Wednesday, December 15, 2010

The Seminar

A fictionalized, factual event.

What happened that February day is a remembrance of sorts, a conditional reminder of human desire and it’s failing. There was a loss of innocence, the dawn of a new understanding and all because of a man who dared to ask the question.

The podium was a two-step, navy-blue platform in front of a tall opaque blue-black curtain that formed the backdrop. Two huge screens draped the sides of the podium for those seated in the far back corners of the hall. The eight ornate chandeliers that dotted the beautifully carved ceiling of this majestic banquet hall were dimmed. The walls were replete with lit sconces of similar beauty adorning the great hall interspersed between each massive exit door. There were several hundred of us sitting in rows in this massive hall that seemed to stymie any attempt at creating an echo especially given its enormous size. One could hear the occasional cough and clearing of the throat or the clink of the pitcher of water decanting into a glass amidst the murmur..

The man who stood behind the dais had both his hands clenched around its edges as if squeezing every bit of energy to comply with the restraints of the time limit. He was done with his last slide presentation at the end of his allotted time, just when the green light on the dais had turned red. With that flourish of color that briefly illuminated his face, he stepped back and let his hands fall to his sides.

“Ladies and gentlemen, there will be a brief question and answer period that entails ten questions. Please answer the questions on the electronic device provided in front of you.”

After the Q&A session had concluded the moderator, a tall man with thick-rimmed glasses stood up and introduced himself. He rifled trough the questions, that had been provided instantaneously graphed into 3D Plots showing how the audience had responded to the multiple choice answers provided. Most of the answers seemed to follow a pattern of acceptance until the eighth question. This question asked if the audience was inclined to agree with experiment A that had been presented by Dr. Good to which 40% had answered in the affirmative and then the next question number nine, which asked the same question about experiment B that Dr. Great had presented to which another 40% agreed. The last question number ten, which asked, “Do you disagree with the two experiments?” was answered in the affirmative by the remaining 20% of the audience.

The lights flickered for a moment and then they came unglued to a full blaze. Everyone exited the room for a coffee break. The cacophony that followed this crowd could be heard easily in the adjoining corridors as the acoustic suppression tiles failed their leitmotif. All forms of expressions with hand gestures and body movements were in display. The supporters of the two experiments were firmly enshrined in their halls of decision.

Soon the coffee break was over and the gathering moved as a uniform controlled herd back through the portals of entry into the banquet hall. “So,” The moderator said as he cleared his throat from the remains of the cookie that he had just consumed with his coffee, “We will have ten minutes of questions from the audience and then present another set of questions for you to answer before starting the next item on the agenda.”

Several hands flew into the air and one by one agreements for each experiment were emphasized by the audience The questions were more like affirmations and as the preceding person asked the same question that the next one was contemplating, the upraised hands went down like dominoes. I noticed the person seated next to me raised his hand. 

He had been furiously working on the electronic devise in his hands.  When presented with the microphone, he proceeded to ask,  “Well if the data is robust on both sides and experiment A, states that the treatment was a success while experiment B shows no benefit by a different author there is something amiss here. Isn’t it? How can two supposedly very well designed and executed studies looking at benefit of the same drug in a given disease show dissimilar results?” He took a deep breath, “Unless there was bias?” The murmur in the hall became palpably uncomfortable amongst this august gathering of intellectually prone clinicians. The discomfiture shed it’s fear onto the two experimenters who now sat on the podium to the right of the dais where the moderator stood ready to answer any questions. But they were not expecting this. Both clasped their hands in unison and one actually crossed his legs.

“Well gentlemen how would you answer that question?”

There were excuses and replaying of the slides from the presentation as if to highlight the importance of the study and the rigor through which the study participants had been subjected and the data collection that had been reviewed by statisticians and worked through by the mathematical modeling software. The commotion seemed to abate as the discussion had taken up more time then intended. The moderator then asked for dimming of the lights and questions number 8,9 and 10 were asked again. The results were different. Now the answer to question number 10 was grossly skewed. Almost 80% were unsure of the two experiment results. The moderator displayed a graph on the screen and the audience broke out into spontaneous applause. The two experimenting authors seem to shrink into their seats with beads of sweat glistening on their respective foreheads.

The two boats of opposing opinions in this sea of knowledge, driven together by the clash of objectivity now were reduced to a raft-like state of a few wooden pieces bobbing up and down aimlessly. The passengers had bailed onto some other unsinkable Titanic that they hoped would carry them to their destination. Yet the lesson learnt was to question the improbable. Sometimes it is the minority opinion that breaks the stranglehold of conformity.

Medicine is the deep and wide ocean where complex thoughts, conflicting views and desires require careful scrutiny. A well-developed idea wins the stage for a brief moment then is readily obscured by a new paradigm. Time deems a hastily won contest a failure. It is the hard-fought intellectual enterprise that withstands the test.

The day ended with more presentations and much aplomb but it belonged to the lone voice that had surfaced and dared to look reality in her face.

Must we not question the seeds that may protect the very elements of our existence one day? Do we not lend ourselves to a critique on substance? Is it not ours to protect the future of the next generation? The answer to all the questions is an unqualified yes!

As the gentlest of gentle souls, I knew, who dwarfed the medical community once, said, “Go forth and question!”

