Friday, December 28, 2012

PLEASE HELP ME OUT HERE


I was talking with a friend who teaches communication in a medical school. She’s getting on (aren’t we all?), so her dean asked her to think about who will replace her when she retires.

She hasn’t been able to identify anyone. She told me, “It seems like younger people just aren’t interested in this field.”

I concur. Four to six times annually I miss the cancer support meetings I normally facilitate because of vacation or illness. In past years competent substitutes like colleagues or their interns were always available to fill in. This year I really had to scramble. There are no more interns, and most of my colleagues were overbooked, tired, and, I realized, past middle age.

The younger psychologists I know who work in hospitals are fully absorbed in issues of diagnosis and medication. They seem to have little or no expertise or even interest in normal communication. It’s as though only a single generation--we 1960s hippies--was touched by the significance of deep contact. What’s to become of this craft?

Maybe I’m missing something. It could be that the emotional aspects of illness are being addressed by some other department. Maybe standard medical practitioners like docs and nurses are finally becoming as compassionate as we’d like. Or maybe social workers finally have adequate time to sit with patients and their families. I just don’t see much of that yet.

So help me out here. What do you see? When I and my ilk shuffle off this mortal coil, what will the experience of sick people be like?

Friday, December 21, 2012

CREATIVE PROCRASTINATION

A few days ago a friend told me, "I've heard the world might end on Friday. That's when I'm scheduled for a colonoscopy. Maybe I should postpone it till next week."

Thursday, December 20, 2012

VIRTUAL HEALTHCARE


Thanks and a tip of the hat to Christine Newsom, MD for sending me an editorial, “Virtual Grief,” from the November 28 JAMA.

Written by Dr. David Wu of the University of Washington’s Palliative Medicine Fellowship Program, the essay describes a significant blemish on the beautiful face of electronic medical records, EMRs. Dr. Wu reports finding an entry, inserted by a social worker, on the record of a patient he’d seen stating simply that the man had been shot and killed.

Dr. Wu hadn’t seen the patient as often as the electronic messages about him—lab and x-ray reports and so on. The man had slowly become virtual: unpresent in the flesh, he was represented by a computer avatar, like a character in a video game. In fact, Dr. Wu realized that as he spent more time with his patients’ EMRs than with them, they’d all gone virtual.

I haven’t been in medical practice many years now, so I’m unaccustomed to electronic record-keeping. When I recently examined a deceased patient’s chart, the nursing notes surprised me. Evidently nurses save time these days by checking a particular box to automatically write a note. If, for example, you want to enter, “Patient asks for more pain medicine than orders specify,” you can do so with a single keystroke, and then another part of the program adds the recommended course of action, “Physician to be notified.” Page after page exhibited only these un-nuanced notes, cleansed of the glorious human contact that must have occurred. 

In saving nurse time, computerized shorthand improves efficiency, which is, I guess, what healthcare’s about these days. A future archeologist reading this chart will surmise that our hospitals weren’t places that cared for people, but factories smoothly efficient in fixing disordered units, and especially in keeping records.

Dr. Wu writes, “Under this system, I’m not as good a doctor as I once was. What I mean is that I’ve come to prize what the system prizes: efficiency over human contact, computerized data over stories, virtual reality over authentic life.” Feeling compelled to inject some degree of humanity into the EMR of his patient, Dr. Wu wrote that it had been an honor to be the man’s doctor.

I hope his heartfelt comment doesn’t get incorporated into the next generation of this EMR software.

Wednesday, December 19, 2012

OBESITY AND DEMOCRACY


The Robert Wood Johnson Foundation says Americans are becoming alarmingly fat. According to a recent Foundation report, “If obesity rates continue on their current trajectories, by 2030 thirteen states could have adult obesity rates above sixty percent, and all fifty states could have rates above forty-four percent.”

Depending on who’s holding forth, obesification results from lack of exercise, passive indoor entertainment, child safety issues, processed foods, and more meals eaten out. Arguments aplenty concern sugar, fats, high-fructose corn syrup, and a slew of additives. The item seldom discussed yet actually at the bottom of our most difficult issues, is: us.

It’s as though our lifestyle, whatever it may be, was handed to us by some authority that forces us to flop onto the couch for another boob-tube dose, gobble junk foods, ignore grocery labels—in sum, abdicate control of our lives. 

That is, we’ve become a passive people. We accept the label “consumer” not only in commerce, but across the board. Healthcare has come to be a transaction between a “consumer” and a “provider.” While a huge majority of us, if asked, think our endless wars--currently against terrorists, cancer, and drugs--are unproductive at best, somehow they continue anyway. While lunatics are gunning down people by the score, we respond by simply ducking.

If we’re going to get back into shape—in our bodies and in our nation—we’ll need to seriously review the life choices we make from moment to moment. There can be no democracy without active, informed participation. What will it take for us to wake up?

Saturday, December 15, 2012

NEWTOWN


I lit a candle yesterday for the dead, wounded and horribly grieving people of Newtown, Connecticut.

I lit it for our Congressional representatives, too, those who sigh that their hearts go out, but lack the spine to keep guns from those who shouldn’t have them.

I lit it for the millions of frightened souls who believe their guns will protect them, while they’ll actually make them and their loved ones less safe.

I lit a candle for the majority of gun owners, who are sober and sane…until they’re not.

I lit a candle for our national mental health. Yes, our mental health: there’s something very wrong with us when we respond to mass random violence mainly by hoping it won’t occur in our town.

Finally, I lit a candle for a country that can’t seem to generate the courage to end this intolerable madness. Maybe we need to remind ourselves that America was once known as “the home of the brave.”

Thursday, December 13, 2012

BODY AND MIND UNDER ONE ROOF


Our local newspaper published a story this week about the Sierra Family Medical Clinic, located in the wilds of San Juan Ridge, fifteen miles outside already-rural Nevada City. The clinic, which has provided cutting-edge care for a quarter-century under the direction of its founder, Dr. Peter Van Houten, recently added an in-house psychotherapist to its services.

Certain lifestyles predictably lead to illness. Examples are poor self-image, addictions, unskilled stress management, and acceptance of toxic relationships. When I practiced standard medicine, I was vexed to find I frequently operated a high-tech turnstile, patching folks up only to return them to the same miseries that corroded them in the first place.

