Monday, November 28, 2011

HAPPINESS

In the psychiatric rotation of my medical training in 1966, my very first patient lamented, “All I want is to be happy. Is that too much to ask?”

Good question. When we talk about being happy, what exactly do we mean? A terrific film, “Happy,” directed by Roko Belic, who made the equally terrific “Genghis Blues,” seriously examines the subject. You can find it at

Happiness depends on how much time we spend in what psychologist Mihaly Csikszentmihalyi calls “the flow.” We’re in the flow when we are absolutely at one with what we’re doing. It’s a magical realm uncluttered by time or obligation or even, as a matter of fact, mortality itself.

We can literally “lose ourselves” in running or in writing, heart-fluttering love, painting, yoga, sex, music, daydreaming, whatever: it doesn’t matter what the activity is. The opposite, evidently, is remaining “in our heads,” experiencing unengaged distance. Gestalt psychology founder Fritz Perls advised, “Lose your mind and come to your senses.”

If you’ve never experienced this total immersion, you might want to take it on as a quest. Unfortunately, it doesn’t get great press in our culture, as we assign productivity a higher value, and I guarantee that the quest for happiness is decidedly unproductive.

Saturday, November 12, 2011

I KID YOU NOT: CHOLESTEROL SCREENING FOR NINE-YEAR-OLDS

An Associated Press news piece yesterday (http://news.yahoo.com/doctors-test-kids-cholesterol-age-11-203530834.html) announced that we’ll soon be screening kids as young as nine years for high serum cholesterol. The new guidelines emerged from an expert panel appointed by the National Heart, Lung and Blood Institute and endorsed by the American Academy of Pediatrics.
The guidelines are based on facts everyone agrees on:
— By the fourth grade, one of every eight U.S. children has high cholesterol, defined as a score of 200 or more.
— Half of children with high cholesterol will also have it as adults, raising their risk of heart disease.
— One third of U.S. children and teens are obese or overweight, which makes high cholesterol and diabetes more likely.

I agree, too. But why is this happening now? One micro-reason is genes: one out of every five hundred people has high cholesterol because of genetic makeup. All the rest, though, comes from—you guessed it—toxic diet and inadequate exercise.
 
In other words, we’ve discovered we’re developing serious disease earlier and earlier in our lives because of unhealthy behavior. We’re going to identify it by large-scale testing, and treat it, of course, with medications.

I have a few problems with this strategy. First, it redefines voluntary behavior as a medical diagnosis; second, it creates an entire new class of “patients” who will consume expensive medications and endure their side effects; and third, it legitimizes and even enables disease-causing behavior.

What amazes me about these guidelines is the degree to which the medical establishment docilely accepts them. We docs should instead be demanding  effective plans for steering kids into healthier behaviors, emphasizing education and parenting.

Oh, my. I get so worked up about these things. Maybe I'm suffering from Inadequate Idiocy Tolerance Disorder (IITD, the silent killer). I need to calm down. A friend advised that I might increase my patience by remembering that we are the distant ancestors of an advanced civilization.


Thursday, November 10, 2011

TECHNOMANIA

A friend forwarded a NY Times op-ed piece this morning (http://www.nytimes.com/2011/11/10/opinion/our-high-tech-health-care-future.html?_r=1&emc=eta1) that scared my socks off. Its author, Frank Moss, an entrepreneur and hi-tech whiz, is obviously well-meaning, but he’s poorly informed about what actually occurs in healthcare.

