"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Rebuttal II:Chris Rangel points out that he never used the words “life unworthy of living” in regard to Terri Schiavo (although I didn't suggest he did.) Apparently, we disagree on whether or not Terri Schiavo is living. (You can read Chris's original three-part series here, here, and here. And Dr. Bradley's post is here):
Even though the word "unworthy" is your choice of words it makes it seem as if I actually stated that Terri Schiavo is "unworthy of living". I never stated any such opinion nor used the word "unworthy". To say that something or someone is "unworthy" implies a value judgment of one's own opinion that may stand independently of any required proof or evidence. I have never stated that Terri Schiavo should die or needs to die or does not disserve to live.
What I have done over the course of three painstakingly written articles is to try and cut through all the rhetoric and misconceptions about the case and to present the clinical facts and the reasons why the Florida courts sided with Michael Schiavo in a mutual decision to remove her feeding tube. I have made no judgments as to the quality of Terri's life except to raise the possibility that most pro-lifers don't consider; if Terri is conscious then how do we know that she is not suffering? I have simply stated that the medical facts of the case point very strongly towards the fact that there is no longer a Terri inside Mrs. Schiavo's body without any evidence to the contrary.
Perhaps you can correct this statement on your blog or explain why you believe that my argument implies that Terri's life is "unworthy of living".
I do have a few questions since you added a link to Dr. Bradley's blog after mine where he made a comparison between Terri Schiavo and a patient with cerebral palsy. Other than for the purpose of being sarcastic, what is the logical reasoning behind many pro-lifers comparisons of Terri's case to patients with other conditions?
1. By comparing Mrs. Schiavo with other patients who have suffered brain damage such as the severely mentally retarded or stroke victims is the implication that if we start allowing PVS patients to starve to death then what is to stop us from allowing these other "undesirable" patients to die? Since these cases of PVS patients on feeding tubes started appearing 30 years ago do you have any evidence that any single case of allowing a PVS patient to die has lead to worse treatment or euthanasia of other brain damaged patients? Is this a realistic concern given the dramatic improvements in the care of mentally handicapped patients over the last few decades or is this just rhetoric on the part of the conservative right?
2. What is the purpose of comparing Mrs. Schiavo with patients who have cerebral palsy or are in catatonic states where their clinical condition appears - on the surface at least - to very closely mirror what Terri looks like in those short video clips? As physicians both you and Dr. Bradley must be aware that you are comparing apples to oranges. You must realize that this appears to be an intentional attempt to confuse the issue for the non-medical reader. The type, degree, and mechanisms of brain damage in these patients is vastly different from what happened to Terri. CP patients primarily have damage to their motor cortex but often have much of their cognition intact. The extensive brain damage evident on CAT/MRI scans of Terri's head in no way resembles anything you would see on a CAT scan of a CP patient (even in severe CP the CAT scan can be normal). Many CP patients are able to communicate in some way no matter how primitive. There is no evidence what-so-ever that Terri is conscious or attempts to communicate or interact in any way (the two physicians who side with Terri's parents can only give their opinions that they believe that she is conscious in some way. Even they have no concrete evidence).
The mechanism of Terri's severe brain damage (cardiac arrest and anoxia), the CAT and MRI scans, the testimony of several neurologists, and her completely unresponsive state for over a decade have combined to convince a Florida court that Terri is no longer capable of consciousness. Do pro-lifers have any evidence to the contrary? No. Can we be sure 100%? No, but this is a dead-end argument because from a logic standpoint, a negative can't be proven. If we do accept that Terri is indeed incapable of consciousness then does this make her "unworthy to live"? I don't know. Like I said, that is a value judgment. All I know is that if we do accept that Terri is no longer conscious but we insist on keeping her body alive then we are practicing nihilistic medicine.