Counselling can interrupt that cycle. Dr. Van Houten reported that when his clinic referred patients to outside therapists, forty percent of them kept their return appointments, but if they saw the clinic’s own therapist that very day, eighty percent returned. Since hardly anyone makes significant lifestyle changes after only a single exposure, this is a major advance.

One wonders why this should be such a revelation. Don’t we all feel that the body and the mind are connected in some way? If so, why shouldn’t a psychotherapist be a natural component of a medical clinic? The way we practice now, we may as well hang a sign over our doorway reading, “We treat only your body; for the way you feel, think, believe, and thus lead your life, shop elsewhere.” Thanks, Dr. Van Houten, for showing the way.

Tuesday, December 11, 2012

HOW ARE YOU DOING? NO, REALLY.


When I asked my sainted old mother how she was, she answered, “I don’t know. I don’t see the doctor till Tuesday.”

Well, that was that generation. Virtually worshipping science, they tended to abdicate their truth to those experts. We’ve come a long way since then. Or have we?

“How are you doing?” When you think about it, that question we routinely ask one another isn’t just surface fluff. “How” is an inextricable feature of every life. We are verbs requiring adverbs. We conduct our unique style of relationships, social processes, eating habits, stress management, exercise pattern, and so on. “How” is a whole lot, actually, yet how do we answer the question? Fine. Not too bad. Can’t complain. For all our complexity, we offer ludicrously anemic responses.

My mother had a point, though. The temple of medical science produces some important answers. Exploration of our physical parts—tests of body fluids, radiological images, biopsies—can reveal much…about “what,” but not “how.”

Most of the folks I know who received sour diagnoses suddenly shifted their attention to their life's adverbs, reconsidering their attitudes and the ways they’d chosen to be in the world.

A couple of decades ago, we bought a home that while certainly livable lacked interior window trim. After seven years, we put it up for sale. We figured it would sell more easily if we finally installed the trim. As I measured, cut, and nailed over several days, I thought, “Blimey, we could’ve been living with trim these past seven years.”

This is my modest way of suggesting that we might have a better time if we examined and enhanced our lives now, before we’re diagnosed. To me, the term “preventive medicine,” which once meant getting PSAs, mammograms, lipid panels, and colonoscopies, has come to mean instead steering toward our best life, beginning now. Then, whatever comes from seeing the doctor next Tuesday, it won’t be the entire story. 

Monday, December 10, 2012

WHAT’S BEHIND CHEMO BRAIN


A small study presented recently at the San Antonio Breast Cancer Symposium (http://www.newswise.com/articles/cognitive-problems-may-be-present-before-chemotherapy-in-women-with-breast-cancer)
suggests that “chemo brain”—the fuzzy thinking that sometimes accompanies chemotherapy treatment—might not necessarily be due to chemo, as fuzziness occurs prior to treatment.

“Chemo brain” was noted—though to a lesser extent—in women with breast cancer who awaited radiation therapy, but not in a control group of women who didn’t have cancer.

So what’s at work here? Maybe breast cancer itself meddles with your mind. More likely, though, as lead researcher Bernadine Cimprich, Ph.D., R.N., surmised, confusion results from the “mental demand and stress of a breast cancer diagnosis.” She wisely added, “Women should not avoid accepting recommendations for lifesaving chemotherapy for fear of ‘chemo brain.’” Dr. Cimprich recommended existing interventions to combat stress after a breast cancer diagnosis, including mindfulness training, psychological support, cognitive behavior therapy, and exercise.

I’m continually surprised that her advice isn’t a recognized component of all cancer treatment. If you’ve been handed any serious diagnosis, you’re all too aware of how this news, by itself, alters your mentality. In our tiny, rural cancer center, our social worker visits every newly diagnosed person to inform them about the many psychosocial interventions available, intended to complement their oncological treatment.

Monday, November 26, 2012

THE SLOW CODE


A friend sent me an article from the Toronto Star (http://www.thestar.com/news/canada/article/1292712--half-hearted-medical-care-for-hopeless-cases) that examines a behind-the-scenes medical practice called the “slow code.” The phrase awakened a dusty memory in me, a list of sarcastic phrases we medical smartasses spoke to one another but were careful never to mention around patients. Like “Five-P Syndrome,” meaning Piss-Poor Protoplasm Poorly Put Together. Or, when some troublesome patient departed, “AMF,” meaning, to put it delicately, “Adios, My Friend.” A “slow code” was cardiopulmonary resuscitation done so desultorily it was sure to fail.

In most hospitals the call for CPR comes over the PA system as “Code Blue” or “Code Three:” a patient is in cardiac arrest, so all hands on deck, stat. The bedside becomes a frightfully dramatic scene, a whirlwind of doctors, nurses, techs, gloved hands, potent drugs slammed through tubing, electric gadgets hooked up.

When I was an ER doc, I participated in plenty of these, and went at each full-bore, even when survival was unlikely. (In fact, unlikely survival is the most likely outcome. A study of ninety-nine thousand CPR attempts found that only two hundred twenty-eight patients, a fifth of one percent, were pulled from death into a normal life. That doesn’t mean we shouldn’t try, only that our expectations need trimming.)

Sometimes the patient is known in advance to be unsalvageable, being too old or frail or irreversibly sick even to survive the trial of CPR. In those instances, the staff would like to have a “DNR,” or do-not-resuscitate, order on the chart, but that’s not always the case, as end-of-life conversations are too seldom conducted. The practitioners who find themselves suddenly at these bedsides do their job, but half-heartedly, hence the “slow code.”

These scenarios aren’t just wasted energy. They can generate gratuitous suffering for everyone involved, especially the staff, who, while cleaning up the post-code mess, wonder what they’re doing in this profession. This all might be avoided were doctors to routinely discuss end-of-life issues with patients and their families. 

One reason they often don’t is that they’re not paid to do so. They’d earn thousands for a brain operation, but not a cent for helping guide people through their darkest hour. A provision in an early version of the Affordable Care Act of 2010 (“Obamacare”) specified paying doctors to hold such conversations. No sooner was this made public than millions interpreted it as “death panels” intent on pulling Grandma’s plug, and the provision was dropped.

As long as we keep end-of-life issues locked in the closet, we’ll continue to slow-code and act in other ways that would make a visiting anthropologist wonder about our mental health.

