Monthly Archives: October 2013

Ever since the days of William Osler, annual physical examinations with one’s doctor have been an accepted and expected part of health care.  But recently the practice has come under some criticism.  Given the dearth of studies showing that physicals lower the risk of death and hospitalization, some experts and organizations state that the annual physical should be abandoned.

I appreciate the effort here to question tradition and to consider if a commonly accepted practice truly has value.  Nonetheless, I believe that in the appropriate patient population, annual physicals serve important functions.  First, they ensure that people are up to date on their health maintenance measures.  Screening for colon, breast, and cervical cancer is proven to save lives.  In my work in hospice and otherwise, I have seen the tragedy of lives radically shortened by a failure to undergo appropriate cancer screening tests.  In my physicals, I also review patients’ immunization records to make sure they have been appropriately vaccinated against tetanus, diphtheria, pertussis, shingles, pneumonia, flu, and hepatitis A and B.  Doing so decreases their chance of suffering from these diseases and helps protect the surrounding community.  Appropriate screening for sexually transmitted infections is also tremendously important.  Through such screening, I have detected cases of HIV and syphilis, thereby enabling effective treatment and preventing the disease from spreading.  Physicals are also a chance to see if a person has high blood pressure, elevated cholesterol, or type 2 diabetes.  People with these conditions often do not present with symptoms, but left untreated they can result in debilitating outcomes such as heart attacks, strokes, blindness, and kidney failure. Finally, there is the issue of hip and vertebral compression fractures. By some estimates, nearly half of all women and 1/3 of men will have fragility fractures in their lifetimes.  Such fractures increase the risk of death and can end or limit many people’s ability to remain independent.  Effective screening and treatment for people with fragile bones can markedly lower their risk of fracturing their hips or spinal vertebrae.

Physicals are also occasions for addressing a person’s health lifestyle and habits.  Smoking, excessive alcohol intake, and drug use can be identified and appropriate counseling given.  I also assess how much a person is exercising and inquire into the state of their nutrition.  Even if people already know the value of staying physically active and eating well, there is value in encouragement and reinforcement.

Physicals also allow me to obtain or review a person’s entire health history, as well as their family’s health history.   This information is usually not addressed during other visits that focus on 1-2 specific problems.  The process of reviewing a person’s complete health history helps put the issues a patient presents at other visits into a helpful context and framework.

Beyond all this, I view physicals as a time to get to know who a person is and what makes them tick.  My task is to help people live longer and better, but what are they living for?  Accordingly, as part of my social history, I usually ask patients something like “what gives meaning and purpose to your life?” or “what do you enjoy doing these days.”  Having a stronger grasp of a person’s values allows me to be a better guide in making health decisions.  And I believe there can be healing in simply sharing and receiving important, formative stories

Reading a novel can seem like a solitary, private pleasure rather than a public-spirited act.  But a recent study published in the journal Science found that after reading literary fiction, as opposed to popular fiction or serious nonfiction, people performed better on tests measuring empathy, social perception, and emotional intelligence.

“Researchers say the reason is that literary fiction often leaves more to the imagination, encouraging readers to make inferences about characters and be sensitive to emotional nuance and complexity.”  Here is a New York Times commentary on the study.  

Dementia is a syndrome characterized by a deterioration in cognitive function that results in behavioral problems and difficulty performing the activities of daily living. Alzheimer Disease is the common form of dementia in the elderly, accounting for about 60-80% of cases.  Under the microscope, the brains of people with Alzheimer Disease have abnormal clusters of protein fragments called amyloid plaques between nerve cells. The brain cells also contain aggregations of abnormal proteins called neurofibrillary tangles.  A new imaging technique called Amyloid PET tracing can measure how much amyloid plaque is present in the brain, but is currently used only for research purposes rather than being clinically available.  Thus, doctors now diagnose Alzheimer Disease based on a person’s presentation in the clinic and by ruling out other causes of impaired cognition such as Vitamin B12 deficiency, depression, and a low thyroid level.

A new study published in Science discovered that in mice, the brain’s system for flushing out toxic waste products is especially active at night.   The study author and University of Rochester neurosurgeon Maiken Nedergaard stated that “sleep puts the brain in another state where we clean out all the byproducts of activity during the daytime.”  These byproducts include the amyloid proteins that make up the plaques found in Alzheimer Disease.  Nedergaard explained that “brain cells shrink when we sleep, allowing fluid to enter and flush out the brain.  It’s like opening and closing a faucet.”  The study found that the harmful beta-amyloid protein clears out of the brain twice as fast in a sleeping rodent than in an awake and active one.

