Category Archives: Medicine and Health

They got stones, I’ll give you that

I was going to call this post “nobody knows the trouble I seen” except that it seems ludicrously self indulgent to whine that one has been living through construction hell when the rest of the world has revolutions, civil wars, hurricanes and so on to contend with. (But, to paraphrase Will Rogers, everything is manageable provided it’s happening to someone else.) This isn’t to say my curmudgeonly instincts have been dormant . One particular item a while back had me seething.

“Sugary drinks are not so sweet”  was the headline in the Health section of the Globe and Mail (24 May 2013).  Apparently, drinking a sugar-sweetened drink a day not only rots your teeth and adds up to empty calories (with the added bonus that it makes New York’s Mayor Bloomburg crazy) but “may increase the risk of kidney stones”.  Gasp. I had to pause to take a sip of my ginger ale* while that sank in.

I puzzed and I puzzed, to reference one of my favorite curmudgeons, the Grinch. Didn’t make sense. How on earth could fructose cause blobs of crystallized minerals to form in the kidney? (To reinforce the point that sugary drinks are Evil the accompanying photo was of a surgeon with a scalpel. Someone had fun with that.)

The research cited was from 2007, published in a journal called Kidney International (2008, 73; 207-212).  The worthiest journal nobody’s ever heard of.  My curiosity got the better of me and I downloaded the article and read through the cringe-inducing prospective study; yet another data-mining expedition hoping to find a “link” between X and Y. (For more on my distaste for the term, see post.) The data? From – wait for it – the appalling Nurses’ Health Study, formerly used to “prove” that taking estrogen was just a boffo idea.  Here, the research cites some 19,000+ women along with some 46,000 men from the Health Professionals Follow-up Study. Impressive numbers. Pity the hypothesis is so feeble.

Not of course to our heroes, researchers Taylor and Curhan, unspecified experts at a renal division/lab at Brigham Young and Harvard who engage in enough statistical jiggery-pokery to make the world go round.  (Pity nobody blinks when data gets tortured.)

Just a few problems here. As I explained, in often far too exhaustive detail in The Estrogen Errors, extrapolating to the general population from the Nurse’s Study is massively problematic. For starters, there’s its basic design, bi-annual self reports, which are notoriously unreliable. We’re all prone to error as any gibbon with half a brain knows: we forget, lie and generally get things wrong. Good grief, most of us stutter when they ask us how much we weigh when we get a new driver’s license. Plus, there’s the healthy user bias – people who respond to any questionnaire tend to be richer, smarter, better off, i.e., healthier than the average bear. Er, person. Often they’re white and frequently younger. All of which means they are not like the real at-risk population who, by and large, tends to be poorer, less educated, older, more diverse, less health and diet conscious, more stressed and sicker. Face it, d’you think you’d have time to sit around reading some blog if you had to work at two or more minimum wage jobs just to put food on the table and pay your rent? Could you even afford an iPad or even high speed internet?

This is on top of the fact that professionals in general can’t stand in for “everyone” and basing one’s conclusions of what these people do (or say) is what’s popularly known as being spectacularly wrong.

What really interested me, though, was what these researchers thought might be going on physiologically. In other words, how did we get from basic sugar metabolism to blobs of crystallized minerals in the kidney? Gremlins? Evil spirits? The authors do obligingly admit that the underlying mechanisms are “unknown” (ah, ya think?!) but postulate various processes, none of which make sense. Hence their masterful use of language:

“Fructose may also increase urinary excretion of oxalate, an important risk factor for calcium oxalate nephrolithiasis. Carbohydrates, along with amino acids, provide the majority of the carbon for glyoxylate and oxalate synthesis, and fructose may be an important dietary sugar influencing the production of oxalate.” (emphasis mine)

 The authors concede backing for their hypotheses are “sparse”; personally I would have said nonexistent. Rats make up the bulk of their research subjects in this section and the one study they cite using humans consists of eleven – yes, 11 – men whose pee was analyzed for calcium loss (versus calcium intake).  Fructose intake made no difference in the calcium these men excreted but the researchers still concluded that the reason fructose laden drinks caused kidney stones “may be related to the effect of fructose intake on urine composition”.  How they concluded this I have no idea. Maybe they were on a sugar high.

The only marginally plausible explanation had to do with uric acid metabolism and for a moment I thought, OK, this might make sense. Then I checked the reference and realized it only applied to people with gout, whose uric acid metabolism is already dysfunctional (that being the definition of gout). 

Kidney stones, by the bye, are hardly that common and rarely if ever life threatening. Even Wikipedia’s overblown, hyperventilating piece on the topic, that sounds as though it was written by a nephrologist who had just passed one, admits that the incidence or number of new cases a year is “0.5%”.  (Of course it doesn’t specify 0.5% of what which is rather an important point, but let’s not nitpick at this late point in the post.)

How did this 5-year-old study even make it into the health news section? Having spent some years as a medical writer and journalist, I can tell you exactly how. A group of people in an editorial meeting, drinking coffee – or pop – were bouncing around story ideas and someone suggested a piece vilifying soft drinks, currently Public Enemy No. 1 (see NYC, Bloomburg).  So, they wrote the headline then they contacted the hapless writer who cast about for some new and nifty problem that could be blamed on aforesaid sugary drinks.  Everyone  knowing full well that the majority of people only read the headline and the first paragraph; it’s only mutants such as myself who check the original research and parse the methods section.

If sugary drinks do give you kidney stones, these people didn’t prove it.

