Thursday, September 11, 2008

Guantanamo prompts psychologists' soul-searching - New Scientist

Guantanamo Bay has become an international symbol for human rights abuse. Now psychologists are trying to decide if it is ethical for them to attend interrogations at the US military base.

Last year the American Psychological Association (APA) reaffirmed its position against cruel, inhuman or degrading treatment (New Scientist, 29 September 2007, p 18). It currently prohibits its members from being involved with torture or abuse. However, members are allowed to participate in military interrogations, provided they don't involve practices such as waterboarding. Psychologists can help interrogators understand detainees and the best way to question them, explains Stephen Behnke, the APA's director of ethics.

Now some APA members are attacking this stance on account of interrogation techniques used at Guantanamo, sometimes overseen by psychologists. Detainees are alleged to have been subjected to sleep deprivation and isolation techniques, practices that the UN Commission on Human Rights classifies as torture. While some APA members argue that psychologists can help make such interrogations more accountable, about 400 others are withholding their membership dues in protest. Protestors dressed in orange overalls also showed up at last week's APA meeting in Boston.

To try to resolve the issue, the APA will soon vote on a resolution that would prohibit members from working in settings where people are held in violation of international law.


MedWire News - Consumer Health

MedWire News is an independent online medical news service. We provide healthcare professional news and consumer medical news, across the whole of medicine.

We publish the day's top news stories from the world's leading international medical journals, international conferences, biomedical research center reports, and government agency bulletins. Every day we monitor these primary sources to bring our users the latest, most important findings in the fast-moving world of medical research and clinical trials.

Some doctors say it's time to stop treating brain cancer as a death sentence - The Boston Globe

WHEN THE NEWS came out that Senator Edward Kennedy was suffering from a malignant brain tumor, my family understood all too well how the Kennedys felt. My brother had recently received the same diagnosis.

The prognosis is brutal. My brother has a glioblastoma, the most serious kind of brain tumor, and the type that experts say likely afflicts the senator. With the current standard treatment, the median survival time is less than 15 months.

As my family learned more about the disease, though, we found reasons for hope. My brother is a marathon runner in his mid-20s. Tall and lean with a head of thick curls, he always exuded health and vitality. The ironies of the situation, while making his diagnosis all the harder to assimilate, also work in his favor. His youth and overall physical functioning mean that his chances are better than the odds would suggest.

But we also found another cause for optimism, which I suspect Kennedy and his family have discovered, too. At a time of expanding medical options, some doctors blame the miserable statistics, in part, on insufficiently aggressive treatment. Last year, Duke neuro-oncologist Dr. Henry Friedman wrote a provocative paper chastising the medical community for approaching glioblastomas as death sentences. Noting that a small but growing number of patients have achieved long-term survival, he pushed for supplementing the standard treatment with additional therapies, including drugs that have not been FDA-approved for this illness. And, more broadly, he advocates a change in attitude.

"There's a nihilism that the disease is hopeless," Friedman said recently. "It's a very difficult disease to treat. But if you approach it as a potentially curable disease, I think that you can do good."

The debate over one of medicine's enduring dilemmas has come to brain cancer. A core principle of the profession is, famously, to do no harm. Medical advances proceed methodically and with caution; new treatments are tested rigorously for safety and effectiveness. But in the case of terminal disease, wrenching choices arise. Sticking with the standard treatment all but guarantees dismal results, and could therefore even be argued to amount to doing harm. Experimental treatments offer more hope, but carry the risk of worsening the situation, robbing the patient of time and quality of life.

In the treatment of brain cancer, where a number of experimental options are emerging but little is known for sure, the stakes are particularly high. When the landscape is shifting quickly, how do you ensure that all patients - not just senators - get the best treatment?

Friedman is a controversial figure in neuro-oncology, and his inflammatory charges have offended some of his colleagues, who bristle at the notion that they're shortchanging patients. Some already treat patients in the aggressive, experimental manner Friedman is urging, or would like to but are constrained by cost (insurance companies often decline to cover drugs that are not approved for the illness in question). Others consider Friedman's approach too risky.