Reading Rangel’s take, one would assume that Terri Schiavo is comatose. She isn’t. (go here and scroll down to see videos of her.) Since her brain injury, she’s been defined by what she can’t do. She can’t swallow on her own, she can’t speak, she can’t move around. But that doesn’t mean there “isn’t any Terri there.”
Rangel accuses Dr. Bradley and myself of confusing the issue, medically speaking, by comparing Terri Schiavo to cerebral palsy. In fact, the Schiavo case isn’t all that different from a severe case of cerebral palsy, which is also believed to be caused by oxygen deprivation or some other insult to the brain. And there are cases of severe cerebral palsy in which the patient is completely and totally disabled - as disabled as Terri Schiavo.
Rangel's other argument is that hard science - CT scans and MRI's - prove the severity and extent of Terri's injury. There’s no way to judge from a CT scan or an MRI whether or not the essence of life has vanished. We can declare a person brain dead, but Terri Schiavo isn’t brain dead. She’s been given the diagnosis of persistent vegetative state which is a descriptive diagnosis (i.e. clinical), based on what a patient can’t do:
The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations.
It’s a very difficult diagnosis to make, and it’s often misdiagnosed. That’s why, in the Schiavo case, there’s been disagreement between expert witnesses about her diagnosis. In fact, ten doctors have said she isn’t in a persistent vegetative state.
One of the conditions that can be confused with persistent vegetative state is locked-in syndrome (emphasis mine):
The locked-in syndrome refers to a state in which consciousness and cognition are retained but movement and communication are impossible because of severe paralysis of the voluntary motor system.... Patients with this syndrome can usually establish limited communication through eye-movement signals. Diagnosis of the locked-in syndrome is established by clinical examination. Brain imaging may show isolated ventral pontine infarction, and nerve-conduction studies may demonstrate severe peripheral neuropathy. Positron-emission tomographic scans have shown higher metabolic levels in the brains of patients in the locked-in state than in patients in a persistent vegetative state. Electroencephalograms, evoked responses, and single-photon-emission computed tomograms do not distinguish reliably between the locked-in and vegetative states.
Note that the only difference between a locked-in state and a persistent vegetative state that can be determined with any certainty is communication through eye movement. Take away the ability to move control eye movements, and the person who's locked-in becomes defined as persistent vegetative. A PET scan may provide some proof of higher functioning, but its use to distinguish between locked-in syndrome and persistent vegetative state is still considered investigational. We simply don’t yet know enough about PET scans, brain metabolism, and the state of being to give absolute credence to PET scan results:
Questions have been raised about the validity of cerebral metabolic studies to determine whether patients in a vegetative state are conscious or can experience pain and suffering. These questions remain unanswered and require further systematic investigation. Whether patients are conscious and have the potential to experience pain and suffering can best be assessed by careful and repeated neurologic examinations.
Here it’s worth noting that some of the doctors who treated Terri Schaivo and the nurses who cared for her, testified that she was responsive. But, what difference does it make, you might ask. She’s still living a lousy life, confined to a bed, unable to communicate with anyone.
The difference it makes is that we don’t know what’s going on inside her head. Even if she can't blink her eyelid, it doesn't mean she isn't having thoughts or feelings. Medical science can’t tell the difference between her inner thoughts and those of, say, Jean-Dominique Bauby, the French writer who wrote a book despite being, for all intents and purposes, the same as Terri Schiavo. The only difference, as far as anyone, the greatest neurologists included, can tell is that he could move an eyelid.
An ordinary day. At seven the chapel bells begin again to punctuate the passage of time, quarter hour by quarter hour. After their night's respite, my congested bronchial tubes once more begin their noisy rattle. My hands, lying curled on the yellow sheets, are hurting, although I can't tell if they are burning hot or ice cold. To fight off stiffness, I instinctively stretch, my arms and legs moving only a fraction of an inch. It is often enough to bring relief to a painful limb.