There are a lot of good reasons to consider soft drinks a treat, not a staple. They’re empty calories; they rot your teeth and many of them contain fairly high amounts of caffeine which can make you nervy and insomniac. But kidney stones? Really?! We think not. And it takes stones to say they do.

 

 

 

* oh get over it. It’s summer. There’s construction outside. Yes, I have the occasional ginger ale or Coke. Sometimes, when I’m especially cranky, two days in a row. Sue me.  

‘ear ‘ear (better yet, turn it down)

The Oscars were last night and no I didn’t watch. To paraphrase Ogden Nash, my interest in the subject would have to grow to be even cursory. (And you thought the curmudgeon in the title was just for alliteration.)

Frankly, I’d sooner mindlessly stare into space. At least it wouldn’t be deafening.

Well, not the Oscars so much; they are, after all, on television and one can turn the volume down. One cannot say the same thing about what the Oscar celebrate: movies.

When was it decided – and who did this deciding and why weren’t we consulted? – that we shouldn’t just hear the sound but feel it vibrate down from our toes to the top of our tinny tin heads? How did going to a movie turn into a full frontal assault on our senses, from movement and colour and flashing lights to that ubiquitous noise they are careful to remind us is the patented Dolby surround sound?

Once upon a time one could go to a movie, yes even action ones without going deaf. I was first in line when those early Star Trek movies came out and I saw the first Die Hard in the movie theatre. It was loud, but I don’t recall coming out feeling like I’d just been put through the wash cycle.

In those days I wasn’t flinching and stuffing my ears with Kleenex or covering my eyes to protect them from the flashing lights that would end up giving me a migraine. The last “action” movie I saw, one of the Johnny Depp pirate movies, well, I left that so dazed and battered that I barely remembered what I’d seen.

How did deafeningly loud become normal? Or is everyone just deaf? 

So much of the noise around us we barely notice. The hum of computers and air cleaners and refrigerators; the constant hum of traffic, the honking, the music blaring out of car stereos … And of course everyone is in their own little world of sound, with those earbuds.

I’m not a total Luddite, I got an MP3 player years ago. I filled it with music. I listened. Then I realized than as I was walking I kept turning the sound up to compensate for the noise all around me – and if I had been listening for a few hours at night there was a constant ringing in my ears. It would go away but what I know about the sensitivity of the ear told me that if I kept doing this it eventually would not and the result would be tinnitus. A ringing that simply never goes away.

I doubt most of the people on the subway or the bus or walking down the street really pay that much attention. Which suggests to me that in a decade or two anything relating to enhanced hearing will make a fortune since most people will be partially deaf. (We should all buy stock now.)

A number of big names – William Shatner, Jerome Groopman (author of the best selling How Doctors Think book) – have gone public with their tinnitus. Experts tell us that it’s probably the result of prolonged exposure to loud noise.

Then there’s the Who’s Pete Townshend, who is essentially deaf. The Who, as you might recall, is credited with having performed the loudest concert in history, at least at the time, circa 1976: decibel level 120. That’s about as loud as a jackhammer. Almost as loud as a jet engine. That’s loud.

Respect the ear – or it’ll give up on you

The human ear is an amazing thing. Inner, middle, outer ear: each have their function, each play a role in funneling sound through tiny cilia (little tiny hairs) and through the ear drum, into the brain where it’s interpreted and experienced. A human ear can pick up the dripping of a faucet in the middle of the night on another floor, hear a symphony or a the swish of even a piece of paper falling to the floor.

It’s amazingly balanced between the inside, conduit to the brain, and the outside world. Precisely balanced in between are three small bones (the smallest bones in the body) that are shaped somewhat like a stick figure or one of those triangles your music teacher would have you play if you weren’t musical enough to actually play something normal (like me). OK, I played piano but she was the one doing that.

These tiny bones can easily work their way out of alignment after a blow to the head or trauma – I believe that today they can be repaired with microsurgery but it’s complicated.  In between are the smallest bones in the body that reverberate in response to the ear drum (timpanic membrane) vibrating in response to sound waves in your environment. Like the tiniest of precision percussion instruments, eventually turning into an electrical pulse that is interpreted through the neurotransmitters in your brain.

Culture often determines what we think of as noise versus music. That dripping tap of which I spoke earlier (which has been known to drive me insane and keep me awake) is, apparently, music to the Shinto-based Japanese mind. I don’t think that anyone truly enjoys a jackhammer however.

Currently I am surrounded by construction noise and have been for the least four months. It is exhausting, tiresome, intrusive and dreadful. And my ears hurt. Even with noise reduction headphones, the noise is unrelenting. The last thing I need is to go out for an evening’s “entertainment” to find myself surrounded by noise, be it the latest James Bond, war film or science fiction flick.

I hope you enjoyed the Oscars. And the nominated films. Just remember that once your hearing is gone, it’s gone. There’s no going back.

So they continue being a pain ..

Painkillers increase risk of car crashes proclaims the headline in today’s Globe and Mail. Apparently, researchers at the “Toronto based Institute for Clinical Evaluative Sciences have found a correlation between even low-dose regular opioid use (two Tylenol 3’s three times a day) and an increased risk of car accidents.

Not a huge risk, the head researcher David Juurlink, hastens to add; certainly nowhere near as high as alcohol, but a risk nonetheless.

