Honoring MLK by Advocating Gun Control

I was trying to think of a medical story about Dr. Martin Luther King Jr. Today we officially celebrate his birthday: January 15, 1929.

Last year I considered the matter of donating blood, one of the many ways you might honor the leader’s commitment to a more civil and cooperative society.

MLK with RFK, both died of gunshot wounds (JFK Library, via Wikimedia Commons)

MLK and RFK, both killed by gunshot wounds (image from JFK Library, via Wiki Commons)

This year I’m struck by the fact that he died at the age of 39. On April 4, 1968, a rifle-wielding criminal in Memphis inflicted a lethal gunshot wound to King’s head and neck.

The recent Arizona shootings serve as a grim reminder of those tumultuous, bloody events. According to MSNBC, King’s son, Martin Luther King III, said: “When incidents occur like what we saw in Arizona, it shows us how much work we must do to create the kind of nation where nonviolence is embraced.”

Meanwhile, Congresswoman Gabrielle Giffords is healing in a Tucson ICU, after extensive neurosurgery and other life-sustaining procedures. This morning her husband, astronaut Mark Kelly, said on Twitter:

@ShuttleCDRKelly Mark Kelly
As my wonderful wife @Rep_Giffords continues to make progress, let us all pause and reflect on this MLK day.
11 hours ago

In honor of the day, and for the future, I wish that more physicians would speak out in favor of stricter gun control laws. Firearms present a public health issue in the U.S. According to the CDC, over 12,000 Americans die each year from homicide involving firearms. The number of non-fatal gunshot wounds requiring hospital care approximates 48,000 per year.


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Internet Surpasses TV as Prime News Source for Young Adults

I must have been reading a magazine when Mashable reported on new findings about the news from the Pew Research Center. A December 2010 survey confirmed that Americans are turning away from newspapers and logging onto the Web. Among young people, the Internet exceeds TV as a news source:

In 2010, for the first time, the internet has surpassed television as the main source of national and international news for people younger than 30. Since 2007, the number of 18 to 29 year olds citing the internet as their main source has nearly doubled, from 34% to 65%. Over this period, the number of young people citing television as their main news source has dropped from 68% to 52%.

The survey, which involved asking 1500 adults in the U.S. about their main source of national and international news, was conducted by phone with land-line and cell phone connections. It follows from other Pew studies, which together reveal some other, interesting trends.

Radio news consumption has been relatively flat over the past decade. The proportion citing TV as their main sources declined in all age groups. However, among people with limited education, TV dominates:

College graduates are about as likely to get most of their national and international news from the internet (51%) as television (54%). Those with some college are just as likely as college grads to cite the internet as their main source (51%), while 63% cite television. By contrast, just 29% of those with no more than a high school education cite the display internet while more than twice as many (75%) cite television.

Pew Research Center for the People & the Press, findings on Americans' news sources, Jan 4, 2011

You can visit the Pew Research Center for the People & the Press analysis for more graphs and information.

As for health care implications – I can only speculate on these trends’ significance and how doctors’ input might shift these curves, or not.

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On the Importance of Giving Blood

The other day I wrote on advances in artificial red blood cells and developing platelets from stem cells. But those methods are in early research phases. Meanwhile, many patients need blood donated by adult humans, now.

I have personally benefited from the generosity of blood donors. Some were strangers: In 1974 I received seven units during and after surgery. I cannot thank those kind people directly, because I don’t know who they are, but I am surely grateful, besides forever fortunate that those units didn’t harbor hepatitis or other now-known viruses. In 2003, friends and acquaintances – a college friend’s wife, who over time has become as a cousin; a generous and strong physical therapist who worked with me then, whom I’ve never thanked sufficiently, among others; and family – stepped in and helped me get through another tough procedure by offering those vital pints.

If you’re healthy and without anemia, please consider donating blood through one of these agencies:

The American Red Cross

America’s Blood Centers

New York Blood Center

Thank you,


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Why the Term ‘Patient’ Is So Important in Health Care

An on-line friend, colleague and outspoken patient advocate, Trisha Torrey, has an ongoing e-vote about whether people prefer to be called a “patient” a “consumer” a “customer” or some other noun to describe a person who receives health care.

