Evidence Based Decisions and the Art of Medicine

“The evidence clearly shows……”

How often have we heard that argument made, trying to influence our choices or behaviors. Experts provide data that support their point of view, often in the face of conflicting information. We would like to believe that we always make rational decisions based on facts. But human nature proves otherwise. We will base our most recent decision on how the last situation played out. Negative outcomes, even if infrequent, have a greater influence on future behavior than their true weight. And as clinicians we are often told, “Judgment comes from experience, and experience comes from poor judgment.”

So it has been very interesting for me in my new position to work with clinicians and systems on best practices for various patient conditions. Unlike the “hard” sciences like physics, mathematics, and chemistry, soft sciences like medicine and pathophysiology have shades of grey. Even the best designed studies are inherently ambiguous, and the literature tends to further this bias by publishing studies where a beneficial difference is found, as opposed to equivalence or detriment. How do we sort through the data and try to come to a rational conclusion?

By analyzing how to analyze data.



Health service researchers have developed an elaborate grid that attempts to balance the potential benefit of an intervention with the strength of the data supporting that intervention. These decisions subsequently form the basis for clinical guidelines, and in many cases, whether the service will be paid for. The strongest recommendations, IA , are the most stringent , and should be generally accepted. III A findings strogly support more harm than good. You can see where the ambiguity comes in. A IC may well be good, but there’s not strong randomized data. By the same token, a IIIC recommendation not to do something is less of an indictment than a IIIA. As a surgeon, who has spent the last 30 years trying to do the best for my patients, often with limited available data, this is clearly a shift in thinking. We were trained to listen and examine the patient and then determine if they were sick and needed an operation. Subsequently, the specifics of the diagnosis would often be revealed in the operating room.

So why is this new paradigm important? Increasingly, with limited resources, we may be steered to provide or defer therapies based on into what evidence category the question falls. Could “Watson,” when he’s not winning at Jeopardy, calmly crunch all the potential permutations and risks to come to a definitive plan? I suppose he could, but I hope we don’t come to that alone.

When I was still a medical student, Arnie Rosenbaum, an internist in my hometown of Canton, took me on rounds. In each patient’s room, he would sit at the bedside, and take their blood pressure, while gently feeling their pulse. Afterwards, I asked why he would do this when the data were already on the clipboard. “Because I always touch my patients and look them in the eye. It really tells me how they’re doing. And when the time comes for me to be a patient, I hope my doctor makes the same human connection.”

My n=1 in this nonrandomized study of internists in Canton Ohio in 1979. But based on my experiences since then, that’s Level IA data in my eyes.

Making the Tough Choices

Two massive earthquakes – 2 very different patterns of death and destruction
I knew this one would be different than a year ago, when people asked- “So are you going to Japan to help?” The answer was quickly “No, they really don’t need me.” By the same token, my colleague Glenn Braunstein, Chair of Medicine at Cedars and a superb endocrinologist, has been bombarded with requests for interviews and advice regarding potassium iodide to reduce the risks of radiation exposure.

The drama unfolding in Japan is no less riveting than what happened in Haiti, but for different reasons. The patterns of death and injury were not from collapsing buildings or lack of infrastructure – it was rapid and massive related to the Tsunami. The Japanese government is well organized to deal with earthquakes and has teams and supplies available. Building codes are strict. But no one could anticipate the difficult decisions related to the Fukushima Dai-ichi nuclear plant. The risks of additional injury and death are significant, and resources are being poured into the area to minimize harm. Although rescue and recovery operations continue, they seem to have taken a lower priority to preventing additional catastrophes.

What we see in action in Japan is similar to other disaster scenarios - the use of triage. Triage actually originated during the Napoleonic wars with Dominque Larrey, a French battlefield surgeon. He designed some of the first ambulances used on the battlefield, would treat enemy soldiers along with his own countrymen. He recognized that you needed to make a best guess at how to get the most good for the most patients, which may mean not treating those who were likely to die, or would consume disproportionate resources. It is a form of utilitarianism where one tries to maximize benefit for the greatest number, even if the decisions may not be best for an individual.

