Saturday, December 25, 2010

Choosing pathology gives two doctors unique learning opportunity with Cuyahoga County Coroner's Office |

CLEVELAND, Ohio -- Dr. Elizabeth Douglas orbited the cool, stiff body on its steel gurney, and examined the 42-year-old man's fleshy canvas of faded tattoos like an art aficionado in a gallery.

She committed each to her notes in painstaking detail and debated whether to use the word "cowboy" or "bandit" to characterize the dull, smudgy image of a horseman midgallop.

But that would be the last time the doctor would let herself consider who the man on the gurney once was -- at least for the next two hours, while Douglas ferreted out a cause of death among his organs and entrails.

Douglas and her counterpart Dr. Jimmie K. Smith, in their fourth month of a yearlong fellowship with Cuyahoga County Coroner Frank Miller's office, have learned that surviving in the world of forensic pathology means cauterizing the heart strings -- acknowledging the sentimental details of each case and moving on to the biology beneath, the science and mechanics of death.

Douglas and Smith, both 32, are among the less than 4 percent of medical school graduates who choose this grim specialty, according to industry research.

The doctors turned down fields such as anesthesiology, pediatrics and internal or family medicine to devote their talents to diagnosing the dead and serving, as Douglas describes it, as the primary care physician for the bereaved.

The coroner's office, which serves 16 counties and conducts as many as 3,000 case investigations a year with 1,200 to 1,500 autopsies, so far has proved to be worthy training grounds for the green doctors.

Already each has performed nearly 100 autopsies at the coroner's office near University Circle in Cleveland --- about twice as many as in the four years they spent as general pathology residents at major hospitals.

And the fellows have worked on some of the region's highest-profile cases.

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The Strange Happiness of the Emergency Medic - Esquire

There is your life before the truck, and there is your life after the truck. An apprenticeship with paramedics shows what it really means to have a bad day.

My first body came on my first shift. It was a Friday night, dark and cold, the wind whipping across the empty fields. We were at a rollover on a country road. Someone had drifted too far into the snow on the shoulder and gone into a ditch. There had been two occupants, but somehow they were fine, not a scratch on them. On the way back to the ambulance — here in Ottawa, the paramedics call them trucks — we stopped to look inside their car, which was still on its roof. There were two barbells that had banged around in there and settled on the ceiling. We were ducking our ears into our coats and talking about how lucky the people were not to get brained when the radio squawked.

Serving a region with a population of just over one million, the Ottawa Paramedic Service answered more than 103,000 calls last year. The calls come over the radio in bunches. In my first five minutes inside the truck, there were calls for a woman having a seizure in a grocery store, an eight-week-old boy choking, a homeless man found unconscious in an alley, an elderly man with difficulty breathing, a possible heart attack in a chicken restaurant. If you just sat inside that truck listening to the radio, you'd believe the world was falling apart. It's madness. But even in the midst of all that screaming and chaos, there are calls that stand out. A Code 4 is a life-threatening emergency, lights and sirens. A Code 4 VSA — vital signs absent — is lights and sirens and a little bit more. This call was a VSA, a woman stretched out in the darkness to our west. Darryl and I jumped into the truck and bucked it.

Darryl Wilton was my mentor and partner. He's thirty-six, tall with a shaved head. If you could request a particular paramedic when you dialed 911, you would ask for him. He's been in the truck for twelve years, and he has seen a lot of things. As part of my training, he showed me published and unpublished media photographs from some recent calls to make sure I had the stomach for the work. He didn't want to have to treat me, too. ("The barrel-over-the-falls effect," he called the bilious uprush that rookies suffer.) There was the motorcycle wreck in which a husband and wife were launched across an intersection like crash-test dummies. There was the poor bastard who had been pulled into a printing press by his right arm. That's when I was introduced to the term "degloving." The guy had lost every shred of skin from his fingertips to his shoulder. His arm looked like an illustration in an anatomy textbook, a collection of red muscle and white flashes of bone and ligament.