Wonderful. Two of my favorite things – correlational studies and experts rambling on about opioids in the same piece with blinkered experts continuing on their merry way, all pleased and sending out press releases (don’t kid yourself, that’s the only way a paper from something called the Institute for Clinical Evaluative Sciences that nobody has ever heard of would get a piece in the Health section of the Globe and Mail).

Um, did it ever occur to these geniuses that the reason people take those drugs, namely pain, might have something to do with those slightly increased numbers of car crashes? I use the term slightly advisedly: the risk increases between 21 and 42% according to the “scientists”. (Scientists in quotes because surely any scientist worth his salt knows that unless you know what you’re comparing something to a percentage – relative risk – is absolutely meaningless.)

Surely pain – which means someone gets more easily fatigued and could become less alert – could have a thing or three to do with it?

Oh no, it’s the opioids.

Of course by the same token, ice creams causes an increased number of drownings. Think about it. In the summer people eat more ice cream – and more people drown. QED.

Last March I wrote a post on Oxycontin and made some disparaging noises (OK, loud, angry noises) about the ado being made about addiction and pain killers. Notably, a Fifth Estate that had me virtually apoplectic with rage. Using largely American stories the CBC newsmagazine insisted that addiction to oxycontin was a  massive problem that we should all get worked up about, especially when it came to First Nations communities in the north.

By contrast, a few weeks ago I happened to come across a BBC mini-documentary about the same topic and the contrast could not have been more marked. I missed the start of the piece but what I did watch was superb. It was a program called “Our World” and the journalist’s name was Linda Sills. (I hope that’s how one spells it.) She had travelled to several communities in northern Ontario, spoken to various tribal elders, artists and addicted individuals and – wonder of wonders – had actually done some research and thought about the subject.

Sills, like the people she spoke to, all agreed that the problem was not opioids (in the ‘80’s it was alcohol and in the ‘90’s glue sniffing) but the situation. The environment. The socio economic conditions. When people are unhappy and hopeless they take solace in drugs, whatever is around, whatever they can get. Solutions are complex, multi-factorial and must emerge from the grassroots of the community itself. An artist who looked to be in his forties, addicted to oxycontin himself, talked of how his art was helping him reduce his drug intake (even though he genuinely looked as though he was still in pain, physical and psychic).

Opioids have been around for thousands of years. Officially they were discovered around the time of the Trojan War (war has always been excellent for medicine) but no doubt people knew of the pain relieving properties of the poppy long before that. They are the single most effective agent in treating pain and although we’ve tried to come up with synthetic variants (Demerol, Fentanyl) and alternatives (non-steroidal anti inflammatories) there simply has never been a drug that works as well, as consistently.

Treating pain with opioids allows people who suffer from chronic pain to function. To have lives. To work, interact with families and friends and feel like the are part of the world.  But in recent years, perhaps with the rise of right wing moralizing in the U.S. and what some people call the rise of the nanny state we have taken a sharp turn away from treating pain to calling individuals who need medication “addicts”.

Our reverence for numeric reasoning and bad statistics naturally hasn’t helped any; after all, what could be more qualitative and unmeasureable than pain, which, by definition, is whatever the person says it is?

 

I stress, Eustress

It’s become such an ubiquitous concept that it’s difficult to imagine how recent a term “stress” really is. When Hans Selye first proposed that all tension, all sources of anxiety created the same kind of reaction within the body it seemed ridiculous. And this was in the fifties to the best of my recollection.  Of course now we all know that too much stress is bad for us and that stress is a factor in disease.

[So so many things that we take for granted – cardiac risk factors, prevention, stress – are such recent concepts. But we think they’ve been around since the year dot.]

Stress is hard on the immune system, affects us hormonally and causes muscle tension and fatigue. It gets in the way of sleep, which causes its own set of problems ranging from poor concentration to anxiety, and depresses normal pain signals. Which is why soldiers and athletes often don’t feel the pain of a major injury and it is only later that they realize they’ve damaged something.

Then there’s the good side of stress, or eustress. Without some stress we would have zero motivation, zero reason to excel or create. That’s why there’s that old graph showing how some stress is good before a major task, say an exam; with some stress performance gets better. But, if it gets too high then performance suffers.

Which we all know from our own experience.

Wandering around Paris what strikes me as well is the extent to which our actual, physical environment can create or reduce stress. When what is around us is beautiful, when we hear laughter, when the sun is shining – well, it’s hard to feel to unhappy or stressed. No accident that depressed areas inevitably are ugly.

It’s hard to be too stressed when one is a tourist in Paris, well, unless one tries too hard to make the French conform to one’s North American ideas of time, speed and interaction.  Personally, something that I think is rather wonderful here is the very formal aspect of saying ‘bonjour’ whenever one walks into a place, any place. It is a way, I think, of humanizing the service person, the waiter, the person in the store. When one stops to say ‘bonjour madame’ or ‘bonjour monsieur’, one has to pause and look at the person and realize this person is not simply part of the scenery, they are an actual human being. It adds a touch of humanity to what is often a rather soulless encounter.

The French are currently pilloried for their dislike of capitalism, their failing economy, their rising youth unemployment.  Several august bodies are miffed that in spite of all of this money markets still love France, which can borrow money at brilliantly low rates, which suggests they’re not worried about France’s future. There’s a palpable sense of outrage about this on the part of business writers, The Economist, various commentators – usually Anglo Saxon. Why? Why does everyone need to conform to the same ideas?

The French fought a revolution which had at its basis the value of the human being.  Extreme wealth, especially ostentatious wealth, is frowned on in France. I can think of worse things.