My vote is: PATIENT.

Here’s why:

Providing medical care is or should be unlike other commercial transactions. The doctor, or other person who gives medical treatment, has a special professional and moral obligation to help the person who’s receiving his or her treatment. This responsibility – to heal, honestly and to the best of one’s ability – overrides any other commitments, or conflicts, between the two.

The term “patient” constantly reminds the doctor of the specialness of the relationship. If a person with illness or medical need became a consumer like any other, the relationship – and the doctor’s obligation – would be lessened.

Some might argue that the term “patient” somehow demeans the health care receiver. But I don’t agree: From the practicing physician’s perspective, it’s a privilege to have someone trust you with their health, especially if they’re seriously ill. In this context, the term “patient” can reflect a physician’s respect for the person’s integrity, humanity and needs.


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On a Velázquez Portrait, and the Value of Expertise

This is an unusual entry into a discussion on the limits of patient empowerment.

In late December the Times ran a story, beginning on its front page, about a portrait in the Metropolitan Museum of Art by Diego Velázquez, the 17th Century Spanish painter. The news was that the tall representation of the teenage Prince Philip IV would be back on display in the European paintings galleries after a 16-month cleaning, restoration and re-evaluation of the work. And, in case you weren’t up on your art history news – the painting really is a Velázquez.

label (ikonic's Flickr)

I learned this morning that the museum received the painting in 1913. It was a gift of Benjamin Altman (that would be B. Altman, as in the department store of my childhood…). The 7-foot portrait was considered a true masterpiece for hundreds of years, its authenticity supported by a receipt signed by Velázquez and dated Dec. 4, 1624. According to the Times now, in 1973 experts at the museum formally revised their opinion of the painting; they down-rated it, saying it’s a product of Velázquez’s studio, rather than of the artist himself.

Velazquez' Portrait of Philip IV, at the Metropolitan Museum

Evidently Michael Gallagher, the chief paintings conservator at the Met, recently became concerned about the painting’s “workshop” label based on his experience upon cleaning another, later Velázquez portrait at the Frick. “Its true condition was obfuscated by the decades of varnish and the liberal repainting,” he said of the Met portrait. According to the Times, Philip’s left eye was missing, possibly from flaking or vandalism. Ultimately, x-ray analyses and careful examination of the cleaned portrait convinced Gallagher and his colleagues of the portrait’s legitimacy.

I was in the neighborhood, so I thought I’d check out the work for myself, in light of this new information. I spent a while staring at it, studying the prince’s hand and other features about which I’d recently updated my knowledge. Still, I realized, there was no way in the world I could tell, on my own and even if my life depended on it, if it were a Velázquez, or not a Velázquez.

Sometimes you have to rely on experts. I don’t have a Ph.D. in art history. Or anything approaching sufficient knowledge of Velázquez and his workshop, Prince Philip IV of Spain, x-ray analyses of oil paintings, varnish and resins, 17th Century receipts and signatures, or similar “cases” – like the related portrait that turns out to be in the Prado, and other works by the same painter – to know the difference.

That’s the thing – in medicine, if you have an unusual health condition, like a rare form of T cell lymphoma or an obscure infection, you may find that you depend on a doctor’s expertise. Recommending the right treatment (which might be no treatment) requires knowing and understanding the correct diagnosis. Figuring out what’s the correct diagnosis requires a lot of knowledge, and experience.

detail of hand, in Velazquez' painting

As for patient empowerment, I think what patients with rare or puzzling conditions can do is to make sure they’re comfortable with their physicians, that their doctors know what about what they’re treating and will admit when they’re unsure of a diagnosis or need more expert, specialist advice. The problem, then, is for doctors to admit what they don’t know, which in the end requires that they be well-educated and able to discern unusual cases and outliers, and take the time to notice – and not dismiss – details about their patients’ stories that warrant further examination and thought.


