The news of Jack Kevorkian's death brought out a large number of laudatory comments in The New York Times (laudatory about the man rather than his death, natch). "I hope that one day the world will look back on the service Dr. Kevorkian provided and will be shocked and saddened to learn that he was ostracized and incarcerated for the practice of providing dignity and some control to those in the late stages of terminal illness," SteveBnh of Virginia wrote in a representative sample of the praise heaped on the crusader for physician-assisted suicide.
Count me among the ostracizers. As the warm comments from seemingly well-informed readers demonstrates, Kevorkian was widely perceived to be a fierce advocate for patient's rights, a promoter of death with dignity, and the victim of a hypocritical and vindictive profession hellbent on maintain its Godlike power over patients. His trial, conviction, and imprisonment in 1999 for second-degree murder has the flavor of martyrdom, reinforcing the admiration of his followers and inviting comparisons to various legendary civil-rights activists.
In reality, Kevorkian was none of these things, but rather a creepy zealot obsessed with death who knew nothing about actual patient care. (I am not using the word "creepy" lightly; read on.) Although he was trained at a bonafide medical school and thus was a "doctor" in the general sense of the term, his training and subsequent practice was in pathology, where his work involved autopsies and analysis of human tissues on slides rather than actually taking care of living, breathing souls with joys and fears--making his public persona as "doctor" a bit misleading, as if he were the same as Marcus Welby, M.D. Kevorkian's nickname, "Doctor Death", didn't come from the notoriety he generated in the 1980s and '90s, but rather from perplexed and amused housestaff during his early days in a wry observation about his peculiar fixation on photographing patients' eyes at the precise moment of death. (Various blogs and websites supportive of Kevorkian state that this is because he wanted the profession to be able to distinguish the moment so that resuscitation could be performed, or something to that effect. It's utter nonsense: even in the 1950's, which some might consider the Dark Ages by medical standards, there were EKGs, a considerably more precise tool to determine death than staring into people's eyes, which seems positively medieval. Whatever his stated justifications, his "death photography" was pure fetish.) Long before he took up physician-assisted suicide as his cause, he bounced from hospital to hospital, disturbing various medical staffs with his distinctly unconventional preoccupations.
He was praised for his compassion despite the fact that he had not only not taken care of living patients except during his internship, but had never received any training of any kind in treating patients with depression (common enough among the terminally ill), palliative care, or any of the diseases that he claimed to treat. His choices reflect this very poor training: among the 130 or more cases in which he was the prescriber of death, several had no terminal illnesses nor were suffering, such as the case of Janet Adkins, who had been recently diagnosed with Alzheimer's disease but aside from mild memory loss was in otherwise reasonably good health.
Even more disturbing were the reports of the death of Judith Curren, a 43 year-old woman who not only didn't have a clear-cut underlying disorder, she had reportedly been a victim of domestic violence. These are not the only cases, but even the inclusion of these two suggests at best a sloppiness in methods, and at worst a murderous instinct hidden under the guise of medical concern for suffering. ("How could I have known?" was Kevorkian's retort after being confronted with the news of the messy life of the Curren family. Perhaps if his only acquaintance with them had not been through a questionnaire, and had been based on caring for Judith Curren in a legitimate medical practice for several years, such surprises wouldn't have popped up.)
In short, Dr. Kevorkian-the-Caring was a total media fabrication. He was a murderer, and if anything was treated gently by the justice system.
Other, far more responsible doctors have spoken out in favor of physician-assisted suicide--doctors who personally knew and ministered to their patients before taking the terrifying power into their hands and helped patients end their lives, doctors who gave such power its proper due, only arriving at that moment after slow and careful deliberation, wholly unlike Dr. Kevorkian's quickie-in-a-Volkswagen butchery. Perhaps the most famous of these doctors is Timothy Quill, a practicing doc in New York who challenged the ban on physician-assisted suicide in the State of New York which was ultimately decided by the US Supreme Court; the court decided 9-0 against Dr. Quill. Even Quill, as forceful an advocate for physician-assisted suicide as could be, found Kevorkian's behavior troubling, saying that he "is very much on the edges of what ordinary doctors do."
I have heard Timothy Quill speak on two occasions and found him an eloquent man whose concerns are ultimately for the health and happiness of his patients. That said, I still believe that physician-assisted suicide is a terrible idea. Ironically, the two times I attended lectures by Dr. Quill mark dramatic shifts in opinion I have had on the subject: the first time happened before I started medical school and was strongly in favor of his ideas, while the second time was a few years ago, after I had undergone more than a decade of medical training, and my attitude had changed considerably.
Generally, the discussions about physician-assisted suicide revolve around two themes. The first is what bizzyblog refers to as "the euthanasia theme song," or having a life that is not worth living. The second deals with the scenario of unbearable and unremitting suffering, which the supporters of physician-assisted suicide regard as the ultimate justification for the practice. This is often where the accusations of "doctors playing God" come in--docs are so invested in keeping people alive that they consider it a personal affront to allow patients to die. (In general, my experience has been the opposite, not withstanding the rather regrettable final few days of my father's life, in which we attempted in vain for several days to have his life-support removed after an episode of sudden cardiac death. Based on what I've seen, it's usually the doctors, and not the families, who see little or no value and much suffering in store for families and patients with terminal illness requiring intubation, PEG tubes and the like, and often have difficulty explaining to families the benefits of "letting nature take its course.")
It turns out that, not unlike the public misperceptions of Dr. Kevorkian, the picture of frequent, unremitting suffering of the terminally ill is for the most part a fiction. Curiously, over the past 20 or so years attitudes about physician-assisted suicide and euthanasia haven't changed a great deal among the general public or physicians in general (those numbers are different from one another, but stable over time). However, one group in which attitudes have changed significantly is among oncologists, who have had a steep drop in approval for those practices.
Why? It's hard to say with complete certainty, but it's likely because oncologists are more aware of, and tuned into, the multiple ways in which terminally ill patients can remain pain-free and finish their lives with meaning and dignity, to paraphrase the article in the link. A telling statistic: among oncologists, surgical oncologists, who deal with the long-term care of their patients far less often, were twice as likely to support physician-assisted suicide as their medical oncologist colleagues. In other words, the further away one gets from the actual practice of death and dying, the greater the fear of pain and suffering among laypeople and physicians alike, and the corresponding increase in support of physician-assisted suicide.
As for judging whether a life is worth living, that's much more straightforward. Physician's have no business judging the worth of any of their patients' lives. That is playing God.
It is not hard to kill onself in the US: over 30,000 people do it each year, and do it in a multiplicity of ways ranging from relatively peaceful to gruesome. And while there are technically laws on the books against suicide and no Supreme Court recognition of a "right to suicide," the practice is tacitly accepted. Suicides are allowed to be buried with everyone else, and the state does not seize their assets. So given the ease by which people can commit suicide, the debate around physicians being involved in the taking of lives has increasingly for me had an odd ring about it. Why must physicians be present to sanctify this process? It has the feel of approval-seeking, and docs shouldn't be in the business of approving or disapproving anything about a patient's lifestyle, except maybe smoking. Even then: maybe.
Doctors cannot take lives; it's not our job and should never be so. If we administer comfort medications that may hasten death to a suffering patient as a side effect, that is more than acceptable. If doctors withdraw tubes or machines that "artificially" keep patients alive, that's fine as well. But there's a big difference between maintaining a morphine drip and injecting a bolus of potassium chloride into a patient. The former is a drug with legitimate medical uses; the latter is never used under any conditions except to kill. Morphine is an everyday drug in hospices across the US; the potassium bolus was a "medication" unique to Dr. Kevorkian. May there never be another one like him again.
--br
Sunday, June 5, 2011
Thursday, May 5, 2011
Racism--The Gift That Keeps On Giving
My philosophy of bedside medicine is founded on trying to be aware of how patients view the world well before I bring that quarter million-dollar scientific education to bear upon their problems. I've met docs who can form a differential diagnosis with greater length, and in faster time, than me, but I've also observed a lot of docs of that ilk who don't have a clue about how to use their stellar clinical acumen to explain to patients what they are thinking. This inability frequently leads to all sorts of problems for patients and their families, either because they are anxious and don't understand what is being told to them, or because they don't understand instructions and are afraid to ask out of a desire not to appear stupid. Being simultaneously intimidating and clueless can have lethal consequences, even when a doc is just as smart as House.
Put yourself into their shoes, I tell my med students, think about how they're feeling when you're talking to them before you start with the technical talk. Imagine, I say to them, how it feels to be lying there, usually half-naked, while an army of White Coats is standing there at your bedside, looking down at you, speaking in a language that sounds vaguely like English but makes no sense at all. (See this clip here, for instance, from the British TV miniseries The Singing Detective, which illustrates this in simultaneous hilarious and exquisitely painful detail. I mean it--follow that link, team! Not only is it a fantastic, biting satire of academic medical culture, it features a much younger Michael "Dumbledore 2" Gambon as well as Imelda "Dolores Umbridge" Staunton. And though made in the 1980s, the medical language--indeed, the medications!--hasn't changed much.) One thing Billy always does when seeing his hospitalized patients is to sit in a chair at patient's-eye level, and if no chair is present, then he gets down on his knees to communicate. It's symbolic, but I think it means a lot.
Being exposed and vulnerable is a universal condition of patienthood, but there are other factors that influence the physician-patient interaction as well, and race is one of the biggies. I don't believe that every interaction between black and white Americans has to "devolve" to race by necessity, but I sure's hell think that it's something to be aware of when you step into a room as a white doc with an African-American patient. I, nor any of my ancestors, were ever involved in any overtly racist act, but that doesn't mean that I shouldn't at least be cognizant of the fact that African-Americans often are leery of white docs, and not unjustifiably so (more on this in a moment).
Race was on my mind today as I listened to a fascinating lecture about blood transfusions. Most Americans have at least a vague understanding that there are 4 major blood types (A, B, AB, and O) each of which can be described as "Rh positive" or "Rh negative"--thus 8 blood types in total. In order to have a blood transfusion safely, these types must be matched to prevent immune responses. The blood types are distributed across all races making "universal" transfusion a generally easy process. (Though some readers may recall an episode of M*A*S*H* taking the topic of race and blood head-on, when a white GI needing surgery tells the surgeons not to give him "any of that black blood"--no doubt reflecting the attitudes of real people in the 50's, when the scene was set, as well as the early 70's, when the episode was filmed. Plus there's the cultural convention in many Asian communities, especially in Japan, that the ABO blood types correlate with personality, and Japanese are even more keenly aware of their blood types than Americans are of, say, our zodiac signs. So we haven't eliminated this brand of nonsense from humanity just yet, but we're getting there.)
It turns out that the ABO and Rh+/- system is just the beginning, and the immune response to blood is a good deal more complicated than this. But in the majority of cases the model of eight blood types is sufficient to save people with the magic of transfusions. (This assumes that people have ready access to blood, which they often don't, for instance, in many northern Mexican communities, as described here, but in the US that's almost never a problem.) The exceptions to this, where patients have to have a host of other blood cross-typing done, are frequently found among patients of African ancestry, in particular among those who suffer from that quintessentially African disease, Sickle Cell Anemia. Whether this is due to the inherent genetic variation in Africans, or whether it's a process of sickle cell disease, is not fully clear to me, but from a clinician's standpoint it hardly makes any difference. Patients who have requirements beyond the eight common types need to be cross-matched for special blood, sometimes very rare blood indeed. One patient under discussion in the lecture today essentially had only one person who was known to have blood that she could accept--in the entire world. And since that patient's donor (a close relative) was still a child, not so much a help.
Anyway, the likelihood that you'll get a match for that special blood is increased if you have a large pool of donors who more closely resemble you genetically. Meaning: from your ethnic or racial group. So Africans and African-Americans--who constitute a major if not the major group of people with these rare reactions to blood transfusion--are the ones most in need of blood donors of African ancestry. And there's the rub, because African-Americans are far less likely to donate their blood, at the rate of 25 to 50 percent the rate of blood donation among whites. This is very much unlike the situation in a group of transfusion-dependent diseases called thalassemias, which sometimes afflict people of African descent, but more often are seen in Caucasians, who have a much larger pool of donors from which adequate matches can be found, and so there are far fewer transfusion crises and dilemmas.
Why is this? Well, if you don't think that American history, filled with its pernicious racism, is grasping with its fetid hands our modern system of blood donation, then you're missing just as much as the brilliant-but-clueless docs I've described above. Leave aside slavery and all of its ill consequences alone for a moment--just consider the treatment of African-Americans at the hands of doctors, some of whom were employed by the Federal Government of the United States, as they were prevented from being cured of syphilis or bombarded with radiation without awareness or consent. Or the story of Henrietta Lacks, whose ultimately fatal cancer cells became the first human cells cultured outside of the body, remaining the workhorse cells for biomedical scientists to this day, a major source of commerce in the scientific world, worth billions of dollars, while her descendants struggle to afford health insurance.
Think about that while you swallow the statistic on the poor rates of blood donation among African Americans when your next sickler needs a transfusion. Does blood donation cause syphilis? No, of course not--but would you trust a system that had treated your brothers and sisters like this for generations? As the Tuskegee Syphilis Study Legacy Committee Report wrote in 1996: "the [study] continues to cast its long shadow on the contemporary relationship between African Americans and the biomedical community."
Indeed. It has not only done that; it has cruelly deprived some members of its own community the lifeblood it so desperately needs. This is why doctors need to be as aware of history as they are of science.
--br
Put yourself into their shoes, I tell my med students, think about how they're feeling when you're talking to them before you start with the technical talk. Imagine, I say to them, how it feels to be lying there, usually half-naked, while an army of White Coats is standing there at your bedside, looking down at you, speaking in a language that sounds vaguely like English but makes no sense at all. (See this clip here, for instance, from the British TV miniseries The Singing Detective, which illustrates this in simultaneous hilarious and exquisitely painful detail. I mean it--follow that link, team! Not only is it a fantastic, biting satire of academic medical culture, it features a much younger Michael "Dumbledore 2" Gambon as well as Imelda "Dolores Umbridge" Staunton. And though made in the 1980s, the medical language--indeed, the medications!--hasn't changed much.) One thing Billy always does when seeing his hospitalized patients is to sit in a chair at patient's-eye level, and if no chair is present, then he gets down on his knees to communicate. It's symbolic, but I think it means a lot.
Being exposed and vulnerable is a universal condition of patienthood, but there are other factors that influence the physician-patient interaction as well, and race is one of the biggies. I don't believe that every interaction between black and white Americans has to "devolve" to race by necessity, but I sure's hell think that it's something to be aware of when you step into a room as a white doc with an African-American patient. I, nor any of my ancestors, were ever involved in any overtly racist act, but that doesn't mean that I shouldn't at least be cognizant of the fact that African-Americans often are leery of white docs, and not unjustifiably so (more on this in a moment).
Race was on my mind today as I listened to a fascinating lecture about blood transfusions. Most Americans have at least a vague understanding that there are 4 major blood types (A, B, AB, and O) each of which can be described as "Rh positive" or "Rh negative"--thus 8 blood types in total. In order to have a blood transfusion safely, these types must be matched to prevent immune responses. The blood types are distributed across all races making "universal" transfusion a generally easy process. (Though some readers may recall an episode of M*A*S*H* taking the topic of race and blood head-on, when a white GI needing surgery tells the surgeons not to give him "any of that black blood"--no doubt reflecting the attitudes of real people in the 50's, when the scene was set, as well as the early 70's, when the episode was filmed. Plus there's the cultural convention in many Asian communities, especially in Japan, that the ABO blood types correlate with personality, and Japanese are even more keenly aware of their blood types than Americans are of, say, our zodiac signs. So we haven't eliminated this brand of nonsense from humanity just yet, but we're getting there.)
It turns out that the ABO and Rh+/- system is just the beginning, and the immune response to blood is a good deal more complicated than this. But in the majority of cases the model of eight blood types is sufficient to save people with the magic of transfusions. (This assumes that people have ready access to blood, which they often don't, for instance, in many northern Mexican communities, as described here, but in the US that's almost never a problem.) The exceptions to this, where patients have to have a host of other blood cross-typing done, are frequently found among patients of African ancestry, in particular among those who suffer from that quintessentially African disease, Sickle Cell Anemia. Whether this is due to the inherent genetic variation in Africans, or whether it's a process of sickle cell disease, is not fully clear to me, but from a clinician's standpoint it hardly makes any difference. Patients who have requirements beyond the eight common types need to be cross-matched for special blood, sometimes very rare blood indeed. One patient under discussion in the lecture today essentially had only one person who was known to have blood that she could accept--in the entire world. And since that patient's donor (a close relative) was still a child, not so much a help.
Anyway, the likelihood that you'll get a match for that special blood is increased if you have a large pool of donors who more closely resemble you genetically. Meaning: from your ethnic or racial group. So Africans and African-Americans--who constitute a major if not the major group of people with these rare reactions to blood transfusion--are the ones most in need of blood donors of African ancestry. And there's the rub, because African-Americans are far less likely to donate their blood, at the rate of 25 to 50 percent the rate of blood donation among whites. This is very much unlike the situation in a group of transfusion-dependent diseases called thalassemias, which sometimes afflict people of African descent, but more often are seen in Caucasians, who have a much larger pool of donors from which adequate matches can be found, and so there are far fewer transfusion crises and dilemmas.
Why is this? Well, if you don't think that American history, filled with its pernicious racism, is grasping with its fetid hands our modern system of blood donation, then you're missing just as much as the brilliant-but-clueless docs I've described above. Leave aside slavery and all of its ill consequences alone for a moment--just consider the treatment of African-Americans at the hands of doctors, some of whom were employed by the Federal Government of the United States, as they were prevented from being cured of syphilis or bombarded with radiation without awareness or consent. Or the story of Henrietta Lacks, whose ultimately fatal cancer cells became the first human cells cultured outside of the body, remaining the workhorse cells for biomedical scientists to this day, a major source of commerce in the scientific world, worth billions of dollars, while her descendants struggle to afford health insurance.
Think about that while you swallow the statistic on the poor rates of blood donation among African Americans when your next sickler needs a transfusion. Does blood donation cause syphilis? No, of course not--but would you trust a system that had treated your brothers and sisters like this for generations? As the Tuskegee Syphilis Study Legacy Committee Report wrote in 1996: "the [study] continues to cast its long shadow on the contemporary relationship between African Americans and the biomedical community."
Indeed. It has not only done that; it has cruelly deprived some members of its own community the lifeblood it so desperately needs. This is why doctors need to be as aware of history as they are of science.
--br
Wednesday, April 27, 2011
Government and Medicine: Legislative and Judicial Follies
I try--I repeat, I try--to construct eloquent blog posts as often as I write them, taking care to choose my words as I tiptoe through the minefields of cyberspastic hyperbole and vitriol. That said, I could do little more than utter "blech" at this news piece that the Massachusetts State House has voted overwhelmingly, as part of an "economic development" bill, to repeal a ban on gift-giving from pharmaceutical companies to physicians that had passed in 2008. For those who have been trapped in solid ice since, say, the mid-1930s and the heyday of the Henry Cabot Lodges and William Morgan Butlers, in Massachusetts, the House belongs to the Democratic party. So how does such a law that seems to once again encourage the wink-wink nudge-nudge relationship between docs and the pill-pushers--particularly when the same legislative body clamps down on labor's bargaining rights in an effort to rein in spending costs--get passed?
Amazingly, the answer appears to lie in...the dining & entertainment lobby. According to Garrett Bradley (D) of Hingham, the sponsor of the measure, the ban stifles business, hurting convention centers and "restaurants where companies typically hosted physician events and dinners." (NB--the quote is from the article, not a direct of Mr. Bradley, though I doubt he'd quibble if the line were attributed to him.) Never mind the fact that this sector of the Massachusetts economy appears to be doing reasonably well, with an increase in overall revenue compared to last year, the measure's backers appear to be saying that it's perfectly fine if a payola-style arrangement is in place, as long as the palms continue to be greased and the filet mignon gets served with the Cabernet.
Blogger-doc Dan Carlat has already staked out the Swiftian rhetorical territory with a delightful skewering of the follies, leaving me and others to play the straight guy. So here goes my best effort: no self-respecting physician compromises the health of his or her patients by allowing themselves to be manipulated by claptrap. There is ample evidence that gift-giving induces an attitude of reciprocation, lucidly-but-luridly described in such books as The Truth About Drug Companies and White Coat, Black Hat, regardless of the actual quality of the product, and that drug reps know this and seize on the vanity of physicians to play them for dupes. Drug companies, however beneficial their societal effects may (or may not always) be, have a responsibility to shareholders, whose primary or sole interest is in the generation of wealth. To anyone in any state of mind other than that of abject denial, this is a primary objective that is in direct conflict with the caring of patients. Thus, doctors cannot accept gifts of any kind from those whose job it is to sell drugs.
A related theme is being played out in the judicial branch of government, as the US Supreme Court is hearing arguments on a Vermont law that bars the commercial use of physician prescription patterns. Based on the early returns, and noting previous Court decisions that take a fairly broad view of "free-speech" rights (at least if you are a corporation), it appears that the law is destined for being overturned. I can't claim to be a legal expert and thus won't even begin to take a crack at the wrangling over the First Amendment, other than to note a certain puzzlement at what passes for "free speech" these days among the Court's "strict constructionist" wing. Did the Founding Fathers really have the selling of a doctor's prescription habits in mind when crafting the First Amendment? I'm thinking not, but I await the peals of derision from my philosophico-legal foils (and loyal readers!) such as Ted Frank, a conservative maverick (I'm not sure if "conservative" is the right word for him; I'm certain that "maverick" is) and who ranks as the second smartest person I have ever had the pleasure of knowing in my life. (And in case anyone might misunderstand, I'm not implying that I occupy the top spot; I doubt I crack even the top 75, and I don't have that many friends.)
Regardless of the legal principles at stake, Chief Justice John Roberts made his contribution to the follies by appearing to frame this as an argument of "restricting the flow of information to doctors," as silly a line that can be uttered in such an august house as SCOTUS. How would withholding prescription info from drug companies prevent them from making their pitch for their drug? How does this even remotely "restrict the flow of information"? The naivete exhibited by the Chief Justice is pretty remarkable (and shared, without surprise, by Justices Scalia and Kennedy). The "it's all data, it's all protected by the First Amendment" argument seems to only work when big business benefits, but not the other way around. The recipe to Coke is just data, too; somehow I don't think the Coca-Cola Corporation considers that to be something that your local Joe can just barge on in and demand. Pray tell, what's the difference?
A hat-tip to Carey Goldberg at WBUR's Common Health Blog, especially for her humoring me in my response of "blech"!
--br
Amazingly, the answer appears to lie in...the dining & entertainment lobby. According to Garrett Bradley (D) of Hingham, the sponsor of the measure, the ban stifles business, hurting convention centers and "restaurants where companies typically hosted physician events and dinners." (NB--the quote is from the article, not a direct of Mr. Bradley, though I doubt he'd quibble if the line were attributed to him.) Never mind the fact that this sector of the Massachusetts economy appears to be doing reasonably well, with an increase in overall revenue compared to last year, the measure's backers appear to be saying that it's perfectly fine if a payola-style arrangement is in place, as long as the palms continue to be greased and the filet mignon gets served with the Cabernet.
Blogger-doc Dan Carlat has already staked out the Swiftian rhetorical territory with a delightful skewering of the follies, leaving me and others to play the straight guy. So here goes my best effort: no self-respecting physician compromises the health of his or her patients by allowing themselves to be manipulated by claptrap. There is ample evidence that gift-giving induces an attitude of reciprocation, lucidly-but-luridly described in such books as The Truth About Drug Companies and White Coat, Black Hat, regardless of the actual quality of the product, and that drug reps know this and seize on the vanity of physicians to play them for dupes. Drug companies, however beneficial their societal effects may (or may not always) be, have a responsibility to shareholders, whose primary or sole interest is in the generation of wealth. To anyone in any state of mind other than that of abject denial, this is a primary objective that is in direct conflict with the caring of patients. Thus, doctors cannot accept gifts of any kind from those whose job it is to sell drugs.
A related theme is being played out in the judicial branch of government, as the US Supreme Court is hearing arguments on a Vermont law that bars the commercial use of physician prescription patterns. Based on the early returns, and noting previous Court decisions that take a fairly broad view of "free-speech" rights (at least if you are a corporation), it appears that the law is destined for being overturned. I can't claim to be a legal expert and thus won't even begin to take a crack at the wrangling over the First Amendment, other than to note a certain puzzlement at what passes for "free speech" these days among the Court's "strict constructionist" wing. Did the Founding Fathers really have the selling of a doctor's prescription habits in mind when crafting the First Amendment? I'm thinking not, but I await the peals of derision from my philosophico-legal foils (and loyal readers!) such as Ted Frank, a conservative maverick (I'm not sure if "conservative" is the right word for him; I'm certain that "maverick" is) and who ranks as the second smartest person I have ever had the pleasure of knowing in my life. (And in case anyone might misunderstand, I'm not implying that I occupy the top spot; I doubt I crack even the top 75, and I don't have that many friends.)
Regardless of the legal principles at stake, Chief Justice John Roberts made his contribution to the follies by appearing to frame this as an argument of "restricting the flow of information to doctors," as silly a line that can be uttered in such an august house as SCOTUS. How would withholding prescription info from drug companies prevent them from making their pitch for their drug? How does this even remotely "restrict the flow of information"? The naivete exhibited by the Chief Justice is pretty remarkable (and shared, without surprise, by Justices Scalia and Kennedy). The "it's all data, it's all protected by the First Amendment" argument seems to only work when big business benefits, but not the other way around. The recipe to Coke is just data, too; somehow I don't think the Coca-Cola Corporation considers that to be something that your local Joe can just barge on in and demand. Pray tell, what's the difference?
A hat-tip to Carey Goldberg at WBUR's Common Health Blog, especially for her humoring me in my response of "blech"!
--br
Wednesday, March 23, 2011
Fukushima Daiichi, and the Perception of Radiation Risk
Evolutionarily speaking, we are as a species hardwired to analyze risk based off of information that's directly in front of us--immediately accessible to our five senses. We're designed not to trust food that smells funny, can instantly calculate how far away we should stay from large cats capable of having us for a snack, and do a host of other things that were very useful for us to eke out a living in Olduvai Gorge.
