Screening for pancreatic cancer has the potential to save lives, but is it practical?

INTRODUCTION: Most patients with pancreatic cancer present with advanced stage, incurable disease. However, patients with high-grade precancerous lesions and many patients with low-stage disease can be cured with surgery, suggesting that early detection has the potential to improve survival. While serum CA19.9 has been a long-standing biomarker used for pancreatic cancer disease monitoring, its low sensitivity and poor specificity have driven investigators to hunt for better diagnostic markers. AREAS COVERED: This review will cover recent advances in genetics, proteomics, imaging, and artificial intelligence, which offer opportunities for the early detection of curable pancreatic neoplasms. EXPERT OPINION: From exosomes, to circulating tumor DNA, to subtle changes on imaging, we know much more now about the biology and clinical manifestations of early pancreatic neoplasia than we did just five years ago. The overriding challenge, however, remains the development of a practical approach to screen for a relatively rare, but deadly, disease that is often treated with complex surgery. It is our hope that future advances will bring us closer to an effective and financially sound approach for the early detection of pancreatic cancer and its precursors.

Lessons in Public (Mis)communication about the Laboratory from the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has put the clinical laboratory in the spotlight. The news media is regularly seeking out interviews with microbiologists, infectious disease specialists, and pathologists. Increased public exposure offers opportunities to improve how laboratory professionals communicate our insights. We can emphasize what is new, unusual, or controversial about our knowledge; utilize social media effectively; and improve relationships with journalists by understanding their workflow and traditions. While public engagement has risks and must be considerate of institutional policies, it also validates our value to patients, policy makers, and employers.

Accepting randomness in medical school admissions: The case for a lottery.

McMaster University's medical school, faced with the need to socially distance during the COVID-19 pandemic, recently replaced their structured admission interview process with a partial lottery. At first, it may seem that leaving medical school admissions partly to chance could erode autonomy and meritocracy. Yet our current system for selecting medical students is strained by a limited predictive ability. In the search for good doctors, we lack meaningful, quantifiable, and comparable criteria. Partial or weighted admissions lotteries can offer us an escape. They have the potential to reduce mental and financial burdens on both applicants and medical schools, avoiding an overemphasis on marginal differences between applicants. Lotteries are also a simple way to address persistent admissions disparities by being truly non-discriminatory. At the very least, lotteries represent a useful benchmark against which we can rigorously compare current and future selection methods.

Strengthening the Medical Error "Meme Pool".

The exact number of patients in the USA who die from preventable medical errors each year is highly debated. Despite uncertainty in the underlying science, two very large estimates have spread rapidly through both the academic and popular media. We utilize Richard Dawkins' concept of the "meme" to explore why these imprecise estimates remain so compelling, and examine what potential harms can occur from their dissemination. We conclude by suggesting that instead of simply providing more precise estimates, physicians should encourage nuance in public medical error discussions, and strive to provide narrative context about the reality of the complex biological and social systems in which we practice medicine.

False-positive pathology: improving reproducibility with the next generation of pathologists.

The external validity of the scientific literature has recently come into question, popularly referred to as the "reproducibility crisis." It is now generally acknowledged that too many false positive or non-reproducible results are being published throughout the biomedical and social science literature due to misaligned incentives and poor methodology. Pathology is likely no exception to this problem, and may be especially prone to false positives due to common observational methodologies used in our research. Spurious findings in pathology contribute inefficiency to the scientific literature and detrimentally influence patient care. In particular, false positives in pathology affect patients through biomarker development, prognostic classification, and cancer overdiagnosis. We discuss possible sources of non-reproducible pathology studies and describe practical ways our field can improve research habits, especially among trainees.

In search of compassion: a new taxonomy of compassionate physician behaviours.

BACKGROUND: Compassion has been extolled as a virtue in the physician-patient relationship as a response to patient suffering. However, there are few studies that systematically document the behavioural features of physician compassion and the ways in which physicians communicate compassion to patients. OBJECTIVE: To develop a taxonomy of compassionate behaviours and statements expressed by the physician that can be discerned by an outside observer. DESIGN: Qualitative analysis of audio-recorded office visits between oncologists and patients with advanced cancer. SETTING AND PARTICIPANTS: Oncologists (n = 23) and their patients with advanced cancer (n = 49) were recruited in the greater Rochester, New York, area. The physicians and patients were surveyed and had office visits audio recorded. MAIN OUTCOME MEASURES: Audio recordings were listened to for qualitative assessment of communication skills. RESULTS: Our sensitizing framework was oriented around three elements of compassion: recognition of the patient's suffering, emotional resonance and movement towards addressing suffering. Statements of compassion included direct statements, paralinguistic expressions and performative comments. Compassion frequently unfolded over the course of a conversation rather than being a single discrete event. Additionally, non-verbal linguistic elements (e.g. silence) were frequently employed to communicate emotional resonance. DISCUSSION AND CONCLUSIONS: This study is the first to systematically catalogue instances of compassionate communication in physician-patient dialogues. Further refinement and validation of this preliminary taxonomy can guide future education and training interventions to facilitate compassion in physician-patient interactions.

"Speaking-for" and "speaking-as": pseudo-surrogacy in physician-patient-companion medical encounters about advanced cancer.

OBJECTIVE: To examine using audio-recorded encounters the extent and process of companion participation when discussing treatment choices and prognosis in the context of a life-limiting cancer diagnosis. METHODS: Qualitative analysis of transcribed outpatient visits between 17 oncologists, 49 patients with advanced cancer, and 34 companions. RESULTS: 46 qualifying companion statements were collected from a total of 28 conversations about treatment choices or prognosis. We identified a range of companion positions, from "pseudo-surrogacy" (companion speaking as if the patient were not able to speak for himself), "hearsay", "conflation of thoughts", "co-experiencing", "observation as an outsider", and "facilitation". Statements made by companions were infrequently directly validated by the patient. CONCLUSION: Companions often spoke on behalf of patients during discussions of prognosis and treatment choices, even when the patient was present and capable of speaking on his or her own behalf. PRACTICE IMPLICATIONS: The conversational role of companions as well as whether the physician checks with the patient can determine whether a companion facilitates or inhibits patient autonomy and involvement. Physicians can reduce ambiguity and encourage patient participation by being aware of when and how companions may speak on behalf of patients and by corroborating the companion's statement with the patient.