Craig Bowron2013-06-19T02:21:27-04:00Craig Bowronhttp://www.huffingtonpost.com/author/index.php?author=craig-bowronCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Craig BowronGood old fashioned elbow grease.Busted Gut? Maybe Trust Your Guttag:www.huffingtonpost.com,2013:/theblog//3.32661842013-05-14T12:09:39-04:002013-05-14T12:09:52-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/10-15 percent of the population struggles with recurrent episodes of abdominal pain, bloating and cramping, combined with bowel habits that bounce around between constipation and diarrhea. This collection of symptoms is called irritable bowel syndrome, and though it won't kill you, it has the potential to send your life literally and figuratively into the toilet.
There's a fictitious but undeniable hierarchy among the seven human organ systems, and the gastrointestinal ("GI") system seems to occupy the bottom rung. As the name suggests, we often think of the human gut as a simple gutter that runs from stem to stern, pulling nutrients off a gravity-fed conveyor belt and then dumping out whatever's left. The lofty brain thinks, the mighty heart pumps, the savvy kidney filters, the gut poops.
But the facts suggest otherwise: The gut -- the esophagus, stomach, small intestine, and colon -- is extremely complex. Its muscular walls are richly imbedded with nerve fibers that help it contract in coordinated waves that mix and move food. Myriad chemicals, neurotransmitters, and hormones exert local control over the digestive process and interact with the liver, pancreas and the rest of the body as well. When we eat or drink, we expose ourselves to infectious ilk and toxic chemicals, so the gut has the difficult task of allowing the good stuff to pass through the lining of the intestine and into the bloodstream (i.e. absorption), while keeping the bad stuff out. For that reason, the gut possesses a heavily-fortified immune system to fend off any unwanted intrusions; unfortunately, that can also lead to food allergies. To complicate matters, the colon has millions of healthy bacteria (not an oxymoron) that live symbiotically with us. It's a guest list that can be altered, sometimes drastically, by antibiotics and even by our food choices.
So the gut doesn't deserve its bottom rung status; in fact, there's a very clear and rich connection between the lofty brain and the not-so-lowly gut. This occurs directly through nerves, and indirectly through stress-related chemicals like cortisol and adrenaline.
Although everyone is stressed out to some degree, and everyone has occasions where they feel their negative emotions in their gut -- "worried sick," for example -- those with irritable bowel syndrome (IBS) seem to have an enhanced sensitivity to the feedback that the gut sends to the brain. As a pattern of gut dysfunction sets in, IBS sufferers can sometimes fall into a shell-shocked state, where even a small amount of cramping can escalate into big worries: Is this going to be one of those diarrheal weekends? Is the pain going to ruin this important business trip? They've developed a conditioned fear response, a pre-programmed neural circuit in their brain that begins firing at the slightest hint of gut trouble, be it real or perceived (to the brain, both are equally real). They are at war with their gut, always fighting it.
Which might make the title of a new book about IBS called Trust Your Gut seem like Jesus' injunction, "Love your enemies." Really? And yet the book's authors, physician Greg Plotnikoff and psychologist Mark Weisberg, mean exactly what the title says: They train their IBS patients to spend time calmly paying detailed attention to their bowel symptoms. The goal is to allow patients to recognize two things: first, that without the associated fear response that can escalate things, most gut symptoms harmlessly pass; and second, that sometimes these symptoms are the gut's way of showing the patient that his or her mind is a whole lot more stressed out than it will admit.
Plotnikoff and Weisberg call this technique neurohormonal retraining:
This important exercise sends a new signal to structures deep inside your limbic brain. You are telling the amygdala and related brain structures, "This sensation is no longer a threat." As you repeat this exercise, the limbic brain starts to signal to the nervous system that these sensations of pain, pressure, and bloating are not a cause for alarm. When this happens, there is a change in the cascade of neurotransmitters and neurohormones that communicate with the gut.
As the book points out, it would be a mistake to suggest that irritable bowel syndrome is all in a patient's head (although that's what patients often hear when their initial workup returns negative). There's a review paper in the New England Journal of Medicine that chronicles all of the physiological abnormalities that have been found inside the gut of IBS sufferers -- increased inflammation, microscopic leakiness of the lining of the intestines, hypersensitive pain receptors, and altered bowel flora, to name a few.
Trust Your Gut tries to bring some clarity and relief to a disabling and complicated disease that we still don't understand very well. We can say this: If you have IBS, it's not all in your head. But as with all humans, your head and your gut are intimately connected.
Disclaimer: I am a colleague of Dr. Plotnikoff's (we work in different areas of the same medical campus), but I have no financial interest in the book or in any other matter with him or Dr. Weisberg.
For more by Craig Bowron, click here.]]>Solar Sex Panels and Heart Disease: Do I Have a Disease or a 'Condition'?tag:www.huffingtonpost.com,2013:/theblog//3.30456112013-04-10T13:07:13-04:002013-06-10T05:12:01-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/
Vendors of balding remedies seem to favor the diseased view, peppering the airwaves with language that instructs me that I am, for example, "suffering from a progressive condition called male pattern hair loss" (as opposed to suffering from a progressive condition called multiple sclerosis, or Alzheimer's, or what have you). They tell me that losing my hair is not normal, but reassure me, "You're not alone," because millions of other men have this not-normal condition. A local ad proclaiming "More hair, more life!" finally forced me to admit that what I'm really dealing with is a life deficit. All of these ads imply that this isn't about my personal appearance -- I have a disease, and I need to treat it.
So when a study in the British Medical Journal barged its way to the front of health care headlines last week (past more weighty topics, like news of a new and highly lethal flu strain in China), I was all ears... and scalp.
Researchers from Tokyo University tried to clarify the strength of a previously-recognized association between male pattern baldness and heart disease. Yes, hair loss increases one's risk of getting skin cancer of the dome, but does it increase the chance that you'll have a heart attack?
They piled through more than 800 medical studies to find just six that met their criteria. Six studies isn't a lot, but together they included nearly 37,000 participants. Association is no proof of causation, so don't lunge for the Rogaine, but for men of all ages, severe balding seemed to increase the risk of developing heart disease by 32 percent. The risk was higher -- 44 percent -- for men who developed severe baldness before their mid- to late-50s.
It was interesting to find that balding can be more objectively categorized than the informal scale I've been using: thinning, getting breezy, deep-denial-but-I-admire-the-effort, and comfortably bald. Several of the studies used the Hamilton-Norwood scale of balding and found that hair loss at the vertex -- the part of the skull where a beanie or kippah would be placed -- carried the strongest association with heart disease. The more severe the vertex hair loss, the higher the risk: 18 percent for mild, 36 percent for moderate, and 48 percent for severe. On the other hand, a receding hairline held no statistically significant association.
Why the association? Are our solar sex panels somehow absorbing mysterious atherosclerosis-causing radiation from the sun? Association is never proof of causation, but it almost always invites speculation. The authors of the study admit that the mechanism for any connection between heart disease and balding remains unclear, but they offer several hypotheses.
Resistance to the normal physiologic effects of insulin is a key component of adult diabetes and of a condition called the metabolic syndrome, both of which lead to heart disease. And insulin resistance has been show to cause constriction of the blood vessels to the scalp. The drug Rogaine (minoxidil) does cause blood vessels to dilate, but it's not clear that that's the way in which it promotes hair growth, and there are other medications that dilate blood vessels that don't stimulate hair growth.
Another hypothesis has to do with the fact that the bald scalp appears to have a more active version of the enzyme that converts testosterone into dihydrotestosterone (DHT), the hormone that causes hair follicles to shrink (the hair loss medication Propecia [finasteride] works by blocking this converting enzyme). There are reports that the heart and blood vessels contain this DHT enzyme. Perhaps, the authors suggest, the heart and blood vessels of the hair-challenged also carry the overactive version of this enzyme, and the excess DHT leads to atherosclerosis.
