Friday, November 25, 2011

It is a great company, trying to great things.  And has done some, from the standard model.  But when Geron announced that they were closing their embryonic stem cell efforts, it was like a lead weight falling on all the hopes of the embryonic promoters.  Geron had persevered where others had failed and got the FDA to approve an embryonic stem cell clinical trial.  As many know, they stopped that trial and closed down the whole division.  Startling to many (especially shareholders).  But the inevitable outcome for efforts that are born of a defiance to the facts of basic biology.  The facts are that the human body, given the right conditions, will rebuild itself.  

For the bulk of modern medical thinking, the adult body was "terminally differentiated," meaning it was a finished product and unrenewable, except for some few exceptions, the liver and bone marrow.  That's one reason bone marrow transplants have been done for 40+ years.  But what was a bone marrow transplant, but a kind of stem cell transplant, with blood stem cells.  And yet, our collective unconscious in medicine remained derived from what we can only think of as a long-standing view of the 'body' as a complete entity, a finished product that then slowly wore out.  As folks have found, bodies do regenerate, although inefficiently.  Think of how an injured brain 'rewires' itself, essentially 'regrowing' the kinds of connections that lead to function.  A transplanted female heart, in a male body, will become partly "male" with male heart cells (cardiomyoctes).  Where did they come from?  And a woman who gives birth to a boy, expecially if she has a sick heart, will find that some of her heart muscle is colonized with her son's stem cells.  The latter has greater relevance about what it is to be an "individual," not just about stem cells.

So, as the real stem cell business, using your own stem cells to cure disease, begins to gain momentum, we may find many of the unspoken presumptions of an old way of understanding bodies will fall away in the face of facts.  But do not look for it to go gladly.  We still hold ourselves above and outside of biology and the natural world.  But underneath it all, we are dynamic, renewable organisms, despite our unwillingness to do that.  Someday, maybe, we will stop fighting nature, supporting the myth of domination.  And then, maybe, we can learn the beauty of living within that nature, and within ourselves.

Monday, November 14, 2011

I was part of a meeting with a handful of noted cardiologist researchers discussing the development of a clinical trial using a medical technology to reduce pain from and incidence of angina.  We have already run a pilot trial that should very good outcomes for treated patients.  The strongest opinions of the group were that the endpoints of the study should be on angina frequency and exercise capacity, as that is the only thing FDA accepts as valid outcomes.  Lots of discussion about how debilitating the condition can be and how there are not good alternatives for folks failing medical management (love that, 'patients failing.'  In my world, medicine is failing the patients, not the inverse - yes, inverse).  Within our technology company, we have always been enamored of imaging, so originally divined to get some kind of imaging for the trials, but that was deemed both unnecessary and potentially pointless, as the images are highly variable, even among symptomatic patients.  A late-arriving cardiologist/researcher, quite young, gave an animated, even slightly angry, defense of images.  Of course, she is an imaging specialist, so did have a dog in the fight, so to speak.  Her argument met the harshest of academic fates, it was simply ignored and the meeting adjourned shortly thereafter.  While we got organized for dinner, she spoke to me under her breath, while looking sharply at the others, "There has to be an objective measure of change, you can't just rely on patient reports, they are just subjective."  I did not push her on this, as I might otherwise (like invoke Roshaman), simply because I wasn't sure she wouldn't get really upset, even as we went to dinner.  I thought about the two 'camps' in this clinical debate.  The older, seasoned clinician researchers were happy to rely on patient reports, because, after all, that is what constitutes the disease itself, is the patient complaint.  The
young researcher seeking objectivity as some kind of 'truth,'
can do so as long as she doesn't examine things too closely.
She might end up making the argument that patients should
be treated on the basis of 'objective' data, independent of
complaints.  That is the basis of lots of therapies, and lots
of unnecessary treatment and side-effects.  But more
interesting is this notion of 'objectivity,' in that even in
mathematics we find, at the core, a subjectivity that cannot
be resolved.  For example, the law of trichotomy lets me
state that any number is odd or even or zero.  Seems pretty
straight-forward.  So is Pi even or odd, as it is clearly not zero? Guess we have to take it on faith that it is one or the other. 

Friday, October 21, 2011

I know that I just wrote a bit about the goofiness of psychiatry, but I just can't leave it alone.  Hmmm...maybe I'd qualify for an obsessive-compulsive disorder there...So read this neat piece, but don't let one see you and definitely don't start laughing to yourself (at least in public).   My new favorite disorder is post-traumatic bitterness disorder (PTED), and a nice piece about it here.

It is kind of a microcosm of all politics.  There are lots of special interest 'disorder' groups, all vying for inclusion.  And the treatments are usually all the same (some medication if you are a psychiatrist or cognitive behavioral therapy (CBT) if you are not.   So here they all are, vying for space.  Hope they all get some.  Oh, and I think that PTED is the weltanshauung of New Englanders.  Since when did people start thinking is was abnormal? 

