Saturday, April 13, 2013

MATTER #1: Do No Harm

THIS WASN'T THE FIRST time that David had tried to amputate his leg. When he was just out of college, he'd tried to do it using a tourniquet fashioned out of an old sock and strong baling twine.

David locked himself in his bedroom at his parents' house, his bound leg propped up against the wall to prevent blood from flowing into it. After two hours the pain was unbearable, and fear sapped his will.

Undoing a tourniquet that has starved a limb of blood can be fatal: injured muscles downstream of the blockage flood the body with toxins, causing the kidneys to fail. Even so, David released the tourniquet himself; it was just as well that he hadn't mastered the art of tying one.

Failure did not lessen David's desire to be rid of the leg. It began to consume him, to dominate his awareness. The leg was always there as a foreign body, an impostor, an intrusion.

He spent every waking moment imagining freedom from the leg. He'd stand on his "good" leg, trying not to put any weight on the bad one. At home, he'd hop around. While sitting, he'd often push the leg to one side. The leg just wasn't his. He began to blame it for keeping him single; but living alone in a small suburban townhouse, afraid to socialise and struggling to form relationships, David was unwilling to let anyone know of his singular fixation.

David is not his real name. He wouldn't discuss his condition without the protection of anonymity. After he agreed to talk, we met in the waiting area of a nondescript restaurant, in a nondescript mall just outside one of America's largest cities. A handsome man, David resembles a certain edgy movie star whose name, he fears, might identify him to his co-workers. He's kept his secret well hidden: I am only the second individual whom he has confided to in person about his leg.

The cheerful guitar music in the restaurant lobby clashed with David's mood. He choked up as he recounted his depression. I'd heard his voice cracking when we'd spoken earlier on the phone, but watching this grown man so full of emotion was difficult. The restaurant's buzzer went off. Our table inside was ready, but David didn't want to go in. Even though his voice was shaking, he wanted to keep talking.

"It got to the point where I'd come into my house and just cry," he had told me earlier over the phone. "I'd be looking at other people and seeing that they already have their lives going good for them. And I'm stuck here, all miserable. I'm being held back by this strange obsession. The logic going through my head was that I need to take care of this now, because if I wait any longer, there is not much chance of a life for me."

It took some time for David to open up. Early on, when we were just getting to know each other, he was shy and polite, confessing that he wasn't very good at talking about himself. He had avoided seeking professional psychiatric help, afraid that doing so would somehow endanger his employment. And yet he knew that he was slipping into a dark place. He began associating his house with the feeling of being alone and depressed. Soon he came home only to sleep; he couldn't be in the house during the day without breaking into tears.

One night about a year ago, when he could bear it no longer, David called his best friend. There was something he had been wanting to reveal his whole life, David told him. His friend's response was empathetic — exactly what David needed. Even as David was speaking he began searching online for material. "He told me that there was something in my eyes the whole time I was growing up," David said. "It looked like I had pain in my eyes, like there was something I wasn't telling him." Once David opened up, he discovered that he was not alone. He found a community on the internet of others who were also desperate to excise some part of their body — usually a limb, sometimes two. These people were suffering from what is now called Body Integrity Identity Disorder (BIID).

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Watsi, a Crowdfunding Site, Offers Help With Medical Care -

Two years ago, Chase Adam, a Peace Corps volunteer in Costa Rica, was riding a bus through a town called Watsi, when a woman got on board asking for money. Her son, she said, needed medical attention and she couldn't pay for it. As the woman walked through the bus, she showed people a copy of her son's medical record. Mr. Adam, who is now 26, noticed that nearly everyone donated money.

The experience gave him an idea.

"I thought it'd be really cool if there was a Kiva for health care," he said, referring to the crowdfunding Web site that allows donors to provide microloans to entrepreneurs in developing countries.

Over the next several months, he devoted his free time to creating a business plan for an online start-up that he named after the town where he got the idea. Watsi, which started last August, lets people donate as little as $5 toward low-cost, high-impact medical treatment for patients in third-world countries.

