vendredi 29 mai 2015

Dr. Mark Vonnegut: On Creativity, Being ‘Crazy’ And Getting Help

Dr. Mark Vonnegut: On Creativity, Being ‘Crazy’ And Getting Help

By Mark Vonnegut, M.D.
Guest Contributor

Being related to a famous person is somewhere between a cruel joke and a minor distraction. My father was immensely talented and worked very hard at his writing, but the degree of his success was a fantastically unlikely bit of luck. There are lots of talented, hard-working artists who don’t make it.

The important thing in overcoming mental illness, whether or not you have a famous last name, is to want things to be better — and being willing to get help to make that happen.

Dr. Mark Vonnegut (Courtesy)

Dr. Mark Vonnegut (Courtesy)

Both of my parents’ families advised them to stay away from one another, as mental illness was rumored to be in each other’s family. The rumors were true, but it wasn’t like anyone then or now comes with any guarantees. It makes us feel more alive to be able to see, listen to and read great art, partly because great art is often the result of great struggle. The idea that artists and “the mentally ill” have inner demons while the rest of us do not is part of what has made it — and continues to make it — so hard to come to terms with mental illness.

The reason the arts and craziness run in families is because crazy people who can sing and dance and paint pictures and write well do a much better job of convincing others to have babies with them than if they’re just plain crazy. Thus has it ever been.

In my career as a mental patient, I started with schizophrenia, worked my way up through manic depression, and have now settled at bipolar disorder. I can joke about it because I recovered sufficiently to get into and through medical school, internship and residency, and have had the enormous honor and privilege of being trusted by parents to help them and their children. I make no bones about it; I make mistakes just like everyone else, but am very proud of how well I do my job.

[Listen on SoundCloud]

I’m also very aware of how easily I could have ended up otherwise — a suicide statistic or just another broken young man who never got well enough to have a life.

The diagnosis doesn’t matter much. What they think you have can give doctors a clue about what to do or not do, but for the person who is suffering, and for those who love him or her, wanting the pain and trouble to stop is enough. Knowing that others have recovered is very helpful; most patients, including myself, have diagnosed themselves as hopeless more than once.

I think my father had PTSD, and Faulkner was a depressed narcissist who drank too much. Who cares? The important point is that in spite of whatever “it” was that they had, they both managed to write magnificent transcendent literature that makes us all a little smarter and less lonely.

What matters is that their art stabilized them and gave them purpose, along with a substantial amount of fame and fortune. We have the relationship between creativity and mental illness exactly wrong; “crazy” people don’t create great art unless they are getting better. The illusion that someone in early recovery can simply chuck their meds and produce great art has sent many gifted young people over the cliff.

Whether or not someone needs psychiatric medication is beside the point. The point is to lead a good life and sustain loving relationships. I’m an optimistic person; on a regular basis I find myself looking in the mirror, hoping to see someone who doesn’t need medication staring back at me. However, seeing as I’m 67, that probably isn’t going to happen. And so, I try to make a little joke to myself as I take yet another dose of antipsychotic or mood stabilizing medication: “Boy, I sure hope this stuff works!”

Medications have side effects. No one who doesn’t need them should take them — I know I certainly wouldn’t. It’s a painful truth that medications and psychiatric hospitals, the faults of which could fill volumes, have both saved me, and made a good life for myself possible. For that, I am grateful.

Symptoms do not a diagnosis make. You can be impulsive, grandiose with flighty ideas and think everything you see on TV is about you without being “crazy.” The thing about being mentally ill is not being able to attend to day-to-day life, or be part of healthy relationships.

The reverse is also true; just because you don’t hear voices, doesn’t make you a model of mental health. One of the problems with mental health diagnosis is how reassuring the process is to “so-called normal” people. The sub-text to me having a thinking disorder is that your thinking is fine. I freely admit that I have an affective disorder, and find the idea that my feelings are more than a little off-base a huge relief — but to jump from my affective disorder to the conclusion that your feelings make perfect sense is just illogical.

There are all kinds of statistics, but the bottom line is that no one among us is 100% crazy, and no one is 100% sane. The chance that you or someone you love won’t need help at some point with what we broadly call “mental illness” is 0.

You don’t need a psychiatrist or a doctor to start the process of recovery. While a full-blown psychotic break involving emergency rooms and psychiatric hospitals is one way to go, I don’t recommend it. You’d think that the humiliation involved in that route would make it easier to accept help, but you’d be wrong. All you need is the desire to have things be different. It’s amazing how readily people accept depression, or alcoholism, or anxiety as the way things have to be. It doesn’t matter if it’s a friend, family member, or professional who tells you that your life can get better; all you have to do is accept the truth as best you can, and be willing to take the next step. Whether that step leads to a therapist, or AA, or NAMI doesn’t really matter.

The good thing about recovery is that it’s progressive. Just like depression, anxiety, addiction, PTSD and all the other diseases tend to worsen over time, a good friend or therapist can progress to a good treatment program, a good job, or appropriate medication. People who get better help other people get better. Someone who manages to find recovery can, and often does, help countless others in ways no one could possibly predict.

I’m a shameless eclectic pragmatist in my work as a pediatrician. Having raised three of them myself, I’m well aware that most adolescent and pre-adolescent boys would rather drink poison than talk with a therapist, but they also don’t want things to go on the way they have been. So I mention therapy as something I can probably get them out of if they’re willing to clean up their room, do their homework, maybe eat a little better and stop swearing at their mother. Most of them think they can do this. I point out that whether things go well or not, they can always go back to swearing at their parents and slamming doors, but regardless, I want to see them again in a week or two to see how the experiment is going. Acupuncture, yoga, IEPs, social skills groups — it truly doesn’t matter.

What Thorazine did for me 45 years ago was make it possible to talk to other people in the dayroom. Had my scraggly, 127-pound, Old-Testament-prophet self told them that I was going to get out of there, make it home with a lot of help from friends and family, work my way up from landscaping to medical school, publish a couple of books and raise three sons, they would have upped my meds, put me back in seclusion, or both.

There ain’t no difference between them and us. We’re all here to help each other through this, whatever it is.

There’s almost always something positive you can do; the problem is believing in that possibility, and letting others help you figure out what it is.

Mark Vonnegut, M.D. is a Boston-area pediatrician who writes and speaks on mental health topics. He is author of two books, The Eden Express and Just Like Someone Without Mental Illness Only More So: A Memoir. Dr. Vonnegut was born in Chicago, the son of Kurt and Jane Vonnegut, grew up mostly on Cape Cod, started a commune in British Columbia, went to Harvard Medical School, completed his internship and residency at Massachusetts General Hospital, and is very proud of continuing to write, paint and play music through it all.

An earlier version of this piece was published by The Clay Center For Young Healthy Minds at Massachusetts General Hospital.

Report: Woman Wins $100M In Transvaginal Mesh Case Against Boston Scientific

Report: Woman Wins $100M In Transvaginal Mesh Case Against Boston Scientific

A Delaware jury has ordered a medical device manufacturer to pay $100 million to a woman who, despite two surgeries, still has pieces of transvaginal mesh embedded inside her.

The News Journal of Wilmington reports the 51-year-old Newark woman was awarded damages Thursday following a two-week trial in Superior Court in Wilmington against Boston Scientific.

Court documents say the woman had transvaginal mesh inserts, a net-like product used to treat incontinence and sagging pelvic organs in women, implanted in May 2009. Since then, she has had complications, including urinary tract infections and pain during sex.

The jury found Boston Scientific, which is headquartered in Marlborough, Massachusetts, failed to warn doctors and patients of the risk of the poorly designed inserts.

Boston Scientific spokeswoman Kelly Leadem says the company dedicates significant resources to ensure products are safe.

Earlier:

jeudi 28 mai 2015

Amnesia Undone: MIT Study In Mice Restores Lost Memories

Amnesia Undone: MIT Study In Mice Restores Lost Memories

mouse neurons1

3-D reconstruction of mouse neurons (Zeiss Microscopy/Flickr Creative Commons)

 

How’s this for a grabber? “Memories that have been ‘lost’ as a result of amnesia can be recalled by activating brain cells with light. In a paper published today in the journal Science, researchers at MIT reveal that they were able to reactivate memories that could not otherwise be retrieved, using a technology known as optogenetics.”

Yes! Does this mean we can reclaim our long-forgotten halcyon childhood days with a bit of a laser boost to the right neurons? Um, no, not today. But it’s still fascinating. That MIT press release quoted above  goes on to explain that the study explores the difference between how a memory is stored — in a group of brain cells called an engram — and how it is retrieved. It quotes Nobel laureate Susumu Tonegawa, who leads the group that did the work, on the evolving concept of what a memory is, in our brains:

“We are proposing a new concept, in which there is an engram cell ensemble pathway, or circuit, for each memory,” he says. “This circuit encompasses multiple brain areas and the engram cell ensembles in these areas are connected specifically for a particular memory.”

