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Archive for the ‘Miscellaneous’ Category

Thursday, October 31st 2013

The Falliability of Memory

I am fascinated by the faliability of memory. Especially episodic memory.

You and I really don’t remember what we think we remember. It is rarely accurate and yet people are utterly convinced of that their memory is accurate. There are obviously huge implications. Think criminal or civil law.

[Dr. Elizabeth] Loftus discovered that she could modify memories with startling ease. After showing a film of a crash, Loftus asked some volunteers if they “saw a broken headlight” and others if they “saw the broken headlight.” Those who got the latter question were twice as likely to say yes – though, in fact, the film showed no broken headlights.

Loftus was fascinated, and she soon turned her attention to criminal trials. Suspicious of the accuracy of eyewitness identifications, Loftus conducted an experiment in which volunteers looked at photographs of six faces while listening to a story of a crime.

One face was identified as the criminal, five as innocents. Three days later, Loftus showed the volunteers four photographs: one of an innocent character from the crime story, and three of new people. Sixty percent of volunteers identified the innocent character as the perpetrator from the story. They recognized a familiar face but muddled their associations with it.

[...]

One study in particular bolstered Loftus’ belief that much memory is malleable. In a now-famous experiment, Loftus told a volunteer that she had spoken with his mother and learned four things that happened to him as a 6-year-old.

She then ran through three real memories and one fake one. The volunteer sometimes claimed to remember the fake memory, which involved getting lost in a shopping mall then getting rescued by an elderly stranger. (Planting a more traumatic memory would be even more illuminating for psychologists, but researchers try to avoid permanently scarring their volunteers.)

Even odder, the volunteer would usually be happy to elaborate on this implanted memory. His panic, his confusion, his relief; it was all there, hidden away in his memory. Except that it wasn’t—it was all in his imagination. With just a small bit of coaxing, Loftus could insert this memory even into the most skeptical minds.

Or psychiatric illnesses.

Psychologists Miriam Lommen and colleagues studied 249 Dutch soldiers were deployed for a four month tour of duty in Afghanistan. As part of a study into PTSD, they were given an interview at the end of the deployment asking them about their exposure to various stressful events that had occurred. However, one of the things discussed was made up – a missile attack on their base on New Year’s Eve.

[...]

Eight of the soldiers reported remembering this event right there in the interview. The other 241 correctly said they didn’t recall it, but seven months later, when they did a follow-up questionnaire about their experiences in the field, 26% said they did remember the non-existent New Year’s Eve bombardment (this question had been added to an existing PTSD scale.)

Susceptibility to the misinformation was correlated with having a lower IQ, and with PTSD symptom severity.

I think this is one of the most fascinating parts of not just cognitive study but all of neuroscience.

Functional neurosurgery may hold promises to improve memory, not just in pathology (such as dementia), but in normal individuals. Initial studies show poor episodic improvement, but who knows what the future holds. And I wonder the implications of that for these “false” memories.

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Thursday, October 24th 2013

The Hands of Healthcare

I’ve previously written about how technology threatens physicians futures. There are some big proponents of computers doing what docs currently do and potentially doing it better. Whether its Watson dong oncology or a machine doing conscious sedation. This latter is the new thing,

Patients are hooked up to Sedasys and sedated intravenously. While connected, a patient’s condition is monitored by the machine. It measures oxygen levels, for instance. If there is a problem, the machine alerts the physician, and is supposed to take action, such as increasing the oxygen supply and stopping the anesthesia, and resumes only if the patient’s condition normalizes.

Patients also wear an earpiece, in case they drift into too deep a level of sedation and need to be awakened. As a doctor or nurse would do, the machine would, through the earpiece, tell the patient to wake up.

Its coming, even for surgeons eventually.

Saving grace might be the lack of a human touch.

Monday, October 21st 2013

Neurosurgery Makes For Drama

I’m sure that homicide detectives watch Law & Order and cringe or that White House or congressional staff watch The West Wing and are put off. Same for some doctors and nurses and other health care professionals. Some medical dramas (and comedies) get it better than others but some are downright gut wrenching to watch.

I obviously have a particularly hard time suspending my disbelief when a show depicts a neurosurgeon.

That seems to happen a lot. Surgeons in general seem to get a lot of focus in medical daramas. In particular it would seem to me the neurosurgeon, cardiac surgeon and plastic surgeon. Despite the fact that neurosurgeons only comprise perhaps half a percentage of all U.S. physicians I’ve come up with at least five shows that have a lead as a neurosurgeon that have premiered in the last five years. It is a mixed bag to say the least.

Here is the ridiculous first scene from the, rightfully, canceled show Do No Harm.

What’s interesting is that this show was a retelling of Dr. Jekyll and Mr. Hyde and hardly a traditional medical drama.

Here is the quality, and sadly ended, Monday Mornings based on Sanjay Gupta’s book of the same name.

Another interesting drama to find a (former) neurosurgeon in is the crime procedural Body of Proof.

And let’s not forget that Jack Shephard on Lost is portrayed as following in his father’s footsteps as a neurosurgeon.

Back to recent more traditional depictions of neurosurgeons in a medical environment we find the short lived 3 lbs and the British House, MD knock off, Monroe.

