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Wednesday, January 17, 2018

On not moving and other dangerous sports

I finally finished reading the many journals piled up on my dining room table, which have been shunted to other flat surfaces for projects or the visits of friends. I didn't read them all well, but I touched them all and read what interested me.

The early October edition of the Annals of Internal Medicine particularly caught my eye. There were two major articles that looked at determinants of health in a slightly different way.

The first used data from the Cleveland Clinic's electronic medical record to see whether the standard prediction calculator that we use to estimate a person's risk for cardiovascular disease works as well in poor as in not-poor neighborhoods. They found that it did not work nearly as well in poor neighborhoods. In fact, whether you have a heart attack or stroke is more determined by whether you live in a poor area of town than whether you have the traditional collection of risk factors for heart disease such as high blood pressure, smoking, diabetes and high cholesterol.

The second took data from a large and ongoing study looking at disparities in stroke incidence based on race and region. They used accelerometers to see what patterns of exercise and lack of exercise were associated with health, specifically heart attacks and strokes and death from these. As one would imagine, being more active is better than being less active. The average person in the study (all of whom were meant to represent average Americans) was sedentary for over 12 hours of a 16 waking hour day, sitting or lying around for over 77% of the time. But it didn't just matter how many hours a person was active in a day, but also how they broke up their sedentary time. It was best to be less sedentary, but if you were more sedentary it was best if you got up and moved around a bit every 10 minutes or so. The people who were less active and had longer bouts of inactivity were 5 times more likely to be dead at the end of 5 years than the people who were more active and had shorter bouts of inactivity. For the active people, it didn't matter that much if they had long episodes of inactivity, but for the inactive ones, it really mattered.

It is tempting to say that poverty and inactivity do not cause ill health, it is ill health that causes poverty and inactivity, but the authors did a pretty good job correcting for this. There may be other factors at work, and I'm sure there are, but it does appear that it is good to walk and move around frequently, even if briefly. It is also true that a person's health suffers in measurable ways when he or she is ground down by poverty. These studies highlight, once again, that efforts put in to making it easier to be healthy by improving the way people live may have benefits much greater than putting a similar amount of money or resources into providing healthcare once a person has already become sick.

Friday, January 12, 2018

Vitamin C and Sepsis: cheap and effective?

Sepsis is one of the most common diagnoses in our hospital that leads to admission to the intensive care unit. Sepsis is the syndrome that comes from uncontrolled, usually bacterial, infection and is not uncommonly fatal. Bacteria are everywhere and live in and on us, in balance with each other and supporting our bodily functions. Occasionally they invade our tissues resulting in infection. The body responds by releasing white blood cells which kill the bacteria by various mechanisms including producing chemicals that make us feel sick. These chemicals raise our temperature, cause our blood vessels to dilate, lowering our blood pressure and raising our heart and breathing rates. Sometimes this whole process causes kidney, heart and lung failure as well as delirium. The infections that can cause sepsis can involve all kinds of bacteria or other microorganisms and start in any of a large number of areas including the skin, lungs, kidneys, brain and abdominal organs.

Our usual treatment of sepsis involves finding the source of the infection and treating that if necessary (removing a diseased appendix or draining an abscess), giving antibiotics to kill the bacteria and giving fluids to fill up the blood vessels which find themselves empty because of being dilated and leaky. We often need to give oxygen because the lungs get wet and give medication that raises the blood pressure by contracting the blood vessels (pressors.)

Despite all of these treatments, sepsis is still sometimes fatal when vital organs fail in ways we can't reverse.

In June of 2017 Dr. Paul Marik, a very accomplished critical care physician trained in South Africa, Canada and the US, published an observational study from his practice at the Eastern Virginia Medical School about treating sepsis with vitamin C in addition to our usual routine. He had been frustrated to see in his practice that patients with severe sepsis were dying despite the best medical care. In one year 19 of 47 such patients died at his institution. When a patient is dying of sepsis it is possible to see it at the bedside, like a slow motion car wreck. The patient is delirious and often unable to breathe adequately. They are placed on a ventilator on supplemental oxygen. Their blood pressure is low and their pulse is high. They are given fluid and pressors in increasing doses which helps a bit, but the fluid leaks into the lungs causing them to fail and the pressors increase the heart rate and the heart beats more sluggishly and the kidneys fail so the fluid builds up further and they die.