We saw triage in Haiti, when we were truly resource constrained. Patients that would have survived in the States, were allowed to die comfortably. Others might have quality of life worse than death. Throughout my surgical career, I have been faced with the decisions – they don’t get easier, but after some time, you gain perspective.

Like it or not, we will be performing some type of high level triage if health care in America is to survive. For now, we seem to have unlimited resources, but just because we CAN do something, doesn’t me we SHOULD. Resources spent in futile care, are resources that could immunize a child, provide safe water, or help educate a generation. This isn’t about Death Panels - it’s about having an honest dialogue about where priorities are placed to stabilize the present and build to the future.

There may be a few setbacks along the way for the Japanese. But a year from now, unlike Haiti, they will be back on their feet and stronger with the knowledge of what they learned.

Freedom of Choice

“All around the world, it’s so easy to see. People everywhere just want to be free..."




I am currently over Ontario enroute from Boston. I look down on the landscape of farms, interspersed towns, and the city of Toronto in the distance. It is a route I have traveled often, especially when I was based in Rochester. I fondly remember trips to Canada, and the palpable sense of a difference in tolerance and priorities as I crossed the border. The newspaper in my seat pocket recounts the unrest in the Middle East, and concerns that oil prices rising above $100/ barrel will inhibit Americas own economic recovery. Gas is $4 a gallon in LA, yet, I don’t see any fewer cars on the road.(Driving, in California, is freedom.) There are protests in countries that we normally don’t recognize as foci of discontent – Tunisia and Liberia for example. We wonder what drives people to risk their lives to overthrow a government, when they know that whatever follows could be as equally oppressive. In a commentary, WSJ columnist Michael Novak notes that the desire for liberty is universal and rooted in basic Judeo – Christian beliefs. We talk of free choice, and consequences – whether to eat the apple, whether to accept a deity or idols, how we choose to do business with one another. What I am realizing is that even the replacement of one corrupt government with another, is an expression of the peoples freedom to choose their destiny. Whether extremists can recognize this basic human value or will continue to oppress women and the less well to do remains to be seen.

I am returning from one of my final weekends in the healthcare management course at the Harvard School of Public Health. As we looked at payment systems, it was not surprising that the US high cost for moderate quality paradigm was again examined. Classmates from Israel, the Netherlands, Australia, Canada, and Dubai discussed their own countries; how resources for health care were collected, how they were pooled, and how they were distributed. We fervently debated market pressures, the malpractice environment, and free market competition. Trying to place any of their systems in the US, despite the fact that there was “more bang for the buck,” seemed untenable.

Then we reframed the discussion, and the light went on – it’s all about choice.
Americans are fiercely independent, and pride themselves on being able to guide their own destitny. There is some sense of social responsibility for the less fortunate, but the disparities between the haves and the have nots are extreme. Americans want free choice in whether they drink or smoke, or want to be able to take a medication in lieu of exercise - and they don’t like to wait. This impatient spirit helped us accomplish great things in the past, but may be blinding us to the realities of the present.

There is no question that the American health system is expensive and inefficient. It is focused on technological repair of disease as opposed to a societal understanding of health, responsibility, and support. We realized that by dealing with the economic disparities, many of the health disparities would be ameliorated.

“My God,” you say, “He’s moved to California and is eating too much granola.”

Not so. I believe in technological advances in medicine to reduce suffering. Surgery is one of the most cost effective ways to return someone to health and being again productive. My classmate, who is Chief of Cardiac Surgery at the Hague, does 8-12 case /week – as part of a well organized integrated system in a relatively small country. It has nothing to do with socialized medicine.



