The .Plan

Using simple caffeine to raise alertness in conjunction with naps during a trip is a winning strategy, Dr. Rosekind said. Caffeine takes 15 to 30 minutes to work, and an effective nap should be less than 45 minutes, to avoid going into the kind of deep sleep that leaves people groggy. So drinking a cup of coffee just before a nap, he said, can ensure that you will awaken with a little extra zip. The caffeine and nap working together “can actually show a performance boost greater than either one alone,” he said. “It’s not rocket science.”
–John Schwartz, “A Cure-All for Jet Lag? Try Caffeine and Naps”, New York Times, April 30, 2008

I described this phenomenon in a talk I gave yesterday, but not nearly so eloquently…

[The sheer abundance of medical knowledge] crowds out an important — in fact, the only — skill that matters in treating a patient: how to critically appraise published clinical trials. Few doctors ever read them. In effect, medicine has become a priesthood of practitioners who never review or learn to interpret the Bible to minister to their flock; they instead rely on secondhand wisdom. Or, worse, on Google.

That is why, for example, the average internist can describe the branching patterns of the major coronary arteries but not the primary clinical trials assessing how much, if at all, various cholesterol-lowering agents cut heart-attack risks. Or, for that matter, whether the trials were soundly conducted… Filling the training vacuum, an unregulated, for-profit industry of information peddlers is emerging to interpret clinical trials and guide treatment.
–Darshak Sanghavi, “Training Daze”, Slate, March 12, 2008

Anjan Chatterjee, tracing out the full, and possibly eventual, implications of enhancement technologies:

People already use legal performance enhancers, he said, from high-octane cafe Americanos to the beta-blockers taken by musicians to ease stage fright, to antidepressants to improve mood. “So the question with all of these things is, Is this enhancement, or a matter of removing the cloud over our better selves?” he said.

The public backlash against brain-enhancement, if it comes, may hit home only after the practice becomes mainstream, Dr. Chatterjee suggested. “You can imagine a scenario in the future, when you’re applying for a job, and the employer says, ‘Sure, you’ve got the talent for this, but we require you to take Adderall.’ Now, maybe you do start to care about the ethical implications.”
–Benedict Carey, “Brain Enhancement Is Wrong, Right?”, New York Times, March 9, 2008

This is a deeply disturbing news item:

The state Supreme Judicial Court ruled yesterday that a doctor can be sued over a car accident caused by his patient, greatly expanding potential liability for the medical profession.

A divided court said that the mother of a boy who was hit by a car and died can sue the physician who prescribed numerous medications to the driver, including narcotics that can cause drowsiness. The mother’s lawyers alleged that the physician, Dr. Roland Florio, who practices in Brockton, failed to warn his patient, David Sacca, about the side effects of the medication and the potential danger of driving while taking them.

Sacca passed out and drove off the road March 22, 2002, hitting 10-year-old Kevin Coombes, who was standing on the sidewalk with a friend.

Justice Roderick L. Ireland, who wrote the lead opinion, compared a doctor who fails to warn a patient about a drug’s side effects that could endanger others to a bartender who serves a drunk customer…

[Dr. Dale Magee, president of the Massachusetts Medical Society] said it’s reasonable to require doctors to warn patients about common side effects of medications. But he said if doctors are required to relay a litany of possibilities and rare potential problems, they could scare off patients from taking their medications. “They may do more harm than good,” he said…

Two dissenting justices said they worried the ruling would drive up medical malpractice rates, among other concerns.

This “introduces a new audience to which the physician must attend — everyone who might come in contact with the patient,” wrote Justice Robert J. Cordy.
–Liz Kowalczyk, “SJC ruling adds to doctor liability”, Boston Globe, December 11, 2007

Peter Ubel publishes interesting stuff. A few years ago, he had an interesting paper on how money can buy happiness (well, for people who fall ill). Now, a new study on the ?debilitating effects of hopefulness:

In a talk at Harvard in September, a team of researchers suggested that one obstacle to emotional recovery, oddly enough, is hope — the belief that your current hardship is temporary.

…The research team, led by Peter Ubel, a physician at the University of Michigan, tracked people who had portions of their colons removed or bypassed, such that the patients couldn’t defecate normally. The condition is extremely unpleasant and leads many people to say they’d rather be dead, Ubel reports. But a colostomy isn’t always permanent. Some patients are likely to heal and have their bowels reconnected. Whether your colostomy is permanent depends on your condition, but were it up to the patient to choose, “almost anybody would choose temporary over permanent,” Ubel says.

So it’s surprising that the permanent-colostomy patients ended up happier six months after the operation than the temporary group, whose members were still holding out hope. Patients with a temporary colostomy experienced a significant drop in life satisfaction versus patients in the permanent group.