Moss recommends juicing our anemic economy with a massive dose of medical technology, on a scale similar to our 1960s man-on-the-moon project. Here are a couple of his suggestions:
It would begin with a “digital nervous system”: inconspicuous wireless sensors worn on your body and placed in your home would continuously monitor your vital signs and track the daily activities that affect your health, counting the number of steps you take and the quantity and quality of food you eat. Wristbands would measure your levels of arousal, attention and anxiety. Bandages would monitor cuts for infection. Your bathroom mirror would calculate your heart rate, blood pressure and oxygen level.
Then you’d get automated advice. Software that could analyze and visually represent this data would enable you to truly understand the impact of your behavior on your health and suggest changes to help prevent illness — by far the most effective way to cut health care costs…
…You might slip a low-cost plastic attachment over your phone display, look into its eyepiece and conduct a cataract exam. The avatar would transmit the results to your human doctor, who would send you a video message explaining the diagnosis and prescribing treatment…
I tend to wax interminably on the threat of healthcare devolving down to a vending machine. Plans like this one come close. They assume illness to be a biomechanical problem fully amenable to technologic intervention. That might be valid if cure were available, but it usually isn’t. The bulk of visits to doctors—especially seniors’ visits—are for chronic (that is, incurable) conditions. Seniors don’t need relentless stabs at cure, then, as much as they need guidance and support in living with their conditions.
Wholly technologic strategies like this don’t recognize the sad fact that a gross proportion of American illness derives from pathogenic behaviors so tenacious (including smoking, alcohol and drug abuse, sedentary lifestyle, poor stress management, toxic exposure, and dysfunctional relationships) that the advice we docs currently know how to offer amounts to water off a duck’s back.
These strategies fail to comprehend the emotional, subjective experience of suffering because it can’t be measured by even the most clever device, so they certainly can't develop any way to address it.
Worst of all, they encourage the abdication of personal responsibility. “Just leave the quality of your life up to us and our machinery,” they say. “Trust us, we’ll treat your suffering; matter of fact, we’re developing a therapeutic texting app even as we speak.”
In the real world, Frank Moss’ suggestion, fascinating though it is, is only more of what doesn’t work now. He’s correct in predicting that expensive technologic bandaids will keep the wheels of commerce spinning, but they won’t materially affect our health or well-being. To quote Dr. John Knowles, the late president of the Rockefeller Foundation and medical director of Massachusetts General Hospital,

The people have been led to believe that national health insurance, more doctors, and greater use of high-cost hospital-based technologies will improve their health.  Unfortunately, none of them will.  The next major advances in the health of the American people will come from the assumption of individual responsibility for one's own health and a necessary change in the life style of a majority of Americans.

Tuesday, November 8, 2011

UNCERTAINTY

What is one to do, now that we’ve learned that early detection of cancer isn’t always as important as we’d thought? Should we get screened or not? Some screening tests, as for cervical and colorectal cancer, reliably lead to effective treatment, but serious questions about others, especially PSAs (for prostate cancer) and mammograms, are emerging.

I’m not writing here about the value of particular tests, though, but about testing per se. Healthcare experts are looking critically at testing itself these days, no doubt because healthcare’s gotten so ridiculously expensive. They’re questioning exactly what’s gained, analyzing cost-benefit ratios. An example is the CT lung-scanning of smokers to screen for cancer. Besides being costly, CT scans, like all tests, are subject to “false positive” results that can encourage unnecessary biopsies and woe. And by the way, they're also subject to false negatives.

Why can’t we have tests without false positives and negatives? We’re far beyond reading chicken entrails at this point, but we’re still not perfect. And you know what? Medical science itself will never be perfect, and not just because we lack some tool. Nobel Prize winners since Werner Heisenberg have reaffirmed that uncertainty isn’t some cosmic condiment, but is, in fact, the only item on the menu.

Recognizing that complete security is a myth, then, how much of it are you willing to buy? In healthcare, will you pay a hundred dollars for an x-ray that carries ninety percent certainty? Or would you prefer the ninety-nine percent certainty of a thousand-dollar CT scan? Or perhaps for two thousand dollars, you’d go for the ninety-nine-point-nine-percent certainty of an MRI. (Whatever your choice, of course, there are no guarantees.)

What’s my preference? My most comfortable approach would be the one that feels, well, most comfortable, after trying a few on. Why not explore your U.Q., your Uncertainty Quotient? People mattering in healthcare includes seriously, responsibly, consciously realizing less our wants and more our needs.