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Lessons from the Wakefield Case

I was almost at a loss for words today, besides having read the morning paper on the upcoming ESP study in a major psychology journal with questionable stats, and my having seen last night the first story on the British Medical Journal‘s report that completely, and maybe finally, discredits Dr. Andrew Wakefield’s anti-vaccine crusade which has caused needless morbidity and deaths in children from preventable illnesses in the U.S. and elsewhere.

So many others have written on Wakefield’s fraud, and considered the role of the press in perpetuating the notion that vaccines cause autism, I wasn’t going to cover it here on ML. But I do think there are a few instructive points from this “lesson” about medical communication and news:

1. People aren’t always rational in their decisions about health care. (This is an understatement.)

2. When most of the population (including journalists and, sadly, some doctors) are ignorant in basic science and statistics, misinformation spreads easily. In effect, our limited educations render us vulnerable to speculation and hype. A result “sounds good” or plausible, so we believe it, never mind the details –

3. Sometimes even educated people are so desperate for an explanation, or for a solution to a medical problem, that they’ll believe a smooth-talking scientist or doctor because they want to believe what he’s saying is true. If vaccines were to cause autism, that would give people a sense of control, i.e. a way to avoid autism.

The truth is that, for the most part, we still don’t know why diseases occur in some people and not in others. Not understanding can be a frustrating, unsatisfying circumstance, because it makes us feel powerless.

That’s it for today.


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A Reversal on End-of-Life Planning

The Obama administration will cut a new Medicare provision to compensate providers for discussing end-of-life care, according to the New York Times. This is an unfortunate reversal.

Too-often, doctors fail to have these discussions with their patients. This happens for many reasons including some physicians’ discomfort with the topic, their not wanting to diminish patients’ confidence in their healing powers, conflicts of interest (infusing chemotherapy is profitable; prescribing palliative home care is barely so, if at all) or simply being too busy to get around to the subject before a patient becomes critically ill and approaches death in an ICU setting. Most physicians need incentives to discuss palliative care options and end-of-life planning with patients in a thoughtful, not-rushed way.

The Medicare provision, which would have provided a small amount of compensation for doctors to spend time communicating with their patients about their preferences – whether they’d want to be kept alive on a ventilator with metastatic, refractory cancer, for example, or whether they’d want to be kept alive in a comatose state with a feeding tube for weeks or months or even years after suffering brain damage from low oxygen, might have helped some people get the kind of end-of-life care they’d choose, instead of what their doctors might give unthinkingly.

Again, I recommend that patients should be pro-active about their wishes. If your doctor doesn’t mention the topic, tell her what you want and document your wishes. Here’s a partial list of sites that provide related information on this subject:

Med­line­Plus on Advanced Direc­tives;

New York State: infor­ma­tion on Health Care Proxy forms and DNR orders

Medicare on Preparing for Your Future Health Care Needs

Fam­ily Care­giver Alliance on End-of-Life Choices

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I Feel Your Pain (not)

A tweet hit me on Sunday evening, from a stranger:


I’m saddened by how many ADULTS can’t get their #rheum 2 understand the level of severity of their pain.What hope is there for my daughter?

I half-watched an on-line exchange about the issue, and then went about my family’s dinner preparations.

The message came from Amy Cunningham, who blogs about her daughter’s experience with juvenile rheumatoid arthritis and uveitis to the starting tune of Van Morrison’s “Brown Eyed Girl.” I couldn’t bear the tracks that followed, playing automatically and disjointedly in multiple browser windows, so I shut them off. But I kept on thinking about the girl’s pain, and the mother’s despair.

I wasn’t alone in that. Turns out that Rheumatoid Arthritis Warrior Kelly Young (@rawarrior) was all over the matter. She’s got a Facebook discussion going on the topic and a post today called Some Rheumatologists Don’t Understand How Much It Hurts.

The problem of doctors dismissing patients’ pain is very real. I know this from my own experiences, like when I fell on the icy sidewalk and broke my right arm in the midst of breast cancer treatment. My elbow became gigantically swollen because my platelets were low – a side effect of the chemo – and as a consequence of a non-steroidal anti-inflammatory agent I was taking for back pain. In the E.R. the doctors gave me enough pain meds only after I’d been made to feel humiliated by some of the staff. Another time, after a 10 hour back surgery in which the orthopedists cut a steel rod fused to my spine and otherwise manipulated that column of nerves, the anesthesiologists laughed in the recovery room, hinting that my pain was due to depression.

