Psychology of Medicine

The D.S.M.’s Troubled Revision - NYTimes.com

2012-01-30T13:56:00.001-05:00

You've got to feel sorry for the American Psychiatric Association, at least for a moment. Its members proposed a change to the definition of autism in the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders, one that would eliminate the separate category of Asperger syndrome in 2013. And the next thing they knew, a prominent psychiatrist was quoted in a front-page article in this paper saying the result would be fewer diagnoses, which would mean fewer troubled children eligible for services like special education and disability payments.

Then, just a few days later, another front-pager featured a pair of equally prominent experts explaining their smackdown of the A.P.A.'s proposal to eliminate the "bereavement exclusion" — the two months granted the grieving before their mourning can be classified as "major" depression. This time, the problem was that the move would raise the numbers of people with the diagnosis, increasing health care costs and the use of already pervasive mind-altering drugs, as well as pathologizing a normal life experience.

Fewer patients, more patients: the A.P.A. just can't win. Someone is always mad at it for its diagnostic manual.

It's not the current A.P.A.'s fault. The fault lies with its predecessors. The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history.

This tension has been high since at least 1917. That's when Thomas Salmon, a future head of the A.P.A. — which was founded in 1844 — noted that psychiatry's "classification of mental diseases is chaotic." He worried that "this condition of affairs discredits the science of psychiatry and reflects unfavorably upon our association" and urged his membership to forge a diagnostic system "that would meet the scientific demands of the present day."

The American Psychiatric Association has been trying to do just that ever since, mostly by leaving behind ideas about the meaning of our suffering in favor of observation and treatment of its symptoms. In 1980, it hit on the strategy of adopting a medical rhetoric, organizing those symptoms into neat disease categories and checklists of precisely described criteria and publishing them in the hefty — and, according to its chief author, "very scientific-looking" — D.S.M.-III.

That book, with its more than 200 objectively described diagnoses, would have made Dr. Salmon proud. By meeting the scientific demands of the day, it was credited by many with having rescued psychiatry from the brink of extinction, and its subsequent revisions have been the cornerstone of the profession's survival as a medical specialty.

But as all those Diagnostic and Statistical Manuals have stated clearly in their introductions, while the book seems to name the mental illnesses found in nature, it actually makes "no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder." And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not "real diseases," at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer. The manual, they go on, was primarily written to give physicians, schooled in the language of disease, a way to recognize similarities and differences among their patients and to talk to one another about them. And it has been fairly successful at that.

Still, "people take it literally," one psychiatrist who worked on the manual told me. "That is its strength in a political sense." And even if the A.P.A. benefits mightily from that misperception, the troubles on the front page are not the organization's fault. They are what happens when we expect the D.S.M. to be what it is not. "The D.S.M. has been taken too seriously," another expert told me. "It's the victim of its success."

Psychiatrists would like the book to deserve a more serious take, and thus to be less subject to these embarrassing diagnostic squabbles. But this is going to require them to have what the rest of medicine already possesses: the biochemical markers that allow doctors to sort the staph from the strep, the malignant from the benign. And they don't have these yet. They aren't even close. The human brain, after all, may be the most complex object in the universe. And the few markers, the genes and the neural networks, that have been implicated in mental disorders do not map well onto the D.S.M.'s categories.

"We're like Cinderella's older stepsisters," a psychiatrist told me the other day. "We're trying to stick our fat feet into the delicate slipper so the prince can take us to the ball. But we ain't going to the ball right now." Which is why we might feel a little sorry for the beleaguered A.P.A.

On the other hand, given that the current edition of the D.S.M. has earned the association — which holds and tightly guards its naming rights to our pain — more than $100 million, we might want to temper our sympathy. It may not be dancing at the ball, but once every mental health worker, psychology student and forensic lawyer in the country buys the new book, it will be laughing all the way to the bank.

Gary Greenberg, a psychotherapist and the author of "Manufacturing Depression," is writing a book about the making of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

http://www.nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html?_r=1&ref=opinion

The child I lost - The Observer

2012-01-28T13:35:00.001-05:00

At 35 weeks, Sarah Hughes's unborn baby inexplicably died. In this heartbreaking memoir she reveals why stillbirth is an experience no mother talks of – and how strangers finally taught her to live with the death

More …

http://www.guardian.co.uk/lifeandstyle/2012/jan/22/losing-iris-stillborn-sarah-hughes

The Long Goodbye - Atlanta Magazine

2012-01-28T09:30:00.001-05:00

Augustus Monroe figured he'd drop dead long before he'd need a nursing home. A decade later, his son considers the weighty financial and emotional costs that come with a parent's immortality.

We thought Daddy was going to die in 2001. He was staggering around the house in his underwear, gasping in pain, his eyes hollow, his face slashed from shaving with an old-fashioned safety razor.
He was eighty-two years old. We took him to a doctor, who said his spine was deteriorating, gave him pills, and suggested he pray. A few days later, Daddy fell at the mailbox, bounced his head on the pavement, and crawled up the driveway, scraping the skin off his knees before collapsing on the front steps. Mama sat in her recliner in front of the TV, worried and clueless, until a neighbor called an ambulance. The EMTs got Daddy propped up in his recliner. He refused to go with them. When I arrived, Daddy was gulping down whiskey. I called the ambulance back, and they took him to DeKalb Medical. Doctors found prostate cancer and operated. My sister and I cried, sure Daddy was in his last days.

That was eleven years ago. Since then, Daddy's long goodbye has drained his retirement income and life savings of more than $300,000. Where's that money gone? Assisted living, mostly. Of course, that amount doesn't account for his medical bills, most of which have been paid by Medicare and insurance policies that were part of his retirement. Daddy's income—Social Security, plus monthly checks from two pensions—pays for the facility where he lives, his taxes, his life insurance policy premiums, and such incidentals as a visiting podiatrist to clip his nails.

And he has been kicked out of two hospices for not dying.

Daddy is ninety-three now and wears a diaper, is spoon-fed, and urinates through a catheter, drifting in and out of deep sleep in which he gasps for air and appears to be dead. Trisha, my sister, texted a picture of him in October to one of her daughters, who texted back: "Happy Halloween!" When he wakes up, his caregivers dress him and plop him in a wheelchair. He rolls around like a child until it's time to eat again.

I cannot imagine that this once-dignified Southern gentleman, who clawed his way out of the grit of a Depression-era tobacco farm in North Carolina and bought a snazzy double-breasted suit with one of his first paychecks, would be anything but humiliated by what is happening to him now—if he had all his faculties. Yet as one of his nurses told me, "Your father has no interest in dying." It is not heroic measures keeping him alive; he just keeps ticking. He takes only two medicines: an antibiotic for a urinary tract infection and OxyContin for the pain in his spine.

At sixty-four, I am at the leading edge of baby boomers who have ringside seats to the slow-motion demise of the Greatest Generation, watching our parents pass away slowly and stubbornly, dying piece by piece over a decade or more, often unwilling or unable to share their feelings. Most of us, such as my sister and I, head into the turmoil of caring for an aging Immortal utterly unprepared.
Daddy used to laugh at Trisha and me whenever we suggested discussing assisted living and long-term care insurance with him. He insisted—with the unshakable confidence of a career civil engineer—that he didn't need to make such plans, that he would simply drop dead one day and that would be the end of it. He refused to discuss it further.

It didn't work out according to that plan, and there was no other plan.

More ...

http://www.atlantamagazine.com/features/Story.aspx?ID=1629702

American Medical News

2012-01-27T15:18:00.001-05:00

American Medical News is the print and online news publication for physicians published by the American Medical Association. No other single publication covers the same spectrum of medical news. It has a large national circulation that cuts across geographic regions, practice settings and medical specialties.

The complete content of American Medical News can be found online atwww.amednews.com. The site, updated Monday through Friday, features all the content of the print edition plus Web-only reporting. The print edition is published in a tabloid-size format 24 times a year.

American Medical News is directed to physicians in private practice and physicians on hospital and managed care staffs, in military service and on medical faculties. Of a total print circulation of over 230,000, about 90% are physicians, primarily office-based doctors in five primary-care specialties. A large portion of the nonphysician readers are medical students.

The other nonphysician readers include health regulators; legislators and their staffs; staffs of state, county and specialty medical societies; administrators of health programs; and journalists. These professional watchers of the health policy scene make up a small percentage of print circulation, but their work has an important impact on the medical profession and health care in America.

http://www.ama-assn.org/amednews/

Doctors still face harsh medical liability realities :: American Medical News

2012-01-27T15:17:00.001-05:00

When looking at the medical liability landscape, doctors will see some recent victories fending off tort reform challenges.

California's $250,000 noneconomic damages cap -- long considered the gold standard among state tort reforms -- was upheld by an appellate court in September 2011. West Virginia's cap of the same amount was declared constitutional by the state's high court in June 2011.

Such reforms enacted or upheld in these and other states are credited with positive results. Doctors who otherwise would have fled to a better liability climate have stayed put. Liability premiums in tort reform states are typically lowered or at least stabilized.

But those strides must be viewed alongside setbacks. In 2010, the Georgia Supreme Court found that state's $350,000 cap unconstitutional, and the Illinois Supreme Court did the same with the Illinois cap of $500,000. Legal challenges are being waged in Missouri, Indiana and elsewhere.

Two recent reports from the American Medical Association provide an even broader reality check on the scale of the challenge that physicians still face.

The first study, issued in November 2011, found that the average expense to defend against a medical liability claim in 2010 was $47,158. That's a 63% increase from 2001. Average expense payments have increased by 43% since 2005. About two in three claims against doctors were dropped, dismissed or withdrawn without payment in 2010, but expenses handling even those dead-end claims average $26,851.

Payments on claims have remained stable, but a small fraction account for a disproportionate share of those payments. Payouts of at least $1 million accounted for 34% of total payments -- a figure the report said underscores the need for caps on noneconomic damages to contain health care costs and premiums.

The second report, released in December 2011, analyzed premium information from 2004 to 2011 collected by the Medical Liability Monitor. Even with improvements in the market, the report shows that many states still have unacceptably high premiums. For example, premiums for obstetrician-gynecologists in some areas of New York hit $206,913 in 2011, a 41% increase from 2004.

Overall stability of premiums, viewed as a generally positive sign, also was reflected in the data. On a national scale, 55% of premiums held steady in 2011, while 15% increased and 30% decreased. The trend of stable rates has held for six straight years.

However, the Monitor survey shows that, despite an overall stable market, premiums vary widely depending on where a physician practices, with general surgeons paying as much as $191,000 in South Florida or as little as $11,000 in Minnesota. Avoiding an increase is relatively slim comfort when it also means being stuck with a six-figure premium from practicing in a liability hot spot.

The toll that medical liability takes on doctors is more than financial. Consider one recent finding: Surgeons who were sued had a 7% higher rate of burnout and a 10% higher rate of experiencing symptoms of depression than those not sued during the two years examined, said a study in the November 2011 Journal of the American College of Surgeons.

The AMA has long fought for tort reforms and continues to pursue solutions to an out-of-whack medical liability environment. The Association is seeking reforms at the federal and state levels, and it supports testing new approaches, such as health courts. Meanwhile, the Litigation Center of the American Medical Association and the State Medical Societies is helping to defend challenges to state caps.

Indeed, it is the states where reforms have been made. Yet the prospect of delivering care under a sound medical liability system should not end at the state line. The two AMA reports and Monitor data present a view of the system as it must be seen and addressed, as a matter of national health policy and tort reform.

http://www.ama-assn.org/amednews/2012/01/23/edsa0123.htm

Heavy Doctors Avoid Heavy Discussions About Weight : Shots - Health Blog : NPR

2012-01-27T15:15:00.001-05:00

Research already demonstrates that physicians are sometimes uncomfortable talking about weight with their obese patients. Now, a new study shows that the doctors' weight makes a difference too.

Physicians who pack on the pounds discuss weight loss less frequently with obese patients than doctors who have normal body mass indexes (18 percent versus 30 percent), according to the report published this week in the medical journal Obesity.

And they're significantly less confident of their ability to provide effective counseling about diet (37 percent vs. 53 percent) or exercise (38 percent vs. 56 percent).

The findings come from an Internet survey of 498 family doctors, internists and general practitioners conducted early last year by researchers at Johns Hopkins. Two-thirds of the physicians were male, almost three-quarters were 40 years old and 53 percent were overweight or obese.

The results matter. More than two-thirds of American adults are overweight or obeseand their medical costs total $147 billion. If heavy doctors won't acknowledge that patients have a problem and offer help, that can be a barrier to effective care, says Sara Bleich, lead author of the new study and an assistant professor of health policy at Johns Hopkins Bloomberg School of Public Health.

A notable finding in the study speaks to the problem: 93 percent of physicians of normal weight said they would be more likely to identify an obese patient when that person was as large or larger than they were. By contrast, this was true of only 7 percent of obese or overweight physicians.

"It seems to be the case that doctors are less likely to diagnose the patient until the patient's weight meets or exceeds their own," Bleich says. This could be because physicians' sense of what's normal changes as they put on pounds and see more excessively heavy patients in their practices, she speculates.

Asked what might explain heavier doctors' reluctance to discuss weight loss, Bleich says, "It could be that they feel that their advice will not hold a lot of weight with their patients, because they themselves are heavy."

Overweight and obese physicians expressed greater confidence in prescribing weight-loss drugs than other doctors, perhaps because they've had personal experience with the medications or with the difficulty of behavior change, she observes.

This isn't the first time that research has shown a link between physicians' personal characteristics and their willingness to advise patients on lifestyle issues. "We know that physicians who follow healthy dietary practices themselves are more likely to spend time counseling patients about diet," says Dr. Robert Kushner, a professor of medicine at Northwestern University Feinberg School of Medicine and clinical director of Northwestern's Comprehensive Center on Obesity.

Other research has shown that physicians who smoke are less likely to help patients quit.

Bleich and her co-authors close their study by suggesting that doctors, who also report high levels of stress, substance abuse and depression, need to be encouraged to take better care of their health, both for their own sake and patients.

http://www.npr.org/blogs/health/2012/01/27/145990665/heavy-doctors-avoid-heavy-discussions-about-weight?

Pain is top concern in Ohio and the nation

2012-01-27T09:43:00.001-05:00

CLEVELAND, Ohio -- High costs and the alarmingly high number of accidental deaths linked to prescription pain pills have made pain treatment a central issue in health care across Ohio and the nation.

A recent report by the Institute of Medicine underlined the urgency of developing better pain-management strategies in the United States, where chronic pain affects more than 116 million people and costs as much as $650 billion yearly in direct medical treatment and lost productivity.

"Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity," the report stated. "Given the burden of pain in human lives, dollars and social consequences, relieving pain should be a national priority."

Americans make up 4.6 percent of the world population and consume 80 percent of the global opiate supply, including nearly all of the hydrocodone supply, according to the American Society of Interventional Pain Physicians.

In August, an Ohio law went into effect requiring special licensing for pain clinics and doctors with 50 percent or more of patients being treated with controlled substances for chronic pain. The law tightly regulates record keeping on patients and mandates subspecialty certification and continuing education in pain management for physicians. The law also limits how many pills doctors can dispense and establishes a system for collecting unused narcotics.

In Ohio, deaths from unintentional prescription drug overdoses have increased more than 350 percent between 1999 and 2008, making it the leading cause of accidental death in the state since 2007.

With the tightening of regulations, learning the best way to prescribe painkillers, including narcotics, is critical for doctors.

The Institute of Medicine report said more research is needed so that physicians have better data to guide them when treating patients -- especially children and the elderly who sometimes cannot express their needs.

"Pain is something that the U.S. health care system doesn't deal with well," said Dr. Alan Hull, associate dean for curricular affairs in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. "We need to work on recognizing and treating pain appropriately."

Given the restraints on doctors' time during standard appointments, he said, "there certainly is a science and art to being able to read patients and develop a relationship with them."

The Institute of Medicine report recommended that medical education programs expand curriculum about pain.

Limited instruction for medical students

A separate study released last month by researchers from Johns Hopkins School of Medicine found that medical school curriculum addressing pain is limited and often fragmented.

"Health care has undergone dramatic changes in the last 25 years," stated the study published in the American Pain Society's Journal of Pain , "but inadequate treatment of pain has persisted." The study stated that the areas of cancer, pediatric and geriatric pain treatment are unaddressed by the vast majority of medical schools.

Dr. Jennifer Kriegler, associate professor of medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, said unlike when she was receiving her training, schools have been doing a much better job of teaching medical students and residents about pain -- especially chronic pain.

Medical schools throughout Ohio are devoting more time to classroom curriculum on chronic pain -- often linked to cases of drug abuse -- and to student observation of patients.

"Treating pain is much more than giving somebody medication," Kriegler said. "That's what students need to know. It takes a multifaceted approach."

Dr. David Ryan, who runs the pain management program at MetroHealth Medical Center, said doctors have to look at the whole patient. "The best pain physicians take time to listen to the patient and understand their problems, taking into consideration both the physical and emotional complexities," he said.

"Because pain is so complicated, it covers almost the entire spectrum of medical training," Ryan said, "as doctors learn the intricacies of how pain works."

'Not all pain is the same pain'

Research shows that pain tolerance varies from person to person, according to the Institute of Medicine report, which recommended that pain management be tailored to each patient's experience.

Dr. Salim Hayek, division chief of pain medicine at University Hospitals Case Medical Center, said patients -- even those with the same injury or illnesses -- perceive twinging, throbbing, aching or soreness very differently.

Pain is important, he said, because it's the body's signal that something is wrong. And, Hayek said, "Not all pain is the same pain." Acute pain from surgery, for example, eventually goes away, but chronic pain in the lower back may linger for months.

Yet, even if levels of discomfort are similar among people, Hayek added: "The drugs don't work on 100 percent of the patients or 100 percent of the pain." Everyone builds up a tolerance to a pain drug, he explained, but this occurs more quickly with younger patients. Doctors need to keep this and other factors in mind when considering a course of action.

The Institute of Medicine report said that managing pain is a challenge, and more research needs to be done to better understand treating pain.

Research already is revealing the negative effects of underdiagnosing and undertreating pain and that the "wait to see if it goes away" approach could have consequences.

Recent studies show that acute pain -- such as that accompanying burns or kidney stones -- should be treated immediately. Otherwise, there can be changes in the central nervous system and spinal cord that cause the pain to become worse. These changes can result in severe pain that lingers long after the original injury or disease is resolved.

Dependence after an acute condition

Physicians strive to find the balance of keeping patients comfortable and avoiding dependency on these powerful drugs.

"If someone has an acute condition, such as a broken ankle, by all means pain drugs can be safely prescribed for a short period of time -- two to five days," Hayek said.

Doctors said that the vast majority of the patients who need pain medications don't abuse them.

Medical students, Kriegler said, learn to start with where the pain begins and then move to family history and what's going on in the patient's life. "You can't get away from the brain being both an emotional and physiological organ," she said.

Dependence on drugs can occur for many reasons.

"A lot of times people take medication for an acute problem," she said, "but then what happens is, when the pain is gone, they realize the medication helped them in terms of something else -- such as easing their anxiety."

In cases where the injury has healed, other physiological sources have been ruled out and the pain continues, Kriegler said, "we need to treat the problem in the brain because that's where the change has occurred."

Even if there is no obvious source, the pain is very real to the patients. So doctors in training are being taught to find additional means to help patients get some relief.

"If a person says they cannot go to work because of pain," Kriegler said, "then maybe what they need is physical therapy." For other patients, regular exercise may help them begin to feel better, and that's a subject worth discussing.

Counseling could be in order for a patient who, for example, has suffered past abuse or has a fear of illnesses recurring because of family history, she said. "Medical students need to understand that if they cannot help patients, they need to get them to the right specialist who can."

Kathy Cole-Kelly, professor of family medicine at Case Western Reserve School of Medicine, said putting the patient in the center of treatment is key.

Cole-Kelly, who teaches communication skills at the medical school, said students are trained to look at the situation from the patient's perspective. That involves asking questions about a patient's life and listening. A patient with headaches may be worried because his uncle died of a brain tumor.

Family beliefs based on different cultures or heritages could be at the center of a patient's complaints about pain, she said. A patient is more likely to understand his situation if the doctor talks through the beliefs with the patient rather than just dismissing him, she said.

Cole-Kelly said medical students can learn these communication skills just as they learn to recognize physical ailments.

Once medical students get to the hospital floors, Kriegler said, they soon realize how emotional the pain can be for patients and their families.

"If you don't deal with the emotional aspects, you are not going to be a good doctor," Kriegler said.

http://blog.cleveland.com/health_impact/print.html?entry=/2012/01/pain_top_concern_in_ohio_and_t.html

Brian Goldman: Doctors make mistakes. Can we talk about that? | Video on TED.com

2012-01-25T22:08:00.001-05:00

Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong.

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

Men More Likely Develop Mild Cognitive Problems - in Neurology, Dementia from MedPage Today

2012-01-25T22:01:00.000-05:00

Men are more likely than women to develop mild cognitive impairment (MCI), with and without memory problems, researchers found.

In a cohort of older individuals living in Olmsted County, Minn., about one in every five who was cognitively normal at baseline developed mild cognitive impairment within three or four years, according to Rosebud Roberts, MBChB, of the Mayo Clinic in Rochester, Minn., and colleagues.

Compared with women, men had higher rates of both amnestic MCI -- which involves a memory deficit -- and nonamnestic impairment, which does not, the researchers reported in the Jan. 31 issue of Neurology.

"Differences in incidence rates by clinical subtype and by sex suggest that risk factors for MCI should be investigated separately for amnestic MCI and nonamnestic MCI, and in men and women," they wrote.

In an accompanying editorial, Kenneth Rockwood, MD, of Dalhousie University in Halifax, Nova Scotia, said that "finding a difference between men and women in the incidence of MCI is not a small thing."

"That is because much of the interest in MCI stems from its widely confirmed status as a risk for progression to dementia," he wrote. "Given that women tend to have a higher risk of dementia than do men, and that even in Olmsted County, dementia incidence is similar between men and women, it is unclear how to square more men in the at-risk state not translating into more men with dementia."

To explore the sex differences, Roberts and colleagues turned to the Mayo Clinic Study of Aging, which used data from the Rochester Epidemiology Project to prospectively assess the development of MCI in individuals ages 70 to 89 who were cognitively normal at baseline.

Every 15 months, the participants underwent evaluations that included the Clinical Dementia Rating Scale, a neurologic evaluation, and neuropsychological testing. The analysis included 1,450 individuals who completed at least one follow-up evaluation.

Through a median of 3.4 years, 19.6% of the participants developed mild cognitive impairment and 0.8% developed dementia.

The rate of MCI was higher for men than for women (72.4 versus 57.3 per 1,000 person-years; HR 1.40, P=0.004) and for the amnestic versus nonamnestic subtype (37.7 versus 14.7 per 1,000 person-years).

For both amnestic and nonamnestic MCI, rates were higher for men and for individuals who completed fewer than 13 years of education.

In addition, individuals who were never married were more likely to develop nonamnestic MCI compared with their married counterparts (HR 2.92, 95% CI 1.10 to 7.75).

About one-third of participants who tested positive for MCI at one assessment subsequently tested as cognitively normal.

In his editorial, Rockwood proposed two explanations for the higher rate of MCI among men, even though women have a higher rate of dementia. First, he said, men generally cannot tolerate deficits as well as women.

"While women might have more things wrong at any age, they can live with them longer than men do; for men, deficits more often are fatal," he wrote. "In consequence, the risk of death might be higher for men with MCI, thereby not allowing them to live long enough to develop dementia."

Another possible explanation, though, is a difference between the sexes in how cognition evolves over time.

"Why men have a higher incidence of MCI but a lower incidence of dementia may come about from how they express the later-life dynamics of cognition," Rockwood wrote.

"For some men, MCI represents incomplete disease expression; alternately, they resist dementia development more," he wrote. "In that way, MCI in men could lend some insight into what prevented dementia might look like. Whether this explanation holds depends, as the authors propose, on further investigation of risk factors for MCI separately in men and in women."

Roberts and colleagues acknowledged some limitations of the study, including possible nonparticipation bias and the relatively homogeneous population of Olmsted County (mostly of European ancestry).

http://www.medpagetoday.com/Neurology/Dementia/30851

In Rating Pain, Women Are the More Sensitive Sex - NYTimes.com

2012-01-23T21:23:00.001-05:00

Do women feel more pain than men?

It has long been known that certain pain-related conditions, like fibromyalgia,migraine and irritable bowel syndrome, are more common in women than in men. And chronic pain after childbirth is surprisingly common; the Institute of Medicine recently found that 18 percent of women who have Caesarean deliveries and 10 percent who have vaginal deliveries report still being in pain a year later.

But new research from Stanford University suggests that even when men and women have the same condition — whether it's a back problem, arthritis or asinus infection — women appear to suffer more from the pain.

There is an epidemic of chronic pain: Last year, the Institute of Medicineestimated that it afflicts 116 million Americans, far more than previously believed. But these latest findings, believed to be the largest study ever to compare pain levels in men and women, raise new questions about whether women are shouldering a disproportionate burden of chronic pain and suggest a need for more gender-specific pain research.