For all the attention it got, as a both a physician and a bald male, I'm not sure what to do with this piece of research. Anyone who has risk factors for heart disease (smoking, high cholesterol, diabetes, hypertension) should address them, regardless of his hairline. Until association is replaced by causation -- i.e., treating balding is shown to lower the risk of heart disease -- I'll continue to consider my male pattern hair loss to be a cosmetic issue, and a receding one at that. Comb-overs and toupees seem to be fading into the past, and bald males have come to understand that fully coiffed males deserve neither our sympathy nor derision: It's genetic -- they were born that way.
For more by Craig Bowron, click here.]]>Rand Paul's Bladder: Patriotism and the Micturition Reflextag:www.huffingtonpost.com,2013:/theblog//3.28525862013-03-12T11:26:43-04:002013-05-12T05:12:01-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/
The issue at stake -- Americans' right to due process before being incinerated by a CIA drone -- was almost overshadowed by the senator's bladder function, which was both derided and praised.
Paul himself blamed his bladder for his failure to break the standing 28-hour filibuster record. "I would go for another 12 hours to try to break Strom Thurmond's record, but I've discovered that there are some limits to filibustering and I'm going to have to go take care of one of those in a few minutes here," Paul admitted as audience members snickered.
I've been involved in a few filibusters, as Rand Paul did yesterday. And what I've learned from my experiences with talking filibusters is this: To succeed you need strong convictions, but also a strong bladder. It's obvious -- Senator Paul has both.
Paul's filibuster was politically gutsy, but was it an act of urological courage?
The human bladder is made of muscle, and because it can relax, pressures inside the bladder remain fairly low until it holds around 300 ccs (there are about 350 ccs in a 12-ounce can). For most people, the first faint sense of bladder fullness comes at 200 ccs, and the urge to void (what urologists call "peeing" or "taking a whiz") comes at 300 ccs. Beyond that, bladder pressures rise sharply and the urge to relieve one's self becomes progressively more intense.
You can pee without your brain, but under optimal conditions, your brain gets to say where and when. The squeezing of the bladder, the "micturition reflex," is a completely autonomic (automatic) reflex commanded by a set of nerves coming to and from the bladder and arcing through the spinal cord. But our brain is able to tone down that reflex (to a certain point) so that the expanding bladder doesn't squeeze. And the brain has voluntary control over the external urinary sphincter, a valve that can cinch down and resist the will of a contracting bladder.
Republican, Democrat, Independent, that's how the healthy bladder works.
How quickly a bladder fills depends on how much urine a person is making, and that depends on a whole host of variables. But the minimum amount of water the kidneys can let go of in a day and still do their job is about 500 ccs, and the average amount of urine produced in a day is about 1,400 ccs -- picture a 1.5-liter bottle of "nature's calling."
So in Paul's case, the numbers look like this: Assuming he started the filibuster on empty, if he got himself dehydrated up there on the podium and was making 20 ccs of concentrated urine every hour, 12 hours and 52 minutes later he'd have had 260 ccs of urine in his bladder. That's well short of the maximal bladder capacity of 400-500 ccs, and it's a bladder volume associated with only mild urge -- neither newsworthy or laudable. On the other hand, if he kept at the fluids enough to maintain a more typical urine output of 60 ccs an hour, then by the end of the filibuster, his senatorial bladder would have been stretched thin by an excruciating 770 ccs -- a heroic act of patriotism and steely resolve.
At this point, only a urinal somewhere just outside the Senate chambers knows the truth. And of course, the CIA.
For more by Craig Bowron, click here.]]>Bright Idea for a Bad Disease, But Will Knowing Early Help?tag:www.huffingtonpost.com,2013:/theblog//3.25306892013-01-25T09:00:00-05:002013-03-27T05:12:01-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/Click here to read an original op-ed from the TED speaker who inspired this post and watch the TEDTalk below.
As a physician, watching Max Little's TEDTalk, "A Test for Parkinson's with a Phone Call," brings up two divergent thoughts.
First, the pompoms.
Who is this guy, this non-MD, thinking he can revolutionize the practice of medicine, without being a doctor? I'd say he's the future. For most of history, the physician has been the prime mover of medical advances. That was particularly true when the practice of medicine involved mostly art (the physician's subjective experience: "One leech, or three?") and very little science (objective research: "What do randomized controlled trials show?"). But now medicine is mostly science and a small fraction art, and the simpler disease processes have already been mapped out. As we delve deeper into the biochemical and genetic complexities of the human body, it seems to me that future innovations in health care will increasingly come from non-physicians like Little, whose scientific expertise and broad imagination will help them become the new leaders in health care.
Besides that, to really innovate one has to be willing to potentially put oneself out of business; in this case, a cheap 30-second phone call may replace an expensive 20-minute test. Like many long-standing institutions, modern medicine, with physician at the helm, is so thoroughly entrenched that it may be incapable of fixing itself. The cure might have to come from the outside.
Screening for disease -- finding it early, before obvious symptoms develop -- works best when there is a treatment available that can capitalize on early detection.-- Craig Bowron
Second, a Nerf dagger.
Little's voice analysis system holds some exciting possibilities for Parkinson's disease, including the ability to monitor disease progression and response to therapy. But his repeated injunction that the technology be used to find the disease early, "before it's too late," may be a little misleading.
Screening for disease -- finding it early, before obvious symptoms develop -- works best when there is a treatment available that can capitalize on early detection. For example, say I plunk you down at home plate in your local baseball stadium. After arming you with a Red Ryder BB gun, I release a ravenously hungry lion from the center field bullpen. As the beast crosses the warning track, I offer you a pair of opera glasses, so that you can better visualize the lion as it begins to pick up your scent. Forget the opera glasses, how about some binoculars? As the lion enters the infield, I offer you a camera with a powerful telescopic lens. Now you can see every hair on his snout, but as long as the only heat you're packing is a BB gun, a better view just prolongs the terror. Early detection of the lion will not affect the outcome.
Currently there are no medications that can stop or even slow the progressive neurodegeneration that manifests itself as Parkinson's disease. All of our medications treat symptoms only. So for now, finding Parkinson's disease early, when the symptoms are so minor that treatment is not indicated anyway, runs the risk of saddling a lot of people with the psychological angst of knowing what they're in for, without any way to change it. Maybe knowing early would help some patients live their lives better or differently, and maybe symptomatic therapy applied very early in the disease could somehow alter the long-term course. No one knows for certain, but with contributions from the likes of Max Little, we press on. Like ballet, progress is a delicate dance.
Ideas are not set in stone. When exposed to thoughtful people, they morph and adapt into their most potent form. TEDWeekends will highlight some of today's most intriguing ideas and allow them to develop in real time through your voice! Tweet #TEDWeekends to share your perspective or email tedweekends@huffingtonpost.com to learn about future weekend's ideas to contribute as a writer.
]]>Flu Vaccine: The Best You Can Do Is Not the Best We Can Dotag:www.huffingtonpost.com,2013:/theblog//3.24722472013-01-15T19:18:06-05:002013-03-17T05:12:01-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/Centers for Disease Control (CDC), 2012-2013 is shaping up to be a highly active flu season. The party started up a little earlier than usual (most commonly, the flu peaks in February) and last Friday the CDC announced that infection rates have officially reached epidemic levels.
About 80 percent of this year's flu infections are coming from an H3N2 influenza A virus, and 20 percent are coming from an influenza B virus. Our old friend H1N1 -- the pandemic 2009 "Swine Flu" -- and a second influenza B virus claim smaller bit roles.
