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Healthcare is a big business in the US, and getting bigger all the time.   The internet and social media have entered the action in response to consumer demand for information as part of a healthy desire for, well, more health.  For the venture capitalist this means opportunity with a capital O.    

  This consumer demand is as old as mankind.  Through the ages, communities around the globe have depended on their shamans, clerics, or medicine men.  Science and evidence base led to startling new developments beginning in the nineteenth century.  As the science of medicine has evolved, the now infamous snake oil salesmen emerged with it.  Travelling across the country, they pawned off Aunt Elmira’s secret miracle health tonic as the cure from everything from hangnail to heart disease.  Read the rest of this entry »

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A couple of the research blogs I follow lately have had some insight that really struck me as they fought off dualism in regards to the thorny issue of psychological vs. physical addiction and the brain, arguing that the elimination of mind and body distinctions is a good thing, as addictive pathways are real, physical represented by neuronal circuits.

This is an interesting argument, that collapsing psychology to the brain mechanisms brain can erase stigma by medicalizing it and making it a matter of physical function.    In addiction it makes quite a bit of sense.  We know what part of the brain is being stimulated, that dopamine reward pathways are building and feeding the habit.  The derogatory statement, “It’s all in your head,” remains technically true, but loses its bite when you can explain it in such a real and tangible way. Read the rest of this entry »

And now, the moment you have been waiting for all week.  No– not that moment.  It is the moment when yours truly presents the best, the brightest, the most informative, interesting, and entertaining of my sojourn on the internet.  Today I have gratitude, no worries, losing recognition of our own face, the God of the future, marrying biblical sisters, Scrubs and the end of life, and a football team without a home field, and eloping six year olds, amongst a lot of other really, really good stuff.  So dig in and enjoy the best of the internet (I could find)- Read the rest of this entry »

First Published May23,2008

We hear a lot on-line about everything that is wrong is medicine. Improvement should always be our aim and this is healthy. I think it does us all a little good to take a step back and realize just what we have. There are some things medicine has done for us I don’t think you could put any price tag on. While most are intensely aware of shortcomings, here is a reminder of just what how powerful modern medicine has been.

1. Antiseptics– In the mid 18th century, around the same time, Oliver Wendell Holmes and a Hungarian physician, Ignaz Semmelweiss, both noticed that when obstetricians washed their hands, it drastically cut the number of mothers who died of fever afterward. Semmelwies reported this observation and was roundly chastised, discredited, and ridiculed. Holmes had actually published this same finding in a medical journal a few years earlier, even advocating disinfectants, where it was uniformly ignored.

Holmes turned prophet when the germ theory of disease emerged two decades later. Joseph Lister learned about the discovery of microbes as the cause of fermentation from Pasteur, theorized they could be the cause of wound infections and developed sterile operating technique with phenol. Infections rates plummeted, Lister’s fame soared, and the mouthwash named after him remains in use to this day.

2. Smallpox eradication– This disease killed an estimated 400,000 people in Europe every year in the 18th century, including 4 sitting monarchs. The mortality rate was 30% and it left survivors scarred for life wherever the sores developed. Sores on the eyes made it the #1 cause of blindness. Edward Jenner discovered the principle of vaccination in 1796, some efforts to organize campaigns to vaccinate were made as early as 1803 by the Spanish, however it took time to accept this wacky idea of injecting disease to get rid of disease.

Inoculation was banned in England in 1842. Over the next ten years the course reversed completely and vaccination was mandated in 1853. By 1900, Smallpox was virtually eradicated in the US and Britain, by 1978, it was eradicated from planet earth except in the freezer at the CDC for some suspect reason.

3. The polio vaccine– In the 1920’s Poliomyelitis was a scourge and a plague that everyone lived in fear of. The initial infection was as common and pretty identical to the common cold or influenza. Most people got, spread it and recovered. However, 10% of those infected had weakness, 1 in 10 of these developed permanent paralysis as the motor neurons in the spinal cord were destroyed.

Vaccination was first developed in the 18th century, and scientists fought to develop the vaccine for over fifty years. It took time to realize there were three different polioviruses, each pretty stable over time. In 1949, Dr. Jonas Salk made a breakthrough when he developed a technique to grow poliovirus in culture, rather than in live monkey brains. He then found a way to weaken the virus and the one of the most massive clinical trials in history was begun. People rushed their children to the doctor and proudly displayed buttons they were polio pioneers.

Today, polio has been eradicated in the Americas and tragically, only exists in very poor nations with poor vaccination rates. The WHO has long held a goal for complete eradication, which is theoretically possible and humans are the only host for the virus.

