Friday, October 14, 2011

Diagnosis - A Total Collapse -

"Can you help me?" The 52-year-old father called out to his son, who was asleep in the other bedroom. It was nearly midnight, and the man, awakened from sleep, tried to get up to go to the bathroom. When he stood, he was surprised to find that his legs had no strength, and he fell. Now he needed help to get back up. His son, 21 and mentally disabled, came into the room. His father quietly talked him through what he had to do to get him onto the bed. Then he picked up the phone and called a friend to come stay with his son. Once that was arranged, he dialed 911.


Dr. Kathleen Samuels, the resident admitting patients to the intensive care unit that night at Waterbury Hospital in Connecticut, had already admitted several by the time she got the call about the man who couldn't walk. He had a life-threateningly low level of potassium in his blood. Potassium is an essential electrolyte, and the body normally holds it at a constant level. The E.R. doctor hadn't figured out why this man's potassium was so low, but he was certain he needed to be monitored in the intensive care unit until they understood what was going on.

Samuels hurried to see the patient. He appeared healthy and seemed surprised that he couldn't walk. He told her that he was well until two days earlier, when he started having pain in his hips and knees. The pain was constant but was worst in the morning and when he walked. He went to the emergency room twice in those two days. The first time, he left after a few hours. He hadn't seen a doctor, but he had to pick up his son from his day care program. He came back the next day, and the E.R. doctor told him it was arthritis and prescribed a painkiller. He didn't get a chance to pick up the medicine, and now he couldn't walk. He had no other medical problems, and he took no medicines. He didn't smoke or drink, and he took care of his two disabled adult children — one of whom had been in the hospital for the past two weeks.


The patient could lift his legs off the bed, but he wasn't able to keep them up if Samuels applied even a little pressure. He had a slight tremor, but the patient told her that he'd had that for years. Otherwise the exam was unremarkable. His labs, on the other hand, were anything but. Not only was his potassium low but so too were his white blood cell count and platelets. His blood sugar was high and so was his thyroid hormone. The thyroid gland tells the body how hard to work, and this thyroid was telling the body to work very hard indeed. But it was only the very low potassium that could kill the man, and that's what commanded Samuels's attention. She made sure that he was given enough potassium to replace what he'd lost and then tried to figure out why he lost it.


Gastrointestinal issues:

Diarrhea and vomiting are common causes of low potassium. This patient said he had neither.

Renal issues:

Potassium is regulated by the kidneys. Although his kidneys appeared normal, he would need more extensive testing.


Some medications cause the kidneys to dump excessive amounts of potassium into the urine, but this patient took no medications.


At 7:30 that morning, Samuels went to the hospital's Resident Report, a daily meeting for physicians in training, where much of the teaching on diagnostic thinking takes place. Residents and teaching physicians gather in a conference room to think through the process of making a diagnosis for a patient admitted to the hospital. This morning Samuels laid out the case of the man who couldn't walk — how the patient looked, what she found during the exam and what his lab results revealed.

As the doctors hashed out the case, Dr. Jeremy Schwartz, one of the chief residents, remembered something. This patient's symptoms sounded just like an illness he'd read about: a genetic disorder called hypokalemic periodic paralysis. "Hypo" from the Greek meaning low and "kalium" from the Latin meaning potassium. In this disease, patients experience transient episodes of severe weakness caused by low potassium. But there was one big difference — this inherited disease is usually first seen in adolescence. This man was much too old to be having his first attack. Could there be a form of the disease that was acquired and not inborn? Could it be linked to something else the man had — to his high thyroid or sugar?

Schwartz was sitting next to the computer in the conference room. He went to a medical reference site and typed in hypokalemic periodic paralysis and hyperthyroidism. As soon as he hit enter, page after page appeared, filled with articles on a disease known as thyrotoxic periodic paralysis.


In the inherited version of hypokalemic periodic paralysis, young men (mostly) are born with cells that can suck up potassium after a high-carbohydrate meal, after exercise, upon awakening from sleep or during times of intense stress. Patients with this genetic disorder can reduce their risk of paralytic attacks by taking medicines that increase the amount of potassium in the blood and by eating a low-carbohydrate diet.

This man didn't have this genetic disease, but having too much thyroid hormone made his body act as if he did. When high levels of thyroid combine with high blood sugar, a high-carbohydrate diet or high stress, cells can take up so much potassium that there's just not enough outside the cell, where it's needed for muscles to work. This patient had it all. Blood tests revealed that he had high levels of thyroid hormone and high blood sugar. He was experiencing high levels of stress because his older son was in the hospital, and in addition, he was living on high-carbohydrate foods from the vending machines there.

Still, hyperthyroidism is common; high blood sugar is common; high-carbohydrate diets and stress are epidemic; and yet this kind of periodic paralysis is rare. Current thinking is that these patients also have a genetic abnormality that predisposes them to develop periodic paralysis if and when they ever develop hyperthyroidism.


The patient was given a small dose of replacement potassium by mouth, and his potassium and his strength returned to normal. The patient was started on a thyroid medication, which alleviated the pain and weakness.


I heard about this patient because I was his primary-care doctor. I last saw him two years before this episode when he made an appointment because he had heartburn. I gave him a medication for the heartburn, but I also noticed that he had a rapid heart rate and a tremor, and I suspected that he had hyperthyroidism. I gave him a lab slip to check his thyroid hormone. He never went.

When I saw him after he was discharged from the hospital, I asked why he had never gotten the blood test. He looked a little embarrassed, but his answer was direct: his complaint had been the heartburn, and the pill I prescribed fixed that. Concerns about hyperthyroidism didn't seem important to him. He didn't care about a body part he had never heard of, possibly causing a disease with symptoms he didn't feel.

All that changed when he lost his strength. Suddenly, he told me, he was quite literally unable to care for his sons. "If I am not around, they will have no one," he told me. So now he takes his thyroid medicine regularly. He gets his blood drawn as often as needed to keep his disease in check.

