Thursday, December 31, 2015
That book was the reason I had come. It was called "Do No Harm," and it was written by the British neurosurgeon Henry Marsh. His job is to slice into the brain, the most complex structure we know of in the universe, where everything that makes us human is contained, and the contrast between the extremely sophisticated and the extremely primitive — all of that work with knives, drills and saws — fascinated me deeply. I had sent Marsh an email, asking if I might meet him in London to watch him operate. He wrote a cordial reply saying that he seldom worked there now, but he was sure something could be arranged. In passing, he mentioned that he would be operating in Albania in August and in Nepal in September, and I asked hesitantly whether I could join him in Albania.
Now I was here.
Tense and troubled, I stepped out of the door of the airplane, having no idea what lay ahead. I knew as little about Albania as I did about brain surgery. The air was warm and stagnant, the darkness dense. A bus was waiting with its engine running. Most of the passengers were silent, and the few who chatted with one another spoke a language I didn't know. It struck me that 25 years ago, when this was among the last remaining Communist states in Europe, I would not have been allowed to enter; then, the country was closed to the outside world, almost like North Korea today. Now the immigration officer barely glanced at my passport before stamping it. She dully handed it back to me, and I entered Albania.
In the arrivals hall, a young man dressed in a bright white shirt came over.
"Welcome to Albania, Mr. Knausgaard. My name is Geldon Fejzo. Mr. Marsh and Professor Petrela are waiting for you at the hotel. The car is right outside."
The car was a black Mercedes, with leather seats and air conditioning. It turned out that Fejzo had just completed his medical training as a neurosurgeon. He was 31 and had studied in Florence. He had also worked as an intern for a few months at a London hospital with Mr. Marsh, as he called him, in the manner long preferred by British surgeons.
"What is he like?" I asked.
"He's a fantastic person," Fejzo said.
Marsh was in Tirana to demonstrate a surgical procedure he helped pioneer, called awake craniotomy, that had never been performed in Albania. The procedure is used to remove a kind of brain tumor that looks just like the brain itself. Such tumors are most common in young people, and there is no cure for them. Without surgery, 50 percent of patients die within five years; 80 percent within 10 years. An operation prolongs their lives by 10 to 20 years, sometimes more. In order for the surgeon to be able to distinguish between tumor and healthy brain tissue, the patient is kept awake throughout the operation, and during the procedure the brain is stimulated with an electric probe, so that the surgeon can see if and how the patient reacts. The team in Albania had been preparing for six months and had selected two cases that were particularly well suited to demonstrating the method.
A study published Wednesday in The New England Journal of Medicine provides some of the clearest information on the subject to date.
The study analyzed nearly 80,000 pregnancies in Oregon, and found that when women had planned out-of-hospital deliveries, the probability of the baby dying during the birth process or in the first month after — though slight — was 2.4 times as likely as women who had planned hospital deliveries.
Out-of-hospital births also carried greater risk of neonatal seizures, and increased the chances that newborn babies would need ventilators or mothers would need blood transfusions.
On the other hand, out-of-hospital births were far less likely to involve cesarean sections — 5.3 percent compared with 24.7 percent in a hospital. They also involved fewer interventions to augment labor, and mothers had fewer lacerations.
Tuesday, December 29, 2015
Monday, December 28, 2015
"Slim by Chocolate!" the headlines blared. A team of German researchers had found that people on a low-carb diet lost weight 10 percent faster if they ate a chocolate bar every day. It made the front page of Bild, Europe's largest daily newspaper, just beneath their update about the Germanwings crash. From there, it ricocheted around the internet and beyond, making news in more than 20 countries and half a dozen languages. It was discussed on television news shows. It appeared in glossy print, most recently in the June issue of Shapemagazine ("Why You Must Eat Chocolate Daily," page 128). Not only does chocolate accelerate weight loss, the study found, but it leads to healthier cholesterol levels and overall increased well-being. The Bild story quotes the study's lead author, Johannes Bohannon, Ph.D., research director of the Institute of Diet and Health: "The best part is you can buy chocolate everywhere."
I am Johannes Bohannon, Ph.D. Well, actually my name is John, and I'm a journalist. I do have a Ph.D., but it's in the molecular biology of bacteria, not humans. The Institute of Diet and Health? That's nothing more than a website.
Other than those fibs, the study was 100 percent authentic. My colleagues and I recruited actual human subjects in Germany. We ran an actual clinical trial, with subjects randomly assigned to different diet regimes. And the statistically significant benefits of chocolate that we reported are based on the actual data. It was, in fact, a fairly typical study for the field of diet research. Which is to say: It was terrible science. The results are meaningless, and the health claims that the media blasted out to millions of people around the world are utterly unfounded.
Here's how we did it.
Saturday, December 26, 2015
This was a man who had peered into my nose and mouth, performed prostate examinations and talked me through afflictions. He knew I was married, had children, and what I did for a living. That he would skip town without notice seemed an abrupt ending. He didn't even tell my health insurance provider that he had shut his doors.
When I arrived the next day, the doctor handed me my records and said he was closing the practice and moving it to Texas. He had not notified anyone because there were too many patients to contact, an explanation I accepted without contention, the way I had adopted so much of his advice over the years.