4. Anesthesia– Humphry Davy reported anesthetic properties of nitrous oxide in a paper in 1800. However, chemists decided it was much more fun as a recreational drug, until it was used in the first painless tooth extraction in 1846. Four years earlier, a surgeon by the name of Crawford Long had discovered diethyl ether had similar effects on the body as nitrous oxide and used it to anesthetize a patient before removing a neck tumor. Ether had this problem of flammability and tendency to explode leading to the development of several other inhaled anesthetics and now many IV anesthetics, which are much easier to administer reliably. This development, more than any other, is what allowed the advent of modern surgery.

5. Antibiotics- Though bread mold had been used to treat wounds by the Egyptians, and several other scientists had documented the penicillium molds ability to kill off bacteria in 1897-1914, the discovery of Penicillin is credited to Sir Alexander Fleming, who discovered the bacteria killer in 1928, just because he had the strange habit of playing around with fungus to see how it beat the bacteria off. He did not believe it would last long enough in the human body to kill bacteria and dropped the study in 1931. It remained for others to develop it for use as a drug and the US government went into large scale production during World War II. As sulfa, streptomycin and many others have been added to the arsenal, bacterial disease has never been the same since, pretty much uniformly sinking like a rock on the list of the top causes of mortality in the developed world.

6. Cracking the human genome– In 1950, A mysterious molecule called deoxyribonucleic acid had long been known to sit in the center of cells innocuously, not doing much. This changed in 1952 when Alfred Hershey and Martha Chase proved that DNA was the genetic material for the T2 bacteriophage virus. James Watson and Frances Crick then discovered the structure of deoxyribonucleic acid (DNA) and the way it could vary with 4 base pairs. This allowed Crick in 1957 to hypothesize the relationship of DNA, RNA , and protein in 1957. He would be vindicated as other scientists cracked the genetic code a few years later. Fast forward forty some odd years and the entire genome of mankind has been sequenced. Our understanding of inherited diseases has skyrocketed, with new information gained every day, multiplying exponentially both new ethical dilemmas and the possibility to treat the untreatable.

7. Medical imaging– In 1895, Wilhelm Conrad Roentgen was playing around with a myterious new “x-ray” he had discovered when he stopped in front of his ray detector and caught a glimpse of the shadow of his own skeleton. Two weeks later he took a picture of his wife’s hand and started us down the road to the entire field of Radiology. X-rays are vital to diagnose and treat bone problems and pneumonias, to name a few. Real time x-ray movies, or fluoroscopy is used routinely in surgery, CT scans gave us the first view of soft tissues, vastly improving the ability to visualize tumors, abscesses. This was followed by MRI, which my specialty is particularly fond of, giving us a chance for the first time to see detailed brain anatomy without radiating or cracking open the skulls of patients. Procedures such and functional MRI and PET are unlocking function and physiology secrets in living patients without laying a finger on them.

8. Acute lymphocytic leukemia– There are 4000 cases of ALL in the US annually, 3000 of these occur in children at a peak age of 2 to 5 years old, making it the most common childhood cancer. 30 years ago it had 100%mortality and was a death sentence. Since then, the development of Bone Marrow transplantation, umbilical cord blood stem cell transplantation and a National registry allowing clinical trials on a massive scale, have lowered that mortality to 20% in five years, for the most common type, 90% go into complete remission with about 60% cured.

9. HIV/AIDS antiretrovirals– Just when you thought we were done with all the major advances these days, along comes a new and deadly plague with knocking out the bodies defenses causing 100% mortality. Intensive study into the human immunodefieciency virus has led to antiretroviral medications that can knock HIV to undetectable levels. While we are still looking for a permanent cure, the current state of the art is bright. Unfortunately, Africa and Asia are in the throes of crisis and the developed/undeveloped gap has reared it’s ugly head, just as it did in the past with vaccines and antibiotics. Here’s hoping for another smallpox type resolution, rather than measles or polio.

10. Insulin- In 1889, Oscar Minkowski and Joseph von Mering decided to remove a dog’s pancreas to test the organ’s role in digestion. The animals keeper noticed afterward that swarms of flies were attracted to the dog’s urine. Thus they demonstrated the first link between the pancreas and diabetes, leading to the discovery of the insulin as the hormone all higher lifeforms use to metabolize sugar from the blood.

Type I diabetes was 100% fatal whenever it hit prior to this discovery, and became treatable for the first time. First the hormone was derived from animals, now gene splicing has enabled the production of genetically engineered human insulin, delivery systems are advancing all the time with the ultimate dream envisioned of the artificial pancreas, or perhaps pancreas insulin producing cell transplantation. Many, many years of life have now been added to both type I and II diabetics around the world.

