Alternative Therapies and Cancer

I was listening to Science Friday a few days ago and heard about a study out of Yale that found that those folks who use alternative therapies instead of standard medical therapies to treat their cancer are twice as likely to die from their cancer. So I thought: "This would a be a great thing to blog about," and I looked it up on the internet. Here's a sample of what came up...

I did my best to blank out the banner ad there. Don't want to impugn any company that wants to advertise on CNN.com! But look at that headline. It seems rather broad, don't you think? It could sound like any alternative therapy in the service of cancer treatment doubles the risk of death. You could read it as "choosing alternative cancer therapy instead of" rather than "in addition to" standard treatment is a risky venture.

In the writer's defense, it did go on to state exactly that, but you know how it is these days. With memes and clickbait and flashy headlines bouncing around on everyone's Facebook feed or Twitter account or randomly popping up when you're googling "alternative medicine", it's easy to see how this might be interpreted.

So I used my fantastic university access to pull the article (which is in electronic publication as of August 10th for a planned release date in print of January 2018). I'll add that to Science Friday's John Dankosky's credit (who was filling in for regular host Ira Flatow) he was careful during his segment to make sure that listeners understood that this was the use of alternative medicine (AM) instead of standard therapy (ST--chemo, radiation, and surgery).

Here's what I found.

First, the researchers did not do a prospective study. That is, they didn't subject cancer patients to randomized treatments of AM versus ST--that would be unethical anyway! What they did do was examine the records of some 560 patients who got ST for 4 types of cancer: prostate, breast, lung, and colon, and matched them to the records of patients who were similar in age, sex, etc. but who opted instead for AM alone to treat their cancer. Ok, so far, so good. The groups were similar enough.

They looked at 5-year survival. This is a pretty standard measure of successful cancer treatment. Basically, if you live 5 years after treatment, you're probably good to go. Here's what they found...

58% of the people in their sample who chose exclusively AM had survived for at least 5 years, in contrast to 78% for all 4 cancers. In statistics, there's a thing called "hazard ratio"--basically, the risk of a chosen hazard (in this case, death). This ratio has to be compared to an "index standard" which is given the number "1". This "1" represents the hazard under standard conditions. The standard condition the authors chose was ST. So, statistically, people choosing AM alone had a hazard ratio of 2.21 to 2.50* or they suffered the "hazard"--death--at twice the rate of those choosing ST.

But there's more.

The study broke out the data and is publishing "survival curves" for all patients and survival by each of the four types. This gets interesting.

Colorectal cancer survival had the widest gap between ST (about 77% survival) and AM (about 30%) at 7 years of follow up.**  The narrowest gap between choosing ST versus AM was prostate cancer, at about 90% and 84% surviving 7 years, respectively. Breast cancer had the clearest display of results clearly favoring ST, more or less matching the overall curves I discussed earlier. Lung cancer looked the worst, with ST survival at about 35% and AM at about 12%. Other cancers? Well, they weren't examined so we don't know.

There's a lot we can ask and say here. What fraction of the deaths may have occurred because of the ST? After all, the commonly-used cancer drug doxorubicin can cause fatal heart failure in some unlucky recipients. This was not able to be teased out of this type of study. The authors note that prostate cancer cases were often early stage and followup--even out to 7 years--may have been too short. However one wonders to what extent an ineffective but largely harmless AM choice might have on reducing prostate cancer deaths compared to ST, which is much more likely to cause serious side effects.

Of note, the striking difference in breast and colon cancer survival rates may reflect the very good protocols now in place for these types of cancer, especially when caught early. Contrast this with lung cancer, which fares poorly with ST anyway. The study also isn't able to highlight individual stories of success with AM--and I have found that such stories are a big driver in why people tend to consider AM-alone as a possible treatment option in cancer. One of the big reasons people say they want to consider AM alone is their impression that ST "poisons" the body, and makes it harder for the body to fight the cancer on its own. In some cases they may be right, but in the aggregate, it seems it is generally not true, at least for some types of cancer.

On my website, under the Medical Conditions section, I share my view that when a cancer has good protocols and high rates of cure, it makes sense to do the ST and use AM as a supplemental therapy to strengthen the system and reduce side effects and the long term effects of ST's like chemo. When someone has a cancer with a poor prognosis under ST, the calculation becomes more difficult. AM alone may be worth a go. If anything, this study tends to reinforce what I was taught in homeopathic training and what I have observed in practice.

The authors argue that the results of this study can be used as a tool to discuss with newly-diagnosed patients with cancer, or with those presenting after a period of time when they've been trying AM exclusively. You know, like, "Oh yes, a study found that using alternative medicine alone to fight cancer means you're twice as likely to die of it." That's efficient if a doctor wants to convince someone to suck it up and take the chemo, but it's hardly a fair and accurate discussion of the results. I don't argue here for AM as a singular cancer treatment--after all, this study didn't state what "alternatives" to ST were used by the cases examined in the study. I suspect the "alternatives" were all over the place. In my practice I have found that "alternative" may mean anything from isopathic homeopathy, to a whole foods diet, to antineoplastons, to healing with crystals, to barking at the moon.

Thus perhaps this study is more about "proving" the superiority of regular medicine to anything else. The authors probably didn't mean to make that socio-political leap on purpose, but no analysis of this study would be complete without paying attention to that point.

The authors meant well, I think. Cancer physicians get really demoralized by the endless parade of deaths they witness. Cancer treatment is still very much a work in progress. So it makes sense that this study would be seen as a way of shaking some "sense" into people who are either scared of ST, or convinced AM is better--or both. However I would argue that it's only part of the story, and the science on this is by no means complete. This study isn't the end of the matter.


Notes:
* This range reflects the 2 types of statistical tests the authors used and is too technical to be of any use to us here. I included both numbers for completeness--and it gets at the "twice the risk" piece being quoted in the news.

** The average followup of all cancer cases in the study was just over 5 years, but some cases had less or more, so individual graphs show this variability. It's not an error.

The "Death" of Obamacare?

Well, the summer's now at it's slackest moment: It's August and all the representatives are home for the rest of the summer...after having failed to "repeal and replace" the Affordable Care Act of 2010. It's common knowledge now that conservative politicians consistently ran on promises to do so. Now that their caucus hasn't been able to come up with a passable plan, Obamacare remains in place while the states and the President try to figure out ways to sabotage it.

Meanwhile, the ACA is more popular than it's ever been!

There's way too much to say about the ACA and the tortuous process of getting from what came before to what we have now. There's been so much written and said about it: It's good. It's bad. It's merely an insurance market reform law. It's socilism. It's "imploding"...or it isn't. With that said, I will focus on here is what the symbol of the ACA says about how our society is evolving.

A few general facts (1):

• Despite our ardent love for a "market-based" private health care system, Medicare remains extremely popular among those older Americans likely to vote against changes in the health care system, and for the repeal of the ACA.

• Despite spending more money per-capita on health care than any other country (Switzerland is a distant 2nd place), many of our health care outcomes (e.g., life expectancy) lag behind our lesser-spending neighbors in the developed world.

