"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
Getting Started: The hardest part of doing anything is getting started. That's probably why most of us never get around to starting our own business until life kicks us in the butt. Freedom's just another word for nothing left to lose, after all. For those who are thinking of striking out on their own, but can't quite get the motivation, there's Guy Kawasaki's The Art Of The Start: The Time-Tested, Battle-Hardened Guide For Anyone Starting Anything. Kawasaki, a former Macintosh evangelist (that's market-speak for salesperson, I think) is no stranger to the techno-geeks among us. Now, he's a venture capitalist, author, and motivational speaker. And evidently, someone who is very adept at landing on his feet.
Although the book is written in the typical motivational, "how-to" style of short, punchy chapters, and peppered with vague motivational platitudes, it also has it's share of practical, useful information - whether your dream is to start a tech firm or a medical practice or a cleaning service. (You can "test drive" it here.) Chapters on refining a sales pitch (keep it short and to the point), writing a business plan (ditto), giving a presentation (down to the ideal number of slides and text size) how to talk to potential investors, creating a partnership (very good advice on when to bring in the lawyers), and how to "boot-strap" (live on nearly nothing until the money starts coming in) cover all the essential bases of any start-up.
I was skeptical at first, but the more I read the book, the more I wished I had it when I started my medical practice. (Instead, I had The Complete Idiot's Guide to Starting Your Own Business and a manual from the American Academy of Family Practice.) And, although those two sources had a lot of the nuts and bolts information I needed, such as how to get a tax ID, and how to decide between an S Corporation or an LLC, they lacked the motivational inspiration and people-skill advice that Kawasaki's has. I never had to worry about explaining to the bank exactly what it is my business does since everyone knows what a doctor's job description is, nor did I have to worry about marketing myself since I already had an established patient base. But I certainly could have used the tips for interviewing potential employees and for interpreting today's vague words of recommendation from former employers. And the chapter on solidfying the details of a partnership, is alone worth the price of the book. (She said as she recalled the ruins of a failed partnership.)
But perhaps the best part of the book is the reminder that even though you may have never had any prior experience running a business, the world is full of corporate masters who had similarly barren backgrounds. Think Oprah Winfrey.
UPDATE: Alwin at Code The Web Socket clarifies the term "corporate evangelist" for me:
A corporate evangelist is not a salesman in the classic sense. The job Guy had was simple in description, difficult in execution: he had to convince companies writing software for the Apple II and IBM PC to port it or write new software for the Macintosh.
The new Mac had a lot of expanded abilities that the other two platforms didn't, but getting companies to learn and exploit those new resources - to invest time and effort in training employees to do it - was a task of Herculean proportions.
My own opinion is that Apple's success - and survival - was due in no small part to Guy's abilities to bring Apple's corporate vision to the rest of America. posted by Sydney on
12/11/2004 11:11:00 PM
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Go in Peace, and Leave the Rest of Us Alone: Here's an ethicist who makes no bones about the real reason for euthanasia:
Better for old to kill themselves than be a burden, says Warnock
BRITAIN'S leading medical ethics expert has suggested that the frail and elderly should consider suicide to stop them becoming a financial burden on their families and society.
Ukrainian Medical Mystery Update: Viktor Yushchenko has returned to Austria for further testing and says he'll release the findings within the next several days.
UPDATE to the Update: It's confirmed, dioxin is the culprit:
Dioxin poisoning caused the mysterious illness of Ukrainian presidential candidate Viktor Yushchenko, a doctor said Saturday, adding that the poison could have been put in his soup.
"There is no doubt about the fact that Mr. Yushchenko's disease has been caused by a case of poisoning by dioxin," said Dr. Michael Zimpfer, director of Vienna's private Rudolfinerhaus clinic.
Zimpfer said Yushchenko's blood and tissue registered concentrations of dioxin - one of the most toxic chemicals - that were 1,000 times above normal levels.
"It would be quite easy to administer this amount in a soup," Zimpfer said, adding that tests showed the dioxin was taken orally. "There is suspicion of third party involvement."
Christmas Shopping: I spent the morning Christmas shopping with my two youngest children. One of the toys we came across was this spare brain. It's amazingly realistic - soft and sticky to the touch and covered with a clear membrane that contains a reddish liquid that sloshes around the brain itself - just like a real brain. We didn't buy one, though. The kids were spending their own money on gifts and they're both too miserly to indulge in gag gifts.
