Death panels won't die

Death panels are back...

...if they ever existed in the first place. But the concept lives on in the minds of Obamacare's political opponents.

Here is the latest incarnation of this dubious claim: the government directs cancer physicians refuse cancer treatment to terminally sick cancer patients who are covered by the Obamacare. It is alleged that if a patient, in the opinion of a physician, is unlikely to achieve the remission, why spend more money on this patent's treatment. In other words, a death panel would chose not to continue to treat this patient since nothing would prolong the patient's life.

On other hand, the same people who cry foul on the Obamacare are busy making the access to health care harder or impossible for millions of low-income Americans. Does not take a genius to realize that someone without medical insurance is unable to get the recommended cancer screening to prevent cancer to begin with.

Some opponents of the Obamacare I spoke with readily admit that they protect the principle that everyone is entitled to chemotherapy to prolong life if they so choose regardless of how futile it may be; it's a right to be given a drug (and thus have the government pay for it). How tricky such an argument is when it is applied by the opponent of the Obamacare. If they claim it is such a right, then how conceptually different is the right to be seen by a physician or have the access to a contraceptive medication?

The opponents of the Obamacare appear less certain on the subject of whether such a cancer treatment at any stage of the disease is in best interest of a patient. It is probably true that majority of opponents of Obamacare have not seen severely sick dying cancer patients with falling blood counts left helpless in face of deadly infections or confined to intensive care units wrapped in tubes and pumps, or bleeding, puking, incontinent, and half-out because of high-dose pain meds. Would anyone want to get a drug that will kill? Those opponents of the Obamacare who would still think that those who suggest to stop the torture belong to death panels are clearly not in the know regarding palliative medicine.

It is far easier to stir a controversy to equate futile treatment with rationing than help people get access to health care to maximize quality of life for many Americans. So please, the political opponents of the Obamacare, wise up, for one day some of you will be in that ICU bed wrapped in tubes begging to end prolonging death.

Russian Blues

Had to go to Russian consulate in New York, and have some observations.

The crowd, anywhere from 5 to 40 people, waits outside. It is pleasant in May, but was bitterly cold in December.

There are lot of elderly folks, and most of them usually attempt to inch in front of the line, to ask a question. Not unusual to see a Russian citizen to inch in front of a line to "ask a question." In Russia questions were usually something like "how much these potatoes cost?" or "any fish left?" One cannot find the answers to these questions from the back of the line.

Since the line is outside, there is no number to take, no seat to occupy, no customer service to inquire. All wait in the same line, asking each other on details of paperwork and procedural details, which clearly nobody knows. Every 5-10 minutes a clerk unlocks the main door from inside, and steps out to let a group of people out and another group in. This is a window of opportunity for elderly emigres to ask a question. The clerk's job is to deflect all questions and get inside as quickly as possible. Some elderly citizens clearly don't know it, and scream the questions, all at the same time. The clerk randomly answers one question, and it is always a variation of a "No," as in "you are wrong, we don't do that, go home," or "your question requires an answer from the Consul, but he is not in today." This latter response clearly is designed to baffle the questioner; if the consul is not in, there is clearly nobody to answer any questions. Another popular question is to request an affidavit of some sort. According to the clerk, such an (or any?) affidavit was ceased to exist 4 years ago. This answer utterly confuses the elderly because the clerk does not offer anything in its place.

Having derailed the attempts to gain the access with questions, the clerk shouts names of those who are allowed in. Actually he does not allow them in right away. He asks why they are there. Clever elderly citizens know this, and stand in line to ask a question. The clerk deflects their questions as well. It appears that some elderly citizens learned that they won't win this game, and have a paperwork that they shove to the clerk. This invariably makes the clerk cease calling names and review the paperwork. I am surprised at that since paperwork is just a fancy way of asking a question. Sometimes if deflects it, but sometimes he allows the person in.

Immediately inside is a narrow hallway framed by a metal detector. I am convinced it is for show. It beeps randomly and did not detect car keys and a phone in pockets. Bags that are passed on the outside of the frame are not examined either. Works for me. There are several chairs in the foyer; several people are waiting there. The clerk ushers me in the next room, "wait for your name is called." People are sitting on two sofas and lean against a large table with "Russian-American" newsletter scattered on it. Someone's name is called to one of the officer's windows. Each window looks exactly like that of customer care booth on the Grand Station Terminal in New York. It has a round microphone/speaker assembly cut in the middle. Under the thick glass, there is a metal box that looks exactly like the one on gas stations where you would put cash, and the register clerk would pull it in, and then will push back the change.

So, someone's name was called. The entire dialog is heard with all personal details including names, addresses, the number and names of children, marital status, the reason for being there. Wild.

Exit is not free. The door is locked, and gets unlocked every few minutes to exchange the visitors. The cycle repeats, questions, deflections, affidavits, paperwork. Some bent universe.

Maps of Us

A fantastic collection of maps showing a tremendous spectrum of our lives. Play here.

Here is how to cure HIV.

HIV depletes the number of CD4⁺ T cells, and causes AIDS by essentially erasing the immune system. To enter a T cell an HIV viral particle must have correct keys to a door on the surface of a T cell. The door opens only when an HIV viral particle "touches down" and attaches to two receptors on the surface of a CD4⁺ T cell, CD4 and CCR5. While an HIV viral particle always binds to the CD4 receptor, in a small number of people, especially of European Caucasian descent, CCR5 receptor could be mutated, and the "key" on the surface of the HIV virus does not "fit" the receptor on the surface of the T cell. In this case, CD4⁺ T cells stay HIV free.