Thursday, November 15, 2012

THINK BEFORE YOU PINK


Who doesn’t want to find a cure for cancer? We give untold millions to organizations who claim that aim, but how can we be sure if our donations will be used as we wish?

Whatever you want to make of the current Petraeus flap, for example, it bears a relevant sidebar. A woman who’s involved, Jill Kelley, operated the “Doctor Kelley Cancer Foundation” along with her husband, a cancer surgeon. The foundation’s tax forms stated that “it shall be operated exclusively to conduct cancer research and to grant wishes to terminally ill adult cancer patients.” Apparently the group spent all its money on parties, entertainment, travel and attorney fees. $43,317 was billed as “Meals and Entertainment,” $38,610 was assigned to “Travel,” another $25,013 was spent on legal fees, $8,822 went to “Automotive Expenses,” $12,807 for office expenses and supplies, and $7,854 on utilities and telephones. By the end of 2007, the charity went bankrupt, evidently having spent not a penny on research or patient services.

A San Francisco group, Breast Cancer Action (bcaction.org/), tracks spurious cancer funds and organizations with a project called “Think Before You Pink.” I recommend consulting their info before you donate to any outfit that claims to help cancer patients.

Today BCA spotted an unusually outrageous ploy. One of Chesapeake Energy Corporation’s sub-companies, Nomac Drilling, which injects plenty of carcinogens and who-knows-what-else into groundwater with its fracking technology, has decided to support those who have breast cancer. An Oklahoma newspaper, NewsOK (http://newsok.com/drilling-rig-to-raise-awareness-of-breast-cancer/article/3722370#axzz2CJXvjk3R), brightly reports,

“Nomac Drilling is going pink. The Chesapeake Energy Corp. affiliate's newest rig will sport a pink ribbon to support breast cancer awareness.”

Chesapeake Energy recently donated $10,000 to Susan G. Komen for the Cure, and intends to make a similar donation in Ohio, where the pink rig is expected to be sent. Said Nomac’s President, “As we work in areas across the country, we hope this pink ribbon doghouse [sic!] serves as a reminder of the importance of finding a cure.”

These folks always emphasize finding a cure. Nothing wrong with that. But when it comes to identifying and eradicating causes of cancer, they’re curiously silent, and I think I know why.

Tuesday, November 13, 2012

PROP 37 BITES THE DUST


Well, California’s Proposition 37 has come and gone. It would have required foods containing genetically modified ingredients to bear labels stating that. I was all for it, as I’d really like to know what I’m eating.

The genetic engineering industry, including Monsanto, DuPont, and Dow, would rather we didn’t know. Their rationale is that such a label would look like a skull and crossbones to customers who aren’t yet convinced GM foods are safe. To defeat Prop 37, agribusiness and chemical conglomerates spent $46 million to blitz airwaves and mailboxes with negative advertising. They swore on bibles that GM foods aren’t dangerous. They claimed 37’s passage would add an average $400 to a family’s annual food bill. (I felt touched that these infamously greedy corporations were suddenly so concerned about my budget.) Anyway, with a million dollars of ads a day, you can probably convince voters the moon is made of cheese, so Prop 37 lost, 54 percent to 46 percent.

Besides Roundup, Monsanto sells a number of crop seeds resistant to that herbicide. Get it? Farmers can plant “Roundup-ready” soy, spray the field with Roundup, and harvest the crop absolutely weed-free. Never mind the long-term effects of Roundup and its breakdown products on the soil, the crop, and the end-users. For such info, check out these sites:




Monsanto’s goal is short-term profit, no matter what. Maybe you’ve heard that when its GM seeds have wafted into neighboring farms, Monsanto has sued those farmers for copyright infringement. If you’re a family farmer, try opposing a multinational bully’s stable of soulless attorneys.

Opposition to GM labeling is only a small step in the corporate plan to dominate American food. Even now, it’s hard to find soy or corn that isn’t genetically modified. Whether these crops truly are safe or not isn’t the current point, since like other synthetic chemicals now in our environment, we won’t be able to determine their safety for a generation or two. The point is that they aim to be our sole food supplier, and when they're effectively a monopoly, they'll charge whatever they like.

Keeping that horrifying prospect in mind, along with Prop 37’s failure, we can choose to buy food locally, minimize or omit our purchase of processed foods, and know our local farmer. What our family doesn’t grow we buy from a local co-op, which supplies itself from local farms. A strictly organic farming family we often deal with hasn’t applied for any organic label because the hoops they’d have to go through—actually designed for large-scale farms—are too extensive and troublesome. But we know these people, and seeing how they operate, we trust them. That’s a lot more than can we can say of Monsanto.

Thursday, November 8, 2012

GOOD LUCK SHOPPING


As the Affordable Care Act (“Obamacare”) kicks in, tens of millions of Americans currently uninsured will be required to buy medical insurance. To meet this windfall, insurance companies are crafting hundreds of new and varied plans. If recent history is any guide, hardly any policy will be simple and straightforward.

I recently received my annual Medicare and You manual, which explains benefits and limitations, allegedly in plain language. I, with a doctorate in this business, ought to be able to understand the subject easily. But I can’t. I’ve tried for years, and still can’t.

It’s not just my fading neurons at fault. Dahlia Remler, a health economist and professor with a PhD from Harvard, wrote in the Washington Post a couple of days ago (http://www.washingtonpost.com/national/health-science/facing-brain-surgery-a-health-economist-finds-the-health-care-market-hard-to-navigate/2012/11/05/0a931b5c-fcf1-11e1-b153-218509a954e1_story.html?wprss=rss_health-science) that she’s as confused a patient as anyone. She wrote, “My difficulties show how hard it is—even for someone who has studied health-care and insurance issues—to navigate the health-care marketplace, particularly when you have a serious medical condition.”

Medicare is a piece of cake compared to private policies. As a service, not a business, Medicare isn’t allowed to make a profit, while private insurance corporations are legally obliged to give their shareholders a return on their investment. So one has to wonder whether private policies’ lengthy verbiage and labyrinthine rules serve to inform or actually mislead. 

But don’t worry. Some newly formed companies will soon offer, for a fee, to guide patients through the insurance marketplace. I guess if I were an insurance company, I’d start one of these, too, and be quite careful where I referred customers to. Ah, but there I go again, into the cynical shadows.