Dr. Marik was apparently aware of pharmacology research in treatment of conditions like sepsis and was aware of animal studies showing improved survival with the use of vitamin C. The evidence is pretty compelling. He decided to try using moderately high doses of vitamin C along with thiamine and hydrocortisone, all of which have theoretical benefit it treating severe sepsis, in a patient who was clearly going down the tubes. The patient improved rapidly and survived the episode. He tried it a few more times and became convinced that it should be part of his routine treatment. After a year of using the Vitamin C 1.5 grams IV every 6 hours for 4 days or until discharged from the intensive care unit along with thiamine 200 mg and hydrocortisone 50 mg every 6 hours, the death rate from severe sepsis in his institution had plummeted, from 40% to 8.5%. He published this in an article in the journal Chest in June of 2017. It was picked up by news organizations and blogs and podcasts and has been adopted at many organizations. There has been reasonable skepticism because his study was observational rather than placebo controlled meaning that factors other than the new protocol could have been involved. A double blind study is underway to more clearly define whether his protocol is effective.

There is some history that leads us to be skeptical. In 2001, Eli Lilly released a biological product called Xigris (activated protein C) which was observed to have improved survival of sepsis by over 6%. It was terribly expensive and was eventually found not to be effective and to cause increased bleeding. It was withdrawn from the market. Several years ago there was evidence that tight control of blood glucose was good for pretty much anything that put our patients in the intensive care units, especially sepsis. Even patients without diabetes were often started on intensive insulin therapy and, after spinning our wheels with this protocol for over a year, it became clear that it was more likely to harm than help in most cases.

Vitamin C has been around for a long time. Linus Pauling, a Nobel Prize winner in chemistry, championed its use in high doses, orally, for prevention and treatment of all kinds of diseases. Research did not support use of high dose oral vitamin C and it faded from prominence. Vitamin C is not very well absorbed when taken orally. In patients with sepsis, vitamin C levels are very low. Vitamin C acts as an anti-oxidant, which makes the blood vessels behave more normally in septic animals, and perhaps septic humans as well. Researchers have also noticed low vitamin C levels in patients with trauma or severe burns or toxic exposures which have similar effects on the blood vessels. In animal models of sepsis, intravenous vitamin C reduced mortality.

A colleague of mine decided to try the vitamin C, thiamine and hydrocortisone protocol and convinced the pharmacy in our small hospital to stock intravenous vitamin C. It is not cheap, but neither is it expensive, compared to most of the stuff we use in hospitals for critically ill patients. A vial containing 25 grams of vitamin C costs around $100. Thiamine and hydrocortisone have negligible cost. My colleague was the first to use it in our hospital and felt that his patient got better more quickly than he had expected from previous experience without using this protocol. I have now used it about 3 times, with patients who were critically ill with sepsis, and they have done well. They get better faster and with fewer complications than we had seen before, but we are not doing a study and cannot be objective. Each patient I treat with sepsis receives care that is probably better than the patient before him or her because I have had one more experience to learn from.

There have been many changes in the last year in how I treat sepsis. I have been more wary of giving excessive fluid to my patients after reading several critical care physicians' critiques of high volume resuscitation, including Dr. Marik's. In previous years I had been very generous with fluids, such that often after 24 hours of "resuscitation" of patients with low blood pressures and sepsis they would have taken in over 5 liters of fluid more than they had put out, with ongoing waterlogging over the next few days. This led to uncomfortable swelling and slower return of normal body functions. It may also have been physiologically unhelpful in ways I had not noticed. I am more frugal now, and more likely to start pressors after moderate hydration. In my training we were taught never to give drugs that caused constriction of blood vessels (vasoconstrictors, pressors) by way of a regular intravenous line, but to always insert a central venous catheter. I am often hesitant to place a central venous catheter in my septic patients because it could lead to various complications and can be time consuming when time is crucial and uncomfortable to the patient. It appears that pressors can often be safely given via a good peripheral IV and so I am more likely to use them early. In addition to attending to supporting vital signs, I try to protect my patients' sleep and mobilize them earlier. I use fewer and different medications to sedate them, which makes their brains recover more quickly. Perhaps some of the improved outcomes I'm seeing are not entirely from IV vitamin C.

Nevertheless, it appears that vitamin C may be an important advance in treating severe sepsis. It is not likely to be harmful. There are ongoing studies which may or may not settle this question. Presently one study is looking at vitamin C alone. It may be that the cocktail including thiamine and hydrocortisone is more effective, or that an approach that combines many interventions will be superior when it also includes vitamin C. It is difficult to know and the studies may be difficult to complete as the standards of care change.

