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Expectations

I was talking to a colleague of mine yesterday. (At least I flatter myself that I am a colleague.  He has a writing job at a prestigious magazine while I, well, don’t.)  We were talking about the doctor-patient relationship, as is our wont, and he said something that stood out to me as the quintessential statement of patients’ expectations about doctors.  It goes something like this:

I expect that when I am sick the doctor, who makes a thousand times more than I ever will, will make me well.

There are two wildly different ideas in this sentence, which as we will see have become conflated in a way that was never intended.  First of all, patients seem to be extremely sticky about money, specifically, how much a doctor earns.  They seem sticky about it to an extent that they aren’t about sports figures and movie stars.  While it seems to bother no one that a player in the NFL makes $20 million a year and that tickets to the home games cost $500, it irks the heck out of people to pay a $15 copay to a doctor who earns 100 times less.  It might be that the NFL player’s purpose is to entertain us, while the doctor’s job is to “serve” us.  Medicine is, after all, considered a service industry.  Maybe making money off other people’s suffering bothers people, although lawyers and bankers are much better at that than doctors.  Historically, doctors expected to get paid very little.  One hundred years ago the doctor who saw you in the emergency room wouldn’t get paid anything at all, unless you were a private patient, in which case you would never go to an ER in the first place.  The doctors who attended in the hospital, rounded, and taught medical students were unpaid.  The money thing is fairly recent, and reflects the amount of money and time invested in education and training.  Our society has chosen to make us pay a lot and then pay us a lot in return.  In countries in which medical education is free or practically so, doctors get paid much less.  And in areas of this country where most people have no insurance or only Medicaid, doctors don’t get paid much here either.

So that’s the first part.  The second part of the sentence is the one that says when I am sick I will go to a doctor who will make me well.  This is also a recent development.  People used to call doctors when they were sick, if they could afford one, but they didn’t have any great expectations that the doctor would heal them.  It was enough that he attended upon them and did the best he could with the limited means he had.  As our ability to treat things has gotten better, expectations have risen, as they should.  At this point, though, the expectation has become that somehow doctors can treat death itself.  Doctors do the best they can with the means they have.  That is all anyone can expect.

The biggest problem with my colleague’s sentence really is that the two ideas in the sentence, doctors get paid a lot and doctors make me well, have melded into a new sentence: When I am sick a doctor gets paid a lot of money so he better make me well.  This is not a statement that leads to healthy doctor-patient relationships.

By the way, my colleague is an award-winning journalist, so when he writes his best-seller he’ll find out just how much more money he can make than his doctor!

Putting Babies To Sleep

OK, nobody panic.  Remain calm and call anesthesia.  Or maybe, if you’re 2, don’t call anesthesia.  The New England Journal of Medicine on Feb. 25 published an article that warns of an increasing body of evidence suggesting that anesthesia is bad for babies.  Denise Grady, a New York Times reporter, said this in her piece yesterday: (http://www.nytimes.com/2015/02/26/health/researchers-call-for-more-study-of-anesthesia-risks-to-young-children.html?ref=health&_r=0)”

“… five experts described a ‘heightened level of concern’ about the potential risks, called the data from animal studies ‘compelling’ and said ‘parents and care providers should be made aware of the potential risks that anesthetics pose to the developing brain.'”

Evidence of this possible risk as been growing since the 1990’s, when the first animal studies came out.  In 2009, the F.D.A. and the International Anesthesia Research Society formed Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots or SmartTots, to futher research this potential problem.  In 2012, SmartTots recommended that elective surgery under general anesthesia be avoided in children younger than 3.  Here is what SmartTots is saying this year (http://www.smarttots.org):

Infants and very young children who are exposed to anesthesia may experience higher rates of learning disabilities and cognitive difficulties than children who are not exposed to anesthesia, according to research and emerging data presented during the SmartTots: Pediatric Anesthesia Neurotoxicity panel at the International Anesthesia Research Society annual meeting in Vancouver, B.C.  “We want to impress upon people that there is a very reliable link between the animal and human data that is rapidly emerging,” said panel moderator Dr. Vesna Jevtovic-Todorovic, M.D., Ph.D., M.B.A., Professor of Anesthesiology and Neuroscience at the University of Virginia Health System and SmartTots Scientific Advisory Board member.

SmartTots warns that “Children younger than 4 years who were exposed to anesthesia for 120 min and longer for at least two times are at high risk.”

So what is this emerging data?  Well, it’s mostly primate and rat data at this point.  Researchers found, for example, that a single 24-hour episode of ketamine anesthesia results in very long-lasting deficits in brain function in nonhuman primates.  Another found that multiple exposures to anesthesia before a monkey is two years old are a risk factor for the development of Attention Deficit Hyperactivity Disorder.  Yet a third paper has demonstrated that common anesthetics, alone and in combination, caused damage in the brain of baby rodents, with widespread death of nerve cells. These rats suffered long-lasting problems with learning and memory, which got worse as they aged.