Anyway, I packed up the Medicare manual and sent it off to a cousin in Ottawa, one of our many Canadian relatives who routinely ask us, “What exactly is wrong with you Americans?” She read the thing and got a good laugh out of it. She gets her healthcare in a national system that covers everything. It’s funded by her taxes. If she were American, she’d pay over $10,000 in premiums for partial coverage. If a Canadian-like system were in place here, she’d pay zero for premiums and about $4,000 annually in taxes for complete coverage. Seems like a no-brainer to me, but God forbid we should copy foreigners.

Tuesday, October 30, 2012

CANCER SCREENING: BLESSING OR CURSE?


The good news is that breast cancer screening for women over fifty saves lives, an independent panel in Britain has concluded. This confirms other studies, including in the U.S.


The bad news is that for every life saved, roughly three other women were overdiagnosed, meaning they were unnecessarily treated for a cancer that would not have threatened their lives. The study reported that the British program annually saves about thirteen hundred women from dying of breast cancer while about four thousand are overdiagnosed. Overdiagnosis leads to unnecessary treatment such as chemotherapy, surgery and/or radiation for a breast cancer that while present, grows too slowly to be life-threatening.

Commenting on the study, Karsten Jorgensen, a researcher at the Nordic Cochrane Centre in Copenhagen who has previously published papers on overdiagnosis, said, “Cancer charities and public health authorities have been misleading women for the past two decades by giving too rosy a picture of the benefits [of mammograms].”

Maggie Wilcox, a breast cancer survivor and a member of the panel that published the report, said the current information on mammograms given to British women was inadequate. “I went into (screening) blindly without knowing about the possibility of overdiagnosis,” said Wilcox, 70, who had a mastectomy several years ago. “I just thought it's good for you, so you do it.”

So how does one navigate these confusing waters? Ms. Wilcox offers a clue, informed consent. Knowing what she knows now about overtreatment, she says she’d still have chosen to get screened. “But I would have wanted to know enough to make an informed choice for myself.”

Monday, October 29, 2012

THE D WORD


Healthcare is too expensive for a number of reasons. The leading one, by far, is that we overuse it.

Too many Americans behave in ways they know will eventually lead to illness (overeating, sedentary lifestyle, unmanaged stress, etc.), and then expect doctors to repair them. They demand the miracles they learned about in ads, often disguised as news—high-tech products and procedures pushed for their profit potential.

A parallel overuse occurs at the end of life. It’s estimated that a third of Medicare patients’ expenses occur during their final year. Attempts to stave off death, though, frequently amount to the prolongation of suffering. Most of us, I think, are aware of that fact now, yet when the event occurs, we tend to submit to futile intervention anyway. Our little inside-the-head voice says, “If you really love Dad, you’ll try to keep him alive.”

One task in authentic healthcare reform, then, is to develop a sense of peace with death. That’s not easy when many Americans fly into hysteria when the D word arises. An early version of the Affordable Care Act ("Obamacare") that recommended end-of-life conversations between families and docs was widely misinterpreted as “death panels” intent on pulling Dad’s plug. 

Tomorrow our local community will host its second annual public forum on healthcare reform. We’ll show a film comparing Canada’s healthcare system with ours, followed by a panel Q&A. Hopefully death-and-dying and other central issues will arise and be openly discussed. Taking such subjects out of the closet is the only way to illuminate them in order to address them intelligently.

Monday, October 22, 2012

IMAGINE YOUR DAUGHTER…


I wrote an article for Sisyphus magazine (http://www.hippocketpress.org/sisyphus) in 2011 which described an oft-neglected issue involving certain pregnant women. I’m republishing it here since it’s a high-profile issue in our upcoming election.

I was trained at Los Angeles County Hospital in the mid-1960s. In those days, if you decided to terminate your pregnancy and were well-off, your family flew you to Japan or Sweden. If you were poor, you sought a local abortionist.

Abortion being thoroughly illegal then, there were no professional standards. Abortionists didn’t need a degree, experience, or, for that matter, scruples. They did their work with whatever came to hand—kitchen tongs, harsh chemicals, even turkey quills. More often than not, their patients/victims developed bleeding, perforation, and infection. When I was on my Ob-Gyn rotation, we daily saw an average of eight to ten women with these complications. Many were as young as twelve, often hurriedly dropped off at the ER by frightened boyfriends or parties unknown. On the average, one died every day.

Imagine that: your daughter, who still keeps dolls in her bedroom, getting secretly pregnant, mutilated by a backstreet criminal, and shamefully dying alone. If abortion once again is declared illegal we’ll return to those days. As always, the wealthy will find little difficulty terminating pregnancies and the less affluent will risk death while their impregnators suffer no risk at all.

To say to these young women, “You should have thought of that before…” strikes me not only as inhumanly callous, but actually supportive of the taking of a human life.

Thursday, October 11, 2012

MEDICATION UBER ALLES!!



CANTON, Ga. — When Dr. Michael Anderson hears about his low-income patients struggling in elementary school, he usually gives them a taste of some powerful medicine: Adderall. [The article says all four kids in one of Dr. Anderson’s patient families are treated with Adderall or an antipsychotic, Risperdal, and the sleep aid Clonidine to counteract the nocturnal stimulation caused by the other drugs.]

The pills boost focus and impulse control in children with attention deficit hyperactivity disorder. Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.

“I don’t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

Dr. Anderson has nailed a problem responsible for much of healthcare’s incredible cost—our tendency to treat social disorders with medications. When kids don’t focus well in school, it’s hardly ever because of a brain dysfunction. It’s because they’re hypersugared, underexcercised, and overexposed to a TV culture that reinforces short attention spans. A pediatrician I know treats ADHD by teaching the parents meditation.

We’re becoming a society bent on medicating virtually all behavior, either to minimize deficits or maximize performance. Last year a National Heart, Lung, and Blood Institute panel, concerned about the increasing rate of type two diabetes in young people, recommended that all kids over the age of nine have their serum tested for cholesterol levels, and those above normal take agents like Lipitor. To repeat Dr. Anderson’s conclusion, “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

This sort of strategy isn’t just ridiculously expensive; it’s expensively ridiculous. A deeper disorder than ADHD or youthful type two diabetes is our bovine submission to the medical-industrial complex. If we gave it any thought, we’d be outraged…but maybe that would require a longer attention span.

