EMC2

No, I have not forgotten the = sign in my EMC2

• is an emerging syndrome that will soon reach epidemic proportions, 
• will be the AIDS of the 2010-30 decades,
• may consume massive health care dollars.

I suspect many of the physicians out there have encountered this syndrome but may not have fully recognized what they were seeing.  further, this new medical challenge may prove even more daunting on every level than treating early AIDS patients.  Medical school education is completely unprepared and have little ability to make the rapid adaptations that would be required to meet this new public health need.

EMC2= Elderly (with) Multiple Chronic Conditions

I can give you many examples from just the last few weeks and I suspect my medicine colleagues could rattle off dozens.   Recently, I was asked to consult on an 85 year old who slipped on some concrete stairs and suffered a skull fracture and small subdural hematoma (blood clot between the skull and brain).  He was lucky and had no real brain injury but he remained in the hospital for over a week because:

1. He developed an arrhythmia that led to extensive medical testing
2. He experienced extreme difficulty urinating and as a result, suffered a bladder infection
3. His degenerative lower back problems greatly inhibited his early mobilization and led to high concerns about the risk of acquiring a blood clot in his leg.

Part of this frustrating syndrome is the social component that almost always accompanies the medical condition.  In this patient, he was the caregiver for his wife who suffered with advanced Alzheimer's dementia.  Not a visit went by when our conversation didn't stray to his concerns about his wife-was his neighbor caring for her properly?  Did she understand why he wasn't there to prepare her meals, help her wash and dress?  Would he be able to return to providing her care when he was released from the hospital?

One of my colleagues estimated that within 2 years, one of every three patient would meet the criteria for EMC2.  Coordinating their care, balancing their social and medical needs, making decisions about complex multi-pharmacy interactions and conflicting health needs (what is good for the heart may be bad for the brain, what is good for arthritis may be toxic to the aging liver/kidney).  Sure, geriatrics has emerged as a specialty but there is remarkably little known about how to best manage these patients, few hospitals have geriatric hospitalists (there are precious few geriatric specialists and even fewer that serve as more than nursing home guardians), and many specialists refuse to defer to a geriatric doctor in managing the many medical concerns of a given patient.

I never like to raise an issue without presenting some constructive suggestions.  The first step is clearly acknowledging the problem and bringing together innovative thinkers across the spectrum of medicine and medical education to develop a rapid response to this raging epidemic.  I promise a future posting to outline some more specific areas that will need to be addressed and some initial steps I hope the medical community will consider.

I think Einstein would approve.

There are only two ways to live your life.  One is as though nothing is a miracle.  The other is though everything is a miracle.

Patient Wisdom

Sometimes my patients utter wisdom that I feel blessed to share with others.  Here is a recent representation from just one day in the office:

• As to my children, I don't worry about the first 10 years (of their lives), it is the second 10 I lose sleep over.
• Parental wisdom comes in waves.  At first children think their parents the wisest humans in the world.  Then there comes a time when they know absolutely nothing.  This may last for 10 years or more.  Then the next generation arrives and suddenly the parents regain their rightful place as all knowing and wonderful.
• You may have been taking care of these types of patients for years but I have been dealing with my mother for more than 40-I think I know her well.
• If you ask the wrong question, you may get an answer you don't need nor want.
• I realize there is a price to pay for everything.
• I can only ask that you do your best and that you are honest.  No one is perfect.

Everyday, my patients share themselves with me.  I am eternally honored by their trust and the wisdom they share with me-it has enriched my life.

Waking Up America

In Sunday's NY Times, Thomas Friedman confronts the issue of what ails America with such directness, it struck me like a bolt of lightning.  In talking about why many of our systems have failed to thrive (e.g. education), Friedman places the balme squarely on individuals and the resultant collective mentality.  He writes:
We had a values breakdown — a national epidemic of get-rich-quickism and something-for-nothingism. Wall Street may have been dealing the dope, but our lawmakers encouraged it. And far too many of us were happy to buy the dot-com and subprime crack for quick prosperity highs.
In contrast, he talks about the "Greatest Generation" and why they succeeded:
First, the problems they faced were huge, merciless and inescapable: the Depression, Nazism and Soviet Communism. Second, the Greatest Generation’s leaders were never afraid to ask Americans to sacrifice. Third, that generation was ready to sacrifice, and pull together, for the good of the country. And fourth, because they were ready to do hard things, they earned global leadership the only way you can, by saying: “Follow me.”
He adeptly depicts our status quo:
For a decade we sent our best minds not to make computer chips in Silicon Valley but to make poker chips on Wall Street, while telling ourselves we could have the American dream — a home — without saving and investing, for nothing down and nothing to pay for two years.
And to tackle our current malaise our national debate must begin between:
Democrats and Republicans who start by acknowledging that we can’t cut deficits without both tax increases and spending cuts — and then debate which ones and when — who acknowledge that we can’t compete unless we demand more of our students — and then debate longer school days versus school years — who acknowledge that bad parents who don’t read to their kids and do indulge them with video games are as responsible for poor test scores as bad teachers — and debate what to do about that.