My diving bell becomes less oppressive, and my mind takes flight like a butterfly. There is so much to do. You can wander off in space or in time, set out for Tierra del Fuego or for King Midas's court. You can visit the woman you love, slide down beside her and stroke her still-sleeping face. You can build castles in Spain, steal the Golden Fleece, discover Atlantis, realize your childhood dreams and adult ambitions.
... when blessed silence returns, I can listen to the butterflies that flutter inside my head. To hear them, one must be calm and pay close attention, for their wingbeats are barely audible. Loud breathing is enough to drown them out. This is astonishing: my hearing does not improve, yet I hear them better and better. I must have the ear of a butterfly. -excerpted from The Diving Bell and The Butterfly. posted by Sydney on
11/15/2003 12:10:00 AM
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Friday, November 14, 2003
Angry Doctors: Received this email in response to this column about internist Howard Dean's claim to have routinely treated five year olds:
Wow.
You FPs are something else.
The "doctors for every age"?
Give me a break.
Your claim that Dr. Dean would not have treated children shows you have NO idea about what takes place in many "rural" areas in the country.
Where do you practice?
There were a couple of commenters on the Tech Central Station site who made similar points, although without the insult to family medicine. Actually, I do have an idea of what takes place in rural areas. I used to practice in one. Internists don't see five year olds. They simply aren't trained to do so. There are some doctors, of an older generation than Dean, who practice general medicine. Their training consisted of a rotating internship for a year in which they learned surgery, pediatrics, obstetrics, and medicine. They call themselves general practitioners, not internists. I suspect my correspondent is of that generation. Dean isn't. His training is in internal medicine, a specialty that concentrates entirely on adult medicine. That's why combined residencies sprang up in pediatrics and internal medicine: 1) to allow people who wanted to specialize yet be able to treat both adults and children, and 2) to allow others the opportunity to be primary care providers for both adults and children.
Besides, Dr. Dean's practice wasn't that rural. He practiced in Shelburne, Vermont, only 7.1 miles from Burlington, home of University of Vermont and its medical school. Dean just isn't the "straight talker" he claims to be.
Prozac Nation: Anti-depressants (and other drugs and chemicals that get poured down drains or flushed down toilets) are turning up in fish:
Bryan Brooks, a toxicologist at Baylor University in Texas, discovered evidence of Prozac, an anti-depressant, in the brains, livers, and muscles of bluegill, caught downstream from the Pecan Creek Water Reclamation Plant in Denton, Texas, near Dallas.
Anti-depressants have the same effect on fish that they do on people: they tend to relax them. That's not necessarily a good thing for the fish, though.
Don't want to be too relaxed if you're at the bottom of the food chain.
The article doesn't mention the concentration of Prozac and other chemicals found in the fish, or whether the fish they tested suffered in any way. It only mentions the studies done in labs, which is not the same thing. They're notorious for using much larger concentrations of substances than are encountered in nature (or in this case, sewage.) The issue deserves a closer look than it's getting from CNN. posted by Sydney on
11/14/2003 01:21:00 PM
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Rebuttal:Matthew Holt rebuts my claim that money isn't the factor motivating Canadian physicians to move South, noting this statement in the survey I linked to:
"Professional factors rated most important by most physicians in both groups were professional/clinical autonomy, availability of medical facilities and job availability. Remuneration was considered an equally important factor by those in Canada and in the United States. Six of seven personal/family factors were rated as more important to their choice of practice location by respondents in Canada than by those in the United States. Current satisfaction was significantly higher among respondents in the United States. Most physicians in each group planned to continue practicing at their current location. Of Canadian respondents, 22% indicated that they were more likely to move to the United States than they were a year beforehand, whereas 4% of US respondents indicated that they were more likely to return to Canada."
What dose this actually say? It says that doctors in both places believed that they were where they were for reasons of professional autonomy, etc, etc AND money. Canadians ranked family/personal issues as more important to them. But American based docs were happier. Canadians were more likely to think about moving.
