Sunday, July 20, 2014

Dislocation, Italian Style -

"SCUSI," I said, calling a nurse in the same tone of casual deference used to summon a waiter, trying to ignore the pain that was blaring like a siren in my mind. It was a glorious day in Milan, and I had planned to spend it having lunch with a colleague, visiting a favorite museum, shopping for shoes. Instead, I found myself staring at the emergency room ceiling in the Ospedale Gaetano Pini, which the ambulance driver assured me was the best orthopedic hospital in the north of Italy. "People come from all over to have surgery here," he said.

It seemed safe to say that few, if any, had come as far as I had. The first time I dislocated my artificial hip, in Pittsburgh, where I live, the hospital staff had propelled me from E.R. to O.R. with an all-hands-on-deck sense of urgency. Now I'd done it again. But the attendants in Milan seemed to be in no hurry. They moved among five of us lying broken on our gurneys and asked desultory questions (any allergies?) as if we were making conversation on a train.

A guest in a country not my own, I was determined to be respectful and congenial. Two nights earlier, I'd been out to dinner in Venice when the American couple at the next table asked a woman nearby to stop smoking. The offender obligingly exhaled in the opposite direction while noting that we were outside, for God's sake; the wife continued to wave her arms as if clearing the air after a stovetop grease fire. Even in this hospital, it was clear that there were local customs at work, and I intended to abide by them.

My eyes kept returning to an LED sign like the one behind the counter at my local butcher. Red numbers appeared in no discernible order. Nor did they seem to correspond to my fellow patients' comings and goings through the doorway that led to relief. It was unnerving and disorienting, this failure to make sense of the system. And I couldn't even blame a language barrier. I had lived in Milan for five years at the end of the '90s, and although my command of Italian now wobbles on occasion, I suddenly heard myself speaking complex sentences without hesitation, tossing off words I didn't know I knew. Adrenaline had apparently kicked my brain into a higher gear, as if the past subjunctive might improve my chances of survival.

Eventually, I was wheeled into an examination room and greeted from a desk on the far side by a silver-haired, Hollywood-handsome doctor whose black-rimmed glasses gave him the vaguely preposterous air of Cary Grant in the role of a paleontologist. Remaining seated, he interrogated me on my medical history, as I, still lying flat, turned my head and replied through the bars of the gurney's railing. A resident in scrubs stood alongside. Any surgeries? Two hip replacements. Where? New York. Two revisions to correct the botched second replacement. Where? The Mayo Clinic. "Rochester!" the resident exclaimed. I hoped the fact that I had been to Mecca would work in my favor here, unlike in some American hospitals, where the mention of the Mayo Clinic seemed to set off cherry bombs of intramural resentment.

The interview over, I was remanded to the holding area. Hours passed. The pain got worse. I was running out of charm.

"Scusi," I said, my voice pitched higher than intended this time. The nurse asked me to rate my pain on a scale of 1 to 10. In the past, I'd been instructed to think of 10 as the worst pain I had ever experienced. On that basis, my pain was an 8. Signora, the nurse replied, shaking his head, if it were an 8, you would be unable to speak. I lay there, contorted, wondering whether the Italians had recalibrated the scale to encompass the worst suffering over the course of human history, saving 10 for saints who were beheaded, shot full of arrows, crucified upside down, whose bones were now enshrined in churches all over the country.

At long last, early that evening, I was wheeled to the O.R. Cary Grant would attempt to put my hip back in place by manipulation, without an incision. This is the best-case scenario, but it doesn't work every time.

And it didn't work this time, I was informed when I awoke. They would try again the next day. I was wheeled to a double room upstairs, where a nurse, in response to my request for water, informed me that the hospital didn't provide water; my friends could buy it for me from a vending machine in the lobby.

As a patient in American hospitals, required to recite my name and date of birth at the start of every conversation, to initial my thigh with a felt-tip pen before surgery, I have been amazed at the extent to which our propensity for lawsuits has shaped our system. And yet, annoying and absurd as these crosschecks may be, the absence of them in Milan was disconcerting. As was the lack of obsessive data tracking: no bedside monitors displaying heart rate and respiration, no middle-of-the-night intrusions by nurses wielding blood-pressure cuffs and thermometers.