"I don't do it for myself," he said. "I have to take care of myself so I can take care of my kids."

Concierge medicine has a cost for all patients -

I've begun seeing a new patient, a retired delivery driver named Donald. Nice guy, friendly and chatty, and a little mystified as he tries to navigate his way through the constantly changing world of healthcare. He had been my patient many years ago, but we parted ways when I left that office. Donald tracked me down because his former doctor had switched to a concierge-style practice.

Concierge medicine — you may have heard of it — is gaining in popularity. Patients pay a monthly fee directly to the doctor, on top of their regular health insurance premiums and co-pays, to secure better access to the physician. Donald told me that the service was promoted to him as an opportunity to improve the doctor-patient relationship. Instead of juggling more than 2,000 patients, the physician would be able to winnow that number to a very manageable 600, enabling him to devote more time to the select few who opted for premium service.

Being a naturally frugal sort, Donald didn't think such a monetary commitment was prudent, especially on his retiree income.

Even among concierge practices, there are different levels. Some doctors charge very high retainers that give their patients access to them 24/7. Physicians have even been known to vacation with their charges, just in case anything goes wrong.

This raises some interesting logistical problems. What if one millionaire is taking his family to Zermatt, Switzerland, and wants a tag-along doctor while at the same time another client has decided that this is the perfect time of year to see Zanzibar, Tanzania? Oh, the decisions! What does a poor concierge doctor do with such a dilemma?

The same week that I inherited this concierge medicine refugee, two very enticing offers came in the mail. One was from a national concierge chain inviting me out to dinner (yes, they have chains, just like Subway or Target). It was a pretty sweet deal: dinner for me and a guest at a high-end steakhouse in a posh neighborhood, and because my time was so valuable, I would also be paid $300 just to show up and listen to the pitch.

The second offer was even better. Featuring a photo of a beautiful Spanish-style resort with palm trees, a cobalt-blue pool and a lush green golf course, it invited me to attend an all-expenses-paid weekend at Newport Beach to hear from "thought leaders" about joining an elite concierge medicine team.

I'm not a golfer, but I gazed longingly at that picture for quite some time, fighting the urge to pick up the phone and reserve a spot. For a sun-starved Seattleite, any offer of a trip to Southern California is hard to pass up, especially toward the end of an unusually rainy winter.

Yet as tempting as those offers are, I don't see myself as a concierge kind of guy. If I were to join, how many of my patients would lack the resources to join me?

I'd have to leave Ann Marie behind. She has a developmental delay and has been my patient ever since I started in practice. I'd leave the scores of young adults who are just starting out in their careers and find it a stretch to come up with their co-pays. And 7-year-old Tony, who wants me to feel his strong muscles at every visit. Caring for these types of patients can be the most rewarding because they often are the most appreciating of the services I provide.

I am troubled by the growing number of concierge practices, even as I understand that the reason they have gained any momentum at all is because patients are more and more disgruntled about the experience of going to the doctor. Try to get an appointment: Well, that will be a three-week wait and then you've got 10 minutes to plead your case, unless of course you're signed up with "The Plan." Then she can see you right after lunch, and can we get you a nice cuppa tea while you wait?

The doctor won't return your phone calls: Oh, we know how you feel. That's why we offer the platinum service with your doctor's cellphone number on the back of your laminated membership card. Will you be paying with Visa or gold ingots?

I know there are concierge services in other lines of business. At Disneyland, for an added fee, you can be escorted around the park and cut to the front of the line to ride those cute little teacups while the other saps wait and wait. And a friend of mine recently paid extra so that he and his wife wouldn't have to wait three hours to ride to the top of the Empire State Building. He figured it was worth the extra 50 bucks because he was in New York only once and he didn't go there to wait in lines.

I understand his point. But it's a sad statement when businesses say, in so many words, that their service is poor, the waits are long — not to worry, though, have we got a deal for you! Pay extra and we'll give you the four-star service you should have had in the first place.

There is something especially jarring about medical care being approached this way. It would be nice to think that everyone could get the attention they deserved when they went to the doctor, whether or not they had a special plan. It would be nice if phone calls were returned on time and appointments were offered before the next equinox, and (everyone's favorite) you didn't have to wait over an hour because the doctor was running behind.

Yes, the problems with access to medical care are huge, even for the insured. And don't get me started on the uninsured, I don't have enough ink for that. Doctors are pressed to see more patients with shorter appointments — and old-fashioned customer service gets lost in the process. But there has to be a better way to fix these problems.

As I wound down my visit with Donald, I thanked him for thinking enough of his time with me so many years ago to hunt me down again. He left, and I settled into my chair, gazed out at another rainy day and took a quiet inventory of how I would stack up against a concierge physician.

I like to think that the service I offer is the same for everyone and that it is close to concierge standards. Still, I mused, maybe I'll dig that invite to Newport out of the recycle bin and pop on down just to see how I stack up. If nothing else, I can work on replenishing my waning vitamin D stores as I sit by the pool.

Steve Dudley is a Seattle physician.,0,2967719,print.story

Ruling Offers Hope to Eating Disorder Sufferers -

People with eating disorders like anorexia have opened up a new battleground in the insurance wars, testing the boundaries of laws mandating equivalent coverage for mental illnesses.

Through claims and court cases, those with severe cases of anorexia or bulimia are fighting insurers to pay for stays in residential treatment centers, arguing that the centers offer around-the-clock monitoring so that patients do not forgo eating or purge their meals.

But in the last few years, some insurance companies have re-emphasized that they do not cover residential treatment for eating disorders or other mental or emotional conditions. The insurers consider residential treatments not only costly — sometimes reaching more than $1,000 a day — but unproven and more akin to education than to medicine.  Even some doctors who treat eating disorders concede there are few studies proving that residential care is effective, although they believe it has value.