In any event, given the stress we all experience when all we focus on is money and making more of it, it seems to me that the French are on to something.

Boundless enthusiasm for Overtreatment

Last week in Slate, sent along by my friend Maryse whose blog, Frogheart  covering nanotechnology, art, technology and so on is immensely popular (one tries very hard not to be too envious of her close-to-a-million visitors daily), based on an update in the respected Cochrane Review: how treatment of mild hypertension essentially useless.

What neither piece points out is that what we call “mild hypertension” today (systolic 140-159) was considered essentially normal a scant fifteen years ago. Well, 140 anyway. Or that thoughtful (often older) clinicians would not consider this hypertensive in older patients today.

Ah, it’s just a number people. A number, determined by a group of individuals, often cardiologists but also other “experts” (many of whom have ties to the drug companies who make antihypertensive drugs) as to what should be considered “normal”.

I’ve spent much of my research career debunking this notion of “normal”.  Particularly as it pertains to physiology, biology and humans, who, as we all know, tend to come in a variety of shapes and sizes and whose health status is determined by many variables, not the least of which is how much money they have and how happy they are in their lives.

Women, of course, have long been outside this matrix – normal consisting essentially of the male body without its circadian rhythms and cyclic hormonal elements, never mind pregnancy or menopause.  The vast majority of clinical trials, the gold standard of evidence as it has been called, excluded woman altogether and even when they tried to bring them in often women themselves wouldn’t play ball.

The reasons seemed complex, social, domestic, personal, economic and psychological.  Women generally have been socialized to be risk averse, which means if they are told they have condition X then they want the damn treatment. They don’t have time to worry about whether or not they’re taking the placebo. Plus, large multi-centre trials require the time not to mention transportation to get to those bi-weekly weigh-ins or tests or what-have-you and women, particularly women over 40 tend to be overwhelmed with children and grandchildren and ageing parents and work and housework and life. “Who’s got the time to enter a trial?” most will ask. “I’ve barely got time to sit down never mind volunteer my time at a clinical trial.”

No doubt there are other reasons but at this point I haven’t researched it. I just know that women are vastly underrepresented in what we optimistically consider evidence-based medicine.

I see something inherently male and American in this perspective, this enthusiasm for aggressive treatment (as the cultural critic Lynn Payer in her wonderful book Medicine and Culture once remarked, there has to be something culturally satisfying in the notion of ‘aggressive’ given how often the term is used in American medicine; even the recommendations for gentler treatment of newborns was advised to be pursued aggressively).  Or overtreatment.

Cross cultural studies have repeatedly shown that countries like Canada, which can’t afford as many cardiac surgeries and procedures as the U.S., as well as countries like Finland, which simply doesn’t believe in them, have the same outcomes as the U.S. In other words, Americans spend huge amounts of time and money doing things – cardiac bypass, cardiac catheterization, stents, etc. – but cardiac patients are no healthier than in countries where they do half the number per capita. All that activity doesn’t result in better health or lower morbidity or mortality.

Less is often more in medicine. And bodies are fragile. Drugs, surgeries, procedures, tests: these are not benign. They exact a toll on the body. And all for what?

All because somebody somewhere decided they know what was best and what magic number was “normal” blood pressure.  Or what an artery “should” look like in a person with no symptoms.

The worst part is that as patients we are complicit in this, increasingly believing that more is better – and reject the notion of watchful waiting, considering a physician who says, “just take it easy for a while, it’ll get better on its own” a quack. So, fewer and fewer physicians say such things. As a doctor once said at a conference I was at: It’s easier to just write the prescription that to take twenty minutes to explain to a patient (who’s not going to believe you anyway) why she or he doesn’t really need it.

But hey, we wouldn’t want to miss out on something that could be really terrific now, would we?!

 

Beware the Bandersnatch my son (aka the “link”)

If I read the word “link” one more time in some ostensibly serious health article I will – well, let’s just say that like Dorothy Parker’s Tonstant Weader I will thwow up.

Looks like a Bandersnatch to me …

Last week “scientists” apparently linked one’s gait as one aged to one’s likelihood of developing Alzheimer’s. Yet another observational study, casting about for some connection to something; naturally they eventually found some tenuous connection somewhere – at least one that they could write a press release about.

(As a researcher once described estrogen – “a drug in search of a disease”.)

No mention of whether this gait thing might have had something to do with other, perhaps undiagnosed, problems such as osteoarthritis or inner ear issues or what-have-you. No, one more thing for us to worry about as we get older – our damn gait.

Earlier headlines with that vile word “link” (plus variations like “linked”, “linking” and so on) always seem to be in the headline, which, of course, is what most people read. So we read that higher levels of Vitamin D3 are linked to all manner of marvelous things, from not getting cancer and heart disease to staying young and sharp and simply mah-velous. Never mind that when you simply test people who are well and compare them to people who are not, measure their “level” of D3 (as though all of us have the same ideal level) and then say, ‘oh, look, high D means better health so why don’t we all take a supplement” you have no way of knowing which came first, the good health or the D3. For all we know, various diseases deplete the body of D3 and the lack of the vitamin is not the cause of the problem but its consequence.

A number of more cautious researchers have been saying exactly this, to no avail. Various and sundry institutions from the Cancer Agency to the WHO have all decided to chime in with their recommendations that people take supplements.

This same kind of nonsense proliferated in the talk around estrogen for pretty much most of the 20th century.  Researchers gushed that women who took estrogen “replacement” therapy (later “hormone replacement therapy” or HRT after it was found that estrogen alone could cause endometrial cancer) kept women young and healthy and prevented heart disease and dementia and probably hives and hangnails.