Wednesday, October 10, 2012

PAY TO MAKE YOURSELF SICK?


Many corporations are now offering financial rewards to employees who demonstrate better health practices. Get a “wellness screening,” for example, and you get a $50 bonus. General Mills offers a monthly $10 to tobacco-free employees. Conversely, Walmart deducts $10 each pay period from employees who smoke. The rationale is that people with unhealthy habits (smokers on average consume twenty-five percent more healthcare services than non-smokers) ought to co-pay.

This has come about because of the huge and ever-increasing cost of medical insurance. Employers are expected to spend $11,664 per employee on healthcare in 2012, up from $10,982 last year. That's expected to rise in 2013 by seven percent, according to a Kaiser Family Foundation survey.

Some unhealthiness, such as familial hypercholesterolemia, is beyond people’s capacity to correct. But most is chosen, and costs everyone plenty. If we had to pay to smoke, overeat, remain sedentary, and ignore stress, would we continue to do it? Interestingly, that’s exactly the way things were before the advent of medical insurance: you got sick, you paid for treatment. We’ve come almost full circle. 

Tuesday, October 9, 2012

LORI HOPE, PEACE TO YOU


If you look at the bottom of this webpage, you’ll see my recommendation to check out my friend Lori Hope’s blog, http://carepages.com/blogs/helpshurtsheals/posts.

Lori died on September 27 from lung cancer. She lived with it all the time I knew her, at least ten years. Along the way, she devoted much of her time to helping others deal with their cancers. In 2005, she published her first book on the subject, Help Me Live: 20 Things People With Cancer Want You To Know. It was so useful and popular that she published a second edition in 2011. 

Lori was as articulate as she was compassionate, and will be sorely missed and forever loved and respected by the rest of us who deal, in one way or another, with cancer.

WANT TO READ YOUR MEDICAL RECORDS?


In recent research published in the Annals of Internal Medicine (http://annals.org/article.aspx?articleid=1363511), over thirteen thousand patients in a hundred medical practices—in Massachusetts, Pennsylvania, and Washington—were given easy access to their records. More than three-quarters reported that this not only helped them feel more in control of their care, but increased their medication compliance. As for their physicians, they reported little effect on their practices. Almost none reported longer visits or more time addressing patients' questions outside of visits.

When I was a kid, open records would have been unthinkable. You couldn’t even get a practitioner to tell you your blood pressure. Medical records were written in professional shorthand (“38 y/o SWM c/o SOB”) not only to save time, but to obstruct lay access. Prescriptions were written in Latin. It would never have occurred to patients to ask to see their chart.

The law—now and even then—never supported that secrecy. Medical information about you is your property. A practice can charge you reasonably for making copies, but must convey your records upon request. 

That being the case, one wonders about the source of traditional resistance. Is it that whoever has the knowledge has the power? Do open records, then, signify a shift in power? In any case, open records is an idea whose time has come, and hopefully will lead to closer patient-doctor relationships. 

Wednesday, September 19, 2012

WHAT DOES IT TAKE…?


According to the Robert Wood Johnson Foundation, more than half of Americans could be obese by 2030. The result will surpass simply living with excess bulk. We’ll see millions of new cases of diabetes, coronary artery disease, and stroke—a constellation of illness that could cost the United States up to $66 billion in treatment and over $500 billion in lost economic productivity.

According to the national Centers for Disease Control and Prevention, a third of American adults are obese today. “Overweight” and “obese” are technical terms. If you’d like to know where you fit in, divide your weight in pounds by the square of your height in inches, and multiply the result by 703. For example, if you weigh 140 pounds and are five feet six inches (that is, sixty-six inches) tall, your calculation would be

 140     x 703 = 22.59
  66 x 66

The result, here 22.59, is your “body mass index,” or BMI. If your BMI is between 25 and 30, you’re overweight, and above 30, obese.

What are we going to do about this? New York City’s recent strategy, limiting sugar-rich drinks to sixteen ounces, has been met with outraged cries of “Nanny state!” It's not only widely opposed, but ineffective, as a determined customer can buy two sixteen-ounce drinks. Or four.

I’m disappointed that we respond to this menace by debating what the government can or should do about it. What can citizens themselves do? Why have so many of us lost touch with our own bodies? Why aren’t we more concerned about our ballooning kids? Our problem is less obesity than failure of consciousness. What does it take to wake us up?

Tuesday, September 18, 2012

Rx: THE GOOD LIFE


According to a Reuters report (http://www.reuters.com/article/2012/09/14/us-cancer-idUSBRE88D1ED20120914), a Mayo Clinic study has found that a program focused on improving quality of life can help people being treated for advanced cancer. Patients who attended the sessions—a combination of physical and talk therapy, along with relaxation techniques and spiritual discussions—reported a stable quality of life during treatment, while patients who didn't get the extra help declined on those measures.

People who have had cancer or any other serious illness won’t be surprised by that finding. They know in their bones that cancer’s more than a tumor. Its accompanying emotions grossly abrade one’s life. Attending to quality, then, not only makes a difference, but ought to be a standard part of cancer treatment.

As a matter of fact, attending to quality ought to be a lifelong function. Why wait for cancer? Most of us tolerate some degree of unhealthy diet, inadequate exercise, toxic exposure, adverse self-image, poor stress management, unfulfilling work, deficient support, or dysfunctional relationships. Do we need that? Can we do better?

Preventive medicine means more than getting regular checkups. Ultimately it means living one’s ideal life. When we consider what that might look like, we entertain images of cruising around in a shiny convertible, tippling champagne, partying, going for the gusto. Thus we compile “bucket lists” that include skydiving, bunji jumping, and other extremes. These images find their way into us via pop culture marketing; they’re not necessarily us. What exactly would your perfect life be like, moment-to-moment, day-to-day? It might not depart significantly from what you’re doing now, or you might sense major challenges to confront.

One of Freud’s disciples, Alfred Adler, routinely asked his patients, “If you were cured, how would you behave?” They’d think about it, finally answer, and then Adler would say, “Then why don’t you do that now?”