Besides providing insight into the mystery of why we need sleep, this interesting study may be a helpful contribution in the quest to someday prevent and effectively treat Alzheimer Disease.  Here is a Washington Post article describing the study published in Science.

The chickenpox that nearly all of us experienced as children is caused by a virus called varicella.  After the pox go away, the virus lives a quiet existence in some of the neurons of our nervous system.  When the virus becomes reactivated, itchy, painful vesicles form.  Receiving an antiviral medication promptly can shorten the duration and severity of a shingles outbreak.  Overall, the vesicles usually crust over within a week to ten days, but in about 10-15% of people, a form of severe, chronic pain lasts much longer.  This condition, called postherpetic neuralgia, occurs most often in people over 60 years old and is fortunately responsive to certain pain medications.  

Shingles occurs in about 1/3 of people during their lifetime.  A vaccine for shingles is available for people 50 years and older.  It is given only once during your life.  For people, between 50-59 years old, the vaccine lowers the risk of shingles by 70%.  For people, 60 years and older, the vaccine decreases the risk of getting shingles by 51%.  The risk of post-herpetic neuralgia (chronic pain from shingles) is reduced by 67%.  

Despite its demonstrated efficacy, in my experience many people decide not to receive the shingles vaccine. The biggest barrier is cost.  Its price is around $250 and Medicare and many insurance plans do not cover it, although some persons’ Medicare prescription drug plan contributes to paying for it at a pharmacy.

I’ll also briefly address three other vaccines.  The flu shot markedly lowers the risk of being miserable with a high fever and body aches for a few days.  But it is especially for important for older folks and those with compromised immune systems to get the flu vaccine since for them, the flu could result in a hospitalization or even death.  

All of us need a tetanus vaccine booster every 10 years to prevent tetanus.  Tetanus is a severe nervous system disorder characterized by muscle spasms.  It is caused by a bacteria that lives in the soil entering a person’s body through trauma to his or her skin.   

The pneumonia vaccine decreases the risk of developing a bacterial infection of the lungs (pneumonia).  It is indicated for all people older than 65 years and in younger people with a condition that renders them at a higher risk of getting pneumonia.  In addition, it is now recommended that an additional pneumonia vaccine, called PCV13, be given to people with compromised immune systems.

I’m sometimes asked by teenagers and young adults how I decided to become a doctor.  More broadly, they wonder: how does a person determine what to do with his or her professional life?  Here are some reflections on the idea of calling from my spiritual tradition of Christianity.

The scholar William Placher writes, a calling is “the idea that there is something . . . God has called me to do and my life has meaning and purpose at least in part because I am fulfilling my calling.  (T)he God who made us has figured out something we are supposed to do—something that fits how we are made, so that doing it will enable us to glorify God, serve others, and be most richly ourselves.” A choice, in contrast, is not a response to God’s call.  It flows instead from our own agenda. 

This raises the question of how God communicates a calling to human beings.  Put another way, how do we discern God’s will for our lives?   Theologian James Gustafson sees God’s call on us manifesting itself as a moral imperative.  He writes, “The presence of poverty, social disorganization, disease, personal anguish, injustice in the distribution of human services, ignorance, and similar factors move persons to seek the education and training to relieve these impediments to human fullness.”  He does not seem to envision God necessarily communicating one particular calling to an individual.  Rather, the person will have “a sense that one’s life experiences, one’s capacities for sympathy and empathy, and one’s moral beliefs and moral sensitivities make it reasonable to choose a certain profession.”

William Placher writes that “most people figure out, usually as part of a community, how God is calling them through prayer and meditation, inward reflection on their own abilities and desires, and looking at the world around them and its needs.”  He quotes Frederick Buechner’s wise statement that God calls you to “the kind of work (a) that you need most to do, and (b) that the world most needs to have done. . . . The place God calls you to be is the place where your deep gladness and the world’s deep hunger meet.”