The study, published Monday in The Journal of Pain, analyzes data from the electronic medical records of 11,000 patients whose pain scores were recorded as a routine part of their care. (To obtain pain scores, doctors ask patients to describe their pain on a scale from 0, for no pain, to 10, "worst pain imaginable.")

For 21 of 22 ailments with sample sizes large enough to make a meaningful comparison, the researchers found that women reported higher levels of pain than men. For back pain, women reported a score of 6.03, men 5.53. For joint and inflammatory pain, it was women 6.00, men 4.93. Women reported significantly higher pain levels with diabetes, hypertension, ankle injuries and even sinus infections.

For several diagnoses, women's average pain score was at least one point higher than men's, which is considered a clinically meaningful difference. Over all, their pain levels were about 20 percent higher than men's.

Unfortunately, the data don't offer any clues as to why women report higher pain levels. One possibility is that men have been socialized to be more stoic, so they underreport pain. But the study's senior author, Dr. Atul Butte, an associate professor at Stanford's medical school, said that explanation probably did not account for the gender gap.

"While you can imagine such a bias," he said, "across studies, across thousands of patients, it's hard to believe men are like this. You have to think about biological causes for the difference."

An extensive 2007 report by the International Association for the Study of Pain cited studies showing that sex hormones may play a role in pain response. In fact, some of the gender differences, particularly regardingheadache and abdominal pain, begin to diminish after women reachmenopause.

Research also suggests that men and women have different responses toanesthesia and pain drugs, reporting different levels of efficacy and side effects. That bolsters the idea that men and women experience pain differently.

One reason for the lack of information about sex differences is that many pain studies, in both animals and humans, are done only in males. One analysis found that 79 percent of the animal studies published in a pain journal over a decade included only male subjects, compared with 8 percent that used only female animals.

In addition, experiments testing pain in men and women have shown that they typically have different thresholds for various types of pain. In general, women report higher levels of pain from pressure and electrical stimulation, and less pain when the source is from heat.

Melanie Thernstrom, a patient representative on the Institute of Medicine pain committee from Vancouver, Wash., said the newest research "really highlights the need for more treatment and better treatment that is gender-specific, and the need for far more research to really understand why women's brains process pain differently than men."

Some researchers believe the pain experience for women may be even more complicated. Women who have given birth, for instance, may have a different threshold for "worst pain ever," causing them to underreport certain types of pain. The bottom line, Dr. Butte said, is that far too little is known about how men and women experience pain and that more study is needed so that, ultimately, pain treatment can be customized to each patient's needs.

"If doctors have a threshold for when they give a dose or start a medication," he said, "you could imagine that the number they are using is too high or too low because a person may be in more pain than they are saying.

"In the end, it comes down to what the brain perceives as pain."

http://well.blogs.nytimes.com/2012/01/23/in-rating-pain-women-are-the-more-sensitive-sex/

Chefs, Butlers and Marble Baths - Not Your Average Hospital Room - NYTimes.com

2012-01-23T21:18:00.001-05:00

The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: "This is like the Four Seasons — where am I?"

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble. Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, "I'll be your butler."

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital. Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such "amenities units," often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

"It's not just competing on medical grounds and specialties, but competing for customers who can go just about anywhere," said Helen K. Cohen, a specialist in health facilities at the international architectural firm HOK, which recently designed luxury hospital floors in Singapore and London and renovated NewYork-Presbyterian's elite offerings in the McKeen Pavilion in Washington Heights. "These kinds of patients, they're paying cash — they're the best kind of patient to have," she added. "Theoretically, it trickles down."

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium of McKeen, leading to refurbished rooms that, like those in the hospital's East 68th Street penthouse, cost patients $1,000 to $1,500 a day, and can be combined. That fee is on top of whatever base rate insurance pays to the hospital, or the roughly $4,500 a day that foreigners are charged, according to the hospital's international services department.

But in the age of Occupy Wall Street, catering to the rich can be trickier than ever, noted Avani Parikh, who worked for NewYork-Presbyterian as in-house project leader when the 14th floor was undertaken. She pointed to the recent ruckus at Lenox Hill Hospital, where parents with newborns in the intensive-care unit complained that security guards had restricted their movements and papered over hospital security cameras in their zeal to please Jay-Z (real name Shawn Carter) and Beyoncé Knowles, whose daughter was born on Jan. 7 in a new "executive suite."

Many American hospitals offer a V.I.P. amenities floor with a dedicated chef and lavish services, from Johns Hopkins Hospital in Baltimore to Cedars-Sinai Medical Center in Los Angeles, which promises "the ultimate in pampering" in its $3,784 maternity suites. The rise of medical tourism to glittering hospitals in places like Singapore and Thailand has turned coddling and elegance into marketing necessities, designers say.

The spotlight on luxury accommodations comes at an awkward time for many urban hospitals, now lobbying against cuts in Washington and highlighting their role as nonprofit teaching institutions that serve the poor. Indeed, NewYork-Presbyterian, which once opposed amenities units, would not answer questions about its shift, and declined a reporter's request for a tour.

In Greenberg, where the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand, the patient who likened her suite to the Four Seasons was not paying for it. She did not want to be identified because her wealthy boss, who picked up the bill, would not want publicity.

During a reporter's unofficial visits to both units this month, however, some people enjoying the perks expressed uneasiness about those priced out. In space-starved New York, many regular hospital rooms are still double-occupancy, though singles are now the national standard for infection control and quicker recovery.

"The concierges act like butlers," said John Frehse, 37, who was visiting his ailing father, Robert M. Frehse, 86, the retired chief executive of the Hearst Foundations. He and his mother, Dale Frehse, paused in their praise of the care to recall the fate of a family friend stuck for three days in the NewYork-Presbyterian emergency room for lack of a hospital bed last winter. At the time, they recalled, the Saudi king had been granted the whole 14th floor for his entourage.

The younger Mr. Frehse contrasted the unit's mouth-watering menu with the "inedible food" his father faced when he was treated on the non-elite second floor. "Here he has mushroom risotto with heirloom tomatoes," he said.

The hospital said in a statement: "NewYork-Presbyterian is dedicated to providing a single standard of high quality care to all of our patients."

At Mount Sinai Medical Center, where the aesthetic of the Eleven West wing is antique mahogany rather than contemporary sleek, and the best room costs $1,600, William Duffy, the hospital's director of hospitality, said his favorite entree was Colorado rack of lamb, adding, "We pride ourselves on getting anything the patient wants. If they have a craving for lobster tails and we don't have them on the menu, we'll go out and get them."

The 19-room unit, which opened 18 years ago but received a recent face-lift, takes in $3.5 million a year, Mr. Duffy said, estimating that 30 percent of its clientele comes from abroad. If the emergency room is backed up, a regular patient may be upgraded, he added: "Bump 'em up to Business, as we say."

Wayne Keathley, Mount Sinai's president, minimized the unit's role in the 1,171-bed hospital, on Fifth Avenue at 101st Street. "It is not nearly as large or elaborate as some others," Mr. Keathley said. He called the money it brought in "a rounding error in my budget," and said that patients came for the clinical care, not the amenities.

In Eleven West's library on a recent Friday, Nancy Hemenway, a senior financial services executive, was reading the paper in a spa-style bathrobe. "I was supposed to be in Buenos Aires last week taking tango lessons, but unfortunately I hurt my back, so I'm here with my concierge," she said.

"I'm perfectly at home here — totally private, totally catered," she added. "I have a primary-care physician who also acts as ringmaster for all my other doctors. And I see no people in training — only the best of the best."

Mr. Keathley said the lack of interns and residents on Eleven West was a function of clinical judgments and limits to the training program, not the preferences of rich patients.

But even the rainmakers — doctors who bring in such patients — can sometimes resent the tilt toward luxury.

"The one misgiving is patients with Medicare, which pays physicians almost nothing," said Dr. Brian Katz, 59, a laparoscopic surgeon in scrubs who took a break in the same library later. "Yet those patients will come up here and pay to enjoy five-star comfort."

Increasingly, hospitals serving the merely well-off are joining the amenities race. Beth Israel Medical Center near Union Square added a "deluxe unit" in 2008, catering mainly to patients after elective orthopedic surgery. The green-carpeted lobby may be more Radisson than Ritz, but its 12 single rooms starting at $450 feature Bose stereos and flat-screen TVs, and chef-prepared kosher food is served on china.

"A very insignificant portion of our beds are identified as deluxe accommodations," said Gail Donovan, the chief operating officer of Continuum Partners, which includes Beth Israel and St. Luke's-Roosevelt Hospital. "Our mission is really to be the safety net hospitals of our communities."

The conflicts echo those of a century ago, in another era of growing income inequality and financial crisis, said David Rosner, a professor of public health and history at Columbia University. Hospitals, founded as free, charitable institutions to rehabilitate the poor, began seeking paying patients for the first time in the 1890s, he said, restyling themselves in part as "hotels for rich invalids."

"Every generation of hospitals reflects our attitude about health and disease and wealth and poverty," Professor Rosner said. "Today, they pride themselves on attracting private patients, and on the other hand ask for our tax dollars based upon their older charitable mission. There's a conflict there at times."

His perspective on McKeen's amenities unit, where afternoon tea is served daily, is colored by the emergency room experience of one of his graduate students on the same hospital campus this month, he added. She spent two days on a gurney in terrible pain from herniated disks, he said, until a dean intervened to get her a room. "She hadn't even been given a bed pan," he said.

http://www.nytimes.com/2012/01/22/nyregion/chefs-butlers-and-marble-baths-not-your-average-hospital-room.html?

The Money Traps in U.S. Health Care - NYTimes.com

2012-01-22T20:55:00.001-05:00

Why does an appendectomy in Germany cost roughly a quarter what it costs in the United States? Or an M.R.I. scan cost less than a third as much, on average, in Canada?

Americans continue to spend more on health care than patients anywhere else. In 2009, we spent $7,960 per person, twice as much as France, which is known for providing very good health services. And for all that spending, we get very mixed results — some superb, some average, some inferior — compared with other advanced nations. Why this is true isn't easily answered.

Health reform is supposed to control costs, but there is no simple avenue of attack. Our aging population has played a role in driving up medical costs, but Germany, Italy and Japan have much bigger percentages of elderly people while spending much less per capita on health care.

The spread of health insurance, which shields patients from price sensitivity, has played a role in driving up our spending. But almost all other advanced industrial nations cover virtually everyone, while we leave 50 million uninsured.

Administrative costs are high here — no surprise given the hordes of clerks and accountants needed to deal with insurance paperwork. And technological advances, which are sometimes highly beneficial and sometimes not, often cost a lot more than standard treatments. (Surprisingly, American doctors lag far behind their counterparts abroad in using electronic health records, which can help avoid costly errors and duplications.) Insurance companies' profits and the high pay of their executives may account for some of the cost differences with other countries, but there is little good data on this.

A recent report from the Organization for Economic Cooperation and Development, a 34-member group that includes the most advanced industrial nations, concluded that spending is high here partly because the prices charged by American doctors and hospitals are higher than they are anywhere else.

The International Federation of Health Plans, in its 2010 comparative price report, documented just how large the price differential can be for a wide range of services. While it's difficult to get data that is truly comparable from one country to another, the trends show Americans paying a lot more than people in other countries for the same services.

Measuring how effectively we spend health care dollars is hugely complicated. But cross-national surveys offer some clues. We're good at giving patients what they want — if they ask for it. So Americans can see a specialist or get elective surgery a lot faster than patients in other countries, according to surveys by the Commonwealth Fund. The surveys also show that Americans are more likely than people in other advanced nations to experience medical errors or problems with uncoordinated care, and to forgo care because it's too expensive.

The O.E.C.D. report rates America at or near the top for survival rates in breast and colorectal cancer but slightly below average in cervical cancer. We rank in the middle of the pack in the percentage of heart attack patients who die in the hospital within 30 days of admission. And we have alarmingly high rates of hospital admissions for asthma and uncontrolled diabetes — an indicator that many patients don't have good primary care, which can prevent costly hospital stays.

Most other advanced countries hold down prices through government regulations. We set prices in Medicare and Medicaid programs. But in private markets, reform has to rely on other means, such as financial incentives for providers to curb costs by coordinating care and improving efficiency. One demonstration program significantly reduced spending by bundling payments to hospitals and doctors to cover all in-patient services connected with heart bypass surgeries.

The idea at the heart of the reform law is that such strategies, once proved effective, could be carried out on a large scale — and eventually bring total spending under control.

http://www.nytimes.com/2012/01/22/opinion/sunday/the-money-traps-in-us-health-care.html?

Doctor and Patient: Why Doctors Can't Predict Life Expectancy - NYTimes.com

2012-01-22T20:52:00.001-05:00

Slender, in her 60s and possessing the stoicism of someone who had single-handedly raised children in the toughest section of the city, our patient faced a difficult challenge of the medical kind. She had diabetes and such severe peripheral vascular disease that even the strongest antibiotics could not heal a long-standing foot infection. She needed an operation.

This grandmother who regularly held court in her hospital room with her extended brood also suffered from high blood pressure and heart disease, and all of us on the surgical team knew that operating would be no easy feat. We could amputate her infected foot, a relatively quick operation that would carry few risks, but she would never walk again. Or we could do an arterial bypass, a more complex operation that would save her leg but that might disable or even kill her before her surgical scars ever healed.

The final decision hinged on our assessment of her likely course, or prognosis. If she was unlikely to live long, we would amputate, because it wouldn't make sense to put her at risk of other life-threatening complications just to save her leg. But to throw out some ballpark figure, an actual number of the weeks, months or years this woman we had grown to care about had left to live, meant shouldering the responsibility none of us were eager to be reminded of – that is, our potential role in hastening her death because of poor clinical decisions based on the wrong prognosis.

A week after her bypass operation, our patient died of a heart attack. The prognosis of her senior surgeon and our entire team — that she would tolerate the surgery and survive long enough to walk again — had been incorrect.

While not all assessments of how long someone has to live result in life-or-death clinical decisions, addressing prognosis remains a challenge for most doctors. And after struggling for several years with determining their own patients' prognoses, a group of physicians at the University of California in San Francisco set out to collect and study all the research that had been done on so-called prognostic indexes, tools that help with determining general prognosis in older patients.

Given the growing use of age-based treatment and preventive care guidelines, the doctors assumed there would be plenty of data to help decide whether, for example, an 80-year-old patient might live long enough to benefit from a colonoscopy, a cancer screening procedure that can have its own set of complications.

But they found little.

Prognosis was rarely, if ever, alluded to in the most popular medical textbooks and on clinical Web sites used by practicing physicians. Even the widely used medical database PubMed, maintained by the National Library of Medicine, had no specific indexing category for prognosis, making finding any published study on the subject like searching for a book in a library before the Dewey Decimal System.

While the researchers were finally able to single out 16 indexes that hold promise in helping doctors predict how long a patient might live, there was"insufficient evidence at this time" to recommend any of them for widespread clinical use. None of the indexes had been tried with groups of individuals other than the initial test group to confirm reliability, and every single one had a potential source of bias. Some studies were never able to follow up on the final outcomes of a substantial subset of patients; others used researchers intimately involved with the development of the prognostic tool, and not impartial observers, to validate findings.

"There's a need for much more research in this area," said Dr. Eric W. Widera, one of the authors of the study, which appeared in The Journal of the American Medical Association. "Compared to diagnosis and treatment, prognosis is like the unloved stepchild of medicine."

A century ago, predicting a patient's life expectancy was an essential part of doctoring. Details relating to the art and science of "prognosticating" occupied a prominent position in textbooks, journals and conversations with patients. That emphasis began to shift as technology advanced, with doctors focusing more and more of their time on treatment and diagnosis.

Economic forces reinforced this new emphasis, as it became clear that while the ability to predict the timing of a patient's death was useful, the tools to treat and diagnose were profitable.

Perhaps even more important, prognosis has now become a potent symbol of the limits of medicine. With a growing array of successful treatments at hand, doctors often have the power to forestall death. But thinking about prognoses means recognizing not only fallibility but also possible culpability.

"Even in the privacy of their own minds, doctors don't like to think about prognosis," said Dr. Nicholas A. Christakis, a professor of medicine and medical sociology at Harvard Medical School and author of "Death Foretold"(University of Chicago Press, 2001), a book on the sociocultural issues of prognosis.

With so little research on how to predict how long a patient might live and few resources to turn to, physicians often end up relying on intuition. But studies have shown that these "guesstimates" can be wildly inaccurate, and that inaccuracy can adversely affect an older patient's quality of life and care. Doctors who are too optimistic may prescribe unnecessary and painful procedures and treatments; those who are too pessimistic may neglect to offer adequate care.

Most current clinical guidelines sidestep considerations about prognosis by relying on simple age-based cutoffs. The United States Preventive Services Task Force, for example, uses 75 as the age to stop routine colon cancer screening. "But age is an incredibly blunt tool," Dr. Widera noted. "We all know of 65-year-olds who are much sicker than some 95-year-olds."

While the authors of the study have created a Web site, www.eprognosis.org, to help physicians and patients access available prognostic tools, they are quick to acknowledge that this interactive tool is only a small part of what doctors and patients need. More work and resources must be devoted to creating accurate assessment tools, testing the reliability of those that exist and teaching doctors once again the art and science of determining, and talking about, prognoses.

"We actually have a moral responsibility to our patients to help provide them with the best prognostic information," said Dr. Alexander K. Smith, another of the study authors. "But somehow, we have lost sight of that responsibility as a profession."

http://well.blogs.nytimes.com/2012/01/19/why-doctors-cant-predict-how-long-a-patient-will-live/?

As Specialists Debate Autism, Some Parents Watch Closely - NYTimes.com

2012-01-21T08:52:00.001-05:00

A debate among medical professionals over how to define autism has spilled over into the public domain, stirring anger and fear among many parents and advocates of those with the neurological disorder, even as some argue that the diagnosis has been too loosely applied.

A study reported on Thursday found that proposed revisions to the American Psychiatric Association's definition would exclude about three-quarters of those now diagnosed with milder forms of autism called Asperger syndrome or "pervasive developmental disorder, not otherwise specified," also known as P.D.D.-N.O.S. These are people who have difficulties with social interaction but do not share the most severe impairments of children with classic autism.

"He was right on the border, they told me when he got the diagnosis; that's what scares me," said Amanda Forman of Flourtown, Pa., whose 5-year-old son was diagnosed two years ago with P.D.D.-N.O.S. After receiving play therapy, occupational therapy and 17 hours a week of behavioral therapy, the boy, who was once unresponsive to other children and engaged in self-destructive behavior, may enter a mainstream kindergarten class next year, his mother said. "What if he has to be re-evaluated? If the criteria were stricter, he might not get these services that have been helping him so much."

The proposed revisions, which would take effect in 2013, are likely to have practical implications for those who would once have qualified for services that experts say can improve an individual's abilities to socialize, learn and ultimately live independently. But they have also ignited a broad discussion over the value of a diagnosis for behavior differences, and how to fairly apportion services at a time when resources are shrinking.

The Diagnostic and Statistical Manual, now under revision, is the standard reference for mental disorders, driving research, treatment and insurance decisions. Since 1994, when recognition of Asperger syndrome was first included as an autism-spectrum disorder, diagnosis of the condition has surged.

Over the last decade, the number of 6- to 21-year-olds with autism in public schools has quadrupled, according to the Department of Education. Such students may get private school placement, a classroom aide or curriculum adaptations. In recent years, 29 states have passed laws requiring insurance companies to provide behavioral therapies and other forms of care to people with an autism diagnosis.

"We have to make sure not everybody who is a little odd gets a diagnosis of autism or Asperger disorder," said Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force making the revisions, which are still subject to change. "It involves a use of treatment resources. It becomes a cost issue."

But some autism advocates argue that acknowledging the neurological basis for socially odd behaviors has benefits beyond eligibility for services, promoting cultural tolerance and a degree of self-understanding that may be lost without it.

"Having a diagnosis helps people understand why we process thoughts and emotions differently and make positive changes," said Michael John Carley, director of the Global and Regional Asperger Syndrome Partnership, which urged members to call the psychiatric association to complain. "Sadly, we may be heading back to the days when our differences are seen through the lens of character deficits rather than in the context of brain wiring."

Even within the medical community, the number of people who would not be eligible for an autism diagnosis under the new criteria is a matter of dispute. Some may fall under a new category, "social and communication disorder," though it is not clear what kind of aid, if any, they would be eligible for as a result.

Catherine Lord, the director of the Institute for Brain Development at NewYork-Presbyterian Hospital, and a member of the committee overseeing the revisions, said that the goal was to ensure that autism was not used as a "fallback diagnosis" for children whose primary trait might be, for instance, an intellectual disability or aggression.

She said the committee's own data shows that very few who currently have a diagnosis would be dropped. And another analysis of the effect of the proposed new definition, published this month in The Journal of the American Academy of Child and Adolescent Psychiatry, found that roughly 40 percent of individuals with Asperger syndrome would not be given a diagnosis under the new definition. That study suggested that altering the criteria slightly could recapture most of those who would otherwise be excluded.

Yet some parents of severely autistic children who are nonverbal, and may need constant care to avoid injuring themselves and others, say they would welcome a narrowing of the spectrum.

"Everyone on the spectrum benefits when money and services available are applied more specifically and appropriately to the individual needs of each person affected," said Mark L. Olson, of Henderson, Nev., whose daughter, 16, does not speak. Mr. Olson has argued on his blog that those with more severe needs have been overshadowed by people with the Asperger diagnosis, who have typical intelligence and language development.

Many comments, on the Web site of The New York Times and elsewhere, expressed the view that autism was overdiagnosed: "Come on, 1 in 100 children today?" one commenter wrote. "This pathology did not exist in the past because we did not label it."

And even some parents of autistic children noted in the debate this week that a diagnosis can be a double-edged sword.

"With it, a child gets needed services," wrote one Boston parent, whose son has a language impairment that makes socializing difficult. "The downside is that a child will be perceived by his peers as being abnormal and shunned socially. I noticed a huge change after my son was diagnosed. Once he got the autism label he rarely got birthday party invitations, for instance."

But like many parents, Ms. Forman, who requested that her maiden name be used to shield her son, said she sought the diagnosis only because her son so badly needed the services it would secure.

"I didn't know that feeling was so prevalent, that autism is so overdiagnosed," she said, having read many of the comments on Web sites. "I just know the amount of work I do for him, and that's not something I would do if I didn't have to do it.

"It's not the easy way out for anybody."

http://www.nytimes.com/2012/01/21/us/as-specialists-debate-autism-some-parents-watch-closely.html?_r=1&src=recg&pagewanted=print

1 in 5 Americans Had Mental Illness in 12-Month Period - MedPage Today

2012-01-20T22:13:00.001-05:00

About 20% of American adults reported having had a mental illness during the preceding year, a government survey found.

The figure rose to almost 30% of those in the 18 to 25 age group, compared with 14.3% of patients 50 and older, according to researchers from the Substance Abuse and Mental Health Services Administration (SAMHSA).

And of the nearly 46 million U.S. adults who reported having had a mental, behavioral, or emotional disorder when surveyed in 2010, some 60% didn't receive any treatment for the condition.

The most common reason for not getting mental healthcare was not being able to afford it.

The researchers noted that although the 20% figure is "relatively high," just 5% reported having serious issues that interfered with their normal activities.

Although more of those with serious mental illness reported receiving treatment, a large proportion -- 39% -- didn't receive any mental health services.

The unemployed, Medicaid beneficiaries, and those living below the poverty level were more likely to have mental illness in the preceding year, as were younger patients. Women appeared to be at greater risk than men (23% versus 16.8%).

Substance use disorders were more common among those with mental illness than among those reporting no disorders (20% versus 6.1%), and the prevalence was even higher among patients with serious mental illness (25.2%).

The findings emphasize the need for mental health treatment specialists to address substance use disorders, and to more extensively integrate mental health and substance use treatment centers, the researchers wrote.

They also reported that many Americans had seriously contemplated suicide over the preceding year (8.7 million), and 2.5 million had actually made suicide plans. Just over a million patients had attempted it.

Signs of mental illness were also seen in American youth, with 8% of 12-to-17-year-olds reporting a major depressive episode -- being in a depressed mood for at least two weeks -- in the preceding year.

Children and adolescents who reported feeling this way were more likely to use drugs than those who didn't have a depressive episode (37.2% versus 17.8%), they found.

The researchers called for screening kids who've had a major depressive episode for substance use disorders.

The data come from SAMHSA's National Survey on Drug Use and Health 2010.

In a statement, SAMHSA administrator Pamela Hyde warned that mental illness is often concurrent with cardiovascular disease, diabetes, and obesity, and that "treatment of the mental illness can reduce the effects of these disorders

http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/30776

Changing Autism Definition Raises Questions - The Slatest

2012-01-20T18:12:00.001-05:00

A new study suggests that many of those on the higher-functioning end of the autism spectrum may no longer meet the criteria for a diagnosis if a new definition makes its way into the Diagnostic and Statistical Manual of Mental Disorders (DSM), the book considered to be the standard reference for mental disorders.