This is what happened in the case of "Berlin patient" Timothy Ray Brown. He has been living with HIV since 1995 controlling it with anti-retroviral drugs. In 2007 he was diagnosed with leukemia. As a part of treatment for leukemia he underwent a hematopoetic stem cell transplant (HSCT, A.K.A. bone marrow transplant,) from an unrelated donor, who actually had a mutation in the genetic code of the CCR5 receptor. As a result of such a transplantation, Timothy's new T cells are impervious to HIV. Whatever HIV he had in his own T cells was presumably wiped out with his entire own immune system in preparation for the transplant. He remains HIV free since 2008.

It did not require a giant intellectual leap to propose blocking CCR5 receptors to make CD4⁺ T cells resistant to HIV. In this case the door on the surface of T cells stays locked, and a person, HIV free. Based on this premise so called entry inhibitors were developed that prevented an HIV virus touching CCR5 receptor. At the same time, those who already have HIV will likely benefit as well. Those T cells infected with HIV make and release new viral particles. But HIV-free T cells with blocked CCR5 receptors are protected from the viral entry. CD4⁺ T cells already infected with HIV die, while those with blocked CCR5 receptors remain uninfected. Over time, at least in theory, all HIV infected cells will die, including those that harbor so called "HIV reservoir," that remains dormant on anti-viral medications. The end result, complete HIV cure.

One of problems with this approach is that CCR5 blocking is not 100% efficient, and the virus gets through. How to make this fence impenetrable?

Well, a new study published in NEJM reported building such a fence by editing CCR5 gene in CD4⁺ T cells. HIV-positive patients with undetectable viral loads and sufficiently high levels of CD4 T-cells had some of their CD4⁺ T cells removed, genetically edited to introduce a specific mutation into the gene coding for CCR5 receptor, and infused back. Following the transfusion, six out of 12 study participants went off anti-viral treatment for 3 months. In these patients the load of HIV increased, but the decline in modified CD4⁺ T cells was significantly lower than in those unmodified ones.

This is a very encouraging results, to say the least. If the number of CCR5-modified CD4⁺ T cells could stay the same or even increase, over time infected CD4⁺ T cells will die leaving the patient HIV-free. The reason why the number of CCR5-modified cells also decreased is the following. Each cell has two copies of the same gene, one from each parent. Thus one needs to edit both copies in each CD4⁺ T cells. The gene editing method proposed in the study did not "edit" each copy of the CCR5 gene, resulting in reduced but existing susceptibility to HIV entry.

There was, however, one patient who inherited one copy of CCR5-mutated gene from one of parents. His CD4⁺ T cells, as all his cells, had one of two copies of CCR5 genes already mutated but it was not enough to protect him from contracting HIV. But he only needed to have one copy of CCR5 gene edited in CD4⁺ T cells. Therefore for him, effectiveness of gene editing was much much higher, and his viral load remained undetectable after he received the infusion of gene-edited CD4⁺ T cells and went off anti-viral therapy.

This is a remarkable study shows the proof in principle and safety of the gene-editing approach. It seems to be only a matter of time, and probably not too distant, when someone will effectively edit both copies of the CCR5 gene to make them insensitive to HIV. HIV will become history then.

Reflection on House of Cards I

If you were like me snowed a bit this past President's weekend, you might have found yourself drawn to the second season of "House of Cards."  The major event that comes in the middle of the first episode is Frank (Kevin Spacey) throwing Zoe (Kate Mara) under the train. He then leaves and seemingly without a trail. At least a trail detective in the second episode cannot find. Lucas (Sebastian Arcelus) examines the surveillance video with one of detectives at the District police department. The detective says there were two witnesses, and both are duds. So Frank washes hands in the first episode, and becomes a president in the last.

Seemingly unstoppable Frank, who was denied the post of Secretary of State in the first episode of the first season frees himself from all allegiances, and with his wife Clair (Robin Wright) presses ahead through power plays and schemes screwing people lives until he becomes a president via vice presidency (thus you may guess requiring a resignation of the elected president in the process). No one seems a worthy opponent who can crack Frank's intentions and bring him down. Several have tried in vain. Journalists investigating the suspicious suicide of the Congressman Russo (Corey Stoll), businessman Raymond Tusk (Gerald McRaney) who in the end sells out President Walker,  the president Walker (Michael Gill) himself briefly gets a whiff of Frank's malfeasance as his (Walker's) political demise nears, but then lets his guard dissipate again in the face of obvious clues of Franks' treason. 

There were lots of chances to make Frank's life more difficult and, in my humble opinion, show more thrilling. But the writers seemed to be so preoccupied with fitting the process from Frank's becoming the VP to his presidency in 13 episodes that many story-lines felt sloppy, underdeveloped, and frankly did not hold water for how clearly unrealistic they were.

In this regard, the story-line that bothers me is the one with Zoe's death. Zoe comes to meet Frank disguised in a fedora and thick-rimed glasses at the train station and ends up under the train; he pushes here onto the tracks after a dialog. He then leaves seemingly incognito, while walking in the direction opposite everyone is running to see what happened, and uncaptured on surveillance tapes. No evidence to suspect or prove a foul play. I am sure everyone watching thought, "Oh c'mon, seriously!" Perhaps the writers wanted to avoid the whole "what if he is captured on the surveillance" story, but we don't need a CSI-style investigation to claim an unrealism of this line of thinking. With cameras watching every corner, Frank (or at least a figure leaving the station) would have been seen and exposed. In fact, the right of the surveillance video Lucas is watching with the detective  (the lower picture) shows where Frank exited after having pushed Zoe. There is certainly the evidence of foul play. So go from there, detective.

This is not to say the Frank should have been exposed and accused of murdering Zoe, but I would have liked to see this plot developed rather than pushing Lucas into deep web and locking him up for cyber terrorism (what a doozy subplot).

Bloody mess

My biggest fear is for the code pager to go off while I am in the restroom.

