Friday, April 13, 2012

New View of Depression: An Ailment of the Entire Body - WSJ.com

Scientists are increasingly finding that depression and other psychological disorders can be as much diseases of the body as of the mind.

  People with long-term psychological stress, depression and post-traumatic stress disorder tend to develop earlier and more serious forms of physical illnesses that usually hit people in older age, such as stroke, dementia, heart disease and diabetes. Recent research points to what might be happening on the cellular level that could account for this.

  Scientists are finding that the same changes to chromosomes that happen as people age can also be found in people experiencing major stress and depression.

The phenomenon, known as "accelerated aging," is beginning to reshape the field's understanding of stress and depression not merely as psychological conditions but as body-wide illnesses in which mood may be just the most obvious symptom.

"As we learn more…we will begin to think less of depression as a 'mental illness' or even a 'brain disease,' but as a systemic illness," says Owen Wolkowitz, a psychiatry professor at the University of California, San Francisco, who along with colleagues has conducted research in the field.

Gaining a better understanding of the mechanisms that link physical and mental conditions could someday prove helpful in diagnosing and treating psychological illnesses and improving cognition in people with memory problems, Dr. Wolkowitz says.

In an early look at accelerated aging, researchers at Duke University found about 20 years ago that brain scans of older people with depression showed much faster age-related loss of volume in the brain compared with people without depression. The reasons for the accelerated aging appeared to go beyond unhealthy behaviors, like smoking, diet and lack of exercise, researchers said.

Recent efforts to study what is behind accelerated aging on a cellular level have focused on telomeres, a protective covering at the ends of chromosomes that have been recognized as playing an important role in aging. Telomeres get shorter as people age, and shortened telomeres also are related to increased risk of disease and mortality.

In several studies conducted at UCSF, researchers have found shortened telomere length to be associated with depression, childhood trauma and other conditions. A study of 43 adults with chronic post-traumatic stress disorder, whose average age was about 30, and 47 healthy control subjects, found shorter telomere length in the PTSD group that equated to an estimated 4.5 years of accelerated aging, Dr. Wolkowitz says. The study was published last year in Biological Psychiatry.

In separate research, scientists in Sweden found similar results. In a study involving 91 patients with major depression and 451 healthy control subjects, researchers from Umeå University concluded that shortened telomere length was associated with depression and greater perceived life stress. The study was published in Biological Psychiatry in February.

Early Aging

People who have major bouts of depression have an increased risk at a younger age of developing conditions typically associated with getting older. This may be because depression makes cells age prematurely, new research suggests.

•Heart disease

•Atherosclerosis

•Hypertension

•Stroke

•Dementia

•Osteoporosis

•Type 2 diabetes

Source: Owen Wolkowitz, UCSF

Scientists say more work needs to be done to figure out exactly how severe a psychological experience must be to affect telomere length. Some research suggests that as few as two episodes of major depression may be sufficient to affect cell structure. Other studies indicate that the more bouts of depression a person experiences, the more impact there is on telomere length.

The "holy grail" of this area of work is to try to find the molecular mechanisms by which depression or stress take their toll on the body, says P. Murali Doraiswamy, head of the division of biological psychiatry at Duke University, who isn't involved in telomere work. Such information could help provide clues about how much of age-related disease is due to genetics versus life experience, and whether it can be reversed, he says.

Researchers also want to understand why not all stressed people develop shortened telomeres. Telomere length is thought to be affected by the body's production of certain stress hormones or inflammatory molecules, which are made in greater quantities when people are stressed or depressed. Meanwhile, an enzyme known as telomerase acts to protect against telomere shortening.

Some people appear to have innate biological protective factors, like higher antioxidant level and anti-inflammatory proteins, according to UCSF's Dr. Wolkowitz.

How individuals experience the stress, cope with it and view the world more generally also are thought to relate to telomere length. In 2009, the UCSF researchers found that a personality characteristic, pessimism, correlated with shorter telomeres and increased production of a chemical produced by the immune system related to stress.

In another study, UCSF researchers brought into the lab 50 women and exposed them to standard experimental tasks known to induce stress: giving a speech about their personal strengths and weaknesses and completing a difficult math problem out loud. Some of the women were caregivers for chronically ill children and therefore had presumably more stressful lives. But telomere length didn't seem to depend on whether a woman was one of the caregivers or not. Instead, the telomeres were shorter only in those women who reported greater levels of anxiety about having to perform the experimental tasks—seemingly the ones who tended to get more stressed about life's challenges. The research, led by UCSF postdoctoral fellow Aoife O'Donovan, was published online in March in the journal Brain, Behavior, and Immunity.

Researchers believe it takes months, or even years, for stress or depression to affect telomere length. However, the level of activity of the enzyme telomerase may be affected more quickly. In a pilot study involving 24 patients with prostate cancer, Dean Ornish, founder of the Preventive Medicine Research Institute, a nonprofit research group in Sausalito, Calif., demonstrated that telomerase activity in blood cells increased after three months of changes in the patients' lifestyle, including lowering of cholesterol and psychological distress. Although the study didn't measure telomere length, the researchers suggested that increased telomerase activity in the patients could be signaling greater telomere protection at the cellular level. The study, performed together with UCSF researchers, was published in the Lancet Oncology in 2008.

Heightened telomerase levels have been found in some depressed people who are given an antidepressant. These patients also show improvement in clinical measurements of their depression. Other depressed patients, however, who don't show clinical improvements after being given medication, also didn't experience an increase in levels of the enzyme. The findings are from a small study published in February in Molecular Psychiatry.

After finding that some psychological conditions appear to affect telomere length, researchers at UCSF are trying to find out whether information about what is going on in a patient's cells can be used to change the person's psychology. In an ongoing study, researchers are telling patients how their telomere length, which can be detected through a blood sample, compares with that of an average person of the same age. Researchers are then tracking whether the patients, armed with that information, are more motivated to adopt a healthier lifestyle.



Wednesday, April 11, 2012

WHO: Dementia cases projected to triple worldwide by 2050 – USATODAY.com

Cases of dementia — and the heavy social and financial burdens associated with them — are set to soar in the coming decades as life expectancy and medical care improve in poorer countries, the World Health Organization says.

Some 35.6 million people were living with dementia in 2010, but that figure is set to double to 65.7 million by 2030, the U.N. health agency said Wednesday. In 2050, it expects the number of dementia cases to triple to 115.4 million.

Most dementia patients are cared for by relatives, who shoulder the bulk of the current estimated annual cost of $604 billion, WHO said.

In its first substantial report on the issue, the agency said the financial burden is expected to rise even faster than the number of cases.

"The catastrophic cost drives millions of households below the poverty line," warned the agency's director-general, Margaret Chan.

Dementia, a brain illness that affects memory, behavior and the ability to perform even common tasks, affects mostly older people. About 70 percent of cases are believed to be caused by Alzheimer's.

In the last few decades dementia has become a major public health issue in rich countries. But with populations in poor and middle-income countries projected to grow and age rapidly over the coming decades, the agency appealed for greater public awareness and better support programs everywhere.

The share of cases in poor and middle-income countries is expected to rise from just under 60 percent today, to over 70 percent by 2050.

So far, only eight countries — including Britain, France and Japan — have national programs to address dementia, WHO said. Several others, such as the United States, have plans at the state level.
WHO said a lack of proper diagnosis is one of the obstacles to better dementia treatment. Even in rich countries more than half of dementia cases are overlooked until the disease has reached a late stage.

"Chemo Brain” Not Always to Blame for Cognitive Declines in Women with Breast Cancer, Researcher Says | MU News Bureau

Women undergoing treatment for breast cancer can experience cognitive declines, such as decreased verbal fluency or loss of memory and attention. Often experienced by patients undergoing chemotherapy, the declines have become known as "chemo brain." However, a health psychologist at the University of Missouri says "chemo brain" isn't always to blame.

Stephanie Reid-Arndt, an associate professor and chair of the Health Psychology Department in the MU School of Health Professions, found that women who had undergone surgery for breast cancer but who had not yet received chemotherapy or hormone-replacement therapy experienced similar cognitive deficits as women undergoing chemotherapy. Patients who were stressed and had passive coping strategies to deal with their stress were more likely to experience cognitive declines.

"Women who reported higher stress levels also performed lower on memory and attention tests," Reid-Arndt said. "It appeared that passive coping strategies, such as denial, disengagement and helplessness, contributed to this relationship. This suggests lacking proactive ways to deal with stress can contribute to patients' experience of cognitive difficulties."

Reid-Arndt said developing effective coping strategies is essential to helping women with breast cancer lower their stress and maintain their cognitive function. Often, women receive a breast cancer diagnosis and immediately begin treatment without having much time to emotionally prepare, Reid-Arndt said.

"Sometimes the women who are most stressed are those who appear to be handling the diagnosis the best; they just may be good at hiding their emotions," Reid-Arndt said. "To help prevent this, women can be encouraged to acknowledge that they're stressed. Women should talk with their health care providers, families and friends about their stress and be willing to accept assistance from others."

