How did Oscar, the death-sensing cat, nose his way into an elite medical journal?

Slate Magazine: By Daniel Engber

...In fact, the popular press accounts of Oscar the Cat provide more scientific analysis than the original journal article—they quote animal behavior experts who speculate on how he might accomplish his feat. Dosa tells us only that 'Oscar the Cat has had an uncanny ability to predict when residents are about to die' and that he's 'presided over the deaths of more than 25 residents' by nuzzling them during their last few hours of life. That's a lot of pre-death nuzzles, but we don't know Oscar's success rate—does anyone keep track of the number of times he nuzzles people who don't die? And we can't separate out causes, effects, and correlations. (As Jay Leno said the other night, 'Anyone stop to think maybe these patients are allergic to cats?')

It wouldn't be that amazing if Oscar really could tell when someone's about to die. After all, we're not that bad at figuring it out ourselves. Since Dosa's essay was published, other researchers have argued that the cat might be using its acute sense of smell to detect a patient's organs shutting down. But you don't need a superhuman nose to suss out the bouquet of death. Kidney or liver failure can cause waste products or acids to build up in the bloodstream, and patients with these conditions sometimes have a noxious or sweet aroma on their breath. ...

In an e-mail, a NEJM representative explained the decision to run Dosa's piece: "From time to time, we publish such personal narratives by physician writers." But this isn't just a personal narrative—it's a piece of magical realism that has been taken for science. If doctors really can use household pets as a diagnostic aid, let's find some genuine research on the subject.

Review: Body of Work

New York Times: Abigail Zuger, M.D.

Body of Work
Meditations on Mortality From the Human Anatomy Lab. By Christine Montross.

It is not easy to write a book about the first year of medical school — not a book anyone would want to read. The usual basics covered in that year’s curriculum are so very basic (cells, molecules and electrical circuits) that students spend much of the year in the library, memorizing facts and grumbling.

Except, of course, for the long hours they spend in gross anatomy laboratory, also a staple of the first-year curriculum. There, every single complicated emotion anyone has ever enunciated about the practice of medicine roars into the open so reliably it is surprising no one has come up with Christine Montross’s idea before. Dr. Montross, a recent medical graduate, has tethered an earnest and readable reflection on the process of becoming a doctor to the methodical dissection of a human cadaver, the first of all too many professional initiation rites.

In the last few years, some of the mystery has been stripped from this particular piece of medical education, thanks to the entrepreneurs behind the traveling exhibition “Bodies” and hundreds of anonymous citizens of China. ...But there is still a world of difference between observing the results of a dissection and personally wielding the scalpel. Medical students generally spend months hunched over a single body once belonging to a generous soul whose name they never learn, but whose intimate medical history they slowly unearth. They use not the miserably fallible tools of the real doctor, but their own two hands. It is the first and the last time most doctors ever see the normal and the abnormal intertwined from head to toe, in three dimensions and shades of beige and gray. ...

And underlying it all is the eternal paradox of medicine: the doctor and the patient who are at once identical and opposite. Before the students dissect out a structure, they instinctively feel for the landmarks on their own bodies. And yet, they cannot identify too closely with their cadavers, or with their patients in years to come, or they will become paralyzed by emotion. ...

By the same token, though, who better to describe the strange terrain between doctor and patient, dissector and cadaver, us and them, than someone actually crossing that no-man’s land? In a few years, Dr. Montross will be on the other side, never to return. That is when she will realize that, as terrifying and humbling it may be to cut up a human body who reminds you of your grandmother, the experience pales beside that of trying to heal a living version, smiling and fully clothed.

Cancer Patients, Lost in a Maze of Uneven Care

New York Times:By Denise Grady

Cancer, more than almost any other disease, can be overwhelmingly complicated to treat. Patients are often stunned to learn that they will need not just one doctor, but at least three: a surgeon and specialists in radiation and chemotherapy. Diagnosis and treatment require a seemingly endless stream of appointments. Doctors do not always agree, and patients may find that at the worst time in their lives, when they are ill, frightened and most vulnerable, they also have to seek second opinions on biopsies and therapy, fight with insurers and sort out complex treatment options.