Placher also helpfully chronicles how the meaning of a calling has changed over time.  The early Christians viewed becoming a Christ-follower as their primary call.  Making Jesus their Lord “made them outsiders to most facets of society.”  In the Middle Ages, when “the vast majority of Christians grew up in the church, surrounded by other Christians,” whether to become a Christian was no longer a real question.  The issue of calling was whether God wanted an individual to stay part of his or her family or join the clergy.  At the time of the Reformation, “the increasing complexity of society offered many people more (professional) choices” and Martin Luther proclaimed the “priesthood of all believers.”  According to Luther, “your job was your vocation (calling), and thus everyone, not just priests, nuns, and monks, was called by God to their particular work.”  Now, in what he views as our post-Christian world, Placher argues that “simply living as Christians could be our calling” since “trying to live as a Christian pushes upstream against the dominant values around us.” Realizing that Christians have struggled over two millennia to discern God’s call on their lives helps us realize we are not alone in our quest for vocational clarity.  It also helps us appreciate that finding our calling does not need to be understood primarily as identifying the perfect fit for our aptitudes and interests.

As theologian Alister McGrath writes of Calvin’s thoughts on this matter, “It is the person working, as much as the resulting work, that is significant to God.”  For instance, Brother Lawrence saw his humble chores of cooking and cleaning as being deeply meaningful when he performed them out of love for God.  He wrote that “is it (not) needful that we should have great things to do. . . We can do little things for God; I turn the cake that is frying on the pan for love of him, and that done, if there is nothing else to call me, I prostrate myself in worship before him, who has given me grace to work; afterwards I rise happier than a king. It is enough for me to pick up but a straw from the ground for the love of God.”  Here he echoes Paul’s admonition in Colossians 3:23 that “whatever your task, put yourselves into it, as done for the Lord and not for your masters.” 

I wonder how my younger son’s autism has affected the kind of dad I am. Playing with any young child can sometimes be taxing work, but one with autism presents unique challenges.  He or she might pay little, if any attention to your efforts to engage, leaving you feeling like you’re giving and receiving nothing in return.  Trying to speak to the child can seem like just talking to yourself—akin to what some people experience when they pray.  After a demanding day at work, trying to connect with him and enter his world can feel more like a chore than a privilege.  But lately something has changed.  My time at night with him is now often the most precious part of my day.

We have a trampoline in our back yard.  In the past, when we jumped together I focused on furthering his development, coaxing him to repeat words I said or make eye contact.  But one day I decided to let my teaching goals go and just be fully present with him.  After a little while I noticed him glance up at me with a bright smile.  He could sense I was having fun instead of straining to make him better.  When he fell down, I would too, tickling him and rubbing his back.  I could feel a loving bond develop.  On and on we jumped.  The back of his hair wet with sweat, my mind free from the stresses of the day.  Now when we arrive home, he grabs my hand and walks me to the back door and to the trampoline for our nightly jumping ritual.

I hope and pray that my son will talk someday.  I will do everything I can to enable him to have that crucial capacity.  But I cannot imagine that words could make us any more close and connected than we are jumping together on the trampoline. 

The always interesting Eric Topol recently conducted an enlightening interview (linked here) with Dr. Paul Offit.  Offit is head of the Infectious Diseases Division at the Children’s Hospital of Philadelphia and author of the new book Do You Believe in Magic?  The book discusses the subject of supplements, vitamins, and alternative/complementary medicine.  

He credits Linus Pauling with giving birth to the idea that megavitamins — large quantities of vitamins greatly in excess of the recommended daily allowance — have a vast array of beneficial activities.  Pauling’s take on this matter had credibility because

he was a brilliant man. He is the only person ever to win 2 unshared Nobel prizes. In many ways he launched the fields of molecular biology and evolutionary biology. He received a Nobel Prize in chemistry as a very young man because he was able to formulate these secondary structures for proteins. He was amazing.

Nonetheless, Offit presents evidence that Pauling’s brilliance did not extend to his opinions on the health benefits of megavitamins.  He postulates that after a breathtaking career, 

something happened to (Pauling) in his mid-60s. Maybe it was just the sin of hubris because he had been so right for so long, where he believed that his notions about megavitamins were correct even when study after study showed that they weren’t correct.

Indeed, as Offit states in his interview, recent studies show that excessive doses of certain vitamins, such as A and E, can be harmful. 