• Americans pay more for medical technology and prescription drugs than citizens of any other country.

• It's not all bad: we have a lower cancer death rate than most countries. We visit the doctor less often than people in developed countries (so why is insurance so expensive?)

So in the 2000s it became apparent that having tens of millions of people uninsured was both a drain on our economy, and a kind of shadow tax on people with insurance, since the payees--doctors, hospitals, and medical products services--weren't simply going to accept non-payment from those uninsured people. The costs were "shared" by charging higher premiums to insurance holders.

Although many developed countries have a single health care payer system--Canada and Britain are the common examples--not all do. Moreover, as President Obama said at a press conference prior to the ACA becoming law, health care is about 1/6th of the American economy. You can't just change that overnight. Fair enough.

But it seems that, in spite of all the protest against the ACA (it was never worse off than about 47% popularity), now that it is threatened, a lot of people are speaking in favor of it. It's funny, I still routinely hear from some patients, and many nurses and doctors that "Obamacare" is what's causing all the problems in health care. Truth is, some of those problems are caused by Congress not fixing some of the problems that cropped up with it as it rolled out. Republican congressmen were too busy trying to repeal it entirely to take the time to fix it. Besides, if they fixed it, then they couldn't use it as foil against Democrats.

If to some this sounds like an editorial, it isn't. I'm just stating the facts (and by the way, none of these facts pay any tribute to Democrats, so I'm not writing a nakedly partisan essay here).

So this is where we are. Why?

Ok, now I'll editorialize!

For a long time, we were a frontier culture in a vast land. While we've always had differences, some severe (anyone remember something called the Civil War?) we've always had this sense of optimism, that just over the horizon, there lies a new land that offers a hope for a new day. Over the course of the 20th century, that frontier came to an end, and now even Alaska is settled all the way to the North Slope. Yes, there are still broad tracts of empty land. There are still new tomorrows to the west (or the east, if you're already out west). But by and large, we feel each other, our neighbors and our nemeses, people we know and people who seem strange and foreign to us, and there's no place to go.

So we've become more tribal, and this has been abetted by the internet. Demographic studies have shown we are tending to move to be with those "like us." Political districts reflect this as well, and a growing number of congressional districts are essentially uncontested. Wealth disparity continues to grow--America has a high disparity between the rich and the rest of us, higher than Europe and Canada, and even higher than much of northern Africa; we're better in that respect than South America and China, but roughly equivalent with Russia (of all places!)--so many of us feel a pinch.

A social conversation has begun to arise about this. What do we do now that we have nowhere else to go, nowhere else to conquer? How should society regulate itself? Am I responsible for my neighbor? One of the recent issues debated in the attempt to repeal the ACA concerned private buyers of insurance on the exchanges who didn't like paying for a basic menu of health care services that they might not ever use--like a man paying for a policy that must include maternity care.

On the face of it, it does seem kinda stupid...until one factors in the relatively low fraction of the cost of that care as it is distributed among many thousands of ratepayers, versus the much smaller fraction of ratepayers who actually use it (women of childbearing age) who would be charged much more without those non-user contributors. Funny, I think was a guy named Jesus who said something about loving our neighbors--what did he mean?

Am I responsible for my neighbors?

If one teases out the scenario, the sense of it sharpens. The man, paying a fractional cost for maternity care, actually gains benefit in unseen ways, like the fact that affordable maternity care lessens infant sickness and death and thus removes hidden costs from society at large--and thus from him as well, at least incrementally. Treating health care costs like an a la carte menu pays homage to our rugged American individualism, but it neglects the complexity of a society whose frontier safety valve shut off nearly 100 years ago. In the end, we all pay anyway.

How should society regulate itself?

In the past doctors were private agents, and so were hospitals (where they even existed). Insurance companies often operate on a for-profit basis, as do ambulances, some hospitals, many nursing homes, drug companies, and the list goes on. But that profit is made on goods and services that an increasing number of Americans see as a "public good", or a "right". Recently-convicted investor Martin Shkreli raised the price of dapsone, a very old and very generic (but also very necessary) drug by 5000% before public shaming caused him to dial it back a bit (it's still unnecessarily expensive)--because he could. It's no crime to price gouge, even when it comes to a matter as serious and as necessary as medical care. Capitalism is king. Or is it?

I have no issue with people getting paid, and I have no issue with private concerns existing to develop and provide unique and valuable services to the sick--heck I'm one of those people who do so! But I think one has to also be aware that the massive scale of some enterprises in health care, the importance of some of its products (like dapsone, or Epi-Pens, or Narcan), and the interconnectedness of that industry, combined with emerging expectations of Americans, has caused us to begin to entertain the possibility that rampant health care capitalism may not be the solution that many believe it is. Maybe it isn't especially moral to get as rich as possible on the backs of sick people.

Finally, I think it is dawning on people that we struggle with an essentially human, and especially American, sense of privilege. We want the best; who doesn't? But when does the "best" begin to come at the direct cost of another, and when--because of that interconnectedness I spoke of earlier--does it actually begins to incur indirect costs to us? 

People say they don't want the high taxes that come with single payer health care, but studies have shown we're essentially paying a "tax" anyway, in the form of high premiums. But instead of that money going to the common good, it goes into the pockets of dirtbags like Martin Shkreli! How is that better?

People say they don't want their health care "rationed"--and yet they seem to have accepted exactly that from heath insurers, who deny unneeded MRIs, CAT scans, new drugs, and unproven therapies. Is that rationing, or is it rationality? In the latter case, people seem to be willing to pay a "tax" to have their care rationed (or rational)--and give a nice extra bit that goes to corporate profit, or to the multimillion-dollar salary of a non-profit executive. (2)

Personally, I'd rather pay a tax I know is going to make my health care easy and portable, and keep the "extra bit" in my own pocket!

But hey, I'm fine. I have good insurance and a job unlikely to end abruptly. But I guess bad things could happen to me too, so I have a stake in this I guess. People need to start thinking more like this in order to hedge against the inevitable--and needing health care is pretty much inevitable, even if for reasons political, religious, or personal one were to choose not to use it. (3) So we better start having this conversation more explicitly. It needs to stop being about Republicans and Democrats, liberals and conservatives and greens and libertarians. The conversation needs to be about "real" things. How can we talk about the utility of a "free market" when that market is clearly opaque? (pardon the pun) What are the real, if indirect, costs to each of us when millions go uninsured or underinsured? Whay are we really paying so much for medicines? (Hint: it ain't research and development.)

Next time you're ill, try pricing the estimated total cost of the affair beforehand. The answer you'll get: "We can't know that until we see you." Show up and ask, and they'll say "We have to run some tests." Inquire on the price of those, and you'll find no answer forthcoming. Being sick isn't what it was. Like our former frontier landscape, health care in America has modernized: it can do a lot, and there's a reasoned approach to doing it. Maybe it's time we stopped treating ourselves like we're living in the 19th century. Maybe we need to start talking about how we're going to deal with reality and stop talking about if we'll deal with it.