Looking at the other countries we discussed, the populations are fairly homogeneous, resources can be concentrated near population centers, and from the time you are a child, there is an understanding that you may need to wait to have your needs met, but they will be. America is vast, we have huge variances in population density and medical resources. There is a safety net available, in public hospitals and emergency rooms but it is not the best way to provide continuity of care.
So how do we tie the unrest in many of the middle eastern countries to public health. And how do we help Americans realize that there must be a change in their perceptions and responsibilities?

It is by understanding that as humans, we want some control of our destiny. Depending on how well our basic needs are met,(remember Maslow’s pyramid?) we are willing to trade some free choice. But when oppression is coupled with poverty, an uprising is inevitable. In a similar manner, American health care is impoverished in the midst of plenty, and the shift must come at the center – with the patient.

Being proactive in your health, making good choices, and partnering with your provider isn’t limiting – it’s the ultimate source of freedom and self actualization.

Henri Ford - Professor of Surgery, Son of Haiti

Sunset Boulevard is worlds away from the spine jarring road between Cap Haitian and Milot. Yet, as I moved slowly toward Children’s Hospital of LA, I recognized that those two worlds would coalesce soon.

Parking in the garage, I took the brightly painted Giraffe elevators to the 8th floor and the department of Pediatric Surgery. There were many familiar names of colleagues with whom I’ve shared lab results and meals at various academic surgical meetings. The Chief of Surgery is one such colleague, Dr. Henri Ford.


I’ve known Henri for more than a decade, as our paths crossed at meetings and other groups. He was the President of a major surgical society and always projected a calm confidence and humility. I knew he was from the Caribbean, but it wasn’t until after the earthquake, that I realized his roots were in Port au Prince. I asked him if I could stop over, not to talk about recruitments and academic politics, but rather about Haiti. He readily agreed.

Henri’s father was both an AME minister and director of immigration in the government. His spiritual core, compelled him to speak out on occasion and this led to a visit from the Tonton Macoutes. Realizing that future opportunities for his family would be limited, he moved them to Brooklyn, where there were some relatives. Henri was 14, and spoke no English. His parents made it clear that English was to become his first language, and he spent many nights struggling through standard high school English texts. During summer school, he met a tutor who was a junior at Princeton. Seeing Henri’s determination and drive she encourage him to apply.

He was admitted with a full scholarship.

Rather than rest on this accomplishment, he continued to accel and fulfill the expectations for himself and his family. Harvard Medical School, residencies in General and then Pediatric Surgery, followed by a stellar academic career in Pittsburgh and now Los Angeles. But he never forgot his roots.


Henri travels back to Port several times a year. He led a group immediately after the quake and you may have seen him with Dr. Sanjay Gupta of CNN, working in primitive conditions. As Haiti moves beyond the one year anniversary, Henri continues to be involved in organizing medical care and working for stability.

We talked of our various experiences and the frustration of not being able to provide even basic levels of care. He shook his head telling me of finishing somewhat advanced neonatal surgery, only to have the child die when he left. We talked of the “Haitian Diaspora” where well intentioned and committed practitioners become frustrated and leave for other countries. I’ve spoken of Jerry Bernard, who learned laparoscopy in the states, but does not have the equipment in Milot. He is staying, as is his internist wife, but I’m afraid they are the exception.

Aid will not flow to Haiti until the government stabilizes and faith is restored. In an ideal situation, 9 regional hospitals will be built, one in each district, and residency programs will train the next generation of providers. Haiti can learn from its successful island neighbor, the Dominican Republic.

But after all the theoretical talk, and the hopes, we both concluded that it will be a long haul. Why do we keep pouring our souls into what seems like an endless hole? Henri was quiet for a moment, then softly said, “Until I returned to Haiti, I didn’t know my raison d’être” I nodded.

In that small office overlooking the Hollywood Hills, two middle aged academic surgeons, successful by many external measures, shared a moment of what they both knew was truly important. And despite the challenges, they will return to Haiti, do what they can, and carry on with faith for the future.

