Monthly Archives: August 2014

The scientist Bert Vogelstein played an important role in understanding how cancer occurs. He is now working on developing what he calls a liquid biopsy. It is based on the fact that nearly every type of cancer sheds DNA into the bloodstream. By analyzing a sample of a person’s blood, a liquid biopsy would indicate whether a person has a cancer in his or her body. The hope would be that by detecting the cancer at an early stage, effective treatment could be started in time to result in a cure.

An article on the concept of a liquid biopsy explains that “making such screening a routine practice in medicine will be challenging. One difficulty is that while the test may detect the presence of cancer DNA in the body, physicians might not know where the tumor is, how dangerous it is, or even whether it is worth treating.”

You can read the entire article in MIT Technology Review here.

Robbin Williams’ tragic suicide has resulted in a proliferation of articles on depression and mental health in general. Last month’s Atlantic contained a fascinating article on the link between creativity and mood disorders such as anxiety and depression. The author Nancy C. Andreasen is a psychiatrist, neuroscientist, and a PhD in literature who has spent many years studying the brains and minds of creative people. Her study found that “80 percent of (the creative people she studied) had had some kind of mood disturbance at some time in their lives, compared with just 30 percent of the control group” she used. You can read the entire article here.

Doctors employ many means and methods in their effort to promote health and alleviate suffering. They ask questions and order tests to arrive at accurate diagnoses. They prescribe medications and perform surgeries. But I’ve sometimes found that the most healing thing I can do is simply listen to a person tell his or her story. The internist Rita Charon writes, that

Once, a young woman came to see me with severe and relentless abdominal pain. She was fidgety, spoke in fragmented speech, seemed clearly to be suffering. She had already seen a gastroenterologist, a gynecologist, and an expert in colitis, all of whom had found no abnormality to account for her symptoms. Since this was my first meeting with her, I asked as a matter of routine about the health of her family members. Her father, I learned, had died of liver failure. As she spoke of his horrible suffering—his abdomen swollen with fluid, his muscles spent, his mind clouded—she put both her hands, fingertips interlocked, almost protectively, over her own upper abdomen. I told her that she used the same gesture to discuss her own symptoms as she had to describe her father’s illness. For the first time in the interview, she became still. She looked down at her hands, now in her lap. We were both silent. And then she said, ‘I didn’t know this was about my father.’

In A Little History of the World, art historian E.H. Gombrich attempts to provide an accessible, comprehensive history of the world for younger readers. It’s a delightful read that makes me want to see the places around the world where the stories he describes took place. Here is a beautiful passage about Lao-tzu.

A wise man lived in China at about the same time as Confucius. His name was Lao-tzu. He is said to have been an official who became tired of the way people lived at court. So he gave up his job and wondered into the lonely mountains at the frontier of China to be a hermit.

A simple border guard at a frontier pass asked him to set down his thoughts in writing, before leaving the world of men. And this Lao-tzu did. But whether the border guard could make head or tail of them I do not know, for they are very mysterious and hard to grasp. Their meaning is roughly this: in all the world–in wind and rain, in plants and animals, in the passage from day to night, in the movements of the stars–everything acts in accordance with one great law. This he calls the ‘Tao,’ which means the Way, or the Path. Only man in his restless striving, in his many plans and projects, even in his prayers and sacrifices, resists, as it were, this law, obstructs its path and prevents its fulfillment.

Therefore the one thing we must do, said Lao-Tzu, is: do nothing. Be still within ourselves. Neither look nor listen to anything around us, have no wishes or opinions. Only when a person has become like a tree or a flower, empty of all will or purpose, will he begin to feel the Tao–that great universal law which makes the heavens turn and brings the spring–begin to work within him. This teaching, as you see, is hard to grasp and harder still to follow. Perhaps, in the solitude of the distant mountains, Lao-tzu was able to take ‘doing nothing’ so far that the law began to work within him the way he described.

So after a long hiatus, I’m attempting to get back into the swing of blogging. With everything else that I have going on in my life, writing something consistently became difficult. But what is doable is sharing articles I’ve recently enjoyed along with brief commentary.

Dr. Danielle Ofri, a fellow internist, writes about her frustration with the tedious process of obtaining prior authorizations for some of her patients’ medications.  As Ofri writes, prior authorizations “are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, the doctor is required to provide a compelling clinical reason” through extensive documentation and sometimes phone calls.  I faced this issue recently when I treated a patient who was suffering from a severe infection of the colon. When the patient’s infection recurred after receiving a course of the first-line antibiotic, I prescribed a different antibiotic that is necessary in this situation. It nearly always works and there are no good alternatives. Unfortunately, rather than fill the prescription, the insurance company sent me a long form to fill out. Then, after immediately filling it out, the insurance company took their sweet time, before sending a fax to tell me they were would not fill the medication. I had to scramble to get the patient an appointment with a gastroenterologist, who, lo and behold, prescribed the same medication I did. But since it was a specialist prescribing it this time, the insurance company approved the medication. As soon as the patient started the pills, their problem resolved.

In Ofri’s similar story, she describes caring for a Mr. V, who

suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer-care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer-care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 asked me to list all the blood-pressure medications that Mr. V. had been on in the past, including dates of initiation and relevant lab values, a request of epic proportions in his case.

The representative went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

Ofri argues that

prior authorization clearly saves money for the insurance companies, at least up front. Many physicians simply give in, because the process is just too arduous.

But prior authorization ultimately ends up costing the health care system. The time and money that medical practices devote to prior authorizations could surely be put to better use for patient care. And it’s not even clear that insurance companies save money in the long run. One study examined the records of more than 4,000 patients with Type 2 diabetes who were prescribed medications requiring prior authorizations. Those who were denied the medications had higher overall medical costs during the following year; not getting the medications probably worsened their conditions. . .

I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.”