The good news from the CDC is that antigen characterization -- a look at the nitty-gritty molecular makeup of the viruses -- shows that three of these viruses (H3N2, B/Yamagata, and H1N1) are well-matched in this year's vaccine. The second B virus, B/Victoria, isn't in there, but it's been active in recent flu seasons and was covered by annual flu vaccinations from the 2010-11, 2011-12 flu seasons.
The bad news is that according to new CDC research released on Friday, getting vaccinated is no guarantee that this year's angel of darkness will pass you by. The CDC's most recent study showed the vaccine to be 55 percent effective against this year's major player, H3N2, and 70 percent effective against influenza B; average the two, and you get 62 percent.
The CDC describes this year's vaccine as "moderately effective," but if your kid comes home with a 62 percent, a "D," you might not describe their effort as moderately effective. Considering that the standard childhood vaccine series provide protection in the 80-90 percent or higher range, maybe that D is more like a C+ or B -.
As the CDC and nearly every health group on the planet will tell you, getting vaccinated against influenza is the best thing you can do to avoid getting infected, and that's still true. But if influenza can roll across the country despite a tightly-matched vaccine, how good are our existing vaccines? And if current vaccines aren't so good, is working harder to get them to everyone -- "universal immunization," the CDC's most recent push -- a real solution, or just a feel-good answer?
The authors' conclusion? Flu vaccine effectiveness has been sharply overestimated, primarily because we've had a hard time knowing for certain who's been infected. Diagnosis on the basis of clinical symptoms alone is difficult because the flu, with its classic symptoms of high fever, muscle aches, sore throat and dry cough, has a lot of imitators. In the CDC study noted above, only 36 percent of the potentially flu-infected patients found by researchers ended up having laboratory-proven influenza.
Since diagnosis of influenza based on clinical symptoms alone is not accurate, we rely on lab evidence. For this recent study, the CDC used a sophisticated technique called polymerase chain reaction (PCR), but many older vaccine studies have relied on a cruder technology that measures flu antibody levels in the blood. For most people, influenza infection raises the body's flu antibody levels four-fold, but we now know that vaccination blunts that response: It's as if the immune system got to practice with the vaccine, so that when the real flu came along, it didn't have to get that worked up about it. Not understanding that vaccination blunts the typical antibody response gives the false impression that people who have been vaccinated don't get the flu, since their antibody levels are less likely to reach higher, confirmatory levels. In other words, this old technology makes the flu vaccine seem more powerful than it is.
With that in mind, the "Comprehensive Influenza Vaccine Initiative" group went through every vaccine effectiveness study available and tossed out those that were either weakly designed or couldn't rigorously tell who really had the flu. Instead, they relied only on strong studies that used either the PCR technology or actually grew the virus in culture from the afflicted's "snot-sicle."
Trivalent inactivated vaccine (TIV) makes up about 90 percent of the vaccine doled out each year. What the research group found was that over a combined 12 flu seasons, TIV was 59 percent effective at preventing the flu, but its performance was somewhat erratic. In a couple of seasons it was 75 percent effective, but there were some studies for some years that found it to only be 16 percent or 22 percent effective. Unfortunately, that data was on healthy adults; the authors found no randomized controlled trials for TIV that met their stricter criteria in evaluating vaccine effectiveness for adults older than 65, or for young children -- the two groups that are most susceptible to a serious bout of influenza. Live-attenuated flu vaccine, the nasal spray vaccine, was 83 percent protective in children aged 6 months to 7 years, but evidence of benefit for other ages, including adults and seniors, was limited or lacking altogether.
"Fifty-nine percent effective" for TIV was quite a bit below what had been the white coat, party line number of 70-90 percent, and the group took a little flak for raining on the parade of the CDC, who has been vigorously recommending universal vaccination since 2010. On an individual or even group basis, it's a completely legitimate argument: Sixty percent effective or 70 percent effective, flu vaccination is still a good idea -- it spares some people what can be a miserable illness, and better yet, it saves some lives.
But the "Comprehensive Influenza Vaccination Initiative" wanted to look at the big picture, and they didn't like what they saw. They found that our overestimation of the current flu vaccine's potency has evoked a confidence and complacency that's kept us from pushing on to something new, to what they termed "game-changing" innovation in influenza vaccine development and production.
"We found a general perception that we don't need a better flu vaccine, we just need to make more of it faster," noted the study's lead author, Dr. Michael Osterholm. He's quick to point out that there's a lot of exciting research going on in influenza vaccination, some of it quite promising, but without a sense of urgency or need, it's hard to raise intellectual or financial capital.
"It takes about a billion dollars to bring a new vaccine to market," Osterholm lamented. "Our group talked with all kinds of investors who said, 'Why would we invest that kind of money to develop a new vaccine, when all we're hearing is this one works -- we just need to figure out how to get it to everyone?'"
Vaccination might still be the best thing one can do, but is 62 percent the best that we can do? The flu virus is always changing and adapting; we should be too.
For more by Craig Bowron, click here.]]>The Science of Regret: Looking Back and Letting Gotag:www.huffingtonpost.com,2012:/theblog//3.23771312013-01-03T08:18:06-05:002013-03-05T05:12:01-05:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/Homer Simpson's "D'oh!" It's a time to look back and marvel at all of the screw ups (d'oh!) -- both personal and professional (d'oh! d'oh! d'oh!) -- that brought us to where we are today. Or to where we are not today.
A German study published earlier this year in Science magazine suggests that Homer Simpson will not age very well. He simply has not been able to disengage himself from his troubles, and according to researchers, that's what emotionally healthy aging is all about.
As the article explains, there's an emerging body of scientific literature that shows that as humans grow older, they tend to experience more positive emotions and fewer negative emotions like anger and regret. The feeling of regret depends on a sense of responsibility for an event, but healthy older individuals tend to disengage from a sense of personal control. Instead of saying "It was my fault, I screwed up," they say, "Screw it, it's not my fault." And they feel better for it!
Here's how the study worked. Study participants were presented with a row of eight boxes, seven containing a gold bar, and one containing a devil. They could start opening the boxes from the left, or from the right, but either way they had to open them in order and the position of the devil was random. They could stop anytime they felt like it and pocket their "winnings," but if they ran into the devil, they lost it all (D'oh!)
Yelling "D'oh!" is one measure of frustration and regret, but these researchers used a sophisticated MRI scanner to measure activity in the deep areas of the brain like the ventral striatum, which seems to code the value of experienced rewards but also that of missed opportunities.
The researchers collected volunteers from three groups -- young adults, depressed seniors, and emotionally-healthy seniors -- and had each of them play the game 80 times. Sometimes they stopped just in time -- the devil was in the very next box, and sometimes the devil was all the way at the end -- they stopped too early and missed out on a lot of phony loot!
What the researchers found was that the young adults and depressed seniors responded in very similar ways: When they stopped too early, their regret led them to play the next round more aggressively. And the more gold they missed out on, the more risk they took on the next round.
But healthy seniors were different. They seemed to let bygones be bygones. Yes, they were disappointed to run into the devil and lose, but the activity in the reward/regret centers of their brains seemed to be the same if they safely quit with three golds, when the devil was in the next box, of if they stopped at three golds but the devil was in the very last box. They didn't get ticked off or beat up on themselves for not having pushed on to win those four additional gold bars. They recognized that the position of the devil was random and out of their control.
The researchers came to similar conclusions when they tested a different group of volunteers, this time measuring things like heart rate and the skin sweat to try and hone in on how angry or regretful the participants were about their choices.
The new year reminds us that time moves on, and that we're all getting older. Even Dick Clark, the seemingly-immortal host of the Times Square New Year's festivities, drew the devil card earlier this year. Although none of us will live forever, we can grow old more gracefully by simply letting go, by saying "screw it" to the things that are beyond our control, what the researchers called "external attribution."