The procedures range from relatively simple ones like fixing a broken limb to more complicated surgery — say, to remove an eye tumor. But the treatments generally have a high likelihood of success and don't involve multiple operations or long-term care.

Operated out of an apartment in Mountain View, Calif., Watsi works with nonprofit health care providers in 13 countries, including Cambodia, Nepal, Guatemala and Ethiopia. The providers identify patients meeting Watsi's criteria; the providers themselves have been vetted by Watsi and its medical advisory team, which includes Dr. Mitul Kapadia, director of the physical medicine and rehabilitation program at Benioff Children's Hospital of the University of California, San Francisco, and a half-dozen other doctors and medical professionals.

The profiles of the patients are posted on the Watsi site, and the online community begins donating. Medical care is given when the health partners decide that it is "medically appropriate," Mr. Adam said. Sometimes that care is given before money is raised on Watsi, and the profile remains on the site so that fund-raising can continue. Watsi maintains an operational reserve for this purpose, he said.

Watsi represents the next generation of charities dependent on online donors, evolving the model started by sites like Kiva. With just a few mouse clicks, Kiva users, say, are able to lend money to a restaurant owner in the Philippines — and to examine her loan proposal and repayment schedule, to read about her and see her photograph.

Charities have long recognized the importance of photographs and narratives in soliciting donations. Watsi's Web site, too, shows vivid images of its patients, and tells their stories. For example, a 9-year-old girl in Myanmar who needs eye surgery has had to miss a year of school because of her condition.

"People like to feel like their donation is making a difference to an individual," said Timothy Ogden, managing director of the Financial Access Initiative at New York University's Robert F. Wagner Graduate School of Public Service. "That's how they like to give — where there's a face and a personal connection."

While Kiva offered pictures and much more from the start, information about its own operations was not always easy to find on its site. In 2009, when donors learned that loans weren't going directly to the people in need but to microfinancing institutions that had already made the loans, there was an uproar.

Even though the model makes sense — microfinancers play an important role in vetting individuals, and by giving them a loan upon request, the borrower does not have to wait weeks or months for money to be raised online — Kiva was criticized for a lack of transparency. It has since clarified how it works.

The kerfuffle pointed out how much information the public demands in the Internet age, particularly when it comes to nonprofit groups, where "the general public is skeptical," Mr. Adam said.

As a result, organizations like Watsi are trying  to extend their microlending transparency to themselves. On Watsi's Web site, there is a Google Doc — an online document that can be shared by various approved users, and updated in real time — that lists details like the name of the doctor providing care, whether that care was delayed for any reason, a screen shot of the PayPal funds transfer, and whether the treatment was successful. The document also shows Watsi's monthly financial statement, which lists the cost of office supplies, salaries and travel expenses. If any problems  occur during or because of treatment, donors are notified by e-mail.

Mr. Adam said his approach was partly in response to the Kiva controversy. But he said he found inspiration in other nonprofits like Nyaya Health, a nongovernmental organization started by Yale graduates that provides free health care in Nepal. Nyaya, which is a Watsi medical partner, has a health wiki that lets people upload the organization's monthly financial reports and minutes from internal meetings.

"I think there's a new batch of these nonprofits starting to emerge," Mr. Adam said. "They're dedicated to helping people understand how things work."

Not that this makes everyone comfortable. After one patient who received funding from Watsi did not survive surgery, some health care partners were "a little spooked," Mr. Adam said, given that the doctor's name was listed on the Watsi site. "Doctors don't want their names to be associated with failure," he said, adding that as a result of that, some medical partners briefly stopped approving riskier treatments as a way to avoid more undesirable outcomes.

And when Watsi began publishing its financial statements, the chief financial officer "was very scared," Mr. Adam said. "He was like: 'What if I made a mistake? People are going to crucify me!' "

People did find a few minor mistakes, as it turned out. "They e-mailed us, and we solved the situation in five minutes," Mr. Adam said. "What we've found is that by being transparent, we're actually crowdsourcing a lot of our work." In effect, the public is  "reviewing all our financials, which is fantastic," he said.

