Monthly Archives: July 2012

Beware the Bandersnatch my son (aka the “link”)

If I read the word “link” one more time in some ostensibly serious health article I will – well, let’s just say that like Dorothy Parker’s Tonstant Weader I will thwow up.

Looks like a Bandersnatch to me …

Last week “scientists” apparently linked one’s gait as one aged to one’s likelihood of developing Alzheimer’s. Yet another observational study, casting about for some connection to something; naturally they eventually found some tenuous connection somewhere – at least one that they could write a press release about.

(As a researcher once described estrogen – “a drug in search of a disease”.)

No mention of whether this gait thing might have had something to do with other, perhaps undiagnosed, problems such as osteoarthritis or inner ear issues or what-have-you. No, one more thing for us to worry about as we get older – our damn gait.

Earlier headlines with that vile word “link” (plus variations like “linked”, “linking” and so on) always seem to be in the headline, which, of course, is what most people read. So we read that higher levels of Vitamin D3 are linked to all manner of marvelous things, from not getting cancer and heart disease to staying young and sharp and simply mah-velous. Never mind that when you simply test people who are well and compare them to people who are not, measure their “level” of D3 (as though all of us have the same ideal level) and then say, ‘oh, look, high D means better health so why don’t we all take a supplement” you have no way of knowing which came first, the good health or the D3. For all we know, various diseases deplete the body of D3 and the lack of the vitamin is not the cause of the problem but its consequence.

A number of more cautious researchers have been saying exactly this, to no avail. Various and sundry institutions from the Cancer Agency to the WHO have all decided to chime in with their recommendations that people take supplements.

This same kind of nonsense proliferated in the talk around estrogen for pretty much most of the 20th century.  Researchers gushed that women who took estrogen “replacement” therapy (later “hormone replacement therapy” or HRT after it was found that estrogen alone could cause endometrial cancer) kept women young and healthy and prevented heart disease and dementia and probably hives and hangnails.

Replacement is in quotes earlier, incidentally, because it makes no sense to consider the hormone level of a woman of 23 normal for a woman at all other stages of life, particularly midlife, when all women’s hormones naturally decline.

Observational study upon observational study found a correlation (“link”)  between women who took hormones and improved cardiac function, fewer heart attacks and strokes, better health, you-name-it.  Well, except for the smidgeon of extra risk relating to breast cancer which epidemiologists dismissed as irrelevant. Of course this was not irrelevant to women, who didn’t rush to take hormones in droves, much to the researchers’ dismay.

Then the other show dropped. The largest clinical trial in history, the Women’s Health Initiative definitely showed that not only did estrogen not protect women from various and sundry age-related conditions, it actually could cause them.  Cardiac disease was higher in women who took hormones and there was nothing “healthy” about HRT at all.

But hey, they had studies that “linked” estrogen use with health and who were we to argue?

A lot of people ask me about supplements, Calcium and D3, this and that, largely, I think, because of those headlines linking this and that arcane nutrient with health. Which is where my problem with all of this lies.

You can print whatever nonsense you want, provided you don’t make it sound as though you know what you’re talking about. Especially in the headline. People actually change their behavior based on these things. People start taking things, adding things, subtracting things. Forgetting that health is multifactorial, complex and begins in the womb.

You won’t have strong bones as an adult if you were malnourished as a child. Wealth tends to lead to health. People are different. And the nutrients we ingest in food are in a balance and ratio that the body can absorb. Versus our best-guess estimate of what an ideal amount of D3 or B3 or T3* might be.

So beware the dreaded link as though it were the bandersnatch. On average, I think the latter is more benign.


*Tylenol 3

On Clutter, Hoarding and Medical Mistakes

Nobody likes a crisp, neat look more than I do – Ikea wouldn’t be the multi-gazillion corporation it is without my patronage throughout the years. I own pretty much every KASSETT and GLOK organizer doo-dad they make. (I like that they sound Klingon.) Given the sheer number of articles, blogs, television shows and companies on clutter (and its crazy cousin in the attic, hoarding) I am clearly not the only person with this particular fascination.

I sometimes think that if I could just create a prefect, clutter-free world then, as Buckminster Fuller suggested, everything I wrote and worked on would be effortlessly beautiful. Of course I sometimes also think of  Roswell and of the aliens that live among us. So it’s not like I’m totally sane all the time.

Trouble is, compared to a lot of people I’m bloody Einstein, given that this mania for de-cluttering the detritus of life appears to have permeated and penetrated into large areas of life; areas that simply do not lend themselves to neat solutions.

Some things are inherently messy and there’s not a damn thing we can do about it.

Take disease/illness and the complexity of patient care, all of which I have gone on about ad nauseum.  Much as we would like to make it all iPad-neat and high-tech cool the reality of surgery and hospitals and elder care and whatnot just isn’t going to be minimalist-zen. And trust me, if you’re a patient you don’t want it to be because if your clinical team decides you’re just a carbon copy of everybody else you’re going to get shoddy care.

Right on cue enter a medical director at the  Birmingham University Hospital in Britain who, enchanted with the local BMW plant’s “flawless”, failure-free operation, wondered how the hospital could duplicate the plant’s figurative tracking down of every “loose screw”.  (Yes, I am biting my tongue.) One assumes the director hoped patients would leave the hospital all shiny with that new car smell …

So, mixing everything from metaphors to minds, a “bespoke computer system” was ordered – no doubt to bring German engineering to an off-the-rack hospital. The cost? Some 4 million pounds sterling or approximately $5.4 million U.S..This computer’s claim to fame was that its operation actually mimicked the dashboard of a car, presumably that of the aforementioned BMW. The dashboard thingies became standard issue at the hospital; their point to “catch” problems before or as they evolved, problems ranging frompost-surgical infection levels and falls to bed sores. Which sounds sensible you might think. Except you’d be wrong.

A computer that posh couldn’t possibly stop at patient problems; where’s the fun in that? So those bedside dashboards also have dials to let managers and ward sisters know when efficiency (“benchmarked against comparable wards and recent performance”) falls, even as response time is recorded to let higher-ups know who and what might be doing poorly. Ouch. So not only is Big Brother watching but his name is HAL.

The mind boggles. German engineered hospital care run with military precision – oops, that has nasty militaristic WWII overtones. Rephrase, rephrase …

(For more see The Economist, 16 June 2012.

Admittedly it is tempting and attractive, to believe that better health, better post surgical and treatment outcomes, fewer medical errors as simply being a matter of organization and method. Problem is, Sherlock, people go into hospital for a reason – and that reason is that they’re sick, injured or otherwise poorly. These days, given cost containment issues, hospitalized patients tend to be really sick. Often they are also old, which means they are frail and have a lot of other things wrong with them: from cardiac issues to arthritis and various and sundry ailments.

True, we do much better with acute care than we did even 40 years ago – brain tumours that would have killed your grandfather can sometimes be removed, e.g., – but the reality of patient care is that some people do get worse and some people die. Even the ones who do all right and go home are rarely if ever  good as new. Surgeries cause scar tissue and pain and a host of other problems. As they used to say, the only really safe surgery is the one they do on the other guy.  No nifty BMW dashboard can change that.

A few more staff nurses might but that’s another story.

So, boys and girls, can anyone tell me what some issues with this perspective might be? Anyone? Anyone except Tiffany? Sigh. OK. Tiffany. That’s right.Human bodies, physiology, biology: these are complex, messy, hard to classify and all too often problems that arise are  idiosyncratic and incomprehensible. Funny that, but bodies don’t tend to have read the textbooks. Many people do well but some do not and each case is different.

True, the medical system does screw up (as America’s Institute of Medicine never stops reminding us) and sometimes errors and problems do lie in systemic, functional issues that ought to be fixed – like that ICU checklist everyone’s so keen on or better labeling on medications and so on. But an over-focus on process and a lack of understanding of the underlying messy complexities of medicine not only aren’t the answer but are increasingly becoming part of the problem.

Talk to any person who’s recently experienced hospital care and what you hear is just how vigilant you have to be and just how essential it is to have someone there with the patient to ensure the clinician walking into the room actually knows who the patient is and what his or her problem might be, what drugs s/he might be on, etc.

Comparing medicine to aviation or to BMW’s is ridiculously reductionist and ultimately counterproductive since one of the basic aspects of physiology is that it is not simply what is done to the patient but what the patient does back so to speak. With drugs, it is not merely the effects that the drug has on the body (pharmacodynamics) but what the body does to the medication (pharmacokinetics). The arrows, should one care to diagram it, go back and forth and every which way.

Treating people like units of production was exactly how this mess all started. And Ikea simply doesn’t have an organizer for that.