Hey Arizona, ur doin' it 'rong...

Gail Collins comes up with a stunning, refreshing rebuke of the idiocy of Arizona's new approach to cut $4.5 million dollars from its state Medicaid expenditures by denying certain types of organ transplants.  The bottom line: government bureaucrats allowed the plug to be pulled on a 32 year-old father.  No, seriously.  This is from a state run by people who said "Obamacare" was going to do just that; when in fact health care reform was put in place, in part, to avoid such devastating consequences of cost cutting in the setting of poor information.

Update (12-17-2010): still sounds like death panels to me.  Wasn't this kind of thing supposed to happen under the watch of "liberals"? Never a state like AZ...

I was, am, and hope to always be naïve.

I hope you think the picture is pretty, but I don’t expect you to be as taken away as I am: I understand that discovering the sight was part of the fulfillment’s process. I take that back, actually. I didn’t discover anything. I just observed some already-well-characterized phenomena.

A couple of months ago, when I just started my PhD training, I saw this image under the microscope. I forgot how much time I spent staring at all the different motor neurons, how they extended their processes to hold figurative hands and pass along chemical love messages. I spent more time taking the highest resolution picture I could, which has been edited to its current state.

If I gave this image to a polite, random neuroscientist, he/she would give me a coy smile and say that the picture was “nice and the TUJ1 antibody stained very well.” If I gave this image to an impatient and nasty, random neuroscientist he/she would scowl at the piece of paper and ask me why I was wasting his/her time: I’m not showing anything new!

I hope this figure will be as stunning to me in a few years, when I’ve read more literature and seen more figures and done more research and graduated with a PhD. Sure I’ll see a lot of similar images; I might be bombarded by them. But I hope to appreciate that the ordinary is beautiful too: because you see it once, doesn’t mean the allure has to fade.

Monday afternoon football update

This weekend in American football:

1. A Rutgers' University student athlete was paralyzed from the neck down after an in-game incident against Army.
Update (10-19-2010): The most recent medical literature says that 90% of patients with complete tetraplegia (aka quadraplegia) at one month post-injury remain complete tetraplegics for good.  After 6 months, there is little change in a person's neurological status caudal to the spinal injury.  In other words, the coming days and weeks will be hugely informative of the athlete's function long into the future.  Here's hoping he regains function.  Also, from what I have gleaned from the news reports, it does not appear that therapeutic hypothermia (TH) was tried.  Recall that TH was used when Buffalo Bills' player Kevin Everett was injured back in 2007.  Although the use of TH in his case is still being debated, he was able to walk within ~one month of the injury.


2. Yesterday's NFL games featured several instances of traumatic brain injuries.

walking, chewing gum

In my recent interactions with one of UCLA's true physician-scientists, I start to get the sense, more than ever before, how this journey is about learning to walk and chew gum...at the same time! Hackneyed cliche aside, I guess I have begun to realize how all of this research and medicine "stuff" isn't so incredibly difficult, but juggling different responsibilities requires intra- and inter-personal patience: transitions are hard, and a deep breath and calm go a long way.  But it's still hard work.

Rethinking traumatic brain injury and its consequences: “repeated brain injury can change your life and your family’s life forever.”

I watch the NFL most weekends, and I won’t lie: I’m mesmerized by the horrific collisions and the looped instant replay that progressively slows down so that I can see faces grimace on impact. After most hits, the players bounce back up, dust and readjust their jerseys, and run back into position to get hit again. After the bad hits -- a lot of the times on the quarterback -- the trainer and then the team physician and then the medics come to the field. An awkward fall or collision can cause a player’s helmet to hit the ground at a ridiculous velocity.

In 2009 Roger Goodell, the NFL commissioner, testified in front of the House Judiciary Committee and did not recognize an association between head trauma suffered in games and brain diseases later incurred by those players. The league promised to “do better” and later that year issued “stricter” concussion guidelines.

Since Goodell’s testimony, the NFL has slowly changed its outlook regarding traumatic brain injury. A sobering poster in team locker rooms acknowledges that concussions can cause “problems with memory and communication, personality changes, as well as depression and early onset of dementia.”

Omitted in the list of concussion-associated conditions is a Lou Gehrig’s-like disease. Lou Gehrig’s disease (amyotrophic lateral sclerosis (ALS)) is a progressive, neurodegenerative condition that affects upper and lower motor neurons. Patients, like Stephen Hawking, are left weakened and atrophied to the point where they can no longer support breathing. The etiology of ALS was thought to be primarily organic. Current studies, however, suggest head trauma can cause a similar disease state. So Lou Gehrig may not have had Lou Gehrig’s disease. A New York Times article reviews his well-documented history of head trauma. Spinal cord pathology samples have shown that others athletes -- boxers and football players -- have been misdiagnosed with ALS. It is hypothesized that the neurodegeneration related to chronic traumatic encephalopathy (CTE) is mediated by neurofibrillary tangles, which are also seen in Alzheimer's.

Whether the neurofibrillary tangles and neurodegeneration are taking place in the motor neurons or temporal or frontal lobes, the fallout is real and serious. Chuck highlighted the sad story of Chris Henry, a former wide receiver for the Cincinnati Bengals, who demonstrated behavioral changes leading up to his accidental death. An autopsy revealed CTE. Malcolm Gladwell surveyed some of the NFL’s horror stories:

“Mike Webster, the longtime Pittsburgh Steeler and one of the greatest players in N.F.L. history, ended his life a recluse, sleeping on the floor of the Pittsburgh Amtrak station. Another former Pittsburgh Steeler, Terry Long, drifted into chaos and killed himself four years ago by drinking antifreeze. Andre Waters, a former defensive back for the Philadelphia Eagles, sank into depression and pleaded with his girlfriend—“I need help, somebody help me”—before shooting himself in the head.”

The sad stories aren’t limited to professional sports. This past April a University of Pennsylvania football player committed suicide. An autopsy revealed CTE, a surprising finding considering his age. These stories are receiving more and more attention, and congress is listening. House committees are working on the Concussion Treatment and Care Tools, and Protecting Student Athletes From Concussions Acts.

While the sports community has slowly increased the awareness of traumatic brain injury, the US Army has some work to do. An NPR investigation reported that Army officials have denied Purple Hearts to soldiers who suffered concussions following explosions. The denial is not a surprise to Gen. Peter Chiarelli who acknowledges the “ongoing resistance to awarding the Purple Heart for so-called ‘invisible’ wounds.” The Purple Heart is a “badge of courage” and a medical resource: recipients receive prioritized medical care from Veterans Affairs hospitals.

Soldiers shouldn’t need a Purple Heart, though, to receive appropriate medical care. Physicians should investigate the association between psychiatric and neurological conditions and traumatic brain injury. Soldiers should be warned of the risks. And the institutions should provide the appropriate medical and social resources. The consequences of traumatic brain injury do not happen overnight.

Friday food for thought

Med students/schools ur doin' it wrong.  Some ideas.  I'm too tired to have an opinion right now.

It gets better

Advice columnist and openly gay activist Dan Savage found himself so moved by the recent suicide of a 15 year-old, bullied and picked-on boy in Indiana, that he started a youtube channel called the "It gets better project."  It's wonderful to see multimedia having potentially life-saving effects; and in the young (particularly openly gay or lesbian), suicide is a leading cause of death.

The creepy cashier and lessons in a heteronormative society

On the occasion of the United States Senate filibustering a repeal of "Don't Ask, Don't Tell" I thought I would share an anecdote from several weeks ago.

