has been for decades.
It’s not as if I’ve not tried to see things from a patient’s point of view. For the vast majority of smoking patients I meet, I really don’t think too much about it aside from how it’s going to make the anaesthetic more difficult and how I’m going to cope with that, but I really do think that Mr Barnes’ story is exceptionally, jaw-droppingly, unfathomable. I’ll turn it around and say that smokers should put themselves in the shoes of others. Put themselves in the shoes of Mr Stone who can’t have the treatment he needs because the NHS can’t afford it. Put themselves in the shoes of the NHS staff who have looked after him through his illness so far and will look after him again when he returns with his recurrence. Put themselves in the shoes of their families who will have to watch them die unnecessarily because of smoking.
You say that smoking was acceptable in his day but Mr Barnes is 52, not 92. People have known about the detrimental effects of smoking since the 1960s. Written, explicit warnings have been on every cigarette packet in this country since 1971, which is roughly when he would have started smoking. To say he didn’t know the dangers cuts no ice. He knew when he started smoking, and he’s been reminded every single day of his life since. He’s taken no heed of all of this for nearly 40 years, and to me, that suggests a hell of a lot of wilful ignorance.

- Michael

Lily said...

Although smoking warnings have been in place since the 70s, in the 70s doctors were also still smoking during their clinics. When one of my consultants graduated 35 years ago he remembers starting smoking himself because it was seen as unpolite and standoffish not to in outpatients. It's only really in the last 20 years that anti-smoking campaigns have really taken off.

I totally agree that there isn't enough money to go around to give everyone care and essentially doing something to damage your own health is a little selfish. My point is more that it's not just smoking. Another example I thought of today was sexually transmitted diseases. As young people we're warned again and again and again, and yet people still have unprotected sex. How much does a lifetime of treatment for hiv cost? Infertility treatment for chlamydia associated PID?

Judging and deciding about care should be two different things. Unfortunately somehow doctors do have to choose where the money goes, but this really isn't right. In an ideal world everyone should recieve the best care and maybe the government needs to focus more on how this can be done. Or maybe I'm just an idealist?

I think you've hit the nail on the head when you say a lot of people don't truely believe the effects of smoking until it's too late. It's hard to see how this can ever be tackled.

H J said...

i knew your post reminded me of something.

not actually a mail reader but i do remember having this pointed out to me a while back. linguistically im disappointed they used swop instead of swap. culturally im disappointed (and yet not surprised) that people are even able to do this; it's a shame we can't take the liver back out of her.

if people arent giving something up it's either because they dont want to change, or, as in the case of this young girl, they are too monumentally ignorant, uncaring, and just plain thick to change.

re lily - how can we treat everyone? we don't live in a utopia. and also, if we COULD treat everyone just like that no holds barred, what would be the point in trying to stop them doing stuff, they'd just say "oh well we'll get treatment, what's the harm?" and medics' jobs would become even more full of needless patients, many of whom would not really be deserving of treatment. im not so sure on-tap treatment for *everyone* is as ideal as you think.

if it were up to me (and i speak with hindsight of course!) the young lady in the example above would not have received her new liver. if you knew she was likely to do something like that, would YOU have given it to her?

Anonymous said...

Adenocarcinoma accounts for 29.4% of lung cancers. It usually originates in peripheral lung tissue. Most cases of adenocarcinoma are associated with smoking. However, among people who have never smoked ("never-smokers"), adenocarcinoma is the most common form of lung cancer. A subtype of adencarcinoma, the bronchioloalveolar carcinoma, is more common in female never-smokers, and may have different responses to treatment.

Anonymous said...

This sort of story really annoys me. I think it's selfish, disrespectful and to be honest, makes a mockery of the health system.

Personally, im in favour of smoking being totally banned. It wouldnt bother me in the slightest, and i know people say "well, should they ban drinking as well?" and actually, if they proved that drinking in moderation had a long term detrimental effect on the body that would later require treatment, or would prematurely kill you, then yes. i do believe they should ban it. i would certainly stop drinking. the fact is though that even scientists say that wine can actually be *healthy*. Guinness has a high iron content. what does smoking give you other than cancer and bad breath?

If all tobacco related taxes were directed to the NHS directly i wouldn't have so much of a problem with it. as it stands, i quite enjoy 'accidentally' knocking the cigarettes out of peoples hands as i bustle past them on the busy London streets.

Dr Michael Anderson said...

Lily, I agree with much of what you say but I do disagree with you when you say that "it's not just smoking." From what I've seen, smoking is quite unique in that smokers still persist with it even in the face of years and years of warnings and in the face of obvious and serious harm to themselves.

To pick up on your examples, if a person person gets HIV/chlamydia/other STI, has treatment but then CONTINUES TO HAVE UNPROTECTED SEX FOR 40 YEARS despite numerous visits to hospital and numerous treatment courses, then I'd certainly view them in the same way as Mr Barnes

If someone continues to drink despite numerous visits to hospital, like the girl that HJ pointed out, then I would still view them in the same way as Mr Barnes.