On a more serious note, the local Hallmark shop has a corner devoted to breast cancer products. (That is one disease that has really taken off commercially.) There were breast cancer ribbon cookie cutters (although you could make that into a ribbon for any cause by changing the color of the cookie icing), breast cancer ribbon jewelry of all sorts, inspirational books, and even a children's book. Its inside was better than its cover suggested. Although, I'd probably have some hesitation giving the book to a child whose parent has breast cancer without discussing it first with their parents. You never know how a family has decided to deal with the big "C." Even little kids know enough about cancer to be scared by the word. (When my husband was a little boy, the doctor told his mom he had a canker sore. My husband was just learning to read, and "canker" was the way he pronounced the written word "cancer." Every sentence he had ever read with that word in it was a sentence full of doom. He claims he was terrified for days before his parents set him straight.)
For parents with cancer, the book When a Parent Has Cancer : A Guide to Caring for Your Children, comes highly recommended. I bought it as a gift once, and had the opportunity to look through it before sending it off. It's very well written, and its author speaks from experience. She's a doctor, a cancer patient, and a parent. But again, the etiquette of sending books like this is tricky. My gift went unacknowledged, and I'll now never know how (or if) it was received. But I've always had the uncomfortable feeling I must have committed a faux pas in sending it.
By screening tumor samples for 21 genes implicated in the disease, the test provides doctors with a much more detailed picture of the nature of breast cancer in each patient. It is a step toward the goal of "individualized cancer care.''
Results described in several studies at the conference show that the test does a good job at identifying women who are least likely to have a recurrence. These women might want to forgo chemotherapy, which has multiple side effects and can cost more than $15,000.
On the other hand, women found by the test to be at high risk of recurrence may still benefit from that knowledge, because their cancers appear to be much more responsive to chemotherapy than those in the low-risk group. A study presented at the conference showed that patients identified as high-risk by the new test were 70 percent less likely to have a recurrence if they had chemotherapy.
The study involved choosing the 21 genes for testing from other studies that showed they correlated positively with aggressive breast cancer expression. The authors then looked for those genes in breast tumors that had been removed as part of another study that looked at the effectiveness of tamoxifen in preventing breast cancer. They developed a scoring system of low, medium, or high risk for recurrence based on the number of genes expressed by the tumors. There genetic assay appears to be quite predictive, more so, in fact, than the usual methods of predicting aggressiveness, such as patient age, tumor size, or how chaotic and immature the tumor cells are:
Many patients (51 percent of the patients in the study) were categorized as having a low risk, and their rate of distant recurrence at 10 years was 6.8 percent. A smaller group of patients (27 percent) was categorized as having a high risk; their rate of distant recurrence at 10 years was 30.5 percent — a risk similar to that observed among patients with node positive disease.
It's not a perfect predictor, however, since some of the low scoring tumors still managed to recur:
A low risk was defined as a recurrence score of less than 18, an intermediate risk as a score of 18 or higher but less than 31, and a high risk as a score of 31 or higher. There were 28 recurrences in the low-risk group, 25 in the intermediate- risk group, and 56 in the high-risk group.
But still, it's a very promising first step toward individually tailored therapeutics. posted by Sydney on
12/11/2004 07:48:00 AM
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Friday, December 10, 2004
Best Buys: Consumer Reports rates drugs. So far, they have only three categories - statins for cholesterol lowering, proton pump inhibitors for esophageal reflux, and non-steroidal anit-inflammatory drugs for arthritis. Not surprisingly, the generics come out ahead. They plan to do other categories in the future. posted by Sydney on
12/10/2004 06:47:00 PM
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Library Science: Books for the blind get a much needed technology update. In other news, some public libraries are loaning out e-books. You no longer have to live in New York to enjoy the inventory of the New York Public Library:
In the first eight days of operation in early November, and with little fanfare, the library's cardholders - from New York City and New York state and, increasingly, from elsewhere - checked out more than 1,000 digital books and put another 400 on waiting lists (the library has a limited number of licenses for each book).
E-books are only one way that libraries are laying claim to a massive online public as their newest service audience. The institutions are breaking free from the limitations of physical location by making many kinds of materials and services available at all times to patrons who are both cardholders and Web surfers, whether they are homebound in the neighborhood or halfway around the world.
