Friday, March 22, 2013

WE'RE MOVING!!

My new book, The Bedside Manifesto, is finally out in the world. It's available as a paperback at Amazon and as an e-book at Amazon, Barnes & Noble, and if you want to support independent bookstores, Kobobooks.

Of course, as an incurable ranter I'll continue this blog. But I'd rather it be a conversation with you, since I get tired of hearing my own voice. Some readers have told me it's difficult to post comments here, and they're right. Even I have trouble with that, and blogspot.com offers no help for it.

SO AS OF TODAY, WE'RE MOVING THE WHOLE SHEBANG TO BEDSIDEMANIFESTO.COM. The site will include the blog, information on the book, and contact capability. It's in its infancy, so you might find a few blips here and there, but please know I'll steadily be tweaking it toward user-friendliness. Thanks for riding along so far, and now arriba y adelante!

Saturday, March 16, 2013

HEALTHY SHOPPING


We Americans tend to think of poison as immediate. I remember seeing BT Collins, Director of the California Conservation Corps, drinking a beaker of malathion in the 1980s to demonstrate his belief that it was safe. Sure enough, he didn’t double up and fall over.

The fact is that many carcinogens and other toxins work their damage slowly, over decades or even entire generations. So when Monsanto flaks declare Roundup “safe,” I don’t believe them, and also doubt their pronouncement that their genetically modified food ingredients are safe. Since we don’t—and can’t yet—know the long term effects of these products, they should at least be labeled so we can make an informed choice.

A move to label, California’s Proposition 37, was defeated in the last election, thanks to the megabucks Monsanto and its corporate accomplices pumped into TV ads. The bad news is that the electorate’s easily hypnotized. The good news is that we have access to something more powerful: the marketplace.

A. C. Gallo, president of Whole Foods, recently announced that the huge chain will require labeling of all genetically modified foods sold in its stores.
This policy, he said, came in response to consumer demand. “We’ve seen how our customers have responded to the products we do have labeled. Some of our manufacturers say they’ve seen a fifteen percent increase in sales of products they have labeled.”

In other words, we may not need to seek legal recourse if we simply shop intelligently by limiting our purchases to foods labeled “No GM ingredients.”

Thursday, March 7, 2013

WHAT DO WE MEAN BY “EVIDENCE-BASED”?


My friend Matt sent me an interesting article from lymedisease.org, written by its CEO, Lorraine Johnson, JD, MBA. You can find it at

Many Lyme patients believe that diagnostic guidelines have been corrupted by industry conflicts (diagnostic tests, vaccines, and insurance) and researcher self-interest. This occurs elsewhere in healthcare, too, which is why there’s a growing interest in “evidence-based medicine,” or EBM. Makes sense, after all. Every sane person would favor a medical style based on research that promises, as its proponents state, to integrate the “…best research evidence with clinical expertise and patient values.”

Trouble is, though, that patient values are frequently overlooked despite any lip-service to the contrary. This happens not from malign intent, but because patient experience is necessarily subjective, so not amenable to scientific measurement. 

Lorraine Johnson writes, “…we need to know how patient values are taken into account. Are patients involved? Whose values and viewpoints are represented?” She mentions that this concern is shared by the Institute of Medicine, along with newly emerging organizations established under healthcare reform, like the Patient Centered Research Outcomes Institute (PCORI), with its budget of $350 million.

So please, when we hear the term “evidence-based,” let’s ask if the evidence includes the person who happens to be sick.

Wednesday, March 6, 2013

REFUSE TO GIVE CPR?


By now you’ve probably heard of the debacle at Glenwood Gardens retirement home in Bakersfield, CA last week, in which 87-year-old Lorraine Bayless died after no one offered her CPR when she’d collapsed. The 911 dispatcher pleaded with people at the home, including a nurse, to resuscitate the woman, but was told that giving any medical help was against company policy. By the time EMTs arrived, Ms. Bayless was unrevivable.

Outrageous, right? But the story bears twists and turns that give one pause.

For one thing, Brookdale Senior Living, which owns the facility, initially said its employee acted correctly by waiting until emergency personnel arrived. Then it issued a new statement saying the employee had misinterpreted the company's guidelines. "This incident resulted from a complete misunderstanding of our practice with regards to emergency medical care for our residents," the Tennessee-based company said.

We don’t know at this point exactly what Brookdale’s policy is, but Ms. Bayless' family said she was aware that Glenwood Gardens didn’t offer trained medical staff but opted to live there anyway. They expressed satisfaction with the care she received, saying her wishes were to die naturally. Unfortunately, though, Ms. Bayless had no “do not resuscitate” order on file.