But we live in the 21st century, and nowadays our ability to perceive and estimate risk is hampered by the fact that many of today's risks are abstract, and require a resonably sophisticated understanding of statistics. Take, for example, a recent discussion found in the Paper Of Record about income distribution in the United States. True--it's not really a round table about "risk" per se, unless you consider radically unequal wealth distribution to be a risk to democracy, as Supreme Court Justice Louis Brandeis did when he said that "we can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both." Still, the NY Times roundtable was remarkable in that all of the contributors, whether approaching the issue from a left or right viewpoint, agreed that most Americans had vastly underestimated how much wealth is held by relatively few. In particular, a study by Michael Norton and Dan Ariely found that not only do Americans think that wealth distribution to be significantly more equitable than it actually is, but that they would prefer it to be even more equitable than what they (wrongly) perceive.
If this isn't a classic example of what George W. Bush would call "misunderestimation" then it's not clear what is, and moreover, it highlights the difficulties people have in making accurate estimates about things like the distribution of wealth in a hugely complex society: the information simply cannot be found by opening your eyes and looking around. In medicine, we see this all the time: people are often terrified of exotic diseases that pose little threat to them, while being utterly blithe to the daily assaults on their bodies--frequently self-inflicted--that are much more likely to send them six feet under. To wit: drinking, smoking, eating poorly and not exercising.
The recent events at the Fukushima Daiichi nuclear power plant have been a case study in this process of risk assessment, and not altogether surprisingly, we haven't done well collectively in harmonizing our level of panic to the actual threat that the reactors pose. Despite a good number of depressing news stories, some cataloging evasive action by non-Japanese governments, it is far from clear how huge an impact the nuclear accident is going to have. While it is already comparable to the Three Mile Island accident in 1979, and is not (yet) as catastrophic as the Chernobyl accident of 1986, the question still remains: just how dangerous is it? Though the story is far from over there with events taking dramatic swings in short periods, the short answer is something like dangerous, but not as dangerous as you think. Not nearly as dangerous as you think.
That point is neatly illustrated, both in sound and visual format, in this news story from Adam Ragusea of WBUR (Boston), and is described as the "Dread-to-Risk ratio" by Andrew Revkin of the Dot Earth blog at NYT. Both pieces have the same useful graphic to give you some sense of the relative levels of radiation that we're talking about. Live within 50 miles of a nuclear power plant for one full year? That will give you about 0.1 microSieverts (uSv) of radiation. (What a Sievert is, is a longer discussion, but we'll just shorthand it here and say that it's some relative value of radiation, and that the higher the number, the more dangerous it gets.) One flight from New York to LA buys you about 400 times that amount (40 uSv). That's not even the round trip! A standard chest x-ray, meanwhile, is worth about 20 uSv. But a mammogram is a whopper, clocking in at 3 milliSieverts--thus about 150 "standard" x-rays and just under forty roundtrip flights from NY to LA. A CT scan can be worth almost twice the amount of the mammogram (5.8 mSv).
(In case I've lost some people on this micro/milli distinction, you need 1000 "micros" to make 1 "milli." I'm going to flip back and forth but will point it out when I do.)
So how do these numbers stack up to the nuclear disasters? If you lived within 10 miles of the Three Mile Island plant during the accident and didn't make a run for it, the total dose of radiation you received was 80 microSieverts--far less than one mammogram. By contrast, one area near the Fukushima plant recorded a total dose in one day of 3.6 milliSieverts: less than a CT but more than a mammogram, though of course we're only talking about one day's worth of radiation. With Chernobyl, the radiation levels fluctuated wildly both in time and place so making a general statement about the radiation is essentially impossible, but had you been moved by some weird spirit to take a stroll on the grounds just last year, about 25 years after the accident, you would have gotten two mammograms' worth of radiation for your troubles: 6 milliSieverts. I won't reproduce the pic here out of respect for copyright but highly recommend it to anyone with the time; Ragusea of WBUR translates this into a tone equivalent, and the radiation from TMI is a blip, while the sound for "mammogram" is substantially longer.
I draw two conclusions from all of this. First, while the troubles at Fukushima are by no means trivial, and for that matter aren't yet finished, I think it's a bit premature to write the obituary for nuclear power. In terms of accidents, it's not nearly as dangerous as most people suppose. The problem with nukes, in the TMI and Chernobyl age as well as today, is what to do with the radioactive waste generated by the plants rather than the risks they pose viz. accidents. Second is that we should try to minimize mammograms! Do only the amount that will help save lives, and not one more after that. This was the logic behind the recently revised US Preventative Services Task Force, which recommended no mammograms to women under 50, and biannual ones to those over. Despite this entirely sensible approach--based on good research with a careful eye toward the risk/benefit ratio of the radiation, it should be noted--there were howls of indignation from people purportedly speaking for women, accusing the very bureaucrats who issued the new recs to be female-hostile, or something like that.
--br
(NB--the first draft of this version, which snuck out prematurely, posted some incorrect calculations with respect to x-rays, mammograms, and NY-LA flights. The corrected version is now present.)
But we live in the 21st century, and nowadays our ability to perceive and estimate risk is hampered by the fact that many of today's risks are abstract, and require a resonably sophisticated understanding of statistics. Take, for example, a recent discussion found in the Paper Of Record about income distribution in the United States. True--it's not really a round table about "risk" per se, unless you consider radically unequal wealth distribution to be a risk to democracy, as Supreme Court Justice Louis Brandeis did when he said that "we can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both." Still, the NY Times roundtable was remarkable in that all of the contributors, whether approaching the issue from a left or right viewpoint, agreed that most Americans had vastly underestimated how much wealth is held by relatively few. In particular, a study by Michael Norton and Dan Ariely found that not only do Americans think that wealth distribution to be significantly more equitable than it actually is, but that they would prefer it to be even more equitable than what they (wrongly) perceive.
If this isn't a classic example of what George W. Bush would call "misunderestimation" then it's not clear what is, and moreover, it highlights the difficulties people have in making accurate estimates about things like the distribution of wealth in a hugely complex society: the information simply cannot be found by opening your eyes and looking around. In medicine, we see this all the time: people are often terrified of exotic diseases that pose little threat to them, while being utterly blithe to the daily assaults on their bodies--frequently self-inflicted--that are much more likely to send them six feet under. To wit: drinking, smoking, eating poorly and not exercising.
The recent events at the Fukushima Daiichi nuclear power plant have been a case study in this process of risk assessment, and not altogether surprisingly, we haven't done well collectively in harmonizing our level of panic to the actual threat that the reactors pose. Despite a good number of depressing news stories, some cataloging evasive action by non-Japanese governments, it is far from clear how huge an impact the nuclear accident is going to have. While it is already comparable to the Three Mile Island accident in 1979, and is not (yet) as catastrophic as the Chernobyl accident of 1986, the question still remains: just how dangerous is it? Though the story is far from over there with events taking dramatic swings in short periods, the short answer is something like dangerous, but not as dangerous as you think. Not nearly as dangerous as you think.
That point is neatly illustrated, both in sound and visual format, in this news story from Adam Ragusea of WBUR (Boston), and is described as the "Dread-to-Risk ratio" by Andrew Revkin of the Dot Earth blog at NYT. Both pieces have the same useful graphic to give you some sense of the relative levels of radiation that we're talking about. Live within 50 miles of a nuclear power plant for one full year? That will give you about 0.1 microSieverts (uSv) of radiation. (What a Sievert is, is a longer discussion, but we'll just shorthand it here and say that it's some relative value of radiation, and that the higher the number, the more dangerous it gets.) One flight from New York to LA buys you about 400 times that amount (40 uSv). That's not even the round trip! A standard chest x-ray, meanwhile, is worth about 20 uSv. But a mammogram is a whopper, clocking in at 3 milliSieverts--thus about 150 "standard" x-rays and just under forty roundtrip flights from NY to LA. A CT scan can be worth almost twice the amount of the mammogram (5.8 mSv).
(In case I've lost some people on this micro/milli distinction, you need 1000 "micros" to make 1 "milli." I'm going to flip back and forth but will point it out when I do.)
So how do these numbers stack up to the nuclear disasters? If you lived within 10 miles of the Three Mile Island plant during the accident and didn't make a run for it, the total dose of radiation you received was 80 microSieverts--far less than one mammogram. By contrast, one area near the Fukushima plant recorded a total dose in one day of 3.6 milliSieverts: less than a CT but more than a mammogram, though of course we're only talking about one day's worth of radiation. With Chernobyl, the radiation levels fluctuated wildly both in time and place so making a general statement about the radiation is essentially impossible, but had you been moved by some weird spirit to take a stroll on the grounds just last year, about 25 years after the accident, you would have gotten two mammograms' worth of radiation for your troubles: 6 milliSieverts. I won't reproduce the pic here out of respect for copyright but highly recommend it to anyone with the time; Ragusea of WBUR translates this into a tone equivalent, and the radiation from TMI is a blip, while the sound for "mammogram" is substantially longer.
