Sunday, October 19, 2014

Why Doctors Need Stories -

A FEW weeks ago, I received an email from the Danish psychiatrist Per Bech that had an unexpected attachment: a story about a patient. I have been writing a book about antidepressants — how well they work and how we know. Dr. Bech is an innovator in clinical psychometrics, the science of measuring change in conditions like depression. Generally, he forwards material about statistics.

Now he had shared a recently published case vignette. It concerned a man hospitalized at age 30 in 1954 for what today we call severe panic attacks. The treatment, which included "narcoanalysis" (interviewing aided by a "truth serum"), afforded no relief. On discharge, the man turned to alcohol. Later, when sober again, he endured increasing phobias, depression and social isolation.


Four decades later, in 1995, suicidal thoughts brought this anxious man back into the psychiatric system, at age 70. For the first time, he was put on an antidepressant, Zoloft. Six weeks out, both the panic attacks and the depression were gone. He resumed work, entered into a social life and remained well for the next 19 years — until his death.

If the narrative was striking, so was its inclusion in a medical journal. In the past 20 years, clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of evidence-based medicine prevails. As a writer who likes to tell stories, I've been made painfully aware of the shift. The inclusion of a single anecdote in a research overview can lead to a reprimand, for reliance on storytelling.

My own view is that we need storytelling in medicine, need it for any number of reasons.

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Friday, October 17, 2014

Doctors Tell All—and It’s Bad - Meghan O'Rourke - The Atlantic

A crop of books by disillusioned physicians reveals a corrosive doctor-patient relationship at the heart of our health-care crisis.

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The Rise of All-Purpose Antidepressants - Scientific American

Antidepressant use among Americans is skyrocketing. Adults in the U.S. consumed four times more antidepressants in the late 2000s than they did in the early 1990s. As the third most frequently taken medication in the U.S., researchers estimate that 8 to 10 percent of the population is taking an antidepressant. But this spike does not necessarily signify a depression epidemic. Through the early 2000s pharmaceutical companies were aggressively testing selective serotonin reuptake inhibitors (SSRIs), the dominant class of depression drug, for a variety of disorders—the timeline below shows the rapid expansion of FDA-approved uses.

As the drugs' patents expired, companies stopped funding studies for official approval. Yet doctors have continued to prescribe them for more ailments. One motivating factor is that SSRIs are a fairly safe option for altering brain chemistry. Because we know so little about mental illness, many clinicians reason, we might as well try the pills already on the shelf.

Common Off-Label Uses
Doctors commonly use antidepressants to treat many maladies they are not approved for. In fact, studies show that between 25 and 60 percent of prescribed antidepressants are actually used to treat nonpsychological conditions. The most common and well-supported off-label uses of SSRIs include:

  • Abuse and dependence
  • ADHD (in children and adolescents)
  • Anxiety disorders
  • Autism (in children)
  • Bipolar disorder
  • Eating disorders
  • Fibromyalgia
  • Neuropathic pain
  • Obsessive-compulsive disorder
  • Premenstrual dysphoric disorder

Investigational Uses
SSRIs have shown promise in clinical trials for many more disorders, and some doctors report using them successfully to treat these ailments:

  • Arthritis
  • Deficits caused by stroke
  • Diabetic neuropathy
  • Hot flashes
  • Irritable bowel syndrome
  • Migraine
  • Neurocardiogenic syncope (fainting)
  • Panic disorder
  • Post-traumatic stress disorder
  • Premature ejaculation

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Thursday, October 16, 2014

Experts Offer Steps for Avoiding Public Hysteria, a Different Contagious Threat -

As health officials scramble to explain how two nurses in Dallas became infected with Ebola, psychologists are increasingly concerned about another kind of contagion, whose symptoms range from heightened anxiety to avoidance of public places to full-blown hysteria.

So far, emergency rooms have not been overwhelmed with people afraid that they have caught the Ebola virus, and no one is hiding in the basement and hoarding food. But there is little doubt that the events of the past week have left the public increasingly worried, particularly the admission by Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, that the initial response to the first Ebola case diagnosed in the United States was inadequate.