Friday, December 3, 2010

My Little Patient

Oncology Times: 
25 November 2010 - Volume 32 - Issue 22 - p 38 
doi: 10.1097/01.COT.0000391442.94138.8f 

He sat rocking in the chair  
Wanting to purge the ill inside 
The ill that was, was so rare 
That no doctor-tools could subside 

His cherubic face fraught with concern 
His blue eyes wide with fear 
His gentle hands clasped in turn 
Waiting for the right words to hear 

A wisp of anger floated by 
Covered quickly by a resolute desire 
A cloaked cloud of inner fear 
Whelmed by the wanton fire 

Past care he was not 
Past cure he was 
Past love he was not 
Past anger he was 

So resolute in his desperation 
And frantic-mad in thought 
Random he was in conversation 
Held together by the fight he fought 

Many since have come and gone 
And many more will come and go 
Not any would look like him 
And not any would take a hold 

Memories linger as times pass 
Riddling the conscience with regret 
Oh how could he not be around 
When others who shouldn't, have 

The truth is vainly exposed 
For he grows more beautiful with time 
The little boy with a rare disease 
Holds the keys to our life's chime 

He lived when he lived 
Yet lives on after he died 
He touched whom he touched 
When life held him in stride

Now thrice his age so removed 
Yet twice the memories abound 
As twice the regret so grooved 
Brings thrice the desire and yearns 

He lives, though he died 
He died and so he lives 
Others live because he died 
He died so others can live 

Past care is never sought 
Past cure is sometimes found 
Past love is never thought 
When deep memories abound 

As Auden's falling torrent flows 
Shaking the assurance of any rose 
And Shakespeare's clock that tells the time 
Shows hideous night in violet's past prime 

With Cranch's rare rose's bloom foiled 
In death its matchless splendor spoiled 
Gives measure to the life's time 
Untrammeled lives, trampled never reaches prime 

My little patient lives, though he died 
A deep memory still so shocking 
That at times I wake up in the night 
And find him in the chair rocking.

PARVEZ DARA, MD, a hematologist/oncologist in Toms River, NJ, also has a blog, “The Arts, 
Sciences and Medicine: The Physician and the art of science and science of medicine,” at 

© 2010 Lippincott Williams & Wilkins, Inc.

Thursday, November 11, 2010

The man who forgot time, whom time forgot

I watched him as he hobbled his way through the parking lot. He was slightly bent at the waist and at the neck. He had a strange bounce to his steps. The up and down motion exaggerated on his bent knees was enough to draw attention, almost like a hop, hop and a skip motion. As he came close to where I sat in my parked car, I could see he was probably in his eighties. His hair fell all the way down to below his shoulders peppered in black and white under a sea of gray. His forehead had receded to his crown and the stubble on his face was a day or two old. If he had a moustache he could do a stand in for Fu Manchu.

My attention was now totally riveted to his being. I saw him stop abruptly to pick up a stray piece of paper and look at it, flipping it back and forth, back and forth looking at both sides. After satisfying his curiosity with what it represented or didn’t, he continued on his way to deposit it in the trashcan. He stood there for a moment and then without much ado he walked towards a lone stray shopping cart, which had been left between the parked cars by a consumer of the store. He pushed it towards the department store. I figured he would take it into the store for collecting his shopped items, but reaching the threshold he deposited the cart where it belonged and then headed towards the donut shop that was next to the grocery store. There he stood by the trashcan. He looked at the garbage within for a lingering minute. Finally his hand went deep into the trashcan from whence he started retrieving several brown bags one at a time. He reviewed their contents and not finding what he was looking for he placed them back in the receptacle. Just as he turned, something caught his attention and he leaned over and pulled out a box of discarded donuts. He opened the box and being satisfied with his discovery, he closed it placing the box under his right arm.

With my social, moral and ethical concerns all in a state of collision, I got out of the car and headed his way. This was a curious example in a world of curious. This elderly man with a bounce in his step, a bent back from the psychological weights in his mind was exploiting the virtues of all social norms against the ills of society. He had managed to do some things in a matter of minutes to convince my skeptical mind of the good that resides in humans.

As I walked closer towards him, I could see his face was weathered to a crusty discolored yellowish brown skin. His eyebrows hung thick over his deeply recessed eyes and there were several skin lesions on his face, the challenges of which would undoubtedly be a dermatologist’s dream. His left hand free from encumbrances was remarkably younger looking then his face belied.

“Hi!” I said.
He stopped, gathering his box in front of him with both his arms, protecting his find.
“Would you like to go in for a cup of coffee?” I asked, not knowing what else I could say to him. How does one introduce oneself in these circumstances?
“No thank you.” He said as he turned to avoid me.
“ I am sorry. I figured if you had a minute, we could both enjoy some fresh hot coffee and donuts together.” I said stammering like a 7 year-old not knowing what to do with my hands flying in different direction for no apparent reason.
“I don’t have any money.”
“My treat.” I said happy for what sounded like an affirmative statement.
“”Why?” He asked in a state of confusion. His eyes now wide and expressive with their arcus senilis bands, reflecting the cataracts from within the dull grey irises.
“Company.” I said and meant it.

We walked in to the donut shop and sat down.
The waitress looked oddly at us both and then turning to my companion she said, “Hey Willie is everything all right?”
Willie, I realized was well known to the waitress, who eyed me with suspicion. I smiled back and said, “Would you please get Willie and me some coffee and some fresh donuts?”
“Sure.” She said as she walked away to complete my order and as she did so, she sneaked a look back over her shoulder still not convinced.
“So Willie, tell me about yourself.” I said.
“Why?” He answered.
“Oh, I am not trying to be nosey or anything. I wish to help if I can.”
“I don’t need anybody’s help. I am fine.”

“Okay. I am sorry. Lets just enjoy our coffee and donuts and if you want to talk, fine. Let me tell you about myself in the meantime.” And I proceeded to tell him a summary version of my present life. He listened as he sipped his coffee and bit into the donuts. He would sigh intermittently during my monologue and mostly remained silent. After he was done with his sugary meal, he wiped his face clean and I noticed the way he handled the paper napkin that this man had been groomed somewhere in time with social manners befitting a gentleman. He thanked me after he was finished eating and drinking. As he started to get up, I called on the waitress to bring a box of dozen different donuts and muffins, which I placed in front of him.
“For me?” he said and for a moment I think there was humility and a total breakdown of his guard, but then as quickly that moment vanished leaving him cocooned in his protective shell.

We parted company that afternoon both traveling to different worlds. From then on, as I drove through the neighborhood streets and the byways, I would look out for him on the pavement. Occasionally I would spot his hopping bent figure trudging along immersed in his solitude. I would wave to him but I never received a response. I wondered if he saw me or even recognized me. It became a fascination for me especially given my brief encounter with him. It was etched in my memory of this gentle soul trampled by age, downtrodden by circumstance and weathered from the outdoors striving to survive as an unwashed, armed only with self-reliance and convictions. Indeed as winter came and the cold winds blew everyone into the comforts of their warm homes, I wondered and thought about Willie. Where was he? What was he doing? How was he staying warm?

