Saturday, January 29, 2011

Campaign brings home hard reality about health care - National Post

How does advertising influence people's behaviour? When it comes to getting people to try a new chocolate bar, it may be easy. But attempting to persuade people to change their bad habits isn't just a matter of giving them the facts and statistics and hoping they will behave reasonably, attendees at a summit in Toronto on advertising and social change heard this week.

Case studies presented at the Institute of Communication Agencies conference illustrate the challenge that ad agencies face in the arena of personal issues such as health, drinking and driving, and sexually transmitted diseases.

Yvette Thornley, manager for the communications branch of the Ontario Ministry of Health and Long-term Care, said partnerships between ad agencies and governments have resulted in great creative executions that have made a clear impact on human behaviour over time, although it is critical that marketers determine before the campaign begins what the biggest obstacles are standing in the way of people adopting different behaviour.

Advertising a free flu shot to Ontarians in 2000 saw an uptick in flu shots from 14% to 34% of the province's population in the first year of the program, and resulted in 30,000 fewer visits to emergency rooms as a result, Ms. Thornley said, but it is an ongoing challenge to get people out for a shot, even if they know they can get one. Now the average is about 35%, although 45% were innoculated last year when H1N1 warnings proliferated.

"Success [in such a campaign] is not defined by the amount of coverage it receives in the media," she said. "It is defined by changed behaviour."

In one of the examples cited, advertising helped ameliorate one of the biggest public health problems in Ontario: the overuse of hospital emergency rooms for non-emergencies. It led to a still-running awareness campaign in 2009 for the province's Ministry of Health and Long-Term Care from Narrative Advocacy Media, a division of Toronto ad agency Bensimon Byrne.

Agency brass knew that consumers were avid seekers of health information on the Web even though a good deal of it is incorrect, said David Rosenberg, chief creative officer at the Toronto agency. At the time the campaign started in early 2009, Ontarians were waiting an average of 9.4 hours in hospital ERs before being seen. The long wait times were happening because they were not going to emergency rooms for actual emergencies and were largely unaware of other health-care options in their area, such as urgent-care centres, medical drop-in clinics or whether or not their doctors belonged to a health network. At the time, 566,000 visits to ERs across the province every year were for non-emergencies.

The biggest hurdle with Ontario residents was the ongoing word-of-mouth horror stories about hospital ER care. "The question was 'How do we contain the horror?' " Mr. Rosenberg recalled, and promote the health-care system as trustworthy and efficient.

"Most people dreaded the thought of heading to an ER," said Amanda Alvaro, managing director at Bensimon Byrne's Narrative Advocacy Media. "So why did they go? Because they didn't think they had any other options."

A website with searchable information by postal code would also be an asset, the agency reasoned, and one that provided information such as average wait times for surgeries. Delivering options to Ontarians became the strategic and creative thrust of the campaign.

One unexpected stumbling block, however, was that the ministry itself lacked a comprehensive list of what health-care professionals offered in terms of services in various areas of the province, and at what hours.

Before they could build a comprehensive database of health-care providers in the province, Bensimon Byrne and the ministry had to do extensive research for reliable information. In the past, promotion of the non-ER options had been left to doctors, clinics and local health-care administrators, and was patchwork and inconsistent in its approach.

After the legwork, the resulting TV and Web campaign has seen the number of non-emergency visits to emergency rooms decline 13% since its inception; overall visits to the ER have declined 10%. Television ads were run heavily on the weekend; after waiting to check on the status of their family member's illness all weekend, people tended to overuse ERs as a default health-care option on Sunday afternoons and Monday mornings, Ms. Alvaro said.

The campaign drove 1.5 million people to the site and sparked more than a million searches -- the site received more hits than OHIP's site--a government first. Fifty-two per cent of people who visited the website reported accessing alternative services to ERs.

The overall average ER wait time declined to 8.6 hours from 9.4.

More recently, the campaign was awarded bronze this week at the Cassies Awards, the advertising competition that judges entries based on their ability to increase business or effect change.

While the Ontario ministry's campaign has been a success, one speaker at the conference said the major impediment to such campaigns is often resources, given that many of them are publicly funded.

"In the [United States] it is a constant struggle," said Les Pappas, founder and creative director of Better World Advertising, a San Franciscobased firm that focuses solely on social marketing. As such, social marketing work is frequently "done by amateurs and overly constrained by politicians," he said. "And in an economic recession, social marketing is the first to go."

Medical students are performing intrusive exams on unconscious patients |

Australian medical students are carrying out intrusive procedures on unconscious and anaesthetised patients without gaining the patient's consent.
The unauthorised examinations include genital, rectal and breast exams, and raise serious questions about the ethics of up-and-coming doctors, Madison reports.

The research, soon to be published in international medical journal, Medical Education, describes - among others - a student with "no qualms" about performing an anal examination on a female patient because she didn't think the woman's consent was relevant.

Another case outlined in the research describes a man who was subjected to rectal examinations from a "queue" of medical students after he was anaesthetised for surgery.

"I was in theatre, the patient was under a spinal (anaesthetic) as well and there was a screen up and they just had a queue of medical students doing a rectal examination," a student confessed.

"[H]e wasn't consented but because ... you're in that situation, you don't have the confidence to say 'no' you just do it."

The author of the study, Professor Charlotte Rees, voiced concerns about senior medical staff ordering students to perform unauthorised procedures, leaving the students torn between the strong ethics of consent in society and the weak ethics of medical staff.

Of students who were put in this position during the research, 82 per cent obeyed orders.

"We think that it is weakness in the ethical climate of the clinical workplace that ultimately serves to legitimise and reinforce unethical practices in the context of students learning intimate examinations," writes Prof Rees.

The study consists of 200 students across three unnamed medical schools in Britain and Australia. Not all participants agreed to carry out the intimate examinations without permission from the patient.

One student refused to take part in an examination of a woman who was "part spread-eagled on the bed and the nurse is (sic) pulling down her jeans at the same time and it was all very complicated and you could see her, she was about seventeen".

Carol Bennett, the CEO of the Consumer Health Forum, said the report was a "poor reflection on these medical schools that they are setting these examples".

"Most people would not be pleased about having medical procedures performed on them without it even being mentioned to them," she told

"Patients should never be examined without consent, particularly by a third party."

Comment is being sought from the Australian Medical Association.

How Meditation May Change the Brain -

Over the December holidays, my husband went on a 10-day silent meditation retreat. Not my idea of fun, but he came back rejuvenated and energetic.

