Medical Topics – Page 6 – education and deconstruction.com

The Antidote

The Book of the Week is “The Antidote” by Barry Werth, published in 2014. This suspenseful saga is about the public drug company, Vertex.

Vertex has created the core substances in drugs that treat niche diseases, such as hepatitis C and cystic fibrosis. It has partnered with various other drug companies to use their resources.

Unconventionally, in the 1990’s, Vertex’s employees were organized into teams working on protein targets rather than those working on different diseases. The company’s teams were demoralized when they failed month after month to come up with a successful molecule.

The cost of American drugs is so high not just because the drugmakers are greedy, but because their employees feel entitled to a large reward for creating an effective product that does minimal harm to patients. They take tremendous risks– acquire pricey, extensive educations in organic chemistry and such, working long daily hours, suffer loads of stress from dealing with grant applications, patent disputes, licensing issues, doctor-insurer issues, undergoing the rigorous process of seeking FDA approval after laboring months or years on a drug substance– possibly applying for approval at the same time as another company with a competing product, and face the possibility of being laid off anytime. This is why life-saving, life-prolonging medicines are astronomically expensive. However, the drugs would not exist, but for the necessary evil of a greed machine that raises the funds to pay for the price of creating them.

Vertex posted a “profit” of more than $2 million in the fourth quarter of 1993, even though it had yet to sell even one pill. Its financial arrangements with its partners allowed it to claim that its income exceeded its expenses. By the end of the 1990’s, however, there were still no actual drugs produced, and the company was likely many years and hundreds of millions of dollars from the market. It was thus a likely takeover target. Some of Vertex’s scientists and lawyers became avid day-traders of the company’s stock in the autumn of 2000, after a deal with Novartis.

Trading rumors fly all the time, and one influential analyst at a big-name investment bank might downgrade a drug company’s stock, causing a selloff. In the early 2000’s, there was an SEC accusation of insider trading against Vertex’s house counsel. Ironically, it is common practice for panel members of the FDA to receive financial support in research-funding from many pharmaceutical companies.

Those companies that are public must answer to Wall Street. Unsurprisingly, at numerous medical conferences, their executives spout cliches such as “…We believe it’s a matter of time before we break this disease wide open and make a really big difference for a lot of people.”

Read the book to learn about actions Vertex took in research, development and finance in order to stay in business twenty years while accumulating losses of more than $1.5 billion; the causes of its high turnover of executives; how it became more geared toward finding commercial applications with its research results, and how it had fared product-wise and financially by autumn 2013.

Genius on the Edge – Bonus Post

This blogger skimmed “Genius on the Edge” by Gerald Imber, MD, published in 2010. This long book describes the career of Dr. William Halsted.

Halsted was born in 1852 in New York City. There was still much ignorance about medicine in his generation. Fatal diseases, such as malaria, yellow fever and tuberculosis were rampant. He developed a passion for medicine at Yale University. The most prominent doctors of his age included Pasteur, Lister, Morse, Hunter, Wells, Koch, Morton, Young and Warren. They spurred progress in sanitation, anaesthesia, and the collection of new information and techniques for treating patients.

In the 1870’s, Columbia College, Physicians and Surgeons didn’t require undergraduate degrees for entry because it was seeking revenue from student tuition. The three-year program was all lectures– no labs, no interaction with patients. In the 1870’s, during Halsted’s internship at Bellevue Hospital, many personnel didn’t wash their hands before operating, and smoked.

In late 1884, Halsted started using cocaine as a local anaesthetic in dentistry. He displayed, “…hyperactivity, rambling speech, inattention, and suspended decision-making ability.” Medical students and their teachers started using cocaine as a pick-me-up. They became addicted. “The drug was readily available in Europe, through Merck, and there was no stigma associated with its purchase.” In late 1886, Halsted went to work at Johns Hopkins Pathological– the “Bell Labs” of medicine. He went to Baltimore because his addiction had wrecked his career in New York. He substituted morphine for cocaine.