I was given a pill and told to swallow it. What is it? I asked. The nurse sighed. It's standard, Signora, she said. So much for the patient's right to know. A nurse entered, pulled aside my gown, stabbed a needle into my abdomen and exited. Back home, I viewed doctors as my partners in the healing process, but not here — my life was in these people's hands, and they would decide what information I needed. I recalled a conversation with an Italian friend whose father's doctor diagnosed cancer and gave him two months to live. I asked how he had taken the news. The doctor had told the family, she replied, but not the patient.

The O.R. for the second time was filled with laughter and banter, swirling above and around me like ripples on the surface of a pond as I lay on the bottom. A male nurse feigned annoyance with an attractive colleague. The surgeon made some joke, and I scrambled to find a comeback. The atmosphere was completely out of keeping with the hushed gravity of American O.R.s, which, in my experience, bore more resemblance to a church service than a party. The Italians I have known and loved are fun, funny, cynical, flirtatious, spontaneous, determined not to let their work interfere with their lives. It occurred to me, as I waited for the anesthesia to turn out the lights, that none of these were qualities I wanted when it came to my health care.

But this time, success. I was immobilized in a brace and returned to my room. A priest entered. "Buongiorno," he greeted me, his eyes taking in the other bed, now empty, and my night stand, where a friend had placed a dozen roses and a tiny jade Buddha. Nice flowers, he said, and left.

If Italian patients were expected to be quiescent to a degree I found incomprehensible, perhaps it was because their relationship to their doctors was more paternalistic than any I had ever known — or wanted. My mother, when she underwent thyroid surgery back in the '60s, regarded her doctor as infallible. But our faith in medicine and its practitioners has since been eroded by a growing awareness of side effects, infection, malpractice and class-action suits. Are errors and complications more common in the United States? Or do Italians, however reluctantly, take bad outcomes in stride, resigned to their fate, while we Americans respond with indignation and crusades for restitution?

Edward T. Hall, the cultural anthropologist who advised members of the State Department in the '50s, wrote that you can live in another culture all your life and you will never completely understand it, but you will come to understand your own. You might think that sickness and health would transcend the differences that put people from disparate countries at odds. But over three days at the Ospedale Gaetano Pini, I came to realize that my assumptions when it comes to medicine are completely in keeping with my bedrock American outlook on life, which, like it or not, revolves around money. As a consumer, I go into every transaction, even surgery, with an expectation of the service I'm entitled to and feel shortchanged when I get anything less.

In advertisements featuring athletes and ballerinas, hospitals in the United States claim to make their patients good as new — a foolproof selling point in a nation of perfectionists fixated on youth. Physical decrepitude, to our way of thinking, is not universal human destiny but a condition that can be forestalled by those who have the means and make the effort. This refusal to come to terms with our own decay is, finally, no more realistic than blind faith in fellow mortals ordained as doctors.

Just before I left the hospital, the resident who knew the Mayo Clinic dropped in to say goodbye. I hope we haven't given you a bad impression of Italian medicine, he said. I assured him that I was grateful for everything they had done.

Friday, July 18, 2014

Fighting a One-of-a-Kind Disease - Seth Mnookin - The New Yorker

Matt Might and Cristina Casanova met in the spring of 2002, as twenty-year-old undergraduates at the Georgia Institute of Technology. Cristina was an industrial-design major with an interest in philosophy; Matt was a shy computer geek obsessed with "Star Trek." At first, Cristina took no notice of him, but the two soon became friends, and that fall they began dating. Within a year, they were married.

The couple had their first child, a son, on December 9, 2007, not long after Matt completed his Ph.D. in computer science and Cristina earned her M.B.A. They named him Bertrand, in honor of the British philosopher and mathematician Bertrand Russell. After a few blissful weeks, the new parents began to worry. Matt and Cristina described Bertrand to friends as being "jiggly"; his body appeared always to be in motion, as if he were lying on a bed of Jell-O. He also seemed to be in near-constant distress, and Matt's efforts to comfort him "just enraged him," Matt says. "I felt like a failure as a father." When the Mights raised their concerns with Bertrand's doctor, they were assured that his development was within normal variations. Not until Bertrand's six-month checkup did his pediatrician agree that there was cause for concern.

