It’s been more than a hundred and ten years since Marie Currie and her colleagues discovered radium and coined the term radioactive. Currie’s groundbreaking work on ionizing radiation would cost her her life. Since then and great realizations have been made about the therapeutic and disastrous effects ionizing radiation promises.
We’ve gotten smarter, more sophisticated, more skilled at manipulating radiation to do the most benefit in medicine and minimize harm. Ionizing radiation has spurned two whole medical specialties. Doctors now describe themselves as radiologists or radiation oncologists. Whole technology has arisen to more precisely diagnose diseases with radiation and to treat them. Radiosurgery, the use of linacs like the Gamme Knife or Cyberknife to more precisely target pathological areas and spare the normal, has been a huge development.
Of course the more technically complicated medicine gets, the more places things can go wrong. Nowhere is medicine as technically savvy or complicated than in in some of the ways we deliver radiation to patients. And, while admittingly slightly alarmist, the New York Times had a recent expose reminding us of that.
At a VA treatment facility in Virginia,
56 patients were treated incorrectly for cancer of the prostate, head and neck, lung, breast and two other malignancies. Thirty-six had been overradiated and 20 more subjected to “errors in technique,” the hospital said.
reported in 2008 that among hospitals seeking admission into clinical trials, nearly 30 percent failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck. The hospitals were all using I.M.R.T., which shapes and varies the intensity of radiation beams to more accurately attack the tumor, while sparing healthy tissue.
“This is a sobering statistic, especially considering that this is a sample of those institutions that felt confident enough in their I.M.R.T. planning and delivery process to apply for credentialing and presumably expected to pass,” said a task group investigating I.M.R.T. guidelines for the American Association of Physicists in Medicine.
Not to quote a comic book or a Sam Rami film but with great power comes great responsibility. To err is human, but we shouldn’t accept it. Every error in medicine is something precious lost to someone, something that should be unacceptable. And when we push the boundaries of technology the odds of mistakes only tick up. Like so much in medicine and life, but to the margins, radiation is a boon and a bust; technology promises to potentially deliver it in more effective and safer ways but only if healthcare knows how to use such technology, only if healthcare respects the power of what it’s dosing out and works to prevent errors.
A joint British and Belgian group has published new findings with fMRI evaluating consciousness in patient’s previously meeting clinical classification for persistent wakeful unconscious states.
We used functional magnetic resonance imaging (MRI) to assess each patient’s ability to generate willful, neuroanatomically specific, blood-oxygenation-level–dependent responses during two established mental-imagery tasks. A technique was then developed to determine whether such tasks could be used to communicate yes-or-no answers to simple questions.
Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity. In three of these patients, additional bedside testing revealed some sign of awareness, but in the other two patients, no voluntary behavior could be detected by means of clinical assessment. One patient was able to use our technique to answer yes or no to questions during functional MRI; however, it remained impossible to establish any form of communication at the bedside.
Functional MRI has been front and center in the news the past several years with claims of scans that can predict people’s responses and actions before they make them and decipher people’s motives or tell us when they’re lying or telling the truth.
And it’s true studies such as those by Monti, et al raise important and serious questions about the right to life and the right to die. In an editorial to accompany NEJM’s publication Dr. Allan Ropper says,
Even in a preselected population, brain activation was infrequent, but it occurred often enough that it will now be difficult for physicians to tell families confidently that their unresponsive loved ones are not “in there somewhere.”
Indeed, the MRC and Belgian group’s efforts are game changers certainly. It, and future studies along the same lines, have made and will make the main stream news and will no doubt be commonly quoteb by anyone faced with a loved one who is awake but seemingly not there by any measure short of fMRI. And they should be. For all the reassurance the medical community gives family and friends the misdiagnosis of persistent vegetative states is a problem. Now further uncertainty is thrown on it.
But as much as the preservation of life and function is an important goal, arguably secondary only to primum non nocere, I still think caution is in order when using information as Monti et al have provided. Dr. Ropper likely says it better than I can,
First, in this study, brain activation was detected in very few patients. Second, activation was found only in some patients with traumatic brain injury, not in patients with global ischemia and anoxia. Third, cortical activation does not provide evidence of an internal “stream of thought” (William James’s term), memory, self-awareness, reflection, synthesis of experience, symbolic representations, or — just as important — anxiety, despair, or awareness of one’s predicament. Without judging the quality of any person’s inner life, we cannot be certain whether we are interacting with a sentient, much less a competent, person. Moreover, persons who look to this study to justify continued and unqualified life support in all unresponsive patients are missing the focus of the findings.