(1) For the sake of time, I didn't cite these, but the facts can be verified easily with Google searches on the relevant terms. Or you can take my word for it.
(2) The CEO of Blue Shield of California was paid over $3,500,000 in 2015.
(3) Wake up at 3 AM with appendicitis, and see if you still feel like health care is a "choice" you can opt to not use!

Vaccination, Health Care Workers & The Law

Public domain from Wikimedia Commons

I just read an interesting article from one of my regular web news services, this one from The Clinical Advisor. Their regular feature Legal Adviser (July 13, 2017) shares a case of a nurse who was fired for refusing an employer-mandated Tdap (tetanus, diptheria, pertussis) booster vaccine for all employees at the hospital. Part of the driver for this was known occurrences of outbreaks of pertussis--whooping cough--which still occur despite the fact that most children are routinely immunized against whooping cough. In fact I still see some patients and families with this condition, which is uncomfortable, but usually self-limiting and non-fatal. (Even though this shouldn't happen, it does. So much for the power of vaccination.)

In vulnerable people, like infants and children, older adults, or people who are sick or have faulty immune systems, it can be very serious or fatal. So it's easy to understand why hospitals want their employees to be immune to it. If one would come down with it, they could certainly infect such vulnerable individuals.

The summary of the case is that a nurse didn't want to get the booster. The hospital wanted a note from her doctor as to why she shouldn't receive the vaccine. The nurse suffered from various allergies and a condition called eosinophilic esophagitis (basically a kind of autoimmune heartburn) and was anxious the vaccine would cause problems related to these conditions. The doctor issued a letter stating the nurse was "medically exempt."

The hospital said this was not enough. They listed the 9 conditions officially listed as reasons to not get the vaccine. They wanted the physician to be more specific. He wrote back to the hospital about the patient's history of "various allergies" and how she was "terrified" of getting the vaccine.

The hospital's employee health services coordinator told the nurse that the doctor's note did not meet the definition of medical contra-indication detailed in the product's official literature and told her to get the vaccine or get fired.

The nurse declined to comply and was fired.

She sued under the Americans with Disabilities Act, but the suit was dismissed in Federal Court, because the employer did try to accommodate the employee: Her provider was to state which specific condition, of the 9 listed, the nurse had in order to exempt her from getting the booster shot.

The Legal Power of Words...

I spared you the technical details of the conditions because they weren't anything this plaintiff had, and are mostly pretty uncommon, so most people don't have them either. Game over? Not quite.

The hospital wanted one of those words. The physician's second letter emphasized the nurse's "anxiety" about the vaccine. That wasn't going to satisfy them. So what could the physician have done differently?

The last condition on the list was "altered immune competence." The plaintiff had this, that is if one considered "competence" to be a system that functions as it should. Typically, regular health care professionals--doctors, nurses, etc.--would consider "competence" to be like "strong enough" and would perhaps interpret "altered immune competence" to mean "lowered immunity." However "altered" means just that--not the regular way it works. The nurse's immune system certainly wasn't working as it should, she had allergies, environmental sensitivities, and an autoimmune condition!

I read this article and decided that I would have responded to the hospital's second request for detailed information by stating that the patient has "altered immune competence"--which is technically accurate from this professional's point of view. Using that logic I could build my case: The patient's condition of "altered immune competence" makes it likely that a revaccination may lead to untoward or catastrophic medical consequences, based on the manufacturer's own data. Further I would have suggested appropriate accommodation (such as reassigning the nurse or asking her to wear a mask during disease outbreaks publicized in the public health notices of her locality).

Fact is, I probably would have done this at the outset, which would have nixed the back and forth communication between my office and the employer. I can't promise this would work, but I think it has a better chance of succeeding, because employers--especially hospitals--are exceedingly legalistic. They also don't like to lose. They want people to comply (sounds like a topic for another blog post!).

This case fell apart because the court found that the ADA doesn't require accommodation for "purely personal reasons" (the nurse didn't want the vaccine and was anxious about it). The court further ruled that "Whether or not the hospital should 'require employees to obtain the vaccine is not a question for the Court to determine.'" Which makes sense. They are judges, not doctors.

Take Home Messages
First, if you have a problem with an employer-required health act, like a vaccination, ask yourself why. If it's personal preference, don't lead with that. It's a loser.

Second, even though there are usually specific reasons listed in the "official" literature for not receiving such interventions, like a given vaccine, there's usually some wiggle room, because many "specific" reasons aren't as specific as they sound. People need to discuss these in a more effective way. For example, the nurse could have asked her physician which of the 9 conditions he or she was concerned about, or potentially could be applicable.

Third, realize that employers have concerns too. They don't want to intrude on the particular medical relationship of individual employees, each of whom is unique. And they want to be covered legally. The reason for refusal needs to be, and appear in print, legitimate.

Occasionally I am asked to issue a letter of medial exemption for patients, usually kids, to avoid certain vaccines. I never issue such letters unless there is a legitimate reason to do so. However, as my first duty is to the patient, I must weigh each request in the context of the total medical picture. Many of my patients have some alteration of immunity. Some such "alterations" may be easily recognized--such as immune depression due to chemotherapy. Others are more nuanced, such as cases of multiple allergies and sensitivities, or ongoing treatment for a condition related to immune competence. This could include a host of things such as asthma, repeated infections, and other immune-related issues.

Thus, I advise parents/patients that not getting a vaccine comes with certain risks. I state this in my letter and in my chart notes. I also use clear, definitive language that helps the school nurse or the employer to understand how the medical condition of the person is related to the vaccine and its risks. I often advise delay rather than a permanent exemption. After all, I don't know how long it will take to treat someone. Let's wait until things stabilize and re-evaluate.

So I'll go back to my first take-home message to come to my last: If no real contra-indication for something like a vaccine or other employer safety measure exists, then patients need to be prepared for what happened to the nurse in this story. We can believe anything we wish, but others are not required to believe it too. If one chooses to live a certain way, one must sometimes accept that consequences attach to that choice. Fortunately, there are enough folks out there like myself who can accept the people whose choices stand apart from the crowd.

Here's wishing you lots of good health...and few "employer mandates"!

Medical Marijuana

So Pennsylvania's medical marijuana supply chain is getting up and running. Licenses have been awarded. A list of diseases has been approved--you must have an approved diagnosis to qualify for a prescription. Here's a link to the list. Soon, growers in PA will begin producing the product, and I suppose some physicians will apply to become registered prescribers of marijuana as well.

Samples of THC and CBD in a lab.

The state's law is restrictive. Only "CBD oil" products can be used. CBD, or cannabidiol (kanna-bid-DI-ol), is one psychoactive component of the plant, and mainly it is calming and sedative. It's also said to regulate how THC acts in the brain--THC being the psychoactive component that makes people high. Smokeable products won't be legal.