It did go off angrily followed by the overhead PA system announcement the code location. The unit to which I was instructed was located a hike away from where I was standing watch, but it's all hands on deck at nights. By the time I get there, running overpasses across the hospital and climbing stairs avoiding slow elevators, the code team localized to that section of the hospital is firmly in control. Anesthesia team is intubating, intensive care unit crew is assessing and making the transfer arrangements. Seeing the order coming out of chaos, I sign off and head back to my tower. One of the intesivists wishes me a good night, "See you at the next code," he says.


Back to my hematology unit, where I am watching over thirty-four patients trusted to me by the day teams, my spectralink house phone goes off incessantly.

"Ms. B. has a fever of 100.8. She _is_ neutropenic; do you want to culture her and start antibiotics?" "Sure, I'll put the orders."

"Ms. M's platelets are 4."
"Yes, I know. I need to speak with the blood bank since she needs special platelets. Is she bleeding anywhere?"

"Ms. L.'s heart rate is 150, and blood pressure in the low hundreds."
"Please do an ECG, and I will be right there."

"Mr. F. has a temp of 103, his rigoring and breathing at 30. He is going to hospice tomorrow morning. What would you want to do, doctor?"
"I will be right there"

"Ms. C. has soft blood pressures, heart rate in 120, and she has not had made urine since the beginning of the shift"
"Give her a liter of normal saline bolus. I will be right there."

"Hi, is this heme service?"
"Yes."
"You have an admission from the emergency room. He just arrived on the floor."
"Oh. What is he here for?"
"I will be right there..."

I look at my spectralink that says "Bloody Mess" where it should be "Hello, World." The code on my floor is just a matter of time. No time for a restroom break.

Code pager goes off again. _Not_ my floor. Where? East Pavilion. Stairs down, bridges, stairs up. Running through the mental checklist of what to do when I get there. Same intensivist joins me on the run, "Get me there the shortest way." "No problem boss, hang on to your badge."

The day team starts to trickle in. Interns first. Early. Hair is still wet. Time to sign out the service back to day teams.

"OK, so Ms. M. got her matched platelets. She is fine."
"Ms. B. had a small temp, cultures sent, broad-spectrum antibiotics. She is fine."
"Ms. L. was in atrial fibrillation, there were no telemetry beds, so I managed her on the floor. She converted back to sinus. Blood pressures stable. But watch her closely today. She will need a cardiology consult."
"Mr. F... had a fever and rigors, but better with morphine"
"Mr. C...needed some fluids."
"Oh, and you have three new admissions."
"But nobody coded."

Nuts and Death

According to the latest diet_vs_death research, nuts are good. On the heels of the PREDIMED strudy (AKA Mediterranean diet study) that showed reduced mortality in subject who would tank themselves up with olive oil and had increased nut intake (30 g a day) comes another nutty study (1). This study looked at nut consumption of about 118,000 people over 30 years (by analyzing results from Nurses' Health Study [76,000 women] the Health Professionals Follow-up Study [42,000 men] cohorts). There was significant reduction in mortality associated with nut consumption. Those who ate nuts 7 and more times per week had 20% less rate of death compared to nut abstainers.

What about the weight gain? Does not appear to be associated with nut consumption. Actually, several studies referenced in the NEJM paper showed reduced waist circumference.

So... go nuts.

Perceptions of Medicare

An interesting report published in NEJM revealed several public misconceptions regarding Medicare:

• more than 60% of respondents think that Medicare spending is rising faster in the last 5 years. In reality, it slowed.
• Only 53% of Americans correctly believed that Medicare is a one of the largest spending items of the federal budget. Only about 30% see Medicare as a major cause contributing to the federal deficit, and almost 25% think this is not a cause at all.
• Majority of public believes that Medicare recipients get benefits worth about the same (27%) or less than (41%) what they have paid in payroll taxes. In reality, on average Medicare beneficiaries paid $1 for every $3 they receive.
• despite the perception that Medicare spending is accelerating, the majority (except those in 18-29 yr group) oppose reductions in future spending on Medicare, and the older people get the more they oppose.
• Poor management by the government, fraud and abuse in health industry, and excessive charges by hospitals were identified as reasons most important why Medicare costs are rising. The cost of new drugs, tests, and treatments was the lowest ranking reason with only 6% identifying it as a cause responsible for Medicare spending.

The following finds are also instructive:

• The overwhelming majority (74%) recognizes Medicare as a federal government program.
• A similar proportion of public (72%) have very or somewhat favorable opinion of Medicare. Among those older than 65 yr, favorability is 88%.
• 
  
• Only 50% are aware that doctors are paid less by Medicare than by private insurers.
• Two-thirds were supportive of fee-for-service payments rather than a capitated model.
• And almost 60% won't vote for a candidate supporting major cuts to Medicare to reduce federal budget deficit.

There are rather large gaps between perceptions and facts.

32

Virtually all conversations about health care with my friends leaning Republican break down along the issue of personal vs social responsibility for an individual maintenance of health. In my opinion, while each of us should strive to to make smart and healthy choices for ourselves individually, we also make choices as a society that improve us as individuals. For example, we as a society decided to subject our children to vaccinations. Our Constitution does not mention vaccinations. And yet everyone can get them. With exception of some fringe individuals and groups, majority seems to agree that there is indisputable evidence that vaccines save lives. While it is an individual responsibility of parents to physically bring a child for shots (although house calls certainly work just as well), it was us as a whole society that made that choice to invest in vaccination programs, manufacturing, distribution, and education. If there were early doubters of this social responsibility, and I am sure there were those who screamed socialism and usurpation of individual rights, vaccines worked and saved lots of lives, not to mention money. And now Republican children also get vaccinated. For free and not feeling as if they are giving up their individual rights. To receive a vaccination became both a social and personal responsibility.