I understood there would be my life before I spent time in the truck and my life after. We raced through the night, and I tried to prepare myself. Darryl prepared, too, but in a different way. He switched his brain into its most methodical gear. It was almost as though he were treating patients in advance of seeing them. "Time is tissue," he said. With every minute that passes before treatment, more body parts that should be pink turn white or blue, and white or blue equals death. As we listened to updates on the radio, he'd ask me what I thought about what was coming, and he would gently guide me toward the likely reality. Code 4's that came in just after snowstorms were often heart attacks — someone goes out to shovel and his heart can't handle the exertion. VSAs early in the morning were often unworkable, because chances were that the victim had died in the night, hours before he was discovered. Then the Code 4 would become a Code 5. "There's clinically dead, which we can work with," Darryl said. "And there's obviously dead, which we can't."

We knew this woman was elderly and laid out in her garage. It was a little after 7:00 p.m., which gave us a few possibilities. It had been snowing pretty hard, so maybe she had a shovel in her hands. (Paramedic calls follow the seasons: Summer sees an increase in trauma; winter brings a spike in medical calls.) Or maybe she fell on a patch of ice and hit her head. Darryl worried that she might have gone down sometime in the afternoon and not been found until someone returned home from work. We both reached into the box between us and pulled out blue nitrile gloves.

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Friday, December 24, 2010

Meet the Ethical Placebo: A Story that Heals | NeuroTribes

A provocative new study called "Placebos Without Deception," published on PLoS One today, threatens to make humble sugar pills something they've rarely had a chance to be in the history of medicine: a respectable, ethically sound treatment for disease that has been vetted in controlled trials.

The word placebo is ancientcoming to us from the Latin for "I shall please."As far back as the 14th Century, the term already had connotations of fakery, sleaze, and deception. For well-to-do Catholic families in Geoffrey Chaucer's day, the custom at funerals was to offer a feast to the congregation after the mourners sang the Office for the Dead (which contains the phrase placebo Domino in regione vivorum, "I shall please the Lord in the land of the living"). The unintended effect of this largesse was to inspire distant relatives and former acquaintances of the departed to crawl out of the woodwork, weeping copiously while praising the deceased, then hastening to the buffet. By the time Chaucer wrote his Canterbury Tales, these macabre freeloaders had been christened "placebo singers."

In modern medicine, placebos are associated with another form of deception — a kind that has long been thought essential for conducting randomized clinical trials of new drugs, the statistical rock upon which the global pharmaceutical industry was built. One group of volunteers in an RCT gets the novel medication; another group (the "control" group) gets pills or capsules that look identical to the allegedly active drug, but contain only an inert substance like milk sugar. These faux drugs are called placebos.

Inevitably, the health of some people in both groups improves, while the health of others grows worse. Symptoms of illness fluctuate for all sorts of reasons, including regression to the mean. Since the goal of an RCT, from Big Pharma's perspective, is to demonstrate the effectiveness of a new drug, the return to robust health of a volunteer in the control group is considered a statistical distraction. If too many people in the trial get better after downing sugar pills, the real drug will look worse by comparison — sometimes fatally so for the purpose of earning approval from the Food and Drug Adminstration.

For a complex and somewhat mysterious set of reasons, it is becoming increasingly difficult for experimental drugs to prove their superiority to sugar pills in RCTs, which was the subject of an in-depth article I published inWired called "The Placebo Problem," recipient of this year's Kavli/AAAS Science Journalism of the Year award for a magazine feature.

Only in recent years, however, has it become obvious that the abatement of symptoms in control-group volunteers — the so-called placebo effect — is worthy of study outside the context of drug trials, and is in fact profoundly good news to anyone but investors in Pfizer, Roche, and GlaxoSmithKline. The emerging field of placebo research has revealed that the body's repertoire of resilience contains a powerful self-healing network that can help reduce pain and inflammation, lower the production of stress chemicals like cortisol, and even tame high blood pressure and the tremors of Parkinson's disease.

Jumpstarting this network requires nothing more or less than a belief that one is receiving effective treatment — in the form of a pill, a capsule, talk therapy, injection, IV, or acupuncture needle. The activation of this self-healing network is what we really mean when we talk about the placebo effect. Though inert in themselves, placebos act as passwords between the domain of the mind and the domain of the body, enabling the expectation of healing to be translated into cascades of neurotransmitters and altered patterns of brain activity that engender health.