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Wednesday, October 15, 2014

Am I Sick? Google Has a Doctor Waiting on Video -

The Internet can be a dangerous place to get medical advice. Stomachaches turn into cancer, stress becomes an endocrine tumor. Crack remedies and strange diets abound. Now Google is playing with a new technology that it hopes will help people find more reliable medical information. It's called a doctor.

Google's "Helpouts" product — a service where people can search for experts and talk to them over video — is running a trial program in which people who are searching for symptoms like pink eye and the common cold can video-chat with a doctor. The company is working with medical groups including Scripps and One Medical, which are "making their doctors available and have verified their credentials," according to a spokeswoman.

"When you're searching for basic health information – from conditions like insomnia or food poisoning – our goal is provide you with the most helpful information available," the spokeswoman said in an emailed statement.

Tuesday, October 14, 2014

With Electronic Medical Records, Doctors Read When They Should Talk -

Will history someday show that the electronic medical record almost did the great state of Texas in?

We do not really know whether dysfunctional software contributed to last month's debacle in a Dallas emergency room, when some medical mind failed to connect the dots between an African man and a viral syndrome and sent a patient with deadly Ebola back into the community. Even scarier than that mistake, though, is the certainty that similar ones lie in wait for all of us who cope with medical information stored in digital piles grown so gigantic, unwieldy and unreadable that sometimes we wind up working with no information at all.

We are in the middle of a simmering crisis in medical data management. Like computer servers everywhere, hospital servers store great masses of trivia mixed with valuable information and gross misinformation, all cut and pasted and endlessly reiterated. Even the best software is no match for the accumulation. When we need facts, we swoop over the surface like sea gulls over landfill, peck out what we can, and flap on. There is no time to dig and, even worse, no time to do what we were trained to do — slow down, go to the source, and start from the beginning.

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Sunday, October 12, 2014

To Become a Doctor -

His first week on night float, Daniel Sanchez heard "Code Blue — Radiology," over the P.A. system, and started running.

"You run," said Dr. Sanchez, 31, a first-year resident at Woodhull Medical and Mental Health Center in Brooklyn, "to wherever the location is, because code blue means the patient is going into cardiac arrest."

He was sure it was a patient of his, a woman in her 60s, who had been admitted for chest pains. His team had sent her for a CT scan.

He ran down the eighth floor hallway, then took the elevator to the second floor. It was his first code blue at Woodhull, a public hospital in Williamsburg. But in Guatemala, where he had worked at a public hospital, San Juan De Dios, as part of his medical school training, he had responded to dozens of these alarms.

"But never with the right resources," Dr. Sanchez said. "There were no monitors or defibrillators on the floor. At least half the patients died."

In radiology, his patient, an African-American woman who had just had a heart attack, was surrounded by emergency department doctors and nurses. A tall physician with braids down her back was quietly overseeing everything. A doctor touched the patient's neck and said, "It's not a code blue — she has a pulse!"

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Saturday, October 11, 2014

Can Big Data Tell Us What Clinical Trials Don’t? -

When a helicopter rushed a 13-year-old girl showing symptoms suggestive of kidney failure to Stanford's Packard Children's Hospital, Jennifer Frankovich was the rheumatologist on call. She and a team of other doctors quickly diagnosed lupus, an autoimmune disease. But as they hurried to treat the girl, Frankovich thought that something about the patient's particular combination of lupus symptoms — kidney problems, inflamed pancreas and blood vessels — rang a bell. In the past, she'd seen lupus patients with these symptoms develop life-threatening blood clots. Her colleagues in other specialties didn't think there was cause to give the girl anti-clotting drugs, so Frankovich deferred to them. But she retained her suspicions. "I could not forget these cases," she says.