I draw two conclusions from all of this. First, while the troubles at Fukushima are by no means trivial, and for that matter aren't yet finished, I think it's a bit premature to write the obituary for nuclear power. In terms of accidents, it's not nearly as dangerous as most people suppose. The problem with nukes, in the TMI and Chernobyl age as well as today, is what to do with the radioactive waste generated by the plants rather than the risks they pose viz. accidents. Second is that we should try to minimize mammograms! Do only the amount that will help save lives, and not one more after that. This was the logic behind the recently revised US Preventative Services Task Force, which recommended no mammograms to women under 50, and biannual ones to those over. Despite this entirely sensible approach--based on good research with a careful eye toward the risk/benefit ratio of the radiation, it should be noted--there were howls of indignation from people purportedly speaking for women, accusing the very bureaucrats who issued the new recs to be female-hostile, or something like that.
--br
(NB--the first draft of this version, which snuck out prematurely, posted some incorrect calculations with respect to x-rays, mammograms, and NY-LA flights. The corrected version is now present.)
Monday, March 21, 2011
The "Back-Door CD4" and Its Ethics, or Lack Thereof
Every year, virtually every first-year medical student gets introduced to medical ethics by learning about the quirky religious beliefs of a small Christian sect: Jehovah’s Witnesses. Based on their interpretation of a passage from Leviticus, Jehovah’s Witnesses consider blood transfusion to be against God’s word, and will thus not accept them, even if their life depends on it. Medical students are introduced to this situation as the classic example of how an American physician is supposed to behave: it don’t matter what your personal beliefs are with respect to the Witnesses, only that you accept their right to their beliefs and, if need be, protect them, defend them, and do whatever else is necessary to let them decide what to do with their bodies. We call that concept informed consent, and it’s the basis of most serious discussions about life-saving medical care in this country. (Of course, I'm talking about adults here; with kids, the situation gets stickier, and with adolescents, stickier still.)
In theory, informed consent is the process by which patients take the reins and make all the genuinely important medical decisions for themselves, while docs serve as something like advisors. Needless to say I’m not talking about the minutiae of medical decision making, like whether to switch a patient from amlodipine to atenolol, but rather the stuff that most patients worry about when they (or their loved ones) walk through the hospital doors: do I want to be resuscitated? do I want to have “everything” done for me? can I refuse some procedures the doctor recommends? These are precisely the kinds of questions where we, as physicians, have an obligation to help patients and their families figure out what they want—that is, not impose on them what we want—and guide them as best we can, even if, indeed, especially if they make decisions that we find shortsighted or wrongheaded or both.
That’s the theory. Fortunately, in terms of practice, most of the time I think we physicians do a pretty admirable job of supporting our patients. You would be hard pressed to find a doctor who thinks it’s acceptable to override the beliefs of a Jehovah’s Witness and force-feed them blood to save their lives. That said, while the core of that philosophy is wholly adopted by the profession, precisely where the boundaries lay can be contentious. And last week I was again reminded that we don’t all agree on what constitutes honoring our patients’ wishes.
It happened when I was hearing about a case of a patient in the Intensive Care Unit fit for an episode of House, M.D. The patient was older without being elderly, and had a respiratory illness that had defied diagnosis despite the best intentions of cardiologists, pulmonologists, infectious disease specialists, and a few other medical professionals to boot. The ID docs, though unsure of what was going on, thought that this was most likely some infection seen in the setting of underlying AIDS, and I, being an ID guy, shared their point of view while hearing the details. Like my colleagues, the question to which I wanted to know the answer was: what was the result of the HIV test? But the patient had adamantly refused HIV testing. And that’s within his right: a doctor can order most blood tests without having to discuss them with a patient, but an HIV test—just like a blood transfusion—is special, and requires a signed form saying that the patient agrees to it. In this case, where a diagnosis of HIV infection might be helpful (more on this later), such a refusal can be maddening. But that is how the rules are set up right now, and once the patient says no, then that’s all she wrote.
However, in this case, that wasn’t all she wrote. HIV is a virus that infects, and destroys, a special kind of white blood cell called a CD4 cell. In general, the further your CD4 cell count drops, the more you are at risk of being infected by the weird organisms that are the sine qua non of AIDS, things like toxoplasmosis, cryptococcosis, penicillium marneffei and a host of other parasites, bacteria and fungi that people with healthy immune systems never develop. A person with a healthy immune system typically has a CD4 count that runs from 500 to 1500, give or take; the definition of AIDS is someone with HIV infection and a CD4 count less than 200.
One of the loopholes of informed consent for HIV testing is that it does not cover CD4 counts.
You can see where this is going. Some doc tried to do an end run around the refusal and checked the patient’s CD4 count. Surprise! It was low, less than 200, although the pattern of the CD4 cells didn’t really look like AIDS (skipping some technical detail here). So then what do you do? You have gotten no closer to the diagnosis, and you have put yourself into the uncomfortable situation where you may be tempted to take action. Sometimes the treatment for some of those weird “opportunistic infections” in AIDS is to just give a person medications for HIV, but you wouldn’t give those meds to a patient without a diagnosis of HIV. In this situation, that wasn’t the case, but what if it were? Would you throw antiretrovirals at the person because his CD4 count was suggestive of HIV—even though the patient unambiguously refused the test? To me, this smells exactly like giving blood to a Jehovah’s Witness: doing what I call a “Back-Door CD4” might seem clever, but it pretty obviously violates the spirit of the patient’s wishes, if not the letter.
Some would argue that the very need to consent people for HIV is outdated. HIV consent was established at a time when the diagnosis was severely stigmatizing, and “positives” could lose jobs, insurance premiums and in general face ostracism from their communities; it also happened at a time when treatment wasn’t exactly effective. Today, the latter is definitely not true, and as I tell my HIV patients all the time, there is no reason to suppose that, should they take their meds every day faithfully, they should live as long as anyone else. Whether the former is true I am a touch skeptical, but I acknowledge that the level of stigma nowhere near approaches where it was twenty years ago. Thus, proponents of the Back-Door CD4 would say that the time for HIV consent has come and gone. Way back in 2004 a doc named LA Jansen wrote in the Journal of Medical Ethics and supposed that the Back-Door CD4 was a form of “conscientious subversion,” something akin to conscientious objection, where a physician acknowledged the existing legal landscape but did his or her own thing based on their personal ethics.
Jansen dresses the term up in calling it “conscientious subversion”; I prefer using simpler language and think of it as a bad idea. By my compass, patients have rights to refuse tests, medications, procedures, and any attempt at thwarting those desires defeats not only the entire point of informed consent, it belies the idea that we are advocates for our patients. Don’t get cute, is what I’d say: we are better than most professions at standing by those we serve. Let’s not mess things up by thinking we know better than they do.
—br
PS—the Jehovah’s Witness example has, for me, not been entirely academic. Twice I have cared for Witnesses who were in situations where transfusion was definitely worth considering, and in one of the cases it was pretty clearly indicated. Like most of my profession, it never entered my mind to try to push the idea on them once I learned of their religious beliefs. For more on Jehovah’s Witnesses and their philosophy behind their refusal of blood transfusions, see here, here and/or here.
In theory, informed consent is the process by which patients take the reins and make all the genuinely important medical decisions for themselves, while docs serve as something like advisors. Needless to say I’m not talking about the minutiae of medical decision making, like whether to switch a patient from amlodipine to atenolol, but rather the stuff that most patients worry about when they (or their loved ones) walk through the hospital doors: do I want to be resuscitated? do I want to have “everything” done for me? can I refuse some procedures the doctor recommends? These are precisely the kinds of questions where we, as physicians, have an obligation to help patients and their families figure out what they want—that is, not impose on them what we want—and guide them as best we can, even if, indeed, especially if they make decisions that we find shortsighted or wrongheaded or both.
That’s the theory. Fortunately, in terms of practice, most of the time I think we physicians do a pretty admirable job of supporting our patients. You would be hard pressed to find a doctor who thinks it’s acceptable to override the beliefs of a Jehovah’s Witness and force-feed them blood to save their lives. That said, while the core of that philosophy is wholly adopted by the profession, precisely where the boundaries lay can be contentious. And last week I was again reminded that we don’t all agree on what constitutes honoring our patients’ wishes.
It happened when I was hearing about a case of a patient in the Intensive Care Unit fit for an episode of House, M.D. The patient was older without being elderly, and had a respiratory illness that had defied diagnosis despite the best intentions of cardiologists, pulmonologists, infectious disease specialists, and a few other medical professionals to boot. The ID docs, though unsure of what was going on, thought that this was most likely some infection seen in the setting of underlying AIDS, and I, being an ID guy, shared their point of view while hearing the details. Like my colleagues, the question to which I wanted to know the answer was: what was the result of the HIV test? But the patient had adamantly refused HIV testing. And that’s within his right: a doctor can order most blood tests without having to discuss them with a patient, but an HIV test—just like a blood transfusion—is special, and requires a signed form saying that the patient agrees to it. In this case, where a diagnosis of HIV infection might be helpful (more on this later), such a refusal can be maddening. But that is how the rules are set up right now, and once the patient says no, then that’s all she wrote.