Perhaps even better an example is our commitment to education. As a society we decided to provide K12 education for free. We could have left it fully in the realm of personal responsibility of well-heeled parents. But no, we decided that education, even though not a Constitution-charted right is a right nonetheless for everyone. Who can argue that by doing so our society became prosperous, with obvious benefits to ourselves, our economy, our lives. We, as a society made a choice to invest in firefighters rather than leaving firefighting an individual responsibility. We probably saved lots of lives and money this way. Did anybody question this idea by arguing that have one's property saved by firefighters is not outlined in Bill of Rights?

All these choices are examples of social insurance that effectively spread risks among all of us. Those who refuse vaccines also get a benefit from herd immunity, a phenomenon that describes protection from disease by virtue of lack of disease due to many vaccinated individual around the one who is not. Those who are vaccinated do not carry pathogens and therefore cannot transmit them to anybody including those who are not vaccinated. A risk of not being educated was spread through the entire population. We decided that education is worth it.

So why is health care so different? Take for example a recent ban on soda in New York City by the mayor Michael Bloomberg (which has been just struck down.) He argued, and not without good evidence, that consuming supersized amounts of sugary beverages cannot be good for one's health. And there seem to be an agreement on this even among advocates of individual rights. Of course, this is because metabolism has no regard for one's position on individual rights. It's all about calories in and calories out, and obesity affects Democrats and Republicans soda-gulpers equally badly. The divide is clearly along the individual freedom to enjoy all 32 ounces of it without a bureaucrat saying that you cannot have it.

And this is a juncture where my understanding of my Republican friends' positions tapers off. They argue that personal responsibility should kick in right before one gulps all 32 ounces of sugary fluid and the society should not intervene. The premise my Republican friends base their argument is two-fold. They argue that these 32 ounces can only hurt the person who gulped them, and as long as that person is aware of consequences (which is of course a gulper's responsibility to find them out), gulp away. The second common problem cited with such "broccoli laws" is their boundaries: people in power could start banning everything they perceive harmful,  and this is a shortcut to a totalitarian state. 

It is easy to see how someone gulping 32 ounces of soda raises health care costs for all of us, in some part because all we, and insurance companies, know the consequences. And insurance companies are in the business of risk assessment, and the one who drinks lot of soda has a higher risk for diseases associated with indiscriminate diets. Insurance companies of course can jack this indiscriminate dieter's insurance premium. But the most important problem is that this gulper's health costs will most certainly be higher over his life time than if he was not such an indiscriminate dieter. And since the goal of insurance is to spread risks over large number of people, the cost translates to all of us. So as a society, wouldn't it be smart to lower our costs by making it a little harder to be an indiscriminate dieter? How much harder? Just get two 16-ounce gulps instead of one 32-ounce drink. We have sacrificed more important civil liberties than this one without much peep.

Our own third-world country

I have recently had a discussion with a friend of mine regarding international rotations during post-graduate medical training (A.K.A. residencies.) A great many programs exist that send residents all other the world on month to two-month long rotations when residents engage in local health care and do lots of teaching and learning. In some cases, these rotations are based in fairly advanced large hospitals, and in others, not so much. My friend had recently returned from such a rotation, during which she had an opportunity to practice in a hospital and teach local medical residents, and extensively travel the country. Not unexpectedly, such rotations could be a lot fun, and have large appeal for global health-inclined crowd.

During the last year of med school I wanted to go on such an international rotation. My partner was at that time working for Partners in Health, which is an organization delivering sustainable international health care for the poor in a dozen of countries. When she heard me talking about setting up an international rotation, she suggested that I would do a rotation in the US but at a place that closely approximates a third-world country, an Indian reservation. That was a great idea, and I spent a month at Gallup Indian Health Hospital working in general medicine and infectious disease clinics, and doing home visits on the Rez.

I wrote a little bit about health care and economic disparities on the Navajo reservation before. And to make it stick, here are a few telling numbers:

• Total population of Navajo Nation: 250,000
• Unemployment rate: 44%
• Families living in poverty: 30.5%
• Homes without complete plumbing facilities: 78.6%
• People living with diabetes: 55,000

Per Capita Personal Health Care Expenditures Comparison (Jan 2012):

• Indian Health Service expenditure on user population: $2741
• Total U.S. population expenditure: $7239

While a lot can be  (and will be) said on the sad state of health affairs on Indian reservations, it is only a part of a bigger picture. In my view the largest problem is essentially lack of sustainable economy on the Rez. With unemployment up to 50%, forty percent of incomes is less than $10K, 82% of incomes are below $50K. Only 11% of those living on the reservation travel less than 20 miles to a grocery store. A lot of money is spent in "border towns," which are not on the reservation. In 2011 Navajo Nation lost more than $200M in sales taxes in purchases in border towns. In comparison, total gross revenue projection for Navajo Nation in 2013 is $247M.

There simply no sustainable jobs because there is no economy as we know it. A brisk search for Navajo businesses returned a smack of links and a website of the Navajo Nation's division of economic development, which really looks paltry on data and initiatives. Similarly, a website of Navajo Nation's Department of Agriculture is a throwback to HTML1 era, which on the face of it has not been updated since September 2010 (but does have information on Department of Agriculture Fourth Annual Conference in 2013 if you look for it).

These are all very broad strokes, and I am sure all devils are in the details, as in any bureaucracy. All sort of politics are in play, not insignificantly between the Navajo Nation and the federal government over resources and land, and I don't pretend to know a first thing about. But what I saw on the reservation gives me a lot of hope.

What I saw one day traveling through a region with a small river was a lot of cultivatable land, lots of crops and greenhouses full of greenery. I saw lot of action in the fields. And this made me think then and now -- there is absolutely no excuse, political or otherwise, to prevent people of the Navajo Nation from making their own land fertile and prosperous. These are hardworking and proud people with fantastic work ethics.

And this is where I stumble, and don't really know what to do about it. One country that comes to mind is Israel. Essentially a desert country, Israel became an oasis, both agricultural and technological. I don't know the numbers, but I dare to guess that the US government invested heavily in Israel economy and infrastructure. Can we do the same here and get rid of a third-world country conditions here at home?