Yikes.  Now, as I said before, don’t panic.  There are a few things to consider when reading about this stuff.

1. Your toddler getting her tonsils out or ear tube put in is not at risk.  Those are 10 minute procedures in otherwise healthy children.  Please do not let your kid suffer years of unnecessary infections and possible hearing loss because of concerns over the anesthesia.  I know people are going to.  Don’t.

2. Very young children exposed to surgeries lasting two or more hours on multiple occasions generally have either severe birth defects or severe injuries of some kind.  I’m not sure you can isolate anesthesia as a cause of brain damage in these situations, in which cognitive development is at risk in multiple other ways.

3. I’m not sure what study Dr. Jevtovic-Todorovic is referring to when she talks about a “very reliable link” between nonhuman and human data.  There is an ongoing multicenter study sponsored by Boston Children’s Hospital which is studying 650 infants getting inguinal hernia repairs, looking for neurodevelopmental outcomes in kids getting regional anesthesia (a spinal) vs. general anesthesia.  Such a study will involve mostly healthy children with anesthetic exposures significantly lower than those SmartTots says are most concerning, but it might help.

4. General anesthesia is not just the drugs we use.  It’s also the type of surgery being done, how much blood loss there is, how much oxygen gets to the patient, how much carbon dioxide builds up, how well blood pressure is maintained, and multiple other factors that anesthesiologists monitor very carefully.  Many of these things are under our control, but all anesthesia and surgery interferes with these systems to some extent.

And since personal anecdote has been shown to be more effective than statistics, I will tell you that my second child had major thoracic surgery at age 3 days.  She was under anesthesia for about 4 hours.  She is now a healthy 4 1/2 year old with no signs of any mental problems except persistent four-ishness. Hope this helps.

The Republican’s Plan

Hey everyone.  In case you didn’t know, the Republicans have put out a proposal for their version of health care reform.  It’s called The Patient Choice, Affordability, Responsibility, and Empowerment Act.  PCARE for short, which is kinda cute.

Here’s the link:energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/114/20150205-PCARE-Act-Plan.pdf.

To interpret, I highly recommend going to Brad Wright’s blog Wright on Health.  He does a great job of evaluating the provisions listed and comparing them to what the ACA has done.  Check it out.

Let them eat dirt.

New Englanders have very bad memories.  That’s the only explanation for why anyone lives here.  Every year in the fall people reminisce about how bad last winter was, and hope that the winter to come will be better.  What these hardy souls don’t remember is that IT NEVER IS BETTER.  It hasn’t been better for the entire history of New England.  NPR did a bit a few days ago about how the Native Americans indigenous to this region survived winter.  Turns out they did just fine, thank you, with solutions to heating and keeping warm outdoors that used natural habitat and took cues from local animals.  The Europeans, having decided their way was better, froze with their wooden houses, smoky fireplaces, and inadequate wool clothing.  The takeaway of the piece was that the Native Americans worked with the environment, and the Europeans tried to change the environment.

The same thing seems to be happening in the world of microbes.  Population studies suggest that as infectious disease incidence goes down and socio-economic status goes up, allergic and immunological diseases become more prevalent.  This is what us medicine folks call “The Hygiene Hypothesis”.  Here’s how the FDA puts it: “This hypothesis suggests that the critical post-natal period of immune response is derailed by the extremely clean household environments often found in the developed world. In other words, the young child’s environment can be ‘too clean’ to pose an effective challenge to a maturing immune system.”

In other words, we have changed the environment.  Unlike the Europeans and New England winters, we have been very effective in changing it.  Now, most of this has been to the good, of course.  Antibiotics and vaccinations, clean water and sewage systems have vastly improved the chances of health and survival for children.  However, in areas of the world in which health and hygiene measures have lagged, infectious disease rates are higher but allergic conditions are more rare.  An excellent review of the hygiene hypothesis can be found in the journal Clinical and Experimental Immunology (H Okada, C Kuhn, H Feillet, and J-F Bach. Clin Exp Immunol. 2010 Apr; 160(1): 1–9)

 According to the ‘hygiene hypothesis’, the decreasing incidence of infections in western countries and more recently in developing countries is at the origin of the increasing incidence of both autoimmune and allergic diseases. The strongest evidence for a causal relationship between the decline of infections and the increase in immunological disorders originates from animal models and a number of promising clinical studies, suggesting the beneficial effect of infectious agents or their composites on immunological diseases. The leading idea is that some infectious agents – notably those that co-evolved with us – are able to protect against a large spectrum of immune-related disorders.
Hence my last post about the dangers of dishwashers.  But here’s my question: isn’t the exchange of infectious disorders for allergic ones kind of what we were going for?  Cholera kills a whole lot more kids than asthma does.  We could all go back to living off the land and having our kids rake hay and muck stalls, thus exposing them to all kinds of presumably useful microbes, but certainly we don’t wish upon them a return to the constant threat of illness.  I guess the best we can do is to be a little less obsessive about cleanliness, a little more accepting of the annual cold and flu season, and a little more willing to make mudpies.  I won’t, however, ever be accepting of New England winter.

We’re going to need more Palmolive…

OK, no.  Uh uh.  Not gonna happen.  Just…no.   It has all gone too far.

We all know that good mothers make their own organic baby food, breast feed until high school,  bleach their babies’ cloth diapers and hang them on hemp clotheslines, and sew fair-trade pure cotton onesies.  Ladies and gentlemen, I’m here to tell you that the very best mothers also don’t use dishwashers.

According to the journal Pediatrics, specifically Bill Hesselmar, Anna Hicke-Roberts, and Goran Wennergren, children who’s mothers use dishwashers are significantly more likely to have allergy-related diseases like eczema, hayfever and asthma than children who’s parents mainly wash their dishes by hand.  Here’s the link: http://pediatrics.aappublications.org/content/early/2015/02/17/peds.2014-2968.full.pdf+html

The authors are basing their research on the so-called “hygiene hypothesis,” in which scientists posit that people in developed countries are growing up in a sanitary environment that does not promote a healthy and robust immune system.  Children’s immune systems are not challenged by foreign microbes, and thus the body is more likely to respond to common, harmless antigens as infectious and mount inappropriate immune responses, i.e, allergies.

I kind of agree that kids should be exposed to bugs.  My little angels have been known to eat the occasional french fry off the floor, I won’t lie.  Having all three of them sick every single Christmas sucks, but I’m assured by the best pediatric minds that a rock-hard immune system is in the offing.  However, in the virulent petri dish that is my local indoor playground, I chase my kids around with the hand sanitizer with the most crazy of the liberal elite east-coast mothers.  Nobody wants a vomiting 3-year-old.

So I understand the effort to keep children from getting sick.  And in all fairness, the authors are not suggesting that our kids be sick all the time, but that exposure to harmless microbes is normal and even helpful.  All good, but the inevitable result of a study like this is the scourge of well-meaning, over-educated, under-employed women nationwide: mommy guilt.
Picture this:  noble stay-at-home mom, wearing her baby 24/7, breastfeeding on demand while sending organic carrots through the blender with one hand and searching the web for college-prep preschools with the other, all the while wondering if the hypoallergenic laundry soap from Whole Foods is really the same one used by Gwynneth Paltrow when Apple was a baby.  Now all those sharp little blender parts, miniature Tupperware with hard-to-open lids, and BPA-free rubber bibs with the little spill pocket have to be lovingly hand-washed to protect little Ashley from the evil hyper-sanitary environment the desperate mother has been otherwise striving for in every corner of her house.
Please everyone.  Let the poor woman have her dishwasher.

Similarity and Probability

This week is school vacation week (because the kids are so exhausted from all the snow days they’ve had this month) and, as usual, many of my 6-year-old’s friends are away.  Specifically, her best friend is in Florida.  Since her best friend is the same age as my daughter and in the same grade and they like the same things, my daughter has correctly deduced that she and her friend are similar.  And if they are similar, they should do similar things.  Thus the question:  “Why didn’t we go to Florida?”

Because we’re idiots, that’s why.  No, I didn’t say that.  I told her some version of We Can’t Afford It Whats Wrong With Snow Go Ask Your Father. It did occur to me, later, that the thought process behind the question, “Why didn’t we go to Florida?” is the same one patients use all the time to assess risk.

Assessments of similarity are natural for humans, being social creatures who like to find others like themselves.  We do this automatically on issues of skin color, accent, socioeconomic status, educational level, etc.  When something bad happens to someone, the people around that victim will tend to look at themselves and find ways to reassure themselves that they are not similar to the victim.  Or, if asked to determine the risk that the same event will happen to them, they will inflate the risk if the number of similarities between themselves and the victim is large. For example, if I have an acquaintance who got breast cancer at age 38, and I’m 38, it might cause me to worry about my own risk of breast cancer.  I might worry more if she was like me in more ways, like she was also a doctor or was also from California or had the same number of kids as me. It might not make much difference to me if some of my information about her were second-hand or gossip, or that being from California is not associated with breast cancer.