Replacement is in quotes earlier, incidentally, because it makes no sense to consider the hormone level of a woman of 23 normal for a woman at all other stages of life, particularly midlife, when all women’s hormones naturally decline.

Observational study upon observational study found a correlation (“link”)  between women who took hormones and improved cardiac function, fewer heart attacks and strokes, better health, you-name-it.  Well, except for the smidgeon of extra risk relating to breast cancer which epidemiologists dismissed as irrelevant. Of course this was not irrelevant to women, who didn’t rush to take hormones in droves, much to the researchers’ dismay.

Then the other show dropped. The largest clinical trial in history, the Women’s Health Initiative definitely showed that not only did estrogen not protect women from various and sundry age-related conditions, it actually could cause them.  Cardiac disease was higher in women who took hormones and there was nothing “healthy” about HRT at all.

But hey, they had studies that “linked” estrogen use with health and who were we to argue?

A lot of people ask me about supplements, Calcium and D3, this and that, largely, I think, because of those headlines linking this and that arcane nutrient with health. Which is where my problem with all of this lies.

You can print whatever nonsense you want, provided you don’t make it sound as though you know what you’re talking about. Especially in the headline. People actually change their behavior based on these things. People start taking things, adding things, subtracting things. Forgetting that health is multifactorial, complex and begins in the womb.

You won’t have strong bones as an adult if you were malnourished as a child. Wealth tends to lead to health. People are different. And the nutrients we ingest in food are in a balance and ratio that the body can absorb. Versus our best-guess estimate of what an ideal amount of D3 or B3 or T3* might be.

So beware the dreaded link as though it were the bandersnatch. On average, I think the latter is more benign.

 

*Tylenol 3

On Clutter, Hoarding and Medical Mistakes

Nobody likes a crisp, neat look more than I do – Ikea wouldn’t be the multi-gazillion corporation it is without my patronage throughout the years. I own pretty much every KASSETT and GLOK organizer doo-dad they make. (I like that they sound Klingon.) Given the sheer number of articles, blogs, television shows and companies on clutter (and its crazy cousin in the attic, hoarding) I am clearly not the only person with this particular fascination.

I sometimes think that if I could just create a prefect, clutter-free world then, as Buckminster Fuller suggested, everything I wrote and worked on would be effortlessly beautiful. Of course I sometimes also think of  Roswell and of the aliens that live among us. So it’s not like I’m totally sane all the time.

Trouble is, compared to a lot of people I’m bloody Einstein, given that this mania for de-cluttering the detritus of life appears to have permeated and penetrated into large areas of life; areas that simply do not lend themselves to neat solutions.

Some things are inherently messy and there’s not a damn thing we can do about it.

Take disease/illness and the complexity of patient care, all of which I have gone on about ad nauseum.  Much as we would like to make it all iPad-neat and high-tech cool the reality of surgery and hospitals and elder care and whatnot just isn’t going to be minimalist-zen. And trust me, if you’re a patient you don’t want it to be because if your clinical team decides you’re just a carbon copy of everybody else you’re going to get shoddy care.

Right on cue enter a medical director at the  Birmingham University Hospital in Britain who, enchanted with the local BMW plant’s “flawless”, failure-free operation, wondered how the hospital could duplicate the plant’s figurative tracking down of every “loose screw”.  (Yes, I am biting my tongue.) One assumes the director hoped patients would leave the hospital all shiny with that new car smell …

So, mixing everything from metaphors to minds, a “bespoke computer system” was ordered – no doubt to bring German engineering to an off-the-rack hospital. The cost? Some 4 million pounds sterling or approximately $5.4 million U.S..This computer’s claim to fame was that its operation actually mimicked the dashboard of a car, presumably that of the aforementioned BMW. The dashboard thingies became standard issue at the hospital; their point to “catch” problems before or as they evolved, problems ranging frompost-surgical infection levels and falls to bed sores. Which sounds sensible you might think. Except you’d be wrong.

A computer that posh couldn’t possibly stop at patient problems; where’s the fun in that? So those bedside dashboards also have dials to let managers and ward sisters know when efficiency (“benchmarked against comparable wards and recent performance”) falls, even as response time is recorded to let higher-ups know who and what might be doing poorly. Ouch. So not only is Big Brother watching but his name is HAL.

The mind boggles. German engineered hospital care run with military precision – oops, that has nasty militaristic WWII overtones. Rephrase, rephrase …

(For more see The Economist, 16 June 2012.  http://www.economist.com/node/21556924)

Admittedly it is tempting and attractive, to believe that better health, better post surgical and treatment outcomes, fewer medical errors as simply being a matter of organization and method. Problem is, Sherlock, people go into hospital for a reason – and that reason is that they’re sick, injured or otherwise poorly. These days, given cost containment issues, hospitalized patients tend to be really sick. Often they are also old, which means they are frail and have a lot of other things wrong with them: from cardiac issues to arthritis and various and sundry ailments.

True, we do much better with acute care than we did even 40 years ago – brain tumours that would have killed your grandfather can sometimes be removed, e.g., – but the reality of patient care is that some people do get worse and some people die. Even the ones who do all right and go home are rarely if ever  good as new. Surgeries cause scar tissue and pain and a host of other problems. As they used to say, the only really safe surgery is the one they do on the other guy.  No nifty BMW dashboard can change that.