A lot of the drive for legalization of medical cannabis in Pennsylvania was from a group of parents of children with various seizure disorders, some parents of children with autism, and so forth. Of course there were other advocates, but really, even the hardest of conservative legislators has difficulty telling sick kids they can't have a medicine that works. This link to Family Practice News shares conference coverage during which one physician in California reports seeing deep changes in some children with autism who use marijuana. It's not stated how they use it (I doubt it is smoked!) and the article also discusses other novel uses of nutritionals and drugs in these children.

Why Medical Marijuana?

People ask me--colleagues, patients--what I think of medical marijuana. There's a lot to unpack in that question.

The drug is still illegal in a large number of states. The federal government still lists it as a Schedule 1 drug (no medical use and highly addictive--of course, neither of these is true, but I won't get into the racist and protectionist mindset in the early 20th century that led to this designation).

Like many herbals, it's not just one drug. Dronabinol has been commercial available for prescription for over 20 years. I used to prescribe a lot of it when I treated AIDS patients. But patients using cannabis say that it isn't the same. Chemically, dronabinol is in fact THC, but again, when you are using the weed, you're getting dozens of other substances. The medical effects of these have barely been studied.

Marijuana makes people high. What does it mean to be "high"? Is it wrong to enjoy a pleasant sensation while you are also addressing your pain, anxiety, depression, stiffness, or other symptoms that you say are treated by smoking (or eating) pot? My students struggle with this. Is it a professional prejudice that we don't want people to feel "good" when they feel better from the medication?

Is "medical marijuana" an excuse to get high? If so, what's wrong with that? Do we have to medicalize experience in order to allow adults to enjoy things that they like? If a professional believes people should be sober at all times (which is a legitimate point of view), do they have the right to impose that on their patients?

Marijuana is among the safest of mind-altering substances. There's never been a fatal overdose. Yet alcohol and tobacco cause many deaths, and are nonetheless legal. Many prescription drugs are known to cause fatalities. Of course, one ought not drive or operate power tools when one is high..., but then isn't that the warning on a bottle of Oxycontin too?

I don't have a problem with marijuana being used for symptom relief, but I think its proponents overstate its effectiveness. It's not for everybody; especially because in many places it is still a black market product, you don't know what you're getting. But if one likes to get high, maybe that's not super important. After all, once the beer and wine start to flow at a party, doesn't everybody (who drinks) feel "better"? To most folks, it matters not that Rolling Rock is being served instead of Bud Lite--it's still alcohol!

I have a big problem with people who think this shouldn't be an option for patients. To me that is just imposing one's own beliefs on others. I'm not against some of the concerns, such as how should we approach this in children? Where does inhaled (smoked) cannabis fit in, when we're talking about health? How regulated should it be? These are all legitimate questions.

From a safety standpoint, I have little to say against its use by patients (mine or anyone else's). I recall warning some of my AIDS and hepatitis patients that their existing criminal records would make buying weed on the street a hazard to their freedom! It's said to interfere with homeopathic remedies, yet I have observed this effect is variable: for some, pot antidotes the remedy, for most it just tends to cause a premature remedy failure, and repeating the remedy works in both cases, except those in which the cannabis use is pathological. (Here I would define "pathological" use as daily, heavy use, perhaps exceeding 1-2 grams/day, or use multiple times a day. This is my definition as there is no consensus on what constitutes "heavy" use. It also exempts those who use cannabis strictly for symptom control. As you can see, these "definitions" are slippery!)

There's good evidence that recreational cannabis use in younger people can affect both coping skill development and maturation of the brain's frontal lobes, which govern impulse control and executive function. But then lots of kids who smoked dope in high school are successful and intelligent citizens.

So when I'm asked about this, I have to frame it in terms of who is asking. Is it a patient asking about trying it for symptom control? If so, that requires an answer tailored to their medical circumstances, but unfettered by my own biases (for or against use). If it's a patient asking about recreational use, the same condition applies: There's just no evidence that modest drug use is terribly hazardous, but I might add "Don't operate your chain saw while you're high!" (And this applies whether you're high on Afghan Kush or Bud Lite.) If it's someone who just wants my opinion, I am freer to admit that I think marijuana should be fully legal for both medical and recreational use.

It's safer than tobacco, alcohol, and to some extent safer than other prescription drugs that are often used to medicate symptoms. There are times when it should be avoided, but this shouldn't be imposed by government, except in the case of children. It should be studied, but studied in ways that account for all of its complexities--and this should obtain when we study any herbal medicine! Legalization, where it has happened, has invited all sorts of improvements, including research, but also including safety: buying correctly labelled, unadulterated cannabis in a store or dispensary is much safer than buying God-knows-what from a guy with a backpack who may or may not be armed!

Pennsylvania is pretty conservative, so it doesn't surprise me that we're late to the table and joining that table oh-so-slowly. I hope that the parochial, racist, oppressive rationales that have driven the Drug War and have maintained prohibition on this herb are dying off. I predict that the changes are going to come faster, and that in a few more years (and election cycles), politicians won't find it convenient to maintain the status quo. I only hope that when that happens, cannabis--medical or recreational--won't end up completely captive to either the pharmaceutical industry or the multinational corporations that produce and market alcohol and tobacco.

Medicine as a "Black Art"

I got an email blast today--one of more than a dozen I get each day--from Medpage Today. A medical blogger and physician, Christopher Johnson, asks "Is medicine still a black art?" He describes the well-known idea that for centuries physicians practiced medicine on the basis of theories about how the body works. This continued until the 19th century, when the scientific method matured to the point at which we began to have evidence for how the body actually does work. The era of Scientific Medicine was born.

Johnson asks a compelling question about medicine using a label which suggests "magic"--basically a kind of inspired guesswork founded on mental pictures of how Nature works. Black art connotes wizardry and a connection to divine power that in turn influences Nature on our behalf. Astrology and the magical practices of various belief systems are other examples. "Black" of course suggests "dark" or "evil", but really it can also mean "unknown" or "mysterious." A "black box".

That article cites another article from February of this year in The Atlantic which details the conflicts between evidence-based medicine, the vastness of medicine and the individual ways in which we all experience health and disease, and the human desire for hope and cure.

If you get a chance, follow the link and check out the article, which I included here in the interest of any of my patients who may have been told to get something or other done when they might not really need it!

The gist is this:

• First, although we've made a great effort to study medicine's methods for what works and what might not (or even causes harm), we still have a long way to go.
• Second, A lot of what passes for "evidence-based medicine" is weaker than we're often led to believe.
• Third, human nature--both among doctors and patients--drives more of what we do (and do not) more than good evidence.

I teach research methods, so for me a lot of this doesn't come as a surprise. Research findings are routinely published as "breakthroughs"--but a lot of that is hype. Research findings aren't often replicated, to verify earlier work. And of course negative findings (that is, what didn't work) is often ignored, because it's more interesting to publish articles about things that did work!

But what interested me more about the Medpage Today article was the use of this term "black art" in the title. 