Soon however springtime followed and the trees blossomed thicker with green hiding the ghostly brown within, my thoughts still remained with this unusual man of grace and strength, human dignity and personal worth.

Not having spotted him in weeks, I went back to the donut shop and spotted the waitress. I asked her about Willie and whether she had seen him lately.

Her young face suddenly and without warning contorted into a mushroom of emotions, “Willie died this winter.” She said and turned away hiding her loss.

I found his obituary. Willie was William J Knowles III. He was a former Marine, An attorney who had graduated from Harvard Law and was a former principal with a large firm in New York. The obituary went on to say that he had lost his family in a tragic accident ten years ago. Mr. Knowles, it read, was hit by a truck in a roadside accident. He had strayed into oncoming traffic while collecting a wind-blown piece of paper from the roadside. He was 72 years old. He had no survivors.

There was such brevity in describing a man who had consumed my thinking. There was such limitation of words where indulgence would have appropriately complemented. His was a life that for a brief moment, I shared. His being touched mine briefly and for many days, weeks and even now many years removed, it still invokes a compassion of sorts. I often wonder about him. He must have imagined a different life for himself. Maybe he had imagined a Caribbean cruise or a trip to Monte Carlo or a walk through the Coliseum in Rome or maybe just Saturday nights in the comforts of his family, Whatever that was seemed never to have been fulfilled. Life had a different ending in store for him, a much lonelier existence.

And so the truth within these words; “the best laid plans of mice and men often go awry,” was laid bare in the life and times of William J. Knowles III of New York. His memory lingers in the few who saw him. His simple acts of goodness unnoticed and selflessly dictated from his inner being served the many that failed to take notice.

Life changed him and he changed others’ lives. We do not know what turns the creek will take. Which pebble will change the direction of the water and whether that change will merge the creek with others to grow into a mighty river of mention, or just end into a unmentioned pool of water, forgotten and left for someone to throw pebbles into it to stir its secrets from within. One never knows.

Wednesday, September 29, 2010

Teachers and Students in Medicine

                                              Knowledge (statue in Turkey)

All hail to the teacher. And yet what has become of the student? The ignominy that resides in hubris leaches out slowly and steadily into our reality. We the teachers now expressively ensconced on the upper rung of the ladder given grief from the publish-or-perish-world conspire to manipulate data to suit the world’s thirst for knowledge. We the teachers face the glut of questions answered with the thin veneer of specialized words that mean nothing and impart nothing. We the teachers hatched into a world belaboring to achieve fame and recognition lose sight of the young student that puts out his or her hand and asks, “May I have a little more sir!” This little person with a brain that is a sponge for knowledge is left threadbare with patches of knowledge, a confusion of ideas and a dose of cynicism that will fit the mosaic of a future reality.

What is it that inspires a teacher must undoubtedly inspire the student. And yet if the inspiration is drawn purely from a function of self-advancement, then all hope for the fundamental grant of imparted knowledge becomes riddled into the fabric of misappropriated facts. It is from this misunderstood and fragmented knowledge base that the mind of the student must grow and encompass and learn to practice in the minefield of human-diseased indignity. How can they, in all likelihood, ever accomplish such lofty goals?

I remember those days when I was a student. They were heady days long in the hour and short on time. There was a constant barrage of questions and answers, some answers were short but paved the way to search for more details while others were to the point needing little exposition. The battle of wits continued between the student and a bevy of very smart, considerate, careful and thoughtful teachers. These were the old guards. Their purpose was to educate and create the models from which new knowledge would sprout. They felt pride in calling someone their student. Their pride flowed in the words “my student.”  We were their calling card.

But most of that is gone now. Today the race to produce circumvents all such glory. The race is all. There is nothing but that race. The teacher walks into the lecture hall rushed for time, gives out a test and sits down at the desk to contemplate his own issues. Remarkably, the students have come to know that never is any time to ask questions. Just listen keep quiet and maybe skip classes and then cram by rote from the textbooks before an exam and graduate with a degree. Some students yearning for better grades espouse the cause of the teacher and become embroiled in the “scientific trials,” only to become what the teacher is.

And there in lies the problem, a perpetuity of this distress. What insights might the student have gathered from the textbook about the clinical nature of his understanding about medicine? He might as well have seen the TV show House, MD and come to a conclusion that irreverence to others including patients and their families is the hallmark of being a physician as long as you can call for every diagnostic test and probe and biopsy any and all organs of the body to determine the malady which, I might add may be determined in large measure with a simple art of history taking and thorough examination. Yet, House MD an actor with no knowledge of medicine and far less as a sympathetic human being, watched by millions as a recalcitrant intellectual, is idolized as a hero. My, My what have we come to? And no you don’t have to become a Sherlock Holmes and trespass into someone’s home to determine there is mold to realize that a fungal pneumonia is a possibility in an immuno-compromised host. It all stems from a dysfunctional nature of thinking. The very essence that makes us humans has been slowly and quietly through mechanisms of studying the study habits and measuring the measure of accomplishments or deifying a phenomenon of teaching that lasts a season of endearment, we have lost and tripped onto this societal debacle.

When did it all go so different that now we need to analyze “how to teach?” and “how to learn” There are countless articles and books and magazine reviews about the art of learning. There are empty words that skim the surface of intelligence amongst the discussants who sit with their noses turned up high and their brows touching their hairline or if not, wrinkling the elegant bald scalp that gives them the air of arrogance, but through all this chicanery, does nothing for the students. Words like “Metacognizant” and “Concept Map” and “Mind Map,”  resound in the circles of these ivory tower individuals that have become so bloated from self that their ballooned faces have turned their eyes into slits from whence they cannot see.

The function of teaching is to educate the student with the known knowledge. This knowledge is not abstract. The basic building blocks are the firmament of Anatomy and Physiology. From there the Pathos that inhabits the human body can be understood. From the knowledge of Embryology a branch of Anatomy becomes the building block of childhood disorders dealing with malformations such as the 

Tetrology of Fallot and Dextrocardia. Equally, knowing the basic understanding of the Kreb’s cycle can help in the understanding of hypoxemia and its effect on various organs and from there to the acid-base disorders that do ensue. It is not the temporary, the latest, the trendy knowledge wrapped in a euphemistic term called "evidence." It is the deep unchanging rule of nature. It is fact.

Similarly understanding the cell growth cycle and the proliferation of the cells into daughter cells hastens the knowledge of how malignancy starts and spreads and how medicines like chemotherapy counteract this wayward behavior. From there the students can garner knowledge of the cell surface receptors that line every cell surface and respond to the various antibodies, hormones or specific chemicals and through knowing this reward themselves with the understanding of the intra and intercellular pathways that motivate the cell to grow, divide and multiply.

The building blocks to “know” medicine are essential to the gaining of a foothold into the reality of disease. Knowing and citing literature about esoteric and unusual medical cases may seem smart and lofty but it isn’t. It is true that the knowledge and understanding of diseases keeps changing like the shifting sands of time, yet the basic mechanisms of health remain constant. Build a strong foundation and the structure shall survive a large measure of time. The gifted Sir William Osler, MD was one such teacher that touched the pinnacle of educating students.

               Sir William Osler, MD

Physiology teaches us the mechanisms of normal activity of each organ and the combined pool of organs within a system. Since most organs are interconnected with vasculature and neural supply they, the organs talk to each other via chemical and neural circuitry. An assault on one is an assault on the entire soma. Learning about heart failure is not about learning the thousands of medicines that keeps the contractility of the heart muscle, nor is it about the extra fluid buildup that needs to be purged. What it is, is the knowledge of heart muscle’s decline from impeded vascular supply or overworked fatigue or age and the congested channels that flow into it, the organs that get flooded with extra blood and become dysfunctional with the excess fluid within their tissues. 

The liver so congested cannot process the food hence the patient loses his or her appetite. 

A continuous congested liver leads to bile-flow stoppage which shows up as jaundice and equally in that chain of events, the inability of the congested kidneys from filtering the excess blood from its waste-products leads to acid-base disturbance from the electrolytes, leading to acidosis. This excess acidity creates a damning effect on the blood factors contained within this humor, which can ultimately lead to a disseminated intravascular coagulation that can cause spontaneous bleeding from any site and can be fatal. It is from here to there to everywhere! 

So the vehicle that transports the “waste” is equally important as the heart that pumps the blood, which is  as important as the liver that filters the food products and makes the blood factors that keep the blood in a congealable state. In essence the cumulative damage from a single organ mishap leads to a multi-organ dysfunction. It is in this measure of understanding that the furtherance of knowledge is achieved. The connectedness of it all!

                         The Doctor by Luke Fields

Once the basic building blocks are firmly entrenched the nuances of each block can then be enhanced with additional information. Knowing the information without the basics is impressive when mouthed but in reality does little for the patient’s health or the physician’s advance in understanding.

So students of medicine, that we all are as physicians, must renew our association with the building blocks now and again to keep ourselves in the loop of understanding.

And teachers of medicine remember the time you are spending with the students is more important then the hours spent citing literature to your cohorts. If you are after fame, remember that the student will echo your name throughout his life. The Galley proof that is held in your hand that makes you expand your chest will soon be placed in a heap; forgotten. It is better to be a giant upon whose shoulders the student learns to stand on and see where others fail to, then an empty suit that hollers and demands silence but gives little in return for that demand. If you are after educating then you are the teacher the student will walk with in lockstep.

Can teaching be mandated and in the same vein can learning be forced? The answer is obvious to all. No and no. Where a student desires to learn and a teacher is passionate to teach the combination can have far reaching benefits for the student and the society in general. It is the passion that emanates from the deliverer of the message and the desire that resides in the receiver, which makes for a great future. It is a powerful reach into the expansion of understanding that is devoutly to be wished. 

Sunday, September 5, 2010

Being a Physician

She had recently celebrated her Emergency Board Certification. After completing her 12-hour shift, which had consumed two extra hours of paperwork and transferring of patient data to her peer, she had finally left the hospital at 1 AM. It was a clear still night; the stars were out in their full majesty. Somewhere in that 25 miles of car ride between work and home, her eyelids grew heavy with fatigue. And then there was a veteran rheumatologist moderately obese from the love of Cheeseburgers who had just completed his “patient-rounds” in the hospital and had made his way back to the parking lot. He felt tired that evening, so instead of starting his car and rushing back home, he wanted to just sit in silence in his car for a moment, to luxuriate in the oft desired but mostly elusive of life’s benefits; respite, unfortunately for him that moment never ended.

Those arduous moments of loss have a pungent vulnerability to them. They sting your senses and dissolve the cloak of aloofness. They come too close for comfort. The sun was still beneath the horizon although the faint echoes of the reddish hues were just beginning to stream the sky. I walked lockstep with my surgeon friend. It was a chilly morning, cloudy with doubt and question of rain and the fine misty breath of my friend dissipated quickly as he spoke of his late night encounter with a ruptured aneurysm. He rubbed his hands while we walked in through the automatic doors together and said, “You know, I think I will go to the ER, I don’t really feel that well.”  Twenty-four hours later after a three vessel bypass he was recumbent in the intensive care unit watching the flickering nonsense on television.

It is a strange life we have, I thought. Strangely attractive for the lofty goals to help human survival and banish misery, and strangely repulsive for the loss of self and banishment from living. So the following day when work had depleted all sense of personal thought and subjugated the sense of loneliness, I made my way to the hospital to care for my patients. It was a cold and chilly day once again but a beautiful clear blue sky as a rejoinder to the recent past. Things were looking up? I thought.

“I walked five steps today.” He said, with a tremulous voice bordering on great joy. He was an elderly man laid up for all the wrong reasons. Medicine was a labyrinth of chutes and ladders for him. He would make the arduous climb to slowly feeling better and then something would eject him down the chute. It gave him comfort to have this modern day vision of healing around him while he lay in the hospital bed. This was not a path he chose and neither was this the environment he preferred; yet there he was concealed behind the dubious smile of doubt and concern. Lets call him Joe.

