From Bedside to Bench

During all my years of practicing medicine, I have been close to research in the institutions where I worked. I have admired and assisted clinical researchers, but I had never felt inclined to join their ranks. When I became the Clinical Director of the Youth Program two years ago, however, that changed. With this new role came the task to promote research and to become more personally involved in the research being conducted in my program and institution.

It is remarkable how much research is conducted in a university teaching hospital, with little funding and most research being conducted off the corner of people’s desks. Most of these researchers are earning their living from their clinical work, with next to no additional funding. Often the only additional funding they receive covers costs related to materials for research and a few hours from a research assistant. It is not unusual for physician researchers to be self-supporting, receiving no direct compensation for this work. This is my experience in psychiatry, but I suspect that it is not much different in other medical specialties.

Much of the research conducted in the clinical programs in which I work is to benefit our programs and our patients, first and foremost. We ask each patient to complete surveys and simple diagnostic measures before and after all programs, in some cases after each session, so that we can be sure that there is value to the programs and therapies we have developed and that we use. In many programs that we are developing, we ask for feedback after each session. For example, if we are starting each session with a mindfulness exercise that no one finds helpful, then we change exercises. All this data provides us with valuable information about the profile of the patients we are treating. It also indicates the type and severity of the conditions being treated in a tertiary care treatment facility.

As I began to consider all the data we have available that patients have given permission for us to use and analyze, I began to consider that, even when I worked as a psychiatrist in private practice, I had a great deal of patient data at my disposal. Occasionally, when a situation I had managed was very unusual, I would discuss with a patient and their family the possibility of sending a short communication about the case to a journal. I had no one to advise me on the process. I had to negotiate and consider the ethics of the situation on my own with the patient and their family. Often the patient and the family had considered their situation to be unique. They were eager to participate in this minimal research process as a specific case discussion to benefit other patients and families who might find themselves in a similar situation.

The minimal level of funding available in universities and the complete lack of funding available to physicians in private practice to pursue limited clinical research underlines the shortsightedness of our single payor. Imagine if research were promoted by Provincial Ministries of Health in Canada, to the extent that expertise and funding were readily available to Primary Care and other specialists in the community, what we might learn to improve best practices in Canada. Imagine if the funding in Alternate Funding Plans was sufficient that every physician in our teaching hospitals could be involved in research without financial penalty, what we might learn about secondary and tertiary care.

An example of the kind of research that is possible when the payor supports it is the study conducted by the United States Center for Disease Control, supported by Kaiser Permanente, is the Adverse Childhood Experiences Study. I learned about this study when I was researching (unfunded, of course) other data we might like to collect in programs. It is “one of the largest investigations of childhood abuse and neglect and later-life health and well-being”.

This is the kind of work we could be doing across Canada. I could not find any evidence of this research, although I would be relieved to know that I was wrong.

 

Book Review: The Undoing Project: A Friendship That Changed Our Minds

The story of the friendship between Daniel Kahneman and Amos Tversky is the story of how our minds lead us to make mistakes. The Undoing Project: A friendship That Changed Our Minds by Michael Lewis focuses on the relationship between two extraordinary psychologists. However, in telling the story of that relationship, Lewis educates the reader about behavioural economics, discipline that arose out of the work of Kahneman and Tversky.

Lewis is a prolific American non-fiction writer, probably best know for his book Moneyball: The Art of Winning an Unfair Game. He is a remarkable storyteller – in fact, even after I had read The Undoing Project, I couldn’t quite figure out whether Lewis had meant to write about a friendship or behavioural economics. Even in the introduction to the book, Lewis hints at this dilemma himself:

“What possessed two guys in the Middle East to sit down and figure out what the mind was doing when it tried to judge a baseball player, or an investment, or a presidential candidate? And how on earth does a psychologist win a Nobel Prize in Economics? In the answers to those questions, it emerged, there was another story to tell.” (p.19)

With this beginning, Lewis tells the story of Tversky and Kahneman and their friendship – and the tale is compelling. Most people would find that they cannot stop reading. Two clever men, both Israeli, with very different personalities are intellectually attracted and out of their collaboration they make discoveries about how we think that will ultimately change how we think.

Those of us who practice medicine are certainly aware of Kahneman’s and Tversky’s work. Their work, as extrapolated in to medicine by Dr. Don Redelmeier, working with Tversky. They examined how errors in medical judgment occurred, and particularly in the case of expert physicians who sometimes ignored the data in favour of their own intuition. Most often, in these cases, the doctor will be wrong. This important work has helped physicians to check their thinking, to confirm that they are basing decisions on facts and not impressions.

Because Lewis uses the history of a friendship to help describe important discoveries about how we think, I found that I learned about Tversky’s and Kahneman’s work without having to think about it. I think most readers would have the same experience.

(I read the hardcover W. W. Norton edition of The Undoing Project: A friendship That Changed Our Minds, published in 2017.)

Journalism and the Scientific Method

Three years ago, I reviewed Seth Mnookin’s book The Panic Virus. In that review, I noted the importance of science reporting in assisting the public’s understanding of scientific research and science in general. Keeping this in mind, I want to highlight an article from the Ottawa Citizen by Elizabeth Payne, a Postmedia health reporter. The article addresses the question, “Could infections cause Alzheimer’s?”

In her article, Payne considers the controversy about the link between microbes and Alzheimer’s disease. She reports that those scientists who favour the microbe hypothesis have made a widespread plea that the public “embrace” their hypothesis.

Payne’s reporting is factual and clear. It leaves the reader with the opportunity to consider whether the microbe hypothesis research supporters or the plague hypothesis supporters are more credible. It calls upon us implicitly to consider both theories, but to remain open to the results of the ongoing research on Alzheimer’s disease. To be open to possibility, to be able to assess alternatives as revealed by rigorous study, is the essence of science. Through her reporting, which points out the conundrum of a controversy in scientific research, Ms. Payne makes it clear why the public should not, in fact, “embrace” a hypothesis until the research and much more consideration yield a clear result.

I am a clinician, not a researcher, but I work in a university teaching hospital affiliated with a research institute and so I have participated in clinical studies. When focused on one’s own research study, it is easy for a researcher to become attached to trends that one believes are emerging from one’s research. I have done enough research to realize how dangerous this is. I have learned that one must be faithful to the scientific method that has fostered the real breakthroughs.

The scientific method is systematic and allows for the modification of the hypothesis. Learning the scientific method is one of the first lessons in science class in elementary school. I remember having to devise experiments in Grade 3, not for a science fair project or research but to demonstrate that I understood the scientific method. That same lesson was repeated at the beginning of many grade school science classes for years to come. The scientific method is fundamental but, like all fundamentals, it is more easily expressed than understood. Ms. Payne’s excellent article reported some news from medical science and reminded us of how difficult it is to learn the scientific method.

(Note: The excellent graphic depicting the Scientific Method included here comes from the Science Buddies Website. Science Buddies is an award-winning, not-for-profit organization dedicated to building scientific literacy.)

My Expertise in Bad News

Most writers love to have a piece that people read over and over and, in general, I am the same way. Having said this, my second most popular blog, which is published on The Scientific Parent website http://thescientificparent.org/, has been reposted and read more often that I ever wanted or would like.

The particular blog is a piece that I wrote for The Scientific Parent at the time of the Lafayette Theatre shooting in July 2015. Almost a year has past and this post has been republished and read so often that it is becoming disconcerting. To me, it emphasizes how often the news is so terrible that we have to worry about its impact on children. We also have to wonder how much to tell children and how much we should try to protect them from seeing or hearing.

I will let you read the piece and use what is useful to you within it, but I want to reflect on some of the times in just this past year when you might have been able to use this little guide on talking to children about terrible events.

Here’s a short list off the top of my head, in no particular order of some of the issues that distressed the youth in my practice, before today’s shootings in Orlando:

  1. Mass Shootings: There are an average of 1 per day in the United States, all of them get coverage and so young people can always find one where the circumstances relate to their situation.
  2. The Paris Attacks in November 2015.
  3. The Refugee Crisis, in Europe especially but also around the world.
  4. The abduction of girls and women by Boko Haram.
  5. The Brussels Attack.
  6. The Attawapiskat Suicide Crisis.
  7. The Fort McMurray Fires and Evacuation.
  8. The attacks in Tel Aviv.

I see only adolescents in my practice. Even though they have mental health problems, like all adolescents they want to change the world. In fact, when they begin to feel better, many of my patients have a new found optimism that they will be able to make a difference. When I wrote this piece for The Scientific Parent, I thought about the advice I have given that people told me was most effective. I am pleased that this advice is useful since I want children and youth to be able to see past these tragic events to a better time.

With that in mind, I left out one piece of advice in that article: the advice to share with them the positive aftermaths of people and communities coming together to heal and care for those affected. Fortunately, these are as certain as the tragedies themselves so watch for them and celebrate them with children. Research tells us that to be hopeful and optimistic begets resilience. In this difficult world, we need to help build resilience.

 

 

A book that rethinks cancer

Book: Malignant Metaphor: Confronting Cancer Myths by Alanna Mitchell (Toronto: ECW Press, 2015)

Cancer is one of the mythological illnesses and in this spare, riveting book Alanna Mitchell confronts the myths that surround cancer diagnosis, treatment and living with cancer as few writers have done. To do this she uses the premise provided by Susan Sontag in Illness as Metaphor (New York: Farrar, Strauss and Giroux, 1978.) Sontag’s premise is that we build mythologies around illnesses we don’t understand. Cancer is one of these illnesses.

