HEALTHCARE AS THOUGH PEOPLE MATTER

OCCUPY YOURSELF

2012-02-11T11:03:00.000-08:00

Since posting “Go Check Your Shampoo Label,” I’ve heard concerns from a number of folks, online and offline. Of course, we’re not only talking about parabens in shampoos, but the entire sea of synthetic chemicals in which we’re immersed—known and potential toxins in our personal products, food, air, water, building materials, and pharmaceuticals. What can we do about it?

Well, we can contact our congressional representatives. The problem with that, though, is that so many of them aren’t our representatives anymore. My hundred dollar campaign contribution doesn’t influence them as much as the hundred thousand dollars handed them by Avarice Unlimited and Carcinogens-R-Us. Did I say “hundred thousand?” Lordy, that’s just a tip these days. That is, I’m sorry to say, we’ve pretty much lost our democracy.

On the other hand, The Market really does work. If we want toxic products to go away, we need only buy healthy ones instead. That means doing our individual research, which isn’t easy, yet more and more a survival requirement.

The industries that peddle toxic crap or oppose honest labeling need their products boycotted. For example, I wrote to Yoplait last year, asking whether their yogurt is made with milk from cows fed bovine growth hormone. They replied, “Studies show BGH is harmless to humans.” I take that as a “yes.” OK, no more Yoplait for me.

Government being useless, it’s up to every single one of us to get educated and act. To promote this notion, I’m developing a strategy:

OCCUPY YOURSELF.

Maybe you’re tiring, as I am, of waving a sign from a freeway overpass or getting tear-gassed on city streets. Though that might be useful in organizing opposition to the sick-making corporocracy, it’s starting to feel quixotic, and in need of a Next Step. OCCUPY YOURSELF means realizing it’s up to us to feel our anger and frustration; decide that this system’s material rewards are chicken feed compared to its injury to our souls; unplug the TV, the corporate spigot into our homes; and behave as though every act is a vote.

It works. For example, for years now our family hasn’t purchased any product whose ingredients include high fructose corn syrup. We’re not the only ones. Evidently a lot of folks have become aware of the link between HFCS and type two diabetes. The Corn Refiners Association, which had promoted it as a “natural” product, recently petitioned the Food and Drug Administration to start calling it “corn sugar,” evidently hoping we might miss that when we read labels. So they’ll push “corn sugar” till buyers catch on, then maybe try “maize sucrose,” but sales will continue to drop until this nonfood finally vanishes from the market.

In becoming more healthily proactive, we’ll be fulfilling the prophecy of John Knowles, M.D. (1926-1979), who was 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."

GO CHECK YOUR SHAMPOO LABEL

2012-02-06T15:29:00.000-08:00

Research published last month in the Journal of Applied Toxicology (http://onlinelibrary.wiley.com/doi/10.1002/jat.1786/abstract;jsessionid=D715345619D8FCC958CF30A4C10424A3.d01t04) indicates I’ve been right to boycott products containing parabens.

Examining human breast tissue collected from forty mastectomies for primary breast cancer between 2005 and 2008, scientists found parabens in virtually all samples. Paraben levels were highest in the upper-outer breast quadrants, where a disproportionate incidence of breast cancer occurs.

The technical name for this class of chemicals (including metaparaben and propylparaben) is para-amino benzoic acid. My inner cynic, forceful as ever, told me manufacturers changed its name to “paraben” a few years ago, when the public was beginning to realize benzoic acid was carcinogenic. “Paraben” is, after all, a friendlier name, more like something in your spice rack: a spoon of curry, a pinch of paraben.

Parabens are in many shampoos, moisturizers, shaving gels, personal lubricants, pharmaceuticals, spray tanning solutions, cosmetics, toothpastes, and processed foods. Serving as preservatives, parabens extend shelf life, not yours.

Does this report mean these cancers were caused by parabens? Not necessarily, but the association is too convincing to dismiss. For some reason incomprehensible to my Canadian relatives, we Americans don’t mind ingesting questionable chemicals until they’re absolutely proven poisonous—not easy to prove, considering cancer’s long gestation, our concurrent exposure to thousands of chemicals, and the FDA’s domination by a paraben-pushing industry. The Canadians have incorporated what they call the “Precautionary Principle” into law. Viewed through this lens, chemicals must be shown to be safe before they’re allowed into the market. So as you might expect, not as many make it as in the U.S.

My point here isn’t to legislate against carcinogenic chemicals. That window’s closed. The people who make a buck off them will bribe—excuse me, I mean lobby—legislators to keep them legal. I’m only telling you this so you’ll consider activating your own Precautionary Principle, and decline buying toxins, period.

IS BEREAVEMENT NORMAL?

2012-01-25T08:46:00.000-08:00

What do you do when you’re a young physician, get sick at the sight of blood, and are desperately in need of psychotherapy? You become a psychiatrist.

That’s what I intended when I began in this biz. My psychiatric training in medical school had featured only two methodologies, psychoanalysis and behaviorism. The former seemed to require a three-piece suit, somberness, and lifelong constipation, and the latter, excision of all emotion. However, the “human potential” movement was just cranking up, replete with consciousness studies, body-mind concepts, and even, bless me, humor. So hoping for more humane training, I investigated psychiatric residences.

I was quickly disillusioned. A fourth approach, psychopharmacology, was rapidly showing all others the door. A class of drugs, phenothiazines, was proving so effective in treating schizophrenia that the bulk of psychiatric research had shifted to chemistry. Almost overnight, psychiatry had simplified down to spare algorithms: diagnosis A, therefore drug B. Indeed, it was evident that sometimes drugs were helpful, but the challenge of exploring the human mind had all but evaporated. Thus a psychiatrist I am not.

Fast forward a quarter-century. I’m attending a continuing medical education luncheon. Pretty good fare, actually: prawns diablo, asparagus with hollandaise, the whole works, hosted by Avarice Pharmaceuticals, which has hired a Prestigious Professor of Psychiatry to inform us simple rural docs that we grossly underdiagnose depression. Were we to perform properly, more of our patients would be taking Happyzac^TM, Avarice’s best-seller.

I think you get the picture. As you read this, the editors of the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), are preparing its fifth edition. They will add and delete various diagnoses after some debate and a vote. Depression will maintain its place in the book. Bereavement, though, being a normal response to loss, has not been considered depression. The “bereavement exclusion,” as it’s called, is being challenged by editors making a case for bereavement being biologically identical to depression. As much as I try to calm my internal cynic, I can’t help but see Avarice Pharmaceuticals behind this push. If AP had its way, just about anything we do might be considered a drug-treatable disorder.

On the other hand, some psychiatrists are pushing back. A report issued by Columbia and New York Universities (http://www.nyu.edu/socialwork/pdf/wakefield.pdf) argues forcefully for the bereavement exclusion. If it's eliminated, says the report, “…there is the potential for considerable false-positive diagnosis and unnecessary treatment of grief-stricken persons.”

Fortunately, my inner optimist tells me maybe this is the beginning of resistance to the drug industry’s colonization of psychiatry. Maybe we’ll once again see this field as a science of wonder, not just an opportunity for profitable chemical manipulation.

ONE IN FIVE AMERICANS MENTALLY ILL?

2012-01-19T11:10:00.000-08:00

A story in Yahoo News today (http://news.yahoo.com/1-5-u-adults-suffers-mental-ills-report-140217713.html;_ylt=AjhGuG5pNfpqpMhJm0jE5t6s0NUE;_ylu=X3oDMTNtZG43MnUxBG1pdANUb3BTdG9yeSBGUARwa2cDMGU2MjNiYjQtMWRiYy0zNTE5LWIxNjYtMTM3ZjkyMzdjODFlBHBvcwMxOARzZWMDdG9wX3N0b3J5BHZlcgMzYjUzM2EyMC00) claims one in five Americans is mentally ill.

That’s a shocking statistic. The report defines “mental illness” as behavior corresponding to a specific diagnosis in the psychiatric Diagnostic and Statistical Manual of Mental Disorders. The DSM list includes psychoses, neuroses, and so-called disorders. Even though some of the latter are invented and lobbied into place by pharmaceutical firms intent on medicalizing even more behavior, one in five is nevertheless an alarming proportion.

I’m not entirely surprised, though. Reading letters to the editor in our local newspaper, it’s obvious many were written on the planet Venus. It’s hard to believe how unconnected with reality so many of our citizens are. This revelation should cause the rest of us to scratch our heads and wonder what’s happening. Genes? Recession? Regression? Heavy metals in the water supply?

I suggest it’s because we’re losing community. It’s heading the way of the dial telephone. Instead of chatting with neighbors on the front steps or attending the grange dance, we collapse onto the couch for another numbing tube dose, with its relentless reminders to consume. We’re a centrifugal society, flying out from our center into private cocoons of dark-windowed SUVs, monitor-lit rooms, and walled neighborhoods. A brilliant New Yorker cover cartoon in October, 2010 depicted parents chaperoning their trick-or-treating kids around a neighborhood, each adult face bathed in the blue light of a cell phone. Online social networks confer the illusion of community in the same way junk food pretends nutrition. Proud to have collected hundreds of “friends,” we nevertheless tweet in solitude. A popular calypso song, “Zombies,” puts it this way:

I journey to me local coffee house to sip a cup and socialize.

All of de tables are occupied by elegant gals and guys.

But nobody say a single word, dey be staring at deir laptop screens.

Wid all of dis classy company, dey prefer to talk to machines.

Dey be zombies, zombies, passing as one of us…

Loss of community means diminished reality testing. We check in—compare notions of the world—with one another less often, and with a level of skill that's shrinking from lack of practice. Civic participation has become less discussion and more non-negotiable sound bites. A popular saying is, “It takes a village to raise a child.” It also takes a village to maintain mental health. We don’t need attention from psychiatrists as much as simply hanging out with one another.

WHAT’S THIS ALL ABOUT, ANYWAY?

2011-12-26T11:05:00.000-08:00

Writing a blog is easy. You just say whatever’s on your mind du jour. You don’t have to be 100% sure of what you’re writing because if you don’t get it exact enough, you can correct it tomorrow. But books, especially paper ones, last longer so are more difficult to set straight. These days, then, as I massage this blog into a book, I need to think more carefully about what I’m writing.

I’ve described here how illness changed during the past half-century. When I was a kid, medical visits were principally for bacterial and viral infections. Now they’re mainly for conditions deriving from pathogenic (disease-causing) lifestyles, including horrendous diet, inadequate exercise, poor stress management, dysfunctional relationships, negative self-image, and exposure to literally a million toxins and carcinogens in our food, air, water, building materials, home products, cosmetics, and even medications. These behaviors predictably lead to obesity, type two diabetes, and much of cancer, hypertension and cardiovascular disease. This notion—that we cause most of our diseases—can be a hard fact to swallow. If you don’t believe it, ask your doctor.

Thinking about this shift critically, I’ve come to realize that pathogenic behavior isn’t intentionally self-destructive. On the contrary, it’s usually an attempt to cope with social demands, some of which can be frankly insane. My friends who began to smoke in their late teens and early twenties did so for peer acceptance; they lit up because their friends did, attracted by cigaret ads touting savoir faire. Alcoholics drink not to bring on cirrhosis, but to anesthetise the pain in their life. A teen doesn’t disappear into the couch-potato video game world aiming to flab his body, but to visit a place where he can win for a change. The compulsive eater doesn’t put away a quart of Ben & Jerry’s in response to a lipid deficit, but because she senses an internal emptiness, a feeling of literal unfulfillment. The employee or spouse who puts up with abuse does so because the prospect of responding to it honestly is even more threatening.

In other words, much current illness arises in unhappiness. Every culture's values inevitably dictate much of its constituents’ behavior. Our culture, leaning massively toward materialism, consumption, and individualism, ultimately breeds feelings of inadequacy, competition and separation. Little wonder, then, that we train our physicians to examine and treat individuals, virtually ignoring the context in which they live. Thus we docs wait in our offices and clinics for patients to show up with the diseases that have finally bloomed from their various unhappinesses, and we repair them enough to return them to their pathogenic lives.

This cycle is obviously ineffectual, not to mention ridiculously costly, but even worse, our treatments perpetuate misery by simply turning down its amplitude. Our patches, our tranquilizers and antidepressants, our BP meds and stents and stomach staplings do little more than numb the pain people have unconsciously chosen to live with. In the most honest light, much of our intervention can be seen as enabling neurotic behavior.

Certainly we should treat the longterm smoker's emphysema and the type two diabetes of the obese, since healthcare without compassion is only engineering. But while we perform those treatments, we need also to exercise commensurate skills in educating, encouraging, and supporting our patients in genuine prevention. Colonoscopies and mammograms have their place, but people need also to awake to the possibility of higher-quality lives, styles that honor their personal value and don’t just clear the lowest bar society offers.

SUFFICIENT ATTENTION SYNDROME: The Subtle Crippler

2011-12-14T09:23:00.000-08:00

The article below was lifted from the current issue of the Journal of Possible Disorders.

In mid-November of this year, Dr. Kevin Bland of the University of Cleveland School of Medicine described a disorder long thought to exist but never before identified, Sufficient Attention Syndrome.

“SAS may be part of the autism range,” said Dr. Bland. “Its sufferers were previously ignored because they tended to avoid online social networks. They’re identifiable, though, by their requirement of unusually long periods to assess their surroundings. They pause in conversations, evidently to think about what was said and what to say themselves. They are employment-challenged by their inability to multitask; in fact, they often seem proud of being monotaskers. Continually dissatisfied with news headlines, they insist on knowing details, too. They don’t watch television because rapid scene changes nauseate them. They’re often shunned because they’re considered too curious and intense.”

Fortunately, treatments are promising. According to Dr. Bland, “Avarice Pharmaceuticals has developed a new drug, Distractin, designed to scramble neural circuits back to normal. We expect in the near future to welcome SAS patients back into fast-track society.”

CONSUMPTION

2011-12-06T09:11:00.000-08:00

We’d do well to ask why obesity is so rampant. I mentioned yesterday that healthcare costs resulting from it exceed those associated with both smoking and drinking. Funny: all these pathogenic behaviors involve the mouth.

Hardly anyone would dispute that we’re a nation of consumers. We were once a nation of creators, inventors, initiators, but now we just sit ourselves down and ingest. The trope’s even pervaded healthcare: during the last thirty or forty years, as our model of healthcare shifted from a service to a commercial transaction, patients and doctors became “consumers” and “providers.” When I hear myself referred to as a provider, I’d like to provide the speaker with a sound drubbing. And the term “consumer” conjures for me the image of those train-sized omnivorous worms in Frank Herbert’s Dune.

Why are we such obligate consumers?

I suspect we aim to fill a void we sense in our core, a feeling that we’re existentially empty. I’ve quoted eating-disorder guru Geneen Roth here more than once: “You can’t get enough of what you don’t need.” The emptiness we feel isn’t material. It’s spiritual, a currency in which our society is painfully poor. Oh, yeah, there’s plenty of religion around, but much of that, it seems to me, is plain old creed, pious language betrayed by actual behavior. As a popular country/western song goes,

I’ve driven my whole life on empty

Still, I think I done pretty good

I got two SUVs and a Hummer,

And a home in a walled neighborhood

Got a boat with a thousand-horse outboard

My TV screen takes up a whole wall

I got lots of stuff, but it’s never enough

‘Cause no one sells love at the mall

I bought me an RV to travel

And seek what might comfort my soul

I yearned to be more than a food tube,

An unfillable, bottomless hole

I parked in the lot of a Wal-Mart

And in high hopes I entered the store

Bought an iPod and a drill and a George Foreman grill

But left as empty as I was before.

‘Cause no one sells love at the mall

They don’t deal with affection at all

True love, you can’t get it for cash, check or credit

‘Cause no one sells love at the mall

Consumerism presumes that nothing of much value exists inherently within us. Maybe this is an extension of the western notion of original sin. Until we sit and get quiet and finally see the wondrous beings that we are, we’ll continue consuming without satisfaction.