I waited in line at the grocery store as the middle-old aged clerk (65-70 years old) struck up this conversation with the young daughter (~6 years old) of a woman buying groceries ahead of me:

Clerk: Hello there young lady.  Do you have a boyfriend?

Girl: No. [giggles, looks away.]

Clerk: Do you want to have a boyfriend?

Girl: I don't know. Maybe.  [looks away]

Clerk: Will you be my boyfriend?

Girl: NO!

Clerk: Why not? You'll get free groceries...

Girl: No.  [looks away].

Clerk: How about this, I'll give you a week to decide.

[Genuinely amused, the mother shakes her head, mumbles a few words about the girl being high maintenance, and then looks up as she hears her daughter, upon leaving yell:

Girl: Good luck, sucker!

Now, I laughed too.  The clerk was just silly. The girl was predictable.  The mother was amused.  And I got to thinking, would people have reacted this way had the girl instead been a boy?  What if the elder clerk was in fact a homosexual, and thus innocently struck up the same conversation with the woman's son.  I doubt anyone (I included) would have acted the same way.  People would say, "Oh, how dare he try to make her son GAY!" "God, he's such a creepy molester!" "What is he, a Catholic priest or something?"  In other words, they are afraid of such behavior, because it might influence the boy.  It might shatter his world view of boys + girls = love.  Quite simply, when the heterosexual "norm" of our society is enforced, even by slightly creepy, but good-natured clerks, we all laugh and move on.  Because we think that society is grooming everyone to be either gay or straight.  Straight is ok.  Gay? No homo.

I doubt it's so straightforward that society's influences play such a large role.  If they did, we wouldn't have had people identify with homosexuality in the dark ages of sexual identity (pre-gay rights/civil rights movement, which is by the way ongoing: see the link above).

I hope my (future) children grow up in a world that embraces both the straight and the gay clerk.  I have enough faith they will know how to figure out their own sexual identity, regardless of some old grocery store clerk's influence.

Kids and antipsychotics

I read bits and pieces of the “Diagnostic and Statistical Manual of Mental Disorders IV” (DSM-IV) during medical school, which was an informative yet frustrating experience: one that I would like to revisit and expand upon when DSM-V is released. My understanding of psychiatric illnesses and their diagnoses and treatments is extremely limited. I can only imagine how difficult it is to care for some psychiatric patients, let alone, children.

Enter Kyle. The NYTimes paints a grim portrait of his struggle with antipsychotic drugs:

“Kyle’s third birthday photo shows a pink-cheeked boy who had ballooned to 49 pounds.”

“Kyle smiles at the camera. He is sedated.”

“He was sedated, drooling and overweight…”

Kyle isn’t alone.

“Texas Medicaid data ... showed a record $96 million was spent last year on antipsychotic drugs for teenagers and children — including three unidentified infants who were given the drugs before their first birthdays.”

Kyle and other children from low-income families “were four times as likely as the privately insured to receive antipsychotic medicines” because it is “cheaper” than psychotherapy, according to a Rutgers U. study.

I wonder what things are like in the prison systems.

20-Somethings

This piece about "20 somethings" and the movement toward recognizing one's 20s as a period unique - not adolescence, not true adulthood - is worth a read, especially if you're a 20-something.

In a way, doing extended post-college schooling may provide exactly what 20-somethings need: a transitional phase, gradually introducing more responsibility, life choices, and adult activities.

Who knows? As for me, I feel as though I identify much more with a "20-something" than a "young adult."

I know what I would want...

Early palliative care with usual treatment.  As the piece by Atul Gawande (linked to in Anthony's earlier post) suggested, early palliative care (hospice) reduced the costs of care, without negatively affecting patient outcomes.  Now this NEJM-published study on metastatic lung cancer shows that it even extends the lives of terminally ill patients.

WTF is up with...

1. Counseling on a patients' goals of care/end of life wishes/advance directives = "Death Panels" ?

2. Building a Islamic community center (which includes a prayer center; by a subdivision of Islam which has NEVER been supportive of or involved in terrorism) two blocks from the former WTC site in lower Manhatten = "Ground Zero 9/11 Victory Mosque" ?




People babble over issues of which they have no understanding.  And worse, they don't even try to understand.  They just babble.


::sigh::

As you know end-of-life care is a big deal...

... that can improve quality of life for dying patients and save the government a lot of money. Chuck C has written about the so-called “death panels”; the NYTimes and other news outlets have expanded the dialogue; now Atul Gawande has written an essay for the New Yorker.

I’d like to focus on one particular part of Gawande’s essay, where he refers to Stephen Jay Gould’s remarkable recovery from abdominal mesothelioma, which inspired Gould’s essay “The Median Isn’t the Message.”

Gould beat a normally lethal cancer. He is the exemplar patient that all physicians would like to have and treat. Gawande admits this sentiment himself:

I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

The reality, as Gawande alludes to, is grim: optimistic hope in sexy, new treatments against diseases that we don’t completely understand. The grim reality, though, funds our futures as physician-scientists. A lot of basic research in a lot of different fields is needed to know which patients will benefit from which treatments. And some times the treatments will be palliative.

Gould studied patient-survival curves. He saw “himself surviving far out in that long tail.” But what does it mean to be in the “long tail”? People are hard at working doing this, particularly with breast and prostate cancer.

First day for first years

Welcome, first years.  On the first day of orientation, we at mstpla.blogspot.com welcome you to the UCLA MSTP.  This is a great city, school, and program.  Here's to productive MD/PhD training!

Longevity, with disparities

The two sentence, data-filled abstract of this article says it all.

"The Advantage of Being Helpless"

Is the human brain as advanced, in part, because of how slowly it develops?  New research suggests maybe so.


Updated, 7/21/2010: Title changed from "The Advantage of Being Hapless" to "The Advantage of Being Helpless." At least I didn't make up a word like "refudiate."

Preventative tests at no cost

Sometimes I wonder whether this blog is simply a link-dump for NYTimes articles.  But nevertheless, here goes:

New rules from the U.S. Government's Executive Branch that insurance companies will be required to cover all costs associated with basic preventative and diagnostic medical tests.  Good news indeed.  Will save the ~100k lives, as quoted in the article and will probably also lower costs.  This, like many other things, is incremental, but it's another notch on the belt.

Challenges, frustrations

Challenges and frustrations -- especially the kind that infuriate us -- tend to provide us with "teachable moments."

That is, if we're ready to learn.

Being ready is easier said than done.

This week in WTF

I'm speechless.

Hospitals as efficient factories of healing

This is so cool!  Taking the genius/efficient/successful and DATA-DRIVEN approach to running companies and making hospitals operate more smoothly is long overdue.

I’m glad I visited Arizona before July 29, 2010…

You’ve probably heard that the federal government is filing suit against the state of Arizona. This isn’t the first time federal authority has found the need to “pre-empt state law when the federal interest is dominant and where there already exists a system of federal regulations.” It happened in our great state of California after our great citizens passed Prop 187 in 1994. I’m trying to imagine institutions like UCLA delaying care “until the legal status of that person has been verified" or holding workshops (like the ones Arizona policemen are receiving right now) to generate suspicion. It’s mind-blowing, really.

“Concerning the Interview”

Mark Twain wrote an autobiography. But he requested a 100-year posthumous release. UC Berkley will soon publish his autobiography, along with many essays, including “Concerning the Interview.”