Of course, if any of these people came to me in need of my help, I'd still do the best I could for them, but somewhere along the line, they should really think about the consequences of their actions. Not just for themselves but for the people around them and for the people like Clive Stone who can't get healthcare because we are spending money on self-inflicted conditions.

jamie said...

I absolutely think that the decision should be left with hospital managers. They, after all, have the fullest picture around resource deployment, case-load and what needs to be done to secure the health of the nation. Junior doctors often bemoan the intervention but by the time they become consultants invariably appreciate it. Per the arguments around cigarette consumption, the author's response should take in to account that not everybody that smokes will eventually end up with pulmonary cancer and that this should be factored in to his calculations. Whilst I don't at all condone smoking, I feel really 'flabbergasted' myself that junior doctors really feel, at such an early stage in their careers, that they understand the complex mechanics of the NHS.

Dr Michael Anderson said...

Jamie, thank your for your input. I am not a consultant and I do not know if the consultants I work with “invariably appreciate the input of hospital management,” so I’m not going to comment on that particularly statement.

Regarding the rest of your comment, I know that not every smoker ends up with lung cancer. This is the argument that smokers and the tobacco industry have used to justify their behaviour for years. Smoking increases your risk of lung cancer up to 13 times, depending on how much you smoke. I also know that it’s not just lung cancer. It’s also ischaemic heart disease, it’s also peripheral vascular disease, it’s also strokes, it’s also emphysema, it’s also COPD, it’s also other cancers such as head & neck cancer, breast and bowel cancer. This is far from an exhaustive list, the number of ways in which smoking makes you unwell is immense. If you take a snapshot of hospital inpatients at any given time, the proportion of people in hospital directly or indirectly due to a smoking-related illness is huge (somewhere between 30 and 50%).

Aside from this, I think that saying “not all smokers get lung cancer” misses the point which was that Mr Barnes’ smoking DID give him lung cancer. He then went through chemo and radiotherapy, got “cured” but still keeps on smoking. It is this that (still) leaves me flabbergasted.

Steve Jones said...

It's a bit late to make a comment on this, but it yet again conflates two different things. Firstly, the case for people to stop smoking, and the second that to do so will save the NHS (and state) money.

This first is a valid social goal. However, the argument that smoking is a net cost to the NHS (indeed to the state) is a much, much more debatable point. The fact is that we are all going to die of something. Some of us will do so without a huge cost to the state depending on the nature of what finally carries us off. However, many of us will live to old age with an increasing number of degenerative diseases of age. Some can be put off with healthy living and care, but something, or very often a combination of diseases, is going to get you one way or another. Some of these are going to be very expensive to treat and continue for many years. It is a fact that expenditure on health and other social services increases with age (on average).

That's quite apart from the tax receipts of the various "sin" taxes.

Now I'm not going to pretend that I have all the numbers to hand on this, but I'd be very interested to see a properly costed average lifetime health expenditure on smokers and non-smokers alike. Just to see if this often run line about smokers costing the NHS and the state more has any basis in fact or if it is just a spurious statistic.

If giving up smoking is a social good, then it should be encouraged in its own right. Rolling out numbers on the saving to the NHS which are based on narrow measures without working out the other costs is not the way to do it.

I should add I am a lifetime non-smoker (and a tax payer). My real suspicion is that the proponents of non-smoking are unwilling to look at the real economics in case it undermines their moral case which should surely stand on its own merits.

Dr Michael Anderson said...

Steve Jones,
Thank you for your comments, you've obviously given this some thought and make good points.

You are right that we all die of something, but my point is that a huge proportion of the NHS workload is due to smoking related illnesses, which are totally self-inflicted. You only have wander around a hospital for a couple of hours to see this or speak to GPs and district nurses about the patients that they frequently see and care for

People have the impression that smokers die quickly. Sometimes they do, but often they don't. They die slowly over many, many years requiring increasing amounts of healthcare as they go - often (as in Mr Barnes' case) they continue to smoke as this is happenning.

You'd think that if your lungs have been destroyed by cigarettes to the extent that you can no longer walk to your own toilet, you'd give up the fags but I've met countless people in this exact situation who continue to smoke.

Like you, I don't have the figures, and I too would love to see a properly costed analysis of lifetime healthcare expediture of smokers vs non-smokers. Unlike you, i suspect that smokers drain vastly more resources than their nonsmoking counterparts.

The numbers would indeed be very intersting indeed.

Anonymous said...

"I don't understand how anyone, knowing the well publicised dangers and the risks, can start smoking" - come out into the real world! Have you any concept of how things are in some places?

Dr Michael Anderson said...

Anon - of course I know how things are in some places, do you not think that people should take responsibility for their own behaviour? Or do you insist the NHS should take responsibility for their behaviour?