NO CHILD LEFT WITHOUT A BEHIND

2011-12-05T11:30:00.000-08:00

The first article I ever published, in Co-Evolution Quarterly in 1980, was entitled “Insurance and the Abandonment of Responsibility.” It pointed out that all else equal, those who take better care of themselves will subsidize, through medical insurance premiums and taxes, the healthcare of those who don’t. Nothing has changed since then.

A major reason healthcare is so expensive is that we simply use too much of it. Americans engage in a number of pathogenic (disease-causing) behaviors until florid disease erupts, and then ask physicians to repair them. We harbor the notion, reinforced by incessant marketing, that medical science can correct just about anything. I can mistreat my heart all I like because when it finally caves in, I can get a new one.

Arguably our most common pathogenic behavior involves diet, obesity being alarmingly endemic. Three-quarters of Americans are overweight or obese, but what’s more distressing is the kid rate, now estimated to be 15-25%. Obesity leads to type II diabetes, cardiovascular disease and hypertension, not to mention disability associated with carrying around all the extra baggage. It’s estimated that obesity costs our society $117 billion annually, exceeding the healthcare costs associated with both smoking and drinking.

Obesity’s become part of our accepted social landscape. Clothing catalogs standardly offer women “plus” sizes, and men, “big and tall.” Airlines debate installing larger seats, or charging passengers double if their bulk flows over the armrest. A man recently sued a burger chain because its seats wedged him in too tightly.

Last week I encountered evidence that obesity is no passing fad. Visiting another town where a new hospital is being constructed, we learned its special obesity ward will feature a ceiling fitted with a mechanical lift system since a good number of patients are now too heavy to hoist without industrial machinery; in addition, too many of the hospital staff themselves can barely carry their own estimable bulk, let alone their patients'.

Someone’s bound to cavil that some obesity is genetically programmed. Right: that proportion is about one in five hundred people. The rest comes from what’s eaten, period. Many pathogenic diets are a product of poverty. Try feeding your family a healthy diet on a minimum wage income. Unable to afford fresh organic groceries, you’ll opt instead for processed foods notoriously richer in preservatives than nutrition. These imitations are cheaper than the real thing, by the way, thanks to government subsidies their manufacturers wangled. Consuming these empty calories, you’ll plump out without being nourished. If people mattered as much as corporate profit does, we’d help them find their way to genuine food.

Too many families who can afford decent nutrition opt for the convenience of prepared foods, and children in these families grow up learning no alternative. If you’d like a shock, watch this video, http://www.youtube.com/watch?v=bGYs4KS_djg&feature=results_video&playnext=1&list=PL35762311C5A7EF37, in which chef Randy Oliver asks a second-grade classroom to identify tomatoes. The poor kids haven't a clue. Maybe they've seen a sliced tomato on a McGutbuster, but never a whole tomato.

I recently related in this blog a report by a prestigious medical board (http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm) about American childhood obesity. The board recommended testing kids for serum cholesterol levels beginning at age nine. It also recommended, between page after page of pharmaceutical interventions, “intense lifestyle management” without spelling out what that might be. Of course, everyone suggests behavioral change along with medications, but in practice that amounts to meds alone. Testing kids and putting them on “corrective” drugs will, of course, keep the wheels of commerce spinning (especially since kids will need additional drugs to deal with side effects), but it won’t do a thing to increase the national health. As a certified curmudgeon, I’m amazed, astonished, and appalled that we evince such impressive expertise in chemical engineering, but are so little interested in a national program to promote personal health responsibility.

HAPPINESS

2011-11-28T11:16:00.000-08:00

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

http://www.thehappymovie.com/film/.

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.

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

2011-11-12T15:48:00.000-08:00

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.

TECHNOMANIA

2011-11-10T10:15:00.000-08:00

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.

UNCERTAINTY

2011-11-08T12:16:00.000-08:00

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.

DO WE WANT NICE DOCTORS?

2011-10-31T13:47:00.000-07:00

In an essay in today’s NY Times, (http://www.nytimes.com/2011/11/01/health/views/the-downside-of-doctors-who-feel-your-pain.html?ref=health) cardiologist Lisa Rosenbaum asks whether “nice” physicians really provide better care than those who are merely technically competent. In this context, “nice” involves interpersonal relationship skills like physical proximity, eye contact, empathy, acknowledging patient concerns, and asking about feelings. Certainly these skills will make the physician more likeable to most patients, but will it improve their care?

Dr. Rosenbaum observes, “…we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.”

This discussion misses what patients yearn for—not so much likeable doctors, but doctors who can ameliorate their suffering while treating their physical disease. Niceness doesn’t treat suffering, and empathy only begins to treat it. Admittedly, both suffering and its effective treatment are objectively unmeasurable, but that’s no reason we physicians shouldn’t either learn how to do it or assign the job to someone who can do it. Instead of teaching medical students how to maintain eye contact or how close to sit, we should be showing them how to listen for elements of suffering in order to draw it out and be comprehended so it can be acted upon. But that’s an art, meaning it takes time, and this sort of profound intervention is not medically reimburseable.

DON’T JUST DO SOMETHING; STAND THERE.

2011-10-26T08:53:00.000-07:00

Please excuse the hiatus in posting. I’ve been putting my time into untwisting this blog into a book. I’ll keep you posted on progress.

The NY Times Well Blog, a reliable source of stimulating issues, ran a sparkling post October 20, http://well.blogs.nytimes.com/2011/10/20/when-doing-nothing-is-the-best-medicine/#more-62303.

In that post, Dr. Danielle Ofri discusses “clinical inertia,” the medical name for doctors doing nothing instead of doing something. She notes that the term is negative, and I agree. It conjures an image of a hypothyroid physician moving slo-mo, as though wading through Vaseline, despite the indication for immediate action. I wonder what Hippocrates would think of “clinical inertia,” having advised, “When it comes to the sick, do the least.”

We docs are trained in doing, and our culture teaches patients to expect us to do, no matter what. God forbid a patient leave the doc without something in her hand—a prescription, a sheaf of test orders, a packet of sample pills, anything to indicate that a medical transaction has actually occurred. An anthropologist would call her departure baggage a “fetish,” a symbol of conferred power.

The issue’s more complex than that, though. If it’s true—and I believe it is—that the bulk of medical visits are for illnesses generated in lifestyle, then less treatment might actually be therapeutic. Emphysema begins with smoking, cirrhosis with drinking, most type two diabetes from overeating, much hypertension from hypertense lives, and so on. Simply patching those symptoms with medical technology can bring relief and is a kind service, but also enables pathogenic behavior. I’m not for firing patients who live self-torturous lifestyles, but on the other hand I need to recognize that my intervention frankly enables that behavior without diminishing it. A more effective strategy would be to attenuate my intervention while requiring more involvement by the patient. Instead of calling that “clinical inertia,” call it plain old restraint.

PREGNANT MOM DECLINES CHEMO SO BABY CAN LIVE

2011-10-17T13:34:00.000-07:00

If you're up for a good cry, read this:

When Stacie Crimm found out that she had finally gotten pregnant at 41, she was overjoyed. So overjoyed that she knew exactly what to do when faced with the decision of whether to save her life or her unborn baby's. After she was diagnosed with neck cancer, Crimm decided to refuse chemotherapy. The heroic mom survived long enough to deliver her 2-pound, 1 ounce daughter, Dottie Mae, and hold the baby in her arms, just once.

“This baby was everything she had in this world," Crimson's brother, Ray Phillips told the news outlet.

For more of this story, go to http://newsok.com/oklahoma-cancer-patient-trades-her-life-so-her-baby-could-survive/article/3613629.

I can’t add a thing.

SIMPLE QUESTION GOES LONG WAY

2011-10-11T10:56:00.000-07:00

A friend asked me, “Do you think herbs actually do something, or not?”

Sometimes you catch a question that hotwires your mind. I got to thinking: how do we know herbs work? Well, why shouldn’t they? Some of allopathy’s most useful medicines—morphine, aspirin, some anti-cancer drugs—derive from plants. The potency of some herbs, and maybe all, is indisputable.

Since we’re asking, how do we know if pharmaceuticals work? Well, sometimes we feel a dramatic change. Most standard medical drugs are designed to be more forceful than herbs or other alternative meds, so their effects can be readily noticeable. (Did I say “more forceful?” Frankly, we often swat flies with cannons.) Anesthetics, antibiotics and analgesics in particular make an obvious sensory splash.

But with some drugs, the question can’t be answered. Adele, a member of our cancer group, wondered if her chemo was working. “I mean, how can you tell?”

“Well, how do you feel?” someone asked her.

“Are you tired?” asked another.

We yearn for a grip on this issue, some metric handhold.

“Well, when’s your next MRI?”

“Oh yeah, my MRI’s next Thursday. That ought to show whether it’s been working.”

That’s when Alec steps in. “You mean if the tumor’s smaller, then the chemo’s working?”

“Sure.”

“And if the tumor’s bigger, it’s not working?”

“Yeah, why?”

“Well, what if the tumor’s bigger, and if it hadn’t been for the chemo, you’d be dead now? Or say the tumor’s smaller, then how do you know if the chemo did that, or if it was your diet or prayer or zest for life?”

Alec can be a bit frontal, but he’s worth listening to. “You go read studies,” he continued, “and they say it works. Well, that’s reassuring, you say. That’s all well and good, but then you think about it: wait a minute, there’s no treatment that’ll work for everyone, so what if it’s me who gets the short end? And you’re back to your original question, ‘Is it working?’ All the statistics in the world don’t matter boo to individuals, anyway. Another guy in this group years ago said, ‘The only numbers I’m interested in are a hundred and zero. Either I’m here or I’m not.’”

So how do we know if this medicine we take is doing what we want it to do? Alec’s right. In most cases, especially in Cancerland, we don’t know and probably can’t know. Probably the greatest source of anxiety among people with cancer is not-knowing. While a tumor might go unfelt, uncertainty tortures around the clock.

Uncertainty is a far more potent feature of the universe than I am. Compared to forces like that, I am, like Job, dust. The realization that I can’t rearrange reality as I’d like can be really annoying. That can invite me to ask myself why uncertainty, such a pervasive, eternal, and undeniable feature of reality, bothers me. If uncertainty is inherently universal, from quarks up, then why don’t I just learn to live comfortably with it? Would dropping my discomfort be risky or dangerous or taboo or illegal, or what?

Abraham Maslow, a founder of the humanistic psychology movement, was one of the few people to study normality. When we crave mental health, what is it, exactly, that we’re after? Of the hallmark list he developed, the one that fascinates me the most is “comfort with uncertainty.”

OK, sounds good. Where do I sign up? Sorry, this is a blog, not an ashram.

Vaya con Dios.

GENUINE DISCUSSION OF HEALTHCARE REFORM

2011-10-10T10:39:00.000-07:00

In this blog I’ve mentioned “Health, Money & Fear,” a film that waxes eloquently on the deeper nature of our healthcare crisis. I and others felt the film is so right-on that we had to share it with our community. If you have forty-seven minutes to spare, check it out online at www.ourailinghealthcare.com. If it impresses you, consider sharing it with your community. One way to do that is embedded in the opinion piece I wrote, below, for our local newspaper...

"No doubt you're aware that health care's current cost can wreck your wallet, but do you also know it eats a growing portion of the national economic pie?

When I graduated medical school in 1967, America spent about 6 percent of its GDP on healthcare. That means one out of every $16 spent for anything went toward healthcare. Now it claims 16 percent, or one out of every $6. At this rate, we'll eventually live in makeshift shacks and shop in dumpsters, but at least we'll enjoy the most expensive health care in the universe.

As I've watched costs climb over the past several decades, I've read what those who study the subject have to say about it. One thing they agree on is that reducing costs can't be simply rearranging who pays for what. There's much more involved. Health care is astronomically expensive because we hold some painfully contradictory values about it. For example, we want all available medical technology, but we want it cheap, which is like insisting that a round-trip hike be downhill all the way. We demand end-of-life care that too often amounts to incredibly expensive prolongation of suffering. We fly into a litigious rage when doctors — that is, human beings — fail to provide us perfect security.

Such contradictions persist mainly because we hardly ever discuss them. Imagine my surprise, then, when I came across the film “Health, Money and Fear.” It makes a case for a national single-payer strategy similar to the California proposal now navigating the legislature as SB810. It goes further, however, in examining our costly cultural issues through interviews with experts I've long respected, including former New England Journal of Medicine editor Marcia Angell, MD, and Oregon Gov. John Kitzhaber, MD.

So I've joined with local medical colleagues who support affordable health care, plus the Nevada County chapter of Health Care for All, to show this film publicly, followed by a town hall-type discussion. A broad swath of Nevada County people, businesses and organizations are co-sponsoring the event. Admission is free and refreshments will be available."
WHEN: Tuesday, Nov. 29, 7PM
WHERE: Nevada Theater

STEVE JOBS GOT IT RIGHT

2011-10-06T10:58:00.000-07:00

In today’s NY Times Well Blog(http://well.blogs.nytimes.com/2011/10/06/so-doc-how-much-time-i-got/#more-61357), Dr. Danielle Ofri writes about the difficulty of informing a patient of his cancer’s lethality. She’s not the only doc who recognizes how hard this can be.

Part of the problem is that although we adults are aware of our mortality, we deny it most of our lives. On his deathbed, William Saroyan said, “I’ve always known I was going to die, but I thought in my case they might make an exception.”

In my practice, facilitating cancer support groups, new members often ask me if they’re going to die.

I answer, “Of course.” What else can I say?

They respond, “Oh, I know that, but will I die from this?”

Here’s how the kindest oncologist I know answers that question: “I don’t know if you’ll die from this, but I do think you’ll live with it the rest of your life.”

What a positive, creative way to frame bad news! Accentuating “the rest of your life,” it simultaneously affirms finiteness and possibility. In an ideal world, frank acceptance of mortality would be a general cultural value. Whether we’ve been diagnosed or not, the sword continually hangs over our heads, poking us to do what we need to do. I can’t put it any better than now-departed Steve Jobs:

“Remembering that I’ll be dead soon is the most important tool I’ve ever encountered to help me make the big choices in life. Because almost everything—all external expectations, all pride, all fear of embarrassment or failure—these things just fall away in the face of death, leaving only what is truly important. Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked.”

HEALING & THE EXXON VALDEZ

2011-10-03T13:59:00.000-07:00

"It seems as if we have confused science with restoration, knowledge with healing.”

I’ve written that sentiment here. But this iteration wasn’t from me, and it’s not about healthcare, at least healthcare for humans. It's by Marybeth Holleman, author of a highly regarded book on the 1989 Exxon Valdez oil spill, The Heart of the Sound.

Holleman feels that science, with its considerable expense, has been overused and undereffective in the still-ongoing cleanup. She writes,

“The massive $400 million spill-research boom in the [Prince William] Sound brought its own unanticipated injury, through intrusive sampling methods and the swarms of scientists, tent camps, boats and planes now in the Sound much of the year.

“About $500 million (half of the entire natural resource damage settlement) has been allocated for research; some say we could have spent ten percent of this amount and learned as much. Then we could have used more of the settlement funds for habitat protection.”

Holleman insists that relentless scientific investigation amounts only to

“…proof that oil hurts animals. While it’s new information, it doesn’t do any good, isn’t restoration, unless some protective measures come from it.”

So what does this have to do with healthcare as though people matter? Maybe I’m deluded, but I see a compelling parallel in our cultural healthcare strategy, the favoring of science over healing. We don’t lean that way because we’re logic nerds, but because science’s reps—thinktanks and developers and manufacturers—knock persistently on our door and natural healing processes don’t. Thus we physicians get paid oodles for performing invasive, expensive diagnostic and treatment procedures, but zilch for just sitting and listening to patients in order to help relieve their suffering.

I’m beginning to think that the healthcare issues I interminably rant about are just one profile of the way our culture faces every challenge—as a problem to be addressed—no, “attacked”—with a high-tech physical toolkit. Certainly imagination would reveal other responses that are at least as effective, and cheaper and gentler to boot.

WHO DOESN’T PALLIATE?

2011-10-01T10:12:00.000-07:00

“I’ve been treating this sixty-year-old woman for emphysema. She's on some meds, plus oxygen at home. She’s smoked a couple of packs of Camels every day for the past forty years, and you know what? She won’t stop. She takes a drag from her cigaret, then one from her oxygen mask, back and forth. I’m tempted to fire her. I mean, this is ridiculous. She claws back any advantage I can give her. What do you think I should do?”