Everyone seems to have a health care provider they swear by — a dentist who can pull teeth without painkillers, a chiropractor who can realign spines one-handed. "My doctor is the best," I've heard countless friends say. Rarely do they say "my doctor is the worst" — partly because people don't usually stay with bad doctors very long, but also because bad doctors aren't always obvious, at least until they do something obviously bad. Like, say, suddenly closing their practice and relocating 2,000 miles away.
Instead of waiting in a long line to register, patients at the new center, the Josie Robertson Surgery Center, will be handed plastic tracking badges that will broadcast their locations in real time, allowing intake coordinators to come directly to them wherever they are sitting. Inspired by modern hotel lobbies and co-working spaces, the family waiting room has semiprivate seating areas and mobile device charging stations. And for people who become antsy while their loved ones are in surgery, there is an Xbox nook for fitness activities.
Operating rooms, too, incorporate "the most advanced technology," according to marketing materials, including the latest surgical robots and "super-high-definition monitors" to display anatomical imaging.
At a Memorial Sloan Kettering outpatient surgery center in Manhattan, innovations include data tracking and other techniques to improve care, but some worry about transparency.
I tried hard to maintain empathy, reflecting that the overdosed, self-poisoned and criminal may no more have brought their problems on themselves than those with skiing or horse-riding injuries or heart palpitations through overwork. But it's complicated: I've stitched up many slashed wrists cut not through willfulness but as a release from intense anguish; I've attended alcoholics for whom alcohol was clearly a substitute for love. I may not have always succeeded, but I always hoped that my humanity, or my professional duty to provide a high standard of care, would step in when my compassion was running low.
Compassion means "together-suffering" or "fellow-feeling" — a sense of identification we feel when imagining another's pain. The word "patient" means "sufferer," and at its most basic level the practice of medicine could be described as the attempt to ease mental and physical pain. If physicians have a surfeit of compassion — if they're too sentimental, or too thin-skinned — they do their jobs slowly, even less effectively. I've worked with colleagues like this: They don't last long in the pressurized environment of the E.R. or the primary care clinic.
Friday, December 25, 2015
But Dr. Ronald Epstein, a University of Rochester professor, wants to change the way doctors approach their patients. Suffering is seen in all corners of hospitals and medical centers — from the emotional pain of a mother who just lost an unborn baby to an older man facing a terminal illness, yet doctors often don't address it.
In a new essay published in the Journal of the American Medical Association, Epstein and a co-author, oncologist Anthony Back of the University of Washington, reviewed medical literature on the ways doctors approach suffering. They found that an approach to suffering is rarely discussed in the medical world, and that this needs to change.
"Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients," the authors wrote. "Some people can do this instinctively, but most physicians need training in how to respond to suffering — yet this kind of instruction is painfully lacking."
Epstein and Back note that physicians can improve their approach by listening to the patient and learning about his/her experience. In addition to the typical "diagnosing and treating," the authors argue that doctors should also "turn toward" the patient, and recognize their suffering. They can do that by asking questions like, "What's the worst part of this for you?" Sometimes an acknowledgment that their pain is real, and that it matters to someone, is all a patient needs to open up.
Monday, December 21, 2015
She mumbled, "4 to 5." The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend's pain.
This is not an anecdote about nurses not doing their jobs; it's an illustration of what our jobs have become in the age of electronic health records. Computer documentation in health care is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself.
Our charting, rather than our care, is increasingly what we are evaluated on. When my hospital switched to bar code scanning for medication administration, not only were the nurses on my floor rated as "red," "yellow" or "green" based on the percentage of meds we scanned, but those ratings were prominently and openly displayed on printouts left at the nurses' station.
Or consider "fall assessments," which a nurse uses to determine a patient's risk of falling while in the hospital — a problem that accounts for 11,000 deaths annually. The assessments ask about medication, mobility issues and confusion to create a "fall risk score," which then generates an appropriate menu of interventions.
A nurse could spend 10 minutes documenting a patient's fall risk, or 10 minutes trying to keep patients from falling. It seems obvious that a computer record of "fall risk" cannot in and of itself prevent falls, but completing those records is considered essential in hospitals. As a result, real fall-prevention efforts — encouraging patients to use the call light, ordering a bedside commode, having an aide do hourly check-ins — get short shrift.
Friday, December 18, 2015
The system's leaders said their central goal was to teach Kaiser's model of integrated care to a new generation of doctors who will be under pressure to improve health outcomes and control costs by working in teams and using technology.
"Health care is evolving at a very, very rapid pace in our country and we have a model of care that's increasingly being looked to as an answer," said Dr. Edward M. Ellison, executive medical director for the Southern California Permanente Medical Group, who is helping to oversee the medical school's creation.
Kaiser already trains about 600 medical residents in its own program, and several thousand more complete a portion of their training in it each year. But its medical school, planned for Southern California, would be one of the first run by an integrated health system without an academic partner, said Dr. George E. Thibault, president of the Josiah Macy Jr. Foundation, which encourages innovation in medical schools.
"If health care is increasingly going to take place in integrated systems," Dr. Thibault said, "a large part of the medical education experience should be what it's like to work in a system like that: the efficiencies and the processes and the ways in which patient care is benefited."
Dr. Thibault added that while Kaiser would not be the only integrated health system involved in medical education, it is "larger than any of them, has greater reach than any of them, greater resources."
Kaiser runs 38 hospitals in eight states and the District of Columbia, with 18,000 doctors working for its affiliated medical groups and more than 10 million patients, mostly in California. It receives a fixed amount for medical care per member, so there is a strong financial incentive to keep people healthy and out of the hospital, a model that Kaiser pioneered and that is now being followed around the country.
Dr. Ellison said Kaiser's use of technology, through electronic medical records and new types of telemedicine that allow patients to receive "care anywhere in a way that's safe and effective," will also be crucial to its medical school curriculum.
Humans repeatedly fail where computers — or humans behaving a little bit more like computers — can help. Even doctors, some of the smartest and best-trained professionals, can be forgetful, fallible and prone to distraction. These statistics might be disquieting for anyone scheduled for surgery: One in about 100,000 operations is on the wrong body part. In one in 10,000, a foreign object — like a surgical tool — is accidentally left inside the body.
Something as simple as a checklist — a very low tech-type of automation — can reduce such errors. For example, in a wide range of settings, surgical complications and mortality fell after implementation of a basic checklistincluding verification of patient identity and body part for surgery, confirmation of sterility of the surgical environment and equipment, and post-surgical accounting for all medical tools. Though simple procedureswould all but eliminate certain sources of infections in hospitals, thousands of patients suffer from them in American hospitals every year.
What she couldn't survive was 11 weeks in Florida hospitals.
Schulte, 64, was living an engaged life—staying in touch daily with her daughter, Stephanie Sinclair, a photojournalist, and taking afternoon drives with her husband, Joe. When she suffered an unexpected bout of seizures in August 2012, doctors said she would need only a short hospital stay until the drugs kicked in to remedy things.
Instead, her treatment triggered a cascade of medical mistakes.
Wednesday, December 16, 2015
The Lancet: Women’s Contribution to Healthcare Constitutes Nearly 5% of Global GDP, but Nearly Half Is Unpaid and Unrecognized
Tuesday, December 15, 2015
A national campaign for electronic health records is driving business for at least 20 companies with thousands of workers ready to help stressed doctors log the details of their patients' care – for a price. Perhaps 1 in 5 physicians now employ medical scribes, many provided by a vendor, who join doctors and patients in examination rooms. They enter relevant information they hear about patients' ailments and doctors' advice in a computer, the preferred successor to jotting notes on a clipboard as doctors universally once did.
The U.S. has 15,000 scribes today and their numbers will reach 100,000 by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations.
Regulation and training are not rigorous. Scribes are not licensed. About a third of them are certified and that's voluntary, according to the sole professional body for scribes. The American College of Scribe Specialists was created by ScribeAmerica's founders in 2010.
"This is literally an exploding industry, filling a perceived gap, but there is no regulation or oversight at all," says George Gellert, regional chief medical informatics officer at Christus Santa Rosa Health System in San Antonio, which uses scribes.
Others suggest that scribes can be a benefit to doctors and patients by shouldering the minutia of recording many of the details on a computer. "They're capturing the story of a patient's encounter – and afterword, doctors make sure everything is accurate. That way the doctor can focus on interacting with the patient and give them good bedside manner," says Angela Rose, a director at the American Health Information Management Association, a professional group that has published a set of best practices for scribes.
Sunday, December 13, 2015
He encouraged her to choose hospice care. Two weeks later, he said to me, his patient's hospice aide came up to him on the ward. "She told me that my patient made her promise that the day she died, she would come find me and tell me. She said my patient wanted to thank me for encouraging her to die the way she wanted to."
I thought of this story at various points while reading "The Death of Cancer," Vincent DeVita Jr.'s fascinating if hubristically titled new book, co-authored with his daughter, Elizabeth DeVita-Raeburn, a science writer. Today, more than four decades after President Nixon declared war on cancer and with so many new weapons in our arsenal supported by big budgets and a decidedly aggressive posture, when is it O.K. to give up? When is it best to surrender?
Saturday, December 5, 2015
A hostile letter from a reader made me stop and think about the torments of waiting that cancer patients endure: waiting for a doctor, waiting for radiation, waiting for the delivery of chemotherapy drugs, waiting through interminable infusions or transfusions, waiting for a scan or a biopsy, waiting for the results of a scan or a biopsy, waiting (sometimes starved and unclothed on a gurney in a hall) for surgery.
The email arrived the day after an essay I had written on cancer language appeared online. Without a salutation, it began, "I hate what I've read by you. Simple as that. Your style is dark and nasty." Let's just say that it did not get any better after that.
But toward the end my correspondent stated, "last week I needed to have a thoracentesis for a large pleural effusion" after a seven hour wait in an emergency room. "That's a serious systemic issue," she emphasized, especially for someone with metastatic disease and a shut-down lung who is forced "to sit five hours, then lie on a stretcher for two more and finally be transferred to a real bed at 4 a.m."
From this account, which triggered memories of my own experiences in the ER, I could interpret her fury at me as anger deflected from its primary source: distress at her condition and at having had to wait so long under such frightful circumstances.
Wednesday, December 2, 2015
Americans remain very overweight. According to the Centers for Disease Control and Prevention, about 38 percent of adults were obese in 2013-14, compared with 32 percent just 10 years ago. This is in spite of huge efforts to get people in the United States to eat more healthily.
Policy makers continue to believe that the problem is people's lack of knowledge that they are wolfing down calorie-rich foods. It is assumed that once Americans know what they are eating, they will eat less, or at least with health in mind. For this reason, many health advocates have called for restaurants to provide people with calorie counts of what they are ordering. Recent mandates mean that by the end of next year, calorie labeling will be required on all menus in chain restaurants and establishments selling food in the United States.
Because many restaurants are already trying menu labeling, we can look at how they have worked, or haven't, and begin to predict how this widespread regulation might function. For instance, researchers looked at data from 66 of the largest chains — those that posted calories and those that didn't — and found that average calories per item were 139 calories lower in restaurants that posted their nutritional information.
Tuesday, December 1, 2015
But the reality is more confusing, as I discovered recently when I tested mine.
It turns out that blood pressure can jump around a lot — as much as 40 points in one day in my case — which raises the question of which reading to trust.
Ever since I wrote about a woman who was in denial about her high blood pressure until she had a stroke, I have been worried that my blood pressure might creep up without my knowing it. I became interested again when I reported that a large federal study of people at high risk for a heart attack or stroke found that bringing blood pressure well below the current national guidelines — a systolic blood pressure below 120 millimeters of mercury instead of 140, or instead of 150 for people older than 60 — significantly reduced the death rate and the rate of heart attacks, strokes and heart failure. The results were so compelling that guideline committees are expected to revise their recommendations.
A week after that study was published, I decided to check my blood pressure with a home monitor before a coming physical examination. The first night, I was startled to find that my systolic pressure was a scary 137. The next night, it was only 117. The next morning, before I saw my doctor, it was a terrifying 152. At the doctor's office, it was 150. I measured it again that night, and it had plummeted to 110. And my diastolic pressure, the lower number, was a rock-bottom 60 that evening.
It seemed unreal. Did I have hypertension because my pressure had hit 152 in the morning? But if I took a drug to bring it down, what would happen if my pressure was trying to go down to 110 in the evening?
I asked a few experts.
"Short answer is, you are normal," said Dr. David McCarron, a research associate at the University of California, Davis, adding that anyone whose pressure goes down to 120 or, in my case 110/60, does not have hypertension. His advice to patients is to abstain from obsessively monitoring their blood pressure.
The reasons for this have not been determined. Traditional cardiac risk models, developed by studying mostly white Americans, don't fully apply to ethnic communities. This is a knowledge gap that must be filled in the coming years. Fortunately, there is a model for doing so: research performed in a small town in Massachusetts over the past seven decades. Known as the Framingham Heart Study, it is perhaps the most influential investigation in the history of modern medicine.
The Framingham Heart Study is a big reason we have achieved a relatively mature understanding of heart disease in the United States — at least for a large segment of our population. It established the traditional risk factors, such as high blood pressure, diabetes and cigarette smoking, for coronary heart disease. Framingham also spearheaded the study of chronic noninfectious diseases in this country, and indeed introduced many doctors to the very idea of preventive medicine.
The impetus for Framingham was clear. In the 1940s, cardiovascular disease was the main cause of mortality in the United States, accounting for nearly half of all deaths. Knowledge of coronary risk factors was spare. As Dr. Thomas Wang and colleagues wrote in the journal Lancet last year, "Prevention and treatment were so poorly understood that most Americans accepted early death from heart disease as unavoidable."
Muizelaar hadn't seen Bradley's latest test results. Her condition had suddenly deteriorated, and new scans revealed that her tumor—a deadly type known as glioblastoma multiforme, or GBM—had returned. It had spread from the right side of her brain to the left frontal lobe, acquiring an ominous winged shape that doctors refer to as a butterfly glioma. A second tumor had sprouted in the region of her brain associated with speech. Bradley, partially paralyzed and dependent on a wheelchair, had already undergone chemotherapy and radiation; her doctors believed that more drugs were pointless. "The radiologist said, 'I've never seen anything grow so fast,' " Bradley's daughter Janet recalled. "He said, 'Call hospice.' That scared the hell out of me."
Bradley, a fiercely self-reliant woman who had raised four daughters on her own, refused hospice care. Finally, Janet took her to Muizelaar, who said that he was unable to help. "It's a blessing to most patients not to linger," Muizelaar, who practiced medicine in California under a license reserved for eminent foreign-trained physicians, told me. "Within four weeks, this woman had regrown a massive tumor, plus a second tumor. There was clearly nothing I could do about it."
Yet the conversation did not end there. An hour before Bradley's appointment, Muizelaar had received tantalizing news about a patient on whom he had performed an exceedingly unusual procedure. The previous month, he had operated on Patrick Egan, a fifty-six-year-old real-estate broker, who also suffered from glioblastoma. Egan was a friend of Muizelaar's, and, like Terri Bradley, he had exhausted the standard therapies for the disease. The tumor had spread to his brain stem and was shortly expected to kill him. Muizelaar cut out as much of the tumor as possible. But before he replaced the "bone flap"—the section of skull that is removed to allow access to the brain—he soaked it for an hour in a solution teeming with Enterobacter aerogenes, a common fecal bacterium. Then he reattached it to Egan's skull, using tiny metal plates and screws. Muizelaar hoped that inside Egan's brain an infection was brewing.
Muizelaar had devised the procedure in collaboration with a young neurosurgeon in his department, Rudolph Schrot. But as the consent form crafted by the surgeons, and signed by Egan and his wife, made clear, the procedure had never been tried before, even on a laboratory animal. Nor had it been approved by the Food and Drug Administration. The surgeons had no data to suggest what might constitute a therapeutic dose of Enterobacter, or a safe delivery method. The procedure was heretical in principle: deliberately exposing a patient to bacteria in the operating room violated a basic tenet of modern surgery, the concept known as "maintaining a sterile field," which, along with prophylactic antibiotics, is credited with sharply reducing complications and mortality rates. "The ensuing infection," the form cautioned, "may be totally ineffective in treatment of the tumor" and could cause "vegetative state, coma or death."
Tuesday, November 24, 2015
As I frequently have written in this column, exercise may cause robust improvements in brain health and slow age-related declinesin memory and thinking. Study after study has shown correlations between physical activity, muscular health and mental acuity, even among people who are quite old.
But these studies have limitations and one of them is that some people may be luckier than others. They may have been born to have a more robust brain than someone else. Their genes and early home environment might have influenced their brain health as much as or more than their exercise habits. Their genes and early home environment also might have influenced those exercise habits, as well as how their bodies and brains responded to exercise.
In other words, genes and environment can seriously confound experimental results.
That problem makes twins so valuable for scientific purposes. (Full disclosure, I am a twin, although not an identical one.) Twins typically share the same early home environment and many of the same genes, and if they are identical, all their genes are the same.
So if one twin's body, brain and thinking abilities begin to differ substantially over the years from the other's, the cause is less likely to be solely genetic or the early environment, and more likely to be attributable to lifestyle, including exercise habits.
Sunday, November 22, 2015
Israeli researchers, writing in the journal Cell this week, have found that different people's bodies respond to eating the same meal very differently — which means that a diet that may work wonders for your best friend may not have the same impact on you.
Lead authors Eran Segal and Eran Elinav of the Weizmann Institute of Science focused on one key component used in creating balanced diet plans like Atkins, Zone or South Beach. Known as the glycemic index or GI for short, it was developed decades ago as a measure of how certain foods impact blood sugar level and has been assumed to be a fixed number.
But it's not. It turns out that it varies widely depending on the individual.
The researchers recruited 800 healthy and pre-diabetic volunteers ages 18 to 70 and collected data through health questionnaires, body measurements, blood tests, glucose monitoring and stool samples. They also had the participants input lifestyle and food intake information into a mobile app that ended up collecting information on a total of 46,898 meals they had.
Each person was asked to eat a standardized breakfast that included things like bread each morning.
They found that age and body mass index, as expected, appeared to impact blood glucose level after meals, but so did something else. Different individuals showed vastly different responses to the same food, even though their own responses remained the same day to day.
"Get me the best cardiologist" is our natural response to any heart problem. Unfortunately, it is probably wrong. Surprisingly, the right question is almost its exact opposite: At which hospital are all the famous, senior cardiologists away?
One of the more surprising — and genuinely scary — research papers published recently appeared in JAMA Internal Medicine. It examined 10 years of data involving tens of thousands of hospital admissions. It found that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town. And this was at the best hospitals in the United States, our academic teaching hospitals. As the article concludes, high-risk patients with heart failure and cardiac arrest, hospitalized in teaching hospitals, had lower 30-day mortality when cardiologists were away from the hospital attending national cardiology meetings. And the differences were not trivial — mortality decreased by about a third for some patients when those top doctors were away.
Saturday, November 21, 2015
In the case, Volk v. DeMeerleer, a psychiatrist, Howard Ashby, was sued after a patient of his, Jan DeMeerleer, shot and killed an ex-girlfriend and her 9-year-old son before killing himself. (Mr. DeMeerleer also stabbed another son, who survived.) The estate of the victims, Rebecca and Phillip Schiering, took legal action, arguing that Dr. Ashby was liable because he had not warned the Schierings. A lower court ruled in Dr. Ashby's favor on the grounds that Mr. DeMeerleer, who had occasionally voiced homicidal fantasies, had made no specific threats toward the Schierings during his treatment.
But last November an appeals court reversed that judgment, asserting that doctors could be required to warn "all foreseeable victims" of potentially dangerous patients in their care. Whether the attack on the Schierings was foreseeable, the court said, should be decided by a jury.
Though the murder of innocents is obviously a tragedy, the Washington State Supreme Court should overturn the appeals court's decision. Not only does that judgment greatly expand the circumstances in which psychiatrists would be required to violate patients' confidentiality; those violations in the end would also not serve the purpose for which they were intended.
Throughout history, doctor-patient confidentiality has been a cornerstone of Western medical practice. The duty to keep patients' information private is written into the codes of ethics of medical organizations, and is even in the Hippocratic oath: "What I may see or hear in the course of treatment," it says, "I will keep to myself."
Thursday, November 19, 2015
At home, she carefully followed the instructions, swabbing inside the mouths of her husband and her daughter, placing the samples in the pouch provided and mailing them to a lab.
Days later, Stokes went online to get the results. Part of the lab's Web site address caught her attention, and her professional instincts kicked in. By tweaking the URL slightly, a sprawling directory appeared that gave her access to the test results of some 6,000 other people.
The site was taken down after Stokes complained on Twitter. But when she contacted the Department of Health and Human Services about the seemingly obvious violation of patient privacy, she got a surprising response: Officials couldn't do anything about the breach.
Wednesday, November 18, 2015
Using a weight-loss app? One created for millennials doesn't help much, study finds - The Orange County Register
If you're rooting for smartphones to solve all our health problems, you're not going to like what the researchers found. The smartphone app didn't help young adults lose any more weight than if they hadn't been using the app at all.
The study, published in the journal Obesity, looked at 365 young adults ages 18-35. A third of the participants used an Android app specifically created for the study, which not only tracked their calories, weight and exercise but also offered interactive features such as goal setting, games and social support.
Another third of the participants received six weekly personal coaching sessions, followed by monthly phone follow-ups. Plus, this personal coaching group was also encouraged to track their weight, calories and exercise via smartphone.
The last third of the participants were given three handouts on healthy eating and exercise – nothing else.
Researchers tracked the young adults' progress after six months, one year and two years. The personal coaching group had lost more weight than the other two groups after six months, but that lead vanished at the one- and two-year follow-ups.
As for the group using the smartphone app, their average weight loss was never more than the other two groups.
Lead author Dr. Laura Svetkey said she and her colleagues were both surprised and disappointed at the results.
"Given the seeming power of cellphone apps and frankly the popularity of these health and fitness apps in the commercial world, we thought this might be a really good strategy to provide effective intervention very broadly and potentially at low cost," said Svetkey, a professor of medicine at Duke University School of Medicine.
Yet, Svetkey says, it's difficult to get the same level of intensity in an app that you might get through personal coaching, and people have the tendency to stop using weight-loss apps after a while.
The number of cases has dropped not because the disease is becoming less common but because there is less effort to find it, the researchers said.
The declines in both screening and incidence "could have significant public health implications," the authors of one of the studies wrote, but they added that it was too soon to tell whether the changes would affect death rates from the disease.
Research shows that people who keep track of what they eat and weigh on a regular basis are more likely to succeed at losing weight and keeping it off. But as the food diary of Steve Lochner shows, food tracking and weight loss is far from simple.
In February of 2012, he weighed a high of 337 pounds. But then he started tracking his eating habits using the Lose It food tracking app. Soon he became a "Super Tracker," detailing virtually every bite of food — good and bad — that he ate over a three-year period, losing more than 100 pounds. Here's how he did it.
Tuesday, November 17, 2015
Millions of people are dying in pain because of the repressive stance the world has taken on drugs. That's because states are obsessed by the fear that people will use controlled medicines such as morphine as recreational drugs, thereby neglecting their important medical uses.
Where you live determines whether you will be able to access to controlled medicines, particularly opiates, when confronting an acute terminal, chronic or painful illness. Ninety-two per cent of the world's morphine is consumed by only 17% of the world's population, primarily the United States and Europe. Seventy--five percent of the world's people in need do not have access to pain relieving medicine.
In other words, most of the global population, outside the affluent countries in the North, dying in pain, including from terminal cancers, do so in the absence of dignified palliative care.
This is a horrendous situation for millions of patients and families. Essential medicines such as morphine, taken for granted as the standard relief of severe pain in the global North, do not enjoy the same status in the global South. Quite the opposite. Chances are, if a person living in any developing country ends up with an illness associated with extreme and avoidable pain, they will endure the pain simply because their government has created obstacles to morphine use in hospitals.
Antibiotic resistance, which can turn common ailments into killers, has reached dangerous levels globally, the World Health Organization warned Monday, saying widespread misunderstandings about the problem was fuelling the risk.
Antibiotic resistance happens when bugs become immune to existing drugs, allowing minor injuries and common infections to become deadly.
This happens naturally, but overuse and misuse of the drugs dramatically speeds up resistance, WHO said, voicing alarm at the results of a worldwide study showing that misconceptions about the threat are widespread, prompting dangerous behaviors.
Sunday, November 15, 2015
Dr. Vandebroek, a Belgian-born ethnobotanist, paused to gaze at herb-infused oils. The vials had names like Amor Prohibido ("Forbidden Love"), for those in search of adventure, and Conquistador, for the timid — both of them big sellers. Bendicion de Dinero Al Hogar ("A Blessing for Money in the House"), which comes in a spray, is also popular. But Dr. Vandebroek was not there to jump-start a flagging love life or curry the favor of spirits. La 21 Division is a regular stop for her, a mile or so from her laboratory at the New York Botanical Garden, where she is the assistant curator of economic botany.
She is conducting a multiyear study of the folk remedies sold in New York's botanicas, more than 100 emporiums that offer products for all that ails the body, mind and soul to a clientele mainly consisting of Latino and Caribbean immigrants. She is compiling guides in English and Spanish describing the plants and their uses. Her goal is to promote "culturally effective and sensitive health care" for a community that is chronically underserved by mainstream medicine.
When medical care is delivered in 15-minute doses, there’s not much time for caring - The Washington Post
A patient in any medical practice rightly wants the visit to take as long as is reasonably required. A healthy 25-year-old with a sore throat is thrilled to be out of my office in less than 10 minutes, after a focused exam and a culture. Most patients, though, don't present a single problem that can be addressed with a targeted answer. The 15-minute visit shortchanges those patients while frustrating the doctors who want to help make them well.
Marvin is thin, 6-foot-4, a 36-year-old commercial mortgage broker with a lineless, hard-to-read face. I've seen him once before, 11 months earlier, so this is considered a follow-up visit, half the length of a 30-minute first encounter.
There's a typical sequence to a 15-minute visit. In the opening phase, researchers who have studied primary-care interactions expect that I would "establish a cordial atmosphere" and "convey interest," and in fact I talk to Marvin about the Yankees' pitching problems. In the history section, I gather data with yes/no questions and tell-me-more-about-that follow-ups. "My back's acting up," Marvin says. Back pain is one of the 10 most common patient complaints in primary care and is almost never life-threatening. This shouldn't take very long if I'm clinically efficient and a clear communicator. Still, I try not to show that I am in a hurry. I do not wear a watch. Did your back pain begin after an injury? I ask. Have there been pain-free days? Are there certain positions or medications that have afforded relief? "It's been bad the past couple of months," Marvin says.
Saturday, November 14, 2015
And this is how things work for Asprey, according to his claims: By experimenting on his own body, he found a diet to end all diets, one that encourages the consumption of rich foods like avocado, steak and butter and requires little exercise to maintain a healthy weight. In the course of developing this diet — the Bulletproof Diet — Asprey says he lost 100 pounds, boosted his I.Q. more than a dozen points and lowered his biological age in the process.
Friday, November 13, 2015
The Apple move was a breakthrough, but a gap remained. "You can't just do research studies on people who can afford iPhones," said Deborah Estrin, a professor of computer science at Cornell Tech in New York.
Shortly after Apple introduced ResearchKit, Ms. Estrin, who is also a professor of public health at Weill Cornell Medical College, started trying to bring similar capability to the other major smartphone software platform, Google's Android. She coordinated the work on a new initiative, ResearchStack, announced on Thursday.
The new software framework will be similar to ResearchKit, which is open source and designed as modular building blocks. The ResearchStack design work is being led by Cornell Tech; Touch Lab, an Android developer; and Open mHealth, a nonprofit start-up focused on software for sharing health data. ResearchStack is being funded by the Robert Wood Johnson Foundation.
ResearchStack is intended to work smoothly with research projects underway that use Apple's ResearchKit. "Researchers can create a study that is independent of what smartphone is used, and they won't have to start from scratch," said Ms. Estrin, who is also co-founder of Open mHealth.
One of the current projects ResearchStack will soon support is Mole Mapper, an app for a melanoma study developed by the Oregon Health and Science University. The melanoma study involves people taking smartphone pictures of moles at regular intervals to track their growth, with the goal of creating detection algorithms and helping people manage the health of their skin.
The key to successful apps for large-scale studies, Ms. Estrin said, is to develop them for individuals as well as researchers. People, she said, have to control their health data and find it personally useful. That is what will fuel "the growing data-sharing movement," she said, prompting millions of people to "contribute to big-data-derived discovery and understanding" in medicine.
Thursday, November 12, 2015
Wednesday, November 11, 2015
The federal agency has been asked to come here and help find answers to a disturbing new trend that is costing lives – heroin mixed with a prescription pain medication.
State and local health experts said they are hoping what they learn during meetings Tuesday at the Hamilton County Board of Health will help them tackle the heroin crisis.
The CDC has a six-person team on the ground in Ohio, meeting with the Ohio Department of Health, and the Hamilton County Health Department.
Officials said they're focusing on a particular part of the heroin crisis – the number of deaths related to fentanyl.
Authorities said fentanyl is a prescription pain medication that has been showing up in heroin. The big mystery is why it's being mixed with heroin.
"We don't fully understand the fentanyl situation, and that's one of the reasons we wanted their help with this," said Dr. Mary DiOrio, the medical director of the Ohio Department of Health.
ODH asked the CDC to help look into the problem.
"We think that some people don't even know that it's in what they're injecting so we're trying to fully understand what people do and don't know so we can target the messages appropriately so we can protect lives," DiOrio said.
We've seen the deadly consequences of fentanyl in Greater Cincinnati.
Kenneth Gentry is facing charges in the overdose death of an Arlington Heights man earlier this year that was blamed on fentanyl.
Authorities said the fentanyl problem causes only a fraction of the deaths heroin alone causes – but it's a problem that's growing quickly.
Authorities said heroin deaths increased 18 percent in Ohio last year to a total of nearly 2,500. In 2014 there were about 500 deaths linked to fentanyl – an increase of nearly 600 percent from the year before.
So what is killing middle-aged white Americans? Much of the excess death is attributable to suicide and drug and alcohol poisonings. Opioid painkillers like OxyContin prescribed by physicians contribute significantly to these drug overdoses.