Thomas Friedman is probably one of the better known opinion writers for the NY Times because of his many best-selling books including The Flat Earth (how the internet is changing the world ), Longitudes and Attitudes (the world after 9-11) and The Lexus and the Olive Tree (globalization).  I was fortunate to hear him speak and to meet him in a small forum afterwards.  I have generally found his writing thought provoking but perhaps mildly simplistic and sometime redundant.  However, this Sunday he wrote this column that is clear, direct and thoroughly appropriate not just for education and politics, but for medicine as well-we need far greater honesty from all sides of the debate and then greater cooperation in finding creative solutions to move forward.

Green Hospitals: Too Much Trash

Finally some early signs that making hospitals more environmentally friendly is no longer "fringe business."  Recently, the NY Times highlighted the challenges facing American hospitals in reducing the enormous amount of waste.  As any surgeon knows well, the operating room is fraught with disposable items where re-usables were standard a decade ago.  In addition, many items that have not been used at all just get tossed!  As the article points out, much of this has been done in the name of patient safety-with the unmerited fear of reprocessing.  In addition to the shear volume of trash, medical waste is three times as expensive as regular refuse to process.  In an era when we recycle so much (think plastic containers into decking), healthcare lags way behind.
There are some people who are looking to turn this trend around.  For physicians, nurses, architects, health care workers or interested patients can join the Green Hospital Movement and access many educational materials and learn how you an make a difference in your own community.  Another good resource for healthcare professionals is Teleosis.
Isn't it time we all got onboard?

Travel and Work

Flew to Paris and before I could say Bon Jour
Off to Lyon, speeding away from that magical place
Arrived safe.

Checked in, nosed around, all around
First in the center then spreading further away
To see it!

Wild views, what food, much history
You're not in Kansas anymore
But happy.

Delivered talk, all new material compiled
Precipitated chatter, so deemed success
Time for home.

Teaching In Lyon

I have the distinct honor of being a guest speaker this week in beautiful Lyon.  When the call came a few months ago (during the dead of winter, several feet of snow on the ground) and they asked if France in May was appealing, I think I took about an entire second to say YES.
There are a few down-sides to this bonanza:

• I will have to fly over and back in just 5 days
• While flying into Paris, will ultimately have less than 2 hours there, all in a train station
• I need to construct an entirely new talk.

But I am not going to complain.  I have been working hard and a few days in a cultural and historical hub as a guest of honor should be restorative.  Will return to regular blogging next week.  Bon Voyage!

Exercising Your Brain

If you are between the ages of 40 and 65 and sometimes wonder if your brain will make it through another day (without forgetting an important name, what you went to the basement to retrieve, etc), take heart-you are not alone! Take heart, it seems that close inspection reveals that while there may be many of these little slips, the middle age brain is doing more than fine.  In this regard, we who are "middle-aged" often feel isolated in our forgetfulness, constantly worried about the threat of dementia so I was thrilled last week to tuned into NPR and listened to Barbara Strauch (NY Times science writer) talk about her new book, The Secret Life of The Grown-up Brain. 

She relates that studies show that "in this middle span, we get higher scores on all our tests in a whole range of areas, including inductive reasoning, verbal memory, vocabulary -- we're better in that span than we were in our 20s." Middle age wisdom then is , "Because the brain sees connections, it sees the full picture."

For me this all makes perfect sense-I often feel like I "get the whole picture" and understand the solution to problems (or diagnoses with patients) in an instant but then may have to write it down so I don't forget it before I can put into action.

And the imporant lesson is that we really must keep exercising our bodies and our brains-beyond crosswords and books.  She even advocates at least a little of intellectual conflict to "juice the brain".  Maybe that explains why I am enjoying my blog so much-it does keep me on my toes.

I read the following excerpt from the book and now know I will get the book (available at all the usual palces like Amazon, Barnes and Nobel, etc):

Indeed, despite long-held beliefs to the contrary, there's mounting evidence that at middle age we may be smarter than we were in our twenties.
How can that be? How can we possibly be smarter and be putting the bananas in the laundry basket? Smarter and still unable, once we get to the hardware store, to remember why we went there in the first place? Smarter and,despite our best efforts to concentrate on one thing at a time, finding our brains bouncing about like billiard balls? (Viking Press, copyright 2010)

Dorothy Height

This special lady died this week at the age of 98.  Her name may not roll off the tongue like Martin Luther King, Jr., Elizabeth Blackwell, M.D., or Susan B. Anthony but this diminutive woman did so much for women (and blacks and all of humanity) that women like me who have become professionals (and particularly in male dominated fields) have much to thank her for.
Dr. Height was born in 1912 and won a scholarship to Barnard College based on her oratorical skills (though she attended NYU).  After achieving her bachelor's and master degrees and advanced study in Social Work, she began her lifelong crusade for equality and equal opportunity.  She also worked tirelessly for voter registration and education.  Presidents from Roosevelt to Reagan to Bush to Obama trusted her as advisor and honored her accomplishments.  May said she had the most remarkable ability to reach across barriers-between women and men, white and those of color, rich and poor. For more details and moving photographs, see NPR's indepth coverage, the National Council of Negro Women (she was Chair and President Emerita), or read her amazing memoir Open Wide the Freedom Gates.

