Is An AIDS Vaccine Really Impossible?

Along with other recent articles, the NYTimes Editorial Board weighed in with a recent op-ed, suggesting that an AIDS vaccine is now considered seemingly beyond our collective reach:

Back in 1984, federal health officials, flush with excitement over discovery of the virus that causes AIDS, famously predicted that they would have a vaccine ready for market within three years. Now, after almost a quarter-century of toil and struggle, the effort has crashed in failure. No one yet knows whether a vaccine to prevent the disease will ever be possible.

Really? While difficult, the title of the piece somewhat contradicts with the content. As the op-ed goes on to state, funding must shift towards finding novel ways to combat AIDS as well as towards prevention / treatment, but should not forsake vaccine research altogether. However, the notion that a vaccine is "impossible" seems defeatist. By shaping public opinion against the notion of a vaccine, which in turn shapes the opinions of those in government and elsewhere who approve funding for such projects, I think pieces like this do more harm than good.

What is Diogenes Syndrome?

My psychiatry attending has mentioned "Diogenes Syndrome" several times in the past two days. As the linked article states, it is a self-neglect syndrome in which elderly people who were previously high-functioning and who have no other medical issues cease to take proper care of themselves. Curious, I looked up this Diogenes fellow. Per Wikipedia, he was an "interesting" guy:

Many anecdotes of Diogenes refer to his doglike behavior, and his praise of a dog's virtues. It is not known whether Diogenes was insulted with the epithet "doggish" and made a virtue of it, or whether he first took up the dog theme himself. The modern terms cynic and cynical derive from the Greek word kynikos, the adjective form of kyon, meaning dog ^[4]. Diogenes believed human beings live artificially and hypocritically and would do well to study the dog. Besides performing natural bodily functions in public without unease, a dog will eat anything, and make no fuss about where to sleep. Dogs live in the present without anxiety, and have no use for the pretensions of abstract philosophy. In addition to these virtues, dogs are thought to know instinctively who is friend and who is foe. Unlike human beings who either dupe others or are duped, dogs will give an honest bark at the truth.

The most well-known anecdotes about Diogenes relate to his ascetic / dog-like behavior:

The stories told of Diogenes illustrate the logical consistency of his character. He inured himself to the vicissitudes of weather by living in a tub belonging to the temple of Cybele.^[16] He destroyed the single wooden bowl he possessed on seeing a peasant boy drink from the hollow of his hands.^[17] He once masturbated in the Agora; when rebuked for doing so, he replied, "If only it was as easy to soothe my hunger by rubbing my belly."^[6] He used to stroll about in full daylight with a lamp; when asked what he was doing, he would answer, "I am just looking for an honest man."^[18] Diogenes looked for an honest man and reputedly found nothing but rascals and scoundrels.

Umm... and you thought the other shoppers at your mall were bad. At least you weren't standing in the checkout line next to an antsy Diogenes at the agora...

Second-Hand Obesity Kills

Like second-hand smoke, second-hand obesity is the impact obesity has on others around the obese person. This is a sad story, but I think this just might be the first instance of obesity leading to the death of someone besides the obese person:

LA JOYA, Texas (AP) -- A 2-year-old boy who died with a fractured skull might have been accidentally crushed by a morbidly obese relative, authorities say. Investigators believe that the woman fell on the child, who was pronounced dead Tuesday, said Bobby Contreras, Hidalgo County justice of the peace.

"It didn't look like there was any foul play from what I saw," he said.

An autopsy was scheduled, with the cause of death to be announced Monday. Hidalgo County Sheriff Lupe Trevino, who called the death "suspicious," said he would wait for an announcement on the cause before deciding whether to file charges. The child was believed to have been dropped off by his mother to spend the day with the bedridden relative, The McAllen Monitor reported Friday.

Sad to say, but it's little surprise that this happened in Texas.

The Crusade Against Vaccines

A recent NYTimes article nicely portrays the stealthy rise of parents withholding vaccinations from their children for non-religious personal beliefs. These "vaccine skeptics" believe they are taking some kind of enlightened view of vaccines as dangerous tools of pseudoscience. As the article notes, the parents are falling prey to a form of information asymmetry:

“The very success of immunizations has turned out to be an Achilles’ heel,” said Dr. Mark Sawyer, a pediatrician and infectious disease specialist at Rady Children’s Hospital in San Diego. “Most of these parents have never seen measles, and don’t realize it could be a bad disease so they turn their concerns to unfounded risks. They do not perceive risk of the disease but perceive risk of the vaccine.”

This misperception of risk leads to comments from parents like this:

“I refuse to sacrifice my children for the greater good,” said Sybil Carlson, whose 6-year-old son goes to school with several of the children hit by the measles outbreak here. The boy is immunized against some diseases but not measles, Ms. Carlson said, while his 3-year-old brother has had just one shot, protecting him against meningitis.