It is unclear how much better Halsted could have performed were it not for his addiction. He did have a brilliant career, but there were bouts of irresponsibility, socially and teaching-wise. He missed classes, started surgery at 10am instead of 8 after a while, failed to show up for meetings, and retreated to his country home for almost half the year. One positive side effect of his addiction was that Halsted delegated complete patient care to residents when he had morphine withdrawal symptoms. So the residents got a golden opportunity they would not have had otherwise, to learn their craft.

Side Note (There’s nothing new under the sun.): “As a group, they [nurses] felt themselves underpaid and overworked.” The Training School taught them to cook and clean. They were required to wear brown Oxford shoes.

Halsted experimented on dogs on and off for a couple of years, between months-long stints in drug rehab. He began seeing human patients for surgery in early 1889. He pioneered the medical-school residency program. He instituted the training of surgeons to train other surgeons. Three other doctors at Johns Hopkins who wrought major change in medicine in the U.S. were William Osler, William Welch, and Howard Kelly. Halsted specialized in surgery for breast cancer and inguinal hernia.

Johns Hopkins wanted to remain on the cutting edge of medicine by opening a medical school but it needed money to do so. Female heirs of prominent, wealthy families raised the money and placed conditions on the school’s opening, requiring gender equality. After much controversy, it opened in the fall of 1893.

Read the book to learn how medicine in America changed through the years of the late 19th into the 20th century, and how, according to this book, Johns Hopkins led the way.

God’s Hotel

The Book of the Week is “God’s Hotel” by Victoria Sweet, published in 2012. This is a medical doctor’s account of the radical changes that occurred at a county-funded hospital, formerly an almshouse in the San Francisco area that treated mostly disabled and elderly patients who were indigent.

The author describes the series of consequences stemming from an ever-increasing annual budget, a power struggle, office and mayoral politics, and bureaucratic shenanigans. There was a tug-of-war over turning the hospital into a psychiatric facility.

Florence Nightingale summed up the field of medicine in a nutshell when she said there have to be checks and balances in connection with practicing medicine, doing nursing, and handling administration. If doctoring becomes too powerful, patients get overtreated; if administration becomes to powerful, too little doctoring is done. When there is excessive nursing (emotionally and spiritually caring for patients), medical progress suffers.

Over the course of several years, a Justice Department investigation and a special relationship with the mayor’s office prompted the hospital’s executives to increase the administrative staff even as the number of patients fell. The additional staff was required to generate assessments, policies and procedures. When an incident resulted in the death of a demented patient and the media gave the facility bad publicity, the executives pointed to budget cuts that caused the understaffing that led to a compromise in safety. The hospital then hired a PR firm, an in-house director of government and community relations, and an assistant medical director to help with all the new paperwork, decisions and questions. Quietly, even more draconian budget cuts were being made to the hospital. Yet there was still enough money to hire the mayor’s communications consultant.

Read the book to learn how misdiagnosis and home care (rather than hospital care) make healthcare significantly more expensive, and of the controversies surrounding the push for progress on one side, and preservation of personal patient care on the other.

Doctored

The Book of the Week is “Doctored” by Sandeep Jauhar, published in 2014. This is an eloquently written autobiographical slice of life from a cardiologist in Long Island, NY, within the last decade.

Dr. Jauhar suggests that America’s broken health care system is the fault of all parties involved– the government, the doctors, the insurance companies and the patients. He writes that his specialty, heart failure, actually generates losses for the hospital at which he is employed. The money is in the installation and monitoring of stents and pacemakers, not prolonged hospital stays of patients. He resists going into private practice because he would be a “…grunt, overtesting, kissing ass for referrals, fighting insurers to get paid” not to mention being forced to pay the out-of-pocket, astronomical cost of medical malpractice insurance. Medical school doesn’t show students the real-world worries of practicing medicine in the United States. One of countless worries of doctors is of lawsuits brought by litigious patients, notwithstanding the malpractice insurance.

Doctors have to deal with a slew of issues peripheral to treating patients; among them, that doctors these days have trouble making a living due to the facts that reimbursement of Medicare and insurance companies to doctors are at an all-time low, and doctors have the burden of student loans while possibly trying to move into their own home and raise a family. This puts pressure on them to engage in the behaviors of private practice mentioned above.

The pay of even an “attending physician” (employee) such as Dr. Jauhar, fluctuates with the amount of revenue he generates for his employer. He writes, “Insurers can make doctors jump through hoops to get paid… tell patients which doctors they can see… restrict medications. But they still cannot…” control the referrals doctors make to other doctors.

Read the book to learn about the (sleazy) strategies used by the medical community to protect itself against (stingy and at times, unreasonable) insurance companies, the author’s moral dilemmas on his own situation told through real-patient anecdotes, and the author’s family life.

Side Note: Despite the flaws in the way health care is provided in the United States– as John and Hank Green (YouTube Nerdfighters) directly or indirectly remind viewers in every video they make lately– people born in the United States have won the world birth lottery, and thus have access to the best life-saving and life-prolonging technology, procedures and treatments, due ironically to the profit motive.

Behind the Gates of Gomorrah

The Book of the Week is “Behind the Gates of Gomorrah” by Stephen Seager, published in 2014. This book describes the personal experience of a psychiatrist working with violent criminals in a state mental hospital in California. He was the only medical doctor on his unit. The rest of the workers who treated the patients were psychologists and nurses. Some of the patients were faking mental illness because they would rather have been there than in prison. All the patients had taken human lives; some in gruesome ways.

Almost every week, there were emergencies with sirens blaring, usually due to patients’ poor impulse control. The patients would engage in physical fighting with eyeglass stems or other sharp weapons they fashioned themselves, just like in prison. But they hurt hospital employees too, even killed a few through the years. The employees were unarmed (unlike prison guards). The patients fought for their legal rights (like obtaining eyeglasses, which they would accidentally-on-purpose damage so as to get a new source of weapons). According to the book, on the author’s first day at work, he had to have ten stitches in his scalp when he was caught in the middle of a patients’ fight.

There was a tendency on the part of the employees to rationalize their bonding with the patients. It seemed to this blogger that the employees were showing signs of “Stockholm syndrome.” In some ways, the employees were actually captives.

Read the book to learn the answer to the question: “If lots of people are mentally ill, and the great majority are not violent, who then should we be worried about?” [the ones who go on shooting sprees] Here’s a hint: It’s not those who have autism, OCD, depression or the “foil-hat-wearing, babbling street schizophrenic.”

Struck By Genius – Bonus Post

This blogger skimmed the repetitive ebook, “Struck by Genius” by Jason Padgett and Maureen Seaberg, published in 2014.

This ebook tells the story of how Padgett, the victim of a mugging, suffered a traumatic brain injury, and not only lived to tell about it, but also experienced improved cerebral processes (along with some negative side effects) due to it.

Padgett developed the conditions of savantism and synesthesia. The former causes his vision to form geometric patterns in everything he sees; he also acquired a natural, conscious talent for mathematics and physics which he had not previously had. Synesthesia means he sees a specific color when he sees a specific number or letter.

Read the book to learn of the psychological problems that have plagued the author since he was violently struck on the head, and the two with which he still grapples; how he finally became sufficiently functional to learn more about his conditions, and to find and contact other people with the same symptoms.

In a Rocket Made of Ice

The Book of the Week is “In a Rocket Made of Ice, Among the Children of Wat Opot” by Gail Gutradt, published in 2013. This ebook is a personal account of a woman who volunteered to assist with caring for children at a precariously funded orphanage in Cambodia, Wat Opot, that specialized in HIV-positive residents.

The author stayed for about five months at a time in the first halves of 2003, 2004 and 2008. She wrote about Cambodian culture, in which there was discrimination not only against people with AIDS, but also against people with dark skin. Skin lighteners sold well because people did not want to be perceived as poor rice farmers. On the occasion when the children were given Barbie dolls and one dark-colored doll, they played with only the former.

Conditions were less than ideal: “…heat, bad water, the risk of contracting malaria or rabies, of catching tuberculosis…” a more common illness than AIDS. Plus, limited technology and education, and groups of boys going on “wildings” in the streets. It was theorized that the AIDS epidemic came to Cambodia in the early 1990’s, when men of various stripes (husbands and truck drivers who visited prostitutes, UN soldiers who went on holiday in Thailand, and Vietnamese military families) spread the disease.

The orphanage’s truly dedicated American director, who had been a medic in the Vietnam War, heroically fed, housed, clothed and medicated all of the residents at Wat Opot. They included some sick adults, and tens of children, some of whom were HIV-positive, who had lost their parents to AIDS. There were many other non-profit groups that claimed to take care of orphaned children, but some had greedy owners who committed fraud or inadequately provided for their charges due to inexperience.

Read the book to learn of the author’s interactions with the children and their caretakers, an unpleasant episode with the World Food Programme, religious observances at Wat Opot, its neighbors, and how some of the children fared as they grew older, or after they left the community.

Keeping Hope Alive

The Book of the Week is “Keeping Hope Alive” by Dr. Hawa Abdi, with Sarah J. Robbins, published in 2013. This ebook is the personal account of a driven, fiercely independent Somalian doctor.

Around 1970, Abdi did seven years of medical training in the former Soviet Union. She then returned to her homeland of Somalia to practice obstetrics and gynecology. Through the years, she married, had two daughters and a son, and in August 1983, built a clinic.

By mid-1992, Abdi had made available a farm and campus on which poor people and war refugees could reside, and receive medical treatment. In addition, she was a law school graduate. She also took in her sister’s large family when they were destitute. She risked her life many times during hostilities between and among Ethiopians and Somalian clans ruled by warlords and sheikhs.

Abdi gathered quite a following because she was so generous to her community. Her dream was that the Somalian people would unite as one country, instead of killing each other in tribal infighting. “People who are fighting will never be able to build.” By the early 2000’s, “… after fifteen years of civil war, the women and youth ran everything, while most of the grown men had either been killed or were away– out fighting or somewhere abroad, trying to make business deals.”

Read the book to learn the details of: Abdi’s trials and tribulations in protecting her property and family, how she was betrayed by her husband; how in some ways, she refused to comply with Somalian/Islamic culture; the cities to which she evacuated her children, and of her interactions with relief organizations, soldiers and journalists.

Confessions of a Surgeon

The Book of the Week is “Confessions of a Surgeon” by Paul A. Ruggieri, M.D., published in 2012.

These days in the United States, with the landscape changing for the worse in some ways in the medical community, all sorts of factors threaten the progression of the livelihood of a surgeon; namely– bad luck, lawsuits, increasing stress and diminishing financial returns. The author details those factors in the context of patient cases he has seen.

The conventional saying about a surgeon’s career is that the first decade is spent learning how to operate; the next, learning when to operate, and the next, learning when not to operate.

With the rapid advancement in imaging technology of late, more and more patients are accidentally learning that they have certain medical conditions. Such incidental findings generate extra worries and expenses, especially if the conditions are life-threatening. The word “cancer” on a medical report automatically stokes a surgeon’s fear of being accused of medical malpractice. The surgeon feels compelled to order more tests for legal protection and containment of medical malpractice insurance costs (which rise even in cases where the surgeon is exonerated) even when there is only a tiny likelihood of malignancy. Yes, the author writes, there are plenty of greedy surgeons who order more tests (or perform unnecessary surgery) just to make more money.

The author is in private practice at a hospital, so he gets all his business through referrals from other medical professionals or patients. Therefore, he is under pressure to “play well with others” in his community, lest he lose business.

“Surgeons frequently have conversations with body parts or organs they are trying to remove. They also have conversations with themselves. It’s a way to blow off steam while your mind scrambled to deal with the unexpected.”

Read the book to learn more about the trials, tribulations and triumphs of people who perform medical operations for a living.