Category: Health

How to Be an Effective Expert Witness

(p. B16) Dr. David Sackett, whose clinical trials proved the value of taking aspirin in preventing heart attacks and strokes, and who helped pioneer the use of exacting statistical data in treating patients, died on May 13 [2015] in Markdale, Ontario.
. . .
His colleagues also appreciated his sense of humor. He recalled that while he was testifying in a case as an expert witness, a lawyer handed him a research paper supposedly proving the safety of a drug that was in dispute. He read the paper and concluded that it was flawed.
“Well, I could take several more days and show you dozens more papers on this topic, but the jury would probably want to lynch me,” the lawyer insisted.
“I would welcome that,” Dr. Sackett said.
“Well, we could meet after the trial and go over these papers together,” the lawyer suggested.
To which Dr. Sackett replied, “No, I meant that I would welcome the lynching.”

For the full obituary, see:
SAM ROBERTS. “Dr. David Sackett, a Health Care Innovator, Dies at 80.” The New York Times (Thurs., May 21, 2015): B16.
(Note: ellipsis, and bracketed year, added.)
(Note: the date of the online version of the obituary is MAY 19, 2015, and has the title “Dr. David Sackett, Who Proved Aspirin Helps Prevent Heart Attacks, Dies at 80.”)

The Bureaucratic Absurdities of Socialized Medicine

(p. 13) Reading “Do No Harm,” Henry Marsh’s frank and absorbing narrative of his life in neurosurgery, it was easy to imagine him at the table. The men, and increasingly women, who slice back the scalp, open the skull and enter the brain to extract tumors, clip aneurysms and liberate nerves, share a certain ego required for such work. They typically are bold and blunt, viewing themselves as emperors of the clinical world. Marsh adds irony to this characterization, made clear in the opening line of the book, “I often have to cut into the brain and it is something I hate doing.”
. . .
Britain’s National Health Service is a socialized system, and Marsh chafes at new rigid rules imposed by its administrators. He is particularly incensed by a mandatory dress code: Neurosurgeons are subject to disciplinary action for wearing a wristwatch. There is scant evidence that this item contributes to hospital infections, but he is shadowed on ward rounds by a bureaucrat who takes notes on his dress and behavior. The reign of the emperor is ending, but Marsh refuses to comply and serve as a myrmidon.
Clinical practice is becoming a theater of the absurd for patients as well. Hospital charts are filled with N.H.S. forms detailing irrelevant aspects of care. Searching for a patient’s operative note, Marsh finds documentation she passed a “Type 4 turd.” He shows her an elaborate stool chart “colored a somber and appropriate brown, each sheet with a graphically illustrated guide to the seven different types of turd. . . . She looked at the document with disbelief and burst out laughing.”

For the full review, see:
JEROME GROOPMAN. “Consider the Comma.” The New York Times Book Review (Sun., MAY 24, 2015): 13.
(Note: ellipsis between paragraphs, added; ellipsis within paragraph, in original.)
(Note: the online version of the review has the date MAY 21, 2015, and has the title “‘Do No Harm,’ by Henry Marsh.”)

(p. C6) Amid the life-or-death dramas of neurosurgery in this book are some blackly comic scenes recounting the absurdities of hospital bureaucracy in the National Health Service: not just chronic bed shortages (which mean long waits and frantic juggling of surgery schedules), but also what Dr. Marsh calls a “loss of regimental spirit” and ridiculous meetings, like a slide presentation from “a young man with a background in catering telling me I should develop empathy, keep focused and stay calm.”

For the full review, see:
MICHIKO KAKUTANI. “From a Surgeon, Exhilarations and Regrets.” The New York Times (Tues., MAY 19, 2015): C1 & C6.
(Note: the online version of the review has the date MAY 18, 2015, and has the title “Books of The Times; Review: In ‘Do No Harm,’ a Brain Surgeon Tells All.”)

The book under review, in both reviews, is:
Marsh, Henry. Do No Harm: Stories of Life, Death, and Brain Surgery. New York: Thomas Dunne Books/St. Martin’s Press, 2015.

Empathy for the Absent

In Practical Wisdom the authors argue for empathy and against rules. There is something to be said for their argument.
But we tend to empathize with those who are present and not those we do not see or even know.
For example in academic tenure and promotion decisions, slack is often cut for colleagues who already have their foot in the door. We know them, their troubles and challenges. So they are tenured and promoted and given salary increases and perks even though there are others outside the door who may have greater productivity and even greater troubles and challenges.
Charlie Munger in an interview at the University of Michigan spoke of how hard it is for physicians to hold their peers responsible when they are incompetent or negligent. They have empathy for their peers, knowing their troubles and challenges. And Munger also says few physicians are willing to suffer the long-lasting “ill will” from their peers who have been held accountable. They do not know so well the patients who suffer, and one way or another, the patients are soon out of sight.
Just as in academics we do not know so well the students who suffer; or the able scholars who suffer, standing outside the door.
Following rules seems unsympathetic and lacking in empathy. But it may be the best way to show empathy for the absent.