"We've seen an increase in denials," said Kathleen MacDonald, education and prevention coordinator for the Gail R. Schoenbach FREED Foundation, an advocacy group for those with eating disorders. "Now, I go to bed every night and I can't answer all the e-mails I get. It's heartbreaking."

Both sides are closely watching the consequences of a major decision by the United States Court of Appeals for the Ninth Circuit, which ruled in August that insurers in California must pay for residential treatment for eating disorders and other serious mental illnesses under the state's mental health parity law.

In the last decade or so, many states enacted similar laws, and, in 2008, so did the federal government. The laws generally require that coverage for mental and behavioral disorders be equivalent to that for physical ailments like diabetes or a broken bone.

But equivalence, or parity, can be tricky to define, and the appeals court ruling is one of the first by a high federal court to interpret the concept.

Blue Shield of California, the defendant in the lawsuit, is already seeking to have the case reheard, arguing that the decision could force insurers to pay for unlimited amounts of treatment, raising insurance costs.

While the ruling applies only to California's law, some experts think it will influence courts, state agencies and insurers elsewhere.

"You'll see it bleed over," said Scott Petersen, a lawyer in Salt Lake City who often represents insurance companies in parity cases.

In New Jersey, Aetna, Horizon and AmeriHealth have agreed to end limits on the number of days of residential treatment they will cover for eating disorders, according to Bruce Nagel, a lawyer who sued the insurers under the state's parity law.

The Parity Implementation Coalition, a group monitoring the federal parity law, has filed about 150 complaints about possible violations, according to Dr. Henry Harbin, a psychiatrist and adviser to the group. Some cases involve denial for residential treatment for substance abuse or mental illnesses by plans offered by companies like Wal-Mart and Coca-Cola Bottling.

An estimated 11 million Americans, mostly young women, suffer from eating disorders, the most serious being anorexia nervosa, in which people starve themselves, and bulimia nervosa, in which they engage in binge eating followed by purging. These disorders, particularly anorexia, have the highest fatality rate of any psychiatric disorder.

The advocates for those with eating disorders, who often cooperate or get financing from residential treatment centers, estimate there are about 75 such facilities for those specific illnesses, and many others for substance abuse and for emotionally or psychologically disturbed children.

Sam Menaged, founder and president of the Renfrew Center, which is based in Philadelphia and is one of the oldest and largest residential treatment centers for eating disorders, said only 60 percent of insurers covered the therapy and that hundreds of people were turned away from Renfrew each year.

The Blue Cross Blue Shield plan for federal employees added language to policies at the beginning of this year specifying that residential treatment for any condition would not be covered. Two months later, citing that change in policy, the Remuda Ranch closed its eastern center for eating disorders, which was in Milford, Va.

Executives at the federal plan said that residential treatment had never been covered and that the new language merely made that more explicit.

Yet Samantha Ascanio, 23, of Gaithersburg, Md., said the plan had covered her four previous stays at a residential center but denied payment this year. She instead enrolled in outpatient programs that lasted more than six months.

Most plans offered to California state employees also added language this year clarifying that residential treatment was not covered.

Advocates and some doctors who treat eating disorders say that hospitalization, which insurers typically cover, might stabilize a patient and restore weight but does not generally treat the underlying psychological issues. Outpatient treatment, which might also be covered, does provide counseling but not round the clock. Residential treatment, they say, occupies a vital niche between those two.

"I don't think I would be alive today if I hadn't gone there," said Jeanene Harlick, who was the plaintiff in the recent California case.

Ms. Harlick, who is 37 and lives in San Mateo, Calif., stayed at the Castlewood Treatment Center in St. Louis from April 2006 through January 2007 to treat her anorexia. She was 35 percent below her ideal weight when she checked in and, within a month, needed a feeding tube.

With Blue Shield declining to pay, Ms. Harlick's parents borrowed hundreds of thousands of dollars against their home.

Residential treatment can cost from hundreds of dollars to well over $1,000 a day, and even though a daily rate is generally lower than a hospital's, patients often stay much longer — for weeks or months. Insurers also say that few standards exist for these types of centers.

"There's a wide variation in licensing across the country," said Jena L. Estes, vice president for the federal employee program at the Blue Cross and Blue Shield Association. "There's a lack of oversight of many of those residential treatment centers."

Ira Burnim, legal director of the Bazelon Center for Mental Health Law, which litigates for better mental health treatments, said that while he was not familiar with eating disorders, "study after study" had shown that residential centers for other mental or emotional disorders were not as effective as treatment at home.

Dr Anne E. Becker, president of the Academy of Eating Disorders and director of the eating disorders program at Massachusetts General Hospital, said that despite a paucity of studies, "There's no question that residential treatment is life-saving for some patients."

Some insurers say that there is no treatment for physical illnesses that is equivalent to residential treatment for mental illnesses, and therefore residential treatment does not have to be paid for under parity laws.

Ms. Harlick's lawyer, Lisa S. Kantor, argued that residential treatment centers were equivalent to skilled nursing facilities, which Blue Shield did cover.

Adam Pines, a lawyer for Blue Shield, countered that residential treatment was more akin to assisted living, which the insurer did not cover.

The Ninth Circuit Appeals judges, based in San Francisco, ruled that residential treatment was medically necessary for eating disorders, and therefore had to be covered under the state's parity law, even if no exact equivalent existed on the physical disease side.

"Some medically necessary treatments for severe mental illness have no analog in treatments for physical illnesses," the three-judge panel wrote. "For example, it makes no sense in a case such as Harlick's to pay for 100 days in a skilled nursing facility — which cannot effectively treat her anorexia nervosa — but not to pay for time in a residential treatment facility that specializes in treating eating disorders."