And of course there is the classic show currently carrying the medical drama torch, Grey’s Anatomy.

And while the number of medical dramas, including the number featuring neurosurgeons, has grown recently the specialty has long held a special place on television it would appear. Consider the 1975 NBC drama Doctors’ Hospital. Here is NBC’s promo for the 1975-76 fall line up, including that show.

The brain has a special place in culture and the idea of operating there holds a certain mystique and provides for acuity and drama. But its more than just the activity of the surgery. Neurosurgeons in particular seem to be players in shows that are more than traditional medical dramas.

There are, to be fair, plenty of examples of other archetypes of physicians portrayed beyond classical medical dramas/comedies. The physician in non-medical sitcoms is easy to think of. For example Frasier or Northern Exposure or Arrested Development or more recently, The Mindy Project. I’m having a harder time thinking of dramatic representations of non-neurosurgeon physicians outside the clinical setting. Perhaps the psychiatrist working with police? But even that is them clinically practicing their specialty.

You should post a comment if you can think of a non-medical drama featuring a physician or former physician.

I think the neurosurgeon appears to hold a special place in drama. I think that’s because in making a drama giving your character a backstory as a neurosurgeon achieves some immediate things. The people who would dare, or achieve, to operate on the brain make for interesting characters who are automatically endued with accomplishment, intelligence and perhaps ego and a rough character. Whether those perceptions are accurate is another thing but there’s no doubt the audience has specific stereotypes of a neurosurgeon. The audience automatically understands something of Megan Hunt or even of Jack Shephard based on the given past as that of talented neurosurgeons.

Such displays probably only reenforce our own egos as surgeons. And sometimes the stylization can be hard to watch.

Thursday, June 6th 2013

Alternatives To Medicaid Expansion

Sunday, April 21st 2013

Giving Away For Healthcare

Medicaid covers a large percentage of nursing home care and it is becoming a strategy (or at least a consequence) for the elderly to give or spend themselves into poverty to become dual eligible.

Millions of consumers have only one plan for covering long-term health-care costs. It’s to spend themselves into poverty until Medicaid — the state-run health-care program for the poor — picks up the tab

[...]

Washington is making another run at the issue. Chernof and 14 other health-care experts have been appointed to a commission on long-term care, created by the tax law that was signed in January. Members include Massachusetts’ Medicaid director, Louisiana’s secretary of health and hospitals and the vice chair of AARP’s board of directors.

[...]

The CLASS act, an attempt to set up a voluntary long-term care insurance program, was included in the health-care reform law but then rejected as unworkable by the Obama administration and repealed by the same law that created the commission. “It was a catastrophe,” says Howard Gleckman, Urban Institute resident fellow and author of the book, “Caring for Our Parents.”

Medicaid as the primary funding for long term care is unsustainable. And it is becoming harder and harder to give away your assests and qualify for Medicaid.

[S]ome people give away their money and property in order to qualify for Medicaid help sooner, a practice known as Medicaid planning.

[...]

The government doesn’t want to finance long-term care for people who are sheltering assets that could go toward paying their bills. So the new rules, which took effect in February 2006, extend the “look back” period from three years to five. If an individual gives away money or property during the five-year look-back, it triggers a penalty period during which he or she is ineligible for government aid.

The penalty period equals the amount given away divided by the average cost of nursing-home care in your area. So, for example, if you give $60,000 to family members and a nursing home costs $6,000 a month where you live, you can’t qualify for Medicaid for ten months.

We’ll see what the commission comes up with but I’ll be surprised at a legitimate solution.

Wednesday, April 17th 2013

Medical X-Rays

Nick Veasey makes art by taking x-rays of everyday, often over the counter, medical supplies. Things like band aids or bottles of acetaminophen. The images are pretty cool.

Monday, April 15th 2013

Iranian Medicine & Sanctions

Like many I have mixed feelings about sanctions against horrific places like North Korea, Iraq and Iran. Muting the costs of the sanctions on the local populace is a difficult task. Loathe to link to anything Alex Jones the article on his site has a number of good links and a number of legitimate points.

They imposed a medieval embargo and tried to starve the nation into submission. The result was over 500,000 dead children, which Clinton’s Secretary of State, Madeline Albright said was a price worth paying. Over the span of ten years, child mortality in Iraq went from one of the lowest in the world, to the highest.

And now, similar things are happening in Iran. For lack of supplies Iran’s health care system is struggling.

Starting last fall, however, Iran appears to have run out of basic surgical supplies, owing to sanctions designed to limit the country’s nuclear program. Despite a “humanitarian assistance” loophole built into the sanctions, reports from inside Iran, some in English and some in Farsi, claim shortages of anesthetics have threatened closures of operating rooms.

[...]

Though it’s legal to sell medicine to Iran, the sales must pass through a byzantine process of currency transfers and third-party banking, to avoid doing business with Iranian financial institutions—most of which are sanctioned. The result is a massive disincentive to do business, her report argues. Pharmaceutical companies, turned off by the risk, simply turn their attention to less demanding markets. “A Western company that wants to sell medicine to Iran has no legal assurance of being paid,” Slavin said.