By then, Matt had a new job, as an assistant professor at the University of Utah's School of Computing. It took two months to get Bertrand on the schedule of a developmental specialist in Salt Lake City, and the first available appointment fell on the same day as a mandatory faculty retreat. That afternoon, when Matt was able to check his phone, he saw that Cristina had left several messages. "I didn't listen to them," he told me in an e-mail. "I didn't have to. The number of them told me this was really bad."

Bertrand had brain damage—or, at least, that was the diagnosis until an MRI revealed that his brain was perfectly normal. After a new round of lab work was done, Bertrand's doctors concluded that he likely had a rare, inherited movement disorder called ataxia-telangiectasia. A subsequent genetic screen ruled out that diagnosis. When Bertrand was fifteen months old, the Mights were told that urine screening suggested that he suffered from one of a suite of rare, often fatal diseases known as inborn errors of metabolism. During the next three months, additional tests ruled out most of those ailments as well.

As Matt tried to get a foothold in his new job, Cristina struggled to care for a wheelchair-bound child whose condition seemed to worsen by the day. When Bertrand was hospitalized, she would stay by his bedside, often neglecting to eat; the constant stress contributed to osteoarthritis so severe that her doctor told her she'd need to have her right knee replaced. In April of 2009, the Mights flew to Duke University, in Durham, North Carolina, to meet with a range of specialists, including a geneticist named Vandana Shashi, whose clinical practice focusses on children with birth defects, intellectual disabilities, and developmental delays. After five days of tests and consultations, the Duke team told the Mights that there was widespread damage to Bertrand's nervous system and that some of his odd behavior—wringing his hands, grinding his teeth, staring into space—was likely due to the fact that his brain appeared to be suffering from spikes of seizure-like activity.

When Bertrand was a newborn, Matt joked to friends that he would be so relaxed as a parent that he wouldn't care which technical field his son chose to pursue for his Ph.D. In May of 2009, the Mights closed Bertrand's college savings accounts so that they could use the money for medical care. That fall, Bertrand was rushed to the emergency room after suffering a series of life-threatening seizures. When the technicians tried to start an I.V., they found Bertrand's veins so scarred from months of blood draws that they were unable to insert a needle. Later that evening, when Cristina was alone with Matt, she broke down in tears. "What have we done to our child?" she said. "How many things can we put him through?" As one obscure genetic condition after another was ruled out, the Mights began to wonder whether they would ever learn the cause of their son's agony. What if Bertrand was suffering from a disorder that was not just extremely rare but entirely unknown to science?

More ...

Monday, July 14, 2014

Why Smart People Are Dumb Patients - The Daily Beast

People who otherwise seem educated and rational continue to refuse vaccinations for their children due to a long-discredited study falsely linking vaccines to autism. They choose herbal remedies instead of well-researched medications and operations to treat serious illnesses like cancer. They flee from modern medicine to visit any other guru possible. But at what cost? What is fueling the mistrust?

Steve Jobs is a classic case in point. In Jobs' 2011 biography, author Walter Isaacson highlighted a tragic mistake fueled by hubris. Jobs could have been very fortunate; a medical exam for something else incidentally picked up an early pancreatic carcinoma. Although pancreatic cancer is usually deadly, Jobs' tumor was felt to be curable with immediate surgery. Yet this brilliant inventor, who revolutionized modern technological society, refused the recommended surgical procedure. He chose herbal treatment instead. By the time he noticed nine months later that he wasn't getting better, it was too late. His tumor had spread, and the next six years became a painful game of catch-up, one that he ultimately failed.       

Isaacson muses, with good insight, that Jobs' tendency toward "magical thinking" was what did him in. In psychology, magical thinking is a term referring to a type of primitive rationalization used by children, before maturity brings about abstract thinking. This thinking can seem innocent and endearing in children; if you will it, it will be. There is a simple optimism in the notion that anything can happen if you want it to. It's only the brick wall of logic that brings the fantasy ride to a bracing halt; adulthood teaches us that there are laws to the world around us that we, for better or worse, have to adapt to. There is no Santa Claus. The Earth isn't flat. People die. Science becomes the lens through which the adult brain peers at life; and the view isn't always pretty.        

