Tuesday, September 21, 2010

The Policeman vs. the Nurse - NYTimes.com

When Colorado Springs cardiac nurse Miriam Leverington was stopped for speeding, she grumbled to the police officer.

"I hope you are not ever my patient," she reportedly told him.

What happened next has become a topic of widespread debate in Colorado and on the blogosphere. The police officer, Duaine Peters, complained to the hospital where Ms. Leverington worked that her comment amounted to a threat, suggesting she might give him poor care should he ever become her patient.

The hospital fired the nurse, and now the nurse has countered with a lawsuit. She says she was merely exercising her right to free speech — and expressing her hope that she never see the policeman again.

The case is now being decided by a federal appeals court, but raises the question of whether nurses and health care workers should be held to a higher standard than other workers.

The Gazette in Colorado Springs is taking its own on-line vote, and so far more than 70 percent of respondents agree the hospital had a right to fire the nurse.

What do you think? Should someone be fired for talking back to a police officer outside the workplace? Are the rules different if the person is a health care worker?


Scientist at Work - Dr. Doug Farrago - A Physician-Provocateur With Reality TV Dreams - NYTimes.com

It probably zipped right by most viewers of "House, M.D.": two brief flashes of doctors on the show reading or carrying a small magazine. But for Dr. Douglas Farrago, it meant something.

For 10 years, Dr. Farrago, a family doctor here, has been the majordomo of said publication: an irreverent, intentionally sophomoric, sometimes scatological medical magazine called Placebo Journal. And though he is not a "House" fan, the product placement was just one example of Dr. Farrago's enterprising streak.

Doctoring is "an algorithmic job," said Dr. Farrago, 45. "You can't just make up things in medicine: 'Let's just try Jell-O.' So I want to do something creative."

There was the time at a medical conference he posted an advertisement for "Oxycotton Candy," parodying the frequently abused drug Oxycontin. Conference organizers "got so mad," he recalled, that "security said, 'You have to take it down.' "

And there were the bumper sticker slogans in Placebo Journal: "My other car was lost in a malpractice suit" and "Maybe Hippocrates was wrong?" Not to mention the magazine's selection ofsexually transmitted disease greeting cards: "Maybe we will date some more, get married and have babies, but until then I think you should know that I have a roaring case of scabies."

"I pride myself on a lot of the lowbrow stuff," Dr. Farrago said.

Ten thousand subscribers, he says, pay $28 a year for Placebo Journal, which is published every two months and skewers the health care system's half-baked mistakes, pokes fun at doctors, patients, insurers and drug companies, or just goes for the gross-out.

"My audiences are physicians," Dr. Farrago said. "They see all this stuff. They don't want to do differential diagnosis and read through complex cases. They just want to take this on the toilet bowl and laugh."

But if Dr. Farrago and two television producers succeed with their latest project, people could be seeing a different side of him. The producers are pitching a reality show in which Dr. Farrago would parachute into communities around the country and help overstretched family doctors care for patients for several days: sort of a medical "Supernanny."

"The goal is to take viewers into both of Doug's lives: the hard-working family practice physician who does everything he can to help his patients get well and stay that way, and the self-described 'King of Medicine' who uses his satirical skills to take on a health care system," according to Bruce Halford, a co-producer with Jeff Mackler.

Dr. Farrago (pronounced fa-RAY-go, like the word meaning hodgepodge) dreamed of being a professional boxer like his brother Matt until, he said, "I realized I wasn't that good."

He became a sports medicine trainer working with boxers, but after one of his boxers got pelted with urine-filled bottles while fighting in Mexico, "I kind of knew it was not my thing," he said, although he has remained close friends with the boxer Lou Savarese.

Then, before medical school, Dr. Farrago squatted to work on an electrical outlet, and to ease pain from a blown-out knee, "I put some towels behind my leg," he said. Voilà, a gizmo was born: the Knee Saver, a foam wedge to cushion one's crouch.

