Better Health: Smart Health Commentary Better Health (TM): smart health commentary



Latest Posts

The right balance for good health

No Comments »

I realize that my last post has probably left you wondering what on earth bulldozers and ballerinas have to do with medicine.  Well, let me lead you down my little mental garden path here and explain.

The dancing event took place right next to the National Academy of Sciences, where the Institute of Medicine (IOM) holds its regular meetings.  It was all the more humorous to see these bulldozers (with rose petal-filled buckets) participating in this awkward dance – right in front of the hallowed halls of medicine’s most prestigious scientific body.  As I thought about what the IOM stands for – the pursuit of truth through objective scientific analysis – and what these ballerinas were up to (reveling in the whimsy of life) it struck me that good medicine might actually combine the two.

Clearly, there are aspects of a healthy life that cannot be well defined by science.  Love, peace, and joyfulness are all nourishing to the mind and body – but quantifying them is rather difficult.  The things that grandma taught us – get your beauty rest, be kind to others, get lots of fresh air, marry a loving man (or woman) – are great medicine, and should be the foundation for a life in balance.

However, the science of medicine is also critically important.  The media thrives on exaggeration and controversy.  If there were a mountain of sand in front of us, and we had the choice to move it with a bulldozer or a teaspoon – the media would have us convinced that the spoon was equally effective.  And this is why we are constantly misled about treatments – we hear about efficacy, but we don’t hear about the relative effectiveness compared to other therapies.  So cinnamon, for example, is touted as a great new treatment for diabetes, when in fact it is only a teaspoon compared to the bulldozer of insulin.

And so I guess I would summarize my musings this way: good health is a dance near the IOM, with bulldozers instead of teaspoons.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The great unveiling

5 Comments »

A psychiatric nurse once relayed an observation to me that I
have been pondering for the last decade.
We were working together in an inner city “dementia unit,” populated
with patients with end stage Alzheimer’s, vascular dementias, and brain
disorders of unclear etiology.
Individuals were parked in geri-chairs in institutional hallways, others
were in bed in 4 point restraints for their own protection, still others were
muttering to themselves in wheelchairs.

We were discussing the case of a particularly unpleasant
patient
– he would swing at people as they got near him, trying to hurt them –
scratching, punching, even biting if you got close enough.  His favorite thing was to grab nurses’, or
other female staff’s, breasts or crotches.  He rarely succeeded at this, since most staff
were aware of his tactics, though he sat in his chair nearly motionless, like a
Moray eel in a reef cave, small eyes and snaggle teeth, mouth open slightly at
all times, taking slow deliberate breaths as he waited for an unsuspecting ocean
dweller to wander inadvertently into his reach.

I asked the nurse how she thought he had gotten to be so
rotten.  She replied simply, “When people
get older they become more like themselves.”

That one sentence has fascinated me ever since.  Could it be that as we age (and our minds
lose their ability to maintain the social graces we were taught), we slip into saying
things in an uncensored manner, and behaving the way we truly want to?  Or is the difference between “sweet little
old ladies
” and “mean old biddies” a matter of how much damage there has been
to their frontal lobes?

The scientist in me would like to explain away all agitation
as an organic brain disorder.  But I just
don’t think we can reduce human behavior to neuroanatomy.  The complexity of a lifetime of circumstances
and individual choices – and their interaction with personality – are soul-defining.

Perhaps age brings wisdom and life experience… or maybe it
unveils the truth about who we’ve been all along.  Either way I have a feeling that when the time
draws near for our bodies to give up our souls, we can catch a glimpse of what people
are “made of” in their final words and deeds.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What is a "medical home" and why do you need one?

No Comments »

Ask any American if they think
their current healthcare system is operating smoothly and efficiently, and
you’ll hear a resounding “NO!”  Adjectives such as
“confusing, complicated, and disorganized” are often used to describe
our current state, and for good reason.  The science of medicine has
advanced enormously over the past 50 years, but somehow this rapid growth in
knowledge has been plagued by chaos.  With every new therapy, there’s a
new therapist – and the result is a fragmented assortment of tests, providers,
procedures, and administrative headaches.  So what does a patient in this
system really need?  She needs a coordinator of care – a compassionate
team leader who can help her navigate her way through the system.
She needs a central location for all her health information, and an easy way to
interact with her care coordinator so she can follow the path she has chosen
for optimum health.  She needs a medical home.

Primary care physicians (especially family physicians, pediatricians, and
internal medicine specialists), are ideally suited for the role of medical team
leader in the lives of their patients.  It is their job to follow the
health of their patients over time, and this enables them to make intelligent,
fully informed recommendations that are relevant to the individual.  Their
aim is to provide compassionate guidance based on a full understanding of the
individual’s life context.  The best patient care occurs when
evidence-based medicine is applied in a personalized, contextually relevant,
and sensitive manner by a physician who knows the patient well.

Revolution Health believes that establishing a medical home with a primary care
physician is the best way to reduce the difficulty of navigating the health
care system.  We believe that our role is to empower both physician and
patient with the tools, information, and technology to strengthen and
facilitate their relationship.  Revolution Health, in essence, provides
the virtual landscape for the real medical home that revolves around the
physician-patient relationship.

