"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Second Hand Book Reviews: There have been some interesting books reviewed in the major medical journals lately. (Note: I haven't read any of them.) Radiant Cool is, according to its subtitle, "a novel theory of consciousness." The premise sounds interesting; a mystery novel that takes its heroine on a journey through consciousness theory. Although, it's difficult to tell from the review in JAMA whether or not it's intelligible to those of us who aren't familiar with the nuances of consciousness theory:
Lloyd serves up a mini-mystery about an obsessive group of academics, immersed in Husserlian phenomenology, poised to crack the code of consciousness. Graduate student Miranda, the cyber-heroine who must eventually contend with a motley crew of fellow travelers, is initially only eager to salvage her dissertation from the clutches of her brilliant but unstable mentor. ....During a succession of mini-strokes, Miranda finds herself on the intimate receiving end of several lessons in neurophenomenology, ranging from temporary right parietal neglect to slamming shut the thalamic gatekeepers to the global workspaces of consciousness....Once intellectual appetites have been well whetted, Lloyd serves up the richer main course - the nonfictional "labyrinth of consciousness": a wide-ranging survey of why mind science must abandon the ruling sensory-centric view of consciousness and confront the grander multi-dimensional mystery that lies at the heart of subjective experience.
Since everyone revels in illustrating neurophilosophical theories, by the time all the sleuthing pays off, the characters have lost definition and the narrative is tied up in knots. Bafflement continues into a stand-alone Part Two as Lloyd leaves his primary story behind for a more academic focus, expanding on a new theory of consciousness developed over the course of the novel.
But the reader reviews gave it anywhere from three to five stars, the highest rating being from a neuroscience student who said it helped him better understand the theories he was studying in class.
Which brings me to the other book review of interest in JAMA, Reel Psychiatry: Movie Portrayals of Psychiatric Conditions, a psychiatric textbook which uses cinematic examples as case histories. (And which Psychscape has already noted, along with a comprehensive bibliography of movies and mental illness.) Using fiction to illustrate psychopathology has a long tradition in medical education. I remember one of my professors in medical school showing film clips of his favorite personality disorders - Elizabeth Taylor in Who's Afraid of Virginia Woolf? (borderline), Lee Remick in Days of Wine and Roses (dependent), and, of course, The Three Faces of Eve, the most famous of all dissociatives.
Numerous historians have written about this momentous revolution in medical practice. Inoculation laid the groundwork for vaccination, immunology, and medical statistics. Carrell's book, The Speckled Monster, adds a new twist to the topic; it is a fictional account based on extensive historical research (the subtitle of the book is "a historical tale"). Her narrative begins slowly but quickly picks up the pace as it interweaves events on both sides of the Atlantic and suggests their mutual influence. It is unapologetically heroic: Lady Mary and Boylston triumphed despite the substantial odds and obstacles against them. Lady Mary took on the formidable London medical establishment, whereas Boylston contended with providential clerics and foreign-trained physicians (particularly the cantankerous Scot, William Douglass). Both were threatened with mob violence. In sweeping and dramatic strokes, Carrell paints the ostracism Boylston endured as he made his rounds through colonial Boston; in England, Lady Mary suffered public criticism for daring to put her children deliberately in harm's way.
Sounds like an eighteenth-century version of Quincy, M.E..
Figures: Jon Robison takes a look at the recommended weight figures and finds them wanting:
In reality, the answer to the question, 'How much should you weigh?' is that it's largely an illegitimate question. The notion that you should weigh a specific amount as determined by any standardized chart or table is an oversimplification since it ignores too many variables and distracts from the larger question which is, 'How do I become healthy and maintain health? posted by Sydney on
3/18/2004 09:06:00 AM
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Too Much By Far: The news that Thomas Scully threatened the Medicare actuary with dismissal if he revealed the true cost estimates of Medicare drug benefits to Congress is disheartening, but in keeping with Mr. Scully's character. (He once refused to testify before Congress, even when they gave him a subpoena.) However, no matter how you look at it, that benefit program is too costly:
Dated June 11, 2003, the document put the cost at $551.5 billion over 10 years. It appeared to confirm what Ms. Bjorklund and her bosses on the House Ways and Means Committee had long suspected: the actuary, Richard S. Foster, had concluded the legislation would be far more expensive than Congress's $400 billion estimate — and had kept quiet while lawmakers voted on the bill and President Bush signed it into law.
Whether it's $400 billion or $500 billion, it's still hundreds of billions too much. And while those Democratic senators are waxing indignant over the price tag, let's remember that their biggest complaint at the time was that the bill didn't do enough for seniors, not that it cost too much.
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3/18/2004 08:50:00 AM
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Real Hearts:Jerome Groopman has an interesting essay on religion and medicine in this week's New England Journal of Medicine (requires subscription). He uses as a starting point for the discussion, his discomfort when a patient asks him to pray for him:
None of the training I received in medical school, residency, fellowship, or practice had taught me how to reply to Anna. And although I am religious, I consider my beliefs and prayers a private matter. Should I sidestep Anna's request, in effect distancing myself from her at a moment of great need? Or should I cross the boundary from the purely professional to the personal and join her in prayer?