The decisions can be agonizing, in part because the quality of cancer care varies among doctors and hospitals, and it is difficult for even the most educated patients to be sure they are receiving the best treatment. “Let the buyer beware” is harsh advice to give a cancer patient, but it often applies. Excellent care is out there, but people are often on their own to find it. Patients are told they must be their own advocates, but few know where to begin. ...

...When she joined a cancer support group, she recalled, “It was amazing to me the different experiences people were having based on what they could afford or who their provider was. I was able to say, ‘If the provider won’t pay, my family will. I don’t care, I’m going for a second opinion.’ ”

In the support group, it saddened her to hear other patients with advanced disease take the word of a single oncologist, because she believes that if she had done that, she would already be dead. She has come to think that survival may depend on money and access, and, she said, on “your own drive and motivation — are you Type A? — your education and your ability to sort through the medical world and the insurance world terminology.”

This promises to be quite a series.
For all the fuss and negative comment about Michael Moore's narrative techniques, he gets some big things right, as this more conventionally reported piece demonstrates.
Many American patients have their troubles securing a first opinion, let alone a second at a mega-center of their choice. And the disparities in approach, expertise, and outcomes are startling in a field supposedly dominated by science and widespread access to research reports. It would be interesting to know more about comparisons in these regards to the better rated universal systems, such as Canada, France and Germany. (Maybe not Cuba on this one, Michael.)

On Trial for your Life

New York Times:By Denise Grady

Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer. Presbyterian showed up with two lawyers, a doctor and a nurse. Dr. Bordenave and a gastroenterologist from Albuquerque testified on Mr. Hendrickson’s behalf.

Mr. Hendrickson and his wife had studied the details of their insurance policy and had also learned — with the help of M. D. Anderson — that in the previous five years, the five surgeons Presbyterian had recommended had performed a total of five Whipple operations.

Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.

A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.

Mr. Hendrickson said it was “tough to stand up to attorneys and doctors. I don’t know why I was able to do it. I’m stubborn, I guess. I don’t like to be told what to do. Too many people, I know, they just let it go and they die.”"

Getting effective care for the seriously ill--known in the trade as "medical losses". There probably is an important place in any health care system for effective means of utilization review--that is, are patients receiving appropriate care likely to be helpful to their condition (and not just to the pocketbooks of those proving expensive interventions). It doesn't follow that reviewers should have strong personal financial incentives (amply documented in Michael Moore's SiCKO) to deny care. This is a challenge for any health care system, perhaps not best addressed at the bedside of each individual patient, but through research and medical consensus panels. Achieving universal coverage will not make all such problems go away, but it will give us a better shot at getting the incentives right--and considerably more humane (except for those patients with unlimited resources...)

Sending Back the Doctor’s Bill

New York Times: By ALEX BERENSON

“I always find it ironic that when I go to doctor groups and such, they always talk about the cost of prescription drugs,” said Dana Goldman, director of health economics at the RAND Corporation, a nonprofit research institute in Santa Monica, Calif.In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending.

Prescription drugs cost, on average, 30 percent to 50 percent more in the United States than in Europe. But the difference in doctors’ salaries is far larger, Dr. Goldman said.

Doctors in the United States earn two to three times as much as they do in other industrialized countries. Surveys by medical-practice management groups show that American doctors make an average of $200,000 to $300,000 a year. Primary care doctors and pediatricians make less, between $125,000 and $200,000, but in specialties like radiology, physicians can take home $400,000 or more.

In Europe, however, doctors made $60,000 to $120,000 in 2002, according to a survey sponsored by the British government in 2004....[T]he lower salaries are a significant part of the reason that European countries spend less on health care than the United States does — a fact liberals avoid mentioning when they preach the advantages of a European-style single-payer system. ...

Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment.

“I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors. ...

Medicare, especially, does not like to second-guess doctors’ clinical decisions, said Dr. Stephen Zuckerman, a health economist at the Urban Institute. “There’s not a lot of utilization review or prior authorization in Medicare,” he said. “If you’re doing the work, you can expect to get paid.”

As a result, doctors have steadily increased the number of procedures they perform on Medicare beneficiaries — and thus have increased their income from Medicare, Dr. Zuckerman said. But the extra procedures have not helped patients’ health much, he said. “I don’t think there’s any real strong evidence of improvements in health status.”