In "Tell Me More", Jennifer Longmire-Wright captures much of Dorothy's essence:
Dr. Height was a bridge-builder who understood that we all had something to gain from coming together.  She...said that there is strength in numbers.  It's okay to ask for help.

One of her stands particularly struck home with me so I will close this tribute with:

The younger generations, she said, are the beneficiaries of what a lot of people worked and gave their lives for. It is important for the young to get organized in how they will serve others, because when people work for something bigger than themselves, there's no way they can help but grow.

Teach your children well

Raising children has never been an easy job-I, for one, will admit it is far more difficult than being a neurosurgeon. And no matter what we think, each generation is as different from their parents as the parents were from their parents.  Difficult as it may be, being a parent carries with it important responsibility to help develop individuals who can become responsible, contributing members of society-to provide a framework of understanding, of commitment, of right and wrong.  Non-parenting is just not an option, not fair to the children, not fair to society.
While there is no right answer, we made the decision to raise our children during their early years with limited TV exposure and little or no computer access.  Many scoffed at us for a whole variety of reasons until the hard studies started to prove that curtailing this activity led to better school performance, fewer behavior problems, etc.
It is no surprise, then that increasing studies are emerging (Violent Video Games Bad) detailing the potential harm of violent video games-especially at early age, for prolonged periods, and those with the most realistic violence.

As a neurosurgeon, I have too often witnessed the sad results of violent youth-the wasted lives, the uncontrollable tears.  Certainly video games are not solely to blame, the problem is far more complex.  But why expose ourselves to any added risk of such devastating actions.
Maybe this "hobby" has become too ingrained in our culture to expect change...but they said that about many negative cultural phenomena in our past (slavery, segregation, women's right to vote, women as physicians/astronauts/lawyers).  Change can happen.

Flat Head News

A paper in Pediatrics has linked "flat head syndrome" with early neurodevelopment disadvantage. http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-0052v1
Ever since the fear of SIDS led to the recommendation that babies be put to sleep on their backs (unlike when I raised my kids and the exact opposite was recommended), there has been a dramatic rise in "flat head syndrome" usually felt to be positional and correctable in the majority of cases with positional correction and other simple interventions.  At the same time a recent study have linked SIDS to a brain stem abnormality. http://www.sciencedaily.com/releases/2010/02/100202171811.htm
So one might ask if all this insistence on putting babies on their backs is really a good thing? Or, in fact, given that most Western babies are placed almost continuously on their backs and only a relatively small percentage get "Flat head syndrome", might these infants have some type of genetic predisposition to developmental delay and as such the syndrome is just that-a linked group of features rather than cause and effect.

Medical Education: Attention Long Overdue

JAMA recently published a review of a very important book (http://jama.ama-assn.org/cgi/content/extract/303/5/458): Radiology Education: The Scholarship of Teaching and Learning.  while the educational aspects of medicine have gotten increasing attention on many levels during the last decade, this book focuses on some critic elements.  In fact the book is organized around three key elements: Education for NonEducators (unfortunately, the majority of doctors who are training the next generation fall into this category), Educational Insights from Practitioners (finally some recognition that some teach better than others and may have an inside tract), and Radiology Education Global Outreach (synthesizing lessons learned from many educational milieu).
Those who direct residency training in all specialties should take note of this book and look long and hard about how to effect similar educational  innovation and introspection within their own training programs.

New Job

After four years of college, four more in medical school, two years as a Visiting Fellow at the NIH, seven (7) grueling years as neurosurgery resident, and 15 years in small specialty practice I threw caution to the wind and joined a multi-specialty practice as their first neurosurgeon. I don't think my story is unique.  In the recent newsletter from CANS, (http://www.cans1.org), one expert stated that solo and small group neurosurgical practices would soon be a thing of the past.  Late 2008/early 2009, I was already aware that  I needed to get ahead of the curve on this trend.  My immediate specialty community is highly competitive and perhaps overcrowded.  Being 50, I knew I had to be able to sustain my practice for another decade so when the fastest growing, most professionally competent multi-specialty group showed interest in recruiting me-it seemed a great opportunity.
What have I given up? Some autonomy, lots of administrative responsibility, working with some treasured employees, and perhaps some of my hard won referral base.
What have I gained? Well honestly, I am just one week into this but I already know that I will be spending a more time being a neurosurgeon and less being a paper-pusher.   This is a definite win-win for my patients.  I feel like I am riding the wave of medicine's future.
I am sure I will have more to say on this subject in the fullness of time.