Another problem with the vitamin and supplement industry is its limited regulation by the FDA.  For this reason, consumers sometimes cannot have confidence about what they are taking.  For instance, Topol notes that 

a number of years ago in The Lancet, there was a very nice randomized trial of glucosamine for knee osteoarthritis. But the problem, of course, is that the preparation that was used in the trial — the one positive trial — you would have a hard time finding that particular preparation and dose because, as you say, it is an unregulated industry.

Offit believes that 

people have this sort of false notion that there is big pharma on one side and then on this other side, there are just a group of people who want to make natural products, and that they are being made by elves and old hippies on mountainsides.  

In reality, the vitamin and supplement and field is a 34 billion a year industry, so that 

there are a lot of people making a lot of money, including big pharmaceutical companies. Pfizer bought Alacer recently, which is probably the biggest maker of megavitamins in the United States. Hoffmann-La Roche has been a player in the megavitamin and supplement game since the 1930s.

Offit also comments on the credibility celebrities like Jenny McCarthy and Suzanne Somers carry with the public despite their absence of scientific or medical training.  Since we know these figures from television and the movies, many people feel they can trust what these famous folks say.  

I have not yet read the book, but it seems that Offit is open to the idea that valuable contributions can come from the areas of alternative and complementary medicine.  He just wants to see a rigorous, scientific approach applied so that we can know what really helps people.

Here are a couple of interesting articles I’ve read over the past few days:

In Aeon, Michael Hanlon explores the mystery of consciousness.  He begins by pondering a bird he sees on a chimney of a nearby house.  

What is it like to be that bird? Why look this way and that? Why be proud? How can a few ounces of protein, fat, bone and feathers be so sure of itself, as opposed to just being, which is what most matter does?

Old questions, but good ones. Rocks are not proud, stars are not nervous. Look further than my bird and you see a universe of rocks and gas, ice and vacuum. A multiverse, perhaps, of bewildering possibility. From the spatially average vantage point in our little cosmos you would barely, with human eyes alone, be able to see anything at all; perhaps only the grey smudge of a distant galaxy in a void of black ink. Most of what is is hardly there, let alone proud, strutting, cock-of-the-chimney-top on an unseasonably cold Cornish evening.

We live in an odd place and an odd time, amid things that know that they exist and that can reflect upon that, even in the dimmest, most birdlike way. And this needs more explaining than we are at present willing to give it. The question of how the brain produces the feeling of subjective experience, the so-called ‘hard problem’, is a conundrum so intractable that one scientist I know refuses even to discuss it at the dinner table. 

Here’s another wonderful passage.

Asked to name the most violent events in nature, you might point to cosmological cataclysms such as the supernova or gamma-ray burster. And yet, these spectacles are just heaps of stuff doing stuff-like things. They do not matter, any more than a boulder rolling down a hill matters — until it hits someone.

Compare a supernova to, say, the mind of a woman about to give birth, or a father who has just lost his child, or a captured spy undergoing torture. These are subjective experiences that are off the scale in terms of importance. ‘Yes, yes,’ you might say, ‘but that sort of thing only matters from the human point of view.’ To which I reply: in a universe without witness, what other point of view can there be? The world was simply immaterial until someone came along to perceive it. And morality is both literally and figuratively senseless without consciousness: until we have a perceiving mind, there is no suffering to relieve, no happiness to maximise.

Ben McGrath’s New Yorker article on The NFL and the Concussion Crisis has changed the way I watch football this fall.  I remember being fascinated by the 1985 Chicago Bears–The Fridge, Jim McMahon and his headbands, Kangaroo Velcro Shoes, the Superbowl Shuffle–it was all so much fun.  I later played high school and a couple years of small college football, dedicating countless hours to trying to become a better player.  All of this makes taking in at least part of the biggest college and NFL games a pleasurable diversion.  

But reading about the frequency and severity of brain injuries suffered by NFL players, I feel disgusted, rather than thrilled when I see a violent hit.  McGrath’s article describes Chronic traumatic encephalopathy (CTE), a condition that is believed to result from accumulation of subconcussions experienced during a football player’s career.   CTE was 

first diagnosed, in 2002, in the brain of the Pittsburgh Steelers Hall of Fame center Mike Webster, who died of a heart attack after living out of his truck for a time. It was next diagnosed in one of Webster’s old teammates on the Steelers’ offensive line, Terry Long, who killed himself by drinking antifreeze. Long overlapped, at the end of his career, with Justin Strzelczyk, who was also found to have C.T.E. after he crashed, fatally, into a tanker truck, while driving the wrong way down the New York Thruway.