The presence of some rudimentary preserved cognition that is indicated by means of functional MRI will no longer be in question, but its meaning will continue to be subject to interpretation.
Be gentle in how we use these new resources to define consciousness; how we use these new resources to define who is still is with us.
I’m a Trojan alum and a huge college football fan. I was sad to see Pete Carroll leave for the NFL but unlike some Trojans (and Vols) I’m happy to see Kiffin return, even without Norm Chow on the staff.
Funny or Die has a half bizarre of a skit Pete Carroll participated in after he decided to leave USC.
Now Pete has always been playful and something of a kidder and the skit is somewhat humorous but I’m not sure I’ll ever understand in full what Pete was thinking when he decided to participate in making it.
Their options are few, and extremely complex, mostly involving legislative tactics that would be difficult to pull off in the best of circumstances, let alone at a time when members are worried they could be the next Martha Coakley – a seeming Democratic shoo-in laid low, in part, by health reform.
And already Tuesday night, Democrats were being forced to come to terms with the prospect that their decades-long goal of health reform might once again fall short, despite getting closer to becoming law than ever before.
Since the initial shock of the loss things have not significantly improved. That’s a stunning admission, that Democratic majorities in the House and Senate may not come through to muster anything of health care reform. Their options are well spelled out across the blogosphere but essentially include the House passing the Senate bill as is, reconciliation or scaling down health care reform to something that could attract a bipartisan vote in the Senate.
Pelosi has been public and clear that she does not think she has the votes in the House for the Senate bill.
That in and of itself should be stunning and dismaying to Democrats and liberals. When history is finally written the political story of my generation is going to be the indecisiveness, incohesiveness and just plain terrible political game played by the Democratic Congressional caucus. In power and out of it Democratic Congressional leadership has been a sham. Gentleman Sam, who?
The fact a generational President, who stepped in with broad support and a Speaker who led her party to historic gains in the House can’t coerce groups like the Blue Dogs and Stupak’s gang into support what is, at least percieved, as once in a lifetime legislation is nothing short of political failure.
Even as the horror of the loss of Kennedy’s former seat wears off the Democrats remain divided and confused and generally thunderstruck. From the DCCC chair to Senator Dodd to comments from Republicans (mp3), there shouldn’t be a lot of hope from liberals.
As John Stewart says, “See, it’s not that the Democrats are playing checkers and the Republicans are playing chess. It’s that the Republicans are playing chess and the Democrats are in the nurse’s office because once again they glued their balls to their thighs.”
Democrats have to elect some actual politicians to leadership roles.
I continue to be of the mindset that meaningful reform was dead long ago. The Senate bill doesn’t offer a lot of hope for cost containment, and thus in the long run, improving access to care. That’s for another post however. I’m merely perpetually surprised the Democrats can’t even get the minimum the Senate managed to squeeze out onto the books.
It goes beyond the Capitol, to Democratic allies who have done just a terrible job with the message to the public.
I’m hardly crying over such; I don’t support reform. But I’m surprised I’m getting my wish.
It’s sacrilege to not want to be the OR if you’re a surgeon, or a wannabe.
I’m guilty of it this rotation. Not only am I not actively seeking out the OR, I’m attempting to avoid it. And today, spending the day in it against my wishes, I’m peeved.
My disdain is multifactorial. Some of the reasons for avoiding scrubbing in are personal and beyond discussion here. But, in part, the fact is I’m tired of general surgery. I want to be a neurosurgeon and if I never see the inside of an abdomen ever again I would be beyond comfortable with that. Even agreeing that any operating time is good learning experience I can’t shake that sentiment.
Toss me anything with a neurosurgical faculty, an osteoma or a shunt or a trauma crani, and I would be there with glee. But I just cannot shake my distaste for what I’ve been doing over the past seven months or for what I had to do today.
Despite my own misgivings about scrubbing in, I can’t understand future general surgeons refusing general surgery (or its subspecialties) cases. I faced such today.
There was a single OR running today with four cases.
There are five residents on my service. It is highly over staffed. Four of the residents want to be future general surgeons. I’m the lone outcast. One was on call, I understand him not wanting to drive across town to scrub in. That left three others, all of whom are seeking to impress the faculty, to garner a good evaluation from this rotation. I’m alone in having my evaluation bear no impact on my future. I’m alone in not wanting to be a general surgeon. And yet I was sent to scrub in.
