Back in 1984, federal health officials, flush with excitement over discovery of the virus that causes AIDS, famously predicted that they would have a vaccine ready for market within three years. Now, after almost a quarter-century of toil and struggle, the effort has crashed in failure. No one yet knows whether a vaccine to prevent the disease will ever be possible.Really? While difficult, the title of the piece somewhat contradicts with the content. As the op-ed goes on to state, funding must shift towards finding novel ways to combat AIDS as well as towards prevention / treatment, but should not forsake vaccine research altogether. However, the notion that a vaccine is "impossible" seems defeatist. By shaping public opinion against the notion of a vaccine, which in turn shapes the opinions of those in government and elsewhere who approve funding for such projects, I think pieces like this do more harm than good.
Monday, March 31, 2008
Wednesday, March 26, 2008
Many anecdotes of Diogenes refer to his doglike behavior, and his praise of a dog's virtues. It is not known whether Diogenes was insulted with the epithet "doggish" and made a virtue of it, or whether he first took up the dog theme himself. The modern terms cynic and cynical derive from the Greek word kynikos, the adjective form of kyon, meaning dog . Diogenes believed human beings live artificially and hypocritically and would do well to study the dog. Besides performing natural bodily functions in public without unease, a dog will eat anything, and make no fuss about where to sleep. Dogs live in the present without anxiety, and have no use for the pretensions of abstract philosophy. In addition to these virtues, dogs are thought to know instinctively who is friend and who is foe. Unlike human beings who either dupe others or are duped, dogs will give an honest bark at the truth.
The most well-known anecdotes about Diogenes relate to his ascetic / dog-like behavior:
The stories told of Diogenes illustrate the logical consistency of his character. He inured himself to the vicissitudes of weather by living in a tub belonging to the temple of Cybele. He destroyed the single wooden bowl he possessed on seeing a peasant boy drink from the hollow of his hands. He once masturbated in the Agora; when rebuked for doing so, he replied, "If only it was as easy to soothe my hunger by rubbing my belly." He used to stroll about in full daylight with a lamp; when asked what he was doing, he would answer, "I am just looking for an honest man." Diogenes looked for an honest man and reputedly found nothing but rascals and scoundrels.
Umm... and you thought the other shoppers at your mall were bad. At least you weren't standing in the checkout line next to an antsy Diogenes at the agora...
Tuesday, March 25, 2008
Sad to say, but it's little surprise that this happened in Texas.
LA JOYA, Texas (AP) -- A 2-year-old boy who died with a fractured skull might have been accidentally crushed by a morbidly obese relative, authorities say. Investigators believe that the woman fell on the child, who was pronounced dead Tuesday, said Bobby Contreras, Hidalgo County justice of the peace.
"It didn't look like there was any foul play from what I saw," he said.
An autopsy was scheduled, with the cause of death to be announced Monday. Hidalgo County Sheriff Lupe Trevino, who called the death "suspicious," said he would wait for an announcement on the cause before deciding whether to file charges. The child was believed to have been dropped off by his mother to spend the day with the bedridden relative, The McAllen Monitor reported Friday.
Monday, March 24, 2008
“The very success of immunizations has turned out to be an Achilles’ heel,” said Dr. Mark Sawyer, a pediatrician and infectious disease specialist at Rady Children’s Hospital in San Diego. “Most of these parents have never seen measles, and don’t realize it could be a bad disease so they turn their concerns to unfounded risks. They do not perceive risk of the disease but perceive risk of the vaccine.”This misperception of risk leads to comments from parents like this:
“I refuse to sacrifice my children for the greater good,” said Sybil Carlson, whose 6-year-old son goes to school with several of the children hit by the measles outbreak here. The boy is immunized against some diseases but not measles, Ms. Carlson said, while his 3-year-old brother has had just one shot, protecting him against meningitis.
“When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.”
Ms. Carlson said she understood what was at stake. “I cannot deny that my child can put someone else at risk,” she said.
I can see how reading random misleading websites about the link between vaccines and autism can lead to confusion and skepticism, but what is sad is that these parents are not typically poorly educated. They have the means and intellect to seek out proper information and discuss the choice. Instead, they seem to buy into the fear and paranoia to the detriment of not only their own children, but other people's children as well.
Stories like this lead me to believe more and more that, in addition to lamaze classes, new parents should be required to take classes about how to care for their impending bundle of joy. The classes would not only teach basic parenting skills (simple things like... babies should drink milk, not water), but also important ideas like the value of vaccinations. If the parents-to-be do not take the class and do not pass a basic test, then a relative who has previously passed the test or Child Protective Services should take custody of their children until they do pass the test.
Radical? Maybe, but think about it: we require such testing before people adopt children. The state also requires testing before one is allowed to drive. The idea in both cases is that these activities can potentially harm other people, so the state wants to ensure that people are capable before entrusting them with the responsibility. Why should parents of natural-born children be any different? As the issue with vaccines and many other cases of poor parenting show (ahem, Britney Spears?), there is a role for the state to play here.
Friday, March 21, 2008
A German retiree is taking a hospital to court after she went in for a leg operation and got a new anus instead, the Daily Telegraph is reporting. The woman woke up to find she had been mixed up with another patient suffering from incontinence who was to have surgery on her sphincter. The clinic in Hochfranken, Bavaria, has since suspended the surgical team. Now the woman is planning to sue the hospital. She still needs the leg operation and is searching for another hospital to do it.How does this even happen? Wouldn't two entirely different surgical teams perform these procedures? Wrong limb operations are one thing - it is easy to see how a patient who comes in with two diabetic feet might get a procedure on the wrong one, but this? How poorly prepared was the OR that no one had any idea whether they were operating on the right person / body part? I guess those OR "time outs" really do serve a purpose...
I guess I inadvertently took this week off for no particularly good reason, but I'll be back next week with new posts.
Friday, March 14, 2008
Another one worth browsing:
Random Note: Today is Pi (3/14) Day!
Thursday, March 13, 2008
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
These incentives reward doctors who perform more procedures. As reimbursement rates fall, volume increases to make up. Even when doctors try to do the 'right thing,' reality forces them to bend to the market. As the author notes:
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was."
To be honest, as a future physician, I suppose I have the "incentive" to not criticize a system that will eventually pay my bills, but I think in the long run, the inefficiencies built into our healthcare system harm physicians as much as anyone else. As costs rise, people will target physicians more and more as sources of the cost. Reimbursement rates will fall further, worsening the downward spiral. As rates fall, physicians will continue to cede power to insurance companies who dictate rates. At the same time, there will be greater demand for non-physician professionals (such as PAs) who can provide similar services at lower cost. All in all, without a change in the incentive structure, physicians will continue to squeeze each other out of the market, and that's not good for anyone.
Wednesday, March 12, 2008
Dr. Simon, a psychiatrist who studies mental health in the developing world, said the Goa strategy grew from a crucial idea. Unlike, say, heart disease and stroke, which can require expensive interventions, depression is relatively simple to diagnose and treat. Many studies have shown that talk therapy and antidepressants lead to significant improvement in most patients.You're telling me! Not to belittle the toll depression takes, but from a diagnostic standpoint, it's not clear to me what more the residents / attendings above me are doing besides SIGECAPS. After 2 weeks of my psychiatry rotation, I'm a SIGECAPS expert!
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Tuesday, March 11, 2008
“Surrogates do it to give their children a better education, to buy a home, to start up a small business, a shop,” Dr. Kadam said. “This is as much money as they could earn in maybe three years. I really don’t think that this is exploiting the women. I feel it is two people who are helping out each other.”To help each other?! If these women are truly so generous, I wonder how many of them would sign up for this task on a voluntary basis. That's right: zero. This is obviously all about the money. To try to frame it in any other way is dishonest.
The framing of the practice does matter a lot to how the enterprise is perceived. Even as the piece praises the payoff to the women, the language belies the dehumanizing commercialization of this practice:
Commercial surrogacy, which is banned in some states and some European countries, was legalized in India in 2002. The cost comes to about $25,000, roughly a third of the typical price in the United States. That includes the medical procedures; payment to the surrogate mother, which is often, but not always, done through the clinic; plus air tickets and hotels for two trips to India (one for the fertilization and a second to collect the baby).Collect the baby? I know this is semantics, but the word 'collect' objectifies the baby. Think about it: you collect your baggage from baggage claim, you collect coins, you call collect. No one collects humans. Well, until now.
Another troubling aspect is the nature of the transaction. Rich Westerners are basically preying on these women's financial situation. Such poverty is implicated in other exploitative practices such as prostitution or substandard working environments. How is this any different? Even if the women are cared for now, what is to prevent unscrupulous providers from entering the market and truly exploiting the women? The whole system seems ripe for abuse.
I suppose this argument is a bit strange, considering that I have previously described a market for organ donations. However, in that post, my implicit assumption was that all sides had relatively equal socioeconomic standing and information. This case differs in that these women are clearly not on the same footing as their benefactors in either resources or education. While I hope some good will come of this arrangement, I fear that the moral hazard is too great to let such a practice continue.