In Blue Shield's request for a rehearing, it argued that the decision would require insurers to pay for treatment of mental conditions "without substantive limits." That would mean better coverage for mental illnesses than for physical illnesses, which would be inconsistent with parity, the company said, adding that it would also increase costs "to the point where some employers may simply forgo offering plans to their employees." Even if policies cover residential treatment, an insurer could still deny reimbursement on the ground that the treatment is not medically necessary for a particular patient.

Katie Bird of St. Paul sought residential treatment last year, saying she had been exercising vigorously while consuming no more than a single hot chocolate on some days. As a result, she said, she experienced heart palpitations and frequently passed out while trying to care for her 3-year-old daughter.

She said her insurer, United Behavioral Health, would not pay the $200,000 it cost for her four months of residential treatment because her weight was not low enough. She sued and reached a confidential settlement.

It is still unclear how much money Ms. Harlick and her parents will recover from Blue Shield.

Ms. Harlick, who lost her job and insurance and is now on disability while studying social work in graduate school, said she hoped the court decision would show people that eating disorders were not just matters of weight and appearance, but serious diseases.

"I just feel like this ruling gives a little more legitimacy to the reality of what this illness is," she said.

Thursday, October 13, 2011

iMedicalApps — Mobile Medical App Reviews & Commentary – A publication by medical professionals

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The Best Medical iPhone Apps for Doctors and Med Students | Social media’s leading physician voice

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Wednesday, October 12, 2011

Treatment for Trauma From Brain Injuries Needs More Study, Panel Says -

Techniques being used to treat psychological lapses from traumatic brain injuries, the signature wounds suffered by troops in Iraq and Afghanistan, appear to be helpful, but lack rigorous scientific support, a government-appointed panel reported Tuesday after completing the most comprehensive analysis of the evidence to date.

The report, completed by the Institute of Medicine at the request of the Defense Department, concluded that some specific methods — the use of special daily diaries, for instance, to improve memory — were backed by more evidence than others. But it concluded that the evidence base over all was too thin to support any guidelines for which therapies to provide to whom.

Since 2009, the Pentagon has provided more than 71,000 hours of so-called cognitive rehabilitation, and its insurer, Tricare, has covered an additional 54,000 hours in private clinics for active duty, National Guard and retired service members, according to Cynthia O. Smith, a Department of Defense spokeswoman.

Such rehabilitation methods have come under intense scrutiny from family members of veterans who suffered traumatic brain injuries, including those caused by nonpenetrating blasts, as well as wounds from bombs, bullets or blows to the head. Some 20 percent of service members wounded in Iraq and Afghanistan have suffered blows to the face, neck or head, and the number of brain injuries has nearly tripled in the past decade, to more than 30,000 from 11,000.

About 1.7 million American civilians each year suffer traumatic brain injury, many from car accidents.

"I think the panel had a slight bias toward wanting these therapies to work, but at the same time it did not overstate the evidence," said Dr. Jordan Grafman, director of the Traumatic Brain Injury Research Laboratory at the Kessler Foundation Research Center in West Orange, N.J., who was not on the committee.

Dr. Grafman said that applying cognitive rehabilitation techniques, which focus on improving memory, attention and decision making, "is almost a no-lose proposition. It's like going to school; you should get better at what you practice and you shouldn't get worse."

How much better is still an open question.

The expert panel reviewed 90 studies published from 1991 to 2011, involving thousands of patients. Some of their injuries were mild, causing subtle memory deficits; others were severe and disabling. The therapies aimed to improve overall functioning, or to achieve more specific goals, like remembering appointments and chores or organizing and planning tasks.

The panel rated two types of treatment, one focused on memory and the other on social skills, as having a "modest" evidence base. It rated other techniques — for sharpening organizational skills, sustaining focus or improving overall functioning — lower still, with only a hint of evidence to back them up.

Dr. Ira Shoulson, a professor of neurology at Georgetown University Medical Center and chairman of the expert panel, said that evaluating traumatic brain injury treatment was inherently difficult because the severity of injuries varies so widely, techniques are often tailored to individuals, and veterans in particular come in with compound problems, including chronic pain, post-traumatic stress and depression.

The people providing the therapy — nurses, social workers, doctors, psychologists and, ultimately, family members — also vary from case to case. And the approach for each individual often has several components, leaving scientists to ask which made a difference.

"That's a lot of moving targets," Dr. Shoulson said. He and fellow panel members called for larger, better-designed trials that use agreed-upon tools to measure effects — something the field is only just beginning to develop.

Therapies for brain injuries are not well studied "because the whole field is Balkanized," said Dr. Nicholas Schiff, a neuroscientist at Weill Cornell Medical College in New York. "Because there's no infrastructure, no organized plan of attack for what happens after a brain injury, at all stages, you're simply not going to find many" large, well-designed studies, he said.

As a rule, therapists do not begin intensive cognitive rehabilitation until months after an injury, to give brain tissue a chance to heal. But the underlying molecular processes are not well understood, Dr. Grafman said.

Small Fixes - The Simplest Health Solutions? It’s Complicated -

It's not that the American health system is completely deficient in small, clever, inexpensive fixes. It's just that sometimes they're awfully hard to find.

The whole system tilts heavily in the other direction. We specialize in giant, cumbersome, ruinously expensive fixes. Thus, while we duly celebrate some clever little tools, we compulsively improve on others until they are almost unrecognizable, and still others we blithely ignore.

Take what must be the greatest cheap medical fix in all of history: the bar of soap. Soap never stops proving itself. As recently as 2005, a study from the slums of Karachi, Pakistan, showed that free bars of soap (and lessons in how to use them) cut rates of childhood killers like diarrhea and pneumonia by half.

But you don't find soap in American hospitals anymore, at least not in its classic solid rectangular form. A variety of expensive improvements have replaced it, all created in response to the various ways in which modern doctors and patients reflexively undermine good, inexpensive tools.