Swabs in Hand, Hospital Cuts Deadly Infections

New York Times:

...Every room and corridor is equipped with dispensers of foamy hand sanitizer. Blood pressure cuffs are discarded after use, and each room is assigned its own stethoscope to prevent the transfer of microorganisms. Using these and other relatively inexpensive measures, the hospital has significantly reduced the number of patients who develop deadly drug-resistant infections, long an unaddressed problem in American hospitals.

The federal Centers for Disease Control and Prevention projected this year that one of every 22 patients would get an infection while hospitalized — 1.7 million cases a year — and that 99,000 would die, often from what began as a routine procedure. The cost of treating the infections amounts to tens of billions of dollars, experts say....

Several European countries, including the Netherlands and Finland, have all but eliminated MRSA through similarly aggressive campaigns. But at many American hospitals, experts say, high infection rates have been accepted as a cost of doing business. Barely a quarter of American hospitals screen patients for bacterial colonies in any methodical way, a recent survey found.

“People don’t believe it’s in their institution, and, if it is, that it’s too big to do anything about, that you just have to accept it...

...[S]ome infection-control experts warn that [certain measures] may have unintended consequences, including lesser care for patients who linger in isolation. Studies have found that patients in isolation are seen by hospital staff members half as frequently and tend to suffer more from falls, bed sores and stress. ...

A major emphasis at the Pittsburgh hospitals has been hand hygiene. Studies have consistently shown that busy hospital workers disregard basic standards more than half the time. At the veterans hospital, where nurses have taken to pushing elevator buttons with their knuckles, annual spending on hand cleaner has doubled.

A Day in the Life of Oscar the Cat

NEJM : David M. Dosa, M.D., M.P.H.

Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar's presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.'s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, 'What is the cat doing here?' The mother, fighting back tears, tells him, 'He is here to help Grandma get to heaven.' Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

On his way back to the charting area, Oscar passes a plaque mounted on the wall. On it is engraved a commendation from a local hospice agency: "For his compassionate hospice care, this plaque is awarded to Oscar the Cat." Oscar takes a quick drink of water and returns to his desk to curl up for a long rest. His day's work is done. There will be no more deaths today, not in Room 310 or in any other room for that matter. After all, no one dies on the third floor unless Oscar pays a visit and stays awhile.

Note: Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families. Oscar has also provided companionship to those who would otherwise have died alone. For his work, he is highly regarded by the physicians and staff at Steere House and by the families of the residents whom he serves.

The best futuristic ideas for killing drug-resistant bacteria

Slate Magazine: By Amanda Schaffer -Bug Zappers
The best futuristic ideas for killing drug-resistant bacteria.

...These warning signs... may make us wish for a gorillacillin—a superdrug—that could destroy any bug under the sun. But as the National Academy of Sciences pointed out last year, such a remedy is unlikely to emerge. And if one did, it would probably be used so widely that resistant strains would quickly evolve. Instead, the future seems to lie with treatments that target specific bacteria by taking cues from how they behave in nature, modulating the human immune system, or intervening boldly in bacterial genetics. Some of these approaches may substitute for antibiotics; others could extend the usefulness of the drugs we have. Here are some of the best big ideas ranked on a scale of 1 to 10, based on their potential promise and sheer intellectual chutzpah.

Since one of these bugs nearly did me in last year, I read this with special interest.

Work-Hour Caps for Medical Residents May Have Saved High-Risk Patients, Study Finds

The Chronicle: By KATHERINE MANGAN

Fewer high-risk patients have been dying in teaching hospitals since accreditors cracked down on medical residents' marathon working hours, but surgery patients seem to be faring about the same as before, according to a report by researchers at Stanford University's School of Medicine.

"It's difficult to say, based on our findings, that the regulations are good for everyone, but they do appear to have a modest impact on some," said Kanaka D. Shetty, a research fellow and lead author of the report.

In 2003 the Accreditation Council for Graduate Medical Education put into effect regulations that limited the working hours for all residency programs in the United States. Work weeks were capped at 80 hours, with continuous duty generally limited to no more than 24 hours. ...

The effect of work-hour restrictions has been the subject of numerous conflicting studies and vigorous debate in recent years, but Stanford researchers said theirs was the largest analysis yet. The article on the study, "Changes in Hospital Mortality Associated With Residency Work-Hour Regulations," will appear alongside another from Yale University researchers, who found that the work-hour limits had resulted in better outcomes on three of seven measures for internal-medicine patients.

