Cuddlefist

“Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label. Indeed, that label is so powerful that many of the pseudopatients’ normal behaviors were overlooked entirely or profoundly misinterpreted.” - D.L. Rosenhan, “On Being Sane in Insane Places,” 1973.

In the early 1970s, David Rosenhan, a psychologist based at Stanford Law School assigned eight people (including himself) who were known to have no psychiatric diagnoses to enter mental hospitals as in-patients. Once admitted, the pseudopatients then dropped the symptoms and announced they felt fine. Now it was time to get out of the hospitals on their own: the pseudopatients’ time in hospital ranged from 7 days to 52 days, during which they wrote down observations. (The hospital staff assumed the writing was pathological: some of the patients suspected the pseudopatients were professors or journalists. “Mentally ill” is not synonymous with “stupid”.) To obtain release, the pseudopatients had to tell the staff they accepted their diagnosis, which was either schizophrenia or bipolar disorder.

You certainly couldn’t do such a study now. If you want to read the write-up (and I think you do!) it’s right here.

So what does that say about psychiatric medicine?

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Synthetic artemisinin might help improve effectiveness and lower the costs of antimalarials

Out of Nature: California-based company Amyris has figured out how to synthesize artemisinin in only three weeks, rather than the usual year and a half. What is artemisinin? It’s an extract of sweet wormwood, which has historically been prescribed in Chinese traditional medicine, and which is processed to become the most effective treatment and preventative for malaria. The Chinese army started working to find an effective treatment for malaria in the ’60s, and discovered that wormwood was the answer in 1972. 

However, some of the malaria plasmodia are developing resistance to artemisia-derived drugs, which is why the World Health Organization recommends against taking ONLY the drugs, and instead recommends multi-drug therapies. There are farmers dedicated to growing and processing sweet wormwood already. If Amyris’ product takes off as predicted, those farmers will need to find other ways to supplement their income. On the plus side, the antimalarials may be more effective, resistance to drugs may be lowered, and the drugs may be less expensive.

From “The Robot Will See You Now”

When we think of breakthroughs in medicine, we conjure up images of new drugs or new surgeries. When we think of changes to the health-care system, byzantine legislation comes to mind. But according to a growing number of observers, the next big thing to hit medical care will be new ways of accumulating, processing, and applying data—revolutionizing medical care the same way Billy Beane and his minions turned baseball into “moneyball.”

[…]

Physicians, after all, do more than process data. They attend at patients’ bedsides and counsel families. They grasp nuance and learn to master uncertainty. For their part, the innovators at IBM make a point of presenting Watson as a tool that can help health-care professionals, rather than replace them. Think Dr. McCoy using his tricorder to diagnose a phaser injury on Star Trek, not the droid fitting Luke Skywalker with a robotic hand in Star Wars. To most experts, that’s a more realistic picture of what medicine will look like, at least for the foreseeable future.

From The Atlantic’s article “The Robot Will See You Now,” about the IBM AI Watson’s foray into medicine and other intersections of medicine and data technology.

(Thanks, S, for the link.)

Hello, it is Monday!

You should have some links:

Anne of Green Gables Had Herpes (And You Probably Do Too!) from Boingboing. 

If You Think You’re Good At Multitasking, You Probably Aren’t, by Nancy Shute. I think most multitaskers think they are better than everyone else at most things (regardless of how much self-esteem they appear to have); I think this because I have a tendency to multitask. Researchers at the University of Utah found that the kind of people willing to multitask tend to be classifiable as “impulsive risk takers.” Multitasking doesn’t make you more productive, but many of the job openings I’ve seen list it as a requirement. 

Dan Savage’s 2006 editorial on how silly it is to insist that marriage is only for hetero people because only heterosexual couples reproduce:

If heterosexual instability and the link between heterosexual sex and human reproduction are the best arguments opponents of same-sex marriage can muster, I can’t help but feel that our side must be winning. Insulting heterosexuals and discriminating against children with same-sex parents may score the other side a few runs, but these strategies won’t win the game.