That's all well and good, but what does it mean in the real world of people getting sick? You can hardly expect the American Medical Association to issue a wink and a nod to doctors, encouraging them to prescribe sugar pills for seriously disabling conditions like chronic depression and Parkinson's disease. Meanwhile, more and more studies each year — by researchers like Fabrizio Benedetti at the University of Turin, author of a superb new book called The Patient's Brain, and neuroscientist Tor Wager at the University of Colorado — demonstrate that the placebo effect might be potentially useful in treating a wide range of ills. Then why aren't doctors supposed to use it?

The medical establishment's ethical problem with placebo treatment boils down to the notion that for fake drugs to be effective, doctors must lie to their patients. It has been widely assumed that if a patient discovers that he or she is taking a placebo, the mind/body password will no longer unlock the network, and the magic pills will cease to do their job.

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Thursday, December 23, 2010

Google Adds the Human Body to Its Search Functions -

On Dec. 16, Google released the first version of its Body Browser, a simulation of the human body. Users can travel, as in the 1980s movie "Innerspace," through various layers of human anatomy, zooming in on internal organs, navigating around bones and peeling back layers of the human body until all that's left are the stringy tangles of the nervous system.

The Body Browser works only in browsers that support WebGL, a new 3-D graphics tool that is appearing in the latest versions of popular browsers like Chrome 9 Beta from Google and Firefox 4 Beta. With WebGL, users do not need plug-ins like Flash or Java — the browser itself can handle complex graphics tasks.

The Body Browser is still a work in progress. Presently, only a female figure is available, and some of the controls are a bit balky. But the ability to zoom straight into a body and fly through it is remarkable — not to mention addictive.

Patient 1, Society 0 -

A young, healthy patient called me recently requesting a CT scan of his head because of his headaches. He described his symptoms, and they sounded to me like migraines. His clinical picture was not suggestive of a brain tumor and I told him so, but he was persistent. "What if I'm the one 35-year-old who drops dead of a brain tumor while you try to figure out what's wrong?" he asked.

It's a tough spot to be in. Sure, there was a chance that his symptoms were being caused by a brain tumor. The chance was exceedingly small, but not zero.

If I did a CT scan for every one of my many patients with headache, I might pick up an otherwise unsuspected tumor in one of out of thousands of them. For that one patient, it would be valuable. For the many more who would have side effects from the scan — from the contrast dye or radiation, or from false positive results leading to yet more tests — it would be harmful. And when finite health care dollars get shifted to unnecessary tests — well, we all lose out eventually.

A study last year in Archives of Internal Medicine highlighted the possible damage of radiation from excessive medical testing. Researchers estimated that 29,000 extra cancers could be caused from one year's worth of CT scans. The radiation from potentially unnecessary mammograms has also raised red flags.

Then, of course, there is also the cost of all this testing — a cost that threatens to bankrupt the health care system and the American economy.

"Being able to say no is the heart of the issue," a health economics researcher said when interviewed by The New York Times about that study.

He is right, of course. So much of decision-making in medicine is in the hands of individual physicians, and it is theoretically in our power to limit unnecessary procedures. But this can create a conflict between what is good for an individual patient and what is good for the health of the entire population.

But can we be a doctor to society? Except for public health doctors, most of us practice medicine in a cocooned environment: one patient with one doctor in one room. We want to do the greater good for society, but this can be abstract, frustrating and time-consuming in a real world with real patients. It may conflict with what is right for the individual. Plus, every doctor knows that you'll rarely be sued by "society," but you certainly can be sued by an individual patient. It's nearly impossible to toe the public-health line when faced with a frightened — or litigious — patient.

Sure, I could possibly justify a CT scan for this particular patient, depending on how I worded my request. Besides — the thinking usually goes — what's the risk or cost of one extra CT scan in the grand scheme of things?

Approaching medicine on the individual level, there probably isn't much added risk or cost. But approaching medicine from the societal level, the effect is huge.

I spoke to my patient for a long time, explaining why I did not think a CT scan was necessary, given his particular symptoms. I discussed the downsides of such scans, but he would have none of it. It was clear that he would never be able to rest easy until he had a CT.

I finally broke down and ordered the scan, but had mixed feelings about it. It wasn't incorrect to order it, but it probably wasn't necessary.

The patient turned out to be upset that the scan could not be done immediately — after all, he was worried about a brain tumor killing him on the spot. This was where I had to take a stand. Yes, the scan was potentially justifiable, but given his clinical presentation, I could not justify calling it "emergent" and asking the radiologists to defer other patients scheduled for scans.