Back in her office, she found that the scientific literature had no studies on patients like this to guide her. So she did something unusual: She searched a database of all the lupus patients the hospital had seen over the previous five years, singling out those whose symptoms matched her patient's, and ran an analysis to see whether they had developed blood clots. "I did some very simple statistics and brought the data to everybody that I had met with that morning," she says. The change in attitude was striking. "It was very clear, based on the database, that she could be at an increased risk for a clot."

The girl was given the drug, and she did not develop a clot. "At the end of the day, we don't know whether it was the right decision," says Chris Longhurst, a pediatrician and the chief medical information officer at Stanford Children's Health, who is a colleague of Frankovich's. But they felt that it was the best they could do with the limited information they had.

A large, costly and time-consuming clinical trial with proper controls might someday prove Frankovich's hypothesis correct. But large, costly and time-consuming clinical trials are rarely carried out for uncommon complications of this sort. In the absence of such focused research, doctors and scientists are increasingly dipping into enormous troves of data that already exist — namely the aggregated medical records of thousands or even millions of patients to uncover patterns that might help steer care.

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Thursday, October 9, 2014

How to Prevent Ebola Panic in the Facebook Age -- Science of Us

To the casual observer, it seems that a new case of Ebola is diagnosed in the U.S. every day, that the disease will soon explode in a terrifying outbreak. Both of these observations happen to be false — most initial reports of Ebola have turned out to be false positives and, because of the United States' modern health infrastructure, it's exceedingly unlikely the disease will spread. But that hasn't prevented a fair amount of hysteria and misinformation from taking hold, and the very social-media tools that could help bring people accurate, panic-suppressing information about the virus are in many cases doing just the opposite.

"Ebola's the kind of disease that zombie movies are made out of," said Abdulrahman El-Sayed, a researcher at Columbia's Mailman School of Public Health. "It's the kind of thing where if you're not close to the science and don't understand the epidemiology of it, it's a very scary-sounding disease — you bleed all over the place, it kills more than 50 percent of the individuals who contract it, it's spreading like wildfire in West Africa." And given that we live in an age in which everyone is just a few keystrokes away from gruesome images of Ebola's symptoms and victims — not to mention from less-than-rigorous news sources stoking hysteria over the disease — experts face unique challenges in communicating key information about the virus to the public.

It is an inherently tricky task from a communications perspective. Ebola is, after all, a deadly and vicious disease. But the conditions that facilitated its spread in West Africa simply aren't present in the U.S., meaning its arrival here, while potentially tragic for those afflicted and their families, does not augur a larger outbreak.

Experts have actually known for a while that Ebola was going to show up in the U.S. Ever since the scope of the West African epidemic became clear, said El Sayed, American public-health officials have been hammering home the same message: "'There is gonna be an Ebola case here, but there's probably not going to be a transmission.'"

But before experts can effectively explain this, they first have to face down the biggest, scariest images of the disease lodged in the public's imagination thanks to both fictionalized accounts and sensationalistic news coverage. "You have to address everybody's worst fears before you can have a logical conversation about it," said El-Sayed.

Sandro Galea, also at Mailman, stressed that "Clear, consistent, honest communication is essential," especially now, during the early days of this outbreak's presence in the U.S., when rumors are running rampant, fueled by a lack of concrete information. "There's no question that uncertainty allows the space for misinformation to spread," said Galea, "which is why those in positions of authority need to be honest when there are things we don't know."

If officials don't get the message out effectively and misinformation and panic do spread, the results are unlikely to be rioting in the streets or toppling of the government (as opposed to the hardest-hit parts of West Africa, where Ebola really has caused varying degrees of societal upheaval), but they can still be damaging.

Galea said a primary symptom of panic over a disease is what he called "Flooding of the health-care system with the 'worried well'" — that is, folks who don't have the disease in question, but who think they do. "Something we learned from the SARS epidemic was that there were many more people who presented to emergency departments and their physicians because they were worried about having SARS than there were who actually did," he said. When these fears escalate, they can be dangerous in their own right, straining the health-care system with hypochondriacs "at a time when you want the system to be robust and able to respond to actual burdens."

