Tuesday, February 23, 2016

Either/or Thinking about Opiate Addiction

An article about "Rehab Rooted in Science" in this morning's New York Times provokes me to rant about one of my pet peeves - either/or thinking about complex medical problems and grouping those who disagree into opposing "camps."

The story describes how Dr, Mark Willenbring, a psychiatrist specializing in addiction treatment, became frustrated at the limited uptake of medication-assisted treatment of opiate addiction, which, according a review of evidence in last year's Harvard Review of Psychiatry, doubles the likelihood of obtaining abstinence.  Dr. Willenbring started his own treatment center, at which he makes extensive use of medications that reduce cravings and help many patients achieve stable abstinence.

The NYT article quotes a counselor who favors abstinence - treatment without medications - as follows:
"Substituting one drug for another is an external solution for an internal problem. [Dr. Willenbring’s approach]  deprives his patients of the opportunity to have a full range of emotional experiences, a change of spiritual perspective and a return to an improved quality of life."
Unless there's rigorous evidence for this view - and there isn't - it's an irresponsible symptom of either/or thinking. It should be a no-brainer that treatment for opiate addiction should combine medications, psychotherapy, 12 step programs like NA and AA, and more, in whatever combination seems best for a particular patient.

When I first entered psychiatric practice I was puzzled when people asked me what "camp" I followed. Was I a Freudian? A Jungian? A medication-oriented psychiatrist? Just what was I?

Sometimes I tried to explain why I thought the question itself was misguided. Sometimes I was provocative - I remember saying things like "if standing on my head and spitting wooden nickels helped my patients get better, that's what I'd do." But if I felt that the person I was talking with needed to put me in a "camp," I said I was a follower of Dr. Adolph Meyer, a distinguished early 20th century psychiatrist who embodied balanced thinking, and whose articles were published as The Commonsense Psychiatry of Dr. Adolph Meyer.

I assume that our earliest ancestors developed "us versus them" thinking as a way or consolidating their tribe. We still see all-too-much tribal thinking all across the globe. Medicine should set an example of thoughtful gathering of evidence, respectful discussion of alternatives, and steady improvement in what we have to offer. Either/or thinking and clumping ourselves into warring camps may give us a "high," but should not be part of our efforts to deal with as difficult a problem as opiate addiction!

Friday, February 19, 2016

All Physicians Should be Doing Palliative Care

Here's a condensed version of a recent conversation I had with a family member:
My family member: The hospital recommended that X should have palliative care. What is palliative care?
Me: Palliative care is a specialty that focuses on symptoms - helping people suffer less and feel better. It's for people who have serious ailments. Its aim is to improve the quality of life for patients and families.
My family member: I'm confused. Isn't that what every doctor is supposed to be doing?
The question pointed to a real problem. Helping people suffer less and feel better is indeed what every doctor who cares for patients is supposed to be doing. So even though I'm a fan of palliative care, we have to ask: why does it exist?

In my view, palliative care exists for three reasons - one good and two bad.

The good reason is that we've developed a lot of knowledge about controlling symptoms and improving quality of life, ranging from medicines and devices to psychological techniques to judicious use of community resources. Orchestrating all of these often requires a skill set beyond that of primary care physicians and subspecialists. Thus the emergence of a new specialty.

Bad reason #1 is the ethos of U.S. health care. It's displayed when we physicians, coming to the end of our potentially curative interventions, say "there's nothing more I can do for you." We should know better! 2,500 years ago Hippocrates taught us that our role was to:

One of my medical heroes is a clinician/basic scientist who cared for a dear friend of mine who had an incurable cancer. My friend came for an appointment after the last known treatment had failed. The physician said, "X, the best thing I can do for you now is to give you a hug." That's what he did. When I met the physician some years later and told him how much I admired him, he thanked me and immediately asked after my friend's spouse. Palliative care was part of what this physician expected of himself! I picture Hippocrates smiling and saying "you got it right."