WBUR’s Rachel Paiste spoke with Dheeraj Roy, a grad student in Tonegawa’s MIT lab who worked on the research. Their conversation, lightly edited:

RP: So what did you find?

DR: We wanted to look at mouse models of amnesia, for the simple reason that there’s very little done today in the field. So we attempted to look at individual memory traces, which we refer to as engram cells, which are sparse populations in several brain regions — the one we worked with is the hippocampus, which is widely known to be involved in memory. And we looked at: Do these memory traces, which we see in normal mice, do they still persist in amnesic mouse models? And if so, is there any way that we can restore or bring back these memories?

And this is actually stemming from a debate in the field: Neuroscientists weren’t sure, when a mouse or a rat or a human can’t remember a memory, is it because the memories are no longer stored or is it because for some reason they can no longer be accessed? So our study really started with that goal: Can we try to tease apart storage problems, where the memory is gone, or retrieval problems, where the memory is there but just needs to be retrieved somehow?

So our findings, I think for the first time, tell us that in certain models of amnesia, memories do persist and, very importantly, at levels similar to what we see in control mice. And that’s actually what was most exciting for us: not just that memories persist — that’s been known for a while — but the fact that we can bring back memories to equivalent levels as control animals is very unexpected.

So the first thing I thought of here, knowing more about pop culture than brain science, is ‘Eternal Sunshine of the Spotless Mind.’ As far as retrieval of memories, is this something that could somehow become used for humans?

I think it will take more research and is years in the future. But if I had to describe how I think this work could be extended, the first thing that comes to mind is the mouse model of Alzheimer’s disease — and in the future, human patients suffering from any sort of memory loss.

I think the first thing we have to do is make a system analogous to what we have with optogenetics, which is light control of neurons, to bring back memories. Could we use something like Deep Brain Stimulation, which is already being used for Parkinson’s disease successfully, in human patients, as well as more recently in Alzheimer’s disease?

So we think that studying the relationship between Deep Brain Stimulation and our specific memory activation in mouse models could give us insight into how this could be extended. If we could come up with a strategy that uses currently available techniques in the clinic, such as Deep Brain Stimulation, that would be fantastic and I think the implications would be amazing.

So what might this mean for people with Alzheimer’s or amnesia or PTSD, a few years down the road?

There are several types of amnesia, so it’s very important for us to first establish that in our model, we were able to find memories persisting. So that would be our first step: In the future, in humans, can we find out in what types of amnesia the memories persist? And once we do, it would be important to find a strategy to bring them back permanently — whether it be memories for a few years or for a decade. Whether amnesia is from PTSD or a stressful event or natural memory loss with aging — memory makes us who we are, and being able to bring it back is where I think the research is taking us. This is the first step but one of many.

Did you look at various types of amnesia?

We started with the most famous type of amnesia, which is this protein synthesis-inhibition-based amnesia. And it’s important to keep in mind that it’s been used in neuroscience for decades. So we wanted to use the most dominant model to try to get an understanding of what happens in this type of amnesia. In the future, we’re looking at expanding this to applying it to the mouse model of Alzheimer’s disease — where, I think scientists would agree, it is possible that memories do persist but no one has ever looked at single memory traces and how technology such as ours may be applied.

I know this would need research that hasn’t happened yet, but does this mean that every memory you’ve ever had may be hiding somewhere in the dark corners of your mind, waiting to be retrieved?

That’s a fascinating question. I wish I could say yes. The way I think of the brain is that memories that are important to us — time with family, a birthday, an eventful day at work, an awards ceremony — these are the sort of memories that, if I had to speculate, would be the most robustly persisting, or would last the longest. I’m not very sure about a day in the park or other memories that weren’t as eventful. But it may be in the future that our technology could be applied to both, to tease apart which ones do persist.

What is most exciting to you about these findings?

To be honest, when we started this experiment, we actually thought that in amnesia, memories do not persist. Like all the other researchers, we thought they were just erased somehow. So the fact that we could unexpectedly be in the lab one day and shine the light in these amnesic mice and get memory retrieval — I still remember that day, and will for the rest of my life and career in research. It was just amazing to see something so unexpected happen, even though our professors and the other scientists in our building would never have guessed that were possible. That gets me excited and keeps me going.

And if you ever lose that memory, you know it can come back, with just a little bit of light!

 

From The Eating Lab: Diets Don’t Work, But Why?

From The Eating Lab: Diets Don’t Work, But Why?

By Jean Fain
Guest Contributor

As soon as Traci Mann’s new book, Secrets From The Eating Lab, hit bookstores shelves, I ordered my copy. Not only because the University of Minnesota psychology professor is one of the leading researchers on the psychology of eating, dieting and self-control, but her 2007 Medicare study on effective obesity treatments was the irrefutable evidence I needed in writing about how diets don’t work — at least not as dieters expect — in my own book on eating with self-compassion.

Diets fail to facilitate significant or sustainable weight loss, Mann argues. What’s more, diets are unnecessary for optimal health.

(Newbirth35/flickr)

(Newbirth35/flickr)

Diets don’t work for a variety of reasons, from biology to psychology. After two decades of studying the scientific literature as well as her own diet subjects, Mann points the finger, first and foremost, at human biology. “Genes,” she argues, “play an indisputable role in regulating an individual’s weight: most of us have a genetically set weight range. When we try to live above or below that range, our body struggles mightily to adapt.”

Second to biology, Mann blames a combination of neuroscience and psychology. Our brains are hardwired to want food for survival, she explains, so restricting calories creates a psychological stress response, which facilitates weight gain, not loss. Also, she adds: “Studies show that willpower, the thing we all blame ourselves for not having enough of, is in many ways a mythical quality and certainly not something that can be relied upon weight loss.”

Whether you’re interested in boosting your health or losing weight, Mann’s best advice is to ditch the diet and adopt her 12 “Smart Regulation Strategies,” her proven mental strategies for reaching your “leanest, livable weight.” Instead of counting calories, for example, she advocates penalizing yourself for succumbing to temptation as well as thinking about tempting foods in the abstract. So instead of thinking about the specific qualities of a glazed donut with chocolate icing, think of a donut as a generic dessert or just one of many breakfast foods.

Mann’s views come as no surprise to me, a therapist who specializes in eating disorders. The big surprise for me in her new book is that I only loved the first half — the half that pinpoints the problem with dieting. The other half, which focuses on her “no-diet” plan, well, I liked it only half as much. Turns out, a good bit of Mann’s plan calls for external changes, like using smaller plates and taking smaller portions, a la Brian Wansink’s Mindless Eating.  Mann prescribes internal changes, too, but none are what I’d describe as truly mindful.

I was tempted to dismiss Mann’s plan as a collection of mental tricks, then I thought better of it. Instead, I set up a mini-interview via email with the professor turned author and I’m glad I did. Not only did Mann have some interesting things to say about dieting — her own experience and that of determined dieters –- but her answers reminded me that there’s no right way to address eating problems. In fact, there are many ways to go. To see if Mann’s way of reaching your leanest livable weight is a way you might want to go, read on.

JF: You’re pretty unusual in that you ditched dieting after just one diet. And yet, you’ve devoted your career to proving diets don’t work. Why is that?

TM: I ditched dieting because the diet I went on made me miserable, and I watched both of my parents cycle through diets and re-gain, diets and re-gain, ad nauseam.

I wouldn’t say that I have devoted my career to proving diets don’t work. My students and I started studying whether diets work mid-way through the last twenty years, as a class project, because we were curious about long-term outcomes of diets. We didn’t set out to show that diets didn’t work, or that they did work. We believe we were as unbiased as possible, because we didn’t care which way the data pointed — it wasn’t the focus of the rest of our work, and we didn’t have a diet clinic to support, nor did we have ties to any industry relevant to dieting (or not dieting).

The focus of my work, from the beginning, was the self-control of eating. I was looking for ways to keep dieters from overeating. Slowly, over the years, I came to realize that nearly everything I studied (e.g., stress, distraction, and others) caused dieters to lose control of their eating, and it began to make sense to me why diets were so likely to fail.

You’re not the first author to write about why diets don’t work, but you may be the most persuasive and entertaining. And yet, I’m pretty sure your book will fail to persuade the masses to stop dieting. Given that diets really don’t work, why do you think dieters insist on dieting?

I think most people who diet do so because of one or more of these reasons: They have been indoctrinated to believe that they cannot be beautiful, worthy, or lovable unless they are thin. They have also been led to believe that not being able to get and stay thin is a sign of weakness, lack of self-control, and personal failings in general. Plus they (or their loved ones) fear for their health and don’t understand that they can be healthy without dieting.