The New York Times looked into both the study, which found that only 45 percent of those diagnosed with higher-functioning forms of autism might meet the new criteria, and the proposed changes to the definition.

The study is authored by Dr. Fred R. Volkmar, who resigned from the panel of experts currently working on the autism defintion. He and the panelists seem to strongly disagree on the purpose and effect of redefining autism.

Essentially, the American Psychiatric Association has appointed a panel to create a new edition of the DSM (which is long overdue; it's been 17 years since the current edition was created), and in re-defining autism, experts are trying to contend with the skyrocketing rate of diagnosis for autism and similar disorders like Asperger syndrome and "pervasive developmental disorder, not otherwise specified," abbreviated to P.D.D.-N.O.S by those in the know. They're doing this by combining all three categories of diagnosis under "autism spectrum disorder," and by narrowing the criteria that must be met for a diagnosis.

The new definition, the panel says, will provide clarity to diagnosing a disorder that badly needs it. While the panelists believe the impact of a new definition will be appropriate, Volkmar's study indicates it might have a much more widespread effect on those with Asperger's or P.D.D.-N.O.S., with a majority losing their diagnosis according to his analysis. Additionally, if he's correct, about a quarter of those currently diagnosed with autism proper would also not meet the critera.

For those who might lose their diagnosis -- or who may never be disagnosed at all -- the stakes are high: without a diagnosis, individuals will lose or be excluded from access to services like special education in schools and disability support. But some experts on autism and its related disorders believe it is often over-diagnosed: as many as 1 in 100 children have such a diagnosis, the Times reports.

You can read the full NYT story here.

http://slatest.slate.com/posts/2012/01/20/dr_fred_r_volkmar_new_dsm_autism_definition_harmful_.html?

Reports of Lost or Stolen Medications: Difficult Conversations - PainEdu.org

2012-01-18T17:09:00.001-05:00

It is not unusual for a patient to report to their prescribing clinician that they have discovered that their prescription pain medication (or the written prescription) has been either lost or stolen, leading them to request a new prescription. It is important to distinguish between lost medications and stolenmedications.

Losing a prescription form or a vial of medications may result from the occasional lapses that all patients may have. If this occurs only once it may not have significant medical implications, and the prescriber may choose to replace it without much concern. Losing a medication more than once, however, may imply that something else is going on. There are many possibilities. Is the patient experiencing some type of cognitive impairment, perhaps one that is being made worse by the medication? Does the patient need a further neurological evaluation? Is the patient impaired by the use of other substances? Should a urine drug screen and some simple labs including CBC, metabolic panel, and thyroid function studies, be done even as early as the first incident of a lost prescription? Is the patient misusing the prescription and running out of it early because they are taking more than prescribed, giving it away, or selling it?

Taking a consistent approach to a lost prescription is made much easier if the provider has reviewed their policy about this with the patient ahead of time. If this has not been done, the first time there is a lost prescription is not too late to create a written patient/provider agreement, outlining each of their roles and responsibilities.

Clinicians in practice with multiple-providers should establish and circulate a uniform, clinic-wide policy among patients and staff, to avoid confusion about what they do. Some practices choose a "one and done" policy, (the first time you lose it I will refill it, but never again), or a stricter policy of zero-tolerance, and no early refills, under any circumstance.

If you are not replacing the lost medication, you will need to inform the patient about the potential for withdrawal, and offer to prescribe medications to help diminish withdrawal symptoms. Prescribing these medications needs to be individualized, based upon the patient's age, presence of other medical problems, use of other medications, and the patient's ability to follow-up.

The problem of reports of stolen prescriptions is more ominous because there is another person involved, and potentially, another person has been put at risk. Medication theft is a situation that requires some form of investigation and should be reported to the appropriate authorities. It is important for the patient to think about who might have stolen the medication.

In my clinical practice I do not provide an early refill for a stolen prescription. Other providers may take a "one and done" approach to stolen prescriptions as well as lost prescriptions. Again, with stolen medication, I will educate the patient about withdrawal symptoms and develop a plan to manage them if they occur.

Repeated medication loss, or theft, is a strong indication that the patient is at high risk and that it is not safe for this patient to remain on this medication. If a medical reason, like cognitive decline, is discovered, this may be successfully addressed so that the patient can continue on the medication. However, if this cannot be done, or if the patient lives in an unsafe environment, the best course may be to taper and discontinue these medications, substituting treatments that are lower risk.

Describing how you address these problems before the patient has begun treatment, and before incidents of lost or stolen medication, is part of your description of the treatment plan, and it demonstrates the principal of shared responsibility.

http://www.painedu.org/articles_timely.asp?ArticleNumber=60&

U.S. to Tell Drug Makers to Disclose Payments to Doctors - NYTimes.com

2012-01-17T08:40:00.001-05:00

WASHINGTON — To head off medical conflicts of interest, the Obama administration is poised to require drug companies to disclose the payments they make to doctors for research, consulting, speaking, travel and entertainment.

Many researchers have found evidence that such payments can influence doctors' treatment decisions and contribute to higher costs by encouraging the use of more expensive drugs and medical devices.

Consumer advocates and members of Congress say patients may benefit from the new standards, being issued by the government under the new health care law. Officials said the disclosures increased the likelihood that doctors would make decisions in the best interests of patients, without regard to the doctors' financial interests.

Large numbers of doctors receive payments from drug and device companies every year — sometimes into the hundreds of thousands or millions of dollars — in exchange for providing advice and giving lectures. Analyses by The New York Times and others have found that about a quarter of doctors take cash payments from drug or device makers and that nearly two-thirds accept routine gifts of food, including lunch for staff members and dinner for themselves.

The Times has found that doctors who take money from drug makers often practice medicine differently from those who do not and that they are more willing to prescribe drugs in risky and unapproved ways, such as prescribing powerful antipsychotic medicines for children.

Under the new standards, if a company has just one product covered by Medicare orMedicaid, it will have to disclose all its payments to doctors other than its own employees. The federal government will post the payment data on a Web site where it will be available to the public.

Manufacturers of prescription drugs and devices will have to report if they pay a doctor to help develop, assess and promote new products — or if, for example, a pharmaceutical sales agent delivers $25 worth of bagels and coffee to a doctor's office for a meeting. Royalty payments to doctors, for inventions or discoveries, and payments to teaching hospitals for research or other activities will also have to be reported.

The Obama administration estimates that more than 1,100 drug, device and medical supply companies will have to file reports, generating "large amounts of new data." Federal officials said they would inspect and audit drug company records to make sure the reports were accurate and complete.

Companies will be subject to a penalty up to $10,000 for each payment they fail to report. A company that knowingly fails to report payments will be subject to a penalty up to $100,000 for each violation, up to a total of $1 million a year.

Top executives are potentially liable because a senior official of each company — the chief executive, chief financial officer or chief compliance officer — must attest to the accuracy of each report.

The new requirements, or something very similar, will take effect soon; in fact, they are overdue. Under the new health care law, the administration was supposed to establish payment-reporting procedures by Oct. 1, 2011. The public will have until Feb. 17 to comment on the proposals, which are broadly consistent with the expectations of industry and consumer groups. After considering the comments, Medicare officials will issue final rules with the force of law.

Consumer advocates have long demanded details of the financial ties between doctors and drug and device companies.

Allan J. Coukell, a pharmacist and consumer advocate at the Pew Charitable Trusts, said: "Patients want to know they are getting treatment based on medical evidence, not a lunch or a financial relationship. They want to know if their doctor has a financial relationship with a pharmaceutical company, but they are often uncomfortable asking the doctor directly."

In an introduction to the proposed rules, the Obama administration says that patients can benefit when doctors and the industry work together to develop life-saving drugs and devices. But, it said, these relationships can also "lead to conflicts of interests that may affect clinical decision-making" and "threaten the underlying integrity of the health care system."

More ...

http://www.nytimes.com/2012/01/17/health/policy/us-to-tell-drug-makers-to-disclose-payments-to-doctors.html?_r=1&nl=todaysheadlines&emc=tha2

The Future of Personalized Medicine - David B. Agus - WSJ.com

2012-01-16T21:38:00.001-05:00

Take a moment to imagine what it would be like to live robustly to the ripe old age of 100 or more. You wouldn't die of any particular illness, and you wouldn't gradually waste away under the spell of some awful, enfeebling disease that began years or decades earlier.

It may sound far-fetched, but it is possible to live a long, disease-free life. Most of the conditions that kill us, including cancer and heart disease, could be prevented or delayed by a new way of looking at and treating health. The end of illness is near.

Today, we mostly wait for the body to break before we treat it. When I picture what it will be like for my two children to stay in good health as independent adults in 10 or 20 years, I see a big shift from our current mod

I see them being able to monitor and adjust their health in real time with the help of smartphones, wearable gadgets—perhaps like small, invisible stickers—to track the inner workings of their cells, and virtual replicas of their bodies that they will play much like videogames, allowing them to know exactly what they can do to optimize every aspect of their health. What happens when I take drug x at dosage y? How can I change the expression of my genes to stop cancer? Would eating more salmon and dark chocolate boost my metabolism and burn fat? Can red wine really lower my risk of heart attack?

From a drop of their blood, they will be able to upload information onto a personal biochip that can help to create an individualized plan of action, including both preventive measures and therapies for identified ailments or signs of "unhealthiness." (Other body fluids—like tears and saliva—might be routinely tested, too.) They would be on the lookout for problems like imbalances in blood-sugar control, a risk factor for diabetes, and uncontrolled cell growth, which could signal cancer. Their doctors won't just examine them once a year; they will continually monitor the next generation of patients, offering advice along the way.

What is equally exciting is that this patient data will be added to a universal database that can be aggregated by powerful search engines like Google and constantly fed into new trials and experiments—speeding up our understanding of which drugs work best for which people. The database might show, for example, that people with a particular genetic profile respond to one type of cancer treatment but not another. As more people anonymously add their health data, this database would become more and more effective as a tool for preventive medicine.

Today, most people who are concerned about their health follow sweeping, general guidelines. If you want to lose weight, you are likely to pick a diet that advises eating more fibrous vegetables and cutting back on processed sugar. If you want to reduce your risk for cancer, you avoid tobacco smoke, exercise regularly and take early detection seriously.

Ari Meisel suffered from the symptoms of Crohn's Disease for years before he decided to overhaul his health-care regimen. He's part of a movement of citizen scientists who are turning their bodies - and their lives - into personal laboratories. WSJ's Christina Tsuei reports.
The problem with health care today is that we don't know enough about the body to practice preventive medicine actively. With limited knowledge, diagnostic medicine makes sense. If we don't know what we're trying to prevent or how best to do it, we have to wait for an obvious symptom to emerge in order to take action. At that point, we're usually treating a disease that has had ample opportunity to progress.

We can do better. To start, we need to appreciate the body for what it is: a very complex network, much of which we don't yet fully understand. When you look at the body from this systemic point of view, you begin to see that a lot of what we know about health is gravely misunderstood.

In 2009, my colleague Danny Hillis—a former Disney engineer who pioneered the development of so-called parallel supercomputers—and I set up a way to measure 100,000 different types of proteins from a single drop of blood. The goal is to evaluate and make sense of the body's intricate inner workings in a way that's much more dynamic and insightful than what DNA alone can provide. Proteins change in your body every minute, depending on what's going on internally. Our ultimate plan is to develop tests, based on protein levels, for illnesses like cancer. Such tests could take the place of invasive techniques like biopsies.

The new Telcare meter marks a significant step toward bringing consumer medical devices closer to the world of modern technology. Walt Mossberg reports.
With each passing year, the technology necessary for this revolution in medicine is growing less expensive. Last week, Life Technologies of Carlsbad, Calif., announced that it will be able to map an individual's entire genetic sequence in one day, for $1,000. Similar tests today cost many thousands of dollars. The ability to follow day-to-day changes in your body's proteins and metabolites is not far behind.

So how do we get to this future?

It has to start with data collection. In 2004, Dell launched a company program called Well at Dell to encourage healthy lifestyles. Employees receive alerts and information customized to their health issues, incorporating their latest test results and treatments and allowing them to make more informed decisions. A newly diagnosed diabetic, for example, might get information about how to monitor blood sugar and watch out for the circulatory problems that often accompany the disease.

Not surprisingly, these corporate health-management tools have come under fire, with most critics worrying about privacy. But we can't expect the health-care industry to continue to innovate and grow if we continue to hoard health information.

The federal agency that administers Medicare pays over half of the medical bills in the U.S., but it doesn't retrieve, organize or mine that data. Imagine how much better the Medicare system could be if all this data were analyzed to improve public health. Or imagine databases from many different sources, private and public, coming together in a centralized network that would look for patterns and try to translate them into new ideas for anticipating and preventing health problems.

Personalized medicine isn't as far away as you might think. Consider what's already happening in genetic profiling for individuals, which is available today for several hundred dollars. I co-founded a genetic screening company and am a big proponent of the technology. It allows us to take a broad look at DNA variations and to assess your risk for certain ailments and what medications, at what dosages, might work best, based on your metabolism. Just because you have one or two markers of genetic risk does not mean that you will definitely develop a particular condition, but the outcome can be affected by changes in lifestyle, or in some cases, by taking medication.

As these and other technologies advance, it will become progressively easier to monitor and maintain our overall health. Then it will be up to us. The promise of personalized medicine depends, finally, not on the tools that become available but on our determination to be informed and willing patients.

—Dr. Agus is a professor of medicine and engineering at the University of Southern California and co-founder of two personalized medicine companies, Navigenics and Applied Proteomics. Adapted from "The End of Illness," to be published Tuesday by Free Press.

http://online.wsj.com/article/SB10001424052970204124204577155162382326848.html

A family learns the true meaning of the vow “in sickness and in health” - The Washington Post

2012-01-16T16:55:00.001-05:00

The dark-oak farmhouse table where Page and Robert Melton spent many a dinner hour is now laden with vases and framed pictures, fragile pieces of their life together that have to be tucked into cardboard boxes. The movers are coming in the morning and, with much still to pack, Page thinks she could be looking at another all-nighter.

She picks up a sepia-toned drawing of blackbirds. They gave each other art in the early years of their marriage, and this was the first thing Page had given Robert. Next, a photo of Robert standing in front of the Virginia statehouse, looking every inch the formidable journalist he was, a guy who could intimidate colleagues with a dipped chin and glance over wire-rimmed glasses.

The next photo is one of her favorites: Robert with family members by the porch of their homey Dutch colonial in Richmond on the morning of their younger daughter's christening, in September 2002. A brilliant fall day, it was exactly one year before the heart attack and collapse that left the 46-year-old father of two with a brain injury so severe he would eventually live in an assisted living facility. How often Page had stared at that photo. Was he ill then? she'd wonder. Was there something she could have seen? Should have seen?

Page shakes off the thought and rolls bubble wrap around the photo, much as she has tried to cushion the hard edges of the part of their bifurcated life they refer to as "after the injury." Robert had come a long way since 2003, when he looked at his wife sitting by his side in the hospital and said, "You seem like a nice lady. How come you're not married?" She had gone home that day and put away the diamond and emerald ring he had given her when he proposed. Looking at it made her too sad.

Seven years later Robert was still mentally impaired and his personality far different than before the accident, but he knew his family, knew he had had a brain injury that upended their lives, and asked lots of questions. He carried with him at all times a reporter's notebook, in which he had written the information most important to him: his daughters' ages — 9 and 11 — and that he has "known my honey" 18 years.

He could remember snippets of his pre-injury life — the made-up song he and Page sang to their girls, his nicknames for colleagues, that he had been an Eagle Scout. And though he still broke Page's heart every day with a sweet and childlike simple-mindedness — repeating his plans to "take meds, wash hands and brush teeth" like a mantra, or excitedly announcing that he'd won a candy bar at a penny toss "and didn't cheat at all" — once in a while, he would say something insightful and completely on point.

Just days earlier, at the Sunrise assisted-living facility where he lived for several years, Robert had looked at Page with earnest eyes and the relaxed demeanor he used to have and asked if it was hard for her to pack up the house: "Does that cause you distress, darlin'? Make you sad?" Page took his hand, and her eyes filled with tears. "We had the best days of our lives and the worst days of our lives in that house," she said quietly. "So, it's very bittersweet to leave it."

"It is bittersweet," Robert echoed.

The girls were so young when Robert fell ill — Hope was 3 and Nell 18 months — that Page was the only one of the four who remembered those days. Page alone knew that Robert loved to work in the yard and tend the azaleas. Or that he liked to write his weekly Virginia politics column in the garage. Or that he held Hope on his lap as he read the New Yorker, letting the quiet daughter who was so much like him point to letters she recognized.

Page was the only one who remembered the day in September 2003 when, just home from the hospital after the heart attack, Robert hugged her in the kitchen and told her everything was going to be all right. Or the moment a day later when he collapsed and stopped breathing.

Wrapping up the contents of their home on the eve of moving day — and the beginning of a new chapter in their lives — Page couldn't help but reach back to those best and worst of times, and one other memorable day:

On a Saturday morning in the spring of 2010, Page had arranged for Robert to come home from Sunrise for breakfast. She had asked Robert's brother Will to drive down from Annandale to be with them and sent the girls out for the morning with Allan Ivie, a friend from childhood who had come back into her life. She had consulted with Robert's doctors and her minister. She cooked up some eggs. She was nervous as she sat down at the big oak table next to her husband of 16 years.

Then she had a conversation with Robert she had never imagined she could have.

* * *

During the eight weeks Robert Hamilton Melton spent at a rehabilitation hospital in Hanover, Va., after his brain injury, he would often pick up a notepad and pen, wander into another patient's room and start talking. Before he remembered anything about his personal life, he remembered he had been a reporter.

Writing under the byline R.H. Melton, Robert, 54, had built his career at The Washington Post, where he worked since 1982 as an editor and a reporter, primarily covering politics in Maryland, Virginia and the District. (He was a colleague of and became a close friend of my husband's.) He was considered the institutional memory, a thoughtful editor and an elegant writer who was often the go-to guy on breaking stories.

In Richmond, where he worked during the final years of his career, he broke stories that rattled the political landscape: One led to the resignation of the speaker of the House of Delegates in 2002, and another resulted in the federal conviction of a former executive director of the Virginia GOP. The Post nominated him for a Pulitzer Prize for beat reporting that year; in 2009, he was inducted into the Virginia Capitol Correspondents Association Hall of Fame.

At 6-foot-5, Robert was an imposing presence, both supremely self-contained and reserved. He listened more than he talked, and he didn't mind that he intimidated people.

"He could be very haughty and very snide," Bob Lewis, a reporter for the Associated Press in Richmond, says affectionately. "He did that to new people, just to see if they could roll with it. If you let it get under your skin, you failed the Robert test."

But beyond the tough exterior was a wickedly funny and loyal colleague and friend.

Growing up in Springfield, the second of five boys born to Mary Hope, a homemaker, and Eston Melton, a chemical engineer, Robert had a knack for language from an early age. At Annandale High, he worked on the school paper, as he did later at the University of Virginia, and, at 17, won a statewide oratorical contest with a defense of the First Amendment.

Page Boinest, a Richmond native and fellow graduate of U-Va., had met Robert in the mid-'80s when she was a junior reporter with UPI helping cover a special session of the Virginia legislature. Through the years, the two crossed paths, and friends even set them up on a date, but they didn't hit it off. Page found Robert private, hard to get to know.

In 1990, Page left UPI to join the staff of then-Maryland Gov. William Donald Schaefer, first as his speechwriter, later as his press secretary. At a business dinner in Annapolis with Robert in 1992, something changed. "I don't know how to describe it, but there was this chemistry between us — it had never been there before," says Page, now 51.

Married in 1995, their life together was a carefree mix of travel, work, politics. Their first daughter, Virginia Hope, was born in 2000, followed two years later by Nell Hamilton. On that day in April 2002, Robert handed their new baby girl to Page. "Now our family's complete," he told her.

It was the happiest day of Page's life.

* * *

On its destructive path up the East Coast in September 2003, Hurricane Isabel ripped through central Virginia, downing trees and leaving thousands, including the Meltons, without power for days.

From his office near the Capitol, Robert was writing story after story about the devastation. He had spent days clearing out his own back yard and was surprised at how tired the work made him.

He was working at his office on Saturday, Sept. 20, when his chest started to hurt. He thought perhaps he had eaten bad salami for lunch, but since he'd had a heart scare before — in 1997, he had been hospitalized with an irregular heartbeat — he walked across the street to the emergency room at the Medical College of Virginia, now Virginia Commonwealth University Medical Center. He was having a heart attack.

On Monday, doctors implanted a stent in one of his coronary arteries. Two days later, on his 46th birthday, he was allowed to go home.

A day later, the power finally came back on in their home. Robert and Page were in the kitchen when Robert pulled his wife into his arms and reassured her: "Everything's going to be okay now. We got the power back, and I'm home."

But the next day, Friday, Sept. 26, at about 4 p.m., the life they had known ended. Page was making dinner. Nell was in a high chair at the dining room table. Robert bent over the chair to scoot it in and suddenly dropped to the floor.

The children started screaming. Page called 911. Robert was barely breathing — then stopped. Page tried CPR. Neighbors came. Power crews in the area came in and tried to help. Page remembers a big burly man holding her 18-month-old. Still no ambulance. A sheriff's deputy came in and tried to revive Robert.

"He was gone," Page says.

Finally, after a half-hour, the volunteer rescue squad showed up. There had been so many cases of chest pains because people had been out clearing their yards that the emergency crew was stretched thin. Page jumped into the ambulance, and it headed to Henrico Doctors, the nearest hospital, about 20 minutes away. Henrico was overflowing and tried to divert the ambulance to MCV downtown. Page screamed at the driver: No, he'll never make it if you go downtown — just go to Henrico Doctors.

The driver did. But Robert had been down for about 45 minutes. When the cardiologist came to talk to Page, he told her, "I can revive him, but you're not going to want me to."

She had to decide on the spot. "Bring him back to me," she told the doctor. "Bring him back to us."

After about 20 minutes, the doctor came out. Robert was in a coma and on life support. The collapse was likely caused by a blood clot thrown off by the stent, doctors said, and Robert would either not make it, survive in a persistent vegetative state or, best-case scenario, come back but not resemble the man she knew.

After three days, Robert woke up. He was talking, mumbling, whispering, but none of it made sense. He didn't know who anyone was. Still, nurses told Page stories of miracles, people who came all the way back. She clung to those.

Doctors told Page that most of whatever progress Robert would make would be in the first year; the lack of oxygen to his brain had caused hypoxic-ischemic brain injury, moderately severe.

Robert spent several weeks at Henrico Doctors, where he had a defibrillator put in, then was transferred to a rehabilitation hospital. He'd had little physical impairment, but his cognitive loss was profound. He had severe language problems, couldn't sit still, was confused and frustrated to the point of violence. And he had no memory — short- or long-term.

The therapists tried all sorts of tools for dealing with the memory loss. They made him a "memory book." They made him lists. One gave him a PalmPilot. Nothing worked. Then one day, Page brought him stories he had written, newspapers, reporters' notebooks, his tape recorder.

He picked up one of the pads, started writing in it, and popped it into his back pocket. For the first time, he remembered something: "I was a reporter. I was a writer, wasn't I?"

After a month in rehab, Robert spent eight weeks at a residential facility for brain-injury patients in North Carolina. By January 2004, he had made enough progress to go home, but after about five months at home, the progress slowed.

He could speak and read and write, but he couldn't hold onto the meaning behind words. He had little judgment or control over his behavior and was increasingly frustrated. "He didn't remember his former life," says Page, "but he knew it was something more than he had at the time."

Doctors told Page that Robert would benefit from someplace with regular activities and a set schedule — a routine that was difficult at home with two small children — as well as caregivers to manage his medications and his own space to recover in. The only long-term choices were a nursing home or an assisted-living facility.

"At that point, it was like the dream died," Page recalls. "It was very hard, because when Robert came home, you have this not-even-rational thought that, 'If I just love him enough, he'll get better.' "

There are not many brain-injury patients at assisted-living facilities, not many healthy 46-year-olds bounding around with lots of energy. So the Meltons had to make it up as they went along when Robert entered Brighton Gardens in Richmond.

The first year was difficult. Robert's presence unsettled the older, feebler residents. He would complain to Page that bingo was boring or that there wasn't much to do. He struggled with his temper.

But, over time, the routine began to ease Robert's anxieties and help him function.

A checklist on his medicine cabinet, "Robert's Recipe for a Handsome Husband," reminded him to shower, shampoo and shave, and caregivers — as well as a companion Page hired to provide stimulation — helped him accomplish those tasks. He ate meals at the same table with the same group of men, all decades older than he.

Eventually, he started to embrace the activities — from beading to Bible studies, even bingo — and slowly his irritability evolved into a warm, jolly nature.

"At some point, he just gave himself up to it," Page says. "And that was huge to me, because I was beating myself up about the fact that he wasn't at home anymore."