“So Doc?” Joe asked with that quintessential cliffhanging question that lingers on the edge of the tongue barely able to roll of it. I knew where he was going with this daily dose of salutation. “Well Joe it will be a few more days.”

“I was afraid of that.” He said, his smile vanishing behind the obvious layer of despondency. I had barely turned to withdraw myself from the room when he asked, “Will I ever be back to myself again?”

I held that question for reasoning a bit longer than I normally would. “Depends Joe, what you mean by that. Are you referring to your thirties, forties, fifties, sixties or your current seventies?”

“Forties would be good but I know you are no magician.” He said, again the smile back on his face.

“Back to where you were functional and all before you came in. That is very possible provided you keep that smile and follow along with my advice.” I don’t know what made me say that to a dying person, but there it was all laid out. The sound waves had crashed against both our eardrums and the promissory handshake and a mental agreement between two parties was hammered out. Although the very premise of such a promise was out of frame with reality I had uttered it and we had both committed it to memory. Even though life and death are extreme colors within the same spectrum, he, unfortunately had by circumstance and age, been granted a passage to the “undiscovered country from whose borne no traveler returns.” But there it was a promise spoken, assimilated, accepted and expected.

Time dilation did take pace as I searched and broke some spines of books and journals that had never been opened in the hospital library. Day after tedious day, the ordeal of finding the right peg to fit the circular hole became a trying ordeal and an emotional drain. Somewhere in there the consequence of reality disturbed the manufactured realm of fantasy. I continued to cheerlead. He needed my best and I was not going to disappoint him. I felt he could see through my limits and yet he played along. Then on the sixth day of searching, I discovered this obscure letter to the editor in a medical journal describing a similar patient in a nearly identical situation. I discussed that with Joe and his family, the ramification of such a trial of medication. He agreed whole-heartedly saying, “I trust you doc.”

A sense of trust weighs heavy on the conscience. It has a way of redefining how you see the world. It provokes thoughts of success and failure. It energizes the spirits and with one turn of the screw pulls the plug. It fills you with promise as equally as it depletes the soul with worry of inability. It is the very essence of humanity based on kinship and yet it has a heavy ball and chain attached. It is the root of the bifurcated self and non-self.

The next morning after that “Hail-Mary” pass, I found him lying in his bed barely coherent with his left atrophied leg hanging over the bed-rail. His responses were barely discernable from known linguistics. The decline was dramatic. The torture of that decision had just begun to weigh in and would lead to a sleepless night of “shoulds and coulds.”

What drives us to spend countless hours advocating an imperfect science? To spend decades of life in the pursuit of learning a science that changes with every season like the colors of the leaves. Science is a constant river of knowledge that flows and remakes the shores of understanding, keeping the delicate sense of balance between right and wrong in constant flux. Ethics abound in the issues of nurture, care, compassion, and comfort and agony-sparing decisions made by the bedside, daily. All those years of experience in that complex grid of nature makes it no easier to fail against her fury.

What drives one to suspend sleep for the care of another? What makes physicians commiserate with the family faced with the difficult decision of life and death for their loved one? What makes a person shun the darkness before daylight and the darkness after sunset to work through and call it a “work-day?”  What makes a physician, eat on the run, sleep on a wink, surround himself/herself with the prattle of pain and grief and call it a life?

The rewards lie in the memories of smiles on faces. The comfort afforded and the lives saved from the brink of death. There is no other profession quite like a doctor’s that lives with the misery of his or her patient only to grant both the dignity of respect, virtues of comfort and in most cases a future.

Patients are like butterflies caught in a gale, confused, frightened and totally overwhelmed. To sooth, to heal and to allow them to circumnavigate the jagged rocks and swirling deep pools of nature’s wrath is hallowed ground.

The word physician relates to metaphysics and is derived from the adjective “physikos,” meaning nature. This nature’s dislocated confusion is remedied by the art and the right sprinkle of science by one such individual called a “physician.”

It is in the healing of the sick and the love of such an endeavor that those inflexible hours of demands compacted between unsocial timelines creating great personal stresses make the trauma to forge against another’s worth the while.

Getting back to our story of Joe; On the third day after the trial therapy Joe was found sitting by his bedside, eating a full breakfast that had alluded him for weeks.

“Doc how did you do it?” he asked as he rubbed his thumb and forefinger on his cleanly shaven chin. I had not. “You did it Joe. Your strength of character and determination.” I said.
“Doc it must be rough on you. Isn’t it?”
“No Joe, seeing you like this makes it all worthwhile.” I replied.

He wheeled himself under the concern of his transporter to the lobby to meet with his family under the banner of balloons and get well cards.

So Dear Joe, whoever and wherever you are, know this that the doctor tending to you has lost the virtues of societal living, worry-free comfort of his/her daily life so he/she can vouch for yours. His/her years of knowledge and experience are there to provide you with the best care and comfort modern medicine can afford. Limit not your thoughts with the media’s snippets of “good doctors and bad doctors.”  The media makes up things as they go along. Their vested interest is as long as the next broadcast and ratings. Diseases are not cured in an hour after subjecting “patients” to countless biopsies of every organ and diagnostic tests as shown on the TV program “House, MD” nor are the doctors crippled with reliance on narcotics with irascible demeanors. Physicians are humans who take pride in healing. Do not cross into the cynicism that plagues the politics of medicine, for many will disavow the goodness in medicine for the sake of personal ambition. Understand this that your physician is there for your healthy life. To him or her you are a person with a past, present and above all a future and that he or she will try, forearmed with the knowledge and the experience, to win the fight for you against the vicissitudes of what diseased your body. Your health is a testimony to his or her endeavor. Trust him/her and have faith in his/her abilities. Let your physician find the key to unlock the virtues of good health for you. It will make you both happy.
So for now Joe, “Live well!”

Sunday, August 29, 2010

My dad says so...

It was 6AM. The sunlight had barely grazed the top of the tower. The morning glory was in full swing. The bucolic English countryside was still mostly asleep. The man stood with his hands and feet tied by leather straps. Eight individuals stood as if in solemn prayer, heads bowed, each in his own recursive thought. The drop distance, calculated based on the prisoner’s height and weight, was figured at six feet and one inches by the Prison Medical Officer who also was in attendance. One of them looked at the time clock overhead and nodded to another, who moved and placed the black hood over the man’s head. The one inch braided rope was tight around his neck.

 The priest prayed for the prisoner’s soul and having done he looked down. The nod that would bring justice to the world against crime without a moment of hesitation occurred. Just before the firmness of the trapdoor dematerialized and the hooded body fell through, a scream emerged, “I am innoc…!” Caught in mid consonant the echoes completed the sentence. The declarative from beyond the grave had reached the living.

His crime was labeled as “murder.” The clues that bore testimony for the evidence included a crow bar that he held in his hand. The wound on the victim was that of a pickaxe, the button near the victim matched the one missing from his overcoat; the bloodstain on his shirt and the treads of his shoes matched the footprints next to the victim. Then there was the death-knell of the numbers of people fitting the description that had been at the victim’s site. He was the one who reported the murder to the authorities and fit the height and general appearances from other observers at the scene. Nothing more needed to be said. It was a slam-dunk – though circumstantial at best.

Twenty-two years later amid the conflicting poisonous thoughts and self-cleansing rituals of a seventy-year-old man, history was purged onto a piece of paper. The dying old man riddled with a cachectic disease expunged himself of his egregious and dehumanizing behavior. He confessed to that murder and other crimes. The folded paper was found in his left hand.

Such are the trials of the human spirit. The judgment dispensed with pomp and vigor with the wrong set of tools to the innocent man.

The same governance applies to statistics and present day interpretation. The H1N1 epidemic that never was more than a seasonal flu, caused a stir worldwide when the UN stepped-in and pronounced that it was a pandemic – a fearful crises. Sometimes in an effort to claim credit for a discovery humans push hard for their personal objectives. The long arm of Tantalus pulls at their collective thoughts makes them see what others cannot and in so doing in their fervor convince, cajole and circumvent and stifle contrary opinion. Once the fever pitch has reduced, a small blurb denounces the myth and the populace is happy that they all live in a clean and sterile world again.

                                 Painting of Tantalus (greed beckons)

To look at the manipulation of small numbers gives us a window into the larger numbers. For instance, if you have a salary of $100 a week and management reduces you by 50%, now your earnings are $50 a week. After a lot of brouhaha and media sponsored criticism, the management agrees to raise your salary back by 50%. Are you back to where you were? No. You are now making $75 a week, since 50% OF $50 is (50+25=75) $75 and not a $100. This is simple but accurate. If some one wants to hide facts they throw in percentages. Listen to the true numbers.

An example worth entertaining: Statins are the new vogue in town, professed as the cardiovascular disease “tamer.” All collective advertisements and the drug labels say that Statins may reduce the relative risk of a cardiac event by 38-46%. That is an impressive statement by any standard. Wow, I can eat the Twinkie and the Crème Brulee and the skin fat of the duck and take a pill without remorse. In fact many a cardiologists, I know go out for a big meal at a restaurant and on their way home pop one of those pills, :It keeps my cholesterol down!” they say. Really. So looking at the real patient numbers of five major studies of a Statin and subdividing them into a basket of 1000 patients for the Statin side and the placebo side gives us the following: 32/1000 patients had a cardiac event while 41/1000 in the placebo category. Add 32 to 41 = 73 now divide by 32 gives you a 43% Relative Risk. Interestingly the cardiologists having been so enamored of this pill have begun to believe in it handsomely, to the point that now they proffer that the “pill” reduces the risk of heart attack. Maybe it is the life-style change, diet change or whole host of advocacies inspired collectively in society that is coming to roost, or maybe it is the “pill” in some small way helping. Further investigating the issues of the side effects of the “pill” are listed as being a paltry 2%. The risks being, muscle fatigue, muscle pain, confusion and cognitive brain function disturbances and liver damage. But comparing 43% to 2% would seem very one-sided and in the realm of the advocates for the “pill.” Yet the 2% is an Absolute Risk and not a Relative Risk. If you were to give the Absolute Benefit from the pill then the answer is 41-32=9. And 9 divided by 1000 = .009% Oops! Here the Side Effects from the “pill” outweigh the benefits don’t they?

  Median means the status of the 50% of those tested.

 “Physiologists must never make average descriptions of experiments because the true relations of the phenomena disappear in the average.” - Claude Bernard.

Lets stay with medicine for a bit longer and look at how statistical manipulations can harm the psyche of the unsuspecting. The responses to therapy in oncology (cancer medicine) used to be categorized as Compete Response (All discernable evidence of disease obliterated or 100% reduction), Partial Response (Where 50% of the discernable disease by diagnostic tests such as scans and X-Rays was reduced) and Minor Response (Less than 50% reduction) Then suddenly one day entering into the 21st Century, the ivory tower decided that Partial Response would be changed to represent disease that had been reduced by only 30%. Why the change one asks? Well, you would show more responders in a study touting benefits of the particular potion and therefore the benefits would sound better and people would rave about it. Really? So instead of monkeying around with these response rates why not just look at Overall Survival Rate or OS. Now that hurts the manipulators! OS cannot be manipulated. Since, there is very limited progress in the absolute survival rates in three-decades does not mean that therapy has not helped. It has in mollifying the disease of cancer, caring for the sick and giving them a sense of wellbeing and chance to enjoy time. Unfortunately progress is not in the form of a giant leap but more in the realm of mini-steps. There is no need to make more of it then you should. Uncertainty is a fact of life. Manipulating to present it a certain way is the function of selfishness or self-righteousness, either way it is abandoning the truth. Unfortunately it is widely used by the media, you know, TV, Newspapers, Magazines etc. Mostly because either they don’t understand or don't really care because of compelling time constraint to put it on the editor’s desk. Unfortunately, it is also as mentioned, sometimes inadvertently used by the white coats for self-aggrandizement or by the government-types- you don’t say- for political messaging. Note I don’t use the word reasoning because to reason requires concept deliberation and understanding!

Another wrinkle in the pages of concepts is the correlation and causality issue. To muddy the waters in the pristine white sands of our thinking, I am reminded of a question posed by a ten-year-old: “Does listening to loud music cause pimple?” I mulled over that one for a while.

“Where did you hear that?”
“My dad told me.”
“The truth is that loud music through the ear buds and headphones cause a hearing loss but do not cause pimples.
“But he is right. My older brother and his friends have pimples and they listen to loud music all the time.” He whimpered.
“You see young kids love Rock bands and Heavy Metal which they listen to in high volume. But the act of listening does not cause the pimples. It only hurts your hearing.”
“But my dad says so…!”
“And he is right for you not to listen to loud music.”

You see the problem. This little boy was scared of the gigantic yellow-tipped angry-red pimples his sibling had and wanted no part of it, but he was conflicted with the causality to ask the question. This brings us to a problem of a Confirmatory Bias, where, if I had answered yes to his question to keep his thinking on the same track, he would go on through puberty in the dark about pimples and loud music. As one grows older one substitutes a different "governing power" for the "dad" and lives happily in fear.

My best friend told me in her youth she followed her father around in household repairs. While he was nailing down a board, she asked him, “Dad why does the nail bend every time you hit it with a hammer?” He answered, “It bends because you are talking too much.” After a while surveying the results quietly she asked, “Why does the nail bend even when I am not talking?”
“Darn, he said this finger keeps getting in the way.” Just like in truth, data keeps getting in the way of a fabled story with hastily built foundations.

The armchair analysis of any scientific study hastens to mind a smattering of causes, a mixture of bias, chance, inference, manipulation and motivation. In medicine since we deal with humans there are multiplicity of competing reasons to objectify a cause with aplomb. The science of medicine is not the same as the science of physics dealing with forces, speeds and vectors defined in units. Medicine does not lend itself to absolutes, it conspires to make stealthy attributes where none are expected and remove those attributes from somewhere else where they do not belong. 

The rudiments of statistical thinking however dates back to 1828 when Pierre Charles Alexandre Louis did some simple mathematical inquiry into blood-letting for pneumonia and infected patients and found that the widely practiced method had no beneficial effect but possibly a deleterious effect. The procedure was ended slowly as the word caught on. There was a minimum of correlational analysis contrary to our present day, where correlations are used to imply causation all the time. The more the analysis is reviewed by the experts in the Media and amongst the laity the more it earns itself a seat amongst the full-fledged irrefutable causes for the malady under review. With that everyone is happy that science has marched on and left in its wake another great victory. Not so fast, because the next turn in the road shows the fallacy of this incomplete link through correlation. Reality is vindicated eventually.

Medicine is indebted and also held in hostage by the brilliance of the bespectacled nearly blind, with full bearded pipe smoking man named Ronald Aylmer Fisher. Fisher could not read due to his eyesight and held most of his opinions through lectures and social communications. He learned to visualize with an imagination unlike any other through multidimensional thinking and came up with the concept of Randomization. This he acquired from W.J. Gossett of the Student t-test fame and merged the two processes of randomization and the t-test to come up with a scientific terminology called analysis of variance or ANOVA utilized widely in science. Unfortunately for all the mathematically developed scientific study method the foundation of proving the null hypothesis to be true is based on a 5% error. All medical studies are based on a CI of 95%. CI stands for Confidence Interval, which means that there is a 5% chance that, the observation of a difference between the studied drug and placebo or standard care or any other comparator is by chance and there is a 95% confidence that it did not. Putting that in perspective one would be hard-pressed to say it’s okay to take the bungee cord jump with a 5% chance of ripping the bungee cord and plummeting to death. I don’t think any one would take that chance, if it were true. Would you? Yet that is what all experiments in science are based on, the decisions of the FDA for drug approval and the studies conducted under the auspices of scientific rigor are based upon the Confidence Interval. In essence you are trying to eliminate 2.5% of the data from the left and right tails of the Normal Distribution Curve (Bell Curve)

Another pesky problem in medicine is that the burgeoning list of medical journals consist large number of published studies made up of small number of patients and therefore subject to question, as authors hurry to publish a result and be recognized. The problem with the small number of patient data reveals a world-class error in interpreting reality. Case in point was an ISIS-4 study that negated a Meta analysis of 7 small trials of 1301 patients proffering that intravenous Magnesium supplementation reduced the risk of death after a heart attack. ISIS-4 study with 58,050 patients randomized to with and without Magnesium, found NO benefit at a cost of millions of dollars. The small numbers with even a single death in one arm makes the other side “statistically significant.” And while we are at it, let me address the famous p-value. The statistically significant p-value of equal or less than 0.05 was Ronald Fisher’s hunch and not a mathematically determined end point. It just made sense to him. But he was dealing with mathematics and agriculture and not human lives. His hunch lives on and gathers more steam as time passes in the stream of humanity.

Imagine that a study showing a difference between 99.82% and 99.88% yields a benefit of 34% (p-value 0.003). The absolute benefit is 0.06%! It would take 1592 patients to show a single patient benefit! This would make for a splash in the medical journals touting the relative risk reduction numbers of 34% in the abstract and the headlines. The reality remains buried in small italics in the belly of the misleading beast if one has the time to review it.

Where is the Life we have lost in living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information? – T.S. Eliot

You can see that manipulation of data to prove something is within the purview of statisticians and mathematicians nowadays to prove the expected bias that the scientist wishes to prove. Ouch! The tactics used nowadays is reductio-ad-absurdum. Reduce the information to its infinite parts and rebuild it to make a mountain out of a molehill (my definition).

In economics as in medicine along with other disciplines, there is a prejudiced view of thought labeled, ”observer bias.” Here one sees what wants to see and stacks the odds in his or her favor to the exclusion of the truth and reality. Therefore the very act of observation is prejudiced from the beginning to give the result that one has contemplated. Upon reaching the desired result, the cry of “Eureka!” is convulsively expelled for others to rejoice in the “discovery.” Thus the art and science of experimentation is corrupted to suit the thinking rather than the other way around.

                     Archimedes: the fulcrum and weight displacement

In reality and with real experimentation most brilliant departures from the norm are made through slow methodical and non-judgmental beginnings. The Archimedes “Eureka” was a boiling and brewing thought process that congealed when he stepped into the bathtub to displace water. 

Newton and the apple, 

the Wright Brothers and the geometry of the wing following many mishaps before success was achieved, confirm the fact that innovation and progress is never made through manipulation or wanton misrepresentation of data. It is the slow contemplative advance till the thought has reached the perfect temperature to yield its virtues like the color of browned sugar.

Large scale Economics suffer from the same quakes that want to absolve the readers from all possible damaging thoughts. When things are going well and the economy is humming along at a fine pace, the demand for products goes up hence the price of the product goes up. Initially the company has to hire more people and the cost of labor has to be translated into the price and then the price maintained to yield a profit for the risk the company has taken. This therefore leads to a higher CPI (Consumer Price Index) and a PPI (Produce Price Index). Ultimately this translates to the rising cost of products, which leads to inflation. The government looks at the inflation rate and reports it monthly. But wait, when the prices are sky-rocketing and the fear that the dollar is not going far enough to buy the necessary amounts of the products, the government steps in to appease the masses by saying, we have to look at the “core” inflation which is ex food and energy. Oh okay. I understand. Maybe.

And then there is the quarterly ritual of the GDP (Gross Domestic Product) Why is always revised downwards after the initial figure? Because once the dancing and partying has ended the revised numbers are far away in the future to affect that past. The partying has already occurred. The moment enjoyed and so what is wrong with a 0.6% downward revision. Move on old chap, you say, don’t be a spoiled sport. Okay?

How about Stocks? Everyday the TV and most every Internet has a stock symbol look up price depicted with a green colored numbers if the stock went up that day or in the dreaded red color if it ventured down due to selling pressure. However if you are not a day-trader then the more important issue is to look for the fundamental and technical value of the stock price action. For instance if it is on a steady decline, but had an up tick on a certain day or week why get trapped there? If for instance a stock not paying any dividends languishes at a constant price, it is like parking your money in the mattress. 

Microsoft comes to mind; if you put money in MSFT in 1999 you would be down on your principle investment today even with the one time dividend! (Just the facts, I am not busting the great company that spawned work for thousands)

“Stars, hide your fires, let not light see my black and deep desires!” cries Macbeth in the face of dark reason. Yeah, there is plenty of light here if you are willing to flip the switch. The generators are humming with energy. So then let us begin with the issue of “Pay for Performance,” euphemistically written as P4P. What in the name of Sam does that mean? How does one contemplate performance in medicine? That patients with terminal disease if they are not cured then the treating physician has a poor performance record and therefore not get paid for services? 

Or for that reason a diabetic with four or five vessel disease and small coronary arteries cannot sustain the post operative recovery in 5 days and be sent home means that the cardiac surgeon has maybe rendered poor care? Or a General Practitioner has failed to prescribe the right medicine for a raging influenza and the patient succumbs to the disease? I mean some one is not thinking, the dark suits in the government maybe have never ever thought of the real issues in medicine.  P4P has hidden dangers written in bold all over it:  Rosenthal JAMA 2005 (294) and BMJ May 2010 (340) articles view these implementations and their dangers.

An example in the United Kingdom where there was a performance related issue with “Ambulance Response Time” for emergencies. The day it was enacted the graph for showing compliance skyrocketed to the peak. Interesting and rapid compliance one would say upon viewing the graph and the newspaper would shower accolades and the National Health System government auditors would bask in their glory of ridding the pesky delays that cost human lives. What happened was manipulation of numbers by the ambulance drivers and the real emergencies got delayed as the less emergent patients nearby were recast as Category A. As a result the unintended consequences cloaked devil came out to play the pipe. What the policymakers do not contemplate are the unintended consequences. Exactly what they wanted to avoid – delays in emergency – happened and cost lives. And these issues of policy reliance on poor information are evidence at every turn of the screw. Those that reason, anticipate and those that anticipate also hesitate in proclamations. A fall from 10 feet above hurts the same whether someone says it is only three feet.

Oh and I can't let this one go. The latest buzzwords in medicine are “Evidence Based Medicine.” Sounds good. You are therefore making decisions on some collected robust data. Now for the three ring binder full of questions, what does one consider evidence? Does eating a high carbohydrate diet as proposed in the past by cardiology societies and the American Medical Association recommendations still apply? No!

Does heavy marathon running constitute good exercise for a healthy heart in face of contrary data showing excess calcium buildup due to trauma? (recent data)

And of course we would all laugh heartily if we were to recommend cigarette smoking to cure chronic cough – proposed in 1899 edition of Merck Manual. 

Then there is the amputation of the limbs to cure Pernicious anemia (that is why it is pernicious because the cause remained unknown and death rate was high) changed to eating raw liver and then regurgitated food products from a doctor to finally a Vitamin B12 sublingual pills and injections. And lets not forget the previously mentioned “blood-letting.” Medicine flows like the river forever changing its shores and its depth. To rely on the past evidence does not do a patient good when better treatment is available and as of yet has not met muster of the ivory tower crowd, but since the “evidence” has not been collected for writing articles it is withheld from patient care. Oh me Oh my! (Read Dr. Jerome Groopman and Pamela Hartzband's article on Evidence Based Medicine, "Why quality care is dangerous" in the Wall Street Journal 2005 @

The consummate skeptic is welcome into the statistical paradise as he considers this jungle of pitfalls with the questioning eye and makes the learned decisions. So there are a few lessons here for all of us: Reading the information with an eye towards the motives, Considering the methodological hiccups in the experiment, Counting the real numbers where percentages are used, Considering the differences between Relative and Absolute Risks and above all Questioning with the same word you dogged your father with, Why!

For Further Reading:

Innumeracy, John Allen Paulos, (Penguin 2000)
The Numbers Game, Michael Blastland and Andrew Dilnot (Gotham Books 2009)
How to Lie with Statistics, Darrell Huff (W.W. Norton 1993)
Biostatistics, The bare Essentials Second Edition; Geoffery Norman and David Steiner (BC Decker 2000)
Big Fat Liars, Morris E. Chafetz, MD (Nelson Current 2005)
Reckoning with Risk, Gerd Gigerenzer (Penguin 2003)