A few more staff nurses might but that’s another story.

So, boys and girls, can anyone tell me what some issues with this perspective might be? Anyone? Anyone except Tiffany? Sigh. OK. Tiffany. That’s right.Human bodies, physiology, biology: these are complex, messy, hard to classify and all too often problems that arise are  idiosyncratic and incomprehensible. Funny that, but bodies don’t tend to have read the textbooks. Many people do well but some do not and each case is different.

True, the medical system does screw up (as America’s Institute of Medicine never stops reminding us) and sometimes errors and problems do lie in systemic, functional issues that ought to be fixed – like that ICU checklist everyone’s so keen on or better labeling on medications and so on. But an over-focus on process and a lack of understanding of the underlying messy complexities of medicine not only aren’t the answer but are increasingly becoming part of the problem.

Talk to any person who’s recently experienced hospital care and what you hear is just how vigilant you have to be and just how essential it is to have someone there with the patient to ensure the clinician walking into the room actually knows who the patient is and what his or her problem might be, what drugs s/he might be on, etc.

Comparing medicine to aviation or to BMW’s is ridiculously reductionist and ultimately counterproductive since one of the basic aspects of physiology is that it is not simply what is done to the patient but what the patient does back so to speak. With drugs, it is not merely the effects that the drug has on the body (pharmacodynamics) but what the body does to the medication (pharmacokinetics). The arrows, should one care to diagram it, go back and forth and every which way.

Treating people like units of production was exactly how this mess all started. And Ikea simply doesn’t have an organizer for that.

Voodoo Medical Science

Where to begin, where to begin.  I get busy with end-of-semester things and head out of town for a few weeks and poof! Bloody chaos.

Women’s reproductive rights suddenly back on the table in the U.S. and the legality of abortion tabled in the House of Commons here as a private bill.  Good grief. Was that plane I took the one in that Twilight Zone episode; the one that goes through the clouds and goes back in time?  More idiocy in the Commons, with this ludicrous Omnibus bill as they’re calling it.  Long guns taken out of the registry which means that automatic weapons can more readily be sold in Canada.  And of course zombie killers. (OK, that last one was ghoulishly interesting, I have to confess.)

And in health care news, as always some bright lights insisting they know what’s best – most recently a report from researchers at McGill (the term researchers usually being code for statisticians) expressing shock, shock I tell you, that drugs are used off-label when this lacks “scientific support”.

Um, OK. So what scientific support would that be? Drug company funded clinical trials – given that all other funding has been cut to the bone? Or do they actually mean data which, I would remind you, does not equal knowledge and can be massaged, manipulated and moulded to fit the theory-du-jour.

One class of drugs these experts took exception to was the use of anti-psychotics in situations where no clinical trials had been done. Years ago a physician friend of mine discovered that one of the anti-psychotics, quitiepine I think, seemed to help a patient with Huntington’s with some of her more onerous symptoms. But of course Pharmacare wouldn’t pay for it because – yup, you guessed it – there was no “evidence” that it worked for Huntington’s.  And naturally we all know that everyone, especially drug companies, are lining up to do an expensive drug trial with a teensy subgroup of patients with a rare, fatal, genetic disease ….

Needless to say, there’s never going to be “scientific support” for this. A point these McGill researchers who’ve clearly never had to deal with an actual patient don’t appear to have twigged to.

Research, clinical trials are expensive, time consuming and difficult to do. Who in their right mind is going to fund one for an old drug that’s no longer on patent that’s been around forever – but that still helps a lot of people? Not going to happen.

The pendulum has so swung so far, moreover, in favour of the stats and the algorithms and the “evidence” that everybody from Obama to your pharmacist to that nice young doctor in the clinic down the road honestly believe that medicine is a science and if we could just figure out the right questions to ask and do the right research (which  angels – taking time out from their dancing-on-a-pin thing – would fund) then All Would Be Revealed and we would all live happily and healthily ever after. As if.

What few people realize, alas, is that the bedrock of “scientific” medicine, the clinical trial, is very recent –though to hear people ramble on about  it you’d swear the dratted thing was on one of those tablets Moses brought down with him.

1948. That’s when the first official clinical trial was conducted: by the first medical statistician on record, Bradford Hill, who gave one group of patients with TB streptomycin (then a very new drug) and another group nothing. The idea took off and before his death in the 1990’s Hill’s book on medical stats (Principles of Medical Statistics) was in its 12th printing.

Hill was no dummy though and realized he’d created a monster. He backtracked. Where once he’d exhorted statisticians to “rise from their humble place” to help medicine become more scientific through the clever application of numbers he suggested we should “relax and reflect”; that such single-mindedness could easily lead to poor patient care: “cookbook medicine”.  It would be better, Hill wrote, if clinical trials were designed to “promote rather than hinder the traditional method in medicine of acute observation … by the clinician at the bedside”.  (All quotes from Richard Horton, the editor of The Lancet writing in 2000 in the journal Statistics in Medicine, “Common Sense and Figures: the rhetoric of validity in medicine” Vol. 19, pp 3149-64)

Probably what Hill had not appreciated in the early fifties as he began his little crusade was the extent to which post-war enthusiasms, technological advances and various social, political and institutional changes – ranging from the ascendancy of the United States to the shifts in finance, corporate influence and law – would transform his notions into a paint-by-numbers fiasco.  Biomarkers and surrogate end points (blood sugar, cholesterol, blood pressure, bone density) would reign supreme and you could feel perfectly fine but be told you had minutes to live.