If vitamin C is shown to truly be helpful in sepsis, it will be in studies that are not funded by pharmaceutical companies. All large and convincing studies are expensive and vitamin C has been around for a very long time and profits no company to any great extent. It is amazing that it has even been studied, when you think about it. It appears to be pretty safe and I intend to continue to use it in severely septic patients until I see evidence that it doesn't work. I may even consider using it in patients with other conditions that cause fluid retention due to vascular leakage. I am not convinced that adequate studies will be done to generate evidence to guide my treatment, which is a small but significant tragedy, and due to the fact that we rely on pharmaceutical companies to fund research on drugs. This has led to disappointments such as Xigris, which have made us shy of innovation.

Tuesday, January 2, 2018

Menopausal Estrogen Replacement: can we start using this again safely?

Estrogen is a miracle drug for many women who experience the drenching sweats, sexual dysfunction and frustrating brain betrayals associated with entering menopause. It comes in expensive patches, less expensive pills or injections, as well as vaginal creams or rings. It has gone in and out of favor with the medical community for decades.

Estrogen is the main ingredient in most birth control pills and has been studied extensively in that context as well as in the setting of women whose ovaries have ceased to produce it as they age. It can increase the risk of migraines, blood clots in the legs or lungs, it can cause benign liver tumors and facial pigmentation. It causes growth of the endometrial cells that line the uterus and can increase benign and malignant tumors in that organ. Some breast cancer cells are sensitive to estrogen and can grow when they are exposed to it, so patients with breast cancer try to stay away from it. In addition to treating the annoying symptoms of menopause, it also increases bone strength and maintains a healthy vaginal lining.

In 2002, at the height of an era of estrogen optimism, when physicians mostly believed that estrogen was good for every woman after menopause, the huge Women's Health Initiative study (WHI) which had started in 1991, reported that the use of estrogen plus progesterone increased the risk of heart attacks, strokes and breast cancer. Doctors responded quickly, and there was a drastic decrease in estrogen prescription. Women still wanted the remedy that relieved their symptoms, but physicians insisted that they stop taking it or at least taper down to very low doses and warned them of dire side effects at each appointment. Eight years later, in 2010, an extension of the study was announced which showed that there were more benefits and fewer risks that had been reported. A nuanced approach was more clearly needed. In that year I wrote a blog which reported on the very mixed results of that trial. I concluded that estrogen was definitely not all bad and was clearly good for some people and for some indications.

This year (actually 2017, which is officially last year as of 2 days ago) another extension of the WHI was released. The article presenting the data can be accessed here.The editorial addressing the findings can be found here. The important points are:

  1. At 18 years after the study began, there is no difference in all cause mortality between hormone users and non-users. There is also no difference in mortality related to breast cancer, strokes or heart attacks.
  2. There still appears to be a striking difference between women who take estrogen alone vs. those who take estrogen and progesterone with respect to developing breast cancer. There is a slight increase in breast cancer risk among women who take estrogen and progesterone which persists after they stop. But there is a more significant reduction in risk of breast cancer among women who take estrogen alone. Women who take estrogen plus progesterone, however, are significantly protected against developing endometrial cancer.
  3. Women who start taking estrogen (with or without progesterone) around the time of menopause have a reduction in all cause mortality (their death rates were lower) during the time they were in the study. 
Sadly, the study, with its beautiful design and over 100,000 participants doesn't entirely answer the question in the title. It appears that taking estrogen and progesterone for about 5.6 years or estrogen alone for about 7.2 years was safe in the setting of this study. Perhaps it was even beneficial. The study did not, however, answer the question of whether taking estrogen for longer than this is safe or whether it provides more or fewer health benefits.

Taking a tangent to the story of hormone therapy for menopause, I would like to express great respect for Bernadine Healy MD who, as the new directory of the National Institutes of Health (NIH) in the early 1990's, secured public funding for the WHI. Such a large study was only possible through federal funding and has provided excellent long term guidance on various issues in women's health which had otherwise been addressed without adequate data. The results continue to accrue and we can expect to see new answers over the next several years, including benefits or lack of benefits for high dose cocoa flavanoids (think dark chocolate), exercise and other aspects of healthy aging. These are questions whose answers would not attract the monetary support of drug or device manufacturers and could only be answered with public support. May the NIH continue to have such good leadership.

Thursday, December 7, 2017

Charitable Giving (Plus musings on the 2017 tax reform plan)

'Tis the season

Every year at about this time piles of mail comes to my box asking for money. I look through the pretty envelopes, some with calendars and return address stickers, some with wrapping paper and greeting cards. Some have cleverly glued nickles or plastic membership cards so I can't recycle them without opening them. Occasionally there is an organization which has devised a new model of charity and I'm glad I looked a little further.

Giving to charity is a privilege which I have because I make more money than I spend. Not everyone has that luxury. Doctors, as a profession, are much better paid than most people in the world. We may have educational debts to pay off, but eventually we usually end up in the happy minority of people who have enough stored value to take care of themselves and their families and to feel secure if they live awhile past retirement. John F. Kennedy used to like the quote from Luke (this is the passage from the New Standard Revised Version, not JFK's) "From everyone to whom much has been given, much will be required; and from the one to whom much has been entrusted, even more will be demanded."

What is Money?
Recently I have come to have a different view of money than I had before. Money is just one way of storing value. It is convenient because it is usually lightweight and durable and it is now possible to represent it digitally, using credit cards or phones to transfer it from one entity to another. It is liquid, meaning that it can be quickly turned into something else like groceries or clothes or medicine. It also does no work while it is sitting around waiting to be used.

There are other ways of storing value which actually do work or give joy or provide comfort. These are usually not as liquid. Examples are stocks, which are ways of giving some kind of company capital for achieving some goal while expecting either a dividend or increase in value of the investment in return for tying up money. Stocks can be sold freeing up money, but the value of a stock is tied to the success of the company and so value stored as stock is volatile. Property is another way to store value. Property can provide a place to live or farm or be rented out for an income. It is not nearly as liquid as stock. Selling property takes time and is never a sure thing. Its value of can also go up and down. If it depends on things that grow on it or are built on it, fires and change in weather can profoundly affect its selling price.

Why not just put it all under a mattress?
The best value storage would be something that makes us happy, was a safe bet and could be turned back into cash whenever we needed it. The most durable way to make me happy is to make my family, my community and the world flourish. Here are some of the ways that this can work:

1. Invest in education: when I educate myself I become more productive. I get happier, better at what I do and when I am better at what I do I am less likely to burn out. I put as much money as I can into my children's education. It turns out I have kids who will turn education into value. This is fortunate. Having happy productive kids is an investment that is liquid, safe and makes the world a better place. There is a community music school in Concord, New Hampshire that pulls people of very different backgrounds to make good music so I support them. I also don't hesitate to donate to scholarship funds and would not vote against a school bond. I support candidates who support public education.

2. Invest in places to love and live: it made sense to buy a place for my kids to live rather than having them rent. The value of the property may be volatile, depending on who wants to live in that place in the future, but that investment provides shelter and a place for people to gather and make community. We have done some remodeling to make our house more accessible when we get old and wobbly and to make sure it can hold many visitors. The monetary value of these things may be unsure, but the real value is solid.

3. Charitable giving: giving money to organizations that share my vision for a more equitable and peaceful world is actually more of an investment than a gift if I do it right. Long ago I heard about a charity called the Potato Project. It is defunct now. They found food that would go to waste because it was surplus and routed it to places that needed food, nationally and internationally. It must have been really difficult, what with the fact that things like potatoes were perishable and that they had to deal with many different organizations, but I loved the idea and gave them money. Now there is a local project that has made national headlines called Backyard Harvest which gleans extra fruit and vegetables from local sources and distributes them via food banks and other programs. This combines community cleanup with a chance for adults and children to get out and do physical work together in order to provide really nourishing food for people in poverty.

Decades ago a the Heifer Project sent me a request for money. It was a novel charity that bought a farm animal for a poor family, trained them how to care for it and expected them to give one or more of its offspring to another family in need. This had a kernel of an idea that has become another excellent charity idea. Microlending including such organizations as FINCA provides low or no interest loans to people who want to start a project but don't have the capital to do it. The ones that got my interest initially were international, primarily lending to women who didn't have as much access to cash as men and tended to be more hard working and financially dependable. There are microlending organizations in the US as well, some of which even service the loans and give the investor a return on their money. When I was in Haiti in the tiny village I sometimes visit to help with farming and health projects, the community had started their own microlending bank, with no donated money, just a little cash box and ledger books. People who had next to nothing put money in, knowing that someday they might need to borrow some for a project or an unexpected death or illness. Money that we donated made it likely that more people could benefit from the loans, but the project was clearly self sustaining. Having this option for people in need means that when we go back, the community will be healthier and the limited money we have to donate will go to projects that can best benefit.

I like to give money to organizations which protect the environment. There are many ways to do this including the Environmental Defense Fund which engages in legal battles and the Sierra Club which has a myriad of projects. I like the approach of the Nature Conservancy which simply buys land to preserve it. That's a pretty expensive way to save a place, but it works. Locally we have The Palouse Land Trust which buys and protects local land from development. This makes it possible for everyone who comes here to walk in the hills and appreciate how amazing they are. We have the Palouse Clearwater Environmental Institute which teaches people about environmental issues and does stream and trail cleanup, has sustainable energy projects and more.

I give a large chunk of money every year to the Unitarian Church I attend. It sounds corny to give to a church, but it makes excellent sense. Without donations, the Unitarian Church would not exist. It has no product for which it charges and its services are free. It provides amply to the community by being a place that productive and concerned people get together to make good projects happen. It makes music in a way that everyone participates. Participatory music is one of the oldest ways that humans have bonded and it doesn't happen in many other settings. It provides counseling for people in trouble and mobilizes resources for people going through hard times. It makes people think about the big issues and pull away from the cycles of worrying and isolation. It needs to pay for heating and electricity and salaries of the people who work there. Walls must be painted and carpets cleaned and coffee must be bought and associated projects supported. The overhead is essentially nil. Every dollar that I give goes to something that matters.

I am associated with a Zen organization in Santa Rosa California whose teachings I benefit from, which means that my patients and my family and friends also benefit from them. Like my church they have no way to make money other than donations, so I donate. With money, peace and wisdom efficiently diffuses via wiser more peaceful students, without money, not so much.

Some of my charitable giving is in funding trips that I take to South Sudan and Tanzania to learn about their healthcare, teach ultrasound and treat patients. These involve large chunks of change, but they are the most clearly positive way I can contribute since, although the visits aren't necessarily sustainable, the teaching and learning are gifts that keep giving. The organization that supports the hospital I visit, Sudan Medical Relief as well as Doctors Without Borders needs money to keep doing what they do, so they get donations as well. A fully local Haitian group (Farming is life = "jadin legim se lavi peyizen") which provides community resources for farming and health gets a stack of cash when anyone I know visits, since they have no reliable way to get money from remote donors. Their work is essentially without any overhead or waste and completely self governed. Since the cash economy is not healthy in the little island of LaGonave it is difficult for a project to be truly sustainable at this point. 

There are charities that I used support and don't anymore, mostly related to my experiences overseas. I used to give to organizations like United Way and the Red Cross. I am sure that they do good work, but I don't know where the dollars go. I do know that money from large organizations with what appear to be deep pockets doesn't necessarily go to projects that sustain themselves. Overseas money is often diverted or spent to do projects at foreigner rates which are much higher than local rates. Donations are best when they act like a lever to make a bigger impact down the line, like a microloan to a small entrepreneur who creates a vibrant business rather than an overpriced bandaid on a preventable injury that will fall off in a few minutes.

The 2017 Tax Bill:
Recently a tax bill passed the senate which does various things with which I disagree. An under-recognized negative aspect is that it discourages people from "itemizing" by removing several ways which people can claim deductions and by increasing the "standardized deduction" which is available only to people who do not itemize. Itemizing is the way that people get a tax deduction from charitable contributions. When I itemize, I do not pay taxes on the money that I donate to charitable organizations. I will continue to give enough in charitable contributions that I will still be better off itemizing than taking the standard deduction, but many people will not. Itemizing has been a traditional way that people are encouraged to give to charity when they move toward being financially comfortable. Giving to charity has meant paying less in taxes. Often taxes pay for the same things as charity, but in a more roundabout way and far less efficiently. The opportunity to give to newer, more sustainable and efficient projects is up to legislators who may have very different priorities than individual taxpayers. I worry about the impact on organizations that are supported by charitable giving.

Overall I would encourage those who have become financially secure to turn stored value into things that sustainably create joy not only for ourselves but for the wider world. Give generously so that it is more than obvious that you should itemize, regardless of what deductions are pinched off. Spend generously on education, your own, your children's and through scholarship funds. Find local groups that have models of giving that you appreciate and give time as well as money. Give, as they say, until it feels good!

(Feel free to comment with other charitable organizations that you think are important to support. The projects I mention are in no way meant to be complete. For instance, I entirely forgot to mention Habitat for Humanity which is a great organization.)

Monday, October 23, 2017

Technology is unkind to the elderly

In about 1990 we got our first computer. I say "we" because my husband and I shared a desktop which I used infrequently. I mostly used it for word processing, and the internet was very young. At the turn of the millenium, my children were using computers and they were limited to 1 hour of computer time a day, which was on a shared desktop. By 2001 I was communicating with my grandmother, then in her late 80's, by email.

My grandmother had received, probably just prior to the millenium, an email machine from her son. It was a little thing on which she could type messages to a dear friend who lived in London. She loved the ability to spontaneously send him a message and get an answer in a day or less. She was a retired reference librarian and had worked in the Bay Area school system where an exhaustive knowledge of the Dewey Decimal System allowed her to connect students to the resources they needed. We thought she would be delighted to have an Apple Macintosh. With such a thing she could query the world of data and feed her insatiably curious mind.

This gift was a failure. Nothing about it was intuitive. Scrolling, clicking, using a mouse, returning to a previous screen, all were lessons that she had trouble learning. She would call one of us or her son when the screen inexplicably looked different than it had and she couldn't find her way back to something familiar. I think she started to die a little when she couldn't make that pretty white computer work. In retrospect she just needed the email machine.

A few years ago my father, now in his 80's, gave me an iPad which he had bought and didn't use. By guess and by golly (as my grandfather would have said) we managed to navigate its passwords and get it transferred over to me. It was cute, but certainly no more useful than a laptop, and rather delicate, so I gradually broke its screen and then it was stolen when I was in South Sudan. On a recent trip, my father showed me his new iPad, which he also didn't use, which he thought I might have use for. He had been seduced into buying it at an Apple store and, likely with the help of some bright millennial, had entered a new password and the answers to some security questions. Being wise, he didn't write the password on the machine itself, since he knows how important password security is, so it is gone. Also, having had a long and very complex life, the answers to the security questions were subject to shifting interpretation. Although he and I contacted customer service, there is no remedy. The pretty iPad with the retina display is now an attractive coaster or possibly something under which to press flowers. (Those of you with a penchant for problem solving will ask about "return to factory settings" or even "jailbreaking." I will just tell you that, after trying these things for 2 hours with someone of legendary computer cleverness, Apple has those options pretty well blocked.)

Technology, by which I mean computers of all sizes including phones and tablets and the like, offers incredible potential to people as they age. Music can fill their ears, raise their spirits and help them to frame their lives as brave and glorious. They can see pictures of far off places which they might not be able to visit again, talk to children and grandchildren while seeing their faces, access reminder notes, pay bills, review bank accounts, donate to charity, play games that tweak their brains in good ways. Computers, at their best, make our worlds larger and extend the capacity of our minds. This is just what we need as we get older. But computers, with their infernal passwords and vulnerabilities to security breaches, their little bitty buttons and sometimes tiny screens, their failing wireless modems and misleading advertising, are making the old feel older.

By the age of 85, about 1/3 of people have Alzheimer's disease, per the Alzeimer's Association. This, of course, vastly underestimates the proportion of elderly people with some kind of impairment in their memory, problem solving or ability to learn new tasks. This group of people need, more than we younger folk, to have access to their medical records and to use the wealth of online resources to remain healthy or monitor diseases. It is precisely the group whose health can most benefit from computers and the internet who are left out. Almost all of the elderly patients I see in clinic decline to use the computerized patient portal. Although I think that the portal itself is pretty easy to use, it is the many steps involved in getting to the portal that are daunting, so much so that our older patients hesitate to even try.

In the UK in 2012, the Prime Minister issued a challenge to make the country more friendly to patients with dementia. This included a Dementia Friendly Technology Charter. The Challenge includes making workplaces and communities more kind to people as their brains age, but also to help them get some benefit from technology. There are quite a lot of technological solutions to the problems of dementia, especially for caregivers, but I don't think that producers of hardware such as computers and tablets are stepping up to the plate. It is perfectly possible to create an iPad that doesn't depend of remembering passwords and reduces vulnerabilities to abuse while allowing users to access music and video chatting and photos and information. The UK has made some headway toward dementia-friendliness. The United States has no such challenge in place and from my vantage point, people are just becoming more marginalized as they age.

I would like to encourage the hugely successful producers of technology to respect their elders to the extent that they create products that will welcome them. The makers of software that is useful enough to become a necessity should think twice before requiring that users have excellent memories. And until our technology becomes more friendly, companies should develop remedies so that people who develop dementia (or have brain injuries) are not effectively shut out.

Sunday, October 8, 2017

How much do we love guns?

A letter written to JAMA (Journal of the American Medical Assn.) by Robert Tessler MD and colleagues at the Harborview Injury Prevention and Research Center in Seattle presented evidence that the United States'  approach to guns has significantly increased deaths from terrorism.

Using the Global Terrorism Database from 2002-2015 they found that, compared to Canada, Europe, Australia and New Zealand, The US has a considerably higher percentage of terrorist attacks that used firearms and firearm related terrorist attacks were more deadly than any other method, including bombs. Of the 2817 attacks in that time period, only a bit over 9% used guns, but these attacks were responsible for more than half of the fatalities.

It's not just terrorism that is more lethal using guns. Suicide attempts are much more successful if they are made with a gun. In fact, over 80% of suicide attempts made with a gun are effective compared to only 1.5% with drug or poison ingestion. Over half of suicides in the US are achieved with a firearm. Suicide is the second leading cause of death for Americans between the ages of 15 and 34.

Gun ownership is considerably higher in the US than in any other country in the world. We have 112 guns for every 100 people. The next runner up country is Serbia with 58 guns per 100 people and Tunisia has the fewest guns at 1 per 1000 people.

Citizens of the US appear to love their guns. Not everyone, but as a nation we are clearly very enamored. Our second amendment, standing right behind the first which grants us free speech,  allows for "A well regulated militia, being necessary to the security of a free state, and the right of the people to keep and bear arms." This was interpreted by the Supreme Court in 1939 to mean that there was a collective right to bear arms, as would be required to have a state militia, and so a law to make sawed off shotguns illegal was felt to be constitutional. In 2008 the Supreme Court interpreted the second amendment to mean that people had an individual right to bear arms and struck down a Washington DC law prohibiting ownership of handguns. Since that time states have expanded gun rights including, in some, the right to carry a concealed weapon without a permit.

There are federal laws that limit gun ownership, preventing some criminals, drug abusers, spouse abusers, children and felons from obtaining them, but state laws are spotty and many people who use guns to commit crimes obtain them legally. There are classes of weapons that people are restricted from owning, based on the idea that there is no reason for a law abiding citizen to need a machine gun or rocket launcher. The strictest of laws which prohibit gun ownership in some countries would be found unconstitutional in the US, but most Americans support some sort of increased restrictions on gun ownership. Taking peoples' guns away is neither practical or legal, even if a majority of citizens felt like it was a good idea.

People who love guns do so for various reasons. The primary quintessentially American reason is that we feel like it is important to have some physical way to prevent our federal government from controlling a helpless population if that government ever goes over to the dark side. I'm not sure this is really realistic given the very advanced weapons systems and surveillance that the military has at their disposal, but I suppose we could strategically make trouble in a guerrilla warfare sort of way.

There are hunters who like to have rifles of various sorts for sport. There are gun enthusiasts who just think that guns are incredibly cool and love the technology. There are civil war re-enacters who love their classic weapons. There are people who live in dangerous areas who believe that having a gun could deter an intruder. There are people who live in Alaska who very realistically know that a grizzly bear is probably watching them when they hike and may decide to eat them. There are also criminals and violent gang members who want to have guns so they can shoot and kill people.

For dozens of reasons, people in the US love their guns. Because of this we have lots and lots of guns and the guns get used to kill children, concert goers, rivals, wives, husbands, lovers, innocent bystanders, congressmen, police officers, the unfairly and fairly accused, newlyweds and so on. We may love our guns, but most of these deaths are intolerable tragedies. Do we really love guns so much that we are able to tolerate the over 36,000 deaths per year due to them? It appears that, since we have so many guns, people tend to use them. (Go figure.) Do we really need so many guns? We seem to have agreed that certain dangerous people should not own and carry guns. Can we just enforce those laws more effectively?

Seattle, according to an article I just read, has enacted a tax on guns and ammunition. This is a creative and constitutional way to address the sheer numbers of guns in circulation. They charge $25 in taxes per gun sold and 5c per round of ammunition other than 22 gauge which is only 2c. This has been repeatedly challenged in court and has so far stood up. We have also done this with cigarettes (which are responsible for over 10x as many deaths, but usually after protracted and ugly illnesses) with some success. Taxing guns may make ownership go down and perhaps even feed back to production to reduce that. It seems like a reasonable approach and could spread.

It seems like we should step away from partisan politics where guns are concerned and decide to engage in moderation. We did that 50 years ago with cigarettes when the surgeon general told us that they caused cancer. We should do it with sugar as well, as our population is becoming fatter and more diabetic. It is never easy to give up that thing we think we love that is really bad for us, but we need to think, as a nation almost perpetually in mourning over some shooting incident or another, if it isn't just about time.

Wednesday, October 4, 2017

Physician Burnout and Suicide

Physician burnout and physician suicide has been getting more attention in the last several years. Suicide among physicians is horribly tragic, and maybe moreso because of several factors. Suicide is the quintessentially most preventable fatal event. In order to prevent suicide, the person killing him or herself needs only not do it. To anyone who knows the victim/perpetrator it seems that if only the right words had been spoken, the right sentiment expressed, comfort offered, their death would not have happened. Among the family and friends of a suicide, this is one of the agonies that is added to the pain of loss. Physicians have a huge number of close contacts, patients and coworkers, who have a pretty intimate connection with them, all of whom mourn their loss and many of whom question whether they might have had something to do with it. Beside the emotional impact of the loss is the very real fact that physicians are responsible for some part of the care of potentially thousands of people who are left stranded by their abrupt departure. There is the very sad fact that someone whose job it was to help people was unable to get the help they needed.

It is not clear that physicians commit suicide at a higher rate than people in other professions, according to a report by the CDC last summer, and although it is the number one cause of death among male medical residents per a study that was released this year, their suicide rate was lower than average for their age group. Although burnout is clearly increasing among physicians, I have not seen any data that shows that suicide is increasing.

I have been a witness to the kinds of stresses that lead to suicide in physician colleagues. So far, knock on wood, none of the doctors who work closely with me have committed suicide. I have, however, been around some pretty spectacular cases of burnout. According to a Medscape poll, 40-60% of physicians show signs of burnout. Surprisingly, the major problem they complained about was the excessive bureaucratic tasks that they had to do. It was not the stress of making life or death decisions but the grinding demands of the computer, the paperwork, satisfying insurance companies, convincing organizations that monitor quality that they were delivering it. Other frequently mentioned complaints included extended work hours and feeling like they were just a "cog in a wheel." My experience is that it takes more than a bad job to push a person over the edge, though. But life is pretty good at offering that little bit more. The breakdown of a marriage, a child with troubles, an illness can take a person who is competently holding on with her fingernails and plunge her into failure. Alcohol and drugs provide respite and destroy that last pretense of being able to do the work. The colleagues I've seen go through this usually step away from practice and may or may not return.

My worst times were early on in my career. During my first year in medical school, I comforted myself with the thought that if things got too bad I could just jump out of the tenth story window of my dorm. After awhile I replaced that with deciding that I would  just go live with my sister and cook for her. The first year was bad because there was just too much stuff to learn and if I stuffed my head full of it, as I needed to if I was going to pass my tests, I couldn't sleep. If I couldn't sleep I couldn't stuff more information into my head so I walked around gripped by fear of failing. Occasionally I was distracted from my misery by some of my really excellent teachers and was eventually saved by a prescription for sleeping pills. These I hoarded and doled out by the fragment so I wouldn't have to ask for more. A boyfriend and increasingly close friendships helped make the second year almost imperceptibly better. By the third year the opportunity to interact with real patients and be of use cured me. Training continued to be stressful, but there was always something rewarding that came back to me from grateful patients or collegial professors which gave me the joy I needed to make the process sustainable.

After completing my residency, I took some time off to find the right job. I got a house with the man who would eventually be my husband and a big yellow dog. The position I finally found was good, though demanding, and I enjoyed learning from other physicians at my work who had different skill sets than I did. I was able to keep up and felt I did a good job. Burnout threatened when my workload increased and I felt like I couldn't keep up. There was always more that I needed to do at work but home needed me too. Having a baby actually helped because the woman who we hired to help take care of her was wonderful and made me feel like home was well taken care of.

Six years ago I transitioned from a pretty sustainable to a very sustainable lifestyle, doing shift work as a hospitalist. My children have fledged and I no longer need to help them with their homework after work or worry about childcare if they get sick. I still do some outpatient medicine, but have not been sucked up into the complexity of documenting for merit based payment or pay for performance systems. I did go through the growing pains of adopting several computerized health records, both inpatient and outpatient, and have experienced first hand how that can make everything seem impossible.

I can see that in a clinic system where an employer was pushing the physician to see more patients in an hour and patients were pushing back to get what they need, administrative tasks could be a big part of burnout. The recipe, I think, for burning out is one cup of impossible and maybe conflicting demands and several tablespoons of feeling like something terrible will happen if you don't meet those demands. When the demands are from both home and work, things get pretty grim pretty fast. If the work is not rewarding, as it would tend not to be when you can't do it properly, then there is no joy to counteract the stress.

Medical offices and hospitals right now are in a time of transition, which makes things particularly bad. We are moving toward making computers do the work that humans find tedious, but the interaction of computers and people is still awkward. We end up doing lots of the work that the computers eventually will be able to do themselves, keeping track of nearly endless and very complex data, remembering schedules invented and tweaked by organizations charged with optimal care for chronic diseases. We are wrestling with computers instead of doing the human job of reading people and helping them solve their problems.

It is not entirely our jobs which lead us to the brink of suicide and beyond. We are humans with sadness and stories and connections which can be difficult or even crushing. But we can make the job part of this much easier. We need to allow computers to do what they do best and have doctors do doctoring. We need to figure out how to unhook a doctors monetary compensation from how many patients we see, so we can keep those patients healthy and out of our offices and hospitals where they belong. We need to not take on more than we can do well, even if that means saying "no" to the person who writes our paychecks.