McGrath notes that

Credit for the public’s increased awareness of these issues must go to the New York Times, and to its reporter Alan Schwarz, whom Dr. Joseph Maroon, the Steelers’ neurosurgeon and a longtime medical adviser to the league, calls “the Socratic gadfly in this whole mix.” Schwarz was a career baseball writer, with a heavy interest in statistics, when, in December of 2006, he got a call from a friend of a friend named Chris Nowinski, a Harvard football player turned pro wrestler turned concussion activist. Andre Waters, the former Philadelphia Eagles safety, had just committed suicide, and Nowinski was in possession of his mottled brain. The earliest cases of C.T.E. had been medical news, not national news. Nowinski’s journalist contacts, as he recalls, were in “pro-wrestling media, not legitimate media.” He needed help.

Schwarz, acting more as a middleman than as a journalist pitching a hot story, set up a meeting between Nowinski and the Times’ sports editor, Tom Jolly, for whom Schwarz had been writing Sunday columns about statistical analysis on a freelance basis. Rather than assign the story to one of his staffers, Jolly suggested that Schwarz write it. The result, “Expert Ties Ex-Player’s Suicide to Brain Damage from Football,” wound up on the front page, on January 18, 2007. It described Waters’s forty-four-year-old brain tissue as resembling that of an eighty-five-year-old man with Alzheimer’s, and cited the work and opinions of several doctors whose research into the cumulative effect of head trauma was distinctly at odds with that of the N.F.L.’s own Mild and Traumatic Brain Injury committee (M.T.B.I.), which had been created by Tagliabue. “Don’t send them back out on these fields,” Waters’s niece told Schwarz, referring to young would-be football players.

 

Ted Johnson, a recently retired New England Patriots linebacker, read the Waters piece and called Schwarz. He was thirty-four- years old and had been locking himself in his apartment with the blinds drawn for days at a time. He believed that his problems had started in 2002, when, he said, his coach, the sainted Bill Belichick, ignored a trainer’s recommendation that Johnson practice without contact while recovering from a concussion. Schwarz accompanied Johnson to a meeting with his neurologist, Dr. Robert Cantu, who said, “Ted already shows the mild cognitive impairment that is characteristic of early Alzheimer’s disease.” Two weeks after the Waters piece, Schwarz landed another freelance submission on A1: “Dark Days Follow Hard-Hitting Career in N.F.L.”

 

Schwarz’s phone kept ringing. Several of the callers were the mothers and wives of football’s damaged men. They represented a readership far less likely to have come across, say, the annual men’s-magazine features about mangled knees, wayward fingers, and back braces, which had hardened almost into a sportswriting trope. In March, Schwarz published another front-pager: “Wives United by Husbands’ Post-N.F.L. Trauma.” Glenn Kramon, an assistant managing editor at the Times who oversees long-term, Pulitzer-worthy projects, read this piece and decided to intervene. Schwarz was given a full-time position, with no responsibilities other than to broaden his new beat’s focus beyond the N.F.L. to the more than four million amateur athletes who play organized football. Although Schwarz was assigned to the sports desk, the Times framed the story as a matter of public health, akin to tobacco, asbestos, and automobile safety. Schwarz covered high schools, helmets, workmen’s comp, coaching, and so on, earning the nickname Alan Brockovich among friends. “You can imagine how many lawyers I hear from,” he once told me.

Schwarz’s math background came in handy, too, as he batted away the statistical objections about the unknown incidence of C.T.E. from skeptical doctors. And Schwarz had the backing of a news organization that did not see itself as having any symbiotic ties to the game’s economic engine. (ESPN, which drives the national conversation on sports, invests more than a billion dollars a year in football broadcasting.) 

 

What we now know, from reading Schwarz, is that retired N.F.L. players are five to nineteen times as likely as the general population to have received a dementia-related diagnosis; that the helmet-manufacturing industry is overseen by a volunteer consortium funded largely by helmet manufacturers; and that Lou Gehrig may not actually have had the disease that bears his name but suffered from concussion-related trauma instead. (Since 1960, fourteen N.F.L. players have had a diagnosis of amyotrophic lateral sclerosis, which is about twelve more than you would expect from a random population sample.) In the manner of Elisabeth Kübler-Ross, Dr. Maroon has delineated four stages in the N.F.L.’s reaction to the reality of brain damage: active resistance and passive resistance, shifting to passive acceptance and, finally, in the past few months, active acceptance. 