In the end, the patient trooped off to the emergency room — the fastest but most expensive and, ultimately, least efficient way to obtain medical care. He learned he did not have a brain tumor and was able to sleep comfortably that night. Score one for the patient, but the rest of us lose out.

Danielle Ofri is an internist at Bellevue Hospital in New York City and editor-in-chief of the Bellevue Literary Review. Her most recent book, "Medicine in Translation: Journeys With My Patients," is about the care of immigrants and Americans in the United States health care system.

Wednesday, December 22, 2010

Medical News: Placebo Effect Is Real, Not Attempt to Deceive - in Pain Management, Pain Management from MedPage Today

The placebo effect works -- even when the patient knows it's a placebo -- demonstrating that it is a 'ritual of medicine' and not an attempt to fool patients, according to the results of a small randomized clinical trial.

In the trial of 80 irritable bowel syndrome (IBS) patients, those who took an open-label placebo showed clinically meaningful -- and statistically significantly -- higher global improvement scores and reduced symptom severity compared with those who got the same physician attention but didn't pop a placebo pill, Ted J. Kaptchuk, OMD (Doctor of Oriental Medicine), of the Beth Israel Deaconess Medical Center and Harvard, and colleagues found.

Surprisingly, the 59% rate of "adequate relief" with the known placebo was substantially greater than the typical 30% to 40% placebo response in double-blind IBS trials and actually comparable to responder rates seen with drugs used for IBS, they reported in the December issue of PLoS One.

While this may seem counterintuitive, the results suggest that physicians don't have to resort to deception to harness the power of the placebo effect, Kaptchuk explained in an interview.

"Conventional wisdom says that in order for a placebo to work you have to convince the patient that they are taking a real drug," he told MedPage Today.

However, the brain appears to respond to placebo in a way that conditions like IBS are susceptible to, Kaptchuk noted.

"We presume that the mechanisms in this study are probably analogous to the mechanisms in concealed placebo studies where we know that placebo treatment activates endogenous opioids or dopamine and can activate specific areas of the brain that modulate pain," he said in the interview.

This effect may have its greatest potential in conditions that are defined by patient complaints and have shown large placebo effects in blinded trials, such as chronic pain, fibromyalgia, and possibly depression and anxiety, he suggested.

"We're not questioning that people have real symptoms and real suffering in illnesses that are defined by self report," he told MedPage Today. "We're saying these kind of illness are more susceptible to modulation of symbol and mind-body effects."

A survey of physicians suggested that about half of them already use sham interventions to harness the placebo effect in their practice.These current study opens up the possibility of doing so without resorting to deception, Kaptchuk noted -- while warning that his group's finding is just a proof-of-concept study that should be treated cautiously.

The trial included 80 primarily female (70%) patients with IBS randomized to no treatment or an open-label placebo presented as "placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes."

Although both groups got the same quality of interaction with their providers to control for the role of the doctor-patient relationship, the placebo group came in significantly higher on the primary outcome measure of IBS Global Improvement Scale score after three weeks of treatment.

Global improvement scores averaged 5.0 versus 3.9 with no treatment (P=0.002), which at the large effect size of 0.79 was clinically meaningful, according to the researchers.

Placebo also reduced symptom severity by 92 points on the IBS Symptom Severity Scale, which was not only 46 points more than with no treatment (P=0.03) but also well above the 50-point threshold for a meaningful improvement from baseline on that scale.

Quality of life showed a trend (P=0.08) for greater improvement with placebo at the end of the trial as well with an 11-point boost over baseline. An increase of 10 points is considered clinically meaningful on the scale used.

"There's a specific effect to the ritual of medicine that, in fact, the caring a doctor gives, the treatments they give irregardless of what's in them is an important component of healthcare and is an potential optional therapy in healthcare," Kaptchuk concluded in the interview.

However, his group cautioned that further study and replication are needed before use of open-label placebo in practice.

Limitations of the trial included a relatively small sample size, too short duration to examine long-term effects, and the possibility of self-selection bias in that the trial may have selectively attracted IBS patients interested in mind-body interventions.

Additionally, the study was restricted to a group of patients with a single diagnosis, which may affect is generalizability.

