Grand Rounds - the best of 2006

Dang. Because of holiday activities, family visits, and irregular Internet access, I fell asleep at the switch and missed my opportunity to contribute to a year's best edition of Grand Rounds, but please check it out in any case. Nick Genes has once again done a superb job of corralling the impressive talents of the medical blogosphere.

Happy reading and happy new year!

Jet lag: science, maybe... but still mice

Today's Washington Post health section features an article that describes - sort of - a research paper on jet lag in mice. The study found that a majority (53%) of elderly mice died (compared to 17% of control mice) after being subjected to a simulated Washington-to-Paris flight; the simulation was done by tweaking light exposure. The rest of the article consists of a non-scientific discussion of how lousy jet lag feels, along with anecdotes from frequent flyers, suggestions of how to prevent jet lag, and a little bit of speculation about effects of light changes on biological clocks.

What I liked: the article puts the new research into context regarding jet lag, some information on its biological effects, and other human studies on (possibly) related effects of shift work. What I didn't like: Extrapolation from humans to mice, and back again. What evidence is there that humans and mice might react the same way to jet lag? Lack of important details on the scientific article - what else did the study measure besides death, which might actually improve our understanding of the biology involved? One of the strengths of animal studies is the opportunity to collect detailed information on brain and other organ function, hormone fluctuations, etc. Finally, aren't there other aspects of airplane flight besides light exposure that could affect health? Dehydration, for example?

An earlier article I found from HealthDay news service via Gannett and USAToday focuses a bit more on the research, and cites some jet-lag research in humans. The writer gives the study's author the last word:

For now, Block isn't recommending that anyone stop traveling. But, the findings should make people more alert to "the fact that time-zone changes can be stressful" and require proper rest and recovery, he said.

Once again, extrapolating back to humans. And while this one is innocuous and qualified enough, why does every bit of research reported in the media have to include a health recommendation? I'd think it would be just as compelling to describe in more detail how the mice experienced jet lag - did they travel first class? drink red wine from plastic cups? have a choice of peanuts over pretzels? And were they told ahead of time that they weren't actually flying to Paris, that it was just a simulation? I'm just saying.

Bottom line: If you want to write about jet lag, please do, but this study isn't mice isn't ready for prime time and in my mind doesn't do much to advance our understanding, at least for readers outside the field.

Necessary but not sufficient

Ezra Klein today reports in the Los Angeles Times on positive developments on the path to universal health coverage in the U.S. Several of these developments were new to me, so I'm grateful to learn about them. And thanks to my Canadian friend Sol, who I know would like to see the U.S. come to its senses, for pointing me to the article.

I do think we need universal coverage, but I don't think it's enough to solve the mess that is health care in the U.S. It won't solve our problems with quality of care, disparities, or cost-containment, though as Klein points out, cost-shifting would be reduced as the uninsured will no longer be forced to delay basic care and obtain it from emergency rooms.

I'm a little skeptical of some state efforts, such as Massachusetts' new requirement that everyone be covered, an initiative sponsored by Republican governor Mitt Romney. Under the new law, many state residents won't be able to afford coverage, or at least meaningful coverage, according to Physicians for a National Health Plan. It does, though, help the insurers expand their market. Cost containment? Unlikely; the plan sounds like another form of cost-shifting to me. And on a national level? We shall see. The insurance industry, who are promoting their own (lousy) plan for expanding coverage (see my previous post, under 'Expanding Coverage'), were powerful enough to deep-six - abruptly and completely - our efforts at single-payer health care, led in the early '90s by the Clintons.

health insurance
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Grand Rounds

Please check out the current edition of Grand Rounds at Nurse Ratched's Place, with a Charlie Brown Christmas theme. Well done, Mother Jones, RN!

Cartoon encapsulates elder care

I admit it; I'm a diehard fan of the sweetly sentimental, but funny and true-to-life Canadian strip For Better or For Worse, and after my email it's the first thing I look at every day. (The other strip I look at is Zits, a not-too-exaggerated look at life with a 15-year-old boy.)

Have a look at today's strip (or click on Dec. 15, 2006 if you're looking at this after today). Backstory: the old man has had a stroke, and can't speak, and he's pretty unhappy about it; his wife, Iris, does all the talking for him and gives most of the care. The strip highlights three key issues: 1. Doctors throwing pills at depression, even when people (especially elders) are already taking a slew of other pills. 2. Caregiver burnout. 3. The need for human connection and support.