I don’t envision my two young sons as ever having much aptitude for or interest in football.  But if they ever do, knowing what I know now, I will do my best to talk them out of it.

I’m honored to be involved in the formation of the new medical school in Austin.  Taking part in this exciting effort has lead me to reflect on the strengths and weaknesses of my own medical school, residency, and fellowship training experiences.  A new article in the Wall Street Journal by Dr. Jonathan David provides some interesting ideas about how medical education in the U.S. could be improved. 

 He writes

The U.S. medical education system is the finest in the world, yet it is very expensive and inefficient. Although each medical school prides itself on the quality and delivery of its curriculum, all medical schools teach basically the same material.

For the first two “preclinical” years, students immerse themselves in the study of normal and then abnormal human bodily structure and function: anatomy, histology, physiology, pathophysiology and related disciplines. The curriculum is largely standardized by national accrediting bodies, and also by common sense (no school could eliminate the study of anatomy), although many schools will add such “extras” as “creative writing in medicine” or “medical drawing.”

Historically, each school has operated in isolation from others nearby, viewing their “brands” as valuable intellectual property to be guarded. For this reason, each of the 170 or so U.S. medical schools invests a huge amount of time and money to develop and implement its course of study. But students generally skip the live lectures to watch videos of those lectures and read the books on their own.

The uncomfortable truth is that medical schools today provide a preclinical education that their students neither want nor need. Students hate live classroom lectures, especially for basic content, and they know they learn better on their own time at their own pace. Yet schools still rely on these educational relics.

A more individualized system of self-study using the latest in digital technology, along with small study groups to integrate knowledge, would provide more effective learning. It seems wasteful to pay 170 anatomy professors to design 170 separate courses and then bill students for this privilege.

I recommend reading the entire piece.  It strikes me that a challenge common to nearly all reform efforts is preserving the wisdom of tradition, while being open to new, unfamiliar ways of doing things. 

There is a lot of talk these days about changing our health care system from “pay for volume” to “pay for value.”  The idea is that we currently reimbursement doctors and hospitals according to the number of services delivered rather than how well they make us.  This perverse system of incentives results in runaway health care spending that doesn’t necessarily result in a more healthy citizenry.

There is certainly truth in this way of thinking.  But to my mind, it drastically oversimplifies the situation.  To illustrate why I believe this to be the case, I present a letter entitled Performance Indicators and Clinical Excellence from the October 5-11th 2013 issue of The Lancet.  The author Chris Kenyon writes:

Attending post-intake ward rounds in various National Health Service (NHS) trusts around the UK, I am concerned that clinical expertise is being crowded out by a need to meet various key performance indicators.

In one hospital, I was told on arrival that the trust had, over a year, moved from the bottom to the top category of performing trusts. I was therefore puzzled when soon thereafter I attended a consultant post-intake ward round where a patient seen had ascending leg weakness mistakenly diagnosed by the admitting doctor as Guillain-Barré syndrome. The consultant spent little time reviewing the history of the patient (missing the history of pseudo-seizures), did not test the patient’s reflexes or power in the legs, and concluded that the patient required intravenous immune globulin. The consultant did, however, introduce all members of the ward round to the patient, check that any drug allergies were filled out on both pages of the drug chart and a checklist of 23 other items, which were ticked off or not according to the consultant’s compliance thereof. A sticker containing the 25 items ticked off was duly placed in the notes, the patient received intravenous immune globulin for their somatisation disorder and the patient contact scored 100% for audit purposes.

On post-intake ward rounds in the past, the consultants would, with a few pertinent questions and clinical findings, recognise the most likely diagnosis. This would determine a streamlined approach to the further investigations and management. Performance indicators are necessary, but with the limited time available for each consultant-patient contact, I wonder how much thought has been put into how the setting of performance targets such as this list of 25 items has crowded out the time available for clinical excellence.

 

I close with words from a sign that hung in Albert Einstein’s office at Princeton.  “Not everything that counts can be counted, and not everything that can be counted counts.”