Of course, this is entirely different from shirking responsibility for things that are partially or fully under our control -- what some scientists (me at least) call "apathetic misattribution," "egocentric bunkering," or "mindlessly blaming others for your own troubles." To that end, as citizens of a gridlocked democracy, we might ask these same researchers to search for and study the responsibility/blame centers of the human brain.
For now, as a middle-aged parent, my primary coping mechanism for dealing with things out of my control is to blame the kids, or Flanders. If I'm going to be an emotionally-healthy senior, I know I'll have to let go of that.
For more by Craig Bowron, click here.]]>Misplaced Curiositytag:www.huffingtonpost.com,2012:/theblog//3.22593462012-12-10T13:19:00-05:002013-02-09T05:12:01-05:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/
In that way, NASA's latest mission to Mars just seems like misplaced curiosity, even to a science geek like me. For certain, there's been no shortage of techno-astro-jet-propelled wonder, and you'd have to have the scientific aptitude of George W. not to get a piloerectile buzz out of watching the Curiosity come to a safe landing. The people who made that buggy fly are some of our nation's best and brightest, the rock stars of rocks and stars.
But forget about the rover's pinpoint landing. The Earth's current ecological status makes the overarching scientific goal of the mission -- "to assess whether the landing area has ever had or still has environmental conditions favorable to microbial life" -- seem way off base.
Here we are, perched on Carl Sagan's pale blue dot, a planet tricked out with everything a living organism might need: water, oxygen, carbon, stable temperatures, not too much sunlight, not too little -- everything but a wet bar. Planet Earth is a diamond, a spectacular gem amidst galaxies and galaxies of lifeless rock piles, so as a local businessman pleads, why go anywhere else? Why so curious about Mars? It's no crime to be Earthnocentric.
I hate to spoil it for NASA, but the habitability of Mars is low, very very low, and it's going to stay that way for a long time. It will be many millennia before we'll be pasturing Martian Holsteins or, for that matter, vats of E. coli bacteria. Meanwhile, Earth remains in a highly habitable, move-in condition -- except that we've got some serious climatic Homeland Security issues to deal with if we're going to keep it that way.
And so last week's news that NASA plans to double down on its Martian bet, with a $1.5-billion Red Planet explorer that will launch in 2020, seems all the more wayward. John Grunsfeld, head of NASA's Science Mission Directorate in Washington, said it wasn't yet clear what the rover would do -- maybe collect and store rock samples or... bring them back to Earth, where we can use them as paver stones on the road to ecological ruin!
Why don't we focus our curiosity on the questions that really need answering?
It's understandable that many people have questions about climate change; the bright minds at NASA certainly do. In fact, they've listed the uncertainties on their website. Scientists don't understand long-term changes in the radiant energy of the sun. They don't understand how aerosols, dust, smoke and soot interact with climate, in some cases warming the atmosphere, in some cases cooling it. Clouds have an enormous impact on climate, but as NASA humbly admits, "current climate models do not represent cloud physics well." We don't understand ocean currents, or where the moisture will or will not fall on a warmer planet, or how much the seas might rise. About half the carbon we belch into the air each year is removed by natural processes, but we don't understand them. We don't understand, we don't understand, we don't understand.
Until we do understand these problems, and until we've developed solutions to deal with them, I'm not especially curious about Mars. "Danger, Will Robinson, danger!" With so much climatic uncertainty and so much at stake here at home, we can't afford to get lost in space.]]>9/11 Diary: Notes From a Hospital in Fly-Over Landtag:www.huffingtonpost.com,2011:/theblog//3.9514892011-09-08T11:20:43-04:002011-11-08T05:12:02-05:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/
Ten years later, 9/11 has come to mean a lot of things, but at that moment it was just the thing itself: we were being bludgeoned with our own fists by an unknown, unseen assailant, and all we could do was take the punch. The images were everywhere, the information nowhere. Here's a record of my day on that day -- it may have been something like yours.
The early morning air was warm like summer, but clean like fall. Even my aging bicycle seemed invigorated as I rolled up to the hospital, stowed it in the bike cage, and walked over to the staff entrance. I took the second of two hallway turns just as Gordy Aamoth, an orthopedist, was leaving the doctors' lounge.
But he didn't look good. He seemed to stagger out the doorway, stumbling for a step or two before regaining his stride, then stepping out into the main hallway to disappear from view. Figuring he must be nursing a bad ankle or knee, I almost joked with him that he should find himself a good orthopedist. But he hadn't seen me, and the moment passed.
Instead I ducked into the doctors' lounge to begin my usual routine -- grabbing a printout of our group's patients and looking around for any of my fellow internists. I quickly found two colleagues, Whitney and Mary, and they asked if I'd heard the news: someone had flown a plane into the World Trade Center (the towers were, to many, still one building). No I hadn't. And for just that moment, it seemed like another Good Morning America news flash -- some desperate soul in a Cessna, exiting this world for the next in a dramatic suicide gesture. I just hoped he didn't take anyone with him.
But something about Mary and Whitney's faces sent me walking back to the TV-covey portion of the lounge, where I was greeted by the image of a gaping, burning, distinctly un-Cessna-sized hole in the side of Tower One.
Part of the art of medicine is recognizing patterns of illnesses, and conversely, recognizing patterns that don't fit. Watching the thick black smoke seething up into a shimmering blue sky, there was something about this pattern that didn't seem to fit. You could scratch the desperado Cessna idea -- the hole was just too big. And how could a pilot capable of flying an aircraft of that size and sophistication be incapable of ditching it anywhere but right into the side of one of the World Trade Center towers?
This seemed bigger than I had initially imagined. Much bigger. Watching the images you could see that anyone in the upper floors would have a hard time surviving the heat and smoke. We stood there and gawked, not sure what to say, feeling like our shoes were welded to the carpet but that our feet couldn't sit still.
I'm not sure if it happened live, while I was watching (you couldn't tell which shots were live and which ones were being replayed because the networks were as reeling and dumbfounded as the rest of us) but suddenly there it was: a monstrous Hollywood-type explosion out of the backside of the second tower. They said it was a second plane. My God, this was serious, really serious. A quick look at the faces crammed into the normally sparsely-populated lounge, and it was dead wood, like the death masks some societies cast of the departed. One had the feeling that we'd be watching a lot of television that day.
Routine being a comfort, Whitney, Mary and I eventually decide to stick to it, so we left the TV area and sat down at a table to divide up our list of patients. But the conversation inevitably drifted back to the television, and Mary mentioned that Dr. Aamoth's son worked on the 103rd floor of the World Trade Center -- she didn't know which building. My mind instantly replayed the clip of Gordy staggering out the door. Obviously he'd been watching the TV. I swallowed hard at horror two steps removed. Where was Gordy dragging himself off to when I saw him? Most orthopedists start their day in the operating room, but I couldn't imagine he was headed that way. If I ran into him again, I would not know what to say.
With the lists done I grabbed some oatmeal and went back, again, to watch the TV. Already time was becoming relative: I knew I wouldn't be late for anything today. Seeing how the hospital routinely slides into a self-induced trance during a Vikings football game, my pager going ghostly silent, whatever was playing out in Manhattan would trump all that. I could make my way up to the floors, to the patients, when I was ready.
Meanwhile the ghastly TV images continued to roll, a montage of horror that quickly grew as the networks picked up different videotape of the disaster from varying perspectives. People jumping from the heat and smoke was absolute terror defined. The adrenaline buzz was wearing off. I lost my appetite. I left the lounge.
Everywhere I went -- every hallway, elevator, nursing station, patient room -- everywhere it was blank looks, emptiness, nothing to say. Perhaps shock is the absence of all emotion. I didn't feel anything and I didn't feel like doing anything, but I knew, eventually, I had to take care of my patients. I needed to make rounds.
But first I grabbed a phone and called my wife to see if she knew. She did, and it was good to hear her voice.