But is a Google Doc enough to make donors feel confident about a group's credibility? "Certainly, I don't think it hurts," Mr. Ogden said. "But do we know that the data they're providing is true?"

"We have a big problem in nonprofit data circles in general about the quality of data," he said, because "the rules for accounting for nonprofits are so lax."

Mr. Adam says such concern is precisely why his organization shows monthly statements line by line. "We provide much more detail about how things actually are working, and specific costs, such as Web hosting and salaries," he said. "You see some  of that on 990 tax forms, but not nearly to the degree of resolution that we have."

WATSI recently participated in an incubator program at Y Combinator, which provides start-ups with seed money along with mentoring. So far, Watsi has raised about $200,000, which has paid for treatment of more than 270 patients.

But as those numbers grow, providing detailed information about each patient and his or her care could prove difficult. Dr. Paul Polak, a social entrepreneur and author of "Out of Poverty," said that much detail was possible in a small operation with few patients, but he asked: "How are you going to do that when you have 50,000?"

Mr. Adam says Watsi is becoming more streamlined. It is developing a system to let its care providers upload patient information directly to a central database. Currently, Watsi enters that data manually into the Google Doc.

Before entering the Y Combinator program, Watsi was paying for an average of three patients a week. Since completing the program, that average is now 17 a week. And three months ago, Mr. Adam and his two full-time co-workers started receiving a salary. (Mr. Adam makes about $45,000 a year.)

"Honestly, that's been the biggest milestone so far, with regard to us personally," he said.

"When I got that first paycheck, despite it being pretty small, I remember thinking that I couldn't believe I was being paid to do something I love so much."

'Good' Patients, 'Bad' Patients -

He was the kind of patient I went to medical school for.
By the time I met him, he had had a rough go of it. After learning the previous year that he had lymphoma, he was fortunate enough to receive a bone marrow transplant — only to have his body promptly reject it. On three separate occasions in the past six months, he had deadly antibiotic-resistant bacteria coursing through his blood. He was just recovering from a bout of pneumonia when the meningitis struck.
Last night, his nurse saw him crying quietly in the corner of his hospital room. She asked our team to meet with him to evaluate whether antidepressant medications might be helpful to bolster his mood. When I entered his room, he greeted me with a smile — weak and pained in his emaciated body, but warm and genuine. I introduced myself as the medical student on the psychiatry consultation service and asked him how he was holding up.
"I'd be lying if I told you it hasn't been tough," he said. "I get down sometimes, but I have so, so many things going for me."
We spoke at length about his family. His twin sons had just graduated from college and had initially planned to work for a nonprofit organization in Nepal, but opted to stay close to home given his medical condition. His daughter ("all grown up now!") was being recruited to play softball at a local college. His wife had been tending to their small restaurant business during his long hospital stay.
"I consider myself to be an incredibly blessed person," he said. "I know I'll get through this."
His body was sick, yes, but his spirit was unyielding.
At the end of our conversation, he expressed his deep gratitude for his caregivers over the past several months: "You guys have made this bearable. Thank you, doctor."