So the next time you read about diminishing returns of medicine in improving our health, take a good look at just where medicine has taken us. I don’t think many people would want to go back. While learning to control costs and improve efficiency, and wise use of technology will be critical to sustaining healthcare in the future, it is hard to overestimate the benefits of modern medicine. What do you think? Did I leave anything out?

First Published April 25, 2008.

 

Becoming the parent of a child with a genetic disease is a harrowing experience. This is likely more true today than it has ever been. We are hardwired to want the best for our children. Discovering they have a life altering condition pulls the rug right out from under parents. Discovering that the very genetic blueprint they passed on to the child is the problem makes this “act of God” personal. Suddenly, it is your fault.

Child birth is an exciting time full of anticipation. What parents often don’t anticipate is the possibility that anything could ever go seriously wrong. I took a first year medical school genetics elective right at the time my wife was expecting our first child. Note to all medical students. DO NOT EVER do this. It is a bad idea. It brought me right down to Earth real quick. It also caused me lost sleep, racing thoughts, and all around needless worry.

I also witnessed firsthand some real parental anguish.  My heart ached for them.  They became very caught up in questions like what the diagnosis actually was, what the chances of having another child with the same problem were, and do they need to have family members tested.  The more understanding we have, the more directed the questions and more uncertain the future.

      This has created or at least accentuated a new phenomenon, gene guilt.  In college I had a cell biology professor who referred to himself as a “genetic cess pool.”  on account of a daughter with spinal muscular atrophy, type I, a fatal recessive genetic disorder.  The irony is that his genes were likely no worse than anyone else’s.  It just happened that he married someone with a matching bad gene.  We likely all walk around with at least a few faulty genes, usually more, among our thousands.  Any one of these could result in disease if we concieve children with someone with the same exact hit.  The odds of that are low, like winning the lottery, only the prize is heartbreaking.

   Some genes are bad enough that disease shows up with just one copy, but for unknown reasons is super mild in some people, who may go undiagnosed until half their children get it.  Other gene mutations, called nucleotide repeats actually worsen through generations until the unlucky one gets disease, and then their children get worse disease.  With X chromosome disorders, the Mother passes a gene to her sons that caused her no problem because she had both a good and a bad copy.  Problem is her son gets the bad gene, and has no second copy because he is male.  Other diseases of the mitochondria are given strictly from the mother.  All of these situations can worsen the guilt and crush the self esteem of the parent. 

     Science compounds the problem with evolution.  We learn that nature’s way is survival of the fittest.  Bad genes are selected out of populations naturally.  With medicine, we have sort of beat evolution over the head by outsmarting nature, at least temporarily.  People with chronic conditions are living longer and better than ever before.   It is a natural step therefore, once we know about a bad gene and see its effect, to wonder if we should not select it out of the population by not having any more children.  This is unnatural selection, if you will.  We reason that we must do something nature has been doing anyway without our input.  Some reason that if they have children they are threatening the gene pool of the race.  I think it is a very flawed mindset.

      Certainly many disagree with me.  During the above mentioned genetic rotation, I met a teenager who was diagnosed with Li-Fraumeni syndrome, a disorder that increases susceptibility to cancer.  Her parents died at a young age, and she was being raised by an aunt.  The conversation between them was profound.  This patient felt emphatically that her life was not a mistake.  To suggest this was perhaps even offensive to her.  Who would want to think their life was a mistake?  For this reason, she insisted that she intended to have kids if the opportunity arose.  The Aunt was mortified. 

      Granted, this patient had not yet experience the ravages of cancer, perhaps her point of view was flawed, but I think she had a point.   This is a tough issue and certainly there are no easy answers.  But I believe we often overestimate the suffering of others.  I can’t help but admire her for realizing she is more than her genes.  Her life was more than her disease.  Individuals have much more contribution to make to society than just their genome. 

    I think this is a point too many people miss, especially us doctors.  We are consumed with patient’s conditions.  The disease too easily become the only reason we relate to them at all.  We start to refer to patient’s who happen to have Cystic Fibrosis as CF’ers, Sickle cell disease as sicklers, with Asthma as wheezers, etc. al etc.  It obscures the fact that we a dealing with living, thinking, feeling human beings.  We physicians wan’t to prevent disease, not enable it.  We grow weary of those who do not take care of themselves and present us with disease.  Too many doctors fall into the snare of exasperation and contempt for the reproductive habits of those we care for.  