However, in this case, that wasn’t all she wrote. HIV is a virus that infects, and destroys, a special kind of white blood cell called a CD4 cell. In general, the further your CD4 cell count drops, the more you are at risk of being infected by the weird organisms that are the sine qua non of AIDS, things like toxoplasmosis, cryptococcosis, penicillium marneffei and a host of other parasites, bacteria and fungi that people with healthy immune systems never develop. A person with a healthy immune system typically has a CD4 count that runs from 500 to 1500, give or take; the definition of AIDS is someone with HIV infection and a CD4 count less than 200.
One of the loopholes of informed consent for HIV testing is that it does not cover CD4 counts.
You can see where this is going. Some doc tried to do an end run around the refusal and checked the patient’s CD4 count. Surprise! It was low, less than 200, although the pattern of the CD4 cells didn’t really look like AIDS (skipping some technical detail here). So then what do you do? You have gotten no closer to the diagnosis, and you have put yourself into the uncomfortable situation where you may be tempted to take action. Sometimes the treatment for some of those weird “opportunistic infections” in AIDS is to just give a person medications for HIV, but you wouldn’t give those meds to a patient without a diagnosis of HIV. In this situation, that wasn’t the case, but what if it were? Would you throw antiretrovirals at the person because his CD4 count was suggestive of HIV—even though the patient unambiguously refused the test? To me, this smells exactly like giving blood to a Jehovah’s Witness: doing what I call a “Back-Door CD4” might seem clever, but it pretty obviously violates the spirit of the patient’s wishes, if not the letter.
Some would argue that the very need to consent people for HIV is outdated. HIV consent was established at a time when the diagnosis was severely stigmatizing, and “positives” could lose jobs, insurance premiums and in general face ostracism from their communities; it also happened at a time when treatment wasn’t exactly effective. Today, the latter is definitely not true, and as I tell my HIV patients all the time, there is no reason to suppose that, should they take their meds every day faithfully, they should live as long as anyone else. Whether the former is true I am a touch skeptical, but I acknowledge that the level of stigma nowhere near approaches where it was twenty years ago. Thus, proponents of the Back-Door CD4 would say that the time for HIV consent has come and gone. Way back in 2004 a doc named LA Jansen wrote in the Journal of Medical Ethics and supposed that the Back-Door CD4 was a form of “conscientious subversion,” something akin to conscientious objection, where a physician acknowledged the existing legal landscape but did his or her own thing based on their personal ethics.
Jansen dresses the term up in calling it “conscientious subversion”; I prefer using simpler language and think of it as a bad idea. By my compass, patients have rights to refuse tests, medications, procedures, and any attempt at thwarting those desires defeats not only the entire point of informed consent, it belies the idea that we are advocates for our patients. Don’t get cute, is what I’d say: we are better than most professions at standing by those we serve. Let’s not mess things up by thinking we know better than they do.
—br
PS—the Jehovah’s Witness example has, for me, not been entirely academic. Twice I have cared for Witnesses who were in situations where transfusion was definitely worth considering, and in one of the cases it was pretty clearly indicated. Like most of my profession, it never entered my mind to try to push the idea on them once I learned of their religious beliefs. For more on Jehovah’s Witnesses and their philosophy behind their refusal of blood transfusions, see here, here and/or here.
Thursday, March 10, 2011
Profile in Courage, Writ Small, But Still
Today was Grand Rounds at my academic medical center. The subject was diabetes and how we--"we" being the medical system as opposed to "we" the individual doctors--can improve outcomes in this disease, which is a killer, and which we (pick whichever "we" you like) stink at treating successfully. The view of the speakers, with which I'm sympathetic, is that we require less gee-whiz bioscience breakthroughs than we do a comprehensive, systematic plan for identifying, following, and ensuring affected patients stay on their meds. None of their suggestions were particularly sexy and didn't involve lots of fancy technology except for using a personal computer. I was persuaded by their assertion that sometimes it's simple but labor-intensive solutions in medicine that are the ones with the best chance of success.
Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.
I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.
So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.
She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)
It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.
Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.
I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.
So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.
She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)
It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.
Wednesday, March 2, 2011
BRB Link Dump
My spiritual and theological leanings are probably just enough to drive everyone concerned totally nuts: I am intellectually atheist, though functionally Jewish, plus I'm fond of various other religions (or at least certain aspects of them). We have a new Rabbi at our Synagogue and while he appears to be a very charismatic man, my own religious leanings are such that I do not look to him for spiritual leadership in any capacity, and I remain a member partly because I like going to synagogue, but mostly because I really like peace between me and my wife.
The point of this rambling being that although I long ago decided to follow my own path and look toward no other man or woman as my spiritual leader, if I had to choose a person, I quite possibly could have chosen Peter Gomes, whose life ended just a little too soon for my tastes earlier this week. Gomes was about the most polar opposite person you could pick for me to follow: he was African-American; I was white. He was Christian; I, an agnostic Jew. He was gay; I, not so much, thanks, though as Jerry Seinfeld noted, not that there's anything wrong with that. He was, for most of his life, a Republican, and I have mostly not been a Democrat because I regarded them as too far to the right. He was something of a dandy with something of a pompous manner of speaking at the most Establishment university in the United States; I am a well-educated though frequently unspeakably crude dude who went to Abbie Hoffman's school and often sneers at The Establishment. On the surface, thus, not my kind of guy.
But once you peel away his formal and sometimes antiquated mannerisms and really listen to Peter Gomes, there is aught but beauty, truth, and light. Here is a brief comment on gay marriage, while here a longer talk with Charlie Rose. He opens the conversation with Rose with a line that elegantly encapsulates why I find him so admirable: "I like the notion that there is much yet to be revealed about the Christian faith; it's not all over yet. It's not a complete story, and we're moving into it. There is much yet to be revealed, and I think our best theological days are ahead of us." If that ain't a bare-bones summary of the philosophy of the great Talmudic masters (that is, the part of the Talmudic masters that I find worthy of attention), then I don't know what is. I have not read any of his books, and my acquaintance with him is largely through talks & other coverage he's received in that peculiar Harvardo-centric fishbowl of Boston media (you could catch his sermons on Sunday morning on WHRB, the Harvard radio station). It may be a tough pill for me to swallow to read a book about Jesus, but in the coming months I may peruse one of his books to stay connected with this eminently decent and astonishingly eloquent man.
More immediate concerns that nobody else in the vicinity of Harvard Yard prematurely join the Reverend Gomes are very much on the minds of Massachusetts public health officials as they scramble to contain a measles outbreak inflicted on the city by an unvaccinated French woman working for the French consulate downtown. What a mess: the super-contagious virus may have spread to a professor at UMass Boston, and thus his students are bearing the brunt of some public health measures, but fortunately seem not to be too bothered by the whole fuss. Though make no mistake, a fuss this is: measles spreads like wildfire and--while not overwhelmingly lethal by Andromeda-strain standards--kills simply by the fact that so many can become infected so quickly. Even a low mortality rate of, say, three percent can be a lot of bodies if tens of thousands become infected. And while the vaccine for measles (the "MMR") is good, it's not perfect, so even vaccinated people are at risk of infection, especially if they haven't been vaccinated in decades. As I noted in a previous entry: this virus is a killer. How this gal got into the US and was allowed to work without having a documented MMR is not fully clear to me, but many are paying the price for her folly.
--br
The point of this rambling being that although I long ago decided to follow my own path and look toward no other man or woman as my spiritual leader, if I had to choose a person, I quite possibly could have chosen Peter Gomes, whose life ended just a little too soon for my tastes earlier this week. Gomes was about the most polar opposite person you could pick for me to follow: he was African-American; I was white. He was Christian; I, an agnostic Jew. He was gay; I, not so much, thanks, though as Jerry Seinfeld noted, not that there's anything wrong with that. He was, for most of his life, a Republican, and I have mostly not been a Democrat because I regarded them as too far to the right. He was something of a dandy with something of a pompous manner of speaking at the most Establishment university in the United States; I am a well-educated though frequently unspeakably crude dude who went to Abbie Hoffman's school and often sneers at The Establishment. On the surface, thus, not my kind of guy.
But once you peel away his formal and sometimes antiquated mannerisms and really listen to Peter Gomes, there is aught but beauty, truth, and light. Here is a brief comment on gay marriage, while here a longer talk with Charlie Rose. He opens the conversation with Rose with a line that elegantly encapsulates why I find him so admirable: "I like the notion that there is much yet to be revealed about the Christian faith; it's not all over yet. It's not a complete story, and we're moving into it. There is much yet to be revealed, and I think our best theological days are ahead of us." If that ain't a bare-bones summary of the philosophy of the great Talmudic masters (that is, the part of the Talmudic masters that I find worthy of attention), then I don't know what is. I have not read any of his books, and my acquaintance with him is largely through talks & other coverage he's received in that peculiar Harvardo-centric fishbowl of Boston media (you could catch his sermons on Sunday morning on WHRB, the Harvard radio station). It may be a tough pill for me to swallow to read a book about Jesus, but in the coming months I may peruse one of his books to stay connected with this eminently decent and astonishingly eloquent man.