The Pentagon has been hit, and this thing is beginning to unfold as a coordinated attack. It dawned on me that hospitals have more TV's than IV poles. The screens are everywhere and today they're all on. The combination of compelling images and universal access meant you could not not watch TV. Hearing that one of the towers had collapsed, I headed back to the doctors' lounge.
It was crowded by then, and I stood next to Jim, a pathologist, and it seemed to us that America had changed for good. I was pretty certain that I was standing in my generation's Pearl Harbor. They replayed the footage of Tower Two collapsing, and the image became the final punch -- the sickening, stunned feeling had now taken its full effect. What was hard to understand was now incomprehensible. A woman I did not recognize and have not seen since hustled into the lounge saying that her husband heard on the radio that the Sears Tower in Chicago had been hit. I stuck around to see if this was true, if it even could be true. Nothing.
I finally headed upstairs to see patients, starting with Nick Rubek on our rehabilitation floor. A WWII vet who survived the last year-and-a-half of the war in Europe, Mr. Rubek had the bars pinned on him when they ran out of officers. Now he was fighting severe rheumatoid arthritis. He didn't have much to say, never did, but shook his head at the images on TV. I'm sure he was wondering if the big war he wandered into could happen again. A friend of his was standing outside the door, waiting for me to leave. He introduced himself as an old VA doc, and said, "This is war, we're going after him," him being "Aslama Ben Ladin." The name of terror was so new that we didn't have it quite right.
I found a seat to write a note and some orders for Mr. Rubek. Gloria, a favorite nurse of mine, sat down quietly beside me and said, "Well, this puts any of our little troubles into perspective." Her daughter had just had a portion of her pelvis removed for a rare and difficult-to-cure bone cancer.
Having seen just one patient, it was back to the lounge. Claus, my unflappable, inimitable German-born professor of medicine had arrived and asked, simply, what good could come of all this. He suggested that it might show us that we can't turn our backs on the world.
If I wasn't staring at a TV, I found the images following me around in my head.
A TV announced the collapse of Tower One, its antennaed steeple disappearing into the blackness as I imagined the conning tower of the Titanic did. Oh God, watch the casualties rise now, to include all the rescuers who rushed in to help. An interview with a former FBI director pointed out that this occurred, in part, because of the personal freedoms that we are granted here. Thousands of people arrive here every day, and we have no way to stop them.
Our lives have changed. Our freedoms have changed.
I heard rumors of a car bomb in D.C..
The hallways were still filled with blank looks and the absence of sound.
I went to see elderly Margaret Stordahl, who was suffering from a painful compression fracture in her spine. I entered the room by telling her, "I'd like to say 'good morning' but there isn't much good about it."
"Yes, you could say that," she replied. She had tears in her eyes, and I thought to myself, "Boy, she's feeling this tragedy quite deeply."
"They say they can't do anything about it, I'm stuck this way," she added.
It took me a few moments to realize she was talking about her back pain, not the World Trade Center. In fact, I couldn't tell if she knew anything about the tragedy. Hers may have been the only TV in the entire hospital, or nation, that wasn't turned on. I didn't ask if she had heard the news. She'd had enough pain.
In the hallway a nurse asked me, "Why do we think we're so invincible?"
There was a rogue airplane somewhere over Pittsburgh.
Be it crisis fatigue or the search for a distraction, the work tempo slowly began to increase. People were talking more.
On the neurology ward, Mike Roche, a paraplegic from advanced multiple sclerosis, pointed to his watch and asked me, "Do you think there's anything coincidental about this happening on this date?" His watch showed "9-11" "What?" I asked him, not getting the clue. "9-1-1," he tapped out on his watch face. "Hmmm, I doubt it," I thought to myself. I didn't answer him.
There were fighter jets over D.C., protecting the airspace. Bush spoke earlier in Florida. People were wondering where he went after that, and if he was okay.
At 11:30 a.m. the director of communications at our hospital posted updates stating that the Mall of America and the IDS Tower had been closed. It identified the specific planes that were kidnapped.
I talked to my wife again, who heard reports that there was one plane down in Seattle, and one down in Philadelphia. She'd been explaining the images to our three-year-old by saying that there had been a bad accident, and that it was a sad day. "But I don't want it to be a sad day!" he cried defiantly.
The name "Islama Benladin" came up again.
At lunch it was Karen, Bob, Mitch and me at a table, and the usually jovial Mitch threw me an exhausted look, saying, "Craig, what is there to say? My mind is blank. I can't think of anything to say." That is, there was nothing to say that would make sense of it all. But by that time of the day, we had a lot on our minds.
Mitch pointed out how this would reach nearly everyone: "Everyone will know someone killed in this thing." Being Jewish and having been to Israel, he said this kind of thing happens there on a smaller scale nearly every day, and he reminded us that in Israel, everyone does military service right out of high school. Bob, a gastroenterologist, said, "This will bring a level of fear into our lives that will never go away." It sounded dramatic, but probably true.
After lunch it was another stop at the doctors' lounge TV. They were showing a new video clip of the second plane boring through the tower, this time from the harbor side. Wow. Multiple views, multiple angles, viewed multiple times, and it still did not seem real.
Tom Brokaw agreed with the VA doc up on rehab, calling it war. A senator said, "We're in a war without borders," but of course war has been coloring outside the lines for decades now--it just hadn't scribbled into ours.
Overhead they announced a 3:15 prayer service downstairs.
The day went on. Thankfully the TV had nothing new to say. The venom had been spent. We kept working. I hit the doctor's lounge one more time for the 5:30 news -- still nothing new. It was as bad as it looked. Worse maybe. The country gasped.
I walked out, grabbed my bike, and rode home through a perfectly blue and perfectly empty sky. All flights had been grounded. I hadn't felt personally threatened today -- the Midwest "fly-over" portion of the country we live in lacks any marquee-status buildings -- but it felt good to be home, to see Steph and the boys.
The local news essentially rebroadcast network video footage from the day. There were only two local stories. One about a Twin Cities woman whose son, a pilot, was among the passengers who tried in vain to retake one of the hijacked planes. The second story talked about people hoarding gas. Some gas stations responded by jacking the prices up to $4 a gallon. The only thing we have to fear is fearful gas prices. It is too soon to know what we will come to know, that Gordy Aamoth's son lies sanctified amidst the Jet-A rubble of Tower Two.
A neighbor woman about my age comes by to say she spent the day making phone calls to check on her people. She has friends who had a beer with some truckers who ship petroleum, and they think we might run out. She suggests we go out and at least top off. She sounds like she's been crying. She sounds like she's been drinking. She says she loves us as she walks off down the sidewalk and into the night.
Yes, we say. It's a good night to love your neighbor.
]]>How We Treat Heart Disease Isn't Good Enoughtag:www.huffingtonpost.com,2011:/theblog//3.8361742011-03-21T08:41:37-04:002011-05-25T18:40:24-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/number one killer, and so physicians take it seriously. If lab tests and history suggest there's a decent chance that the pachyderm in the room is coronary artery disease, you will be admitted to the hospital and treated aggressively.
Either sooner (within minutes in the case of a heart attack) or later, you will likely undergo a coronary angiogram, the gold standard test for cardiovascular disease. The procedure entails threading a small catheter into the opening of the coronary arteries, then injecting a chemical that makes the inside of the arteries appear white on X-ray. A healthy artery looks smooth and wide open. A diseased artery looks narrowed and beaded -- or in the most severe cases, completely blocked.
Researchers followed nearly 700 patients who presented with a heart attack or a threatened heart attack. Each patient had an angiogram to identify the blockage that was causing the problem; the culprit blockage was then ballooned open (a procedure called angioplasty) and a small wire mesh device called a stent was inserted to keep the blockage from reoccurring. That's a typical angiogram procedure, but in this study, each patient also went on to be evaluated with a newer technology called "catheter-directed intravascular ultrasound." The idea was to use the more discerning eye of intravascular ultrasound to assess how many atherosclerotic blockages, a.k.a. "plaques," the angiogram may have missed.
