Recently in Science / Technology Category
I attended a wonderful presentation a few days ago by Ajit Varki, a physician and scientist at the University of California San Diego and head of the Center for Academic Research and Training in Anthropogeny. That word, "anthropogeny" was a new one for me. It means, 'explaining the origin of humans, or 'the science or study of human generation.' Varki's long standing interest in sialic acid receptors that are plentiful in all our cells led him to discover that we lost one variety of that receptor some time ago when we diverged from our nearest relatives, the apes.
The work of Varki and his colleagues is particularly helpful in the gene versus environment debate. A spate of recent articles have pointed out that the human genome project hasn't as yet yielded the treasures that were promised. Our science fiction fantasy was that we'd map your
genome, and predict that on a Tuesday in September in 2022, you would
wake up with a heart attack or a brain tumor (and presumably there were thing we could to help you avoid that fate). It turns out that even though we now have identified many areas on the human chromosome linked to diseases like diabetes, they simply are not very useful to predict that the patient will get diabetes.
For example, if I see an overweight patient walk into my office, that sight alone is
a better predictor of their risk for diabetes than any genetic test I
might order. If a pack of cigarettes shows in his pocket and his finger nail is yellow, I know a lot about his risk of sudden death from heart disease. I must say that as a clinician, this is somewhat reassuring, the notion that you still have to use your eyes and senses and earn the patient's trust to learn the kinds of things that may have put him or her at risk for various illnesses. It also says we have much to learn about the environment and its influences on us.
Dr. Varki's group suggests that even 'nature versus nurture' is too simplistic a debate, and that we as humans evolved because of a dependence on learned behaviors and social interactions that may have been advantageous. It may be that even things like breastfeeding among animals are learned behaviors and are not hard wired! His work makes for fascinating reading and it would be folly to try to summarize.
As I was preparing this piece, I read in the NY Times about a bear named Yellow-Yellow in the Adirondacks who has managed to get past a bear proof food container that stymies all other bears. Surely this learned behavior will give Yellow-Yellow a survival advantage if that becomes the only source of food available. The big question is can she and will she teach it to her fellow bears, or to her mate and to their progeny? The fate of the universe rests on such questions.
07/07/09 9:02 AM
Medical Tests: "Does it work?" matters less than "Does it pay?"
When President Obama speaks about funding health reform, he keeps emphasizing that the money needed to achieve his goals of covering the uninsured, is already in the system:
"Two thirds of the cost would be covered by re-allocating dollars that are already in the health care system, taxpayers are already paying for it, but it's not going to stuff that's making you healthier." (From his appearance on ABC's Prescription for America).
I recently came across a great resource (thanks A.J.!), the California Technology Assessment Forum whose goal is to assess new and emerging technology. It is edifying to look at the list of tests it has assessed, pages of them, and to see how few meet its criteria for a test that improves health outcomes and is safe and effective. And yet the tests are being done and we are collectively paying for them.
Hats off to the President for taking on health care reform, because if you read the CTAF's list of tests that are ineffective, you are also looking at a list of device manufacturers and others who are doing very well on these procedures and tests--every one of them is going to battle him tooth and nail, primarily through their lobbyists in Congress. I sense the President is doing the right thing by taking the message to the public, to us, counting on our sense of outrage to say it is enough.
One of my former students, a brilliant physician who has gone into a rural practice where he does it all--delivers babies, takes care of children, adults, performs procedures--wrote the following to me (tongue in cheek) and I have his permission to use it:
"I justify ordering expensive and unnecessary tests in the following way: It is clear that the current health system is unsustainable. The sooner it collapses, the sooner we can start over again, hopefully with something better. I intend to do my part to bring the system to its knees as soon as possible. (That's only funny because I'm not that way.)"
It's only funny because he truly isn't that way.
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It's a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions--a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending's note, blood tests, imaging studies, nurses' notes, consultants' notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
"the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it."
Simon anticipated by 40 years the issue I've been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns' generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone's signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn't be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I've felt that my time at our patients' bedsides, examining them (because only the exam can tell you if there is pain and if it's better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam's words --poverty of attention-- which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap--time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient's data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It's the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he'll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let's see what he reports. I have no doubt we will both learn something.
A newsletter from our Stanford medical school library reminds me that fifteen years ago, if I wanted to get the latest scoop on a disease, I'd have had to walk through the stacks where our library displayed the 3,600 journal titles its owns. Then, once I collected the bound volumes containing the articles I wanted, it was off to the photocopier area. An hour later (provided my coins and the machine lasted), I'd be done.
These days, my medical library (fittingly called the Lane Medical Library and Knowledge Management Center) has 6,500 journal titles available on line, along with 8,150 eBooks and 680 databases. Since this virtual library never closes, I can 'walk' through the stacks at three in the morning.
This ease of access characterizes so many aspects of medical practice: I can access x-ray images of my patients from any computer; I can write my progress note in the patient's chart from wherever I am, even from home, because we use an electronic medical record and not a paper chart.
Progress is great! Who wants to go back to the old ways of hunting in the file room in radiology for an x-ray image, only to find someone checked it out for a conference and didn't return it. No more hunting for the right image in a thick manila folder in which the films are out of order.
But . . . I find I do miss visiting my colleagues in their dark dens, their lairs in the radiology department; similarly, I miss the camaraderie of seeing and interacting with colleagues from other disciplines as we congregate around the chart rack at the nurses' station; I miss the serendipity of running into a student in the library. I miss the hush of the stacks, the miasma that speaks of old books and collected wisdom, and how so often it was the book parked next to the book I had come to find that turned out to be the real treasure. Will I ever make that kind of discovery in a virtual library?
Abraham Verghese