The interview is an important, whacky, at-times-stressful component of the MD-PhD application process. It is an opportunity for applicants to distinguish themselves (for better or worse) from a crowd of incredibly promising applicants. While Twain’s perspective as the interviewee is astronomically different than the prospective MD-PhD student’s perspective (try saying that ten times fast), his comments deserve some serious thought.

“The Interview was not a happy invention. It is perhaps the poorest of all ways of getting at what is in a man.”

Amen. On the interview day, schools like to lighten tone by saying, “Oh, the interview is a way for us to get to know you,” when in reality, the interview is an interaction that has been repeated over so many times (in past interviews or in front of the mirror or good friends) that it is essentially a rehearsed exercised: aka The Shpeel. I guess an interview is better than nothing. But I imagine there are moments when interviewees yield shadows of themselves in the wrong light (again for better or worse).

“You know by experience that there is no choice between these disasters. No matter which he puts in, you will see at a glance that it would have been better if he had put in the other: not that the other would have been better than this, but merely that it wouldn't have been this; and any change must be, and would be, an improvement, though in reality you know very well it wouldn't. I may not make myself clear: if that is so, then I have made myself clear--a thing which could not be done except by not making myself clear, since what I am trying to show is what you feel at such a time, not what you think--for you don't think; it is not an intellectual operation; it is only a going around in a confused circle with your head off. You only wish in a dumb way that you hadn't done it, though really you don't know which it is you wish you hadn't done, and moreover you don't care: that is not the point; you simply wish you hadn't done it, whichever it is; done what, is a matter of minor importance and hasn't anything to do with the case. You get at what I mean? You have felt that way?”

Give this some time. The first time I read it, I scratched my head. I’ve read it a few more times, and I’m not sure whether I really understand it. Perhaps that is the point (read: “it is not an intellectual operation”), and I’m empathizing with the experience, which I imagine is more generalizable, beyond the scope of just an interview. I personally found that the application process had me “going around in a confused circle with your head off,” especially when I thought too hard about questions that are unanswerable but unavoidable on ye-good-olde interview trail. The most blaring example was “Why MD-PhD?” I had answers to questions like this. They were tailored to fit my portfolio. But the deeper questions found ways to pop up. What did I do? Acknowledge them, and let them be. As if they were going anywhere. Hehe. And this abstraction segues into the last quotation that I will torture you with:

“Yes, you are afraid of the interviewer, and that is not an inspiration. You close your shell; you put yourself on your guard; you try to be colorless; you try to be crafty, and talk all around a matter without saying anything: and when you see it in print, it makes you sick to see how well you succeeded.”

(N.B. that I was not sick with success, unlike Mark Twain; but his zinger was too good to exclude.)

Now read the first quotation I provided. I’m not trying to be a Debbie Downer; I’m not trying to be jaded or pessimistic; but maybe these characteristics are seeping through my attempts at realism. And that reality also includes the many fun moments of the interview trail, like eating good food with the new friends and colleagues I met in the big or small city that I had never been to before. Ye-good-olde interview trail is an experience. “You get at what I mean?”

"If Homelessness Were Genetic"

I strongly recommend this deeply moving, thought-provoking, and beautiful poem, pondering what might happen to how we "treat" homeless individuals if they suffered from the genetic disorder of "homelessness."  This being instead of the status quo, where we do little to ascertain the causes and effective treatments (or solutions) for homeless persons.  I really have nothing else to say, other than read it!

The plot continues to thicken...

Chronic Traumatic Encephalopathy (CTE) is the name researchers have given to the pathological changes associated with repeated blows to the head, e.g. those from playing in the National Football League.  In the news today are the results of a post-mortem analysis of 26 year-old Chris Henry's brain.  Henry, who died in what was deemed an accident -- falling out of a moving pick-up truck during a domestic dispute, was said to have the tangles and plaques deemed pathognomonic for CTE.  At some point, the NFL will properly explore this and more fully fund research into it.  Until then, the Super Bowls and Sunday NFL marathons will continue.  You know, the band kept playing on the Titanic too.

[Also, I'd be curious as to what the brains of other football (a.k.a. "soccer") players look like.  "Headers" don't seem like benign meetings of the cranium and ball to me...something my mother worried mightily about when my sisters and I used to play organized soccer in our youth.]

Alzheimer’s and the NYTimes revisited

Chuck C highlighted a NYTimes article about familial Alzheimer’s Disease (AD). Today I read a NYTimes article about the use of PET probes to identify AD.

Familial AD has guided current thinking re. the pathophysiology of AD: i.e. the role of amyloid plaques. The three genes implicated are amyloid precursor protein (APP) and presenilin 1 and 2. It is hypothesized that amyloid beta proteins (in particular aβ42) aggregate – and to make a long and complicated and continuously changing story short – cause inflammation and havoc that results in neuron loss. The cortical and subcortical neuron loss manifests as cognitive impairment and dementia, which are the basis for the clinical diagnosis.

Clinical diagnoses are imperfect. The push for markers is strong and lucrative. The NYTimes article that I mentioned earlier highlights the work of Daniel Skovronsky (who is an MD, PhD in industry) and the development of a F18 PET probe targeted against amyloid plaques. In short, the probe identified amyloid plaques that were confirmed in post-mortem autopsies. The work is a technical advancement over the prior C11 amyloid probe. I don’t know the probe’s sensitivity or specificity. And remember that the gold standard is a post-mortem autopsy staining for amyloid plaques.

Amyloid plaques may not be the whole story, though. Transgenic mice that express “abundant” amyloid plaques did not show a strong correlation with neuron loss, in particular the hippocampus. Individuals vaccinated against aβ42 cleared amyloid plaques, but the effects did not protect against neurodegeneration. Other hypothesized processes include i) hyper-phosphorylated tau mediating the formation of neurofibrillary tangles, ii) a decrease in acetylcholine synthesis, and iii) the loss of locus ceruleus neurons that synthesize norepinephrine. The complicated picture correlates with the current understanding of most AD cases, which are sporadic. Out of the many genes screened for associations with sporadic AD, APOE4 is the strongest risk factor. There are probably many more unknown protective and risk factors.

Skovronsky’s probe and other probes (including the ones tested here at UCLA) are baby steps in the right direction. Non-invasive, laboratory diagnostic tests are the holy grail of neurological and psychiatric diseases. And besides their diagnostic applications, in-vivo imagining has the potential to delineate amyloid and tau’s contributions toward the pathology and progression of AD. The NYTimes article states that “20 percent of people over 60 with normal memories had plaque”; these patients “were still statistically in the normal range,” and they “did worse on every memory test than the control group.” What does this mean? I smell longer studies.

But even more lucrative than diagnostic tests are pharmacological treatments. Acetylcholine esterase inhibitors (e.g. donepezil) and NMDA agonists (e.g. memantine) are symptomatic treatments only. I imagine pharmaceuticals have been salivating for some time… Meanwhile, the basic science must continue! Here is some bed-time reading.

Why Medicine?

It is personal statement season, and 2011 med school applicants are faced with the daunting task of answering the question, "Why do you want to go to medical school?"

Tough question to answer in 5300 characters or fewer.  Not sure I ever wrote a good personal statement, or that I could in the future.  Two years from now I will have to, for residency.

Something to look forward to.

And then there's always the wisdom of this guy, talking to graduates at Stanford recently.  If you acknowledge that the practice of medicine needs to, and is, changing, maybe the field is for you.  Or maybe it is not.

Paper writing...