It turns out that the standard angiogram misses a lot of plaques. In this study, conventional angiograms documented a total of about 1,800 of these blockages, whereas intravascular ultrasound found 3,100 -- despite the fact that ultrasound can't even "see" the last third of an artery the way an angiogram can. Not only did the angiogram miss a lot of blockages, but it often underestimated the severity of the blockages it did find. For example, angiograms found just 12 high-grade blockages; intravascular ultrasound found 283.
Over the following three years about 20 percent of the study patients returned to the hospital with more heart problems, and many of them had another angiogram to try to identify where the new blockage was. For about half of the returnees, the new problem was caused by the growth of a previously noted, but small (and therefore unstented) blockage. In the other half of cases, the chest pain occurred because a previously placed stent had closed off. That's a 50/50 split despite the fact that small unstented blockages outnumbered the larger stented blockages by more than two to one.
The researchers were also interested in whether there were any particular features on the initial ultrasound that could have predicted which blockages ended up causing problems in the follow up period. Coronary artery blockages aren't just a pile of cholesterol goo, stuck to the side of an artery. They are in essence a wound, fixed in place -- a mixture of different material and cell types going through cycles of healing and/or recurrent damage. But an angiogram can only document the severity of a blockage; it cannot peer inside this wound the way an ultrasound can.
It turned out that even when a particular blockage had all three of the most ominous ultrasound features the researchers could identify, there was only an 18 percent chance that that particular blockage would go on to cause an acute coronary problem. Call it "Whac-a-Mole Cardiology:" yes, an angiogram or ultrasound may identify a series of blockages, but we still can't predict which one will pop its head up out of the hole so we can bang it over the head with a stent.
Don't get me wrong: stents can save lives. In certain heart attack situations, angioplasty and stenting has dropped short-term mortality rates from 13 percent to 3-5 percent; in other situations, it can prevent "after-shock" heart attacks and readmissions for angina. But treating a heart attack in the here-and-now is different from preventing one in the future, which stents don't do very well. That's because, as this study showed, we're lousy at picking which blockages we should use them on, and also because stents don't always stay open: they can slowly scar shut, or quickly clot off. As a cardiologist colleague of mine says, "We've created a new disease -- the stent."
Of course we wish that stents worked better as preventive therapy for heart attacks. In fact, some interventional cardiologists wish so hard that they'll go ahead and place a stent anyway. This practice is so common that it's been given its own term, the "oculostenotic reflex," meaning that if an interventional cardiologist sees a stenosis (a higher grade blockage), he or she will reflexively stent it. In a 2006 focus group study of cardiologists in the San Francisco Bay area, one admitted, "We all agree that we don't know if we're doing the right thing, but if there's a lesion [blockage], we'll fix it."
In some cases, wishful thinking bows to greed, as angiograms are a lucrative procedure. With some regularity the multi-million-dollar exploits of stent cowboys like Baltimore cardiologist Dr. Mark Midei end up in a New York Times expose . It's unclear what percentage of stents (560,000 were placed in 2007) are unnecessary, but cardiologists will admit, at least privately, that it's a common practice. And it's clearly part of the sucking sound we hear coming from our health care premiums. Medicare alone spent $3.5 billion on stents in 2009; Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic told the New York Times, "We're spending a fortune as a country on procedures that we don't need."
The conclusion to this latest research might be "Oops, the best test we have to evaluate our country's most lethal health problem isn't all that good." If the conventional angiogram is moving down the podium, will there be a new gold standard? Many believe it will be either CT or MRI angiograms -- like intravascular ultrasound, these allow us to more accurately view the atherosclerotic scars that define coronary artery disease. Because stress tests can only detect severe disease (blockages of 70 percent or more), CT or MRI angiograms are also increasingly being used as a much more definitive screening test that can find coronary disease much earlier in its development.
In the meantime, if it took an angiogram and a stent to push that elephant off your chest, be grateful but not falsely reassured: you have been treated for coronary artery disease but not cured of it. The 90 percent blockage the cardiologist ballooned and stented may now be 100 percent open, but you'll need to be on medication to keep that stent open. And as this latest research shows, it's very likely that there are remaining smaller blockages that the angiogram either underestimated in size or didn't see at all. These could loom large in your future unless you aggressively treat the risk factors -- smoking, high blood pressure, bad cholesterol etc. -- that caused them to sprout up in the first place. Whenever possible, choose a smoke alarm over a fire engine.
]]>Mammography Debate: Even Physicians Can Get Emotional About Sciencetag:www.huffingtonpost.com,2009:/theblog//3.3779722009-12-04T12:31:08-05:002011-11-17T09:02:45-05:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/be the fray.
Consider the American College of Radiology's official counterpoint, which began with the sensational headline: "USPSTF Mammography Recommendations Will Result in Countless Unnecessary Breast Cancer Deaths Each Year."
Countless? No, in fact one of the clinical reviews that informed the United States Preventive Services Task Force (USPSTF) new recommendations put up a very specific number of how many women would die of breast cancer under the new guidelines. In order to prevent one woman aged 40-49 from dying of breast cancer, 1,900 women would have to be screened for a ten-year period. Weighing the benefit of saving one life against the harms generated by the screening process -- primarily the additional testing that women with falsely positive screening mammograms would have to go through -- the USPSTF decided that it was no longer worth recommending routine screening of women in this age group.
Putting it another way, the USPSTF decided that in a ten year span, it would be better to let one women die of breast cancer than to have 1899 women undergo testing that in the end would be of no benefit, or even some detriment, to them. Universal screening is, after all, a kind of a lottery in which everyone agrees to put something at risk, with the hope of being the One who wins it big. Some people go for lotteries, while others abstain.
Of note, the task force continued its counting, concluding that screening 1,300 women aged 50-59 for 10 years would prevent one death, and that only 400 women aged 60-69 would have to be screened to save one life. In these age groups, the USPSTF enthusiastically supported mammographic screening.
The recommendation not to routinely screen women aged 40-49 for breast cancer came as a reversal of guidelines previously issued by the USPSTF in 2002. Understandably, this felt like a betrayal to those who've dedicated their energies to fighting breast cancer, particularly to women who've had their lives saved by a mammogram.
Why did the USPSTF do an about-face? The report states that the new recommendations were based on data from several new randomized controlled studies on breast cancer screening, and from a new, more sophisticated review of previous data. New data, new review, new recommendations.
The American College of Radiology (ACR) found the new recommendations to be more flawed than novel, and they came out swinging. If you're not in the sciences, you'd be surprised at how subjective objective data can be. It seems that the facts often vary, and when they don't, their interpretation does. Though physicians would like to present a unified, spotless lab coat appearance to the public, a certain kind of scientific wrangling goes on all the time. But the ACR's statement appeared more inflammatory than educational, more K Street lobbying than scientific debate. If entrenched vitriol is a genre of literature you enjoy, you should read the entire statement for yourself .
Attacking the science as 'seance'
It's well recognized within my profession that USPSTF screening recommendations tend to be more conservative than those issued by other prevention groups. But that wasn't the nuanced argument the American College of Radiology statement was trying to make when it claimed the USPSTF recommendations ignored "valid scientific data" and "direct scientific evidence from large clinical trials," were "inconsistent with current science," and were, in a word, "unfounded." On the contrary, the recommendations were heavily "founded" and based on a comprehensive review of the most current research. One may disagree with the conclusions that the USPSTF drew from the data, but to repeatedly accuse the task force of being more seance than science is, well, "unfounded."