Monday, March 10, 2008
Friday, March 07, 2008
In some sense, doctors are salespeople too. However, we are not selling a product, but rather the idea that we can treat a patient effectively. Trust is an even more valued item between patients and doctors as compared to salespeople and clients. Under this assumption, it would be interesting to see if patients regarded doctors who mimicked them in the subtle ways described in the article to be 'better' physicians, or more empathetic ones. Of course, there are limits to the imitation:
Social mimicry can and does go wrong. At its malicious extreme, it curdles into mockery, which is why people often recoil when they catch of whiff of mimicry, ending any chance of a social bond.Yet, perhaps a bit of imitation wouldn't hurt. After all, it is the sincerest form of flattery, no?
Thursday, March 06, 2008
The patient was an elderly male from a minority group. At first glance, he seemed to be a nice enough gentleman, but perhaps from one of the lower social strata. I don't think I made any conscious judgments about the patient as my preceptor began describing various treatment options. My preceptor tried to explain the options to the patient in terms the patient could understand. However, I was surprised to hear the patient respond with the technical terms for the procedures (terms that, frankly, I did not know myself). My attending could not hide his surprise as well. He gave the man a puzzled look, to which the patient replied, "Last time, you gave me a booklet about my condition. I read it."
Well, duh. Why should we have expected any less?
At first, I'll admit that I just found this amusing and was glad that the patient was so invested in his own health (and, I still find this fact reassuring). However, my narcissistic side soon started to reflect on my own visceral response to this exchange. Why had I expected this patient to be any less interested in his own health than the most well-to-do appearing patient? I suppose to some degree we cannot help our prejudices, and should strive to mitigate them and certainly never act on them. I cannot tell what exactly led me to have low expectations of this patient (his race? his age? his speech patterns?); regardless, these low expectations surely would shade whatever treatment decisions I would make. Perhaps, were I the physician, I may subconsciously choose to be less aggressive with his treatment, or not describe the options as fully. I certainly hope that I treat all my patients the same, but such pre-formed expectations are hard to dislodge if one is not even aware of them.
So, how should we change these low expectations? Clearly, the long-term solution requires social change in terms of education, healthcare delivery, and cultural attitudes. But, for now, perhaps a more modest systemic solution is necessary. I believe that the low expectations I had were formed partially due to repeated interactions with patients and families who were unaware and ill-informed about their diagnoses. To change this, the healthcare system should adopt a uniform standard for informing patients about their diagnoses, especially for major/chronic illnesses like cancer or diabetes. There is already a precedent in place: all children's vaccinations require a Vaccine Information Sheet that explains what the vaccine does and the associated benefits and risks. Why not expand this system to all disease conditions? Perhaps there is some roadblock I am not aware of, but it seems like this would be within the realm of possibility. Such a standardized system would greatly shift the expectations doctors have regarding their patients. Of course, some patients will still be poorly informed, but at least there would be a basis for educating our patients. Perhaps, by educating the patients, we may broaden our own perspectives as well.
Wednesday, March 05, 2008
According to a recent story, a Starbucks barista found out that one of her longtime customers needed a kidney transplant. She went out, got herself tested, matched, and now plans to donate her kidney to her customer.
See? This is what I've been talking about! It's clear that there is a coffee-for-kidneys market out there! Maybe Starbucks can offer other organs alongside its Paul McCartney CDs.
Read more about other views on organ donation, or how colas can cause kidney disease.
Tuesday, March 04, 2008
Damn. Poor primary care docs.
The piece raises several interesting points about how reimbursements (and thus, salaries) are determined for physicians in the United States. The system is clearly skewed towards the specialists. I don't think this should necessarily affect the decision medical students face when choosing whether to specialize or not, but in the future, it will be interesting to see whether the pendulum swings the other way as the population ages and demand grows for primary care doctors relative to specialists. The market will solve everything, right?
Monday, March 03, 2008
In somewhat related news, a diabetes study was partially halted after deaths when it was noted that patients with tighter glucose control actually had more deaths than the group with less stringent control. In some sense, this is a much more disturbing piece of research. Even if the cause of a disease is unknown, as long as it can be treated, there is not as much concern. But if the cause of metabolic syndrome/diabetes becomes more convoluted and the treatment becomes less clear, medicine's ability to care for the increasing ranks of diabetes patients is much more limited.
Bring back New Coke! Or not: read more about how sodas are associated with gaining weight as well as chronic kidney disease.