“When I began to read about vaccines and how they work,” she said, “I saw medical studies, not given to use by the mainstream media, connecting them with neurological disorders, asthma and immunology.”

Ms. Carlson said she understood what was at stake. “I cannot deny that my child can put someone else at risk,” she said.

I can see how reading random misleading websites about the link between vaccines and autism can lead to confusion and skepticism, but what is sad is that these parents are not typically poorly educated. They have the means and intellect to seek out proper information and discuss the choice. Instead, they seem to buy into the fear and paranoia to the detriment of not only their own children, but other people's children as well.

As a public health issue, this is quite alarming. Vaccines work not only due to immunologic principles but also social ones. The social aspect is due to the herd effect, where increasing immunization rates help protect those who are not immunized yet or have poor immunity. If parents do not vaccinate their children, the effect is potentially much larger than merely having their own child get sick.

Stories like this lead me to believe more and more that, in addition to lamaze classes, new parents should be required to take classes about how to care for their impending bundle of joy. The classes would not only teach basic parenting skills (simple things like... babies should drink milk, not water), but also important ideas like the value of vaccinations. If the parents-to-be do not take the class and do not pass a basic test, then a relative who has previously passed the test or Child Protective Services should take custody of their children until they do pass the test.

Radical? Maybe, but think about it: we require such testing before people adopt children. The state also requires testing before one is allowed to drive. The idea in both cases is that these activities can potentially harm other people, so the state wants to ensure that people are capable before entrusting them with the responsibility. Why should parents of natural-born children be any different? As the issue with vaccines and many other cases of poor parenting show (ahem, Britney Spears?), there is a role for the state to play here.

Oops! In For A Leg Operation, Out With A ... ?

A German woman went in for a leg operation recently, but came out with something else entirely:

A German retiree is taking a hospital to court after she went in for a leg operation and got a new anus instead, the Daily Telegraph is reporting. The woman woke up to find she had been mixed up with another patient suffering from incontinence who was to have surgery on her sphincter. The clinic in Hochfranken, Bavaria, has since suspended the surgical team. Now the woman is planning to sue the hospital. She still needs the leg operation and is searching for another hospital to do it.

How does this even happen? Wouldn't two entirely different surgical teams perform these procedures? Wrong limb operations are one thing - it is easy to see how a patient who comes in with two diabetic feet might get a procedure on the wrong one, but this? How poorly prepared was the OR that no one had any idea whether they were operating on the right person / body part? I guess those OR "time outs" really do serve a purpose...

I guess I inadvertently took this week off for no particularly good reason, but I'll be back next week with new posts.

How To Choose A Medical Specialty

I'm sure many people have seen this flowchart image before, but since I'm at this stage of my medical school career I figure it was worth re-posting (courtesy of hvattum.net). I'm pretty lazy, and sometimes the light hurts my eyes, so.... hmm... what's really sad is that this chart seems as a good a way of picking a specialty as my last 2.5 years of medical school experiences. D'oh.

For more detailed advice, here are some books you may find of interest:

Another one worth browsing:

Beyond just reading though, I recommend finding upperclassmen, residents, and attendings who share your interests. Talk to everyone: the people closer to where you are in your training can tell you the right steps to take right now to meet your goals, while the ones further down the road (like department chairmen) can give you a big-picture assessment of the field and where it is headed. After that, it's up to you to figure out if you want to go down that road yourself, or blaze a new trail altogether different!

Random Note: Today is Pi (3/14) Day!

Updated 2015-12-10

Why Incentives Matter (Even For Physicians)

The inexorable rise of healthcare costs in America is no secret. As a recent NYTimes article notes, there are several reasons underlying the increase in costs:

Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.

The most important factor, however, may be the perverse financial incentives of our current system.

These incentives reward doctors who perform more procedures. As reimbursement rates fall, volume increases to make up. Even when doctors try to do the 'right thing,' reality forces them to bend to the market. As the author notes:

Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.

“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was."

To be honest, as a future physician, I suppose I have the "incentive" to not criticize a system that will eventually pay my bills, but I think in the long run, the inefficiencies built into our healthcare system harm physicians as much as anyone else. As costs rise, people will target physicians more and more as sources of the cost. Reimbursement rates will fall further, worsening the downward spiral. As rates fall, physicians will continue to cede power to insurance companies who dictate rates. At the same time, there will be greater demand for non-physician professionals (such as PAs) who can provide similar services at lower cost. All in all, without a change in the incentive structure, physicians will continue to squeeze each other out of the market, and that's not good for anyone.

Want more? Check out how salaries vary across medical specialties, or the Democratic candidates' healthcare proposals.