Cleveland Clinic CEO: Health Reform is “Already in Place”

Cleveland Clinic CEO: Health Reform is “Already in Place”

Solstice. The first day of internship.

The first day of internship fell on solstice. There is probably some symbolism in it, something about fertility. Ten days of orientation were certainly fertile on the amount of information and welcomes. Some smart folks were writing the names people they met in notebooks. So many times we were assured that by this time next year we will be pros. I really believe it when my program director said that whatever problem we would encounter, they have had already solved it. So, technically, there should be no problems. 

Still I wanted to hear something else on the first day of internship and every time when things go south down in the trenches, why I volunteered for this. And this is why I am writing it down, so that when I am in doubt I can get back here and re-read it. 

 

Seven hundred thousand people declare bankruptcy every year due to medical bills.

 

There are three types of care: necessary, preventive-sensitive, and supply-sensitive. Necessary care is care that is, well, necessary. It constitutes the smallest fraction of Medicare expenditure, but is under the heaviest regulatory oversight. Preventive-sensitive care is care that has more than one option, care chosen is determined by opinions. For example, PSA testing, mastectomy/lumpectomy. This type of care also makes up a smaller fraction, about 25%. Supply-sensitive care is the type of care that is determined not by specific treatments but by frequency of treatment. This type of care makes up 60% of Medicare expenditure and includes imaging, consults, ICU admissions. This type care sees the least regulatory oversight. 

Some interesting observations: the more hospital beds, the more admission; the more cardiologists, the more angios; the more cath labs, the more catheterizations. This is what supply-sensitive care is about. When Atul Gawande talked about El Paso, TX vs McAllen, TX, this is what he meant. A larger number of doctors in McAllen made McAllen the most expensive town in the US to get health care. And by far not the best care.

One third of Medicare goes to care in the last 2 years of life. One sixth of Medicare goes to care in the last 60 days. "Medicalization of death." Google it.

Benefit vs expenditure plateaus, and even goes down. 

 

The number of men needed to have their PSA checked to avoid one death due to prostate cancer is one thousand per ten years. While doing this, we will miss 4 prostate cancers that will result in death. At the same time, fifty men will be overdiagnosed. But can we talk this math with a patient? Success stories are what we hear and what shape our measure of chance of survival. How many people do you know who tell you about failures? This is not unlike playing a lottery. We all want to play a lottery because we only see winners. But how many losers are on the news telling that they lost? Watch Dan Gilbert. 

 Obesity and diabetes trends.

Cancer. The same tumor has different cells. Cancer cells in mets are different from those in the parent tumor. Responses to the same treatment are different. Genetics of tumors and people matter more than ever. No longer can we apply the same treatment to people with the same disease.

How we track and understand health care determines implications for the heath of our patients.

Three are more than 6 billion cell phones. The wireless future of medicine.

 

 Internship will be over by the next solstice. With these issues and promises, the question is why would one not do medicine?

eFax allows free receipt of faxes.

Many blue moons ago I used to have a free eFax account to receive occasional faxes. Then eFax went rouge on its freebie crowd, yanked all free accounts, and now only has two options, Plus and Pro. Either of these options cost more than a fax machine. Turns out at this day and age I still need to receive very occasional fax from someone who is not fully living in clouds. All free fax-in options I've checked are setup in some way that essentially makes the whole service moot. For example, faxdesk offers a free fax-in service but the phone number lasts only 4 hours, and you cannot order more than one number every 48 hours. Technically can work, practically, not very much.

Turns out that eFax still has this free fax-in option. It is located here. Go and get, and have your faxes sent to your mailbox free. The number is going to be chosen randomly for you, but who really cares.

Alcoholism among Native Americans

In the May 5 column, the Times Nicholas Kristof cites Anheuser-Busch, the company that makes the Budweiser and the bestselling beer in the US, Bud Light, for perpetuating alcohol dependence and addition among Native Americans and as an example of corporate greed and predatory practices. He calls for the boycott of Anheuser-Busch's products.

A small liquor shop in the town of Whiteclay, Nebraska (population 10; yes 10) sells about 13,000 cans of beer and malt liquor a day. Whiskey Tango Foxtrot? Most of this alcohol ends up at the Pine Ridge reservation that is located just a stone-throw away over the state line in South Dakota, and which bans alcohol on its territory. With the a closest major city more than two hours away, Whiteclay is where residents of Pine Ridge go to get alcohol. The most of it ends up on the reservation.

Pine Ridge is home to approximately 45000 Oglala-Sioux Native Indians living on the swath of land roughly the size of Connecticut. Last year tribal police made more than 20000  alcohol-related arrests that made up more than 90% of all arrests. But tribal police has no jurisdiction over Whiteclay since it is in Nebraska. The drink of choice at Whiteclay is Hurricane High Gravity Lager, a malt liquor brewed by Anheuser-Busch. The tribe alleges that the whole purpose of Whiteclay is to sell to Natives since there is no one else around to sell alcohol to. The tribe sues A-B and other brewers for $500M arguing that they sell alcohol knowingly of its illegal import and consumption on the reservation.
 The effects of alcohol on the reservation residents are visible and severe. Kristof gives the following statistics: "As many as two-thirds of adults there may be alcoholics, and one-quarter of children are born suffering from fetal alcohol spectrum disorders." Alcohol feeds crime, domestic violence,  suicide, risky behaviors that lead to significant health problems such as injuries and sexually transmitted infections including HIV, unintended pregnancies, etc.

