Thursday, June 16, 2016
The doctor recommended infusions of cyclosporine, a powerful immune-suppressant drug. Vik looked it up and learned that the drug, often given to transplant recipients, in rare instances can increase the risk of fatal infection and certain cancers. And if cyclosporine didn't work, the next intervention would probably be the surgical removal of his colon. Vik might have to wear a colostomy bag for the rest of his life.
"I had a feeling there had to be a better way," he told me recently. (Worried about being stigmatized, Vik asked that I identify him only by his first name.) He began researching ulcerative colitis and discovered that the prevalence of inflammatory bowel disease — an umbrella term that includes both ulcerative colitis and Crohn's disease — had increased markedly in the United States over the 20th century. Yet the disease was less common in the developing world. He learned that exposure to dirt and unsanitary conditions early in life seemed to protect against these and other inflammatory diseases later. And then he encountered an explanation for the correlations in the research of a scientist named Joel Weinstock.
Weinstock, a gastroenterologist now at Tufts University, thought that parasites were to blame. But it wasn't their presence in the human digestive system that was causing the rise; it was their absence. To survive for years in another animal, parasitic worms, known as helminths, counter their hosts' defenses. Because an out-of-control immune response against native bacteria was thought to drive inflammatory bowel disease, Weinstock's insight was that parasites' ability to disarm the immune system might prevent the disorder. The broader implication was that the disappearance of parasites — largely eradicated from American life in the early 20th century through improvements in sanitation — might have left our immune systems unbalanced, increasing our vulnerability to all types of inflammatory disorders.
Wednesday, June 15, 2016
Listening for What Matters: Avoiding Contextual Errors in Health Care - Saul J. Weiner, Alan Schwartz
Our book, Listening for What Matters: Avoiding Contextual Errors in Health Care, published January 2016, is now available from Oxford University Press USA.
We argue that physicians are not all prepared to understand patients' individual life contexts and tailor their medical care to the patient. This problem is real, pervasive, costly, and not addressed by the American health care system or process of medical education. Using the results of hundreds of medical visits in which actors and real patients wore hidden recorders, the book give examples of crucial patient context that physicians failed to appreciate and the medical errors that can result from this failure. It tells the stories of patients whose care was compromised by these failures, and the research that revealed the magnitude of the problem. It explains how these errors can be minimized through changes in how doctors are trained, changes in how medicine is practiced and paid for, and ways for patients to assert their individual circumstances during visits.
Tuesday, June 14, 2016
It didn't work.
In an unusual arrangement, the American Diabetes Association let hundreds, if not thousands, of in-person attendees see new data on Novo Nordisk A/S's blockbuster diabetes treatment Victoza more than an hour before its official release to the public and the markets. That's atypical for such sensitive data, which are usually shared only with journalists and researchers who have agreed to abide by strict terms, under threat of losing future access.
As the Monday afternoon presentation neared, attendees posted on Twitter pictures of the packed hall, of the crowds waiting to get in, and of the projection screens touting the trial's name: "LEADER."
After warning attendees not to share the information they were about to post, presenters in the hall put up slides showing that Bagsvaerd, Denmark-based Novo's drug cut heart attacks and strokes by 13 percent and and improved survival, while also lowering blood sugar rates and a host of other complications. While good news for diabetics, it was less than investors had hoped.
Within minutes, some Twitter accounts were posting pictures of the charts, including key slides that showed the drug's success in reducing deaths. And as fast as the posts went up, the medical society's communications team issued online pleas for them to stop.
"#2016ADA slides include unpublished data and are the intellectual property of the presenters," the association tweeted at accounts who posted the data. "Please delete immediately."
If this place has done its job—and I suspect it has—you're all scientists now. Sorry, English and history graduates, even you are, too. Science is not a major or a career. It is a commitment to a systematic way of thinking, an allegiance to a way of building knowledge and explaining the universe through testing and factual observation. The thing is, that isn't a normal way of thinking. It is unnatural and counterintuitive. It has to be learned. Scientific explanation stands in contrast to the wisdom of divinity and experience and common sense. Common sense once told us that the sun moves across the sky and that being out in the cold produced colds. But a scientific mind recognized that these intuitions were only hypotheses. They had to be tested.
When I came to college from my Ohio home town, the most intellectually unnerving thing I discovered was how wrong many of my assumptions were about how the world works—whether the natural or the human-made world. I looked to my professors and fellow-students to supply my replacement ideas. Then I returned home with some of those ideas and told my parents everything they'd got wrong (which they just loved). But, even then, I was just replacing one set of received beliefs for another. It took me a long time to recognize the particular mind-set that scientists have. The great physicist Edwin Hubble, speaking at Caltech's commencement in 1938, said a scientist has "a healthy skepticism, suspended judgement, and disciplined imagination"—not only about other people's ideas but also about his or her own. The scientist has an experimental mind, not a litigious one.
As a student, this seemed to me more than a way of thinking. It was a way of being—a weird way of being. You are supposed to have skepticism and imagination, but not too much. You are supposed to suspend judgment, yet exercise it. Ultimately, you hope to observe the world with an open mind, gathering facts and testing your predictions and expectations against them. Then you make up your mind and either affirm or reject the ideas at hand. But you also hope to accept that nothing is ever completely settled, that all knowledge is just probable knowledge. A contradictory piece of evidence can always emerge. Hubble said it best when he said, "The scientist explains the world by successive approximations."
The scientific orientation has proved immensely powerful. It has allowed us to nearly double our lifespan during the past century, to increase our global abundance, and to deepen our understanding of the nature of the universe. Yet scientific knowledge is not necessarily trusted. Partly, that's because it is incomplete. But even where the knowledge provided by science is overwhelming, people often resist it—sometimes outright deny it. Many people continue to believe, for instance, despite massive evidence to the contrary, that childhood vaccines cause autism (they do not); that people are safer owning a gun (they are not); that genetically modified crops are harmful (on balance, they have been beneficial); that climate change is not happening (it is).