First, we automatically capture these things for our own personal use: Bars of soap left in any public place are likely to disappear in short order. (That is why toilet paper rolls are generally locked into their little metal houses.)

Second, we find fault with them. People will actually use the observation that bar soap is "dirty" as an excuse not to wash their hands. (Studies have shown that you will not pick up somebody else's germs from a piece of soap, however dingy it may look.)

Finally, we ignore them. Who notices a bar of soap? It does nothing for you unless you notice it — but it is so humble and boring; and sudsing, rinsing and wiping are so pedestrian. Also, if you are in a hurry, they seem prohibitively time-consuming. Studies continually show low hand-washing rates among rushed hospital personnel. Hence the large-scale adoption of more convenient liquid products, and the slow segue into alcohol-based hand sanitizers, which obviate the rinsing and wiping.

And lo, a simple good thing has been tweaked until it is no longer simple. Instead of soap now we have a gigantic selection of luridly colored products augmented with every variety of additional germ killer imaginable.

Some of these concoctions are indeed far more potent than ordinary soap in dispatching germs, when tested under careful laboratory conditions. No one has managed to prove that any of them controls infection rates in a hospital (or, for that matter, in a home) better than universal, assiduous scrubbing with regular, inexpensive, plain old soap.

Other little miracle tools are just as widely disrespected. No one taking medication should be without one of those little plastic pillboxes with one or more compartments for each day of the week; these are heroic tools, overlooked, underpriced and invaluable.

Granted, many people take too many medications and would be well advised to skip a few. The lives of some, though, depend on accurately sorting through the contents of a plastic bag full of hoary amber bottles with indecipherable labels. Setting the pills out a day or a week at a time in nice, clean little plastic rooms can dissipate the chaos instantly.

The most recent good little thing to hit the modern hospital is the checklist. Dr. Atul Gawande, the writer and surgeon, has called it a tool "almost ridiculous in its simplicity." And indeed, it is no more than an ordered list of things to get done.

Schoolchildren have made these lists for centuries, but doctors, incredibly, have not. In arenas like the operating room — where success depends on the integration of many different agendas, a dozen kicking chorus lines moving seamlessly across the stage — medical professionals working together never thought to make a master list.

Then Dr. Peter J. Provonost, a critical care specialist at Johns Hopkins, showed several years ago that a variety of endemic hospital problems could be virtually eliminated with checklists. Lists efficiently overcame staff forgetfulness, haste and overconfidence, and rates of intravenous catheter infections, pneumonias and a variety of medical errors plummeted. Checklists are now becoming routine; whether they will go the way of the bar of soap, improved beyond all recognition, remains to be seen.

We often overlook easy little fixes because they lie just tantalizingly out of reach, near yet very far. Weight loss is a prime example. It can solve and prevent many horrific medical problems, yet somehow it seldom happens. And so we are forced to deploy our usual giant, cumbersome and expensive tools for heart problems, joint pains and the rest.

Five years ago my patient Harry was teetering at the 300-pound mark — a 35-year-old with the medical problems of a much older man. Diets just didn't work. He managed to stop smoking, but then he got even larger.

Then he started medication for hepatitis C, an expensive combination of drugs with many of the side effects of chemotherapy. People grow weak and achy with this treatment, as if they had the flu for months. Often, as in Harry's case, they lose their appetite.

Six months later we had to call the whole thing off; his hepatitis was a relatively resistant strain, and the treatment was doing nothing for the disease. But remarkably, it had improved his health anyway. Harry was almost 100 pounds lighter, and his blood pressure, blood sugar and cholesterol levels were now perfect.

You could call it the $20,000 diet — the approximate cost of all the drugs — and in some sense, given that he has managed to keep most of the weight off, you even make a case that it was worth it. Certainly weight-loss surgery would have cost a similar fortune, and the long-term complications of obesity probably even more.

But even so, what a peculiar, postmodern fable his story is, as are many of the circuitous routes we wind up traveling when the great little shortcuts elude us.

Dr. Abigail Zuger, an infectious-disease physician in Manhattan, is the health book reviewer for Science Times.

Tuesday, October 11, 2011

Cancer Screenings Are a Gamble -

Early October brought two developments in the world of cancer screening: the beginning of Breast Cancer Awareness Month, with its calls for regular mammograms for women, and a new recommendation from the United States Preventive Services Task Force that healthy men not undergo screening for prostate cancer.

It's a stark juxtaposition: screening is good for women and bad for men. But just how different are these two cancer screening tests?

The answer is: not very. Neither is like the decision of whether or not to be treated for really high blood pressure. That's an easy one — do it. Instead, both breast and prostate cancer screening are really difficult calls, and the statistical differences between them are only of degrees. Reasonable individuals, in the same situation, could make different decisions based on their valuation of the benefits and harms of screening.

Personally, as a 56-year-old man, I choose not to be screened for prostate cancer (and, were I female, I believe I would choose not to be screened for breast cancer). Some of my patients have made the same choice, while others choose to be screened. That's O.K., because there is no single right answer.

Screening is like gambling: there are winners and there are losers. And while the few winners win big, there are a lot more losers.

It's easy to understand why. When doctors screen for early cancer, all the incentives — cultural, financial, professional and legal — line up in one direction: Don't miss it. As a result, doctors overreact to even the tiniest abnormalities, which leads to the two basic harms of screening: false-positive tests and overdiagnoses.

False positives are really common in both breast and prostate cancer screening. (When it comes to screening, all numbers should be viewed as estimates because the data vary for different populations and practice settings, but numbers do help give a sense of the order of magnitude.) Approximately 15 to 20 percent of women and men who are screened annually over a 10-year period will have to undergo at least one biopsy because of a false-positive mammogram or P.S.A. — prostate-specific antigen — test.

It's a matter of opinion to what extent patients with false-positive tests are losers — the physical complications of biopsies are generally short-lived. But they certainly don't benefit from the procedures. And in the interim, they're made to worry that they have cancer.