He said the experience was so transformational that he has committed to meditating for two hours a day, once in the morning and once in the evening, until the end of March. He's running an experiment to determine whether and how meditation actually improves the quality of his life.

I'll admit I'm a skeptic.

But now, scientists say that meditators like my husband may be benefiting from changes in their brains. The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants' meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

But how exactly did these study volunteers, all seeking stress reduction in their lives but new to the practice, meditate? So many people talk about meditating these days. Within four miles of our Bay Area home, there are at least six centers that offer some type of meditation class, and I often hear phrases like, "So how was your sit today?"

Britta Hölzel, a psychologist at Massachusetts General Hospital and Harvard Medical School and the study's lead author, said the participants practiced mindfulness meditation, a form of meditation that was introduced in the United States in the late 1970s. It traces its roots to the same ancient Buddhist techniques that my husband follows.

"The main idea is to use different objects to focus one's attention, and it could be a focus on sensations of breathing, or emotions or thoughts, or observing any type of body sensations," she said. "But it's about bringing the mind back to the here and now, as opposed to letting the mind drift."

Generally the meditators are seated upright on a chair or the floor and in silence, although sometimes there might be a guide leading a session, Dr. Hölzel said.

Of course, it's important to remember that the human brain is complicated. Understanding what the increased density of gray matter really means is still, well, a gray area.

"The field is very, very young, and we don't really know enough about it yet," Dr. Hölzel said. "I would say these are still quite preliminary findings. We see that there is something there, but we have to replicate these findings and find out what they really mean."

It has been hard to pinpoint the benefits of meditation, but a 2009 study suggests that meditation may reduce blood pressure in patients with coronary heart disease. And a 2007 study found that meditators have longer attention spans.

Previous studies have also shown that there are structural differences between the brains of meditators and those who don't meditate, although this new study is the first to document changes in gray matter over time through meditation.

Ultimately, Dr. Hölzel said she and her colleagues would like to demonstrate how meditation results in definitive improvements in people's lives.

"A lot of studies find that it increases well-being, improves quality of life, but it's always hard to determine how you can objectively test that," she said. "Relatively little is known about the brain and the psychological mechanisms about how this is being done."

In a 2008 study published in the journal PloS One, researchers found that when meditators heard the sounds of people suffering, they had stronger activation levels in their temporal parietal junctures, a part of the brain tied to empathy, than people who did not meditate.

"They may be more willing to help when someone suffers, and act more compassionately," Dr. Hölzel said.

Further study is needed, but that bodes well for me.

For now, I'm more than happy to support my husband's little experiment, despite the fact that he now rises at 5 a.m. and is exhausted by 10 at night.

An empathetic husband who takes out the trash and puts gas in the car because he knows I don't like to — I'll take that.

Tuesday, January 25, 2011

Worry Grows About Aging Doctors’ Fitness to Practice -

About eight years ago, at the age of 78, a vascular surgeon in California operated on a woman who then developed a pulmonary embolism. The surgeon did not respond to urgent calls from the nurses, and the woman died.

Even after the hospital reported the doctor to the Medical Board of California, he continued to perform operations for four years until the board finally referred him for a competency assessment at the University of California, San Diego.

"We did a neuropsychological exam, and it was very abnormal," said Dr. William Norcross, director of the physician assessment program there, who did not identify the surgeon. "This surgeon had visual-spatial abnormalities, could not do fine motor movements, could not retain information, and his verbal I.Q. was much lower than you'd expect."

Yet "no one knew he had a cognitive deficit, and he did not think he had a problem," Dr. Norcross continued. The surgeon was asked to surrender his medical license.

One-third of the nation's physicians are over 65, and that proportion is expected to rise. As doctors in the baby boom generation reach 65, many are under increasing financial pressures that make them reluctant to retire.

Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. But physicians are hardly immune to dementia, Parkinson's disease, stroke and other ills of aging. And some experts warn that there are too few safeguards to protect patients against those who should no longer be practicing. "My guess is that John Q. Public thinks there is some fail-safe mechanism to protect him from incompetent physicians," Dr. Norcross said. "There is not."

Often the mechanism does not kick in until a state medical board has found it necessary to discipline a physician. A 2005 study found that the rate of disciplinary action was 6.6 percent for doctors out of medical school 40 years, compared with 1.3 percent for those out only 10 years.

In 2006, a study found that in complicated operations, patients' mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations.

Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. Yet "the profession of medicine has never really had an organized way to measure physician competency," said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation. "We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis."

Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a small cadre of hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements. But such policies have met resistance from rank-and-file doctors.

"I do not believe that diminished competence attributable solely to age is a significant factor in the underperformance of most poor-performing physicians," Dr. Henry Homburger, 64, professor of laboratory medicine at the Mayo Clinic, said by e-mail. Mental illness like depression, substance abuse and a "failure to maintain competence through continuing education far outweigh age as causes of poor performance, in my opinion," he wrote.

Others doubt that a single type of exam can be used to assess the performance of doctors from a variety of specialties. "More research is needed for us to define what combination of cognitive and motor issues are important," said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons.

Physicians do have to meet minimal requirements to continue to practice. To renew a medical license in most states, doctors must complete a certain number of hours of continuing medical education every year or two.

This does not impress experts like Dr. Norcross. "You can be asleep during those courses and no one would know," he said.

Even the tougher new policies of specialty boards do not usually apply to older physicians, who, because of "grandfather" clauses, are not required to renew their certification — an expensive, time-consuming process.

They are being encouraged to do so voluntarily, but few do — less than 1 percent of the 69,000 so-called grandfathered members of the American Board of Internal Medicine, for example.

Doctors with mild cognitive impairment may not be aware they have a problem or their performance is flagging. Changes are often subtle at first: a person may not be able to recall words, learn new material, apply knowledge to solving problems or multitask.

These deficits can make it hard to carry out the latest recommendations for diagnosis and treatment, learn new computer-based technology, remember prescribing details about medications, or function well in a stressful environment like the emergency room.

Only when a doctor's behavior starts to become odd are other physicians, nurses and patients likely to take notice.

Medical professionals are supposed to report colleagues' unsafe practices and bad behavior. But doctors are reluctant to confront their fellow physicians, especially their seniors, who may have trained them. "Sometimes we empathize too much and have difficulty making the hard calls when we need to," Dr. Norcross said.

Doctors often cover for physicians who are becoming less sharp, by having another surgeon in the operating room or by regularly reviewing their cases, Dr. Green said.

Dr. John Fromson, associate director of postgraduate medical education at Massachusetts General Hospital, cited a case at another medical center in New England, where physicians noticed cognitive changes in the 77-year-old chairman of internal medicine.