This book is personal. Mitchell follows her brother-in-law’s and her daughter’s journeys with cancer. With dignity and an open mind, she examines the fictions that persist around the diagnosis of cancer and, in particular, that nagging view that, if you have cancer, then you’ve done something wrong. Most poignant was Mitchell’s account of her daughter’s brush with cancer and the myths she immediately encountered:

“Above all, I felt guilt. That it ought to have been me…That I ought to have been able to forestall this somehow…I replayed every second of her childhood that I could remember, wondering what I had done to fail her in this way.” (p. 155)

What is most important about Mitchell’s book is that the science is so thoroughly explored. She does a very credible job of examining what science exists around the homeopathic and naturopathic treatments of cancer. However, she also examines the most prevalent metaphor that health care systems and providers use in relation to treatments: the metaphor in which treatment is likened to conflict or a war. We have all heard those metaphors, even use them – fight cancer, combat heart disease, an arsenal of treatments.

How does the war metaphor benefit the treatment of cancer? Does it give us the energy to cope with the rounds of investigations, treatments, hospitalizations? Perhaps it does. What this metaphor does not do, however, is help us to understand the randomness of cancer in many cases. Cancer sometimes strikes out of the blue. We all know people who have no family history of cancer, who live healthy lives, eat organic food, exercise, and still get cancer. Do you notice how we seek reasons for these anomalies? Do you see how strongly we believe the myth that science will find all the answers – even when we know there are questions we haven’t even considered?

For the question Does science have the answers? Mitchell makes this point:

“The point is that if you think you can pinpoint the cause, then you can fool yourself into thinking that you can avert the cause. It’s deeply egotistical. It’s life played as a grand insurance policy. Our myth-making around cancer stems from the same impulse. Because we don’t know exactly why most of it happens, we weave a makeshift wisdom around it, a false prophet, which seeps into the common story and feeds our hunger to understand why. The guilt is a byproduct, a way to assign blame and seek absolution. It’s a lesser evil than the forces of randomness. And it gives us the illusion of control.” (p.163)

Mitchell posits that other metaphors might serve us better in our quest to understand our lives in the context of cancer. To me, this may be where other knowledge: literature, philosophy, faith may serve us better in managing disease. We speak of “random acts of kindness” but aspects of all illnesses are random, too.

Think about how so many good events in our lives are seen as serendipitous: falling in love, meeting a best friend, finding the “perfect house”. We don’t seem to agonize over why these things happened. We have a view that the best things are often random. Why can the worst things never be random?

In medicine, our excessive reliance on science (e.g. double blind trials, evidence-based practice) blinds us to the realities that we might confront illness more effectively if we remembered that the root of science is not just science. As Mitchell states: “…dream, experiment, fail and then dream again.” (p. 184)

Trying to understand cancer, or any illness, scientifically fails to help most of us live well with illness. The only thing certain about our lives is death. As the illnesses that will kill us develop, we need metaphors that feed our souls as well as sustain our physical comfort. Death is not our fault.

SoMe: You, Me and Health Care

Have you ever participated in an online event? If not, let me introduce you to these and consider briefly how such “virtual meetings” might improve the conversations we are all having about health care.

Last Wednesday, I participated in two online events – I can actually say that I participated in both events at the same time. One was an hour long tweet chat from 9-10 pm. This was the weekly @hcsmca tweet chat. You can find out more about this weekly event here along with a very detailed description of how you can join. This online event is held every Wednesday , usually from 1-2 pm Eastern Time. It is held from 9-10 pm Eastern Time the last Wednesday of every month. You can find out what the weekly topic is by following @hcsmca on twitter. The chat is for anyone interested in health care.

The second event I participated in was #BellLetsTalk Day. This event was inaugurated in 2010 as part of an effort to end the stigma surrounding psychiatric illness. Over $6 million was raised this year alone in a twenty-four hour online event. Bell pledged 5 cents for every post, tweet, retweet, text, etc. that contained #BellLetsTalk in the text. Throughout the day, whenever I had a minute, I would generate more retweets and add to conversations. I’ve talked about #BellLetsTalk before, however, so I’m not going to consider it further.

What interests me most about online communication is that it breaks down barriers, allowing me to participate in conversations from the comfort of my own home. I am the kind of person who goes to community meetings and learns so much that I wonder why I don’t go more often. However, I quickly realize that I often don’t feel like battling traffic or weather to get to meetings. Well, there is no need to worry about either at an online meeting. An online meeting is very accessible.