Thursday, September 6, 2012

KNOW-HOW AND KNOW-WHY


A new procedure, bronchial thermoplasty, is becoming available to people who suffer severe asthma. It consists of introducing a tube called a bronchoscope into the airway and then heating the lungs, lobe by lobe, to 149 degrees Fahrenheit. This apparently reverses the smooth muscle swelling characteristic of asthma. Post-treatment studies indicate fewer attacks and fewer hospital visits. It costs around twenty thousand dollars.

Understandably, insurers are reluctant to cover it, their rationale being that it’s still “experimental.” So some—or maybe most—asthma sufferers will go without bronchial thermoplasty. This seems a shame, say many, since the multiple hospital visits and treatments that the procedure might obviate will cost far more than twenty thousand dollars.

This exemplifies healthcare’s predicament. New and possibly effective technologies are constantly coming down the pike. What they have in common is breathtaking cost: high-tech is inarguably expensive. Someone needs to pay for it, and it will inevitably be end-users, either through taxes or higher insurance premiums. The more optimistic view is that high cost in a single treatment is possibly cheaper than dozens of hospitalizations. I find it hard to take sides on that, but it makes me recall the observation a friend from Mumbai offered me: “You Americans have a lot of know-how; what you seem to lack is know-why.”

That is, we could ask ourselves why there’s so much asthma these days. In our little rural county, asthma incidence has increased along with constant rise in ozone, a known cause. Now one of every six of our kids is asthmatic. Our ozone isn't created here, but drifts here from population centers, where it’s generated by internal combustion exhaust.

We treat asthma—and a host of other preventable illnesses—only after it’s gotten to the emergency department level. We could choose to prevent much of it by providing ourselves cleaner air. By the same token, we could prevent much of cancer by questioning the presence of thousands of chemicals added to our foods and other products, and much of cardiovascular disease with personal habit changes. 

But our political system is gridlocked, and our healthcare system limits its jurisdiction to flagrant disease. Insisting on overt disease development instead of sensible prevention, we’ll be faced with dilemmas such as the efficacy versus cost of high-tech procedures like bronchial thermoplasty. A genuine “breakthrough” in American healthcare will be to address illness far earlier in its development. That would require a sharp increase in personal responsibility and civic participation. Are you willing?

Monday, August 27, 2012

THE GLOBAL HEALTHCARE CUL DE SAC


I’ve written here ad nauseam that no matter what healthcare policy the U.S. pursues—the the Affordable Care Act (“Obamacare”), old-fashioned fee-for-service, national single-payer, or the mishmash we currently suffer under—healthcare costs will eventually bankrupt us.

When we take a disciplined, knowledgable look at why healthcare is so grotesquely expensive, the usual suspects—doctors’ incomes, hospital billing practices, malpractice issues, nonpaying patients—fall by the wayside. Sure, they exact some cost, but are dwarfed by a single megaproblem: we grossly overuse medical technology...and there’s new hi-tech coming down the pike daily, with ever greater price tags.

We hear about growing lines of patients awaiting services in the U.K. and Canada, and now the same sort of news is emanating from Cuba and China. Check out http://news.yahoo.com/cuba-campaign-takes-free-health-care-142839515.html?_esi=1 and http://news.yahoo.com/chinas-chaotic-health-care-drives-patient-attacks-131133300.html?_esi=1.

Cuba’s system is entirely socialist, meaning the government owns the facilities and employs the practitioners. Besieged by increasing costs, Cuba's health sector has already endured millions of dollars in budget cuts and tens of thousands of layoffs, and it became clear this month that Raul Castro is looking for more ways to save. A media campaign is now discouraging what it terms “frivolous” medical visits. Its theme, on posters in clinics and ads on state TV is, “Your health care is free, but how much does it cost?”

China’s system is, surprisingly, more and more market oriented, with patients covered by private insurance. Demand has so grossly expanded that facilities are insanely overcrowded, doctors glaringly overworked, and patients infuriated to the point that several have murdered their doctors. Said Yanzhong Huang, an expert on China's health reforms at the Council on Foreign Relations, “The supply cannot catch up with demand, you have long waiting times, doctors on average spend five minutes with patients and don't have time to communicate well with their patients, and that creates problems." Does that sound familiar here?

According to an expert at the World Health Organization, much of dissatisfaction with healthcare occurs when “…people don't know the limitations of medical care and they expect that if they pay, the cure will come.” That should also sound familiar.

I don’t see any way out of this dead end except stopping, quieting down, and redesigning healthcare after publicly exploring its most basic questions: what is healthcare about, anyway? What do we mean by “illness,” “treatment,” “suffering,” “healing,” and “cure?” How are body and mind related? How are lifestyle and illness related? What’s the doctor’s responsibility? The patient’s? The caregiver’s? What happens when they meet, and what should happen? When is it okay to die? What level of care do we owe one another?

Thursday, August 23, 2012

THE MEDICAL OFFICE


I’m hearing stories about wonderful doctors whose offices are less than wonderful, actually reminiscent of the stiff 1950s. My friend Miriam told me,

“Last time I visited my doctor, the receptionist didn’t say a thing to me, just pushed a sign-in sheet across the counter. Soon a woman called me in from the waiting room. Walking ahead of me, she asked how I was—a nice touch, but really, she wasn't even looking at me. And who was she, anyway? A nurse? Another patient? For all I knew, she could’ve been someone who’d wandered in off the street. Am I supposed to ask? Is it up to me to teach manners to grownups? She weighed me, took my temperature, and left the examining room. In a few minutes, Dr. D came in. Now, him I love. Right away he lifted my mood. Afterward, he walked me out, hugged me, and moved on to his next patient. The woman behind the desk said, 'We don't take Medicare anymore. Today's visit is seventy-seven dollars.' She was like a clerk selling me chewing gum, take it or leave it. She handed me a bill with my name on it, misspelled.

“I know Dr. D cares about me. I'm lucky he's my doctor. But his office staff acts like their customers might be burglars. If they were any more negative, they’d assault patients. Wouldn't they enjoy their work more if they were friendly? How can Dr. D not notice how anti-healing his staff’s low morale is?”

Imagine you work in a medical office, dealing with patients who can be out of sorts, demanding, even intimidating. You hear them wail in the examining rooms, and your daily office buzz includes saddening details of their miseries. You spend hours with insurance company phone robots, careening through algorithms in search of the dubious prize, an argument with a live representative. All this can harden you—to patients, to your work, and to your own feelings. Little wonder medical office workers’ morale can decline to the point that they treat their customers coldly.