Interesting concept, although I'm not sure how they get the material returned. Does it automatically become non-functional after two weeks? Whatever, it would be wonderful to see medical libraries adopt this sort of policy. Most medical journals are far too expensive for humble practicing physicians. As a result, most of us only subscribe to one or two. (Usually The New England Journal or JAMA in the States.) It would be great to have access to the original papers we read about in the news. Of course, the publishers of those journals probably wouldn't agree.
UPDATE: A reader who has checked out e-books explains how it works:
You wanted to know how the checkout period of ebooks worked.
Yes, the copy you download only works for that amount of time.
The way it works in King County, WA (I've got a Palm OS PDA and so I have
downloaded a few here)
1. It's a proprietary format.You have to have the reader for that type
loaded on your browser.
2. You get access for a specified amount of time. After that, you can't
access it anymore.
3. There are a limited number of ebooks you can have out at once.
Protecting the Family Jewels: Be careful where you put your laptop:
Research published yesterday in the journal Human Reproduction has found that laptops, combined with the thighs pressed-together posture needed to balance them, give off enough heat to raise the temperature inside testicles by nearly three degrees celsius. posted by Sydney on
12/10/2004 08:11:00 AM
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Not a Slippery Slope: My thoughts on utilitarian bioethics and the Dutch at Tech Central Station.
P.S. Some information that didn't make it into the column but that's worth mentioning for what it says about the uses of euthanasia to ease societal burdens rather than individual burdens is the data found in this survey of Dutch adult euthanasia practices from 1990 to 2001. About 39% of deaths are hastened in some manner, and shockingly, about 1000 of those each year are done without the patient's request.
The very elderly (over age 80) account for an increasing proportion of the hastened group, from 41% in 1990 to 45% in 2001, while other age groups are decreasing. At the same time, the proportion of hastened deaths administered by nursing home physicians has increased from 17% to 24% while other specialities have decreased or stayed the same. The proportion of hastened deaths administered to cancer patients has remained about the same (from 30% to 29%), while heart disease is decreased (29% to 25%), but hastening death for "other or unknown" illnesses (which would include dementia) has increased from 40% of such deaths to 46%.
No wonder more Dutch doctors said in 2001 that they feared healthcare economics was playing an increasing role in pressuring physicians into euthanasia decisions.
P.P.S. And in the more things change, the more they stay the same, see this synopsis of a popular German film from 1941, Ich Klage an (I Accuse).
NOTE: I the first P.S. has been edited to correct grammatical mistakes from the first edit and to read "hastened deaths" instead of euthanasia. Technically, euthanasia is active killing of a patient, but the categories in the study refer to all actions that make death come quicker, including treating pain with high doses of morphine.
UPDATE: Healthcare policy blogger Matthew Holt thinks I've crossed the line of civility by equating the Dutch, Singerian ethics, the Sudanese, and Yugoslavians. I disagree. The Sudanese and Bosnian Serbs are no less human than the Dutch and Peter Singer, and therefore no more evil. Likewise, the Dutch and Singer are no more innately good.
The only difference between them all are the groups of people they've chosen as too troublesome to tolerate. For the Dutch, it's severely handicapped infants. For Singer, just about any infant that no one wants. For the Sudanese, it's non-Arab Africans. For the Bosnians, it was Muslims. The attitude remains the same. Once a society accepts that it's OK to devalue one group because they are a burden, then no group is safe. Which group is chosen just depends on who holds the power.
UPDATE: Hmmph. Just had a chance to read Matthew's full post at the office (for some reason, Internet Explorer on the Mac I use at home renders his posts too large to be viewed easily in their entirety. I have to keep scrolling horizontally which is difficult.) Somehow, I find the argument that opposing infant euthanasia is a closer cousin to opposing masturbation than embracing infant euthanasia is to genocide less than convincing. posted by Sydney on
12/08/2004 05:15:00 PM
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Risk Factors: Does being born in May and in the Northern Hemisphere increase the risk of developing multiple sclerosis? Not by much. According to the data, the researchers expected 1,619 Canadians born in May from 1926 to 1970 to have multiple sclerosis. Instead, 1,675 did. For Britain those numbers were 978 vs. 1,137.