Psychiatry in the Third World

In "Psychotherapy for All: An Experiment," the author describes a new program that trains non-physician health professionals how to diagnose and treat depression and anxiety in the Third World. The program, which is based in Goa (a region of India), addresses the huge need that exists for such services in these areas. While the Goa (see image) program is relatively limited in scope, data collected from the effort if positive may help fund more such programs in the future. As the article notes, non-physicians diagnosing psychiatric illnesses is cost-effective:

Dr. Simon, a psychiatrist who studies mental health in the developing world, said the Goa strategy grew from a crucial idea. Unlike, say, heart disease and stroke, which can require expensive interventions, depression is relatively simple to diagnose and treat. Many studies have shown that talk therapy and antidepressants lead to significant improvement in most patients.

You're telling me! Not to belittle the toll depression takes, but from a diagnostic standpoint, it's not clear to me what more the residents / attendings above me are doing besides SIGECAPS. After 2 weeks of my psychiatry rotation, I'm a SIGECAPS expert!

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Rent-A-Womb: The Exploitation of India's Poor

Reading "India Nurtures Business of Surrogate Motherhood," I couldn't help but feel a chill run down my spine. The article describes the booming business of Western couples who are unable to reproduce naturally paying surrogate mothers in India to carry fetuses to term. The proprietors of the businesses in India try to put a positive spin on the story, extolling the financial benefits to the women. And, truth be told, the practice does produce a significant amount of income for these women. However, what I found to be truly ridiculous was the following assertion:

“Surrogates do it to give their children a better education, to buy a home, to start up a small business, a shop,” Dr. Kadam said. “This is as much money as they could earn in maybe three years. I really don’t think that this is exploiting the women. I feel it is two people who are helping out each other.”

To help each other?! If these women are truly so generous, I wonder how many of them would sign up for this task on a voluntary basis. That's right: zero. This is obviously all about the money. To try to frame it in any other way is dishonest.

The framing of the practice does matter a lot to how the enterprise is perceived. Even as the piece praises the payoff to the women, the language belies the dehumanizing commercialization of this practice:

Commercial surrogacy, which is banned in some states and some European countries, was legalized in India in 2002. The cost comes to about $25,000, roughly a third of the typical price in the United States. That includes the medical procedures; payment to the surrogate mother, which is often, but not always, done through the clinic; plus air tickets and hotels for two trips to India (one for the fertilization and a second to collect the baby).

Collect the baby? I know this is semantics, but the word 'collect' objectifies the baby. Think about it: you collect your baggage from baggage claim, you collect coins, you call collect. No one collects humans. Well, until now.

Another troubling aspect is the nature of the transaction. Rich Westerners are basically preying on these women's financial situation. Such poverty is implicated in other exploitative practices such as prostitution or substandard working environments. How is this any different? Even if the women are cared for now, what is to prevent unscrupulous providers from entering the market and truly exploiting the women? The whole system seems ripe for abuse.

I suppose this argument is a bit strange, considering that I have previously described a market for organ donations. However, in that post, my implicit assumption was that all sides had relatively equal socioeconomic standing and information. This case differs in that these women are clearly not on the same footing as their benefactors in either resources or education. While I hope some good will come of this arrangement, I fear that the moral hazard is too great to let such a practice continue.

Which Personality Disorder Are You?

Ever wonder what personality disorder you might have? Well, take this quiz!

It's admittedly unscientific, but at least it's only six questions (compared to the monster 50-100 q quizzes I saw elsewhere). I know that there is a role for defining these various disorders, but I think it is unfortunate that there is not a personality type called 'normal' or 'appropriate.' It seems like psychiatry always has to label patients with something, even if they are fully functional. For example, when newly-diagnosed cancer patients are in the hospital, they often feel a bit anxious about their treatment and/or a bit depressed about their situation. This seems perfectly normal, yet a psychiatrist's note will label them with "adjustment disorder." Really? Isn't that how a normal person would react? If anything, I would be more concerned if the patient were perfectly happy and did not seem emotionally affected at all by his/her diagnosis. Anyway, my 'dependent' self is too concerned about your criticism to keep writing about this.

Relating to Patients by Mimicry?

Perhaps imitating one's patients sounds outlandish, but according to new psychological research as described in the NYTimes' article "You Remind Me of Me," such mimicry plays a key role in establishing rapport in everyday social interactions. The article describes how salespeople use mimicry to subconsciously build trust with their clients. I suppose one can view this as nefarious, but it makes sense that to gain trust, the salespeople would want to behave like their clients in order to understand their clients' perspectives.

In some sense, doctors are salespeople too. However, we are not selling a product, but rather the idea that we can treat a patient effectively. Trust is an even more valued item between patients and doctors as compared to salespeople and clients. Under this assumption, it would be interesting to see if patients regarded doctors who mimicked them in the subtle ways described in the article to be 'better' physicians, or more empathetic ones. Of course, there are limits to the imitation:

Social mimicry can and does go wrong. At its malicious extreme, it curdles into mockery, which is why people often recoil when they catch of whiff of mimicry, ending any chance of a social bond.