This was asked of me by a physician friend who’s aware of my interest in medical ethics. What would you do? Me, I’ve learned generally to answer every question with another question.

I said, “Well, you’ve thought of firing her. Why haven’t you?”

“I’d feel awful. She’s doing herself in, but she’s still my patient.”

“What does it mean to you—that she’s your patient?”

“I’m her doctor. I guess that means I’ll stand by her no matter what. This is really beyond what I was trained in, diagnosis and treatment. What I’m doing with her is only palliative.”

“Only palliative?”

“I’m not a hospice doctor. I don’t do palliative.”

“You don’t?”

SUDDEN UNEXPECTED NOCTURNAL DEATH SYNDROME

2011-09-19T20:31:00.000-07:00

A couple of years ago I was chatting in the corridor of a university medical center with a cardiologist I know. Quite a personable physician, he's an associate professor of medicine, at the top of his craft.

I asked him one of the naïve questions I habitually put to my colleagues. "Tell me," I said, "do you ever think of your patients as soft-hearted or heavy-hearted? Stone-hearted? Heartbroken? That kind of thing?"

"Sure, my patients go through the same kind of social trials and tribulations everyone does."

"What I mean is: do you ever think they're telling a single story, not two? That their cardiomyopathy might express that they've been too big-hearted, or that their heart aches because of a great loss?"

Suddenly he remembered an appointment and marched off, leaving me to guess he was avoiding this conversation. Understandable, since after all, if you're a Catholic priest you don't want to be seen discussing Mormonism in St. Peter's cathedral.

The September issue of Atlantic magazine reviews a book by Shelley Adler, Sleep Paralysis: Night-mares, Nocebos, and the Mind Body Connection (http://www.theatlantic.com/life/archive/2011/09/the-dark-side-of-the-placebo-effect-when-intense-belief-kills/245065/.) Part of the book describes the death, in their sleep, of 117 Hmong men who'd immigrated to the United States. They were posthumously diagnosed with "Sudden Unexpected Nocturnal Death Syndrome," or SUNDS. Adler concludes,

"It is my contention that in the context of severe and ongoing stress related to cultural disruption and national resettlement (exacerbated by intense feelings of powerlessness about existence in the United States), and from the perspective of a belief system in which evil spirits have the power to kill men who do not fulfill their religious obligations, the solitary Hmong man confronted by the numinous terror of the night-mare (and aware of its murderous intent) can die of SUNDS."

When you die of SUNDS, what exactly is the physiological culprit? No one's sure, but one hypothesis is a cardiac arrhythmia. Whatever the mechanism, though, the question remains: why that, and why in this person, at this time? I'd like to ask my cardiologist friend if these 117 men had troubled hearts before they died.

SUNDS sounds like death by voodoo curse, doesn't it? Actually, it's known around the world. In

Indonesia

, it's called digeunton ("pressed on"). In China, it's bei gui ya ("held by a ghost"). The Hungarians know it as boszorkany-nyomas, "witches' pressure." If this phenomenon isn't exclusively native to the Hmong, it's worth studying not as a supernatural visitation, but as still further evidence that the mind affects the body.

Of course, we already know that. The love of our life enters the room, and our hearts flutter. A stranger is rude, and our blood pressure rises. Nine-year-olds have no trouble discovering this principle on their own, yet it seems totally alien to medical practice. We docs are trained to see human beings as biomechanical devices, organisms driven by genes, diet, hormones, and other physical forces, almost to the exclusion of influences from their inner world. It's as though we studied traffic accidents by taking cars apart, hardly glancing at the driver.

Believing healthcare to be wholly a "scientific" endeavor, we suspend our common sense, deferring to those who regard only the measurable as worthy of analysis. I suspect we do that so readily because even though lifelong experience tells us that body and mind are inevitably connected, we have trouble entertaining an image of how that works.

Alright, try this. Look in a mirror. See your face carefully, imagining what this person is thinking. Now remember the last time you were angry. You'll see that in your face. In fact, recall anger and try not to display it, however subtly.

We constantly speak what's called "body language." We can't stop. Try turning it off and a proficient observer will call you on it, saying you're trying not to express yourself, which, of course, is an expression. A simple body-mind model, then, is this: when you look at Willy's physical presence, you're seeing his mind in action. (It gets more complicated when Willy speaks, as the language of the mouth doesn't always coincide with that of the body, but that's for another day's blog.)

Why not give this model a try for a couple of days? Look more carefully at others while mumbling to yourself the mantra, "Actions speak louder than words." Then report in, eh?

THE R WORD

2011-09-16T09:09:00.000-07:00

When the subject of healthcare reform arises, I don't get involvedmuch in its economics, since whatever plan we ultimately adopt will bankrupt us…unlesswe "ration" healthcare.

Ah, the R word. The phrase "rationing healthcare" is politicalpoison, but what exactly does it mean?

When I was a kid, there was no such thing as health insurance. Peoplepaid for care retail, out-of-pocket, buying only what they could afford. Don'thave enough money for that serum you need? Well, get a loan from someone or gowithout. To be fair, though, this was before the great blooming of medicaltechnology, and care was much cheaper.

When insurance companies got into the act, they weren't going topay for just anything, so they set up rules, guidelines, parameters. That'srationing, too. Medicare, which cranked up in the mid-1960s, did the same. Infact, any healthcare payer that decides to operate without payment boundarieswill soon go belly-up.

Soinstead of flying into hysteria when we hear the R word, let's consider callingit what it actually is. This blog is loosely named after the title of a classicbook by E.F. Schumacher, Small Is Beautiful: Economics As Though PeopleMattered. Schumacher's principal advice was to address problems in reasonablescale. His phrase, "appropriate technology," meant that you you don't need a 3,000kilowatt power plant for an village well in India, that every home gardendoesn't need its own tractor, and that every head injury doesn't require anMRI.

In healthcare,sometimes clinical judgment will call for expensive technological intervention,and fortunately, it'll be there when when it's needed. When it's not needed, itshouldn't be done--not because of "rationing," but because we'll beusing technology appropriately.

LAPTOP MEDICINE

2011-09-08T16:24:00.000-07:00

In today's NY Times Well Blog http://well.blogs.nytimes.com/2011/09/08/when-computers-come-between-doctors-and-patients/,Dr. Danielle Ofri observes that healthcare is the only major industry not fullycomputerized…and she doesn’t wholly lament the fact.

To me, electronic medical records (”EMR”s) are like steroids: usefuland at the same time potentially hazardous. Steroids can ease symptoms, even savelives, and they can also cause diabetes, insomnia, personality changes, and ahost of other horrors. EMRs solve significant problems in medical practice,being portable, transmissible, and of course legible compared to physicians’notorious scribblings. On the other hand, as Dr. Ofri points out, "…bothphysically and psychologically, [the computer] has placed a wedge in the doctor-patientrelationship."

I’ve griped aplenty here about how crowded the medical examining room hasbecome. Fifty years ago it was a sanctum of intimacy, occupied only by patientand doctor. Then an insurance agent stepped in to verify that the company wasn’tblowing its money. Soon an attorney dragged a chair in, followed by the otherparty’s attorney. Then came a smattering of bureaucrats, pharmaceutical reps,and whoever else felt they had a stake in the proceedings. And now, theubiquitous computer. I can’t even count the number of people who’ve told me howthey resent seeing only the back of their doc’s head as he/she types into thelaptop.

Neither is Dr. Ofri wild about having to favor machine over patient. Shewrites that she compensates by devoting more attention to the physical exam.“Once the patient and I have broken free from confines of the desk, with itsdictatorial PC, we have a more comfortable realm, that of touch. As soon asthere is skin-to-skin connection, conversation flows more easily. In theabsence of a machine lodged between us, the traditional doctor-patientrelationship is restored.”

Hallelujah! But, alas, there is then the matter of arranging diagnostic testing,medications, and appointments, all mediated by computer. So the personal aspectof the medical visit—the touching, the contact, the deeper conversation—is nowsqueezed between the computer-dominated beginning and end.

“If you keep going where you’re going,” a nurse once advised me, “you’ll getwhere you’re headed.” Let’s look where medical practice is headed. Let’ssuppose practitioners’ compensation continues to get pared down, furthershortening the average visit time (now less than ten minutes). Designers ofmedical software—smart folks who wish to free up the doc’s time—will developmore sophisticated products such that the doc won’t have to key in a coherentnarrative, only select a macro—or even speak a command—and a fuller report willappear in the record.

If I were a software developer, I’d go further by wondering why the doc needs to get involvedeven eliciting a history when the patient can check off a list while inthe waiting room, which is converted instantly into ahistory on the EMR. And if, as Dr. Ofri suggests (and I agree), the exam is lessuseful than the history in securing the diagnosis, then as a secondaryfunction it can be largely automated.

I won’t shilly-shally here: the ultimate destination is what in my darkestmoments I’ve long predicted: healthcare from vending machines. Excuse me, Imean “healthcare” from vending machines.

Dr. Ofri’s to be commended on mourning the intimacy lost to computers. In that feeling,I suggest, she represents the bulk of practitioners, physicians and others who harbor implicit reservations about EMRs. I think that's what accounts for whyhealthcare is one of the last American endeavors to be computerized.

Other strategies are available. Here’s one alternative, which I admit might sound outrageous at first: smaller EMRs. Virtually all diagnostic tests are easilydigitized, but as for doctors’ notes, what amount, after all, do we need? I rememberthe chief resident on a ward of the huge county hospital where I trained, ayoung guy who was promoted to that position because he flat-out kneweverything. He’d see patients with the most complicated medical problems andthen sum up their cases with a single sentence, a short, elegant statement whichallowed any knowledgeable reader to instantly understand the situation.

I admit I don't have answers, only a few itchy questions. I'd love for more people to be in on the discussion. We’re drifting toward a vending machine future because those who are mostinvolved in healthcare, the two original examining room occupants, are all butsilent, having abdicated the chore to people who design, well, vendingmachines.

SOMETIMES A USEFUL TOOL

2011-09-06T18:17:00.000-07:00

Being in the listening/talking business, I feel like I've developed a dependable view of civil discourse's boundaries.

For example, people generally say they'd rather not talk about death. It's morbid, icky, a total bummer. That is, it's taboo. To break the taboo is to risk being considered one of civilization's discontents. If that describes me, so be it, but I'll persist in it since it's a source of unending fascination and in any case a universal certainty.

Some folks with cancer have noticed that the "C" word is also widely taboo. Interestingly, as a powerful conversation ender, it can be used to one's benefit.

A friend who has cancer told me, "My social club came at me again. The president called to ask me to work the desk all next weekend. I told him I couldn't because my brother will be visiting. He said to just leave my brother home. Then I told him I'd too tired to do it, and he asked why I was so sure of that. There was no shaking him. Finally I had to play the cancer card. Told him my tumor was acting up, which it is, a little, maybe. Or could be. Anyway, he apologized and got off the phone fast."

Is that okay to do?

I used a similar ploy a year ago. I was soaking one early morning at a hot springs. The sun was rising over a silent paradise, and there wasn't another soul around. Then a big guy in a ten-gallon hat lumbered in.

"Hi, how you doon?"

I smiled and offered a pleasantry, hoping he'd move on. But no.

"Been here long? Where you from? How's that water, huh?"

I said, "I don't mean to offend you, but I'm on a silent retreat. I'd rather not talk."

He held up his palms. "Hey, that's cool. Nobody has to talk. Tell me, can you stay overnight in this place? What's it cost?"

"I need to let you know why I'm here," I said. "I have a terminal condition."

I don't have cancer or any illness, as a matter of fact, only the condition we all have. But hearing this, the guy was poleaxed. Like my friend's club president, he couldn't handle it. He tipped his hat and walked rapidly out.

If you play the "T" card, let me know how it turns out.

MY SEROTONIN MADE ME DO IT

2011-09-03T10:38:00.000-07:00

I'm shifting today into amore cerebral mood, questioning a principle many of us take for granted.

Let's start with an onlineitem,
http://www.drugaddictiontreatment.com/addiction-in-the-news/addiction-news/addiction-as-a-brain-disorder/,which claims that a new definition of addiction might dramatically shiftits popular image, much as the American Medical Association changed our view ofalcoholism when it lifted it out of the gutter by defining it as a disease.

Following four years of consideration by eighty experts, the American Societyof Addictive Medicine (ASAM) now defines addiction as "…a primary, chronicdisease of motivation, brain reward, memory and related circuitry…" Thisnew definition shifts emphasis away from behaviors and focuses more on braindysfunction.

That is, addiction is now a brain disease. Indeed, there's evidence forthis view. The website says, “Twenty years of neuroscience has proven thatchemical changes in the brain can help explain the difficulty a personexperiences when trying to break free of addictions even after detox and treatment.”

That’s a carefully worded statement. It doesn’t say chemical changes in thebrain “cause” addiction, only that it coexists with those changes. Brainchemistry alterations are also associated with depression, aggression,meditative states, and a host of other emotions and behaviors.

It's easy, then, to jump to theconclusion that chemistry drives subjective experience: we’re hooked orblue or angry or in love because our neurotransmitters bend us that direction.

But it ain't necessarilyso. In fact, conscientious scientists take pains not to state the case likethat since—now, get this: no one’s ever proven a causal relationship. Nevertheless,hearing of such research again and again, we develop the notion that chemistryinevitably creates our experience. That's the view I was taught in medschool. Our physiology professor called human beings “sacks of enzymes.” Heinsisted that all we can do is jump or spit—that is, operate muscles or glands.He said we’re nothing more than molecular contraptions, and that any consciousnesswe sense in ourselves is actually an illusion orchestrated by chemical play.

The point is critical. Ifwe're to craft a style of healthcare as though people matter, we need to seeourselves as something beyond chemically directed gadgets. Fortunately, myprofessor's perspective isn't the only one available.

Another possibility is,strangely, the opposite, that consciousness drives chemistry. For example,the feeling of depression—or addictive craving, or anger, or any emotion—changesbrain chemistry. In this view, we’re primarily emotional beings whose moleculestag along accordingly. When I'm peaceful, I release brain endorphins, not theother way around. (Of course, this looks more complex when, say, we fall into alongterm depression; the consequent depression molecules, so to speak, become residentenough to create a vicious cycle.)

A third possibility is that chemistry and emotion are two profiles of onesingle phenomenon, like lightning’s flash and thunder. Neither causes theother. The problem with this view is that it admittedly can’t answer thequestion of where human behavior ultimately comes from. If you find yourself inthis camp, you need to get comfortable living with mystery.

So what's the answer? Are we primarily chemical gizmos, emotional beings orutter mysteries? Sorry, but there’s no way even to reliably research the issue.Think about that. How would you devise an experiment? You’d necessarily have toinclude subjective consciousness—a messy business, what with its time lag andquestions of interpretation and honesty—in a project you’d prefer to becleanly objective.

So we can't know, but still need to live a life. So we choose, and can chooseonly from preference. How do I wish to see myself, as having free will or as trappedby my chemistry?

I don’t raise this issue just to exercise my intellect in order to stave offdementia. The fact is that our choice of self-image dictates our behavior. If Iview my obesity and type 2 diabetes, say, as something visited upon me by aquirk of chemistry, I'll likely feel powerless to personally challenge it, and insteadput myself in the hands of chemical engineers. But if I understand that it results from decades of chosen behavior, I might decide deliberately to altermy life.

I've long ranted here about how illnesses in America are so commonly based inlifestyle. Everyone's capable of converting their behavior from pathogenic tohealthy, but only provided they sense the personal power to do so. Too much ofmedical practice amounts to enabling neurosis, and that itself isn't healthy. We'lldo better as we realize that chemistry isn't our master, but our servant.

OUR HEALTHCARE SYSTEM AND THE JAPANESE IMPERIAL COURT

2011-08-29T09:58:00.000-07:00

The August 25 edition of the NYTimes Well Blog (http://well.blogs.nytimes.com/2011/08/25/an-insurance-maze-for-u-s-doctors/) relates a study showing how much American doctors spend just trying to get compensated by insurance carriers.