Friday, October 14, 2011

Vote for my disease....

I think that folks know I am a big fan of psychiatry, having worked in it and studied it for 25 years now, on and off.  I still think Nietzsche's definition is most apt, "Psychology was born of idleness."  Especially in that we understand to day that the mind/personality/your noun here is an apparition of the concatenation of  the nonlinear activity in the biological substrate (which I pointedly would not reduce to the 'brain' nor, in fact, to the individual, but more on that later).  So the LA Times ran this great article about upper middle class white folk who want to medicalize their children's behavior (and note, I did not call it 'bad' behavior...it is contrary to the parents' desires, but may be fully warranted as a measure of resistance).

What we have here is the usual kind of 'evolution' in psychiatry and psychology.  More and more non-conformist behavior becomes pathological, which means treatable, which means billable.   Think of it as medicating puppies for urinating in the house. Lots of incentive, but virtually no real need.  That is the prescription psychiatry has followed since the introduction of pharmacological interventions.  It is also why they are on the lowest rung of the medical hierarchy. But back to the point.  The point is that psychiatric 'disorders' are decided by a vote.  Folks vote new ones in and old ones out.  I'm personally pulling for 'disruptive mood dysregulation disorder,'  in that the phenomenal inanity of it is majestic.  But, more importantly and more interestingly, I am pulling for Cecelia.  Keep kicking, kid.  Eventually the adults will go away....

Friday, September 30, 2011

Resistance, Rebellion and Death

I was invited to attend the Galien Foundation conference in NYC this week.  They are planning on it evolving into the Davos of healthcare.  They have quite a slog. So here is one issue we discussed.  Only between 50-75% of prescriptions are filled, 30% of those taken as prescribed and only 15% refilled as directed.  So someone points out the 'compliance' for things made by Apple is phenomenally higher. Why is it?  One is so important and the other almost trivial. Apparently, I was the only semiotician in this crowd of CEOs, CMOs, and big pharma board members.  So, I had to comment, yes, out loud with a mike, that it was pretty obvious. Apple signifies hip, cool, young, healthy, high status and medication is a simple reminder of the phenomenal reduction is status, the "anti-Appleness" of the patient.  In the end, it is requiring the patient to affirm their horrible status everyday.  As Certeau taught us, it is the 'inversion that animates resistance'.  The 'non-compliant' patient is just that.  In the act of not taking that medication, they assert their rejection of the imposed status, reclaim their personhood in the face of a machine they cannot resist otherwise, the perpetual documentation of their failure to be "successful," to be healthy, to be young.  It is the only act they control.  After this comment, delivered at the end and shrugged off by the moderator with the comment "Public Health people have been working on this for years..." several folks approached me to concur, the best comment, from a health care policy lawyers was, "I can;t believe someone actually used the word 'semiotics' in this kind of meeting!  Never heard that before and it was exactly right."  Two of the panelists even stopped me to chat about it.  But it is so obvious. Medicine embraced science as a social stepping stone, out of the lower class and into the highest.  So all the transactions of clinical medicine can be characterized as power relations, where the only act of rebellion that remains is to refuse what is in your hand.  But refusing medication can mean death.  So what is unusual about revolutions entailing that kind of sacrifice?  Here is to all those risking death to salvage their self-esteem. Maybe "The Rebel:" should be required reading in medical school.  But maybe not.

Monday, September 26, 2011

Gaming the Pharma Model

In a great frenzy of activity, researchers showed that a component of red wine appeared to improve longevity and decrease chronic disease in several animal models.  So compelling the evidence, Glaxo Smith Kline paid $720 Million for the company, Sirtris, that did the work. 

Even the Sirtris founders, who were now GSK employees, created an outlet to sell the compound as a nutriceutical (albeit in low doses) and GSK had to force them to give up their on-line company.  It is a great read, all in all, about what can go wrong in the race to find the 'silver bullet' for any disease, much less a host of them.  Not only that, but, in the end resevatrol turns out to be an unlikely candidate for anything, save the emotional interest in pharma producing 'silver bullets.'  But as you know from reading here and everywhere, the wholly non-linear and complex nature of, well, nature, precludes, in general, these kinds of single solutions to complex problems.  Creating health is the outcome of multiple, simultaneous events, most of which we can only 'nudge' in the best direction.  Health, like disease, is a trajectory through time, not a problem in plumbing or simple engineering.  But hope springs eternal.  And apparently, so does money to support the dream.  Like geopolitics, our discourse on health is riven by minute, local activity which, in aggregate seems to point to some underlying logic, principle, or postulate that can be discovered by reducing the problem to some set of simple parts, like a lawn mower engine.  And, no matter how we try, like Leonard Cohen sings, "You can add up the parts, but you won't get the sum."  Why?  'There's a crack, a crack in everything.  But, he reassures us, 'that's how the light gets in'. Listen to it. Anthropologist, I think, are in the business of light, no matter how small the cracks.