Your tips for achieving our “leanest, livable weight” suggest that, in order to make healthy choices, we need to trick ourselves. That, given human biology and psychology, people aren’t all that capable of doing what mindful eating subjects do: find satisfaction in smaller portions. Is that really the case you’re making or are you making a different case?

That’s an interesting way to put it. We need to trick our subjects into thinking we are studying something (anything!) other than their eating, because subjects don’t behave naturally if they think we are observing what they eat. So we do need to trick our subjects in order to study them.

But the strategies for reaching your leanest livable weight aren’t tricks. The strategies try to find ways to make human nature work for us, instead of against us. For example, it’s human nature to struggle with willpower. (I don’t know anyone who doesn’t!)  So some of the strategies help us avoid situations in which we would need a lot of willpower. They do this by taking advantage of human nature to make it easier to avoid unhealthy foods and access healthy ones. For example, strategies about putting obstacles between ourselves and unhealthy foods take advantage of most people’s tendencies toward laziness. They aren’t tricks. They work even if you know about them and are fully aware of them.

Similarly, strategies about creating habits and forming certain intentions are not tricks, but once we form them, they are more likely to kick in automatically right when we need them. And I eat a vegetable first every night at dinner. Not because it’s a trick, but because I’ll eat more of it when I am at my hungriest, and when there are no other temptations around. It’s just working with human nature instead of battling it.

Jean Fain, LICSW, MSW, is a Harvard Medical School-affiliated psychotherapist and the author of “The Self-Compassion Diet.”

Asthma, Lyme Disease, Salmonella: How Climate Change May Worsen Your Health

Asthma, Lyme Disease, Salmonella: How Climate Change May Worsen Your Health

The link between climate change and extreme weather is widely known. But as the planet warms, what about the risks to your own personal health?

I asked U.S. Environmental Protection Agency Administrator Gina McCarthy, a Boston native in town to deliver the commencement address at UMass Boston (her alma mater), to give some specific examples of how climate change can impact human health. Here, edited, is our conversation.

RZ: So, feel free to get scary here, what should people know about climate change and their own health?

GM: As temperatures rise, smog gets worse and allergy seasons get longer, which makes it harder for our kids to breath. We know that increasing the ozone, the ground level smog, makes it difficult for kids — and also the elderly — to breath, it impacts their lung function. So, you’re going to see a dramatic rise in the number of kids with asthma who experience bad air days.

So, the allergy season gets longer, and this is related to the warmer temperatures as well as the later fall frosts, which means plants produce pollen later in the year. The length of the ragweed pollen season has increased in 10 of 11 locations studied in the Central U.S. and Canada.

This season is awful: I have a little allergy this year for the first time. I found myself sneezing, my eyes watering. Even the dog went on some kind of antihistamine. I felt sorry for her.

You also mentioned ticks, what will happen in their world?

Warmer temperatures also bring increases in vector born diseases — Lyme disease, mosquito and tick-borne diseases, and expanded seasons. What we see is that the Lyme disease areas are expanding and the number of cases is increasing. Among the states where Lyme disease is most common [New Hampshire, Delaware, Maine, Vermont, and Massachusetts], on average, these five states now report 50 to 90 more cases per 100,000 people than they did in 1991.

You can clearly see the geographic region expand. Also, West Nile Virus is expanding. Our climate assessment tracks geography and seasons getting longer, expanding. As temperatures get higher, the entire ecossystem changes. I was in in Aspen, the winters are getting shorter.

Screen shot 2015-05-28 at 1.11.33 PM

Are there any other diseases we should brace for?

There are also water and food borne diseases: salmonella, that relates to food potentially sitting out, the higher the temperature the more salmonella outbreaks. The same with water — anything that’s a bacteria — it’s going to increase in warmer weather.

But what we’ll probably notice most will be the air quality, right?

Everybody knows that with some of these extreme weather events, wildfires happen and that decreases air quality as well. That results in a direct public health impact.

Also, the EPA is working on reducing carbon pollution in power plants, and when you look at carbon pollution reductions, you can also reduce particulates, all these other pollutants that come along for the ride. So when you reduce carbon pollution in the power sector, if you clean them up, you’re able to capture a lot of direct public health benefits.

Every dollar we invest in EPA’s plan to cut carbon pollution would return up to $7 in health benefits for the American people, and in 2030 alone, the U.S. will avoid up to 100,000 asthma attacks and 2,100 heart attacks as a result.

So what are you going to tell the UMass grads tomorrow?

You know I went to Umass…I got a degree in social anthropology. It’s very beneficial, particularly working with congress.

I’m going to tell them how much the world has changed … how their opportunities are limitless and I want them to embrace the change. I’m going to tell them climate change is one of the biggest public health, environmental, national security and economic threats we face. I think they know the science and now is the time to take action. I need them talking and embracing the opportunities for a low carbon future.

mercredi 27 mai 2015

Latest Checkup Podcast: Teen Zombies, From Sleep To Porn To Impulsive Choices

Latest Checkup Podcast: Teen Zombies, From Sleep To Porn To Impulsive Choices

(Photo: Hypnotica Studios Infinite, Flickr Creative Commons)

(Photo: Hypnotica Studios Infinite, Flickr Creative Commons)

News bulletin: Teens are … different. They’re caught betwixt childhood and adulthood, but they’re no simple hybrid of the two — they can sometimes seem more like a separate species.

In the latest episode of The Checkup podcast, we explore three important aspects of the adolescent mind:

• Do you beg your teenager to go to sleep earlier so he or she can function? Well, it turns out they physically can’t do that, explains Dr. Marvin Wang, a pediatrician at Massachusetts General Hospital on a mission to make school start times later.

• Also, why adolescent brain development is the culprit behind so much bad (and sometimes law-breaking) decision-making and reckless behavior.

• And, a sex therapist talks about how Internet porn can sabotage a teenager’s ability to have a normal romantic relationship.

In case you missed other recent episodes: “Power to the Patient” looked at ways we can all feel in more control of our health care; “High Anxiety” explored hormones, parenting and fear of flying; and “Sexual Reality Checks” examined penis size, female desire and aging.

But lists get tedious — why not just subscribe?

Each week, The Checkup features a different topic — previous episodes focused on college mental health, sex problems, the Insanity workout and vaccine issues.

If you listen and like it, won’t you please let our podcasting partner, Slate, know? You can email them at podcasts@slate.com.

mardi 26 mai 2015

Public Pay: UMass Med School Chief Now Earning Nearly $900K

Public Pay: UMass Med School Chief Now Earning Nearly $900K

Infographic by Reuben Fischer-Baum at Deadspin.com, reposted with permission.

Infographic by Reuben Fischer-Baum at Deadspin.com, reposted with permission.

This time around, I’m feeling about a hundred grand more like an appalled taxpayer than a proud Bay Stater.

A couple of years ago, we posted the map above under the headline, “Highest Public Pay: Coaches In Most States, Med School Chief In Mass.” The map — which we re-posted with permission from Deadspin.com — had earlier been titled “”Everything Wrong With America In One Simple Image.” I expressed my pride that I live in a blue state where the highest-paid public employee is not a football coach but a medical school chancellor.

At that point, the Boston Globe reported, “At $784,468, the top 2012 salary ­belonged to Michael F. Collins, who holds dual roles in the University [of Massachusetts], as chancellor of the medical school and ­senior vice president for health sciences at the university. He was also the state’s highest paid employee in 2011.”

Now, according to a post by David Art of MASSterList, the latest numbers are in on salaries in Massachusetts state higher ed, and the top spot holder is once again Michael F. Collins, but with, by my count, $113,010 more a year:

“Michael F. Collins, Chancellor of UMass Medical School, with salary of $897,478, topped the list of the highest-paid educators in the state higher education system in 2014.”

I can only repeat the plaintive question I asked in 2013, with $113,000 more emphasis:

“Of course, public employees’ salaries need to be comparable to private-sector salaries if we want to attract good people to public service. But is there not also something called “enough”? At what point does a taxpayer-paid or nonprofit salary become unseemly?”

lundi 25 mai 2015

What You Really Need To Know About Dense Breasts

What You Really Need To Know About Dense Breasts

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

From left: 1) a breast of normal density showing fat (white), fibrous tissue (pink) and glands within the rectangle, while a cancer is present (circle). This illustrates the fact that cancer can occur in breasts of any density; 2) an extremely dense benign breast without any fat, composed of pink fibrous tissue and minimal amounts of glands; 3) an extremely dense breast involved by cancer (infiltrating haphazard small glands), in contrast to Fig 2, but very similar in appearance, demonstrating the subtle similarities. (Courtesy Michael Misialek)

By Michael Misialek, M.D.
Guest Contributor

Reading the pathology request on my next patient, I saw she was a 55-year-old with an abnormality on her mammogram. Upon further investigation I discovered she had dense breasts and a concerning “radiographic opacity.” The suspicion of cancer was high based on these findings and so, a breast biopsy had been recommended. As I placed the slide on my microscope and brought the tissues into focus, I immediately recognized the patterns of an invasive cancer. Unfortunately the suspicion had proven correct.