The study, published in today's edition of Health Affairs (http://content.healthaffairs.org/content/30/8/1443.abstract) estimates that while Ontario, Canada, physicians spend an annual average $22,205 interacting with Canada’s single-payer agency, their American counterparts spend $82,975. American physicians' office staffs spend 20.6 hours weekly interacting with health plans—nearly ten times that of their Ontario counterparts. If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.

How to account for our persistence with such an obviously wasteful strategy? I don't believe we Americans are masochistic, just poorly informed. If we looked seriously at our own experiences in this system, we'd scream for reform.

For example, I recently saw my own doctor just to get a prescription refill. Ours is an older community, so most of his patients are on Medicare, which reluctantly but continually reduces physician payments. This leaves him earning less than some on his staff, so he's limited his participation in Medicare. That means that I needed to pay cash for my visit, assured that I'd somehow be reimbursed. Sure enough, a check arrived a few weeks later from somewhere in

Georgia

that paid me for half the visit. And a month after that, his office sent me a check paying most of the remainder, along with an explanatory letter. I wondered, then, how much it cost simply to reimburse me.

American healthcare's financial "system" is as complex as seventeenth-century Japanese imperial court manners--and even worse, it's riddled with unnecessary middle people who bleed it without adding value.

Again, I urge you to see the video "Health, Fear & Money" at www.ourailinghealthcare.com, a gloriously clear explanation of our Gordian healthcare knot.

ANOTHER SYNDROME BITES THE DUST

2011-08-26T16:33:00.000-07:00

Every day we hear about a new medical breakthrough, but how many remain on the stage two months later?

Well, I came across a genunine one today, destined for permanence. The lead article in this month's Journal of Questionable Diseases, it's entitled "Finally! Help for the Dreaded Bad Manners Syndrome," and I reprint it here.

Five-year-old Timmy Castelfiore-Padilla (not his real name) skitters around the examining room like ball lightning, colliding ferociously with walls, furniture, and people.

"Look out, loser!" he screams at his mother, lingering long enough to kick her shin. Ms. Castelfiore-Padilla cries out and falls to the floor in agony, hissing between clenched teeth, "You see, Doctor? He's always like that."

But don't jump to conclusions, for Timmy is not a hideous monster. Along with thousands of other unfortunate children, he suffers from Bad Manners Syndrome, or "BMS."

Timmy’s doctor, O. Dayton Splint, MD, is a world-renowned BMS authority. Thanks to dedicated scientists like him, we've come a long way toward understanding this scourge. Dr. Splint outlines the history of BMS. "It's hard to believe," he explains, "that until a few years ago these were 'nasty' children, and we treated them accordingly. Of course, we persecuted adults in those days who later turned out to suffer Ethical Deficit Syndrome, Corporate Greed Disorder, and other chemical imbalances we didn’t recognize at the time.

"Through research, we learned that these kids are actually victims of their own physiology. Finally the government took notice and began a crash program to find the cause and cure."

Ignoring Dr. Splint, little Timmy has made his way into the clinic's backyard, where he's found a hatchet and has begun to hack apart a wooden fence.

Undaunted, Dr. Splint continues. "Suddenly, these kids were no longer criminals, but healthcare consumers. Institutions everywhere got grants to treat Bad Manners Syndrome with a variety of drugs. But since most patients went on to state prisons regardless of treatment, we figured we'd better look into it further."

A nurse finds Timmy in the backyard and says something to him. He turns toward her, a carnivorous expression on his face, and, hatchet in hand, gleefuly advances.

Dr. Splint continues, "We eventually discovered that Bad Manners Syndrome results from an abnormality in a particular protein, called 'obnoxin.' Its molecules, which are normally tightly coiled, begin to unwind in these children, and that's when demonic behavior begins."

In the backyard, a determined Timmy takes craftsmanlike swipes at the nurse. Obviously an old hand at such play, she grabs Timmy's wrist, disarms him, and tosses him onto his back.

His filthy epithets penetrate the clinic's thick plate windows.

"Knowing the cause," says Dr. Splint, "we've gone on to develop an effective treatment: we simply re-compact the uncoiled obnoxin. Compaction must be done rather forcefully, and in an area where a good deal of it is stored."

The nurse has comfortably seated herself and placed little Timmy face-down across her legs. With a strong right arm, she begins to compact the errant obnoxin in his buttocks. Whap! Whap! Whap! His yells announce another successful treatment. The molecules are compacting just right.

Concludes a satisfied Dr. Splint, "It's the most dramatic cure since penicillin."

"HEALTH, MONEY AND FEAR"

2011-08-18T11:53:00.000-07:00

I recently saw a terrific video about healthcare reform, "Health, Money and Fear." Produced by emergency physician Paul Hochfeld of Corvallis, OR, it comprehensibly addresses the obscenely high cost-to-benefit ratio of our healthcare quasi-system by tracing it to its guiding values, our notions about self-image, lifestyle and responsibility. You can view it free online and purchase it, if you like, at www.ourailinghealthcare.com.

When I mentioned to a friend that I'd bought a copy, she told me she had one, too. Turns out there are several in this community, owned by excited fans who, like me, want to show it to others.

Maybe we're drawn to it because it heralds a shift in the argument. Until now, discussions have been limited de facto to the economic realm, reform as who's-going-to-pay-for-what. This supplies the media with no end of side debates about rationing, entitlements, malpractice suits, and "socialized" medicine, slowly convoluting the issue into a Gordian knot. "Health, Money and Fear" is a deep slice through complexity to the problem's core, the values that drive healthcare's economics. The people interviewed in Hochfeld's film--like Dr. John Kitzhaber, emergency physician and former Governor of Oregon--know what they're talking about, both medically and civicly.

This is heartening progress. I plan to show the film locally, publicly, along with friends who agree it's a document whose time has come. If you see the film, please let me know what you think.

NEW-AGERS ENLIGHTEN HOSPITAL PRACTICES

2011-08-09T11:41:00.000-07:00

If you read this blog and get worked up--either about my subjects or my rant style--and need to cool your adrenals, here's something a little different.

Those of us who wonder whether "alternative" modalities will eventually integrate with mainstream medicine need wonder no more after reading the below, from the current issue of the new-age magazine PARADIGM!

Two years ago, James Dancing Rainbow would not have held his current job. In fact, hardly anyone would even have imagined its existence. Rainbow shows funnyvideotapes to hospitalized patients to make them laugh—which is to say help them heal.

Many hospitals now accept the notion, first popularized by former Saturday Review editor Norman Cousins, that laughter is an invaluable healing tool. Rainbow's hospital, St. Vitus General in Mill Valley, California, founded its Humor Therapy Department in 1989. It stocked its library with tapes of the Marx Brothers, Candid Camera, Woody Allen, and Dan Quayle, and hired James Dancing Rainbow--formerly James T. Limpet--as its Senior Humor Technician.

“I guess I like it,” concedes Rainbow, pushing VCR buttons for a patient. “What the heck, it's a job.”

The patient, a man blooming with tubes like a modern Medusa, watches the Three Stooges on his screen. They make silly faces, throw pies, take pratfalls. The patient remains stone-faced.

“I'm coming back in an hour to get the machine,” Rainbow advises. “That tape's on for you to laugh at, Turkey, so don't make me feel like I wasted my time, y'hear?” And James Dancing Rainbow moves on to his next patient.

Wide acceptance of humor therapy has brought additional “new-age” techniques into mainstream medical practice. At another bedside in the same hospital, Transition Counselor Summerfall Winterspring notices on her clipboard that her patient is terminal.

“So tell me, Ms. Dwuff,” she asks, “have you gone through the bargaining stage yet, or are you still in denial? No use burying your head in the sand about dying, you know.”

Ms. Dwuff, a crusty critter despite her years, springs upright. “Dying?! I'm not dying any more than you are, you impudent whelp! I'm just lying here!”

“Aha!” responds Ms. Winterspring confidently, tapping her pencil on her lower lip. “You're in the anger stage. I'll send you our Anger Specialist, Ms. Clearlight.”

Exhausted, the patient drops back onto her pillow. She moans, “I’m too tired to argue. Just bring me that Dan Quayle video, will you? All I really need is a laugh.”

In the cafeteria three floors below, Certified Caring Technician Rhonda Crystalwater is taking her coffee-and-cigarette break. “Rough day today,” she explains, blowing smoke pyramids. “Twenty-eight biorhythms and three more aura readings to do, one reiki, two fleiki, and Christ, the elevator's kaput.” She indicates her copious belly. “Can't climb stairs. Chemical imbalance.”

These innovative healing methods have so won over St. Vitus General’s patients that all its departments have found some new-age approach. The obstetrical ward was converted into a home-style delivery suite, complete with kerosene lighting and underwater deliveries in the department’s hot tub, all to an endless-loop tape of Pachelbel’s Canon in D. The Surgery Department replaced its antiquated green gowns with bright tie-dyes. Through the public address system comes not the standard metallic voice paging doctors, but that of Shirley MacLaine reading the Course in Miracles. In-house psychiatrists now channel Freud and Jung. And St. Vitus General bubbled to the top of the new-age column when it recently introduced play therapy into its Intensive Care Unit, renamed the “Peekaboo I.C.U.”

The hospital even tried to change its name to “St. Vitus Holistic,” but snagged on a lawsuit brought by the McDonald's Corporation, which patented the word “holistic” in 1975. According to a leak from the hospital's Board of Directors, a second choice may be “St. Vitus Biodegradable.”

DON'T LISTEN TO THE WORDS. LISTEN TO THE MUSIC

2011-08-05T13:45:00.000-07:00

Hats off to one of my medical school psychiatry professors, Dr. Werner Mendel. Every week he performed a fascinating practice before a rotating audience of students. When my turn came, an inpatient, Mr. S, was shown into the room and introduced to us. The next ten minutes, Dr. Mendel engaged the man in small talk: how are you doing? Is the food okay? Have you had visitors? Then the patient returned to the ward.

Dr. Mendel began. "Mr. S was born in Appalachia but moved as a teenager to New Orleans. He entered the Navy at the outbreak of the war, and served in the Pacific. He was captured and spent time in a Japanese POW camp. He was married but now divorced. He's a longtime heavy smoker…"

He backed up each point in his biography of Mr. S with an observation. "Of course, you noticed his anchor tattoo, the slight bow when he entered the room, the pale band around his fourth finger…" We students had been clued into Dr. Mendel's act, so we'd sat at the edge of our chairs, almost painfully attentive, yet we missed ninety percent of what he had noticed. Afterward, the ward's psychiatrist read to us from Mr. S's chart; needless to say, the stories matched.

Astonished that so much valuable information might universally hide in plain view, I coveted his skill. Afterward, I cornered him in the corridor. "Please, please," I begged, "tell me the secret."

I wasn't the first to ask. He told me what he told everyone: "Don't listen to the words. Listen to the music."

(An interesting aside: Dr. Mendel once performed a study in which trained psychoanalysts treated one group of patients, and hospital employees with no formal training treated a second group. Guess which group showed the most and least improvement. Right! Understandably, Dr. Mendel was startled by the results and repeated the experiment, with the same outcome.)

Decades later, Dr. Mendel's advice became clear: words can lie, but the body always tells our truth, inevitably expresses our mind.

Yet we maintain a myth that body and mind are separate: I "have" a body and I "have" a mind, and hardly ever do the twain meet. I don't know why we assume this; whatever Darwinian advantage it has eludes me. We so deeply believe body and mind are two unconnected entities that we act astounded when we learn that an event involving one affects the other. Unmanaged stress causes insomnia? Well, I'll be. Cancer can cause anxiety? Knock me over with a feather.

It takes our finest scientific minds, then, to reveal that, as I reported yesterday, negative events in our personal histories predispose us toward illness. Today I read its obverse: a better life is more likely to be longer. According to research published in May by the American Psychological Association (http://psycnet.apa.org/journals/hea/30/3/268/), a positive social atmosphere in the workplace confers longevity. In this study, employees who enjoyed collegial support and positive social interactions were less likely to die over a twenty-year period than those who reported a less friendly work environment. Well, as I live and breathe! What'll they think of next?

If we're to move toward a healthcare style in which people matter, we'll need to leave the duality behind. When we honestly see that body and mind are one, then preventive medicine is no longer just a search for incipient disease. It's living, moment to moment, as enjoyably as we can.

TREMENDOUS DISCOVERY: TRAUMA CAN SICKEN US

2011-08-03T08:56:00.000-07:00

Recent research is making it obvious that much of disease originates with traumatic experiences. A landmark study done by Kaiser San Diego (http://www.cdc.gov/ace/index.htm) demonstrates how closely adverse childhood experiences ("ACEs") correlate with health problems in adulthood. Now two articles in this week's Journal of the American Medical Association (find both at http://jama.ama-assn.org/content/current) further validate not only that relationship, but suggest an approach to treatment.

One article, from Australia, shows that women who were raped or sexually abused tend to suffer a lifetime of mental disorder and psychosocial disability, including impaired quality of life, overall disability and increased suicide attempts.

In the same issue, a study of over a thousand former child soldiers in northern Uganda who suffered from post-traumatic stress disorder were helped most by simple narrative therapy--that is, talking about their experiences with trained nonprofessional counselors.

Wait a minute. Let's back up a bit. Isn't it already obvious that sexual abuse can confer lifelong problems, or that a child soldier will be prone to PTSD? You'd think we wouldn't have to prove this through scientific research, yet there's something in our culture that declines to make the reasonable link. It's expressed in that non-advice, "Get it behind you." It wasn't pleasant, but it's over now, so get on with your life. People with cancer often tell stories about such "encouragement" from well-meaning friends.

But we don't get over it. These experiences change who we are. In order to understand what we've been through and thus our current existential location, we need to talk about it. Matter of fact, that's all most psychotherapy is. But it needn't even be called psychotherapy, as the Ugandan "counselors" were nonprofessionals. It could equally be part of friendship, people caring deeply enough about one another to ask the right questions. Hopefully this will become a popular skill as we renovate healthcare as though people matter.

GREAT HARDWARE, TERRIBLE SOFTWARE

2011-07-29T10:30:00.000-07:00

A friend recently took a bad bicycle spill. Along with assorted other injuries, she broke her jaw and hand. A helicopter flew her to a major trauma center, where she was promptly triaged and her jaw laceration stitched. She learned that her injuries were relatively minor compared with people who were brought in with missing limbs and lacerated livers. Naturally, those in more serious condition were attended to before she was. During the next fourteen hours she lay on a gurney, requesting repeatedly that she be seen, but no one even came to put ice on her broken hand.

The contrast between the light and dark sides of American healthcare is ever more visible. Our medical technology, our hardware, especially in regard to treatment of trauma and infectious disease, can be truly wondrous. Where we are scandalously lacking is in our low-tech software, our ability to communicate.

However we're encouraged to pretend otherwise, healthcare isn't simply another commercial transaction. Deep personal issues, often questions of life and death, are involved, so it's an EMOTIONAL process. This makes communication absolutely central to the medical encounter.

We commonly think of optimal communication as clear speech, but those of us who labor in these fields know than nine-tenths of communication is sensory reception--listening, observing, sniffing, empathizing. Thus one of the most important people in the private medical office is the receptionist: he or she sets the emotional tone of the visit.

Every WalMart store features a greeter. "Hi, how are you? Welcome!" Smart medical operations like the Mayo Clinic do likewise, and even assign employees or volunteers to accompany patients throughout their visit. They don't just advertise that they "care." They demonstrate it. If my friend's trauma center wasn't simply a repair factory but actually a caring place, she would not have had to endure fourteen hours of a fractured hand without even a little ice on it.

More about this soon, as her trauma center visit exemplifies much about what's right and wrong in our healthcare system.

MORE ON CHRONIC PAIN

2011-07-20T09:04:00.000-07:00

That NY Times Well Blog article about chronic pain (http://community.nytimes.com/comments/well.blogs.nytimes.com/2011/07/18/giving-chronic-pain-a-medical-platform-of-its-own/)

struck a nerve, so to speak. There are now over a hundred comments on it, and several here on this blog, consistently stressing two points, drugs and subjectivity. My thanks go out to all commenters.