Beauty in a Time of Chaos

On the way to work today, I was listening to NPR discussing the current unrest in Egypt. Apparently, some of the intensity has died down, but there has sprung up a large tent city in the middle of downtown. Protests continue, but people are also finding other ways to channel their energy.

They are making art from the trash that has been discarded by the thousands of people that gathered.

I couldn’t find pictures on line, but the descriptions are pretty uplifting. One young man fashioned a plane from plastic cups and rags. Asked what it represented, he said it was the way that Mubarak would be leaving the country. Others created Egyptian flags from scraps. They expressed their energy through creative development.
Even in the aftermath of the quake, the street leading to Hospital Sacre Coeur was awash with color. Although the vendors could be a bit aggressive at times, the art was remarkable. It celebrated the past, and the bright colors reflected the light with hope for the future. Even the brick wall, where the water supply faucet was mounted, was transformed into a street scene.
You express yourself where you can.

I was returning, and wanted to keep a small reminder with me of the people of Milot. One of the artists gave me this simple woven bracelet. The markings have faded with wear. Some of the pieces were local stones that otherwise sat on the roadside. It’s just string and stones, yet it is more. We all can look at an object, but feel the emotion that goes with it.

Trash is in the eyes of the beholder. Find inherent beauty and hope wherever you can.

In the Public Eye

The mobile TV vans and Kleig lights began to clog the streets around the hospital. In a well practiced protocol, security kept them at a distance, to assure appropriate privacy for patients and staff. Given our location it is not uncommon for high profile individuals to be treated here. Maintaining a professional level of confidentiality is foremost, and is pushed by those sighting the public’s yearning to know.

Such is the conundrum of being in the public eye.

The media has a powerful influence on society. Governments use the ability to control information as a tool to control their citizens. In the US, we discuss the rights of a free press and numerous Supreme Court rulings have sided with this right. In the past, significant events could be withheld from the public, if it was felt that knowledge would be disruptive. President Grover Cleveland discovered a tumor in his jaw several months after inauguration. Given his cigar smoking history, it was no doubt malignant, and the doctors of the day recommended excision. Cleveland was concerned that knowledge of his illness would be disruptive to upcoming legislation dealing with a financial crisis. After a delay, he arranged to be treated aboard a friend’s yacht as it sailed up the East River. Nitrous oxide anesthesia was delivered, and historical accounts suggest concern on the part of the physicians, as the patient was a set up for what we now know was sleep apnea. The surgery was successful as was a prosthesis placed to reconstruct his jaw and allow him to speak normally. All this was kept secret from the press, and reportedly, even the vice president.

Could you imagine that today?

We are struggling with finding a balance of full disclosure of every known fact or supposition and the requirement that some things need to kept within a limited group to allow free and open discussion, leading to well thought out recommendations. The Watergate affair profoundly changed our trust of government and placed the press in the position of both reporter and influence agent. In all of my leadership courses, I am learning how to interact with media and others in the public eye. It is a different set of skills.

Those that are at risk of being subjected to the glare of the media are also able to turn that harsh light in a more positive direction. I spoke of the Thalians and their work in mental health. Celebrities and politicians have been able to turn attention to significant issues like Rowanda, US illiteracy, “Jerry’s Kids”, and Haiti.

In the year since the quake, we haven’t seen as many of the positive stories as we have the riots, corruption and tire burning. So let me take a minute to use this public eye to pass on some excerpts from an uplifting note from CRUEM president Dr. Peter Kelly who just returned from Sacre Coeur.

