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.