Page visited Robert every day at first and eventually every other day, and the girls came for lunch every Saturday. When Brighton Gardens was sold to another company, Robert moved to Sunrise along with much of the staff, which had grown to love him and his family.

Today, he looks healthy and fit, and walks with confidence. Page makes sure he dresses well, and glasses at the end of his nose still give him a professorial look. But within seconds of meeting him, it's clear his mind is impaired. It's hard to know how much he comprehends, even when he answers a question. Conversations are limited and disjointed.

He sometimes latches onto the sounds of words rather than their meaning — saying, "Give my regards to Broadway," for instance, when he's told a friend "sends his regards." He often falls back on stock phrases or song lyrics.

The most striking thing about Robert is his personality. Once reserved and a bit aloof, Robert today is talkative and exuberant. He seems to spill over with wide-eyed joy and gratitude. He calls everyone "darlin' " or "babe" or "bro.'"

"Mabel, I cannot thank you enough for that toilet tissue," he'd say to the short Colombian woman who cleaned his room at Sunrise.

His outsize gregariousness — a reflection of an "organic personality disorder," says Nathan Zasler, his brain injury medicine specialist — enlivened the quiet halls full of wheelchairs and walkers there. As did his family.

Once, Page brought in leis and sunglasses, and grass skirts for the girls, so the four of them could lip-sync "Cheeseburger in Paradise" at the Sunrise talent show. "We brought the house down, didn't we?" she says to Robert on a later visit.

It sparks something else. "Do you know what I remember?" he asks Page. "I remember the Sailboat Song. Did you come up with that, darlin'?"

It was the made-up song they sang to their daughters at night.

Sitting together in the assisted-living home, Page starts to sing it softly, and Robert joins in, tapping time on the table and staring off into the distance:

All I want is a sailboat day. And we'll head toward the Chesapeake Bay. And we'll laugh all the way. Oh, won't it just be wonderful.

"After my injury, did the girls ever join in the chorus, hon?" Robert asks.

"I don't know," Page says. "But after you were in the hospital, I kept singing it, because it reminded them of you."

More …

http://www.washingtonpost.com/lifestyle/magazine/a-family-learns-the-true-meaning-of-the-vow-in-sickness-and-in-health/2011/11/04/gIQAahyAdP_print.html

Premiers to meet as medicare lies in its sickbed - Montreal Gazette

2012-01-16T07:26:00.001-05:00

OTTAWA - The fate of medicare is on the line as Canada's premiers meet next week in Victoria.

The two-day gathering, which starts Monday, comes at a time of potential peril to the country's health-care system.

Spending has been running rampant in recent years, cutbacks are on the way, long-promised national reforms are nowhere to be seen and an aging and growing population is putting even more strain on the system.

The premiers are looking for a solution to their problems and some are hoping Prime Minister Stephen Harper's Conservative government eventually comes to the table with cash to assist in reforms and initiatives such as home care and seniors care.

But so far, Harper is cautiously standing back - giving provinces a long-term funding plan that falls short of what many premiers had wanted, urging them to get their spending under control and stressing the importance of keeping the future system financially sustainable.

That new approach from Ottawa - a stark contrast to previous Liberal federal governments that sought to ensure national standards are in place for medicare - has left premiers scrambling with different reactions.

Western premiers don't necessarily mind Harper's hands-off strategy, while some other premiers have voiced concerns that medicare could be headed toward a patchwork-quilt system that lacks equity between regions. In short, for now at least, a national solution to the looming crisis appears out of sight.

Still, several premiers interviewed this week by Postmedia News indicated a determination to seek innovative solutions to the enormous task that lies before them.

"There are some big issues in health care that we have to address and I think it's going to take some political courage to do that," said British Columbia Premier Christy Clark, who will host the meeting.

She said provinces should not shirk from the challenge of reforming the system now that Harper's government has left the task in their hands.

"We will eventually bankrupt the system if we keep going the way we are. And so we have to find ways to try and make the system sustainable."

Ontario Premier Dalton McGuinty said his province has spent recent years working hard to improve the system through innovation - thereby lowering surgical wait times and ensuring more patients have a family doctor.

But he said Harper needs to be at table to work with provinces collectively on a plan forward.

"As my dad used to say: 'Nobody is as smart as all of us. And nobody is as strong as all of us.' So I think we have missed an opportunity to come together and tackle this challenge together."

Most premiers are annoyed at how the federal government has undercut a process they thought would lead to health-care talks. In December, federal Finance Minister Jim Flaherty unilaterally unveiled a non-negotiable funding plan that runs to 2024, but which falls short of what provinces had hoped for.

Federal health-care transfers will continue to increase by six per cent until 2016-17. After that, increases will only be tied to economic growth including inflation -_currently roughly four per cent - and never fall below three per cent.

This week in Ottawa, parliamentary budget officer Kevin Page released a report concluding the plan will place a huge financial burden on the provinces. He expects cash transfers to the provinces to grow at 3.9 per cent annually, on average, from 2017-18 to 2024-25 - compared to provincial-territorial health bills, which he forecasts will grow by 5.1 per cent a year.

Moreover, if the funding plan stays in effect beyond 2024, the implications are stark: The federal share of medicare spending would gradually fall from its current level of 20.4 per cent - eventually hitting 13.8 per cent in about 40 years, and then 11.9 per cent two decades after that.

In provincial capitals, the premiers are now confronting many challenges. Among them:

o Avoiding slash-and-burn approaches as health spending is reined in.

o Finally moving the system away from its institutional focus on reactive hospital-based acute care, to one where publicly insured medical treatment is delivered closer to home (in private clinics or, indeed, at home).

o Getting a grip on the "cost-drivers" of the system, most notably, prescription drugs - which can be cheaper if provinces join together to buy in bulk.

o Figuring out which medical procedures - from knee surgeries to caesarean sections - are actually worth the cost to the system and whether there should be fewer of them.

o Doing a better job of informing Canadians (particularly young people who are increasingly overweight and obese) about the importance of lifestyle - diet, exercise, smoking - to their own odds of living a long, healthy life.

o Preparing for the demographic wave that is fast approaching: The population is getting older. These are citizens who will increasingly need health care, and after decades of paying taxes they will expect results. Provinces must grapple with the costs, and confront ethical questions surrounding end-of-life care.

Alberta Premier Alison Redford says provinces must find innovations and understand that health care "does not begin the day a person walks into a health-care facility but very often the underlying causes are issues that deal with social policy, poverty, domestic violence."

Saskatchewan Premier Brad Wall says the country needs a more "fulsome and informed debate" about how medicare dollars are being spent.

"We need to be focused on better patient care and better value for taxpayers," Wall says of the provinces.

"Continued economic growth is also vital to long-term funding of health care, lest the system become even more unsustainable. And, since working Canadians are healthier Canadians, the two issues are inextricably linked."

Quebec Premier Jean Charest says it's important for the federal government - which transfers billions of dollars in equalization payments to provinces in addition to health transfers - to get the entire package right.

"At the end of the day, we want the overall transfers to be equitable and fair. And we would not want to be in a situation where there's an increase in one area and a decrease in another where the net outcome is negative."

New Brunswick Premier David Alward believes a crisis is looming - particularly with the aging population needing care - and that some hard questions need to be asked about why the country isn't getting better results for its health-care money.

"We need to have a real, honest, open discussion of the future of health care in our province and country," he said.

"We do have a good health-care system, we have great people in that system. But it does need innovation, it does need accountability as well. Not being prepared to have that discussion, I think we all, as political leaders, do a disservice to the people we represent."

Welcome to the Great Health-Care Debate of 2012.

Canadians have seen this before. They witnessed their cherished medicare system falling apart in the 1990s - as hospitals closed, medical staff were laid off and patients lined up for hours at hospital emergency wards.

The shock to the national psyche led to a royal commission headed by former Saskatchewan premier Roy Romanow.

His 2002 report proposed significant hikes in federal funding for provincially delivered medicare systems. Just as important as the extra cash, he stressed, was the need for major reforms in areas such as pharmacare, primary care and home care.

Then-prime minister Paul Martin promised a "fix for a generation" and summoned premiers to Ottawa for a high-stakes summit in September 2004.

After locking themselves up in the old train station near Parliament Hill, the leaders cracked a deal and held a news conference in the middle of the night.

Provinces were guaranteed a 10-year deal with $41 billion in extra health-care funding with a guarantee that federal transfers would rise by six per cent annually. In return, provinces were expected to initiate reforms.

With the exception of shorter wait times for some medical procedures, however, the much-heralded accord fell flat.

In 2011, it's expected the country's health tab, which includes government spending and how much Canadians pay out of their own pocketbooks, will have reached $200.5 billion - up from $107 billion just a decade ago.

That's $5,811 per citizen on health care last year. Or seen another way, it represents 11.6 per cent of GDP.

The public/private split on health care spending hasn't changed in recent years.

The public portion (governments, primarily the provinces,) is still 70 per cent - $140.9 billion. Meanwhile, the private portion of the tab (households and private insurance companies) Is 30 per cent - $59.5 billion.

All the while, it has been the provinces and territories that are at the heart of the health-care system.

For four years in the mid 1990s provincial and territorial health spending slowed to a virtual halt. Then the taps were opened. In 1995, provinces and territories spent $49 billion on health care. In 2011, the tab is expected to have reached $130.3 billion.

Policy expert Don Drummond, a former senior Finance Department official, is among those who have delivered a blunt message in recent months.

"For the amount of money spent, the system should surely be delivering better results," he wrote in a report for the C.D. Howe Institute.

"Things will only get worse as health care eats up every other public service like an insatiable Pac-Man. I do not believe the public will allow governments to levy ever-increasing taxes to avoid that scenario. So the system must be reformed."

http://www.montrealgazette.com/news/Premiers+meet+medicare+lies+sickbed/5994093/story.html

Behavioral and Social Science Foundations for Future Physicians - Association of American Medical Colleges

2012-01-13T06:28:00.003-05:00

Health is a product of the interactions among biology, genetics, behavior, relationships,cure them.

Medicine now faces complex societal problems like addiction, obesity, violence, and end-of-life care, which require behavioral and social science research and interventions. To take advantage of enormous medical breakthroughs, people must trust, afford,
and have meaningful access to health care. Improving the health of the public involves addressing health disparities and ensuring patient safety, as well as engaging the social and political aspects of health care governance, financing, and delivery.

Behavioral and social science research and practice have generated significant improvements in the health of the public, reduced tobacco use and diet modifi- cations being two prominent examples. Our deepening understanding of mind/ body interactions and effective methods of changing health behavior have also led to health improvements. Biobehavioral approaches are effective in treating mental illness and substance abuse, and in managing chronic illness. The sights of behavioral and social sciences in health care are set on learning theory's contribution to neurological disease, memory research, gene-environment interactions, and influences of social integration on health (1). The sciences that undergird these areas of improvement and promise are critical ingredients in the training of future physicians.

A complete medical education must include, alongside the physical and biological science, the perspectives and findings that flow from the behavioral and social sciences. Medical educators now face the challenge of how best to teach

behavioral and social sciences to students and professionals. Physicians fortified with the knowledge, skills, and attitudes outlined in this report will be equipped to provide outstanding patient care, address unanswered questions about human health, and fulfill the mandate to improve the public's health. The panel offers the recommendations
that follow to guide medical educators in fulfilling their duties toward students and the patients who entrust to us their care.

Full report:

https://www.aamc.org/download/271020/data/behavioralandsocialsciencefoundationsforfuturephysicians.pdf

New AAMC Report Stresses Role of Behavioral and Social Sciences in Medical Education - AAMC

2012-01-13T06:28:00.001-05:00

Understanding how lifestyle, behavior, and economic status affect health, and applying this knowledge to medical practice is vital for future physicians, according to a new report from the AAMC (Association of American Medical Colleges). "Behavioral and Social Science Foundations for Future Physicians" is designed to help medical educators understand what behavioral and social sciences to include in their curricula, and provides a framework to help prepare future physicians to address complex social challenges and unhealthy behaviors that can lead to premature death, chronic disease, and health care disparities.

"In addition to medical knowledge, a well-rounded physician must understand the cultural, familial, economic, and demographic factors that affect health and disease," said AAMC President and CEO Darrell G. Kirch, M.D. "To deliver quality patient-centered care, today's doctors need to be equipped with effective methods to help people change behavior to optimize health."

Behaviors and the social determinants of health such as smoking, diet, exercise, and socioeconomic status account for more than 50 percent of premature disease and death in the nation, according to the report. Behavioral and social sciences can assist physicians in developing the right questions and identifying concepts from these disciplines that will provide insight into the many influences on health. For example, applying principles from psychology, epidemiology, or political science can help a physician caring for a newly diagnosed breast cancer patient. By taking into consideration a patient's available support system, access to health care, and how breast cancer is distributed across populations, a physician is in a better position to develop an effective health strategy for treating the disease.

Developed by an expert panel of physicians, scientists, and educators, the report draws from earlier publications that identified key behavioral and social science domains, professional roles for physicians, and supporting competencies. This new report combines the two, creating a teaching and learning matrix that easily can be applied in a clinical setting. It also provides competency frameworks, methods for evaluating professional behaviors, educational strategies, and performance outcomes.

The report is the companion to "Scientific Foundations for Future Physicians," a 2009 publication released by the AAMC and the Howard Hughes Medical Institute (HHMI) that developed competencies related to the biological, physical, genetic, molecular, and mathematical sciences, as well as foundations of knowledge and reasoning.

https://www.aamc.org/newsroom/newsreleases/271088/newaamcreportstressesroleofbehavioralandsocialsciencesinmedical.html

The anatomy of a ripoff - NY Daily News

2012-01-12T23:05:00.001-05:00

In September, my teenage son was rushed by ambulance from the Renaissance Fair in Tuxedo, N.Y., to Good Samaritan Hospital in Suffern after choking on a piece of turkey. The care he received was appropriate; the bill was anything but.

The charges, in fact, were mind-boggling. A statement the hospital sent to my insurance company, Aetna, showed that Good Samaritan billed $22,214.92 for a four-hour emergency room visit that included a physical exam, sedation, endoscopy and extraction of the stuck food.

Even more astonishing, Aetna agreed to pay only $2,885.67 for the services — just 13% of the bill — and the hospital settled for that amount.

How could those numbers possibly be reconciled?

To shed light on the real value of the medical services my son received, I consulted with billing experts and with administrators at Aetna — though not with representatives of Good Samaritan, who refused to return repeated phone calls. It also happened that my son had a second choking episode two weeks after the first, and the charges for his treatment at Somerset Hospital in Pennsylvania were included on the same Aetna statement. So I was able to compare bills for similar procedures at two emergency rooms.

What I learned was that the numbers printed on hospital bills often bear no relation to reality.

That hospitals grossly inflate their charges, expecting insurance companies to radically cut the bills while hoping to wring bigger fees out of the uninsured. That the bill inflation can include double-charging for procedures.

As but one example of what I discovered, consider Ondansetron HCl, an anti-nausea medication that both hospitals administered to my son. Good Samaritan charged $439.90 for the drug; Aetna allowed $77.63. Somerset charged $6.52; Aetna paid $3.26.

Medicare pays 17 cents per dose.

This confusion is reflected up and down the bill, with multiple, conflicting prices for each medication and procedure. There are the sky-high costs that a hospital will claim reflect its expenses, and the much lower fees it accepts under contract with insurance companies. What's missing from this complex web is any hint of what the services a patient received actually cost.

The driving force behind all this, according to Aetna, is the way hospitals and the government do business.

The rates that insurance companies pay are negotiated based on what they believe a hospital's true costs are. But then those rates are jacked up an average of 30% to 50% to make up for money that hospitals lose in treating patients who don't have private insurance — which is the majority of them. So to make up the difference, they overcharge patients who are insured. This practice is called cost-shifting.

More ...

http://www.nydailynews.com/opinion/anatomy-a-ripoff-article-1.1002077

U.S. survey finds respondents' stress level far from ideal - latimes.com

2012-01-12T22:12:00.001-05:00

News flash: Americans are stressed out.

On a scale of 1 to 10, residents of eight U.S. metropolitan areas told psychologists they rated their level of stress as 5.2, according to survey results released Wednesday. That may not sound so terrible — except that these Americans also said their ideal level of stress would be around 3.6.

"Have we reached the point of becoming a chronically stressed nation?" said Michael Ritz, a clinical psychologist in Irvine who serves as the public education coordinator for the California Psychological Assn. "The data might suggest we've reached that point where it just [becomes] a fact of life."

Concerns about work, the economy and money were the main sources of all this stress, according to the survey conducted by the American Psychological Assn. Understandably, 44% of the 1,226 people who participated in the nationwide study said they were more stressed now than they were five years ago.

But 27% of respondents said their stress had receded over that period.

"The data actually surprised me, because it seems stress should be more prevalent in terms of the economy, people's concerns about unemployment, about making ends meet," Ritz said.

Residents of Los Angeles and Orange counties are about as stressed as the rest of America — but they're probably better equipped to deal with it, the survey found.

For instance, they said their ideal level of stress was 3.9, so their actual stress level of 5.3 wasn't as far off the mark as in the country as a whole.

And, according to the study, more adults in the two counties say they've done better at eating more healthfully than Americans overall (48% versus 44%), exercising more (45% versus 39%) and losing weight (39% versus 30%).

"It's possible that it has to do with the climate," said UCLA clinical psychologist Emanuel Maidenberg, who wasn't involved in the survey. "There are more opportunities to use natural resources and be outdoors to do things that are involved in stress reduction, like physical exercise."

Residents of the two counties are also more inclined to seek professional help to deal with their stress, the survey found. Significantly more agreed that a psychologist could help with managing stress (51%) than did Americans in general (41%).

Overall, of the eight major metropolitan areas surveyed, Los Angeles and Orange counties were probably best prepared to better cope with stress, Ritz and Maidenberg agreed. And that could translate into better physical health in addition to better mental health.

"Stress contributes to chronic illnesses, like heart disease, diabetes and obesity," Ritz said, adding that about three-fourths of healthcare dollars go to dealing with chronic maladies.

http://www.latimes.com/health/la-he-la-stress-20120112,0,7275379.story

Do We Need Doctors Or Algorithms? - Vinod Khosla | TechCrunch

2012-01-12T17:19:00.001-05:00

I was asked about a year ago at a talk about energy what I was doing about the other large social problems, namely health care and education. Surprised, I flippantly responded that the best solution was to get rid of doctors and teachers and let your computers do the work, 24/7 and with consistent quality.

Later, I got to cogitating about what I had said and why, and how embarrassingly wrong that might be. But the more I think about it the more I feel my gut reaction was probably right. The beginnings of "Doctor Algorithm" or Dr. A for short, most likely (and that does not mean "certainly" or "maybe") will be much criticized. We'll see all sorts of press wisdom decrying "they don't work" or "look at all the silly things they come up with." But Dr A. will get better and better and will go from providing "bionic assistance" to second opinions to assisting doctors to providing first opinions and as referral computers (with complete and accurate synopses and all possible hypotheses of the hardest cases) to the best 20% of the human breed doctors. And who knows what will happen beyond that?

Assessing Current Healthcare

Let's start with healthcare (or sickcare, as many knowledgeable people call it). Think about what happens when you visit a doctor. You have to physically go to the hospital or some office, where you wait (with no real predictability for how long), and then the nurse probably takes you in and checks your vitals. Only after all this does the doctor show up and, after some friendly banter, asks you to describe your own symptoms. The doctor assesses them and hunts around (probably in your throat or lungs) for clues as to their source, provides the diagnosis, writes a prescription, and sends you off.

The entire encounter should take no more than 15 minutes and usually takes probably less than that. Sometimes a test or two may be ordered, if you can afford it. And, as we all know, most of the time, it turns out to be some routine diagnosis with a standard treatment . . . something a computer algorithm could do if the treatment involved no harm, or at least do as well as the median doctor (I am not talking about the top 20% of doctors here—80% of doctors are below the "top 20%" but that is hard for people to intuit!).

So what's wrong with this situation? This is by no means an exhaustive list, but it sets up a nice springboard:

Physically having to go to your doctor's office makes sense for the most part, except that a lot of the basic tests are either visual (tongue and throat check) or auditory (listening to the breath and vibrations in the abdomen). Time plus cost will often discourage people from taking that first step to visit a doctor. Most of the time a Dr. A could at least advise you when it is worth visiting based on your normal body functions, your current indications, and your locality's current infections and other symptom trends.
A lot of the vitals being tested for (e.g. blood pressure, pulse) can now be routinely done at home or even with the help of an iPhone and an explosion of additional possibilities will emerge in the next decade.
You are the one telling the doctor your symptoms.
The doctor has to inquire (probably every time) into any possible history of each symptom, test results, and illnesses, except when he does not have time for you in that village in India.
The prescriptions are still done on paper, requiring you to, again, physically go to a pharmacy and pick up what you need there. So compliance is an issue.

Looking at this, I cannot help but think that this is a completely antiquated system (regardless of whether it is healthcare or not)!

Going down the list, we find a pretty negative assessment. The vital signs could all be determined with the help of mobile devices, the operation of which do not require years of training and a certification. You will be able to do this by yourself—Philips already is using the iPhone camera to try to measure vital indicators, others will be even more innovative and as an insurance company it would be cost-effective to give them to every insured person for free. Skin Scan is measuring your risk of skin cancer from a photograph of a skin lesion. Telemedicine is accelerating and a Qualcomm company is measuring heart rates using an iPhone. Cell phones that display your vital signs and take ultrasound images of your heart or abdomen are in the offing as well as genetic scans of malignant cells that match your cancer to the most effective treatment. Ear infection and skin rash pictures and more will all be mobile phone based, often supplemented by the kind of (fractal) analysis that Skin Scan does, and more than what the doctors naked eye could usually see.

The history of symptoms, illnesses, and test results could be accessed, processed, and assessed by a computer to see any correlation or trends with the patient's past. You are the one providing the doctor with the symptoms anyway after all!

Any follow-up hunts for clues could again be done with mobile devices. The prescriptions—along with the medical records—could relocate to electronic and digital methods, saving paper, reducing bureaucracy, and easing the healing process. If 90% of the time the doctor knows exactly the right kind of diagnosis from these very few and superficial inputs (we haven't even considered genetics yet!), does it really require 10+ years of intense education for every diagnostician?

The fault is not entirely with the doctors, though. Most of us don't know what set of symptoms warrant the full-scale attention of medical personnel, so we either go all the time or we do not go at all (save for emergencies). We also cannot realistically expect any (even our family) doctor to remember every single symptom and test result over the years, definitely not in a government hospital in China. Similarly, we cannot expect our doctor to be able to remember everything from medical school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth. This is why, every time I visit the doctor, I like to get a second opinion. I do my Internet research and feel much better.

Identifying Emerging Trends In Healthcare

But I always wonder why I cannot input my specific test numbers and have a system offer me a "second opinion" on the diagnosis since it has all the data that the doctor has and can use all my current and historical data effectively. In fact, it is not hard to imagine it having more data than the doctor has since my full patient record would be at the tip of its digital brain, unlike the average doctor who probably doesn't remember my blood glucose levels or my ferritin from two years ago. He does not remember all the complex correlations from med school in which ferritin matters—there are three thousand or more metabolic pathways, I was once told, in the human body and they impact each other in very complex ways. These tasks are perfect for a computer to model as "systems biology" researchers are trying to do.

Add to it my baseline numbers from when I was not sick, which most doctors don't have and if they did 80% of physicians would be too lazy to use or not know how to use. Applied Proteomics can extract tens of gigabytes of proteomics—what my genes are actually doing instead of what they can do—baseline data from one drop of blood. Oh, by the way I have my 23andMe data to add my genetic propensities (howsoever imprecise today, but improving rapidly with time and more data). The doctor uses a lot of imprecise judgments too as most good doctors will readily admit. My very good doctor did not check that I have relative insensitivity, genetically, to Metformin, a diabetes drug. It is easy to input the PDR (the Physicians Desk Reference), the massively thick, small-font book that all physicians are supposed to know backwards and forwards. They often don't remember everything they read, in med school but it is a piece of cake for computers. The book on your typical doctor's desk is probably not current on the leading-edge science either. Confirmed science and emerging science are different things and each has a role. Doctors mostly use confirmed science, the average doctor not understanding and pros and cons of each or the expected value of a treatment (benefit and harm). And our 18^th century tradition of "first do no harm" dictates that if a treatment hurts ten patients a year but saves a thousand lives we reject it.

With enough examples, today's techniques for language translation (or newer techniques) can translate from human lingo for symptoms ("I feel itchy" or "buzzy" or "reddish bubbly rash with pimples" or "less energy in the morning" or "sort of a stretch in my tendon" and the myriad of imprecise ways symptoms are described and results interpreted — these are highly amenable to big data analysis) into medical lingo matching the PDR. With easy input of real medical results into a computer and long-standing historical data per patient and per population, which a human cannot possibly handle, and patient and population genetics, I suspect getting a second opinion of my diagnosis from Dr. A is a reasonable expectation, and it should certainly be better than a middling physician's (especially in less developed countries like India, where there is a dire shortage of trained physicians).