Just a few patients earlier, an almost identical history had prompted another breast biopsy. This time the results were far different, a benign finding and obviously a sense of relief for the woman. Every day these stories unfold; the never ending workup of abnormal mammogram findings. Both radiographically and microscopically, it can be challenging at times sorting out these diagnoses, particularly in the face of dense breasts.

But what, exactly, are dense breasts and why are they suddenly in the news?

Breast Tissue 101

Breast tissue is actually made up of three tissue types when viewed under the microscope. The percentage of each varies between patients. There is fat, fibrous tissue (the supporting framework) and glandular tissue (the functional component). This is what I actually see under the microscope. Cancer can occur in fatty or dense breasts. It can be toughest to assess when the background is dense.

Biopsy, considered the gold standard in diagnosis, may even prove difficult to interpret when in the background of dense breasts. Dense breasts can hide a cancer, making it more difficult to detect both by mammogram and under the microscope.

Breast density has taken a lot of heat recently. A new study published in the Annals of Internal Medicine found that not all women with dense breasts and a normal mammogram warranted additional screening, as was previously thought. Understandably this report has received much attention. The authors found nearly half of all women had dense breasts. This alone should not be the sole criterion by which additional imaging tests are ordered since these women do not all go on to have a cancer. Clearly other risk factors are at play.

Confusion All Around

This is confusing for patients and doctors alike, especially when it seems as if screening guidelines are a moving target. Recently, the American College of Physicians issued new cancer screening guidelines: among these was mammograms, being recommended every two years. This too is getting a lot of press.

The American College of Radiology, American Cancer Society, Society of Breast Imaging and American College of Obstetricians and Gynecologists recommend yearly mammograms beginning at age 40.

Breast density is a subjective factor measured by the radiologist and is reported using the Breast Imaging Reporting and Data System. This ranges from almost entirely fatty to extremely dense. The Massachusetts Radiology Society provides an overview of the BI-RADS categories which are based on four measures of increasing density.

Currently 21 states now require providers to inform patients whether they have dense breasts — Massachusetts is one of them. The law is far from perfect. There is variability in how results are provided.

And there are other problems: increased false positive rates from using additional tests such as MRI and ultrasound, not to mention the increase costs associated with such screening. Most states do not mandate insurance coverage in these circumstances. Currently it has proven cost effective in only high risk patients. It is unknown how and if additional screening methods should be employed in those with average risk. Despite these problems, mammogram is still the best screening method, having been documented to reduce breast cancer deaths.

But imaging alone should not be assessed in a vacuum. Individual risk stratification is needed, emphasized by the Annals of Internal Medicine study. The Massachusetts Radiology Society offers resources for both patients and doctors.

There are also calculators available to help assess a woman’s risk of developing breast cancer. These typically factor in age, race, family history, a history of breast biopsy and density.

Biopsy interpretation by pathologists has come under controversy recently where a study in the Journal of the American Medical Association found diagnostic discordance among pathologists when presented with grey zone diagnoses.

What do we know about the pathology and population trends of those undergoing screening mammograms is that we are definitely diagnosing breast cancer more frequently. Breast density does play a factor. Those with dense breasts or a positive family history have a higher likelihood of being diagnosed with cancer.

However breast density is not the only factor. As the Annals study found, a patient’s personal, genetic and family history are all important in gauging individual cancer risk. This underscores the importance of collaborative care and shared decision making between a patient and their doctor. The extended care team, including pathology, radiology, surgery, oncology and primary care, collectively work to deliver personalized care.

An educated patient is our greatest asset. Be your own advocate. Ask questions and learn. As I finalize the report on my patient, I page radiology to discuss the findings. The dominoes have been set in motion.

Dr. Michael Misialek is associate chair of pathology at Newton-Wellesley Hospital and assistant clinical professor of pathology at Tufts University School of Medicine.

vendredi 22 mai 2015

Why We Need To Talk Now About The Brave New World Of Editing Genes

Why We Need To Talk Now About The Brave New World Of Editing Genes

Screen shot 2015-05-21 at 7.48.44 PM

(Image: NIH)

 

It was standing room only in the Harvard Medical School auditorium last week, the atmosphere electric as an audience of hundreds hummed with anticipation — for a highly technical talk by a visiting scientist, Dr. Jennifer Doudna of Berkeley. Near the front sat the medical school’s dean, Dr. Jeffrey Flier.

“I don’t believe in my years at Harvard Medical School I’ve ever seen a crowd of this magnitude for a lecture of this kind,” he said.

The draw?

“The draw is, this is one of the most exciting topics in the scene of biology today.”

Visiting scientist Jennifer Doudna of UC Berkeley, a pioneer of the gene-editing technology CRISPR, speaks to a rapt Harvard Medical School audience on May 14, 2015.

Visiting scientist Jennifer Doudna of UC Berkeley, a pioneer of the gene-editing technology CRISPR, speaks to a rapt Harvard Medical School audience on May 14, 2015.

That buzzworthy biology topic is a revolutionary new method to “edit” DNA that has spread to thousands of labs around the world just in the last couple of years.

Suddenly, it’s no longer purely science fiction that humankind will have the ability to tinker with its own gene pool. But should it?

Learn This Acronym: CRISPR

The hot new gene-editing tool is known by the acronym CRISPR, for “clustered regularly interspaced palindromic repeats.” It acts as a sort of molecular scissors that can be easily targeted to cut and modify specific genes.

CRISPR occurs naturally in bacteria, but scientists are now learning to harness its power to alter DNA for research across the board — cancer, HIV, brain disease — even to make better potatoes. Just this week, the journal Science published a paper on possibly using CRISPR to try to stop female mosquitoes from spreading deadly diseases.

CRISPR looks particularly promising for human diseases that hinge on just one gene, like sickle-cell anemia or cystic fibrosis. Someday, the hope is, CRISPR and gene-editing tools like it will let us cure what are now lifelong diseases by simply deleting and replacing a baby’s “broken” gene.

“The name — definitely it’s a bit jargony, but it is actually an incredibly easy tool to use to manipulate DNA,” says Katrine Bosley, the CEO of Editas Medicine, a Cambridge biotech company founded by leading CRISPR scientists to develop treatments for genetic diseases.

Editas Medicine CEO Katrine Bosley (Courtesy)

Editas Medicine CEO Katrine Bosley (Courtesy)

“Part of the reason there’s this incredible excitement in the scientific community,” she says, “is that, as many people have picked it up and tried it, it’s worked for them. I’ve had scientists say to me, ‘I tried it and my first experiment worked!’ Now, that almost never happens. Not only does it almost never happen in science generally, it’s even rarer with a very new technology like this.”

Back in the laboratory area of Editas Medicine, scientist Deepak Reyon uses CRISPR to make genetically modified cells and mice. These “models” are key for studying diseases and looking for possible cures — and they’re now far faster and easier to create.

“We can think about generating models at a rate of even two or three models in a week,” he says. “We used to think about generating one mouse model in a year. Ten years ago, people would work on making one model for their PhD thesis.”

Making People Nervous

So — sounds great, right? CRISPR is such a step forward that it’s been compared to going from a manual typewriter and White-Out to computerized word processing, with a lovely “Find” function that lets you search out and correct a given word. The buzz around CRISPR includes loud whispers of “Nobel prize,” and a pending dispute over potentially very valuable patents.

But CRISPR is also making some people, including some scientists, very nervous. It’s raising the prospect of creating “designer babies” — manipulating genes to bolster intelligence, say, or immunity to disease — in ways that future generations will inherit. Remember “Brave New World”? Or the genetic “haves” and “have nots” in the movie “Gattaca”?

“The question is called,” Bosley says, “when you have a technology that suggests something is possible as opposed to wholly theoretical.”

The current reality, though, is that making designer babies is still very much science fiction. Chinese scientists reported in April that they had used CRISPR to edit the genes of human embryos that could never grow into babies anyway — but it didn’t work very well.

And CRISPR has a long way to go before any parent would ever want to use the technology on a baby, because it’s clearly not safe. It’s not specific enough to hit only the genes you’re targeting — it could change others as well. That’s a challenge more immediately for making CRISPR-based therapies for patients with genetic diseases, which must be highly specific.

Dr. Keith Joung at Massachusetts General Hospital is working on that targeting problem.

Dr. Keith Joung (courtesy)

Dr. Keith Joung (courtesy)

“We now know that we can make a change at a desired target, a so-called on-target site,” he says, “but what has been less clear is if we are causing changes elsewhere in the genome, at so-called off-target sites. So these would be unintended changes to the DNA.”

To his knowledge, CRISPR-based therapies have not yet been tried in human clinical trials, he says.