...tires me out.  So does thinking about this.  And this.

A health plan, 2 bucks a year

I'm not passing judgment one way or another about Rwanda's national health plan, but it strikes me as a positive start and model for health care in developing African nations.  It's interesting how some basic and dirt cheap measures are apparently  improving outcomes for Rwandans...

When the “Step One Adventure” (SOA) began...

... I considered posting updates, which sounded like a good idea, i.e. until I realized that most of my writing would be filled with angst and more angst. A little time has provided an emotional buffer, and I feel a somewhat comfortable providing commentary.

If you’ve taken SO, you know what I am talking about. If you plan on taking SO, you will soon. For everyone else, don’t worry: you aren’t missing out. Here are the cliff notes.

In a tiny little carrel on the eight floor of a building called “the Stacks,” I spent most of my day reading through “First Aid,” “BRS Pathology,” and “Rapid Review Pathology,” while doing USMLE World questions. Midway through my studying, I fled the stacks for my parent’s home. I drank better coffee, ate home-cooked meals, finished a first pass of the material, and started to make some headway on the Q-bank. When I returned to West LA, I avoided the stacks. My room became my cave. The days were spent hunched-over in front my computer, doing questions, questions, and more questions until I developed UWorld-burnout to go along with First-Aid-burnout. I tweak my back from poor posture; I developed a mild fungal infection on my left elbow. At this point my body hated me and I was ready to get the SOA over with.

There were times during the process when evil little thoughts tempted me to postpone my test date. “Anthony, you could do better if you had an extra week.” “Anthony, there is so much more high yield material to go over.” Now that I’ve taken the exam, I could not imagine the unnecessary suffering I would have put myself through. I accepted the gaps in my knowledge. And as Chuck C told me, I had to “trust the preparation.”

The preparation was both hellish and useful. The experience forced me to work really hard for a substantial amount of time. And while I worked hard, I tried harder to keep sight of the bigger picture: life will go on after the test. The SOA wasn’t fun, but there people out there who are having much less fun all the time. Let’s count our blessings, folks.

Alzheimer Disease - "earlyonset" and new therapies

NYTimes has a popular piece about an extended family, ravaged by early-onset (earlyonset) Alzheimer Disease and how a study using vaccines and anti-amyloidogenic medications is attempting to see whether early interventions might affect disease course.  Given how difficult the disease has been to treat thus far, I'm not terribly optimistic about the current studies.  But in order to get to the promised land of developing treatments that dramatically affect outcomes, sometimes the best researchers can do is continue to soldier on.  At the very least, new insights are sure to emerge...

One year??!

In T-minus one year, I will be finished with my PhD and heading back to the clinical side of things.  I got to thinking about this at a BBQ tonight at a collaborator/thesis committee member's house.  Several of us graduate students were shooting the research-shit -- how many papers, how long will it take, how little we know.

I will have my PhD in one year's time, but do I really have the mind of a scientist?  At this point, I can't help but think how woefully inept I am at planning, executing, analyzing, and proposing scientific studies.  Though I've come leaps and bounds about how to think about science (so much of it seems like OBVIOUS common sense, so much else of it seems uncertain and difficult to grasp), I still feel as though I don't know shit.  Maybe that means I actually am on the path, and that I've made much progress.  Perhaps; time will tell.

Failing trials...

Gov't sponsored cancer drug trials are doing it wrong, big time.

To me, this issue is fairly complex and does not just simply boil down to the need for a "better managed and funded" system.  It requires a fundamental change in the way drugs are developed, evaluated, and then applied to certain disease states.

Treating the scars of war

Warrior transition units for members of the U.S. armed services are rife with problems.

Posting slow-down

I've been slammed by work in the past few days, dealing with many time-sensitive issues (a rarity in research).  More posting...and soon.

Nothing to see here, folks...

...nothing to see.

(h/t: A.Z.)

Change we can believe in

President Obama has instructed his HHS secretary, Kathleen Sebelius, to develop rules that enable patients to appoint "visitors" with the same rights and privileges as family members, and hospitals may not go against the will of the patient on the basis of "race, color, national origin, religion, sex, sexual orientation, gender identity, or disability."

It warms me to see our President doing something about an issue that has tormented same-sex couples for as long as they and their partners have been faced with medical issues.

Regardless of how one feels personally about the issue, no one can deny that the patient possesses autonomy in who he or she designates to be the equivalent of "next of kin."

Because to not do this, we are systematically denying patients a fundamental right.

Photo at Capitol, 3-21-2010

As promised, and as much for my own recollection down the road as for anyone's enjoyment at the present, here is photo my sister took of me, just about an hour before the house passed health care reform on 3-21-2010.

Infections persist

Hospital-acquired infections -- and all of the expense, morbidity, and mortality associated with them -- aren't yet under control.

A great NYTimes blog to check out

The New Old Age blog on the NYTimes is an outstanding resource, both for persons who care for or have elderly people who are a regular part of their lives AND for anyone going into the medical or related fields.  Two recent posts, one on drivers with varying degress of dementia and another on the aging drinker are must-reads.

Agriculture report

Too much of a good thing tends to be problematic.  A normal equilibrium is disrupted, and it is difficult to predict what may happen.  This is one of the problems with genetically-modified crops, though it's not completely clear-cut.  The future of genetic modification in agriculture is very much uncertain, and the benefits and drawbacks are fiercely debated at the present.  Read this for more.

On the flip side, there are about 1 billion under-nourished persons on the planet.  With lower crop yields in areas particularly susceptible to the effects of climate change, that number promises to increase, perhaps by as much as 230% by 2050, without substantial increases in crop yields elsewhere in the world.  Read this for more. (Subscription to Science may be required.)

H1N1 - it's all in the structures

A new report published in Science lays out the structural basis (in the antigen hemagglutinin) for the marked similarity between the "Spanish Flu" H1N1 of 1918 and the "Swine Flu" H1N1 of 2009.  Most notably, the antibody response to the 1918 strain confers immunity to the 2009, and the structural basis of this is shown in the study.  Awesome!  (Subscription required to read the full text.)

This week's least surprising story

Let me understand this: researchers who were paid by a pharmaceutical company developing a particular treatment were more likely to report positively on the drug's effects on patients.  Shocking.  And I'm not saying the relationships/reasons are totally obvious, either.  But to me, this is similar to how people who study a particular protein and, say, get the bulk of their grant money for studying that protein, are likely to publish studies stating how important protein x is.  I wrote about this back in 2008.

The road ahead is well traveled

Second year of medical school is nearly over. Finals will be done this Wednesday. Assessment Week will end on April 23. Boards are scheduled for June 4. Wow, how time has flown by.

To celebrate the first two years of medical school, our class hosted a little shindig atop the hills of Westwood, with free booze and food and some speeches. The event was not bitter-sweet. I feel ready to move on. Perhaps the sentiment will change. Maybe not.

Don’t get me wrong: I’ve thoroughly enjoyed my two years in medical school. I could not have asked more from my peers and mentors. I’ve grown in a comfortable environment. While the curriculum was not perfect, it was good. If I had to enter my third year of medical school, I feel like I would be ready. I’m on my way to adult-like responsibilities that are real and serious. Strange.

I don’t know what to expect of graduate school. But I am mentally ready. I am mentally ready to finish the year strong with boards, a break, and research. I’ll take more classes and do more research. I’ll stop taking the classes and continue research until I’ve completed enough to resume MS3. The granular roadmap is in place. Now it is time to fill in the details.