I may still need a surgeon (though robotic surgeons like those from Intuitive Surgical are on the way too) or other specialists for some tasks for a little while and the software may move from "second opinion" (in three years? Or seven?) to "bionic software" for the physicians (in five or ten years, with enough patient data?). Bionic software, again, defined here as software which augments and amplifies human understanding.

But I doubt very much if within 10-15 years (given continued investment and innovation and keeping the AMA from quashing such efforts politically) I won't be able to ask Siri's great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get today from the average physician. Instead of asking Siri 9.0, "I feel like sushi" or "where can I dispose a body" (try it…it's fairly accurate!) and with your iPhone X or Android Y with all the power of IBM's current Watson computer in the mobile phone and an even more powerful "Nvidia times 10-100" server which will cost far less than med school with terabytes or petabytes of data on hundreds of millions (billions?) of patients, including their complete genomics and proteomics (each sample costing about the same as a typical blood test).

IBM's Watson computer, I understand, is now being applied to medical diagnosis after handling imprecise and vague tasks like winning at Jeopardy, which experts a few years ago would have said could not be done. "Computers cannot match the judgment of humans on these kinds of tasks!" And with enough data, medical diagnosis or 90% of it is an easier task than Jeopardy.

Already Kaiser Permanent already has 10 million real-time medical records with details of 30,000,000 e-visits last year with caregivers and computer modeling of key diseases per individual that data scientists would love to get their hand on. Already, according to IDC 14% of the US population is using their phones for medical help and 200 million health and fitness related mobile applications have been downloaded according to pyramid research. Fun stuff, though early. They are probably two generations away from systems that are actually useful.

A more elaborate vision, one that is not very useful today because of lack of enough data and enough science, is defined in Experimental Man and websites like Quantified Self. Though they feel like toys today, they are much further along than the mobile phone was pre-iPhone in January of 2007. And data, the key ingredient to useful analysis, and diagnosis, is starting to explode exponentially—be it genetic data, proteomic data or physical data about my steps, my exercises, my stress levels or my normal heart and respiration rates.

My UP wristband or something like it (disclosure: I am an investor in Jawbone)) will know all my sleep patterns when I am healthy and how many steps I take each day and may have more data on my mobility if I ever get depressed than any psychiatrist ever will know what to do with. Within a few years, my band will know my heart rate at all times, my respiration rate, my galvanic skin resistance (one parameter among multiple ones used to measure my stress level), my metabolic rate (should cost about $10 to add to the band by measuring my CO2 in my breath and may detect changes in my body chemistry too like when I get a certain type of cancer and traces of it show up in my breath).

All my "health data" as well as my "sick data" and my "activity data" will be accessible to Dr. A (and location when I was stressed or breathing hard or getting the allergic reaction and what chemicals were nearby or in the air—did toluene exposure cause me to break out in a rash from that new carpet or trigger a systemic reaction from my body?). I doubt I will be prescribed an arthritis medicine without Dr. A knowing my genetics and the genetics of my autoimmune disease. Or a cancer medicine without the genetics of my cancer when the genetic sequence (once per life) costs far less than a single dose of medicine. In fact all my infectious disease treatments may be based on analysis of my full genome and my history of exposure to viruses, bacteria and toxic chemicals.

Constant everyday health data from non-medical devices will swamp the "sickness tests" used in most medical diagnosis and be supplemented by detailed genetic, proteomic and sick data with bionic software and machine learning systems. Siri might even remind me one day that my heart rate while sleeping has gone up abnormally over the last year, so I should go run some heart sickness cardiograms or imaging tests. Obviously, Siri's children and its server friends will be able to keep up with the latest research and decide on optimal strategies based on patient preference ("I prefer to live longer even if it means all the fancy treatments" or "I want to live a normal life and die. I prefer to spend more of my time with my children than at the hospital" or "I like taking risky treatments"). They will take into account known research, early pioneering approaches, very complex interrelationships and much more.

My best guess is that today a physician's bias makes all these personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what "preferences " are being incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing countries, in my estimation.

Envisioning Future Healthcare

Eventually, we won't need the average doctor and will have much better and cheaper care for 90-99% of our medical needs. We will still need to leverage the top 10 or 20% of doctors (at least for the next two decades) to help that bionic software get better at diagnosis. So a world mostly without doctors (at least average ones) is not only not reasonable, but also more likely than not. There will be exceptions, and plenty of stories around these exceptions, but what I am talking about will most likely be the rule and doctors may be the exception rather than the other way around.

However fictionalized, we will be aiming to produce doctors like Gregory House who solve biomedical puzzles beyond our best input ability. And India, China and other countries may not have to worry about the investment in massive healthcare or massive inequalities in the type of physicians they might have access to. And hopefully our bionic software (or independent software someday) will be free of the influence of heavily marketed but only minimally effective drugs or treatment regimes or branding campaigns against generics or lower-cost and equally effective, more affordable drugs and treatments. Dr. A will be able to do a cost optimization too both at the patient level and at the policy level (but we may choose, at least for a decade or two, to reject its recommendations—we will still be free to be stupid or political).

What is important to realize is how medical education and the medical profession will change toward the better as a result of these trends. The vision I am proposing here, though, is one in which those decades of learning and experience are used where they actually matter. We consider doctors some of the most learned people in our society. We should aim to use their time and knowledge in the most efficient manner possible. And everybody should have access to the skills of the very best ones instead of only having access to the average doctor. And the not so "Dr. House' doctors will help us with better patient skills, bedside manners, empathy, advice and caring, and they will have more time for that too. If computers can drive cars and deal with all the knowledge in jeopardy, surely their next to next to next…generation can do diagnosis, treatment and teaching in these far less uncertain domains and with a lot more data. Further the equalizing impact of both electronic doctors and teaching environments has hugely positive social implications. Besides, who wants to be treated by an "average" doctor? And who does not want to be an empowered patient?

The best way to predict this future is not to extrapolate the past and what has or has not worked, but to invent the future we want, the one we believe possible!

http://techcrunch.com/2012/01/10/doctors-or-algorithms/

A Simple Soda Tax Could Cut America's Health Care Tab By $17 Billion - Business Insider

2012-01-10T19:21:00.001-05:00

Americans love guzzling their sports drinks and soda, but getting every state to slap a one cent tax on the beverages might be a stretch.

A new study published in the journal Health Affairs posits that taxing one-cent per ounce on sodas might cut consumption by as much as 15 percent for Americans 25 to 64.

We drink 13.8 billion gallons of the sweet stuff each year which comes out to 70,000 calories or 45 gallons per person.

The team, led by Columbia University's Claire Wang, estimates the tax would shave $17 billion off related health care costs and boost America's revenue by $13 billion (if enacted in 2010).

The tax could also sidetrack our diabetes and obesity epidemics, as the drinks are linked to both. The authors explain:

"Over the period 2010–20, the tax was estimated to prevent 2.4 million diabetes person-years, 95,000 coronary heart events, 8,000 strokes, and 26,000 premature deaths, while avoiding more than $17 billion in medical costs. In addition to generating approximately $13 billion in annual tax revenue, a modest tax on sugar-sweetened beverages could reduce the adverse health and cost burdens of obesity, diabetes, and cardiovascular diseases."

More than a dozen states levy a soda tax, just not at the rate proposed here. Soda taxing is a hot-button topic, much like obesity and cigarette smoking. But whether such a tax would cut consumption remains unclear. A 2009 study published in the New England Journal of Public Medicine found that such taxes would be "too small" to cut consumption, while "the revenues are not earmarked for programs related to health."

The American Beverage Association offered a different take: "This paper is nothing more than another attempt by researchers and their supporters who have long advocated discriminatory taxes on beverages to promote a beverage tax, which will have no impact on public health. Consumers do not support these taxes and recognize them for what they truly are – a money grab to raise revenue, as noted by the authors themselves."

http://www.businessinsider.com/a-one-cent-soda-tax-might-slash-health-care-costs-by-17-billion-2012-1?

Really? Can You Die of a Broken Heart? - NYTimes.com

2012-01-10T06:47:00.001-05:00

The emotional pain of losing a loved one can take a toll on the heart, at least metaphorically. But can it trigger an actualheart attack?

In a large new study, scientists have confirmed what the medical world has long suspected: The so-called broken-heart syndrome is real. The study, published on Monday in Circulation: Journal of the American Heart Association, found that a person's heart attack risk is 21 times higher than normal the day after a loved one dies.

Over time the risk of an attack declines, but it remains elevated within that first month. In the first week after a loved one's death, for example, the risk was six times higher than normal, said Elizabeth Mostofsky, the lead author of the paper and a postdoctoral research fellow at Beth Israel Deaconess Medical Center in Boston.

"If a bereaved person is having symptoms like chest pain, they shouldn't simply say, 'Oh, I'm dealing with the stress right now' and ignore it," she said.

Other studies have uncovered greater heart and mortality risks in the weeks and months after the loss of a spouse, a child or another loved one, but the new study is the first systematic look at the immediate effect. The researchers interviewed nearly 2,000 people hospitalized for heart attacks over a five-year period and controlled for variables like health and history of disease.

Those with previous heart risk factors were more vulnerable, but the odds increased even for those with no coronary history. Dr. Mostofsky pointed out that bereavement could provoke depression, anger and anxiety, all of which can elevate the heart rate and blood pressure and increase blood clotting.

http://well.blogs.nytimes.com/2012/01/09/really-the-claim-grief-can-cause-a-heart-attack/

OpenNotes Project

2012-01-10T06:46:00.001-05:00

OpenNotes is a demonstration and evaluation project exploring what happens when the medical record becomes far more transparent than in the past. Through their health systems' secure websites, primary care doctors are inviting their patients to read the notes they write about them following visits, e-mail correspondence, or phone conversations. More than 100 doctors and 20,000 patients are participating.

The study is being conducted at Beth Israel Deaconess Medical Center in Boston,Geisinger Health System and its primary care practices in rural Pennsylvania, andHarborview Medical Center in Seattle. It is supported by a major grant from theRobert Wood Johnson Foundation Pioneer Portfolio, supplemented by grants from the Drane Family Fund, the Koplow Family Foundation, and the Katz Family Foundation.

In the July 20, 2010 issue of the Annals of Internal Medicine, the OpenNotes investigators published a Perspective: "OpenNotes: Doctors and Patients Signing On."It explores in some detail the issues our project addresses. On December 20, 2011, the OpenNotes baseline, pre-intervention findings were published, also in the Annals, in a paper entitled, "Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look Ahead." The Annals is kindly providing both the Perspective articleand the baseline findings paper free on its website.

http://myopennotes.org/index.shtml

A study encourages people to take the doctor’s notes home after exams. - NYTimes.com

2012-01-10T06:44:00.001-05:00

In an old "Seinfeld" episode, Elaine goes to see a dermatologist about a rash, and is left sitting on the table in the exam room, alone with her medical chart. She opens the folder and almost immediately makes a sour face.

" 'Difficult'?" she says, reading aloud.

Let's face it: We've all tried to imagine what the doctor's been scribbling during our visits, what is to be found in that intimate record of frailties and phobias that we never see, even though it is all about us.

"The medical record is information that really belongs to the patient, but it's treated like a classified document," said Susan B. Frampton, president of Planetree, a nonprofit organization based in Derby, Conn., that promotes patient-centered approaches to health care. "It's symbolic of the power differential in health care."

Patients have a legal right to their records, though access can prove difficult. What would happen if patients were encouraged not just to see their medical records but to take them home, study them and really own them?

A research collaboration called OpenNotes has set out to answer this question, publishing the first results of a study on physician and patient attitudes toward shared medical records last month in Annals of Internal Medicine. For patients, at least, this seems to be an idea whose time has come.

The goal, said Dr. Tom Delbanco, a principal investigator of the study, is to engage patients more fully in their own health.

"That's the great challenge in medicine: getting patients to be more active in their own care," said Dr. Delbanco, a professor of medicine at Harvard Medical School. "What we're doing is opening the black box and letting you look inside."

Ultimately, he and the study's lead author, Jan Walker, a member of the research faculty at Beth Israel Deaconess Medical Center in Boston, envision a record that is jointly written: with physician and patient input information, with some negotiation about the details and an agreement on how to proceed.

Dr. Delbanco and his colleagues recruited more than 100 primary care doctors who were already using electronic health records to volunteer to share their medical notes with patients. The researchers asked both participating doctors and doctors who declined to join the project about expectations and concerns, and surveyed nearly 38,000 patients.

The patients were from three very different communities: Beth Israel Deaconess, Geisinger Health System of Danville, Penn., and Harborview Medical Center in Seattle.

Doctors were ambivalent about opening their records, concerned that patients would demand more of their time as a result, or be worried and confused, said Ms. Walker, the study's senior author. But patients were enthusiastic: 90 percent thought they would be more in control of their care if they saw the notes. They weren't worried about being confused. Most said seeing the record would help them take better care of themselves: They would better remember the treatment plan, understand it and take their medication.

"Knowledge is power," Ms. Walker said. "A patient goes to the doctor only once in a while, but in between visits, you're making all kinds of decisions that affect your health every single day."

Candice Wolk, a 39-year-old mother from the Boston area who just gave birth to twins, is a good example. During her first pregnancy checkup, her obstetrician noticed a dark spot on her back and suggested she follow up with a dermatologist. But in the excitement about her pregnancy, she forgot — until she read over the notes from her visit.

Even before M. D. Anderson Cancer Center in Houston started using electronic medical records, administrators gave patients their paper files to carry from doctor to doctor.

Now, cancer patients say having password-protected access to their electronic records helps them absorb complex information about treatment and follow lab tests.

"It never upset me, except the first time I read about my bones," said Paul Grabowski, 60, of Houston, who has two forms of blood cancer and has developed bone loss that causes severe pain. "I heard about it from my doctor, but it's different when you read it in black and white."

Open medical records can help H.I.V. patients track viral loads and other disease markers, and motivate patients to take their medication, said Dr. Bob Harrington, a professor of medicine at the University of Washington in Seattle who is medical director of the Harborview Madison H.I.V. Clinic.

For indigent patients, access to records may help even more because they move frequently and their care is often fragmented, said Dr. Joann G. Elmore, professor of medicine at the University of Washington School of Medicine and one of the study authors.

Weight is a particularly sensitive topic in records, the researchers have found. Doctors who use the word "obese" in their notes may risk alienating patients.

"It might be better to say the patient is '20 percent over ideal body weight' rather than 'a jovial obese man came into my clinic,' " said Dr. Thomas W. Feeley, head of the division of anesthesiology and critical care at M. D. Anderson, who co-wrote an editorial accompanying the new study.

Further, experts worry about notes being shared with patients who have mental illness orsubstance abuse problems.

Most doctors do not think that showing patients their records will increase lawsuits; patients may even be able to point out mistakes or omissions. But other concerns remain.

Will physicians' notes change if they know patients are reading them? Will patients withhold information they don't want recorded? Will they be more likely to seek a second or third opinion?

The shared medical record, Dr. Delbanco said, "is a new medicine. It's designed to help more people than it hurts, but invariably it may hurt some patients. Medicines are never perfect."

http://www.nytimes.com/2012/01/10/health/policy/project-puts-records-in-the-patients-hands.html?src=recg

Should we erase painful memories? - Salon.com

2012-01-07T17:44:00.001-05:00

This article was adapted from the upcoming book, "Memory: Fragments of a Modern History," available in January from the University of Chicago Press.

One of the most tenacious themes of 20th-century memory research was the idea that people tormented by the memories of terrible experiences could benefit from remembering them, and from remembering them better. The assumption — broadly indebted to psychoanalysis — was that psychological records of traumatic events often failed to be fully "integrated" into conscious memories. As long as these records remained "dissociated," the sufferer was compelled to "relive" them instead of benignly remembering them. The more fully and appropriately one remembered terrible events, the more attenuated would be their emotional power.

But in the 1990s — a time when psychoanalytic assumptions were being challenged as never before — neuroscience researchers developed a new framework for thinking about remembering, forgetting, and the mind's record of past events. One result was a highly controversial new paradigm for treating traumatic memories. The problem with bad memories, these new researchers claimed, is not their complex and unresolved relation to one's sense of self, but the simple fact that they are unpleasant. These researchers defined emotional memory not in terms of repressed ideas, but by certain patterns of neuron action and the chemical changes they triggered. The next step was to change these patterns.

In the 19th century, character was commonly portrayed as something that was built up by daily experience and personal choices, through the memories and habits created by those everyday events. Character was the result of how one responded, moment by moment, to the challenges of daily life, because those responses built up a kind of internal machinery of habit. Character was defined, in a way, as an accretion of memory. The idea of "building character" meant striving to make appropriate choices because the hardware one created would become difficult or impossible to change later.

One scholar of the present day who has expressed concerns about memory dampening has used a different analogy to describe the relation between memory and personality, but nevertheless one that describes personality as being made out of discrete memories. William B. Hurlbut, a consulting professor in human biology at Stanford University, wrote that "the pattern of our personality is like a Persian rug." It was built "one knot at a time, each woven into the others. There's a continuity to self, a sense that who we are is based upon solid, reliable experience. We build our whole interpretation and understanding of the world based upon that experience or on the accuracy of our memories."

As recently as the 1990s, people who thought of themselves as survivors of terrible trauma often defined themselves in relation to what they remembered (or what they did not): They were survivors because they had survived certain defining events.Their character as mature adults came from "working through" these terrible memories. But there were also "survivors" who felt they had not truly survived their memories. They described a wounded self whose bad experiences stood in the way of personal realization. This latter convention involved the idea of a hidden, unimpaired self encumbered by adverse conditions. The idea is similar in some respects to the characterization used in the marketing of recent psychotropic drugs, especially Prozac. These drugs' enthusiasts sometimes declared that taking them allowed their "true" selves to emerge, often for the first time.

Philosophers, therapists, filmmakers and bloggers have been quick to reflect on the implications of memory erasure. One of the best-known projects to explore the subject is the 2004 film "Eternal Sunshine of the Spotless Mind," in which the main character attempts to have memories of his ex-girlfriend deleted from his mind pharmaceutically. The film embraces the new neuroscience of emotion, focusing on memories of feelings and the complex ways different kinds and parts of memories are stored in different places in the brain. Central to the plot is the idea that memories with different emotional associations are stored differently.

http://www.salon.com/2011/12/31/should_we_erase_painful_memories/singleton/

Study of Medicare Patients Finds Most Hospital Errors Unreported - NYTimes.com

2012-01-07T10:47:00.001-05:00

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the "adverse events," according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to "track medical errors and adverse patient events, analyze their causes" and improve care.

Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.

"Despite the existence of incident reporting systems," Mr. Levinson said, "hospital staff did not report most events that harmed Medicare beneficiaries." Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

Federal investigators identified many unreported events by having independent doctors review patients' records.

The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.

Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said.

When the National Academy of Sciences issued a landmark report on patient safety in 1999, many experts said that hospital employees were often afraid to admit mistakes. But that no longer appears to be the main obstacle to reporting, federal investigators said.

More often, Mr. Levinson said, the problem is that hospital employees do not recognize "what constitutes patient harm" or do not realize that particular events harmed patients and should be reported.

In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or "suspected that the events were isolated incidents unlikely to recur."

To clear up confusion, Medicare officials said they would develop a list of "reportable events" that hospitals and their employees could use. In addition, the Medicare agency said, hospitals should give employees "detailed, unambiguous instructions on the types of events that should be reported."

The Obama administration and hospital industry leaders have placed a high priority on reducing medical errors. But, the report said, at many hospitals, this high-level commitment has not been translated into practice.

The inspector general found that "hospitals made few changes to policies or practices" after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any "systemic quality problems."

Organizations that inspect and accredit hospitals generally "do not scrutinize" how hospitals keep track of medical errors and other adverse events, the study said.

The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.

More than 2,900 hospitals have joined the administration in a "partnership for patients" intended to reduce errors and save 60,000 lives in three years.

At least 27 states have laws that require hospitals to report publicly on infections that patients develop in the hospital, according to the National Conference of State Legislatures, up from 6 at the end of 2005.

In view of the state laws, Obama administration officials said they were not proposing new federal requirements for the public reporting of adverse events.

http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html?src=recg&pagewanted=print

12 entrepreneurs reinventing health care - CNNMoney

2012-01-06T10:19:00.001-05:00

These 12 startups are working to make medical care more affordable and efficient -- a change that could save billions of dollars and save lives.

http://money.cnn.com/galleries/2011/smallbusiness/1112/gallery.health-care-entrepreneurs/index.html

FBI crackdown on unproven stem cell therapies - health - 05 January 2012 - New Scientist

2012-01-05T05:56:00.001-05:00

They are the modern equivalent of snake oil merchants: clinics that charge desperately ill people thousands for unproven stem cell "cures". Now the US federal government is cracking down on one of the most notorious – and the defendants include a scientist at a leading research university.

Vincent Dammai, of the Medical University of South Carolina in Charleston, is named in a federal indictment as part of a team that allegedly received more than $1.5 million from people with cancer and neurodegenerative diseases.

The charges follow an investigation by CBS News into Lawrence Stowe of Fort Worth, Texas.

Stowe was filmed claiming that infusions of stem cells, given by his associate Francisco Morales at a clinic in Mexico, could reverse symptoms of amyotrophic lateral sclerosis – a fatal and incurable form of motor neuron disease.

Dammai's role, according to the indictment, was to extract stem cells from umbilical cord blood collected by Jesus Alberto Ramon, a midwife in Del Rio, Texas. Dammai and Ramon allegedly worked with Global Laboratories of Scottsdale, Arizona, which supplied the cells to Morales. Fredda Branyon, who ran Global Laboratories, pleaded guilty to supplying an unapproved treatment in August.

The case underlines concerns that some mainstream researchers could be abetting clinics offering unproven stem cell therapies. "I'm personally very happy that the FBI and the Food and Drug Administration has stepped in," says Larry Goldstein, a stem cell biologist at the University of California, San Diego. "I hope that it serves as a warning signal."
Morales, Dammai and Ramon, all named in the indictment, were arrested in December. Stowe, named i

While Dammai is alleged to have been a knowing participant, other scientists may have been duped into supplying cells that are later used by rogue clinics. To avoid this, biologists should ask for credentials when responding to requests for stem cell samples, argued bioethicists Zubin Master of the University of Alberta in Edmonton, Canada, and David Resnik of the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina, in the journal EMBO Reports last July (vol 12, p 992). They should also make recipients sign contracts detailing how the cells will be used, the pair added.

Internet searches reveal several hundred clinics offering unproven stem cell treatments, says Douglas Sipp of the RIKEN Center for Developmental Biology in Kobe, Japan. How many, if any, have obtained cells from mainstream biologists remains a mystery. "By nature these clinics are opaque and secretive," says Sipp. "We really don't know what's in the vials."

http://www.newscientist.com/article/dn21329-fbi-crackdown-on-unproven-stem-cell-therapies.html

How Yoga Can Wreck Your Body - NYTimes.com

2012-01-05T05:50:00.001-05:00

On a cold Saturday in early 2009, Glenn Black, a yoga teacher of nearly four decades, whose devoted clientele includes a number of celebrities and prominent gurus, was giving a master class at Sankalpah Yoga in Manhattan. Black is, in many ways, a classic yogi: he studied in Pune, India, at the institute founded by the legendary B. K. S. Iyengar, and spent years in solitude and meditation. He now lives in Rhinebeck, N.Y., and often teaches at the nearby Omega Institute, a New Age emporium spread over nearly 200 acres of woods and gardens. He is known for his rigor and his down-to-earth style. But this was not why I sought him out: Black, I'd been told, was the person to speak with if you wanted to know not about the virtues of yoga but rather about the damage it could do. Many of his regular clients came to him for bodywork or rehabilitation following yoga injuries. This was the situation I found myself in. In my 30s, I had somehow managed to rupture a disk in my lower back and found I could prevent bouts of pain with a selection of yoga postures and abdominal exercises. Then, in 2007, while doing the extended-side-angle pose, a posture hailed as a cure for many diseases, my back gave way. With it went my belief, naïve in retrospect, that yoga was a source only of healing and never harm.

At Sankalpah Yoga, the room was packed; roughly half the students were said to be teachers themselves. Black walked around the room, joking and talking. "Is this yoga?" he asked as we sweated through a pose that seemed to demand superhuman endurance. "It is if you're paying attention." His approach was almost free-form: he made us hold poses for a long time but taught no inversions and few classical postures. Throughout the class, he urged us to pay attention to the thresholds of pain. "I make it as hard as possible," he told the group. "It's up to you to make it easy on yourself." He drove his point home with a cautionary tale. In India, he recalled, a yogi came to study at Iyengar's school and threw himself into a spinal twist. Black said he watched in disbelief as three of the man's ribs gave way — pop, pop, pop.

After class, I asked Black about his approach to teaching yoga — the emphasis on holding only a few simple poses, the absence of common inversions like headstands and shoulder stands. He gave me the kind of answer you'd expect from any yoga teacher: that awareness is more important than rushing through a series of postures just to say you'd done them. But then he said something more radical. Black has come to believe that "the vast majority of people" should give up yoga altogether. It's simply too likely to cause harm.