Meanwhile, according to the Associated Press, Bakersfield police are trying to determine whether a crime was committed when the nurse refused to help even find someone to perform CPR, the Kern County Aging and Adult Services Department is looking into possible elder abuse, and the state Assembly's Aging and Long-term Care Committee is investigating to see whether legislation is needed.

Ms. Bayless herself, of course, would supply the most useful input, but she’s sadly unreachable. This entire misadventure illustrates the train wreck than can occur when there’s less than full and documented communication around dying, a subject that’s evidently still painfully taboo.

Tuesday, March 5, 2013

INVISIBLE SUFFERING


My new book, The Bedside Manifesto (to be published within the next month), argues that authentic healthcare reform won’t result from any juggle of its economics, only from reviving its center, the venerable “bedside manner.”

I needed to know what other authors were saying, so read piles of books on the subject, almost all written by physicians. Their titles include words I, too, use, like Relationship, Caring, Listening, and Compassion. Yet astonishingly, they’re almost all about diagnosis: pay better attention to the patient and you’ll diagnose more accurately.

Of course, a proper diagnosis leads to optimum physical treatment, and who wouldn’t call that a good thing? Yet none of these good doctors write about patients’ feelings. What’s the shape of their suffering, regardless of diagnosis? How can they be helped to feel better, right now, before any medical treatment?

The authors who do address patients’ feelings are those who work in palliative care. Here, at the apparent end of life, where diagnosis is no longer paramount, comfort is the priority.

Doctors tend to focus on literature within their own field, where there’s plenty to keep up on. To them, palliative care can feel outside mainstream medicine. In fact, end-of-life specialists lament that in the medical mind, a hospice is only somewhere to go to die. While that’s usually true, it’s more, too, as it offers long-sought comfort. A friend of mine who recently engaged hospice services told me, “Finally, no more chemo that makes me sick. The hospice nurses are interested only in me, not my illness. They hear me and keep me comfortable and as pain-free as possible.”

I’d love to see the hospice ethic extend into mainstream medicine. Why shouldn’t every patient with any condition receive this sort of personal attention and comforting? 

Monday, March 4, 2013

LIFE AT ANY COST?


An essay in the Sacramento Bee by Dr. Michael Wilkes, a professor at U.C. Davis School of Medicine (http://www.sacbee.com/2013/02/28/5222449/dr-wilkes-high-drug-costs.html#storylink=misearch#storylink=cpy) posits that pharmaceutical costs are not only going through the roof, but may be rising above the drugs' level of usefulness. He cites a drug used to treat melanoma, the cost of which is $120,000 for four treatments. If the drug succeeds, the patient’s life might be extended a few months. The majority of new cancer drugs cost at least $20,000 for a 12-week course, and often people need multiple courses and multiple drugs.

Of course, Big Pharma contends that drug development is an incredibly costly endeavor without no guarantee of return on investment. For a counter-argument, look up pharmaceutical firms’ even more incredible annual profits. A current fact of life is that healthcare is subject to corporate control, period. If you’re going to wait for that to change, don't hold your breath.

One possible resolution may reside in an old Jack Benny joke. A mugger, the story goes, flashes a gun at Benny and cries, "Your money or your life!" There's a pause. The mugger repeats, "I said, 'Your money or your life!'" Benny says, "I heard you. I'm thinking."

If four melanoma treatments for $120,000 might extend my life for four months, I ought to think: is that worth it? Should my family entertain bankruptcy for extending my side-effect-ridden existence for a short time? I'm finding that an increasing number of patients and their families who face this kind of question are opting for gracefully dying. It takes courage to fight, and it also takes courage to submit. As we become more sophisticated philosophically, life-at-any-cost looks less acceptable, and we become better shoppers.


Wednesday, February 20, 2013

MENTAL HEALTH DISORDER: GOING ALONG TO GET ALONG


Tonya Battle, an African-American nurse at Hurley Medical Center in Flint, Michigan, claims a note was posted on a nursery assignment clipboard reading “No African-American nurse to take care of baby.” Ms. Battle has sued, seeking punitive damages. The hospital’s president explained that the father bore a swastika tattoo, which concerned supervisors about the staff's safety.

This being the United States in the twenty-first century, whoever received the father’s request should have bellowed, “Dude, even the state of Mississippi just ratified the Thirteenth Amendment. You can either accept the nurses we give you or take your business elsewhere.” But no. According to Ms. Battle, the note in question was later removed, but black nurses weren't assigned to the baby's care for a month.

What troubles me about this story isn’t the racial angle as much as the fact that more staff—of any race—didn’t scream bloody murder. We seem increasingly reluctant to take moral stands. Ms. Battle served as Rosa Parks here, but why weren’t more voices raised? The major issue is, I think, deference to authority.