Thinking it would help baseball catchers, Dr. Farrago obsessively hawked it at spring training and to trainers, many of whom "were really rude," he said. (One said he would use it to defecate in the woods.) Then he read about the knee surgery of the Cleveland Indians catcher Sandy Alomar Jr. Dr. Farrago sent a Knee Saver to Mr. Alomar's orthopedic surgeon, and after first being told "he doesn't like it," he noticed Mr. Alomar using it during a division series game. It caught on, and was accepted in 2001 into the Baseball Hall of Fame.

Dr. Farrago went on to create a short-lived Web venture to stream university medical talks to doctors, and then, 10 years ago, he started Placebo Journal.

"I guess I was burning out in this job," he said. "Everybody's got a monkey on their back, and they want to give you their monkey. They'd leave and feel good, but I'd go home with 25 monkeys."

Fancying itself the Mad magazine of the medical world, Placebo Journal features "True Stories of Medicine" and odd-looking X-rays submitted by doctors, as well as sections like "My Favorite Munchausen," about patients who invent or exaggerate medical problems. It loves jabbing Big Pharma and insurers; in 2005 Cigna HealthCare complained to Dr. Farrago's then-employer, a health system, when he printed a physician survey from the fictitious SickNa HealthCare, its logo like Cigna's tree, but full of dead leaves.

Doctors and patients are fair game, too. A full-page movie ad reads: "He smokes. He drinks too much. He never stops eating. He rarely gets off the couch. He is The American Patient."

A doctor's want ad seeks "a corrupt pharmacologist," able to "create and mass-produce tablets made of useless and harmless compounds, and be willing to sell them labeled as narcotics and/orfibromyalgia treatments."

And in a parody of opponents of Gardasil, the vaccine given to girls to prevent the sexually transmitted human papillomavirus, Placebo Journal advertises "Godasil — the first and only faith-based vaccine," which "uses a higher power to bring about immunity for your little girl."

"It's sophomoric, it's black, it's dark," said Dr. Marc Grobman, an internist in Wilmington, Del., who displays the fake ads in his drug sample cabinet. One favorite: an ad for Sexapro, which erases sex drive. He has submitted several anecdotes of "silly things patients say," including the woman "who thought she had gotten diverticulitis after being stuck by the needles of a Christmas tree."

Dr. Theresa Langdon, a family practitioner in Portland, Ore., collects every installment, calling it an "adult medicine comic book" (her husband tracked down the debut issue for her birthday). "I balance it out by reading The New England Journal compulsively," she said.

More ...


Sunday, September 19, 2010

Autism’s First Child - The Atlantic

In 1951, a Hungarian-born psychologist, mind reader, and hypnotist named Franz Polgar was booked for a single night's performance in a town called Forest, Mississippi, at the time a community of some 3,000 people and no hotel accommodations. Perhaps because of his social position—he went by Dr. Polgar, had appeared in Life magazine, and claimed (falsely) to have been Sigmund Freud's "medical hypnotist"—Polgar was lodged at the home of one of Forest's wealthiest and best-educated couples, who treated the esteemed mentalist as their personal guest.

Polgar's all-knowing, all-seeing act had been mesmerizing audiences in American towns large and small for several years. But that night it was his turn to be dazzled, when he met the couple's older son, Donald, who was then 18. Oddly distant, uninterested in conversation, and awkward in his movements, Donald nevertheless possessed a few advanced faculties of his own, including a flawless ability to name musical notes as they were played on a piano and a genius for multiplying numbers in his head. Polgar tossed out "87 times 23," and Donald, with his eyes closed and not a hint of hesitation, correctly answered "2,001."

Indeed, Donald was something of a local legend. Even people in neighboring towns had heard of the Forest teenager who'd calculated the number of bricks in the facade of the high school—the very building in which Polgar would be performing—merely by glancing at it.

According to family lore, Polgar put on his show and then, after taking his final bows, approached his hosts with a proposal: that they let him bring Donald with him on the road, as part of his act.

Donald's parents were taken aback. "My mother," recalls Donald's brother, Oliver, "was not at all interested." For one, things were finally going well for Donald, after a difficult start in life. "She explained to [Polgar] that he was in school, he had to keep going to classes," Oliver says. He couldn't simply drop everything for a run at show business, especially not when he had college in his sights.

But there was also, whether they spoke this aloud to their guest or not, the sheer indignity of what Polgar was proposing. Donald's being odd, his parents could not undo; his being made an oddity of, they could, and would, prevent. The offer was politely but firmly declined.

What the all-knowing mentalist didn't know, however, was that Donald, the boy who missed the chance to share his limelight, already owned a place in history. His unusual gifts and deficits had been noted outside Mississippi, and an account of them had been published—one that was destined to be translated and reprinted all over the world, making his name far better-known, in time, than Polgar's.

His first name, anyway.

Donald was the first child ever diagnosed with autism. Identified in the annals of autism as "Case 1 … Donald T," he is the initial subject described in a 1943 medical article that announced the discovery of a condition unlike "anything reported so far," the complex neurological ailment now most often called an autism spectrum disorder, or ASD. At the time, the condition was considered exceedingly rare, limited to Donald and 10 other children—Cases 2 through 11—also cited in that first article.

That was 67 years ago. Today, physicians, parents, and politicians regularly speak of an "epidemic" of autism. The rate of ASDs, which come in a range of forms and widely varying degrees of severity—hence spectrum—has been accelerating dramatically since the early 1990s, and some form of ASD is now estimated to affect one in every 110 American children. And nobody knows why.

More ...


Deciding Not to Screen for Down Syndrome - NYTimes.com

Amy Julia Becker is expecting her third child in January. She is 32 years old, and her age, plus the fact that her first child was born with Down syndrome, magnifies her odds of a chromosomal abnormality in this pregnancy, leading her doctors to suggest prenatal testing. In spite of the odds — or perhaps because of them — and her husband have declined the tests. In a guest post today, she explains why.


by Amy Julia Becker

My pregnancy has been an easy one. No morningsickness, more than ample weight gain, minimal aches and pains and good rest. Yet as my husband, Peter, and I walked into the doctor's office for our first prenatal appointment, I said, "I am dreading this visit."

Our daughter, who is now 4½, has Down syndrome. She was born when I was 28. Although there is no known cause for Down syndrome (the presence of an extra 21st chromosome), as soon as I conceived Penny, my chances of having another baby with Down syndrome increased significantly, from 1 in 1,000 to 1 in 100. Those chances only increase further as I age.

But my dread as I walked into the doctor's office didn't come from the thought that this new baby might have an extra chromosome. My dread arose from the prospect of talking to a doctor about prenatal testing. The American Congress of Obstetricians and Gynecologists recommends prenatal screening for Down syndrome for all pregnant women, regardless of age. Screening tests can include an ultrasound to measure aspects of the baby's anatomy and blood tests to measure hormone levels in the mother. These tests accurately identify babies with Down syndrome 85 percent to 90 percenty of the time.

Peter and I know the statistics. We know the health complications associated with Down syndrome — heart defects, intestinal abnormalities, celiac disease, low muscle tone, developmental delays. We know that Down syndrome brings with it more intensive one-on-one attention in the early years and more doctor's visits throughout childhood. We know it brings with it more uncertainty as the child grows up.

More ....


Social Reinforcement as a Path to Better Health - NYTimes.com

Is your social network making you fat? Are your friends and family influencing you to smoke and drink more, or to sleep less?

And if our relationships contribute to behaviors that erode our health, can social networks be harnessed to improve it?

These are seminal questions in "network science" — an emerging field that examines how behavioral changes spread through social networks. By social networks, I don't mean virtual, will-you-"friend"-me? simulations, but old-fashioned, flesh-and-blood relationships. You know, people you actually see in person regularly — friends, relatives, co-workers, neighbors.

"It's a very old thing that we do, like ants, arranging ourselves to live in social structures," says Dr. Nicholas A. Christakis, a Harvard professor who studies health and social networks. "Really, humans have arranged themselves into networks for hundreds and thousands of years."

Dr. Christakis and his research partner, James H. Fowler, an associate professor at the School of Medicine at the University of California, San Diego, created an international uproar in 2007 when they published a study on obesity. In it, they reported that fat could be catching — spreading through social ties. One of the study's findings was that a person's chance of becoming obese increased 57 percent if the person had a friend who became obese. Another surprising finding of the study, published in The New England Journal of Medicine, was that one's chance of becoming obese was influenced not only by the weight gain of friends but also by friends of friends who gained weight.

Since then, the researchers have examined how other health-related behaviors and conditions — drug use and sleeplessness among teenagers, smoking and happiness — spread through social networks. And they have published a book explaining their work, titled "Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives."

Now Dr. Christakis and Professor Fowler, as well as other scientists, are turning their attention to a new research area: how to harness social networks to promote public health.

Of course, we already know that people can and do change their health habits when they seek out and participate in new social groupings. Weight Watchers, anyone?

But how do we extract information from existing social networks to improve public health?

One method is to identify social connectors, people who spend time with more friends than average — and are thus exposed to more germs and are more likely to be among the first to contract contagious diseases like the flu. If health officials could find and track those social butterflies, they could tap into an early-detection system for epidemics and figure out whom to vaccinate first in order to slow the spread of disease.

Last winter, Dr. Christakis and Professor Fowler tried just such a strategy — monitoring people's friends — to track the spread of H1N1 flu at Harvard. They monitored 744 undergraduates who were either selected at random or were named as friends by the randomly selected students. Then they followed the undergrads, using their electronic medical records, to identify which students went to the university health service complaining of flu symptoms.

The method is based on "the friendship paradox" — the counterintuitive idea that your friends have more friends than you do. In other words, you're more likely to be friends with popular people than with loners. And those popular people tend to be closer to the core of a social network.

In the Harvard study, published Wednesday in the scientific journal PLoS One, the flu developed about two weeks earlier in the friend group than in the randomly selected group. The results, the study leaders say, indicate that public health officials could use friend monitoring like sentinel nodes in the human body, as an early-detection system for disease.

Friend monitoring systems could also be used to identify flu trends faster than methods now used by the Centers for Disease Control and Prevention — or on Google, for that matter — because the friend system pinpoints signs of an epidemic before it peaks in the general population, Professor Fowler says.

"This method, although we have studied H1N1, could be applied to anything that spreads — smoking, weight gain," he says.

Some researchers are also studying how a social network's structure affects the speed at which people adopt and stick to health habits.

To that end, Damon Centola, an assistant professor of economic sociology at the Sloan School of Management at M.I.T., conducted an experiment with more than 1,500 people. He created a Web-based health forum where they had access to and could rate health information sites.

Professor Centola then randomly assigned participants to one of two social network designs: one was set up like a residential neighborhood, with clusters of overlapping ties among neighbors; the other was a casual network where people did not share social ties.

Each participant was matched with other members, called "health buddies." Although people could not contact their buddies directly, they received e-mail from the system about their buddies' activities on the site.

The neighborhood structure turned out to be much better than the random social network at prompting people in the study to join and participate in the health forum, according to Professor Centola's report, published this month in the journal Science. More important, Professor Centola says, the more e-mails that people received about the activities of their health buddies, the more often they returned to the forum.

IN the real world, he says, this means the amount of social reinforcement you give to people to improve their health habits may be more important than who is encouraging them to do so. In other words, a local community network of friends and neighbors may be more important than a remote celebrity spokesman in stopping the spread of, say, sexually transmitted diseases among teenagers.

"It makes a bigger difference how you connect people than who is there in influencing desirable behaviors," Professor Centola says.

It also tells us that while weight gain among our friends and friends' friends can make us fatter, our close connections may also lead us to better health choices, like going to the gym more often or stir-frying more vegetables.

But if we are to make lasting changes in our health habits, Dr. Fowler says, we may need social reinforcement in which our friends, not to mention our friends' friends, change their habits with us.

And that's no small order for a social network.