Apparently, in what will be a loss for the rest of us, For Better or For Worse cartoonist Lynn Johnston and her strip are going into retirement very soon.

"Startling" - if true

The New York Times online reported today that breast cancer rates (for "the most common form of breast cancer," not specified) in the US dropped 15% from August 2002 to December 2003, and the only explanation the experts can think of is that use of hormone therapy dropped off sharply after the results of the Women's Health Initiative were released. Here's the press release from the MD Anderson Cancer Center; I couldn't find the context for the 15% but I trust that the author got it from the investigators. (Note: That's one of the tricky things about news reports on unpublished data.)

The report is fascinating. It really is a bunch of experts - evidence-based experts at that - sitting around saying, in effect, "Huh. Yup. I guess that's what it must mean," but tentatively, because, as one of them points out, epidemiology (or non-randomized observational studies) cannot prove causation. Particularly this type of study, of ecologic design, which compares population-wide rates of hormone use with cancer incidence. The drop in hormone use is what some people - environmental scientists, for example - call a "natural experiment." The Women's Health Initiative was the only randomized study (read: experiment) to look at health effects of hormone therapy (Prempro, specifically), and breast cancer was one whose incidence was slightly elevated, along with heart attacks, stroke, and blood clots. The Wyeth spokesperson interviewed for this article was skeptical of the explanation, and said that more studies need to be done; sure (see below), but there is not going to be another study on the scale of the WHI to replicate a causal relationship. Sorry.

A good point made in an AP article is that stopping hormones may in part have slowed the growth of existing tumors, which could still come to light at a later date. Another factor to look at is screening, but you'd really have to see dramatic changes in screening utilization to explain these results. Clearly, there's a lot more interesting work, and closer looks at the numbers, to be done on this finding.

Questions: Is the observed 15% drop comparable to the magnitude of increase of breast cancer incidence seen in the hormone arm of the WHI, given competing causes of breast cancer (which, to be honest, we don't really understand) and given the 50% drop in hormone use? Could tamoxifen use explain some of the decline?

Also, have there been concurrent drops in heart disease and stroke? We don't collect those data as systematically as we do cancer incidence (via the Surveillance, Epidemiology, and End Results system), but I imagine that cohort studies such as the Nurses Health Study will be able to look at these conditions.

breast cancer
hormone therapy
health news

Health Wonk Review

The newest edition of Health Wonk Review is up at the MSSP Nexus Blog. Check out Managed Care Matters, in which Joe Paduda discusses the tradeoffs between cost, quality, and patient responsibilities.

This week in health care policy

The 109th Congress passed seven health care-related bills before wrapping up for the year, as summarized at Kaisernetwork's Daily Health Policy Report. According to AAAS' Center for Science, Technology, and Congress, the NIH Reauthorization Bill, HR 6164 increases NIH's budget by 5% for each of the next three fiscal years. It also creates a "common fund" for research that falls across different disease areas, or beyond the purview of individual institutes. Much of the health care quality improvement research I've written about could fall into this category, so with luck we'll see fewer such projects fall been the cracks.

Pay-for-Performance (P4P) is now a reality... or it will be as of July, 2007. One of the bills passed by Congress this session (HR 6408) gives physicians a 1.5% bonus just for reporting data on certain quality-of-care measures. According to Kaiser, Rep. Henry Waxman doesn't think federal officials know enough about how to measure quality to make P4P meaningful. The conservative Heritage Foundation, on the other hand, thinks it takes autonomy away from physicians. MedPAC, not surprisingly, wants docs to get a bigger cut for reporting.

I'd say elements of both criticisms are true, but both also lack nuance. The federal government actually has a fair amount of experience measuring quality, as evidenced by HHS' Hospital Compare; whether such measurement translates into improvement remains to be seen. Regarding Heritage, we know that when physicians are entirely left to their own devices, non-evidence-based care can result. However, requiring levels of 100% compliance for given quality measures can result in too much medicine, and also does not leave room for patient preferences as well as physician autonomy.

That's not the case with this bill, however, which is the easy part - it only involves the reporting of quality data. The achievement of particular levels of quality, though, is down the pike. Bottom line: proceed with caution.

The Institute for Healthcare Improvement, led by Don Berwick, on the heels of their 100,000 Lives campaign, has just launched their Protecting 5 Million Lives from Harm campaign. The goal is to encourage hospitals to implement straightforward reforms to improve patient safety by setting firm goals. One can quibble about the numbers achieved by 100K Lives (as the Wall Street Journal did, described and attached here), because while it's hard to pinpoint the cause of a death, it's even harder to attribute accurately the cause of non-deaths. As the WSJ article said, many people "admire [Dr. Berwick's] goals, but question his number." However, that campaign did engage 3/4 of the hospitals in the U.S., which is a success in and of itself. The new campaign, basically an extension of 100K Lives, will have an opportunity, one hopes, to mobilize hospitals to institute life-saving patient-safety measures and not present estimates of lives saved before the numbers are ripe (i.e., peer reviewed).

Grand Rounds

This week's medical blogging Grand Rounds is up at Anxiety, Addiction and Depression Treatments. TheEditorInChief has done a great job of categorizing and summarizing a wide variety of posts. (As of deadline, I was still recovering from my hosting gig last week, so nothing from me in there.) Anxiety etc., by the way, in addition to offering a great breadth of information on addiction and mental health, has a heck of a blogroll that I need to spend some time investigating.

Cell phones still not linked to cancer

The Knight Science Journalism Tracker has done a nice job of wrapping up the news coverage of yet another update of the large Scandinavian epidemiology study in this week's Journal of the National Cancer Institute.

I don't know whether people are still worried that cell phones cause cancer, but they sure don't seem to be worried that cell phones cause traffic accidents.

Doctors communicating with patients -what's the right amount of information?

I was a little annoyed at my doctor's office recently - just a little. I was having some odd symptoms and, being a little neurotic, I had done a bunch of reading on Graves disease (which my sister had) and perimenopause and went in to have my hormones checked. My doctor, being an agreeable person, agreed with me that these were reasonable things to look at and sent me away with the appropriate lab slip (or maybe they drew the blood themselves, I can't remember now). He finished up with "No news is good news," which is what he always says - it means I don't have to call in, because if the test is negative, they won't call, but if it's positive, they will.

Now, I never trust that system to work, so I always call anyway. But this time, the person who answered the phone, after pulling out my chart, said "Everything's fine." I had to prompt her for more information, and for that, she had to ask the tech to call me with the actual results. The tech then said, "Everything's fine; the tests were negative."

Negative for...? Actually, the tests I had were supposed to report a hormone level that was part of a range. Presumably, different parts of the range had different meanings. I said, "Can you be a little more specific?"

"Your thyroid hormones were normal, and your estrogen levels were normal." Normal for whom? In what context? Any uncertainty? I gave up and made another doctor's appointment. Not having met my deductible for the year, I was paying good money for those tests. The sum of what I got from the doc was more reassurance that everything was fine. Maybe I was overintellectualizing what to him were just negative results, but never did anyone offer to go over the actual numbers with me, and their meaning in terms of the possible range of values, and whether there was any uncertainty in the tests. I asked a few more questions about perimenopause, and got a couple of useful answers, but, in addition, there was still no further light shed on my symptoms, and in the end they mostly went away and I decided not to worry about it. So I didn't have Graves disease, nor was I perimenopausal, at least according to those tests.

So even though I was, in the end, somewhat reassured, sometimes I'd just like to understand what's going on, and possibly armed with information to make choices. Is that unreasonable?

In this month's issue of GoodBehavior, Jessie Gruman, Executive Director of the Center for the Advancement of Health addresses this very topic.

In this new world of "personal responsibility" and perplexing health care choices, the accurate communication of the risk of treatments and tests is going to be as important as any new vaccine or miracle drug. Even if message-communication improves, message-comprehension may not.

As a patient, I need to have a choice between knowing the bare minimum and then asking my doctor to recommend an action and having the full range of trade-offs out on the table and subject to discussion until I am comfortable with my choice.

Was my doctor assuming I wouldn't understand the complexity of a message, did he feel inadequate to try to explain, did he not have enough information (or knowledge) himself, was he pressed for time?

Ultimately it's a tricky dance between two humans. Finding the right balance is hard. I don't want to have to change doctors every time someone doesn't communicate quite the way I'd like, but I also don't want to have to always push, repeatedly, to get the information I need. And to be honest I don't always know what I need to know.

Grand Rounds, Volume 3, Number 11

Welcome, all, to this week's Grand Rounds. Thanks to everyone who worked with me to get the party started - what a great group of bloggers! As of tonight, I've had 37 submissions. Alas, I can't fit them all in with comment, but I will at least link each somewhere in the post.

In the Trenches

I love the stories from the front lines of practice.

Protect the Airway tells a compelling story about saving a cancer patient from an overdose of pain meds, and rising above judgment to give her the care she needed in while treating her like a human being.

Kenneth J. Trofatter describes the role of prenatal aneuploidy screening and patient counseling in making a tragic birth outcome a little less difficult - moved me to tears!

Sid Schwab of Surgeonsblog muses on the real-life tensions between surgeons and medical types; the real thorn in his side is internists referring to what they do as "cognitive work," which seems to imply by contrast that surgery is non-cognitive.

On a cheerier note, GruntDoc demonstrates what young wannabe docs can do to make an impression on him - a little sucking up never hurt anyone.

Kim at EmergiBlog offers docs for a little consideration, please - clean up your own sharps, for starters - and let her do her job, and do it safely. Furthermore:

I can appreciate the fact that you find the nursing notes indispensible. I’ve worked with doctors who could not have cared less if I had written haiku all over the front of them, so your appreciation of my documentation is admirable.

Your willingness to take my notes from me at any time, regardless of how critical my patient is or how imperative it is for me to chart-as-I-go is NOT admirable.

Scalpel or Sword recounts the unorthodox career path of an ER doc - don't judge him because of his training!

Research
Hsien-Hsien Lei at Genetics and Health reminds us that, hello, the genome is complex, people, so don't be shocked by phenomena such as copy-number variants.

The genome is already interesting and complex enough without the need to overdramatize it.

That means not just the media, but you, too, scientists.

Yes! Steven Palter, docinthemachine,
tells us how you to live to 100: just make sure your mom is under 25 when she gives birth to you. Oh... wait a sec... Anyway, IF that association holds up (I'd love to see the epidemiology study - can someone find me a copy?), and IF you have access to a time machine, the secret is in the telomeres.

Dr. Anonymous briefs on this week's new research findings on chemo-brain - now there's evidence of a neurologic basis for the phenomenon; with luck, the findings could spur further research to understand and address the problem.

Policy, Public Health, and Insurance

Bloggers interviewing bloggers - what a great idea. Nothing like a good one-on-one dialogue to add show-biz sparkle to a blog. I don't know about you, but I'm picturing Jon Stuart or Ellen DeGeneres behind a big desk, with, oh, Maureen Dowd or maybe Sting in the hot seat. Even if the interview actually occurs via email. A mutual admiration society, you say? Sure, why not?

To that end, rdoctor interviews Hank Stern of InsureBlog, where Hank offers some opinions on health insurance and the health care crisis. Then Hank offers his own post: further thoughts on the recent survey of Americans regarding who should pay more for health insurance.

Colorado Health Insurance Insider bemoans the waste of money from "routine" childbirth procedures like episiotomy (no longer recommended as a routine procedure, by the way) and unindicated cesarean sections. (I'd add that the docs blithely disregarding prior discussions with moms in these cases is pretty egregious as well.)

Dr. R.W. Donnell, in Notes from Dr. RW, urges readers to beware of "woo" - scientifically unsupported alternative medicine - particularly when it's combined with allopathic offerings. Dr. RW, and others, I'd like your thoughts. Not to plug alternative medicine - ANY modalities used on patients should be tested if possible in randomized studies - but how can patients be sure that "standard" procedures and treatments are evidence-based? What about that full-body scan, or the drug that's been around so long no one's ever tested its safety in an RCT? Is that not, in effect, a form of woo, too?

Fixin' Healthcare offers some thoughts on the role of academic medical centers in health reform. I'd like to hear more about this!

Then in Tales from the Emergency Room and Beyond, Cous in CA makes a case for offering the human papillomavirus (HPV) vaccine to men...

while The Blog that Ate Manhattan takes HPV test manufacturers to task for undermining the doctor-patient relationship.