The topics for these meetings can be very timely. For example, the #hcsmca tweet chat last week considered whether health care professionals have the same rights of free speech on social media as other users. This is the summary of the conversation.

The chat considered two blogs, one of which was mine. The comments caused me to consider how I decide what to say and how I express my opinion.  I am as careful as I can be not to release another’s story. On this blog, I always state what permissions I have obtained and note whether the information is already in the public domain. I do try to present views or opinions that have a different angle that those that have already been publicly expressed, but my goal is to do this in such a way as to be heard. I do change my mind when convinced that I have erred or not had all the evidence. Some people seem to more freely express their opinions online than in person, as if it is easier to speak their mind when they do not have to look someone in the eye. This is one of the risks, blurting something out in a tweet.

Personally, I miss people’s reactions, verbal and nonverbal, when I am expressing an opinion. These are communications that I rely on when deciding whether what I am saying makes sense or not. In this respect, social media lets me down. What is not disappointing, however, is being able to discuss a clinical problem from the perspective of patient, care provider, family member and healthcare journalist. There are so many elements of a clinical issue that can be considered in an online forum because literally anyone can participate. Also, if I am reminded of an especially good article or website during an event, I can find it because I have all my own resources at my fingertips. I like that – how often have you wanted to answer someone right away with the research that proves your point?

There is so much potential for social media and the internet in healthcare that I cannot get my head around it. The #hcsmca chat on Wednesdays begins to consider some of that potential. I am finding that the views expressed are helping me to be more informed about healthcare and the internet.

With my new interest, I am reading articles I would never have looked at previously. For example, look at this month’s issue of Daedalus, the Journal of the American Academy of Arts and Sciences, which is entirely devoted to the internet.

Some of the concepts described are so innovative that I can barely understand them but they do convince me that online meetings promote a more thorough consideration of issues than some face-to face meetings. You should join us sometime at the #hcsmca chat and see what I mean.

Book Review – “Universal Foam” by Sidney Perkowitz, Anchor Books, 2000

I cannot even remember how I found this book among the Ottawa Public Library’s lists, but I did and then was attracted to the subject as a matter of science. This is an informative book on an interesting subject that can easily be read on a snowy afternoon – preferably with a cappuccino. You will learn more about foam in those few hours than you ever thought possible. You may even bubble over with enthusiasm and spend another afternoon considering some chapters in greater detail or looking up Perkowitz’s references.

This is a witty, somewhat playful book and it encourages the reader to do what I just did above which is only excusable as an illustration of the properties of foam and its universality in our lives. Perkowitz begins with a description of the basic science of foam and then proceeds to illustrate these properties through considerations of types of foam with which we are all familiar. By beginning with familiar types of foam, the reader visualizes foams properties in the context of a substance she knows well – milk foam on a cappuccino or the foam of a mousse or soufflé. For example, the proteins in milk are the surfactant and heating the milk denatures the protein – breaks apart the bonds of a spherical protein such that it “unravels into long coil-shaped molecules” (page 48). I read those phrases thinking, “That’s how that works.”

From edible foams, Perkowitz moves on to such useful foams as shaving foam and foamed plastic and, again, we learn more properties of foam as they are illustrated in these substances. Then, however, the reader is brought into one of the main premises of Perkowitz’s book: understanding foam helps us to understand life, since the cellular matrix on which all life is based highly resembles foam.

From this consideration of how foam mimics the cellular matrix, Perkowitz begins a discussion of the foams that are present in the earth’s structure: pumice, sea foam. These descriptions allow the reader to consider the “global role of foam and its ties to the innermost and outermost processes of our planet” (page 145).

Perkowitz’s final consideration is of foam beyond the boundaries of earth into our solar system and galaxies beyond. I was fascinated by his account of how panels of aerogel will be deployed by the Stardust spaceship to trap small particles from the coma of the comet WILD-2. These small particles, we are told, “will slam into the aerogel at speeds of 14,000 miles per hour. Among all known materials, aerogel is the only one that can bring these tiny hyperbullets to a screeching halt with little damage.” (page149) Those few trapped particles will be studied to help us learn more about the cosmos.

Apart from the value of foam in learning about the cosmos, Perkowitz ultimately discusses how even the universe is structured like the bubbles of foam, how quanta are related to foam and “how the big bang theory views the cosmos as an expanding bubble of space and time that is now billions of light years across.” (page 157). A physicist himself, Perkowitz often reminds the reader of the tremendous contribution of the 20th century’s iconic physicist, Albert Einstein. Perkowitz’s book, however, brings to mind Einstein’s quote, which example this book follows:

“The eternal mystery of the world is its comprehensibility.”