The lawyers arguing against gay marriage before the Supreme Court RIGHT NOW are using the argument that marriage should only be for hetero couples because they are the only ones who can accidentally produce children. John Scalzi points out that that “polyamorous bisexuals in same-sex open marriages might wish to dispute this line of ‘reasoning.’” Well, yes, that is certainly one flaw. I know everyone usually points to child-free couples, but I appreciate Scalzi’s inclusiveness!

Speaking of flawed, John Ioannidis argued in 2005 that biomedical research is inherently so because of their designs, bias, and analyses. Researchers test more false hypotheses than true ones and

if researchers test many more false hypotheses than true ones, it’s inevitable that most significant results will be wrong. That’s because 5 per cent of a very large number is always going to be bigger than 80 per cent of a very small one.

(Covered by Technology Review.)  Leah Jager at the US Naval Academy and Jeffrey Leek at the Johns Hopkins Bloomberg School of Public Health created a mathematical model to estimate the number of false positives likely to be included in their giant sample of 77,430 papers published in the New England Journal of Medicine and the Lancet. They use the expectation-maximum algorithm to reckon that the number of false positives is 14%- better than Ioannidis’ claim, but worse than 5%, the “industry standard” p-value. (For more information on p-values in research study analysis.)

Other analyses disagree: for example, Bayer reported in Nature in 2011 that they were unable to replicate the majority of their results on drug targets in in-house trials; if you’re unfamiliar with “drug targets,” it’s the technical term for the receptor in your body whose behavior is modified by a drug compound, e.g. thyroid hormone receptors and Synthroid. 

An upside to Greece’s economic woes: cleaner air. Air pollution has been steadily decreasing in Greece since 2002, but it really picked up between 2008 and 2011, correlating with lower fossil fuel consumption, industrial activity, and financial crisis. One soon-to-be-measured downside: dirtier air. The cost of oil for heat rises, as does illegal logging so that Greeks can stay warm.

And last but not least (in case you missed it somehow), Jonathan Coulton covered and re-arranged Baby Got Back years ago. Glee got ahold of it, covered it on the show (appearing to use his actual instrument tracks), and didn’t credit Coulton, who is understandably upset. In response, he “covered” their cover of his cover- which is to say he is re-releasing his original cover- for supporters to purchase on iTunes.

The Cultural Assumptions Behind Western Medicine.

“As important as these acknowledgements of culture are, it should be recognised that culture, more broadly, can also be understood as the meanings, technologies and practices that gather around medicine within western societies.

Despite the objectivity implied by the scientific principles underlying western medicine, it is still underpinned by a host of assumptions and beliefs developed through living in western culture. The white coat worn by doctors is a potent symbol of efficiency and hygiene, for instance, and the bleeping medical machines found in the hospital setting convey their own meanings of high technological prowess.

[…] Even within the western world, there are significant national differences in how scientific medicine is understood and practised. These differences can be particularly evident in controversies over medical innovation, such as human embryonic stem cell research.

Major differences between western countries are also apparent in health-care spending and statistics of drug prescriptions and medical techniques. A comparative study showed that the French tend to be less obsessed with germs and hygiene but are more focused on the health of their livers – and their doctors treat them accordingly.

Americans, on the other hand, are generally germ-aversive and favour “fighting” disease aggressively. Their doctors have a highly-technical “no-holds-barred” approach to testing for and treating disease. And US health-care costs are the highest in the world partly as a result of this.”

This is a short read, and worth your time, if you’re interested in the intersection of culture and medicine (which is broader than most people acknowledge).

Physician-Created Electronic Health Records

Rowley is one of the anomalous few who are equally skilled tweaking patient health and computer code. He never planned to be an MD; he was studying information science. Some of his college buddies were pre-med; they volunteered at a free health clinic in Baja California. Because Rowley grew up bilingual (born in Mexico City), he offered his services as a translator. Volunteering at the clinic was a “life-changing” experience, prompting Rowley to switch majors and go to medical school, ultimately starting a medical practice. But he still enjoys geeking out.

Of course, Rowley started his practice using paper charts (it was 1983), but became increasingly frustrated by not having the information he needed, such as the results from a blood test from 2 days ago. “100% of my charts were 80% right” (complete), Rowley said.

So, the doctor started inventing new workflows and documents to better manage the practice. He created a succession of Word documents and organized them into a database of sorts. This became the first electronic record system he used. Later, he wrote macros that would serve as templates.