Homeopathy could be considered a black art, and certainly most docs view it as worse than that. I find it interesting that most positive clinical research about homeopathic treatment is ignored or dismissed as flawed. It seems that most allopathic medical research suffers from the same problem. 

I have and continue to practice both homeopathic, and when it's needed, allopathic medicine as part of my nursing practice, and one thing I have learned is that patients are individuals, problems are often strange, and the methods for addressing both of these concerns still do rely more often on art than science. One thing I emphasize with my students is that Evidence Based Practice (whether nursing or medicine) is both non-individualized and probabilistic.

Ok, what I mean is that EBP examines groups of people, not individuals, and its conclusions are aimed at increasing the likelihood of a good outcome, and minimizing the chance of a bad outcome. In short, it assumes that all people are pretty much the same (at least in the researched population), and it doesn't offers any certainties--it merely offers good and bad chances.

I think it's important to remind my students of this because as clinicians, our aim at the end of the day is to treat people, not groups. One size does not fit all. Of course I don't mean to excuse the practices of providers described in the Atlantic article for engaging mass practices based on faulty evidence! One such practice is the use of the blood pressure medicine atenolol to prevent a first heart attack in people with somewhat elevated blood pressure. You can read their article for details. But my point is: people are still unique, and we ought to be careful giving people things that could potentially harm them when our certainty-of-outcome is only slightly better than placing a bet at a roulette table.

The problem is two-fold. Medical providers are being rewarded for following practices that may not always be well-supported by science--at least not as well-founded as we are taught. Furthermore, much of the evidence we do get is skewed by small sample sizes, greed, publication bias, and the low rewards that flow from health care science that emphasizes non-medical interventions, like diet and exercise. 

Which brings me back to homeopathy. Granted, it's weird, and it does seem to fly in the face of classical science like chemistry and physiology. But it also has a low risk of immediate and intermediate harm, and certainly doesn't itself put people in the hospital! (Albeit sometimes homeopaths would do well to abandon homeopathy when it's not working, and use something more effective for the problem at hand.)

I like the fact that I have a lot of less harmful tools at my disposal: homeopathy, herbs, nutritionals, and of course lifestyle modification, which I try make happen with a technique called motivational interviewing, basically a fancy term for discussing with people their goals and readiness for change, and of course continually encouraging and commending them on the small changes they are willing to undertake at a given moment in their lives. Too often the lifestyle advice I hear providers give goes something like this:

You should eat better and lose some weight and stop smoking.

That's about as helpful as swinging a stick to catch butterflies!

Then there are the many stories I hear from my RNs of nurses and doctors scolding patients for not being more effective changers of their lifestyles. What could be less helpful to motivating a patient who has now achieved remembering to check her blood sugars at home than to tell her:

Humph. These aren't very good. If you don't get these down I'm going to put you on insulin shots.

There is hope. There are agents out there trying to make real sense out of the research, to give better context to what works and what doesn't. I'll be touching on some of this in coming blog posts. And while I emphasize more effective change methods like motivational interviewing and therapeutic listening with my students (I hope they'll put these into practice!) I am seeing some evidence that other clinicians are doing this too. Finally, there's more momentum pushing general hygiene measures such as decreasing one's intake of processed foods (the whole foods movement and urban gardens), getting more exercise (anything at all helps!) and getting more help to kids, such as early childhood interventions and measures to relieve poverty.

The next time you hear about a great new study that says something that sounds marvelous, especially if it's expensive and technically complex, you might think, "Really?" Maybe not.

A Few Quick Bits

Well I'm back after a whirlwind month--April tends to get very busy with grading papers and projects attending to all of the other things on our to-do lists before things go quiet at campus over the summer. So here I will share a couple of things I've been saving up this past month.

Your "Brain" is Bigger than Your Brain 

Researcher Sarah Garfinkel at the University of Sussex, which I found on the site Science of Us (New York Magazine's website) has been studying the connection between our traditional "center of consciousness" and the rest of the body. In this piece from nymag.com in January, Drake Baer reports on her team's findings concerning awareness of one's own heartbeat and how it influences what we think. Here's a link to the article, if you want to check it out.

The gist of it is this: We tend to think of our "mind" as residing in our brain, and the brain is an organ, and it connects with, receives information from, and sends information to our "other" organs. Garfinkel  suggests that perhaps we're thinking about this wrong, that the brain is embedded in the entire body, which is kind of an extension of the brain. More simply, your entire body is your brain. Your consciousness is just you--"balls to bone", as the The Oracle says to Neo in The Matrix.

In the article Garfinkel says,

“I think the general public kind of knows it instinctively, they know if they exercise they feel better, they know their mood changes, their cognition and memory increases; people who meditate also see changes in their cognition and emotion.... It’s a responsibility of the scientific community to better understand these mechanisms and promote them as scientific — I feel instinctively that there’s a split where people think there are ‘scientific treatments’ like drugs, and there’s these ‘alternative treatments,’ and why do we need the distinction? [emphasis mine] If we can look at body-brain mechanisms, they can be scientific treatments as well — we just don’t yet know the mechanisms.”

This isn't new, and even the research exploring this notion isn't new, and some of it goes back thousands of years. Without getting into detail here, the idea that the body and the mind are not two but one--the bodymind--is something we have intuitively grasped since the Greeks (and perhaps earlier, although I'm not historian) and certainly by the Chinese, who developed a holistic medical system that recognizes and exploits this understanding of the intraconnectedness of ourselves.

Several nurse theorists have proposed this understanding of how we are "in the world" since the 1970s: unitary beings from nerve cell to the surface of the skin, but nursing research on this concept has been limited and the notion remains more philosophical than practical. Garfinkel, and researchers like her in psychology, nursing*, and medicine as well as other disciplines are beginning to crack the code of what this might mean in a more practical sense going forward.

I'll probably return to this concept in a future piece.

7 "Questionable" Clinics

This is a piece a saw at Medscape, a webservice for physicians and nurses that specializes in practical information for practice (like, a comprehensive catalog of diseases and their presentation, work-up, and treatment--very useful), news, and opinion. (I link to it here, but it requires a sign-in, so you may have trouble getting to the original.) Author John Watson begins by saying that,

"For many of the physician contributors to the blog Science-Based Medicine..., which takes aim at unfounded medical practices and beliefs, the continued rise of integrative medicine...represents one of the most exasperating trends in contemporary healthcare."

Yes, trying to understand why so many people insist on exploring the limits of human health utilizing technologies and philosophies outside of those "approved" by the masters of The Factory is very exasperating!

Acupuncture point model

One contributor states, "Some clinics just offer acupuncture, for example, and others offer the complete buffet dinner of nonsense." Of course, he's implying that both acupuncture and traditional Chinese medicine are "nonsense"--which is weird because both have good scientific evidence to demonstrate their efficacy for many conditions.** An editor at SBM adds "Integrative medicine is very good at co-opting certain science-based modalities, such as nutrition, exercise, and lifestyle changes, which they identify as somehow being alternative or integrative, when in reality it's just medicine."

Wow. He's a genius!

