Month: January 2016

Categories
Emotion General Lifestyle

Thank you for being a patient: A reflection on gratitude and its place in medicine.

I was walking through Target a few days ago when I noticed a banner had been discarded in a pile of clearance items. “Give Thanks,” it read. Assuming that the banner was a Thanksgiving leftover, I quickly moved along to a different aisle. Later that day, I started thinking about that banner, and its lowly place in the clearance bin. Gratitude has become a seasonal commodity. From November to mid-December, we’re reminded to give thanks, be grateful, and celebrate others through food and gifts. Unfortunately, the half-off banner serves as a reminder that the notion of gratitude can become “out-of-season” as we turn the page on the calendar.

One of my personal rules for daily life is to live each and every day with a grateful heart. I think this idea comes from having practiced yoga for more than a decade, where gratitude is a foundational tenant. At the end of almost every yoga class I have ever attended, both teacher and students bow their heads and say, “‘Namaste.” Namaste is a Sanskrit word which, loosely translated, means ‘the goodness in me honors the goodness in you.’ For me, this sacrosanct moment at the end of class is what makes yoga different from any other activity I have engaged in. As the instructor thanks me for allowing him or her to share the practice of yoga, I can both thank the instructor, as well as take a moment to thank myself for taking the time to do something good for myself. In contrasting my own personal attitude of gratitude with the Hallmark-esque notion that gratitude is a seasonal commodity, I began to wonder what place gratitude might have in the practice of medicine.

In my brief time as a student doctor, I have witnessed patients struggling with complex challenges that I never even considered prior to medical school. It’s true that many patients will visit us when they have a stuffy nose or an itchy rash, but just as important are patients who see us when they are struggling to quit addictions, deal with a major life change, or manage their own healthcare on a limited budget. It is these patients, especially, with whom it is imperative that we as healthcare providers work with to build trusting relationships. I believe that the first step of building such a relationship is an expression of gratitude. I want to thank patients for being brave, for reaching out, and for asking to get help. I want to tell them how very grateful I am that they have respected themselves enough to value their health, and for trusting me, or one of my colleagues, to help them make very important and potentially challenging life changes. Essentially, I want to say Namaste.

As we leave behind the snow-dusted magic of the holiday season, we should not let gratitude melt away like a snowman. Gratitude should be a part of our daily lives and a cornerstone of our medical practice. It only takes a moment to let our patients know how thankful we are for being part of their journey to wellness, but I predict that the impact it has on our physician-patient relationships will be long lasting.

 

Featured image:
The Stethoscope by Alex Proimos

Categories
General Opinion Public Health

The Policy on Policy: Why Medical Students Need to Learn About Healthcare

A 27-year-old woman is woken up by a sharp, stabbing pain in her lower right abdominal quadrant. She feels feverish, nauseous and weak. If you’re a medical student, you want to get a thorough history and test for a positive Murphy’s sign or rebound tenderness. You’re thinking it sounds like appendicitis. If you’re a doctor, you want to examine the patient and consider an appendectomy as a treatment option. You’re thinking of all the cases of appendicitis you’ve seen, and how well your education prepared you to diagnose and treat this condition. Except, none of that happens if this patient is never seen by a doctor. None of that happens if this patient instead, uninsured and unemployed and alone, decides to wait it out because it seems like her only option. None of that training in diagnosis and treatment makes any difference if that patient doesn’t have access to the care that could have saved her life.

The issue of healthcare policy is complicated, and oftentimes controversial, especially when presented in the framework of a political debate. As healthcare providers, however, the issue becomes less of a political one and more of an ethical one. The reported number of uninsured Americans ranges from 29 million1 to 45 million2, with tens of thousands of preventable deaths caused every year by lack of access to care3. That could mean a young woman dying of sepsis when her appendix ruptures, or an inmate asking a parole board to keep her in prison so she can continue to receive cancer treatment, or any number of similarly startling stories being told every day, across the country, about people who we know how to treat if we’re just given the chance.