I’m trying not to get ahead of myself. First things first: i.e. 1) study hard through finals and until boards, and 2) stay healthy by a) exercising, b) eating well, c) sleeping, and d) valuing my relationships.

The road ahead is well traveled with a lot of trails. A picture of my path is attached below.

Would you prescribe a hallucinogen...

... for depression or other psychiatric conditions? Timothy Leary thought it was a good idea. “Turn on, tune in, drop out.” The rest is history.

There are three types of hallucinogens: psychedelics, dissociatives, and deliriants. Ketamine is a dissociative used to induce and maintain general anesthesia (even in pediatrics). Ketamine is widely abused. Ketamine’s cousin, PCP (aka angel dust), is also an NMDA antagonist.

Drugs exist, can have medical purposes, and are used recreationally when accompanied by curious effects. Ketamine is an example. So is morphine. So is dextroamphetamine. The list goes on, and a lot of the drugs are psychoactive.

It’s old hat: people develop addiction to drugs and behaviors that are legal and illicit. Some drugs feed and burn-out the nucleus acumbens faster and more effectively than others. Some drugs have a greater social cost. Why are some drugs legal and others not? It’s a combination of the abovementioned questions and more issues (e.g.. social norms, social histories, etc., etc.) that are beyond this over-simplified post.

Now read this article.

The studies are being funded, even here at UCLA (See the second to last paragraph.). What will the research tell us about psilocybin – a partial agonist of 5-HT2A and –HT1A (serotonin) receptors – and its potential use in psychiatric conditions; who knows. Let’s remember, though, that in Leary’s day, functional imagining did not exist, high-throughput sequencing did not exist, evidence-based medicine was not a la mode.

Get over taboos, and let the evidence speak for itself.

The here, the now

I spoke with my younger sister today, and as usual, she had a wonderful thought for a Sunday afternoon (obviously paraphrased):

There is no need to stew over who we might become, what we might do, and where we might go in the minutes, hours, days, weeks, months, and years ahead. What we have at the present is more than enough to sustain us. The moment in which we live is the most important one.

These are especially timely words, both for those who ponder their next steps -- all you re-visiters out there, persons in flux within their ongoing schooling (e.g. transition to PhD phase), and everyone else, wherever they find themselves -- and those of us attempting to extract meaning and peace in the present. It truly is all about the here, and the now. Life pulses along.

That's what I'm talking about

Doctor and writer, Atul Gawande, proposes that we all have a role in determining whether health care reform is successful. He also offers some historical lessons from the early days post-Medicare passage.

Health Care Reform REDUX

Finally, I present my run-down of the last year's events leading to the passage of the Affordable Health Care for America Act. So, the bullet-ed run-down:

*About one year ago, early in his first term in office, President Barack Obama laid out an ambitious goal: to have health care reform passed before the end of his first year in office.

*He wanted it to be hopey, changey, and bipartisany. Mistake number 1.

*So, in the Senate, a "Gang of Six" -- Max Baucus (Mont.), Jeff Bingaman (N.M.) and Kent Conrad (N.D.); and GOP Sens. Charles Grassley (Iowa), Mike Enzi (Wyo.) and Olympia Snowe (Maine) -- was assembled. The thought was that if bipartisan ideas went into the legislation (WHICH THEY DID), both parties would be able to vote for the bill. Mistake number 2.

*The "Gang" stalled and stalled, got nothing substantive done before the summer recess. Giant Mistake number 1.

*Media, special interests, opposed legislators, and any and all saboteurs-de-healthcare descended on the "Summer of Townhall Hell" where angry constituents admonished their democractically-leaning colleagues for hinting that they were supporting A) Death Panels, B) Health Care rationing, C) The Government interfering with Medicare, D) Mandatory and state-sponsored abortions, E) Defying the will of a minority of elected officials (Republicans), F) All of the above, and then some.

*With endless lies, spin, misinformation, and anger widely disseminated by the media, public support for health care legislation began to decline. Recognizing that bills are drafted, debated, voted upon, and passed by the legislature, the White House declined to intervene too much (per its role to sign bills into law and to enforce existing laws of the land). Constitutional role be damned, Giant Mistake number 2.

*Remarkably, despite death panels and major updates on health care reform from such renowned experts and Sarah Palin and Betsy McCaughey, by Christmas legislation had cleared both the House and the Senate. All that was left was for the two bills -- which had similar amounts of spending, deficit reduction, language on abortion, proposed changes to medicare; while differences on excise taxation of Cadillac union healthcare plans and kickbacks for equivocal moderate Democrats' participation -- to be merged in conference, filibuster prevented by 60-member cloture vote, and sent to the President's desk before long.

*Martha Coakley -- Attorney General of the State of Massachusetts -- managed to lose the special election for the Senate seat long held by Ted Kennedy. With Scott Brown, the Republicans had their 41st vote -- enough to successfully filibuster any and all changes to the Senate health care bill after conference committee between the House and Senate. Pundits of all shapes and sizes, party affiliations and persuasions, declared health care reform dead.

*Then, Democrats -- most notably Pres. Obama, who has a knack for coming back from behind (as an example, see this video of him dismantling Clark Kellogg in the presidential version of H-O-R-S-E, aka P-O-T-U-S), grew a pair and remembered how all parties in the majority have tended to use budget reconciliation as a way to bypass the often outdated/overstated/all-too-often-threated filibuster. So, despite objections to the contrary, they put "on the table" budget reconciliation. It came down to this: if the House could pass the Senate Bill verbatim along with another bill making changes to the Senate's bill, then the Senate could pass the changes using budget reconciliation. However, people wondered whether Mr. Obama could support this. He was still giving the impression that "all options were on the table."

*On 29 January, 2010, President Obama schooled the shit out of House Republicans. He showed that, unlike his noble objectors, he had thought through why reform needed to happen, and relatively all at once. He demonstrated that he had anticipated the kinds of questions he would be asked. And when conservative mouthpieces like Fox news cut away, while liberal mouthpieces like MSNBC are so happy it looks like they are scandalously satisfying themselves on air, you know something big has happened. And indeed it had. The rest of what happened was relatively predictable.

*More opposition and rabble-rabbling occurred. The "summit" at the Blair House produced no evidence of consensus or Republican support. And the President continued to look like the adult in the room. And he said, pretty unequivocally, that he was done playing games and he expected health care reform to pass.

*Then, Nancy Pelosi went to work, whipped up the votes over a period of about two months. A few hiccups here, a few there (such as the "deem and pass" almost-debacle which wasn't necessary because it wouldn't have changed anything anyway, but WSJ always seems not to care about the facts), and suddenly, it was down to "just" abortion (yay!) and with a little wrangling here and there an executive order would confirm what was already in the Senate bill to begin with.

*Late in the evening of 3/21/2010, the House passed the Senate Bill, along with some fixes. Two days later, this was signed into law. By the following week, all of the changes were, too, passed into law.

I will post my photo, in front of the Capitol, on 3/21/2010 as soon as I can find it.

The real work of fixing health care -- insurance, delivery, disparities, outcomes, disease management, coverage for everyone, and so on and so forth -- is what comes next. I intend to vigorously follow and post on how this can and will be accomplished.

Many tweaks will be needed, perfection is not a realistic goal, but doing nothing is certainly no option...

It shouldn't begin in the clinic, and that's all right

I can't count how many times I have heard applicants, accepted students, or first year students talk about how "jazzed" they are that the curriculum at a given medical school starts off with "clinical" coursework from "the first day of classes." It's all the rage these days. Why start with your nose in the books when you can begin by actually seeing and treating patients? After all, that's what doctors do, right?

In a quest to meet these expectations, medical schools do everything to be "clinical" from the start: patient interactions begin on day one, medical history-taking is taught before any principles of cardiovascular or pulmonary physiology are explored, every opportunity is taken to emphasize the "clinical" relevance in all aspects of medical education, and small groups are formed ("Problem-Based Learning" [PBL]) to discuss "clinical" cases.

Must. Have. Clinical. Only. Always.

Relax, people.

Let's not kid ourselves. Simply discussing how a topic (say, for instance, the molecular development of a certain type of cancer) relates to a clinical diagnosis (say, a diagnosis of melanoma) does not mean that the curriculum is "clinical." It means it's putting basic scientific curriculum into the proper context. Contextual learning is not clinical learning, and nor should it be. If one were to start Day One of medical school learning the clinical aspects of melanoma, it would mean learning treatment algorithms, the principles of managing Il-2 patients, and the best practices for detecting and treating recurrent lesions. That approach of course wouldn't work if someone has no idea about skin physiology and anatomy, to say nothing of basic cancer biology.

My point is not to dismiss all clinical learning from the beginning. I think that the way in which doctoring/clinical skills are introduced in the first and second years of medical school are hugely beneficial. To be thinking about how a history is taken is a huge asset to how students learn the material.

To dismiss the first two years' physiology, anatomy, pathology, and so on -- in favor of watered down, "clinically-oriented" curriculum -- is to do a disservice both the medical students and the medical school as an institution. There is no substitute for having an understanding of the basic science of medicine. To whatever extent that material can be integrated with clinical examples is both instructive and beneficial. However, when it is replaced or challenged by students, faculty, and administrative powers-that-be with comments to the effect of "we want only the clinical 'high yield' info," core elements of the medical school experience are eliminated. And then everyone loses.

So please, let's refrain from obsessing over whether it's clinical and focus instead on whether the information is integrated, useful and necessary. I would bet all that "basic" science -- anatomy, physiology, histology, pathology, molecular biology -- is crucial to the education of the doctors of the future. The algorithms and protocols can wait. The basics need their place in education, too.

Saying "No"

The NYTimes comes through again with an excellent, and succinct(!), piece on how medicine needs more research, more information for patients, and changes to billing/reimbursement that reward quality rather than just quantity of care.

This is the beginning of what I have claimed for a while. Health care reform needs to happen, and then we (as physicians, students, nurses, administrators, patients, families, and so on) need to be part of the change.

And it can be done.

and yes

I still plan to do a big health care reform redux. Perhaps on this Easter Sunday? Later...

The struggle against dying

This profile of Desiree Pardi -- a palliative care specialist who went to extraordinary lengths to stay alive despite incurable, metastatic breast cancer -- points out just how difficult it is for individuals to face their own mortality. Even when it was her job, Dr. Pardi was unable to help herself give up, give in, and go in peace.

Bodies altered

Check out this NYTimes slideshow of "bodies altered in the pursuit of beauty." Haunting, revealing, and worth looking at.

"And yes Mr. Vice President, you're right... "

Listen for yourself.

I will offer a long summary of the run-up to health care reform, but for the time being I am waiting to see whether the Senate will pass the "fixes" through reconciliation. Today, Senator Max Bacus (D-Montanta) suggested that perhaps not all the fixes would pass muster under the "Byrd Rule" which limits what falls under the category of "budgetary" changes [to avoid filibuster, changes to the original senate bill can be only budgetary in nature]. This would mean a potentially painful back-and-forth between the House and Senate. However, lots of things Bacus (and other Senators for that matter) have said to this point haven't turned out to be true. So who knows? Besides, the Senate bill (fury over "kickbacks" to poor people needing health coverage aside) is pretty damn good on its own. So I still think this is all good. But now is the time for the real work to begin.

It is done...(now the Senate can finish)...

In my final hours in our nation's capitol, the major hurdle - the House passing the Senate bill plus reconciliation fixes - to health care reform passing has been cleared. The Democrats (because of the leadership of the president and of the party) finally did what they promised: health care reform is not a goal. It is a reality.

More thoughts to come (and my photos in front of the Capitol Rotunda).

This is a moment.

Now is the time for us all to take charge in making health care better in the United States. Thanks to the Congress, we now have a fighting chance.

Close!

I'm here in DC, preparing anxiously for a celebration (FINGERS CROSSED) that will happen if the U.S. Congress finally grows a pair and passes reform. More to come, but it's very likely I will go over to the Capitol Rotunda later and snap a photo to celebrate the most important passage of Health Care reform since the birth of Medicare decades ago.

Do it!

the equinox

I woke up this morning and realized that my bedroom’s sliding glass door was wide open. I left the door open, put on a tank top and pair of shorts, ate my breakfast, and had an amazing “commute” to school on my bike. The sun was really sunny. The breeze was really breezy.

If yesterday and today and tomorrow are signs of what is to come – when spring is in full swing and the fever is full blown – then Yippee-ki-yay. Spring is going to be nice. Summer will be nice too. But winter wasn’t that bad. Sure we had some rain, some wind, and some cloudy days in LA. But let’s celebrate anyway: the good, the slow, and the non-idyllic times passed. Let’s take a moment and appreciate everything wonderful around us. This Saturday the earth and sun will dance, like they have been for more years than I count, and at 1:32 PM EDT they will pause to change hands. The sun’s leading the earth, but it takes more than one (us included!) to tango.

Exercise is good, mmmmkay

Read this nice and tidy round-up of some of the research suggesting how good exercise is for people, particularly as they age. Somewhat of an obsessive fitness freak, I find this to be validation of my current lifestyle. Note that just about every organ system, as well as physiological and pathophysiological process, is affected for the better by exercise.

New Rule, ctd.

Another new one:

If there will be drastic cuts in education spending, then there should also be cuts in Medicare spending.

Fair is fair.

"Let's Get it Done"

President Obama today, flanked by white coat and scrubs-clad medical professionals, said that the time for debating and floundering is over and it's time to pass a comprehensive health care reform bill -- one that he looks forward to signing into law.

Could this be the beginning of the end of the clusterf*&* of HCR, for now? We shall see.........

Molecularly-targeted therapies: hope, and challenges

This is a riveting three-part series about new approaches to treating metastatic melanoma. The road to progress is filled with peaks and valleys, and there's a long way to go. The challenges to targeting the molecular "engines" of proliferating cancers are immense. The NYTimes piece offers a sense of the emotional roller coasters faced by the physicians leading early clinical trials and the patients clinging to the few extra months they have to live.

Enough, ctd.

Think it's not a problem that millions are uninsured? Think again.

Enough.

Now I give up.

Health care reform looks to be in peril. Again. What's new?

As a future health care professional (resident, fellow, attending), I have taken an active role in writing, talking, and stewing over HCR debates currently going on in this country.

There has been an abundance of misinformation, grandstanding, and frustration. Many of us who are intimate stakeholders in this game -- who will provide the care in the future -- have wanted it to work. The non-medical professionals -- the citizens, the congresspeople, et al -- have framed the debate in their terms. They say reform, in its current manifestations, is unpopular. They say the American people want to start over. They say health care in America is the best in the world.

OK, let's try it. Let's keep things where they are.