But Let’s Start Talking…

So CRISPR is still in its early days, but the discussion about using it to alter the human gene pool has already begun in the scientific community — mostly with calls not to cross the line into meddling with human heredity. Though some argue that if and when we can make humanity better — especially by eradicating diseases — maybe we should.

At Harvard Medical School, CRISPR pioneer Doudna said a big scientific meeting this fall would discuss the issue.

The first question, says Boston University bio-ethicist George Annas, is: “Should we ever use this technique on human embryos that are destined to become children? I actually think the answer to that is no.” (Read a fuller discussion with Prof. Annas here: A Taste of the Looming Ethical Debate On Gene-Editing Humans.)

He argues that the world needs to create a new global body to regulate changes to the human gene pool, maybe called something like The Human Species Protection Agency.

“We need new structures, new oversight, new transparency,” he says. “The scientists can’t do it alone.”

As the science of CRISPR keeps forging ahead, Annas and others are saying, we’d better start talking about where we want it to go — and how far.

Further reading: All CRISPR coverage by Antonio Regalado of Technology Review, particularly this vivid overview: “Engineering The Perfect Baby

Further listening: On Point: Re-Engineering Human Embryos

Q&A: A Taste of The Looming Ethical Debate On Gene-Editing Humans

Q&A: A Taste of The Looming Ethical Debate On Gene-Editing Humans

Boston University bio-ethicist George Annas discusses the ethical issues raised by powerful new gene-editing technology.

Boston University bio-ethicist George Annas discusses the ethical issues raised by new gene-editing tools that may eventually allow humankind to control its own genetic legacy.

The powerful new gene-editing tool CRISPR is sparking excitement in biology labs — but also calls for a broad discussion about limits, and whether we should ever meddle with the human gene pool. I asked Boston University bio-ethicist Prof. George Annas for his take. Our conversation, edited:

CG: So scientists are saying we should start talking about using CRISPR to alter the human gene pool. What would a conversation like that even sound like?

GA: The conversation is not about CRISPR per se. It’s about: Now that we have techniques to edit the human genome, should we edit the human genome, and if so, for what purposes?

We’ve had this conversation around cloning in the mid-1990s. Most but not all scientists, and almost everyone in the public, agreed we should not try to clone a human being, use our genetic knowledge to make a genetic duplicate human being. And we’ve had very good luck: it’s turned out not to be possible to clone a human being. At least, we don’t know how to do it yet.

But with CRISPR, it seems much more likely that sometime in the not-too-distant future — though it may be decades, this gene editing technology will be dependable enough that someone is likely to try to use it on a human embryo.

This will be a big and dangerous step—dangerous for sure to the resulting child. Many people have no trouble with using genome editing on animals and plants, so long as you’re not harming the animal in a way that makes it suffer. But children do suffer. So the first question is: Should we ever try to edit the genomes of human embryos that are destined to become children? I think the answer is no.

I agree with the scientists who say that it’s definitely not safe to do it now because we can’t predict what other things CRISPR will do to the rest of the genome. We know very little about the genome, and what impact taking out one or a series of base pairs — with CRISPR, you can take a series out — is going to do to the rest of the genome, and hence to the whole organism as it develops.

And the problem with germ-line genetic engineering at the level of the embryo —

— Making genetic changes that will be passed on forever —

Potentially, yes. First they will be passed on to this baby, and this baby will become an adult. And if this “engineered” baby has children, the new traits will be passed on to the next generation, and so on.

So an initial question — and scientists agree with this — is, how many generations do you need to prove that a particular method of genome editing is safe? I would guess most scientists would say, at least four or five. Well, we can do four or five generations in zebrafish or in rats or in fruit flies pretty quickly.. In humans, however, it’s going to take you probably 100 years. So, how many children would you want to follow, and their offspring, for 100 years before you are ready to conclude that editing the human genome is safe for children?

That strikes me as a question that we can’t answer. Because we cannot prove it safe without putting human children at terrible risk of harm, we can’t subject any human child to this experiment. That’s because children can’t consent, and their consent is necessary as a matter of ethics because there are good reasons to anticipate that something will go horribly wrong.

And more broadly, there are potential implications for the whole human race, if we start engineering evolution — ?

I would take the strong position that until we get some mechanism by which the human species can be represented, no one should be permitted to do any experiment that is potentially species-endangering, that could put the entire species at risk of serious damage or even extinction.

I think if genome editing ‘works’ and you can actually produce — and to simplify the discussiion I’ll use the old eugenics terms – “designer” babies that are better babies, smarter babies, stronger babies, babies that would be significantly different from the run-of-the-mill babies — then, I would argue, and some people think this is a little far out — that one of two things will happen:

Either we’ll be horrified at these new humans or super-humans or sub-humans and kill them preemptively before they kill us, or they will become so superior they’ll take over the world and either enslave or kill us.

In either event, we’ll have two types of humans — one of which will be seen as sub-human by the other one — and this will promote what I call “genetic genocide”, one group killing the other based on a perception that the other is subhuman or super-human. If there is any reasonable risk of this happening (1% over the next 3 centuries?) then I believe no one has the moral warrant to put the human species in such a risky position, in the position of creating potential species suicide.

So then we just shouldn’t do it…

Certainly not now. Ultimately, what this comes down to — and scientists understand this argument — is, who has the burden of proof? Do the people who want to use this technique have the burden of proof that it’s safe, or, more likely, not safe? Or do people who want to prevent the use of this technique on human embryos, on children, do they have the burden to prove that it’s dangerous in order to outlaw this use?

Right now, because we don’t have a lot of data, whoever has the burden of proof loses.
Proponents can’t prove it’s safe — they don’t know how to do that. And opponents can’t prove it’s dangerous (although from the Chinese experiments, it can be concluded that the techniques they used are dangerous). But mostly we’re currently in the same position we were in with human cloning: little data and lots of talk.

It does seem like, given how young and still imperfect this technology is, maybe these calls for prudence and caution may be a bit premature…

They may well be. It could turn out that none of this is going to work; it could be like cloning. We imagined, for example, an army of clones to be turned into workers or fighters, some pretty horrible scenarios, but mostly what people imagined was that cloning would be the entrance to germ-line genetic engineering. That was the real problem. It would make genetic engineering easier to do by creating multiple identical embryos to work with. Nobody really wanted to simply duplicate existing humans — they wanted to make a better human. Just as most parents want their children to have better lives than they have had; parents want a “better baby.”

The Chinese have a goal of being the worldwide leaders in genomics in the coming century — so it’s not clear to me, even if we have a ban or moratorium on genome editing, that some Chinese researcher, and the Chinese have already done the experiment on non-viable embryos, wouldn’t do it on viable embryos.

So then, even more, you need a world body to say, ‘You can’t do this.’

You do need a global governing or regulatory body — or at least, a world consensus. We actually already have 40 countries that have outlawed germ-line genetic engineering, legislation that was mostly passed in the context of the cloning debate.

What I argued during the cloning debate, and the argument has equal force in the genome editing debate, is that it is perfectly appropriate to use CRISPR to make medicine, but it should not be used to make babies. At least we should draw that line for now. I do believe you should be able to do research on embryos, but you shouldn’t be able to implant them in a uterus (real or artificial) and have them grow up into a baby, because that’s a child — and (as I’ve already said) you shouldn’t be doing research on children, certainly not at this point and maybe ever.

As a matter of ethics, you always do research first on someone who can consent to it for themselves, someone who can understand the risks and potential benefits and voluntarily agrees to undertake it. That’s never going to be the case for a child or human embryo. So we should never get them involved at all — or not until very late in the game.

The undeniably appealing thing is, though, mightn’t there be families with terrible genetic diseases who could eradicate those diseases by fixing their own genes?

The answer to that is yes, but there are many other ways to do it, such as through donor egg, donor sperm, and adoption.

True, but the other appealing aspect I see — and yes, this is far out and science fiction — is that given the record of humanity, tinkering with our gene pool to make us better might not be a bad thing. What if we could be smarter, less aggressive, less evil? I know that presupposes a lot of genetic knowledge we don’t have now, but what if it were possible, why not become better?

That begs the question of what’s better. And those characteristics — — love, honor, compassion, whatever you think of as good — to what extent are they mostly genetic, or are they mostly environmental?

It’s complicated. If nothing else, we’ve learned from the Human Genome Project in the last 20 years that life is really complicated. It’s not just one gene, one protein — genes influence each other in many different ways, ways that we’re barely beginning to understand.

The notion that you can use CRISPR to change one gene or part of a gene and that’s all it’s going to change in the genome — it’s not so simple. Even if you could find a gene — which you can’t — for happiness or joy, your children might get the joy gene and also the homicidal maniac gene. They may go together — you may have a good time killing people.

