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Archive for September, 2012

Thursday, September 20th 2012

The MRIs Aren’t Large Enough Or The People Aren’t Small Enough

David Washington has encountered a hurdle to getting the medical treatment he needs to return to work as a mechanic: He can’t find an imaging device large enough to accommodate his 630 pounds.

The 57-year-old Mr. Washington hurt his back at work last year, but said surgeons won’t operate without a magnetic resonance imaging, or MRI, scan to evaluate his injury.

“I’ve been looking for an MRI for a year,” he said, a saga that has included fruitless phone calls to imaging equipment makers such as Siemens AG and General Electric Co., and a two-hour trip from his home in Wheaton, Md., to a Virginia clinic only to find he was too large for their equipment.

The above from a WSJ piece looking at how the growth in American obesity is impacting patient’s ability to get medical imaging. A hat-tip to The Atlantic for the link.

I don’t have the data for, but I imagine neurosurgeons utilize MR imaging as much as any other specialty. MRIs in particular are a problem for those morbidly obese patients. More than once in my training care on a brain tumor or a spinal cord injury has required patient transfer away from the acute care hospital to an outside facility for lower quality open MRI because the patient’s weight precluded the use of any of the many MRI machines at the hospital of presentation. It is a real world problem that delays care. Now there are more applicable and likely real world reasons that the very large should be working diligently to reduce their weight; this is a rare concern but, still, it’s something else to consider. I’m not sure the solution is larger machines but smaller people.

Tuesday, September 11th 2012

Who Cares About The Physiology

Long before I read this excellent post from Dr. Karen Rommelfanger, I’ve also wondered about the lack of intentional use of placebos in patient treatment. Not that in clinical practice the prescription of placebos doesn’t happen, because it does. Maybe not with maliciousness or whole intention, but I can think of situations where say a patient with poorly controlled, poorly explained symptoms requests a therapy with low harm but low or no efficacy just as a matter of appeasement. Studies certainly back up the idea that physicians use placebos.

While the ethical arguments against the intentional use of placebos are well spoken, I think the issue is becoming less and less black and white within the bioethics community. Beyond Dr. Rommelfanger’s piece, here is a piece by Michael Brooks in The Guardian.

Giving a placebo is not the same as doing nothing, which means that sometimes prescribing a placebo is better than doing nothing. People are not biochemical versions of computer programs, where a particular input will give a particular output. Being a doctor isn’t about being handcuffed by evidence-based medicine, it’s about using skilled judgement in tandem with the best available evidence – including evidence about the efficacy of placebos.

Placebos are not without there downsides for sure. There is a level of deception in adding legitimacy to patient’s with psychosomatic symptoms. Considering the lack of success in strategies that attempt to convince Conversion disorder victims they are not sick however, placebo therapies deserve a consideration. I think there is a way to describe potential placebo treatments to patients so that they understand risk-benefits, the key element in making an informed decision, without describing the strategy as a placebo.

Intentional placebo therapies deserve consideration in some scenarios and shouldn’t be painted off as completely unethical.

Wednesday, September 5th 2012

Not Even All Physicians Understand Acuity Apparently

I’ve written about trying to communicate acuity to families. Maybe that needs to be expanded to encompass the same to other physicians.

To be fair I’m sure some of this, perhaps much of it, rests solely on my shoulders. Recognizing that I’m still going to make an accusation that talking life and death with families and patients is a skill not fostered in many providers. More accurately for this anecdote, and importantly for the care of patients, some physicians flat out fail to recognize the necessity of such discussions and decisions by families.

A while back I saw in consult a young man with a subdural hematoma who had been found down at home after days unseen. He was young but it was a serious injury that had, presumably, persisted unmitigated for some time, likely on the order of > 24 hours. It was not an unreasonable question about how the parents would want to proceed. And while I can’t offer quotation marks this is near verbatim from the consulting physician:

- I don’t think you can blame a parent for not wanting to make a life or death decision about their child on the spur of the moment
- I don’t think a family’s decision has any bearing on triage

These comments came as they got more and more frustrated with my lack of transfer orders while I had lengthy conversations with the family and awaited their decision on whether to proceed with surgery or not. The argument was that I should transfer the patient to the neurosurgical service and the family could then take their time deciding on whether to proceed with surgery or not. My argument was that if the family elected for end of life care there was no need for transfer.

To be fair I’ve changed the story considerably, for obvious reasons, but attest fully that those consulting physician comments are essentially synonymous with the actual quotes. I don’t feel comfortable adding the quotation marks lest I transcribed a word here or there. I’ve left out my own parts of the conversation that prompted those remarks, and thus considerable context. But I would argue there is no context you can give those comments where they are not incredibly naive. Everyday physicians throughout the hospital ask families to make spur of the moment life and death decisions. Everyday a family makes a decision for or against a laparotomy in an unstable trauma patient or a craniectomy in a patient with a head injury. And the decision is, often, to go now or not at all. This story doesn’t completely reflect that urgency but the principle remains. It was at that moment that the surgery offered maximal benefit. There’s no decision to wait until tomorrow or the next day, it is now or we discuss other options such as maximal medical care or end of life care.

The discussion with families obviously lacks that crassness but, as I’ve discussed previously, frankness is not always a bad thing. In a very empathetic way the family needs to be aware that they need to make a quick decision. And so for a consulting physician to hold it against me that I was awaiting a family’s life or death decision before proceeding seemed surreal and disconnected. It still does. It is hard to imagine a physician so removed from the reality of acute care in a large county hospital. It is hard to imagine a physician who would hold in so low regard a family’s wishes in determining the next step in care.

I think that this particular conversation was the most remarkable I’ve ever had with another physician concerning patient care. Maybe my incredulousness is misplaced. With admittedly only half of essentially a made up story, my side, at your disposal let me know in the comments if you think I’m way off base.

Tuesday, September 4th 2012

Automating Healthcare

In 1982 Vinod Kholsa was one of the four founding fathers of Sun Microsystems. Since he’s been a major player in the Silicon Valley venture capital community. So, there was some noise made when a man of that stature, at the Health Innovation Summitt in San Francisco last week, said that “80% of doctors can be replaced by machines.”

Let me just say I’m an optimistic futurist and I think that no human endeavor is immune from automation. Whether we dismiss them I’m sure in my lifetime a computer written novel and song will, by any objective measure, be masterpieces. Economic and human capital issues and consumer comfort aside, cab drivers and airline pilots and even physicians are largely replaceable by machines. While his 80% figure might be high, or maybe not, I don’t think there is anything remarkable about Vinod Kholsa’s basic premise that in interpretation of tests, even radiographs, diagnosis and prescription of treatment computers will be better than man. I think surgeons and proceduralists are safer for a while.

But there’s more to health care than treatment. As Dr. David Liu points out over at The Health Care Blog,

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort.


There are some things that may never be codified or driven into algorthims. Call it a doctor’s experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Consider the reversal of the trend of self checkouts at supermarkets.

“It’s just more interactive,” Wearne said during a recent shopping trip at Manchester’s Big Y Foods. “You get someone who says hello; you get a person to talk to if there’s a problem.”

It’s difficult to imagine a quick embrace, if ever, of a health care system devoid of the human touch. You might indeed someday soon have better care offered by a machine, but primarily the human element, the comfort of the patient, is going to prevent Vinod Kholsa’s dream from coming to fruition in any sort of timely fashion…even if the technology allows for it.