He was highly respected and had trained most of the physicians at the center, so they were reluctant to confront him. Instead, they gave him a retirement party, hoping he would take the hint. "But he didn't," Dr. Fromson said. "He kept on working."

Dr. Fromson staged an intervention, at which four or five of the doctor's close colleagues confronted him as compassionately as they could. "We reaffirmed our concern and caring for him, and asked him to hand over his medical license," he said. "He became quite tearful, but he did."

To lift this burden from peers while protecting patients, 5 percent to 10 percent of hospitals around the country have begun to address the issue of aging physicians more systematically, said Dr. Jonathan Burroughs, a consultant with the Greeley Company, which advises hospitals and health care companies.

"The other 90 to 95 percent are not willing to take this on," he said. In some instances, their efforts have been squashed by a vocal medical staff.

At Driscoll Children's Hospital in Corpus Christi, Tex., Dr. Karl Serrao, the credentials chairman, decided to move slowly and enlisted the staff's help in drafting a policy for aging physicians. The staff expressed concerns about age discrimination, losing the valuable experience of older physicians and invasion of privacy. Now the hospital's policy states that when doctors 70 and older are up for reappointment, they must undergo cognitive and physical exams that assess skills specific to their specialty.

Dr. Burroughs says that screening physicians may be a more compassionate route than doctors think. "By identifying the issue early enough, it enhances their chance of being able to practice longer," he said. When a cognitive deficit is discussed openly, the physician's practice can be simplified, he can reduce his patient load, and his partners can regularly monitor and assess his work.

"But once something bad happens," Dr. Burroughs said, "he'll get his license taken away."

Doctors are failing the empathy test: study | Posted | National Post

Doctors are routinely missing or ignoring moments that beg for empathy and need more training in responding to human emotions, an article in Canada's leading medical journal says.
Researchers from the University of Toronto and Duke University in Durham, N.C., say studies suggest doctors fail up to 90% of the time to respond to emotional cues from their patients.
"Empathy is the ability to understand another's experience, to communicate and confirm that understanding with the other person and to then act in a helpful manner," the authors write in the Canadian Medical Association Journal.
But, in real practice, doctors "infrequently articulate" empathetic responses, they say.
The team points to a recent study, published in the Archives of Internal Medicine, in which researchers analyzed 20 transcripts from recordings of 137 consultations between doctors at a U.S. Veterans Affairs hospital and patients with lung cancer.
In all, 384 moments or "empathetic opportunities" when patients expressed fears, worries or concerns were identified. Physicians responded empathetically to only 39 of them, or 10%.
In one exchange, a doctor tells a patient with biopsy-confirmed lung cancer that most likely the entire lung will need to come out.
"All right?" the surgeon asks.
Patient: "OK. That's the darkest picture."
Physician: "Yeah. That's the darkest and the most likely."
Another study, this one involving nearly 400 videotaped conversations between 51 oncologists and 270 patients with advanced cancer, found doctors responded only 22% of the time during moments when patients expressed emotions such as "I've got nothing to look forward to."
"For about 80% of the time, doctors don't know how to acknowledge emotions," says Dr. Robert Buckman, lead author of the article.
Dr. Buckman, an oncologist at Princess Margaret Hospital and the University of Toronto's faculty of medicine who lectures regularly on doctor-patient communication, says that when doctors respond with empathy, patients have less anxiety and depression. They're more likely to comply with treatment and less likely to lodge malpractice complaints.
But training around communication and empathy has lagged behind education in other areas.
"We come into medical school and we're probably quite normal human beings," says Dr. Buckman.
"Unfortunately there is so much to learn that, in some respects, maintaining the human being stuff gets beaten out of you, because you've got to learn the nine different kinds of associations with parathyroid hormone over secretion, or the 20 different causes of hypercalcemia.
"It's really important that you do know that, but it's also important that you learn how to acknowledge human feelings."
Doctors fear that empathy "is something you're born with — either you are empathetic, or not," Dr. Buckman says. "That is rubbish. Empathetic communication is something you can learn," in as little as a half-day workshop, he says.
He teaches medical students and doctors how to identify the emotion and its source. "Then you make a response that shows you've made the connection — 'What I've just told you is obviously very upsetting,' or, 'That comes as a bad shock, doesn't it?' "
There's no ideal script, he says. "There's probably 80 different ways you can phrase the words. All you have to do is see what the emotion is, see where it started and show the other person that you've made the connection."
Lisa Machado, a 38-year-old mother of two, was diagnosed with chronic myeloid leukemia just over two years ago. "A cancer diagnosis can be pretty devastating," she says.
"Even though … it's highly treatable, and I've got medication and it's working, it has been so critical for me to have a doctor where I can just go in and sort of go down those dark roads."
Doctors miss "a whole piece of the patient by not dealing with the scary things that go through your mind," she said. "Whether your fears are rational or not, they're still very real."

Monday, January 24, 2011

Finding Health Care Canada

My name is Janet Walker and I am Canadian. I founded this website that is powered by people, informed by visitors and paid for by me.

I am a nurse who believes that no Canadian should be in pain or should have to wait for medically necessary treatment. Making information and tools available that could help Canadians find the care that they need is one way of contributing to a solution.

Another way of contributing to a solution is to to bring forth and share the experiences of Canadians who are waiting for care or who have found care in the private sector. Their chronicles and their words of advice are valuable to other Canadians waiting for care and also to those who are working towards improving our healthcare system. I invite Canadians with healthcare experiences about access to share their stories with me. I believe that these stories need to be told. I am that storyteller. By publishing the real experiences of real Canadians, we can raise awareness about some key difficulties and encourage decision makers to bring about the necessary changes. Canadians want healthcare for all. Let's make it a proud reality instead of an empty slogan.

The Jay Cutler Criticism Is The Reason Why The NFL's Concussion Problem Is Not Going Away

The biggest talk of the NFC Championship Game was not the Packers stifling defense or even Caleb Hanie's near-miraculous comeback ... it was about a much bigger question: Is Jay Cutler a wimp?

Cutler continues to be lambasted on Twitter and TV and not just by Bears fans disappointed with another playoff exit. Several current and former NFL players questioned Cutler's injury, his toughness, and his heart after he left the game in the third quarter with a knee injury and did not return.

In the end it doesn't matter whether Cutler really was injured or not (even though all his teammates insist that he must have been), what this incident proves is thatthe NFL's smash mouth "warrior" culture — and the crippling injuries and concussions that go with it — is not going away.