The book mentioned is:
Schwartz, Barry, and Kenneth Sharpe. Practical Wisdom: The Right Way to Do the Right Thing. New York: Riverhead Books, 2010.

The interview with Munger is:
Quick, Rebecca (interviewer). “A Conversation with Charlie Munger.” University of Michigan Ross School of Business, Sept. 14, 2010.

It Takes Longer to Explain a Medical Bill than It Takes to Explain Newton’s Second Law

(p. 4) I CONFESS I filed this column several weeks late in large part because I had hoped first to figure out a medical bill whose serial iterations have been arriving monthly like clockwork for half a year.
As medical bills go, it’s not very big: $225, from a laboratory. But I don’t really want to pay it until I understand what it’s for. It’s not that the bill contains no information — there is lots of it. Test codes: 105, 127, 164, to name a few. CPT codes: 87481, 87491, 87798 and others. It tells me I’m being billed $29.90 for each of nine things, but there is an “adjustment” to one of $14.20.
At first, I left messages on the lab’s billing office voice mail asking for an explanation. A few months ago, when someone finally called back, she said she could not tell me what the codes were for because that would violate patient privacy. After I pointed out that I was the patient in question, she said, politely: “I’m sorry, this is what I’m told, and I don’t want to lose my job.”
. . .
One recent study found that up to 90 percent of hospital bills contain errors.
. . .
Before you embark on the journey of decoding your bill, you might also want to have a look at a tutorial — Understanding Your Medical Bill — produced by the Khan Academy, an online educator, and the Brookings Institution in Washington. It’s a bit over 12 minutes. That’s about five minutes longer than the Khan Academy’s tutorial explaining Newton’s second law.

For the full commentary, see:
ELISABETH ROSENTHAL. “The Medical Bill Mystery.” The New York Times, SundayReview Section (Sun., MAY 3, 2015): 4.
(Note: ellipses added.)
(Note: the date of the online version of the commentary is MAY 2, 2015.)

To FDA Aging Is Not a Disease, So FDA Will Not Approve Drugs that Extend Life

(p. D1) Some of the top researchers on aging in the country are trying to get an unusual clinical trial up and running.
. . .
The trial aims to test the drug metformin, a common medication often used to treat Type 2 diabetes, and see if it can delay or prevent other chronic diseases. (The project is being called Targeting/Taming Aging With Metformin, or TAME.) Metformin isn’t necessarily more promising than other drugs that have shown signs of extending life and reducing age-related chronic diseases. But metformin has been widely and safely used for more than 60 years, has very few side effects and is inexpensive.
The scientists say that if TAME is a well-designed, large-scale study, the Food and Drug Administration might be persuaded to consider aging as an indication, or preventable condition, a move that could spur drug makers to target factors that contribute to aging.
. . .
(p. D4) Fighting each major disease of old age separately isn’t winnable, said S. Jay Olshansky, another TAME project planner and a professor at the school of public health at the University of Illinois at Chicago. “We lower the risk of heart disease, somebody lives long enough to get cancer. If we reduce the risk of cancer, somebody lives long enough to get Alzheimer’s disease.”
“We are suggesting that the time has arrived to attack them all by going after the biological process of aging,” Dr. Olshansky said.
Sandy Walsh, an FDA spokeswoman, said the agency’s perspective has long been that “aging” isn’t a disease. “We clearly have approved drugs that treat consequences of aging,” she said. Although the FDA currently is inclined to treat diseases prevalent in older people as separate medical conditions, “if someone in the drug-development industry found something that treated all of these, we might revisit our thinking.”

For the full story, see:
SUMATHI REDDY. “To Grow Old Without Disease.” The Wall Street Journal (Tues., March 17, 2015): D1 & D4.
(Note: ellipses added.)
(Note: the online version of the story has the date March 16, 2015, and has the title “Scientists’ New Goal: Growing Old Without Disease.”)

Incandescents Better than LEDs at Allowing a Good Night’s Sleep

(p. D6) Studies have shown that such light, especially from the blue part of the spectrum, inhibits the body’s production of melatonin, a hormone that helps people fall asleep.
. . .
Devices such as smartphones and tablets are often illuminated by light-emitting diodes, or LEDs, that tend to emit more blue light than incandescent products.