Yet, perhaps a bit of imitation wouldn't hurt. After all, it is the sincerest form of flattery, no?

The Soft Bigotry of Low Expectations of Patients

The 'soft bigotry' phrase was often used by President Bush in his campaigns with reference to education (it's not clear where the phrase originated). However, I think the phrase also applies to healthcare professionals and how they interact with their patients. The notion of discrimination in healthcare is not new. However, I was surprised to find myself carrying these biases in a recent patient encounter.

The patient was an elderly male from a minority group. At first glance, he seemed to be a nice enough gentleman, but perhaps from one of the lower social strata. I don't think I made any conscious judgments about the patient as my preceptor began describing various treatment options. My preceptor tried to explain the options to the patient in terms the patient could understand. However, I was surprised to hear the patient respond with the technical terms for the procedures (terms that, frankly, I did not know myself). My attending could not hide his surprise as well. He gave the man a puzzled look, to which the patient replied, "Last time, you gave me a booklet about my condition. I read it."

Well, duh. Why should we have expected any less?

At first, I'll admit that I just found this amusing and was glad that the patient was so invested in his own health (and, I still find this fact reassuring). However, my narcissistic side soon started to reflect on my own visceral response to this exchange. Why had I expected this patient to be any less interested in his own health than the most well-to-do appearing patient? I suppose to some degree we cannot help our prejudices, and should strive to mitigate them and certainly never act on them. I cannot tell what exactly led me to have low expectations of this patient (his race? his age? his speech patterns?); regardless, these low expectations surely would shade whatever treatment decisions I would make. Perhaps, were I the physician, I may subconsciously choose to be less aggressive with his treatment, or not describe the options as fully. I certainly hope that I treat all my patients the same, but such pre-formed expectations are hard to dislodge if one is not even aware of them.

So, how should we change these low expectations? Clearly, the long-term solution requires social change in terms of education, healthcare delivery, and cultural attitudes. But, for now, perhaps a more modest systemic solution is necessary. I believe that the low expectations I had were formed partially due to repeated interactions with patients and families who were unaware and ill-informed about their diagnoses. To change this, the healthcare system should adopt a uniform standard for informing patients about their diagnoses, especially for major/chronic illnesses like cancer or diabetes. There is already a precedent in place: all children's vaccinations require a Vaccine Information Sheet that explains what the vaccine does and the associated benefits and risks. Why not expand this system to all disease conditions? Perhaps there is some roadblock I am not aware of, but it seems like this would be within the realm of possibility. Such a standardized system would greatly shift the expectations doctors have regarding their patients. Of course, some patients will still be poorly informed, but at least there would be a basis for educating our patients. Perhaps, by educating the patients, we may broaden our own perspectives as well.

I'd Like A Latte To Go and a Kidney, Please

According to a recent story, a Starbucks barista found out that one of her longtime customers needed a kidney transplant. She went out, got herself tested, matched, and now plans to donate her kidney to her customer.

See? This is what I've been talking about! It's clear that there is a coffee-for-kidneys market out there! Maybe Starbucks can offer other organs alongside its Paul McCartney CDs.



Read more about other views on organ donation, or how colas can cause kidney disease.

On Salaries and Medical Specialties

A friend of mine sent me a link a while back comparing wages in primary care versus specialties (PDF).

Damn. Poor primary care docs.

The piece raises several interesting points about how reimbursements (and thus, salaries) are determined for physicians in the United States. The system is clearly skewed towards the specialists. I don't think this should necessarily affect the decision medical students face when choosing whether to specialize or not, but in the future, it will be interesting to see whether the pendulum swings the other way as the population ages and demand grows for primary care doctors relative to specialists. The market will solve everything, right?

Diet Sodas and Metabolic Syndrome

Diet sodas just can't catch a break! Apparently, metabolic syndrome is tied to diet soda. The concept of metabolic syndrome always seems a bit fuzzy to me, but I basically like to think of it as "pre-diabetes." At any rate, given the other recent news about diet sodas possibly leading to increased weight, it seems like there's just no way to enjoy a soda anymore like we used to.

In somewhat related news, a diabetes study was partially halted after deaths when it was noted that patients with tighter glucose control actually had more deaths than the group with less stringent control. In some sense, this is a much more disturbing piece of research. Even if the cause of a disease is unknown, as long as it can be treated, there is not as much concern. But if the cause of metabolic syndrome/diabetes becomes more convoluted and the treatment becomes less clear, medicine's ability to care for the increasing ranks of diabetes patients is much more limited.


Bring back New Coke! Or not: read more about how sodas are associated with gaining weight as well as chronic kidney disease.