But I have no sympathy for the people who start complaining about escalating costs, overcrowded emergency rooms, and denials of care. Does this sound callous? Absolutely. But enough is enough.

I'm trying to finish a PhD and get back to the wards. I'm trying to become a good doctor. And the whole public debate on health care reform is so pathetic, so "missing the point," so embroiled in death panels; and now, in today's news the opponents of reform (after all "we have the best health care in the world") are suddenly "noble" opponents [go to the New York Times, David Brooks column, examine Politico.com for analysis of the "tie goes to the GOP", and so on]. Look, people who think it's all good: if it's so good for you, then I'll see you in ten years. I'll treat you, but it's going to cost you.

Because everyone thinks it's hunky dory, cool. I will still have a job, I will still get paid, and you're going to pay. So let's all go in on this experiment. See how it works for you.

It's not going to be pretty.

Oh hey blowhards in Congress

Things and people I object to (vis a vis the health care reform "summit" today):

1. People arguing against health care reform, with the conclusion, We have the best health care system in the world. [No, we don't. We have probably the highest quality of care, in a number of top-notch health centers; it's the best health care when and if people can afford the care. Otherwise, we're disgracefully average among developing nations, for a SHITLOAD MORE OF THE COST.]

2. People arguing against health care reform, arguing it costs too much and will raise the deficit, who proceed to rail against cost-cutting measures in medicare, saying, But our seniors won't want their benefits slashed. It's partisan hack-ery; it's pandering; it's hypocritical; it implies that every dollar on medicare is a dollar well-spent.

3. Equally ignorant/partisan Democrats.

4. John McCain.

5. People who have good health care, with comprehensive coverage, who say that people who lack health insurance should start health savings accounts. If someone makes $20.00/hr, how much of that do you someone can set aside into a HSA? What if the person gets cancer? What about this person's children?

6. People who think medical malpractice reforms will magically cure health care of its ills. [No, it won't. States, like CA, who have adopted reforms, are seeing absurd increases in premiums.]


OH HEY LEGISLATORS: HEALTH CARE REFORM NEEDS TO HAPPEN, INCREMENTAL APPROACHES DON'T WORK. OH, AND YOU SUCK.

I have a new rule: no one in congress gets health care until the 30+ million people in this country without health care get it.

Great, problem solved.

Obesity shortens lifespan, BIG caveat

A recent newsworthy study in NEJM looked at Pima Indians, from their youth to adulthood, and the data suggest that being obese at a young age and having "pre-diabetes" increased the likelihood of early death.

But, this study was done in Pima Indians, and the Pima have long been known to have a severe predisposition to diabetes and obesity (they frequently show up in medical textbooks as the prototype for a population susceptible to type 2 diabetes); and Native American populations throughout the US and North America have a number of other serious co-morbidities (low socioeconomic status, high substance abuse rates, etc) that could make this study difficult to generalize to the rest of the US population, which of course is highly heterogeneous.

So, this study - targeting a very small and genetically unique population in the US - should be taken with a sizable grain of salt.

Questions, Answers

Brief, and certainly random, thought:

Research becomes exceptionally challenging when data can be filtered, distilled, treated, and then presented in such a diverse number of ways so as to obscure the initial question one was attempting to answer. At that point, finding an answer isn't really the problem. Understanding where the question is hiding is the challenge; searching is lonely work, in the sterile confines of a blanked mind...

What?

Step 1: Notice practices reportable to the medical board authorities.
Step 2: No one listens to you.
Step 3: Write letter to medical board.
Step 4: Get fired for blowing the whistle.
Step 5: Get indicted in state court for blowing the whistle.

I mean, say what you want about how things are in California, but really, Texas? That's shady. That there was good basis for complaining about what the physician did seems to be obvious (duh?) evidence against going after the whistle blower...But who knows.

FYI: blows to head cause problems

This is a NY Times editorial pointing out the absurdity that the NFL et al have only recently learned that long-term brain damage results from single, or repeated, blows to the head. The science has long been robust. The denial, persistent.

Finish the job, pass the damn bill

Invigorated by recent (and declared, by many, successful) Q&A sessions with House Republicans and Senate Democrats, President Obama is renewing his call for Congress to pass comprehensive health care reform legislation. I hope neither he nor the Congress lets up. Who knows what will happen in the mid-term elections. In the meantime, costs are soaring, and the system is unsustainable.

Concussions in youths

Testifying before congress, Dr. Bennet Omalu states youths who suffer from concussions should be sidelined from participation in sports for at least three months in order to avoid long-term brain damage. Interesting that the sports medicine community appears to be stepping up its research and activism re: traumatic brain injury. This testimony, in effect, says to parents: FYI, concussions are traumatic brain injuries.

Meanwhile, in the NFL

The NFL's "Cardiovascular Committee" is mulling over the idea of requiring all NFL players to have echocardiograms when they enter the league, as a way to screen for abnormalities such as hypertrophic cardiomyopathy (which Adam Gaines is presumed to have died from).

It's fascinating to see how sports leagues address the health of their players, particularly in football, where young men are part of one of the world's most finely-tuned and closely-watched experiments in traumatic injuries.

It's also a little grotesque.

The ranting will continue until morale improves

To anyone bothering to read this blog, a few notes about the recent barrage of posts on health care reform (HCR), I just want to say why I'm ranting so much. Here are two (somewhat) unrelated thoughts as to why:

1) If you go to med school, you have decided you want to get into the health care "game." Therefore, you become a part of this "game" - you and it are linked. Like in avatar, you take your pony tail and fuse it with the health care dragon. You and it form a connection. To deny this is to not just be ignorant; it almost suggests nihilism - if you fail to care about what you do for the majority of your life, how can you say you really care about anything?

2) Empathy. Empathy. Empathy. The very best doctors all have empathy. And cultivating a sense of empathy is a lot harder than it seems. I think that, at the age of 26, I'm only beginning to think about how to live with a sense of empathy. It's perhaps the most important quality one can have. After all, we care for other human beings. That might sound cheesy, but it's the truth.

The imperative for HCR

I am always going to have good health insurance. As an MD/PhD student, I am covered well by my home institution. As a resident, I will be covered by my employer. And as a future faculty member, I will have coverage. And I will always have work, because there certainly isn't a surplus of physicians. But to me, doing something about health care is so vitally important because how medicine is done in the future depends on reform. Right now, the practice of medicine (the science, techniques, decisions, etc) is, for better or worse is tied to institutional realities (profits, contracts with insurance, medicare reimbursements, kickbacks from pharma, etc). So forgetting the moral argument for making health care accessible for the uninsured, the very manner in which I as a future physician practice health care is threatened by inaction by our government. I have a HUGE stake in all of this. I want to practice medicine in a sustainable fashion. I want more end-of-life consultations (a.k.a. "death panels," which have been shown to lower costs), comparative effectiveness research, evidence-based medicine, value-based insurance pilot programs; I want an end to fax machines and paper medical records. In short, I want to be a part of the future movements that solve health care's problems, rather than exacerbate them. To me, as a future American physician, it's a form of patriotism.