The fact that players and media would criticize anyone for not being injured enough is all you need to know about why players risk brain damage and paralysis just to play on more down.

Take this typical comment from ESPN commenter and former Bronco Mark Schlereth, an outspoken critic of the league's new rules on hits to the head.

"As a guy who had 20 knee surgeries you'd have to drag me out on a stretcher to Leave a championship game!"

Think about what he's saying: The only acceptable excuse for not playing in a game is the complete inability to walk. (Apparently, the motorized cart that took him to the locker room was all that spared Steelers center Maurkice Pouncey from criticism when he left the AFC title game with an ankle injury.)

Schlereth considers his still busted legs a badge of honor, but he is one of the lucky ones. He has a good post-football job with nice health insurance and is still relatively young. And, yes, even when he reaches his sixties and requires a cane or walker to get around, he may still insist it was all worth it.

But what about the players who only had two knee surgeries, because they never played again after the first one? What about those with herniated backs, degenerative hips, and yes, traumatic brain injuries, because they played football when they shouldn't have?

The reason those injuries happen is because players who play hurt are lionized and those who don't are humiliated. Because Jay Cutler didn't push himself to the absolute limit and stretch his body beyond what any doctor would consider acceptable, he's a punk who doesn't deserve to be a starting quarterback in the NFL. And guys like Mark Schlereth and Mike Golic are the reason why.

The ex-players say, "That may not be fair, but that's the mentality of football." Well, the mentality of football ruins lives. The mentality of football shatter bodies. The mentality of football left Schlerth with a leg that doesn't bend right and it left Andre Waters with the brain of a 85-year-old Alzheimer's patient.

Maybe that's the game we're going to be left with and maybe every football player from pro to Pop Warner who signs up for a helmet is willing to accept that. But it may also become a game that a lot of peoplearen't willing to stomach, from a league says one thing, but practices something much different.

If they NFL seriously wants to end the parade of concussion victims with damaged brains and former players with life-altering injuries, the way the game is played has to change. They way the players and coaches treat those who are hurt has to change.

Of all the people, Bears fans should be the most understanding of the dangers.. Chicagoan Michael Wilbon criticized Cutler for not being as good as the oft-injured Jim McMahon, apparently forgetting another story from just a few weeks ago: The one where McMahon admitted that he has no short-term memory any more, the price of dozens of hits he probably shouldn't have taken.

We guess he's not the only one who has trouble remembering.

Physician Demand for iPad EMRs is Growing. Are Vendors Ready? - Software Advice, Inc.

The answer to that question is a surprisingly resounding "No!" The medical software industry is far from supporting the iPad on a meaningful scale. Buyers would think that vendors eager to grow market share would quickly adopt new, flashy technologies, but software vendors are surprisingly slow to react. Electronic health records vendors need to get on board or face the prospect of losing market share to faster-moving competitors.

There is no doubt that buyer demand for the iPad is surging. A past Software Advice poll (below) found that nearly 35% of healthcare providers were "very likely" to purchase a tablet PC in the next year. Don't forget that the iPad enjoys 87% market share of the tablet PC market. That's a lot of potential customers looking for iPad EHRs.

However, there are very few vendors well-positioned to benefit from this trend. In fact, only two EHR systems currently on the market were built from the ground up for the iPad:

• Nimble – Released by ClearPractice in October, 2010.
• Dr. Chrono – Founded in 2009 with their first release in 2010.

Aside from these two companies, only a handful of other vendors (most notably AllScripts and Quest) have released iPad apps to supplement existing EHR systems. I should note there are other systems on the market that are accessible from the iPad's web browser, but they are not native iPad apps. (Some readers might be wondering about MacPractice. Their system does run on the iPad via a VNC interface, but it's not a native iPad app either.)

So where are the 300+ other EHR software companies? They have iPad apps "in the works," but not ready yet. This really comes as no surprise. The medical software industry is notoriously slow to adopt new technologies. Have you ever seen your doctor's office running a system that looks like it is from the 80s? We hear from these practices every day. Plenty of software vendors are still selling outdated, DOS-based systems with Windows interfaces (we will withhold names to protect the innocent).

As a result of this slow movement, we expect a number of newer software companies to quickly gain popularity and seize market share from vendors who are slow to move. Interestingly, a number of garage-based startups are already poised for growth: medical iPhone and iPad app developers.

There are currently well over 10,000 medical apps available in the App Store. These apps range from basic ICD-9 lookup tools to more advanced apps to track patient SOAP notes. While many of these small developers won't have the resources to scale and develop sophisticated EHRs, some just might have the ability (and the guts). These potential movers include some of the more popular medical apps.

More ...

What is EMR Software?

Electronic health records (EHR) software, also known as electronic medical records (EMR) software, are software systems that provide a longitudinal, electronic version of a patient's health history. Information commonly found in an EMR includes a patient’s progress or SOAP notes, problems, medications, vital signs, past health history, immunizations, laboratory data and radiology reports, to name just a few. In addition to storing patient information, these systems are often integrated with medical billing software or practice management software for a fully-integrated workflow. The market offers a wide range of web-based EMR systems, as well as systems installed on-premise.

Herbert Pardes: The Coming Doctor Shortage -

As they celebrate their 65th birthdays at the rate of 10,000 a day, Baby Boomers are now approaching the stage of their lives when they will need more medical care. But they—along with everyone else—are going to have a hard time getting appointments.

The doctor shortage was fostered in 1996 when Congress capped the number of new doctors Medicare would pay to train, a practice that continues to this day. Teaching hospitals, which now make up about 10% of hospitals nationwide, depend on those Medicare funds to pay about two-thirds of the cost of doctor-training. (Training costs include residents' salaries, malpractice insurance, equipment, the extra time that teaching procedures add to patient care, as well as the added costs associated with caring for the sickest patients.)

Recently, the President's National Commission on Fiscal Responsibility and Reform proposed cutting Medicare funding to train doctors even further, by $60 billion through 2020. If this cut is enacted, the doctor shortage would get far worse.Training new doctors has substantial costs because of all they must learn and how carefully they must be supervised. Without Medicare reimbursements, many hospitals could not afford to maintain these critical training programs. Already, 30% of hospitals lose money, according to the American Hospital Association, and even more barely break even. Across the country, demand for doctors exceeds supply.

The numbers are striking.

Health-care reform will add an estimated 32 million people to the ranks of the insured, driving them to seek medical attention that in the past they may have avoided due to expense. The aging population will also create much greater demand. The number of seniors who need more medical care is expected to soar to 72 million by 2020—nearly double today's number.