Drugs--especially opiates, or narcotics--are, in the short run, a miracle and a blessing. When I was an ER doc, one of my most satisfying experiences was to inject a bolus of morphine into the vein of someone writhing on the table from a kidney stone. I'd say, "Count to ten." By seven, they'd sigh and smile.

Take opiates for awhile, though, and problems can appear, and not necessarily addiction. Sometimes we'd keep hospitalized patients on opiates for a couple of weeks, sending them home with a diminishing dose. I never saw a single one become addicted, though I recognize some people with a craving personality do get hooked. A more common problem is side effects, including agonizing constipation, lethargy, and even disorientation. Considering that we develop tolerance to opiates, chronic users will require progressively higher doses and suffer proportionate side effects. In addition, the feds do indeed maintain a regressive attitude toward opiates, reflected in the fearful reluctance of many docs to prescribe them at all. (I've mentioned elsewhere in this blog the usefulness of that phrase that knocks around in cancer support circles, "No one should be allowed to treat a disease they haven't had themselves.")

The other theme in all these comments is subjectivity. Some policies limit opiate prescriptions to cancer patients, since, evidently, they're not faking. Cancer is objectively real, and everyone knows it can hurt. For those patients who don't have verifiable pathology, though, who knows whether their pain is "real" or not? So it is that many people are slog through their lives today treating their severe pain with Tylenol.

This brings to mind the previous blog entry, about prospective medical students being screened for communication skills (http://well.blogs.nytimes.com/2011/07/10/screening-for-a-better-medical-student/). A proficient communicator--that is, someone who listens fully and speaks truly--is therapeutic, period. When people know their suffering narratives have been heard, they feel better. Beyond that, being heard begins to help them live with their symptoms rather than devote their lives to avoiding them. Of course, this level of practical compassion isn't achieved through med school application interviews. It needs to be a perennial element of medical training.

MENTAL ILLNESS AND GUNS

2011-07-13T08:11:00.000-07:00

There's wide agreement that firearms in the hands of mentally ill people--for example, Tucson's Jared Loughner--constitutes a public health threat. Even the late Charlton Heston, when president of the NRA, stated in a video on that organization's website, “…we all agree that guns don’t belong in the hands of people who are mentally incompetent, so gun-buy background checks ought to include mental record checks…” Yet strangely, laws intended to protect patient privacy also protect their arms ownership.

A man in our town is mentally ill and known to be armed. I suspect he exemplifies similar situations around the country. When he's properly medicated he presents no problem, but when he goes off his meds his behavior become so erratic and threatening that his neighbors call the police. The police arrive to find the man composed. The frustrated neighbors tell them he's a mental patient who was acting crazily till twenty minutes ago, and give them his psychiatrist's name. The police call the psychiatrist to ask if the man is indeed his patient. The psychiatrist, obeying the Health Insurance Portability and Accountability Act, ("HIPAA," pronounced HIP-a), says he's not permitted to tell them whether the man is his patient. The police are left, then, with neighbors complaining about a man who's acting, at least for the moment, eminently sane.

Can there be no solution? In 2002, the state of California enacted a law, AB 1424, which recognized that people who are seriously mentally ill can occasionally appear sane. The law stated that mental health professionals qualified to involuntarily hospitalize can no longer rely exclusively on their momentary meeting with a patient. They must consider a longer and wider history, including information provided by a patient’s family and others.

Yet even here there remains a disconnect, as police officers aren't qualified to diagnose mental disorders. They could legally arrest this man in order to bring him to a mental health professional, but they haven't done so, possibly because of liability should the man be found normal. Taking into account, then, the possibility of an error in one direction or the other, our society's current ethical ambience seems to favor protecting the man's gun ownership over protecting public safety.

Are you aware of similar situations in your locale? What's your take on this?

SELECTING MEDICAL STUDENTS FOR COMMUNICATION SKILLS

2011-07-11T11:06:00.000-07:00

Excuse me, please. I haven't blogged as often as usual the past couple of weeks because it's finally summer here. Need I explain further?

I'm moved to write today, though, because of a fascinating development in medical school admissions strategy, outlined in an article in today's NY Times Well Blog, http://www.nytimes.com/2011/07/11/health/policy/11docs.html?pagewanted=1.

Of course, medical schools continually tweak their admissions procedures. When I applied, which was shortly after Lincoln's assassination, there had been a push for more "rounded" students. My science grades were mediocre but I shined in languages. The standard interview question was, "Why do you want to be a doctor?" I was able to respond correctly ("To help people") trilingually, so I was in. My class consisted mainly of science nerds, but a few poets and artists, too--all of whom became psychiatrists, by the way--and a couple of really entertaining weirdos. The class following ours featured a concentration of political activists; when they organized the hospital staff and led them out on strike, the admissions committee scrapped its progressive policy and returned to admitting science nerds, period.

Now some leading schools, including Stanford and UCLA, are beginning to screen for communication skills. Applicants are given multiple interviews which include discussion of ethical problems involving payment, alternative remedies, circumcision, and so on. The schools wish to address two increasingly visible problems in medical practice: doctors' generally suboptimal communication skills and the growing need for partnership between physicians and other practitioners.

This new admissions strategy looks progressive but one wonders how it will survive in generally unfriendly soil. It will need to compete within the extant atmosphere of medical training and practice, where human contact is still considered an endeavor somehow less useful than hard-nosed science. It'd be nice if this strategy were the beginning of intense communication training all through the medical curriculum.

At any rate, this admissions strategy won't reveal its usefulness until the students move into practice. Considering the length of professional training, we might not see an effect for a decade. But I'm hopeful.

WHAT'S TO BE DONE (OR NOT DONE)?

2011-06-29T13:33:00.000-07:00

A friend has been visiting his mother in a hospital ICU. She's old and frail and may well be dying.

He wrote this to me:

I was thinking of your blog yesterday as I sat in her room waiting. A load of technology--wires, tubes, machines--being applied to her body by a pack of mortals. Not one magician or demigod in the crowd. Staff tripping over tubes as they add yet another medication and IV pump. Apply another mask and sticky crap to her beautiful face. Piles of discarded supplies. Top down control, nurses know what to do but can't until they obtain an "order" which requires tracking down the overloaded doctor.

It all feels so bumbling. Not that I see the people as incompetent. On the contrary, I experience them as skilled and caring. The bumbling and fumbling comes from trying to fix something that may not be "fixable." Maybe I just don't get it. It's painful to watch Mom suffer. It's hard not knowing where it ends or where it goes to next.

So he's suffering, too. If he asked for advice, what would you say?

DR. JEKYLL AND HIS MR. HYDE OFFICE STAFF

2011-06-28T16:55:00.000-07:00

My friend Theresa told me she'd just had a visit with her doctor and left confused.

"About medical stuff?"

"No," she said. "Dissonance."

She said she'd been reluctant to go to Dr. D's office but never quite knew why, and now maybe she was learning why.

"Dr. D's a terrific physician," she said. "He's warm, knowledgeable, tolerant--a great human being. That's why I wondered why I didn't like visiting. Now I realize it's his staff."

She went on. "It came to me today that his office is a factory! Or maybe an insurance bureau, I don't know, but I'd never think of it as a remotely healing place. I check in and soon a woman calls me in from the waiting room. Walking ahead of me to an examining room, she asks how I am. I mean, she isn't even looking at me. And who is she, anyway? A nurse? Drug rep? Another patient? Am I supposed to ask? Is it up to me to teach plain old manners to grownups? She weighs me, takes my temperature, and leaves the room. In a few minutes, Dr. D comes in and right away he lifts my dark mood. Afterward he walks me out to the front desk, hugs me, and goes to see his next patient, I guess. The woman at the desk says, 'We don't take Medicare. Today's visit is seventy-seven dollars.' She's like a clerk selling me a train ticket. She hands me a bill with my name on it, misspelled.

"So here's what's confusing. Dr. D cares about me. I'm lucky he's my doctor. But his office staff acts like they're his competition. If it weren't for his charisma, the place would get closed down as an anti-healing black hole. Now, how can a guy like that not notice that disparity?"

I've had similar experiences. Why do medical offices so often feature an ambience ranging from vapidity to frigidity? When I was a kid, back in the germ days, the style was cleanliness. You knew it was a medical office because you could smell the isopropyl alcohol and eat off the white tile floor. For today's diseases, which stem mainly from lifestyle and aging, the old cold cube doesn't work. Why not opt for qualities that comfort and encourage trust? Look, office staff: "providing" healthcare to "consumers" isn't just another business. Besides, wouldn't you enjoy your work more if you felt friendly and compassionate?

My suspicion is that Dr. D is aware of the flavor of his office. He likes his employees and finds them efficient. He has no idea, though, that every element of a medical office can be a placebo. The furniture and the lighting are potential placebos, as well as the first word from the receptionist, who as tone-setter is arguably the most important person on the staff. Look, Dr. D: give your staff permission to be the caring people they are, and by the time you see your patients in the examining room, they'll already be half-treated.

MATERIALISM AS MENTAL ILLNESS

2011-06-22T09:05:00.000-07:00

Neurosis is characterized by an idée fixe, as Freud put it--a view of the world that one refuses to reconsider even when confronted with valid opposing evidence. Jung said, "…people become neurotic when they content themselves with inadequate or wrong answers to the questions of life." One example is obsessive-compulsive disorder, a common manifestation of which is repetitive handwashing. I've washed my hands thirty times now, but I figure they're still not clean, so here goes again.

Suppose I feel my life is empty, that I lack something vital. I sense a void inside me, yearning to be filled. So I try a little retail therapy. I buy a Giants baseball cap, hoping that will do the trick. It doesn't work, though, so I buy a George Foreman grill. Nope. I know! A Chrysler PT Cruiser convertible! That satisfies me for a day or two, but then the empty sensation returns. Its pervasive discomfort slowly turns my life into a search for the literal fulfillment I seek, though I gradually forget why I'm doing it. I look for my Grail in food, sex, drugs, and a hundred other things, to no avail. My idée fixe is that my deliverance must come from something in the material world. But my deficit isn't material. No thing will suffice.

This is America's painful conundrum. Attracted by clever marketing, we're mesmerized by things. Way down deep, we know new underwear or another wristwatch won't make us whole, yet we buy anyway, persuaded by ingenious advertisements that don't promote their ostensible product as much as they promise love, security, ecstasy.

As we adhere to this glamorous but useless route, our internal skills atrophy. We come to believe that love, security, and ecstasy are actually qualities of products and not of us. We forget who we really are.

If this isn't a socially significant mental illness, hardly anything else is worthy of the name.

But it's treatable. One effective approach is knowledge of mortality, a revelation I see regularly in cancer support groups. Most cancers aren't immediately life-threatening. Having cancer doesn't mean you're going to die tomorrow, but it does underline the certainty that none of us are here forever. Thankfully, that realization is very often a lever for renovating one's life: what are my deepest values after all, and how passionately am I living them? One of my joys in this work is hearing people say, "I'm just beginning to understand what's really important."

IT SEEMS CRAZY

2011-06-14T09:29:00.000-07:00

AARP's June 1 news bulletin features an article, "Before and After Weight-Loss Surgery," which unabashedly recommends gastric bypasses as a corrective for obesity.

This operation is effective for its stated end, weight loss, which can help type 2 diabetes to disappear as well. The picture's not all rosy, though. At first, post-op patients can eat only small amounts of pureed foods. When they graduate to solids, they need to be carefully chewed or they don't go down. Some pills are too large to digest; alcohol, carbonated drinks and caffeine are verboten; protein, vitamin and mineral supplements are necessary. Some patients need to wait two hours after a meal to drink water or other liquid. But hey, they lose weight.

Obesity is epidemic in America. In 2004, the National Institutes of Health reported that nearly two-thirds of U.S. adults were overweight or obese. Over a million Americans have had a gastric bypass, which costs about $35,000 and, like other interventions, isn't getting any cheaper. Do the math.

Not everyone's wild about this tendency. Comments one surgeon, "When I put on my public health hat, I have to admit that it seems crazy. But I'm a clinician. I treat patients who have tried everything else, who have type 2 diabetes and other complications of obesity, and they're desperate. This is the only thing we can offer that allows for a cure."

The operative phrase here must be "…the only thing we can offer…" Why can't we offer anything else? Our ability to put people on the moon is, in my mind, totally useless except for the fact that it demonstrates the efficacy of American will. Why can't we offer anything else to the obese? How is it we can deftly rearrange people's insides but don't have a clue to helping them modify their behavior?

In addition, the expenditure feels unseemly, to put it mildly. The millions of people in the world who go to bed hungry could be nicely fed with this money we spend hopefully to correct our overeating .

Overuse of expensive interventions is a kind of selfishness, but there's something even more destructive at work: abdication of personal power, actually a reversal of the American "can-do" ethic. We're more and more assuming the role of "consumer" rather than doer. In my next blog entry, I'll make a case that consumerism may well be a form of mental illness.

I LOOK FORWARD TO NO MORE HOSPICES

2011-05-27T10:30:00.000-07:00

Earlier this week, while conversing with a group of hospice volunteers, a question germane to hospices arose: why are families so often referred too late?

Here and elsewhere, hospices complain that their patients come to them within a week or two of dying, so that just when services begin to get coordinated, death intervenes. That's a pointless loss, considering what hospices have to offer in the way of personal and family counseling, symptom control, and respite. In continuing medical education sessions, we docs are repeatedly encouraged, cajoled, and begged to refer people earlier. Yet this tardiness persists, and one has to wonder why.

Around here, you're eligible for hospice care when your physician certifies that you'll likely die within six months. (Of course, some patients outlive the six-month prediction, and "graduate" from hospice.) Third parties, including Medicare, pay for hospice services only when that's the exclusive intervention. In other words, you can't receive treatment that's hopefully curative while you're in hospice. The decision to enter hospice, then, means letting go of every thought of recovering.

Hardly anyone looks forward to that eventuality. Doctors' reluctance to recommend hospice can derive from the notion that doing so might connote medical failure. Patients and their families don't want to hear the H word, either, as it can dash hope and fracture protective denial. All parties, then, may understandably conspire to avoid hospice until the Reaper is pounding on the door.

It doesn't have to be that way.

Hospices are founded on the principle of palliation, sometimes called "comfort care." The message is, "We've done what we can to cure you; now we'll do our best to make you comfortable." That's a humane thing to do, of course, but one wonders why we need to choose between cure and comfort. Why don't we apply palliation even when lives aren't threatened? Are not hospice services like counseling and expert pain control useful for virtually every patient and affected family?

For that reason I look forward to the day when there are no more hospices, and all care is palliative.

AMERICA SERIOUS ABOUT POLLUTION CONTROL

2011-05-17T13:28:00.000-07:00

Anyone who thinks Americans don't care about environmental poisons have another think coming. Check out this news article in today's Indianapolis Register:

The Orrin Hatch Nuclear Power Plant lies on a rocky, arid plain ten miles from Turgid Gulch, Wyoming. It was built atop an abandoned toxic landfill which was formerly the property of Greener Than Green Corporation, manufacturer of ecologically sensitive automatic weapons.

There are no structures within sight of this nuclear facility except for a solitary single-family home exactly one thousand yards away, hugging the far corner of the landfill.

The home is that of Evan Ricketts, his wife Maryjane, and their four children. Ricketts, a thin, balding, wrinkled, fretful, peeling, twitching man who had been the landfill's caretaker, worries about his sparse neighborhood.

“I’ve started to think this might not be a healthy place to live,” he says. “The air’s thick and pink, like cotton candy. You can’t take a breath but for coughing up this yellow stuff with rusty flecks in it. We get bad smells in the house, like to gag a maggot. Gas bubbles rattle the floorboards, and you can feel the foundation grind around at night. We used to be able to drink the water even though we had trouble keeping it down, but then it got too sticky to flow through the pipes. Now we haul in water from Turgid Gulch.”

One wonders why they haven’t moved away.

Maryjane Ricketts chuckles ruefully at the question, coughs into an oily rag, and answers, “We put the house up for sale, but no one would come look at it, not even realtors after the last one’s car sunk through the driveway. When the air's a little clearer you can still see part of the bumper. So we’re stuck, I guess.”

As if the toxic soup upon which their home floats weren’t enough, the Ricketts were affected last year by what the Nuclear Regulatory Commission called a “minor malfunction” at the Hatch nuclear plant. Technicians later admitted that a few of them were “horsing around,” as they put it, and accidentally released several million gallons of radioactive water deep into the landfill. This loss of coolant caused an entire wall of the plant to melt away. Although this was the wall that faced the Ricketts' home, the NRC determined that radioactive contamination was limited to a radius of exactly nine hundred yards, a hundred short of the Ricketts’. Following natural underground contours, the wall's molten concrete cooked the Ricketts’ septic tank in seconds and vaporized their toilet.

“Hoo-eee, that was a close call,” concedes Evan Ricketts, “but to tell you the truth, we've all felt a little puny since then. Can’t quite put my finger on it. Little things, like my bleeding gums and these lumps in my neck. The wife, she miscarries every month or so. The school nurse tells us the kids are about half the size they ought to be, but I can’t tell because I can’t see so good anymore.”

The Ricketts’ problems baffled their family physician, who finally called in the Wyoming Health Department. Its studies concluded that no pollution standards were exceeded and no laws had been broken.

Despite increasing attention to their situation, things did not go well for the Ricketts. “Got laid off,” mutters Evan Ricketts, “and I can’t get work now ‘cause I’m too well known. They call me ‘Hot Rocks Ricketts,’ and when I go for job interviews they make me just slip my papers in under the door. Can’t get on the welfare because we own our own home. We don’t know what we’re gonna do.”

Documents relating to the Ricketts’ dilemma meandered through the nation’s capital until they reached the legendarily incorruptible Government Accountability Office. A full-scale GAO investigation turned up vast amounts of information that had been suppressed, and its final report led to indictments of the current operators of the power plant, the CEO of Greener Than Green, the Director of the Wyoming State Health Department, and the Ricketts’ personal physician.

All were charged with income tax evasion.

As for the Ricketts, their friends and neighbors haven’t let them down. This past month, a thousand local residents staged a help-a-thon, “Hands Across Turgid Gulch,” in which they raised enough money to buy the Ricketts a new trash compactor.

###

Thanks, Indianapolis Register. News like that renews my faith in humanity.

MORE ART, FEWER DOODADS

2011-05-16T16:25:00.000-07:00

Most of us agree with the truism that healthcare is a science and an art. But during the past few decades the art has gotten lost behind the MRI machine. "Use it or lose it," we say in this business. Less utilized, healthcare's art atrophied. Now we seniors remember it, but too many younger docs aren't aware healthcare was ever anything but science.

Science is about the objective, measurable world. It's about logic and precision, which we're awfully good at. Our remarkable scientific hardware lets us perform wonders undreamed of a century ago. Lacking the softer edges art conferred, though, it's drifted from human experience toward more manipulable technology. Check out the reports of robot "doctors" and online psychiatric algorithms, for example. I joke about medical care dispensed from vending machines, but we're not far from it today.

When we in the healthcare professions comprehend our work as essentially science, we gradually abdicate our interpersonal art, the skill of communication. We begin to lose our senses of compassion, forgiveness, joy, skepticism, perspective, and humor.

Patients daily tell me about their healthcare experiences. Most are praiseful and grateful, especially for the medical science that's been applied to them. When they express dissatisfaction, their complaints are uniformly about personal contact. Patient A says his doctor faces his laptop instead of him. Patient B says the staff lost his records. Patient C complains that a nurse was condescending. Patient D says his doctor devastated his hope.

We can replace organs, but it sometimes takes two weeks to fax a test report. We can obliterate germs that once wiped out half a continent, but fail to hear our patient telling us we're not adequately treating her pain. Our hi-tech is great, our low-tech often wanting.

Our science outperforms our art simply because we place more focus on it, and here's why: it makes money.

When I was in training, we handed penny balloons to post-op patients with instructions to blow them up a couple of times a day. The back-pressure kept their lungs inflated, and so warded off pneumonia. No balloons these days, though. Instead, patients are given complex, expensive gadgets that do the same thing at a hundred bucks a pop. We're not just talking about these breathing doohickeys here, but thingamabobs and doodads throughout the medical office and hospital. If you wonder about the source of healthcare's skyrocketing costs, here's a good place to look. We overuse medical technology, and mainly for these reasons:

It gets marketed heavily.
Having heard about it in many forms of infomercial, patients demand the "latest."
It's expensive, so needs to be used in order to amortize its costs.

Compare that with, say, communication. This low-tech intervention doesn't get hawked because no one has yet been able to patent language and so corner the market on it (though I'm sure a number of corporations are looking into it). Since communication isn't commercialized, consumers don't hear about it; no wonder they assume healthcare and technology are identical. Finally, communication is free, so what could it possibly be worth?

Still, some practitioners here and there are intent on preserving healthcare's diminishing humanity. You can tell who they are. They sit still when they're with you, look you in the eye, touch you, ask you questions about you as well as your illness, and listen to you carefully without interrupting. Robots can't do that.

ABUSE ROLLS DOWNHILL

2011-05-09T10:57:00.000-07:00

There's a thoughtful essay in the NY Times Well Blog today by Theresa Brown, RN, on doctors disparaging nurses in front of patients (http://www.nytimes.com/2011/05/08/opinion/08Brown.html?src=me&ref=general).

One might think of this abusive practice as anachronistic, a vile remnant of the 1950s, but it's still very much alive.

A reader who commented on Ms. Brown's piece (#2, MKM) noted that as a former hospital clerical worker, he/she had probably received more abuse from nurses than from doctors. That's the way the chain works: abuse rolls downhill. Almost without exception, child abusers had been abused themselves as children.

I doubt docs will stop abusing anyone until their own abuse stops. From my own training in the 1960s, I recall that freshman medical students suffered a status somewhere below mollusks. Sophomores and juniors were noticed, but mainly as nuisances, like rodents. Seniors found that the summit they’d attained was at the same time dirt on the shoes of interns, who in turn were nameless drudges to resident physicians. And so on up to the pyramid’s apex, the Chair of the Department, who glowed with success while fretting about the associate professors clawing at his or her ankles. From what I hear, medical training is a little more humane now, but the atmosphere remains unquestionably vertical.

Still, re-education is possible. My guess is that the docs who disparage nurses in front of patients (along with other abuses) do it unthinkingly, almost as a matter of course. They have no idea they're damaging people, and if they did, they might behave differently. A nurse or other colleague can take them aside, as a nurse once did with me, and advise, "Doctor, if you keep going where you're going, you're going to get where you're headed."

WE'RE ALL BEING WATCHED

2011-05-05T09:14:00.000-07:00

Maggie, a woman in our cancer support group, told a touching story yesterday.

She has breast cancer of a type similar to what a friend had. The friend died after a particularly unpleasant course about twenty years ago, leaving a young daughter, Amy.

Maggie had been reluctant to see Amy, fearing she'd reignite Amy's memories and her fears of going the way her mother had. But they did meet recently, and after they'd spend some time together, Amy said, "You're going through this differently than my mother did. It seems to have made you stronger and more dignified. Watching you, I'm no longer frightened of breast cancer."

I've heard that there's more than one of us on the planet so we can be examples for one another.

FACTORY VS. CHURCH?

2011-04-29T12:32:00.000-07:00

A man in our cancer support group spoke this week about the difference between two medical offices he'd visited.

"I wish Dr. A had seen me in his waiting room," he said. "At least there were windows there. An assistant finally called my name and led my wife and me to an examining room where there were no windows, nothing on the walls, only an old People magazine. We waited there for twenty minutes, and finally the doctor came in. Discussing it as we drove home, we both felt kind of disrespected.

"We might not have even commented on it, except that last week we'd been to see Dr. B. Now, his office is full of life. In the waiting room are plenty of plants and an aquarium. There are beautiful framed photos on the wall. We weren't put into an exam room until the doctor was ready to see us, and what a difference: carpeting, wallpaper, a window--a really homey place…"

You might think that docs are cognizant of what goes on in their offices, but often they're oblivious. Years ago, when I'd bring my father to his oncology visits, I ground my teeth as we waited and waited in the aptly named waiting room. I eventually realized the office ran a standard ninety minutes late. One afternoon, as we were leaving, the receptionist assigned us the next visit. I noted it would be at 1PM.

"Okay," I said, "we'll be here at 2:30 on the nose."

"No, the appointment's at 1."

"You know as well as I do," I said, "that we won't be taken into an examining room till 2:30. My father's eighty-five. He can't take that."

Later that day, the doctor phoned us. He told us he was appalled and humiliated. He truly hadn't known how long patients waited. He went on to make changes in his office operation, and from then on we waited no longer than ten minutes.

Treatment isn't restricted to chemicals and physical procedures. It includes esthetics, too. Does the medical office atmosphere feel like a healing sanctuary in which you're treated each moment with compassionate regard, or more like an impersonal industrial workplace? In other words, does the ambience make you feel better or worse?

In the Middle Ages in Europe, when there were no hospitals at all, churches took in the sick. The nuns (that history, incidently, is why British nurses are often still called "sister") possessed the medical acumen of the time, which was close to zero. However, their patients inhabited sacred architecture, were bathed in stained glass light, and treated with food, rest, quiet and dignity.

We needn't choose between chilly high-tech interventions and beautiful surroundings; why shouldn't healthcare comprise both? In fact, why would practitioners want to work in an ungracious setting?

Left to their own devices, healthcare's corporate owners will tend to change things only in ways that increase profits. I've long predicted that if current trends continue, we'll eventually receive diagnosis and treatment from vending machines.

That's the default, but feedback from patients--that is, customers--will have an effect. I've made it a personal practice to send e-mails to the docs I've seen as a patient, evaluating the care I was given. My messages are usually of praise, but sometimes they're critical. I encourage other patients to do similarly since there's hardly any mechanism in healthcare that honors patients' experiences.

One exception is the Kaiser Permanente system, which for the past several years has incorporated patient satisfaction into its formula for paying its physicians. Imagine what healthcare economics would look like if patient satisfaction were a major value everywhere.

SPARE PARTS R US

2011-04-26T17:20:00.000-07:00

How should we respond when some hi-tech advance savages our sense of morals? Read this article, from this month's Genetix Biz, and see what you think…

FETAL FUTURES UP; NEW FACILITY PROMISES BUMPER CROP

Intergene, a wholly owned subsidiary of FleshTek Industries, having recently predicted a banner year, invited this reporter to tour its new state-of-the-art facility.

Set within gently rolling hills outside Gaithersburg, Maryland, Intergene’s complex announces itself only by its user-friendly sign, “Dr. Frank’s Farm,” and the several security checkpoints through which visitors must pass.

“Dr. Frank,” actually Dr. Franklin Stone, the trim, scholarly research physician who pioneered the science of fetal husbandry, explains the farm’s homey atmosphere.

“We make it look as rustic as any other farm,” he says, “in order to make science more palatable to lay people. Our security personnel dress in blue jeans and ginghams, the research buildings look on the outside like old barns, and we even leave rusty harrows and plowshares near the parking lot.”

Indeed, a casual observer might see this as a commercial chicken farm instead of what it actually is, a factory in which human fetuses are cultured for organ harvests.

His technicians carefully join selected human ova and sperm, replicate the product several hundredfold, and nurture the fetuses in artificial wombs until organs are needed. Since each fetus’ genetic makeup is completely known, perfect recipient matches are a matter of course.

Dr. Stone explains the advantages of this technology: “People in need of organs need no longer suffer painful, undignified delays while blind chance selects donors of unknown background and medical history, who may or may not be immunologically compatible. We have what they need on stock right now. And as for the fetuses, our polyvinyl wombs are far more secure and nutritive than the traditional model. It’s a win-win.”

While Intergene can anticipate a bullish market in fetus futures this year, the project is not without its problems. One, for example, is shelf life. As yet, the fetuses cannot be frozen, so Intergene must allow full development and delivery. The delivered products are maintained in good shape in a closed compound.

“It actually works out well,” Dr. Stone explains, “since occasionally we need a child-sized organ. On the other hand, we’re starting to wonder what we’ll do when products reach maturity. For example, what if they breed with each other? Or, say, what if one escapes from a facility with less careful security than ours? Or the worst-case scenario: what if one learns language?”

Dr. Stone raises weighty ethical issues here that have not escaped academic notice. Dr. Arlen Cypher, Bioethicist-in-Residence at the Prestigious Institute-On-The-Hudson, has studied the issue for several years. “While heuristic in concept," Dr. Cypher says, "fetus farms may be congruent with teleological modelling.” Dr. Cypher currently heads a Presidential task force charged with further clarifying the field.

Unsurprisingly, some religious officials have gotten involved. Monsignor Francis X. O'Shaughnessy, a spokesman for the Philadelphia archdiocese, advises, “Granted, these fetuses were conceived and nurtured outside the motherly womb, but at least we should give them the benefit of the doubt by baptizing them.”

The Monsignor’s advice strikes Dr. Stone humorously. “Ridiculous!” he chuckles. “Baptize them?! You can’t baptize them! They’re patented!”

So while Intergene’s fetal futures rise and Dr. Stone returns to his husbandry, significant questions remain. The last word for now is from bioethicist Dr. Cypher: “One thing is absolutely certain: we need more research.”

The article made me angry enough to write a letter to my Congressman, until I learned he also represents FleshTek Industries.

CONSUMERS AND PROVIDERS: A PERVERSION OF LANGUAGE

2011-04-25T11:39:00.000-07:00

Do you wonder why the discussion of healthcare reform revolves around money--who pays for what--while the actual process, the intimate contact between patient and physician, seems to have no relevancy at all?

It's because the medical examining room has in recent decades gotten crowded by third parties. Government agents, lawyers, insurance minions, and a horde of sharply dressed sales reps have worked their way in, importing their particular language, a tongue rich in self-serving euphemism.

Take "affordable" medical insurance, for example. You can actually afford a policy provided you shift your budget from decent food to bulk carbohydrates, but its deductible and copay requirements can edge you toward bankruptcy. That "oral administration fee" on your hospital bill is twenty bucks for handing you your aspirins. When hospitals lay off nurses in order to pay larger bonuses to administrators, they call it "downsizing," which sounds cleaner, like calling a car "pre-owned" rather than used.

Language is both descriptive and prescriptive. It expresses what we make of our world and also influences what we see. Call members of the other tribe "cockroaches" enough, and eventually they'll look subhuman. In the same way, labeling medical practitioners "providers" and those they serve "consumers" has gradually reduced our concept of the healthcare transaction to the transfer of a commodity, a standardized, generic product. I'd like a quart of healthcare, please. This practice enriches the examining room's interlopers at the cost of the original occupants' well-being.

I'm happy to learn that on this subject I'm not just another curmudgeon in the wilderness. Economist and Nobel laureate Paul Krugman, wrote in the NY Times a few days ago (http://www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=1),

"The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough."

The next time you hear "consumer" and "provider" in the same sentence, then, please take a breath and set the poor speaker straight.

HUMAN ERROR FACTOR

2011-04-18T10:58:00.000-07:00

Sometimes I think I'm too hard on us plain old folks. I expect us to live up to our species name, Homo sapiens (sapient: wise, sage, discerning), but then I remember our characterological Achilles heel, error. It's built in. No human is free of human error.

But don't abandon hope, for Science might yet conjure a remedy. Check out this article from last week's Progress magazine.

To err is human, they say. But is it? Are we fated eternally to miss typos, get lost, splash sauce onto our shirts?

Not necessarily, claims Dr. Gladys Taylor, Chief Investigator in the Serology Branch of the respected Sloan-Smithson Institute in Albany, New York. According to Dr. Taylor, human fallibility actually represents a chemical imbalance. “It seems,” she says, “that we're on the verge of isolating the blood factor responsible for blunders. Barring any further mishaps, we'll have our breakthrough any day now.”