US Drug Watchdog Urges All Facebook & Social Network Users To Tell Their Friends About The Darvocet & Darvon Pain Pill Recall & Severe Heart Damage

The US Drug Watchdog is urging all US adult members of Facebook, or all social networks to post a message to their friends regarding the recalled pain pills Darvocet, and Darvon, out of fear many millions of US adults could still be using these drugs. Used to treat mild to moderate pain, propoxyphene is sold by prescription under the brand names Darvon and Darvocet, a drug which also includes acetaminophen, and has been linked to potentially fatal heart rhythm abnormalities in users, heart attacks, and even death. The group says, " we received three calls this week from individuals using Darvocet, they had not heard of the recall, However, all three have had recent heart attacks." They say, "with more than 22 million users of Darvocet, or Darvon in the United States, and a recall barely a month old, our greatest worry is many to most victims, or loved ones of victims of heart rhythm abnormalities, heart attacks, or even death would have never realized that these drugs could have been the cause, or contributing factor." The US Drug Watchdog is urging Facebook, or social network users to post a message on their Facebook, or social network about the Darvocet, or Darvon recalls, with a link to the US Drug Watchdog's web site at http://USDrugWatchdog.Com

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Tuesday, December 21, 2010

A Doctor’s Mammogram Mission Turns Personal -

Dr. Marisa Weiss scheduled her mammogram this spring, just as she does every year. She had just turned 51, and after having annual scans for a decade, she knew what to expect: her dense breast tissue made reading the films difficult — "like looking for a polar bear in a blizzard" — and the technician would probably ask her to sit for a few extra views.

This year was different. After Dr. Weiss went home, she got a call from the doctor's office.

"They said, 'Can you come back, now?' " she recalled. "I said I'd prefer not to, and they said, 'Are you sure?' And I realized at that moment that it was more serious."

Dr. Weiss, who soon learned that she had an invasive Stage 1cancer in her left breast, is not just any physician. A radiation oncologist and a specialist in breast cancer, she founded a popular Web site,, for women seeking comprehensive information about the disease, and she considers herself a woman with a mission. She sees patients three days a week, but she devotes four days a week to the site, which draws millions of visitors from 250 countries each year. She is writing her third book on breast cancer for a general audience.

A year ago, when a federal task force issued new guidelines relaxing the recommendations for mammography screening, Dr. Weiss was one of their fiercest critics. Mammograms aren't perfect, she said at the time, but they save lives. Now she says one may have saved hers.

In the annals of medicine, Dr. Weiss's story is just that: a story, an individual experience of the kind scientists dismiss as anecdotal, no reason to rethink policy. But it underscores the lingering, uncomfortable questions about when and how often to undergo breast cancer screening, and how to balance the benefits of early diagnosis with the harms of mammography — including false positive results that can lead to unnecessary biopsies and overtreatment.

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Monday, December 20, 2010

A Real Science of Mind -

In recent years popular science writing has bombarded us with titillating reports of discoveries of the brain's psychological prowess. Such reports invade even introductory patter in biology and psychology. We are told that the brain — or some area of it sees, decides, reasons, knows, emotes, is altruistic/egotistical, or wants to make love. For example, a recent article reports a researcher's "looking at love, quite literally, with the aid of an MRI machine." One wonders whether lovemaking is to occur between two brains, or between a brain and a human being.

There are three things wrong with this talk.

First, it provides little insight into psychological phenomena. Often the discoveries amount to finding stronger activation in some area of the brain when a psychological phenomenon occurs. As if it is news that the brain is not dormant during psychological activity! The reported neuroscience is often descriptive rather than explanatory. Experiments have shown that neurobabble produces the illusion of understanding. But little of it is sufficiently detailed to aid, much less provide, psychological explanation.

Second, brains-in-love talk conflates levels of explanation. Neurobabble piques interest in science, but obscures how science works. Individuals see, know, and want to make love. Brains don't. Those things are psychological — not, in any evident way, neural. Brain activity is necessary for psychological phenomena, but its relation to them is complex.

Imagine that reports of the mid-20th-century breakthroughs in biology had focused entirely on quantum mechanical interactions among elementary particles. Imagine that the reports neglected to discuss the structure or functions of DNA. Inheritance would not have been understood. The level of explanation would have been wrong. Quantum mechanics lacks a notion of function, and its relation to biology is too complex to replace biological understanding. To understand biology, one must think in biological terms.

