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.