I certainly agree that humans are not at their pinnacle, and we’re not such a wonderful species. Half the world seems to be spending half its time killing each other. Can we do better than the humans we have now? Yes. Will we do it through genetics? I doubt it, any more than we’ve been able to do it through drugs.

There’s a school of thought that says if science can do it, it will do it. Given how surprisingly well CRISPR has worked so far, if we do get to the point where we can tweak the human genome very nicely, do you think we will?

This is my favorite thing that scientists say, and they say it without thinking twice: ‘You can’t stop us — the technology is not stoppable.’

‘The genie out of bottle — ‘

And they say that in the same breath that they say, ‘We’re going to learn how to control nature.’ And what they’re really saying is, ‘We think we can control nature but we know we can’t control ourselves.’ And that’s why people other than scientists have to say, ‘You’re right, you can’t control yourselves, that has to be someone else’s job. Because the science is now so powerful that its potentially dangerous – its products now include things like nuclear weapons, bacterial and viral weapons. Scientists don’t get to decide if or when these will ever be used on humans. ‘

Scientists can’t be trusted to control themselves, so we need to come up with an effective alternative structure.

Scientists have tried to self-regulate. At Asilomar [a 1975 conference that set guidelines for using recombinant DNA], the scientists decided the structure would be physical containment — a big laboratory, a biosafety 4 lab – and biological containment, whatever recombinant DNA creature escaped from the lab, it was engineered so that it couldn’t live outside the lab.

And that has helped…

Those safeguards are great, for bacteria and viruses. Not so great for people or animals… So we need new structures, new oversight, new transparency. The scientists can’t do it alone.

So there needs to be a new human species regulatory agency?

Yes, I’d call it the human species protection agency.

The HSPA!

I know it sounds strangely utopian (or dystopian) because the world can’ t cooperate on anything.

And I can imagine China would say no…

And China would say no, who are you to tell us what to do? So there’s got to be payoff for being involved in this.

You’d first have to want to create this agency, and right now the will’s not there. Historically it’s taken a tragedy for us to say, ‘Oh, we’ve got to regulate that.’ Something horrible has to happen.

I can imagine the image of a gene-engineered baby…

People did say that about cloning: If the first clone is born terribly deformed, or if something is horribly wrong with the child, that’s the end of human cloning.

The main challenge is to make sure any proposed experiment is public, so people get a chance to comment on it before it’s a fait accompli, before it’s finished.

Well, the CRISPR scientists themselves are saying they want public dialogue…

They are. If you want to be really cynical, you could say they are just doing that to throw us off. ‘Don’t worry, leave us alone, we got this, we’re going to have a conference and all the scientists will get together and decide.‘
No, you’re not going to decide! You don’t get to decide that. Scientists get to decide the ‘can‘ questions but not the ‘should‘ questions, at least not when they are using dangerous technologies.

So what’s your prediction? How will this play out?

Oh, somebody’s going to try to use this gene editing to make a better baby at some point. But hopefully we’ll get saved the same way we were saved on cloning, in that it’s just not going to work.

Embryos are much more complicated than most people give them credit for — you have to go through millions of cell divisions to make a baby. The chances of all of them coming out right after you’ve taken the genome and edited it — even edited it perfectly — are extraordinarily low. What are the odds that if you take a cell and make a radical change in its DNA composition, that things either stay the same or get better? Not high.

That’s in the near future. In the far future, no one can predict 250 ahead, or even 25 years ahead….

jeudi 21 mai 2015

Why The Primary Care Problem (Lower Status, Pay) Matters

Why The Primary Care Problem (Lower Status, Pay) Matters

By Jeff Levin-Scherz, M.D., M.B.A.
Guest Contributor

Medscape just published its annual physician compensation survey. The survey includes almost 20,000 physicians and is performed on line – so it’s probably not entirely representative.

Also, the survey results are self-reported, and physicians generally underreport their income.  But the comparative reported income among specialties is informative. This survey is among the largest available, and does not require an expensive paid subscription.

Medscape survey

Medscape survey

The results are no surprise. But they’re worth noting: Specialists make 45% more than primary care physicians, and orthopedists make 224% more than pediatricians.

The majority of respondent physicians were employed, and men consistently make more than women in the same specialty. Women have the largest representation in specialties with the lowest incomes.

Physician income was a bit lower in the northeast but higher in the northwest. Massachusetts’ physicians report that their income is 46th in the nation.

Medscape survey

Medscape survey

Internists are the least satisfied in their job (47%), and the least likely to choose their specialty if they could choose again (25%), but high in the rankings of specialties where the respondent would choose medicine again (71%).

Family physicians were only slightly more likely to choose the same specialty again as internists (31%), yet they were the most likely to say they would choose to go into medicine again (74%).

Pediatrician income is among the lowest of all specialties, yet they are twice as likely to say that they would choose the same specialty. Internists and family physicians would go into medicine again, but they would go into subspecialties, and not do general primary care. The high cost of health care in the U.S. is in part due not to a shortage of primary care physicians, but also due to a surplus of specialists.

Why does all this matter?

The American College of Physicians reported on the impending “collapse” of primary care in 2006.  There have been efforts to change this situation since, including “patient centered medical homes,” and short-term enhanced Medicaid primary care fee schedules built into the Affordable Care Act.

The continued relatively lower pay of primary care physicians and the lack of job satisfaction of general internists and family physicians means that our historic way of delivering primary care is about to change.  Much future primary care is likely to be delivered by nurse practitioners or physician assistants, and some office-based primary care will be supplanted by telehealth or by apps with underlying algorithms.

The Medscape survey suggests that we will continue to face serious challenges to continue to deliver the highly personalized primary care which many of us value, and the highly coordinated care needed by the frail elderly and those with serious chronic illnesses.

Medscape survey

Medscape survey

The problem is about money, of course, but also about perception: the average pediatrician in this survey was paid $189,000 per year, the lowest amount of any of the surveyed specialties. Still, this is in the top 6% of all earners in the U.S.

The Primary care perception of being underpaid is related to the high earnings of specialists, and this will only change if there are large decreases in specialist income.

Modest increases in primary care income just won’t change this perception, and huge increases in primary care income would be hard to afford.

Recent efforts to train more physicians are not likely to lead to more practicing primary care physicians unless we are more successful at improving the lifestyle and status of those who practice primary care. We’ll just likely have more specialists, and our costs of health care will continue to be the highest in the world.

Jeff Levin-Scherz, MD, MBA is an assistant professor at Harvard Medical School and Harvard School of Public Health. He blogs at Managing Healthcare Costs, where an earlier version of this piece was published.

Your Doctor, Always Available, For A Monthly Fee

Your Doctor, Always Available, For A Monthly Fee

Dr. Jeff Gold runs a direct primary care office. (Jesse Costa/WBUR)

Dr. Jeff Gold runs a direct primary care office. (Jesse Costa/WBUR)

For 10 years, Jeff Gold, showed up to a job he wanted to love: being a family doctor.

“I was busy as a bee,” says Gold, 39, with 2300-2500 patients, seeing 20 or so a day.

Rushing, from one patient to the next, calling insurers who wouldn’t approve prescriptions, filling out paperwork that didn’t seem relevant to his patients, Gold kept asking himself, ‘is this what I signed up for?’

“I thought I was gonna help everybody and spend time with everybody and it’s impossible to do,” Gold says.

So Gold quit, wrote a business plan to be a doctor who does not take insurance, hired one staff member, a nurse, and borrowed almost $400,000 to outfit a two-exam-room office next to a candy shop and café in Marblehead.

Gold may be the first physician in Massachusetts practicing under a model called direct primary care.  For a flat monthly fee, Gold offers patients one hour, same day appointments, no wait. The doctor is available 24/7 in person, at the office, at the patient’s home, via text, email or Skype.

His fee is a sliding scale based on age. It starts at $30 a month for children age 0 to 21, and caps at $125 for patients 65 years and older. Patients get 12 visits a year. Anything more is a $20-$25 charge.

This is not concierge medicine, where patients typically pay to join a small practice in addition to their co-pays or co-insurance.

Gold takes care of anything considered primary care. If you need a few stitches, that’s included. If you sliced through a major blood vessel or muscle, you’ll still have to see a surgeon and still need a health insurance plan to pay for that surgeon.

Gold opened for business in February. He has 300 patients so far. Gold’s business plan shows he’ll turn a profit with 700-800 patients, a goal he says is achievable next year.

So who would pay an extra $75 or so a month for care that’s already covered by insurance?

“I’m willing to try,” laughs Steve Bird, and “see what happens.”

Bird, a 59-year-old commercial fisherman from Marblehead, saw Gold at the doctor’s former practice. He stopped by the new office to check it out, and because he has an earache.

Right away, says Bird, it felt different, “180-degrees different. I can see the doctor when I want to see the doctor, not when the doctor wants to see me.”