Beyond a boycott or a variation thereof, solutions suggested in readers' comments included shutting down the liquor store hoping those without cars won't be able to go very far to the next liquor outlet (you can see how those with cars will make all the profit), eliminating the demand (no word on how), closing down the reservation (!), expanding the reservation to include the White Clay store and thus making it illegal (you can see how this is an especially doomed solution),  taxing sales and using proceeds to fund education and alcohol detox and rehab programs. The blame is invariably poured on reservation residents for the lack of personal responsibility, on A-B and the likes for corporate greed, and tribal leaders for inadequate and incapable governing, incompetence and corruption. There is no

Several readers suggested decriminalizing drinking and possession of alcohol on the reservation. This might seem as a sure recipe for worsening the situation, but studies and experience in countries like Netherlands showed that legalization of (some) drugs (and certainly alcohol) moves the issues from the criminal system into the realm of public health, where it belongs.  Several more countries like Belgium and Portugal have decriminalized drugs. In the case of Portugal, which abolish all criminal penalties for personal drug possession including cocaine and heroin, illegal drug use by teenagers had declined, the rate of HIV infections among drug users had dropped, deaths related to heroin and similar drugs had been cut by more than half, and the number of people seeking treatment for drug addiction had doubled. None of the nightmare scenarios such as increases in drug usage among the young and the transformation of Lisbon into a haven for “drug tourists” have occurred. (http://www.cato.org/pubs/wtpapers/greenwald_whitepaper.pdf). It is worth noting that decriminalization does not mean legalization. In Portugal, drug possession for personal use and drug usage itself are still legally prohibited, but violations of those prohibitions are deemed to be exclusively administrative violations and are removed completely from the criminal realm. Instead of prison sentences, drug users and alcoholics are targeted with therapy and harm reduction.

Alcoholism is a severe problem on many reservations across the country; there are a number of causes that feed it, and no single solution is going to be sufficient. But whatever approach is used, it must be non-penalizing. Instead it should be protective of harms of alcohol and drug use.

Health disparities and IHS

Indian Health Services (IHS), an agency within the Department of Health and Human Services, was created in 1955 to broader effort to reform health care on the reservations. In its initial survey IHS found that total mortality was 20% higher, infant mortality was 3 times higher, life expectancy was 10 years lower, and infectious diseases and accidents were more prevalent; however, heart disease and cancer were less common. In 1970s life expectancy was two thirds the national average, and the incidence of infant mortality (1.5 times), diabetes (2 times), suicide (3 times), accidents (4 times), tuberculosis (14 times), gastrointestinal infections (27 times), dysentery (40 times), and rheumatic fever (60 times) also were above the national average. Although still above the national level, by 1990 incidence of  tuberculosis was reduced by 96%, infant mortality by 92%, pulmonary infections by 92%, and gastrointestinal infections by 93%. However, disparities persisted. American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). Life expectancy at birth is five years less than that of the U.S. All Races population (72.5 vs. 77.5  years).

Congress passed several bills aimed at improving conditions on reservations. In 1975 Congress enacted Indian Self-Determination and Indian Assistance Act followed by 1976 Indian Health Care Improvement Act. These acts gave tribes more control over their health services. For the fiscal year 2012, the budget of IHS is $4.6B (for comparison, Veteran Administration total budget was $127B).

Despite a significant progress, disparities remain. Many causes were proposed and debated throughout several centuries, from invocations of providence in environmental factors such as diet, living conditions, and climate to more deterministic causes such as behavioral, genetic, and socioeconomic. Some blamed personal choices, others argued that roots of disparities lie in disrupted social conditions following colonization and continues to this day due to exploitative policies of the federal government (e.g. uranium mines, water rights). That disparities cut across a number of diseases challenges the belief the disparities are the product of inherent susceptibilities of American Indians. Instead, and rather much more likely, the health disparities arose from the disparities in wealth and power that have endured since colonization.

Going West

For the next four or five weeks I am working at Gallup Indian Medical Center (GIMC) in Gallup NM, on the border of the Navajo Reservation. Located about half way between Albuquerque, New Mexico, and Flagstaff, Arizona, Gallup was settled in 1881 as a coal mining town and became a stop for the railroad and the Interstate Highway of Route 66 in the past and the present I-40. Route 66 still goes through Gallup, and much of local sites bear history of that era. In the 1930s, 40s, and 50s Gallup has seen a lot of motion picture crews with a long list of movie stars and even two presidents, President Reagan and President Eisenhower. GIMC is a 100-bed Indian Health Services hospital that serves American Native patients, primarily Navajo. While here I will do inpatient medicine, HIV, ID, and general medicine clinics, and do home visits to Navajo patients. And of course hope to do a lot of traveling and site seeing. 

Praying with Patients

In a cramped curriculum of medical education, there is hardly enough room for anything not directly related to learning how the human body works and fails. Yet on occasion, I find us students, exasperated from discussions of arcana and enigma of diseases and dodging academic curve balls ceaselessly thrown at us by well-wishing faculty, pleasantly distracted and wondering in and through the matters of spiritual province.

One of the dilemmas crisscrossing the canvas of patient-doctor relationship is that of praying with patients. Should a physician fend off the patient's request and choose to distance with references to own precepts that do not allow him or her to join in with a plea that may be as meaningful as a medicine. Would professional boundaries of an encounter be overstepped? Is praying a private personal matter, or private to a relationship, just like the matters of sexuality, psychiatric, or legal concerns?

While the modern medicine segregates theology and science on the basis that the latter affords practical packages of knowledge that at hands of its practitioners often translate into objective improvement of organic health, Hippocrates, Maimonides, and Rene Laennec (inventor of stethoscope and a devout Catholic) practiced at God's behest and will, as messengers and deputies of God. Certainly, the environment these forebears lived and practiced was less secular than ours, but practitioners of medicine of the past and religious figures of the community -- rabbi, imams, and priests, have frequently embodied the same person

So what should a modern physician do? Does the white coat confer an obligation to evaluate every action from the perspective of the benefit to the patient? Or, citing atheistic viewpoint, refuse? Or launch into a discussion whether praying actually confers any health benefit. The conflict arises for physicians when the role of a sensitive human being conflicts with the boundaries of a medical persona. Sometimes these boundaries are too rigid and a physician should enact the role of the caring human even if it may feel uncomfortable or embarrassing not to maintain the professional veneer. On the other hand, the boundaries could protect both patients and physicians. May be we are asking a wrong question? Rather than to look at a prayer as a treatment of material afflictions, perhaps a better question would be whether a prayer can positively affect emotional state of mind. And if you don’t like the word prayer, substitute it with meditation.