More immediate concerns that nobody else in the vicinity of Harvard Yard prematurely join the Reverend Gomes are very much on the minds of Massachusetts public health officials as they scramble to contain a measles outbreak inflicted on the city by an unvaccinated French woman working for the French consulate downtown. What a mess: the super-contagious virus may have spread to a professor at UMass Boston, and thus his students are bearing the brunt of some public health measures, but fortunately seem not to be too bothered by the whole fuss. Though make no mistake, a fuss this is: measles spreads like wildfire and--while not overwhelmingly lethal by Andromeda-strain standards--kills simply by the fact that so many can become infected so quickly. Even a low mortality rate of, say, three percent can be a lot of bodies if tens of thousands become infected. And while the vaccine for measles (the "MMR") is good, it's not perfect, so even vaccinated people are at risk of infection, especially if they haven't been vaccinated in decades. As I noted in a previous entry: this virus is a killer. How this gal got into the US and was allowed to work without having a documented MMR is not fully clear to me, but many are paying the price for her folly.
--br
Tuesday, February 22, 2011
Doctors in Wisconsin Sign Fake Sick Notes for Protesters; Civilization to Collapse Shortly
Whenever I begin to think that I have Sold Out in life and have embraced respectable living and taken an establishment career track, something will happen to remind me that, whatever desires I might nurture in the bosom of my soul to be acceptable and thus accepted, I am in fact a person with a fringe philosophy that most in my profession would consider dangerously radical.
A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.
I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."
Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.
To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.
--br
UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.
A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.
I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."
Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.
To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.
--br
UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.
Monday, February 21, 2011
Michele Bachmann, the First Lady, Breast Milk, and Much Ado About Nothing
It makes for a very intriguing headline: could some political spat somehow realign self-identified liberals with Michele Bachmann, and conservatives with Michelle Obama?
At first, while glancing at the NYT headline, "A Breast Feeding Plan Mixes Partisan Reactions," I thought that perhaps the moon was indeed in the Seventh House, and Jupiter had aligned with Mars.
But as much as NYT and some other outlets would like to have you believe that we've reached the Age Of Aquarius, I'm thinking more that we've reached the Age of Same-Old, Same-Old, with a page from the Mountains Out Of Molehills playbook.
To recount the mini-saga, last week Representative Bachmann fired a broadside at the First Lady during an interview with radio host Laura Ingraham for "the government's role in breastfeeding," as Ingraham's website proudly chirps. Ms. Obama has been promoting breastfeeding for almost a year now, from what I can find on the WhiteHouse.gov website, but Bachmann was reacting to the latest news that the IRS had announced that breast pumps, which can cost up to several hundred dollars, would be available for a tax break. Bachmann first complained about the tax break--something very un-Republican like--by complaining that "government is the answer to everything." She then added, "to think that government has to go out and buy my breast pump—you want to talk about nanny state, I think we just got a new definition,” in classically Bachmannian rhetoric which is either exasperatingly stupid or chillingly cynical, since a tax break in no way implies that the government is going to purchase breast pumps for the mothers of America.
[That's my emphasis, by the way. Also, I have been unable to find the link to the actual IRS announcement, though many outlets report on it, as TIME does here, or ABC News does here--the ABC News link is dead.Typing in "breast pumps" into the IRS search engine turns up nothing, and searching IRS.gov on "breasts" does turn up a lengthy document released in August, though I could find no breast pump references while perusing it. Nor could I find a press release on tax breaks for devices designed for the liberation of boob juice. Needless to say, I am having an enormous amount of fun tonight.]
Anyway, the story received attention from media outlets in search of culture-war fodder or some such, and lots of outlets, even including ones across the Pond, ran with it. Which, no doubt, is precisely what Representative Bachmann had hoped for, even if the attack made no real sense: she's in the headlines. Maybe this is part of a coordinated effort to put her name in the mix for the 2012 Republican Presidential primaries, and chip into the Republican/conservative gal-appeal of Sarah Palin, who, perhaps sensing a missed opportunity, got in a shot in at the First Lady in a speech in Long Island.
Who knows? Who cares? But the Times article tried a new slant: the reactions from party loyalists were flipped. "On blogs and in interviews, some liberal Democrats found themselves agreeing with Representative Bachmann...some conservatives, meanwhile, stood up for Mrs. Obama for promoting what they said was a healthier choice," the Times reporter, Kate Zernike, observed.
Which is technically correct, as the article goes on to quote some self-described liberals siding with the utter nonsense of Ms. Bachmann, and conservatives siding with Ms. Obama. But as numbers go--and after a not-exhaustive and not-scientific but well-intentioned reading of comments at the soft-left Times, the soft-right WaPo, the harder-left Salon and a few other places to boot--I found no evidence of massive political realignment. I found a small number of comments from self-described conservatives supporting the First Lady, a good many more criticizing her, and more than half of those totally missing the point...but no comments from liberals defending Bachmann.
(As a side note, I read the Salon comments with a certain horror--the comments section has become a den of lefty sleaze. On many topics I am of one mind with Salon's editorial staff, and I share in their righteous fury at the various injustices of the world, but reading the comments section of pretty much any Salon political article these days is chilling. Civility is considered quaint as commenters attempt to outvulgarize each other, and the menacing allusions to violence would make you think you had just walked into a Tea Party rally. It's disturbing.)
I was feeling quite proud of this analysis until I discovered this article from HuffPo that explains how Zernike used one anonymous commenter, and a second equally anonymous "progressive mother in Brooklynite" as a source to gin up what amounts to a fake article. NYT should be a bit embarrassed; if it isn't Billy is on their behalf.
--br
PS--The Billy Rubin Blog is up to four--yes, count 'em, four!--followers! Please feel free to get on board, or get an RSS feed so that new entries will be sent directly to your e-mail and you won't have to check back every so often for updates. We appreciate it!
At first, while glancing at the NYT headline, "A Breast Feeding Plan Mixes Partisan Reactions," I thought that perhaps the moon was indeed in the Seventh House, and Jupiter had aligned with Mars.
But as much as NYT and some other outlets would like to have you believe that we've reached the Age Of Aquarius, I'm thinking more that we've reached the Age of Same-Old, Same-Old, with a page from the Mountains Out Of Molehills playbook.
To recount the mini-saga, last week Representative Bachmann fired a broadside at the First Lady during an interview with radio host Laura Ingraham for "the government's role in breastfeeding," as Ingraham's website proudly chirps. Ms. Obama has been promoting breastfeeding for almost a year now, from what I can find on the WhiteHouse.gov website, but Bachmann was reacting to the latest news that the IRS had announced that breast pumps, which can cost up to several hundred dollars, would be available for a tax break. Bachmann first complained about the tax break--something very un-Republican like--by complaining that "government is the answer to everything." She then added, "to think that government has to go out and buy my breast pump—you want to talk about nanny state, I think we just got a new definition,” in classically Bachmannian rhetoric which is either exasperatingly stupid or chillingly cynical, since a tax break in no way implies that the government is going to purchase breast pumps for the mothers of America.
[That's my emphasis, by the way. Also, I have been unable to find the link to the actual IRS announcement, though many outlets report on it, as TIME does here, or ABC News does here--the ABC News link is dead.Typing in "breast pumps" into the IRS search engine turns up nothing, and searching IRS.gov on "breasts" does turn up a lengthy document released in August, though I could find no breast pump references while perusing it. Nor could I find a press release on tax breaks for devices designed for the liberation of boob juice. Needless to say, I am having an enormous amount of fun tonight.]
Anyway, the story received attention from media outlets in search of culture-war fodder or some such, and lots of outlets, even including ones across the Pond, ran with it. Which, no doubt, is precisely what Representative Bachmann had hoped for, even if the attack made no real sense: she's in the headlines. Maybe this is part of a coordinated effort to put her name in the mix for the 2012 Republican Presidential primaries, and chip into the Republican/conservative gal-appeal of Sarah Palin, who, perhaps sensing a missed opportunity, got in a shot in at the First Lady in a speech in Long Island.
Who knows? Who cares? But the Times article tried a new slant: the reactions from party loyalists were flipped. "On blogs and in interviews, some liberal Democrats found themselves agreeing with Representative Bachmann...some conservatives, meanwhile, stood up for Mrs. Obama for promoting what they said was a healthier choice," the Times reporter, Kate Zernike, observed.