For the full story, see:
KATE GALBRAITH. “WIRED WELL; Can Orange Glasses Help You Sleep Better?” The New York Times (Tues., APRIL 7, 2015): D6.
(Note: ellipsis added.)
(Note: the online version of the story has the title “WIRED WELL; Can Orange Glasses Help You Sleep Better?”)

Brin: Regulatory Burden Discourages Health Entrepreneurs

(p. A13) Earlier this month, at a private conference for the CEOs of his portfolio companies, venture capitalist Vinod Khosla interviewed Google co-founders Sergey Brin and Larry Page, asking them if the company might jump into health care. “It’s just a painful business to be in,” Mr. Brin replied, later noting that “the regulatory burden in the U.S. is so high that I think it would dissuade a lot of entrepreneurs.”
Mr. Brin is right. As a neurosurgeon-scientist and entrepreneur who co-founded a bioelectronic medicine company that deploys implantable technology to supplant drugs, I wish he were wrong.
. . .
. . . entrepreneurs should be allowed to carve out their own turf and let patients choose their own level of risk.
Consider the case of Goran Ostovich, a burly, 47-year-old truck driver from Mostar, Bosnia. Mr. Ostovich has suffered from long-standing rheumatoid arthritis and needed near-permanent bed rest. With his hands and wrists swollen and aching, he could no longer hold on to a wheel or even play with his small children. He tried a variety of medications. None worked.
When I met Goran at his doctor’s office in 2012, however, he didn’t seem at all afflicted with the disease. That’s because, one year earlier, he had been offered the opportunity to be the first participant in a clinical trial of a new therapy based on my invention. He received a bioelectronic implant and rapidly improved.
. . .
Since news of this clinical trial’s success became public, people from all over the U.S. stricken with rheumatoid arthritis have emailed, called and sent letters pressing for their shot at potentially effective–but not yet FDA-approved–treatments.
. . .
Some patients are very willing to take a calculated risk, . . .

For the full commentary, see:
KEVIN J. TRACEY. “Let Patients Decide How Much Risk They’ll Take; Take a tip from Sergey Brin: The health-care regulatory burden stops entrepreneurs from getting into the game.” The Wall Street Journal (Mon., July 28, 2014): A13.
(Note: ellipses added.)
(Note: the online version of the commentary has the date July 27, 2014, and has the title “Let Patients Decide How Much Risk They’ll Take; Take a tip from Sergey Brin: The health-care regulatory burden stops entrepreneurs from getting into the game.”)

How a Chavista Uses Her Chávez T-Shirt

(p. A1) CARACAS, Venezuela — Mary Noriega heard there would be chicken.
She hated being herded “like cattle,” she said, standing for hours in a line of more than 1,500 people hoping to buy food, as soldiers with side arms checked identification cards to make sure no one tried to buy basic items more than once or twice a week.
But Ms. Noriega, a laboratory assistant with three children, said she had no choice, ticking off the inventory in her depleted refrigerator: coffee and corn flour. Things had gotten so bad, she said, that she had begun bartering with neighbors to put food on the table.
“We always knew that this year would start badly, but I think this is super bad,” Ms. Noriega said.
Venezuelans have put up with shortages and long lines for years. But as the price of oil, the country’s main export, has plunged, the situation has grown so dire that the government has sent troops to patrol huge lines snaking for blocks. Some states have barred people from waiting outside stores overnight, and government officials are posted near entrances, ready to arrest shoppers who cheat the rationing system.
. . .
One of the nation’s most prestigious public hospitals shut down its heart surgery unit for weeks (p. A12) because of shortages of medical supplies. Some drugs have been out of stock for months, and at least one clinic performed heart operations only by smuggling in a vital drug from the United States. Diapers are so coveted that some shoppers carry the birth certificates of their children in case stores demand them.
. . .
The shortages and inflation present another round of political challenges for President Nicolás Maduro, who has vowed to continue the Socialist-inspired revolution begun by his predecessor, the charismatic leftist Hugo Chávez.
“I’ve always been a Chavista,” said Ms. Noriega, using a term for a loyal Chávez supporter. But “the other day, I found a Chávez T-shirt I’d kept, and I threw it on the ground and stamped on it, and then I used it to clean the floor. I was so angry. I don’t know if this is his fault or not, but he died and left us here, and things have been going from bad to worse.”

For the full commentary, see:
WILLIAM NEUMAN. “Oil Cash Waning, Venezuelan Shelves Lie Bare.” The New York Times (Fri., JAN. 30, 2015): A1 & A12.
(Note: ellipses added.)
(Note: the online version of the commentary has the date JAN. 29, 2015.)