A good resource for information on healthcare policy is the Commonwealth Fund’s 2014 analysis of our healthcare system compared to 11 other industrialized countries.3 The U.S. spends the most on healthcare per capita each year ($8,745), yet has the highest rate of potentially preventable deaths (96 per 100,000 people) and the highest infant mortality rate (6.1 deaths per 1,000 live births). Given the state of our broken system, it seems strange that medical students are essentially unaware of these issues until they enter the working world. Why are we not exposed to the struggles of healthcare policy in medical school? While it is certainly true that students are already saturated with information, it seems there are few subjects more universally applicable to graduates than learning about the system they will be working in.

To get an expert’s thoughts on the matter, I spoke with T.R. Reid, a leading author and journalist in the field of health policy. His bestselling book, The Healing of America, explores foreign models of healthcare and how we can learn from those systems to reform our policies at home. He currently serves as the chairman of the Colorado Foundation for Universal Health Care, which has recently placed an amendment on the 2016 ballot that would create the first state-initiated universal healthcare system by opting out of the Affordable Care Act.

 

Why do you think it is important to teach health policy in medical school?

The United States has the most complicated, the most inefficient, and the least equitable healthcare system of any rich country. Doctors are graduating into it and they don’t know what a mess it is… I think we need to prepare doctors for what they’re going to face. The second reason is, as a country, we need to fix our healthcare system. It’s ridiculously expensive, it leaves 33 million people uninsured, and the impetus to change has to come from doctors.

Health policy can be very broadly defined. What is the most important element of policy to incorporate into medical education?

The most important point is that a decent, ethical society should provide healthcare for everyone who needs it… In almost all other rich countries, healthcare is considered a basic human right and if you think about what a human right means, a human right is something the government is obliged to provide for you. You have a right to an education. You have a right to vote. If you get charged with a crime, you have a right to a fair jury, a fair judge, and a defense lawyer. We provide that because we’ve decided those are basic rights that every American ought to have. All the other countries say that’s also true for healthcare. If you’re sick and need medical care, you should get it and we have to provide it. The United States has never made that commitment… If you don’t make the basic moral commitment to provide healthcare for everybody then you end up with the American healthcare system, where some people get the world’s finest care in the world’s finest hospitals with no waiting, and 33 million people barely get in the door until they’re sick enough to go to the Emergency Room.

What changes do you foresee in the next ten years, or how do you think the current healthcare landscape will change by the time current medical students are actually in practice?

In the first place, I’m absolutely certain that we will get to universal coverage in our country and I believe we’re going to do it at a much lower cost than what we’re spending now. I’m quite optimistic that we’re going to improve our system. I think that’s going to happen… I don’t think we’re going to get there nationally. I’m convinced the way we’re going to get there is state-by-state…That’s how we got to interracial marriage, that’s how we got to same sex marriage, that’s how we got to female suffrage, that’s how we got free public education. It all starts in two or three states, the rest of the country sees that it works, and says ‘let’s do that’… The reason I’m confident in this is that we’re about to do it in Colorado. We got the initiative on the 2016 ballot. When people see a good idea working in some states, they copy it. Colorado is going to prove to the country that this can work, I hope.

As you’ve been campaigning in Colorado for universal healthcare, have you noticed that misconceptions about socialized medicine are still pervasive in public opinion? Does this influence people’s level of support or questions they raise?

The notion of limited choice and long waiting times in Canada is an issue for us…Our critics say ‘they’re going to bring Canadian medicine to the United States.’ Well, Canada covers everybody, they spend half as much as we do on healthcare, they have significantly better population health, they live longer, they have lower rates of neonatal mortality. But they still keep people waiting. I think it’s wrong to say we’re going to put the Canadian system here but that is a powerful argument…My answer is in fact Australia and South Korea have exactly the same model and they have shorter waiting times and broader choice than the United States.

In your book you examine foreign models of healthcare in detail and you described in a 2009 article in the Washington Post several ‘myths’ the American public believed about health care abroad4. Do you think American misconceptions have changed at all since the passage of the Affordable Care Act?

I think Americans still don’t like socialized medicine. Even if they don’t know what it is, they know it’s bad. That’s still true. Many Americans think other countries have limited choice and long waiting times, which is true in some countries, but many countries have broader choice and no other country has the kind of in-network, out-network business that our insurance companies have created. No other country does that…American companies and device makers say government intervention stifles innovation. I think there’s no question that in other countries regulations drive innovation. Cost controls drive innovation because they have to innovate to make their products cheaper.