I started to correct him — technically I wasn't yet a doctor — but thought, ah, forget it. Our interaction had left me energized. The next evening I donned my white coat and strode into the bustling emergency room with renewed confidence, ready to heal.
I started my shift with a woman in her mid-20s who sat cross-legged on a stretcher in the hallway, bouncing up and down with a wide-eyed, unhinged look on her face as she vacillated between singing and crying. As I approached to introduce myself, a viscous ball of saliva and mucus left her mouth and landed squarely on my left cheek.
"Be careful: She's a spitter," a nurse advised as he rushed past. "PCP and alcohol. Give her a few minutes to calm down."
I moved on to an elderly man who was lying on a nearby stretcher and moaning, and I softly asked what had brought him to the hospital. No response. I shook him gently and asked again, louder this time. He opened his eyes just enough to see my face and muttered something entirely incomprehensible.
Suddenly, behind me, the spitter let me know she wanted to leave. She took off her socks and started flapping them about. "I'm ready to go."
I began to feel frustrated and disengaged, a far cry from the feelings I'd had the day before.
Across the room, a thin, disheveled man hunched awkwardly over the edge of his stretcher. He had strange cuts and bruises scattered across his face and arms and had been waiting to be seen for almost an hour. According to the chart, he was 47 years old, but he looked at least 60. He had come to the E.R. in withdrawal from alcohol, as he had once every few months.
I asked my supervising physician if he had time to accompany me to see the man. Rushing away to see a new patient, he looked over his shoulder and said, "I'm not going to check on a drunk while he's throwing up."
I was shocked by how bluntly and callously he spoke. But I wondered whether this was the kind of calculation that busy doctors make all the time. Are we constantly shortchanging patient encounters we find difficult, troublesome or otherwise unrewarding?
As I approached the patient, he was calm but tearful. "I don't want to live like this anymore," he whispered. He told me how frustrating it had been for him to struggle with alcohol, how he had tried, time and again, to quit. He had worked in construction but lost his job last year. His girlfriend left him a few months later.
"It seems like you're going through a tough time right now," I offered.
"I've been going through a tough time for 14 years," he responded — ever since his daughter died in a car accident.
Like many of my classmates, I entered medical school with an idealized notion of medicine. But I will leave with the knowledge that the reality is far more complex. There are patients who don't listen, who can't listen; who try, who don't try; who smile, thank and love; who steal, curse and hate. Each of these patients deserves the full extent of our respect and abilities. But too often those most in need of our compassion are least likely to receive it.
The balancing of complex emotions, time constraints and limited resources will only become more difficult with the influx of millions of previously uninsured people into our medical system. As we continue to carry out the Affordable Care Act and enter an era of tremendous change, we must confront our natural tendencies to favor patients we find pleasant — especially when it comes at the expense of those we find less so. We must recognize that sometimes the patients who behave the worst are those who are hurting the most.
Dhruv Khullar is a student at the Yale School of Medicine and the Harvard Kennedy School, where he is a fellow at the Center for Public Leadership.

Thursday, April 11, 2013

Holistic Review — Shaping the Medical Profession One Applicant at a Time — NEJM

Modern medicine has been characterized by rapid and accelerating progress in biomedical sciences as the foundation for clinical practice. In 1910, the Flexner Report established these sciences as the core of medical education.1 Admissions committees at U.S. medical schools have, for the past century, focused their attention largely on predictors of success in the foundational science curriculum, relying heavily on academic performance in the biologic and physical sciences and scores on the Medical College Admission Test (MCAT) in selecting applicants for medical school.
Abundant data support the contention that performance in the medical school science curriculum and on the U.S. Medical Licensing Examination (USMLE) Step 1 are predicted by performance on the MCAT and in the undergraduate science coursework required of medical school applicants.2Key aspects of behavior, character, and performance that are essential for the practice of medicine, however, cannot be predicted from these measures. In addition, performance on standardized tests and in undergraduate sciences is influenced by myriad social, demographic, and economic factors that limit the utility of these measures in large segments of the potential applicant pool for medical school.
Over the past decade, individual medical schools, supported by the Association of American Medical Colleges (AAMC), have been working to expand the frame of reference for evaluating applicants for medical school. These efforts have come together under the "holistic review" rubric endorsed by the U.S. Supreme Court in 2003: "highly individualized, holistic review of each applicant's file, giving serious consideration to all the ways an applicant might contribute to a diverse educational environment." Under such an approach, a school "seriously considers each `applicant's promise of making a notable contribution to the class by way of a particular strength, attainment, or characteristic — e.g., an unusual intellectual achievement, employment experience, nonacademic performance, or personal background.'"3
The AAMC Holistic Review Project has defined holistic review in medical school admissions as "a flexible, individualized way of assessing an applicant's capabilities by which balanced consideration is given to experiences, attributes, and academic metrics . . . and, when considered in combination, how the individual might contribute value as a medical student and future physician."4
A holistic review process therefore emphasizes attributes, including learning ability, that are associated with excellence in physicians. Applicants are evaluated according to criteria that are institution-specific, mission-driven, broad-based, and applied consistently across the entire applicant pool at a given school. Holistic review does not abandon the assessment of aptitude in science. Rather, it places such measures in the broader context of the applicant's life experiences, with a particular focus on adversities overcome, challenges faced, advantages and opportunities encountered, and the applicant's demonstrated resilience in the face of difficult circumstances. Each factor, be it the undergraduate grade-point average (GPA), the MCAT score, or the leadership roles assumed in volunteer service organizations, is evaluated in the context of the complete portfolio of information available about the applicant. That is, a given level of accomplishment for one applicant may look very different in the context of another applicant with a different life story. Medical schools have many more qualified applicants than they can realistically interview, so holistic principles must be applied from the initial screening through the entire admissions process for their desired effect to be realized.
The imperative for a diverse physician workforce in an increasingly diverse society is one important driver of the move to take a more expansive view of excellence in medical student selection. This more comprehensive approach to considering a multitude of factors in evaluating all applicants provides a context for the inclusion of race, ethnic background, language, culture, and heritage, among other factors, in a way that is educationally sound and legally viable. The AAMC's Experience–Attributes–Metrics Model includes consideration of many dimensions of applicants, broadening the context in which their development, accomplishments, and potential can be evaluated. The metrics include grade trends in addition to the usual GPA and MCAT scores; attributes range from fields of interest, intellectual curiosity, and maturity to languages spoken, gender identity, and family status; and experiences may include everything from education and research to general life experiences.
In 2003, the Boston University School of Medicine (BUSM) became one of a number of U.S. medical schools to launch a systematic transition from a traditional admissions model based largely on the review of academic metrics to a comprehensive, holistic review process. It was a slow and deliberative transition, but by 2008, changes in the BUSM admissions program were clear and substantial, and the effects were evident in the entering class of 2009.
The BUSM Committee on Admissions first developed a mission statement for itself that reflected the concepts in the institutional mission statement and then created a set of decision-support tools using performance metrics, characteristics, and behaviors that are identified in that mission and used in a clearly defined and universally applied manner. The table shows one such tool: a list of desirable traits for physicians matched with the elements of applicant data that reveal or predict those traits. Direct measures of these traits are often unavailable, so proxies are used. Holistic review is an information-hungry process; electronic processing greatly facilitates both the application and the evaluation of the program. Experiences, attributes, and academic metrics are evaluated and scored in a systematic and consistent manner across the entire applicant pool, with due consideration to the demonstrated validity of various criteria in predicting success in both medical school and medical practice. The BUSM program uses structured interviewing, rigorous training of participating faculty and staff, and systematic evaluation of data elements, all of which minimize the influence of conscious and unconscious bias.
Since BUSM became engaged in holistic review, the profile of its entering class has changed dramatically. Other factors, including changes both at the school and within society at large, have certainly influenced the school's ability to select and recruit strong students, but holistic review is at the core of the process. Students are culturally, linguistically, racially, ethnically, and demographically more diverse than previous classes, and according to the standard measures of undergraduate GPA and MCAT score, they are at least as well prepared academically (the average GPA and average MCAT score were 3.66 and 33.62 for the entering class of 2012, as compared with 3.57 and 31.68 for the entering class of 2008). Students from groups underrepresented in medicine now make up approximately 20% of the entering class, as compared with 11 to 12% before the adoption of holistic review. We observe that students are more frequently engaged in our campus community and in outside activities, and graduating students pursue a broad range of specialties and career paths. The general sense of the faculty, particularly those who teach our small-group problem seminars, is that the students are more collegial, more supportive of one another, more engaged in the curriculum, and more open to new ideas and to perspectives different from their own. Some of these observations are subjective and difficult to quantify, but there is a striking, and uncoached, consensus among the experienced faculty members.
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Wednesday, April 10, 2013

How Exercise May Help Memory -

Two new experiments, one involving people and the other animals, suggest that regular exercise can substantially improve memory, although different types of exercise seem to affect the brain quite differently. The news may offer consolation for the growing numbers of us who are entering age groups most at risk for cognitive decline.
It was back in the 1990s that scientists at the Salk Institute for Biological Studies in La Jolla, Calif., first discovered that exercise bulks up the brain. In groundbreaking experiments, they showed that mice given access to running wheels produced far more cells in an area of the brain controlling memory creation than animals that didn't run. The exercised animals then performed better on memory tests than their sedentary labmates.
Since then, scientists have been working to understand precisely how, at a molecular level, exercise improves memory, as well as whether all types of exercise, including weight training, are beneficial.
The new studies provide some additional and inspiring clarity on those issues, as well as, incidentally, on how you can get lab rats to weight train.
For the human study, published in The Journal of Aging Research, scientists at the University of British Columbia recruited dozens of women ages 70 to 80 who had been found to have mild cognitive impairment, a condition that makes a person's memory and thinking more muddled than would be expected at a given age.
Mild cognitive impairment is also a recognized risk factor for increasing dementia. Seniors with the condition develop Alzheimer's disease at much higher rates than those of the same age with sharper memories.
Earlier, the same group of researchers had found that after weight training, older women with mild cognitive impairment improved their associative memory, or the ability to recall things in context — a stranger's name and how you were introduced, for instance.
Now the scientists wanted to look at more essential types of memory, and at endurance exercise as well. So they randomly assigned their volunteers to six months of supervised exercise. Some of the women lifted weights twice a week. Others briskly walked. And some, as a control measure, skipped endurance exercise and instead stretched and toned.
At the start and end of the six months, the women completed a battery of tests designed to study their verbal and spatial memory. Verbal memory is, among other things, your ability to remember words, and spatial memory is your remembrance of where things once were placed in space. Both deteriorate with age, a loss that's exaggerated in people with mild cognitive impairment.
And in this study, after six months, the women in the toning group scored worse on the memory tests than they had at the start of the study. Their cognitive impairment had grown.
But the women who had exercised, either by walking or weight training, performed better on almost all of the cognitive tests after six months than they had before.
There were, however, differences.
While both exercise groups improved almost equally on tests of spatial memory, the women who had walked showed greater gains in verbal memory than the women who had lifted weights.
What these findings suggest, the authors conclude, is that endurance training and weight training may have different physiological effects within the brain and cause improvements in different types of memory.
That idea tallies nicely with the results of the other recent study of exercise and memory, in which lab rats either ran on wheels or, to the extent possible, lifted weights. Specifically, the researchers taped weights to the animals' tails and had them repeatedly climb little ladders to simulate resistance training.
After six weeks, the animals in both exercise groups scored better on memory tests than they had before they trained. But it was what was going on in their bodies and brains that was revelatory. The scientists found that the runners' brains showed increased levels of a protein known as BDNF, or brain-derived neurotrophic factor, which is known to support the health of existing neurons and coax the creation of new brain cells. The rat weight-trainers' brains did not show increased levels of BDNF.
The tail trainers, however, did have significantly higher levels of another protein, insulinlike growth factor, in their brains and blood than the runners did. This substance, too, promotes cell division and growth and most likely helps fragile newborn neurons to survive.
What all of this new research suggests, says Teresa Liu-Ambrose, an associate professor in the Brain Research Center at the University of British Columbia who oversaw the experiments with older women, is that for the most robust brain health, it's probably advisable to incorporate both aerobic and resistance training. It seems that each type of exercise "selectively targets different aspects of cognition," she says, probably by sparking the release of different proteins in the body and brain.
But, she continues, no need to worry if you choose to concentrate solely on aerobic or resistance training, at least in terms of memory improvements. The differences in the effects of each type of exercise were subtle, she says, while the effects of exercise — any exercise — on overall cognitive function were profound.
"When we started these experiments," she says, "most of us thought that, at best, we'd see less decline" in memory function among the volunteers who exercised, which still would have represented success. But beyond merely stemming people's memory loss, she says, "we saw actual improvements," an outcome that, if you're waffling about exercising today, is worth remembering.