On some fallacies in neuroscience research-

When you ask something like “where is creativity in the brain” you assume that researchers can somehow isolate creativity from other emotions and behaviors in a lab and dissect it apart. This is very, very difficult, if not impossible. Neuroimaging (almost always) relies on the notion of cognitive subtraction, which is a way of comparing your behavior or emotion of interest (creativity) against some baseline state that is not creativity.

Imagine asking “where is video located in my computer?” That doesn’t make any sense. Your monitor is required to see the video. Your graphics card is required to render the video. The software is required to generate the code for the video. But the “video” isn’t located anywhere in the computer.

But if activity in that region increases as you’re “more creative”, clearly that’s strong evidence for the relationship between that brain region and creativity, right?

Just like how when your arms swing faster when you run that means that your arms are “where running happens”.

Sometimes a study can be all kinds of valid, and strong correlations can be drawn, and yet it doesn’t mean a goddamn thing. Thanks, @medskep.

How many established standards of medical care are wrong? It is not known. Medical practice has evolved out of centuries of theorizing, personal experiences, bits of evidence, expert consensus, and diverse conflicts and biases. Rigorous questioning of long-established practices is difficult. There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. Given this conundrum, it is possible that some entire medical subspecialties are based on little evidence. Their disappearance probably would not harm patients and might help salvage derailed health budgets. However, it is unlikely that specialists would support trials testing practices that constitute their main source of income. Instead, the research community performs studies of modest incremental value without even knowing whether the basic standards of care are appropriate.

Prasad V. Reversals of Established Medical Practices: Evidence to Abandon Ship. JAMA: The Journal of the American Medical Association. 2012;307(1):37.

Read the whole article here.

(Source: twitter.com)

Public Health/Medicine Crush of the Day

Jack Wennberg is a physician, researcher, and public health professional who started researching health disparities in the 1970s. The difference between his work and a lot of the work I hear about in school is that his research points to cases of overtreatment in areas where there are more surgeons.

Wennberg had begun to demonstrate a clear connection between a community’s supply of health-care resources—such as surgeons and hospital beds—and how much surgery the residents of that community received. More surgeons and more beds equaledmore procedures. Put simply, supply seemed to drive demand.

(Emphasis mine.)

Much of his early research dealt with disproportionate numbers of children having their tonsils removed. Wennberg called the procedure “a large-scale uncontrolled surgical experiment”.

But who cares if some kids who didn’t need their tonsils out are getting them removed? There are several reasons why this matters:

1. The children were being exposed to greater risk of hospital-acquired infections and complications from the tonsillectomies.
2. Unnecessary procedures drive up the cost of insurance premiums.
3. A surgical procedure is being justified not by science, but by protocol. “This is the way we’ve always done it” is not good science.

If every Medicare provider in the country spent at the same rate as the lowest 10% of providers in the program, overall costs would be slashed by 30%. That alone is enough to pay for the elusive Medicare drug benefit. Additional savings might well accrue if we could implement shared decision-making, reduce underuse of preventive services, and reduce medical errors.

I’ve alluded to the fact that my dad’s a doc here before. When I was younger, he told me that the secret of medicine is that much of it is more of an art than a science. Wennberg has spent a great deal of his career proving that point. He questions the system, the protocol, and the substitution of tradition for science, and because the medical system is overdue for an overhaul (or at least a reevaluation of priorities), his work is important. It’s heartening to see other doctors and healthcare practitioners building on his research and examining the procedures and outcomes associated with the United States healthcare system. 

h/t @medicalskeptic

Some thoughts on “How Doctors Die”:

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it.

From How Doctors Die. My parents, who are healthcare professionals, have both said similar things, although my mother has fought cancer several times. My father told me once that medicine involves science, but is really an art. In cases that involve life-or-death, it seems to be even more of an art: a doctor or nurse must balance what the patient (or more often, the patient’s family) wants with what is realistic. What the author characterizes as “excessive treatment” cannot guarantee miracles. 

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures.

The more I hear about medicine, the more I think that the real miracle when a patient is really so close to dying is dying with minimal pain. I don’t know. I hope that I’m never in a position to make that decision, but I am sure I will be, in the (hopefully far-off) future.