Another example might be Autism.  A parent could see a child with Autism who has been vaccinated and compare that child with their own.  The more the autistic child is similar, or appears to be similar, to the parent’s own child, the more worried about autism that parent might be.  Having assessed that the two children are so similar, the parent decides he’d better make them a little less similar, so he’ll decide not to vaccinate his child.  He decides not to vaccinate in part because other parents who share similarities with him have chosen not to.  The fact that vaccinations and Autism are not linked or that the information he has about the autistic child might be false don’t impact his decision as much as you’d think.

The problem is that the trope “It could happen to anyone” is not really true, because judgements of similarity and risk don’t have the same rules.

Assessment of risk, or probability, must include information about average population rates and rates of the event in question in different demographic groups.  Assessing probability also requires that the information you have is as accurate as possible.  Assessment of similarity has no such restrictions.  You can decide someone is similar to you regardless of how common the traits between you are in the population or how reliable your source of information is.

Nevertheless, patients equate similarity and probability all the time. This is why choices that patients make can seem irrational or crazy, and patients can get labeled as “worriers” or “malingerers”.  Same thing with parents.  Same thing with any question in which we are asked to make an impossible prediction.  Comparing ourselves to others is natural and automatic, and forms the basis for more decisions than we would like to acknowledge.  Yet another example of how medicine is not an exact science, because humans are involved.

Give me an easier question!

I’ve been practicing a lot of Paganini.  Paganini, for those of you who weren’t paying attention in music appreciation class, wrote crazy difficult violin music.  Practicing, of course, is supposed to lead to improvement in performance.  Practicing Paganini, however, mostly leads to improvement in my well-honed ability to tell myself I suck.

If you were to ask me on one occasion “What is the probability that you would ever perform Paganini in public?” the answer would be “zero to none”.  But ask me on a different day, when I played a little better, and I might say “unlikely, but maybe someday”.  Then ask me right after I’ve had a lesson in which my teacher says something encouraging and I might say “someday.”  My answers go from completely hopeless to quite hopeful.

My responses can be explained by three observations made by Daniel Kahneman in Thinking, Fast and Slow. My first response – slim to none – is given when I have a negative assessment of my ability.  This is an example of what Daniel Kahneman calls The Affect Heuristic.  He says that “The dominance of conclusions over arguments is most pronounced where emotions are involved.”  Similarly for the second answer – unlikely, but maybe some day.  The third response has not only to do with the Affect Heuristic but the Mood Heuristic.  Being asked a question about the probability of me playing Paganini after being encouraged by my teacher made my assessment more positive.  This would be true even if my teacher had been encouraging about an completely different composition written by a completely different composer.

What I have done is substitute a hard question for an easy one.  In this case the actual probability that I would ever perform Paganini is very hard to calculate.  So my brain substitutes the question “how do I feel about Paganini, or about myself, right now?” which is easy to answer. Richard Feynman, the Nobel-prize winning physicist, did this all the time with math.  When asked to calculate the cube root of 1729.03 in his head, Feynman substitutes the question “how long is a cubic foot?” because a cubic foot is 1728 cubic inches and thus the answer has to be around 12.  I can do that in my practice room too: instead of asking “How do I play this passage of ascending thirds?”  I can ask “how would I play it if I needed to play only the top note of each third?” which is easy.

Patients do the same thing in making decisions.  If you ask someone if they want to get a mammogram at 40 or wait until 50 what you are really asking the person to do is calculate the probability of getting breast cancer between ages 40 and 50 and not finding it until it is too late.  This is a very difficult calculation to do, even if the patient understands the statistics on breast cancer.  So the patient substitutes in a series of different questions with easier answers: How scared am I of breast cancer?  What is my current mood?  Am I optimistic or pessimistic in general right now? How do I feel about the doctor asking me the question?  Do I like him or her?  If the doctor mentioned a recent case in which a 42 year old woman had been diagnosed with breast cancer and then asked the patient if she wanted to get a mammogram at 40 or 50, the answer would change in favor of starting at 40.  If the doctor made reassuring remarks about how low the patients chances are, the answer might change toward 50.

The same thing happens in end-of-life discussions all the time.  The question “Do you want us to do everything to keep you alive if there is little chance of a good outcome?” is difficult to answer.  So the patient or family member asks an easier one: “How do I feel about my loved one right now?”  “How do I feel right now?”  “How much emotion comes up when I think about death?”

These responses are automatic – our brains will jump to an answer to a difficult question by substituting in an easier one because it is more comfortable with some sort of answer. The problem is that the answers to the easier questions can change over time, and are influenced by our mood and the way the questions are sequenced.  The frustration, for the doctor, comes from thinking that everything is settled when it was only settled for a specific moment in time.  The challenge for doctors is to remember that medicine is not an exact science because humans are involved, and humans like easy questions.

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