   We are too obsessed with perfection in this country.  We airbrush pictures of models, causing young women to starve themselves to meet a nonexistent ideal.  We celebrate beauty, strength, speed, endurance.  We reject difference.  It is a natural social response with ugly consequences.  Just as the sick, albino or deformed chick will be relentlessly assaulted by the rest of the brood, we can have a visceral revulsion witnessing malformation, scarring, or amputation.  For me, this is the human flaw we really need to work on, not the diseases.   As we gain the power to manipulate our genome, how will we decide what is appropriate to treat and what is not.  Short height is now an indication for human growth hormone therapy.  I find that disturbing. 

    We need to learn to see the beauty in our flaws.  Only then will we really see the beauty in humanity.  I believe our imperfections are a centrally important part of our being  here in the first place.  Forty years ago, a French philosopher named Jean Vanier founded a religious community devoted entirely to living and worshipping among developmentally impaired adults.  Speaking of Faith featured L’arche in a podcast with some profound, moving, and amazing descriptions of what we can learn from them.  I encourage everyone to take a listen. 

     The dystopian movie Gattaca takes a look at just where a culture of perfection can lead.  It isn’t pretty.  In the 1930s a madman rose to power with a dream of a blonde haired, blue eyed master race setting off the most massive conflict in world history.  Will we as a people fall prey to the same ideas as we develop the power to actually make it happen?

First Published 2/29/2008.

     For over 20 years our country and its undying commitment to capitalism have tried desperately to slow mushrooming healthcare costs, and failed miserably. HMOs, Capitation, things that business was confident would succeed where those fiscally incompetent doctors failed, fell flat. Patients, it seems, did not tolerate their health and well-being treated as a business. I suppose business was part of the problem. After during WWII, with wages fixes and worker shortage, jobs starting sweetening benefits with healthcare and insurance to compete. It turns out patients and workers really, really like this system. It removes us from feeling any of the pain in our wallets with doctor visits and poor health.

Speaking in strictly capitalist, business terms customers were going to receive services from physicians, while a third party, insurance companies and businesses footed the bill. This removes some of the natural checks on inflation of cost. The patient and the doctor can now gang up on the third party payer, making control of spending difficult. So as an economist, obviously we just need to restore the marketplace, right?

It really depends on how one envisions healthcare. I can’t see going to the doctor or hospital the same as shopping for a new SUV, or getting cable TV. Our health is a fundamentally different thing, central to our quality of life, our independence, even the pursuit of happiness. Is it something people deserve or something we buy, dependent on our resources and wealth?

Without question it is dependent on our wealth to some extent, because it is creating a very real drag on our economy. Businesses have been weighed down with the cost of healthcare to the point where even the most heartless capitalist is demanding that the government do something to fix this mess. We spend more on healthcare by far than any other nation in the world. In spite of this, we have huge inequities in care with a mushrooming population of “working poor.”

These are people who have jobs and contribute to society, eliminating their eligibility for medicaid, but don’t have access or resources to get health insurance, so they go without. These people do take themselves out of the equation. The price checks work, as they stop seeing the doctor, that is until their uncared for hypertension, diabetes, cancer, lands them straight in the hospital desperately ill, devouring resources. But hey, a recent study actually showed this saves us money. We should just let them shorten their lifespan right?

You could even go so far as to say they deserve it for not taking care of themselves. If they just ate right they wouldn’t get hypertension or diabetes, right? Problem is fat, sugar, processed food are very cheap. Fresh fruit, vegetables, unprocessed grains are not so cheap and take time to prepare, time that could be spent working away at your minimum wage job to make ends meet. No, I am afraid blaming the poor has become an American pastime, one I am deeply ashamed of.

I have witnessed it firsthand. In medical school, our catholic hospital often received “patient dumps” from another large private hospital. These were medicaid patients, the cost of their care being eaten by the hospital. Medicaid pays substantially less than the actual cost of healthcare with the thought being that Hospitals and Doctors can take the hit as doing their share of charity work. This being the real world, the cost is passed on to everyone else through inflated costs to cover losses caring for the poor. These losses would be very manageable if the poor were evenly distributed among us, and everyone took in their share. Alas, the poor are concentrated in the inner cities, the victims of family flight to the suburbs, or in rural areas where the resources are scarce. We now have laws outlawing patient dumping and ERs everywhere are becoming the primary health care clinic for the poor. ER physicians are frustrated, burnt out and cynical. Many of them blog about it. Many of them grow contemptuous of those they care for. It is sad really.