Sunday, September 18, 2011

Evidence-based Medicine


If you look at a dollar bill, there is a pyramid on it, with many an arbitrary and even conspiracy-like interpretations.  But it is really an icon for evidence, at least in medicine.  So here we have the hierarchy of evidence in medicine, the kind of rationalized approach that we may think, or desire, at least, to create a kind of medical practice that has a familiarity and similarity everywhere we might go.  Sort of standardizing care, like a McDonald's.  Everything is the same, with allowances for local types of disease, say Lyme Disease in the Northeast or the plague in the Southwest, some places might have expertise in the lobster roll and others might add green chile to a burger.  But hidden within is the unavoidable truth that like regional tastes, the more 'standardize' a treatment is based on the 'best evidence', the less likely it is to apply to an individual case.  I might eat at a McDonald's in Albuquerque, but that doesn't mean I even like green chile, or even know what it is, as I hail from the Northeast. The assumptions fit a population, like evidence from a randomized, controlled, double blind study, or a review.  But, for any one person in that 'group,' the assumptions may not fit.  This is the tension between medical practice and medical knowledge.  The knowledge can be standardized, but practice is an individual act, the history and condition of the patient meet another set of conditions and histories, that of the clinician.  An example from neurosurgery:

In a traumatic brain injury patient, presented at rounds, the dutiful residents present the case to the attendings. "Pt. X has a TBI, brain stem involved. We did X, Y, Z and then used anti-hypertensives to keep her blood pressure below 160..."  The Chairman interrupts, "Does her BP want to stay there or are you fighting or keep it there?"  The residents hesitate, trying to ascertain why that statement is made.  The Chairman mercifully continues, "If the patient wants her BP to be higher, she is telling you that she is trying to perfuse her brain and she needs the higher pressure..."  The resident responds, "In these cases, a BP above 160 could lead to a stroke..."  The Chairman interrupts, "But that is the point, if she needs more perfusion and you prevent it, what's the difference?  It is another kind of ischemia (lack of blood flow)."  This is another kind of 'stroke, so to speak, no blood flow due to medical intervention rather than the unwanted stroke.  The outcome is identical.  The residents look around, not knowing whether the 'evidence-based' approach is beyond reproach.

This vignette, repeated in medical rounds around the world is the collision between experience and evidence.  The individual case reveals itself as an anomaly, outside of the hierarchy of evidence and concealed in the hierarchy of experience.  The practice of clinical medicine is like a walk in the city.  The city planners (the evidence-based medical approach) lays out the 'design' to the highest efficiency.  But the individual walking through the city, like the clinician, has desires that may not conform, nor should conform to the existing path, the evidence.  In architecture, these divergent, but necessary paths, are called 'desire lines'.  Each patient, in the hands of the skilled clinician, create unique paths, to get from disease to health. But without the rational constraints of only evidence.



Thursday, August 25, 2011

The Gaze

"The sovereign power of the empirical gaze."  Or so says Foucault.  One of the kinds of 'evidence' from practice is the list I posted last, that there are a plethora of diseases, syndromes, and otherwise unpleasant conditions named after doctors (MDs and PhDs) and few 'cures' so named.  Some procedures, but nothing like the pantheon of eponymous disease.  Foucault's proposition, that clinical medicine emerged from the transition from metaphor to mapping (my short-hand) would suggest exactly that, the definition of the condition, the generalization of the gaze within the discipline of clinical medicine, would yield the highest accolade, a 'naming,' like the discoverer of a new celestial object.   The 'fact' therein is that the object is just that, objective.  But, the crux of the matter for Foucault, clinical medicine and most of us cats, is that there is a subjective experience of that 'objective' disease that will, in all cases, differ from the object.  I know, that is too dense and ineffective a sentence, even if I believe accurate.  So, for the celestial example, it is as if all observers (nee, clinicians) had a different view of the object, so essentially the 'celestial body' became an ensemble of all views, a composite object of observations, e.i. non-objective.  That is compounded in the clinic in that every 'disease' is literally personified, as if a meteor had a consciousness that both observed its own condition and that of those who observed it, in a kind of post-modern recursion (as much as I hate that). Every human affliction is a unique experience with a completely non-linear trajectory.  But the clinic is not capable of enveloping that uniqueness, as it is simply the expression of an 'empirical gaze.'  Fairly clear why our admonishments and initiatives in health care cannot be effective.  But the nature of the 'gaze' precludes the mirror.

Wednesday, August 24, 2011

By anyother name...

Why are diseases named for doctors, but aside from the Heimlich maneuver, not too many cures or treatments?

From wikipedia:


A

[edit] B

[edit] C

[edit] D

[edit] E

[edit] F

[edit] G

[edit] H

[edit] J

[edit] K

[edit] L

[edit] M

[edit] N

[edit] O

[edit] P

[edit] R

[edit] S

[edit] T

[edit] U

[edit] V

[edit] W

[edit] X Y Z