Dr. Jeff Gold and his patient Steve Bird, who is being examined for an earache. (Jesse Costa/WBUR)

Dr. Jeff Gold and his patient Steve Bird, who is being examined for an earache. (Jesse Costa/WBUR)

Bird might save money. He has health insurance, but his plan includes a $2,000 deductible, which Bird hasn’t met. So at a regular doctor’s office, he’d pay the total cost, $200-$300 for this visit and the procedure to clear wax out of his ear. But with Gold’s direct primary care plan, this visit is covered under the flat monthly fee.

“In the long run, I don’t think it will be any higher than what it is right now,” Bird says. “There won’t be the co-pays and the big deductible.”

But is this model, direct primary care, just a different way of paying a doctor or is it a new form of insurance? The state’s Division of Insurance is reviewing this question. At issue: whether Gold and doctors who open similar practices should be regulated as insurers and whether they need large cash reserves in case their patients get really sick. In the world of health insurance, this is known as managing risk.

13 states have passed laws that say direct primary care is not insurance, but the rules in many states are not clear. The Massachusetts Division of Insurance is investigating the question.

“From a consumer protection point of view, we at the Division have a role to regulate anything that may be an insurance risk,” says deputy insurance commissioner Kevin Beagan. “We need to understand whether there are any promises to provide services for a fee that constitute insurance.”

“We are a service,” says Gold, “not insurance.”

Many doctors share Gold’s frustration with 10-15 minute appointments and would be happy to drop from 2500 patients to about 750, as Gold plans to do. But that worries Dr. Michael Hochman who studies changes in primary care at UCLA.

“We already have a shortage of primary care clinicians,” says Hochman. “It’s possible that if too many patients get into situations like this it could exacerbate the primary care shortage.”

Hockman says there are a number of ways doctors are trying to fix primary care practices, including working in teams to reduce stress on doctors and give patients more attention.

On the question of whether direct primary care will make the primary care shortage worse, Gold says, “don’t blame the victim.”

Under the current system, he argues, primary care doctors are burnt out, changing specialties and retiring early. Many patients feel short-changed and aren’t happy.

“I really think it can fix this whole system,” Gold says,” from the ground up.”

mercredi 20 mai 2015

Why To Exercise Today: Researcher Says It May Slow Tumors

Why To Exercise Today: Researcher Says It May Slow Tumors

MilitaryHealth/flickr

MilitaryHealth/flickr


This just in from Runner’s World: Exercise Fights Cancer Tumors Directly.

A heartening headline, no? A great many caveats are surely in order — the eternal “rats are not humans,” in particular — but the piece describes interesting research suggesting that, to anthropomorphize a bit, tumors don’t like it when we exercise. From Runner’s World:

Kansas State University exercise physiologist Brad Behnke has been studying prostate-cancer tumor growth in rats that either exercise or are sedentary. As with humans, rats divert blood flow to the muscles when exercising. The result, in Behnke’s research to date, is a 200 percent increase in tumor blood flow during exercise.

That sounds like it could be a bad thing, at least if more blood flow “fed” tumor growth, and accelerated metastasis (spread of the disease to other organs). However, the opposite is what occurs, according to Behnke.

“When a tumor lacks oxygen, it releases just about every growth factor you can think of, which often results in metastasis,” he explained to Runner’s World Newswire by email. “Simply speaking, the tumor says, ‘I can’t breathe here, so let’s pick up and move somewhere else in the body.’”

When a tumor is bathed in oxygen, on the other hand, its activity tends to slow. In an earlier paper, Behnke demonstrated a 90 percent decrease in “tumor hypoxia” (low oxygen) among rats that engaged in long-term, moderate-intensity treadmill exercise. “As far as I know, this is the largest reduction in tumor hypoxia of any intervention, including drugs,” he said.

Another study by a different group of researchers has shown that aerobic exercise can lead to “normalization of the tissue microenvironment in human breast tumors.” In other words, exercise can help the tissue return to its pre-tumor state, or forestall development of a more aggressive and dangerous cancer.

Behnke is also exploring whether exercise could help make anti-cancer therapies like radiation more effective.

Hat-tip to Tom Anthony.

mardi 19 mai 2015

Financial Relief Finally On Its Way For Meningitis Outbreak Victims

Financial Relief Finally On Its Way For Meningitis Outbreak Victims

A vial of injectable steroids from the New England Compounding Center is displayed in the Tennessee Department of Health back in 2012. (Kristin M. Hall/AP)

A vial of injectable steroids from the New England Compounding Center is displayed in the Tennessee Department of Health back in 2012. (Kristin M. Hall/AP)

Lyn Laperriere, a retired automobile industry worker living in Michigan, was having back pain in the fall of 2012 when he received a dose of steroids produced at the former New England Compounding Center in Framingham.

Lapperiere was a drag racer and was looking forward to the winter bowling season. But a week after receiving the shot he checked into a hospital. Forty-two days later, his wife Penny Laperriere agreed to take him off life support. He was 61.

“We did everything together,” Penny Laperriere recalled. “So when he passed away, life for me came to a screeching halt too.”

Lyn Laperriere was one of 64 people who died after receiving a dose of steroids produced at the former New England Compounding Center in Framingham. (Courtesy Penny Laperriere)

Lyn Laperriere was one of 64 people who died after receiving a dose of steroids produced at the former New England Compounding Center in Framingham. (Courtesy Penny Laperriere)

More than two and a half years after NECC recalled all of its products after steroids the compounding pharmacy produced were linked to a nationwide meningitis outbreak, some financial relief may finally be on its way for the relatives of the 64 who died and the 750 who were sickened as a result of receiving injections of the tainted drugs.

A federal bankruptcy judge on Tuesday indicated he would approve a $200 million settlement to compensate NECC’s creditors, including victims of the outbreak.

‘There’s Been No Financial Help’

Penny Laperriere, who’s now 58, couldn’t afford to keep the house she’d shared with her husband. She had an auction to sell off the couple’s things and moved close to her sister. She’s received lots of bills, but no money to help with what became the deadliest case of contaminated medicine the country’s history.

“That’s the hard part, there’s been no financial help for me or any of the patients who are still living with this,” she said.

Laperriere started a support group for victims of fungal meningitis who’ve had to cash in retirement funds, file bankruptcy and still face mounting medical bills. Patients and those who lost loved ones will file claims for a share of the $200 million settlement beginning next month. Laperriere has no idea what to expect.

“Anything I get will be a gift,” she said. “I’m not expecting much because there are so many hands in the pot.”

Laperriere says she’s been warned that lawyers’ fees and liens from hospitals and insurers who provided care will eat up a good deal of the settlement. But lawyers who negotiated the agreement say it’s much better than they expected after looking at just the insurance and assets of the pharmacy owners.

“Many people thought there would be no way to craft together a fund, let alone a $200 million fund that would start paying back or compensating victims for their injuries and their loss,” said David Molton, an attorney with the law firm Brown Rudnick.

Victims Want More Accountability For NECC Owners

About $50 million of the settlement comes from former pharmacy owners. The rest of the $200 million is from organizations that contributed to avoid liability, including a clinic that administered the shots and a company that cleaned the compounding pharmacy.

Many victims and survivors are angry that they have suffered while the owners of the pharmacy have not been held accountable and are, in some cases, still living in their homes.

Attorney Bruce Singal offered a statement on behalf of New England Compounding Center’s former co-owner and head pharmacist Barry Cadden.

“No such statement can convey the profound sense of sadness Barry feels about these tragic events,” Singal said. “He can only hope that the settlement confirmed today can give the victims some small measure of comfort from the terrible suffering they have endured.”

Cadden and 13 other former employees or investors in the pharmacy are awaiting trial on criminal charges. They pleaded not guilty when arraigned last year.

Related:

Report: Judge Approves $200 Million Settlement Plan For NE Compounding Center Victims

Report: Judge Approves $200 Million Settlement Plan For NE Compounding Center Victims

A Massachusetts bankruptcy judge gave verbal approval for a $200 million settlement plan for victims of a national meningitis outbreak linked to the New England Compounding Center, the Boston Business Journal reports.

WBUR

WBUR

At least 64 people died, and over 750 were sickened due to tainted steroids from the NECC, according to the CDC.

A news release from lawyers involved in the case says that payouts to victims and other creditors could start before the end of the year:

Judge Henry J. Boroff of the United States Bankruptcy Court for the District of Massachusetts today said he would approve the Chapter 11 Plan of New England Compounding Center (“NECC”), the compounding pharmacy involved in a deadly national meningitis outbreak.  Under the confirmed Plan, approximately $200 million will be available to compensate NECC’s creditors, including victims who became ill or died as the result of receiving an injection of the tainted steroid. Over 98% of creditors that voted on the Plan voted to accept the Plan…

The Plan establishes a Tort Trust for compensating those persons that have suffered personal injury and/or death due to allegedly contaminated drugs compounded by NECC.