There does, however, appear to be a significant trend in relation to birth month and multiple sclerosis. The actual number of multiple sclerosis sufferers exceeded expectations in the spring and summer months ( April through July) and fell below expectation in the fall and winter (August through December). Is it the month of birth or the month of conception that's the risk factor? Children born April through July are conceived July through November, and therefore in utero during cold and flu season. It would be interesting to know if there is also a spike in the incidence of multiple sclerosis among those born in the years of bad flu outbreaks. posted by Sydney on
12/08/2004 07:43:00 AM
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Alcohol Awareness: When I was growing up, it seemed like the age of 14 was when a lot of my peers began to experiment with drinking. Later, as a physician in training, it always seemed to be the younger teens who had to be admitted to the intensive care unit with acute alcohol poisoning. Here's an educational website for just those kids - The Cool Spot. posted by Sydney on
12/08/2004 07:18:00 AM
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Ukrainian Medical Mystery Update: Viktor Yushchenko's Austrian doctors are now certain he was poisoned:
Specialists in Britain, the United States and France had helped to establish that it was a biological agent, a chemical agent or, most likely, a rare poison that struck him down in the run-up to the presidential election, he said. Doctors needed to examine Mr Yushchenko again at the clinic in Vienna to confirm their diagnosis but were in no doubt that the substance was administered deliberately, he said.
“This is no longer a question for discussion,” Dr Korpan said. “We are now sure that we can confirm which substance caused this illness. He received this substance from other people who had a specific aim.”
...A parliamentary investigation found no evidence of poisoning.
But Dr Korpan said that toxicologists and other experts at laboratories in Britain, the US and France had since examined Mr Yushchenko’s blood samples and medical records. “We will reveal the results in the near future and confirm the cause of this mysterious illness,” he said. “We need to check him again here in Vienna. If we received him today, we could finish the whole investigation in two or three days.” posted by Sydney on
12/08/2004 01:29:00 AM
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Tuesday, December 07, 2004
Depressed? Too Bad: The British drug regulatory authorities have turned their attention from Paxil, to Effexor:
Yesterday, U.K. regulators said the drugs should not be prescribed for patients with mild depression and, instead, suggested doctors promote such options as counseling. The agency also called for stronger warnings about side effects after a drug is stopped.
Overall, the regulators found the benefits of antidepressants outweighed the risks in adults. But they also noted Wyeth's Effexor was linked to a higher rate of deaths from overdose than other drugs and the pill may cause heart problems.
As a result, U.K. regulators said Effexor should only be prescribed by specialists and should not be given to any patient with heart disease. Wyeth said it will challenge the agency's recommendations.
"We don't think there's any scientific basis for this decision," Joseph Camardo, Wyeth's senior vice president of medical affairs, said.
He said the number of patients who took an inappropriate amount of Effexor and experienced a heart problem was "fewer than a dozen." The number of Effexor patients who took an appropriate dosage and suffered a heart problem was fewer than worldwide, he said.
Does Effexor cause heart problems? It could, potentially. Here's a report of it interfering with an implantable defibrillator, but this review of the literature found little evidence of cardiac side effects.It probably isn't terribly toxic to the heart, but it might increase the risk of heart problems a little bit. Hard to say. Guess we'll have to wait until the data the British have is made public.
posted by Sydney on
12/07/2004 11:58:00 AM
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Celebrex Gets a Reprieve: Celebrex, a close relative of Vioxx, is managing to hold its own in the heart safety contest:
For this latest study, researchers at the University of Pennsylvania School of Medicine reviewed records on 1,718 people who had been admitted to 36 hospitals with a nonfatal first heart attack, and compared them to 6,800 people who had not had a heart attack from the same geographical area.
People who had taken Vioxx had a 2.72 times higher chance of having a heart attack compared to people taking Celebrex.
People taking Vioxx also had a higher risk for heart attack than did patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen and naproxen.
"It appears that not all cox-2 inhibitors are the same with respect totheir effect on heart risk," said Stephen Kimmel, an associate professor of medicine and epidemiology at Penn. "We can't exclude a small increase in risk from Celebrex. We just didn't see one here."
Hard to say how much significance to place on this study without knowing how well the researchers controlled for differences between groups of people. Was there something about Vioxx users (aside from Vioxx) that made them more vulnerable to heart attacks than the Celebrex users? (age, smoking habits, cholesterol, etc.)
posted by Sydney on
12/07/2004 11:42:00 AM
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Somehow every baby I know has gotten a flu vaccine but many of my elderly patients, (who are, by the way, much more vulnerable to the flu as a whole) have gone wanting. posted by Sydney on
12/07/2004 11:30:00 AM
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Role Model: Anyone out there whining about all the holiday pressures, please take a moment to think of this guy. Wounded in a terrorist attack and he still manages to pass his medical exams. posted by Sydney on
12/07/2004 11:22:00 AM
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Resources are limited. Ditto for government budgets. And so choices have to be made, notwithstanding the dual fictions that health care is "free" and that those who need it will not be denied. Someone has to be denied, and guess who that is increasingly: the elderly. Why "waste" expensive procedures and devices and medicines on someone who is going to some eternal reward relatively soon when a far more deserving (read: politically defensible) patient also is on the waiting list?
Alas, it does not, it will not, it cannot stop with the elderly. "Free" health care in Canada means that waiting lists are long, patients deteriorate while waiting, such "cheaper" devices as plastic artificial knees are used in place of aluminum ones, and those who can travel and pay for medical care go to the U.S. And those who cannot? Well, they suffer. As day follows night, health care will be denied the mentally ill, the desperately tiny prematurely born, those whose prospective "quality of life" in someone's politicized view will be inadequate. That is the tragic road toward which nationalized compassion inexorably will lead. This is not because the system is afflicted with correctible inefficiencies or because budgets are not fully funded or because doctors/hospitals/pharmaceutical producers/insurers/bureaucrats/name your goblin are greedy/corrupt/uncaring.
It is because "free" health care cannot overcome the basic and eternal condition of mankind: Wants exceed resources.
Hope for Spinal Cord Injuries: And it isn't from stem cells, but from polyethylene glycol, better known as anti-freeze:
PEG acts as a kind of 'molecular Band-Aid,' Borgens explained. Injury causes 'holes' in nerve cell membranes in the spinal cord. PEG seals the hole, sort of the way liquid soap creates a film on the round part of a bubble wand. That patch lets the nerve cell reconstruct itself. PEG is flushed out of the body within about two hours, Borgens said.
Researchers previously had tested PEG on guinea pigs. Beginning in 2001 and through last year, research was conducted on 19 dogs that sustained severe spinal cord injuries. All of the injuries occurred in accidents, Borgens emphasized -- none of the dogs was deliberately injured for the research.
In each case, the dogs were taken to their veterinarian soon after the injury and then referred to one of the participating universities.
It will be a while before the stuff can be tested in people, but for now, it looks like life might get a little better for dachshunds. posted by Sydney on
12/06/2004 08:57:00 AM
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Ukrainian Medical Mystery Update: Saturday's New York Times had an detailed synopsis of Ukrainian opposition leader Viktor Yushchenko's illness:
He arrived first on Sept. 10, severely ill and unable to walk, after five days of terrible abdominal pain. Initial testing showed that he had a high white-cell count and elevated liver and pancreas enzymes, suggesting inflammation of those organs. His tests were negative for all the obvious possibilities, like hepatitis caused by a virus.
Scans showed that his liver, pancreas and intestine were, indeed, swollen. Internal examinations of the intestine using an endoscope found he had ulcerations - essentially bleeding abrasions - of the stomach and throughout his intestine and bowel as well. Ulcers are typically not spread out in that way.
The doctors gave him supportive care, like intravenous fluid and a restricted food intake to rest the digestive tract. As he gradually recovered strength, he opted to get back to the campaign trail. Already, doctors noticed that he was developing odd lesions on his face and trunk.
Ten days later, the candidate returned, after three days of what he called excruciating back pain. Its source was again a mystery, since related lab tests and scans were normal.
The pain was so severe that doctors had to place a large intravenous line into Mr. Yushchenko's chest and essentially nearly anesthetize him with huge doses of opiates. Because opiates depress respiratory functions, his breathing rate slowed, and his vital signs had to be constantly monitored. More medicine would have required that Mr. Yushchenko be placed on a respirator, Dr. Zimpfer said.
....The issue has persisted because of the obvious disfigurement and discoloration of his face, which is swollen and pocked with large bumps and cysts, and is a dusky grayish color. The left eye is bloodshot and sometimes waters.
...The candidate refused a biopsy of his face - which doctors suggested to try to narrow down the causes - because he did not want to campaign with stitches. But dioxin and related toxic chemicals are detectable in the body years after exposure. Ms. Gerashchenko said tests for such substances had still not been performed.
High-dose exposure to a chemical would seem to be a reasonable speculation. His photographs are suggestive of chloracne. Too bad he's been too busy to get an adequate diagnosis. He must be a Type A+ personality. posted by Sydney on
12/06/2004 07:47:00 AM
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