Friday, August 27, 2010

Why medicine is not like groceries

When I was in training as a Resident and a Fellow, I remember taking only a couple of sick days over the entire 6-year period. And I had to stay home because I could not stop praying to the porcelain Goddess during a bout of a particularly nasty flu, despite a vaccination. I actually took pride in my health record, and attributed it directly to being rather sickly as a child. Well, not really sickly; I just contracted all of the childhood illnesses that prevailed at the time in my geography.

Yes, I spent my childhood in Odessa, Ukraine, where I got vaccinated against polio and smallpox, but not against measles, mumps, rubella, chicken pox, whooping cough or any other diseases that our children in the West will never contract. So, every couple of months I would succumb and have to stay home with a fever and a rash, and my mother would call my pediatrician who would come and visit me in our home promptly to examine me and, most of the time, reassure my mother that I would likely survive this time. And then, at the end, I was promptly seen at the clinic to be sure that I had recovered completely.

This is why Dr. Gaulte's entry on KevinMD got me thinking. I know that we have a hard time seeing shades of gray, but see them we must. Even if something seems bad to its core, some things about it may not be horrible. For example, we can argue whether home visits are the most efficient way to practice medicine, but we cannot argue the fact that healthcare in the USSR afforded me access to this primary care service. As it afforded it to every citizen, child or adult. Yes, I am thankful that I did not require any serious life-saving interventions, as those would surely have been either unavailable or substandard. But then again, why should the need for heroics be the rule and not the exception in a relatively healthy population? Should we not instead throw our energies into addressing common things? My point is that, despite its many undisputed flaws, the socialized medicine in the USSR provided access to a healthcare system when it was needed, albeit not one that I would want if I required some state-of-the-art intervention. But again, the vast majority of a reasonably healthy population should not routinely require high technology medicine. So, a modicum of access to a reasonable system is not something to sneeze at. Take it from someone who lived it and did a lot of sneezing. And lest I be misquoted, I want to be very clear that I am not in any way advocating emulation of the Soviet style system, but merely pointing out that some things about it were not all bad. Just as some things about our catastrophe-focused system are not all bad. What is needed, as always, is some middle way.

Another point about the post. Comparing healthcare access to food? As already pointed out by a commenter, our food system is far from an example of free market success, as it is heavily subsidized by our tax dollars. Of course, one can argue that this centralization of food production has been a huge environmental and health disaster for our nation. So, this would appear to be an argument for decentralizing everything. If only healthcare were as simple as food... 

Food happens to be a very bad analogy for our healthcare system, and here is why. Although we now indulge in high-technology food engineering, the reality is that food is a simple enterprise. If one has access to even a small plot of land, virtually anyone can produce their own food. As an example, people in cities and suburbs are beginning to raise their own back-yard chickens, and community gardens are springing up in large urban centers. If one cannot grow his/her own food, farmers' markets are making a big comeback, and not just in rural areas. These locally grown healthy alternatives to mass-produced E. coli and salmonella-contaminated products are inexpensive, and many farmers are willing to barter their wares for services and products that customers can offer. So, food, while necessary for survival, is fundamentally a low-tech enterprise. Along these lines, one could compare food to medicine, but the medicine prior to the Industrial era, when technology was non-existent and our doctors and farmers had far more similar business models. A doctor was a part of the community, there were no $10,000-a-week treatments, and bartering was acceptable in the doctor's office. Today's impersonal behemoth healthcare system with its fancy shiny and expensive gadgets, coupled with reimbursement rates in direct proportion to higher technology utilization, can hardly be compared to authentic food production. Simply put, while almost anyone in theory is able to access good food cheaply (the fact that we choose not to does not impact this point), no such possibility exists in the current healthcare system in the US.

Well, time to summarize my ramblings. 
Point #1: Not everything in an evil system is evil. It is useful to recognize paradoxically good points and see whether and how we can apply them to our situation. 
Point #2: Comparing access to healthcare to access to food is sophomoric at best, perpetuating a false analogy.
Point #3: Can it be that Roemer's rule is at play in our entire healthcare system? That is, since we have built a system for catastrophic health crises, now catastrophic health crises must be the rule and not the exception?
Think about it. Tell me if you think I am correct or completely out in the left field.            


Thursday, August 12, 2010

Allopathic medicine and CAM: Nonoverlapping magisteria revisited?

Stephen J. Gould is known to most of us as the evolutionary biologist who brought much scientific thought on evolutionary science to the public. A self-acknowledged Jewish agnostic, he also struggled with how to help the world hold two seemingly conflicting philosophies: that of science and that of religion. He discusses some of his views in this essay and at more length in his book Rocks of Ages. In the essay he says the following:
The lack of conflict between science and religion arises from a lack of overlap between their respective domains of professional expertise—science in the empirical constitution of the universe, and religion in the search for proper ethical values and the spiritual meaning of our lives. The attainment of wisdom in a full life requires extensive attention to both domains—for a great book tells us that the truth can make us free and that we will live in optimal harmony with our fellows when we learn to do justly, love mercy, and walk humbly.
Gould coined the idea of "nonoverlapping magisteria" to describe the complementarity of rather than a conflicted relationship between these two domains of human condition. In this view he echoes another iconic scientist of the last century, Albert Einstein, who concluded that "Science without religion is lame. Religion without science is blind". Both scientists seem to boil the complementary nature of the two fields down to the idea that science asks the question "how?" and religion asks the question "why?", both so necessary for our understanding of life in this Universe. Thus, forcing oneself or others to choose between the two creates a false dichotomy so prevalent in our discourse today.