Overdiagnosis is less common, but much more consequential because it leads to unnecessary treatment. Screening finds abnormalities that meet the pathological definition of cancer, yet will never go on to grow or cause any symptoms, let alone death. Sometimes patients choose to wait and see if the cancer grows, but most opt to treat it; once you're told you have cancer, it's difficult to wait and see what happens next.

Patients who are overdiagnosed are the big losers here. They undergo surgery, radiation and chemotherapy unnecessarily. And then there are the associated complications: chemotherapy can cause nausea and radiation can burn normal tissue; breast surgery can be disfiguring, and prostate surgery can lead to bladder and sexual dysfunction.

Doctors don't know which patients they are treating unnecessarily, but they know how the unnecessarily treated patients got there in the first place — because they were screened for cancer.

Now let's consider the winners — those who have avoided dying from breast or prostate cancer by getting screened. While there is some debate about whether they really exist, my reading of the data is that they do, but they are few and far between — on the order of less than 1 breast or prostate cancer death averted per 1,000 people screened over 10 years. That's less than 0.1 percent.

Overall, in breast cancer screening, for every big winner whose life is saved, there are about 5 to 15 losers who are overdiagnosed. In prostate cancer screening, for every big winner there are about 30 to 100 losers.

You may look at these numbers and decide that both tests are good gambles — or that both are bad gambles.

Or you might try to distinguish between the two. Overdiagnosis is more common following prostate cancer screening and is arguably more consequential, as there is a higher risk of long-term complications from prostate cancer treatment. So maybe mammography is the better gamble.

Or you might make a different calculation and consider what happens without screening. For breast cancer the first sign is typically a breast lump, which in most cases can now be treated very successfully. (The real success in the war against breast cancer has been improved treatment, not screening.) But the first sign of prostate cancer typically occurs too late for the disease to be treated successfully. So maybe P.S.A. testing is the gamble to take.

The truth is that neither test works that well. Even with screening, most people destined to develop deadly, untreatable cancers will still do so.

When it comes to breast and prostate cancer screening, there are no right answers, just trade-offs.

H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, is a co-author of "Overdiagnosed: Making People Sick in the Pursuit of Health."

Sunday, October 9, 2011

Comedians and Others Are Joking About Cancer -

It takes a lot of particles to form a wave. Julia Sweeney, the former "Saturday Night Live" cast member, speaking self-deprecatingly of her pioneering 1996 one-woman Broadway show about having cancer at the same time as her brother, said, "When I was doing 'God Said Ha,' people would say, 'You're finally making cancer funny. People haven't done that before.'

"But I didn't really see it that way. I mean, I found 'Love Story' pretty funny."

The existence of (not to mention the critical and commercial success of) the frank new cancer comedy film "50/50" prompts the question, "How did we get here?"

You can draw a line, however tenuous, that starts with Edith Bunker finding a lump on her breast and ends at Debra Winger languishing melodramatically in "Terms of Endearment." Or one that zigzags from Murphy Brown to Samantha in "Sex and the City" to Cathy Jamison (Laura Linney) in "The Big C." Or even one that starts with the mother of a cancerous baby praying to a god she calls "the Manager of Marshall Field's" in Lorrie Moore's gorgeous 1997 New Yorker story "People Like That Are the Only People Here" and ends with David Rakoff riffing on the word "schwanomma" in his recent book "Half Empty."

But by what scarily graphic and blunt route do we end at Seth Rogen and Joseph Gordon-Levitt in "50/50" manipulating a surgery scar so that it "talks" like Kuato, the "Total Recall" humanoid?

Securely located in the Judd Apatow bromance genre, the funny and affecting "50/50" puts a young radio producer, Adam (Mr. Gordon-Levitt) and his foul-mouthed chauvinistic friend, Kyle (Mr. Rogen), through a narrative arc of trauma and heartbreak and hostility after Adam is diagnosed with a rare form of spinal cancer.

We see the two men use Adam's cancer to pick up women; we see Adam's mother drop the "C card" in an effort to get someone to lower the air-conditioning; we see Kyle tell Adam that, were he his girlfriend, he'd be pleasuring him "every 30 minutes and baking you cookies." And, oh, there's a Patrick Swayze joke, too.

Will Reiser, who wrote "50/50," was told that he had a rare form of spinal cancer six years ago while working on "Da Ali G Show," and lived through the experience with his real-life best friend, Mr. Rogen. "I was 25 at the time," Mr. Reiser said. "I didn't know how to talk about it. I didn't have the emotional tools."

So, in a world in which Elisabeth Kübler-Ross's five stages of grief were an increasingly hoary comic meme, in a world in which people were publishing books with titles like "I'd Rather Do Chemo Than Clean Out the Garage" and "Not Now ... I'm Having a No Hair Day," Mr. Reiser and Mr. Rogen adopted a coping mechanism not dissonant with the times: they joked about the funny cancer movie that they might one day make.

Ask any purveyors of cancer comedy for the names of who they think paved the way for them, and you'll get different answers. Jenny Bicks, a breast-cancer survivor who wrote Samantha's storyline on "Sex and the City" and who now is on the crew of "The Big C," said, "Julia Sweeney made it O.K. to say, 'This happened to me.' "

Fran Drescher, whose 2002 memoir "Cancer Schmancer" included a chapter about losing her 19-year-old Pomeranian and her uterus in the same year, said: "Richard Pryor and Gilda Radner. They found the funny bone and allowed people not to be so scared."

The comedian and podcast host Marc Maron (who, though never diagnosed with the disease, tells a joke about a cancer scare he had after eating licorice one day) points to the late comedian Robert Schimmel, who used to tell an unprintable joke involving the Make-A-Wish Foundation and Dolly Parton.

