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Monthly Archives: October 2013

Couple Interesting Reads

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.

 

 

 

 

 

 
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Posted by on October 15, 2013 in Uncategorized

 

Reforming Medical Education

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. 

 
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Posted by on October 10, 2013 in Uncategorized

 

Paying for Performance

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.
 
In this story, the doctor had met all of the quality measures.  The auditors assessing the “value” of the doctor’s care could feel good about what he had done since the checklist of performance indicators had been completed. The only problem is that the patient was given a wrong diagnosis and, therefore, received a very expensive, unnecessary, and potentially harmful treatment.  This is illustrative of an important defect in the way that doctors’ performance is being measured.  These quality measures all assume the presence of an accurate diagnosis.  But, in fact, making the right diagnosis–finding the real reason for what is wrong with the patient–is one of the most challenging and patently crucial parts of helping a sick person get well.  And yet I am not aware of a quality measure that takes this important clinical activity into account.  The quality indicators instead focus on whether people’s cholesterol, blood pressure, and diabetes readings are at goal and how many have received their age-indicated vaccines and cancer screening tests. These are no doubt important parts of care, but to reduce being a good doctor to this is a grave error.  
 
With all its flaws, the current fee-for-service is often an indirect measure of quality–perhaps in some instances superior to a method based on quantifiable quality indicators.  In Austin, where I practice, there is a particular orthopedic surgeon known both in the medical community and among patients for getting very good results with his knee and hip replacements.  It, therefore, takes a long time to get an appointment and a surgery date with him.  This is not because he is looking to do more surgeries.  Indeed, he is known to turn away people seeking joint replacements if he does not believe doing so would be appropriate.  He is busy because doctors and patients know he is good at what he does.  This is same reason that many of the best doctors’ schedules are full.  And this is something that people working to reengineer our health care delivery system often seem to miss. 

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.” 

 

 
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Posted by on October 8, 2013 in Uncategorized

 

Does Cranberry Juice Prevent Urinary Tract Infections?

Urinary Tract Infections (UTIs) are among the most common problems I see in my practice.  Since they are usually easy to treat, UTIs are sometimes a welcomed break from the more complicated, time-consuming issues I encounter.  Nonetheless, complications from UTIs (such as kidney infections and sepsis) result in more than 1 million hospital admissions annually in the U.S.  Cranberry juice blocks bacteria from adhering to the urinary tract.  So for decades cranberry products have been used to prevent UTIs.

 

An article in the most recent issue of the Journal of the American Medical Association (JAMA) analyzed 13 studies testing whether cranberry products really do decrease the incidence of UTIs.  The study concluded that “overall, cranberry products were not associated with lower rates of symptomatic UTIs.”  The study’s authors acknowledge that they cannot definitively conclude that cranberry products don’t prevent UTIs, only that there is not robust scientific evidence to support their use for this purpose.  The article hypothesizes that perhaps not enough of the active ingredient (proanthocyanidin) in cranberries was consumed to be able to prevent UTIs.  It states that “in theory, a patient would need to consume 224 to 280 grams of cranberry juice twice a day indefinitely to achieve any potential benefit” in preventing UTIs. 

 

If somebody with recurrent UTIs is interested in trying cranberry juice to address the problem, I see no harmful effect from doing so except for the increased sugar and calorie intake. 

 

So what does work to prevent UTIs?  A couple of common sense solutions are staying hydrated and urinating immediately after sex.   For women suffering from frequent UTIs, using a topical estrogen cream and/or taking a regular low dose antibiotic for prevention have both been shown to be effective.

 
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Posted by on October 5, 2013 in Uncategorized

 

Brittle, Splitting Fingernails

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Practicing primary care medicine resembles the off-and-on activity of the game of baseball.  The routine of annual check ups and minor problems can suddenly be interrupted by the discovery of urgent, life-threatening conditions like pneumonia, pulmonary emboli, and coronary artery disease.  As internist Danielle Ofri writes, “In contrast to specialists who have their diseases cut out for them—cardiologists get patients with heart problems, pulmonologists get patients with lung problems—the general practitioner has the far more challenging task of sifting out serious illness from the vast sea of aches and pains that afflict the human race.  And this is what we fear, that one of these hundreds of patients will indeed harbor some grave illness and that we will miss it.”

 

But preventing, detecting, and treating serious health conditions are not the only tasks that matter.  It’s also worthwhile and satisfying to effectively address the minor annoyances that afflict people.  Accordingly, I thought I’d share some pearls an esteemed dermatology colleague shared with me yesterday about brittle fingernails.  This occurs when superficial grooves in the nails lead them to split.  To treat this problem he recommends an over the counter Biotin 3 mg pill daily, applying moisturizer to the nails regularly, and avoiding excessive water exposure to the nails.  If this is not effective, there is also a new, expensive product called Nuvail that can be applied to fingernails to prevent friction on the nail surface and protect against the effects of moisture.

 
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Posted by on October 3, 2013 in Uncategorized

 

Are Electronic Cigarettes a Safe Alternative to Smoking?

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Nearly everyday in my practice I see the tragic, avoidable results of smoking:  A woman with emphysema that requires her to be constantly connected to an oxygen tank, a man with a cancer in his throat that has robbed him of the ability to eat or speak, fatal and debilitating heart attacks and strokes that occur at much too young of an age.  The list goes on and on.  Indeed, nearly 450,000 Americans each year die of complications of smoking.  Anything that can help avoid this great amount of human suffering deserves our consideration.

 

Accordingly, I offer the following reflections on electronic cigarettes.  First of all, what are they?  As a Medscape article explains:

“Electronic cigarettes — e-cigs — look like cigarettes in size and shape, but they are nonflammable, so you don’t smoke them. Instead, you “vape” them.”

While nicotine is the substance that causes pleasure and addiction to cigarettes, it is not what causes the manifold maladies that result from smoking tobacco.  Rather, it is the other noxious, toxic chemicals in tobacco that harm and kill.  So, do e-cigs have any of these toxic chemicals?  A new study in the journal Tobacco Control analyzed vapors from a dozen e-cig brands and also found some toxic substances.  But these toxins were found at levels 9 to 450 times lower than in regular cigarette smoke. 

 

While e-cigs don’t appear to expose people to the same high level of toxins that real cigarettes do, they effectively reproduce the nicotine rush produced by inhaling smoke from burning tobacco.  Thus, they have the potential to be a much less harmful way for people addicted to nicotine to continue to get their fix.  Thus, for my patients who are not interested in smoking cessation, I recommend they change to e-cigs as a less toxic option.

 

Nonetheless, I share some of the concerns voiced by others about e-cigs.  Since using e-cigs might seem to be a safe practice, they may promote nicotine addiction and possibly be a pathway to smoking tobacco.  People who otherwise might have quit smoking altogether may now transition to long-term e-cig use, thus inhaling the low levels of toxins the Tobacco Control study revealed.  Finally, there is the concern that e-cigs are used by some smokers, not to quit their habit, but as a way to smoke (or vape) in public places where smoking tobacco is banned. 

 

In sum, however, it appears to me that e-cigarettes offer a much less harmful alternative for tobacco smokers who are unwilling or unable to end their addiction.

 

 

 
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Posted by on October 1, 2013 in Uncategorized

 
 
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