My response was frank annoyance, hardly professional, but I figure hardly misplaced in full.
It’s true I’ve managed to avoid the OR but for a handful of times and left the responsibility (and may I opine, privilege) to the general surgery wannabes on the services. I imagine them figuring I needed to shoulder my share of the ’scrub in burden’. But what a ridiculous notion. The fact general surgery residents figured scrubbing in as a burden; essentially refused several general surgery cases out of what I can’t help but call laziness is bizarre and worth criticism.
My own avoidance of operating experience is something of laziness although my reasons on this particular rotation, as I said, are complex. But if anyone could be afforded an excuse for such it’s myself; with nothing at stake on this rotation unlike all the others.
And while throwing ones fellow residents under the bus is something of a shameful act I have to ask about today, “What the hell?”
The one guy with the most legitimate (at least I feel so) excuses for not going into the OR is prodded in so everyone else can take a lazy breather?
If I’m ever in an acute care setting I want to be the specialist. I want to be hidden behind the wall of a consult. I don’t want to be the front line guy.
As much as I love shift work, detective work, immediacy in medicine I was turned off of specialties like emergency medicine because of scenarios like this:
I think just about anything should be able to be marketed to us, through any commercial medium. That’s not a terribly popular opinion however. The United States is one of the few in the world where direct to consumer marketing of drugs and medical devices is prominent. And you find medication adds all over the television and publications and even sometimes on display media. Increasingly your finding direct to consumer advertising of pharmaceuticals online as well. Like all advertising online advertising is regulated by the FDA. However, some of the online marketing opportunities fall into highly grey areas, as you might imagine as new technologies are utilized to pitch you drugs.
The FDA is holding a public meeting today about online and social media use by big pharma and medical device makers. Here’s the WSJ Health Blog describing the goals of the meeting.
The FDA says its holding the meeting this week to get input on “making policy decisions on the promotion” of drugs and medical devices on “the Internet and social media tools.”
Those schedule to speak at the meeting include people from trade groups (AdvaMed and PhRMA); Internet companies (Yahoo, Google); drug makers (Pfizer, J&J, among others); and assorted ad agencies, consumer advocates and the like.
As you might imagine whenever an internet and social media-saavy group is engaged, the commentary on the meeting has been real time and copious. You can find threads on Twitter or numerous blog posts detailing what went down during day #1 of the public hearing. Eye on FDA has some commentary on the conflicting agendas of various groups who have been given voice at the meeting.
New Scientist profiles the Wellcome Collection’s Exquisite Bodies exhibit looking at the portrayal of human anatomy in the Victorian era. I can almost guarantee that the next time I’m in London I will be at the Wellcome Collection; looks very interesting.
There’s no doubt that American physicians earn more than the rest of the western world. Even when you factor in the cost of medical education in the United States (and it is substantial) a medical degree remains something of a better investment in this country than essentially anywhere else. This is largely because doctors has far more control over their earnings in this country than do those in other western countries. As physicians here in the U.S. we’re largely fee based and not salaried.
Now physician income, likely, tallies somewhere between 10 and 20% of all health care spending in America. Depending on who you talk to that’s either substantial or it’s not. But the fact is that even when physicians don’t earn directly they drive health care costs with incentives, even if not financial, to promote health care spending in the form of tests/procedures/referrals.
As you might imagine, health care reform likely foreshadows changes to physician reimbursement in this country…at least in the long term.
Both NPR and the NY Times have recent articles on physician earnings under the shadow of healthcare reform.
Doctors who choose to work in nonprofit clinics seem to view their professions more as a calling than as a job. There is evidence that when medicine was less adversarial than it is now, American doctors were both happier and more respected, even though their incomes were much lower. Doctors elsewhere also remain satisfied and respected, though they are paid less than their American counterparts.
In time, medical schools will be able to attract plenty of talented people willing to accept positions under the Mayo model, where they would spend more time healing patients and less time fighting insurers. Any of the current health reform bills would help start this transition.
I’m not saying that physicians earn too much in America. They don’t. Indeed most healthcare systems undervalue physician services. I know much economic work goes towards valuing human life, which is always questionable, but I have hard time believing anyone would truly value the life of a loved one when it comes to health care services. Especially acute care services where mortality or severe morbidity are on the line there is essentially topless value to the services provided by physicians and the rest of the healthcare professions.
Despite that healthcare reform MUST eventually level off physician reimbursement in order to control healthcare costs. It is coming, whether it is fair or not, so get ready for it.