Discussing psychology in neural terms makes a similar mistake. Explanations of neural phenomena are not themselves explanations of psychological phenomena. Some expect the neural level to replace the psychological level. This expectation is as naive as expecting a single cure for cancer. Science is almost never so simple. See John Cleese's apt spoof of such reductionism.

The third thing wrong with neurobabble is that it has pernicious feedback effects on science itself. Too much immature science has received massive funding, on the assumption that it illuminates psychology. The idea that the neural can replace the psychological is the same idea that led to thinking that all psychological ills can be cured with drugs.

Correlations between localized neural activity and specific psychological phenomena are important facts. But they merely set the stage for explanation. Being purely descriptive, they explain nothing. Some correlations do aidpsychological explanation. For example, identifying neural events underlying vision constrains explanations of timing in psychological processes and has helped predict psychological effects. We will understand both the correlations and the psychology, however, only through psychological explanation.

Scientific explanation is our best guide to understanding the world. By reflecting on it, we learn better what we understand about the world.

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Drug Combinations That May Cause Major Drug Interactions Common Among Seniors... -- ANN ARBOR, Mich., Dec. 17, 2010 /PRNewswire/ --

More than half of older Americans who were prescribed antidepressants for the first time were already taking a medication that could adversely interact with the antidepressantaccording to a new study from Thomson Reuters.
For one-fourth of the seniors in the study, these were potentially major drug interactions.
The research, published by the American Journal for Geriatric Psychiatry, illustrates the complexity and challenges of prescribing antidepressants to older patients.
"We found a concerning degree of potentially harmful drug combinations being prescribed to seniors," said Tami Mark, Ph.D., the paper's lead author and director of analytic strategies at Thomson Reuters.
Among the 39,512 new antidepressant users in the study, 25.4 percent were prescribed antidepressants and another medication that could cause a major interaction. An additional 36.1 percent had potential moderate interactions and 38.5 percent had minor or no interactions.
Pain medications were most often identified as having the potential for major interactions with antidepressants, accounting for more than one quarter of all potential major interactions among seniors in the study.
"These findings reinforce the need for clinicians to be aware of potential drug-drug interactions and the importance of close patients monitoring," Mark said.
The presence of contraindications or interactions increased the probability of patients switching antidepressants by 19.5 percent.  
The study also found that 5.6 percent of study subjects had a documented side effect from the antidepressants they were prescribed, most often insomnia, somnolence and drowsiness. Overall, the presence of a side effect was associated with a 4.7 percentage point increase in drug switching (from 16.5% to 21.7%) and a 3.7 percentage point increase in discontinuation of treatment (from 22% to 25.7%).
Data for the study were derived from the Thomson Reuters MarketScan® database of Medicare claims. Potential drug interactions were identified using Thomson Reuters DRUG-REAX® System. Study subjects, who were aged 65 years or older, were new antidepressant users who were diagnosed with depression between July 1, 2001, and December 31, 2006.

Serious Mental Health Needs Seen Growing at Colleges -

Rushing a student to a psychiatric emergency room is never routine, but when Stony Brook University logged three trips in three days, it did not surprise Jenny Hwang, the director of counseling.

It was deep into the fall semester, a time of mounting stress with finals looming and the holiday break not far off, an anxiety all its own.

On a Thursday afternoon, a freshman who had been scraping bottom academically posted thoughts about suicide on Facebook. If I were gone, he wrote, would anybody notice? An alarmed student told staff members in the dorm, who called Dr. Hwang after hours, who contacted the campus police. Officers escorted the student to the county psychiatric hospital.

There were two more runs over that weekend, including one late Saturday night when a student grew concerned that a friend with a prescription for Xanax, the anti-anxiety drug, had swallowed a fistful.

On Sunday, a supervisor of residence halls, Gina Vanacore, sent a BlackBerry update to Dr. Hwang, who has championed programs to train students and staff members to intervene to prevent suicide.

"If you weren't so good at getting this bystander stuff out there," Ms. Vanacore wrote in mock exasperation, "we could sleep on the weekends."

Stony Brook is typical of American colleges and universities these days, where national surveys show that nearly half of the students who visit counseling centers are coping with serious mental illness, more than double the rate a decade ago. More students take psychiatric medication, and there are more emergencies requiring immediate action.