His genius would be more impressive if medical curricula actually bothered to really teach physicians how to integrate these things into their own practice, rather than jamming people end to end into 15 minute visits to fix problems that could be dealt with in more ecological ways. Physician Andrew Weil has argued for this elsewhere (and earlier): that getting people to, say, exercise isn't just about telling them to go exercise (when clearly, the physician doesn't appear to get any!), it's about a philosophy of holistic understanding of the physis, the body--or what Garfinkel might just call the Whole Brain.

These "alternatives" on their list, as the SBM editor points out, are alternatives because medicine has divested itself of imagination at the clinical bedside. Don't complain about people co-opting your schtick if you yourself have walked away from it!

The article then lists 7 clinical practices:

• "Alternative" cancer treatments
• Chelation
• Stem-cell clinics
• Ketamine clinics
• Clinics that prescribe testosterone a lot (for pretty much everything)
• Dental clinics that specialize in mercury filling removal and replacement

(I swear, I counted it twice and only came up with these six.)

I'm not going to comment on each of these here today. I will note that the people that Watson interviewed for the piece don't apply much discrimination to their analysis. All of the practices are just bogus, and "fraudulent." Yes, I don't care for fraud either, but one has to ask the question: if people could get hope and a listening ear from their regular doctors, don't you think there wouldn't be so much of a market for some of these practices?

I realize that some of these practices could potentially hurt some people sometimes (and I have actually seen that happen, so it is real), but regular medicine just assumes that when people get hurt within their model, it's just bad luck.

So what if my "proven" cancer treatment gave you permanent nerve pain and you died of your cancer anyway, after suffering through that misery. Just bad luck I guess!

Look, I'm not all gung-ho on a lot of the stuff in the list above, either, but then I am a homeopath, so I feel like I'm giving most of my patients the answers they seek, and a lot of the practitioners who try the stuff on that list are often just trying to do the same. At least I give them an option and some hope. Some don't benefit; most do. At the least the ones whom I couldn't help don't end up with permanent nerve pain or heart failure (cancer drugs), suicidal mania and tics (antidepressants), drug addiction (opioids), or other bad outcomes from the medicine.

I have covered this conflict before, and it's exemplified in these two pieces I caught on the internet. Medicine, as a professional culture, needs to maintain an open mind, encourage experimentation (and maybe even collude in it), and stop trying to make everything they study--and everyone else--fit into their imagined model of the world. Critics of "alternatives" to the medicine they learned in school are really criticizing something they don't want to understand, because of its implications. Those implications include slowing down, taking time, making less money, incorporating more hands-on healing, and taking some modest risks with the unknown. It may mean doctors learning to meditate, eat better, learn yoga or tai chi, and embracing the stories, cultures, health traditions, and arts of their patients.

Old timey doctors used to do this more, back before The Factory took over our medical landscape. Maybe some of these "alternative" practitioners are trying to bring it back.

Peace

*This link points to just one example of such nursing research, a study I did a few years ago, but it's just one of hundreds of examples.
** For example, I recently learned that an "approved" treatment for a certain type of leukemia--Arsenic trioxide, a remedy also found in homeopathic medicine--originated from studies of ancient Chinese medical texts. 

The "Real Issues"

Earlier this month I wrote that I'd need more time to think about this issue of what's at the root of our drug problems. The other night I had the privilege of joining a speakers' panel of area complementary and alternative medicine providers at a graduate class of nurse practitioner students. One of the things that came through most clearly from all of us was the multifactorial nature of the human experience of health and disease.

Another thing that came out clearly was the dual nature of our relationships with physicians--I'll note that no physicians were on the panel. To be fair, I don't know if the instructor tried to bring a physician onto the panel, although I know who's who around here: It's likely that there simply wasn't anyone available. Both physicians whom I know actually "get" this are in various stages of retirement. One I know of would speak for one of my classroom panels at Penn State because I wouldn't pay him for it.

So that "dual nature", what about that? Well, we all agreed that physicians are often a key part of the healing journey for many people. Although most physicians I've ever know view themselves as the key part of any health journey--even though they receive little instruction in holism and therapies beyond Western biomedicine. So yes, they can be very important, but they are not the only part, and in some cases they aren't necessary at all. (In fact, sometimes they are an impediment to health!)

Conversely, trying to integrate our work with that of physicians? Well, we all agreed that's a fraught adventure, at best. After all, why would physicians, say, refer someone for Reiki? They don't even collaborate very well amongst themselves! We'd like to work more with them, but they view us as variously as unimportant parts of a plan hatched by eccentric patients, as cranks, or as nuisances. They don't understand energy medicine, chiropractic, spirituality, homeopathy, nutrition, art, dance, or culture.

Ok, ok. I'm painting them here with a rather broad brush, and I know for sure that some docs aren't described by what I'm saying here.

But don't underestimate the acculturation of physicians. Acculturation is the process of beginning with ordinary people and imbuing them with a certain cultural stamp. The acculturation process that physicians undergo is very powerful. Western biomedicine is the most powerful, and most important system. It treats diseases, and when it tries to prevent them, it relies on simple instruction to patients, which patients are expected to follow, and when they don't, physicians can feel absolved of responsibility.

It is prescriptive, and not just in the literal sense of writing drug prescriptions. Students are told they are the final word on matters of health and healing. They're "in charge". They are taught to act.

I have to say that, in person, the outward results of this acculturation are not uniform. Culture doesn't trump personality. But depending on the peculiarities of personality to yield a large crop of physicians who are spiritual, holistic, imaginative, and who think cooperatively with practitioners outside their own discipline is unlikely. Some medical schools are taking an approach closer to that proposed by Dr. Andrew Weil: a curriculum that cultivates such thinking as I detailed in this paragraph. But we're a long way from that being a universal educational goal in American medical schools.

Then there's the practical pressures faced by physicians once they graduate and begin practice. Pressures to produce revenue, pressures to adhere to "evidence-based-practice" guidelines that are based on population models, pressures to conform to a system that demands data, pressures to prescribe the newest, most expensive drugs, pressures to follow the law and also guard against liability, all of these bear on the poor guy or gal in the white coat who now works in a corporate-owned medical office in a gigantic health care system.

It shouldn't come as a surprise that most authorities estimate physician suicide at about 1 physician per day! Drug abuse rates are at or somewhat higher than the general population. So, considering both the social authority and power of being a physician and the expectations society places on our doctors, I don't find it that surprising that younger docs seem more willing to share, to collaborate with others .

Maybe they are just tired of having every-single-thing on their own shoulders. Maybe they want to spread the liability around. I don't know but whatever it is, I'm glad for it.

So like a lot of things, culture changes with time. So maybe the culture of American drug dependency will change with time too. My patients complain that doctors want to "prescribe a pill for everything" and yet so many American do just want a pill for everything. Is it any wonder we've ended up where we are?

Pain in the Age of "The Opioid Epidemic"

I've been doing some far-ahead prep for a class I will teach again this year in May to advanced nursing students. Pain management is a topic they're really interested in, and I think I've mentioned this previously on this blog. So I've been freshening my understanding of the topic since last year.