Bad reason # 2 is time. When physicians ask each other about the most meaningful moments in our clinical careers, the stories are often about palliation - making contact, relieving suffering, bringing comfort. But the way we have structured medical roles makes it very difficult to spend the time required for giving good palliative attention. Rather than finding ways to make more humane practice possible, we've created the specialty of palliative care.

I have regular contact with primary care residents, and over the years a number have chosen further training in palliative care. It's not that they've turned against primary care - it's that they concluded that palliative care was the best way for them to practice medicine as they hoped to when they went to medical school. This is also why some physicians in practice choose the "concierge" format, in which they limit the size of their practice and make up for lost income by charging a fee for "belonging" to the practice.

But my belief that when we physicians care for patients we should all be doing palliative care isn't, alas, practical in 2016. I ended the dialogue by saying - "In principle you're right - every doctor should be doing that. But it isn't happening. Palliative care is a great idea for X. Go for it!"

Wednesday, February 17, 2016

Viagra and the Political Genius of Mary Lou Marzian

Most readers have probably heard about a bill Kentucky State Representative Mary Lou Marzian proposed in response to Kentucky's most recent intrusion on a woman's right to choose:
A health care practitioner shall:
(1) Require a man to have two (2) office visits on two (2) different calendar days before the health care practitioner prescribes a drug for erectile dysfunction to him;
(2) Prescribe a drug for erectile dysfunction only to a man who is currently married;
(3) Require a man to produce a signed and dated letter from the man's current spouse providing consent for a prescription for erectile dysfunction; and
(4) Require a man to make a sworn statement with his hand on a Bible that he will only use a prescription for a drug for erectile dysfunction when having sexual relations with his current spouse.
Representative Marzian, a retired nurse, wanted to expose the hypocrisy behind Kentucky's new law requiring a women to receive "counseling" 24 hours before having a legal abortion, in hope that Kentucky women would join her in saying "enough is enough." Not surprisingly, her proposal has gone viral. It's an act of political genius. Rather than offering another rant, she takes the precedent of legislative intrusion into medical care to its logical extreme - but focused on men.

In addition to being hilariously funny, her bill represents a philosophical argument Socrates would have been proud of. His distinctive technique was to take an inadequately thought through position and show how it leads to conclusions his interlocutor cannot accept. If a picture is worth 1,000 words, a spoof like the bill Representative Marzian proposed is worth 10,000 or 100,000.

Hats off to a Kentucky legislator with the guts, wisdom, and delicious sense of humor to come up with the proposal she made!

(See here for an op ed by Representative Marzian in the Kentucky Courier Journal.)

Sunday, February 14, 2016

"Guilty mind" and the jailing of Professor Anna Stubblefield

I've had several conversations about the justice or lack thereof in the sentencing of Professor Anna Stubblefield since I posted about her four days ago. One person made a strong case against any jail time on the basis that (a) although every reputable professional society that has examined "facilitated communication" has concluded that it is bogus, it's not illegal to use the "technique," and, most importantly, (b) Anna Stubblefield did not have what in legal terms is called "guilty mind" (mens rea).

If I erroneously take your suitcase from the airline carousel because it looks exactly like mine, I'm not guilty of theft. But if when I get home I decide to keep it because I like the content of yours better than mine, I've become a thief. The difference is in my knowingly and intentionally appropriating your property. That's guilty mind.

My critic was right. In initiating a sexual relationship with D.J., a disabled man, Professor Stubblefield (a) believed he had given enthusiastic consent via "facilitated communication," that she was (b) fulfilling his wishes (as well as hers), and that (c) bringing a disabled, previously uncommunicative 32 year old into the shared human world was an ethically admirable act. That doesn't look like a guilty mind. How could jailing her for rape possibly be ethically allowable?

That argument troubles me too. But here's my response. "Facilitated communication" (placing the uncommunicative person's hand on the facilitator's hand to guide writing at the keyboard) has been decisively and definitively shown to be a false theory. The writing comes from the "facilitator," not from what believers in the false theory call the "communication partner."

But given the widely known results of scientific evaluation of "facilitated communication," and the multiple condemnations of it by reputable professional societies, Professor Stubblefield should have known that D.J. could not give valid consent. She should not have accepted her experience at the keyboard as evidence for consent.

Another interlocutor invoked the history of science. Haven't there been examples of theories widely regarded as false that were later determined to be true?

Yes, there have.

Professor Stubblefield and her co-believers in "facilitated communication" are entitled to believe that mainstream science is wrong, and to make ethically allowable efforts to disprove the scientific consensus. But they're not entitled to invade the rights of others, as by "determining" that consent for sexual relations has been given. Similarly, the occupiers of the federal wildlife refuge in Oregon are entitled to argue that the federal government is acting wrongly, but they are and should be liable for trespass for acting on their beliefs.

Still, from the perspective of ethics, sentencing Professor Stubblefield to 12 years in prison makes no sense. She's not a danger to others as long as she neither commits nor incites actions like hers with D.J. That would be a condition of probation. She did not have a guilty mind. Although her case is not a slam dunk, I hold to my view that given 25 years of well publicized scientific findings,  she was not entitled to act on her beliefs.

In my view, the jury was correct in defining her actions as rape. But guilt is one thing and sentencing another. The sentence may be consistent with state law, but the 12 year sentence does not fit the crime.

Friday, February 12, 2016

Sharing our Experience of Illness

In the last couple of month I've developed a problem involving circulation to my toes and foot. The formal name is "acrocyanosis." Colloquially it's called "blue [or purple] toe syndrome." Though the medical literature describes it as painless, what I have hurts. It's commonest in younger people and uncommon in someone my age.

I'm a strong believer in the potential value in learning from others who have a similar condition, but Google didn't produce much, and the diagnosis was not listed on the excellent Patients like Me website. I respect the physicians I've been dealing with, but I was hoping for practical tips about coping from people who have experienced the condition themselves.

While I was musing about the topic of peer networks, my friend and former colleague Al Martin published a post exemplifying what I had in mind in his always engaging Age with Spirit blog. I don't have the condition Al is writing about (Parkinson's Disease), but if I did his post would be a treasure.

Years ago a patient of mine who was about the age I am now developed post herpetic neuralgia, a painful condition that can follow shingles. The pain added to the depression I was treating her for. Like Al, she was an activist, and she wrote about her experience on the web. A young woman from the UK contacted her. My patient, a wise and generous person, "coached" the younger woman on coping with chronic pain. I assume the coaching was helpful to the woman in the UK, but I know it was helpful to my patient.

The famous "twelfth step" in AA is perhaps the best known expression of the idea of peer support: "Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics..." Here's what AA says about the twelfth step:
Here we turn outward to our fellow alcoholics who are still in distress. Here we experience the kind of giving that asks no rewards. ..When the twelfth step is seen in its full implication, it is really talking about the kind of love that has no price tag on it.
My patient with post herpetic neuralgia felt a kind of love for the young person in the UK. If I had Parkinson's Disease, I would feel a spirit of solidarity and love coming to me through Al Martin's post:
This posting is a personal look at my experiences with a chronic brain disease -- Parkinson’s Disease (PD) -- in contrast to the way that the experience looks to others. We view problems that affect the brain with particular dread, because we see the brain as the determinative of who we are as people. Diseases may seem fearful or tragic to those who don’t have them, but the experience may be quite different for the person with the problem. Friends often aren’t comfortable asking about the details, and the person with the problem may not feel comfortable volunteering them spontaneously. As a result, an important part of someone’s interactions can be governed by assumptions. In the following paragraphs are some of my experiences with PD.
This posting is a personal look at my experiences with a chronic brain disease - Parkinson’s Disease (PD) -- in contrast to the way that the experience looks to others. We view problems that affect the brain with particular dread, because we see the brain as the determinative of who we are as people. Diseases may seem fearful or tragic to those who don’t have them, but the experience may be quite different for the person with the problem. Friends often aren’t comfortable asking about the details, and the person with the problem may not feel comfortable volunteering them spontaneously. As a result, an important part of someone’s interactions can be governed by assumptions. In the following paragraphs are some of my experiences with PD.My story begins in 2008-09. 
For some time, I had noticed a deterioration of my handwriting, which I attributed to the kind of tremor and unsteadiness that lots of older people get when they try to do fine work   I also noticed trouble buttoning my buttons. In fact, I asked a friend of mine, a neurosurgeon, if he noticed any similar difficulty with aging. He laughed that his terrible handwriting had gotten worse, and passed it off as normal aging. In the latter part of 2008, I began to notice chronic fatigue and over the next few months, the fatigue worsened, and I began to lose weight. My immediate concern was some hidden form of cancer, and in early 2009, I saw my internist, who, although he didn’t say it, had the same concern. He began ordering tests, at first a panel of blood tests and a chest x-ray, and eventually a CT scan of the abdomen. All of them were normal, and we were stumped.
On a chance, I mentioned the trouble that I had over two years, deteriorating handwriting and poorer coordination of my right hand.   He referred me to a neurologist, who within 10 minutes told me that I had PD. Among other things, he could see the stiffness in my movements and noticed that I didn’t swing my arms when I walked. He referred me to a Parkinson’s specialist, who confirmed the diagnosis and started me on one of the milder drugs for the disease.   It helped. My symptoms were very mild at the time. No one else noticed them. I could do virtually everything that I used to do, and my fatigue lessened. I was surprisingly incurious about the disease. I had, of course, learned a little about PD in medical school, the rhythmic tremor (which I didn’t have), the stiffness, rigidity, lack of facial expression, and the tiny shuffling steps. I didn’t want to know any more. As long as I was functioning well, I wasn’t interested in knowing more details about where this train was going. 
Although tremor is the best-known symptom of PD, its hallmark is what is called bradykinesia, a slowing of movement and stiffness of muscles that eventually can result in immobility. PD is due to death of nerve cells that produce the neurotransmitter Dopamine, particularly in a midbrain collection of deeply pigmented neurons called the Substantia Nigra (black substance). This lack of Dopamine results in the typical symptoms of PD, tremor, bradykinesia, rigidity and difficulty with balance. As PD has become better understood, it is clear that the disease causes much broader symptoms including difficulty with speech, voice, swallowing, constipation, weakness, double vision and in some dementia. It is a disease that is readily treated with medication early on, but which progresses despite treatment with medication eventually becoming less effective. 
My reaction to being told I have PD was very consistent with the well-known process of grieving any loss. The first stage for me was denial. I was told that I had PD. I knew what it was supposed to do, but I felt almost no emotion. The long-term consequences were abstract to me. My symptoms were mild; I could do almost anything that I used to do, and it wasn’t visible to others. I didn’t speak about it to friends. The few times that I did, the friend would look like I just said I had untreatable cancer and say something like, “Oh my god; I’m so sorry,” which I wasn’t ready for at that point. At times, I questioned whether I needed the Dopamine medication or even whether the diagnosis was correct. Maybe I would be the one where it didn’t progress or would spontaneously go away. When I saw someone with severe PD, I might be briefly shaken, but then put it out of my mind. 
After 3-4 years, it became evident that the disease was slowly progressing, and the diagnosis was undeniable. I threw myself into an exercise program in the hope that through muscle strength, it could be overcome. I read that exercise, particularly that which involves movement, like biking, swimming, walking or tai chi, is important because it does help loosen the muscles, but I couldn’t exercise my way out of the disease. What started as a little stiffness, at times has become the sensation that my muscles are in glue and that any sustained physical effort is very hard. My voice has become soft; I tend to walk with a stoop and my face transmits less expression unless I pay attention to it. When I get up from a chair, I have to take several shuffling steps to get my balance and my legs moving. With PD, one’s muscles don’t automatically cooperate as they used to. It is said that you are damned to a conscious life, because you need to concentrate on everything you are doing and how to do it. 
I am aware of what advanced PD looks like to others. Moving slowly with stuttering steps, a trembling hand and a blank stare showing no emotion makes it appear that the person is not really there. I am not at that point, but if I live long enough I probably will be. Similar to someone who has had a severe stroke, outside impressions may be worse than the reality. The disability is real, but most PD patients are mentally intact despite responding more slowly. Most PD patients are quite ‘with it’ and anxious to be engaged socially. 
PD seems to hold a particular place in people’s minds as a terrible progressive disease from which there is no recovery. True as that is, most people with Parkinson’s live long and productive lives, albeit with handicaps that must be addressed. But as with any chronic disease, one manages the best one can and usually remains the same person inside of all of the daunting, outward physical signs. It is important to patients like me that people around us realize that, or one can become socially isolated. 
Eventually, as with any chronic disease, I have to plan for the future. Planning for later is of course wise, but it confronts me with a reality that I would just as soon forget. As the complications worsen, I have to deal with more limitations. As much as the limitations may look terrible to someone on the outside, one learns to live within them and find new sources of satisfaction. It may sound Pollyannaish, but in some ways, it is a good time to grow internally, a time to appreciate life in a deeper way, to take one day at a time and to appreciate the companionship of people I care about. We don’t get to choose our diseases, and the worst curse is to withdraw and become isolated because your illness makes people anxious.

Wednesday, February 10, 2016

"Facilitated Communication" and the Sentencing of Professor Anna Stubblefield

Anna Stubblefield, former chair of philosophy at Rutgers, has been sentenced to 12 years in prison for rape of D.J., a 31 year old man with severe cerebral palsy who she insisted was mentally competent to consent to a sexual relationship. His family, the state, and the jury, saw him as severely disabled in cognition as well as motor capacity and incapable of a consensual relationship. (See here for my October post on the situation. Make sure to read the thoughtful comments as well!)

Professor Stubblefield "communicated" with D.J. by "facilitated communication," also called "supported typing," a technique in which the otherwise non-communicative person's hand is used to "guide" the facilitator at a keyboard. Multiple professional organizations, most recently the International Society for Augmentative and Alternative Communication, have studied the technique. The distinguished international review committee didn't mince its words: "...messages generated through Facilitated Communication are authored by the facilitators rather than the individuals with disabilities. Hence, Facilitated Communication is a technique that has no validity." (See here for the systematic review and here for the Society's formal position statement). Other groups, including the American Association on Mental Retardation, American Psychiatric Association, and the American Academy of Pediatrics, concur.

But facts don't change the position of true believers. Sadly, the sense of being beleaguered has led advocates to circle their wagons and advocate more vehemently. Professor Stubblefield's parents were educators with a passionate commitment to facilitated communication. They brought her up to have the same convictions, as she is doing with her own 16 year old daughter. People with severe disabilities like D.J. are often stigmatized and warehoused. Bringing out hidden potential, as dramatized so well by Daniel Day-Lewis in My Left Foot, is a noble aim. 

The pseudo-science of facilitated communication nests with concerns about social justice. Advocates feel that a misguided society is thwarting the efforts of (a) families to get help for their disabled children, (b) facilitated communication practitioners to carry out their belief that they can relieve suffering, and (c) disabled persons seeking to realize their potential. That's a powerful mix!

I see Professsor Stubblefield as a tragic victim of this witches' brew of passionate belief in a view that we all wish were true, but, alas, isn't. From the perspective of ethics we should ask - what is the right societal response? Here are what I see as the key considerations:
  1. Facilitated communication has been proven to be a false theory.
  2. It still has committed adherents who argue for the theory on the basis of anecdotes.
  3. The anecdotes don't change the fact that the theory has been disproved.
  4. Anna Stubblefield passionately believed (and, from what we know, still believes) that facilitated communication could rescue otherwise hopelessly disabled people.
  5. She is not a sexual predator. No one suggested a pattern of exploitation on her part. (Unlike my own profession, where there have been psychiatrists who recurrently exploited patients for sex.)
  6. She fell in love with D.J.
  7. She firmly believed that D.J. loved her in return and was mentally competent to consent to a sexual relationship.
  8. As I said in my previous post, even if D.J were competent, he was, in effect, Professor Stubblefield's patient, and having sex with him was unethical..
  9. The jury found her guilty of initiating a sexual relationship with a person who could not consent. Despite her belief that the relationship was consensual, it must be seen as rape.
Professor Stubblefield does not appear to be a risk to society the way a serial rapist is. She believed she was doing something with D.J., not to him. But although a female professor of philosophy who has set out to help a severely disabled person does not fit our ordinary conception of a rapist, the fact that you love the person you are having non-consensual sex with does not change the fact that the action is rape.

For that reason, I see some time in jail as an appropriate societal response. But twelve years is excessive. From the perspective of ethics, a short incarceration, to make clear that society does not tolerate rape, even if false beliefs led the perpetrator to misperceive the rape as a positive, caring action. Jail would be followed by an extended period of probation that included prohibition of any and all practice or advocacy of "facilitated communication." In addition, Professor Stubblefield should make a full apology to D.J.'s family. To me that seems like the  right outcome for this tragic situation.

Monday, February 8, 2016

Physicians as "Counsellors"

One of my favorite moments in music is the spectacular chorus in Handel's Messiah:
For unto us a child is born, unto us a son is given,
and the government shall be upon His shoulder;
and His name shall be called Wonderful, Counsellor,
the mighty God, the Everlasting Father, the Prince of Peace.
Within the chorus, I find the word "Counsellor" especially moving. An article I recently read in JAMA - "The Physician's Counsel" - helps me understand what moves me so powerfully.

The author, Donald Misch, tells how at the end of his mother's life, he was the decision-maker for whether to prolong treatment or "pull the plug." He felt an intense need to talk with his physician, who was also a friend, about the decision:
 I did not need another physician to assess the situation intellectually and medically, and yet it was clear that my [physician] friend’s words were critically important to me. I needed a physician’s counsel to let my mother die. This was true even though I was, and am, a physician, dually trained  in internal medicine and psychiatry, and I had on many other occasions helped other families struggle with similar decisions. I needed a physician—not simply other family members or friends or advisors (although all of these were helpful as well)—to tell me that under the particular circumstances of my mother’s situation, my conclusions were reasonable. Because all decisions about significant others in one’s life are laden with emotion, conscious and unconscious meaning, and history, I needed to be sure that my motives for making this irrevocable and lethal decision were not contaminated by my longstanding conflictual relationship with mother. I needed a physician to assure me that my judgment was consistent with my mother’s wishes and her best interests.
I've often written about health care as a "calling." (For examples, see here, here , here, and here.) I think the need Dr. Misch felt reflects the patient's side of what "calling" means. When we're feeling vulnerable we long for a "Counsellor." In Christian faith, it's "the mighty God, the Everlasting Father, the Prince of Peace." In health care it's the caretaker who we trust and rely on.

Many years ago a religious couple from another state came to see me. A friend who they trusted had been my patient, and gave them my name. Their daughter was involved with a man who was less religiously observant than they were. They asked me - should they cut off contact with their daughter?

I was startled. This wasn't the kind of issue I was accustomed to dealing with in my psychiatric practice. I asked why they didn't consult their pastor at home. They said, "he's new, and we don't respect him." After a moment of internal debate I decided to accept the "Counsellor" role they had given me. Was their daughter's potential spouse an honest seeming person? Yes. Was he a drug user? No. Did he treat their daughter well? Yes. Was she happy? Yes. After some more discussion I gave them my counsel. They should not sever ties with their daughter. The family relationship was more important than their views of proper religious practice.

The woman in the couple jumped up. "See - that's what I told you!" Her husband looked a bit crestfallen, but accepted my advice. I never saw them again, but 10-15 years later I heard indirectly that their daughter was happily married to the man I'd been told about.

Dr. Misch's article reminded me of another - Dr. Franz Ingelfinger's 1977 medical ethics lecture, unfortunately titled "Arrogance." Dr. Ingelfinger, editor of the New England Journal of Medicine and one of the world's experts on esophageal cancer, developed esophageal cancer. He tells us that with regard to the difficult question of whether to undergo chemotherapy and radiation after surgery:
I received from physician friends throughout the country a barrage of well-intentioned but contradictory advice. As a result, not only I, but my wife, my son and daughter-in-law (both doctors), and other family members became increasingly confused and emotionally distraught. Finally...one wise physician friend said, "What you need is a doctor." He was telling me to forget the information I already had and the information I was receiving from many quarters, and to seek instead a person who would dominate, who would tell me what to do, who would in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief."
Medical practice has its mundane moments, but at it's best it embodies what the chorus in the Messiah is singing about. What a privilege it is to be allowed to be a "Counsellor"!


Saturday, February 6, 2016

Curing Depression with Light: Let the Sun Shine in

In an elegant Canadian study, light outdid Prozac in a head-to-head comparison as treatment for nonseasonal major depression.

The study design is fascinating. Patients were randomly assigned to one of four groups: (1) light and a placebo pill; (2) Prozac and placebo light (an ion emitter modified to hum softly but emit no ions); (3) light and Prozac; and, (4) placebo light and a placebo pill.

The informed consent process involved deception. Subjects were told that the researchers were comparing light to ion treatment, and that half of the devices would be inactive. They were not told that all of the supposed ion emitters were inactive and all of the light units were active. The ethical rationale for allowing deception was that (a) the study goals could not otherwise be pursued, (b) the study had significant scientific and clinical merit, and (c) the deception posed no significant risks to the subjects.

The most effective monotherapy was light. Prozac alone was barely better than placebo. Light combined with Prozac was the most effective arm of the study, but not by much.

Light has been recognized as an effective treatment for seasonal affective disorder (SAD), but has not been rigorously evaluated for non-seasonal depression. If I were still in practice and saw a non-suicidal depressed patient who preferred not to use medication, I would recommend light treatment as part of our initial approach, combined with whatever form of psychotherapy fit the patient best.

We're a pill-happy society, and psychiatry, alas, has tilted away from non-pharmacological approaches to care. If Cazorp (Prozac spelled backwards) were a new pill that beat Prozac as decisively as light did in the Canadian study, the Cazorp company's stock would go through the roof. If further research confirms the Canadian findings, light should become a standard part of the initial response to depression. But although there's some financial opportunity for device manufacturers, inexpensive do-it-yourself light boxes are relatively easy to construct, so we're not likely to see a light boom analogous to the dominant pill boom.

Money talks, so pills thrive. Light cures, but produces little financial (as opposed to clinical) profit. Ergo, pill-popping wins hands down.

Thursday, February 4, 2016

Accountable Health Communities and Primary Care

Last month CMS announced an "Accountable Health Communities" initiative:
The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery.
I think the initiative is a very big deal!

The US health system is badly out of whack. 95% of the trillion dollars we spend on health care each year goes for acute medical treatment, but 60% or the preventable deaths are caused by "social" factors. In the brief appointments that are too characteristic of medical practice, it's difficult for physicians to learn about a patient's social circumstances. And I know from the brilliant and idealistic primary care residents I teach that they feel their training has not prepared them to know what to do in response to the stories they hear from their patients.

I believe the disconnect between what typical medical care involves and the existential circumstances of our patients' lives is a major contributor to the high rate of "burnout" and "demoralization" among physicians. When physicians and patients feel deeply connected, medical interventions are more effective and both parties experience intrinsic satisfaction. Sadly for all, this connection often does not occur.

Dr. Heidi Behforouz, a colleague at Harvard Medical School, has written usefully about "rethinking the social history." Here's her diagnosis of the problem young physicians like those I have the privilege of working with encounter:
Physicians often see patients with complex social situations as a burden — requiring extra work that is neither reimbursable nor central to our core clinical expertise. Unfortunately, we inculcate these attitudes in trainees, implicitly and explicitly, perhaps because  of our discomfort with hearing difficult stories or our sense of powerlessness or incompetence in addressing these root problems. Whereas biologic pathology may present specific targets for intervention, social or structural pathology is difficult to treat.
 The CMS "Accountable Health Communities" initiative is designed to explore organizational models that foster a stronger connection between the "medical" and "social" aspects of our patients' lives. Strong links to community resources, new skills for understanding social contexts, and improved tools for recording social information in a useful form, will all be required.

When health organizations move from being strictly "medical" to becoming "health communities," we'll have created settings in which medical, nursing, and other health professional students can learn how to do what William Osler urged a century ago: "the good physician treats the disease; the great physician treats the patient who has the disease."

Tuesday, February 2, 2016

Dreams of the Dying

A fascinating New York Times article about the dreams of people who are close to death brought to my attention a study of end of life dreams and visions carried out by clinicians at a Cheektowaga (a suburb of Buffalo) hospice and published in the Journal of Palliative Medicine.

The researchers systematically followed 66 hospice patients to ask them on a daily basis about dreams and visions. 87% reported having these experiences. The majority were comforting. The brief summaries cited in the article are moving.
28 days before his death, Barry (age 88) dreamt of driving somewhere unknown and was comforted by hearing his mother say, ‘‘It’s all right. You’re a good boy. I love you.’’ 
4 days before his death, Roger (age 73) dreamt about his best friend from childhood and saw him running out of the house with his glove and bat while laughing. They had shared a love of baseball throughout life. 
37 days before her death, Barbara (age 52) dreamt of her deceased father and brothers, hugging her and ‘‘welcoming her to the dead.’’ They seemed to be preparing to go somewhere but ‘‘they haven’t said’’ where.
The researchers conclude:
The results of this study suggest that a person’s fear of death often diminishes as a direct result of ELDVs, and what arises is a new insight into mortality. The emotional impact is so frequently positive, comforting, and paradoxically life affirming; the individual is physically dying, but their emotional and spiritual identity remains present as manifested by dreams/visions. In this way, ELDVs do not deny death, but in fact, transcend the dying experience, and present a therapeutic opportunity for clinicians to assist patients and their families in the transition from life to death, thereby providing comfort and closure.
But the researchers tell us that despite the commonness and value of such experiences, patients, families, and clinicians report being reluctant to openly discuss end of life dreams and visions for fear of ridicule and doubts concerning medical legitimacy. This is the downside of our hyper scientific approach to health care. Apart from the constraints of time that plague medical practice, young physicians I have worked with report that although dealing with spiritual/existential matters like end of life dreams and visions seems enormously valuable for both patients and physicians, they don't feel  they have developed the skills and depth of understanding that is required.

Years ago, when I taught medical students at the Howard University clinic in Washington, DC, many of our patients came from the rural South. I was impressed with how often they reported visions of a dead family member. As we listened to these experiences, it was clear that the patients were not hallucinating or experiencing psychosis. The exchanges they reported - like the dreams of the patients near death - were meaningful to them, and to us. And towards the end of his life, when I was visiting my three-times widowed father in Florida, he told me that he was expecting a "visit" from his own father, who came to him in dreams every year or two, in a way that gave comfort and joy.

The study I've summarized is potentially very influential. By making such personal experiences the focus of scientific study they bring what might be seen as solely the spiritual matters for pastors to deal with or psychopathology to be treated by psychiatrists within the orbit of what clinicians can listen to, work with, and learn from.