Perhaps, there is no good single answer for everybody. But I will pray to have wisdom to find one for myself.

Being in the center of medical education, in fact its object – a medical student – affords a unique freedom that often does not survive as we progress towards seniority – the freedom to choose one's path in medicine and to form one's opinion about tenets upon which medicine rests.  And its gray zones. While meanings of some principles, such as primum non nocere, transcend inclinations and interpretation, a great majority of others are debatable inconclusive minefields of uncertainty. One of such areas currently attracting a lot of attention is the research involving embryonic stem cells.

While it is widely believed, by supporters and opponents of the ESC research, that stem cells indeed hold an enormous regenerative potential, how to unleash such a potential is a matter of gritty debate. The central place in this debate is taken by ethical concerns.  Such concerns drove the former president George W. Bush to limit federal funding to ESC research, only allowing such spending for investigations with ESC lines existing prior to the ban. This was claimed as an approach that would preserve the balance between ethics and scientific progress, and was hoped to satisfy sensibilities of those who oppose the ESC work on the one hand and on the other, thirst for development of new therapies by those who believe that such research is the holy grain for the preservation of human health. Furthermore, it was argued that the ESC ban would itself serve as a catalyst-in-disguise, prompting the development of new technologies, in a fashion not dissimilar to a clever work-around for a problem that cannot be solved head on. Indeed, clever ideas were put forward, and the field of stem cells was advanced by the development of so called induced pluripotent stem cells (iPSCs). These are the cells that were coaxed into ESC-like cells by clever molecular trickery. The key word here is ESC-like, for it is not yet known for sure whether these iPSCs are indeed identical to ESCs in every way, or simply appear indistinguishable at the level of detail we are currently capable to look. While some studies showed that iPSCs and ESCs are indeed quite similar in many ways, differences are also beginning to be identified. For this reason among others, the use of iPSCs in therapeutic trials lies in a foreseeable but indeed remote future. In meantime only ESCs can serve as a gold standard to further characterize the fidelity, potential, and safety of iPSCs.

Another argument often stated by opponents of embryonic stem cells research aims to question the very need for such science. They argue that instead of focusing on emotionally-loaded ESC research, we should escalate support for adult stem cells, which are considered ethically-safe. These are the cells that already found in human body, and are also capable of maturing into several types of cells, albeit with a potential restricted to fewer types of cells. If an ESC cell can become any mature cell in the body, the fate of an adult stem cells is restricted to a certain lineage or organ tissue. For instance, a hematopoietic stem cell can give rise to all cells found in blood, but it cannot mature into, say, a brain cell, at least based on the current knowledge. Proponents of adult stem cell research claim that adult stem cell research would not only leave embryos alone and alive, but also have been shown to have generated therapeutic strategies in treating and even curing many diseases. The ESCs have not been used to treat any disease, not to mention cure one.

At the first glance, this is a true statement. Indeed, the most well-known example of using adult stem cells in treatment is bone marrow transplant, which has been used for decades in treatment and even cure of cancers of blood. The argument, however, has two significant flaws. The adult stem cell research has been going on for more than five decades, during which the field had time to evolve, and research led to production of super-efficient drugs and treatment regimens. The ESC research is much younger, with the first human embryonic stem cell (hESC) line created from a fertilized egg in 1998; iPS cells were first created in 2006. To expect the ESC research to generate viable treatments in such a short period of time is unrealistic, and to suggest that that such research is less profound because of lack of therapeutic solutions is ignorant. It is ever more ignorant to argue that one avenue of research should not be pursued because a similar research has borne out viable treatment options. One who professes this point of view point of view should be asked if they would agree to be satisfied with penicillin as an only option to fight infection diseases rather than developing vaccines and other anti-microbial agents.

Scientific intricacies, however, are not the part of the ethical debate for the most part. Instead, in the epicenter lies the conflict of dogmas. The opponents of the ESC research state that in their view life begins at conception, and by destroying an embryo one destroys an individual. The activists and proponents of the ESC research follow a line of thought summarized by Harvard paleontologist and evolutionary biologist Stephen Jay Gould, "I do not grant the status of a human life to a clump of cells in a dish, produced by fertilization in vitro and explicitly destined for discard by the free decision of the man and woman who contributed the components."

An individual vs a clump of cells in a dish.

It is wishful thinking to suggests that this conundrum can be resolved based on definitions and clever logical sequences, for no dogma can be altered. Yet, there are examples when long-held believes and thinking yielded to innovations without quite leaving the scene and often without even having been invoked. In most of such examples, the benefit of action and innovation is usually recognized in hindsight. Consider the related concept of in-vitro fertilization. Roman Catholic Church (RCC) opposes the IVF on the grounds that it violates the rights of the child, and deprives conjugal fruitfulness of its unity and integrity. Yet, a number of Catholic women and families have undergone such a procedure and have been given an opportunity to have children, something that the RCC cherishes. A similarly divisive ethical issue of gay marriages has been under constant push-pull court battle; while only six states (CT, IA, MA, NH, NY, VT) and the District of Columbia have now recognized it, people aren't waiting -- they live and enjoy each other’s company. What seems to have happened is that the decision on where to draw the line has shifted from the government and other institutions to individuals. It might happen to the ESC research debacle. People for whom ethical concerns about the wholesomeness (and holiness) of an embryo is an unalienable principle might in the future consider the regenerative fruits of the ESC research, and perhaps even take advantage of them. When they do, we, physicians, must leave the dogmas behind, accept the wholesomeness of a patient and his or her decision, and help enable them to live meaningful lives.