So I read this article by Betty Ferrell, really a transcription of a speech she gave to nurses at the American Society for Pain Management Nursing in 2005--fully a decade from today's "opioid epidemic," which came up on our radar around 2015 and continues today. I addressed this earlier last year (June 5) when I argued that the tide of medical opinion was changing and that as a result I feared pain would be undertreated.

So far, I haven't seen that. But then, so far, I haven't seen a whole lot of change in prescribing habits either. So maybe not much has changed on the ground yet.

Anyway, Farrell's speech focused on the the ethics of pain treatment, and talked about nurses' presence when ministering to patients in pain--we're not doing our best when we're just slinging pills around. She focused on the story of pain. It's one thing to treat acute knee pain after having a surgical repair following an accident. You take your pills for a few days, do your therapy, and things get better pretty quickly. You forget about it pretty soon.

It's another thing to suffer chronic pain. It's unlikely to go away. It's trickier--I mean really--the neurology of chronic pain isn't the same as acute pain. Farrell tells the story of a patient who wonders when the meds will stop working. What will she do then? I've seen this: patients in this sort of pain enjoy brief moments of relief, hours, days, or weeks...and then things go unstable, the meds need to be changed. A colleague of mine, her husband recently had a "pain pump" installed. This implantable device pumps pain medication directly into the spinal cord. It's a big, permanent step. The story of the pain changes. It is now never, ever going completely away. And the man? He's now part cyborg. My colleague views it as a change for the better for him, but it's also hard for him to cross that border into knowing the permanence of it, as symbolized by the machine implanted in his hip.

The other side of this epidemic is the still-large number of overdoses from both prescription opioids and from heroin. The latter is often because people get hooked on Vicodin and Norco and Percocet when they get it from their doctors. Why is this?

In our effort to not undertreat pain, we started handing out large amounts of narcotics for everything from back pain to sinusitis to dental pain to acute injuries. Some people "liked" the feeling that came along with the drug. It's not always that they got "high"--some of them just report feeling "normal" for the first time.

I've shared with students that some people may be genetically deficient in producing their own native opioids, endorphins. Could it be that the incidental prescription for Tylenol#3 (with codeine) after a wisdom tooth extraction leads them to a contact with a chemical that fills in their deficiency? We tend to think of such people as weak, or that they like to party. That's true sometimes, I guess, but mostly it seems that some folks just find that the dentist's prescription puts them in a state of mind that they find more normal than they've felt in a long time.

Is it any wonder then that, lacking an ongoing source of prescription opioids, they might turn to heroin. In the TV series Mr. Robot, the character Elliott, played by Rami Malek, begins the series taking morphine he gets on the street. He also buys Suboxone, a drug he can take later to relieve the symptoms of withdrawal. His character isn't a party-head. Really, he has social anxiety and a sense of separation from others around him. He's medicating.

I've had patients who self-medicated with all sorts of things. We hardly understand psychopharmacology, after all. So why not expect people to experiment on themselves, to try to free themselves from dependence on a medical system that views them as enemies of good order? I get this all the time in class. I am teaching a course on substance abuse that I have taught several times before. The students (most anyway) begin the course in this state of mind: We know what's good for you.

And yet those same students always confirm the general lassitude of physicians when tackling this complexity of human psychoneurology. Some docs easily and readily over-prescribe habit-forming drugs. Others routinely look for reasons to withhold them. I'm not saying all docs are bad. I'm just saying that most docs are like most people, flawed. Problem is, they hold a powerful key.

In 2013 the Diagnostic Statistical Manual came out in its 5th edition. The "DSM", as people in psych call it, is the manual of psychiatric diseases. It details the criteria for diagnosing people with "depression", "generalized anxiety", "bipolar disorder" and so on. Trouble is, we don't have a real understanding of the underlying pathology of these "diseases".

In Hashimoto's thyroiditis, we know the immune system attacks the thyroid gland. In strep throat we know that strep bacteria cause an infection. In juvenile diabetes, we know that the insulin-producing cells of the pancreas die off. We know the pathology, and so we know what we have to do to fix it, and we can predict how people will respond to medicines for these diseases.

We have no such certainty in diseases that reside partly in that 3 pounds of tissue between our ears. So depression, bipolar disorder, anxiety, alienation, and chronic pain are all...well, mysteries. Even today, the DSM-5 does no more than catalog behaviors so we can label people for insurance reimbursement. It doesn't tell what's really going on, and our efforts to medicate are, at best, educated guesses.

If you think patients don't know this on some intuitive level, you're wrong. That's why people experiment on themselves. I'm not excusing the bad behaviors of addicts. I am indicting the lack of imagination, compassion, and depth among people in my own industry.

So pain management in this time of high anxiety about narcotics, pain management in an age of rising numbers of overdose deaths from those narcotics? I don't think any of this is going to get at the real issues.

That's pretty grim. I'll have to give this some more thought for another blog.

Zika Update

A confluence of events in recent weeks made me think about Zika...so what's new?

We're back at school, and I've met with the students again in their clinical rotations. A couple of young women in the group are either recently married or planning a wedding this spring. Another student of mine is pregnant with her second child.

New families.

So I thought I'd check in or this problem, which has faded from the news recently, and provide some updates.

My dad sent me this recently from BottomLine Personal, a business publication that also includes a variety of interest features. This piece interviewed entymologist Joseph Conlon with the American Mosquito Control Program. Traveling to warmer climates this winter? Conlon reminds us that all mosquito repellents are not created equal. Of course "DEET"--diethyltoulamide--is a very common and effective repellent. We're often told to make sure our bug repellents have this ingredient.

There are data that confirm that DEET isn't the safest thing for humans, but it's pretty safe. Some will suffer from rashes (which can happen with any chemical) and others from mood changes that are usually transient. I've used DEET occasionally without too much concern, although I don't often use bug repellents anyway, so my exposure is small. 15-35% concentrations are reportedly protective. (Avoid use in children less than 2 months old.)

Picaridin is another effective repellent in 15-19% concentrations, and is reportedly less likely to cause skin irritation (especially under clothing) than DEET. Both chemicals work by blocking the ability of insects to smell human odors, so they don't find a target. Both are synthetics.

Want a "natural" alternative? According to the AMCA, oil of lemon-eucalyptus in concentrations reaching 40% is effective. Interestingly catnip (Nepeta cataria) is also effective, although suitable concentrations have not yet been determined. Para-menthane diol (from eucalyptus) and 2-undecanone (from the rue plant) are two others the Centers for Disease Control note are effective.

So where are we on Zika transmission, and what are the hazards?

In mid-2016 the New England Journal of Medicine confirmed the link between Zika and the dangers to developing fetuses, however the spectrum of harms caused by the virus remain under study. Risks of fetal harm in Zika exposure run quite a wide range, from 1 in 100 to about 1 in 8! Some 6 to 11% of women infected with Zika during the first trimester suffer harm to the developing baby's brain, based on data from an outbreak in Bahia State, Brazil.