PHYSICAL PLANT

Our physical plant has expanded to include a new maintenance building/warehouse on the land by the nutrition center. This will house the maintenance department and housekeeping department as well as be a storage place for their supplies. Next to it is the prosthetic lab and solar powered water purification system. There is a garage and service pit for our vehicles as well. Our new laundry building is on the rear of this property and the oxygen generating equipment is in a building next to the generator building. There are 2 new generators outside the building waiting to be installed.
When I arrived there was a team of 20 volunteer electricians from California who were completing rewiring of our hospital. All of the supplies needed to do this were donated. These volunteers worked 16 hour days to complete this job without disrupting patient care.
A team from CRS arrived to discuss the addition to our lab. They feel that this can be completed by the end of February. Their opinion was that our lab was the best they had seen in Haiti and with our addition we will be able to perform testing that is not available elsewhere in Haiti.
CRS is also coordinating a network of Catholic hospitals in Haiti and we are part of that network. They are instituting a post graduate training program for nurses and physicians and will fund the renovation of our auditorium and provide the equipment to allow us to participate in this program. They will also fund the conversion of a room on our housing compound into a library with computers and internet access so the students have a place to study. Finally they will fund the conversion of our existing depot into a 2 story housing compound with rooms, bathrooms and common areas for 52 volunteers and students.
The reason we are able to convert our existing depot into housing is that we now have a large storage building called a sprung building that was donated and constructed behind mission house. This building is 60X100 feet and 30 feet high. We have shelving that extends to the ceiling and a forklift to enable us to move supplies. We have contracted with a bar coding company( thanks to a generous donation) to bar code all of our supplies. This will enable us to track our usage and needs. Representatives from the bar code company were at HSC this week beginning the training and implementation of this system. There were also volunteers helping with moving and organizing the supplies. We will be able to access this system by the internet so we can coordinate our donations and also volunteers can see what medications are available and what are needed for their trips.

EDUCATION

We held our first week long symposium in January. The topic was Diabetes Mellitus and we invited physicians and nurses from other hospitals to attend. We had speakers from the US and Haiti who were experts in Diabetes Mellitus. It was standing room only for every lecture and at the end of the week over 300 people were screened for Diabetes and Hypertension. It was a tremendous success thanks to the efforts of our education committee. We have 3 more symposia scheduled for this year. Emergency medicine/ ICU in March, neonatal care in May and pediatrics in June.
During the earthquake relief efforts it became apparent that their was a need for a nursing school and post graduate nurse practitioner program. We have been in discussion with Northeastern University, CRS, Malteser International and the Minister of Health to determine the feasibility of beginning these programs. We are hopeful that we will be able to work with the Catholic healthcare network in Haiti to begin construction sometime in the next year. Our goal is to ensure that these programs are sustainable before we begin construction. Until we are able to begin we have started a scholarship program to send 10 students a year to nursing school in Port au Prince. They will do their clinical training at HSC and will commit to returning to HSC when they complete their training. We had a testing and screening program in the fall to choose the 10 candidates from the town of Milot. They began their training in November with much excitement from the students as well as the town.
Finally we purchased land to the east of the hospital which can be used to expand the hospital and build new clinic areas and cafeteria for the staff. We are developing the plans for this expansion with the assistance of an architecture firm from Indianapolis who are donating their services. We will be beginning in March the public phase of a capital campaign to finance this expansion.

PATIENT CARE

The cholera outbreak seems to be decreasing. When I arrived there were 14 cholera patients. During the week it increased to 25 but had again decreased to the teens by the end of the week. The patients are arriving earlier so they can be controlled quicker and discharged sooner. Our public health teaching seems to be having an effect. The bulk of the care is being provided by our Haitian staff with volunteers working side by side. We try and adjust our staffing needs based on our volunteer numbers.
At the present we have 119 part time Haitian staff in addition to our 250 full time staff. Most of the part time staff are nurses and housekeeping. We currently have the following Haitian physician staff: 3 Internists, 1 General surgeon, 2 full time Family Physicians and 1 part time, 3 Pediatricians, 3 OB/Gyn, 2 General Practitioners, 3 Social residents, 1 part time Ophthalmologist. Another General surgeon will be starting in March and an Internist in February.

Perhaps this won’t raise network ratings as much as the latest riot or celebrity breakup, but in my book, it has a whole lot more impact on what we strive to be as people and a society.

Have a great week, and try to keep your mug shot off the front page.