If medical students are interested in health policy, how can they get involved and learn more, especially as things change?

The best way is what several medical schools have done, which is to put into the curriculum a course on health policy… I say this to every medical school dean I ever meet, ‘you ought to have a course on health policy’ and many of them say ‘I wish I could do that’ or ‘I’m thinking about it’ but some say ‘I’ve got four years to teach the entire human body and everything that can go wrong with it, don’t get me into that mess. It’s beyond our jurisdiction.’

Final thoughts?

Everybody who is sick should have access to healthcare in the world’s richest country. We have to fix this system and your generation of young doctors is going to be a powerful force for change.

 

Sources

  1. CDC National Health Interview Survey Early Release (2015)
  2. Institute of Medicine, National Academy of Sciences (2009)
  3. Commonwealth Fund (2014)
  4. Reid, T.R. “Five Myths About Health Care in the Rest of the World” (2009)

Featured image:
Healthcare Reform Initiative Announcement by Maryland GovPics

Categories
Clinical Innovation Opinion Technology

The 21st century Frankenstein Revival

Background

Human head transplantation (the head anastomosis venture project – HEAVEN) has been for a long time merely a neurosurgical and medical theoretical concept that did not enjoy much attention among the medical community. However, in recent times, there have been voices trying to revitalize this question. Italian neurosurgeon, Dr. Sergio Canavero, is one of the most prominent protagonists in this regard. The idea behind this concept is to help people who have severe physical disabilities (such as neuromuscular dystrophies or tetraplegia), but have an intact head and brain. There is a vast array of medical, ethical and physiological questions and obstacles that are ahead of this endeavor. Despite a lot of skepticism, Dr. Canavero has laid out a couple of transplantation protocols he believes can get the job done. In these protocols, he tried to answer and address every possible challenge that is expected to occur during this delicate and immensely complex procedure. The main purpose of this short article is to analyze the crucial components of his protocols and try to determine if they have any rational scientific relevance and ethical/medical justification.

Why do it?

Before you chop someone’s head off, you’d better have some good reasons, right? This is fundamental. In medicine, conditions are treated if the potential benefits of the treatment outweigh the potential risks. For each particular disease state, there has to be a justified medical indication and logical/rational foundation behind treatment. This is the sine qua non of every medical intervention. You have to bear in mind that anything you do has to lead, ultimatively, to a better quality of life. In that regard, I doubt that this procedure would accomplish that goal  at the present moment and it principally acts as an academic exercise, albeit lethal one. I generally do not support doing things just for the sake of doing them, especially in medicine where such behavior can be costly and unethical. Sure, you can become hero of the day and act in a „told you so“ manner if things go your way, but what if they don’t?

Even if you theoretically manage to overcome the technical and technological barriers that are inherent to this procedure, the question still remains: will this person experience improved quality of life? Dr. Canavero’s logic is that people who suffer from severe and/or progressive neurological conditions, e.g. muscular dystrophy or quadriplegia, could potentially benefit from this procedure. How? Well, if your peripheral nervous system does not work but you do have preserved cognitive functions (brain and brain stem), then you would be able to theoretically join healthy brain with healthy body of a deceased donor. The idea is that this body would be donated by those people who were clinically confirmed as brain-dead due to, for example, severe head trauma, but still had a fully functional body to offer. On the other hand, the „recipient“ of the body would give an informed consent that he/she is willing to undergo a body transplantation procedure, regardless of a high risk that this procedure could end in death. In  popular jargon – „people who have nothing to lose“ are the group of people that are targeted as candidates for this procedure in Dr. Canavero’s opinion.

Feasability

Dr. Canavero laid out 2 operative protocols that provide a theoretical framework for this type of experiment. One of them is called HEAVEN1 and addresses head-to-body anastomosis, while the other is named GEMINI2 and features a spine fusion protocol. The physiological obstacles that Dr. Canavero needs to overcome in order to succeed in this endeavour are tremendous, but I will try to briefly tackle the 4 major ones.