Which is technically correct, as the article goes on to quote some self-described liberals siding with the utter nonsense of Ms. Bachmann, and conservatives siding with Ms. Obama. But as numbers go--and after a not-exhaustive and not-scientific but well-intentioned reading of comments at the soft-left Times, the soft-right WaPo, the harder-left Salon and a few other places to boot--I found no evidence of massive political realignment. I found a small number of comments from self-described conservatives supporting the First Lady, a good many more criticizing her, and more than half of those totally missing the point...but no comments from liberals defending Bachmann.
(As a side note, I read the Salon comments with a certain horror--the comments section has become a den of lefty sleaze. On many topics I am of one mind with Salon's editorial staff, and I share in their righteous fury at the various injustices of the world, but reading the comments section of pretty much any Salon political article these days is chilling. Civility is considered quaint as commenters attempt to outvulgarize each other, and the menacing allusions to violence would make you think you had just walked into a Tea Party rally. It's disturbing.)
I was feeling quite proud of this analysis until I discovered this article from HuffPo that explains how Zernike used one anonymous commenter, and a second equally anonymous "progressive mother in Brooklynite" as a source to gin up what amounts to a fake article. NYT should be a bit embarrassed; if it isn't Billy is on their behalf.
--br
PS--The Billy Rubin Blog is up to four--yes, count 'em, four!--followers! Please feel free to get on board, or get an RSS feed so that new entries will be sent directly to your e-mail and you won't have to check back every so often for updates. We appreciate it!
Friday, February 18, 2011
Will Doctors Be Relevant in the World of Watson?
Like so many other people, I watched Jeopardy this week with rapt attention as I saw IBM's uber-computer Watson clean the clocks of Jeopardy's two greatest champions, Ken Jennings and Brad Rutter. My reaction--that of fascination bordering on the point of awe simultaneously mixed with a not insignificant amount of apprehension--was probably also shared by a good number of viewers. Did we witness the creation of something worthy of comparison to the Brandenburg Concertos, or Frankenstein? No way to know at the moment. Check back with the Billy Rubin Blog in about four or five decades. I promise to do a follow-up entry at that time.
While watching the informational clips during the Jeopardy show in the first round, where various Big Bluers explained the mission and the challenges of developing Watson, I was struck by how Watson could be used in medicine. Give it a patient who explains their symptoms, then feed Watson with basic lab or other clinical data, and you could easily produce a computer doc that would rival the best in the biz. IBM seems to have had the same thought, as Carey Goldberg of the CommonHealth blog notes, as they have partnered with Nuance Communications of Burlington, MA to set up computer systems built on the advances gained from the making of Watson.
Leave aside the rather terrifying fact that this could deprive me of a job in the decades to come, it's not hard to see the ways in which a Doc Watson could outperform a flesh-and-blood physician. Take, for instance, the news story this week about the neurologic event of TV anchor Serene Branson, which earned speculation from ER physicians as well as a Happy Hospitalist as to the diagnosis (for a prescient discussion of the media portrayal, see Gary Schweitzer's HealthNewsReview entry here). Leave aside the dramatic videotape of Ms. Branson for a moment. What's the diagnosis?
The immediate speculation was that Branson suffered a Transient Ischemic Attack or "mini-stroke." To me, this never quite made sense for the simple fact that Branson is young, and TIAs are typically a disease of people in their 6th decade and beyond. Of course, there are outliers, as demonstrated by the sad story of professional baseball pitcher Darryl Kile, who died in his sleep in midseason at age 33 and was found at autopsy to have obstruction of two major coronary arteries, which is extremely unusual for one so young. So although a TIA seemed possible, I thought that the list of possible diagnoses included things like Multiple Sclerosis, and since I'm an ID doc I immediately thought of neurologic diseases associated with HIV. Other docs weighed in on the blogs and several proposed the possibility that this was a complex migraine headache This is now the official diagnosis of the authorities who have cared for her at the UCLA medical center (though, as Happy notes, this pronouncement came from a neurosurgeon, which from a medical standpoint is very odd and not entirely appropriate).
The diagnosis might be spot-on but it's a tough one to make. What could a Doc Watson do that we couldn't? Watson would be able to take the patient's age, take the information from all the data generated by her care (vital signs, physical exam findings, the history of garbled speech, any pertinent information from her family and social history, labs and radiologic tests) and arrive at a mathematically precise risk assessment for each of these various diagnoses, just as it did in trying to answer Alex Trebek's questions. (Yes, I know, it's the other way around in Jeopardy. Let's just move on.)
That is, I can note in a vague way based on my learning in medicine that TIAs are less likely to occur in younger people, but I have no idea the precise numbers; for Watson, I would assume that it would be a small matter to incorporate hundreds of epidemiologic studies allowing it to calculate multiple probabilities for all sorts of diseases. It's not that Watson would be doing anything different than what we do every day when we form differential diagnoses on patients, it's just that Watson would have three huge advantages: it could access considerably more information than we can (we are limited by how much we can read, and then remember, while for Watson that's just a download), it can then take that information and process it orders of magnitude more quickly, and it can describe the likelihood of an uncertain diagnosis with a precision that is virtually impossible for a lone human physician to do in live time while seeing a patient.
I'm not a computer specialist and don't know the inner workings of Watson, but I don't think this is wild speculation on my part. I suspect that we're not far away from being able to feed information into Watson-like programs that will help our diagnostic accuracy increase tremendously in the years to come. I also suspect that there will come a point where Watson-like programs will obviate the need for physicians. Hope I'm retired by that point!
Hat tips to Grunt Doc, Gary Schweitzer, Happy Hospitalist, CommonHealth.
--br
While watching the informational clips during the Jeopardy show in the first round, where various Big Bluers explained the mission and the challenges of developing Watson, I was struck by how Watson could be used in medicine. Give it a patient who explains their symptoms, then feed Watson with basic lab or other clinical data, and you could easily produce a computer doc that would rival the best in the biz. IBM seems to have had the same thought, as Carey Goldberg of the CommonHealth blog notes, as they have partnered with Nuance Communications of Burlington, MA to set up computer systems built on the advances gained from the making of Watson.
Leave aside the rather terrifying fact that this could deprive me of a job in the decades to come, it's not hard to see the ways in which a Doc Watson could outperform a flesh-and-blood physician. Take, for instance, the news story this week about the neurologic event of TV anchor Serene Branson, which earned speculation from ER physicians as well as a Happy Hospitalist as to the diagnosis (for a prescient discussion of the media portrayal, see Gary Schweitzer's HealthNewsReview entry here). Leave aside the dramatic videotape of Ms. Branson for a moment. What's the diagnosis?
The immediate speculation was that Branson suffered a Transient Ischemic Attack or "mini-stroke." To me, this never quite made sense for the simple fact that Branson is young, and TIAs are typically a disease of people in their 6th decade and beyond. Of course, there are outliers, as demonstrated by the sad story of professional baseball pitcher Darryl Kile, who died in his sleep in midseason at age 33 and was found at autopsy to have obstruction of two major coronary arteries, which is extremely unusual for one so young. So although a TIA seemed possible, I thought that the list of possible diagnoses included things like Multiple Sclerosis, and since I'm an ID doc I immediately thought of neurologic diseases associated with HIV. Other docs weighed in on the blogs and several proposed the possibility that this was a complex migraine headache This is now the official diagnosis of the authorities who have cared for her at the UCLA medical center (though, as Happy notes, this pronouncement came from a neurosurgeon, which from a medical standpoint is very odd and not entirely appropriate).
The diagnosis might be spot-on but it's a tough one to make. What could a Doc Watson do that we couldn't? Watson would be able to take the patient's age, take the information from all the data generated by her care (vital signs, physical exam findings, the history of garbled speech, any pertinent information from her family and social history, labs and radiologic tests) and arrive at a mathematically precise risk assessment for each of these various diagnoses, just as it did in trying to answer Alex Trebek's questions. (Yes, I know, it's the other way around in Jeopardy. Let's just move on.)
That is, I can note in a vague way based on my learning in medicine that TIAs are less likely to occur in younger people, but I have no idea the precise numbers; for Watson, I would assume that it would be a small matter to incorporate hundreds of epidemiologic studies allowing it to calculate multiple probabilities for all sorts of diseases. It's not that Watson would be doing anything different than what we do every day when we form differential diagnoses on patients, it's just that Watson would have three huge advantages: it could access considerably more information than we can (we are limited by how much we can read, and then remember, while for Watson that's just a download), it can then take that information and process it orders of magnitude more quickly, and it can describe the likelihood of an uncertain diagnosis with a precision that is virtually impossible for a lone human physician to do in live time while seeing a patient.
I'm not a computer specialist and don't know the inner workings of Watson, but I don't think this is wild speculation on my part. I suspect that we're not far away from being able to feed information into Watson-like programs that will help our diagnostic accuracy increase tremendously in the years to come. I also suspect that there will come a point where Watson-like programs will obviate the need for physicians. Hope I'm retired by that point!
Hat tips to Grunt Doc, Gary Schweitzer, Happy Hospitalist, CommonHealth.
--br
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