"It's so different from how people might stereotype the concept of college counseling, or back in the '70s students coming in with existential crises: who am I?" said Dr. Hwang, whose staff of 29 includes psychiatrists, clinicalpsychologists and social workers. "Now they're bringing in life stories involving extensive trauma, a history of serious mental illness, eating disorders, self-injury, alcohol and other drug use."

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse.

The need to help this troubled population has forced campus mental health centers — whose staffs, on average, have not grown in proportion to student enrollment in 15 years — to take extraordinary measures to make do. Some have hospital-style triage units to rank the acuity of students who cross their thresholds. Others have waiting lists for treatment — sometimes weeks long — and limit the number of therapy sessions.

Some centers have time only to "treat students for a crisis, bandaging them up and sending them out," said Denise Hayes, the president of the Association for University and College Counseling Center Directors and the director of counseling at the Claremont Colleges in California.

"It's very stressful for the counselors," she said. "It doesn't feel like why you got into college counseling."

A recent survey by the American College Counseling Association found that a majority of students seek help for normal post-adolescent trouble like romantic heartbreak and identity crises. But 44 percent in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.

The most common disorders today: depression, anxiety, suicidal thoughts, alcohol abuse, attention disorders, self-injury and eating disorders.

Stony Brook, an academically demanding branch of the State University of New York (its admission rate is 40 percent), faces the mental health challenges typical of a big public university. It has 9,500 resident students and 15,000 who commute from off-campus. The highly diverse student body includes many who are the first in their families to attend college and carry intense pressure to succeed, often in engineering or the sciences. A Black Women and Trauma therapy group last semester included participants from Africa, suffering post-traumatic stress disorder from violence in their youth.

Stony Brook has seen a sharp increase in demand for counseling — 1,311 students began treatment during the past academic year, a rise of 21 percent from a year earlier. At the same time, budget pressures from New York State have forced a 15 percent cut in mental health services over three years.

Dr. Hwang, a clinical psychologist who became director in July 2009, has dealt with the squeeze by limiting counseling sessions to 10 per student and referring some, especially those needing long-term treatment for eating disorders or schizophrenia, to off-campus providers.

But she has resisted the pressure to offer only referrals. By managing counselors' workloads, the center can accept as many as 60 new clients a week in peak demand between October and the winter break.

"By this point in the semester to not lose hope or get jaded about the work, it can be a challenge," Dr. Hwang said. "By the end of the day, I go home so adrenalized that even though I'm exhausted it will take me hours to fall asleep."

For relief, she plays with her 2-year-old daughter, and she has taken up the guitar again.

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Med Schools Flunk at Keeping Faculty Off Pharma Speaking Circuit - ProPublica

As medical schools wrestle with how to keep drug companies from corrupting their faculties, Stanford University is often lauded for its tough stance.

The school was one of the first to stop sales representatives from roaming its halls in 2006. It cut off the flow of free lunches and trinkets emblazoned with drug names. And last year, in a blow to its physicians' wallets, Stanford banned them from giving paid promotional talks for pharmaceutical companies.

One thing it didn't do was make sure its faculty followed that rule.

A ProPublica investigation found that more than a dozen of the school's doctors were paid speakers in apparent violation of its policy—two of them earning six figures since last year.

Dr. Philip Pizzo, the dean of Stanford's medical school, sent an e-mail to all medical school staff last week calling the conduct "unacceptable." Some doctors' excuses, he wrote, were "difficult if not impossible to reconcile with our policy."

He was not the only school official caught off-guard.

Faculty at a half-dozen other institutions—including division chiefs—also lectured for drug firms in the last two years, ProPublica found, despite restrictions on such behavior. The University of Pennsylvania, the University of Pittsburgh and the University of Colorado Denver, among others, have launched reviews.

Conflict-of-interest policies have become increasingly important as academic medical centers worry that promotional talks undermine the credibility of not only the physicians giving them, but also of the institutions they represent.

Yet when it comes to enforcing the policies, universities have allowed permissive interpretations and relied on the honor system. ProPublica's review shows that approach isn't working: Many physicians are in apparent violation, and ignorance or confusion about the rules is widespread.