Then it was EBM guru, David Sackett who picked up where Hill left off. Ably assisted by the new profession of health economics whose sole purpose it was to assist payers (like HMO’s in the U.S. and governments of countries with public health care) cut costs (and realized this statistical scientific rhetoric could aid their cause), the newly minted evidence-based medicine or EBM took off like wildfire, leading to the proliferation of guidelines and Hill’s cookbook medicine.

Sackett also backtracked, emphasizing that “the practice of evidence based medicine means integrating individual clinical expertise with the best available clinical evidence” everybody pretty much ignored him. After all, who cared if patients were different and physiology, difficult; as long as you had your bullet form guidelines and decision trees.

Meanwhile, everybody forgets that evidence has serious limitations, not the least of which is human error, external validity (in other words the people in the trial are not representative of the people in the community who actually take the drug or use the treatment) and conflicts of interest. At best even the best designed of trials tend to encapsulate a narrow slice of life which is not the reality of medical care which tends to be centred around the elderly and those with chronic conditions. (duh)

The old and the sick, precisely the people who use medicine, are excluded from clinical trials; in fact as Bradford Hill pointed out, the clinical trial “at best shows what can be accomplished with a medicine under careful observation and certain restricted conditions”.  I won’t even mention the exclusion of women from trials until the NIH stepped in in the ‘90’s to enforce its own regulations because the top of my head would blow off and that would create such a mess.

Ironically, where scientific medicine and epidemiology do excel is at giving us clues as to what doesn’t work, e.g., in common preventive measures such as mammography and PSA testing. But we don’t like those recommendations so we ignore them.

Turns out the “science” of medicine is like the Sasquatch. Often sighted and excitedly talked about but not actually real.

Oxy-Addiction-Nonsense Goes on

When I began writing these musings on the general idiocies going on all about us I wrote something to the effect of, “well, somebody has to say something”. (see post). Too true. So. In recent weeks you may have noticed some rumblings about Oxycontin, an opioid painkiller being discontinued; the replacement drug is similar but apparently less easy to abuse (OxyNeo).

The drug manufacturer has kept the price the same. Government health plans do not appear to have been as circumspect; my understanding is that there are plans afoot to delist the new drug and make it harder for people with chronic pain to have their pain meds covered. Terrific.

Just as noxious is the addiction narrative that has taken over  all discussion around this subject – with all its moralistic, judgemental overtones.  I keep waiting for a nice Puritan gentleman in a stove top hat to mince up and stick a big red A on someone.

A promo for the CBC’s Fifth Estate proclaims that addiction to Oxycontin costs us all, as taxpayers, untold amounts and they’re shocked, shocked, that this has been going on for so long.

Um, exactly what nefarious something has been going on? People in pain had some access to a medication that could provide a bit of relief? People in hospital who’d had surgeries and procedures were able to survive without being in agony? How did pain become a crime – and that tiny fraction of people who take a drug for purposes other than what it was intended for turn into such objects of scorn?

So yet again, another abbreviated history lesson. About 50 years ago we began to realize that how medicine treated pain was stuck in the Dark Ages. How that happened was some physicians who realized their post-surgical pain relief was a giant joke. (And being doctors didn’t give them any special status – which must have come as a real shock). They realized what patients went through, being accused of faking or exaggerating or being drug seeking addicts when all they had was pain.

Medicine’s treatment of pain was a “cool and callous disgrace” according to one doctor writing at the time.

With time things gradually changed, a bit. There was research and Melzack and Wall’s seminal book on pain and major scientific effort (see the International Association for the Study of Pain, IASP, site for more.) We began to understand that if  acute pain was well controlled the odds of it becoming chronic went down. That sometimes chronic pain happened – sometimes for no reason (hence the term ‘idiopathic’ which essentially means who-the-hell-knows) and sometimes because of underlying conditions like rheumatoid arthritis or scar tissue from a former injury. (Occasionally even as a result of iatrogenesis – caused by medical intervention, in other words. Some test or procedure gone wrong.)

Heck, we didn’t even realize until maybe 45 years ago that children felt pain. Infants.  Which explains those bone chilling videos from some years ago where baby boys’ screams as they were being circumcised were simply attributed to, I don’t know. Joie de vivre?

We didn’t even concede that post surgical and post traumatic pain was worse at the start (right after the surgery) and better a few days later. Hence PCA – patient controlled analgesia – where individuals can give themselves a programmed amount of medication when they feel pain rather than waiting for the requisite number of hours to have passed before the nurse could give them a dose.

We even realized that we could give the dying a modicum of dignity and autonomy by controlling their pain. Because really, who on earth would care if a dying person got ‘addicted’ to morphine? Which they don’t but that’s another story.

Most important we began to realize that there’s nothing ennobling about pain. Pain just hurts.

Not that you’d realize it these past weeks as the moralistic jingoistic nonsense carries on in the media with the Oxycontin issue. Nope, the real issue is addiction. Tsk tsk.

Lost in all this is any sophisticated thinking or mature discussion as we forget the complexities of pain; how physical pain is exacerbated by stress and fatigue and hunger and other conditions. So that phrase we bandy about: ‘most common in northern communities’ might actually have its basis in what actually goes on in those northern communities.

First Nations reserves without gobs of mineral reserves and cash where individuals live  socio-economic conditions most of the rest of Canada would find unacceptable. After all, if your community and your culture are not valued; if your hopes are few and your living environment horrid – perhaps addiction might be the natural result. So Sherlock, perhaps addiction is the symptom, not the underlying “disease” (if we wanted to reduce our argument to mere medical parametres).