  1. Brain perfusion problems – in only a few minutes post-decapitation, it is expected that neurons will be exposed to a hypoperfusive state, ultimately resulting in brain tissue death.
  2. Fusion of two ends of the spinal tract – this has never been done before in humans.
  3. Reparation and regeneration of neuronal connections and spinal tracts/projections within the CNS and the restoration of the motor and sensory functionality.
  4. Post-transplantation complications – this includes potential tissue transplant rejection reactions that are immunologically mediated.

Should we do it?

At this point, we just do not know enough about the proposed procedures. Some of them have been performed on animal models and some were done only in a Petri dish. Results obtained through animal experiments and in-vitro molecular models might not correlate (and most commonly they don’t) with human physiology. In the early 1970s, American neurosurgeon Robert Joseph White performed the first monkey head transplantation onto a body of another monkey3. The recipient monkey lived for 8 days, and there were no surgical complications encountered. However, the monkey was quadriplegic since the surgical protocol did not address the problem of spinal fusion4. This resulted in a monkey who was completely paralyzed from the neck down, but who could still eat and follow objects with its eyes since the cranial nerves, brain stem and other brain structures were intact and perfused by the circulatory system of the donor’s body. Moreover, it was reported that the transplanted head could hear sounds and smell/taste food. However, immunologic reactions in the form of graft rejection ensued and the monkey died from them.

In this regard, Canavero’s protocol is essentially just a „compilation“ of biotech solutions for a wide spectrum of problems in medicine. Successful translation of any of these theoretical concepts into the clinical arena would be a giant leap in medicine. However, strictly lege artis, there is no strong evidence that these techniques will be successfull at all. Patients undergoing this procedure could be left in much more catastrophic and miserable conditions than those endured prior the procedure. Transplantation of a human head onto a new human body should not be perceived merely as transplanting a flower from one pot to another. We do not know how the brain would interact with the new neurochemical and biochemical milleu of the body that it just received. How would the brain integrate and process new signals arriving from the newly discovered periphery? How would the brain process perception and information coming from these new muscles and other body structures? These problems were emphasized in a recent letter written by Dr. Cartolovni and Dr. Spagnolo, published in the Surgical Neurology International journal. In this letter, the authors argue that Canavero’s perception of the human body functional framework is strictly mechanistic, and largely disregards the importance of body self-cognition, which plays a real part in the formation of human self.

Additionally, they state that head transplant procedures raise significant social and ethical problems in terms of organ donation. A leading medical ethicist, Dr. Arthur Caplan from NYU’s Langone Medical Center, states that the implications of this procedure are far-reaching and extremely dangerous from the ethical and medical standpoint. Similarly, Dr. Jerry Silver from Case Western University states that he perceives human transplants as a barbaric method at this point in time. Moreover, he said that he does not expect such procedures to be successfully performed for at least the next hundred years.

In my opinon, we are not ready for this type of procedure, at least in light of the most recent evidence-based medicine. Even if the tremendous technical difficulties could be surpassed, it still remains a question how the brain (center) would integrate with the periphery. At this point, I assume that the brain would be overwhelmed with the amount of input that it would receive from the periphery, ultimately leading the transplant recipient to derangement, pain and insanity. The prospects of this experiment are simply grim and unfavorable, with our present knowledge and, therefore, I would advocate for its halt.

References

  1. Canavero S. HEAVEN: The head anastomosis venture Project outline for the first human head transplantation with spinal linkage (GEMINI). Surg Neurol Int. 2013;4(2):S335-42.
  2. Canavero S. The „Gemini“ spinal cord fusion protocol: Reloaded. Surg Neurol Int. 2015;6:18.
  3. White RJ, Wolin LR, Massopust LC Jr, Taslitz N, Verdura J. Primate cephalic transplantation: Neurogenic separation, vascular association. Transplant Proc. 1971;3:602-4.
  4. White RJ. Hypothermia preservation and transplantation of brain. Resuscitation. 1975;4:197-210.
  5. Čartolovni A, Spagnolo AG. Ethical considerations regarding head transplantation. Surg Neurol Int. 2015;6:103.

Featured image:
Floating head, neck redone by TaylorHerring

Categories
Lifestyle Public Health Reflection

Can social justice replace medicine?

