Saturday, March 14, 2015
Reading his chart, I have an ominous feeling that this visit won't be simple.
A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.
He suffers from both congestive heart failure and renal failure. It's a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.
Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can't blame him.
Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.
With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.
After 30 years of practice, I know that I can't possibly solve this man's medical conundrum.
A cardiologist and a nephrologist haven't been able to help him, I reflect, so how can I? I'm a family doctor, not a magician. I can send him back to the ER, and they'll admit him to the hospital. But that will just continue the cycle. . . .
Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it's useless to try.
Then I remember a visiting palliative-care physician's words about caring for the fragile elderly: "We forget to ask patients what they want from their care. What are their goals?"
I pause, then look this frail, dignified man in the eye.
"What are your goals for your care?" I ask. "How can I help you?"
Every Friday, Pulse--voices from the heart of medicine publishes and distributes a first-person story or poem, together with a visual image or haiku, about health care.
Launched in 2008, Pulse was created by members of the Department of Family and Social Medicine at Montefiore Medical Center and Albert Einstein College of Medicine in collaboration with colleagues and friends around the country.
At a time when the pioneering work of Rita Charon has established the value of narrative medicine--an approach that places a premium on personal perspectives within a healthcare encounter--Pulse makes narrative medicine available to all and accessible to anyone.
Pulse tells the story of health care through the personal experiences of those who live it--patients, health professionals, students and caregivers. While medical care is often rightly criticized for being cold and oblivious, Pulse highlights the humanity and vulnerability of all its actors. In doing so it promotes the humanistic practice of medicine and encourages advocacy for compassionate health care for all.
Wednesday, March 11, 2015
Monday, March 9, 2015
Sunday, March 8, 2015
Cole teamed up with University of Chicago social psychologist John Cacioppo, who had already been tracking 166 healthy middle-aged adults for three years, periodically asking them how socially isolated they felt and gathering all manner of biomedical, psychological, social, and economic data. Cole and Cacioppo took blood samples from 153 of the study subjects and focused on the eight most socially secure people and the six loneliest, who had scored highest on the UCLA Loneliness Scale for the past three years. When Cole ran these 14 subjects' white blood cells through a microarray analysis, he spotted more than 200 genes that were expressed differently between the two groups. Many of the genes dialed up in lonely individuals were involved in inflammation, while the downregulated genes tended to be associated with antiviral response, antibody production, and restraint of inflammatory responses.
It was a tiny sample, but the implications of the study, published in 2007, were great: loneliness, it seems, shapes one's health by controlling the "dimmer switch" for whole networks of immune-related genes. Indeed, this overexpression of proinflammatory genes and suppression of anti-inflammatory and antiviral genes might explain why lonely people are more likely to succumb to a variety of diseases, and why HIV ravages socially isolated people more quickly than their more connected peers. "It was gratifying to see the story [of how loneliness affects health] move beyond the genotype to include the functional aspect of the genome," says Cacioppo.
Jeffrey Hammerbacher is a number cruncher — a Harvard math major who went from a job as a Wall Street quant to a key role at Facebook to a founder of a successful data start-up.
But five years ago, he was given a diagnosis of bipolar disorder, a crisis that fueled in him a fierce curiosity in medicine — about how the body and brain work and why they sometimes fail. The more he read and talked to experts, the more he became convinced that medicine needed people like him: skilled practitioners of data science who could guide scientific discovery and decision-making.
Now Mr. Hammerbacher, 32, is on the faculty of the Icahn School of Medicine at Mount Sinai, despite the fact that he has no academic training in medicine or biology. He is there because the school has begun an ambitious, well-funded initiative to apply data science to medicine.