Not just students but celebrated teachers too, Black said, injure themselves in droves because most have underlying physical weaknesses or problems that make serious injury all but inevitable. Instead of doing yoga, "they need to be doing a specific range of motions for articulation, for organ condition," he said, to strengthen weak parts of the body. "Yoga is for people in good physical condition. Or it can be used therapeutically. It's controversial to say, but it really shouldn't be used for a general class."

Black seemingly reconciles the dangers of yoga with his own teaching of it by working hard at knowing when a student "shouldn't do something — the shoulder stand, the headstand or putting any weight on the cervical vertebrae." Though he studied with Shmuel Tatz, a legendary Manhattan-based physical therapist who devised a method of massage and alignment for actors and dancers, he acknowledges that he has no formal training for determining which poses are good for a student and which may be problematic. What he does have, he says, is "a ton of experience."

"To come to New York and do a class with people who have many problems and say, 'O.K., we're going to do this sequence of poses today' — it just doesn't work."

According to Black, a number of factors have converged to heighten the risk of practicing yoga. The biggest is the demographic shift in those who study it. Indian practitioners of yoga typically squatted and sat cross-legged in daily life, and yoga poses, or asanas, were an outgrowth of these postures. Now urbanites who sit in chairs all day walk into a studio a couple of times a week and strain to twist themselves into ever-more-difficult postures despite their lack of flexibility and other physical problems. Many come to yoga as a gentle alternative to vigorous sports or for rehabilitation for injuries. But yoga's exploding popularity — the number of Americans doing yoga has risen from about 4 million in 2001 to what some estimate to be as many as 20 million in 2011 — means that there is now an abundance of studios where many teachers lack the deeper training necessary to recognize when students are headed toward injury. "Today many schools of yoga are just about pushing people," Black said. "You can't believe what's going on — teachers jumping on people, pushing and pulling and saying, 'You should be able to do this by now.' It has to do with their egos."

When yoga teachers come to him for bodywork after suffering major traumas, Black tells them, "Don't do yoga."

"They look at me like I'm crazy," he goes on to say. "And I know if they continue, they won't be able to take it." I asked him about the worst injuries he'd seen. He spoke of well-known yoga teachers doing such basic poses as downward-facing dog, in which the body forms an inverted V, so strenuously that they tore Achilles tendons. "It's ego," he said. "The whole point of yoga is to get rid of ego." He said he had seen some "pretty gruesome hips." "One of the biggest teachers in America had zero movement in her hip joints," Black told me. "The sockets had become so degenerated that she had to have hip replacements." I asked if she still taught. "Oh, yeah," Black replied. "There are other yoga teachers that have such bad backs they have to lie down to teach. I'd be so embarrassed."

More ...

http://www.nytimes.com/2012/01/08/magazine/how-yoga-can-wreck-your-body.html?pagewanted=print

U.S. twin births have doubled in three decades: study | Reuters

2012-01-04T23:04:00.001-05:00

The number of twins born in the United States has doubled in the last three decades largely as a result of fertility treatments, with one in 30 infants born in 2009 a twin, the Centers for Disease Control and Prevention said on Wednesday.

"The increases are quite widespread, affecting all age groups and all parts of the country," said Joyce Martin, a CDC epidemiologist and coauthor of the new study.

More than 137,000 twins were born in the United States in 2009, accounting for one in every 30 babies. That compares to 68,339 twins born in 1980 when just one in 53 infants born was a twin, the CDC said.

A third of the increase in the twin birth rate can be attributed to women waiting longer to have children, the CDC said. From 2000 to 2009, more than 35 percent of all births were to mothers ages 30 and over, up from 20 percent in 1980.

The number of twins per 1,000 births rose in all 50 states and doubled in Connecticut, Hawaii, Massachusetts, New Jersey and Rhode Island.

Treatment for infertility such as in-vitro fertilization accounts for much of the remainder of the increase in twins, the CDC said.

"We seem to be making improvements, refinements to fertility-enhancing therapies, so that could then result in a lowering of the increase of the pace in twin and other multiple births," Martin told Reuters.

Twin births are riskier than single births, she said.

"Infants born in twin deliveries are at greater risk of poor outcome," she said. "They are born smaller, they are born earlier. They are more likely not to survive the first year. Most twins do fine, but they are at higher risk."

http://www.reuters.com/article/2012/01/04/us-twins-idUSTRE8031YP20120104

It Costs More, but Is It Worth More? - NYTimes.com

2012-01-04T11:12:00.001-05:00

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

The higher price would be worth it if proton beam therapy cured more people or significantly reduced side effects. But there is no evidence showing that this is true, except for a handful of rare pediatric cancers, like brain and spinal cord cancer. For children, the treatment does a better job of limiting damage to normal brain cells and reducing the risk of cognitive impairment and hearing loss. But — fortunately — fewer than 3,500 American children get these cancers each year. It is impossible to keep all nine existing proton beam centers in full use, much less the approximately 20 others in planning or construction, with so few patients.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. There has not been a single randomized trial, only small, short-term studies. Such trials cannot evaluate the therapy's long-term outcomes, nor resolve the concerns that some experts have raised regarding a potentially increased risk of hip fractures, bowel problems or other delayed effects associated with the therapy's treatment for prostate cancer.

So why is the venerable Mayo Clinic building two proton beam facilities? Because it's competing against Massachusetts General Hospital, M. D. Anderson in Texas, the University of Pennsylvania, Loma Linda in California — all of which have one. With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.

One solution is for Medicare to simply refuse to pay for proton beam treatment except for diseases where there is valid evidence that it is clinically superior, as many private insurers do. This would certainly help keep costs down, and it would also encourage manufacturers and researchers to actually conduct studies comparing proton beam therapy to other treatments.

However, it is often difficult to begin clinical trials without some reimbursement for the treatment that is being studied. So a second option is "coverage with evidence development." In this approach, Medicare would pay for proton beam treatment for patients with prostate and other cancers, but only if the patients were enrolled in a randomized trial that would compare the outcomes of their treatment to those from surgery, other kinds of radiation or active surveillance. Medicare has used this approach sparingly, but it should be applied to more cases like this one.

The most promising option is a new approach called dynamic pricing. Medicare would pay more for proton beam therapy, but only for diseases that are proven to be treated more effectively by the therapy than by other forms of radiation. For cancers like prostate, it would pay only what it pays for the cheaper alternatives. But if studies were done showing that proton beam therapy was better than other treatments, the payment would go up. If no studies were done, or the new evidence demonstrated no advantages, then coverage would continue, but at the lower reimbursement.

Of course hospitals could continue charging patients more for proton beam therapy, and patients who wanted the treatment could pay the difference themselves. But this should not be seen as unfair to those who can't afford it, because there are alternatives that are just as effective.

Everyone wants the best available care, especially for life-threatening diseases like cancer. But that doesn't mean Americans should pay exorbitant costs for treatments that can't be shown to be better than other, cheaper, options. If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked.

Ezekiel J. Emanuel, an oncologist and former White House adviser, is a vice provost and professor at the University of Pennsylvania. Steven D. Pearson, a general internist, is the president of the Institute for Clinical and Economic Review at the Massachusetts General Hospital's Institute for Technology Assessment.

http://opinionator.blogs.nytimes.com/2012/01/02/it-costs-more-but-is-it-worth-more/?pagemode=print

Nowhere to Go, Patients Linger in Hospitals, at a High Cost - NYTimes.com

2012-01-04T11:11:00.001-05:00

Hundreds of patients have been languishing for months or even years in New York City hospitals, despite being well enough to be sent home or to nursing centers for less-expensive care, because they are illegal immigrants or lack sufficient insurance or appropriate housing.

As a result, hospitals are absorbing the bill for millions of dollars in unreimbursed expenses annually while the patients, trapped in bureaucratic limbo, are sometimes deprived of services that could be provided elsewhere at a small fraction of the cost.

"Many of those individuals no longer need that care, but because they have no resources and many have no family here, we, unfortunately, are caring for them in a much more expensive setting than necessary based on their clinical need," said LaRay Brown, a senior vice president for the city's Health and Hospitals Corporation. Under state law, public hospitals are not allowed to discharge patients to shelters or to the street.

Medicaid often pays for emergency care for illegal immigrants, but not for continuing care, and many hospitals in places with large concentrations of illegal immigrants, like Texas, California and Florida, face the quandary of where to send patients well enough to leave. Officials in New York City say they have many such patients who are draining money from the health system as the cost of keeping people in acute-care hospitals continues to escalate.

But even if Medicaid pays for some care, taxpayer dollars are ultimately being consumed by patients who could be cared for in nursing homes or other health facilities, and even at home if supportive services were available. Care for a patient languishing in a hospital can cost more than $100,000 a year, while care in a nursing home can cost $20,000 or less.

Patients fit to be discharged from hospitals but having no place to go typically remain more than five years, Ms. Brown said. She estimated that there were about 300 patients in such a predicament throughout the city, most in public hospitals or higher-priced skilled public nursing homes, though a smattering were in private hospitals.

One patient, a former hospital technician from Queens, has lived at the city's Coler-Goldwater Specialty Hospital and Nursing Facility on Roosevelt Island for 13 years because the hospital has no place to send him, Ms. Brown said. The patient, who is in his mid-60s, has been there since an arterial disease cost him part of one leg below the knee and left him in a wheelchair. The city's public health system declined to provide the names of any long-term patients or make them available for interviews, citing confidentiality laws.

Five years ago, Yu Kang Fu, 58, who lived in Flushing, Queens, and was a cook at a Chinese restaurant in New Jersey, was dropped off by his boss at New York Downtown Hospital, a private institution in Manhattan, complaining of a severe headache. Mr. Yu was admitted to the intensive-care unit with a stroke.

Within days, he was well enough for hospital personnel to begin planning for his release, but as an illegal immigrant (he had overstayed a work visa a decade ago), he was ineligible for health benefits. And no nursing home or rehabilitation center would take him. Neither would his son in China nor the Chinese government, although the hospital volunteered to fly him there at its expense.

Mr. Yu's protracted hospital stay was first chronicled in an article in The New York Times in 2008 about the treatment of uninsured immigrants.

Mr. Yu remained in the hospital for over four years until he was transferred last spring to the Atlantis Rehabilitation and Residential Health Care Facility, a private center in Fort Greene, Brooklyn, after the federal government certified him as a "permanent resident under color of law," essentially acknowledging that he could not be returned to China and qualifying him for medical benefits.

"This gentleman cost us millions of dollars," said Jeffrey Menkes, the president of New York Downtown. "We try to provide physical, occupational therapy, but this is an acute-care hospital. This patient shouldn't be here."

Mr. Yu said that the hospital had treated him well, but that he had made enormous progress in regaining his ability to walk through his rehabilitation regimen at Atlantis. He hopes to return to China when he is well enough to be discharged.

"Here, I am very happy," he said. "This is very nice — No. 1."

New York Downtown serves a largely immigrant population, and many patients have no insurance or proof that they are in the United States legally, which is necessary for discharge purposes and eventual reimbursements, said Chui Man Lai, assistant vice president of patient services at the hospital.

"These patients often arrive in the emergency room acutely ill and unaccompanied, and we have to treat them until they can be discharged safely," Ms. Lai said. "The hospital is required, by law and its mission, to care for these patients."

Health professionals refer to them as "permanent patients," trussed in red tape and essentially living in hospitals already operating on thin margins. In some cases, health care professionals say, grown children leave ailing parents at the hospitals and go on vacation. Officials call that practice a "pop drop."

Though the problem is particularly severe in the municipal hospital system, longtime patients place a financial burden wherever they end up.

New York Downtown spends about $2 million annually for such patients out of an operating budget of about $200 million. An acute-care patient can cost the hospital more than $1,500 a day.

Hospitals are reluctant to complain publicly about such patients for fear of being perceived as callously seeking to dump nonpaying patients. Elected officials are generally loath to be seen as encouraging illegal immigrants by changing reimbursement formulas. The issue was never addressed during the debate over national health care legislation.

Longtime patients, meanwhile, risk getting sicker because they are exposed to diseases that fester in hospitals.

"At times there is a fine line regarding who meets the criteria to be admitted to a hospital, but if there's no way to immediately contact a family member and the patient needs nonmedical help or is homeless, you're obligated to provide shelter," said Dr. Warren B. Licht, who recently retired as New York Downtown's chief medical officer after seven years to return to full-time clinical practice in the wellness and prevention center that he founded there. "You can't kick a patient out of the hospital."

New York Downtown, Dr. Licht said, has offered to pay for nursing home care for patents who are uninsured and are illegal immigrants, but care facilities are reluctant to risk taking patients for fear that they would be saddled with unexpected and unreimbursed expenses.

"If the patient does not have or cannot obtain health insurance to pay for the next level of care, other non-acute-care health facilities won't routinely accept a patient," Dr. Licht said.

New York Downtown has four or five patients out of a total of 180 who have no place to go, he said, adding, "It cost us several million dollars a year in a hospital struggling to keep its head above water."

http://www.nytimes.com/2012/01/03/nyregion/nowhere-to-go-patients-linger-in-hospitals-at-a-high-cost.html?_r=1&nl=todaysheadlines&emc=tha29&pagewanted=print

In Tight Times, Medical Schools Market Themselves : NPR

2012-01-04T06:56:00.001-05:00

Hospitals stepped up their advertising in 2011, and some newcomers to the national marketing game are academic medical centers. While the coast-to-coast commercials help attract faculty and students, they're also aimed at getting more paying patients to travel for treatment.

The biggest spenders on advertising are, not surprisingly, the household names in medical care. Mayo Clinic, Mount Sinai and New York Presbyterian led the way for the first half of 2011. Overall, hospitals shelled out 20 percent more during that period than in the previous year, according to the research firm Kantar Media.

One of the newcomers trying its luck on the national stage is Vanderbilt University Medical Center. In one recent ad, the facility promised that "the most amazing part is that the most amazing part is yet to come. That's the promise of discovery."

In the last year, the Nashville-based teaching hospital bought sponsorship time on CNN, Fox News and NPR.

Vanderbilt's chief marketing officer, Jill Austin, says that the marketing campaign has many goals.

"We think of it almost as a service to the public, to get the word out," she says.

The Vanderbilt ads focus primarily on treatments for cancer and heart disease that are based on an individual's DNA. But Austin says that luring patients hasn't been the primary goal.

"Ultimately, it helps us attract students to Vanderbilt [as well as] faculty and staff," she says. "We ourselves are proud of the work that we do, so it's really focused in that direction."

But despite what some institutions might say, the thrust of national marketing isn't recruiting or even fundraising, says Joel English of the Milwaukee-based marketing firm BVK.

"There are ancillary benefits to an effective national or regional campaign," English says. "That said, during a time in health care where dollars are precious, I don't believe those would be the key reasons for a national campaign. I think the key reason is to attract more patients."

Several teaching hospitals have tried raising their national profiles in recent years. The University of Pittsburgh Medical Center launched a multimillion-dollar campaign in 2005. The University of Michigan Health System has been on NPR; it also bought ads in The New York Times Sunday Magazine.

English says a lot of the impetus comes from shrinking Medicare and Medicaid reimbursements, which put a particular squeeze on teaching hospitals.

"To sustain their research and education and patient care, they have to extend beyond their traditional geographic boundaries," he says.

The concept is relatively new. Twenty years ago, you wouldn't catch an academic medical center using its name and the term "marketing" in the same sentence, says Betsy Gelb, a University of Houston marketing professor.

"We have gotten to the point where it isn't a dirty word," she says.

Gelb points to nearby MD Anderson Cancer Center, part of the University of Texas. It launched its first national campaign in 2009.

As one ad puts it, "There's only one you, and only one MD Anderson."

The TV spots and print ads are meant for the eyes of patients who've gotten a tough diagnosis. But Gelb says that as much as anything, the institution wants its name in front of physicians who ultimately make patient referrals.

The goals vary, Gelb says, and most are hard to measure.

"You can't necessarily quantify it," she says, as in, " 'Hey, 56 patients came in last year.' But you can say the difference from before to after is significantly positive, or it isn't."

As for the latest to broaden its horizons, Vanderbilt reports a "statistically significant change."

The University of Michigan Health System, however, wasn't exactly thrilled with the results of its national ads. A spokesman says it recently moved its national marketing away from pricey traditional media and to the Web instead.

http://www.npr.org/2012/01/04/144622719/in-tight-times-medical-schools-market-themselves

Book Excerpt: Confessions of a Surgeon By PAUL A. RUGGIERI - WSJ.com

2012-01-03T20:52:00.001-05:00

"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall. I was fed up with its failure to work as advertised by the manufacturer. The stapler had probably cost less than $100 to make. The hospital paid $300 for it (and then billed the patient, or insurance company, $1,200). Now the thing didn't even work.

I do not react well to imperfection inside the operating room. I cannot tolerate it in the tools I use, the staff assisting me, or myself. Defective devices—I can have them replaced. Unmotivated staff—I can have them removed from the operating room. I haven't quite figured out yet what to do with myself.

Several months earlier, I had performed the same operation on a 66-year-old patient, using an identical stapling device. Everything seemed to have worked perfectly until the patient developed severe complications four days after his surgery. We soon discovered the cause: the nonperformance of the stapling device.

Surgeons are control freaks. We have to be. And when things don't go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums. These explosions are a go-to reaction when we're confronted with the ghosts of prior complications.

When the stapler hit the wall, I had been in the operating room for more than four hours, struggling to remove a diseased segment of colon from someone I'll call Mr. Baker, a 330-pound middle-aged man. Trying to keep his fat out of my way during the operation had been a continuous battle. The pain in my upper back reminded me that I was losing the fight.

Obese patients create more physical work for a surgeon during any type of procedure. The operations take longer, tie our upper body in knots and leave us with fatigue and frustration. Obese patients also automatically face an increased risk of complications like infection, pneumonia and blood clots during recovery.

If the difficulties posed by Mr. Baker's obesity weren't enough, he had been steadily losing blood during the procedure. His tissue reacted to the slightest graze with more bleeding.

Why does this guy have to bleed like this? As if it were his fault. Here I was blaming him, even though I was the one causing the bleeding. But in surgery, it always has to be someone else's fault. It's never the surgeon's fault.

Interestingly, after an operation, most surgeons tend to underestimate the amount of blood that was lost. Whether it's ego or denial, they can't help themselves.

The reality is that blood loss can be measured. Hospitals know which surgeons are losing blood, and how much, during every operation. They have data from their operating rooms, but the public cannot get access to this information. And this information matters, too. A large amount of blood lost during an operation can be a harbinger of complications to come.

Like poker players and their cards, surgeons are sometimes only as good as the patients they are dealt. Obesity, excessive scar tissue from a previous surgery in the same area, disease that is more advanced than anticipated—any one of these physiological conditions creates more work and a more difficult environment for the surgeon.

Even before the surgery begins, underlying or chronic conditions such as a history of hypertension, cardiac disease or lung disease put patients at risk for complications. Today, based on your medical history, surgeons can usually analyze, quite accurately, your risk of complications (or death) before setting foot in the operating room. All you have to do is ask.

I had no idea how bad Mr. Baker's colon disease would be until I opened him up and looked inside. It was a mess. If I were playing poker and this man's anatomy were the hand dealt, it would be time to fold.

"That is one of the ugliest pieces of colon I've ever seen." I grabbed the scrub nurse's hand. "See, touch that thing. Look how inflamed it is." When given the chance, scrub nurses love to touch organs in the operating room. "OK, don't poke it too hard, it will start to bleed again." Her hand drew back onto the instrument stand. I was in for a long night.

Tonight, the diseased colon on the menu was angry, cursing and taunting me: "Good luck, Mr. Big-Time Surgeon, trying to remove me." Surgeons frequently have conversations with the body parts or organs they are trying to remove. We also have conversations with ourselves; it's a way to blow off steam while our minds scramble to deal with the unexpected.

"By the time you are done with me, your back muscles are going to be in a heap of pain," the colon went on. "Looking forward to that drive home in your new Porsche? Well, too bad. It's going to have to wait. You better take your time or I'll come back to haunt you in a few days." I could hear the colon laughing at me. I was crying inside.

"Nurse, hand me a curved scissors." Finally, I was granted a little success in freeing up one end of the colon. But that was short-lived. More bleeding. I hate this. And I had cut myself. I stared at my finger. "Nurse, I need a new glove." The outer skin under my glove was breached, but not deeply.

"Almost got you," the colon said. I could not shut the thing up. "How do you know I don't have hepatitis or H.I.V.?"

Just great, I thought. Now I have something else to worry about.

"You're going to earn your fee tonight, Dr. Surgeon." The colon kept talking. "I hope you're not in this business for the money, like the last guy who operated on me. Between what Medicare pays you, the phone calls in the middle of night and the time you spend guiding my recovery, I figure you will make about $200 an hour for this operation. How does that grab you?"

Should have gone for my M.B.A., I mumbled to myself. Big mistake going into medicine, never mind surgery. If I could only go back and do it over again.

The colon's rant continued: "Wait, subtract what it costs you in overhead to bill for this operation (double that if the claim gets rejected), plus malpractice costs for the day, and we are now at $150 an hour. And how could I leave out the biggest expense of all? The price of the mental stress from worrying about me after the surgery (and double that if there's a complication). Now, I figure you're under $100 an hour. Plumbers make more than that just to step inside your house. I bet they sleep well at night. Just remember, Dr. Surgeon, nobody put a gun to your head. You chose this profession."

I could swear that the thing was laughing at me. "Forget about keeping those dinner reservations tonight. You and me, we're going for breakfast once this is over."

—Adapted from "Confessions of a Surgeon" by Paul A. Ruggieri, M.D. (Berkley Books).

http://online.wsj.com/article/SB10001424052970204720204577128481569245646.html?

On Being Ill - Virginia Woolf (1926) - Wikipedia

2012-01-01T11:42:00.001-05:00

"Considering how common illness is, how tremendous the spiritual change that it brings, how astonishing, when the lights of health go down, the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to light...it becomes strange indeed that illness has not taken its place with love, battle, and jealousy among the prime themes of literature. Novels, one would have thought, would have been devoted to influenza; epic poems to typhoid; odes to pneumonia, lyrics to toothache. But no; ... literature does its best to maintain that its concern is with the mind; that the body is a sheet of plain glass through which the soul looks straight and clear."

http://en.wikipedia.org/wiki/On_Being_Ill

The Fat Trap - NYTimes.com

2012-01-01T06:23:00.001-05:00

For 15 years, Joseph Proietto has been helping people lose weight. When these obese patients arrive at his weight-loss clinic in Australia, they are determined to slim down. And most of the time, he says, they do just that, sticking to the clinic's program and dropping excess pounds. But then, almost without exception, the weight begins to creep back. In a matter of months or years, the entire effort has come undone, and the patient is fat again. "It has always seemed strange to me," says Proietto, who is a physician at the University of Melbourne. "These are people who are very motivated to lose weight, who achieve weight loss most of the time without too much trouble and yet, inevitably, gradually, they regain the weight."

Anyone who has ever dieted knows that lost pounds often return, and most of us assume the reason is a lack of discipline or a failure of willpower. But Proietto suspected that there was more to it, and he decided to take a closer look at the biological state of the body after weight loss.

Beginning in 2009, he and his team recruited 50 obese men and women. The men weighed an average of 233 pounds; the women weighed about 200 pounds. Although some people dropped out of the study, most of the patients stuck with the extreme low-calorie diet, which consisted of special shakes called Optifast and two cups of low-starch vegetables, totaling just 500 to 550 calories a day for eight weeks. Ten weeks in, the dieters lost an average of 30 pounds.

At that point, the 34 patients who remained stopped dieting and began working to maintain the new lower weight. Nutritionists counseled them in person and by phone, promoting regular exercise and urging them to eat more vegetables and less fat. But despite the effort, they slowly began to put on weight. After a year, the patients already had regained an average of 11 of the pounds they struggled so hard to lose. They also reported feeling far more hungry and preoccupied with food than before they lost the weight.

While researchers have known for decades that the body undergoes various metabolic and hormonal changes while it's losing weight, the Australian team detected something new. A full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the "hunger hormone," was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome that set them apart from people who hadn't tried to lose weight in the first place.

"What we see here is a coordinated defense mechanism with multiple components all directed toward making us put on weight," Proietto says. "This, I think, explains the high failure rate in obesity treatment."

While the findings from Proietto and colleagues, published this fall in The New England Journal of Medicine, are not conclusive — the study was small and the findings need to be replicated — the research has nonetheless caused a stir in the weight-loss community, adding to a growing body of evidence that challenges conventional thinking about obesity, weight loss and willpower. For years, the advice to the overweight and obese has been that we simply need to eat less and exercise more. While there is truth to this guidance, it fails to take into account that the human body continues to fight against weight loss long after dieting has stopped. This translates into a sobering reality: once we become fat, most of us, despite our best efforts, will probably stay fat.