As a result, some faculty physicians stay on the industry lecture circuit, where they can net tens of thousands in additional income.

Critics of the practice say delivering talks for drug companies is incompatible with teaching future generations of physicians. That's because drug firms typically pick the topic of the lecture, train the speakers and require them to use company-provided presentation slides.

"You're giving someone else's messages, someone else's talk, someone else's judgments," said Dr. Bernard Lo, a medical professor at University of California, San Francisco who chaired anational panel examining conflicts of interest in medicine. "We don't allow our students to use someone else's work."

Reporters compared the names of faculty members at a dozen medical schools and teaching hospitals with ProPublica's Dollars for Docs database of payments publicly reported by seven drug companies. Lists of the physicians whose names matched were provided to the universities and hospitals for verification and comment.

Because the majority of the more than 70 drug companies in the United States don't report such payments, the review provides only a glimpse of possible lapses at schools. As more companies make their speaker fees public, additional faculty will likely show up, several university officials said.

Those who study conflicts of interest in academia say the findings point to a significant problem for teaching hospitals. Schools should not only have a policy— many do not — they need to enforce it. Absent that, others will police their staffs for them using drug company payment websites.

"For God's sake, if the media can look at these websites, why can't we?" said David Rothman, president of the Institute on Medicine as a Profession at Columbia University. "Why trust if you can verify?"

Most universities were unwilling to confirm whether individual faculty members flagged by ProPublica had erred, making it difficult to tally all offenders.

At Stanford, officials said some faculty members provided proof that they had not violated the policy because they used their own lecture materials or stopped speaking as soon as it took effect.

But others conceded they were in the wrong.

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“God Help You. You're on Dialysis.” - Magazine - The Atlantic

Every year, more than 100,000 Americans start dialysis. One most of the bill, the government has kept confidential clinic data that could help patients make better decisions. How did our first foray into near-universal coverage, begun four decades ago with such great hope, turn out this way? And what lessons does it hold for the future of health-care reform?

In October 1972, after a month of deliberation, Congress launched the nation's most ambitious experiment in universal health care: a change to the Social Security Act that granted comprehensive coverage under Medicare to virtually anyone diagnosed with kidney failure, regardless of age or income.

It was a supremely hopeful moment. Although the technology to keep kidney patients alive through dialysis had arrived, it was still unattainable for all but a lucky few. At one hospital, a death panel—or "God committee" in the parlance of the time—was deciding who got it and who didn't. The new program would help about 11,000 Americans for starters, and for a modest initial price tag of $135 million, would cover not only their dialysis and transplants, but all of their medical needs. Some consider it the closest that the United States has come to socialized medicine.

Now, almost four decades later, a program once envisioned as a model for a national health-care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis—about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world's highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy's, or France's, or Japan's, thousands fewer kidney patients would die each year.

In a country that regularly boasts about its superior medical system, such results might be cause for outrage. But although dialysis is a lifeline for almost 400,000 Americans, few outside this insular world have probed why a program with such compassionate aims produces such troubling outcomes. Even during a fervid national debate over health care, the state of dialysis garnered little public attention.

Over the course of more than a year, I reviewed thousands of inspection reports and interviewed more than 100 patients, advocates, doctors, policy makers, researchers, and industry experts to get a grasp on American dialysis care. The findings were bleak: at clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care. Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. The government withholds critical data about clinics' performance from patients, the very people who need it most. Meanwhile, the two corporate chains that dominate the dialysis-care system are consistently profitable, together making about $2 billion in operating profits a year.

One reason that dialysis's problems have evolved out of the health-care spotlight is that kidney failure disproportionately afflicts minorities and the dispossessed. But given a patient pool growing by 3 percent a year and the outsize 6 percent bite that the kidney program takes from the Medicare budget, we ignore dialysis at our own risk. "We're offering our patients a therapy we wouldn't accept for ourselves," said Dr. Tom F. Parker, a Dallas nephrologist and national advocate for better care. More and more leaders in the field, he told me, "are starting to say this isn't sufficient."

As the United States moves to expand access to health care, dialysis offers potent lessons. Its story expresses the fears of both ends of the ideological spectrum about what can happen when the doors to care are thrown wide open: neither government controls nor market forces have kept costs from ballooning or ensured the highest-quality care. Almost every key assumption about how the program would unfold has proved wrong.

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