Scientists have long attributed mistakes in our species to a hypothetical protein, Human Error Factor (HEF). But the substance had never actually been identified until Dr. Taylor's team inadvertently benefited from a series of tragedies caused by human error. Her technicians secured blood samples from Union Carbide engineers in Bhopal, India, former nuclear reactor operators in Chernobyl and Three-Mile Island, and random Pentagon employees.

“These people were rich in HEF,” smiles Dr. Taylor. “It just bubbled up to the top of their specimens and formed a crust--an imperfect crust, at that.”

From that sample, her laboratory isolated almost pure Human Error Factor. “We could have purified it completely,” explains Dr. Taylor, “but for technical limits in our equipment. So we've ordered more accurate gear. Actually, we've had to order it three times now. First it got lost in shipping, and the next time the parcel service truck ran off the road.”

When scientists finally have pure HEF at their disposal, they'll be able to program bacterial colonies to mass-produce antibodies to it so that eventually we’ll be able to vaccinate ourselves against mistakes.

According to Dr. Taylor, “Development will take a few years, since, like all vaccines, we'll need to test it on lab animals first, then on detainees and whoever. Only then can we give it to humans.”

Dr. Taylor's pioneering has stimulated research elsewhere. Other labs have reported, for example, that while all people carry HEF, some have more than others. The spectrum ranges from computer software engineers—who have three times the average concentration—to Presbyterian ministers, who seem totally free of the substance.

“One statistic has me worried, though,” Dr. Taylor admits. “Public officials seem to rank high in HEF; in fact, the higher the official, the higher the HEF level. Therefore we've asked the Surgeon General to test our highest government personnel. I hope he gets our letter soon. We tried to call him, but operators kept misdirecting us.”

Unsurprisingly, Dr. Taylor's suggestion has not found a champion on Capitol Hill. “Preposterous!” thunders Rep. Samuel Chadwick (R-NH). “Members of Congress aren’t the ones to test for this human error stuff. Test athletes! Test welfare queens!” And Sen. William Sims (D-NM) asks, “What’s all this talk about incompetence in government, anyway? If it's so common, why have I missed it?”

WHAT WOULD YOU DO IF IT WERE YOU, DOC?

2011-04-13T14:09:00.000-07:00

A group from Duke University and the University of Michigan wondered whether a choice in treatment that physicians would make for themselves might differ from what they'd recommend to a patient. How do researchers dream up such ideas, anyway? Well, when they looked, sure enough, there was a dramatic difference. You can find the abstract at http://archinte.ama-assn.org/cgi/content/abstract/171/7/630.

The researchers presented physicians with two hypothetical treatment alternatives. One choice carried a higher likelihood of dying, but a higher quality of life if they didn't die. I call this the "quality" choice. Choice number two--I'll call it "quantity"--involved a greater chance of survival but with troubling aftereffects. The docs were asked to recommend one of the two treatments for a patient, and also one for themselves if they were the patient.

38% of the docs chose "quality" for themselves but only 25% recommended it to their patients. In a scenario with another hypothetical illness, 63% chose "quality" for themselves but only 49% chose that for their patients. In other words, the docs would usually advise patients to opt for probable quantity over quality of life while they'd choose the opposite for themselves.

What sense are we to make of this double standard? Maybe physicians assume that patients want survival at all costs. But they really can't know what patients want unless they ask. One of the authors, Dr. Peter Ubel, concluded from this study that patients shouldn't request advice until their doctor understands them better, including how they weigh issues such as quality versus length of life. Said Dr. Ubel, "I think the doctors, when they were imagining themselves as the patients, were saying, 'Yes, there is a higher survival, but I don't want to put up with these horrible side effects.' On the other hand, when they are making recommendations for the patients, it is easier to push those emotions aside.''

Medical doctors have traditionally been taught, implicitly but thoroughly, to push their emotions aside. But here's a situation where that skill--if you want to call it that, and not a disability--can actually degrade treatment. After all, obtaining medical care isn't the same as, say, obtaining a pair of socks. The relationship between seller and buyer of socks is inconsequential, but the patient-doctor link is fraught with life and death issues. If healthcare is to be conducted as though people matter, it must necessarily honor the emotions of all parties.

WE PROTECT CHEMICALS MORE THAN CHILDREN

2011-04-12T12:27:00.000-07:00

What is a poison? Socrates swallows the hemlock, clutches his belly, and dies, right?

We think of poisoning as immediate, but unfortunately for us and especially our children, that's almost never the case. Most poisons--and we live amidst thousands of them--exert their effects in small but cumulative increments, over years and decades. Examples are the many organic compounds that permeate our lives, like food additives, pesticides, and plastic breakdown products. Isolated doses might be rather harmless, but long-term aggregate exposure can be tangibly hazardous.

For example, in every school in my region, employees regularly apply herbicides to the landscaping, that practice being ostensibly cheaper than hand-weeding. They try to do this on weekends and holidays, allowing time for the chemicals to degrade before kids are present. When I inform parents about this practice, they usually respond that their children don't seem to have suffered ill effects. This is unjustifiably sanguine, ignorant of the fact that multiple exposures over years add up.

Take the herbicide glyphosate, brand name Roundup, of which we use plenty. In 2007 alone, American farmers applied 185 million pounds of it, double the amount used only six years earlier. Roundup's been effective not only in wiping out crop weeds, but also in keeping gardens and golf courses pristine.

Its manufacturer, the Monsanto Corporation, has also genetically modified corn, soybeans and cotton to be "Roundup Ready," or immune to the herbicide's effect, so that farmers can grow crops amidst weed-killing concentrations of glyphosate. It's understandable, then, that some U.S. farm organizations say this chemical is too beneficial to give up. But critics say glyphosate may not be as safe as initially believed, and farmers should be cautious.

For one thing, Roundup is beginning to fail its own purposes. Just as pathogenic bacteria exposed to antibiotics mutate resistant strains, weeds are learning to ignore Roundup. More than 130 species have developed herbicide resistance in the United States, raising the question of whether this chemical is morphing from Dr Jekyll into Mr. Hyde.

Roundup might be harmful to human health as well. The EPA is now examining a study that claims to have detected concentrations of glyphosate in the urine of farmers and their children in two American states. Higher levels were found in farmers who did not wear protective clothing when they used glyphosate or who otherwise improperly handled it.

The agency also said it's looking at a study partly sponsored by the National Institutes of Health that found some users of glyphosate had a higher risk of multiple myeloma, a cancer affecting bone marrow, than people who never used the chemical. The Institute of Science in Society has called for a global ban on glyphosate, citing research showing the chemical has "extreme toxicity," including indications it can cause birth defects. The EPA plans to rule on whether to ban glyphosate possibly by 2015.

Canada

is also re-evaluating glyphosate, but through a different lens. Where the United States offers chemicals the same protection it offers citizens--innocent until proven guilty--Canada follows what's called the "precautionary principle," which bans chemicals with suspected toxicity.

We need to rethink our concept of poison. Since the poisons we actually live with are subtler than we've believed, we've developed public health policies that award chemicals greater protection than children in a schoolyard.

WHAT'S REAL?

2011-04-07T10:30:00.000-07:00

I suppose yesterday's post left some readers scratching their heads. Is Post-Mature Birth Syndrome a real phenomenon, journalistic hyperbole, or an outright hoax?

I'm not going to answer, but I do wish we'd ask ourselves that question every time we hear about the latest medical "breakthrough." So here's another one, from the Journal of Medical Breakthroughs…

PATHOLOGICAL NICENESS SYNDROME: KILLER WITH VELVET GLOVES

Nancy Simpson considered herself a reasonably happy, average, normal woman. She’d raised two children while her husband, Ted, pursued his career selling insurance. The kids went away to college, she and Ted began to make each other’s acquaintance anew, and still...something wasn’t right.

“I should have felt terrific,” she complains. “Accomplished. Complete. But I was miserable. I felt drained and exhausted, as though something had sucked my energy away.”

She visited doctor after doctor. One told her that her thyroid was deficient, but the replacement he prescribed made her insomnic and jittery. Another doctor gave her antidepressants, which only sagged her out more. Working her way through the medical system, she was told she was prematurely menopausal, manic-depressive, malingering, fibromyalgic, and allergic, depending on whom you believe, to alcohol, carpeting, yeast organisms, her own blood sugar, and irony.

“I thought I’d live out my life reading National Geographics in doctors’ waiting rooms,” she sighs, “but finally I found Dr. Beane, who diagnosed PNS.”

Dr. T. Richards Beane and PNS, or Pathological Niceness Syndrome, are almost synonymous in medical circles. A trim, sober-looking man in his middle years, Dr. Beane describes the syndrome as a persistent need to behave more nicely than conditions warrant.

“Almost all PNS patients,” he explains, “are women. We aren’t sure about its source. But suffice it to say that compulsive niceness marinating over many years can brew up a volcano of anger. These patients are rich in bile and heavy in spleen.”

Dr. Beane favors behavior-modification therapy. At his clinic, the Institute for the Study of Niceness in Boise, Idaho, highly trained technicians coax the afflicted away from their ingrained pleasantness.

On a Thursday afternoon, one of Dr. Beane’s technicians, Jean Armentraut, mentions to her group of three PNS patients, “Oh, I’m terribly thirsty. A little iced tea would be so nice.”

The two newest patients, Marie and Wanda, leap from their seats. “Let me do it,” pleads Marie. “Wanda did it last time.”

“Oh, no!” answers Wanda. “I was just about to go to the kitchen anyway!”

Ms. Armentraut turns calmly to Mildred, the veteran patient, who has remained silent, and comments, “Mildred hasn’t had a chance to contribute. Mildred, why don’t you get the tea?”

Mildred bares her canines. “Jean, why don't you take a flying…”

Technician Armentraut turns proudly to the interviewer. “As you can see,” she beams, “Mildred’s making marvelous strides.”

PNS treatment becomes more intense, building upon each small success. Later, male technicians with five o’clock shadows and filthy T-shirts will scream at patients orders to mend socks, chicken-fry steaks, and fetch cold brewskis.

Like Nancy Simpson, millions of women may actually not be allergic to their wallpaper or their conjugal sheets, but instead suffer this most insidious of diseases. The last word for the moment is from Dr. Beane, who advises, “One thing is for sure: we need more research.”

POST-MATURE BIRTH SYNDROME: THE SUBTLE CRIPPLER

2011-04-05T15:35:00.000-07:00

Finally, an authentic breakthrough...

“I was never on time to anything,” Meredith Yolk recalls. “I was late every day to school --every day for thirteen years! It was so embarrassing. I was late for my graduation, late for job interviews, always late to work. I even kept my husband waiting at the altar. It felt as though a clock inside me had been set wrong.”

Meredith Yolk is literally correct, for she is one of millions of Americans who suffer a malady totally unknown even five years ago, Post-Mature Birth Syndrome, or PBS. Its victims were born later than they should have been. A half-hour delay at birth becomes the half-hour of lateness that will haunt them the rest of their tragic lives.

According to Dr. Karl Mandrake, Chief Investigator at the respected Sloan-Smithson Institute in Albany, New York, approximately one in ten Americans suffers PBS. “And the tragedy,” says Dr. Mandrake, “is that most of its victims believe they have a personal shortcoming, not a disease.”

Dr. Mandrake goes on to explain this strange condition. “The normal human gestation period is nine months, with the child born at the minute and hour of conception. Although you may know that ten percent of us are born prematurely, you probably weren't aware that another ten percent are born a few minutes to several hours after the ideal delivery time. During this delay, the fetal brain secretes an abnormal hormone called ‘procrastinin.’ Once born, the poor person is perpetually tardy because procrastinin holds up his or her internal clock exactly the duration of birth lateness.”

The World Health Organization reported recently that post-maturity is unevenly distributed. For example, while it is virtually unknown in Scandinavia, some researchers claim to be able to smell procrastinin--so high is the level--throughout the American legal system. It is in post-maturity hotbeds such as this that scientists have isolated pure procrastinin for research purposes. Dr. Mandrake’s group even succeeded in creating antibodies to procrastinin, hoping to immunize PBS victims into punctuality. Unfortunately, all their experimental subjects died following the injection.

“You see,” explains Dr. Mandrake, “PBS shifts one’s entire time line such that our immunizations inadvertently left the subjects no time at all. At least we were able to console their families with the knowledge that a late birth means a late death: had our experiment not killed them, they actually would have died sooner.”

Of course, little of this discussion is useful to Meredith Yolk. “The worst thing about my PBS,” she complains, “is that we’ve been unable to have a child. My husband suffers from premature ejaculation, you see, and when you add his problem to mine, I think you can understand our distress. How can I get pregnant if he ejaculates before I even get home?”

Currently Meredith is undergoing behavior modification therapy at the Sloan-Smithson, where technicians deliberately postpone all activities to confer on their patients the illusion of punctuality. What is it like, finally, to feel on time? Meredith Yolk’s eyes well with tears. “I can’t believe it! I’m not late! Maybe one day I’ll lead a normal--even a useful--life.”

"NO ONE SHOULD BE ALLOWED TO TREAT A DISEASE THEY HAVEN'T HAD"

2011-03-29T15:54:00.000-07:00

No one should be allowed to treat a disease they haven't had.

That phrase has arisen more than once in cancer support groups I've facilitated. People get annoyed, frustrated, and even injured by the insensitive behaviors of some healthcare practitioners. It's not that anyone's uncaring; the fact is that unless you've been there, you don't know what it's like.

In a series appearing in the NY Times Well Blog, cancer researcher Dr. Peter Bach relates accompanying his wife Ruth through Cancerland. Each installment reveals another aspect of living with cancer, especially what people actually suffer from--cancer's emotional consequences.

In today's piece (http://community.nytimes.com/comments/well.blogs.nytimes.com/2011/03/29/hit-by-the-reality-of-cancer-treatment/),

Dr. Bach tells of going with Ruth to her first radiation appointment. They were first seen by a young medical resident who recited every point of her history. This was painful for them, and, when you think about it, unnecessary. He writes, "[the resident] was oblivious to the agony he was causing us as he perfunctorily rattled off the events…" But that's what doctors do, right? That's part of the medical ritual. The problem is that many who perform it are unaware of the suffering it can cause.

A half-dozen medical doctors have been members of cancer patient support groups I've facilitated. Finding themselves on the less familiar end of the stethoscope, every one of them said, at some time and in some way, "I had no idea…"

The only popular representation of this issue that I've seen is the film, now twenty years old, "The Doctor." William Hurt plays a rather cold, aloof surgeon. After learning he has cancer, his attitude begins to shift. He gradually develops compassion such that he'll never return to his previous style of practice.

Fortunately, the development of compassion doesn't require a life-threatening illness. We can contact and appreciate cancer, say, without physically having it, for it's emotionally contagious. Peter Bach suffers from his version of Ruth's cancer. That is, he's now touching the semipermeable membrane that separates the experience of patient and doctor.

I'd predict that as fine a physician as he's been, this good man will now find even more compassion in his dealings with patients. I hope, as a couple of commenters suggested, that he gently educate the medical resident who dragged him and Ruth through the pain of their history.

YOU CAN'T GET ENOUGH OF WHAT YOU DON'T REALLY NEED

2011-03-24T09:58:00.000-07:00

According to author Fran Lebowitz, "Food is an important part of a balanced diet."

Come again? Many of her readers think of Lebowitz as a cynic. But to us cynics, she's the kid who points out the Emperor's nakedness.

Health requires a balanced life diet, some of which is nourishing food. The rest includes feelings of worth, adequate exercise and rest, the joys of learning, intimate relationships, and other factors.

Of a healthy life diet's ingredients, few are physical. Feelings of worth and intimate relationships, for example, aren't things, but ways of living, so they can't be sold as "health" products. The physical ones, though--food, vitamins, supplements, exercise machines, surgical procedures, you-name-it--can be and are sold, to the tune of more than $25 billion annually.