If a medical office were selling widgets instead of conducting healthcare, the staff might be forgiven its emotional distance with the traditional apology, “Business is business. Don’t take it personally.” But healthcare isn’t about widgets. It’s about people in their deepest pain and need, who are suffering, defenseless, pushed to their edge. If they’re to matter in healthcare, we who work in it need to feel and act from a deeper humanity.

I recommend this more from a medical sense than a moral one. It can’t be emphasized enough that patients need comforting. They need to leave the medical appointment feeling better than when they came in. Toward that end, arguably the most important person on the staff is the receptionist, who sets the visit’s emotional tone. Every member of the staff is potentially a placebo, able to make the patient feel better. An ideal visit is one where the patient is already half-treated before even seeing the doctor.

I could offer suggestions touching on office design, staff behavior, traffic flow, and other features, but every office is different. Instead, I suggest trying this: when business is slow, how about a staff member pretending to be a patient, going through each procedure that a patient would, and afterward writing a paragraph or two about how it felt? When everyone’s done it, you can all go out for pizza and beers (at office expense) and talk about changes you might like to make.

Wednesday, August 22, 2012

REP. AKIN AND MENTAL HEALTH


By now everyone’s heard about Rep. Todd Akin’s (R-MO) comment that women only rarely get pregnant from “legitimate” rape. Aside from his view being erroneous and brutish, it’s an example of increasingly endemic poor mental health.

Unless some alien force had captured his tongue and ventriloquized him, what he said was what he believed. His claim that he “misspoke” amounts to flatly dishonest groveling; misspeaking occurs on the level of single-word choices and typos, and this was a complete idea. Believing that “legitimately” raped women rarely get pregnant, he probably harbors a slew of other off-the-wall opinions he takes to be fact.

It seems more Americans are doing similarly, believing that climate change is a tree-hugger hoax, the 9/11 attack came from Iraq, the world was created in one week six thousand years ago, and Obama’s a Kenya-born Muslim. Never mind evidence, science, and logic—we’ll believe anything we damn please.

Obviously, this is no way to run a democracy. But it’ll get even worse unless we push for regular reality testing. It’s not enough to demand that Mr. Akin withdraw from the Senate race. We need to let him and the millions of others who operate from hermetic wishful thinking know they’re not only flat-out wrong, but actually circling the sanity drain.

Saturday, August 18, 2012

THE CAUTIONARY PRINCIPLE


As I recently slurped a Yoplait yogurt, I wondered whether its milk came from cows given bovine growth hormone. I emailed the customer service department, and got my answer the same day: “There’s no evidence to show rBST is harmful to humans.”

I took that to be a yes. I don’t know if rBST is a curse or a blessing, for that matter, but I don’t see any need to ingest even a homeopathic dose of it. Exercising my sacred American consumer Right of Choice, I scratched Yoplait off my shopping list.

Bovine growth hormone has cleared the bar of the Food and Drug Administration. It’s a low bar: the FDA admits into the marketplace thousands of untested chemicals it lumps together as GRAS, or “Generally Recognized As Safe.” GRAS isn’t cautionary; it’s more like, as kids say, whatever. In the cautionary view, questionable chemicals aren’t citizens (at least not until the Supreme Court meets) so they don’t have the right to be considered innocent until proven guilty beyond a doubt.

In Canada, the Cautionary Principle happens to be the law. We visited a relative in an Ottawa suburb, and learned it’s hard to buy Roundup there. If you’re absolutely determined, you can get it, but only if you post a sign in front of your home saying you’re using it. To your greener neighbors, your sign may as well say, “I Whip My Children.”

Read the ingredients on the back of your shampoo bottle. How many of them would remain there if the U.S. were to adopt the Cautionary Principle? (By the way, have you ever wondered how those who make shampoo choose its 141 ingredients?) Of course, we’re talking more than shampoo. It’s time we did something to end the relentless contamination of our food, household agents, building materials, personal products, and even medications.

Much of this pollution resides in stuff I don’t need anyway. Browsing in Safeway, I peeked at a sandwich’s ingredients list. Why does a turkey sandwich need three different artificial coloring agents? Somehow my life will limp along without Yoplait and Safeway sandwiches.

Don’t hold your breath waiting for Congress to fix this. The folks who make this stuff will wail that the Cautionary Principle will wreck their business. Hundreds of thousands will lose jobs. The national economy, now only derailed, will tumble over the precipice. The beginning of the end of civilization as we know it. In other words, the usual. And Congress won’t pass any law that threatens the end of civilization as we know it.

But here’s the good news: we don’t need Congress. All we have to do is enact the C.P. ourselves. All the time. Every act, including every purchase, is a vote. To paraphrase Arlo Guthrie, if only one person stopped buying Yoplait, he or she would be called an eccentric. If two stopped, we’d called it an emerging cult. Three, though, is a conspiracy, and when four do it, corporations begin taking notice.

Johnson & Johnson, for example, plans to remove potentially dangerous chemicals from nearly all its adult toiletries and cosmetic products worldwide by 2015. Its announcement didn’t call them hazardous, only "chemicals of concern." Fine. That’s the Cautionary Principle at work. We don’t have to revive Congress or rely on Friends of the Earth and Physicians for Social Responsibility. All we have to do is to buy exactly what we want and not to buy what we don’t want.

Monday, July 30, 2012

CAREGIVERS AS PATIENTS


Working with people who have cancer, I come into abundant contact with their caregivers, usually their spouses. I’ve written here about how the caregiver suffers, sometimes more than the patient does. Caregiving is all-consuming, unrelenting, exhausting, and too often under-appreciated. The physicians and others who treat patients assume that their mandate is to serve the patient, and that caregivers’ tribulations are outside medical responsibility.

Little wonder, then, that caregiving is such a hazardous occupation. Studies have found that caregivers are at risk for high blood pressure, impaired immunity, and cardiovascular disease. Spousal caregivers age 66 or older have a 63% higher mortality rate than noncaregivers the same age. It’s not as if we really need those studies; just ask a caregiver.