Reid-Arndt hopes to apply the findings to help patients with other types of cancer cope with their illnesses, stress and cognitive declines. She said health care providers can identify and help patients who are at risk for cognitive declines by evaluating patients' stress levels and coming up with effective ways to manage their anxiety.

"Teaching patients proactive ways to deal with stress can help them improve their quality of life as well as maintain their cognitive function," Reid-Arndt said.

Reid-Arndt noted previous research has looked at depression and cognitive decline among cancer patients, but depression has not been linked to cognitive decline. Being depressed and feeling stressed are unique and should not be confused, Reid-Arndt said.

"Just because women with breast cancer are stressed doesn't necessarily mean they're depressed," she said. "It just means they're feeling overwhelmed and need some help."

The study, Stress, Coping and Cognitive Deficits in Women After Surgery for Breast Cancer," was published in the Journal for Clinical Psychology in Medical Settings. The study was funded by the University of Missouri System Research Board. Cathy Cox from Texas Christian University co-authored the study.

http://munews.missouri.edu/news-releases/2012/0410-chemo-brain"-not-always-to-blame-for-cognitive-declines-in-women-with-breast-cancer-mu-researcher-says/

Mental health concerns rise with cosmetic surgery boom - Korea Times

"This is the nose you'll see most if you go clubbing these days," said Sumi Lee, a university student in Seoul. She gestured to an ad for a posh plastic surgery clinic, showcasing "before and after" images of a rhinoplasty patient. 

"I call it the Gangnam nose, and half of my friends have it. If I could afford it, I'd get it too."

Lee isn't alone. A country renowned for its dramas, music and high tech culture is swiftly becoming famous for surgically altered faces. The International Society of Aesthetic Plastic Surgery reported that Korea has the second highest rate of plastic surgery procedures per capita in the world after Hungary. 

A survey conducted by the Seoul city government reported over 50 percent of women under the age of 30 went under the knife in 2011, and 31.5 percent of participants over the age of 15 expressed intentions of having surgery in the future.

Last year, the Ministry of Education distributed a booklet aimed at educating students about "plastic surgery syndrome," or the unhealthy preoccupation with surgery.

"It isn't uncommon for students to return from vacation with a new nose or double-lidded eyes," says Sheri Grant, a high school teacher in Seoul. "I had one girl come back that I didn't even recognize; she had her entire face made over."

What had inspired this penchant for shape-shifting in a nation where traditional Confucian teachings depict the body as "a cherished ancestral inheritance"?

From an evolutionary perspective, women's desire for beauty is instinctual, so understanding it is helpful in distinguishing the "healthy" from the "unhealthy."

Reports by prominent Korean match-making services reveal that marriage-seeking women prioritize the following attributes in descending order: Economic capacity/occupation, personality, family background, appearance. 

Men, however, answered similar surveys in the following order: Beauty, personality, economic capacity/occupation, family background. 

The results show that for women, a good job out-ranks a handsome face. But for men, beauty comes before brains and bucks.

Another contributing factor might be the nature of the Korean cosmetic industry itself, which is especially attractive to ambitious medical students. Unlike the situation in fields such as internal medicine or general surgery, cosmetic procedures are not regulated by the government, nor are they covered by national insurance. 

This allows doctors to negotiate, dole out discounts, or raise prices in accordance with fame. Not surprisingly, savvy advertising is prominent in subway stations, conventional media, and most notably, through the wide eyes and high bridged noses of the hottest celebs. 

Healthy vs. unhealthy 

At what point is surgery unhealthy?

The difference between healthy and unhealthy plastic surgery can be vague, and is rife with controversy. 

There is no legal requirement for surgeons to demand psychological screening for patients, though parental permission is required for those less than 18 years of age. 

Surgery that is considered healthy are those in which we can understand the motivation of the patient to get the surgery from a common sense standpoint, the cost of the surgery does not exceed economic capacity, the patient does not seek excessive or repeated surgery, the patient is satisfied with results, and that leads to a rise in self esteem.

The most extreme disorder related to appearance is body dysmorphic disorder, a condition marked by a delusional level of concern about a physical trait. Interestingly, reports have shown that one third of rhinoplasty patients suffer from the condition. In 2007, a U.S. study showed that women who get cosmetic breast implants are nearly three times as likely to commit suicide as other women, and had a tripled risk of death from drug and alcohol abuse.

Although there is no arguing that successful 'nipping and tucking' has bolstered many careers, boosted confidence, or combated unwanted genetics, there are those who wish that the adage "it's what's inside that counts" could be more prominent in today's society.

"I don't know if I agree with plastic surgery, really," says Grant. "The girl who had her face made over became a completely different person. She went from being the shy kid to the most popular kid in class. She did, however, say that she went through excruciating pain, and it cost her parents a fortune. I hope it was worth it."

Kelly Frances is a guest columnist from Ontario, Canada, and is currently living in Seoul. She welcomes topic suggestions from readers and can be reached at kellyfrancesm@gmail.com. Park Jin-seng is a psychiatrist and psychotherapist who specializes in family therapy.

http://www.koreatimes.co.kr/www/news/art/2012/04/147_108586.html

Tuesday, April 10, 2012

Giving Patients Choices in Colon Cancer Screening - NYTimes.com

A new study shows that patients are far less likely to undergo screening for colon cancer if their doctors recommend only colonoscopy, rather than offering other screening options.

The research suggests that offering patients at risk more choices might help increase the rate of testing for a disease that has long been associated with low screening rates. Survival rates for colorectal cancer are high when the disease is found early and treated, but nationwide, screening for the disease lags far behind that for breast and cervical cancers. Health authorities recommend that everyone be screened for colon cancer after the age of 50, or sooner in those who have additional risk factors, like a family history of the disease.

Colonoscopies are widely considered the gold standard when it comes to screening, but many patients fear the procedure and the bowel-cleansing preparation it requires, and many skip the test. Doctors rarely tell patients they have other options, like the fecal occult blood test, which is less accurate at detecting cancer but is far less invasive, requiring only that patients collect a tiny stool sample to be tested for traces of blood.

In the new study, published in Archives of Internal Medicine, researchers looked at what happened when roughly 1,000 people at moderate risk for colorectal cancer in the San Francisco area were given one of three screening options. In one group, doctors recommended only colonoscopy. In another, they offered their patients only a fecal occult blood test, requiring a stool sample. And in the third, they discussed with their patients both tests and gave them the option of choosing either one.

At the end of the study, the contrast among the groups was stark. When offered only colonoscopy, 38 percent of patients went through with screening. But nearly double the number of people went through with screening in the other groups – 67 percent of people in the group offered stool tests, and 69 percent in the group that was offered both options. The researchers noted, importantly, that a positive stool test was followed up by a colonoscopy to complete the screening.

Historically, most gastroenterologists prefer to offer only colonoscopies because they feel the other tests are inferior, but it is clear that many people would rather forgo screening altogether than undergo a colonoscopy, said the lead author of the study, Dr. John M. Inadomi, a professor and chief of the division of gastroenterology at the University of Washington. "I think what this shows is that patient preferences should be identified, because that's the way you're going to increase adherence to colon cancer screening," he said.

"No matter how effective we believe a colonoscopy is," he added, "if a patient doesn't do it, then it's not doing anything for them."

Health authorities say that as many as 60 percent of deaths from colorectal cancer could be prevented if everyone over 50 were screened regularly. And yet according to a large nationwide study in 2005, the most recent figures available, only half of adults over 50 reported that they had undergone a colonoscopy in the previous decade or a stool test with a home kit in the previous year. Screening rates are especially low among members of racial and ethnic minorities.

In the current study, roughly 60 percent of participants had completed screening after a year. Latinos had the highest rates of completion, at 63 percent, followed by Asians, at 61 percent. White patients were most likely to choose colonoscopy, whereas nonwhites showed a strong preference for the noninvasive stool test.

In an accompanying editorial, Dr. Theodore R. Levin, a gastroenterologist at Kaiser Permanente Medical Center in California, said the idea of a "preferred" screening test should not mean what doctors prefer, but what both doctors and their individual patients want.

"Many patients prefer to have a stool testing option, and including that option results in more patients being screened," he wrote.

http://well.blogs.nytimes.com/2012/04/10/giving-patients-choices-in-colon-cancer-screening/?src=recg&gwh=4B2814D62942F9FF02884D3A8A1BC6F1

Geriatric Emergency Units Opening at U.S. Hospitals - NYTimes.com

Phyllis Spielberger, a retired hat seller at Bendel's, picked at a plastic dish of beets and corn as her husband, Jason, sat at the foot of her hospital bed, telling her to eat.

Although she had been rushed to Manhattan's busy Mount Sinai Hospital by ambulance when her leg gave out, the atmosphere she encountered upon her arrival was eerily calm.

There were no beeping machines or blinking lights or scurrying medical residents. A volunteer circulated among the patients like a flight attendant, making soothing conversation and offering reading glasses, Sudoku puzzles and hearing aids. Above them, an artificial sun shined through a skylight imprinted with a photographic rendering of a robin's-egg-blue sky, puffy clouds and leafy trees.

Ms. Spielberger, who is in her 80s, was even getting into the spirit of the place, despite her unnerving condition. "It's beautiful," she said. "Everything here is wonderful."

Yet this was an emergency room, one specifically designed for the elderly, part of a growing trend of hospitals' trying to cater to the medical needs and sensibilities of aging baby boomers and their parents. Mount Sinai opened its geriatric emergency department, or geri-ed, two months ago, modeling it in part after one at St. Joseph's Regional Medical Center in Paterson, N.J., which opened in 2009.

Holy Cross Hospital in Silver Spring, Md., opened one of the first geriatric emergency departments, which it calls a seniors emergency center, in 2008, and its parent organization, Trinity Health System, runs 12 nationwide, primarily in the Midwest, and plans to open six or seven more by June, a spokeswoman said.

Dr. Mark Rosenberg, chairman of emergency medicine at St. Joseph's, said he had consulted on more than 50 geriatric emergency rooms to be opened across the country, from Princeton, N.J., to California, overcoming initial resistance from doctors and nurses who saw assignments to the units as scut work.

"They thought it was a bedpan unit, focused on nursing home patients," Dr. Rosenberg said. "When they finally realized this was the unit that gave better health care to their parents and grandparents, they jumped onboard."

Hospitals also have strong financial incentives to focus on the elderly. People over 65 account for 15 percent to 20 percent of emergency room visits, hospital officials say, and that number is expected to grow as the population ages.

Under the Affordable Care Act, the health insurance overhaul passed by Congress in 2010, hospitals' Medicare payments will be tied to scores on patient satisfaction surveys and how frequently patients have to be readmitted to the hospital. (The Supreme Court is considering whether to overturn another section of the law, and if it does, whether it would have to throw out the entire law.)

Even in their early stages, patient satisfaction ratings for Mount Sinai's geri-ed are "off the scoreboard," said Dr. Andy Jagoda, the hospital's chairman of emergency medicine.

Patients who are picked up by ambulance can choose which hospital to go to, if circumstances and travel time allow.

At Mount Sinai, all arrivals go through triage in the regular emergency department and are sent to the geriatric department if they are over 65, know their name, were able to walk before the day of the hospital visit and are ranked 3, 4 or 5 on a standard emergency severity index of 1 to 5, with 1 being the sickest. Someone with a broken hip would probably qualify, but someone with an acute heart attack would most likely have to be stabilized in the regular emergency room first, said Dr. Kevin M. Baumlin, the vice chairman of emergency medicine, who founded the geriatric emergency room.

The geriatric E.R. — eight beds and six examining rooms — resembles a clinic more than it does an emergency room: there are nonskid floors, rails along the walls, reclining chairs for patients and thicker mattresses to reduce bedsores. To keep the noise down, the curtain rings and rods around the beds are made of plastic instead of metal.

"One of my pet peeves is the noise that curtains make," Dr. Baumlin said. "You know, that metal clackety-clack sound."

Volunteers interact with patients to keep them alert. The artificial skylight, which turns dark at night, is intended to combat "sundowning" — agitation and confusion at the end of the day. "I have to say I thought it was the hokiest thing I ever heard of, but it turns out it's a big satisfier," Dr. Jagoda said.

Then there is one of Dr. Baumlin's favorite innovations, what he calls the geriPad, an iPad that lets patients have a two-way video conversation with a nurse, or touch the screen to ask for lunch, pain medication or music.

A calmer patient is usually a satisfied one, but advocates of the trend toward geriatric E.R.'s say there are also medical reasons for placing a special focus on the elderly. Being treated in the emergency room is often the beginning of a slide for older patients: within three months of being sent home, up to 27 percent have another emergency, are admitted to the hospital or die, studies show.

Dr. Ula Y. Hwang, a researcher at Mount Sinai who co-wrote a 2007 paper on the concept of the geriatric emergency department, said the classic emergency room focus on speed could lead to mistakes with elderly patients, whose condition is often complicated by their being on many medications, having more than one sickness and being unable to express what is wrong with them clearly.

Dr. Rosenberg, of St. Joseph's, said his hospital had been able to reduce unscheduled return visits to the emergency room to 1 percent of cases, from 20 percent. Patients still return, he said, but they return because the hospital has called them at home, found they are not getting better, and called them back to the hospital before their condition, like pneumonia, becomes a crisis.

Still, the move toward specialized emergency rooms for the elderly has skeptics, who see them as little more than marketing gimmicks.

Dr. Alfred Sacchetti, chief of emergency services at Our Lady of Lourdes Medical Center in Camden, N.J., said he thought setting up geriatric emergency rooms, or even pediatric emergency rooms, was a distraction from the goal of giving optimal treatment to all.

Dr. Sacchetti said he had not seen evidence that geriatric emergency rooms provided better outcomes for patients, but to the degree they did improve care — for instance, if the thicker mattresses did cut down on bedsores — then those improvements should be extended to all emergency patients.

"What's the best outcome for the patient?" he said. "I don't miss your diagnosis, I treat you appropriately, I treat you quickly and you have a good outcome. Or, I miss all of those things but son of a gun, we look like the Four Seasons. There's nothing that says you can't do both."

Dr. Jagoda, the emergency medicine chairman at Mount Sinai, admitted that he, too, was skeptical at first. But, he said, up to eight elderly patients a month were falling in the regular emergency room, and that alone was troubling enough for him to want to try something new. None have fallen in the geriatric E.R., he said.

One mission of the geriatric emergency room is to look at the context of the emergency. So a pharmacist might look at drug interactions, and a visiting nurse might be sent to the home of a patient who fell to look for trip hazards.

As for Ms. Spielberger, who was taking 13 or 14 drugs, the pain in her leg led doctors to find a heart problem, her husband said later. She was admitted to the hospital for one night and sent home, Mr. Spielberger said, with the advice to let it be. It is a visit she would rather forget, except for that skylight.

"It was fantastic," she said. "I called my family to tell them about it."

http://www.nytimes.com/2012/04/10/nyregion/geriatric-emergency-units-opening-at-us-hospitals.html?nl=todaysheadlines&emc=edit_th_20120410&pagewanted=print

Monday, April 9, 2012

Club Med - Affordable Health Care in Thailand and Costa Rica : The New Yorker

This year, a few hundred thousand intrepid American travellers will head to places like Thailand and Costa Rica, in search of something that they can't find in the United States. They won't be looking for Mayan ruins or ancient Buddhist temples, but something a bit more practical: affordable medical care. These medical tourists will be getting root canals, knee surgeries, and hip replacements at foreign hospitals. If health-care costs in the U.S. keep rising—and especially if Obamacare is overturned by the Supreme Court—more of us may soon be joining them.

For decades, wealthy people from developing countries have come here for care, but these days medical tourists travel all over the world. And while it's hard to disentangle the stats from the hype—a number of countries portray themselves as favored destinations—it's clear that millions of people are now doing this. The Bumrungrad hospital, in Bangkok, treats four hundred thousand foreign patients annually. Malaysia had almost six hundred thousand medical tourists last year. And South Korea had more than a hundred thousand, nearly a third of them American.

For Americans, the attraction is obvious: medical care is a lot cheaper abroad. At CIMA Hospital, in Costa Rica, for instance, hip-replacement surgery costs around fifteen thousand dollars, roughly a sixth of the average here. So far, though, various factors have kept a lid on demand. Logistics can be challenging, and insurance companies have been leery about reimbursements for care overseas: they already get big discounts with U.S. hospitals, and they risk a public-relations disaster anytime something goes wrong abroad. Above all, patients have been wary. We trust the quality of foreign-made televisions and cars, but we haven't taken that leap when it comes to foreign doctors. People worry about the lack of legal recourse, and the sheer unfamiliarity of medical tourism makes people hesitant to try it. A few years ago, the grocery-store chain Hannaford set up a partnership for the benefit of its employees with a well-accredited Singaporean hospital. Singapore is one of the most prosperous countries in the world, but medical care there is still significantly cheaper than in the U.S., so the arrangement looked like a model for how medical tourism might work. But none of Hannaford's workers were interested in going to Singapore.

There are a host of forces that could change this. The quality of medical facilities in developing countries has risen dramatically, and the private hospitals that cater to tourists often feature technologies similar to those in American hospitals. (This has its problematic side: many of these high-end hospitals are in countries where citizens struggle to get basic care.) Furthermore, new companies are making treatment abroad easier and more attractive. Blue Cross/Blue Shield has started a company called Companion Global Healthcare, which connects patients with hospitals around the world. Political events could also quickly make medical tourism considerably more attractive. If Obamacare is overturned, forty million Americans without insurance will stay that way. If Medicaid and Medicare are cut sharply, the cost of American health care will eventually become prohibitive to many senior citizens. And if health-care costs keep soaring fewer employers will offer health insurance. That doesn't mean that Americans are soon going to jet halfway around the world for an ingrown toenail, but it's easy to envisage regional systems becoming common, with Americans heading to places like Costa Rica and Mexico, and Western Europeans going to places like Hungary and Turkey.

If more Americans sought care abroad, it wouldn't just save them money; it could also help control medical costs at home. Medical tourism can be considered a kind of import: instead of the product coming to the consumer, as it does with cars or sneakers, the consumer is going to the product. More medical tourism would increase free trade in medical services, something there has not been much of in the past. The U.S. has been religious about breaking down barriers to free trade, especially in manufacturing and service industries, exposing ordinary workers to foreign competition. But health care has been insulated from the forces of globalization. This has been great for hospitals and doctors, but less good for consumers. It's one reason that the cost of health care has risen so much faster than that of almost everything else.

It has been generally assumed that medicine is inherently a local business. But that would change if we allowed Medicare and Medicaid funds to be spent in foreign hospitals, or if insurers cut consumers in on the savings from treatment abroad. And if domestic hospitals actually had to compete with places like Bumrungrad or CIMA, the way American car companies have to compete with Toyota and Honda, they might be forced to become more efficient. Even an increase in domestic medical tourism—people journeying to lower-cost U.S. hospitals, like the Cleveland Clinic—would help. There are other ways to bring free trade to medicine, too. As the economist Dean Baker has argued, making it easier for foreign doctors who met standardized requirements to practice in the U.S. would hold down costs and improve service. In addition to exporting patients, we could import doctors. Politically speaking, of course, this all seems improbable, because the medical industry is a powerful lobby and uninterested in competition. But the reality is that, unless we find some other way to rein in health-care costs, the logic of free trade in medicine is going to become harder to resist.

http://www.newyorker.com/talk/financial/2012/04/16/120416ta_talk_surowiecki?printable=true

The Other Coast by Adrian Raeside


Do You Really Need That Medical Test? - Editorial - NYTimes.com

If health care costs are ever to be brought under control, the nation's doctors will have to play a leading role in eliminating unnecessary treatments. By some estimates, hundreds of billions of dollars are wasted this way every year. So it is highly encouraging that nine major physicians' groups have identified 45 tests and procedures (five for each specialty) that are commonly used but have no proven benefit for many patients and sometimes cause more harm than good.

Many patients will be surprised at the tests and treatments that these expert groups now question. They include, for example, annual electrocardiograms for low-risk patients and routine chest X-rays for ambulatory patients in advance of surgery.

The doctors were prodded into action by a conscience-provoking article by Dr. Howard Brody, director of an institute that explores ethical issues in health care, published in The New England Journal of Medicine in early 2010. Dr. Brody criticized the performance of medical groups during the health care debates, saying they were too concerned about protecting doctors' incomes while refusing to contemplate measures (beyond malpractice reform) to reduce health care costs.

He urged each specialty society, using rigorous scientific approaches, to develop "top five" lists of tests and treatments whose elimination for major categories of patients would save the most money quickly "without depriving any patient of meaningful medical benefit." A foundation established by the American Board of Internal Medicine financed a successful test of the approach in three primary care specialties and then encouraged a broad range of specialty groups to develop their own lists.

The first nine, including cardiology, oncology, radiology and primary care, issued "top five" lists last Wednesday. Among items on those lists are: cardiac stress tests for annual checkups in asymptomatic patients; brain imaging scans after fainting; antibiotics for uncomplicated sinus infections that are almost always caused by viruses, which are not treatable with antibiotics; imaging of the lower spine within the first six weeks after suffering back pain; and bone scans for early prostate and breast cancer patients at low risk of metastasis.

The societies developed the lists after months of analyses and reviews of the medical literature by expert committees. In some cases, the groups showed admirable statesmanship by proposing cuts that would affect their incomes, as when radiologists proposed limits on various tests they perform and gastroenterologists proposed limits on the frequency of colonoscopies.

Eight additional societies will release their lists next fall, expanding the campaign to cut waste more broadly through the health care system. Ultimately, the societies ought to develop top 10, 20 or 50 lists if there is enough evidence to make that possible.

Patients must take responsibility as well. They must discipline themselves not to request care of little or no value. To help patients make informed decisions, Consumer Reports is developing more-accessible versions of the lists and will join other organizations in disseminating them.

Patients with comprehensive health insurance may not care much if needless tests are performed. But if health care costs continue to soar, patients will be shouldering more of the financial burden. And there can be serious health consequences from unnecessary treatment, including excess radiation, adverse drug effects, exposure to germs in medical institutions and even exploratory surgery or biopsies when scans produce a false positive.

Eliminating needless care is not rationing. It is sound medicine and sound economics.

http://www.nytimes.com/2012/04/09/opinion/do-you-really-need-that-medical-test.html?nl=todaysheadlines&emc=edit_th_20120409&pagewanted=print

Sunday, April 8, 2012

Poor Participation Hobbles California’s Drug Oversight - NYTimes.com

Byung Sik Yuh, the owner of Nichols Hill pharmacy in Oakland, filled more than 5,000 online prescriptions for addictive painkillers before the California State Board of Pharmacy moved last year to revoke his license. The patients who picked up the prescriptions at Mr. Yuh's pharmacy had never met their doctors, nor had physical examinations. They filled out a brief online survey and paid an anonymous doctor to write prescriptions over the Internet.

Today, a contrite Mr. Yuh, who agreed to pay $150,000 in fines to avoid having his license revoked, says he supports the state's prescription drug monitoring program, a real-time online database that displays a patient's prescription drug history. As attorney general, Gov. Jerry Brown promoted the online database in 2009 as a new solution to the prescription drug abuse epidemic.

Using the system, Mr. Yuh could have instantly looked up the prescription histories of his customers and refused to provide medication to a patient whose drug shopping habits seemed suspicious or out of control. More than 40 states are using similar systems to help curb prescription drug abuse.

But in California, the system has not put a dent in prescription drug abuse because enrollment in the drug-monitoring database program is optional, and neither Mr. Yuh nor thousands of other pharmacists and doctors in the Bay Area and the state, are enrolled. Of more than 30,000 doctors and pharmacists in the Bay Area, only 86 are signed up to use the system, according to records obtained by The Bay Citizen.

And although federal authorities are spending millions of dollars to expand systems across the country, money and staffing for California's program is almost entirely gone, after Governor Brown slashed $71 million from the Department of Justice budget.

After marijuana, prescription painkillers are now considered the most abused drugs among youth in the United States, according to a national annual survey. Overdoses, mostly on prescription drugs, are the No. 1 cause of accidental deaths in the United States, surpassing motor vehicle accidents, and nearly 11 people die every day from prescription drug overdoses in California, according to the United States Centers for Disease Control and Prevention. The C.D.C. reported in January that every year since 2003, more Americans have died from prescription painkiller overdoses than from heroin and cocaine combined.

If California does not fix its system, "it will pay a huge price in terms of people who end up dying whose lives could have been saved, of people overdosing and going into hospitals, or nursing homes, or ultimately on disability," said John Eadie, the executive director of the Prescription Monitoring Program Center of Excellence at Brandeis University in Waltham, Mass. "The health care costs are massive."

California's system was beset by problems almost from the outset. Unlike in Arizona and Utah, where enrollment is mandatory, California's system has drawn few participants. Statewide, in the first year, only 282 pharmacists and 1,559 prescribers, of more than 165,000, enrolled in the program. Today, the numbers are larger but still dismal: 1,216 pharmacists and 6,755 prescribers are registered.

The program shut down completely in November because of the budget cuts; it is back online now, but so far this year only two new prescribers in the Bay Area have enrolled in the program; no pharmacists have registered.

Doctors who use the system said it is slow and cumbersome and lacks the capability to analyze data systematically.

"It's hit or miss," said Dr. Richard Gracer, who runs a pain management clinic in San Ramon. "Once in a while it's slow. Sometimes it gives the wrong answers. If the amount of doctors who should be using it signed up, it would probably die right away."

Mike Small, a former administrator from the Investigation and Intelligence Bureau at the Department of Justice who inherited the task of running the California system from a former staff of 13, said that in just its third year, the system is already "old and falling apart."

"Doctors don't want to spend 10 minutes waiting when they have a patient in front of them," Mr. Small said.

"It was clunky on arrival," said Dr. Scott Fishman, professor and chief of the Division of Pain Medicine at the University of California, Davis, who said he uses the system regularly. "It's not the high-tech information technology system it could be."

Bob Pack, who formed the Troy and Alana Pack Foundation in Danville after his two children died in a car crash caused by a driver under the influence of prescription drugs, said the California system is reactive, rather than proactive.

"Right now, they go and backtrack and say, 'O.K., this guy prescribed too much to Michael Jackson, let's look at him,' " Mr. Pack said. "They're not making the best use of the system."

Sixteen states use their prescription monitoring programs to proactively send reports to pharmacists and prescribers about patients who appear to be doctor shopping, according to a 2011 survey of state programs. Eight states send such reports to law enforcement agencies, and seven states send reports to licensing agencies.

Some states employ staff or have automated systems that identify patients who appear to fill an excessive number of prescriptions, and the doctors who serve them. Then they reach out to licensing boards, law enforcement agencies, or the doctors themselves. In California, the same type of data collects in the system until a complaint or tip prompts state investigators to find it.

In 2010, Senator Mark DeSaulnier, Democrat of Concord, proposed that manufacturers of certain types of prescription drugs pay an estimated 1 percent of their profits, or a total of about $5 million a year, for improvements and operating costs of the monitoring program, including data analysis software. The bill failed to make it out of committee.

Mr. Brown said in 2009 that the system would cost about $3.5 million for three years. Mr. Small, who now runs the system, estimated that an overhaul would cost about $1.2 million, including $800,000 in annual personnel costs and about $400,000 for maintenance.

According to Mr. Eadie of Brandeis, more than 20 states have instituted a fee to pay for monitoring systems, paid by hospitals, health care facilities, drug distributors and manufacturers, and others involved in the use of controlled substances.

But Mr. Pack, who is trying to gather signatures for a ballot initiative in support of Mr. DeSaulnier's proposed fee, said it will be a challenge. "The ship is sinking and the captains don't want to do anything about it," he said.

Even Mr. Yuh, the Oakland pharmacist who filled thousands of online prescriptions, said he believes the system is a good idea. In 2006, he received a call from a "smooth talker" with a proposition: $5 for every online prescription the company sent to be filled. The prescriptions soon began pouring in from doctors and patients all over the country.

In 2010, after learning his license could be revoked, Mr. Yuh wrote an open letter to his fellow pharmacists across the state. "I am ashamed to have to write this letter and admit my stupidity, actually my extreme short-sightedness caused by greed and induced by promises of quick easy money," he wrote.

Mr. Yuh told The Bay Citizen that he still regrets his decision to fill online prescriptions, but that he will not sign up for the state's online prescription system until it is mandatory. "In the pharmacy world, every minute there is constant work," he said. "If an order comes, we have to move it out as fast as we can. There's no time to think about it."

http://www.nytimes.com/2012/04/08/us/poor-participation-hobbles-californias-drug-oversight.html?hpw=&pagewanted=print

The Autism Wars - NYTimes.com

THE report by the Centers for Disease Control and Prevention that one in 88 American children have an autism spectrum disorder has stoked a debate about why the condition's prevalence continues to rise. The C.D.C. said it was possible that the increase could be entirely attributed to better detection by teachers and doctors, while holding out the possibility of unknown environmental factors.

But the report, released last month, also appears to be serving as a lightning rod for those who question the legitimacy of a diagnosis whose estimated prevalence has nearly doubled since 2007.

As one person commenting on The New York Times's online article about it put it, parents "want an 'out' for why little Johnny is a little hard to control." Or, as another skeptic posted on a different Web site, "Just like how all of a sudden everyone had A.D.H.D. in the '90s, now everyone has autism."

The diagnosis criteria for autism spectrum disorders were broadened in the 1990s to encompass not just the most severely affected children, who might be intellectually disabled, nonverbal or prone to self-injury, but those with widely varying symptoms and intellectual abilities who shared a fundamental difficulty with social interaction. As a result, the makeup of the autism population has shifted: only about a third of those identified by the C.D.C. as autistic last month had an intellectual disability, compared with about half a decade ago.

Thomas Frazier, director of research at the Cleveland Clinic Center for Autism, has argued for diagnostic criteria that would continue to include individuals whose impairments might be considered milder. "Our world is such a social world," he said. "I don't care if you have a 150 I.Q., if you have a social problem, that's a real problem. You're going to have problems getting along with your boss, with your spouse, with friends."

But whether the diagnosis is now too broad is a subject of dispute even among mental health professionals. The group in charge of autism criteria for the new version of the Diagnostic and Statistical Manual of Mental Disorders has proposed changes that would exclude some who currently qualify, reducing the combination of behavioral traits through which the diagnosis can be reached from a mind-boggling 2,027 to 11, according to one estimate.

Biology, so far, does not hold the answers: there is no blood test or brain scan to diagnose autism. The condition has a large genetic component, and has been linked to new mutations that distinguish affected individuals even from their parents. But thousands of different combinations of gene variants could contribute to the atypical brain development believed to be at the root of the condition, and the process of cataloging them and understanding their function has just begun.

"When you think about that one in 88, those 'ones' are all so different," said Brett Abrahams, an autism researcher at Albert Einstein College of Medicine. "Two people can have the same mutation and be affected very differently in terms of severity. So it's not clear how to define these subsets."

Some parents bristle at the notion that their child's autism diagnosis is a reflection of the culture's tendency to pathologize natural variations in human behavior. Difficulty in reading facial expressions, or knowing when to stop talking, or how to regulate emotions or adapt to changes in routine, while less visible than more classic autism symptoms, can nonetheless be profoundly impairing, they argue. Children with what is sometimes called "high functioning" autism or Asperger syndrome, for instance, are more likely to be bullied than those who are more visibly affected, a recent study found — precisely because they almost, but don't quite, fit in.

In a blog entry, Christa Dahlstrom wrote of the "eye-rolling response" she often gets when mentioning her son's autism by way of explaining his seeming rudeness: "The optimist in me wants to hear this as supportive (Let's not pathologize differences!) but the paranoid, parent-on-the-defensive in me hears it as dismissive."

There are, Ms. Dahlstrom acknowledges, parents of children with autism whose challenges are far greater. And perhaps it stands to reason that at a time when government-financed services for such children are stretched thin, the question of who qualifies as autistic is growing more pointed. " 'You don't get it; your kid is actually toilet trained,' " another mother told her once, Ms. Dahlstrom recalled. "And of course she was right. That was the end of the conversation."

But Zoe Gross, 21, whose autism spectrum disorder was diagnosed at age 4, says masking it can take a steep toll. She has an elaborate flow chart to help herself leave her room in the morning ("Do you need a shower? If yes, do you have time for a shower?"). Already, she had to take a term off from Vassar, and without her diagnosis, she says, she would not be able to get the accommodations she needs to succeed when she goes back.

According to the C.D.C., what critics condemn as over-diagnosis is most likely the opposite. Twenty percent of the 8-year-olds the agency's reviewers identified as having the traits of autism by reviewing their school and medical records had not received an actual diagnosis. The sharpest increases appeared among Hispanic and black children, who historically have been less likely to receive an autism diagnosis. In South Korea, a recent study found a prevalence rate of one in 38 children, and a study in England found autism at roughly the same rate — 1 percent — in adults as in children, implying that the condition had gone unidentified previously, rather than an actual increase in its incidence.

Those numbers are, of course, dependent on the definition of autism — and the view of a diagnosis as desirable. For John Elder Robison, whose memoir "Look Me in the Eye" describes his diagnosis in middle age, the realization that his social awkwardness was related to his brain wiring rather than a character flaw proved liberating. "There's a whole generation of people who grew up lonelier and more isolated and less able to function than they might have been if we had taken steps to integrate them into society," he said.

Yet even some parents who find the construct of autism useful in understanding and helping children others might call quirky say that in an ideal world, autism as a mental health diagnosis would not be necessary.

"The term has become so diffuse in the public mind that people start to see it as a fad," said Emily Willingham, who is a co-editor of "The Thinking Person's Guide to Autism." "If we could identify individual needs based on specific gaps, instead of considering autism itself as a disorder, that would be preferable. We all have our gaps that need work."

http://www.nytimes.com/2012/04/08/sunday-review/the-autism-wars.html?hpw=&pagewanted=print

“The Errors of Their Ways” by Rachel Giese | The Walrus | April 2012

DURING CHRIS HICKS' third year of studies at a small medical school in southern Ontario, he developed a fear, one that must torment all aspiring physicians: that he would kill a patient — or, worse, all of them. His dread grew as he prepared for his 2003 clerkship, when medical education shifts from the classroom to the actual work of caring for patients in hospitals. He and his fellow students practised resuscitations on mannequins. Time after time, he tried to save his mannequin, and time after time it died. So he was terrified when he met his first real patient, a cyanotic baby girl who had turned blue from lack of oxygen. "I thought, 'The killing spree begins,'" he says.*

But the infant survived, and so did Hicks, and a few weeks later he found himself on a neurology rotation, caring for a man in his sixties who had recently suffered a spinal cord infarction, a stroke that left him paralyzed from the chest down. The patient was affable and cheerful, despite his illness. Hicks liked him. The plan was to move him into a rehabilitation hospital or long-term care facility once his condition was stable.

A common complication in immobile patients are pressure ulcers, sores that develop where the skin meets the surface of a bed or a wheelchair for long periods. They can appear quickly: within hours, a warm, reddish or purplish spot turns into an open wound, and within a day or two the flesh becomes necrotic. Often they don't heal, and if an infection develops and spreads to the bone or the bloodstream it can be fatal. These sores are particularly pernicious among the elderly and those who suffer from circulatory problems, diabetes, drug and alcohol addictions, or poor nutrition. The sicker the patient, the more serious the risk.

To prevent tissue damage from lack of blood circulation, patients must be turned every two hours. As a student, however, Hicks was unfamiliar with pressure ulcers and their treatment. After the patient had been on the neurology ward for a few weeks, he developed a large sore, about the size of a man's palm, over his sacrum. The attending physician and the nursing staff knew the patient was at risk for bedsores and had ordered a special air mattress that reduces their incidence, but the hospital only had two, and both were in use. Still, given that the potential for sores had been recognized, Hicks was unsure why the ulcer had developed: Had the nurses neglected to turn him? Had the attending physician forgotten to instruct them to do so? Should Hicks have examined the man more thoroughly to determine whether he was developing sores? Was this a case of negligence, or a failure to communicate?

A plastic surgeon was called in to treat the ulcer and debride the wound. Because of his paralysis, the patient couldn't feel anything, and Hicks remembers with horror listening to him happily chat with them while the dead tissue was dug away from his back, exposing his spine. Two days later, when Hicks returned to the ward, he looked at the patient's chart. In capital letters, the plastic surgeon had written, "This was a medical error and it needs to be explained to the family as such." Hicks remembers the moment, he says, "like it was the Kennedy assassination. I thought, that's the end of my career."

When the attending physician explained the situation to the family, they were understanding, even after the patient developed sepsis, a bacterial infection. In many cases, this would have set off a chain of mounting treatments and attendant complications: a prolonged stay in the intensive care unit; more antibiotics; and invasive procedures, such as intubations, that can cause damage or infection. The patient's condition improved, however, and he was eventually able to leave the hospital.

Hicks, a lanky man with schoolboy glasses and a scruffy beard, is now in his early thirties. He works at St. Michael's Hospital, a teaching facility in downtown Toronto, as an emergency physician and trauma team leader. Eight years afterward, this early experience continues to shape his interests as an academic; at the University of Toronto's medical school, he conducts research in the fields of team performance, patient safety, and error prevention. He still wonders about his role in the case, and whether a better medical student would have recognized the ulcer sooner. Back then, he says, "I assumed that it was a knowledge problem, that when I learned more I wouldn't make those kinds of mistakes."

Writ large, the entire medical profession has been engaged in its own long stomp from ignorance to knowledge, from bloodletting and incantations to an ever more precise understanding of anatomy and disease, germs and genetics. Today the practice of medicine draws from a variety of disciplines, including biology, chemistry, physics, engineering, computing, and psychology, and the field exemplifies the triumph of human intelligence, diligence, and creativity. Vaccinations have eradicated polio from developed countries and are poised to do the same in the developing world. Kidneys, hearts, and lungs can be removed from one body and transplanted into another. Ultrasound and magnetic resonance imaging enable non-surgical access to the mysteries of the womb and the brain. Deadly micro-organisms are vanquished by antibiotics, shattered bones are mended, and sheared-off limbs are reattached, or replaced with bionic prostheses. Laser eye surgery allows the myopic to cast off their glasses like pilgrims at Lourdes. Three medications released over the past fifty years — the birth control pill, Prozac, and Viagra — have fundamentally altered our sexual, emotional, and social lives.

Yet as the tools for healing proliferate, so do the difficulties in determining and executing correct diagnoses and treatments; each discovery creates new opportunities for mistakes, side effects, and dangers. Modern medicine is plagued by adverse events such as the one suffered by Hicks' patient: potentially preventable, unintended injuries or complications caused by health care management itself. They encompass the out-and-out mistakes (such as misdiagnoses or surgical slips), as well as the system breakdowns that bedevil hospitals (inconsistent hand washing protocols, or poor communication during patient transfers). A 2004 study estimates that 7.5 percent of Canadians who are admitted to hospitals each year experience at least one adverse event. These errors are responsible for more than a million extra days spent in medical facilities, and the resulting annual death toll may be as high as 24,000.

Consider some notable cases: in the 1980s, negligence in the testing of blood products by the Canadian Red Cross allowed the spread of HIV/AIDS infections to 2,000 people and hepatitis C to at least 30,000 others. More recently, the bungling of pathology reports in Newfoundland and Labrador led to hundreds of patients being given inaccurate breast cancer screening results. And according to a 2011 report from the Organisation for Economic Co-operation and Development, Canada ranks among the worst of the thirty-four member nations for adverse events related to surgery. The list of mishaps reads like a series of David Cronenberg plot treatments: obstetrical trauma, foreign objects left inside the body during procedures, accidental punctures or lacerations, and post-operative sepsis.

Even the most temperate doctors call this state of affairs an "epidemic" of errors, and unfavourably compare safety records in medicine with those of other high-stakes, high-pressure professions such as aviation. More troubling is just how intractable and complicated the problem remains. The most obvious, culpable offenders — the pill-pushing quack, or the cowboy with a scalpel — are the outliers, and the most dramatic mistakes, such as amputating the wrong leg, are comparatively rare. Rather, medical error consists of thousands of small screw-ups and oversights: the unnecessary cases of post-surgical deep-vein thrombosis, or the one in ten patients given the wrong dose or type of medication. These misadventures persist despite, and even because of, medicine's growing sophistication and our increased expectations of its efficacy. So if we want to understand medical error and why it is so prevalent, we must start with the question that has dogged Chris Hicks for nearly a decade: how is it that a man admitted to a well-run twenty-first-century hospital to be treated for a stroke can leave sicker than when he arrived?

T
HE AMERICAN medical industry has long known about the problem of adverse events, largely due to the rise in malpractice claims in the 1980s. When Hicks began his medical training, the received wisdom surrounding medical error was heavily influenced by malpractice litigation: someone had screwed up, and they would have to pay for it. Error was viewed as resulting from ignorance or negligence — doctors or nurses gone rogue. Even the long-standing tradition of morbidity and mortality rounds (M&Ms, open discussions between physicians about their mistakes) contributes to this perspective. M&Ms often focus on content or skill — on what a doctor didn't know, or didn't know how to do.

To determine whether litigation was improving or hindering care, the Harvard Medical Practice Study in 1991 quantified the scope and nature of medical mistakes. Its findings, chief among them significant rates of death and disability caused by medical mishaps, were startling. But the results didn't achieve traction outside the medical field until 2000, when the National Research Council published To Err Is Human: Building a Safer Health System, based on a report by the US Institute of Medicine. Among its most shocking statistics: "Preventable adverse events are a leading cause of death in the United States…at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors."

Shortly afterward, the British Medical Journal devoted an issue to the subject. "In the time it will take you to read this editorial, eight patients will be injured, and one will die, from preventable medical errors," the opening article announced. "When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment."

It's so embarrassing, and the threat of litigation so unnerving, that physicians have long been reluctant to discuss mistakes. The BMJ editorial goes on to note that "we tend to view most errors as human errors and attribute them to laziness, inattention, or incompetence." Like Hicks, many doctors were taught that individual diligence alone should prevent medical errors, and that admitting their existence could lead to lawsuits, humiliation, or job loss. In Canada, Ross Baker — now a professor of health policy at the University of Toronto and director of graduate studies at the university's Centre for Patient Safety — followed these discussions with anticipation. He and his colleagues across the country involved in the then nascent health care safety movement hoped the alarming data would incite action here in Canada. Instead, To Err Is Human was viewed as proof that the American system was fundamentally flawed. So in 2004, Baker and Peter Norton, now a professor emeritus in family medicine at the University of Calgary, published a paper, The Canadian Adverse Events Study. "There was no conspiracy to hide this information," Baker says. "No one had looked carefully at the data before." The researchers erred on the conservative side in their estimate of preventable medical errors (by their count, up to 23,750 patients had died as a result of these mistakes in 2000), opting not to include incidents if they suspected any doubt or ambiguity about whether such occurrences constituted mistakes, which suggested that the problem is actually larger. (No formal follow-up has been done since.)

Paradoxically, the problem has been exacerbated as the field of medicine has grown more complex. In the 1960s, as scientific and technical wisdom developed, physicians began to specialize, which vastly improved medicine — the more narrow the focus, the greater the expertise and skill — but it meant that an individual patient's care was now shared among multiple practitioners. In the case of a child who suffers a head trauma, for example, her treatment may be handled by dozens of professionals: paramedics, emergency doctors and nurses, a neurologist, a neurosurgeon, an anesthesiologist, surgical and ICU nurses, pharmacists, pediatricians, residents and medical students, occupational therapists, and so on. As the patient is handed from one to the next, myriad opportunities arise for her medical history to be lost, for conflicting drugs and treatments to be prescribed, for lab results to be delayed, for symptoms to be overlooked, and for confusion in the transmission of vital information.

James Reason, a British psychologist specializing in human error, has dubbed this "the Swiss cheese model," in which small, individual weaknesses line up like holes in slices of cheese to create a full system failure. And in a modern hospital environment — a busy, stressful setting with many competing priorities, where decisions are made under duress, with frequent shortages of nurses, beds, and operating rooms — a patient's care slipping through the holes at some point is almost inevitable.

Failings in teamwork and communication compound these flaws, which according to patient safety research lie at the core of preventable adverse events. Baker likens the health care field to "a series of tribes who work together but don't really understand one another." To put it less diplomatically: egos, territorialism, and traditional hierarchies can create toxic environments in hospitals, where senior physicians disregard input from nurses and junior staff, who in turn become resentful and defensive.

The patient safety movement Baker helped initiate in the early 2000s profoundly changed the conversation about medical error. It was no longer a matter of assigning blame, but of improving bad systems. In Canada, the Halifax Series, an annual symposium about quality in health care, was launched in 2001; and a few years later, the Canadian Patient Safety Institute, an advocacy and research body, opened its offices in Edmonton and Ottawa. Hospitals across the country recruited safety experts to advise them, and to encourage physicians and other practitioners to talk more openly about adverse events.

The focus on flawed systems made addressing the problem an easier sell, especially as it became evident that the rampant problems in health care were errors of omission, not commission. While the old malpractice model routed out villains, the systems approach tackled the day-to-day snafus that frustrated everyone: long waits in the emergency department, under-stocked supply rooms, vague lines of communication, and so on.

To Kaveh Shojania, co-author of the 2004 book Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, shocking statistics about medical error are useful mainly as headline grabbers, drawing attention to more quotidian concerns about quality improvement. Shojania, an internist at Sunnybrook Health Sciences Centre in Toronto and director of the Centre for Patient Safety at U of T, says the root of the problem is the ad hoc way medicine was established over its long history. He compares it to a series of cottage industries that developed with no larger organizing vision. The medical industry has grown so vast and complicated that tackling inefficient systems is akin to untying a Gordian knot.

In his cluttered office on the sprawling Sunnybrook campus, Shojania, an Eeyore-ish fellow in a rumpled suit, navigates through stacks of files, books, and papers to show me an image on his computer. It's a drawing of a Rube Goldberg pencil sharpener, a ridiculously convoluted device that involves a kite, an iron, an opossum, a rope, a woodpecker, and moths. That's the current medical system, he tells me by way of analogy. "This isn't an issue of incompetent people making stupid mistakes," he says. "It's many average, decent people working in poorly designed systems. Most medical mistakes were accidents waiting to happen."

T
ALK TO any error expert, and the conversation turns, inevitably, to Tenerife, in the Canary Islands, March 27, 1977, when two commercial jumbo jets collided on a runway, killing 583 people. A series of small mishaps set the accident in motion: one of the planes had been diverted from another airport, and there was pressure to make up time; fog obscured the runway; and the directions from the control tower may have been unclear, leading one pilot to believe he had clearance to fly. The most chilling aspect of the disaster was that the pilot disregarded the warnings from his co-pilot, who told him not to take off. At the time, such maverick behaviour was standard, but Tenerife changed that. The aviation industry began to emphasize crew resource management (CRM) techniques: more teamwork and collaboration; improved communication; and greater adherence to protocols, through the use of checklists, which break down the complex operation of planes into more manageable, standardized chunks.

Aviation has had tremendous success with this approach, lowering its rate of fatal accidents even as the number of flights worldwide has increased. In 1991, all the jet airplanes in the world logged about 20 million hours in flight, a number that leaped to over 46 million in 2008. During that time, the rate of fatal accidents has declined steadily toward zero, with Canadian and US operators performing better than the global average.

Three decades after Tenerife, in January 2009, US Airways 1549 made its miraculous emergency landing on the Hudson River. As it happened, the captain, Chesley Sullenberger III, was an aviation safety expert, and the industry credited the secure landing to the flight crew's strict observance of CRM techniques.

As with the airline industry, the practice of medicine requires discipline, teamwork, complex decision-making under pressure, and a facility with evolving science and technology. So when Peter Pronovost, a physician at Johns Hopkins Hospital in Baltimore, Maryland, was searching in 2001 for models to improve patient safety, he turned to aviation checklists for guidance. In particular, he was seeking a way to reduce infection rates from central lines, catheters inserted into large veins in the neck, chest, or groin to deliver medication, draw blood, or monitor heart function. Such infections are common enough to be considered unavoidable in hospitals, yet their cost to the system is immense.

Inserting a central line is tricky: in the neck, for instance, a doctor must negotiate a needle around the clavicle to find the subclavian vein, and meanwhile avoid hitting the carotid artery or sticking herself. Once the line is in place, there's a potential for infection, especially if the procedure was performed under less than sterile conditions. To mitigate that risk, a doctor should don clean gloves, a mask, and a gown; cover the patient with a full-body drape; and disinfect the area on the patient's body (an ultrasound probe wrapped in a sterile cover is often used to guide the needle). Following this protocol takes about three to ten minutes and appreciably lowers the chance of harm and infection. In the past, doctors often took shortcuts, typically because supplies weren't right at hand, or the procedure wasn't standardized at their facility.

Pronovost devised a simple solution: all the necessary equipment was to be assembled and stored in a bundle or on a cart, and a nurse would consult and monitor a short, step-by-step checklist while the doctor inserted the line. When the Michigan Health and Hospital Association implemented the central line checklist statewide in 2003, hospital-acquired infections dropped from 2.7 per 1,000 patients to zero; within months, hundreds of lives were saved, along with millions of dollars in costs to treat infections. Many North American hospitals have adopted a central line protocol, and the checklist method has been adapted to other functions, such as monitoring patients at risk for bedsores.

The checklist encourages collaboration and empowers other staff to speak up if they notice the doctor veering from the protocol — a classic CRM virtue. It also prevents physicians from relying on automatic behaviour, the kind of unconscious momentum that develops when performing an oft-repeated task. Running on autopilot isn't necessarily a bad thing: doctors must retain a great deal of information and act swiftly. But automatic behaviour can also cause slips, particularly in high-stress situations, when medical practitioners can forget critical details. The checklist forces them to be methodical. It does their thinking for them.

Here in Canada, the checklist protocol is also changing how medications are recorded and tracked upon patients' admission to and release from hospital. About half of patients experience accidental drug discrepancies upon admission to acute care hospitals, and at least 40 percent on discharge. For example, an ongoing prescription might not be dispensed to them during their hospital stay, or a new medication used in the hospital might be contraindicated with one they already take. To remedy this, hospitals are now required to create an accurate list of a patient's home prescriptions on admission. A 2008 pilot study at Sunnybrook Hospital found that half of the discrepancies caught by the new reconciliation method could have caused harm had they not been identified and corrected.

As a model for medicine, though, the aviation approach has its limitations. Even with smarter, more efficient practices such as checklists, vexing human factors remain. In the case of the medication reconciliation strategy, practitioner buy-in presents the most significant hurdle: doctors say they are too busy to handle more paperwork; nurses feel that monitoring medication is a doctor's responsibility; and pharmacists, who are in the best position to perform the task, can't do it because hospitals can't afford to hire more of them. The dilemma is one of too little time and too few resources, says Shojania, and the targets are perpetually moving. There are ever-more diseases and diagnoses to understand, medications to juggle, procedures to study, and technologies to master.

Shojania shows me another image on his computer, of a person's wrist wrapped in five medical bracelets that snake halfway up to the elbow, each noting a different risk or indicating a reminder about the patient's care plan. Taken separately, each of these wristbands provides valuable information, but as a whole they can create, rather than lessen, confusion. Even for a systems type like Shojania, this takes the systems approach too far: "Who is even going to bother to look at all of those?"

T
HE PENDULUM may have swung too far. Perhaps adverse events don't just result from faulty systems, but also, as some experts suggest, from faulty thinking. The myth persists that doctors are judicious, rational creatures of science, yet even the best clinicians can be biased by any number of factors: their age, gender, class, or emotional state; their personal and professional histories; the team around them at any given moment; and their level of fatigue or stress. How much of what physicians do wrong is because the way they think is wrong?

Dalhousie University in Halifax has become a research and training hub for teaching doctors to think better. This is in large part due to Patrick Croskerry, an emergency doctor with a Ph.D. in clinical psychology, and a renowned expert in the fields of cognition, clinical decision-making, and medical error. On an unusually hot and humid November afternoon, I am ushered into an office at Dalhousie's medical school to meet with him and two of his colleagues: Preston Smith, senior associate dean of medicine, and David Petrie, an emergency physician and trauma team leader.

Early in his career, Croskerry was struck by the role of cognition in clinical decision-making, the mental processes doctors engage in when determining a diagnosis and a course of treatment. In the 1990s, well before the issues of medical error and patient safety were widely discussed, he began to study and write about the various factors that affect a physician's judgment, from unconscious biases to the impact of stress and time pressure. Diagnosis, for instance, is among the most crucial tasks in medicine and must be performed correctly, he says. Yet despite all the diagnostic technologies now at doctors' disposal — blood tests, X-rays, CAT scans, and so on — they still exhibit a 10 to 15 percent failure rate. Why do they get it wrong so often?

To make his point, Croskerry relates the example of a gifted young Halifax linebacker who recently reported for a football game despite having been sick for over a week. It was a tough game and he played hard, but at halftime he felt ill and signalled the team's doctor, who took a quick history of his illness: fever, cough, sore throat, headache, and fatigue. Convinced it was pneumonia, the doctor wrote the player a prescription for antibiotics and told his parents to take him home and put him to bed.

But the parents were worried and called an ambulance, and when the paramedics arrived they asked the athlete to explain his symptoms. Paramedics work on algorithms, utilizing systematic procedures to efficiently deduce medical priorities from the evidence and symptoms they observe. In this case, the paramedics heard "sore throat and coughing" and the doctor's diagnosis of pneumonia, so they only examined his chest, assuming a healthy young athlete couldn't be suffering from anything serious. They suspected the parents were overreacting but took him to a hospital anyway. There, the triage nurse listened to the paramedics and put him in a low-priority area. Eventually, he saw a physician, who as part of his routine check palpitated the young man's belly, which was tender. The doctor sent him for a CAT scan, where the imaging revealed that he had a ruptured spleen. As it turned out, the football player had infectious mononucleosis, which can cause swelling of the spleen. During the game, he had been hit several times, and as a result the inflamed organ had burst.

This, Croskerry says, is exactly how otherwise smart, well-trained professionals can make such incorrect diagnoses. Point by point, he dissects the errors: the first doctor did a "drive-by" diagnosis, the paramedics couldn't see past the patient's youth and general good health, and the triage nurse got caught up in the diagnostic momentum. This was mainly the fault of what psychologists call "anchoring." The practitioners ignored multiple possibilities for the cause of the linebacker's complaints and seized upon the first and most notable pieces of information. Once that anchor was down, they ignored all other details and neglected to investigate further.

Anchoring is just one example of more than a hundred identified heuristics, cognitive shortcuts that could also be called common sense, or rules of thumb, beliefs based on experience and intuition. The practice of medicine uses heuristics all the time — symptoms A, B, and C usually suggest X diagnosis, or this type of person is more prone to this disease than that one — but heuristics also play a major role in biased thinking. Israeli psychologists Daniel Kahneman and Amos Tversky wrote a formative paper in 1974 on heuristics and biases in judgment and decision-making. They identified several factors, a widespread one being representativeness, illustrated by the idea that, say, librarians tend to be sober and methodical, or that boys love to play with toy guns. As the authors note, "These heuristics are highly economical and usually effective, but they lead to systematic and predictable errors." In other words, these generalizations hold up most of the time, but some librarians are, in fact, risk-taking party animals, and some little boys prefer Barbies.

Many of these biases are widely recognized in medicine, such as "psych-out error"; or the dislike or disregard for mentally ill people, who may be assumed to be delusional or drug-seeking. Another common bias is gender: women are often misdiagnosed when they have heart attacks, which are seen as mainly affecting men. Overconfidence in one's own intuition and expertise constitutes another cognitive pitfall. Then there's Sutton's slip, named after a criminal who, when asked by a judge why he robbed banks, replied, "Because that's where the money is!" Less conspicuous possibilities may be overlooked in favour of obvious ones.

To reduce the instances when heuristics fail, physicians need to develop meta-cognition, an awareness of why they think what they're thinking. Historically, medical school has focused on content and skill, not critical thinking; Croskerry calls the traditional training "filling coconuts with a lot of facts." He instructs physicians to recognize their biases, teaching them to take themselves out of the immediate pull of the situation and say, "I've just locked on to something. Why did I come to that particular conclusion, and what else should I be thinking of?" — which applies to groups as well as individuals. "If the whole team is stampeding toward a diagnosis, we want someone to detach themselves and ask, what else could this be?"

The capacity for meta-cognition has become even more critical as medicine has progressed. Preston Smith pulls out his smart phone and lays it on the table. "The medical database is doubling every three to five years," he says, "but all that content is now readily available on devices like this." That's undoubtedly a boon, but understanding how to wade through this information requires clear thinking and self-awareness.

Indeed, as medical intervention pushes its limits, extending lifespans, curing previously fatal illnesses, and stimulating the body's capacity to heal, sound judgment will serve as one of a physician's most necessary skills. "You can fill that coconut up with every medical fact ever known," David Petrie says, "and that still won't lead to good decisions. In the future, as we continue to know more and continue to have more treatment options, there will be far more of a premium on complex problem solving."

Yet, as compelling and as intuitive as this approach may seem, demonstrating its efficacy could prove impossible. Did a doctor make the right diagnosis because he recognized his bias and corrected it, or because the evidence was particularly clear? Croskerry readily acknowledges that addressing medical error through sharpening cognition and decision-making doesn't easily offer quantitative evidence of success. But does that matter? "It's a little like jumping out of a plane without a parachute," he says. "I'm not sure we need to do a study to show that it's a bad idea."

THIRTY-SIX-YEAR-OLD man named John is lying on stretcher with his head and neck stabilized by a brace, in a trauma room at St. Michael's Hospital. He's barely conscious, he's sweating, his breathing is rapid, and he has soiled himself. One of the paramedics who brought him in explains to the four doctors in the room that the man was found on the floor of the shipping warehouse where he works, covered in an unidentified liquid. It appears that he fell from a height, perhaps a catwalk, and suffered a lung injury.

The physicians start the usual procedures: they insert an IV, monitor the patient's vital signs, assist his breathing with a manually pumped bag valve mask, and order chest X-rays. Then the situation falls apart. His blood pressure drops, and his breathing is reduced to gurgling wheezes; the doctor tries to intubate him, but he can't get the tube through John's airway. The X-rays reveal no trauma, just fluid in the lungs. The team is confused about the diagnosis, and they move slowly and uncertainly about their tasks, second-guessing their theories aloud, then falling quickly into silence. Meanwhile, the paramedic, now wheezing and coughing himself, won't stop talking, and he hovers around the exam table, offering suggestions. In an attempt to get rid of him, one of the physicians orders him to go see a doctor. "But aren't you a doctor?" the paramedic snaps back.

Eventually, the team deduces that the patient is reacting to a toxic chemical. John starts having a seizure. While urging the doctors to call poison control, the paramedic collapses against a wall. They fumble, because they don't know the number. He recites it to them, then he too falls into a seizure. A phone consultation with a toxicologist confirms that John was exposed to a dangerous insecticide that still covers his skin and clothing. The paramedic has been exposed to it, and likely so have the physicians. They look at one another: no one has bothered to put on a mask, gloves, or a gown. "Oh, shit," the team leader says with resignation. Everyone stalls. John and the paramedic seem forgotten.

Just then, Ken Freeman, a fifth-year resident who has been observing the scene from behind a two-way mirror in the next room, enters and ends the simulation session. Chris Hicks, who has been playing the paramedic, gets up from the floor. The four physicians — three medical students and a first-year resident — abandon John, an expensive high-tech mannequin, to his lonely gurgling and spasms, and shuffle into a conference room to debrief.

Medical schools rely on such exercises to train doctors before they see real patients. In St. Michael's state-of-the-art simulation centre, students and residents are taught to perform surgeries, intubations, and other procedures on robotic patients that are programmed to sweat, breathe, convulse, blink, maintain a pulse (or not), and have heart attacks. The setting exactly mimics a real examination, trauma, or operating room. Roger Chow, the amiable wizard-behind-the-curtain technician who operates John's physiology from a computer, has a perfectionist's commitment to vérité. When I met him before the session, he was emptying the contents of a colostomy bag under the mannequin's butt. Later, he would feign an excellent Darth Vader rasp into the microphone: John's gasping voice.

Hicks uses these simulations to develop teamwork, communication, and reasoning abilities. As artificial as the scenario felt at the start, within minutes the students were caught up in the curious symptoms, the jabbering interloper's interruptions, the awkwardness of solving a problem with a group of strangers, and the humiliation of being wrong. This forms the nexus of the systems and cognitive approach: learning to work efficiently and competently within a group, and to think clearly and rationally under pressure.

Freeman opens the discussion Socratically: "So, how do you think it went?" One student looks mortified: "Well, I think we killed our patient, so it didn't go well." Another, the most senior participant, says the team was fragmented and couldn't figure out how to operate as a group, and they became too flustered by Hicks. Someone else regrets forgetting to put on gloves, what seems like an amateur mistake. After listening for a few minutes, Freeman gently reminds them of what they did right. They remembered the ABC's, he tells them, a mnemonic for "airway, breathing, and circulation." He adds that intubation is especially difficult to perform on a mannequin, because its rubber throat is stiff. Hicks tells them he has witnessed experienced doctors subjected to a similar simulation, and has watched all of them walk past a shelf stacked with gowns, masks, and gloves without grabbing them.

The conversation continues in this vein for a half-hour, and later they will spend another two hours learning about toxicology and how to treat poisoning. Freeman and Hicks say little, allowing the students and the resident to interrogate themselves and each other. Questions are raised about the team leader's role, how to vocalize information and suggestions, how to handle distractions like the chatty paramedic, and how to respectfully challenge a colleague's decision. This freedom to openly parse their mistakes and faulty thinking is important. Perhaps when dealing with a real patient, they will be more confident in asking for help, questioning their colleagues, or consulting a checklist.

A few weeks earlier, over coffee, Hicks had told me that one of the reasons he decided to become an emergency physician was that he hated the idea of not knowing how to handle a crisis. The specialty appealed to him because emergency and trauma present all kinds of acute situations, involving every part and system of the body. I remembered this after the debriefing, when Hicks told the group that poisoning cases such as this are atypical, and that as emergency doctors they may only encounter a few of them during their careers. Still, they will spend the day immersed in the subject, aiming to refine their knowledge, because that's what doctors do — and it's what we need them to do.

Training will never entirely inoculate doctors from making mistakes, because science and medicine are too complex and too imperfect, and human beings inevitably remain terminal cases. But in its ideal form, the medical profession looks something like this: a group of serious, curious, compassionate practitioners perpetually grappling with how they can do better.

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