‘Social injustice is killing people on a grand scale.’
– Marmot (2)

Despite the leaps and bounds that science has made over the past century, with all its shiny new techno-gadgets and ever-advancing drugs, the primary reason for our good health today lies in something much less sexy: vaccinations, clean water and sanitation- changes that we take for granted.

We live in a world that is changing every second. Bigger cars, faster phones, all the information at our beck and call: from the education that is offered to our kids, to the healthcare that is offered to our decaying bodies.

The hospital of today is a far cry from the one half a century ago. The minute you walk into a hospital your senses go haywire. You have stepped into the world of the future. The full scale of our technological advancement greets you within these four walls. The bizarre beeping overwhelms your ear canals, screaming into your brain as the alarms screech constantly in the background. The reams of wires trail along the floor of the wards, wrapping themselves around their patients like Christmas presents, offering nourishment to bodies overwhelmed with disease. We are living in the world of machines, and it is upon them that we place our hopes of immortality.

Everyone knows of the success story of Science. We are bombarded by the media, informing us of the next new cancer drug, the gene unlocked that will solve all our problems. What we forget is that we are not merely organisms residing within a vacuum. Nor are we machines ourselves, whose very pores can be zapped with electrodes, transforming our very identity. We are human beings living and breathing on this planet Earth. We digest the world around us. We are not merely scientists of the world within ourselves, of the DNA that twirls inside our cells. We are also manufacturers of the world around us; of the houses we live in, the food we eat and the lives we live. Perhaps the answer to a better, healthier life lies here instead.

But, is this the role of the doctor? Shouldn’t we leave this task to the politicians, to those who have the power to make these important decisions? Isn’t the duty of the doctor ultimately towards her patient, towards that individual who is sitting opposite, rather than to humanity as a whole? I believe Virchow, the German Doctor, described it best when he said:

‘Medicine is a social science and politics is nothing else but medicine on a large scale.’ (1)

Of course there are diseases that can only be fixed by looking inside our own bodies – diseases that come from within, that cannot be changed by any amount of control over one’s environment; Huntington’s Disease is one example.

But if you take a quick glance at the causes of mortality in both the USA and the UK, you will find that the majority of these diseases are significantly related to one’s lifestyle. The top leading cause of death in both the UK (3) and USA (4) is Heart Disease, which has very strong links with lifestyle, including smoking (5), a high-fat diet (6) and poor exercise (7).

In the past, when tuberculosis and polio wreaked havoc upon the population, the role of the doctor was to prescribe medication; to act as the priest who offered the gift of life through his knowledge and wisdom. Yet now, this power lies upon the patient. Our lives are no longer cut short by the plague, but by the pathways we choose to make while we are still alive.

The role of the doctor continues to change along with society. The doctor is the servant of the public. As our ailments in life continue to revolve around these pathways that we choose to take, so must the doctor focus her gaze away from the leaves of her prescription pad and begin to question the foundations of such paths; the reasons behind these choices, the thoughts and actions that lead a person towards their own destruction.

It is not enough to simply inform someone by saying ‘you need to do more exercise.’ Anyone who has made a New Year’s Resolution to do so will understand this. Even in the UK, a country where healthcare is free, one’s health is still dependent upon how much one earns. The richer you are, the longer you will live (8). How is it that in this day and age, this is still the case? Healthcare is a right. And as doctors, it is our duty to ensure this edict is followed. The politician may sit upon his throne and hand down his judgments, but it is the healthcare professional who is in contact day in and day out with the most vulnerable and marginalized.

Indeed, there are some excellent examples of attempts to try and balance this injustice within our society; free school meals in the UK which lead to improved nutrition in children (9) and the ban on public smoking to try and reduce passive smoking (10) are just two examples. These changes in legislation lead to the question: how much control should our government have over our own decisions towards our health? If someone wishes to smoke and drink all their life, then that is their right. Autonomy is one of the principles the doctor must follow; today’s healthcare system revolves around the patient and her choices. No longer does the doctor hold authority over the patient’s body. Yet this does not mean we cannot improve the world around us; we are still capable of building a healthier society, a society in which we will not only live longer, but be happier in as well. Free education and housing are two examples of societal changes that do not necessarily impose upon our personal rights, yet can lead to healthier childhoods and happier families.