For a lot of people opioids (oxycontin, morphine, methadone, codeine or the synthetic variants like demerol and fentanyl)  – especially in conjunction with other techniques like exercise, self hypnosis, pacing oneself and other such things – allow people with chronic pain to function. Unfortunately, pain clinics that give people that broader perspective and help them learn not to rely solely on drugs have slowly been disbanded over the years (we prefer spending money on high tech toys) so now more people rely solely on medication to help them cope with pain.

I had thought, erroneously as it turns out, that we had matured somewhat when it came to our attitudes towards pain; that we understood that pain is the one condition that unites us all – wherever we live, whoever we are. But I suppose all that thinking was giving us a headache, and without any Oxycontin on hand ….

 

(to be continued)

Inflammatory Remarks

Not long after I had managed to hurl myself down the Canada Line stairs (thankfully, not headlong) last week; even as I nursed giant multicolour bruises and a lump below my knee I found myself reflecting on the extraordinary, combined, resilience and fragility of the human body.

like that ..

On the one hand, practically before my eyes, the immune system response was set in motion by the trauma: a lump the size of a goose egg beneath the knee that felt rock hard but was clearly filled with fluid; puffiness, tenderness, redness … Well, you get the picture. We’ve all been there at some point or another.

That basic inflammatory reaction was described nearly 2000 years by a Roman observer, Celsus, who – in the best empiric tradition circa 30 AD – listed the characteristics tubor (swelling), rubor (redness), calor (heat) and dolor (pain).  In response to the cellular debris that the blow had dislodged the immune system dispatches macrophages, neutrophils and various and sundry immune compounds to begin “eating” them. (The term phage was coined by a late 19th century Ukrainian immunologist, Metchnikoff, whose real expertise was food and digestion; when he observed that even a starfish ‘defended’ itself from a thorn by sending along these tiny immune substances what he saw looked like eating so he called them big eaters, macro-phages.)

The heat is generated by increased blood flow to the affected region and the redness is due to dilated blood vessels. Meanwhile, the pain serves a very useful purpose: it keeps you off the leg (or arm or what-have-you). Of course the inflammation itself is a source of pain as it acts on the nerve endings – and tugs at the skin which becomes tender as a result.

All this many years later we’ve only managed to add one more characteristic to Celsus’s, namely loss of function which is pretty damn obvious. When something’s swollen and red and painful, you tend not to favour it, and, as I found out with the leg I came down fairly hard on, it keeps you from overusing it which allows the immune system to do its thing. Bloody clever of physiology, don’t you think, creating its own splint?

The body’s resilience, adaptability and sheer cleverness never cease to amaze me. The immediate gastric response to something bad we’ve eaten, often accompanied by nausea, vomiting and diarrhea that in essence expels whatever is overtly causing the problem. The sneezing and sore throat that’s a response to a viral infection. The immediate skin response when it’s been broken and bacteria have become lodged within. Of course the immune response can also go haywire and maladaptive, as in rheumatoid arthritis which is inflammation in response to nothing. But that’s the price we pay for having this self-adjusting system inside that keeps us ‘safe’; anything that’s designed to kill can also turn on the host. As in friendly fire.

I have tried, incidentally, to put many of my military metaphors in quotes because I’m only too well aware that the immune system’s real response is not conflictive or militaristic but an attempt to achieve balance within the body. We are all a giant morass of bacteria and viruses and parasites and microbes; it is only at those times when something overwhelms that the reaction spirals out of control. In my recent case, that fall down the stairs. But that’s also why we succumb to a cold when we’re stressed or not sleeping or grieving or generally below par. It is not the virus “attacking” but our immune system not able to stay within its normal homeostatis.

(A brilliant, fairly old, book for anyone who’s interested in this idea is The Tao of Immunology by Mark Lappe, which I recommend highly.)

On the flip side of that resilience is also immense fragility. It would have been simplicity itself, had my fall taken a different turn, to imagine a broken bone or worse – brain damage, cognitive impairment, seizures, even death. I can list off without too much thought several people I’ve known to whom this has happened.

Years ago there was an ad, a simple print one, that showed an empty wheelchair and had as a tag line something to the effect of “it only takes an instant to change a life”. Which of course is true. One split second of inattention at the wheel – or on a set of stairs at the train station – or a simple glance at a text message can irrevocably change one’s life. Forever. All those cool new prosthetics and potential advances in neuroscience and this and that notwithstanding.

This is why I simply do not understand why we are so ready, so willing, so damn trusting when it comes to subjecting ourselves to screenings, such as colonoscopies, that can go sideways, nick the bowel and have one in ICU. Or willingly line up to take our radiation with a CT scan (which, I would remind you, emits up to 400 times as much radiation as an x-ray depending on the vintage of the machine) only to hear that the knee will get better on its own and if it doesn’t we’ll eventually need surgery. Um, and you needed a picture to tell you that?

Bad things can happen and inattention – that multitasking of which we are so proud – occasionally means mishaps.  But when people essentially feel perfectly fine; when a person has the means and wherewithal to eat reasonably well and exercise; when we have enough money to do some of the things we like to do not to mention procure the basics of life, why on earth must we be so hypochondriacal as to always worry about possible future ill health? Especially when all those dire (and erroneous) statistics like ‘one woman in four’ will end up with osteoporosis turned upside down means that three women in four will not?

How did we all become such neurotics anyway?