How wrong they were –

Medicine is a very macho profession. For the record – when I had my wisdom teeth removed, I had them all taken out at once and returned straight to work in the lab. I drew my own blood for experiments with lymphocytes, countless times. Once I inserted my own intravenous catheter, while pregnant. When my spine started to crumble, I had trouble acknowledging the pain for several years. I felt embarrassed, compromised by it. In the year before surgery, I had a CT myelogram (which involves a lumbar puncture), went home and prepared for a journal club presentation the very next day. And so on. Only later, when I could hardly walk, I mentioned my limitation because I needed to cut back on my time standing while on rounds at the hospital. Some colleagues were sympathetic, but others were less generous.

Being tough has its merits. But denying pain, or suggesting that people who complain about their symptoms are weak, is not helpful to anyone. Pain can be very real, and disabling.

I think the problem for some doctors is one of arrogance; they perceive pain as something that happens to “others” and not to them, as if it were a sign of weakness or a character flaw. For some, the denial of patients’ pain may be some kind of strange defense mechanism, a psychological device by which they distance themselves from those affected, and so it might seem like it couldn’t happen to someone like them.

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On the Value of Open-Mindedness

Three recent stories lead me to my opening topic for the year: the value of open-mindedness. This characteristic – a state of receptiveness to new ideas – affects how we perceive and process information. It’s a quality I look for in my doctors, and which I admire especially in older people.

Story #1 – on the questionable effects of echinacea

Echinacea Purpurea flower (Wikimedia Commons)

The first article, published in the Dec 21 Annals of Internal Medicine, considers the potential of echinacea in treating the common cold. The results of a 4-armed, randomized study involving 719 patients with symptoms of an acute respiratory infection (“a cold”) were inconclusive, at best. A skeptic might say of the trial, sponsored by the National Center for Complimentary and Alternative Medicine (NCCAM), that it proves once and for all that echinacea is therapeutically useless. Another reader, perhaps versed in the flower-derived substance’s purported effects in other and earlier cultures, might charge that the investigators chose the wrong preparation, derived from roots of the E. angustifolia and E. Purpurea species, or that the researchers picked the wrong dose to observe an effect of the drug on the duration and intensity and biological effects of a common cold.

I’ve never tried echinacea and have no financial or other particular interest in this compound. But having read the article a few times, I’m disappointed, even unsettled by the results. After so many studies, many of which are referenced in the Annals paper, and now this costly, NIH-sponsored finding of what’s essentially no effect, it’s hard to say that echinacea is helpful to anyone. At the same time, I don’t think there’s sufficient information to say that it doesn’t work in preventing or reducing the intensity of an upper respiratory tract infection, or that it doesn’t work in some individuals who have symptoms like a runny nose and sore throat.

According to the ACP Internist (where I am a contributor):

…The study’s lead author, Bruce Barrett, MD, PhD, told USA Today that echinacea’s supporters would probably consider the findings positive but that those who oppose it for the common cold would consider the study “the nail in the coffin.” The director of the study’s primary funding source, the National Center for Complementary and Alternative Medicine, told USA Today that the center doesn’t plan to support future similar research, since existing data make clear that Echinacea’s benefit for the common cold, if any, is “very modest.”

Still, we don’t know if echinacea might work better as a tea prepared from dried roots or somehow otherwise ingested by people who are sick, as opposed to the pill compound that was given to participants in the Annals study, or if an extract compounded from a different combination of Echinacea flower species might do the trick.

So if a doctor’s open-minded and her patient wants to try taking echinacea tea for a blossoming cold, she might tell the patient that there’s not much evidence based on published trials of the herb, and that in fact so far the echinacea data aren’t supportive of a meaningful effect in any patient group. At the same time, there’s probably little risk of trying echinacea, in that it seems to have few untoward effects. And the patient and physician might then observe what happens, and draw limited if any conclusions based on that person’s individual, n=1 experience with echinacea.

A closed-minded doctor might tell her patient that echinacea isn’t worth trying, in any form. In her mind, she considers the substance is a sort of natural or home-remedy that has no role in modern medicine. She might even feel it’s a waste of her time to discuss the alternative treatment with her patient, and perceive the patient as being uncooperative if he or she tries taking it against her advice.

Echinacea – “white swan” variety, Wikimedia Commons

Patients’ attitudes vary, as do their doctors, and given a choice of physicians patients probably choose doctors whose personal philosophies roughly align with their own.

For now what I’ll say is this: I respect it when a doctor admits uncertainty, and is willing to try something of low cost and low toxicity, for which the evidence is thus-far unclear. (Of course, if we extend this argument to a discussion of more costly and potentially toxic drugs – like new cancer treatments, we’d need to weigh more carefully the potential harms of a treatment against the unproved benefit.) In principle, though, I like the approach of an open-minded doctor, who recognizes the limitations of published data, and is willing to explore an unproved approach to a problem in a way that’s transparent: as long as the doctor doesn’t sell the echinacea, and is honest with the patient about the lack of evidence to support its use, it seems OK.

Paper #2 – on an incredible effect of known placebos

Another, curious December story, Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome, appeared in the strictly on-line journal PLosONE. The article is perhaps more definitive, as it is more puzzling: the investigators observed that when people with irritable bowel syndrome (IBS) took placebo drugs in a clinical trial, even though they knew they were receiving a placebo and not real medication, they felt significantly better than those patients who didn’t receive the open-label, placebo treatment.

As a reader and scientist, I cannot understand this observation except to say most likely it’s an experimental fluke. But the study’s statistics were strong, and the trends internally consistent, rendering it likely that what the investigators reported could be reproduced. The patients’ symptoms are highly subjective in IBS, although they can be debilitating and costly. My conclusion, trying to be open-minded about a result that seems improbable if not impossible, is that maybe there are things we don’t really understand about how “medicine” affects humans.

The ethical implications of this finding – that “placebos work” – are interesting, if it’s true (which I wouldn’t conclude based on this one study reported in PLoS, or anywhere). For now what I’d say is the results are intriguing. I’m curious to see if these results are reproduced, and how the ethical implications will be ironed out in our modern medical community.

Piece #3 – on the brain’s maturity, flexibility and “cognitive fitness”

Finally, I’ll note a Dec 31 op-ed piece that appeared in the Times: This Year, Change Your Mind, by Dr. Oliver Sacks, the neurologist and author. In this thoughtful essay, he considers the adult brain’s “mysterious and extraordinary” power to adapt and grow: “I have seen hundreds of patients with various deficits — strokes, Parkinson’s and even dementia — learn to do things in new ways, whether consciously or unconsciously, to work around those deficits.”

With appropriate and very-real respect, I question Sacks’ objectivity on this subject – he’s referred some of the most outstanding (i.e. exceptional) neurological cases in the world. And so it may be that his careful reports are perfectly valid but not representative; for most of us, the adult brain’s capacity to establish new circuitry for language learning or music appreciation may be limited. What his stories do show is that unimaginably strange things happen in our brains, at least occasionally. And maybe we should just accept that and take notes (as he does so carefully), and keep an open mind –

Finally, he writes:

…all of us can find ways to stimulate our brains to grow, in the coming year and those to follow. Just as physical activity is essential to maintaining a healthy body, challenging one’s brain, keeping it active, engaged, flexible and playful, is not only fun. It is essential to cognitive fitness.

I’m inspired by the notion of keeping a fluid, active mind. It’s not easy to keep abreast of new data, and to read the literature critically. While some people become more withdrawn in adulthood, resting on comfortable routines and reliable sources, I choose the opposite: reading blogs, scanning Twitter, checking out lectures on YouTube, watching new TV shows, listening to my kids and students. How much better it is to approach information with an open mind, to take it in and contemplate its ramifications, than to simply say “no, that’s impossible.” As far as my doctors are concerned, I hope that’s their attitude, too.

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