Let’s say you are a single working mother – you are only just reaching your rent each month. You can only work part-time because you need to pick up your son from nursery every afternoon. You have no family who can look after him. This leaves little money for food, so you mainly feed your son. His diet is very poor, not only because of the little you can afford, but you yourself have never learned how to cook. Your own childhood consisted of fast food and the occasional apple or banana handed to you by a father who you rarely saw. You live in a very deprived neighbourhood. You cannot afford heating, and your son is constantly sniffling and coughing, hiding under his hole-infested jumper that you managed to grab from a local charity shop. You are isolated – your husband has left you, you have no one to talk to and your neighbours scare you. When you’re not working, you stay at home for your own safety, and ultimately for your son’s. You try to remain happy for your son. You want the best for him. But you are scared. You are scared for the future, you are scared about your next paycheck, you are scared about being burgled, being mugged, having your son taken away from you. You are scared about becoming a failure, of disappointing your son. You start drinking a glass of whiskey each evening to help you calm these anxieties. You gradually spend more and more money on alcohol, an attempt to grasp control of these spiraling criticisms that constantly call into question your ability to be a mother. But this does not always help. As the days turn to weeks, your thoughts begin to gain a voice of their own, almost screaming through your ears; you are a bad mother. A failure. Maybe you’d be better off somewhere else. Your son would have a better life without you. He wouldn’t have such an awful mother.
You eye the packet of paracetamol lying on the table. What would happen if you weren’t here? Wouldn’t your son lead a happier life? He would no longer have this dark mark tainting his existence. He might even be happy… What do you do?

In various points throughout this story, one could take out their pen and draw a mark where someone could have intervened. Not necessarily to offer medication or money, but things such as social support; someone to help look after the son in the afternoons, advice on how to apply for jobs, or housing in a more residential area. A helpful hand to hold on to during the darkest periods, a pat on the back, a shoulder to cry on, an ear to listen. How different would this story be if these simple interventions had been available?

It is very easy for us, the next generation, to caress our mobile phones and laptops that fit in both hands. It is easy to see the world as decaying pieces of rubble to improve, gadgets to insert, wires to wrap around and transform. No doubt this way of thinking has changed our healthcare; it has saved many lives. But we must never forget that humanity is not a machine itself. It cannot be controlled by our remote controls and our drugs; we must look further afield in order to truly appreciate the complexity of the human being. When we look at the human body, at a life that has been lived hard and is ending early, we see not genes that have played havoc, but decades of depression, underlying abuse, a cigarette to cope, a bottle of beer to forget. Addressing these problems is a task that requires us to go beyond our scientific skills. It requires us to understand the emotional lives of our patients.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” 
– Anne Frank

References

  1. (with acknowledgements to Siân Anis), J. R. A. (2006). Virchow misquoted, part‐quoted, and the real McCoy. Journal of Epidemiology and Community Health, 60(8), 671.
  2. World Health Organisation. 2008. Inequities are killing people on grand scale, reports WHO’s Commission [Online[. Available at: http://www.who.int/mediacentre/news/releases/2008/pr29/en/
  3. Office for National Statistics. 2013. What are the top causes of death by age and gender? [Online]. Available at: http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-and-wales–series-dr-/2012/sty-causes-of-death.html [Accessed: 13th October 2015]
  4. Centers for Disease Control and Prevention. 2015. Leading Causes of Death [Online]. Available at: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm [Accessed: 13th October 2015]
  5. British Heart Foundation. Smoking [Online]. Available at: https://www.bhf.org.uk/heart-health/risk-factors/smoking [Accessed: 13th October 2015]
  6. World Heart Federation. Diet [Online]. Available at: http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/ [Accessed: 13th October 2015]
  7. Myers, J. 2003. Exercise and Cardiovascular Health. 107:e2-e5
  8. Royal College of Nursing. 2012. Health Inequalities and the Social Determinants of Health. London: Royal College of Nursing
  9. BBC News. 2013. All infants in England to get free school lunches [Online]. Available at: http://www.bbc.co.uk/news/uk-politics-24132416 [Accessed: 13th October 2015]
  10. Bauld, L. 2011. The Impact of Smokefree Legislation in England: Evidence Review. England: Department of Health

Featured image:
Human Genome by Richard Ricciardi