Coversation is Interruption

"There are qualities that have been ascribed to the stereotype of Jews that are also ascribed to the stereotype of women who step out of line and it's about being loud, it's about being strident, it's about wearing bright colors. It boils down, I think, to making yourself obvious in a place where you're not supposed to be and if you are, you should at least have the decency to shut up and wear beige."-Judith Arcana, Interviewee, Conversation Is Interruption by Graham Street Productions

Would you notice frameless art?

The Washington Post published this sweet article Monday, April 9th (which I got via Arts and Letters Daily's RSS, an aggregator of great articles across the Web). It's kind of long, but so deliciously poignant. Also there is a transcript of the online chat between the article's author, Gene Weingarten, and the readers.

Would you stop?

Nuts and Bolts of CCLCM I

They call it Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Mouthful of proper nouns and eponyms. Well, the name doesn't tell you a whole lot what CCLCM is and what it isn't. Of course, there is the web site with the brochure de rigueur, and student blurbs about the program. There are also a lot of the "unpublished." If you dig a bit deeper into the mantle of the Internet (or shall we say, Google), you'd find lots of interesting bits and pieces publicly available. For instance, the first mention of CCLCM I was able to find is here, made by Dr. Fishleder, the executive dean of CCLCM. By the way, CME minutes is by itself a very interesting resource. Even though it is Case's CME, College's Curriculum Steering Committee is reporting to the CME, and thus minutes include discussions relevant to both programs. I sure will be coming back to check what the curriculum committee is thinking, and what dynamics to expect, given they keep posting them.

Then, there is Dr. Fishleder's presentation, which I found on the AAMC website. It gives you a very thorough overview of the program's philosophy, organization, rationale, and financial arrangements. I have to tell you that a lot of questions that prospective students asked faculty during the Second Look weekend would have been answered by this presentation. The penultimate slide of the presentation shows the increasing number of applications (604 in 2004, 728 in 2005, and 1071 in 2006). The most current numbers I found for the 2007 admission cycle were posted in the CME minutes (almost at the end). As of December 13, 2006, the number of applications received by the College Program was 1,239, a 15% increase since 2006. And there are only 32 of us in the class. Pretty competitive, if you follow that sort of rankings. I think it is so competitive that I'm not sure whether I would have gotten in had I applied a year later.

If you seriously considering applying to this school, there is an absolutely must-read blog, which I regard as the spokesblog of the program. It will tell you more than you ever wanted to know and then some.

Revisit of the Revisit

Back from Cleveland where I went for the second look weekend. To second-look what? When was the first? you may ask. The first one was during med school interviews in March of 2006. I was accepted to matriculate in 2006 to Cleveland Clinic Lerner College of Medicine (CCLCM), but chose to defer a year. Why and what happened in between is a long story for another post sometime when its retelling would earn me a sizable offer from a major publishing house.

Meanwhile, don't trust anyone saying that Cleveland is the poorest city in America two years in a row. Well, technically they are correct, but between us, they are just naysayers, someone, when invited to visit Cleveland Botanical Gardens, would hear Cleveland rather than Botanical Gardens. And so their tushes freeze in well warmed-up chairs. For those with portable tushes, Cleveland Botanical Gardens are worth seeing. And those with macro lenses and patience, it's an El Dorado of nature photography.

The Cleveland Clinic campus, which is about a mile away from that of Case U. is being actively developed. A new Heart Institute is taking shape, and a big pit is dug for some other building, which looks grand on pictures plastered on the construction vehicles. Unfortunately nobody I asked knew what it was going to be.

Downtown Cleveland is also being developed and growing like crazy mostly because all warehouses are being converted to condos. They are converted so fast that one of the buildings was mostly finished before some genius noticed that it didn't have an elevator for three ground floors. So they ended up attaching one on the outside of the building. How do I know this? From the trusty driver of the Lolly-the-Trolley that the school has arranged for us to tour Cleveland. The driver, a woman in her early sixties animated with dark energy (what would be a good GRE word for it?), praised parking lots as life-savers ("There are way too many cars on the roads, we need places to park them.") I expected her to be pro-public transportation since she's a bus driver. At another interactive occasion she asked if anyone was from Canada. As it turned out, there were none on board, but two people admitted to visiting the septentrional neighbor. But it didn't matter whether you were a native or a tourist, she had a line, "See those Canada geese? Take them back home _with you_, they don't have Green Cards." So now you know, dear Canadians, come prepared with Green Cards. If geese become subjects for the immigration debate, so will you.

In fact this line made me a tad defensive on the inside. As any foreigner will tell you, if you don't start thinking about getting a Green Card from day one, you need a sanity check. And to get one isn't easy. Before you get one, you're pretty much a nobody with no rights whatsoever. We foreigners have to prove to INS (now DHS) people sitting literally in caves (there are a number of caves under St. Louis, MO left over from old-time breweries now used by the National Record Center for storage and sorting of all immigrational paperwork) that we are worthy people. Not easy even when you have a Ph.D. and several publications to your name.

I've been in this country only six years before I decided to apply to med school. I took MCAT twice because the first time I missed the bubble in Bio/Orgo answer sheet. So if I managed to get into med school (and I got into several), you can too. Good luck.

Next time more about the Cleveland Clinic College of Medicine.

Preparedness

"[Dr. Virginia Apgar] even carried a scalpel and a length of tubing in her purse, in case a passerby needed an emergency airway -- and, apparently, employed them successfully more than a dozen times. "

From "The Score" by Atul Gawande. The New Yorker, Oct.9, 2006