The CDC still advises travelers that women and their partners planning pregnancy should wait to get pregnant until 8 weeks after traveling to Zika-affected areas.  Men should wait up to 6 months after such travel to impregnate their partner. Similar guidelines apply in cases where someone's suffered actual symptoms of Zika exposure. Unfortunately, symptoms of Zika infection are very similar to symptoms of the flu. with fever, rash, and aches and pains common. Testing for Zika is tricky because some viruses cause false-positive results, and the immune reaction of Zika doesn't always trip the existing tests--causing false negatives. Pregnancy prevention remains the best strategy when Zika exposure is suspected. Condoms remain the standard for prevention of passing the infection between sex partners.

The brain changes in a fetus affected by Zika remain difficult to evaluate, even with serial ultrasounds and amniocentesis, so if a pregnant family is concerned about this, evaluation by a physician or nurse midwife familiar with current guidelines should be consulted initially, and referral to a specialist physician is recommended. If you're concerned about Zika exposure and are maybe planning a family, see your nurse practitioner or physician for an individualized discussion about your risks.

It's a great time of the year to travel to warmer climates. In the northern hemisphere winter, mosquito activity does decline, but unlike here in Pennsylvania, it doesn't go to zero. So the southern U.S., the Caribbean, and Central America may still have enough activity to warrant caution. Zika doesn't have to cause us panic, but it should cause us to carefully evaluate travel plans with respect to family planning.

Reference:
Grand rounds: Zika virus (2017, January). From https://www.cdc.gov/zika/pdfs/facilitationguidefaqs_pregnancy.pdf 

Health Care in Society and the Demise of Obamacare

The Affordable Care Act is due to disappear. The incoming administration and Congress are working on making it so. This is the culmination of a long dream of politicians and pundits on the conservative side of the political spectrum. Now, they'll get their wish.

But what is it a wish for? Is it really a wish for wasteful, costly health care with millions of Americans uninsured? Do Republicans really want to go back to a time when people showed up in the ER for routine care, and then stuck the hospital with the bill? Are they aiming for a return to medical bankruptcies? I doubt it.

The ACA was a compromise among the many, moneyed, players in health care: hospitals, pharmaceutical manufacturers, insurance companies, and doctors. Smaller--and less well-heeled--players also participated to some extent: citizens, nurses, consumer advocates, and social welfare organizations such as churches did have their voices heard. The product was the ACA, a law which essentially reformed the insurance marketplace, and a law which gave every player something they wanted, and also placed demands on every player. It wasn't perfect, but it was a step.

The Republican Party and groups of conservative citizens fought it from the moment it passed. "Obamacare" became a slur, like "communism", despite the fact that the ACA was a market-based solution to our insurance market problem, and despite the fact that the major elements of it were essentially based on a policy solution originally proposed by the conservative Heritage Foundation.

Now this is my blog, so in addition to sharing evidence and facts, I also get to share my opinion. I argue that there were two main reasons the ACA became a focus of Republican and conservative rancor. In the former case, the Republican Party, it was pure politics. First, I think it galled the party that Democrats managed to do their thing--create a market-based solution to a social and economic problem, a solution that had the potential to be popular (think: keeping your kids on your policy until they're 26, getting insurance coverage for pre-existing medical conditions).

Second, Republicans saw a political opportunity, and this is related to the latter case, "conservatives". Here I'm talking about less politically-connected, ordinary folks with a particular political point of view. The "tea party" types who saw the ACA as a government intrusion, who saw it as an erosion of their freedom to go without insurance, I guess. Fact is, I have more respect for these folks. I don't agree with them. I think that as our society evolves it is inevitable that we'll have to trade some of our "old rights" for new ones. But hey, I get it. It's a political philosophy, a point of view.

My view is that Republicans saw this disaffected minority (and they have been a minority) as a potential addition to their voting base, a way to seize control of hundreds of local congressional districts. That's just cynical, and I hold them in the lowest esteem for it. If Obama and the Democrats had somehow managed to pass a law greatly expanding Medicare--a "public option" for everyone--and Republicans wanted a market-based solution instead, they'd have a case. But this? This was just political calculation.

Criticisms of Obamacare abound, but what's not much talked about is that any massive legislative act has to be amended and tweaked to work. Unintended consequences happen. This law could have--should have--been adjusted several times in the 6 years since it passed. Republicans, having taken control of the House of Representatives in 2010, could have worked to make that happen. They didn't, because they saw more political opportunity in just obstructing change.

Now, they have their wish, and their "replacement" solutions are sounding either weak or complicated or both. The fact that they need a replacement highlights just how popular the ACA is, now that some 20 million more people have coverage. It's hard to believe that navigating health care insurance could get more complicated, but House Speaker Paul Ryan's current sketch of a plan promises to be just that.

Really? They think that's what Americans want? To have to phone 3 hospitals to see who has the cheapest appendectomy? Changing doctors every year, because every year you have to be on the internet looking for a cheaper option than you currently have? Look, I get the whole "smaller government" thing, but I have to wonder at what point does ardent political philosophy fail the practicality test?

I'm not at all certain about what will happen. Obama was smart. His namesake health care reform isn't perfect, but it showed a large fraction of the voting public a glimpse of a better life. That's not going quietly. Now that Republicans have control, what will they do? Maybe they'll just fix what's wrong with it and give it a new name, like "Patriot Care" or maybe name it after that new president-guy. The essentials will persist but they can take their claim to it, which will make them feel better about their brand.

Or maybe not.

Americans are going through a trial right now. We're arguing with one another about what post-frontier America looks like. This trial began in the turn of the 19th to the 20th century: unions, communism, socialism, environmentalism, the Great Depression, Social Security, Medicare and Medicaid were all being fought over as we left behind the Old World order and tried to figure out what sort of New World order would be fitting for America. Something consonant with our culture but oriented to the challenges of a very different world. Where is that balance?

For about the last 20 years there's been this see-saw between one view of our future and another. Neither is perfect, but both reflect the aspirations of ordinary people, even if those aspirations often get hijacked by politically cynical agents of vested interests.

My view is that health care is a right, and it's a right that materially contributes to both the health of our people and the health of our economy. I know others disagree (but the facts argue in my favor--a blog for another day perhaps). I believe that we all must accept that we can't have (and really don't need) everything we think we do. Some call this rationing, but I just call it rational health care. A relief valve in the form of a free, side market could co-exist, but there's no evidence it would detract from a robust public or hybrid public/non-profit health care system. There's no evidence this would necessarily dumb-down our medical research enterprise--although it might rectify the imbalances imposed by the profiteering which is a troubling feature of our current system (see my blog post from 8/29/16).

Over the coming weeks and months we'll see how Washington's new political leaders tackle this issue. They have to do something, because promises were made, no matter how empty or pointless those promises seem now. Having failed for 6 years to work with the previous leadership on revising Obamacare, Republicans now have to deliver something.

Let's hope it's an improvement.