What’s the advantage of having a medical home?  Jeff Gruen, MD, Chief
Medical Officer of Revolution Health:

1.  Care is less
fragmented: how many times have you heard of friends with multiple medical
problems who are visiting several physicians, each of whom has little idea
of what the other is doing or prescribing, and none of which are focusing
on the big picture?    When a single physician is also
helping to “quarterback” the care, there is less chance that
issues will fall between the cracks, and less chance that consumers will be
put through unnecessary and costly tests or procedures

2.  Care is better:
studies have shown that excellent primary care can reduce unnecessary
hospitalizations and assure that preventive tests are performed on
time.   One study for example showed that the more likely
it is that a person has a primary care family physician, the less likely
it is that they will have an avoidable trip to the hospital.  This
makes intuitive sense: a physician who knows you is critical to have if
you were to get very sick and need alot of medical
attention.

3. Care is more holistic:
medical care is part art and part science and good care requires the
clinician to understand something about the whole person they are caring
for.  Many complaints that are seen in primary care practices are
physical manifestations of underlying emotional, family or adjustment
issues.  A good primary care clinician who knows the individual and
family is more likely to strike the right balance between appropriately investigating
physical causes for complaints, and addressing more subtle underlying
causes

So to physicians and patients alike, we say, “Welcome home to Revolution Health.”

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Made in America: The Institute of Medicine

1 Comment »

I had dinner with a small group of people recently – and Harvey Fineberg, President of the Institute of Medicine, was our dinner speaker. A few things struck me as he reviewed the history of this 37 year old institution.

First of all, The British Medical Journal published a thought-provoking article about the top 5 things that Britain and the US could learn from one another’s healthcare systems. Of all the possible things that they could highlight about US Healthcare, the Institute of Medicine was listed in the #1 slot.

Well, my goodness – is that the very best of what US medicine has to offer? The IOM?

Maybe so. Here’s the Reader’s Digest version (forgive me Dr. Fineberg) of the history and purpose of the IOM.

President Lincoln founded the National Academy of Sciences back in 1863 for the purpose of advising the public in an objective manner on matters of science.  The NAS has expanded to include 3 newer organizations: the National Research Council (1916), the National Academy of Engineering (1964), and  the Institute of Medicine (1970).

The IOM consists of members elected by peers in recognition of distinguished achievement in their respective fields. It has about 1,200 members. But here’s why this organization is so unique: all of the members VOLUNTEER their time! Can you imagine another organization that could get 1,200 doctors to work for free? Yes, they volunteer – and they do so gladly because it is an honor to be part of the task force to advise the public in an objective manner on matters of medicine. The IOM gets no money from the government, it survives on donations and volunteerism.

The IOM is uniquely positioned to formulate unbiased assessments of important medical questions. It is medicine in its purest form – the facts and the data are the only foundation of their analyses. No government funding, no pharmaceutical intervention, no personal agendas. Just the pursuit of truth.

Apparently the IOM produces 1 report per week! The most famous of which may be their “To Err Is Human” (2000) report which uncovered the shocking frequency of medical errors, and included recommendations for new patient safety initiatives.

A lesser known report actually debunked lie detector tests…

And so, as I considered Dr. Fineberg’s description of the IOM I began to realize why other industrialized nations are jealous of our institute. I am so glad that President Lincoln had the foresight to create an objective, “collective wisdom” vehicle for advising the nation. The question now becomes: does the nation hear what they’re saying?

I think it would be wonderful for the IOM to allow Revolution Health to be an outlet for disseminating their information to the public. After all, our mission is to empower consumers with the most credible health information available… and my friends, after hearing Dr. Fineberg’s speech, I don’t think it gets any better than the IOM.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Cancer: do we really understand it? Part 2

No Comments »

-Continued from previous post

In contradistinction to these patients exposed to tumor cells who did not develop malignancies, other studies have shown that normal cells can become malignant in an environment where a malignancy had developed. One study, for example, followed two leukemia patients whose bone marrows were eradicated with radiotherapy and who subsequently received bone marrow transplants from normal donors. Two to four months following the procedure, the transplanted bone marrow donor cells were found to have become leukemic.(11)

Clearly, cellular environment plays a critical role in cancer development. Malignant cells infused into a normal environment may not produce a tumor while normal cells placed into an environment that had previously harbored a tumor can become malignant. We are no longer even sure from what cell type a particular cancer develops. Stomach cancer in mice has been shown to originate not from the lining cells of the stomach, as we had thought, but from bone marrow cells responding to experimentally-induced stomach inflammation.(12) The problem may be the environment not the “malignant” cell.(13)

Are we at least able to recognize clinically significant cancer? Can we confidently say, as one judge did when defining pornography, “I know it when I see it.?” Apparently not.