Assigning intent: the government made me do it
The ACR went on to depict the USPSTF as being a government pawn bent on reducing costs by rationing care, noting that the task force was "created by a federal government-funded committee," and that "The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) gave HHS the authority to consider USPSTF recommendations in Medicare coverage determinations for additional preventive services."
But is federal funding for health research a bad thing? Because the alternative has increasingly become a plethora of biased, industry-sponsored studies, and I've had my fill of those. I'm not out to demonize the health care industry, but their loyalties are to shareholders first and patients second. Dolphins don't swim for pleasure: it's who they are. And businesses exist to make money, the more the better. Industry-sponsored studies are understandably designed to put their pill or device in the best possible light, and we've seen repeated instances where the industry either slow-tracked or left unpublished studies that appeared to have unfavorable results. Under the heading, "Don't ask the barber if you need a haircut," if we chose a health care system where private-industry is both the dog and the leash, we're destined to go wherever the dog wants. And the dog prefers high profits over low profits.
The Voice of Reason
The antithesis of the American College of Radiology's provincial, turf-protecting press release is an LA Times op-ed piece by breast cancer specialist Dr. Susan Love. "Weighing the Benefits of a Mammography" is a smartly-crafted, honest, forward-thinking view of the complexities of breast cancer and breast cancer screening.
"Although we all would like to think that public health pronouncements are the unmitigated truth about any issue, rarely is that the case," wrote Dr. Love. "We can only give our best guess, based on the available data and our understanding of the disease. Luckily, research continues, hypotheses are reformulated and new recommendations are made."
Love wrote that the shift in guidelines was not the result of a government or insurance company conspiracy, but came about because a lot has changed since the last recommendations were made in 2002. She pointed out that we now have a different understanding of the biology of breast cancer, realizing that "breast cancer" is really "breast cancers"--different kinds of breast cancer growing at different speeds and with different levels of aggressiveness. She pointed out that mammograms are less accurate in the denser breast tissue of younger women, who also are more sensitive to the carcinogenic effects of low-dose radiation. Love quoted a 2005 British study suggesting that it is possible for women to develop breast cancer because of the cumulative radiation from yearly mammograms.
"The public anger at these recommendations is understandable," wrote Love. "But it should be directed at an honest effort to evaluate the benefit of mammography, and at the fact that we still don't know the cause of breast cancer or how to prevent it. Early detection is not our best prevention -- it's not even prevention. It just finds cancers that are already there."
The Rx for what is ailing our health care system
If we're ever going to get control of the Beast -- a health care system that is draining everyone's bank account and making some people sick--we'll have to hold honest, publicly-digestible discussions about what each particular medical intervention can do for us in terms of lives lengthened or lives improved; and what it will cost us, both personally and financially. That's because science can only inform us; it can't tell us what to do. Part in parcel to these discussions will be an admission that if our health care resources are not limitless, when we choose to do one thing, we choose against another. If you want to call that rationing, fine.
Who will lead those discussions? Political leaders have proven incapable of giving the public any bad news (we tend not to re-elect those who do), and the insurance and health care industries have their profits to think about. That leaves physicians and health care scientists to lead us through these increasingly complex choices. The American College of Radiology's response to the USPSTF recommendations is a reminder that physicians can be entrenched and profit-driven. And Dr. Love's response is proof that in our best moments, we physicians deserve the trust that patients and the public have honored us with.
]]>America's Health Care Addictiontag:www.huffingtonpost.com,2009:/theblog//3.3013182009-09-29T14:10:15-04:002011-05-25T14:10:19-04:00Craig Bowronhttp://www.huffingtonpost.com/craig-bowron/Substantive health care reform will only come with a cultural shift that recenters public expectations and puts the science of health care, and health care outcomes, back in charge
Science is what we use to keep from fooling ourselves.
-- Richard Feynman
On occasion a patient arrives in the hospital so sick, in so many ways, that as a physician it's hard to know where to begin. Health care reform feels the same way -- so many things wrong, so complex and interrelated, that delving into it can produce a catatonic sense of helplessness. Detailed media reports begin to sound like Charlie Brown's teacher, an incomprehensible garble that's over our heads.
Where to start? Because the symptoms of our ailing health care system are primarily financial -- health care simply costs too much -- most Americans believe the solution will be financial as well. The three health care reform proposals from the Senate and the House seem to confirm this, with a bevy of financial proposals like "affordability premium credits," "insurance pooling mechanisms," tax penalties for the uninsured; plans for increased efficiency and performance, and decreased abuse and fraud. To physicians like me, all of this sounds like a meth addict who finally admits to having a problem: meth is too expensive. If he could just get his finances in order, his troubles will go away.
The fleecing of America, one co-pay at a time
America, it's time to sober up. We've become addicted to high-cost, high-tech, average health care, and breaking this addiction will solve our financial problems, not vice versa. Data from the Organisation for Economic Co-operation and Development showed that in 2006, the United States spent $6,567 per capita on health care, edging our nearest competitor, Switzerland, by 52% and putting us 90% higher than many of our global competitors. And what have we gotten for this spending spree? Average health care. No comparisons suggest otherwise. This doesn't mean we don't do some things really well; in fact, America has arguably been the world's leader in health care innovation. It's just that for broad indicators of health, we're shooting par.
How does a country with perhaps the most innovative health care system in the world produce average health care outcomes? It's simple: much of the innovation hasn't delivered. This is what the American public doesn't get, and what's hard for a physician to admit to: the benefits of modern medicine have been oversold. We've assumed that the same science and technology that so dramatically revolutionized human life in the 20th century, taking us from horses to horsepower to nuclear power, would do the same thing for human health.
It's true: we are living longer than ever. Life expectancy in the U.S. nearly doubled in the past century, but the sharpest gains came in the first half of the century, well before any significant medical advances, even before the discovery of antibiotics. In 1900 the average U.S. citizen lived to age 47, and by 1950 the average life expectancy was 67. This unprecedented change came from improvements in nutrition and control of infectious diseases (sanitation being critical) that drastically reduced infant and child mortality. Which makes sense -- if you want to change the health of a rural village in Central America, don't build them a dialysis center and an MRI: dig a latrine and drill a well.
Life expectancy plateaued from 1955 to 1975, and despite an explosion of medical knowledge and technology, thereafter the graph has resumed a softer steady pitch, with subsequent gains being largely due to improved treatment of high blood pressure and diabetes. As we turn the corner on the 21st century, U.S. life expectancy is 77, and the two most common causes of preventable disease are human-derived pandemics of smoking and obesity. Certainly life expectancy is not the sole measure of health, but superimpose the soft rise of the U.S. life expectancy curve with the steeply pitched rise in health care spending and you don't need to be an economist to see that we're not getting a lot of bang for the modern health care buck.
This dichotomy between what America spends on health care and what we get in return is moored to an unshakeable belief in the power of technology to radically change our lives, even our health. The infatuation became so deep that we stopped applying scientific rigor to the health care sciences. We quit asking the tough questions: it may be fascinating technology and great science, but is it great medicine? Every new medical device, new pill, new therapy must be better than the last one, and the steep price tag proves it. Sounds ridiculous? One need only look as far as the financial crisis, where our infatuation with the power of unfettered markets kept us from asking the honest questions: are derivatives "real" or are they just funny money?
Bone marrow transplants for breast cancer: Health, American Style
The use of autologous bone marrow transplants (ABMT) in the 1990s for treatment of advanced breast cancer exemplifies the many factors that make Health, American Style so expensive but also inept. The story begins in 1990, when a study showed that for women with cancer extending into a number of lymph nodes, treatment with ABMT offered a 40% improvement in three-year survival rates compared to standard chemotherapy. The study was hobbled by methodological issues that seriously weakened or even nullified the results, and insurers refused to pay for it. But for physicians and patients dealing with the terrible predicament of advanced breast cancer, ABMT -- despite its significant toxicities, infection risks, and published mortality rates of zero to seven percent -- appeared to be a promising treatment. Individual women sued their insurers to get one, and for reasons that were more often legal than scientific -- so called "judge-made insurance" -- many of them won. Under intensive lobbying pressure and seeing a legal precedent forming, some states enacted laws mandating insurers pay for ABMTs. Rather than bear the legal expenses, in time insurers began paying for ABMTs, but only if patients agreed to enter a randomized control trial.