More ...

http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=print

Durezol And Durasal, Don't Get Them Mixed Up, FDA Warns - MedWatch

2011-12-29T22:25:00.001-05:00

Eye drug Durezol (difluprednate ophthalmic emulsion) and wart remover Durasal (salicylic acid) may sound similar, but getting them mixed up can happen, and with potentially serious consequences, the Food and Drug

Durezol is prescribed for patients with inflammation linked to eye surgery.

The FDA informs that it has received several reports of Durezol and Durasal mix-ups. Fortunately, the mistakes were spotted before the patient received their prescriptions in most cases.

The FDA adds that health care professionals have complained about the names of the two drugs, saying they sound too similar, and worry about potential medical errors.

Pharmacists should be especially vigilant when filling Durezol prescriptions, the Agency adds. The risk of injury is much greater if an eye-surgery patient gets the wart remover, than the other way round. Even so, errors in either direction should be avoided.

When drugs are submitted to the FDA for approval, the Agency carefully screens their proprietary names for similarities. However, Durasal (salicylic acid) is an OTC medication that did not undergo the approval process. That is why the two names exist side-by-side in the pharmacies.

Durasal came onto the market not long after the FDA approved Durezol.

The FDA has written to Elorac Inc. regarding removing Durasal from the market. Elorac has not responded, neither has it issued any kind of recall.

Pharmacists, doctors, other healthcare professionals and patients should check the drug's packaging and label information carefully.

Any medications that appear to have a potential for confusion regarding their names should be reported to theFDA's MedWatch Safety Information and Adverse Event Reporting program. Patients and doctors should also report any side effects linked to Durezol or Durasal usage to MedWatch.

http://www.medicalnewstoday.com/articles/239767.php

Chocolate bar for lunch? Is this an ‘occupational hazard’? - The Globe and Mail

2011-12-29T07:23:00.001-05:00

You're working late, and eating dinner from a vending machine yet again.

Could your diet of Twinkies and Cheetos be a job hazard?

If you're a shift worker, it could well be, according to the medical journal PLoS Medicine.

An editorial in this month's issue of the journal makes a case for thinking about unhealthy eating as a new occupational health hazard. It highlights research that shows an association between shift work and an increased risk of type 2 diabetes.

While a disruption of circadian rhythms (which regulate one's metabolism) and a negative impact on sleep are contributing factors, workers' eating patterns "are obvious targets for intervention," the editorial says.

According to a press release, "Shift work is notoriously associated with poor patterns of eating, which is exacerbated by easier access to junk food compared with more healthy options."

The editorial points out that shift work is expected to become more common as the realm of work increasingly extends around the clock. And shift work, it says, has the potential to speed up the progression of the global epidemic of obesity and diabetes.

The editorial notes that employers and legislators have taken steps to reduce workers' exposure to tobacco smoke, suggesting they should tackle unhealthy eating in a similar manner, and make it easier and cheaper for workers to eat well. One workplace, the Cleveland Clinic, has taken a lead in this area, it says.

In an effort to keep health-care costs in check, the Cleveland Clinic in Ohio took a hard line to improve the health of its employees, The Washington Post reported earlier this year. It fired physicians who refused to quit smoking. It eliminated almost all fried foods, sugary sodas and trans fats from its campus. It offered free fitness and stress-management classes to its workers. And it began keeping track of its employees' blood pressure, lipids, blood sugar, weight and smoking habits. If any of these are "abnormal," the clinic requires that a doctor certify that the employee is taking measures to control them or else they don't receive an insurance rebate.

http://www.theglobeandmail.com/life/the-hot-button/chocolate-bar-for-lunch-is-this-an-occupational-hazard/article2285453/?cmpid=nl-news1

A young woman struggles with oxy addiction and recovery - Tampa Bay Times

2011-12-28T20:17:00.001-05:00

ST. PETERSBURG, Florida

When her mom came to pick her up for drug court that morning, Stacy Nicholson was still high.

She staggered to the door, fumbled with the bungee cord that kept it closed, blinked back the sunlight.

"You ready?" asked her mom.

Stacy and two of her cousins had been holed up for months in this rundown house, shooting crushed-up pain pills. Used syringes littered an end table. Stacy's mom had kept telling her: Someone in this house is going to die.

Stacy, then 28, knew she was right. Days before, she had told her mom she was tired of stealing and doctor shopping to get pills. She was in trouble for skipping her last court date, so today, she planned to turn herself in.

"Okay," Stacy said. "Let's go."

She twisted her long, honey-colored hair into a knot. Zipped her sweatshirt. Underneath, she was wearing two bras, a tank top, two white T-shirts and three pairs of panties.

She wanted to be sure she would have a change of underwear in jail.

COURTROOM 10 WAS PACKED when Stacy and her mom, Sherry Alkire, slid into the back row. It was Feb. 1, a Tuesday.

More than 100 women, most 20 to 40 years old, filled the wooden benches. Some were visibly pregnant. Others trailed toddlers. Many of the women struggled to hold up their heads.

Just before 9 a.m., a thin, chestnut-haired woman in a black robe strode through the back door. "All rise!" called the bailiff. "The honorable Judge Dee Anna Farnell presiding."

The judge raised her arms and smiled. "Welcome to Ladies' Day," she said. America's first all-female drug court was in session.

Soon the judge called Stacy's name. Stacy slouched down the aisle, clasped her hands behind her back and hung her head.

Eighteen months earlier, she had been arrested for using a fake prescription to buy oxycodone, the painkiller she had been snorting or shooting for four years. The charge carried a possible five-year prison sentence.

The judge had offered a deal: Plead guilty and go on probation. If you go through rehab, if you go to 12-step meetings and get a job and stay sober, you can stay out of jail — and have your felony record wiped clean.

For a while, Stacy had tried. But then she failed a drug test, stopped going to counseling, started skipping court. Now she faced a sentence of 10 years instead of five.

The judge could send her to a long-term treatment facility or halfway house. Or she could put her in prison for violating her probation.

Farnell asked Stacy about her children. Stacy said her 12-year-old daughter had been staying with her paternal grandparents for almost a year. Her mom was taking care of her 2-year-old son.

"What are you going to test positive for today?" asked the judge.

Stacy shuffled her Air Jordan slides. "Well, I've been smoking and drinking. So marijuana and alcohol." She paused. "And benzos. And maybe …"

The judge shook her head. "Okay," she said. "What do you want to do? Do you want to opt out? Or keep trying?"

Stacy wanted what a lot of addicts want: to get clean, but also to get high. She wanted to have her kids back, but also to have no responsibility. She wanted to feel better, and to feel nothing.

She wiped her nose on her shoulder, looked up and said, "I want to keep trying."

PRESCRIPTION DRUG abuse kills 40 Americans every day. That's more than a threefold increase in the last decade, according to the U.S. Centers for Disease Control and Prevention.

Oxycodone is the deadliest drug of all. An opiate found in such painkillers as OxyContin and Percocet, it's prescribed after surgeries and car wrecks, and to people in chronic pain.

Others take it just for the high. The drug works by blocking the spinal cord's pain receptors. It doesn't make the pain go away, but prevents people from feeling it, creating a sense of euphoria. Soon, they need to take more to get the same pleasurable escape.

Oxy makes junkies out of people who would never buy from a street dealer. It is everyman's high, heroin in a pill.

Of all the oxycodone prescribed in America in the first half of last year, 98 percent was dispensed in Florida. According to the state medical examiner's office, an average of seven Floridians die from prescription drug overdoses every day — more than from car accidents.

In recent years, Pinellas has lost more people to prescription drugs than any other county in the state — 249 just last year. That's an increase of 60 over the year before.

"Everyone knows someone who has gone through this addiction and you just feel so helpless. It's a horrible, vicious disease," said Pinellas County sheriff's spokeswoman Marianne Pasha.

"These aren't Dumpster-diving drug addicts," she said. "These people are getting their pills from doctors. It's the person in line beside you at Publix, the woman next to you in the pew at church."

A few years ago, drug court Judge Farnell started seeing more and more women charged with prescription drug abuse. By 2009, almost half of her drug court defendants were women.

That year, Pinellas County received a $900,000, three-year federal grant to fund substance abuse treatment for women in drug court.

That's how Tuesdays became "Ladies' Day."

Instead of punishing the women, the judge offers them a chance to start over. They come to court once a month. She creates incentives for them: Do yoga, run a 5K, quit smoking, and we'll waive your $52 monthly probation fee. She makes sure they know how to get a bus pass. If she gets a bad vibe about a boyfriend, she'll order a woman to steer clear of him.

She tells defendants, "You can do this. It's going to be hard. But it will be worth it."

When a woman slips, the judge scolds her and sends her back to jail to detox. Then she offers another chance.

About 500 defendants came to court on Ladies' Days this year. St. Petersburg Times journalists attended week after week. They interviewed dozens of women. They followed addicts as they bounced between jail and treatment, stayed in abandoned houses, looked for jobs and stumbled toward recovery or relapse.

One woman let the journalists follow her all year.

Stacy Nicholson grew up in St. Petersburg. A streetwise, Southern-fried tomboy, she loves the Florida Gators, Chevy pickups, Lil Wayne and Toby Keith. She believes in dream catchers and her Gemini horoscope, craves Cocoa Puffs and smokes Newports. She never wears makeup, always spritzes on Victoria's Secret body spray. When it comes to men, she likes the smell of trouble.

Her history of drug use and dysfunction stretches back to puberty. She tried marijuana at 13 and alcohol at 14, had her first baby at 16 and her second, with a different man, at 27.

But the pursuit of the oxy buzz erased any chance of a productive life.

For addicts, using quickly becomes a necessity, not a choice. Getting the next pill becomes more important than work, friends, family, even food. The addict's values shift to justify whatever it takes to get more oxys. Hard workers can no longer hold jobs. Smart students drop out. Good moms neglect their kids, drain their bank accounts, steal from family members.

If addicts stop using, they suffer horrible symptoms: vomiting, headaches, intense bone pain. That's why many are afraid to even try to get sober. They need to stay high so they don't crash.

After Stacy got hooked, she lost her personality, spark, motivation. Every new boyfriend was a red flag, but she never saw it. She dragged her kids from bad apartments to cheap motel rooms, and finally gave them up.

In Judge Farnell's court in February, Stacy entered what everyone agreed was a fight for her life. She could get better, or she could become one of Florida's seven a day.

She had a lot going for her: a mother who supported her even after all the times Stacy had broken her heart. Two children who desperately needed her love and attention. A treatment program backed by almost $1 million in taxpayer money. Drug counselors who wanted her to succeed. Other recovering addicts eager to share their experiences at 12-step meetings. An empathetic judge who was willing to give Stacy chance after chance, if only she would try.

Working against her: a little blue pill and Stacy's need to numb herself with it.

More ...

http://www.tampabay.com/features/humaninterest/article1206405.ece

The High Cost of Failing Artificial Hips - NYTimes.com

2011-12-28T07:14:00.001-05:00

The most widespread medical implant failure in decades — involving thousands of all-metal artificial hips that need to be replaced prematurely — has entered the money phase.

Medical and legal experts estimate the hip failures may cost taxpayers, insurers, employers and others billions of dollars in coming years, contributing to the soaring cost of health care. The financial fallout is expected to be unusually large and complex because the episode involves a class of products, not a single device or just one company.

The case of Thomas Dougherty represents one particularly costly example. He spent five months this year without a left hip, largely stuck on a recliner watching his medical bills soar.

In August, Mr. Dougherty underwent an operation to replace a failed artificial hip, but his pelvis fractured soon afterward. The replacement hip was abandoned and then a serious infection set in. Some of the bills: $400,776 in charges related to hospitalizations, and $28,081 in doctors' bills.

"I'm sitting here on a La-Z-Boy meant for someone who is 80 and I'm 55," said Mr. Dougherty, who lives in Groveland, Ill., and works at Caterpillar, the heavy equipment manufacturer. His bills are "five times as much" as he paid for his home.

The so-called metal-on-metal hips like Mr. Dougherty's, ones in which a device's ball and joint are made of metal, are failing at high rates within a few years instead of lasting 15 years or more, as artificial joints normally do. The wear of metal parts against each other is generating debris that is damaging tissue and, in some cases, crippling patients.

The incidents have set off a financial scramble. Recently, lawsuits and complaints against makers of all-metal replacement hips passed the 5,000 mark. Insurers are alerting patients that they plan to recover their expenses from any settlement money that patients receive.Medicare is also expected to try to recover its costs.

While his insurer has covered his bills so far, Mr. Dougherty said he was preparing to sue his surgeon, who may have implanted the device incorrectly, and Johnson & Johnson, which produced his artificial hip, to help recoup some of the insurer's money.

"All these payers want to be paid back," said Matt Garretson, the founding partner of the Garretson Resolution Group, a firm in Cincinnati that manages product liability cases.

Until a recent sharp decline, all-metal implants accounted for nearly one-third of the estimated 250,000 hip replacements performed each year in the United States. Some 500,000 patients have received an all-metal replacement hip, according to one estimate. A new study found that no new artificial hip or knee introduced during a recent five-year period — implants that included some of the all-metal hips — were more durable than older devices, and 30 percent were worse.

One troubled all-metal model, implanted in 40,000 patients in the United States, was recalled last year by the DePuy division of Johnson & Johnson. As of October, some 3,500 patients had filed a lawsuit involving that device.

There is no data on the number of all-metal hips that have failed prematurely in this country because the outcomes of orthopedic procedures are not formally tracked by the government or private companies.

But extrapolating from overseas data and the estimate of metal hip use here, tens of thousands of patients in the United States may have to undergo operations over the next decade to replace the implants, said Dr. Art Sedrakyan, a researcher at Weill Cornell Medical College of Cornell University, who is studying the hip problem.

A decade ago, Sulzer Orthopedics paid a record $1 billion to settle claims by 6,800 patients who received artificial hips and knees that were contaminated with industrial oil during the manufacturing process. "We have been dwarfed by this," said Teresa Ford, a lawyer who worked at Sulzer at the time and is now in private practice.

Device producers have taken differing stances to covering patient expenses. Zimmer Holdings, which says its all-metal implants are safe, has settled hundreds of patient claims, lawyers involved in those cases say. Also, DePuy is covering costs related to the device it recalled last year, the A.S.R., or Articular Surface Replacement.

DePuy would not comment on how much it had paid in recall-related costs. But a spokeswoman, Mindy Tinsley, said in a statement that DePuy was working with patients and insurers.

Things have not gone smoothly for everyone who has taken DePuy's payment offer. One patient, Paula Laverty, received a hospital bill for $41,578 and a call from the facility warning her that the bill would be turned over soon to a collection agency.

Ms. Laverty, of Cape Elizabeth, Me., said she spent weeks calling the firm handling claims related to DePuy's A.S.R. She said she eventually learned that the implant maker had paid the hospital $18,000 for her replacement procedure and that the $41,578 represented the remaining charges.

This month, DePuy made an additional payment to the hospital, according to Ms. Tinsley, the company spokeswoman.

Along with A.S.R.-related cases, DePuy also faces over 560 lawsuits in connection with the all-metal version of another hip model, called the Pinnacle, the device that Mr. Dougherty received. Because the company says that the model is performing well, costs for its replacement are being borne by Medicare, insurers or patients themselves.

To recoup their expenses, insurers typically notify patients through lawyers that they expect to be reimbursed from any settlement money that patients receive, rather than pursue their own lawsuits with the device makers. Also, Medicare is expected to enforce new laws next year that will make it easier for the agency to recover taxpayer dollars spent treating patients injured by problem drugs and medical devices, legal experts said.

Still, some patients are weathering some of the financial impacts on their own. While Charmin McCune, a teacher in Wylie, Tex., is recuperating well from a recent replacement operation, she said that she and her husband, also a teacher, have had more than $12,000 in expenses that have not been covered by insurance.

Mr. Dougherty, the Illinois patient, underwent a procedure this month to get a new hip implant. All went well, he said, so he hopes to spend next year back on his feet and at work.

"You can't do anything," he said of his current situation. "You see your wife doing everything for you. It is just not right."

http://www.nytimes.com/2011/12/28/business/the-high-cost-of-failing-artificial-hips.html?_r=1&nl=todaysheadlines&emc=tha2&pagewanted=print

Robert Ader, Who Linked Stress and Illness, Dies at 79 - NYTimes.com

2011-12-26T11:58:00.001-05:00

Dr. Robert Ader, an experimental psychologist who was among the first scientists to show how mental processes influence the body's immune system, a finding that changed modern medicine, died on Tuesday in Pittsford, N.Y. He was 79.

His death followed a long illness and complications of a fracture suffered in a fall, his daughter Deborah Ader said.

Dr. Ader, who spent his entire career as a professor of psychiatry and psychology at the University of Rochester School of Medicine and Dentistry, conducted some of the original experiments in a field he named himself, psychoneuroimmunology.

His initial research, in the 1970s, became a touchstone for studies that have since mapped the vast communications network among immune cells, hormones and neurotransmitters. It introduced a field of research that nailed down the science behind notions once considered magical thinking: that meditation helps reduce arterial plaque; that social bonds improve cancer survival; that people under stress catch more colds; and that placebos work not only on the human mind but also on supposedly insentient cells.

At the core of Dr. Ader's breakthrough research was an insight already obvious to any grandmother who ever said, "Stop worrying or you'll make yourself sick." He demonstrated scientifically that stress worsens illness — sometimes even triggering it — and that reducing stress is essential to health care.

That idea, now widely accepted among medical researchers, contradicted a previous principle of biochemistry, which said that the immune system was autonomous. As late as 1985, the idea of a connection between the brain and the immune system was dismissed in an editorial in The New England Journal of Medicine as "folklore."

"Today there is not a physician in the country who does not accept the science Bob Ader set in motion," said Dr. Bruce Rabin, founder of the Brain, Behavior and Immunity Center at the University of Pittsburgh Medical Center, who considered Dr. Ader a mentor. "He attracted interest in the field and made it possible to prove that 'mind-body' is real."

Dr. Ader said his breakthrough began in 1975 with what he called "scientific serendipity."

He and a fellow researcher, Dr. Nicholas Cohen, were conducting an unrelated experiment about taste aversion involving rats and saccharine-sweetened water when they stumbled on a mysterious phenomenon.

In the experiment, one group of rats was given sweetened water accompanied by an injection that caused stomach aches. (A control group got only the sweetened water.) When the injections stopped, and the rats that had experienced stomach aches refused to drink the water, researchers force-fed them with eye-droppers in order to complete the experiment's protocols.

Dr. Ader and Dr. Cohen had expected the conditioned rats to refuse the drink. They had not anticipated that forcing them to drink would eventually kill them, however, which it did, some time afterward.

The two reviewed their protocols and guessed that the drugs used in the injections might have had some bearing on the deaths. They could have used any drug that caused stomach pain without doing serious harm. But the researchers discovered that they had unwittingly picked Cytoxan, which besides causing stomach aches suppresses the immune system. At first they suspected that the rats had died from an overdose of Cytoxan. Then they determined that the dosage the rats received had been too low to support that explanation.

So they developed a theory, which became a landmark of medical science as further experiments proved it correct: The rats died because the mere taste of saccharine-laced water was enough to trigger neurological signals that did indeed suppress their immune systems — exactly as if they had been overdosed with Cytoxan. The rats succumbed to bacterial and viral infections they were unable to fight off. It was an example of the so-called placebo effect, only in this case it did not fool the brain into thinking it had been given something beneficial but rather the opposite.

The findings were "incontrovertible," Anne Harrington, a Harvard professor of the history of science, wrote in the 1997 book "The Placebo Effect."

"The fact that he had achieved this in rats rather than humans was a further blockbuster," she continued, "because it undermined the frequent assumption that placebo effects were a product of peculiarly human interpersonal processes."

Robert Ader was born on Feb. 20, 1932, in the Bronx, the older of two sons of Mae and Nathan Ader. His father, who owned a liquor wholesale company, died in a car accident in 1945 when Robert was a teenager. After graduating from the private Horace Mann School in the Riverdale section of the Bronx, he received his bachelor's degree from Tulane University and, in 1957, his Ph.D. in psychology from Cornell.

Soon after, he became an assistant professor in the department of psychology at the University of Rochester, where he went on to hold many teaching and research posts. He retired in July as a professor emeritus of psychosocial medicine.

Besides his daughter Deborah, he is survived by his wife, Gayle; three other daughters, Janet, Rini and Leslie Ader; and a grandson.

Since he inaugurated the study of psychoneuroimmunology (usually referred to as PNI), Dr. Ader had to defend its premise against doubters in the medical establishment and later to disassociate it from New Age therapies that he called "flaky" because they had not been grounded in solid scientific experimentation.

Deborah Ader, a psychology researcher, said a sense of modesty had been at the core of her father's curiosity as a scientist.

"My father used to say, 'I just didn't know any better,' " she said, recounting how he had described his pioneering research.

He told her, she recalled, "I didn't know the immune system wasn't supposed to be connected to the brain."

http://www.nytimes.com/2011/12/26/science/robert-ader-who-linked-stress-and-illness-dies-at-79.html?pagewanted=print

Affluent Children Are More Physically Fit Than Poor Ones - NYTimes.com

2011-12-26T06:30:00.001-05:00

Every Monday, Sycamore Valley Elementary in Danville challenges its students to run a "Smile Mile" together after school. Some parents even run with their children. Photos of the student joggers' grinning faces are posted in the cafeteria. On a recent Monday afternoon, there were 41 smiling faces on the wall.

Students at Sycamore Valley have a lot to be happy about when it comes to their physical fitness. Fifth graders there got the best scores among all of their Bay Area peers on the 2011 statewide Physical Fitness Test.

Eighty-three percent of the fifth graders tested at Sycamore Valley aced the test by receiving healthy scores on all six different measurements — of aerobic capacity, abdominal strength, upper body strength, trunk strength, body composition and flexibility, most of them gauged through physical activity. One part of the Physical Fitness Test measures a child's body composition, usually through body mass index, which is calculated using weight and height and is used to determine who is overweight.

Statewide, only 31 percent of public school students performed as well, according to the California Department of Education.

An analysis of state data by The Bay Citizen revealed a large variation in how fifth graders in Bay Area elementary schools perform on the test. The schools that performed the best have few students from low-income families, for reasons that experts say are not surprising. At Sycamore Valley Elementary, in an affluent suburban community, not a single student was eligible to receive a free or reduced-price lunch because of low family income last year, according to the state's data.

Across the Bay, in San Francisco's Mission district, none of the fifth graders at Cesar Chavez Elementary School received six healthy scores on the test. More than a quarter of them were found to "need improvement" on every measure of fitness.

At Cesar Chavez, where Spanish is the first language for many, more than 85 percent of the students are eligible to receive free or reduced-price school lunches. In the school district that includes Cesar Chavez, Hispanic and black students are less likely to receive healthy scores than their Asian and white peers, the state data show.

Students at Sycamore Elementary have a dedicated "physical education specialist" on campus to help them train for the test. Those at Cesar Chavez do not.

"There is an inequity problem with the availability of quality physical education between schools of varying socioeconomic status," said Drisha Leggitt, executive director of the California Association for Health, Physical Education, Recreation and Dance, a nonprofit organization.

Robert O'Brien, Sycamore Valley's physical education specialist, who favors shorts even when the temperature dips into the 40s, is fond of slogans like "exercise, not extra fries." He leads students as young as 6 in sit-ups, jumping jacks, push-ups and running, striving to get all of them moving, while giving their classroom teachers time to prepare other lessons.

All 21 of the elementary schools in the San Ramon Valley Unified School District, in which Sycamore Valley is located, have a physical education specialist like Mr. O'Brien.

"Having dedicated physical education teachers can make a big difference in students' performance on the test," said Linda Hooper, an education, research and evaluation consultant for the California Department of Education.

The San Francisco Unified School District has just 15 physical education specialists for all 76 of its elementary schools. Spread thin, they work with about half the schools at any time. According to Michelle Zapata, the physical education program administrator for the district, Cesar Chavez was among the 38 schools that had no physical education specialist on campus.

Advocates for child health warn that failing to teach children how to be active and healthy will have long-term consequences.

"It comes as no surprise whatsoever that such enormous inequities would be present," said Dr. Harold Goldstein, executive director of the California Center for Public Health Advocacy, a nonprofit organization. "It is grossly unjust and will have health and economic impacts on the state of California for generations to come."

Sycamore Valley Elementary maintains a focus on health outside of physical education class time. Parents are not allowed to bring in cupcakes or other potentially fattening treats to celebrate birthdays. Instead, gifts of pencils or erasers to classmates are substituted.

Parents also contribute financially. Fund-raising pays for a twice-a-week movement class for kindergarteners that is not required by the state. In the fall, the school's Parent Teacher Association gave Mr. O'Brien a $375 grant to buy new basketball hoops, and he also leads an after-school sports camp that helps raise money to buy sports equipment.

Each fall, the PTA holds a "fun run" fund-raiser, in which students are sponsored to run laps during school. It raised nearly $10,000 this year.