I think that this one in imponderable. It doesn't say that the Canadian's didn't care about money--they cared equally to those based in the US--but it does not (as you imply) say that they don't and that they moved to the US for other reasons. Unless the abstract says different things to the main piece I'd say that it's at the least inconclusive. But there are 2 key factors I mention in my piece that are persuasive to me:
1) The $ amounts I link to in my piece are real--docs make more here & its not secret
2) Despite that (or whatever other reasons may be making the move attractive) the amount of emigration is low, in fact extremely low based on the salary differences and the supposed superiority of practice conditions here. Your real question should be why are there any docs left in Canada? (the answer from this paper seems to be so they can stay near their parents and have built-in baby sitters.)
Point taken. Canadian doctors come here for better working conditions AND money. posted by Sydney on
11/14/2003 07:46:00 AM
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Wednesday, November 12, 2003
Buffalo Chest: Learned this today from The New England Journal of Medicine. One of the advantages that nature has given humans is that our lungs are kept in separate compartments, so if one lung collapses, the other can keep functioning. Sometimes, though, the two packages end up communicating, a condition that's known as buffalo chest (requires $$$ for full article):
A single pleural space is sometimes called "buffalo chest" because the absence of anatomical separation of the two hemithoraxes resembles that in some North American buffalo, or bison. This anatomical anomaly helped the Indians of the Great Plains to thrive on hunting bison, which can be agile and reach speeds as high as 40 miles (65 km) per hour. An arrow or a single wound to the thorax frequently resulted in bilateral tension pneumothoraxes and the incapacitation of the bison. posted by Sydney on
11/12/2003 08:34:00 AM
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Tour of the Med Blogs: Finally had some time yesterday to catch up on my blog reading. Dr. Jacob is blogging live from the American Medical Informatics Association meeting.
Medrants has a post with some very thoughtful and valuable comments on the difficulties of narcotic prescribing.
RangelMD has devoted three lenghty posts to the Teri Schiavo case, in the last of which he argues that she's life unworthy of living. Dr. Bradley explains the error in that logic.
And Grunt Doc looks at a blame-game going on at a US hospital in a surgery-related death, with comments and follow-up links from Dr. Parker the scalpel man. posted by Sydney on
11/12/2003 08:18:00 AM
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Canadian Models:Matthew Holt has a well-researched and link-rich response to my column on Canadian doctors. I think, however, that he underestimates the seriousness of the doctor emigration problem in Canada. Organized Canadian medicine certainly sees it as a problem. And, while he gives anecdotal evidence that the reasons for it are chiefly money, the one survey I could find on the topic indicated otherwise. posted by Sydney on
11/12/2003 07:56:00 AM
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Tuesday, November 11, 2003
Forgive Us Our Debts:Cut-to-Cure had a lively discussion a couple of weeks ago about a story in the Wall Street Journal that detailed hospitals' efforts to collect bad debt - including having debtors arrested. It got him thrown off one reader's blog list (although I think they've since made up). Dr. Parker and most of his commentors are sympathetic to the hospitals. I confess. I am, too. There are few instances in which a person can't at least pay something, even if it's just a few dollars a month. To repeatedly and completely ignore an outstanding bill as these people did is just irresponsible. And as the WSJ article pointed out, the hospitals all made efforts to work something out before resorting to the law.
I'm probably more sympathetic to the hospitals now that I'm in solo practice than I would have been a couple of months ago as an employed physician. I have a better idea now who is and who isn't paying me for my services. The insurance companies aren't. Medicare isn't. A lot of my affluent Medicare patients who travel to Florida every winter aren't paying their portion. But my on-the-edge-of-poverty-widowed-alcoholic Medicare patient is. My single working mother with no insurance coverage is. I have the sense that this comment from Dr. Parker's November 6 post is spot on:
I participated in a study at our institution where we tracked the percentage of collections. It was surprising to see that the uninsured actually paid a significantly greater percentage of their bills when compared to those with insurance. Rough numbers revealed that collections from insurance companies were about 47%, while collections over time from the uninsured were over 80%. The practice of calling patients no-pays, because they don’t have insurance, was not supported by the numbers.