Thus, it seems that an opioid overdose epidemic is at the heart of this rise in white middle-age mortality. The rate of death from prescription opioids in the United States increased more than fourfold between 1999 and 2010, dwarfing the combined mortality from heroin and cocaine. In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.
The drug is a new class of cholesterol-lowering agents called PCSK9 inhibitors. Its cost and how we are paying for it illustrate why we all need to care about not only our own health care bills but also those of our neighbors. And it helps focus the debate about drug prices on two questions: What is the value delivered by the drug, and can that be linked to its price? And how should such value-based prices be implemented?
In July, the Food and Drug Administration approved the first of two new PCSK9 inhibitors that lower the bad type of cholesterol, LDL. Studies suggest that they can reduce it by up to 60 percent, compared with a placebo, and reduce it up to 36 percent more than statins and a drug called ezetimibe. However, there are no definitive data on how much these drugs actually reduce heart attacks, strokes and deaths from heart disease. Researchers suggest they might decrease the likelihood of such bad outcomes. For example, one preliminary study found that taking the drug lowered the overall chances that a patient would experience a heart attack or stroke, or hospitalization or death from heart disease, to 1.7 percent from 3.3 percent. The definitive studies will be out in 2017.
Drugs like these can help us lead longer, more productive lives. The problem is that the companies producing these drugs — Amgen, Sanofi and Regeneron — announced that the retail price for a prescription would be more than $14,000 per patient per year. The price is particularly steep given that these drugs may need to be taken for the rest of the patients' lives. How much patients pay directly would depend on their insurance plan.
By the time the stock market began to recover and our savings were again at a comfortable level, I had become conditioned to associate my nightly bathroom trips with "worry time." I would worry about everything: home repairs, trip planning, medical issues and all the vicissitudes of old age, fears of infirmity, dying and seeing my friends and loved ones die.
One night two weeks ago, for the first time in seven years, I realized that the worry demons had not appeared and that I had gone several days without hearing from them. This was a direct result, I believe, of changes that I made to my life over the previous two months. My tools consisted of a tiny amount of the tranquilizer clonazepam and three concurrently undertaken therapies, all new to me: psychological therapy, awareness meditation and religion. I call religion new in the sense that I had pretty much stopped believing in God when I was 20 years old. I call it a therapy because it helped to heal what ailed me.
My call to action began one evening when my blood pressure reached 199. For the previous six months my blood pressure had been jumping around. I had started monitoring it myself with a home machine. For two weeks I would take my blood pressure, meditate, check it again, meditate more, etc. At first, I was able to correlate a finding that proved to me that my blood pressure dropped after meditating, but on this night the numbers went the other way. My blood pressure increased after meditating and I panicked. I checked it repeatedly until it hit 199. I rushed to the bedroom and told my wife that she might have to call 9-1-1. She recommended that I take a Xanax, lie down and try to relax, and for God's sake stop taking my blood pressure. (She has since hidden my machine.)
The next morning we saw our family doctor. He gave me a prescription for clonazepam and said he thought I would be fine. I was more concerned than he was, and I asked if he could recommend a psychologist. Soon I began weekly visits with a clinical psychologist, Dr. Henry Kimmel, in Encino, Calif. I also started meditating regularly for one hour each night, with the aid of a free online service through the Mindful Awareness Research Center at the University of California, Los Angeles. I now had two therapies plus a drug to help arm me against the nighttime attacks in my bathroom.
He thrust his hand into the gash, grasped the beating heart and squeezed, to the tempo of 100 beats a minute.
Noticing bleeding from the right ventricle, Dr. Hashimoto stopped pumping to sew up the hole. The pulse recovered, and blood pressure climbed.
Concerned there might be more bleeding in the belly, Dr. Hashimoto moved to stop blood flow to the aorta. He struggled a bit to position the clamp.
"Remember your anatomy," the attending physician, Dr. Marc de Moya, advised over Dr. Hashimoto's shoulder.
Moments later, Dr. de Moya pronounced the procedure a success.
Yet no one's life had been saved. Dr. Hashimoto, a third-year-resident at Massachusetts General Hospital, had been practicing what is known as an emergency department thoracotomy on a rubber and plastic dummy that — but for the fact that it did not have a head — felt and acted remarkably like a human body.
A new analysis of data from a large national study has found that carrying fat around the middle of the body greatly raises the risk for heart disease and death, even for those of normal weight.
Doctors usually determine obesity by body mass index, or B.M.I. — calculated from height and weight — but the calculation does not distinguish between fat and lean muscle weight. Measuring waist-to-hip ratio presents a different, and possibly more accurate, picture because it accounts for central obesity, or visceral fat, the fat stored around the internal organs.
Waist-to-hip ratio is waist measurement divided by hip measurement. According to the World Health Organization, a ratio higher than .90 for men or .85 for women defines central obesity.
It has been known for some time that having an "apple" shape increases the risk for disease and death. But the new study found that a man of normal B.M.I. with an abnormally large belly has an 87 percent higher risk for death than a man with the same B.M.I. but a normal waist-to-hip ratio. Pot-bellied women of normal B.M.I. have a 48 percent higher risk than women with normal B.M.I. and normal belly fat.