According to a 2010 report by the Association of American Medical Colleges, the increased demand means that our nation will need an additional 130,000 doctors, both general-practice physicians and specialists, 15 years from now. That's about 20% more doctors than we have currently.

But doctors are aging, too. Almost a third of doctors in the country—about 250,000—are over the age of 55. By 2020 they plan on retiring.

Right now we train roughly 16,000 doctors a year. To keep pace with demand, this nation will need to train an additional 6,000 to 8,000 each year for the next 20 years. If we increased the number of training slots today, it would take seven to 10 years for the new doctors to see patients (four years of medical school, plus three years of residency and additional specialty training).

In many parts of the country, the shortage of doctors is already a reality. Statistics from the Health Resources and Services Administration say that 10% of the population lives in an area where there is an inadequate supply of health-care providers. These people may wait months to see a doctor. Sometimes no specialists exist where they live. While some responsibilities of doctors can be absorbed through other trained medical professionals, including nurses and physician assistants, they don't have the same unique expertise. If we don't make changes, long waits and limited access will become much more common for all patients.

The first step should be a political version of the Hippocratic oath: Do no harm. The deficit commission's recommended cuts in training funds must be set aside.

Secondly, the cap enacted in 1996 on training new doctors should finally be lifted. These two steps would go a long way to addressing our country's medical needs.

Patients searching fruitlessly for a physician or waiting months for a routine appointment are glimpsing what could be the future for millions more. That future is preventable, and we must ask Congress and the Obama administration to make sure it is.

Dr. Pardes is president and CEO of New York-Presbyterian Hospital.

F.D.A. Is Studying the Risk of Electroshock Devices -

Federal regulators are weighing whether to downgrade the risk classification of electroshock devices, reinforcing what many psychiatrists consider a deepening acceptance of electroshock in modern therapy.

The procedure has had a resurgence in recent years. And an estimated 100,000 Americans — two-thirds of them women — undergo the treatment for major depression and other illnesses each year. Patients, anesthetized, receive a jolt of electricity from electrodes for several seconds, inducing a brain seizure and convulsions of up to a minute.

The American Psychiatric Association and other leading specialists are recommending that the Food and Drug Administration downgrade the devices to a medium-risk category from high risk, a move that will be reviewed by an agency advisory panel in Gaithersburg, Md., this week.

To some extent, the review has renewed the debate over electroshock. In 1990, F.D.A. staff proposed declaring the devices safe for major depression, but never took final action amid an uproar by opponents.

If the F.D.A. downgrades the devices to a medium-risk category, the equipment could be promoted and sold without new testing. Such a downgrade would place the devices in the same risk category as syringes and surgical drills.

If the F.D.A. leaves the devices in the high-risk category, however, manufacturers may, depending on the agency, have to withdraw them from the market.

The F.D.A. could require safety and effectiveness tests that have not previously been done. By regulating the devices, the F.D.A. is indirectly regulating the procedure.

The agency could make a formal decision later this year. The F.D.A. usually, but not always, follows recommendations of its advisory panels.

Supporters, including mainstream psychiatrists, say the treatment is much safer than it once was and could pass a rigorous F.D.A. review. But they assert that the device manufacturers cannot afford those tests.

"These tend to be mom-and-pop operations," said Dr. Matthew V. Rudorfer, a psychiatrist and top specialist at the National Institute of Mental Health. "So I think the dilemma might be that undergoing new expensive clinical trials might be too expensive."

Opponents, including some groups of former patients, maintain that electroshock can cause memory loss and brain damage that outweigh its short-term benefits.

"It's all trial and error — it's all experimental," said Vera Hassner Sharav, president of the Alliance for Human Research Protection, an advocacy group in New York. "All the years it's been controversial and there have not been clinical trials. Why not?"

Only two manufacturers, Somatics L.L.C. of Lake Bluff, Ill., and the Mecta Corporation of Lake Oswego, Ore., make the devices in the United States. The F.D.A. has asked them to submit all safety and effectiveness information as part of an agency review to be released before the advisory committee meeting beginning on Thursday.

Dr. Richard Abrams, who founded Somatics in 1983 with Dr. Conrad M. Swartz, and has written a textbook on electroshock, wrote the F.D.A. to say that none of his patients in more than 10,000 sessions over three decades had reported prolonged memory loss.

Dr. Swartz, who, like Dr. Abrams, is a retired psychiatry professor, said in an e-mail that any cognitive side effects from Somatics' latest device "are distinctly less than they had been." But he said Somatics could not afford an in-depth safety study that the F.D.A. could require if it left the devices in the high-risk category. That could cost millions of dollars.

"There is not nearly enough money in this industry to begin to pay for clinical trials that would be substantially larger than those already in the medical scientific literature," Dr. Swartz wrote.

Mecta would not comment. "We always get negative press," said a woman who answered the telephone at the company's headquarters and did not give her name. "Too bad, because it's good equipment."

Somatics and Mecta each have annual revenue exceeding $1 million, according to Dun & Bradstreet. Dr. Swartz, asked about the revenue figure, said Somatics, like Mecta, was a private company. Their Web sites do not list prices or sales figures.

More than 1,000 hospitals and outpatient clinics in the United States use the two companies' devices, according to Dr. Charles H. Kellner, a leading researcher, professor and chief of geriatric psychiatry at Mount Sinai School of Medicine in New York.

"It's a treatment for the most severe form of depression," Dr. Kellner said. "It can really be life-saving."

The F.D.A. review was recommended by the Government Accountability Office in 2009 as part of an examination of the regulatory status of electroshock and about 20 other less controversial medical devices, like pacemaker electrodes and implanted blood access devices for hemodialysis. They were grandfathered into F.D.A. regulations when the agency was given more authority over medical devices in 1976.

The G.A.O. said those devices should go through the stringent approval process for high-risk devices or be reclassified as medium or low risk. A medium-risk designation could include adding controls like performance standards and patient registries.

The treatment costs $1,000 to $2,500 a session, and typically involves three sessions a week for two to four weeks, Dr. Kellner said. The fee includes the services of a psychiatrist and anesthesiologist. The equipment itself costs about $15,000 and may last years.

Patients are given short-term full anesthesia, a powerful muscle relaxant to prevent pain and subdue convulsions, and a mouth guard. The electrical current causes a grand mal seizure with convulsions usually lasting less than a minute, doctors say. Five to 10 minutes later, the patient awakens and can usually go home within two hours.

A federally financed study in 2007 found long-term memory loss and other cognitive problems, especially for female patients, from the treatment at seven New York facilities. The study, of 347 patients, was the first such large-scale study of side effects, despite what its authors called "over 50 years of clinical use and ongoing controversy." The study also said methods and voltage varied widely among practitioners.