Mr. Reiser cited Larry David. "Without Larry David, there probably wouldn't be a movie like '50/50.' " The seventh season of Mr. David's show "Curb Your Enthusiasm" saw the curmudgeon get into a literal drag race with his girlfriend Loretta's doctor so that Mr. David could break up with Loretta before she was given a diagnosis of cancer.

"That's Larry's character's way of dealing with life," said Vivica A. Fox, who played Loretta and who said she had no qualms about the material. "He's someone you want to strangle."

If we were to categorize the various forms of cancer comedy, the huge majority would fall under the category of bewildered yawps in the face of tragedy, be those yawps bathetic ("Terms of Endearment") or thorny ("Curb Your Enthusiasm").

But two other categories suggest themselves as well. Though graced with a wonderfully sweet boy-girl romance, "50/50" is, like the comedian Tom Green's 2001 cancer special on MTV, a spiky elbow in the oxygen tent, decidedly more graphic and blunt than other works. In Mr. Green's special, one of the comedian's colleagues held up Green's dissected testicle in a plastic bag and compared it to chicken.

Similarly, in "No Cure for Cancer," a stand-up routine on Showtime in 1993, the comedian Denis Leary said he craved throat cancer because "you can make a lot of money with a voice box."

A third type of cancer humor freights the experience with glamour, sprinkling the medical trauma with the pixie dust of positive thinking and Manolo slingbacks. Marisa Acocella Marchetto's graphic memoir, "Cancer Vixen," recounts a "fabulista life" of a girl-about-Manhattan.

Kris Carr, who made the documentary "Crazy Sexy Cancer," espoused the worldview that "cancer needed a makeover and I was just the gal to do it!" The glamour quotient needn't be clothing-related: we also see the tendency in the max-your-credit-card whirlwinds of "The Big C" and the films "The Bucket List."

It's the rare cancer patient or survivor who would protest the wealth of cancer comedy out on the cultural landscape. As Ms. Bicks said, "The larger message here is, 'Don't wait to get sick to figure out what makes you happy' " — a message that most people, regardless of their health, want and need to hear.

That said, those works that fall into either the graphic or the glamorous categories often incite criticism. "When I saw the ad for '50/50,' I thought, 'Do I have to watch that?' " Ms. Sweeney said. "Or 'The Big C.' I love Laura Linney. There are so many aspects of that show I'd love. But I watch that show in real life."

"I saw the pilot of 'The Big C,' where Laura Linney's character chose not to get treatment," Ms. Marchetto said. "That bugged me. She's so full of life and she chose not to live."

Mr. Rakoff takes exception with the "crazy sexy" ethos. "It seems like the oncological chapter of the covert war on women," he said. "Often preached by women against women, which is often just a variant on the pressure on women to not get epidurals during pregnancy and die in labor like in the Victorian age. It sounds like, 'You should go to chemo in sky-high Jimmy Choos!' And if you don't you're a lazy bitch who deserves to die of cancer. It's like, 'Why aren't you wearing purple and stuffing dollar bills into some guy's jock strap in Dubai?' Because I don't feel very well, thanks."

But in the end, criticism of any particular cancer comedy may simply be a sign that the work in question has achieved one of its main goals: to get people talking.

"Anytime you put yourself out there and expose your vulnerabilities, you're adding to the conversation," Mr. Reiser said. "I hope people take away the idea that there's no right or wrong way to respond to the disease. We all screw up."

Indeed, it's only through talking that this sometimes-volatile vein of humor can achieve its more counterintuitive goal: heedlessness.

As Mr. Rakoff put it, "One of the most heartening things to me when I thought I was going to lose my arm was that, whenever the topic of that morning radio show 'The Takeaway' came up, people would say, 'I hate "The Takeaway!" ' Whereupon I'd say, 'Well, you know the host, John Hockenberry, is in a wheelchair because of a car crash?' And they'd say, 'I don't care.' I thought, That's where you want to get to: 'I don't care if he has one arm. I hated his last book!' That's where you want to be."

Brain Injury and Building a New Life Afterwards -

Jane Rosett is an artist at work on a multimedia project, "Adaptivitudes: Navigating My Brain Injury Rehabilitation," and currently a brain injury patient at Spaulding Rehabilitation Hospital.


"WANT a piece of gum, Jane?" asked my friend Andrée.

"What?" I asked her.


I didn't know what she was talking about.

"It's Trident."

It was delicious.

That evening, I told my friend David about my day's big discovery. "It's called gum and you chew it and it's fun and there's this one kind that will let me blow bubbles!"

"Yes, it's called bubble gum, Jane," he told me, patiently.

Fifty-nine months ago, I was wearing my seat belt and my car was stopped when another vehicle hit me, causing my head to fracture the windshield. That damaged my right temporal lobe, one of my neurologists explained when he told me I had a traumatic brain injury. I lost my long-term memory, and have been a brain injury patient within Harvard Medical School's teaching hospitals ever since.

At 45, I was jolted into an entirely new existence. Memories that connected different parts of my life fragmented and vanished. It took 26 months before I was able to thread my way back unattended to the house I had lived in for 17 years.

I am often amazed to find that people recognize me when I have no recollection of them. People who love me grieve what they claim to experience as the loss of elements of my personality that I cannot recall having been part of me. Others tell me that I seem to have become an altogether different person. I am told that I used to be a real "people person." Today, however, I can barely stand being around people. And I can get irritable in a nanosecond. I am told that my work before the accident pertained to the AIDS pandemic; I was a treatment activist, founder of several early AIDS organizations and a photojournalist, as well as an artist. But I have no more memory of a photo on the cover of The New York Times of an exhibition I curated 10 years ago than I do of a watercolor I painted when I was 3 years old. When I see my pre-accident work, I am introduced to it as if for the first time. As if it was created by anonymous. Did I make that? So I'm told.

I am sometimes fed my own résumé by strangers in the street. One day, a woman introduced me to her children as "one of Mommy's sponsored artists." I looked more confused than her 1-year-old.