Eventually ABMTs became unconditionally covered, "standard therapy" if you will, despite further evidence that the initial study was deeply flawed, and that the improved response with ABMT seemed to last only a few months and came at a cost of serious side effects. High quality randomized control studies initiated to answer this critical question were hampered by very low enrollment: women (and many oncologists) were so enamored by (and hopeful for) ABMT that they refused to take the risk of entering a trial and ending up in the standard therapy arm. In the end, only one in ten patients who had an ABMT in the 1990s did so within a clinical trial, perpetuating our ignorance of whether the treatment was a sham or a ray of hope. So it wasn't until the year 2000 that there were enough good studies to conclude that the treatment was ineffective.
This is the story of ABMT for breast cancer, and also American health care: faddish, technology-avid, heavily lobbied and political; ruled by an innate feeling that the more complex the care, the better it must be. With the best of intentions, over a ten-year period we spent an estimated $3.4 billion on a treatment that didn't work. Embracing hope, to borrow from the Obama campaign, we turned a blind eye to science, and the forty-one thousand women who were treated with an ABMT suffered for that delusion. As an internist, I helped take care of some of these women: they suffered.
Vioxx, leaf blowers, and the allure of liqui-gel
Remember Vioxx, the new arthritis medication developed by Merck and first brought to market in 1999? Because it had a reduced risk of stomach ulcers compared to other arthritis medications, it looked to be a good drug for patients with chronic arthritis pain, those with rheumatoid arthritis for example. No one, including Merck, directly claimed that Vioxx worked better than standard pain medications like ibuprofen or acetaminophen, but a media blitz depicted a revived Dorothy Hamill triple-lutzing across the TV screen, and Americans clamored for Vioxx to the tune of over $2 billion dollars a year. When the drug was pulled in the fall of 2004 because of an increased risk of stroke or heart attack, the tab was over $10 billion.
The flip side of the belief that complex, high-cost care guarantees superior health care is that simple, inexpensive measures must be "cheap" and ineffective. Not so. Take heart disease for example. A recent paper in the New England Journal of Medicine attributed only seven percent of the decline in deaths from coronary artery disease since 1980 to angioplasty and bypass surgery combined. For a techno-fascinated country, it doesn't necessarily make sense that controlling risk factors and taking a few pills could work as well as a complicated, definitive-sounding "Roto-Rooter" procedure like angioplasty, or open heart surgery for that matter.
Metaphorically speaking, we're a country that will pick a leaf blower over a rake any time. Even though a rake lasts indefinitely, always starts, carries no electric or gas bill, provides exercise to the user, and dethatches as it goes. We're a people that believe Advil and Motrin work better than generic ibuprofen, even though it's the exact same drug at one-third the price. Oh, the power of a candy-coated shell, the allure of liqui-gel!
Why water the flowers AND the weeds? Putting science back in charge of a consumer-driven health care system
If American health care is over-hyped, and over-valued, then health care reform that simply pays less for everything is doomed to failure. Legislation that waters both the flowers and the weeds less may allow you to save water, but it makes you a lousy gardener.
To that end, there are some hopeful signs in the current Congressional health care proposals, and also in the American Recovery and Reinvestment Act (ARRA) passed in February of this year. All of these include funding to evaluate the effectiveness and appropriateness of individual health care services and procedures. As encouraging as it is to see that perhaps we're finally ready to apply scientific scrutiny to the science of health care -- so-called "evidence-based medicine" -- it remains unclear how we will implement this newfound knowledge.
Although the ARRA established a council of clinical experts to compare the effectiveness of various treatments, the council won't be able to establish clinical guidelines or to "mandate coverage, reimbursement, or other policies for any public or private payer." An information sheet on the House plan reads, "Under this proposal, doctors, nurses, and patients will make medical decisions, not big insurance companies or the government." But wait a minute! This is how we got into this mess in the first place. We live in a consumer culture, where the customer is king. This is the health care system we've demanded and allowed: glitzy and impatient; created to fight disease, yes, but also to soothe our insecurities about our own health and mortality. When it comes to health care, Americans want everything, the works: an antibiotic "just in case" the bronchitis isn't from a virus; an MRI of the back, not because the clinical scenario is worrisome, but because we've been reading about spinal cord tumors on the Internet.
If we can't have everything, because the science shows that "everything" (like bone marrow transplants for breast cancer) offers no benefit but some risk, or because the new pill (Vioxx for example) offers marginally more benefit for summarily more cost, is this "rationing" health care? People shudder at the term, but we all make daily decisions based on what we can and cannot afford. As we've now proven, any limited supply must be either rationed, or exhausted.
When the white coat becomes a straitjacket: physicians prove incapable of reigning in health care costs
So who is it that's going to say "no"? Physicians haven't been able to for a variety of reasons. As human beings and as businesspeople, we want our patients to like us. We want them to be relieved, comforted, satisfied. Acting aggressively gives us a proactive, competent air, and it validates the patient's symptoms, in the same way that not ordering an X-ray can seem to trivialize the patient's problem. Rather than being relieved that it wasn't pneumonia, a patient may leave the office grumbling, "They didn't even do an X-ray." Giving patients what they want -- meeting their expectations, efficacy and costs be damned -- keeps them happy, if not healthy; and happy patients don't sue.
Yes, some physicians practice the unproven for profit, gaming a system which stupidly pays more for doing more, regardless of the efficacy of "more". But most physicians dabble in the gray zones of medicine because doing something avoids having to discuss the sobering details of the latest medical research ("Here's why you don't need this test"), the likes of which contribute to a sense of professional ineptness. A published review of the most recent science on diabetes reads with colloquial frankness, "Enough already! Randomized trials show that tight glucose control in patients with long-standing type 2 diabetes isn't beneficial." The headline asks physician readers, "How Much Evidence Do We Need to Change Practices in Which We Firmly Believe?"
If physicians and patients are incapable of following evidence-based, rational, clinical guidelines, then the only thing that will put a stop to our health care spending spree is for the entity who is paying for it -- be it private or government insurance -- to stop paying for it. For competitive or legal reasons (both in the case of bone marrow transplants for breast cancer), private insurers have had difficulty saying "no" to unproven therapies. And for as long as affordable health care is seen as cheap health care, no one will sign up for what they perceive to be a "Penicillin&Gauze" insurance option. I'm no fan of big government, but perhaps a government insurance option based on the best available medical research, where hard science dictates the behavior of bureaucracy rather than the other way around, would create a new, more realistic playing field.
Purging unhealthy health expectations
While it's uncertain what, if any, kind of health care reform legislation will be passed, Congress cannot mandate what our country may need most: a cultural shift in the expectations of what modern medicine can and cannot do for us. This may be no easy task. Look at us: we're a nation that's outlawed Lawn Jarts, but not cigarettes; a country that's gone cuckoo for Cocoa Puffs and diet pills but not for healthy food; a drive-up-window-society simultaneously hooked on physical convenience and fitness centers.
We all want a health care system that will continue to innovate and evolve. When I was in training in the early 1990s, patients infected with HIV came into the hospital with a high fever and no blood pressure and died in a hurry. HIV medications changed all that, a miracle in our time. We need to keep chasing down miracles, but we won't build a futuristic health care system by bankrupting the current one. We'll get there by paying for proof, by developing a keen eye for treatments that are both great science and great medicine, and by admitting to our anxiety-ridden souls that life will forever have limits and uncertainty.
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