Dr. Rudorfer, associate director of treatment research in a division of the National Institute of Mental Health, says modern electroconvulsive therapy, or E.C.T., as its supporters prefer to call it, is much better than earlier practices, like those portrayed in "One Flew Over the Cuckoo's Nest."

"As surprising as it might seem, it never went away," Dr. Rudorfer said of the treatment. "The field has had ample opportunity to get rid of E.C.T. and it's still with us because it seems to occupy a small but important niche in treatment."

But Dr. Rudorfer and other scientists still do not know just how the treatment or brain seizures act to improve moods. "We're still looking," he said. "It's been very difficult to tease out the 'active ingredient' from among the many changes in the brain that accompany having, and stopping, the therapeutic seizure activity."

Patients appear to have mixed views, judging from comments to the F.D.A. and electroshock-related Web sites. Some say it saved their lives, some say they suffered too much memory loss, and some say both.

In addition to its use in cases of severe depression, the treatment is used in some cases where speed is essential, like psychosis or suicidal behavior, for catatonia and in elderly patients who take so many other drugs that they cannot safely add a powerful psychiatric drug.

Dr. James H. Scully Jr., medical director and chief executive of the American Psychiatric Association, wrote the F.D.A. recently to say the treatment was "extremely effective and safe." It provides relief some 80 percent of the time, he wrote. Dr. Scully and the psychiatry association also say there is no evidence it causes brain damage.

A task force is updating the association's 2001 recommendations on the treatment. Its report is at least a year away.

"People use it because it works," said Dr. Laura J. Fochtmann, a member of the task force, professor and director of the Electroconvulsive Therapy Service at Stony Brook University Medical Center, Long Island.

"These disorders can be extremely life-threatening, and when it works, it can be dramatically effective," she said.

Opponents of electroshock include some patient advocacy groups, but the opponents, clearly, are outnumbered among physicians.

Dr. Peter R. Breggin, author of more than a dozen books including one about electroshock and a consultant in personal injury cases involving drugs and the therapy, says he is the only American psychiatrist he knows who opposes the treatment.

"It's a big money-maker," he said. "I would say if anything it's been on the increase because there's a market that's been exploited, that is the elderly depressed women on Medicare. The reason for that is they're covered, and there's no one to protect them. What commonly stops shock treatment is a family member saying 'over my dead body.' "

Depressed older people, Dr. Breggin said, can be helped more by a pet or conversation.

Last year, two psychology professors, John Read of the University of Auckland, New Zealand, and Richard Bentall of Bangor University, Wales, criticized electroshock after reviewing studies comparing it with simulated treatment. Their findings were published in Epidemiologia e Psichiatria Sociale, a peer-reviewed European psychiatric journal. "The cost-benefit analysis is so poor that its use cannot be scientifically justified," Dr. Read wrote in an e-mail.

John Breeding, a psychologist and member of the Coalition for Abolition of Electroshock in Texas, said that state had banned electroshock for youths under 16 and required second opinions for treating the elderly, giving it the strictest rules in the nation.

"It's a very strong treatment for despair and hopelessness," he said. "It's a temporary blunting of your feelings, so you feel better for a while, then you feel worse, and now you've got the memory loss and brain damage."

Doctor's diagnosis drew laughs, but it saved woman's life

As the all-too-familiar number flashed on his cellphone shortly before 9 p.m., Dan Landri-gan reflexively braced himself for bad news. The caller was one of the doctors treating his wife, Donna, who had been in a coma for four months. "She sounded pretty choked up," Landrigan recalled.

"I think we've found out what's making your wife sick," the specialist at the University of Rochester's Strong Memorial Hospital told him, as a wave of relief flooded his body. "I was completely shocked," said the telecommunications executive, now 37. "My hope for so long was that this was the phone call I was going to get."

Doctors at three Upstate New York hospitals had been stymied by Donna Landrigan, whose case was unlike any they had seen. The previously healthy 35-year-old mother of three had initially become so psychotic she had to be tied to her hospital bed to keep her from hurting herself or attacking others. A few weeks later she had been placed in a medically induced coma to protect her from the continuous seizures wracking her brain, spasms that could have killed her.

Every promising lead had seemed to turn into a dead end, and the dangers of prolonged coma, including severe brain damage, were mounting. Things looked so hopeless that doctors had begun discussing whether to suggest terminating life support.

That phone call on April 29, 2009, was the first good news in months. It represented both a turning point for the Landrigans and vindication for the second-year neurology resident who had closely followed Donna's case since December 2008, when she was initially hospitalized. The startling diagnosis that Nicholas Johnson proposed, he recalled with understatement, had been met with "a little bit of laughter" by senior physicians, amused by the exotic and sometimes outlandish diagnoses made by residents.

This time Johnson's spot-on deduction, and his persistence, not only solved the mystery but also saved Donna's life. Her case, which made medical history, was recently described in the journal Neurology.

"For someone to beat this is amazing," said neurologist James Fessler, director of the Strong Epilepsy Center, who also was involved in treating her.

The first sign of Donna's illness occurred shortly before Halloween 2008, when she complained of severe headaches, then a stiff neck. A spinal tap revealed viral meningitis, and she spent three days in the hospital; once home, she got progressively worse. Most noticeable was her increasingly strange, often paranoid, behavior, which involved the couple's twin sons, then 11, and their daughter, who was 4 at the time.

A stay-at-home mother whose life revolved around her children, Donna recalled what happened the day she forgot to bring a snack for her daughter's preschool class. "You would have thought someone had died, I was that emotional," she said recently, summoning one of the memories she retains from that time; the next seven months are a blank.

Doctors counseled patience and warned that recovery might be bumpy. "We would chalk up any weird symptom to her just getting better," Dan recalled.

The night of Dec. 4, while talking on the phone, he realized that Donna had not returned from the garage. He found her face down on the concrete floor beside her minivan; she was unresponsive and her mouth bore foam from an apparent epileptic seizure.

Donna regained consciousness in the ambulance but was incoherent and combative. After a day or two of tests at a hospital, a psychiatrist was summoned. He told Dan that Donna was a secret alcoholic in the throes of withdrawal. Dan said the psychiatrist flatly dismissed his protests that Donna was strictly a social drinker.

A few days later, after it was clear alcohol wasn't Donna's problem - the seizures and psychosis had lasted too long - she was transferred to a larger hospital affiliated with the University of Rochester. Johnson was one of the doctors who crowded into her room that first day. "I remember he was the quiet guy in the back of the room," Dan said.