Yet even as adults, many of us still cling to the wishfulness of childhood wonder. In some cases, it can be a magnificent and inspiring force. Not unlike the mantra of the movie Field of Dreams—build it and they will come—the power of the human imagination can be transformative. Jobs was willing to think outside the box, literally and figuratively; he combined elements of intuitive playfulness with the usually dry complexity of computer science. He made adult-level toys for the masses, because he believed in his own dreams.         

But sometimes one needs to sober up. In particular, the area of modern medicine seems particularly feared by people who otherwise employ reasonable amounts of logic to the world around them. It's perfectly normal—important, even—for people to be anxious about health and illness. Life and death are nothing to joke about. Yet the hardest thing about illness for people to face can be the lack of control, the uncertainty around one's fate. People notoriously avoid the doctor for this reason; magical thinking pops in. If no one tells you you're sick, you're not sick. So don't let the doctor tell you you're sick. Never mind that it's the doctor who can cure you.        

Say one does finally go to the doctor, gets the bad news, and then gets the doctor's recommended advice on treatment. A typical physician goes through 14 credits of tough pre-medical science and mathematics college courses, takes a difficult admissions exam, and only 5-10 percent of these hardworking candidates get accepted to medical school. After two years of intense advanced-level biology and biophysics courses (likened by many to "drinking from a fire hose") and two more years of rapid-fire clinical rotations, one enters residency for another four to seven years, and often an additional fellowship after that.      

Still, many patients fall into the rut of "noncompliance," or "nonadherence" as it has more recently been termed: the refusal, intentional or not, to follow a doctor's medical recommendations. Skipping visits, medications, lab work, and procedures.         

More ...

Thursday, June 19, 2014

Who Can Speak for the Patient? -

Our patient was never going to wake up. He had an unrecoverable brain injury. The prognosis had become clear over time. As the patient's attending physician in the intensive care unit, I arranged a meeting with his sister, the only visitor we'd seen for days, and explained. She was resolute. "He'll wake up," she said. "He's a fighter. Do everything you can to keep him alive."

The next day I told the social worker what the patient's sister had said. "What about the wife?" the social worker asked.

That was the first I'd heard of a wife. A spouse is the official next of kin. No decision should ever be made without the spouse. But I hadn't known she existed. I discovered that she visited the patient after her work shift, usually at 8 p.m. By that hour, our team was gone. The doctors on night duty were on for emergencies, not conversation. And so she was invisible to us.

How could we have missed this most basic and vital piece of information? It's easier than you might think. The sister didn't get along with the wife and apparently wasn't moved to tell us of her existence. The social worker had been out sick, and his replacement assumed that we knew. And we had a concerned sibling at the bedside who fulfilled our mental checkbox for who makes an acceptable surrogate decision-maker.

We hastily called a meeting with the wife. She arranged to leave work early, and she met us in our conference room. Feeling a combination of shame and relief at the averted disaster, we apologized for not being in touch. We didn't mention that we hadn't even known about her.

She was shocked by our grim prognosis. Angry. But then, with resolve, she stepped into her role as decision-maker. He would never want to live this way, she said. His father had suffered a devastating stroke years ago and her husband had remarked several times, "Don't keep me alive if I'm like that." She wanted to bring him home immediately with hospice support. Another day in the I.C.U. would have gone completely against his wishes.

As Dr. Atul Gawande described so beautifully in his book "The Checklist Manifesto," checklists improve medical care. I use a variety of them on my daily I.C.U. rounds. One assesses each organ in the body, moving systematically from nose to toes. Another evaluates settings on the breathing machine.

By systematizing my approach, I'm confident that I'll always remember the many different steps involved in treating a patient with cardiac arrest. I'll be more prepared to start tube feedings or begin to wean the patient off the ventilator when the time is right.

But despite my checks and balances, I had almost allowed the wrong person to make crucial decisions for this vulnerable patient. And I had nearly excluded a wife from her rightful place on her husband's team. Missing this crucial piece of information would have caused far more suffering and damage than any miscalibration of a ventilator.

I realized then that I needed another checklist, one that puts patients, and not just their organs, in the center. It would account for the human needs that we weren't always taught to prioritize, ones that didn't seem fatal if overlooked — clearly identifying the patient's next of kin, communicating with the family and identifying the goals of care, asking about symptoms like pain, delirium, shortness of breath. My critical oversight would not have happened had I sought out the social worker on the first day to confirm the true next of kin. He thought I knew. I thought I knew. We both were wrong.

Now, years after that incident, I use my patient-centered checklist on every critically ill patient I see in intensive care. After I go through the cardiovascular system, the pulmonary system, the kidneys and the ventilator settings, I turn to the presenting resident and say, "Now let's do the patient-centered checklist."

I have never since misidentified a surrogate decision-maker. And I know that I am doing a better job at managing my patients' symptoms. A checklist that addresses the human needs of a vulnerable patient is as crucial as those that deal with his organ function. After all, care is about the whole patient, not just his parts.

Wednesday, June 11, 2014

New AAMC Guidelines Released to Prepare Medical Students for Residency Training and Improve Patient Safety - News Releases - Newsroom - AAMC

A new set of guidelines from the AAMC (Association of American Medical Colleges) will help bridge the gap between patient care activities that new physicians should be able to perform on day one of residency training, and those they feel ready to perform without direct supervision. With the goal of improving patient care and safety, the guidelines are the first formal outline of the activities and requisite competencies and behaviors that every graduating medical student should be able to perform upon entering residency.

"As the nation's medical school graduates prepare to begin their residency training in July, ensuring they have the confidence to perform these activities is critical for clinical quality and safety," said AAMC President and CEO Darrell G. Kirch, M.D. "These guidelines take medical education from the theoretical to the practical as students think about some of the real-life professional activities they will be performing as physicians."

Working with a group of graduate medical education experts, the AAMC developed the Core Entrustable Professional Activities (EPAs) for Entering Residency in response to feedback from residency program directors about the clinical preparedness of entering residents, and from emerging literature documenting a performance gap at the transition point between medical school and residency training. The guidelines include 13 activities that all medical students should be able to perform, regardless of specialty, to standardize the expectations for both learners and teachers and better prepare students for their roles as clinicians. The core EPAs—which include activities such as gathering a patient history, prioritizing differential diagnoses, and recommending tests—were chosen as the framework for the guide because they offer a promising approach for assessing the real-world impact of a resident physician's education on patient care.

The guidelines describe expected behaviors and provide clinical vignettes demonstrating how new residents ready to be entrusted for performance without direct supervision would handle each of the specific EPAs. This summer, the AAMC will engage a few medical schools to launch a multi-year pilot and develop a learning community to share ideas about how the EPAs can be broadly implemented.

Friday, June 6, 2014

Anesthesiology News - A Farewell Letter to Residents

It is that time of year again. Just when we have all the confidence in the world that you know enough to do no harm, it is time for you to graduate and start your careers!

These are a few things I know for sure about your career in anesthesia:

  1. You are going to make mistakes. In the beginning, there will be more than you expected; and as the years move forward, there will be less. My advice is pay attention to your mistakes. The growth potential from our failures is exponentially higher than from our successes. Own your mistakes; people tend to have more respect for those who are honest than those who point fingers. If nothing else, you will be able to sleep better at night.
  2. Someone will die on your table. This is anesthesia. You are aware of the life-and-death stakes. I hope you will be able to learn something from the case. Becoming a better anesthesiologist from these cases is one way we can honor our patients. And most importantly, pay attention to your own well-being. These events have the potential to be very traumatic. Please talk to someone whom you can trust about your experience and feelings. Just because you are a doctor does not mean that you are immune to the human response to death.
  3. You will save a life, likely many times in the course of your career. It is quite possible that you will not receive the recognition you deserve for your efforts on behalf of your patients. Realize that without you, those patients most likely would not have made it off the operating room table. Pay attention to your successes so that you can build on them—and repeat them.
  4. You never are really finished. After what feels like 24/7 in the operating room for three years, you are thinking that nothing will come through those doors that you can't handle. Wrong. Residency is just a foundation. You have much left to learn about your craft. My hope for you is that you continue to learn every day for the rest of your career. If you are paying attention,the learning will happen naturally with little effort.
  5. Duty hour regulations, two breaks and a lunch are over. Nobody cares anymore if you are up for 24 hours straight. If you are going home exhausted, you are probably doing a great job.Pay attention to your life beyond medicine. It is so easy in our profession to burn out, or worse, turn to drugs or alcohol to cope with the daily stresses of our jobs. If you have friends, parents, a spouse or children, pay attention to them when you are not at work. One day, you are going to retire. The time you invest in these relationships is far more important than what kind of doctor you were. Anesthesia is a fantastic career, but you must have a life outside the operating room—it will keep you sane.

Most of all, I wish you a life filled with all that you deserve. Medicine is a noble profession, and you have chosen a field that takes patients through a vulnerable, stressful event in their lives. Be aware of your contributions, and take pride in your work. I take pride in my work, and you are certainly a huge part of my job. It matters to me that you are paying attention, and that you give a damn. While I am sad to see you go, it is part of our cycle of life in medicine. Be good, and know that I am proud of you, and thank you for all that you will do for our field and for our patients.

As always,


Ellen R. Basile, DO, is assistant professor in the Department of Anesthesiology at the University of Oklahoma and the Children's Hospital at OU Medical Center, in Oklahoma City.

Mental-Health Debate - Princeton Alumni Weekly

A recent lawsuit and coverage in The Daily Princetonian have prompted a campus debate about how the University treats students dealing with depression and other mental illnesses. Some students and mental-health advocates argue that these policies threaten to undermine student confidence in the University's counseling offerings, discouraging students from seeking help.

In March, a student sued the University, seven administrators, and the Board of Trustees in federal court. The student, who attempted to commit suicide, withdrew for a year and has since returned to campus. The lawsuit alleged that University officials disclosed confidential counseling records to campus administrators, who he said left him no choice but to withdraw. He also alleged that the officials discriminated against him because of his mental illness.

The student's lawsuit follows a similar complaint he made to the U.S. Department of Education's Office of Civil Rights. The office dismissed all of the student's claims and closed the case in April, University spokesman Martin Mbugua said.

In an anonymous op-ed in the Prince, another student recounted the decision to voluntarily take a year off without telling the University it was for mental-health treatment. The student wrote that when the University found out, it required the medical records from treatment as a condition for the student to return to campus.

Zhan Okuda-Lim '15, chair of the Princeton Mental Health Initiative Board, said the controversy could affect the willingness of students to seek help from Counseling and Psychological Services. The University reported that 17 percent of undergraduates and 21 percent of graduate students use CPS offerings each year.

"Students that I have spoken to ... have said that 'I'm worried if I went to CPS and were really open and honest, the next thing is I get an email'" about having to leave campus, Okuda-Lim said.

Representatives of the University's health and campus-life offices vigorously defended their approach to mental health. Without exception, they argued, the University acts in the best interests of the student and the campus, regardless of liability or public-relations considerations.

Administrators met with students, wrote letters to the Prince, and released an FAQ last month to clarify their policies.

About 35 students withdrew or took a leave of absence last year due to a "self-described mental-health issue," Mbugua said in a statement. In only three to five cases, he said, the student did not initiate the withdrawal conversation.

The University contested the assertion that it automatically forces students who have attempted or considered suicide to withdraw. "Most students who have been hospitalized because of an acute suicidal crisis can return to campus and resume their studies in the same semester, and many do," Mbugua said.

In the lawsuit, the student alleged that officials acted rigidly, without a "meaningful interactive process" between the student and administrators. Mbugua said that the University's general practice is for college deans to work closely with a student to develop an individualized plan for academic accommodations.

But, he said, "if the student continues to be at extremely high risk (perhaps because of a refusal to engage in appropriate treatment) for a longer period, then it becomes less likely that the student would be able to manage his or her academic obligations" and therefore should leave campus. Requiring a withdrawal has occurred fewer than five times in the past decade, according to the University's FAQ, but a student "may not unilaterally decide to remain enrolled when the evaluation indicates that his or her life may be at stake."

As part of the consultation process, the University requests medical information to determine whether the student can safely stay on — or return to — campus, said Calvin Chin, the CPS director.

As for routine visits to CPS, all information is kept confidential unless there is "imminent danger to self or others" or if the student chooses to authorize the release, John Kolligian, executive director of University Health Services, wrote in a statement.

Mental health has become a controversial issue at other colleges. Two students at both the University of Pennsylvania and George Washington University (GWU) committed suicide in 2014. At Harvard University, a student and a recent graduate committed suicide on campus this year. A dental student at Columbia University was found dead in the Hudson River last month from suicide.

Against this background, the rights of students facing mental illness, and the responsibilities of universities, have gained national attention. GWU and the City University of New York both settled lawsuits brought by students who had been removed from campus.

An underlying question in those cases and others is whether a school should force or encourage suicidal or depressed students to leave campus. At Princeton, if students fall too far behind on their coursework, "the student, in consultation with the dean, may conclude that it makes better sense to withdraw," Mbugua said, until "the student is able to focus on academics with less impact from a health condition."

Requiring students to leave can be counterproductive, said Darcy Gruttadaro, director of the Child and Adolescent Action Center at the National Alliance on Mental Illness. "Forcing them off campus is punitive and is not fair to the student, because you're making a fundamental change to their life circumstances," she said, which can hurt their recovery.

University officials pointed out that they must also act in the best interest of the campus, not only of individual students. Cynthia Cherrey, vice president for campus life, addressed this issue in a letter to the Princesaying the University must "protect as fully as possible the health and well-being of all members of the campus community."

In recent years, Mbugua said, the University has boosted counseling resources, reduced wait times for non-urgent care, and expanded group therapy and workshops.

Okuda-Lim said he appreciates the administration's willingness to engage with students, and he said he hopes the University will take feedback seriously. "Moving forward, actions are going to speak bounds and bounds more than words," he said.

Thursday, June 5, 2014

Apple's on-stage HealthKit goof proves it still has to earn the trust of the health community | VentureBeat | Health | by Mark Sullivan

Monday at Apple's Worldwide Developer Conference, an image flashed up on the screen behind VP of Software Engineering Craig Federighi. It was a screen shot from Apple's new Health app (or a mockup thereof), showing a user's blood glucose level.

But Apple biffed the measurement for blood glucose level, as Aaron Rowe of biochemical testing device maker Integrated Plasmonics pointed out. It's measured in mg/dL. Apple's slide said "mL/dL."

Of course, this probably says nothing about the finished version of the Apple Health app we'll see released with iOS 8 next fall. But it does raise an important issue for any company embarking on the new frontier of healthcare biosensing and informatics, no matter what form: To achieve the vision of a unified, consumer-driven health platform, they're going to have to get the real, clinical healthcare stuff right.

It's no secret that many in the healthcare community have serious doubts about the accuracy of the consumer health apps and gadgets available today. And a number of studies have reinforced those doubts. Consumer apps and devices are often inconsistent in their findings, reporting very different results in two tests of the exact same conditions. Clinicians are especially suspicious of apps that rely on the user to self-report key body metrics.

And that's just the data collection part. The hard part is processing the data and taking meaning from it in a way that improves care. If developers don't get this right, caregivers won't use the consumer health data collected in their apps, devices, and platforms.

"It will be really important for companies to justify their interpretations of the information they provide to achieve physician buy in," said Dr. Molly Maloof, a San Francisco Bay Area clinical physician focused on health optimization. "Otherwise, these consumer-focused devices will be written off as health toys rather than health tools."

More ...

Tuesday, June 3, 2014

When Doctors Ignore ‘Do Not Resuscitate’ Orders - The Daily Beast

When it's my time to go, I hope it happens without a fuss.

In the event that I suffer from a terminal illness, once the point has been passed where a return to health or meaningful quality of life is no longer a realistic possibility, when further treatment will do nothing but fill my days with more of itself, then I want that treatment to end. Though I hope such plans are a long, long way from ever being enacted, my husband and other loved ones know that I would not want "heroic" measures to prolong my life, and would choose a peaceful rather than a protracted death.

I am not alone in this. A new study in the online journal PLOS One reports that most of my fellow physicians feel the same way. The authors of the study surveyed over a thousand doctors, and just over 88 percent of them reported wanting an advance directive that would stipulate "do not resuscitate" (or DNR) status at the ends of their lives. I would have answered precisely the same way.

Those results do not surprise me in the least.

I cannot imagine going all the way through medical school, to say nothing of residency, without witnessing cases where patients received medical care that prolonged their existences but not their lives. It is a common enough occurrence that I would generalize it to essentially every graduate of medical school. We've all seen patients given interventions that preserved the functioning of their organs without any hope that the people themselves would have anything but misery to number out their days.

Why is this so? Why does the same study report that doctors will often override an advance directive if it conflicts with their clinical decisions that further treatment is warranted? Why would we order medical care that we do not want for ourselves?

At io9, George Dvorsky mentions the cynical possibility that physicians might do this for the sake of charging for lucrative end-of-life treatments. In the Pulitzer Prize-winning play Wit the central character is subjected to prolonged end-of-life interventions because her doctors care more about their medical studies than about her. I would love to believe that this never really happens, that members of my profession put the wishes and well being of their patients before any other considerations, but I would be a fool to be so naive. Sadly, even the mother of a close friend of mine was treated in this manner. I am sure that this happens, as loathsome as I know it to be.

However, I do not believe that most physicians opt for extensive treatments for their dying patients for this kind of reason. I suspect that for most of us, it's due to a more complicated and less appalling set of considerations.

First of all, prolonging and supporting patients' health and life is the entire reason for taking care of them in the first place. With the limited exception of medical providers who specialize in palliative care, we strive for our patients to recover, to leave our practices and clinics cured, or (failing that) well enough to have a baseline quality of life that justifies our being involved in their care in the first place. Letting go of this cardinal goal can be immensely difficult. If we can't make people better, then what exactly is it that we're accomplishing?

Further, there is always the fear of being accused of not doing all we could. The more we treat a patient, the less ambiguous our attempts to give them the best care possible. What better defense can there be against the threat of legal action than a full-court press at the very end? Though it's a difficult factor to quantify, I suspect this kind of rationale undergirds a lot more of the aggressive end-of-life care that patients receive than many medical providers would care to acknowledge.

There seems to be little space for any kind of nuanced or challenging conversation along these lines in our society at this time. One need look back no further than 2009 and the blight on our political discourse that comprised the "death panels" discussion, in which quondam vice-presidential aspirant Sarah Palin proclaimed that the Affordable Care Act would empower faceless bureaucrats with the authority to pull the plug on grandma.

Deemed the "Lie of the Year" by PolitiFact, what the law would have done (before the specific provision was stripped) was compensate doctors for appointments where they actually talked with patients about their wishes for end-of-life care. Thanks to the former governor of Alaska, physicians who choose to sit down with people and hear what they would want if they were dying cannot get paid for doing so.

But really, this kind of conversation is hard for doctors in general. We are not nearly as good as we ought to be at talking about the reality that even the best we can offer won't fix everything, and that everyone eventually dies of something. In modern medicine, every death is a defeat, and every illness is merely a chance to prove our worth as diagnosticians and healers.

As a pediatrician, I am generally spared this kind of conversation. Almost all of my patients are basically healthy. But even when I had a chronically ill patient who had a DNR order and was showing signs that he might be dying, I made sure to mention that more aggressive treatment was available should the mother opt to choose it, though I certainly did not push for it.

Watching a patient die without trying to stop it is not only contrary to our impulse to fix things, but it is obviously an irrevocable clinical decision. I can understand all too well how members of my profession would be terrible at making it.

And yet we must do better. We cannot routinely deliver medical treatments that we would not want for ourselves if patients have made the same decisions we would. I would want my loved ones to advocate fiercely on my behalf to have my end-of-life wishes honored, and we must improve our ability to honor similar wishes when they come from people who have entrusted their care to us. Dying patients are among the most vulnerable that we will encounter in our careers, and our duty to minimize suffering we would spare ourselves is a sacred one.