Along the same lines, I am struck by the nearly always contentious and occasionally hostile conversation about the role of complementary and alternative medical (CAM) modalities alongside of our traditional Western style allopathic medicine. Both sides seem to imply that there is no room for both in our healthcare. And while the allopathic side holds up scientific method and evidence as the oracle of their field, the CAM practitioners, with equal zeal, cite tradition, spirituality and mystery of the human body as the central dogma in theirs. And when each is subjected to a critical appraisal by the other's methods, failure is the most frequent, if not unexpected, result.

So what is the answer? Should allopathic medicine, the side that right now holds much greater power and sway over our healthcare system, let in these pseudo-scientific usurpers even without any scientific evidence that they do any good? Should the two just coexist side by side, much like suggested by Einstein and Gould for science and religion? Well, it's complicated.

It is hard to argue with a straight face that the earth is flat or that it is indeed only six thousand years old, given the plentiful fossil record to the contrary. Believing an ancient text verbatim and denying the reality of the evidence to the contrary is not only a logical fallacy, it betrays stupidity and petulance. Similarly, denying that uncontrolled hypertension is the cause of coronary disease is ridiculous. However, given the complexity of the organism, we know that it is not the only cause of coronary disease. Furthermore, there may be causes that we have not discovered yet because we have either not thought to look or are unable to discern because we do not yet have the necessary scientific tools. This is to say that we know a lot, but probably not everything.

Now, let's move on to treatment of hypertension. The way we establish whether a modality works is through randomized controlled trials, where we look for differences in outcome based on the differences in the main exposure, in our particular case, the treatment for hypertension. Randomization is meant to ensure that the two groups being compared are not different from one another in any systematic way, and we reassure ourselves that randomization worked by looking at aggregate physiologic measures of the two groups, such as average blood pressure, average age, etc, and seeing if they are the same in both groups. If they are roughly equivalent, we say that the randomization worked, and all the differences in the outcome we see must be due to the experimental intervention, in our case the blood pressure treatment.

But what are we unable to measure? Oh so much! The burgeoning science of neurobiology, for example, has raised so many interesting questions about not only what the mind can do to the body, but what the body can do to the mind (please forgive this dualistic language). Why is this important? Because, due to our lack of adequate tools until recently, and because of the overwhelming complexity of the subject, we have traditionally neglected to include any measures of our patients' and trial subjects' neurobiological milieu into the consideration of differences between groups. But if randomization takes care of other systematic differences, should it not take care of the neurobiological ones? Perhaps, but without understanding the magnitude of variability of these characteristics in a population, one cannot begin to know how large a swathe of the population has to be enrolled in a study in order to smooth out these potential differences. And this goes for other so far unknown or unidentifiable characteristics. So what we think we learn from these trials is, much like in any other branch of science, subject to interpretation within the context of our knowledge today, and is, therefore, far from the universal and immutable truth. And the more we learn, the less absurd certain heretical ideas of the past seem. It's OK, we are all in good company. Even Einstein was not infallible: when he said that "God does not play dice with the Universe", he was alluding to his skepticism with regard to randomness of quantum motion, which has since been confirmed.  

But I stray from my main question, which is "Is the dichotomy between allopathic medicine and CAM a false one?" Well, what if we broaden the argument. We know that a human being is a fairly complex animal. As I alluded to above, we are only now beginning to put the data from neurobiology behind the phenomena of the human condition that have been observed for millennia. Such human impulses as the need to be surrounded by nature, compassion and need for retribution are all gaining scientific underpinnings in neurobiological research. So, what we already knew and understood about ourselves is now being explained (the "how") by science. This is comforting, and it should make my evidence-based allopathic colleagues pleased. It should also please the CAM practitioners, as the traditional views of what it means to be human are being validated.

So, what am I driving at? Krista Tippett in the Introduction to her latest book Einstein's God says that "opinion polls create false dichotomies". Since we live in a time when polarization seems to be the norm (just look at our political discourse), it is natural for allopathic medicine and CAM to retreat more deeply into their own corners and to become more entrenched in and convinced of their own singularity. This is the wrong approach. Humans are not all easily-understood physiology, but we are also not all spirit and mystery. We are in fact both. Some of the conditions we define as physiologic illnesses are nothing more that the products of our distorted expectations and philosophies. Some of our impulses to treat cancer with CAM alone are misinformed. If acupuncture seems to help my neighbor with her subjective symptoms of menopause, so be it, I am happy for her, even if I do not fully understand how it works. If yoga gives me a sense of well-being, yet there are no randomized controlled trials to validate this assertion, so what? Perhaps more "N of 1" trials are the way to go for CAM, I don't know. But I do think there is something to the subjective experience, even if we call it placebo effect, which incidentally implies that it is your own organism, with the help of an external stimulus, that has achieved the desired end. Why is this bad? Especially if there is no adverse consequence to counterbalance it? Granted, we have to be conscious of the attendant costs in this mammoth healthcare system of ours. Well, I for one am not averse to subsidizing my neighbors' well-being, even if the science tells me the effect is no different from a placebo. We already pay a premium dollar for interventions that only seem to work in a small minority of individuals who qualify for them based on well-accepted scientific evidence. And this is not even getting into the discussion of how much adverse reactions cost, even when there is no individual benefit of treatment.

It is true that science sets a high bar for gathering evidence. But one must acknowledge the inherent subjectivity in how we define endpoints of importance, and a complete antithesis to clinical sensibility of pursuing the p value. Medicine is and will remain inexact, part science, part art. To hold these two seemingly different philosophies together does not present an internal conflict for anyone, just as holding the methods, aims and philosophies of allopathic practice and CAM should not. Bridging these as nonoverlapping magisteria in healthcare can eliminate much of the conflict felt by the medical profession, and promote a more open-minded and humanistic approach to our public's health.                              


Monday, August 9, 2010

Requiem for my father

My father passed away about two weeks ago after battling a brain tumor for some time. Initially diagnosed with an extensive inoperable mass one and one-half years ago, upon presenting with a focal seizure, he did well with only one medication for seizure control for about ten months. Around Christmas of 2009, however, he landed in the hospital in status epilepticus that took three days to control. After these days of florid hallucinations alternating with pharmacologically achieved stupor, he came out of it remarkably cognitively intact, still able to quote poetry and sing Italian opera arias in their entirety. Although he was now unable to use his legs, he eagerly accepted the prospect of getting back on his feet by working hard in physical therapy. And though this never came to be, he managed to survive for additional seven months.

But my Dad was not your average guy. A survivor of World War II, an immigrant from the Soviet Union, a retired professor of mechanical engineering, he was at once a brilliant and an infuriating man. His stubbornness knew no bounds, and, even though he did not have the affinity for competitive sports, his drive to win was strong. He was a survivor by his nature and by his experience. So, when he was faced with the choice of a rapid decline and death versus some form of treatment for his tumor, he opted for the latter. As he and my mother put it, "doing nothing was not an option". So, when offered 6 weeks of radiation (5 days/week, with the risk of cognitive decline, the prospect of which terrified him as much as dying) together with oral and intravenous chemotherapy, he bravely accepted all.

As the days and the weeks of his treatment wore on, he would give me regular updates on how many radiation sessions he had completed and how many were still left to go. He suffered side effects with minimal complaining and never lost hope that the treatment would help him achieve a measure of meaningful recovery. This was not to be.

While I accompanied my parents to many of his appointments, I did not go to them all. And for this reason, I cannot say for sure what was said in some of them, and how different the content might have been from what they actually heard. But I did make the point of talking to every one of the specialists on the phone after they saw my father. They were all appropriately measured in their enthusiasm and recommendations while talking with me. But did they have the same demeanor with my family? Did my parents, both highly educated but neither medically savvy, take their enthusiasm for palliation as a promise of a cure? More importantly, are similar offers to try to prolong life by well-meaning and compassionate physicians to their desperate patients routinely misinterpreted on a grand scale by thousands as promises of cure? Is it possible that most people accepting the wonders of Avastin and other high tech interventions do not really internalize the reality that this and similar wonder drugs may give them merely two months of additional life? And further, do they think that these added months will be "normal" life?

Well, in my father's case, he got superb care at every institution he went to. His doctors and nurses were knowledgeable, compassionate, humane; in other words they were everything that healthcare professionals should be. Yet their eagerness to help a desperate and scared man may have inadvertently registered as false hope for results that were unlikely. My father tolerated his treatments, but over time began to exhibit cognitive decline, at first subtle, then more pronounced and made exquisitely more painful by his over-achiever baseline. He eventually succumbed to aspiration pneumonia after we made the painful decision to provide him with comfort care only.

After seven months of this most intense good bye, my mother now understands end-of-life issues better than many healthcare professionals. She is a seasoned and experienced decision-maker in a grave situation. But this experience comes at a steep price and a little too late, since I hope she is never faced with having to apply it again to a highly personal situation. She will not regret any of the choices that she and my Dad made in this journey -- they were all correct for them. But I have once again to question the wisdom and utility of making available treatments that make a difference at the slightest of the margins, that cost the society enormous resources and exact such high emotional costs from patients and their families.

Death is a natural conclusion to a life. Since we are not that good at "just sitting there", the vocabulary of "do nothing" needs to change to "helping patients die with dignity and comfort". The manipulative rhetoric of "death panels" has to be replaced with empathy and compassion. We are not above the laws of the Universe, we are not above the laws of physics and biology. We have to reposition our societal attitude toward death as an avoidable nuisance. And we have to ask: what are we prolonging in many of the cases that we treat at the end of life -- life or death? In his better days, my Dad might have asked an analogous question: are we living longer or does it just seem longer? And then he would have chuckled. Rest in peace, Dad.