Up close and personal: Personalized Medicine

Haaretz :

The medical world has known for a long time that one size does not fit all. Two people who take the same anti-cancer drug, for example, may react differently to it. One might develop dangerous, even life-threatening side effects, whereas the other will benefit and experience almost no side effects. The same drug can bring about the disappearance of the malignancy in one patient and have no effect on another. These extreme differences derive from the genetic differences between people. In the same way that a single gene is responsible for different eye colors, a particular gene in different people can lead them to metabolize the same drug either quickly or slowly. People are differentiated from one another in terms of how well a drug is absorbed by the intestines, how well it metabolizes in the liver, how much it secretes in the kidneys - and all these elements determine how much of the drug the individual takes remains in the body and how it will affect him. If the drug metabolizes quickly, its effect will be limited and the dosage will have to be increased. By contrast, if it metabolizes slowly, or is eliminated slowly from the body, it is liable to generate serious side effects to the point of threatening a patient's life.

One of the cardinal contributions of the Genome Project is the knowledge it provides about the scale of genetic diversity. The tremendous technological leap that occurred in the wake of the project now makes it possible to identify the diversity in certain genes. This, in turn, will make it possible to adapt the treatment to accommodate the patient's personal genetic makeup, to accord him the best and safest treatment, to reduce the side effects, to predict the prospects of survival, and more. This is not science fiction. It has already begun to happen. "Personal medicine" signifies not only a trend, but a new sphere in medicine, which is rapidly gaining momentum. In fact, it is one of the hottest subjects in the medical world today, on the agenda of almost every medical conference and described as the medicine of the next generation.

This is clipped from a long story. Not much original to those familiar with the topic, but a convenient summary with a bit of an Israeli perspective.

Psychiatrists Top List in Drug Maker Gifts

New York Times: By GARDINER HARRIS

WASHINGTON, June 26 — As states begin to require that drug companies disclose their payments to doctors for lectures and other services, a pattern has emerged: psychiatrists earn more money from drug makers than doctors in any other specialty.

How this money may be influencing psychiatrists and other doctors has become one of the most contentious issues in health care....

These and other stories have helped to fuel a growing interest among state and federal officials to document and restrict payments to doctors from drug makers. At a gathering last month at Columbia Law School in New York, state attorneys general from across the country discussed ways to get similar data for their states.

And today, the Senate Special Committee on Aging, which is led by Senator Herb Kohl, Democrat of Wisconsin, will hold the first of a series of hearings on the issue, which could lead to legislative proposals to restrict and require disclosure of payments and gifts to doctors from drug companies nationwide.

Several lawmakers on Capitol Hill have expressed interest in such legislation, including Senator Charles E. Grassley, Republican of Iowa. “A federal law requiring public disclosure of payments to doctors could be very effective if it was carefully monitored and consistently applied,” Mr. Grassley said.

Kidneys and Hearts

Salon.com | News Wires: By LAURAN NEERGAARD (AP)

WASHINGTON -- Hearts and kidneys: If one's diseased, better keep a close eye on the other.

Surprising new research shows kidney disease somehow speeds up heart disease well before it has ravaged the kidneys. And perhaps not so surprising, doctors have finally proven that heart disease can trigger kidney destruction, too.

The work, from two studies involving over 50,000 patients, promises to boost efforts to diagnose simmering kidney disease earlier. All it takes are urine and blood tests that cost less than $25, something proponents want to become as routine as cholesterol checks.

'The average patient knows their cholesterol,' says Dr. Peter McCullough, preventive medicine chief at Michigan's William Beaumont Hospital. 'The average patient has no idea of their kidney function.'...

Indeed, the new research is highlighted in this month's Archives of Internal Medicine with a call for doctors who care for heart patients to start rigorously checking out the kidneys -- and for better care of early kidney disease.

The link sounds logical. After all, high blood pressure and diabetes are chief risk factors for both chronic kidney disease and heart attacks.

But the link goes beyond those risk factors, stresses McCullough: Once the kidneys begin to fail, something in turn accelerates heart disease, not just in the obviously sick or very old, but at what he calls "a shockingly early age."