The Tort Trust will be funded by the proceeds of the Trustee’s settlements with NECC’s shareholders, various clinics and health care providers that administered NECC drugs, and companies that had business relationships with NECC. Those parties will receive releases from NECC-related liability, as well as injunctions in aid thereof, in exchange for their substantial contributions.  The Trustee and the Committee anticipate that distributions to victims from the Tort Trust may commence before the end of the year.

The Centers for Disease Control estimates that at least 751 people nation-wide have been diagnosed with fungal meningitis or other serious injuries as a result of the administration of NECC products.  At least 64 deaths have been confirmed.

Paul Moore, the Chapter 11 Trustee of NECC and a partner at the law firm of Duane Morris LLP, which also serves as his counsel, said: “My principal mission since the day I was appointed was to recover as large a sum as possible for the benefit of those who died or suffered serious injuries as a result of this tragic outbreak. I am pleased to have succeeded…”

Stay tuned for a more detailed report by WBUR’s Martha Bebeinger later today.

lundi 18 mai 2015

Ending ‘The War’ And Giving Up ‘The Fight': How Not To Talk About Cancer

Ending ‘The War’ And Giving Up ‘The Fight': How Not To Talk About Cancer

Not a good analogy for cancer: "A Battle Scene" by Luca Giordano, late 17th century, Norton Simon Museum. (Wikimedia Commons)

Not a good analogy for cancer: “A Battle Scene” by Luca Giordano, late 17th century, Norton Simon Museum. (Wikimedia Commons)


By Dr. Isaac Chan
Guest contributor

Hers was the face of someone defeated by cancer. Our conversation was grim. She wanted to “fight,” to continue treatment. But there were no more options.

I vaguely remember speaking, feeling hopelessly ill-equipped. I, too, felt defeated. As a young physician and aspiring oncologist, I wondered: How do we prepare ourselves and our patients for these conversations?

Thankfully, I am not alone in struggling with this question. A new theme in medicine has emerged: How to talk about dying. As a field, oncology has been at the forefront of this movement. Some suggest making exposure to end-of-life encounters mandatory during medical school. Others stress creating systems and providing more resources for patients and doctors to encourage earlier planning for death.

But in order to facilitate and advance this difficult conversation, we must first change the very words we use to discuss cancer.

When the National Cancer Act was signed in 1971, our nation’s political and social will was focused on a “war on cancer.” Our widespread use of this language is rooted in a propagandist history promoting the belief that, with enough resources, this is a conflict we will win. Consequently, victory became defined only by “defeating cancer,” or finding a cure.

A visit to the American Cancer Society website asks you to join the “fight against cancer;” and a majority of public cancer-related media is packed with more war imagery. While the war description of cancer has resulted in unprecedented attention and fundraising for cancer care, research and survivorship, a balance should be reached between these successful efforts and language that is a realistic assessment of what can be accomplished today, for the patient, right now.

Cancer is a unique disease. To take the war analogy further, cancer is not a foreign agent infiltrating our bodies, such as an infection — cancer is a coup d’état, a tumorous growth from within us. One of the great paradoxes of cancer treatment is that targeting cancer inevitably means targeting our own bodies.

Yet because we conflate cancer and conflict, physicians and patients often find themselves in the midst of an unintentional civil war, fighting for life to the very end. We have inadvertently created a culture where death is considered a failure, and life extension equals life.

It’s time we changed our rhetoric. Words affect perception, and for some patients, a “cure” is not always an achievable goal. Choosing words that no longer focus on cancer’s destruction gives patients and physicians the freedom to engage in discussions about other treatments such as palliative care, removing the suspicion that any course other than “fighting to live” somehow means “giving up.”

So how do we make this change? As with most things in medicine, it begins with the patient.

Once faced with a cancer diagnosis, the physician’s temptation is to start the patient down a pre-determined path of treatment. Instead, we should take a step back before pursuing the details of what to do next. A recommended but not often used script is to first ask the patient: What do you understand about your illness and what do you want to know? Who among your friends and family can provide support? What are your goals in life – both short- and long-term?

And while it creates a sense of camaraderie, we should avoid phrases such as “we will fight this” or offer vague hope. Rather, I caution patients with advanced cancer that therapy may be the life-saving option currently helping them achieve their goals, but there may come a time in the future when additional medical therapy will actually impede their enjoyment of life. This is akin to the technique of framing discussions in a way to hope for the best but prepare for the worst.

Physicians can guide patients through these discussions by involving palliative care specialists, whose role is to improve quality of life through symptomatic and psychosocial support. This support ranges from treating pain, insomnia, and anxiety to addressing spiritual needs and helping patients understand their disease and cope with related stress. Engaging their services soon after a cancer diagnosis has been shown to not only consistently improve survival, but also health literacy and other disease-associated outcomes, such as depression. Studies show that these effects even extend to patient caregivers.

However, a barrier to more use of palliative care is the misconception that palliative care and hospice are one and the same, that accepting palliative care means “surrendering” to the disease. While hospice focuses on end-of-life comfort, palliative care provides support throughout the spectrum of illness, from diagnosis to death. Once this concept is explained, palliative care is often more easily embraced.

The result of having these exchanges and involving palliative care early in the course of the disease is to break the false dichotomy between cure and failure. This strategy broadens the patient’s and physician’s ability to receive and provide care. But these are very difficult conversations and are filled with fear and anxiety. How does one address a patient who feels terrified when told to “prepare for the worst?” It is crucial for a physician to normalize these conversations, perhaps by saying “I discuss this with all my patients who face a serious diagnosis,” and then to provide reassurance that their patient will receive comprehensive medical care, whether it is curative, palliative, or both.

As physicians grow to embrace a more holistic view of cancer treatment, the public discourse surrounding death and disease must also evolve. Online tools such as “Let’s Have Dinner and Talk About Death” are a step in the right direction. Ending the “war on cancer” is another.

Let’s stop the talk of battles and instead raise awareness by celebrating the remarkable stories of those who succumbed to cancer and those who are currently living with cancer. As one of my patients eloquently told me, “Death is not a threat but the condition that maximizes my life.” Our medical interventions, while powerful, are not the only way to maximize life. And partnering with my patients to figure out how is the best part of my job.

Isaac Chan, MD, PhD, is a resident in General Internal Medicine at Boston Medical Center.

vendredi 15 mai 2015

Really? ‘Only A Game’ Questions NFL Medical Advisor On Football Safety

Really? ‘Only A Game’ Questions NFL Medical Advisor On Football Safety

(Kevin Domingue/Flickr Creative Commons)

(Kevin Domingue/Flickr Creative Commons)

I’ve said it before and I’ll say it again: A child of mine will play tackle football over my dead body. A young brain is too precious a thing to risk. And though the data are not all in, we know plenty about the potential brain damage of repeated head hits, including recent findings that linked youth football to cognitive impairment. Oh, and let’s not forget the 2013 study that found that a single season of contact-sports head blows could affect learning and memory.

So I was surprised to learn from an excellent commentary this morning by WBUR’s Bill Littlefield of Only a Game fame that a prominent Boston medical leader was touting football’s safety. From the Boston Globe here:

Dr. Elizabeth G. Nabel, the president of Brigham and Women’s Hospital and the National Football League’s new adviser, said Tuesday that football is safer than it has ever been, but she called on the NFL to commit more money to medical research and better educate the public about sports injuries.

Nabel, 63, in her first public comments as the NFL’s chief health and medical adviser, said that if her children were still young, she would allow them to play football. She noted that her son, now 29, played football in the eighth grade.

“I think football is getting safer all the time,” Nabel told reporters at the NFL’s offices in New York.

Really, Dr. Nabel? You’ll understand if I want to seek a second opinion — maybe from a former NFL player who can’t remember his own kids’ names.

Bill Littlefield’s commentary – As Concussion Crisis Mounts, NFL Turns To … Cardiology Specialist? — points out that Dr. Nabel’s impressive CV does not seem to include any expertise in brain trauma. He writes:

Experience as a hospital administrator would not seem to be the key qualification for a person charged with advising the heads of an industry where the most significant problem is a 30 percent rate of brain damage among the workforce.

He concludes:

She said she felt that “we’re at the beginning of understanding the long-term effects of repetitive head injury,” which means she’s in favor of more study, a strategy long favored by people who didn’t believe that smoking caused cancer.
She further said that she spends about one day per month and some nights and weekends working for the NFL, which is not surprising, because being president of an enormous hospital is a tough job that probably takes up a lot of time.
All of which suggests that the NFL is not so dumb when it comes to choosing a medical adviser.
They avoided a neurologist with experience in brain trauma who might have been able to devote more than one day a month to addressing a problem the league hopes you will ignore.

Readers, thoughts? Reactions? Read Bill Littlefield’s full commentary here and the full Globe story here.