Duke's Tisch Brain Tumor Center does have a reputation for being pioneering and aggressive, although it hasn't cured glioblastoma at a higher rate than other medical centers. In initial reports about Kennedy's treatment, the mention of a surgical option was conspicuously absent, but then he flew to Duke for surgery with Dr. Allan Friedman (a colleague, but not a relation, of Henry Friedman). We know few further details about Kennedy's medical situation, but that sign indicates that he has decided to attack his tumor with a formidable arsenal.

Such an approach holds appeal for many patients, who, when faced with a prognosis this discouraging, are inclined to try anything and everything that seems remotely promising, even in the face of looming risks. Ben Williams, a psychology professor at the University of California at San Diego and the author of the 2002 book "Surviving 'Terminal' Cancer," recovered from a glioblastoma diagnosed in 1995. Taking his treatment into his own hands, he took an array of drugs and "alternative" medicines that his doctors frowned upon.

"You tell me I'm going to be dead in a year," he recalls thinking. "What do I have to lose?"

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Agency for Healthcare Research and Quality (AHRQ)

Agency for Healthcare Research and Quality (AHRQ) supports health services research initiatives that seek to improve the quality of health care in America. AHRQ's mission is to improve the quality, safety, efficiency, effectiveness, and cost-effectiveness of health care for all Americans.

AHRQ is a home to research centers that specialize in major areas of health care research such as quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, and health care organization and delivery systems. It is also a major source of funding and technical assistance for health services research and research training at leading U.S. universities and other institutions, as well as a science partner, working with the public and private sectors to build the knowledge base for what works—and does not work—in health and health care and to translate this knowledge into everyday practice and policymaking.

Large series of fact sheets:

Research syntheses:

Deadly Delay,Why are minorities with cancer getting diagnosed late? (Newsweek)

On a hot summer day in 2006, an African-American woman walked into the emergency room at Grady Memorial Hospital in Atlanta complaining of a large sore on her breast. Her family had urged her to go to the hospital, she said, because the stench from the infected wound had become intolerable. Doctors discovered a cancerous tumor so large it had burst through her skin.

When Otis Brawley, then medical director of the hospital's cancer center, asked the woman when she had first noticed a lump in her breast, she recalled that her son had been in second grade. He was now a high school junior. Even after the tumor first broke through her skin, she admitted waiting nearly two more years to seek treatment. She had no health insurance, she explained. Apparently she hadn't realized that, as a public hospital, Grady accepts and treats the uninsured. Despite the intense treatment that followed—a mastectomy, along with radiation and chemotherapy—her cancer was already so advanced that she was dead within a year.

Her case might seem extreme, but Brawley says at Grady's cancer center, where the majority of patients are minorities and many are uninsured, "that sort of thing happens several times a year." When he examined hospital records, he found that, on average, about 40 percent of the breast cancer patients treated there have already reached stage IV, for which the five-year survival rate is just 20 percent (versus nearly 100 percent for those diagnosed at stage 1). By comparison, only a small percentage of the patients he saw at Emory University's cancer institute, which serves a largely white, middle-class population, had progressed to a late stage when they were diagnosed.

The situation at Atlanta's public hospital is hardly unique. In a new study, which will be published in the March issue of the journal Lancet Oncology, researchers at the American Cancer Society (ACS)—where Brawley is now chief medical officer—analyzed records of more than 3.7 million cancer patients diagnosed between 1998 and 2004 throughout the country. They found that minority and uninsured cancer patients like the woman at Grady Memorial Hospital have a significantly higher risk than white patients and those with private insurance of having reached an advanced stage of the disease by the time they are diagnosed or seek treatment. That means they are more likely to endure excruciating, and often more expensive, treatments and they are more likely to die from the cancer.

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The Assertive Cancer Patient

Jeanne Sather, author of The Assertive Cancer Patient, is an outspoken advocate for the cancer patient's point of view. She has written about taking part in clinical trials, living withincurable cancer, "pink ribbon" marketing run amok, strategies for getting through cancer treatment, how to help when a friend has cancer, and much more.

Jeanne has also been interviewed by major newspapers on such topics as her firing while in cancer treatment, writing your own obituary, and teaching doctors how to say goodbye to dying patients. Jeanne coined the term "MIA doctors" to refer to doctors, in particular oncologists, who disappear when their patients are dying. When she was diagnosed with breast cancer in 1998 at age 43, she started writing about cancer. First she wrote about her own experience, with a weekly feature on the OnHealth Web site called "Jeanne's Diary" that chronicled the ups and downs of her first series of cancer treatments.


September is the anniversary of my cancer diagnosis, and this month is the 10-year anniversary. And while I celebrate this anniversary as a milestone--I've survived 10 years, after all, despite recurrences and metastases to my bones--it is also a difficult anniversary: The weeks following my mammogram were the most difficult of my life. I was afraid. I was angry. And the medical care I received was less than optimal--The attitudes of the doctor, nurses, and other staff who took care of me during this diagnosis period added to my distress, big time. That is one reason I always give priority to people who write to me who are newly diagnosed. I understand what they are feeling, and I want to do whatever I can to help.

Here's what I wrote in "Jeanne's Diary," 10 years ago.

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Find Out What Doctors Think With Online Surveys, randomized testing and market research

Doctors directly influence more than a third of the entire USA health care economy. Consider these important facts:

  • 902,000: number of physicians in the USA in 2005
  • $2.1 trillion: USA healthcare expenditures in 2006
  • $274 billion: sales of physician-prescribed medications in 2006
  • $587 billion: cost of various patient services and devices ordered by physicians and healthcare providers in 2004

Doctors directly control nearly $1 trillion in USA healthcare expenditures, and act as the foundation of our health care system. Doctors influence millions of patients to spend billions of dollars. Doctors have huge personal purchasing power since many are also entrepreneurs with substantial incomes, and doctors typically require sophisticated equipment costing thousands to millions just to equip a single practice.

Doctors are also enormous connectors! Many teach in universities, all require continuous medical education, and typically work through hospitals where they interact with a variety of people and companies unequaled by any other profession.

Whether you are doing market research on medical devices, pharmaceuticals, medical education or on other healthcare issues, doctor survey results will help you make the right business decisions.

We help you reach out to the doctors who are your most important customers, and you can gain priceless information at an extremely low cost. When you conduct doctor surveys, you gain insights that reveal trends shaping the medical industry and your business. You may also get new customers, since cleverly designed surveys can also be used to influence physician thinking about your company, products and services.

Can you think of a more influential group in society? What doctors think really matters!

** provides survey results below as a public service to the medical community to stimulate innovation and improve the quality and economics of healthcare.

Wednesday, September 10, 2008

Fewer U.S. med students choosing primary care --

CHICAGO - Only 2 percent of graduating medical students say they plan to work in primary care internal medicine, raising worries about a looming shortage of the first-stop doctors who used to be the backbone of the American medical system.

The results of a new survey being published today suggest more medical students, many of them saddled with debt, are opting for more lucrative specialties.

Just 2 percent of nearly 1,200 fourth-year students surveyed planned to work in primary care internal medicine, according to results published in the Journal of the American Medical Association. In a similar survey in 1990, the figure was 9 percent.

Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.

"I didn't want to fight the insurance companies," said Dr. Jason Shipman, 36, a radiology resident at Vanderbilt University Medical Center in Nashville, Tenn., who is carrying $150,000 in student debt.

Primary care doctors he met as a student had to "speed to see enough patients to make a reasonable living," Shipman said.

Dr. Karen Hauer of the University of California, San Francisco, the study's lead author, said it's hard work taking care of the chronically ill, the elderly and people with complex diseases -- "especially when you're doing it with time pressures and inadequate resources."

More ...,0,706812.story

Tuesday, September 9, 2008

Sermo's twist on social networking

Sermo, the rapidly growing social network for doctors, gets a shot in the arm Monday when it announces a partnership with drug giant Pfizer. Sermo is one of the more interesting commercial implementations of the social networking concept. The doctors who join the service - and more that 30,000 have already signed up - use it to discuss diagnoses and treatments with their peers. The site makes money not through advertising - which it believes would be anathema to physicians - but by letting paying clients like investment firms and drug companies "listen in" on the doctors' conversations. As an incentive to its members, the site pays doctors $100 for highly rated postings.

Monday, September 8, 2008

Cases - Perhaps Death Is Proud; All the More Reason to Savor Life -

At my job, people die.

That's hardly our intention, but they die nonetheless.

Usually it's at the end of a long struggle — we have done everything modern medicine can do and then some, but we can't save them. Some part of their body, usually their lungs or their heart or their liver, has become too frail to function. These are the "good deaths," the ones where the family is present and knows what to expect. Like all deaths, these deaths are difficult, but they are controlled, unsurprising, anticipated.

And then there are the other deaths: quick and rare, where life leaves a body in minutes. In my hospital these deaths are "Condition A's." The "A" stands for arrest, as in cardiac arrest, as in this patient's heart has all of a sudden stopped beating and we need to try to restart it.

I am a new nurse, and recently I had my first Condition A. My patient, a particularly nice older woman with lung cancer, had been, as we say, "fine," with no complaints but a low-grade fever she'd had off and on for a couple of days. She had come in because she was coughing up blood, a problem we had resolved, and she was set for discharge that afternoon.

After a routine assessment in the morning, I left her in the care of a nursing student and moved on to other patients, thinking I was going to have a relatively calm day. About half an hour later an aide called me: "Theresa, they need you in 1022."

I stopped what I was doing and walked over to her room. The nurse leaving the room said, "She's spitting up blood," and went to the nurses' station to call her doctor.

Inside the room I found my patient with blood spilling uncontrollably from her mouth and nose. I remembered to put on gloves, and the aide handed me a face shield. I moved closer; I put my hand on her shoulder. "Are you in any pain?" I asked, as I recall, thinking that an intestinal bleed would be more fixable than whatever this was. She shook her head no.

I looked in her eyes and saw ... what? Panic? Fear? The abandonment of hope? Or sheer desperation? Her own blood was gurgling in her throat and I yelled to the student for a suction tool to clear it out.

The patient tried to stand up so the blood would flow into a nearby trash can, and I told her, "No, don't stand up." She sat back down, started shaking and then collapsed backward on the bed.

"Is it condition time?" asked the other nurse.

"Call the code!" I yelled. "Call the code!"

The next few moments I can only describe as surreal. I felt for a pulse and there wasn't one. I started doing CPR. On the overhead loudspeaker, a voice called out, "Condition A."

The other nurses from my floor came in with the crash cart, and I got the board. Doing CPR on a soft surface, like a bed, doesn't accomplish much; you need a hard surface to really compress the patient's chest, so every crash cart has a two-by-three-foot slab of hard fiberboard for just this purpose. I told one of the doctors to help pick her up so I could put the board under her: she was now dead weight, and heavy.

I kept doing CPR until the condition team arrived, which seemed to happen faster than I could have imagined: the intensivists — the doctors who specialize in intensive care — the I.C.U. nurses, the respiratory therapists and I'm not sure who else, maybe a pulmonologist, maybe a doctor from anesthesia.

Respiratory took over the CPR and I stood back against the wall, bloody and disbelieving. My co-workers did all the grunt work for the condition: put extra channels on her IV pump, recorded what was happening, and every now and again called out, "Patient is in asystole again," meaning she had no heartbeat.

They worked on her for half an hour. They tried to put a tube down her throat to get her some oxygen, but there was so much blood they couldn't see. Eventually they "trached" her, put a breathing hole through her neck right into her trachea, but that filled up with blood as well.

They gave her fluids and squeezed bags of epinephrine into her veins to try to get her heart to start moving. They may even have given her adenosine, a dangerous and terrifying drug that can reverse abnormal heart rhythms after briefly stopping the patient's heart.

The sad truth about a true cardiac arrest is that drugs cannot help because there is no cardiac rhythm for them to stimulate. The doctors tried anyway. They went through so many drugs that the crash cart was emptied out and runners came and went from pharmacy bringing extras.

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Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God and Diversity on Steroids by Julie Salamon (2008)

May. 06, 2008 At Maimonides Medical Center in Brooklyn, N.Y., some 67 different languages are spoken. A private institution, it's among the largest 5 percent of the nation's hospitals, treating (in 2003) 38,667 inpatients as well as 127,319 more people in its outpatient clinics. Each year it trains nearly 500 new doctors from all over the world. Maimonides' E.R. is a scene of orchestrated chaos, especially at 2 p.m., which for some reason is the crush time for emergency rooms. Because the hospital stands in a neighborhood full of new immigrants -- as well as being rooted in an established community of Orthodox Jews -- many of the people who enter the E.R. are undocumented and/or uninsured, and have waited until the last minute to seek treatment. "Our patients never have one problem," says the residency program director. "They almost always have a heart attack compounded by a urinary infection compounded by muscle breakdown ... There's never one clear explanation for the pathological phenomenon we see in a lot of our patients."

In 2005, Julie Salamon -- an author and journalist best known for "The Devil's Candy," her account of the disastrous filming of "Bonfire of the Vanities" in 1990 -- spent a year deep in the teeming organism that is Maimonides Medical Center. She negotiated unfettered access to staff ranging from the cleaning crew to the chairman of the board (although some spoke more freely than others). The resulting book, "Hospital: Man, Woman, Birth, Death, Infinity, Plus Bad Behavior, Money, God and Diversity on Steroids," will surely be catnip to that peculiar breed of person who's fascinated by anything having to do with hospitals and doctors, but as Salamon observes in her prologue, she also viewed Maimonides as an "epicenter" of something larger, a forum for the social forces buffeting the city and nation, "a petri dish of the post-9/11 world."

Despite being related to two nurses, I've never had much interest in hospitals (or been able to sit through an episode of "ER"), but as Salamon expertly sucked me into the saga of Maimonides, I realized that this was about more than white coats, scalpels and beeping consoles. This place was 21st century America in a microcosm.

Of course, "Hospital" does deliver hefty servings of the staple ingredients of medical drama: arrogant doctors, controversial administrators, fed-up nurses, shell-shocked residents and plenty of patients whose stories alternately warm and break your heart. (The one missing element, thank God, is an overwrought love story.) There's the 24-year-old single mother, an uninsured, undocumented immigrant cashier, who has to be told that, due to the cancer that has metastasized throughout her body, she won't live long enough to see her two kids go to school. And there's "Mr. Zen," another uninsured cancer patient -- hospitals are required to treat people who walk into the emergency room until they are able to walk out the door -- a stoic and considerate man in spite of the "excruciating" pain he suffered. He became a staff favorite, and in his final hours, his attending physician sat by his bed reading a Buddhist text called the Heart Sutra. "I'm not sure exactly what he knew at that point," said the doctor, but "it was the least I could do for him."

And -- of course! -- there are the arrogant, preening surgeons: the fading cardiac "star" with his cowboy boots and a photo of Hemingway hung in his office; the medical director so competitive that, when Salamon tells him she accompanied one doctor as he saw a dozen patients the night before, boasts, "You should follow me around. I see about thirty in the day. I'm like a ballerina." The hospital is riven by two major, long-standing physician feuds, each between a pair of former medical partners, and each one, by various accounts "absolutely about money," or, conversely, entirely "personal ... We felt we were treated like chattel." The eccentric president of the hospital, Pam Brier -- a tiny woman given to bizarre pronouncements like, "I want you to know I'm considered one of the great constipation experts in the borough of Brooklyn" -- alternately snubs and mothers her employees, flying an ill staff member's daughter into town (first class), then scheduling the opening ceremonies for a new cancer center so that the director of the center has to rush back from a conference in order to be there.

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Amazon Canada:

NYT Blog:

Rethinking the War on Cancer -

We Fought Cancer…And Cancer Won.
After billions spent on research and decades of hit-or-miss treatments, it's time to rethink the war on cancer.

Curbing Antibiotic Use In War on 'Superbugs' - The Informed Patient -

Some two million people acquire bacterial infections in U.S. hospitals each year, and 90,000 of those patients die as a result. Although antibiotics generally kill or inhibit the growth of susceptible bacteria, they also allow some bugs to survive and become resistant to the drugs. The current epidemic of MRSA -- a form of drug-resistant staph found in hospitals and places such as school locker rooms -- is just one example of the growing number of bacteria that have developed resistance to common drugs.

Now, two of the leading hospital purchasing groups are mounting new campaigns to reduce the use of antibiotics. VHA Inc., an alliance of more than 1,400 nonprofit hospitals, has launched a "Bugs and Drugs" program to help member institutions identify and manage resistance to antibiotics. Premier Inc., which represents more than 2,000 hospitals, is urging members to adopt antimicrobial stewardship programs and offering an electronic data-tracking system to help monitor the use of certain drugs.

At the University of Wisconsin Hospital and Clinics in Madison, Sarah Bland, senior clinical pharmacist, calls herself the "antibiotic police." Working with an infectious-disease specialist, she uses Premier's software program, called SafetySurveillor, to track the antibiotics prescribed in the 450-bed hospital. The aim is to get doctors to use the narrowest-spectrum antibiotic possible -- a drug that is designed to attack only the bacteria causing a specific infection.


Chronic Disease Battle Requires Better Tools - The Doctor's Office -

The biggest challenge in primary-care medicine is dealing with the complications of obesity, diabetes and hypertension.

We have drugs to treat the conditions. But we don't have potent enough public health measures, patient education and follow-up monitoring to avoid the heart attacks, strokes and chronic kidney problems that come with the modern disease territory.

At my office we use a disease registry to track our patients with diabetes, heart disease and high blood pressure. We use it to generate recall lists of people who are overdue for follow-up visits or lab tests. Most veterinary offices do that routinely, but not enough medical offices.

In an insurance-driven world where a high volume of office visits is the only practical way to earn a living, managing patients with multiple chronic diseases is a money loser. Seeing four patients over the course of an hour pays much better than helping a patient with complex problems for a full 60 minutes.

My office has invested heavily in an electronic medical record to track and monitor chronic conditions with little financial return.

Still, the system helped me notice that a patient's control of his diabetes had been slipping for a year. Repeating the mantra of diet and exercise wasn't getting us anywhere. He would promise to do better, yet the results never improved.

Adding more pills over the last year wasn't improving his blood sugar either. It was time for a radical lifestyle adjustment or the start of insulin. He wasn't happy about either option but reluctantly agreed to give insulin a go.

He has been coming into the office about four times a year. And his employer-based insurance was paying for his visits, but missing work to make appointments with me during normal business hours was costing him his attendance bonus and undermining my efforts to get tighter control of his diabetes.

We got around that by using email. He started sending me spreadsheets of his blood sugars every few days, and I gave him advice for adjusting his insulin and diet when he got off track. His blood sugar came down to near normal within two weeks.

Managing chronic diseases between visits is uncompensated work for doctors, yet the need for such care is huge.

The current financial disincentives to providing proper care for chronic disease are daunting, and the waste created by ignoring the problem is growing as the population ages.

Teaching patients to take care of themselves effectively should be paramount because it works. It's also cheap compared with a lifetime of drugs. Self-management makes all the difference in preventing long-term complications or avoiding a disease in the first place.

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What doctors don't tell you -

Physician David Newman has written a book about the secrets your doctor keeps from you. But he's not talking about "secret cures" that sell books on alternative medicine. Instead, his new book, Hippocrates' Shadow: Secrets From the House of Medicine (Scribner), is all about the secrets that hide in plain sight in medical journals and hospital hallways:

•Doctors don't know as much as you think they do. For example, they don't know what causes most cases of back pain or what makes it better.

•Doctors do know that many of the tests, drugs and procedures they order and prescribe either do not work or have not been proved to work. Case in point: They keep prescribing antibiotics for colds and bronchitis.

•Doctors disagree, often, about everything, including whether that chest X-ray you just had really shows pneumonia.

•Doctors like ordering tests better than they like listening to you.

"These doctors are not bad human beings," says Newman, a New York City emergency department physician who also has studied philosophy, worked as a paramedic and served at an Army hospital in Iraq. He now trains medical students and residents at Columbia University and St. Luke's/Roosevelt Hospital Center.

Time limits, lawsuit fears and the demands of insurers deserve some blame for the truth gap, he says, but medical training and traditions play big roles.

Take the antibiotic problem. Studies show half of patients who go to a doctor with a cold are prescribed an antibiotic. Colds are caused by viruses; antibiotics kill only bacteria.

"Doctors think patients want a prescription," Newman says. They also know, he says, that patients feel better once they get that "magic pill."

But doctors should know, he says, that patients are just as satisfied when physicians take a few minutes to listen, explain why antibiotics won't help and suggest some symptom relief — relief that won't come with side effects such as diarrhea, yeast infections and allergic reactions.

Likewise, he says, doctors don't like to admit that many test results are not as black and white as they appear. Communicating shades of gray is harder, he says, and not taught in medical school. And while patients assume doctors rely on science, "it's not uncommon for the decisions we make to be entirely based on opinion," Newman says.

Letting patients in on secrets like those would allow them to make better, more healthful choices, he says.

Other doctors will argue with some of Newman's views. For example, he says routine mammograms don't save lives, a conclusion at odds with those of the American Cancer Society, the National Cancer Institute and other medical groups.

But the idea that Americans get worse medical care than they realize — often because they get too many, not too few, tests, drugs and procedures — is gaining ground.

Think about this summer's recommendation from the U.S. Preventive Services Task Force that men over 75 should stop getting blood tests for prostate cancer (because they are more likely to be harmed by prostate cancer treatment than to die from the disease). Or read Overtreatment, a 2007 book by former health journalist Shannon Brownlee, just out in paperback. She writes that the biggest problem is doctors and hospitals "get paid more for doing more."

Whatever the causes, part of the cure must be straight talk, Newman says: "There is a lot of personal responsibility in this. It's all about patients and doctors communicating."

The Gross Clinic - Thomas Eakins, oil on canvas, 1875

"One of the most powerful, horrible, yet fascinating pictures that has been painted anywhere in this century...but the more one praises it, the more one must condemn its admission to a gallery where men and women of weak nerves must be compelled to look at it, for not to look at it is impossible."

Sunday, September 7, 2008

NPR: My Cancer

After that day, your life is never the same. "That day" is the day the doctor tells you, "You have cancer." Every one of us knows someone who's had to face that news. It's scary, it's sad. But it's still life, and it's a life worth living. "My Cancer" is a daily account of my life and my fight with cancer.

Objective Ratings of Health and Medical Journalism is a website dedicated to:

• Improving the accuracy of news stories about medical treatments, tests, products and procedures.

• Helping consumers evaluate the evidence for and against new ideas in health care.

Health Business Blog

Obama v. McCain on health care

Now that the Republican and Democratic conventions are behind us, I'm planning to write a series of posts to provide my perspective on the candidates' health care proposals. I'll follow the framework laid out by the Kaiser Family Foundation's in its side-by-side summary of the candidates' positions. The posts will appear every few days and I'll conclude a week or so before election day with an overall summary and an endorsement of one candidate's plan.

Here's the framework:

  • Overall approach to expanding access to coverage
    • A. Requirement to obtain or offer coverage
    • B. Expansion of public programs
    • C. Premium subsidies to individuals
    • D. Premium subsidies to employers
    • E. Tax changes related to health insurance
    • F.  Creation of insurance pooling mechanisms
    • G. Changes to private insurance
    • H. State flexibility
  • Cost containment
  • Improving quality/health system performance
  • Other investments
  • Financing

Well - A Guided Tour of Your Body - Interactive Feature -

Changes in our health are inevitable as we get older. But while doctors tell us to focus on the basics — eat right, exercise and keep cholesterol and blood pressure in check— is there more that we need to know about staying well as we age?
In this special section, you'll be able to learn the best that science and medicine can offer for taking care of yourself. You can also test your knowledge and read more health news at the Well blog.

Essay - Condolence Note After a Death Difficult for Doctors -

Condolences, Felt but Not Expressed


Not long ago, soon after we put our pet dog to sleep, I received a handwritten note from our veterinarian expressing her condolences. The letter was not brief — she described my children's fondness for little Rudy and how caring they were as his condition worsened. It was thoughtful and personalized, not something she had simply dashed off.

In contrast, during my 25 years of caring for humans I have written only a handful of similar notes to families after a loved one's death.

This difference struck me again recently when the father of an acquaintance died in my hospital. He was a lovable guy, very much himself at all times, no matter the physical wreck he became as cancer progressively cornered him. He spoke with the same shrewd but amused tone even when in pain, insisting that we discuss only the important facts, not a bunch of medical baloney — facts about the Knicks or what was showing at the Guggenheim, whether the latest Tom Hanks movie was any good and did my wife like to cook?

Since his death, I have intended to write his family a note. But I haven't, and I suspect I never will. My hesitancy, compared with the graciousness of my vet, has led me to wonder where I have gone wrong.

In my defense, surely there are basic differences between the vet's situation and my own: responding to a dying, then dead, pet does seem less involved than the struggle against human mortality. And given the likelihood we would buy a new dog, it may just be good business to drop a few words. Or perhaps the explanation is nothing more complicated than the usual: doctors are blowhards, too self-important to bother to scribble the note, too lazy, too smug.

I doubt it is any of these reasons. Rather, I think doctors have a strange way of grieving their patients.

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Life in the Balance - Dr. Thomas Graboys - Review - NYTimes

A Doctor Transformed, Into a Patient

Doctors get seriously ill just like ordinary people, and some of them never recover from the shock. If of a literary bent, they are often moved to reflect for posterity on this disruption of the natural order, detailing their former hubris and the enlightening misery of health care experienced from the other side of the bed.

Against this generally lackluster collection of memoirs, Dr. Thomas Graboys's stands out as a small wonder. Unsentimental and unpretentious, it manages to hit all its marks effortlessly, creating a version of the old fable as touching, educational and inspiring as if it had never been told before.

The story's success lies partly in its almost mythic dimensions: Dr. Graboys rose high, and he fell hard. Until age 50 he was a medical version of one of Tom Wolfe's masters of the universe: a noted Harvard cardiologist beloved by colleagues and patients, happily married to a tall, beautiful blonde. He was a marathon runner, a demon on the tennis courts and ski slopes, and, if he says so himself, a particularly handsome guy.

Then everything fell apart. Over a terrible two-year period Dr. Graboys's wife died a lingering death from colon cancer. In his grief he barely noticed that he was not functioning quite as well as usual. Those around him figured his fatigue and uncharacteristic fumbling were only to be expected. He pulled himself together, met another woman, and then collapsed on the wedding day — the beginning of physical problems that could no longer be ignored.

It was Parkinson's disease, the neurological condition that makes the body stiffen and shake, but it took Dr. Graboys many months to take the irrevocable step of giving his problems a name. During that time he went through every rationalization that sick people use to wish away their symptoms, then moved smoothly from denial to deception. "I'm just tired," he snapped to concerned colleagues, even as he began taking surreptitious clinical notes on his own case.

Only when the chief of neurology at his hospital cheerfully hailed him in the parking garage — "Tom, who is taking care of your Parkinson's?" — was the terrible word said aloud. Dr. Graboys finally understood that the jig was up.

From this moment his memoir unfolds in multiple layers, some predictable, some quite unexpected.

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