For a realistic and compelling view of this phenomenon, see the recent film “Compliance,” about employees in a fast-food restaurant who humiliate a fellow worker at the behest of someone claiming to be a cop. I guess they weren’t aware of Gandhi’s advice, “Never do the wrong thing, even if the authorities require it.”

Saturday, February 9, 2013

TO CONTROL GUN VIOLENCE, LOOK BEYOND MENTAL ILLNESS


Even the AMA has been saying many years that gun violence in America is a public health issue. Seeing it as such plugs it usefully into the subject of mental health. Unfortunately--and surprisingly--though, that's something we don't have a practical handle on. Plenty of us are way off the beam but not diagnosable under present standards.

Those who are frankly psychotic actually aren’t responsible for much violent crime. In all our gun massacres, few shooters had ever been designated insane. They were odd, alright, but not enough for anyone to summon the white coats. After they finally exploded, neighbors uniformly commented, “Well, he was a little strange. Kept to himself, got angry easily, and oh, yeah, he had a lot of guns.”

One endemic oddness these days combines anti-social isolation with fear. How many Americans are coiled in terror this very moment, eager to strike out in protection? How many will shoot relatives or harmless visitors as suspected intruders? How many of us, fearing any social confrontation, will homicidally “stand our ground?”

The soon-to-be-published fifth edition of psychiatry’s bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), won’t feature diagnoses like “doesn’t get along well with people,” or “frightened enough to own an armory, but not full-on paranoid.” Some other country’s DSM might consider these conditions abnormal, but here they’re arguably the norm.

We don’t need laws that address mental health as much as we need mental health itself. We can start by asking why Americans own one gun per capita, ten times the world average. As Gandhi asked armed-to-the-teeth Khyber tribesmen, “What are you so afraid of?”

Monday, February 4, 2013

IF YOU ARE WHAT YOU EAT, YOU MIGHT BE IN TROUBLE


Amid the abundant downers in the news—climate change, gun massacres, worldwide misogyny—at least one positive is emerging: we’re beginning to care more about what we eat.

School districts around the country are realizing they’ve been feeding kids trash lunches. New programs are serving local organic veggies and other nutritious foods, bought locally and often at lower prices than corporate crap. Until recently, hospitalized patients could literally die of malnutrition; now, here and there, decent food is finding its way in.

Even when food looks okay, dubious but invisible elements can lurk within. Do you know if your food was irradiated for shelf life, creating potentially carcinogenic free radicals? Do you know what your chickens or beef cattle were fed? Reuters reported today that Russia will ban imports of American turkey, beef, and pork due to concerns about the use of the feed additive ractopamine, a growth hormone. Ractopamine is banned in some countries because of concerns that it could remain in the meat and cause health problems, despite scientific evidence showing that it’s safe.

When you consider claims of “harmlessness,” please keep two caveats in mind. First, the exculpating research was almost always done by the corporation that sells the stuff; ‘nuff said. And second, that research takes only the short term into account. Dozens of serious toxins don’t reveal their effect for decades or even entire generations. That fact alone makes most additives and processes corporate dreams in terms of liability: we’re exposed to so many questionable substances that we can’t prove a cancer that appears today was caused by something ingested twenty years ago.

What do we do about that? I actually don’t think we need protective laws as much as we need to educate ourselves about food and buy only what we know to be healthy. The “invisible hand of the market,” as economists call it, takes care of business: the American turkey that Russia will no longer import is a $516 million loss for the ractopamine crowd.

Monday, January 28, 2013

WHO'S WITHOUT A LITTLE HYPOCRISY?


I’ll bet no one’s values are mutually consistent. Sooner or later, we run up against a contradiction that makes us feel nuts, like wanting to enjoy gravity-fed water while living on a hilltop, or traveling five-star first-class and expecting to meet the colorful locals. I don’t mind these disparities, actually. In fact, I rather enjoy them as abiding proof of our fallibility.

That’s what Catholic Health Initiatives, a nonprofit that runs some 170 health facilities in 17 states, recently bumped up against. According to the Colorado Independent, a thirty-one-year-old, seven-months pregnant woman arrived in extremis at one of CHI’s hospitals in 2006. To make a tragic story short, she and her twin fetuses died. Her husband filed a wrongful death lawsuit against CHI, claiming a timely caesarean delivery would have at least saved the babies.

The lead defendant, Catholic Health Initiatives, is committed to the Church’s position that the unborn are full-fledged people, with all rights pertaining. Colorado state law, though, defines “person” as someone born alive. 

So here’s where things get sticky. Attorney Jason Langley, representing CHI, argued that the wrongful death claims are invalid since the fetuses, having not been born, weren’t legally people. That is, Catholic Health Initiatives refutes the dogma that fetuses are people from conception onward when that would mean losing a lawsuit.