The president recently stated that we actually have universal health care in this country. He was referring to our “safety net”, government and community hospitals. In fact all hospitals are now required by law to take care of everyone who walks through their doors, regardless of ability to pay.

I have spent a good portion of my training in county and inner city hospitals and I have seen our safety net in action. I have watched as a hospital has closed, causing an overflow of the poor to other hospitals. When the poor arrive in too large of numbers, the old patients get spooked. They equate care for the poor with substandard care. They leave and take their insurance with them. The end result is that, indeed, care for the poor becomes substandard. Morale in these hospitals is exceedingly low. They go bankrupt, they cut staff and wages to make ends meet, they outsource, then they die. All the while, patients with money cause the suburban hospitals to thrive, explode, and expand. This is what it means to make healthcare a commodity. This will destroy our “safety net.” This is a crisis.

A main argument I have seen on other blogs against a single payer system is that people will expect more, waste more and everything will cost more. They state that patients won’t tolerate the rationing of healthcare that a single payer system will require. Governments won’t control the spending because it is politically harmful. I agree. I can tell you right now, patients don’t tolerate rationing. We have a tiered system with quality going to the highest bidder. This is capitalism, welcome to America, right?

I just can’t embrace it. My stomach has turned watching the market in action as hospitals are destroyed and the face of the poor ground upon. The resources available to medicine are not unlimited. We do have to face this. Personally I believe a single payer system would at least be a huge improvement over the fractured system we have now. You could tax business what they are paying for healthcare right now, eliminate all the duplication of beuracracy in insurance companies and with the money you save, put it toward real quality that benefits everyone, all without raising costs, which you could fix with inflation adjustments to force economic responsibility. Since we spend twice as much on healthcare as any other nation, we would have the best system in the world instead of the most wasteful.

Realistically you would still have two tiers. The Uber rich, I am sure, would feel they wanted something better and would pay out of pocket to doctors that would only be too happy to oblige. If they pay taxes and foot the entire bill, I suppose it is only fair. They would be a definite minority. The important thing is that healthcare would become a resource that we share.

There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.

The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.

I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.

This is why collectively, we need to move to protect healthcare and medicine and distribute it among ourselves equally. Yes this means placing some trust in the government, which after all represents all of us. I am just enough of a hopeless optimist to suggest this is something we must fight for. In the end, I have to come down believing health care is a right, inextricably tied with life, liberty, and the pursuit of happiness. I leave you with this closing thought about what I believe society should and can be.

“We need to speak up, to say boldly why we fight for good schools, why we build houses for the homeless, why we protect open space, why we look after the ailing and the elderly, why we pay taxes without grumbling, why we honor government as a force for public good. In a society obsessed with competition, we need to say why we practice cooperation. In a culture addicted to instant gratification, we need to champion long-term healing and the welfare of coming generations.”

Scott Russell Sanders

There is a dirty little euphemism we all learn about in medical school called health care disparities.  It seems the health care system is better at treating heart disease in men compared to women, hypertension in whites compared to blacks, and in keeping rich people healthier across the board in every category compared to the poor.  The problem runs deep enough and fundamental enough that it appears no one is immune.  It is the problem of poverty that I find particularly perplexing. Read the rest of this entry »

Every man can, if he so desires, become the sculptor his own brain“.
             Santiago Ramon y Cajal (1852-1934)
                             Spanish Neuroscientist

  Life is distinguished from the inanimate by its ability to recreate itself and hold a pattern.  Throughout our lives, The very material we are made up of is recycled or regenerated.  Every few weeks we completely change out the cells that compose our skin.   The body is constantly in a state of regenerating itself.  Even the bones are borrowing or depositing calcium throughout our lives.  The machinery of our cells are constantly disposing of waste, replacing damaged portions, killing cells that are old or dysfunctional and making new ones.  All this processes are kept in order by our genetic information.  In essence the only thing that holds our form and keeps it from weathering away and degenerating is our DNA.  This is the master set of instructions that our cells use to replace, rebuild, and develop us into the body we now have.  It is the ultimate difference between the collection of elements that is us, and a rock.

     However, there is much more to what we are than just the DNA blueprints.  I remember a moment at the beginning of my very first year of medical school that really brought this home to me.  In anatomy we had to memorize every crater, every bump, every nodule, line and crevice in every bone in the body.  As we learned about these landmarks, we learned that they form not as part of some genetic program, but as a reaction to stress forces from pulling tendons and ligaments, triggering a reaction that caused the cells in that part of the bone to duplicate and reinforce the bone as needed.  In other words, our actions determine the shape of our bones every bit as much as our genes.

Read the rest of this entry »

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