Autopsies on people who died of non-malignant causes have caused us to re-examine our definition of cancer. Patients with previously treated Hodgkins disease—showing no clinical evidence of tumor and thought to have been cured, who died of unrelated causes—were found on autopsy to have residual foci of the disease.(14) Although thyroid cancer is diagnosed in only 1 in 1000 adults between the ages of 50 and 70, on autopsy it has been found in 1 of 3 adults.(15) The prevalence of clinically apparent prostate cancer in men 60 to 70 years of age is about 1%; nevertheless, over 40% of men in their 60s with normal rectal examinations have been found to have histologic evidence of the disease,(16) and autopsy studies have found evidence of prostate cancer in 1 out of 3 men by age 50(17), a finding which rises to 7 out of 10 men by age 80.(18) Similarly, clinical breast cancer is diagnosed in 1 out of 100 women between the ages of 40 and 50;(19) on autopsy it was found in a startling 1 out of 2.5 women in this age group. Moreover, over 45% of the autopsied women had more than one focus of breast cancer and 40% had bilateral breast cancer.(20)

What, then, is cancer? What is responsible for the clinical behavior of cancer, sometimes lying dormant and undiagnosed because it causes no symptoms, sometimes progressing inexorably to death?

For the present, we don’t know the answers to these questions. We have developed treatment programs that offer the best current options for cure, but we should, and do, remain unsatisfied with these approaches. First, because they don’t always work and, second, because with rare exception, they are based on trial and error, not on an understanding of the disease process we are treating.

Once we identify the processes responsible for the accumulation of cells into tumors, we can treat these conditions more effectively, reduce or eliminate the side effects associated with many of our current “best practice” treatments, and remove the terror currently shadowing cancer the way terror used to shadow diseases like syphilis, tuberculosis, and pernicious anemia before we learned how they were caused and developed treatments directed at those causes. We are making progress. Stay tuned.

REFERENCES

1. Bennington JL. Cancer of the kidney – etiology, epidemiology and pathology. Cancer 1973;32:1017-29

2. Salvador AH, Harrison EG Jr, Kyle RA. Lymphadenopathy due to infectious mononucleosis: its confusion with malignant lymphoma. Cancer 1971;27:1029-40

3. Lukes RJ, Tindle BH, Parker JW. Reed-Sternberg-like cells in infectious mononucleosis. Lancet 1969;2:1003-4

4. Agliozzo CM, Reingold IM. Infectious mononucleosis simulating Hodgkin’s disease: a patient with Reed-Sternberg cells. Am J Clin Pathol 1971;56:730-5

5. Mirra JM, Kendrick RA, Kendrick RE. Pseudomalignant osteoblastoma versus arrested osteosarcoma. A case report. Cancer 1976;37:2005-14

6. Taubert HD, Wissner SE, Haskins AL. Leiomyomatosis peritonealis disseminata. Obstet Gynecol 1965;25:561-74

7. Croslend DB. Leiomyomatosis peritonealis disseminata: a case report. Am J Obstet Gynecol 1973;117:179-81

8. Mintz B, Illmensee K. Normal genetically mosaic mice produced from malignant teratocarcinoma cells. Proc Natl Acad Sci 1975;72(9):3585-9

9. Lanman JT, Bierman HR, Byron RL Jr. Transfusion of leukemic leukocytes in man. Hematologic and physiologic changes. Blood 1950;5:1099-1113

10. Greenwald P, Woodard E, Nasca PC, Hempelmann P, Dayton P, Maksymowicz G, Blando P, Hanrahan R jr, Burnett WS. Morbidity and mortality among recipients of blood from preleukemic and prelymphomatous donors. Cancer 1976;38:324-8

11. Thomas ED, Bryant JI, Bruckner CD, Clift RA, Fefer A, Neiman P, Ramberg RE, Storb R. Leukemic transformation of engrafted human marrow. Transpl Proc 1972;4:567-70

12. Houghton J, Stoicov C, Nomura S, Rogers AB, Carlson J, Li H, Cai X, Fox JG, Goldenring JR, Wang TC. Gastric cancer originating from bone marrow-derived cells. Science 2004;306:1568-71

13. Bluming AZ. Cancer: The eighth plague – A suggestion of pathogeneisis. Isr J Med Sci 1978;14:192-200

14. Dorfman RF. Biology of malignant neoplasia of the lymphoreticular tissues. J Reticuloendothelial Soc 1972;12:239-56

15. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma of the thyroid. A “normal” finding in Finland. A systematic autopsy study. Cancer 1985; 56 (3): 531-8

16. Montie JE, Wood DP Jr, Pontes E, Boyett JM, Levin HS. Adenocarcinoma of the prostate in cytoprostatectomy specimens removed for bladder cancer. Cancer 1989;63:381-5

17. Oottamasathien S, Crawford D. Should routine screening for prostate-specific antigen be recommended? Arch Intern Med 2003;163:661-2

18. Pienta KJ, Esper PS. Risk factors for prostate cancer. Ann Intern Med 1993;118:793-803

19. Feldman AR, Kessler L, Myers MH, Naughton MD. The prevalence of cancer, estimates based on the Connecticut Tumor Registry. N Engl J Med 1986; 315:1394-7

20. Nielsen M, Thomsen JL, Primdahl S, Dyreborg U, Andersen JA. Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. (Br J Cancer 1987; 56:814-9

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles