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Helping Primary Care Treat Minds As Well As Bodies

A doctor's office waiting room. (veggiesosage/flickr)

A doctor’s office waiting room. (veggiesosage/flickr)

Sometimes, medical doctors view their patients only from the neck down.

But that is unwise: Over 70% of primary care visits today are related to psychosocial issues – things like anxiety or depression manifesting themselves as chronic pain, stomach aches or heart palpitations.

And, according to Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical Center, these underlying problems create all sorts of complications. “Mental health conditions complicate the treatment of everything else,” he said. “If someone has diabetes and depression, symptoms of their depression may make it harder for them to manage their diabetes.”

Of course, the problem is exacerbated by patients not even being aware that they have any underlying conditions. Doctors have to try to solve problems that “patients can’t even name,” said Phillips. He gave a quick assessment of the system today: overworked primary care physicians struggle to treat conditions in limited time and often with limited resources.

Phillips envisions a system for addressing all of these issues that would begin with mental health: Continue reading

Every Minute Of Exercise Could Lengthen Your Life Seven Minutes

stopwatch

At a recent dinner party, a geeky friend of mine was cheerily justifying the piles of money he spends on a personal trainer. He’s feeling so great that it’s worth every cent, he exulted, “And the best part is the return on the time! Every minute you spend working out comes back to you, because you’ll live that much longer!”

“Really?” I wondered. I knew vaguely that being active lengthens life expectancy, but was the return on time spent really 1 to 1?

Certainly, I hoped it was. It’s a daily struggle to make the time to exercise, and the current federal health guidelines call for at least 150 minutes a week of moderate exercise — a lot of time that somehow manages to seem like even more, magnified by the “should” it adds to so many days. There are hundreds of other reasons to exercise, and the one that works best for me is wanting to feel at my best on that very day. But it would be very comforting, I thought, if I knew that all of that time would come back to me.

Not only do you get the time back, it comes back to you multiplied — possibly by as much as seven or eight or nine.

Let me cut to the happy conclusion: It seems that it does. And then some. If you play with the data of a recent major paper on exercise and longevity, you can calculate that not only do you get the time back; it comes back to you multiplied — possibly by as much as seven or eight or nine.

To quote Tom Anthony, a regular CommonHealth reader with a Harvard physics degree who kindly helped me with the math, “I wish I could get these paybacks in the stock market.”

This is all a bit of a public health parlor game, of course, resting on averages and approximations. You, personally, could work out ten hours a week and still die flukishly young. But the math looked so striking that I asked for a reality check from Dr. I-Min Lee of Brigham and Women’s Hospital, a Harvard professor and senior author of that recent paper, “Leisure Time Physical Activity of Moderate to Vigorous Intensity And Mortality: A Large Pooled Cohort Analysis.”

Yes, she confirmed, she had not calculated out the question before, but according to her data, a middle-aged person who gets the recommended 150 minutes per week of moderate exercise — defined as the level of brisk walking — can expect a 1-to-7 return: seven extra minutes of life gained for each minute spent exercising.

Some background: Continue reading

One Harvard Researcher’s Surreal ‘Dr. Oz Show’ Experience

http://api.soundcloud.com/tracks/78285910

Last week, we linked to a skeptical New Yorker article about what could be called “The Dr. Oz Problem.” As The New Yorker puts it, much of what Dr. Mehmet Oz, otherwise known as “America’s Doctor,” propagates is sound medical science. But…

“…That is why the rest of what he does is so hard to understand. Oz is an experienced surgeon, yet almost daily he employs words that serious scientists shun, like ‘startling, ‘breakthrough,’ ‘radical,’ ‘revolutionary,’ and ‘miracle.’ There are miracle drinks and miracle meal plans and miracles to stop aging and miracles to fight fat…

In each of those instances, and in many others, Oz has been criticized by scientists for relying on flimsy or incomplete data, distorting the results, and wielding his vast influence in ways that threaten the health of anyone who watches the show.”

Dr. Pieter Cohen (Courtesy)

Dr. Pieter Cohen (Courtesy)

We sent a shout-out to our readers, asking if anyone had encountered health-care problems that stemmed from Dr. Oz’s more dubious reports, and one response — or rather, one surreal story — came in from Dr. Pieter Cohen, a general internist at Cambridge Health Alliance and assistant professor of medicine at Harvard Medical School. He appeared on a 2011 “Dr. Oz” show that you can watch here, if you don’t mind the ads.

You can listen to him tell the cautionary tale in the 10-minute audio file above by clicking on the play button, but here are some highlights. First, an advisory: Dr. Cohen emphasizes that he has the utmost respect for Dr. Oz as a brilliant surgeon. “This is in no way an indictment of his clinical abilities, which are amazing,” he says, “so it remains a mystery why the show is veering off in the direction it is.”

Dr. Cohen begins with some fascinating history of the “rainbow” diet pill fad of decades past, and the many doctors who were willing to prescribe them despite the risk and lack of solid evidence of benefit.

Now to more recent history: Dr Cohen was invited onto the Dr. Oz show to discuss the “hCG diet,” a crash diet aided by shots of the pregnancy hormone hCG. He assumed that he would be partnering with Dr. Oz “to help Americans realizes that this is another fad and potentially dangerous,” he says. Because in fact, there have been “a dozen randomized controlled trials to show that it doesn’t work, it’s no different than injecting salt water. The risk issues come down to the very restrictive diet” of only 500 calories a day, which can cause gallstones and other problems.

But no…. Continue reading

‘Ethically, Is This Right For Doctors To Do?’ Help A Terminal Patient Die?

(Photo illustration by Alex Kingsbury/WBUR)

Ravi Parikh, a fourth-year student at Harvard Medical School, faced conflicting messages.

The American Medical Association, which he belongs to, and the Massachusetts Medical Society oppose Question 2, the measure on next month’s state ballot that would allow terminally ill patients to ask a doctor to prescribe them life-ending drugs.

Harvard Medical School student Ravi Parikh

In contrast, The American Medical Student Association, which he also belongs to, supports it.

Ravi faced conflict within as well. He’d applied to medical school for the usual reason — to heal patients, as spelled out in the Hippocratic oath — not to help them die.

But his medical education introduced him to the complexities of modern American dying.

It stressed patient autonomy as a “central guidepost.” Yet he saw patients losing control as they neared death. “No patient that I have spoken to wishes to die in pain, alone, or hooked to a ventilator,” Ravi said, “and yet that is the way in which many patients pass away in the ICU.”

Seeing similar confusion about the ballot measure among his peers, Ravi and fellow fourth-year Grant Smith helped organize a panel discussion for all local medical students earlier this month at Harvard.

It let the audience pepper panelists on each side of the issue with questions, and also use the teaching tool of a case study: A hypothetical elderly man with metastatic cancer who comes to his doctor asking for a lethal prescription.

That case discussion, Ravi said, brought out a valuable consensus among the opposing panelists: All agreed on the need for more and better end-of-life discussions with patients.

But on the “toughest question” — “Ethically, is this right for doctors to do?” — there was no clear answer, he said. Rather, each side argued that its position represented the true embodiment of “Do no harm.”

‘This conversation involves an irresolvable dilemma.’

If Ravi and his fellow students remain conflicted, they can at least be comforted that they are in plenty of good company.

By all indications, the ballot measure presents an extraordinarily difficult problem of medical ethics — a problem wrestled with nationally as states consider physician-assisted suicide laws. Thus far, only Oregon and Washington have passed them; polls suggest that Massachusetts may be next.

The ethical issues involved are hard and deep enough to divide not just medical associations but medical staffs — a Massachusetts General Hospital panel presented arguments for and against Question 2 earlier this month — and seasoned ethicists.

Consider the Boston-based Community Ethics Committee, a group of 18 diverse volunteers who gather to craft opinions on some of the thorniest of bio-medical issues. Continue reading

On Being Gay In Medicine: A Leading Harvard Pediatrician’s Story

Dr. Mark Schuster, Harvard Medical School professor and Chief of General Pediatrics at Children’s Hospital Boston

Dr. Mark Schuster is the William Berenberg Professor of Pediatrics at Harvard Medical School and Chief of General Pediatrics at Children’s Hospital Boston. This essay is based on remarks he made as the featured speaker at the Children’s Hospital Boston GLBT & Friends Celebration in June, 2010, and has just been published in the journal “Academic Pediatrics.” We post it here with his permission.

The first time I stood before a large audience to speak was when I was 13 years old. It was at my Bar Mitzvah. I walked up to the podium, looked out over the sea of faces, and thought to myself, I am a homosexual standing in front of all of these people. And I wondered what would happen if I told them.

That was in 1972, and even mentioning the word homosexual, unless paired with an expletive or derogatory adjective, would have been unacceptable at my synagogue. It would have been unacceptable in my home, my school, or any place I knew. I could not have conceived of telling my doctor. I assumed that I would never say out loud that I am a homosexual. The idea that I would someday be able to stand in an auditorium, stand anywhere, just a few miles from where I live with my husband, our two sons, and our dog, with everything but the white picket fence, was not something I could imagine.

He made it clear that he wasn’t going to operate on a lesbian. Then I heard a voice shout, “So, she’s a lesbian, what does it matter!” And then I realized that the voice was mine.

 

Today I stand on a different stage. The Children’s Hospital Boston GLBT and Friends group asked me to share my story as part of its celebration day. How I got here, what I learned along the way, especially at Children’s, and how the world changed — these are what I will talk about.

A decade after I considered turning my Bar Mitzvah into a public confessional, I entered medical school at Harvard. Some students had started a gay group the year before. They had scoped out the territory, searched for role models, and come up nearly empty. In a creaky old closet, tucked way in the back, they found a world-renowned senior physician at Children’s. He advised against starting the group, offering that it was much better to be secretive about being gay so that no one would bother you. I’ve heard that same advice many times from men and women from earlier generations who had fewer options in their day.

Around the same time, a Harvard physician I later met was just coming out. He was spotted at a social event with someone his hospital’s Chairman of the Board suspected was gay. The Chairman reported to the hospital that he thought the physician was gay too and said that people like that should not be allowed to work there. Continue reading

A Step Toward Health Benefits Of Exercise In A Pill?

Bruce M. Spiegelman of Dana-Farber in his lab

We’re a long way from being able to bottle the myriad benefits of exercise, but a study just out in the journal Nature looks like a promising step in that direction. It describes the discovery of a naturally occurring hormone christened irisin — pronounced like the name “Iris” with an “in” tacked on the end — that is elevated during exercise in mice and humans.

Irisin appears to be a possible key to the positive effects of exercise on blood glucose and energy expenditure — and thus on Type 2 diabetes and obesity. And because it is naturally occurring, it could be tested in humans fairly soon, perhaps in a couple of years.

But before we get to the science, a word from the study’s senior author, Dr. Bruce Spiegelman of Harvard Medical School and the Dana-Farber Cancer Institute. To all the negativity-mongers (my phrase, not his) out there who will grumble (my verb, not his) that this discovery will just enable more slothfulness, and would be unnecessary if all those couch potatoes would just get off their butts and eat better, please consider:

“The last thing in the world we’re trying to do is substitute for diet and exercise,” Dr. Spiegelman said. But first of all, there are many people who can’t exercise, whether because of paralysis or age or illness, he said. Work on irisin could potentially help them.

Second, yes, everybody should exercise and eat right but they don’t. Obesity and diabetes are worldwide epidemics costing untold billions, he points out. If irisin proves able to help fight them, it could benefit all of us.

Our conversation, lightly edited:

So where did the name irisin come from?

Iris is the Greek messenger goddess who carried messages between humans on earth and the gods on Olympus. We didn’t want to name it for any specific function because we don’t know what all of those are going to be, and what the most important are going to be, so instead we named it for its messenger function.

So what did you already know, and what did you find out?  Continue reading

Harvard Med School Class of ’14 Wets Its Pants (In Video Parody)

http://www.youtube.com/watch?v=5ygTTdZpECI

Members of the Harvard Med School class of 2014 have a long, stressful, sleep-deprived way to go until they graduate, but at least they have a powerful sense of humor — and extremely high production values! — to help them through. According to its YouTube and Facebook text, The Jubilee Project and the Harvard Class of ’14 produced the 3-minute video above — a med-school parody of Lonely Island’s “Jizz In My Pants.” (I wonder if I could even write that title if this were a newspaper?) Sophomoric, yes, but so well done, and guaranteed to produce (disbelieving) smiles…

Hat-tip to Tinker Ready for the tweet!

 

Primary Care Has A Cinderella Moment

http://www.youtube.com/watch?v=SRt1BVa6tlU

Long the lower-paid and under-appreciated workhorse of medicine, primary care had a definite Cinderella moment yesterday at Harvard Medical School. And it seemed to hint at a whole new era to come, in which primary care stops being such a medical Rodney Dangerfield.

The scene: The first annual innovations conference at the medical school’s Center for Primary Care, a new institution created with the help of a $30 million anonymous donation.

The speaker: The new provost of Harvard, Dr. Alan Garber, freshly imported from Stanford and, it just so happens, himself a primary care physician who kept practicing through his years at Stanford even as he also focused on health policy and economics.

The acoustics were hard, so here’s the text of the clip above. Dr. Garber had begun by noting that it appears that national health reform is here to stay, and that it pushes medicine away from “fee for service” — payment for each procedure — and towards more global or overarching forms of payment and care.

I believe that there is no group of physicians that is better positioned to lead the efforts toward these new forms of payment, and toward surviving and thriving with the new payment requirements, than the primary care physicians.

And you can even see the recognition of this fact by the specialties, many of whom are clamoring, for example, to be designated as patient-centered medical homes.

So it’s an unfamiliar situation for many of us who’ve been in primary care for some time. We have to seize this opportunity. Continue reading

Meet Cooper, Harvard’s First Therapy Dog

 

Seen yesterday at Harvard Medical School’s Joseph B. Martin Conference Center. My first reaction: Damn, that dog is cute! Then: But come on, can even the cutest dog really make inroads on the stress of a place like Harvard? And then: I wonder if we could get one for WBUR?

I knew therapy dogs were growing in popularity, but hadn’t realized they’d reached this far into the mainstream medical establishment. Wikipedia notes:

therapy dog is a dog trained to provide affection and comfort to people in hospitalsretirement homesnursing homesschools, people with learning difficulties, and stressful situations, such as disaster areas.

Which begs the question: Does Harvard’s stress rival a disaster area’s?

The Harvard Gazette recently ran a suitably fluffy story about Cooper here; on the serious side, it notes that Cooper is part of prodigious wellness efforts at the university, meant to alleviate stress and promote health. Harvard Health Publications also wrote about Cooper here, including the evidence base: Continue reading

Study: Use Ritalin To Wake Patients Up Sooner After Surgery?

Ritalin is famed as a drug for Attention Deficit Disorder, but a new study in rats suggests that its effects on the brain’s arousal circuits could also be used to wake patients up sooner after surgery.

Why bother? Several reasons, from saving health care money to possibly reducing post-operative delirium.

Dr. Emery Brown, a neuroscientist and anesthesia expert at MIT, Harvard and Massachusetts General Hospital, explains the new research, led by Mass. General’s Dr. Ken Solt, just out in the journal Anesthesiology. He is a co-author on the paper.

This is a major new result because it shows that we can wake the brain up from general anesthesia. Currently at the end of surgery, the anesthesiologist just lets the anesthetic drugs wear off and the patient regain consciousness.

We decided to study the possibility of devising a strategy to wake patients up from general anesthesia. In this paper we show that it is possible to administer to rats methylphenidate (Ritalin) -— the same drug that is used to treat attention deficit hyperactivity disorder (ADHD) in children. This drug actively induces emergence of the animals from general anesthesia.

‘This is an exciting experimental finding that has to be replicated in humans.’

It is not that the anesthesia is being reversed. Rather the arousal pathways, most likely the dopaminergic and noradrenergic pathways, are being activated to allow the brain to overcome the effects of the general anesthesia and the animal to awaken. It is known that Ritalin blocks the reuptake of dopamine to maintain the brain levels of this excitatory neurotransmitter.

This is an exciting experimental finding that has to be replicated in humans. If this pans out, it could change anesthesiology practice by initiating use of a drug that is already known to be safe to actively induce emergence from general anesthesia.

This would have important implications; possibly reducing cognitive dysfunction in the elderly and delirium in children after general anesthesia. Continue reading