I’m beginning to realize that one way to get practitioners to take caregivers more seriously is to identify them as patients. Suppose a man with cancer, say, visits a doctor along with his wife. What would their care look like if the doctor recognized there were two patients to deal with?

Truly, doctors aren’t generally equipped to address caregivers’ problems, but they can be referred to appropriate professionals and support services. Where there’s a will, there’s a way, but wills and ways depend on first seeing the situation.

Wednesday, July 25, 2012

COMPASSION FATIGUE


We who are helpers need to know our resources are limited. I recently suffered my first instance of compassion fatigue (check out http://www.compassionfatigue.org). My practice is hearing the anguish of sick people and caregivers. Several of my friends got seriously ill during the past month, and others died of illness and accidents. Maybe the stars were in unfortunate alignment. Anyway, it got to be more than I could handle, and pain began to saturate the air in our home. My wife pointed out that I was exhausted, and was getting angry without provocation. 

I finally realized that I couldn’t take on any more, and told people that. I turned off the phone and gave my e-mail a couple of days rest. Now I feel refreshed, and I’m sure I dodged a stress-induced illness.

Have you experienced anything like that?

Monday, July 16, 2012

DIE IN THE STREET?


There are now 50.7 million medically uninsured people in the United States, one of every six of us. More, actually, since many who believe they’re insured learn at the most inopportune time that their policy, despite high premiums, is so thin and narrow that it’s virtually worthless.

What are the uninsured to do? Traditionally, we’ve directed emergency departments to serve them regardless of their ability to pay. We do that because the alternative is to let them die in the streets, which can create a traffic and disposal problem. 

In treating them, emergency departments, mandated to maintain expensive equipment and hypertrained staffs, turn out to be awesome money losers for hospitals. For their part, hospitals try to compensate by soaking those patients who are insured or seem solvent. (The ED that treated me for two hours a few months ago billed Medicare ten thousand dollars, and accepted eight hundred.) That is, we are all paying through the nose, via taxes and premiums, for the expensive, however desultory, care indigent patients receive.

We could look at this and say, “Wait a minute. We’re essentially paying for the care of the indigent anyway, and because they use EDs, paying through the nose. Why not cover them instead with standard care, for less?” 

That’s what a sane society would do, but we’re not there yet. As Winston Churchill said, “Leave it to the Americans to do the right thing…after they’ve tried all the wrong ones.”

Wednesday, July 11, 2012

DIETARY SUICIDE



Thanks to Michelle Obama’s interest in Americans’ epidemic obesity, we’re hearing more these days about eating disorders, even this innovative one, described in last Sunday’s supplement to the Boise, Idaho Times

DIETARY SUICIDE FAD

An ambulance sits vigilantly in the floodlit parking lot of the Burger Blitz in suburban Lincoln, Nebraska. Its two attendants quietly observe a particular patron inside the restaurant, a man who has been eating ravenously. 
 
The man suddenly stops mid-chew. A few morsels tumble from his distended craw. He shudders, turns the color of a plum. In mortal agony, he grasps for a breath beyond his reach, and finally pitches forward into the remnants of his meal, a cardboard bucket of chicken bones, ketchup, and lard.
 
“Let’s hit it,” cries the taller attendant. They leap out, pull a collapsible gurney from the ambulance, and roll it into the restaurant. 
 
The 26-year-old manager, Bobby Lee Dilworth, meets them at the table. Like the other employees, Dilworth wears a tiny checkered chef’s hat adorned with the well-known Burger Blitz emblem, a cow grinning from a meat grinder. 
 
“Evening,” says the shorter attendant, unbuckling the gurney’s straps.
 
Dilworth nods. “Third one this week,” he complains, wringing his hands. “I wish something could be done. Last night one just laid there getting stiff while other customers waited for the table. It’s not fair, you know what I mean?”
 
The attendants take this as a professional challenge. “Well, here,” says the taller one, “we'll deal with him while you clean up the table. Place'll be back to new in a minute.”
 
Skilled though they are, the attendants nonetheless cause some little commotion. Several patrons look up curiously from their boxes of Gutbusters and Chicken Tetrachloride. Perhaps they do not know what has happened, but then again, perhaps they do.
 
Perhaps they are aware of the trend that has begun to sweep the Midwest like prairie fire: suicide by gluttony.      
 
The foremost expert on this phenomenon is Dr. Karl Mandrake, Chief of the Nutrition Department at the respected Sloan-Smithson Institute in Albany, New York.
 
“This fad shouldn't surprise anyone,” Dr. Mandrake confides over lunch. “After all, we are a nation of consumers, so what could be more natural than for consumption itself to become a popular form of suicide?
 
“Most of these self-destructive acts have occurred in fast-food outlets for economic reasons,” Dr. Mandrake continues, folding his Reuben sandwich to wrestle it into his mouth. “Look at it this way: twelve or fifteen GooBurgers or Fat Dogs or whatever they’re pushing these days are still cheaper than a bottle of sleeping pills. In fact,” he grins, leaking a rivulet of mustard onto his tie, “you even have change coming.”
 
The owners of these restaurant chains seem surprisingly unbothered by the fad. Harold Colon, President of the National Faux Food Association, says, “Suicide is tragic, but we must face facts. The fact here is that to us, these people are customers, too. Let me tell you, customers are very special people—even though I’ll admit these folks sometimes make a mess. From some of the stories we’ve heard, you’d think the other customers would walk out. But they don’t. That’s what we call in our business ‘brand loyalty.’ Anyway, we feel fortunate that hardly anything disgusts our clientele.”
 
The issue is causing battle lines to be drawn.
 
On one side is the U.S. Surgeon General, who has recommended that fast-food restaurants employ full-time security guards to enforce healthy eating practices and verify that patrons carry suicide insurance.
 
On the other side is the might and wile of the fast-food industry. Explains Faux Food Association’s Colon, “In business you find a need and fill it. One chain is now trial-marketing a package that caters exclusively to suicides. They offer the meal—a meal especially rich in embalming preservatives, I might add—and the cleanup, and burial in a large styrofoam box. Their motto is, ‘We do it all for you.’”
 
In a way, one concedes, this is progress. But is it good for the country in the long run? Researcher Dr. Mandrake answers, through a mouthful of blackened redfish and creamed spinach, “That's not for me to say. I don’t get involved in politics. I’m just into health.”