[...]

Because banks can’t do deals in direct ways with Iran, it’s extremely risky for a pharmaceutical company to extend credit there. But pharmaceutical deals are huge, and almost always conducted on delayed payment.

“Novartis and Pfizer used to give their distributors something like 20 to 50 million [dollars] in credit,” said Namazi. “From the day you needed the medicine to the day it was in the pharmacy was three weeks. If you needed it fast, DHL would get it to you the next day.”

Instead, Iran’s entire national health system has to operate on a cash-and-carry deal. And DHL no longer services Iran, he said.

The United States should have a stated goal of preventing Iran from gaining nuclear power and indeed more, regime change in Iran. I don’t support a unilateral strike to achieve such. And apparently I don’t support sanctions either. Do I contradict myself? Well then, I contradict myself.

Monday, January 28th 2013

You Are Going To Die

Sometimes the New York Times puts out poignant opinion pieces. Often these are essays of Tim Kreider. Indeed, his piece, The ‘Busy’ Trap, is amongst the most on the nose things I’ve ever read. But this is about something more pertinent to this blog. Last week The New York Times published this,

Segregating the old and the sick enables a fantasy, as baseless as the fantasy of capitalism’s endless expansion, of youth and health as eternal, in which old age can seem to be an inexplicably bad lifestyle choice, like eating junk food or buying a minivan, that you can avoid if you’re well-educated or hip enough. So that when through absolutely no fault of your own your eyesight begins to blur and you can no longer eat whatever you want without consequence and the hangovers start lasting for days, you feel somehow ripped off, lied to. Aging feels grotesquely unfair. As if there ought to be someone to sue.

It is well worth a read.

Monday, October 29th 2012

Hackable Medical Devices

As we become more and more reliant on active, implanted biotechnology the opportunities for malicious manipulation of such rise. The hacking of medical devices isn’t a new threat. I’ve commented on it, as have publications more prominent than this blog. The issue has taken on enough of intellectual seriousness that it has prompted the creation of a multi-institutional center, the Medical Device Security Center. In 2008 that group published a method of wirelessly accessing information from some models of pacemakers and then injecting active attacks to change the performance of the pacemakers. After publication they presented the same at Defcon.

At the Black Hat Conference last year an independent researcher presented a theoretical method of wirelessly changing the serum glucose readings of an implanted diabetic pump.

An attacker could intercept wireless signals and then broadcast a stronger signal to change the blood-sugar level readout on an insulin pump so that the person wearing the pump would adjust their insulin dosage. If done repeatedly, it could kill a person. Radcliffe suggested scenarios where an attacker could be within a couple hundred feet of a victim, like being on the same airplane or on the same hospital floor, and then launch a wireless attack against the medical device. He added that with a powerful enough antenna, the malicious party could launch an attack from up to a half mile away.

The most recent, highly publicized hack devised by researchers is one concerning implantable cardiac defibrillators. At the Breakpoint conference in Australia this year,

In a video demonstration, [researcher Barnaby] Jack showed how he could remotely cause a pacemaker to suddenly deliver an 830-volt shock, which could be heard with a crisp audible pop.

[...]

In 2006, the U.S. Food and Drug Administration approved full radio-frequency based implantable devices operating in the 400MHz range, Jack said.

With that wide transmitting range, remote attacks against the software become more feasible, Jack said. Upon studying the transmitters, Jack found the devices would give up their serial number and model number after he wirelessly contacted one with a special command.

With the serial and model numbers, Jack could then reprogram the firmware of a transmitter, which would allow reprogramming of a pacemaker or ICD in a person’s body.

Any attacks on medical devices requires more than a common level of expertise but to one dedicated probably something within the ability to be self taught. There are much bigger public health issues, even within the biotechnology sphere, including the function and operating safety of such but this remains a scary prospect and one that deserves more attention. Medical device makers need to put more into the security of these devices and the FDA needs to place a focus on making sure device makers are doing such.

Thursday, July 19th 2012

I Love My Pager

As long as I’m a resident and I’m not serviced by a call center I will love my pager. I say this despite my love of all things tech.

And apparently I’m becoming slightly anachronistic.

Doctors don’t want to carry a pager anymore. They want to carry their iPhone or their Android device.

The quote above comes from Brian Edds, for Ancome Software, in an NPR story titled ‘Are Pagers Obsolete?’. So many I’m out in the minority, but I want my pager. I’ll be brutally honest about why but I don’t want people to be able to reach me on a whim. At least not while I’m a resident. I’ve written before about the abuse of communication with resident physicians. About how matters are triaged ineffectively at academic centers, partly I suspect, because it seems as less of a faux pas to call a resident, as say, a ‘real’ doctor out in the private world.

As such, I don’t want my phone ringing while on call. I return my pages timely but I want that barrier wherein I have to return the call. That barrier where I can triage the calls myself. A text page about a missing home medication can wait until I’m done with a procedure, a page from the ER may need more immediate scrutiny. A phone call takes away some of that discretion. And until the amount of frivolity goes down, until I’m out in the world practicing and deciding the systems in which I’ll practice, I want my pager.