In 2007, I ran into Alice and Amma, a couple who said we'd been friends and colleagues for over 20 years. Amma recently reminded me that at first I didn't believe them, and how upset they'd been. And that it was Rifkah, my dog Rifkah, who solved the standoff by recognizing them. I figured that if Rifkah knew them then maybe I did, too. I have no idea.

I once believed that I could not grieve for what I do not remember. I no longer believe that. I do grieve for what I can no longer connect with. Phantom memories. "Your pies!" "Your bread!" Friends tell me they miss my baking. One woman whom I still don't recognize told me I used to shred beets into my chocolate cake batter. Her comment reintroduced me to an evaporated passion I no longer remembered and had not missed until then.

More than four and a half years post brain damage, memories still do not serenely knit back together as in those nifty "How the Brain Heals" neurology cartoons. Shards of memories pierce my consciousness before fragmenting and melting into fresh half-syllables. Some memories hover in shadows. Others gouge and flee.

Initially, memories came back in my dreams and later through my writing and photography. It's the images, not the words, that come back to me.

My friend Andrée, a physician who treats patients with traumatic brain injuries (though she isn't one of my doctors), offers me the clinical word for what I am describing: diaschisis, sometimes said to be Greek for "shocked throughout." She explains that neuroplasticity lets me bypass damaged parts of my brain and forge new neuronal communication routes so I can access, or remember, sensory information that I received as a word, from another place from within my brain and in an entirely different format. Like an image. "So for example, if your brain receives the word 'love,' it can recall the word 'love' as an image of a heart," Andrée explains.

Thank you, neuroplasticity!

My cognitive problems are exacerbated by chronic physical pain from the damage to my nervous system. Glass-shard-wielding fire ants shred my body's meridians. Acupuncture helps a lot. And so does ice. And so does not talking about it, as talking about my pain only makes it worse. As do hectic, high-sensory situations, mean people and the electric buzz of lights and computers.

I am very lucky that my neurologist sent me to Spaulding Rehabilitation Hospital's brain injury program last year. The Defense Department says that, between 2000 and 2010, more than 200,000 service members suffered traumatic brain injuries. Domestic emergency rooms report approximately 1.7 million T.B.I. diagnoses (and 52,000 T.B.I.-related deaths) annually. But very few people with brain injuries receive any sort of treatment beyond acute care. It is a big deal to be somewhere where nobody will laugh at you for rediscovering gum at age 50.

My physical therapist helps me relearn how to put one foot in front of the other without corkscrew-torquing my spine.

My occupational therapist helps me relearn basics of daily life, like what a kitchen pantry is.

I yearn to grasp the practical mechanics of how my specific broken brain ticks, and what ticks it off, how it heals by itself and what I can do to help.

I believe that the No. 1 reason I'm alive today is that I never stopped working. My work grounds me. I spend much of my time writing; I am slowly learning to write with my right hand, to conserve dexterity in my dominant left. This process helps me to downshift my perpetually cycling brain.

As I struggle to remain connected to the threads of my life, I follow every thread when I write. One thread leads to another, leads to 4 threads, leads to 12 more. And before I know it, I've written 543 pages.

Mapping my broken brain includes photographing from my adapted pedal kayak on the water outside the hospital. I navigate the series of locks that separate the Charles River from Boston Harbor. It's an area of stillness and abstractions, where distinctions — between river and bay, between confining diagnoses and liberating health — dissolve.

While nothing can prepare anyone for a traumatic brain injury, 25 years of AIDS and disability activism turned out to be excellent boot camp for navigating these last five years as a patient within an alienating system. Some hallmarks of AIDS advocacy — the importance of first-person perspectives and the sense of community among H.I.V.-positive people — don't apply to brain injury patients, who are too often intimidated about speaking up on our own behalf. Attempts to engage with our new worlds through work and creative expression, even simple questions about our health care, are interpreted as symptoms to be treated, sometimes with inebriating drugs. And traumatic brain injuries destroy connections between and within people — so how are we to build a self-empowering community?

But my AIDS and disability activism taught me how to fight for my rights. I might not recognize my own sister, but I know my Americans With Disabilities Act, and the terms "reasonable accommodation" and "least restrictive environment" are hard-wired into my brain. Fighting for my rights requires me to learn self-compassion. And compassion trumps stigma.

I broke my leg last year, and it took me and my physical therapist a week to realize it, because my broken leg was unremarkable compared to my chronic neuropathic pain. Then, it was spooky how much more attention my cast and crutches elicited from both strangers and doctors than my broken brain does, even though my invisible cerebral disabilities cause more pain.

It is no wonder suicide remains a significant cause of death among people with a traumatic brain injury diagnosis. My speech language pathologist tells me I am a "survivor." I tell him I do not feel like a survivor, I feel like someone who is still fighting for her life. I am afraid of what will happen to me. I don't say that because I'm suicidal, but because I can't keep living the way I am now.

Brain injury rehabilitation is time-consuming and far from the sexy dramatics of pharma-funded clinical trials and fancy trauma toys. In other words, brain injury rehabilitation can be more complex than brain surgery. It is about forging new connections and experiences and learning to live with the dynamic, non-linear realities of my reconfigured brain. It is not about recovering inaccessible memories of my life before my accident.

If you want to connect with someone who has a traumatic brain injury, hire us, include us in conversations that regard us instead of speaking about us in the third person in front of our faces. And instead of pressing us about what we "must" remember from our past, simply be present with us. People with traumatic brain injuries are often scolded for having "no sense of time," but the present is, for many of us, our only authentic time.

So when you see us, please don't be offended if we don't remember weathering earthquakes with you, baking your birthday cakes or bouncing your babies on our knees. We're struggling to make sense of a world that seems brand-new — sometimes wonderful, often overwhelming — with all the courage we can muster.