There are reasons such straining is more likely to take place in 2014 than it might have been in, say, 1974. As Dietram Scheufele, a science-communications researcher at the University of Wisconsin pointed out, Americans get their health news and information in a vastly different way now than they did in the recent past.

"The big problem that agencies [like the CDC] have is that they, in most cases, can't communicate with audiences directly," he said. According to Scheufele, this was less of a problem back in the days when there were more reporters immersed in public-health and epidemiology beats, he said — and back when Americans had fewer sources of information. Today, though, he thinks there are fewer competent "middlemen" positioned between experts and mainstream audiences, and there's also a lot more social media — which is, by its nature, agnostic on the question of which information is accurate.

So yes, one can argue — as El-Sayed and Galea did — that the CDC's recent Twitter Q&A, in which it addressed some pretty scary questions, was an effective, modern way of cutting out the middleman altogether and communicating with the public directly. But Scheufele pointed out that there might be limits to this approach: "What's the Twitter following of the CDC? I'm sure it's much less than what Jenny McCarthy has, who routinely writes against vaccinations and everything else." (He's right: TheCDC has 378,000 followers, a number dwarfed by McCarthy's 1.23 million.)

It cuts both ways: People have as much access to information — including from trusted sources — as ever before, but they are also are enmeshed in networks, on Facebook and elsewhere, that might serve them heaping doses of panic rather than some much-needed perspective.

"On the one hand, the internet has democratized everything, which is excellent," said El-Sayed. "On the other hand, science is one of those places where there is a right answer. We don't always know it, but it's not a matter for public debate and conversation and opinion."

Security Theater Morphs Into Ebola Theater -- Science of Us

Is the government doing enough to protect us from Ebola? At a time of widespread panic and misunderstanding, it's a hot question — one that has generated a lot of conversation and at least one memorably nonsensical rant from Nancy Grace. And this week, the Centers for Disease Control announced plans to institute Ebola screening for passengers arriving in the country (as of this writing, we don't yet have details as to what this will look like).

As it turns out, this is a pretty pointless move from a public-health standpoint, but it can still tell us something interesting about how governments respond to a fearful populace.

During a segment on the screening program on yesterday's Morning Edition, reporter Anders Kelto interviewed Larry Gostin, a global health professor at Georgetown. "Let's not have the false impression that this is a tried-and-true method and it's gonna keep Ebola out of the United States — it's just not the case," said Gostin. There's little evidence such screening would actually detect Ebola patients, he explained.

It raises an obvious question: Why, then, is the government instituting this policy? Gostin's response:

[People who are scared] insist to their government, "Do something. It doesn't matter what it is — show us that you're doing something. Tell us that we have no risk." And governments, even if they know better, will sometimes respond to that political outcry. They're under a lot of pressure to do something, [to] make the public feel reassured even if it really doesn't make them safer.

Remember that Ebola just doesn't appear to be a major threat to the U.S. — none of the factors that turned it into a West African pandemic are present here. That doesn't mean people aren't freaking out, though — and understandably so given how horrific a disease this is. So how does the government respond? Um, we'll screen people at airports! Yeah! Which leads to an odd situation in which the government wins political points for taking ineffectual action against an imaginary threat.

Odd, yes, but not particularly uncommon. Think of all the 9/11 TSA reforms that people love to gripe about. Was taking off our shoes going to provide any sort of meaningful defense against the next Al Qaeda plot? Probably not (just ask the administrators at the many, many top-tier airports around the world that did not enact these measures). But even as we complained and struggled to bend over and get our footwear off, it made us feel like the authorities were responsive to our fears. At a time of great uncertainty, that was important.

The same logic applies here. As human beings, we derive a real psychological benefit from tangible evidence that the people charged with protecting us are doing a vigilant job — even when the substance of the action in question is questionable. So thank you, government, for soothing our misplaced Ebola fears in a highly visible but ultimately ineffectual way. Or something?