"Health" product advertising is so successful that folks line supermarket aisles trying to divine from labels whether this pill, this gel, this patch, this fruit, this soymilk will awake the happiness that's languished within them. If only I had the proper supplements, the right omega oil, the ideal balance of carbs to fat…

Evidence is accumulating, though, that the greatest determinants of disease incidence are our past experiences and the life choices we make, not our daily intake of zinc. For example, if you were traumatized in childhood, you'll likely be exquisitely vulnerable in adult life to a range of serious diseases. See the effect of these "Adverse Childhood Events" in a 2009 Scientific American review,

http://www.scientificamerican.com/article.cfm?id=childhood-adverse-event-life-expectancy-abuse-mortality . My blog entry "Contact As Treatment" (http://healthcareasthoughpeoplematter.blogspot.com/2011/02/contact-as-treatment.html) related recent findings demonstrating social contact as a cheap and effective way of treating chronic illness.

Absence of disease is the notion of "health" that most of us grew up with. If we had a course in health, it no doubt emphasized the four basic food groups, regular checkups, and avoidance of drugs. That's fine as far as it goes, but fairly desiccate: what about the juice that makes us want to hang around? Isn't being loved as important as a well-balanced meal? Aren't humor and creativity and sex vitamins at least as essential as riboflavin?

The idea that health is an enjoyable life is gaining ground in our culture. Meanwhile, many of us will continue to graze product shelves in a futile search for fulfillment. Eating disorder guru Geneen Roth (author of When Food Is Love and many other sharp books) advises, "You can't get enough of what you don't really need."

MENTAL ILLNESS AND GUNS: A PUBLIC HEALTH ISSUE

2011-03-15T11:10:00.000-07:00

Since January, when Jared Loughner shot six people to death and wounded thirteen others in Tucson, more two thousand (yes, two thousand!) Americans have lost their lives to firearms.

These scandalous numbers finally motivated President Obama to address gun violence last weekend. Politically cautious as always, he recommended enforcing laws that are already on the books. For example, the FBI's National Instant Criminal Background Check System (NICS), a database of names prohibited from obtaining guns, is far from fully implemented. Mr. Obama said, "We must do better."

True, if the NICS system had been strictly administered, it would probably have kept Seung Hui Cho from killing thirty-two people on the Virginia Tech campus.

But even perfect NICS operation wouldn't have affected Jared Loughner or the many others who haven't been legally designated as mentally ill. In Arizona, a person must be at least eighteen years old and have a qualifying psychiatric diagnosis and a resulting functional impairment to earn that designation. Though considered weird in his every circle, Loughner was never diagnosed--largely because he never sought treatment--so he was perfectly free to buy guns.

In California and most other states, a court order is required for designation as mentally ill, but the process can't reach that level until a mental health professional certifies one as a danger to self or others, or gravely disabled. A mentally ill man in our town shot three people to death ten years ago. Long a patient in our county's public mental health system, he should have reached the court, but no attempt was made to bring him there. His shoddy and negligent treatment was due in part to gross mismanagement and in part to gross underfunding.

In his talk on gun violence, the President failed to mention mental health treatment, a more effective approach to this conundrum. Instead of improving treatment, we're decimating it. Over the last three years, the states have reduced mental health budgets by $2.1 billion, and more slashing is on the way. In a stroke of perverse genius following the Tucson shootings, Arizona's Governor Jan Brewer announced her intention to cut $35.9 million in mental health services.

Maybe the President feels that embroiling himself in the states' choice of budget cuts will generate political blowback he doesn't need now. But I suspect he avoids the subject because he's aware of something more subtle: the bulk of people who are dangerously mentally ill will simply not come to professional attention. A this point in our history, we have no social or legal mechanism for keeping weapons from the hands of people whose minds are perilously aberrant, but still hold down jobs, attend school, and function more or less within boundaries we call normal. As weirdly as Jared Loughner behaved, he never triggered a serious mental health alarm until the shootings.

Many years ago, I worked in a federal facility. An employee was sent to me for a mental health evaluation because he was frightening his coworkers. A coiled spring of anger, he frightened me, too, especially when he revealed that he kept his car trunk filled with guns. I phoned his brother, a local deputy sheriff, to relate my worries that this man was a time bomb. His brother told me he was equally concerned, but there was nothing he could do, as the man had broken no laws and wasn't crazy enough to generate a court appearance. As far as I know, the man never exploded.

I believe this is no rare situation, and it's as ridiculous to allow it as it is dangerous. Do I have a solution? No, but I do suggest a course of action: we need to conduct a national dialog about the actual issue, which is mental health. Discussing gun violence as though it's solely about guns is a waste of time…and lives.

PLAYING IT SAFE

2011-03-09T09:14:00.000-08:00

I was chatting with a friend in line in the post office. She told me that a couple of weeks ago, hiking with friends, she'd gotten dehydrated and fainted. She recovered in a few minutes. The group continued its hike and returned home uneventfully. When she told her husband, a nurse, what had happened, he insisted on bringing her to the local emergency room to check her out thoroughly.

She was examined, had an MRI, blood tests, and, "…just to play it safe…," was observed in the hospital overnight. A physician she'd never seen before visited her there. He said, "If you fainted, you shouldn't be driving. I've asked the Department of Motor Vehicles to suspend your license." The medical workup turned up no findings, and she went home the following morning.

She was in the post office to send off forms requesting restoration of her driver's license. She wasn't pleased by her hospital experience, especially its expense since they were uninsured. She asked me, "What do you think that whole thing cost?"

Knowing how insanely expensive American healthcare is, I facetiously guessed fifteen thousand dollars.

She said, "How did you know?"

What's to be learned from this debacle? When we want to "play it safe," how safe is safe? At what point do we accept risk and, ultimately, mortality?

We tend toward applying full-bore medical technology in every case for a couple of reasons. First, it's available, so what the hey, especially in those instances when someone else pays for it. Second, it seems to be the responsible thing to do. What if, God forbid, we miss the…(fill in the blank)? Third, if you really love your spouse who fainted, you'll leave no stone unturned.

Still, this approach is more often troublesome than helpful, as medical investigations can be confounding. We need to remember, for example, that all diagnostic procedures bear false positives and false negatives. CAT scans can show "tumors" that don't actually exist, and miss tumors that imitate normal structures. The same is true of the physical exam and every conceivable test. When a false positive occurs, it doesn't announce it's false, of course, so it can generate further testing. And just because a test result is "normal" doesn't necessarily mean everything's hunky-dory.

There are ways to approach this conundrum with better balance. Here are a few recommendations:

1. Become more knowledgeable medically. Do you know, for example, that dehydrated hikers can faint? Do you know how to treat a sick kid's fever?

2. Accept that it's impossible to guarantee perfect safety. You already do, to some degree: everyone draws a line they consider reasonable. E.g., hardly anyone wants a series of pulmonary function tests when they have a cough.

3. Be aware that other folks, drawing different lines, might ignite your fear. Your nurse spouse might insist you go to the E.R. Your doctor might want to run a few tests, "just to be sure."

OUR POOR PSYCHIATRISTS

2011-03-07T09:58:00.000-08:00

Leave it to the NY Times Well Blog to come up with salient issues. On March 5 it published "Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy"(http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?pagewanted=2&_r=1&ref=health).

The piece describes how tough practice is for Pennsylvania psychiatrist Dr. Donald Levin. Schooled in the classical "talking cure," he's discovered his craft's devolution is perfectly parallel to that of family practitioners: insurance rewards short visits. Spend decent time with patients, and soon you'll be eating nothing but ramen.

About the time Dr. Levin began his training, I, too, looked into becoming a psychiatrist. My medical school's style of psych training was paleolithic, confined to behavioral therapy, which I found repulsive, and psychoanalysis, which was expensive, interminable, and relatively ineffectual. Peeking into psych residencies, I found it was something entirely different, a Brave New World of psychoactive drugs. Phenothiazines were revolutionizing schizophrenia treatment, and drug after designer drug was sliding down the pipeline to treat other conditions. In other words, it looked like psychiatry would soon become behavioral engineering through pharmacology. Nope, not for me.

Sure enough, that's what happened. My shrink friends' practices gradually turned toward fifteen-minute drug adjustments. New chemicals were touted as treatments for almost every kind of behavior, as though Big Pharma was outright inventing drug-treatable maladies. Indeed, that's today's state of the "art."

A friend who's a psych nurse in Massachusetts told me she took a week-long intensive refresher course in psychiatric medications. It was so replete with exceptions, variations, deviations, and qualifications that when it ended she approached the instructor and said, "Let me get this straight: it's a total crap-shoot, right?" The instructor nodded, "Right."

The psychiatrists and other docs who went into this business for its deliciously deep human contact are justified in feeling this terrible loss. I hear their complaints personally and read reams of them online. What are they to do to treat their pain, a potential source of depression? Of course, they can find some pill to take--and many do. But they can also approach their situation with genuine therapeutic intent, say, by seeing a well-trained non-MD counselor.

The essay contrasts Dr. Levin's experience with that of a former colleague, Dr. Louisa Lance, who practices personal-contact psychiatry. She courageously cut ties with insurers, so she no longer works for them, but solely for her patients. Treating fewer patients in a week than Dr. Levin treats in a day, she says, “Medication is important, but it’s the relationship that gets people better.”

(BEEP) HOW PAINFUL THAT MUST BE FOR YOU (BEEP)

2011-03-05T09:47:00.000-08:00

In an op-ed piece in the NY Times February 26 (http://www.nytimes.com/2011/02/27/opinion/27verghese.html?_r=1&scp=1&sq=treat%20the%20patient,%20not%20the%20ct%20scan&st=cse), Stanford physician and author Abraham Verghese critiques the use of computers in healthcare.

He sees them as a two-edged sword: marvelous in their capabilities, and at the same time a hazardously distractive presence. He writes, "…the complaints I hear from patients, family and friends are never about the dearth of technology but about its excesses." Its excesses amount to relentless intrusions into the patient-practitioner relationship.

One example is reported by DreamsAmelia, a reader of this blog and author of her own powerful blog, Shelved in Cyberspace (https://dreamsamelia.wordpress.com/). She writes, "…our nurse…had her back to us while she filled out a computer screen and asked my daughter to rate her pain--not even making eye contact, let alone holding her hand!"

You get what she means. You've probably had a similar experience.

We might take this tendency more lightly if it weren't occurring across society. Remember the New Yorker cover around last Hallowe'en? It depicted parents accompanying their trick-or-treating kids. Each parent's face is illuminated by the bluish glow of the cell phones they're consulting. That is, we're relating more and more, day by day, to machines instead of to one another. The "friend" we have in cyberspace is hypothetical compared to the warm, fleshy one we can sit with knee-to-knee, heart-to-heart. And try though we might, we'll never develop a compassionate robot.

Patients aren't the only ones discomforted by medical technomania. I've heard healthcare practitioners complain that hi-tech intrusion is supplanting the human contact that had been the source of joy in their profession.

If this phenomenon is distressing, we need to do something about it, since if we don't, who will? We can begin by simply saying so, and move on to behave as we feel we should. Change never occurs any other way. As Gandhi advised, "Never do the wrong thing, even if the authorities require it. Always do the right thing, even if the authorities forbid it."

THE RIGHT TREATMENT

2011-03-03T18:56:00.000-08:00

When Jack, a recently diagnosed member of our cancer support group, said he hadn't yet chosen a treatment, other members voiced their concern.

“Cancer cells don’t take time off, you know,” advised one.

Jack said standard oncology was too toxic for his taste, so he’d first like to try alternative approaches like dietary regimens and coffee enemas. Two weeks later, though, he hadn’t begun alternatives, either. Other members began to lean on him, even suggesting that his strategy was flat-out wrong. During a lull in the conversation I found them looking my way, presumably because as group facilitator and ostensible medical arbiter, it was up to me to convince Jack of The Truth.

That moment begged the question of “support's” nature. Would supporting Jack mean aiming to extend his survival? Maximize his life quality? Keep him from wasting his time with quacks? Help him access a miracle? What are we after, here, anyway, in a world that has no guarantees?

It's strange that while knowledge of cancer generates confusion in the newly diagnosed, everyone else knows clearly what to do. Opinions flood in, along with books, clinic ads, diets, prayer cards, crystals and affirmations. Apparently there are as many routes as ways to slice an onion. Obviously, no one can buy into all of them, especially the ones that are mutually contradictory.

This emotional maelstrom following diagnosis is one of those rare moments poets describe, the intersection of crisis and opportunity. While the stakes are high and treatment choices abundant, there's little clue as to which might prove most effective. That's why a helpful act at this point is to simply stop and contemplate the situation. When we do that, the question, “What to do?” becomes, “What are my deepest values, anyway? What do I really believe in?”

Over my forty-some years in this business, I’ve seen people choose hither and yon. Sure, most opt for standard oncology, and most of those throw in an alternative or two as well. Some go wholly for alternatives. Of those approaches, many look weird even to me, and I’m not exactly orthodox. Occasionally, when someone heads toward an intervention I believe to be harmful (one example: intravenous hydrogen peroxide), I warn them. A few people opt for no treatment at all. And you know what? An individual's success—defined sometimes as longterm survival, sometimes as contentment—correlates best with his or her faith in the chosen direction.

These are adults, after all, making mortally personal decisions. I'm not about to frog-march them down to the oncology clinic since I’m not sure which way I’d go if I were diagnosed. My own history includes treatments that range from standard medicine to visualization to pranayama. I don’t feel mandated to influence anyone toward any particular treatment.

To me, support has come to mean helping people navigate this slippery reality. It's no easy task for any of us since, as the Wise Ones say, “If you can see the path, it can’t possibly be yours.”

So what does Jack need? For him, now, support consists of unconditional love. In fact, when should it not?

HORROR DU JOUR: PUBLIC HEALTH IN POLITICAL HANDS

2011-02-24T09:40:00.000-08:00

In 1854, as a cholera epidemic ravaged London, physician John Snow reasoned that it spread via contaminated water. When he created a map of cholera incidence, he discovered that most cases clustered around a public water pump on Broad Street. He talked city authorities into simply removing the pump's handle, and the epidemic ceased. It was soon found that sewage was contaminating the pump's source.

Physicians still avert disease through public health activism, but today they labor mainly in third world countries. In the United States, doctors haven't been taught much about public health; they almost exclusively wait in their offices for sick people to appear.

That leaves the issue to politicians, an abdication tantamount to letting your cat babysit your infant. With few exceptions, politicians have little education in, or even regard for, science.

Take Maine's Governor Paul LePage, for example. He said something truly remarkable yesterday about bisphenol-A, or BPA, an ingredient in plastic bottles. BPA has been identified for decades as a "xenoestrogen," a molecule that, mimicking the female hormone, causes problems in humans, especially in fetuses.

Here's what Gov. LePage said: "If you take a plastic bottle and put it in the microwave and you heat it up, it gives off a chemical similar to estrogen. So the worst case is some women may have little beards."

Trust me, they won't have little beards, but their kids will be at risk for neurological troubles and feminization. Maybe the Governor would be more concerned if he knew women exposed to BPA might deliver boy babies with small penises.

It's not just his ignorance that disturbs me. He's laughing off the issue, ridiculing people who are justifiably concerned about a dangerous chemical. If he goes on to claim that BPA's never been undeniably proven hazardous, he'll be right, strangely enough. By its nature, science can only show likelihoods, never certainties.

Many chemicals are toxic only in the long run. They can take years to decades to make their effects known. Considering that span plus the fact that thousands of BPA's cousin molecules--in food additives, medications, cosmetics, household products, and outright pollutants--constantly act together on us, their individual culpability is extremely difficult to prove. In terms of liability, these chemicals are a manufacturer's dream.

Americans honor the principle that a defendant is innocent until proven guilty. That's just, but we perversely apply it to chemicals as well as people. Canadians see it differently, employing what they call the "precautionary principle." This legal standard states that if a chemical is suspected, even in the absence of scientific consensus, to cause harm to the public or to the environment, the burden of proof that it is not harmful falls on the manufacturer.

I recently saw a film about the hazards of herbicides. It included an interview with a member of a city council somewhere in Kansas, as I remember, who voted with a majority to ban all herbicide use in that city. He explained, "Look, if I'm right about this, then it's likely several kids won't have cancer twenty-five years from now. If I'm wrong, then there will be a few more dandelions people will have to pick by hand."

One hopes someone educates Governor LePage about values along with basic science. If, as he joked, BPA did indeed cause women to grow little beards, would that concern him, or would he feel it's more important to continue the use of BPA?