Mental Illness from A Societal Perspective and a True Walk of Fame

He is a fixture outside the gates of Hospital Sacre Couer. A tall disheveled man, in his 50’s, he paces along the sidewalk, yelling obscenities, and gesturing wildly. The locals keep an eye on him, and by evening, he has disappeared, only to return the next day. I never felt concerned, and it appears that he has struck a peaceful coexistence with his fellow citizens.

A vivacious, eloquent English teacher, she began to forget names and addresses in her early 50’s, and rapidly developed early onset Alzheimer’s disease. Given her otherwise good health, she required nursing home care for 15 years until her death.

Another young man is introspective and well groomed. He sometimes laughs inappropriately, seems to have problems with impulse control, and understanding social norms. He has been diagnosed with Asperger’s syndrome, and his parents are at a loss of what to do.

A brilliant surgeon at the peak of his career suffers a bicycle accident. Despite a helmet, his brain is injured enough that it leads to a significant personality change. His ability to support and enjoy his 5 children is altered forever.

…and then there the Tuscon shooter, whose unclear need for recognition and driven by as yet unknown demons, killed and maimed many. How can he be included with the others?

Such is the broad spectrum of brain and mental illness. And along that continuum is how society chooses to deal with the victims.


In medical school we learned of French physician Philippe Pinel who supervised the unchaining of mentally ill patients in 1794 at La Salpêtrière, a large hospital in Paris. Pinel believed in treating mentally ill people with compassion and patience, rather than with cruelty and violence. Prior to that, the mentally ill were subjected to restraint and torture. In museums, I’ve examined trephines, used to drill holes in the skulls of the insane, in hopes of releasing the spirits. In some cases, the fortuitous draining of a traumatic subdural hematoma led to clinical improvement and reinforced this therapy.

The age of modern psychoanalysis began to bridge the gap between spiritual dogma and an appreciation of the complex responses of the human brain to outside stimuli, including trauma and abandonment. As we have gained the ability to watch the brain function in realtime, using functional MRI, addictions, schizophrenia, and depression are being redefined at a molecular level. New and more effective therapies will be developed.

Yet we all have twinges of discomfort when we see the homeless on the streets and wonder if they are just looking for their next drink. We debate gun control after shootings, without understanding that increasing social isolation may be the driving factor in these senseless events. We have no problem donating money for kids with cancer, but sometimes it is difficult to get behind calls to increase funding for mental health. As a society, we all suffer, yet it still remains in the shadows.

I park my car behind The Thalians building here at Cedars. The sidewalk out front has stars in it just like Hollywood Boulevard. Yet I didn’t recognize any of the names. When I went to the website, I learned that The Thalians was founded in 1955 by a group of young actors and allied professionals from the film industry who wanted to give back some of their blessings to the community. They met at actress Jayne Mansfield’s home to discuss how they could use their time, talent and energy to help children with mental health problems. Taking the name from Thalia, the Muse of Comedy and the Shepherdess of straying and lost lambs, the first Hollywood “celebrity” charity was born, and just four short years later, The Thalians Clinic for Emotionally Disturbed Children at Mt. Sinai Hospital was established. When Mt. Sinai and Cedars of Lebanon merged, The Thalians pledged $1 million toward the construction of the first building on the new campus, which was named in their honor: The Thalians Mental Health Center.

Each star represents a significant donor and from what I understand, the annual Thalians Ball is not to be missed, even if it wasn’t at The Playboy Mansion.



The way to eliminate darkness is to expose it to light. As you may have surmised, other than the Arizona vignette, all the people I mentioned, I know. Some are family members. Treating mental illness may not be as quick or dramatic as resecting a pancreatic tumor that encases the portal vein, but the long term return on investment for the patient, those they love, and society, can’t be underestimated.

In Haiti, there are few handguns, and the mentally ill would have a hard time wreaking large scale havoc with a machete. The US is different. Means for destruction are easily available. We can only hope that young men like the Columbine shooters and Loughner are recognized and helped before they explode again in violence.