It might seem strange that patients who are better off objectively were less satisfied with their lives, yet the finding makes sense: “If your condition is temporary,” Ubel explains, “you’re thinking, I can’t wait until I get rid of this.” Ubel says thoughts like these keep you from moving on with your life and focusing on the many good things that remain.
–Marina Krakovsky, “Hope Can Be Worse Than Hopelessness”, New York Times, December 9, 2007

This week’s New Yorker has an essay by Atul Gawande on the complexities of ICU care. He describes a former patient who was losing all of his organs, one by one.

I called his sister, who was his next of kin, and told her of the situation. “Do everything you can,” she said.

So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident “lined him up.” She inserted a thin, two-inch-long needle and catheter through his upturned right wrist and into his radial artery, and then sewed the line to his skin with a silk suture. Next, she put in a central line—a twelve-inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to—inside his vena cava at the entrance to his heart—she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.

We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of a hundred-per-cent oxygen every minute. We dialled the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood-pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous-pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt in his body as well. He was, we liked to imagine, a simple machine in our hands.

But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway eighteen-wheeler hurtling down a mountain.
–Atul Gawande, “The Checklist”, New Yorker, December 10, 2007 [emphasis added]

The newest issue of The Christian Century describes one aspect of what a church ought to look like:

During the testimony portion of that Sunday’s worship service, Karen confessed for the first time that years earlier she had killed a woman while driving drunk. She had served five years in a Minnesota prison as her punishment, and then, despite promises to herself and others, she began drinking again. She spent two more years in a county workhouse. “The judge told me I was a menace to society”, she recalls.

Earlier in the week Karen had gone to pastor Jo Campe in a panic. Tom, another Central Park United Methodist Church member, had just shared a traumatic experience with her: he was feeling excruciating pain over the loss of his girlfriend in an accident caused by a drunk driver. Tom was unaware of Karen’s past, and she didn’t tell him. “I knew that he would hate me, and that I wasn’t going to be able to stay at the church. I didn’t belong there”, says Karen. Pastor Campe knew that Karen, a recovering addict who had been clean for fewer than two years, did belong at Central Park; he also knew that Karen would have to learn this the hard way — by telling her story.

First she told it to Tom — and braced herself for his anger. But Tom smiled. He had been to his girlfriend’s grave that morning — exactly five months after her death — and asked for a miracle. Karen’s story of redemption, he told her, was that miracle.

Then Karen gave her testimony in worship. She shook as she climbed the steps to the microphone. The talk could go so wrong, and she feared that the 200 people in the pews would be disgusted with her. She couldn’t blame them; she loathed herself. But when Karen was finished, she received hugs. Then she helped serve the bread and the juice.
–Stan Friedman, “Church in recovery”, The Christian Century, November 13, 2007

There is something about trying to be present to people struggling with addictions that is simultaneously frustrating (or infuriating) and heart-melting. This episode of recovery is going to be different, he promises you, and despite your training you manage to get sucked into it — and then your heart sinks as you read through 10 years of CPRS notes describing year after year of anguish, unchange, and social destruction.

It strikes me as rather unreasonable that, within a culture that prizes autonomy and freedom above interdependence and obligations, we hold certain assumptions — about courage, fidelity, and hope — of our physicians. Where might addiction psychiatrists acquire the convictions and character necessary to sustain medicine as a morally worthwhile activity? Should not the ethos of the marketplace dominate?

…as he picks up on the common historical theme: everyone and their mother has a plan for the health care morass. But when we can’t agree on a compromise plan, then we default to plan B: do nothing.

Our health-care morass is like the problems of global warming and the national debt—the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems. Large majorities profess support for fundamental change. Yet when it comes to specific solutions we balk. A big reason is the cost… Then we get bogged down in the innumerable, wearying complexities: whether abortions will be covered, whether states will be allowed to design their own systems, what’s an acceptable co-payment for drugs—and on and on…

If, in 2009, we actually swear in a President committed to universal health care, the fight will turn ugly…

People on the right will attack the plan as a tax-and-spend nightmare, because it will have to include some mixture of increases in business and personal-income taxes. And they’ll say that it dictates your medical choices and gives government too much control. People on the left—Moore included—will attack the plan as a boondoggle for insurance companies, because it isn’t single-payer, and will say that it gives government too little control. Others will attack it for what it does or doesn’t do about malpractice litigation, birth control, acupuncture, and so forth. The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again.
–Atul Gawande, “Sick and Twisted”, The New Yorker, July 23, 2007

I’m glad I didn’t go to medical school in the 70’s…

The concept of the standardized patient has been around for decades, but only in recent years have medical schools made training with them a regular part of their curriculum. I talked to a 50-ish physician friend about my experiences, and he said when he was in medical school and it was time for the first rectal/genital exam, the students were told to pair off and examine each other. “So, do you pick someone you like, or someone you don’t like?” he recalled. “Either way, it’s lose-lose.”
–Emily Yoffe, “Playing Doctor”, Slate, July 4, 2007