And here, for me, is the moral argument. What has grated me the most during the HCR debacle is that the nihilists running Washington (I leave the president out of the nihilists camp, because I believe he actually gets the importance of HCR.) have some of the best and most expensive health care in the world. They say, "Let's take a breather, the American people are frustrated with how we are approaching this...Health care reform can wait." Yes, to those who have coverage, HCR can wait. Tomorrow, when a member of congress experiences chest pain - worried he might not be re-elected in the fall - he can go to a medical center of his choice and be worked up for a possible myocardial infarction (heart attack). When the barrage of medical bills arrive, the employer (we, the people, of whom 30 million plus lack any kind of insurance coverage) will pick up the tab. And so, the congressman returns to work, owing nothing for his care. A second job will not be necessary to pay for stenting the congressman's coronaries. Bankruptcy will not be necessary. The belt will not need tightening. In short, there will be no sacrifice required to treat the congressman's damaged heart. You see, I don't think lawmakers really understand what it's like to lack health insurance. I don't think they really get how bad it is, to be sitting in the emergency department or intensive care unit knowing that financial ruin looms. I don't think they get it. As a medical student, I have seen patients who don't have insurance, and their look is noticeably different from those blessed to have health insurance. They become consumed with trying to emerge from illness and bankruptcy. Just like you can spot homeless people in a crowd, you can spot uninsured patients in a hospital. The weight of their problems is palpable.

The Senate bill is far from perfect. But it's a vital first step. And I just don't think the privileged few who run Washington really get it. They seem totally devoid of empathy. I hope President Obama shows that he does and fights.

HCR experts: Senate bill far better than nothing

The New York Times has a link to the PDF of a letter from 47 health policy experts, many who are progressive and many who are non-partisan, urging the U.S. House to pass the Senate's bill and negotiate the contentious points through reconciliation later. I couldn't agree more. It's time to turn the corner on health care and do something. Now.

Medicare coverage and outcomes

This is a recent NEJM piece, broadly discussing how medicare considers coverage for treatments, diagnostics, etc; it suggests it isn't easy - but is essential nonetheless - to define short and long-term outcomes (not just medical but also economic and social) in deciding how limited resources are appropriately allocated.

I'll try to post more on this, and other topics relating to how health care reform should and can happen, in future posts.

Health Care Reform: The Urgency of SOMETHING

It was only a matter of time before my blood began boiling over the current health care debacle in Washington, D.C. The nihilism that ensued yesterday after the Democratic party lost its "supermajority" in the U.S. Senate was no doubt the catalytic event. So, with that brief preamble, I enter the murky waters.

As a stakeholder in the health care system - a future MD/PhD academic physician - I am deeply concerned about the current state of affairs in the system. The cost of delivering care is astronomical, with health care expenditures comprising ~16% of GDP, with no signs this number is going down anytime soon (by 2020, it will be close to ~20%). Despite the amount of treasure (personal, governmental) being devoted to health care, 15% of Americans have no health insurance. The largest government-run health insurance program - or more accurately, entitlement program - is Medicare. Estimates are that with no changes to the current system, Medicare will be insolvent by 2018. If future physicians think that this is no big deal, consider the fact that Medicare funds residency programs - it provides the salaries and other institutional support. So this is a big deal.

OK, those are some of the grim numbers. In short, we spend too much, we have no way to pay for health care if the status quo persists, and something must be done. Physicians don't wait for patients to go into multi-system organ failure (MSOF) before treating a patient with antibiotics, blood pressure support ("pressors"), ventilation assistance, and dialysis, etc, so why have we as a nation waited for the health care system to spiral into the shape it is currently in?

It's hard to say exactly why things have gotten so bad, and even more, it's hard to explain why the government has been so complacent. I think a big part of the problem is that bringing all of the players in the health care system - the doctors, the hospitals, the nurses, the technicians, the labor unions and employers who decide how to fund insurance policies, the insurance companies, the pharmaceutical companies, the diagnostic companies, the medical device manufacturers, the government, the patients, the lawyers - and having them agree on how to change the system and on which sacrifices they can accept is a massive (some think insurmountable) challenge. That is easier said than done, especially when said interest groups have varying degrees of influence ($) on Republican, Democratic, and Independent members of Congress.

I cannot say how exactly we should fix the economics of this broken system. I haven't looked at enough data, I don't understand all of the market forces at work, medical reimbursement practices; and I don't think most people in congress truly understand this either. And that's one of the first problems: the blowhards on both sides of the aisle in Washington use their opinions and empirical observations as a guide. Few (if any?) employ a rigorous treatment of the data. And that's the first place we need to start. As someone who has invested years of my life to learning how to design and execute good research, I think a first bold step would be to take the same hard look at medical care. That is, we need all of the pilot programs, evidence-based medicine approaches, properly placed incentives for good care, data sharing, electronic medical records, preventative measures - we need it all. These are the relatively cheap components of current proposals out there.

Whether - and how - to mandate insurance coverage for the whole citizenry of the United States is another question. The current proposals have done nothing to significantly change the costs of delivering care with respect to a mandate. They simply say that people should have coverage, the government will help if financially people have problems, and once covered, it's business as usual. So that's really not a good aspect of the current legislations.

Here's my take on health care reform: First, I want the death panels! So-called death panels - rather, having medicare reimburse physicians for having the difficult "goals of care" or "end of life" discussions is actually one of the best ideas that has been floated around, and it's one of the most politically polarizing elements of the reform legislation. And yet, it's one of the best damn ideas out there. Think about it: the bulk of medical care costs in a lifetime are incurred in the final months of a patient's life. Do a degree, this is unavoidable: if you get cancer and there's a chance to be cured, you'll try to treat it. But what if there is "no hope"? Or, more elegantly put, what if the realistic goals of care are palliative rather than curative? At that point, costs can be reduced dramatically (consider some of the data: http://www.reuters.com/article/idUSN06415881). But what's interesting is that when interventions are halted, usually suffering diminishes. The problem is that, all too often, doctors, hospitals, and providers in general either don't want to, don't know how to, or are financially incentivized not to have discussions about drawing down care and bringing people home. And so, more drugs are delivered, more treatments performed, more suffering ensues, all because who really wants to pull the plug on grandma? And sadly, most of the time, no one bothers to ask grandma what she thinks! And when they deem it time to ask grandma, she's already drugged up on sedatives/anti-anxiety/anti-psychotic drugs, in a hopeless ICU-induced delirium. At that point, few family members would be willing (and fairly so) to make executive decisions about where to go with care. Wouldn't it make good sense for patients - starting at a young age - to periodically have discussions with their doctors about end of life goals? Doctors ask whether patients sleep with men, women, or both; they ask whether it's cocaine, marijuana, heroin, meth, and/or all of the above; they ask about booze; they ask about depression; they ask about aches, pains; they ask about what concerns us the most. Why aren't they paid to have discussions about dying. After all, it's the one thing that will happen to every patient. And yet, this is the kind of stuff that has been maligned by opponents of health care reform legislation.

I want the pilot programs. The same kinds of government-funded and maintained programs that helped the agricultural industry in the U.S. become modernized could benefit health care immensely. And some of the privately- or state-funded programs already in existence prove this can work. Atul Gawande talks at length about this in a recent New Yorker piece. Note that he spends little, if any, time talking about public options versus mandates versus deals with pharmaceutical companies. He's talking about fundamentally changing how health care is delivered in the United States by empowering doctors and hospitals to make changes that benefit themselves, their patients, and the nation's finances as a whole. It will not happen overnight, but it can transform health care.

To make health care a truly sustainable and cost-controlled industry in the country will require more than just giving more people coverage in the same broken system. It will require innovative and progressive approaches to delivering care in the years to come. As examples, end of life discussions, in addition to numerous pilot programs embedded within current proposed legislation, offer some (of many) compelling ways to cut costs and do something rather than nothing when it comes to health care in the United States.

Stakes is high.