How Air Conditioning Can Improve Metabolism

(p. 14) Sleep is essential for good health, as we all know. But a new study hints that there may be an easy but unrealized way to augment its virtues: lower the thermostat. Cooler bedrooms could subtly transform a person’s stores of brown fat — what has lately come to be thought of as “good fat” — and consequently alter energy expenditure and metabolic health, even into daylight hours.
. . .
“These were all healthy young men to start with,” . . . [senior author Francesco S. Celi] says, “but just by sleeping in a colder room, they gained metabolic advantages” that could, over time, he says, lessen their risk for diabetes and other metabolic problems. The men also burned a few more calories throughout the day when their bedroom was chillier (although not enough to result in weight loss after four weeks).
. . .
The message of these findings, Celi says, is that you can almost effortlessly tweak your metabolic health by turning down the bedroom thermostat a few degrees. His own bedroom is moderately chilled, as is his office — which has an added benefit: It “keeps meetings short.”

For the full story, see:
GRETCHEN REYNOLDS. “Let’s Cool It in the Bedroom.” The New York Times Magazine (Sun., JULY 20, 2014): 14.
(Note: ellipses added.)
(Note: the online version of the story has the date JULY 17, 2014.)

The academic paper discussed above, is:
Lee, Paul, Sheila Smith, Joyce Linderman, Amber B. Courville, Robert J. Brychta, William Dieckmann, Charlotte D. Werner, Kong Y. Chen, and Francesco S. Celi. “Temperature-Acclimated Brown Adipose Tissue Modulates Insulin Sensitivity in Humans.” Diabetes 63, no. 11 (Nov. 2014): 3686-98.

Fishing with Mosquito Nets, Where Food Is the Binding Constraint

(p. 1) BANGWEULU WETLANDS, Zambia — Out here on the endless swamps, a harsh truth has been passed down from generation to generation: There is no fear but the fear of hunger.
With that always weighing on his mind, Mwewa Ndefi gets up at dawn, just as the first orange rays of sun are beginning to spear through the papyrus reeds, and starts to unclump a mosquito net.
Nets like his are widely considered a magic bullet against malaria — one of the cheapest and most effective ways to stop a disease that kills at least half a million Africans each year. But Mr. Ndefi and countless others are not using their mosquito nets as global health experts have intended.
Nobody in his hut, including his seven children, sleeps under a net at night. Instead, Mr. Ndefi has taken his family’s supply of anti-malaria nets and sewn them together into a gigantic sieve that he uses to drag the bottom of the swamp ponds, sweeping up all sorts of life: baby catfish, banded tilapia, tiny mouthbrooders, orange fish eggs, water bugs and the occasional green frog.
“I know it’s not right,” Mr. Ndefi said, “but without these nets, we wouldn’t eat.”
Across Africa, from the mud flats of Nigeria to the coral reefs off Mozambique, mosquito-net fishing is a growing problem, an unintended consequence of one of the biggest and most celebrated public health campaigns in recent years.
The nets have helped save millions of lives, but scientists worry about the collateral damage: Africa’s fish.
. . .
“The nets go straight out of the bag into the sea,” said Isabel Marques da Silva, a marine biologist at Universidade Lúrio in Mozambique. “That’s why the inci-(p. 10)dence for malaria here is so high. The people don’t use the mosquito nets for mosquitoes. They use them to fish.”
But the unsparing mesh, with holes smaller than mosquitoes, traps much more life than traditional fishing nets do. Scientists say that could imperil already stressed fish populations, a critical food source for millions of the world’s poorest people.
. . .
In many places, fish are dried for hours in direct sunlight on treated mosquito nets. Direct sunlight can break down the insecticide coating. Anthony Hay, an associate professor of environmental toxicology at Cornell University, said fish could absorb some of the toxins, leaving people to ingest them when they eat the fish.
“It’s just another one of these ‘white man’s burdens,’ ” Mr. Hay said, referring to William Easterly’s well-known book critical of foreign aid by the West. “We think we have a solution to everybody’s problems, and here’s an example of where we’re creating a new problem.”
. . .
For Mr. Ndefi, it is a simple, if painful, matter of choice. He knows all too well the dangers of malaria. His own toddler son, Junior, died of the disease four years ago. Junior used to always be there, standing outside his hut, when Mr. Ndefi came home from fishing.
Mr. Ndefi hopes his family can survive future bouts of the disease. But he knows his loved ones will not last long without food.

For the full story, see:
JEFFREY GETTLEMAN. “Meant to Keep Mosquitos Out, Nets Are Used to Haul Fish In.” The New York Times, First Section (Sun., JAN. 25, 2015): 1 & 10.
(Note: ellipses are added.)
(Note: the online version of the story has the date JAN. 24, 2015, and has the title “Meant to Keep Malaria Out, Mosquito Nets Are Used to Haul Fish In.”)

The book referenced by Professor Hay, is:
Easterly, William. The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good. New York: The Penguin Press, 2006.