Friday, June 8, 2012
Thursday, June 7, 2012
Toward the end of last month, Mike Sevilla, MD, spoke to a crowd of 100 at the Connecting Healthcare + Social Media Conference on why physicians ought to be on social media. Although multiple such outlets exists — Facebook, Google+, LinkedIn — none have appealed quite so strongly to physicians as Twitter.
Here are 10 physicians, in no particular order, who have mastered the art of Twitter.
1. Kevin Pho, MD – @kevinmd With approximately 53,000 followers, Kevin Pho, MD, tops our list of doctors to follow on Twitter. Pho blogs regularly at KevinMD.com and is on USA Today's board of contributors. He is consistently cited by major media outlets, and touts his blog as, "the Web's leading destination for proactive physician commentary on breaking medical news."
2. Mike Sevilla, MD – @drmikesevilla Formerly known as Dr. Anonymous, Sevilla tweets regularly and is the blogger behind FamilyMedicineRocks.com. He is known for being an advocate for physicians on social media, all while giving followers and blog readers a behind-the-scenes look at life as a family practitioner. He also hosts Family Medicine Rocks on Blog Talk Radio, where he reviews current industry events, news, and all things social media.
3. Val Jones, MD – @drval Val Jones, MD, is a power tweeter and the founder behind Better Health, LLC, a network of 130 plus medical bloggers, which includes content partners like the Centers for Disease Control and Prevention, the American College of Physicians, and Harvard Health Publications. Jones is the "anchor blogger" behind the network. Previously, she was the author of "Dr. Val and the Voice of Reason," which won The Best New Medical Blog award, back in 2007.
4. Tim Sturgill, MD – @SymTym Tim Sturgill, MD, is an emergency physician, manager, and director of social media at Emergency Medicine Physicians. He tweets regularly and has been blogging since 2004 at Symtym.com. Sturgill takes an active interest in not only emergency and disaster medicine, but also health law, policy and ethics, health informatics, and, most notably, social media.
5. Bertalan Meskó, MD – @berci Bertalan Meskó, MD, tweets regularly and is a speaker, blogger, consultant, and founder of Webicina.com, a collection of curated social media resources. On ScienceRoll.com, Meskó blogs about his "journey in genetics PhD and medicine through Web 2.0," as well as the integration of medicine, web services, and social media. Meskó graduated from the University of Debrecen Medical School and Health Center in 2009 and maintains a Hungarian medical blog as well at MedIQ.blog.hu.
6. Shelley Binkley, MD – @healthewoman Shelley Binkley, MD, tweets regularly and is an OBGYN advancing "healthEpeople." Binkley also founded HealthEwoman.org, where she writes brief articles on an array of topics pertaining to woman's health, making it easy for visitors to search and find quick answers to their questions. On HealthEwoman.org, Binkley makes clear she blogs for the sake of transparency and access, all while, as a physician, acting as a "sounding board to discuss [options] and together arrive at good medical decisions."
7. Mark Browne, MD – @consultdoc Mark Browne, MD, is a physician consultant, focusing on bridging healthcare, quality, and finance. He tweets regularly and blogs at the Pershing Yoakley & Associates Healthcare Blog,Bridging Business & Healthcare. Browne is clinically trained in both internal medicine and pediatrics and has more than 10 years experience in physician practice management and hospital executive settings.
[See also: Social media could 'accelerate clinical discovery'.]
8. Joseph Kim, MD – @DrJosephKim Joseph Kim, MD, is a physician executive and founder of MedicineandTechnology.com, NonClinicalJobs.com, MedicalSmartphones.com, and MobileHealthComputing.com. Kim has spoken nationally on topics pertaining to continuing medical education, mHealth, and social media. He is also the president of MCM Education, and he is a regular contributor to Physician Executive Journal.
9. Jay Parkinson, MD – @jayparkinson Jay Parkinson, MD, is a pediatrician and preventive medicine specialist who tweets and blogs regularly at blog.JayParkinsonMD.com. He is also the founder of Hello Health, a combination of a secure social network and an EMR that enables doctors and patients to connect both in their office and online. Fast Company called Parkinson the "doctor of the future," and he was listed as one of the Top 10 Most Creative People in Health Care. Parkinson also recently launched a design firm, The Future Well.
10. Mehmet Oz, MD – @DrOz Mehmet Oz, M.D. is a cardiac surgeon at New York Presbyterian Hospital, author and host of The Dr. Oz Show. He tweets regularly to more than 1,800,000 followers, and he blogs at DoctorOz.com. Oz has recently spoken on current business and technology challenges facing small physician practices. Oz also maintains his fan base on Twitter though the hashtags #OzTip and #OzApproved.
Wednesday, June 6, 2012
The report, published Wednesday in the journal Applied Physiology, Nutrition and Metabolism, estimated the total cost of a life of lassitude had reached approximately $6.8 billion in 2009, or 3.7 per cent of all health care costs.
Study author Ian Janssen mined a variety of data sources to arrive at the figures, which account for both the direct and indirect cost of physical inactivity.
Janssen said his estimates of physical activity levels throughout the country were based on Statistics Canada's Health Measure Survey, which tracked the movements of some 5,000 participants using an accelerometer.
This data was combined with scientific literature on the risks physically inactive people run of contracting seven common chronic diseases, as well as figures from Health Canada estimating the cost of treating those conditions.
Running those results through a series of mathematical models, Janssen said the direct cost of treating conditions associated with a sedentary lifestyle amounted to more than $2.4 billion. The indirect costs -- which he described as the loss of personal and financial productivity due to poor health -- added up to slightly above $4.3 billion, he said.
"It's important for people to understand that this is a very costly behaviour," Janssen said in a telephone interview from Kingston, Ont.
"We often think of medical care as the diseases themselves. We don't realize that those diseases are caused, in large measure, by our lifestyle behaviours and choices."
The report suggests the costs associated with sedentary lifestyles have been steadily increasing since 2001, a year in which Janssen pegged the overall cost at $5.3 billion or 2.6 per cent of total costs.
The most recent numbers can be explained in part by population growth and the country's aging demographics, Janssen said.
A stronger factor, however, is the increasingly reliable data illustrating exactly how little exercise Canadians are getting.
StatsCan's Health Measures Survey previously relied on self-reported data to gauge Canadians' exercise routines. Since the most recent survey relied on numbers gathered through electronic monitoring devices, however, Janssen said the country's dismal activity levels were clearly spelled out for the first time.
Between 2007 and 2009, only 15 per cent of adults were getting the recommended 150 minutes of weekly exercise. The country's youth were still more sedentary, with only nine per cent achieving the minimum amount of activity.
The report cautions that by only focusing on seven chronic diseases and workforce productivity, many cost drivers have not been factored into this most recent analysis. Still, the report said, the findings speak for themselves.
"Physical inactivity has surpassed epidemic proportions in Canada and accounts for a significant portion of health care spending," the report said.
Canada is not alone in shouldering a hefty price tag for a sedentary population. Janssen found seven per cent of Australia's economic health burden comes from inactivity, while direct costs account for between 1.5 and 2.5 per cent of health care spending in Switzerland, the U.K. and the United States.
Janssen said the widespread nature of the problem speaks to the complexities health care providers face when trying to address it.
"It's a very difficult thing to fix," Janssen said. "We're talking about something a lot of people don't necessarily like to do, they don't necessarily know how to do it .... It's simple in theory, but in reality it's very difficult to get people to engage in physical activity to improve their health."
Angela Torry, education Co-ordinator with the Alberta Centre for Active Living, agreed, adding most Canadians fail to appreciate the link between their inactive lifestyles and the chronic diseases they develop over time.
Janssen's research, she said, may shed light on that relationship for those who respond to economic facts.
For the rest of the country, however, Torry speculated the data would serve as only a minor incentive to get moving.
The more immediate physical, psychological and social benefits of an active life will do more to motivate Canadians to change their ways, she said.
"Yes the economic impact is important, but it's not necessarily the driving force behind what we do," she said. "We believe physical activity is important even beyond the numbers."
Tuesday, June 5, 2012
Doctors were told last month that we should stop doing so many screenings for prostate cancer with the prostate-specific antigen test. We learned that sigmoidoscopy is a cheaper, easier and effective alternative to colonoscopy for colon cancer screening. And a study I led turned up strong evidence that routine lung cancer screenings are justified only for people at high risk because of heavysmoking in the past.
Regular mammograms aren't necessary for women in their 40s and are needed only every two years for women ages 50 to 74, the United States Preventive Services Task Force has decided. For many women, Pap smears are required only every three years, not every year, the group also says now.
This deluge of do-less recommendations results from research into tests and procedures that have been arguably overused. You'd think these pronouncements would bring a sea change in the way patients are treated in this country. But my guess is that little will change. Many doctors, maybe most, will ignore these findings and keep doing what they have been doing all along.
The PSA test will still be ordered as a matter of routine, not selectively administered after careful discussion with patients. Colonoscopy will remain the accepted primary method for colon cancer screening. Radiology centers will continue to offer lung cancer screening to people who are unlikely to get lung cancer.
Why? Health care critics are quick to point to the profit motive. And it's true that gastroenterologists, radiologists, urologists and physicians of all stripes make money from procedures that may not be necessary. But the real obstacle is not money. It's the culture of doctors, and that will be very hard to change.
In medical school, I was given textbooks and made to memorize long lists of obscure facts, most of which have never come up in practice. Then I sat at the knee of master doctors. I followed them around. I learned to emulate what they did and how they thought. Over the years, I gained some approximation of their mastery. At times, I've even found myself mirroring how they stood and leafed through a patient's chart.
Subtly, and then overtly, I learned that as long as I trusted my instincts, I was probably going to be right. Because doctors know best.
Ours is a comfortable hegemony, particularly if you do not question it. It has teeth, too. A strong defense to a malpractice lawsuit is that you did what other doctors in your community would have done — the "community standard" test. Citing anodyne research written by faraway experts to back up your actions is a less preferable strategy.
Against the gravitational pull of doctor-knows-best culture, research studies that fail to confirm current practice often have surprisingly little effect on our behavior. Guidelines written by academic types only impact the fringes of our practices. And despite the apparent move toward evidence-based medicine and comparative effectiveness research, most of us still feel that our own experiences and insights are the most relevant factors in medical decision-making.
You really see this tension in cancer screening. Doctors who want to prevent cancer apply these tests as if they were treatments, as if getting a mammogram were somehow like prescribing anantibiotic. Our experience tells us these tests catch cancer in some patients — the woman in the exam room could be one of them. Complications can be handled. We've all handled them before.
But this is where our reliance on our instincts and experience may betray us. Screening involves a test conducted on a healthy person, not a treatment given to a sick person. It's comparatively easy for a doctor to see whether a treatment is working; that data point shapes our instincts and informs our experience going forward.
Screening is far less instructive for physicians. We can never tell how often a test makes an individual better or improves her prospects of survival. Neither is it possible to measure the effect of screening in your own practice. You must screen hundreds of patients to prevent a handful of cancer deaths. With routine mammography, you'd have to screen more than 1,000 women in their 40s to prevent just one breast cancer death.
Relying on individual doctors' judgments regarding whom to screen has already had bad consequences. A majority of cases of cervical cancer today are in women who have not had adequate Pap testing, even though we've had that test for more than half a century.
It is time for us to own up to our shortcomings in cancer screening, and we must start by acknowledging a hard fact: Doctors sometimes don't know best. We are terrific at inventing new tests that can be performed on people. But we have been less good at figuring out which people should have them.
Sunday, June 3, 2012
One study, published in the Journal of the American Medical Association, found no increase in patients' cancer risk. The second study, which ran three weeks later in the British Medical Journal, found the risk for developing cancer to be low, but doubled. Which conclusion was correct?
It is hard to tell, and the answer may be inconclusive. The main reason: Each analysis applied a different methodology and neither was based on original, proprietary data. Instead, both were so-called observational studies, in which scientists often use fast computers, statistical software and large medical data sets to analyze information collected previously by others. From there, they look for correlations, such as whether a drug may trigger a worrisome side effect.
The Food and Drug Administration says it is reviewing the conflicting U.K. data on the class of osteoporosis treatments known as oral bisphosphonates. The outcome matters given that millions take the drugs world-wide. If a substantial cancer risk is proven, it will force doctors to reconsider how they prescribe such drugs.
Merck & Co. says its Fosamax—one of the most popular drugs in the class—has been prescribed 190 million times since first being approved in 1995. Michael Rosenblatt, chief medical officer at the company, says that clinical trial data and more recent reports based on patient use "do not suggest an association between [the drug] and esophageal cancer."
While the gold standard of medical research is the randomly controlled experimental study, scientists have recently rushed to pursue observational studies, which are much easier, cheaper and quicker to do. Costs for a typical controlled trial can stretch high into the millions; observational studies can be performed for tens of thousands of dollars.
In an observational study there is no human intervention. Researchers simply observe what is happening during the course of events, or they analyze previously gathered data and draw conclusions. In an experimental study, such as a drug trial, investigators prompt some sort of change—by giving a drug to half the participants, say—and then make inferences.
But observational studies, researchers say, are especially prone to methodological and statistical biases that can render the results unreliable. Their findings are much less replicable than those drawn from controlled research. Worse, few of the flawed findings are spotted—or corrected—in the published literature.
"You can troll the data, slicing and dicing it any way you want," says S. Stanley Young of the U.S. National Institute of Statistical Sciences. Consequently, "a great deal of irresponsible reporting of results is going on."
Despite such concerns among researchers, observational studies have never been more popular.
Nearly 80,000 observational studies were published in the period 1990-2000 across all scientific fields, according to an analysis performed for The Wall Street Journal by Thomson Reuters. In the following period, 2001-2011, the number of studies more than tripled to 263,557, based on a search of Thomson Reuters Web of Science, an index of 11,600 peer-reviewed journals world-wide. The analysis likely doesn't capture every observational study in the literature, but it does indicate a pattern of growth over time.
A vast array of claims made in medicine, public health and nutrition are based on observational studies, as are those about the environment, climate change and psychology.
The numbers are expected to increase as more databases become available and generate more studies. One massive undertaking, for example, is the National Children's Study. Conducted by the National Institutes of Health, it will collect data on thousands of American children, all the way from birth to age 21, and assess how genetic and environmental factors may influence health outcomes.
Yet these biomarkers "are either completely worthless or there are only very small effects" in predicting heart disease, says John Ioannidis of Stanford University, who extensively analyzed two decades' worth of biomarker research and published his findings in Circulation Research journal in March. Many of the studies, he found, were undermined by statistical biases, and many of the biomarkers showed very little predictive ability of heart disease.
His conclusion is widely upheld by other scientists: Just because two events are statistically associated in a study, it doesn't mean that one necessarily sets off the other. What is merely suggestive can be mistaken as causal.
That partly explains why observational studies in general can be replicated only 20% of the time, versus 80% for large, well-designed randomly controlled trials, says Dr. Ioannidis. Dr. Young, meanwhile, pegs the replication rate for observational data at an even lower 5% to 10%.
Whatever the figure, it suggests that a lot more of these studies are getting published. Those papers can often trigger pointless follow-on research and affect real-world practices.
The problems aren't entirely new. In the late 1980s and early 1990s, a raft of observational studies consistently suggested that hormone-replacement therapy, or HRT, could protect postmenopausal women against heart disease. Tens of thousands of women were given the drugs on that basis.
It was a bad call. Many of the studies were eventually undermined because women who used the drugs were healthier than those who didn't, and thus had lower rates of heart disease anyway. Later controlled trials suggested that not only did HRT fail to protect against heart disease, but it might have increased the risk.
Observational studies do have many valuable uses. They can offer early clues about what might be triggering a disease or health outcome. For example, it was data from observational trials that flagged the increased risk of heart attacks posed by the arthritis drug Vioxx. And it was observational data that helped researchers establish the link between smoking and lung cancer.
Jan Vandenbroucke, a professor of clinical epidemiology at Leiden University in the Netherlands, dismisses some of the drawbacks of observational studies, saying they tend to be overblown. He notes that even controlled trials can yield spurious or conflicting results.
"Science is about exploring the data…it has a duty to find new explanations," he says. "Randomized controlled trials aren't intended to find any explanations."
In the case of most observational studies, investigators plumb existing databases, looking for associations between different variables—thus generating an observation or a "discovery."
That technique can yield confusing results. Between 1995 and 2008, the FDA received reports of 23 people, most of them women, who were diagnosed with esophageal cancer after taking an oral bisphosphonate. Similar reports came in from Europe and Japan.
The use of bisphosphonates has soared in recent years. In the U.K., about 10% of women over the age of 70 take the drugs, so even a small increase in cancer risk would indicate many new cancer cases.
At Queen's University in Belfast, cancer epidemiologist Liam Murray and his colleagues decided to assess the tumor risk of bisphosphonates. They embarked on an observational study using a computerized database containing anonymized patient records for about six million people in the U.K.—one of the largest such databases anywhere.
At roughly the same time, a separate group led by Jane Green of the University of Oxford, began a similar examination of the same U.K. database. The teams were unaware of each other's projects.
The Murray team found that the increase in esophageal or gastric cancer risk was 7% higher in those who took the drug versus those who didn't, leading to the conclusion the use of the drugs "was not significantly associated" with either cancer.
The Green paper in BMJ found the esophageal cancer risk was 30% higher for those on the drugs, and that the risk of esophageal cancer increased when the drugs were prescribed 10 or more times, or for longer than five years.
In other words: in the normal U.S. and European population, one out of every 1,000 people aged 60 to 69 will get the cancer. But for those who take Fosamax and other related drugs, the incidence rises to two in every 1,000.
There could be several reasons why the studies arrived at different conclusions, including varying methodologies. The Murray study first identified users of the drugs, matched them to random people of the same sex and age in the population, and then tracked them until some developed cancer.
The Green team identified the cancer cases first and then assessed which drugs they had been given in the past.
"We were looking forward, they were looking backward," says Christopher Cardwell, a medical statistician and co-author of the Murray paper in JAMA.
The opposing impressions provoked Daniel Solomon, a rheumatologist at Brigham and Women's Hospital, to co-author a long opinion piece in the journal Nature Reviews in June. "Each of these methods introduces potential for different types of biases," says Dr. Solomon. "But what we can say is that both studies rule out a large increase in risk. We have learned at least that from the papers."
Dr. Young of the National Institute of Statistical Sciences takes a more skeptical view. He notes that because the Green study reports on three different variables at once, it introduces errors due to the classic problem of "multiple testing."
Dr. Green acknowledges that her team didn't adjust for multiple testing. She also notes that because information about the patients isn't consistent, "this database may not be the ideal place to look."
So is the conclusion in the Murray paper the correct one?
Not necessarily. The authors of that study acknowledge that their work has less statistical power than the Green paper, and that "poorly measured or unmeasured causes of bias may have masked an association" between the drugs and cancer.
There is another question. Each study only followed patients over five years or less. What if esophageal cancer develops over a longer period, say, 10 years? In that case, the design of both studies would be invalid.
"It's not that one paper is right and the other is wrong," says Dr. Young. "There is enough wrong with both papers that we can't be sure."
But this "war room" does not belong to a hospital. It belongs to Philips, a Dutch electronics company. Mr Goudswaard, the head of innovation for Philips's home-monitoring business, has no medical training. His speciality is the consumer.
The past 150 years have been a golden age for doctors. In some ways, their job is much as it has been for millennia: they examine patients, diagnose their ailments and try to make them better. Since the mid-19th century, however, they have enjoyed new eminence. The rise of doctors' associations and medical schools helped separate doctors from quacks. Licensing and prescribing laws enshrined their status. And as understanding, technology and technique evolved, doctors became more effective, able to diagnose consistently, treat effectively and advise on public-health interventions—such as hygiene and vaccination—that actually worked.
This has brought rewards. In developed countries, excluding America, doctors with no speciality earn about twice the income of the average worker, according to McKinsey, a consultancy. America's specialist doctors earn ten times America's average wage. A medical degree is a universal badge of respectability. Others make a living. Doctors save lives, too.
With the 21st century certain to see soaring demand for health care, the doctors' star might seem in the ascendant still. By 2030, 22% of people in the OECD club of rich countries will be 65 or older, nearly double the share in 1990. China will catch up just six years later. About half of American adults already have a chronic condition, such as diabetes or hypertension, and as the world becomes richer the diseases of the rich spread farther. In the slums of Calcutta, infectious diseases claim the young; for middle-aged adults, heart disease and cancer are the most common killers. Last year the United Nations held a summit on health (only the second in its history) that gave warning about the rising toll of chronic disease worldwide.
But this demand for health care looks unlikely to be met by doctors in the way the past century's was. For one thing, to treat the 21st century's problems with a 20th-century approach to health care would require an impossible number of doctors. For another, caring for chronic conditions is not what doctors are best at. For both these reasons doctors look set to become much less central to health care—a process which, in some places, has already started.
Make do and mend
Most countries suffer from a simple mismatch: the demand for health care is rising faster than the supply of doctors. The problem is most acute in the developing world, though rich countries are not immune (see article). It does not help that health care is notoriously inefficient. Whereas America's overall labour productivity has increased by 1.8% annually for the past two decades, the figure for health care has declined by 0.6% each year, according to Robert Kocher of the Brookings Institution and Nikhil Sahni, until recently of Harvard University. But it is in poor countries that interest in alternative ways of training doctors and in alternatives to doctors themselves has produced the most innovation.
One approach to making doctors more efficient is to focus what they do. India is home to some of the world's most exciting models along this line, argues Nicolaus Henke of McKinsey, who leads the consultancy's work with health systems. Britain has 27.4 doctors for every 10,000 patients. India has just six. With so few doctors, it is changing the way it uses them.
Your correspondent recently watched Devi Shetty, chief executive of Narayana Hrudayalaya hospital in Bangalore, making careful incisions in a yellowed heart, pulling out clots that resembled tiny octopuses. It looked difficult. Some of the other tasks at Narayana Hrudayalaya hospital do not, and are not. Dr Shetty's goal is to offer as many surgeries as possible, without compromising on quality. To do that, he ensures that his surgeons do only the most complex procedures; an army of other workers do everything else. The result is surgeries that cost less than $2,000 each, about one-fifteenth as much as a similar procedure in America.
The trick is repeated in other areas of health care. India's LifeSpring hospitals slash the price of childbirth by augmenting doctors with less expensive midwives. The costs are about one-sixth of those in a private clinic. The Aravind Eye Care System offers surgery to about 350,000 patients a year. Operating rooms have at least two beds, so surgeons can swivel from one patient to the next. Most important, for every surgeon there are six "eye-care technicians"—young women recruited and trained by Aravind—who perform the myriad tasks in the operating room that do not require a surgeon's training.
Other problems have inspired other solutions, with technology filling gaps in the labour force. The Bill and Melinda Gates Foundation supports a programme that uses mobile phones to deliver advice and reminders to pregnant women in Ghana. In December the foundation and Grand Challenges Canada, a non-profit organisation, announced $32m in grants for new mobile tools that will help health-care workers diagnose various ailments. In Mexico, worried patients can phone Medicall Home, a "telehealth" service. If a patient needs care, Medicall Home can help to arrange a doctor's visit. But about two-thirds of patients' concerns can be addressed over the phone by a doctor (often one only recently qualified).
These programmes are expanding. Medicall Home is rolling out its service in Colombia and plans to be operating in Peru by the end of the year. Aravind has exported its training model to about 30 developing countries. Dr Shetty already has 14 hospitals in India. He plans to add 30,000 hospital beds in big health complexes and small hospitals there over the next seven years, as well as build a hospital in the Cayman Islands.
Technology does not just allow diagnosis at a distance—it allows surgery at a distance, too. In 2001 doctors in New York used robotic instruments under remote control to remove the gall bladder of a brave woman in Strasbourg. Robots allow doctors to be more precise, as well as more omnipresent, making incisions more neatly than human hands can. As yet they are enhancements for surgeons more than they are replacements, but that may change in time. Military drones started off being flown by officers who had gone through the expensive rigours of flight school; these days other ranks with far less exhaustive training can take the controls.
I know that philosophers concern themselves mostly with abstract and very general questions in epistemology, metaphysics, logic, ethics, etc.. By and large they do not approach philosophical questions from a personal perspective. Even death can be approached as an intellectual or conceptual problem. However, when Santa gave me my cancer diagnosis for Christmas 2011, abstract philosophy and my personal experience unavoidably came together. I now wonder if I can write in a very personal way about the universal truth that we are all going to die, what this means, and if there is anything of general import that I can express about what is happening in my own case. This breaks some common views of what philosophy is, but I do not have time to care about that now. So I am addressing you from a personal perspective, from my frame of life, and I ask your indulgence.
Let me state my tentative conclusion at the start. I do feel that having studied philosophy seriously for 46 years allowed me to keep my calm when the doctor gave me my diagnosis after a routine CT scan. For a second, I sat there feeling nothing at all. However, the next thought that came to me was gratitude for the life I have lived. Maybe other people do not feel this. Kubler Ross famously discusses five stages of grief and loss: denial, anger, bargaining, depression, and acceptance. I seemed to skip the first four. This is not to say that I instantly reached acceptance, but I did come first to gratitude. Now, after six months of living with lung cancer, I am trying to understand what acceptance of death may amount to.
Each of us can only judge and describe the world from our own time frame. If I had been much younger, my response to the diagnosis might have conformed more to Dr. Ross's formula. The world looks very differently at different stages of life. Nevertheless, how one has looked, thought, and felt about life and death throughout one's life has to make a difference at the end. In my case, the lens through which I have considered life has always been philosophical. Snatches of philosophical thoughts have lodged in my mind since I was was young. These are like seeds that took root deep in my mind and have matured and grown over the years. Now I feel that they are bearing fruit, helping me to live a new and deeper life. One nugget stands out to complete this first meditation on life and death.
Plato's famously stated that "Philosophy is a preparation for death." The Greek word that Plato uses for 'preparation' is 'Melete' and the root meaning is 'care' or 'attention'. It can also mean 'meditation,' 'practice' or 'exercise'. So are philosophers supposed to 'practice' dying, or simply to recollect the fact of mortality as they live their lives? What difference will that make?
I confess a great love of Plato and his amazing Socrates. However, I cannot go along with his tentative conclusions. We know what Socrates argues in the Phaedo. The reason that practicing philosophy is a preparation for death is that Socrates believes that the soul and the body are separable, that the soul is immortal, and that a very different after-life awaits those who have lived a good or evil life. Therefore, it behooves us to separate our own soul from our body as much as possible while we live and to detach ourselves from the preoccupations of mundane life.
The reason that I admire Socrates in the Phaedo is that after giving his 'proofs' of the immortality of the soul, he has the greatness to admit that his arguments are only the reasons he personally accepts to advance his position. He does not claim that they absolutely prove the soul is immortal. It is a postulate of Socrates' practical metaphysics. In fact, he says that if he is wrong, and death is total extinction, then he will never know he is wrong, and his folly will be buried with him.
So in what sense can the study of philosophy be a preparation for death if one does not accept metaphysical dualism? I do not accept any such thing, but I still feel that my study of philosophy has helped me prepare for my present state. Does this mean that the study of any topic in philosophy will have this effect? I do not think so. I am not at all sure that one would prepare for death very well by spending 40 years working in the salt-mines of post-Gettier epistemology, nor in picking over all he convoluted arguments in mereology and inductive logic.
To see how the study of philosophy might be of value in preparing to die, we have to go back to the root meaning of 'philosophy' as the 'love of wisdom'. Wisdom is not a topic that comes up very much in contemporary philosophy. It was more to the fore in the ancient world, where wisdom, ethics, and the question of living a good human life were brought together in a philosophical approach to living. For me, loving wisdom has to do with taking up the largest possible perspective in which to live one's life, going all the way back to the Big Bang, including all of space and time, the natural history of the universe, the geology of the earth, and the total history of animals and human beings on this planet spinning through a gigantic universe. It covers all the natural cycles of life and death and sees everything as part of this comprehensive whole. Somehow, living in this context has helped me see life and death as part of a seamless process. Death shadows life as naturally as the shadow one casts on the ground on a sunny day. There is no point in denying it, and no point in worrying about it. Perhaps acceptance lies in this direction.
The case involves Michael Snyder, a geneticist who was both the lead author and the subject of a study on genomics reported in the journal Cell. The study began with the sequencing of Dr. Snyder's genome, which showed that he was at high risk for Type 2 diabetes. Then the research team did extensive blood tests every two months or more, keeping track of 40,000 molecules in Dr. Snyder's cells. About midway into the 14-month study, analyses showed that Dr. Snyder had indeed developeddiabetes.
"My genome did predict I was at risk," he said, "and because I was watching out, I detected the illness pretty early."
The research team monitored the molecular changes closely as the disease developed. The illness was treated successfully while in its early stages, long before it might have been if Dr. Snyder had relied on a conventional visit to the doctor.
"This study is a landmark for personalized medicine," said Dr. Eric J. Topol, a professor of genomics at the Scripps Research Institute in La Jolla, Calif., and author of "The Creative Destruction of Medicine."
The study "is an unprecedented look at one person's biology, showing what can be accomplished in the future," he said. "This kind of granular information will one day allow doctors to manage illness in an altogether different and precise way."
The business of personalized genomic medicine has long been expected to blossom as low-cost sequencing of the human genome becomes available from the many companies now working in the field. Currently, the price of human genome sequencing is typically about $4,000, saidGeorge M. Church, a genetics professor at Harvard Medical School. But within a year, he said, it could be down to $1,000 or even less.
Dr. Snyder, a professor and chairman of the genetics department at the Stanford University School of Medicine, said he wasn't worried when his genome sequencing showed at the beginning of the study that he had a high risk for Type 2 diabetes.
"The disease doesn't run in the family," he said, "and I'm a touch on the thin side, so I don't fit the usual stereotype." Still, he kept a close eye on his glucose levels.
Then, in the midst of the study, he caught a cold. "I have two little kids," he explained. "They get sick periodically," passing their colds on to others.
It was this viral infection that apparently prompted the onset of diabetes, possibly because of stress. "The cold was a bonus," Dr. Topol said. "We have not been generally associating viral infection with this type of diabetes. It is possible that the viral infection added additional stress."
Dr. Snyder treated his diabetes through a change in diet — he eliminated desserts — and a doubling of his typical bike-riding regimen. He also returned to running. "It took about six months," he said, "but my glucose levels came back to normal, allowing me to avoid medication."
He said that because he typically schedules checkups with his doctor only once every two or three years, the disease would have long remained undiagnosed had it not been for the case study. "Probably no one would have caught my glucose shooting up for at least 18 to 20 months," he said. "By then, I could have had damage."
Dr. Snyder's blood sample analyses were comprehensive. "We measured as many molecules as we could," he said. "That meant we included my RNA, my proteins, my metabolites and my autoantibodies." The research team analyzed about three billion data points.
Such exhaustive tests are not currently possible for most people, Dr. Topol noted. "Right now," he said, "the price makes the procedure impractical."
Dr. Snyder said the cost to collect molecular data from each blood sample was about $2,500 — which did not include the cost of analysis. But the price for tests similar to Dr. Snyder's will also decline in the future, Dr. Church said.
And not all of the 40,000 molecules that Dr. Snyder tracked need to be included in every study. "The approach can be scaled down and particularized to the individual," Dr. Topol said. "The team showed that it is feasible to manage and interpret data this way in the future."
Dr. Church looks forward to the day when current research becomes a routine clinical procedure that combines inherited genomic information with analyses of RNA, proteins, metabolites and microbes in our bodies.
"One day, almost everything you wish the doctor would analyze will be measurable and interpretable," he said. 'It will be so much less expensive to do this because of technical improvements."
Dr. Church is the founder of the nonprofit Personal Genome Project,which sequences and makes public the genomic and trait data of volunteers.
Dr. Snyder is a co-founder of a company, Personalis, in Palo Alto, Calif., that is developing software and other tools to interpret genomes after sequencing. Elaine R. Mardis, co-director of the Genome Institute at Washington University in St. Louis, said Dr. Snyder's study points toward the joining of genomic medicine and standard medicine.
"The real message here is that conventional medicine doesn't have to be replaced or supplanted by genomic medicine," she said. "The integration of blood tests with genome sequencing adds so much granularity and precision."