The Fremont County District Court ruled in CHI’s favor. The plaintiffs appealed, and now the case is heading to the Colorado Supreme Court. I find myself wanting to point a finger here, but I’d probably do better to search out and revise my own hypocrisies. 

Wednesday, January 23, 2013

TOO MUCH SOFT DRINK OR TOO MUCH SOFT LIFE?


Such a flap! You’re probably aware of the New York City ordinance banning soda servings larger than sixteen ounces. Mayor Bloomberg introduced it in an attempt to reduce incidence of obesity and type two diabetes, especially among young people.

Since then, opponents have raised a slew of objections, mainly along the lines of nanny government. Now comes a particularly creative protest: the rule is racist. The NAACP's New York state branch and the Hispanic Federation have joined beverage makers and sellers in trying to stop the rule from taking effect March 12. A hearing is set Wednesday. Critics say the soda rule will unduly harm minority businesses and "freedom of choice in low-income communities."

When I first heard of Bloomberg’s quest, I assumed he was doing it simply to publicize the hazards of massive soft drink ingestion, since the rule is clearly unenforceable: if a sixteen-ounce Coke doesn’t satisfy you, all you need to do is buy another.

The issue made me wonder why we feel change needs to come from legislation rather than from grass-roots education. Why do we feel it’s up to government to improve our diets or clean our air or decelerate climate change? Considering this nation was founded by hyperdedicated activists, how have we become so passive?

The harm we suffer from imbibing ten gallons of high-fructose syrupy soft drinks annually is negligible compared to our astonishing passivity. If Mayor Bloomberg is serious about improving New Yorkers’ health, he’d recommend they get up off their La-Z-Boys and get active in their communities.

Friday, January 11, 2013

HEART-TO-HEART CONTACT


“Sit on my bed and talk to me,” Ms. Keochareon said. 

The students hesitated, saying they had been taught not to do that, to prevent transmission of germs. What they knew of nursing in hospitals — “I’m here to take your vitals, give you your medicine, okay, bye,” was different, after all.


Martha Keochareon, a 59-year-old woman who’d graduated from Holyoke Community College nursing school in 1993, was dying from pancreatic cancer. She asked her alma mater if they’d be interested in having their students see her for intimate exploration of the dying process. They were indeed interested, and Ms. Keochareon was delighted to teach the students they sent.

One instructor observed that when students eventually ran out of asking her medical questions, they practiced what she called “therapeutic communication” instead. “The way we’ve learned in school and haven’t applied enough is just saying, ‘I’m glad to be with you; you must be frustrated; you look uncomfortable.’ And let the patient just talk and talk and talk, and see where they’re at.”

Ms. Keochareon died December 29, having pioneered a profound teaching tool. I hope this sort of heart-to-heart teaching spreads.

Thursday, January 10, 2013

WHAT TO DO ABOUT CANCER


James Watson, who won a Nobel Prize for co-discovering the double-helix structure of DNA, is no lightweight in molecular biology circles. Yesterday he criticized our decades-old “war on cancer” as “…not likely to produce the truly breakthrough drugs that we now so desperately need.” You can find a full report at

Watson takes particular aim at antioxidants. Though these are regarded by many as shields against cancer, some researchers feel the opposite may be the case, so don’t fill up on acai berries and dark chocolate just yet. “The time has come,” Watson said, “to seriously ask whether antioxidant use much more likely causes than prevents cancer.”

As interesting and important as that issue is, it distracts us from something at least equally fruitful, identifying and acting on environmental carcinogens. In his book The Emperor of All Maladies, winner of a 2011 Pulitzer Prize, oncologist Siddhartha Mukherjee emphasizes repeatedly that the most effective and safest treatment for cancer is prevention. We know today that we inhabit a virtual sea of known and possible carcinogens in our food and water, the air we breathe, and pollutants we allow. Powerful business interests, though, try to distract us from doing anything about them.

Energy companies would rather we didn’t know what chemicals are in the high-pressure slurry with which they fracture (“frack”) underground faults to extract natural gas. Plastic companies resist attempts to ban bisphenol A (BPA) from drink containers and food cans. Monsanto, Dow, and their corporate cousins successfully invested millions in California’s recent election to defeat Proposition 37, which would simply have mandated labeling genetically modified foods as such.

Let me suggest again that we consider Canada’s approach to this issue. Under its “precautionary principle,” dubious chemicals are banned, period. By contrast, America affords chemicals the same status as criminal defendants—innocent until proven guilty beyond a reasonable doubt. Our trouble is that it’s hard to discern the precise action of a molecule among hundreds of thousands of other possible culprits, and which exerts its toxic effect slowly, over years or decades.

So while we do our best to seek better treatments for existing cancer, we need to demand far more aggressive prevention measures, including our own smarter shopping and continual pressure on legislators.