Health Business Blog offers some thoughts on how to make biotech drugs cheaper, since the difficulty in standardizing their manufacture makes it hard to produce viable generic alternatives.

And finally, let's have a belated moment of silence in honor of World Aids Day (Dec. 1); Dr. Deborah Serani offers a few facts and figures to ponder.


Adolescent Health

Mother Jones at Nurse Ratched's Place offers a tough-love approach to misbehaving adolescents and the parents who let them get away with it. Not in my hospital, she admonishes.

Andrea Giancoli of The Family Fork ponders bariatric surgery for teens - is it too risky for kids?

And in a bit of news sure to stir up discussion, Nancy Brown at Teen Health 411 tells of web-based networks (e.g., via Facebook) of people who'll buy Plan B for underage women, no questions asked.

The Patient Perspective

Good for Amy Tenderich of The Diabetes Mine - she's written a guidebook for diabetics on managing their care, in collaboration with Dr. Richard Jackson of the Joslin Diabetes Center in Boston. The book takes into account disparities in diabetes care, and how hard it is to keep up if you're among the 90% of patients who don't meet the ideals of blood glucose, blood pressure, and cholesterol.

Six Until Me describes an intimate moment of mutual caring, in which a man administers his partner, who is a diabetic, her insulin for the first time. Some excellent writing here.

Hands-on Advice for Practitioner and Patient

Jolie Bookspan in The Fitness Fixer presents a strength and balance exercise that involves sitting on the floor (and getting up again) without using your hands. Harder than it sounds!

Not My Second Opinion offers practical tips for patients and docs on how to deal with wounds. In the blogger's perspective,

I'm fond of scars. They impart a sense of history with pain and suffering, then regeneration and recovery. They mark a person as different and the scar-bearer is changed forever.

For parents, some myths about child safety from Dr. Enoch Choi...

and a post from Clinical Cases and Images on the limits of treating anemia in chronic kidney disease.

Mental Health

If you were dying of cancer, you'd be mad, too, says Dr. Crippen, the NHS Blog Doctor. He asks for common sense in mental health treatment, as well as hospice care, for the terminally ill, and spare him the political correctness.

Tales from the Womb recounts an encounter the writer had with a patient who goes on at great length to demonstrate to the doctor that he is Jesus Christ. This excerp is nice:

“You're telling me that you are totally drug free, right now, as we're sitting here talking?” I found this much harder to believe than the fact that he thought he was Jesus Christ.

Thank goodness, some hope in a depressing world. JonMikel, MD, at Unbounded Medicine presents a new treatment for depression. Harmless, though? I don't know... I still think I'd like to see the RCT data - what if you get hit over the head with one?

And some words from the Anxiety, Addiction and Depression Treatments, advocating for better mental health treatment for prison inmates and parolees.

Combating Hype in Health News

Two bloggers after my own heart:

Sandy Szwarc at the Junkfood Science carefully takes on media flogging of the benefit of folate supplementation in lowering homocysteine levels (another alleged benefit), for preventing heart disease. She also takes the media - and the federal government - to task for misrepresenting the risks of the so-called "obesity crisis."

Paul Auerbach at Outdoor Health regrets the hype surrounding an "attack" on a trainer by an orca (killer whale) at Sea World - they're wild animals, after all, not house pets.


Spirituality

Last two. Then can I go to bed?

In Rickety Contrivances of Doing Good, Susan Palwick - a wonderful writer - describes the role of the ER chaplain...

and Cynthia King at Cancer Treatment and Survivorship offers guidance on spiritual help that family members can offer relatives with cancer.

Whew!

And for completeness:

The Neonatal Doc
MSSP Nexus
Sumer's Radiology Site

Next week's Grand Rounds will be hosted at Anxiety, Addiction, and Depression Treatments.

Pre-rounds interview

Thanks very much to Nick Genes for interviewing me at Medscape. (You may have to register to see the link, but it's free.)

Deadline reminder

Just a quick reminder that your Grand Rounds submissions are due to me at emily [dot] devoto [at] gmail [dot] com tomorrow, Sunday, Dec. 3, at 6 pm EST.

Keep 'em coming!