His essay is an examination of the inadequacies of medical education in dealing with the spectrum of religious beliefs and how they affect our patients. But, in moments like this, it isn't so much a theological validation that patients want. It's simply a human connection. The appropriate response is to reach out, touch her hand or arm, and say, "Yes, I will pray for you." Even if the doctor's an atheist. posted by Sydney on
3/18/2004 08:32:00 AM
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Replacement Hearts: The artificial heart inched a step closer to FDA approval yesterday. An advisory panel voted overwhelmingly to recommend a descendant of the Jarvik artificial heart as a bridge for those waiting for transplants of real hearts:
A type of artificial heart - a temporary device to keep certain near-death patients alive long enough to receive a heart transplant - moved a step closer to the U.S. market yesterday. A panel of scientific advisers to the Food and Drug Administration voted 10-1 to recommend FDA approval.
There are serious questions about who should get the CardioWest Total Artificial Heart. Though it requires cutting out the bottom half of the heart to implant, advisers concluded it could benefit a small number of patients. "These people are dying who don't have any good alternative," said Dr. Judah Weinberger of Columbia University. The FDA isn't bound by the panel's advice, but usually follows it.
Insuring the Uninsured: A recent poll found that most employers favor employment-linked health insurance. Well, what it really found is that most employers would like to be able to provide health insurance for their employees. It's easier to attract and keep good employees if you offer health insurance. But, the truth is, it's very hard for small businesses to offer health insurance.
I have two employees. I'm in danger of losing one because she needs health insurance. There are very affordable individual plans in our area, but the insured has to sign a waiver that says their employer is not compensating them in any way for the premium. The plans that are available for small businesses in our area cost anywhere from two to four times as much as the individual, independent plan. There should be an easier way for small businesses to provide insurance (without having to pay a hefty membership fee to a coalition of small businesses) posted by Sydney on
3/17/2004 08:32:00 AM
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An adhesive patch that uses a tiny electric current to deliver pain medication through the skin does the job about as well as conventional intravenous devices, researchers said on Tuesday.
The patch resembles a credit card and is affixed to the patient's upper arm or chest after surgery. Both the patch and some intravenous delivery systems allow the patient to self-medicate by pressing a button, according to a company-funded study.
....'(The patch) is able to deliver a potent pain reliever through the skin with a very, very tiny electric current at the demand of the patient,' said study author Gene Viscusi of Thomas Jefferson University Hospital in Philadelphia. 'This is a miracle of miniaturization.'
It also allows the patient more freedom of movement than the traditional intravenous method does, which is a big plus when people are recovering from surgery. The sooner you can get up and moving, the quicker your recovery. posted by Sydney on
3/17/2004 08:12:00 AM
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Eye of the Beholder: Researchers say that parents can't recognize obesity in their own offspring:
'A third of the mothers and 57 percent of dads actually saw their obese child as normal,' said Alison Jeffery, a member of the research team at the medical school.
'Quite a few parents are not recognising it as a problem. They are not recognising the health risks either,' she added in an interview.
The article doesn't say how obese the kids in the study were. But, categorizing someone as obese or overweight just based on their appearance is often tricky. I once had a partner who labelled every woman over 135 pounds "obese" regardless of what her BMI actually turned out to be (he never took the time to figure it.) He would write it right there in the record, "mildly obese, moderately obese, obese, morbidly obese," depending on his impression. He wasn't nearly as loose and free with the obesity label for men, though. They usually had to weigh over 250 pounds before he called them obese. posted by Sydney on
3/17/2004 08:07:00 AM
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Lucrative Drugs: The counterfeit drug business is booming:
The FDA currently has 22 counterfeit drug investigations under way, according to McClellan. That has increased fourfold from the late 1990s, when the agency averaged only five such investigations a year. It is scheduled to address drug wholesalers, manufacturers and other industry officials Wednesday in an effort to raise awareness of counterfeit drugs.
Watch out for those internet and mail-order drug deals. Although, apparently retail pharmacies have fallen victim to unscrupulous wholesalers, too. posted by Sydney on
3/17/2004 07:54:00 AM
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Tuesday, March 16, 2004
From Small Things: A world-wide public health initiative that had its roots in a study funded by a Canadian mining company that operates in Papua New Guinea, and that relies on drugs donated by (gasp!) a pharmaceutical company, had made tremendous strides against tropical disease:
During the past four years, 80 million people have been successfully treated for elephantiasis, one of the world's most disfiguring diseases.
How disfiguring is elephantiasis? This disfiguring. And, as the article points out, before it wreaks its cosmetic havoc, it leaves people weak and lethargic. In Papua New Guinea, they noticed academic improvement and better growth in children after treatment. There's so much that could be done to improve the world's health, if we weren't distracted by more glamorous diseases.
All Eggs in One Basket: Yesterday's New York Times ran a front page article on "good cholesterol" vs. "bad cholesterol" that included this vignette:
Many are like 60-year-old Thomas E. Siko of Chagrin Falls, Ohio, who thought he had nothing to worry about. Heart disease runs in his family on both sides, but no doctor had ever suggested cholesterol-lowering medication. His H.D.L. level was high, at 72, and his L.D.L. only mildly elevated, at 121. (National guidelines say that an L.D.L. level of less than 100 is optimal; 100 to 129 is near or above optimal, depending on other factors; and above 130 is high.)
But last year, after being tested for what he thought was indigestion, Mr. Siko ended up having bypass surgery. Now, with a cholesterol-lowering statin, his L.D.L. level is down to 72 while his H.D.L. is 70. He feels fine. 'I run four miles a day,' Mr. Siko said.
Reading that case history, and the rest of the article, one can easily come away with the impression that high cholesterol is the only risk factor for heart disease. It isn't. The number one cause of coronary artery disease is aging. And at age 60, Mr. Siko was no spring chicken. Chances are, even if his cholesterol levels were as low as they are now, he still would have developed coronary artery disease. Maybe it would have happened a few years later than sooner, but it would have happened. Now, he has a new set of clean coronary arteries (fashioned from veins, which aren't subject to the same ravages of a lifetime of blood pumping through them.) What other risk factors, such as smoking, elevated cholesterol, and high blood pressure, do is hasten the rate of damage of coronary arteries, and thus increase the risk. To suggest that taking large amounts of cholesterol lowering drugs will eliminate coronary artery disease either in an individual or a general population is just wrong. There are more things in heaven and earth, Horatio.... posted by Sydney on
3/16/2004 08:24:00 AM
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Cats and Dogs: Lawyers and physicians in northeast Ohio are collaborating on a cure for the malpractice insurance crisis:
The Institute for Community-Based Medicine and Law is a collaboration between the University of Akron School of Law and the Northeast Ohio Universities College of Medicine, or NEOUCOM. Its goal is to create a forum for ``critical thought and debate'' among doctors and lawyers, said Maria Schimer, NEOUCOM's general counsel.
``There's the legal camp... and there's the medical camp,'' she said. ``And we don't really talk to each other, so we end up blaming each other for a lot of things. We need to be willing to put aside our own beliefs and say, `OK, let's look at this. Let's see what we can do.' ''
The discussion and debate will be driven by the group's own research and analysis, Schimer said. First up: a thorough review of court records to study each medical malpractice case that has made it to trial in 17 counties, including most Northeast Ohio counties, plus Franklin and Hamilton.
Our Strange Poverty: Victor Davis Hanson spent some time recently in the waiting room of his local hospital's emergency room, and noticed something. If the nation's emergency rooms are the last refuge of the poor, the people who were waiting in his town's ER didn't seem poor by most of the world's standards. (No permalink, may be gone by the time you click the link) :
Cell-phones and new pick-ups—whether they are products of cheap Chinese labor or easy American credit—are nevertheless optional expenditures. One really does make a decision of sorts to buy on credit a 30,000 twin-cab Ford pick-up, or pay $100 a month for a cell-phone family-plan than purchase cheap HMO health insurance. Perhaps there was a general sense then among those waiting for the doctor that while the government does not provide new cars or cell phones it really does, after all, extend free health care. In any case, if the emergency room in one of the poorest towns in this nation is a litmus test of horrific poverty and neglect, then it is a strange sort of poverty that about 5 billion on the planet outside our borders could only envy.
UPDATE: A reader notes that someone often ends up paying for that "free" care, even if it's not the patients:
I think we need to be honest about the fact that there are a lot of people in the United States who claim medical indigency but who clearly have the means to pay something for their care yet evidently do not, and perhaps with the blessing of our governments and hospitals. Not having insurance is unfortunately sometimes passing as the equivalent of not having any obligation to pay.
The implication of the writer is that there are plenty of people in California who think themselves entitled to enter the U.S., legally or illegally, make money, buy what they want with their earnings, but when they need any kind of medical care, even routine care, expect the taxpaying public to foot their bill. I don't know how pervasive this is in California, but I do know it exists in similar ways elsewhere. I know also that in other places--Denver, for instance--hospitals have confronted this kind of behavior more aggressively, demanding deposit payments from patients who use the E.R. for non-life or limb threatening emergencies.
What the writer didn't mention is just how much care is provided by way of the E.R. and not paid for by the hospital, the government or by the patient. Hill-Burton and its succeeding legislation may pay for the hospital to keep its E.R. staffed and open, and for the E.R. doctors to be working, but when the E.R. turns to ask for consultation--from non-E.R. doctors, the support often ends. The orthopedist coming in to evaluate that broken arm, or the neurosurgeon called in to treat that threatening aneurysm often get stiffed, many times even when the patient has insurance. Few E.R.s get by without having to call in consultants for anything that is complicated or that requires surgery, and that care, which also carries liability risk and personal cost to the doctor providing it, is not covered by federal funding. In some places, unpaid consulting has reached abusive levels, sufficient to drive doctors to resign from hospital staffs.
Many communities have created outsized expectations by letting patients use E.R.s for non-emergencies and allowing politicians to create and define a notion of "rights" to medical care as if these were somehow the same as "rights" to assemble or to enjoy free speech. Letting this kind of behavior pass is really shameful, and it deserves to be called for what it is: poor stewardship of the public treasure under the color of "charity".