Although I'm sympathetic to the hospitals, right now, I'd like to throw the insurance companies in debtors' prison. posted by Sydney on
11/11/2003 04:40:00 PM
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Drug Wars: ACE inhibitors, those drugs that just yesterday the media were saying doctors are too stupid to use, are in the news again. This time, the angle is that they're more dangerous than a more expensive alternative, and the expensive alternative is just as effective:
The 14,000-patient Valiant study, presented at an annual meeting of the American Heart Association, showed that Novartis' drug Diovan was as effective as captopril, which is part of a class of drugs called ACE inhibitors.
ACE inhibitors are often associated with serious side effects such as coughing, rashes and allergic swelling of the face, the lips and the breathing passage. Captopril is an older generic drug originally marketed by Bristol-Myers Squibb Co. under the name Capoten.
"This trial provides evidence that this is a suitable alternative, a clinical alternative, and I do believe it will affect clinical practice," Dr. Raymond Gibbons of the Mayo Clinic in Rochester, Minnesota, told a news conference.
Gibbons is chairman of the American Heart Association's annual Scientific Sessions and was not involved in the clinical trial.
He may not have been involved in the trial, but he's continuing the pharmaceutical company boosterism that has become a tradition at the American Heart Association, which receives a good deal of money from the industry. The majority of people tolerate ACE inhibitors. Only about a third stop them due to side effects. Fortunately, this time the New England Journal of Medicine, and Reuters, is on the ball:
Editorial writers for the New England Journal of Medicine, where the study is being published, were not as convinced as Gibbons and Novartis, which hailed the study.
They said ACE inhibitors have a proven track record of reducing death and non-fatal heart attacks in more than 100,000 patients who have previously had a heart attack, compared with the relatively new data for ARBs. The editorial added that the cost of Diovan at the doses used in the study is about four to six times as high as the cost of using generic captopril at the doses used in this study.
Because of those two factors, "ACE inhibitors remain the logical first-line therapy for high-risk patients" after heart attacks, the editorial said. However, it added that there is now an alternative strategy for those patients who can't tolerate ACE inhibitors.
Conquering Fear: Researchers say that Seromycin, a drug currently used for tuberculosis, can help phobics forget their fears:
Since it was already approved for use in people, he and Barbara Rothbaum, director of the school's trauma- and anxiety-recovery program, tested it on 28 acrophobics, people afraid of heights.
Each got a pill just before their two virtual-reality therapy sessions, in which computerized goggles are used to simulate going up a glass elevator in a hotel lobby. Nobody knew whether the pill was a placebo or one of two doses of D-cycloserine, the 500 milligrams used for TB or one-tenth that dose.
One participant dropped out. When checked one week after and three months after the second session, the 10 patients who had gotten placebos did slightly better than they had at the start. But the 17 on the drug — the dose didn't seem to matter — did as well as or better than people who had finished the usual course of eight treatments, Davis said.
The research was presented at a meeting, so there's no way to compare the data, but it sounds interesting. To think that the key to conquering fear may lie in just one small protein molecule in the brain.
Common Denominator:Here's a good idea. Putting important medical and personal information in the refrigator where emergency medical personnel can easily find them if they have to come to your home. Everyone's got a refrigerator. posted by Sydney on
11/11/2003 07:47:00 AM
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Life's Worth: There's an interesting malpractice trial going on in my town. The physician admits he made a mistake. What's at issue, though, is how much the plaintiffs should be awarded. They initially sought 3.5 million dollars in damages for the death of their baby, which occurred entirely through the fault of the doctor. The catch is that the baby was a three-inch ten week old fetus. How much value should the courts attach to life they've already deemed not worthy of living? posted by Sydney on
11/11/2003 07:40:00 AM
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Dude Therapy: A large trial of the effectiveness of marijuana in treating multiple sclerosis just concluded:
The researchers found little objective evidence that cannabis benefits people with MS but, subjectively, a majority of patients felt cannabis improved some of their symptoms.
Stupid Doctors: Once again, doctors are being portrayed in the media as too stupid to provide basic care:
Doctors have known for a decade that drugs called ACE inhibitors are a cornerstone of care for congestive heart failure, yet a nationwide survey released yesterday shows that nearly one-third of patients are sent home from the hospital without this lifesaving treatment.
The report documents what many see as a dangerous reality of modern medicine: Doctors often fail to offer, or simply don't know about, the most basic elements of care for the many conditions they see daily.
Just why doctors do not give patients the treatments that experts universally agree work best is not always clear, although those who study the situation say the reasons probably range from forgetfulness and haste to ignorance.
The accusation is based on a study that looked at how many people discharged from hospitals with a diagnosis of congestive heart failure went home with a prescription for an ACE inhibitor, a class of drugs that's been shown to improve heart function and outcomes for that disease:
The newest survey found that 31 percent of patients considered ideal candidates for ACE inhibitors are sent home without them. Even at elite teaching hospitals affiliated with medical schools, more than one-quarter don't receive them.
First, let's put the study's findings into perspective - 69 percent of patients do go home with ACE inhibitors. Now, why do one-third of heart failure patients go home without them? Maybe because one-third of the patients in the study had contraindications or side effects. When you consider that one side effect alone, cough, occurs in up to 20% of people who use ACE inhibitors, then you can understand why a third of people might go home without them. (The cough is often mild but annoying enough that people beg to stop the drug to be rid of it.)
It's hard to tell from the story if side effects and contraindications were taken into account by the study, since it was based on a paper presented at a meeting rather than one published in a journal. However, studies that involve matching discharge diagnoses with treatment seldom take the time to track down such nuances. It's too labor intensive and time consuming to read through all of the charts.
Which brings us to the problem of guidelines and the studies that evaluate their implementation. The purpose of guidelines is just that - to guide therapy. But the message inherent in studies like this is that guidelines should be the standard of care for everyone. There's just one problem. Although a drug or treatment may, on paper, confer the greatest advantage for the treatment of a disease, in the real world not every drug or treatment can be applied equally to all people. In the real world, drugs have side effects. In the real world, each patient's situation is unique. And in the real world, treatment has to be tailored to the individual patient. To do otherwise is just bad medicine.
posted by Sydney on
11/10/2003 06:37:00 AM
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Sunday, November 09, 2003
Identity Crisis: There are a lot of reasons I would never vote for Howard Dean. For one thing, I disagree with the majority of his positions. But, even if I were idealogically aligned with him, I'd have trouble voting for him because of statements like this:
As many of you know, I'm a doctor. I'm an internist, and I take care of all ages, pretty much five to 105.
There's an inherent untruth in that sentence that escapes most non-physicians. Howard Dean is an internist, a doctor trained in internal medicine, which means he treats adults, not patients "5 to 105." (Familiy physicians are the ones who do that.) I've yet to meet an internist who feels comfortable treating a five year old, unless they graduated from a combined residency in pediatrics and internal medicine.
This may seem like splitting hairs, but it isn't. Marcus Welby was a family physician. Dr. Kildare was an internist. The difference is all in the archetype. Dean's got to be consciously aware of this. If he opened with the same claim in front an audience of physicians, his claim to be an internist who treats five year olds would immediately call into question the veracity of everything that follows. He does it in front of audiences of laymen because he knows he can get away with it. And because it suits the personal narrative that politician Dean is trying to spin for Dr. Dean. posted by Sydney on
11/09/2003 11:40:00 AM
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