By then Donna was so violent that she would pull out her IVs, scratch herself uncontrollably and thrash wildly, insisting that people were trying to kill her. Massive doses of antipsychotic drugs had little effect; she required a round-the-clock nurse and virtually stopped eating.

At home Dan had his hands full: The couple's young daughter cried for her mother every night, and the boys, though stoic, were clearly scared. "I was terrified," Dan recalled. "I had this vision of my entire life unraveling in front of me."

Three days after her transfer, the news grew more ominous: An EEG showed that Donna's brain was being ravaged by continuous seizures, a condition known as nonconvulsive status epilepticus. Unless doctors controlled the seizures, she would die.

Running out of time
Because of her age and sex, and the fact that the usual causes of her symptoms - meningitis, HIV, substance abuse and several forms of encephalitis - had been ruled out, Johnson early on thought she might be suffering from an extremely rare, newly identified illness he had heard about two years earlier, while interviewing for a residency at the University of Pennsylvania.

Josep Dalmau, a neuro-oncologist at Penn, and his colleagues had published studies describing anti-NMDA receptor encephalitis, a rare reaction seen in young women to a common ovarian tumor called a teratoma, which is typically harmless. In some patients, antibodies produced to fight the tumor, which contains nerve cells, also attack nerve cells in the area of the brain that can trigger seizures. Removing the tumor stops the seizures and can lead to a full recovery, particularly if treatment is initiated within three months of the development of symptoms. Fewer than 200 cases of the illness have been reported worldwide, none with seizures as severe as Donna's.

When Johnson, then 28 years old, proposed the diagnosis shortly after Donna's arrival, "there was some incredulity" among senior physicians, he said. That faded as doctors pursued, then discarded, other diagnoses.

"They were willing to let me order the tests I thought were needed," Johnson said of his skeptical supervisors. In late December, a sample of Donna's spinal fluid was sent to the Mayo Clinic, home of one of the world's preeminent pathology labs.

In the meantime, doctors tried various drugs, which failed to improve her condition. In late January, after she had been transferred to the intensive care unit at Strong hospital, her results came back. Tests for 100 viruses and other seizure triggers were negative, but doctors had found one unknown antibody. The only way to determine whether it was related to the newly identified illness was to send it to Dalmau, who had developed a test for it. Within days, the results from Penn were in: The sample matched.

More ...

One in four students are depressed: study

University doctors should start routinely screening for depression in their young patients, urges a new Canada-U.S. study that found one in four students who showed up at campus health clinics had symptoms of clinical depression — and one in 10 students had recently thought about suicide.
College health professionals not involved in the study say the findings confirm what they see on campus, with a growing number of students needing care for sometimes-serious mental-health problems.
The reasons behind the problems may include the pressures of a society that no longer guarantees success to young university graduates, and young people being simply less equipped to cope with life's challenges, experts suggest.
At the University of Calgary, the number of students presenting at the campus Wellness Centre with psychiatric issues doubled between the 2005-2006 academic year and 2008-2009, said Debbie Bruckner, the university's director of health services.
"By far the most common presenting concern is around depression or depression-related issues," said Ms. Bruckner, though their initial complaint is often something else, such as difficulty sleeping, upset stomach or headaches. "The world is more complex. The kind of pressures that are on students now are more severe, from a number of different angles."
The trend may be partly a function of the unique qualities of the so-called Millenial children — those who started attending post-secondary institutions around 2000, said Peggy Patterson, a University of Calgary education professor. Raised largely by Baby Boom parents, they are more open than predecessors about discussing psychological problems, but also bear the marks of a protective upbringing.
"They are more confident but they have led more sheltered lives. The world feels like a more dangerous place," Prof. Patterson said. "Because of the more sheltered lives they've led, they have fewer coping skills."
Another factor behind the increase is that institutions are taking in students with disabilities and mental-health problems who in the past — without the help of modern medication and more accessible campuses —would not have made it.
The researchers at the Universities of Washington and Wisconsin in the U.S. and at the University of British Columbia administered a detailed survey to 1,622 students who visited campus health centres for a variety of mostly physical issues.
About 25% disclosed signs of clinical depression—answering affirmatively to such questions as "I feel sad all of the time" — while one in 10 admitted to suicidal "ideation" in the previous two weeks, said the study just published in the American Journal of Orthopsychiatry. Depressive symptoms were strongly linked to reports of dating violence, emotional abuse and smoking.
Dr. Elizabeth Saewyc, a UBC nursing professor and one of the authors, said she was somewhat taken aback by the findings. She and her colleagues recommend that college health clinics ask all their patients a few questions to determine whether they might be seriously depressed, "so we can help them before it gets really out of hand."
"The fact that we have one in four of our university students who go to these clinics who actually scores in the ranges for clinical depression suggests there are a lot of distressed young people out there that we're not providing help for," said Dr. Saewyc, an expert in adolescent health.
Dr. Stan Kutcher, an adolescent psychiatrist at Dalhousie University in Halifax, cautioned that some of the study's findings were over-stated. The survey that students completed could tell only if they had depressive symptoms, not necessarily if they were actually suffering from clinical depression, he said. And a majority of the 10% with suicidal thoughts said "I have thoughts of killing myself but wouldn't carry them out," which is not nearly as worrisome as the smaller portion who said "I would like to kill myself," Dr. Kutcher said. Still, he said depression and other mental illness is, indeed, a major health issue in that age group and clearly needs more attention.
At McGill University in Montreal, students often arrive at the campus clinic complaining of something physical—from fatigue to premature ejaculation — when the real underlying problem is psychological, said Dr. Pierre-Paul Tellier, director of student health services.
"Frequently they don't recognize these symptoms as symptoms of stress, anxiety and depression."
Dr. Tellier said demand on the university's separate mental-health service has been climbing, which he attributes partly to a broader range of teenagers being admitted to university, and a greater awareness and diagnosis of mental-health problems. The clinics see some 19-year-old students who have been on antidepressants for two or three years, he said.
In Edmonton, the University of Alberta added five new psychological counsellors last year to meet demand but could probably use more, says Nick Dehod, the student union president, who is also lobbying for the addition of a one-week fall break in part to help students deal with stress.
"We see a lot of students who face all kinds of pressures, and in turn they struggle with depression, anxiety, all sorts of mental health issues."
Dr. Kutcher and others, though, wonder if universities could handle the demand for service — whether provided by non-medical counsellors, family doctors or psychiatrists — if patients were routinely vetted for depression.
"The problem we have with any screening is, 'What are we going to do with the positives?' " he said. "You should make sure the services are there."
Institutions have to be careful, as well, not to overreact if they find widespread signs of mental distress, Prof. Patterson said.
"It's not necessarily a problem," she said. "We don't want to pathologize the fact that, 'Oh no, they all have stress issues.' It's a stressful world we live in."