Vaccine fears, for example, have persisted despite decades of research showing them to be unfounded. Some twenty-five years ago, a statistical analysis suggested a possible association between autism and thimerosal, a preservative used in vaccines to prevent bacterial contamination. The analysis turned out to be flawed, but fears took hold. Scientists then carried out hundreds of studies, and found no link. Still, fears persisted. Countries removed the preservative but experienced no reduction in autism—yet fears grew. A British study claimed a connection between the onset of autism in eight children and the timing of their vaccinations for measles, mumps, and rubella. That paper was retracted due to findings of fraud: the lead author had falsified and misrepresented the data on the children. Repeated efforts to confirm the findings were unsuccessful. Nonetheless, vaccine rates plunged, leading to outbreaks of measles and mumpsthat, last year, sickened tens of thousands of children across the U.S., Canada, and Europe, and resulted in deaths.
Over the following year I got married, started teaching seventh and eighth grade, and began work on a novel. Every week or so the disequilibrium sneaked up on me. The feeling was one of disorientation as much as dizziness, with some cloudy vision, light nausea and the sensation of being overwhelmed by my surroundings. During one eighth-grade English class, when I turned around to write on the blackboard, I stumbled and couldn't stabilize myself. I fell in front of my students and was too disoriented to stand. My students stared at me slumped on the floor until I mustered enough focus to climb up to a chair and did my best to laugh it off.
I was only 29, but my father had had a benign brain tumor around the same age, so I had a brain scan. My brain appeared to be fine. A neurologist recommended I see an ear, nose and throat specialist. A technician flooded my ear canal with water to see if my acoustic nerve reacted properly. The doctor suspected either benign positional vertigo (dizziness caused by a small piece of bonelike calcium stuck in the inner ear) or Ménière's disease (which leads to dizziness from pressure).
Unfortunately, the test showed my inner ear was most likely fine. But just as the marijuana had triggered the dizziness the year before, the test itself catalyzed the dizziness now. In spite of the negative results, doctors still believed I had an inner ear problem. They prescribed exercises to unblock crystals, and salt pills and then prednisone to fight Ménière's disease.
All this took months, and I continued to be dizzy, all day, every day. It felt as though I woke up every morning having already drunk a dozen beers — some days, depending on how active and stressful my day was, it felt like much more. Most days ended with me in tears. Teaching was nearly impossible; I was unable to write because of blurry vision, and my wife became a caretaker more than a partner; I became addicted to message boards for dizziness, vertigo, benign positional vertigo and Ménière's disease. Anonymous posters described how their medications didn't work and their doctors couldn't cure them. They couldn't keep their jobs; their friends didn't understand them; and their spouses left or tried to be supportive, but eventually both suffered.
Finally, my doctor recommended a new neurologist who performed some simple tests and casually gave me a diagnosis of vestibular migraines, a condition that didn't exist in medical journals 20 years ago.
Sunday, June 12, 2016
The study discovered that hand hygiene compliance at SCVMC differed significantly when health professionals knew they were watched, versus when they were not.
"The level of hand hygiene compliance when staff did not know they were being watched was surprising," said Maricris Niles, MA, infection prevention analyst, Santa Clara Valley Medical Center, California. "This study demonstrated to us that hand hygiene observations are influenced by the Hawthorne Effect and that unknown observers should be used to get the most accurate hand hygiene data."
"Hand hygiene is one of the most important ways to prevent the spread of infection, and yet it can be one of the most difficult benchmarks to improve," said Susan Dolan, president of the Association for Professionals in Infection Control and Epidemiology. The study is being presented at the association's annual conference.
Inspired by a 2014 study that found emotional motivators more effective than traditional messaging, this study aimed to evoke the feeling of dirtiness in health-care workers. The images were tested many times over two months in four hospital units with the lowest rates of hand hygiene compliance.
After the images were shared, observations showed that every unit experienced at least an 11% improvement in hand-washing, and one unit increases by almost 50%.
"Hospital staff wanted to wash their hands after looking at the book and picturing similar contamination on their own skin," said Ashley Gregory, an infection prevention specialist who co-led the project.
A new analysis of common treatments for these three conditions, using a database of 250 million patients' records from four countries, has found that at least one in 10 patients received a course of drugs that no other patient with the same condition did. In other words, more than 25 million people were essentially being treated by guesswork.
Though that may sound surprising, a lot of the time trial and error is, in fact, how medicine works. The progression of a disease depends on many factors such as age, weight, and genetics. Doctors can't always know precisely how a patient will respond to a given treatment. The decision about which drug to use, and what the patient will accept, is complicated, influenced by everything from official medical guidelines to what health insurance will cover to what the patient has read on the internet. In many situations, the best a doctor can do is to make a calculated guess, see how you respond, adjust, and repeat.
But the simple fact that such massive analyses are now possible might help reduce this kind of guesswork. In the study, published on June 6 inthe Proceedings of the National Academy of Sciences, researchers led by a group from Columbia University found that 24% of patients being treated for hypertension had unique treatment regimens: That is, no other patient underwent the same sequence and dosing of up to 18 drugs from start to finish for three years.
Even depression, notoriously complex to treat, seems to have a more standardized drug regimen than hypertension: About 11% of the patients were treated in a unique way. Diabetes patients are more consistent, with 75% of them starting on metformin, generally the recommended front-line drug. Nearly 30% of those stick to just that drug for their whole treatment. Yet, in the end, even among diabetics, 10% got unique treatment regimens.