Even the school's location supports fitness. It is next to a park, near a sweeping open space of rolling hills dotted with oaks. The park features a play structure, a basketball court, a bocce court and athletic fields, where Mr. O'Brien sometimes holds physical education lessons.

Many elementary school students in the suburbs also play sports outside school, including basketball and lacrosse.

Rebecca Adams, president of the Sycamore Valley Elementary PTA, said her children, who are in the first and third grades, participate in indoor soccer, swimming, gymnastics, baseball and softball, depending on the season.

Not all their activities are organized by adults. "A lot of kids play outside in their front yard," said Ms. Adams, who lives less than a mile from the school. In-line skating, biking and tag are popular.

"My kids play outside all the time," she said.

At Cesar Chavez Elementary School, physical education lessons, taught by classroom teachers, are held on a fenced-in blacktop lot below a huge, colorful mural of the school's namesake. In the mural, Mr. Chavez, the late civil rights leader, is surrounded by a crowd of children as he carries a banner that reads "Help me take responsibility for my own life so I can be free at last."

On the urban school's blacktop, the basketball rims have no nets. "We don't have a field or a park next door," said Catalina Rico, the school's principal.

Most of the students' parents, many of whom are immigrants, cannot give extra money to help beef up its programs. Some families are homeless, and many others are struggling financially.

"A lot of our kids have been traumatized by poverty, violence, their parents being deported," Ms. Rico said.

For those families, regular exercise in a safe place after school may be out of reach.

If parents are working two jobs, Ms. Rico said, "who is going to take them to the park?"

http://www.nytimes.com/2011/12/25/us/affluent-children-are-more-physically-fit-than-poor-ones.html?hpw=&pagewanted=print

Opting to track, not treat, early prostate cancer | Lubbock Avalanche-Journal

2011-12-22T22:05:00.001-05:00

WASHINGTON — John Shoemaker visited six doctors in his quest to find the best treatment for his early stage prostate cancer — and only the last one offered what made the most sense to the California man: Keep a close watch on the tumor and treat only if it starts to grow.

Very few men choose this active surveillance option. Yet Shoemaker is one of more than 100,000 men a year deemed candidates for it by a government panel. That's because their prostate cancer carries such a low risk of morphing into the kind that could kill.

The risk for them is so low, in fact, that specialists convened recently by the National Institutes of Health say it's time to strip the name "cancer" off these small, lazy tumors.

In the meantime, the panel wants more of those men offered the option of delaying treatment until regular check-ups show it's really needed. That endorsement promises to fuel efforts by the Prostate Cancer Foundation and a few other groups to spread the word to the newly diagnosed.

Shoemaker's journey shows how difficult that may be, from doctors who don't even bring it up to the fear factor.

"With prostate cancer, you hear the "C'' word, so to speak, and people freak out," says Shoemaker, 69, a businessman from Los Altos, Calif., who was intent on examining all his options.

Five years after his diagnosis — and five biopsies plus numerous blood tests and ultrasound scans later — Shoemaker's happy he found a surgeon who argued against immediate treatment. He's confident his prostate tumor hasn't grown, and avoided the pain and side effects of surgery or radiation.

Some 240,000 men a year in the U.S. are diagnosed with prostate cancer.

Earlier this month, the NIH-appointed panel found that most have the low-risk kind, a legacy of using problematic PSA blood tests to screen healthy men for possible signs of this slow-growing cancer that will affect most men's prostates if they live long enough.

Yet 90 percent of such men choose immediate treatment such as surgery or radiation, risking serious and long-lasting side effects, such as impotence or incontinence, without good evidence about who will live longer as a result. One recent study tracked 731 men diagnosed with early stage prostate cancer for 10 years and found no difference in survival between those who had surgery and those who weren't treated unless they went on to develop cancer symptoms, an older option known as watchful waiting.

Active surveillance is much more aggressive than watchful waiting — men get regular scans, blood tests and biopsies to check the tumor, although the NIH panel found the degree of monitoring can vary by medical center. Active surveillance is designed to monitor men closely enough that they can get curative treatment quickly if it looks like they'll need it, well before any symptoms would begin.

"It's not treatment versus no treatment; it's about timing of treatment," Shoemaker's physician, Dr. Peter Carroll of the University of California, San Francisco, told the NIH. He's a well-known prostate cancer surgeon who also leads one of the country's few large active-surveillance programs, tracking more than 900 men for over five years. Most are treatment-free so far, and none has gone on to die of prostate cancer.

What's the advice for men? The NIH panel said men with a PSA level less than 10 and a Gleason score that's 6 or less are candidates for this type of active surveillance. The Gleason score measures how aggressive prostate cancer cells look under the microscope. Urologists can provide those numbers.

Then what? Today, what men decide to do next largely depends on the advice of the specialist they wind up seeing, and many either don't offer active surveillance or present it in a negative way, as doing nothing, the NIH panel learned. There's also the patient's instinctive "get it out" reaction.

Enter the National Proactive Surveillance Network — at http://www.npsn.net — a collaboration of two large active-surveillance programs, at Johns Hopkins University and Cedars-Sinai Medical Center, with the Prostate Cancer Foundation. First, it aims to educate men about active surveillance.

Within a few months, an interactive section of the site will be added to link men with doctors who offer active surveillance and track how they fare with input straight from the patients themselves, said Hopkins' Dr. H. Ballentine Carter.

"To me, it's an individualized approach rather than the one-size-fits-all approach of treating everyone," Carter says.

Beyond whether and how men choose surveillance, behavioral scientist Kathryn Taylor of Georgetown University wants to know how they decide to stick with it. About a quarter of men abandon the observation approach within two or three years, and as many as half by five years, the NIH panel learned. It's not clear how much of that was because they needed treatment, and how much was just the anxiety or getting tired of repeat biopsies.

Taylor is beginning a study of 1,500 newly diagnosed, low-risk prostate cancer patients at Kaiser Permanente in Northern California to see how many are told about active surveillance and what helped or hindered their decision.

"Living with untreated cancer is very difficult," she says, "and not everybody can do it, not surprisingly."

http://lubbockonline.com/health/2011-12-20/opting-track-not-treat-early-prostate-cancer#

Doctor and Patient: A Medical School More Like Hogwarts - NYTimes.com

2011-12-22T20:00:00.001-05:00

It's been clear for several years now that while aspiring doctors may start medical school as happy and as healthy as their non-doctoring peers, four years later they aren't.

More than 20 percent end up with depression, more than half suffer from burnout, and in any given year, as many as 11 percent contemplate suicide. All of these statistics, of course, bode poorly for patients. Doctors who are burned out are more likely to make errors and to lose sight of the altruism that led them to go into medicine in the first place.

Fortunately, the subtext of this growing body of data — that there is something toxic about the medical education process — has not been lost on the educators who run this country's medical schools. Some have hired mental health experts for their institutions, created counseling centers and set up confidential Web sites and hot lines; others have developed elective courses in meditation and mindfulness, switched from letter grades to pass-fail systems and revamped class schedules to foster better work-life balance.

Despite the good intentions, their efforts continue to be stymied by one thing: Students aren't participating. As one educator recently told me, "I keep seeing the same 10 students at all these events, and I'm not even sure they're the ones we need to be reaching."

But one medical school, Vanderbilt, in Nashville, appears to be succeeding, with a Student Wellness Program that includes activities like yoga classes, community service events, healthy cooking classes, forums on nutrition and sleep, and a mentoring program that pairs senior students with newer ones. The key to its success? Empowering and partnering with those who have the most at stake — the medical students themselves.

Aside from an annual daylong retreat and a weekly medical humanities course, "most of the ideas are generated by the students themselves," said Dr. Scott M. Rodgers, the associate dean of medical student affairs, who started the program with a group of students six years ago and continues to be its guiding force. "We just try to come up with any necessary money."

One example of this unique collaboration is the program's college system, which assigns students to one of four "colleges," each with its own set of faculty advisers. Instituted nearly five years ago and intended simply as an improvement over a traditional but more random advising program, the new system was also set up in a way that allowed Vanderbilt students to introduce innovations.

They ran with it. Drawing on cultural cues that resonated with their peers — in this case the Harry Potter stories — they took an active role in naming the colleges after former medical school deans and imbued each with a particular personality. Completing the picture were artfully designed crests, designated college colors and devised mottos in Latin that range from the more noble ("Primus Inter Pares," or "First Among Equals") to the tongue-in-cheek put-down ("Commodum Habitus Es," or "You Have Just Been Owned").

As college loyalties began to develop, students organized friendly competitions that promoted healthy habits and community service. These events culminated four years ago in the first College Cup, a now annual weekend affair where pride runs deep. Amid bagpipes and a marching band, colleges vie to outdo one another in events like a 5-K run, an "Iron Chef"-style cooking competition and a trivia contest.

"These programs keep you from putting your whole self-worth on the next exam," said Kathleen Weber, a first-year student who was also quick to point out the superiority of her own college, Batson.

There are critics, however, who charge that with so much to learn in so little time, medical students — and their future patients — would be better served if they expended more, not less, effort on studies. Others have voiced concern that students end up feeling a "reverse pressure" to choose extracurricular activities over studying.

But proponents are quick to counter that medical students in general aren't people who must be persuaded to study. What they need is encouragement to balance academic dedication with the self-care that will sustain them in the long run. "You can't keep running on fumes," said Dr. Johanna N. Riesel, a former medical student at Vanderbilt now in her second year of surgical training at Massachusetts General Hospital in Boston. "You have to learn how to maintain some sense of equilibrium and sanity in a relatively insane process."

While no one yet knows the long-term effect of Vanderbilt's innovations – or, for that matter, of any programs designed to promote "wellness" — Dr. Rodgers and his colleagues and students at Vanderbilt remain committed to their initiatives. For them, the implications of medical student depression and burnout are simply too important to ignore.

"It's a challenge for anyone to stay healthy and happy," Dr. Rodgers said. "But when doctors are able to stay healthy and happy, that means patients get physicians who are more compassionate and selfless. They end up with doctors who really have the energy to invest time in them."

http://well.blogs.nytimes.com/2011/12/22/a-medical-school-more-like-hogwarts/?pagemode=print

Close to Home

2011-12-20T10:24:00.001-05:00

As Patient Records Are Digitized, Data Breaches Are on the Rise - NYTimes.com

2011-12-20T05:26:00.001-05:00

One afternoon last spring, Micky Tripathi received a panicked call from an employee. Someone had broken into his car and stolen his briefcase and company laptop along with it.

So began a nightmare that cost Mr. Tripathi's small nonprofit health consultancy nearly $300,000 in legal, private investigation, credit monitoring and media consultancy fees. Not to mention 600 hours dealing with the fallout and the intangible cost of repairing the reputational damage that followed.

Mr. Tripathi's nonprofit, the Massachusetts eHealth Collaborative in Waltham, Mass., works with doctors and hospitals to help digitize their patient records. His employee's stolen laptop contained unencrypted records for some 13,687 patients — each record containing some combination of a patient's name, Social Security number, birth date, contact information and insurance information — an identity theft gold mine.

His experience was hardly uncommon. As part of the 2009 stimulus bill, the federal government provides incentive payments to doctors and hospitals to adopt electronic health records. Some 57 percent of office-based physicians now use electronic health records, a 12 percent jump from last year, according to the Centers for Disease Control.

An unintended consequence is that as patient records have been digitized, health data breaches have surged. The number of reported breaches is up 32 percent this year from last year, according to the Ponemon Institute, a security research group. Those breaches cost the industry an estimated $6.5 billion last year. In almost half the cases, a lost or stolen phone or personal computer was responsible.

In a blog post, Mr. Tripathi describes the days after the theft as a "vortex." Fresh in his mind was a similar, albeit smaller, breach at Massachusetts General Hospital just months earlier in which a hospital employee left detailed clinical records for 192 patients on a subway. The breach had cost the hospital $1 million in settlement fees.

"We're a nonprofit with 35 people on staff," says Mr. Tripathi. "A million-dollar fine would have decimated us."

Mr. Tripathi says his nonprofit had just enacted a policy requiring that all patient files be encrypted, but had yet to decide on an encryption provider. All that stood between a determined computer thief and his patient data was a few passwords.

Mr. Tripathi went to work assembling a crisis team of lawyers and customers and a chief security officer. They hired a private investigator to scour local pawnshops and Craigslist for the stolen laptop. The biggest headache, he says, was deciphering how much about the breach his nonprofit needed to disclose.

Health organizations are required by federal law to report data breaches that affect more than 500 people to the Department of Health and Human Services. The department's Office of Civil Rights publishes the equivalent of a data breach "Wall of Shame" on its Web site — which today includes 380 breaches affecting more than 18 million people.

Mr. Tripathi said he quickly discovered just how many ways there were to count to 500. The law requires disclosure only in cases that "pose a significant risk of financial, reputational or other harm to the individual affected." His team spent hours poring over a backup of the stolen laptop files. Of the nearly 14,000 patient records on the stolen laptop, most records did not warrant disclosure. In 2,777 cases, for instance, a record listed only a patient's name.

Complicating matters were liability rules. In the eyes of the law, Mr. Tripathi's nonprofit is a contractor that acts on behalf of health providers. The legal burden of protecting patient data actually falls on his clients: the physicians and hospitals who entrusted his nonprofit with their files.

"The laws create a perverse outcome," he says. "It was our fault, but from a federal perspective, it wasn't our breach."

Mr. Tripathi narrowed down the group of patients whose data put them at serious risk for identity theft to 998 people across seven physician practices. Only one practice broke the 500-patient threshold requiring disclosure on the Department of Health and Human Services Web site.

His office got to work notifying the affected patients of the data breach. They offered free credit monitoring — though less than 10 percent took them up on the option — spending a total of $6,000.

In the aftermath, Mr. Tripathi says his company destroyed all patient data on mobile devices and temporarily prohibited employees from removing patient data from clients' offices. The company now mandates that all data be encrypted, and employees are required to tell health providers what data they will need to access and how they plan to use it.

He never found the stolen laptop, and the incident, all told, cost his nonprofit $288,000.

In many ways, Massachusetts eHealth Collaborative got off easy. In October, a desktop computer containing unencrypted records on more than four million patients was stolen from Sutter Health, a nonprofit health system based in Sacramento. A rock was thrown through a window to gain access to the computer. The theft is now the subject of two class-action suits, each of which seeks $1,000 for each patient record breached.

"Breaches are going to be one of the big challenges as more physicians and hospitals adopt electronic health records," Mr. Tripathi says. "We're entering a brave new world."

http://www.nytimes.com/2011/12/19/technology/as-patient-records-are-digitized-data-breaches-are-on-the-rise.html?nl=todaysheadlines&emc=tha26&pagewanted=print

Should dentists offer health screenings? – - CNN.com Blogs

2011-12-18T06:11:00.001-05:00

Each year, nearly 20 million men, women and children in the United States fail to see a family physician or similar health care professional, but they do pay at least one visit to the dentist, according to a new study in the American Journal of Public Health.

For this segment of the population, dentists may be the only doctors in a position to spot the warning signs of chronic illnesses, such as diabetes, and provide referrals or advice to prevent serious complications, says Shiela M. Strauss, Ph.D., the lead author of the study and an associate professor at New York University's Colleges of Dentistry and Nursing.

Oral or dental abnormalities can signal a broad range of body-wide health problems, including HIV, sexually transmitted diseases, eating disorders, and substance abuse, in addition to diabetes. In a previous study, for instance, Strauss and her colleagues found that 93% of patients with gum disease (such as gingivitis) also met the criteria that should trigger blood-sugar screening under American Diabetes Association guidelines.

"I'm not advocating for dentists to become general health care providers," Strauss says. But, she adds, dentists can easily measure blood pressure and administer simple screening questionnaires - both of which could potentially make a big difference to the health of someone at risk for diabetes who hasn't seen a doctor recently.

In the new study, Strauss and her team analyzed data from the Medical Expenditure Panel Survey, a nationally representative government-sponsored survey of health care use. In 2008, the researchers found, roughly one-quarter of adults did not see a physician, nurse practitioner, or other general health care provider - but of that group, 23% did see a dentist. The pattern was similar among children.

It's not clear what's leading these people to see a dentist but skip medical care. Most of the adults - and nearly all of the kids - had health insurance, so lack of coverage can't fully explain it. In fact, the authors note, the dentist-only group was "quite diverse" ethnically, socioeconomically and geographically.

It could be that dental problems - unlike some chronic diseases - are often too painful to ignore, Strauss says, or it could be that dentists are simply better than doctors at reminding patients when it's time for a checkup.

Getting dentists in the habit of screening for health conditions will probably require changes to dental-school curricula, the researchers say. However, dentists and dental hygienists are typically already trained to check blood pressure and conduct other types of general medical screening.

And while they might be hesitant to take on more patient responsibilities, Strauss says, doing so may have unexpected benefits. She points to the experience of some Swedish dentists who participated in an insurance plan that required them to implement diabetes screening for their patients.

"The reputation got out there that these were dentists that really cared about the patients," she says. "It was an initial investment of a bit more time on the part of the dentist, but it reaped great rewards for them in terms of growing their practice."

http://thechart.blogs.cnn.com/2011/12/15/should-dentists-offer-health-screenings/

As Doctors Use More Devices, Potential for Distraction Grows - NYTimes.com

2011-12-16T15:32:00.000-05:00

Hospitals and doctors' offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies.

But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.

This phenomenon has set off an intensifying discussion at hospitals and medical schools about a problem perhaps best described as "distracted doctoring." In response, some hospitals have begun limiting the use of devices in critical settings, while schools have started reminding medical students to focus on patients instead of gadgets, even as the students are being given more devices.

"You walk around the hospital, and what you see is not funny," said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

"You justify carrying devices around the hospital to do medical records," he said. "But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting."

"My gut feeling is lives are in danger," said Dr. Papadakos, who recently published an article on "electronic distraction" in Anesthesiology News, a journal. "We're not educating people about the problem, and it's getting worse."

Research on the subject is beginning to emerge. A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55 percent of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.

About 40 percent said they believed talking on the phone during surgery to be "always an unsafe practice." About half said the same about texting. The study's authors concluded, "Such distractions have the potential to be disastrous."

Doctors and medical professionals have always faced interruptions from beepers and phones, and multitasking is simply a fact of life for many medical jobs. What has changed, doctors say, especially younger ones, is that they face increasing pressure to interact with their devices.

The pressure stems from a mantra of modern medicine that patient care must be "data driven," and informed by the latest, instantly accessible information. Annual investment in gadgets and other technology by hospitals and doctors has soared into the billions of dollars.

By many accounts, the technology has helped reduce medical error by, for example, providing instant access to patient data or prescription details.

Dr. Peter W. Carmel, president of the American Medical Association, a physicians group, said technology "offers great potential in health care," but he added that doctors' first priority should be with the patient.

Indeed, doctors and nurses face growing pressures to listen carefully to patients, provide customer service and show empathy as they look for subtle cues that might explain an illness.

"The computer has become a good place to get a result, communicate with other people," said Abraham Verghese, a doctor and professor at the Stanford University Medical Center and a best-selling medical writer. "In the interest of preventing medical error, it's a good friend."

At the same time, he said, the wealth of data on the screen — what he frequently refers to as the "iPatient" — gets all the attention.

"The iPatient is getting wonderful care across America," Dr. Verghese said. "The real patient wonders, 'Where is everybody?' "

It is hard to know the precise impact that distracted doctoring has on patient care, because it is hard to measure. But at least one example puts the risks in sharp relief.

Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cellphone, Mr. Eldredge said.

"He was making personal calls," Mr. Eldredge said, at least 10 of them to family and business associates, according to phone records. His client's case was settled before a lawsuit was filed so there are no court records, like the name of the patient, doctor or hospital involved. Mr. Eldredge, citing the agreement, declined to provide further details.

Others describe multitasking as relatively commonplace.

"I've seen texting among people I'm supervising in the O.R.," said Dr. Stephen Luczycki, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. He said he had also seen young anesthesiologists using the operating room computer during surgery.

"It is not, unfortunately, uncommon to see them doing any number of things with that computer beyond patient care," Dr. Luczycki said, including checking e-mail and studying or entering logs on a separate case. He said that when he was in training, he was admonished to not even study a textbook in surgery, so he could focus on the rhythm and subtleties of the procedures.

When he uses computers in the intensive care unit, he regularly sees what his colleagues were doing before him.

"Amazon, Gmail, I've seen all sorts of shopping, I've seen eBay," he said. "You name it, I've seen it."

Dr. Luczycki is also a huge fan of technology's positive impact on medicine. So, too, is Dio Sumagaysay, administrative director of 24 operating rooms at Oregon Health and Science University hospitals, even though he has heard about or witnessed instances of people using devices during critical moments.

In early 2010, he heard several complaints that doctors or nurses were using their phones to check or send e-mails even though they were part of a team intubating a patient before surgery.

Mr. Sumagaysay established a policy to make operating rooms "quiet zones," banning any activity that was not focused on patient care. He later had to reprimand a nurse he saw checking airline prices using an operating room computer during a spinal operation.

Medical professionals say young doctors can be particularly susceptible to distraction because they have grown up being constantly connected.

At Stanford Medical School, for example, all students now get iPads, which they use to read medical texts and carry with them in hospitals but are also admonished not let get in the way of their work.

"Devices have a great capacity to reduce risk," Dr. Charles G. Prober, senior associate dean for medical education at the school, said. "But the last thing we want to see, and what is happening in some cases now, is the computer coming between the patient and his doctor."

http://www.nytimes.com/2011/12/15/health/as-doctors-use-more-devices-potential-for-distraction-grows.html?nl=todaysheadlines&emc=tha23&pagewanted=print

Emergency contraceptives over the counter: Are they more dangerous than other drugs? - Slate Magazine

2011-12-15T16:37:00.001-05:00

Health and Human Services Secretary Kathleen Sebelius overruled the FDA's recommendationthat emergency contraception be made available over the counter to patients of all ages on Wednesday. Her argument was that its effects on 11-year-olds have not been thoroughly studied. Critics pointed out that many over-the-counter drugs are far more dangerous than emergency contraceptives. What's the most dangerous drug you can buy without a prescription?

It's hard to say. As far as the Explainer can tell, no researcher has ever compared the fatality rates of every drug available over the counter—probably because the number of deaths from overdose of antacids and many other products is so small as to make the study a waste of time. There is, however, a large body of research on pain relievers. Analgesic overdoses are pretty common in the United States. In 2000, poison-control centers received more than 130,000 calls from people who believed they had taken a dangerous amount of an over-the-counter painkiller. Nearly one-half of those calls concerned acetaminophen, best known as the active ingredient in Tylenol. Approximately 0.2 percent of those cases ended in death. That's higher than the reported death rate for nonsteroidal anti-inflammatory drugs like Advil (ibuprofen) and Aleve (naproxen), but lower than the fatality rate for aspirin. (Aspirin is technically in the same category, but is often separated for research purposes.)* However, most of the aspirin deaths appear to have been suicides, while accidental overdose is more common than intentional overdose for acetaminophen. Between the years 1990 and 1998, 458 people died from taking too much acetaminophen.*

Pseudoephedrine, a very common cold medication, is also implicated in a number of deaths every year. In 2004, for example, poison-control centers reported 21 deaths in which the chemical was involved. However, most of those patients took a cocktail of drugs—often including acetaminophen—and many of the cases were ruled suicides. It's also not entirely correct to call pseudoephedrine an over-counter drug. A 2005 act of Congress forced retailers to move it behind the counter because of its use in the production of methamphetamine.

Of course, many other drugs can be fatal if you go way overboard. Even Epsom salts, which are commonly used as a laxative, can cause cardiac arrest. A hospital in Scotland reported a case of attempted suicide by Epsom salts in 2009. The woman ingested an incredible 4.4 pounds of the stuff. She suffered some acute cardiac complications, but doctors were able to save her.

It's not easy to determine the fatal dose of over-the-counter drugs. Take the example of acetaminophen. A person's ability to handle the drug depends on a variety of factors, including the condition of their liver, how much they've eaten, and whether they take the pill in conjunction with alcohol. (Bad idea.) Compared to other over-the-counter drugs, acetaminophen has a relatively narrow safety margin—that is, the difference between a safe-but-effective dose and an overdose is relatively small. Doctors have reported liver failure from as little as 2.5 grams in a day, which is 1.5 grams less than the approved limit.

The FDA has considered reducing the approved daily dose (PDF) of over-the-counter acetaminophen, but that wouldn't help in all cases. Many patients don't realize how much of the drug they're taking. Those who are prescribed the painkiller Percocet, for example, might take over-the-counter acetaminophen as an adjunct for different or breakthrough pain. The problem is that Percoset contains acetaminophen, and the combination can easily put them over the dose limit.

What's the fatal dose of emergency contraceptive? Nobody knows. The drug certainly has side effects, like nausea, vomiting, dizziness, fatigue, and the like. Women who use the morning-after pill as their regular form of contraception can also experience some menstrual irregularities. But no one has taken a fatal dose of Plan B.

http://www.slate.com/articles/health_and_science/explainer/2011/12/emergency_contraceptives_over_the_counter_are_they_more_dangerous_than_other_drugs_.html?