Sunday, January 23, 2011

The Woman Who Was Wasting Away -

The woman mumbled and ran a shaking hand through her dark mass of tangled curls. Her husband could barely make out what she was saying over the din of the emergency room at the John Muir Medical Center in Walnut Creek, Calif. "Rewind it," she said, raising her voice, looking at her husband. "Rewind it," she pleaded. Her husband squeezed her hand and forced a smile. Over the last four months she often repeated this phrase when she was confused. He wasn't sure what she meant, but he wished they could rewind their lives and return to the way they were half a year earlier, before his previously healthy 64-year-old wife became sick.

It all started one day when his wife suddenly felt dizzy. She was fine lying flat, but the room spun wildly whenever she tried to sit up. After a day or two, the dizziness became a terrible prelude to waves of nausea and uncontrollable vomiting. But it wasn't just her stomach: by the end of the week she could barely stand up — her whole body felt weak and off balance. Then she started seeing double. That's when she went to the hospital. She was in and out many times since then, but she hadn't improved.

Dr. Robert Chance Algar, the neurologist who cared for this patient in the months after she fell ill, was startled by how much worse she looked than when he saw her three weeks earlier. She had lost a lot of weight. Her eyes were sunken; her skin was sallow. She could not walk at all. Despite his best efforts, his patient was clearly getting worse.

The patient's husband explained that she hadn't been able to hold anything down for several days: even water came right back up. That morning she became confused, and he knew from experience that that meant she was dehydrated. He took her to the E.R. and then called Algar.

As Algar spoke with the patient, he realized that she didn't know she was in the hospital. Her eyes did not move in unison — causing the double vision. And her irises jerked back and forth whenever she looked up or to the side — a condition known as nystagmus. Her speech was slurred. And Algar (who is my nephew by marriage) was struck by the odd, uncoordinated way in which she moved her arms and legs. When he tapped her knee and ankle with a reflex hammer, the usual brisk jerk was missing.

When she was first admitted to the hospital months before, her doctors thought she had suffered a stroke. A CT scan and an M.R.I. showed otherwise. They wondered if she had an infection. It seemed unlikely: her white-cell count was normal, and a spinal tap showed no signs of meningitis or encephalitis. There was, however, one clue in the spinal fluid: the liquid contained an abnormally high amount of protein. Algar focused on that: her symptoms, coupled with the high protein, matched a pattern he recognized for Guillain-Barré syndrome. Guillain-Barré occurs when the immune system mistakenly attacks the nerves as they run from outside the brain and spinal cord to various parts of the body. People with this illness usually have a paralysis that starts in the legs and moves up the body, but in one variant, the paralysis can start in the eye muscles.

At the time, Algar ordered a blood test to look for proof of the disease, but he knew it would take weeks to get the results, and this patient was too sick to wait. He decided to begin treating her before the results of the test came in. If she got better, he would know he had the right diagnosis.

The problem with treating an illness before it is confirmed through testing is that the patient can worsen while being treated for a disease she doesn't have. And this patient was far too sick to riskwasting time. So Algar also sent off blood to look for H.I.V. or Lyme disease — two common infections known to cause unusual neurological symptoms. And he ordered another M.R.I. of the brain to look for signs of anything else he might have missed.

The patient began her treatment, and she seemed to get better at first. The double vision vanished; the coarse tremor that accompanied her every movement diminished; and her speech improved. But she was still vomiting four or five times a day, she was still losing weight and she still couldn't walk. Even before the test came back negative (as it did several weeks later), it was clear that she didn't have Guillain-Barré.

Now that his patient was back in the hospital, Algar went over her chart once more. Whatever it was, it wasn't going to be one of the usual suspects. Could it be an unexpected type of infection? Algar sent off blood and spinal fluid looking for a dozen or so rare infections. Could it be an autoimmune disease like lupus? He ordered tests to look for these diseases.

He finally found something that he thought might be useful. Two months before her symptoms started, the patient had an operation. According to the hospital notes, she had a pelvic mass. It turned out to be a fibroid — a benign tumor of the uterus — but in the operating room, the surgeon noted a small irregularity on the surface of her left ovary. He biopsied the tissue, but the pathologist couldn't see anything in the tiny sample. This additional history, however, provided Algar with another clue: most cancers trigger the immune system to create antibodies that target and destroy cancer cells. Sometimes, especially in cancers of the ovaries or breasts, these antibodies can attack cells in the brain as well, a phenomenon known as paraneoplastic syndrome. This injury to the brain can produce dizziness, double vision, vomiting and a severe loss of coordination.

Algar quickly sent off the test to look for the antibodies. It took almost two weeks, but the result finally came back — positive. So the patient clearly had a cancer; the question was where. A CT scan of the chest, abdomen and pelvis did not reveal any sign of cancer. Algar was disappointed but not surprised: this paraneoplastic syndrome often shows up long before there are any other signs of disease. But what if the abnormality the surgeon saw on her ovary during her prior surgery was the first blush of cancer?

If so, she should have her ovaries removed even though there was no sign of cancer. But would the patient be willing to take this risk? Her answer was an immediate yes. If there was even a small chance that an operation would bring an end to her four-month ordeal, it was a chance worth taking.

The surgery was scheduled for that week. Afterward, the surgeon visited the patient's husband in the waiting room to break some bad news. He had seen no sign of cancer in the tissue he removed. Although the final answer would come from the pathologist, the surgeon was not optimistic. The patient's husband fought back tears. He had watched his wife suffer for so long, and there still seemed to be no end in sight.

The pathologist's report came the next day. A nine-millimeter tumor was found in her left ovary. Seeing this, Algar felt a flood of relief. He had recommended the surgery on a hunch — a well-grounded hunch — but he had no way of knowing whether a tumor would be found.

It is strange to welcome a diagnosis of ovarian cancer, and yet Algar, the patient and her family knew it provided a long-needed answer. A second surgery found additional cancer in a lymph nodeand, once the patient awoke from this operation, the nausea and dizziness lessened significantly.

That was three years ago. Since then the patient has struggled to relearn the basics — how to walk, how to talk. But she doesn't have ovarian cancer, and she's slowly getting better. And for this patient and her family, that's enough for now.

Lisa Sanders is the author of "Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis."