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.

How Coincidental!

It just so happens that I'm coming off what turned out to be a pretty bad cold. It's funny, because I'm a health care provider, right? I mean, how can we get sick? And when we do, don't we know all the tricks for beating it it quickly?

Nope.

Ok, yeah, well, some. Normally I'd either drop some professional quality echinacea or eat some raw garlic at the very first hint of symptoms. (If you're trying this at home: it's just one clove of garlic and you have to eat it with something bland.) This time the initial symptoms were really mild for over a day and I thought I'd let it roll.

Well it turned into a whole lot of no fun, but after a couple of days things started to improve and I'll be fine. I have no evidence for this whatsoever, but I believe that every once in a while it's good to give your immune system a proper workout. I think it could prevent worse things later, but like I said, I've got no proof for this.

Beliefs about our health, beliefs about how we can (and can't) control our health abound, and I've found are often really personal. A lot of them are shared. For example, a lot of my female patients of childbearing age dislike the idea of using chemical means of birth control because some can interfere with having menstrual periods. Here in particular I'm talking about oral contraceptives like Seasonale or injections like Depo-Provera. They tell me that it feels strange and somehow unnatural or unclean to halt the process the body has of clearing the lining of the uterus, as happens each month during normal menstrual periods.

I haven't been able to locate any evidence that halting this process, or minimizing it, actually leads to a "buildup" of any toxic substance, or leads to any higher risk of disease...although all of these drugs do lead to potentially higher risks of things like stroke or breast cancer. Presumably that's just due to the drugs themselves.

In regular medicine, we have various recommendations that are said to be based on scientific evidence. Do this. Don't do that. Patients express some frustration to me about how often these recommendations seem to change, and how often they are in conflict with one another. To be fair, there are a few really carefully researched, very specific recommendations that change little over time. For example, don't smoke cigarettes.

But then there are those that are flung about from TV news anchors, Facebook newsfeeds, the daily paper, and pop-up ads on the internet. It's not that all of those recommendations are bad, but it does highlight that there's a spectrum of health recommendations that spans from really sound and worth paying attention to, to those that are nascent and possibly just fleeting static.

In the previous blog I wrote about intention. Intention manifests itself in various ways, from focused, meditative thought designed to influence a specific bodily response or symptom, to mere behaviors, such as declining a sugary snack in order to maintain a health body weight. Intention doesn't exist in a vacuum. It is nested within a matrix of other aspects of our psyche and experience. Critical thinking is another aspect. Combine a strong behavioral intention with an uncritical analysis of your Facebook newsfeed about something like, say, the need for vitamin D, and you might get someone taking gigantic doses of vitamin D daily, for no purpose--and potentially to a bad end.

After all, just because it's a vitamin doesn't mean that taking a truckload is automatically good for you. And some evidence shows it can be bad--but that little caveat doesn't seem to get passed around on Twitter so much.

And don't imagine I'm letting regular medicine off the hook here. For decades doctors pushed women into taking hormone replacement therapy after menopause. Until a large analysis found that this significantly increased risks for strokes! One can argue, the doctors meant well, but I lived through that and found that most doctors were too easily buying the "research" of pharmaceutical companies, and too readily latching onto the notion that "one pill can do it all": prevent heart disease and osteoporosis, treat hot flashes, improve post-menopausal sex life, increase energy, improve sleep, etc. etc.

Hormones were the wonder drugs that worked wonders...until they killed you, apparently.

Intention is more than just wanting to do the "right" thing. It's about intending to do your thing. During my recent bad cold, the latter part came on, that's the part where my nose got really stuffed up. I hate that. I really hate when I want to sleep, because it makes me breathe through my mouth. Now there're drugs for this, and I have those. But I dislike using nasal sprays. They make my throat sore, taste lousy, and my nose easily gets "addicted" to them.

So I do this thing where I can focus on my nasal passages, and see them swollen and red, which I know is due to a normal physiological response to to a virus. Then I sit or lie still, close my eyes, and focus with each breath on reducing the inflammation, sucking out the excess fluids in the tissues, draining them away...

And gradually, my nose starts to open up. This works about 50%--it never gets totally unstuffed--and it works about 75% of the time. It's good enough for me. But what about the times when it doesn't work? What about the fact it doesn't fully resolve the symptom? Is that a failure on my part? Is it underdeveloped mental discipline? Does it even matter?

In the previous article, I highlighted a conflict between intention and responsibility. If we can control what happens to us, then when bad things happen, we have "failed." On the other hand, if we aren't responsible, if intention doesn't "work", then whatever happens to us isn't our fault. It's just bad luck.

Now one could easily argue that the only things that matter are behavioral, and proven by medical science. So if you get lung cancer and you smoked, you did this to yourself. If you got lung cancer and you didn't smoke, you just have bad luck. This is where a lot of health care providers are. It means you can easily sort people into piles, "blameworthy" and "blameless." Now I could further ague that this just makes nurses and doctors sanctimonious twits, but then that wouldn't be a very deep analysis. (Even if it feels true sometimes!)

This analysis suffers from several problems. First, we don't know everything. Look at hormone replacement therapy. Oops. Second, we don't actually know that other forms of intention have an impact on health. Maybe there's more to it than we know now. In my experience a lot of doctors and nurses acknowledge the existence of some mysterious power of the mind, or perhaps the spirit. However, unless they are religious, they often don't know what else to do with that information.

One evening in the ICU I had a student come to me and ask me to explain how a woman could still be alive when her "numbers" on the monitors were "incompatible with life." The woman was dying, and the family had been gathering all day from the places they lived. There was one more person--I think it was a son--who was still traveling to the hospital. I told her, "When the son gets here, she'll die within an hour or so."

I could say this because I'd seen it before. It happened exactly as I predicted. By the way, the woman was never conscious the entire shift we were there, until about 7 PM when she briefly seemed to be conscious. Then she died.

What is "intention"? Is it a coherent thought? Is it a mood? Is it the energetic "work" expressed by the sum of the being's narrative, or "story"? Is it a technique? Or is it something more complicated? Is an "intention" ever really one thing, one direction, one thought, one action? And if it isn't, how can we be so certain of our ourselves as healers? How can we say of a patient (as I have heard many times)? "Oh that guy's evil! He doesn't take his meds. He gives the nurses a hard time!"

Hey, I'm not saying some people aren't evil. I'm not getting that metaphysical. Rather most people aren't "evil", it's just that we either refuse to listen or can't understand their "story", the story they are writing with their life, as if it were our place to judge.

I started out this blog with a simple share about getting a cold. Really, you could say I "allowed" myself to get a cold, perhaps out of a belief about immune health that may or may not be true. What I don't know, and what nobody does, is what would have happened if I had tried to abort it with one of my methods. Would it have worked or not? What does that mean? Was I irresponsible? Was I more responsible than the busy professional who says "I never let myself get a cold"? Or did I actually do the right thing, and sometime down the road I'll be rewarded for it? We can't know this.

To understand intention means to understand that--whether one knows it or not--one is telling a life story. Like all good stories, there will be surprises. Not all endings are happy, and sometimes the unhappiest event in a tale ends up manifesting redemption. We just don't know. We want to know, because we all want to be free of suffering, we want to live long and prosper, we want to know it's going to be okay.

For nurses and doctors and other professionals out there ministering to the sick and injured, it means stepping back from prejudice based on what we think we know. It means withholding judgments. It means not seeing a patient as a subject, but as a storyteller. It means trying to learn from that story even as we are participating in the telling of it. For caregivers, family, and friends it gets a bit more complicated, since they have been more intimately "in" the person's story than any of us healers ever get. But I think it still matters. I heard family say, "Oh why doesn't dad just stop...?" fill in the blank with drinking, smoking, whatever. It doesn't matter, the overall slant is the same. It is painful when loved ones do things that seems to contradict survival, but it is part of the story they are telling. In the end, that's all we are left with anyway.

Until our own story ends.

Intention: Radical Medical Science and Its Consequences

Happy New Year!

There's this thing where people say "Oh man, good riddance to  last year!"

For me, 2016 was a pretty great year. It had its bad moments..., and of course there was the election. That was just a whole lot of unpleasant. Anyway, we ring in the new year, hoping, even intending it to be better than last. We make new year's resolutions, which is a way of saying "I'm going to do better, be better." Intent is what drives new choices. When we aren't honest about our intent, or when we don't fully understand our intent, things may not work out in favor of our resolutions. Our resoluteness seems feckless, and we feel guilty. But if we really understand what we want, we can either accept who and what we are, or work to realign our intentions.

New Year's Eve we had a party, and we were talking about this idea of intention and and behavior change with respect to smoking, and we all agreed that what's really hard about quitting is that smoking is just so great. It's contemplative, these days it's often private (as smokers have gotten pushed outdoors), and it comes with a dopamine hit with every puff.

Get the patch. Use the gum. You still get the dopamine hit..., but you don't get the behavior. It's the act of smoking that makes it so successful. In fact any "addiction" is one part neurochemistry but an equal part behavior. Behavior includes the people you do the habit with, the lifestyle, the "hobby" of it, including all the little gadgets, or brands, or devices that go along with it--whether you're talking about the iconic red and white packaging of Marlboro cigarettes, the craft of marijuana smoking pipes, or one's "works", the syringe and needles of injection drug use.

Yes, I know that many addicts aren't so fancy about such things, but the social aspect (for example, hanging out with other junkies, who may also be your friends) validates my point. Addiction is as much behavioral as it is neurochemical.

Anyway, I'm going to turn my attention to the title of today's blog: radical medical science. I am appropriating this term to mean the medical science advocated by so many thought leaders in what has been called "new age" medicine, in which it is said that the use of intention, directed thinking and belief, creates a new health reality. Self-help guru Anthony Robbins, physician Deepak Chopra, author of guided imagery audio CDs Belleruth Naparstek, and The Intention Experiment's Lynne McTaggart are just a handful of those who argue that nature demonstrates to us that our thoughts can reshape reality.

I'll get to the point here: I happen to think they are right. What I don't know--and no one seems to--is how much we can reshape reality, and how it actually works.

Throughout my recent entries, I have maintained a theme that emphasizes the limits of today's material-based understanding of Nature, and specifically, of our own biological nature and the implications of that for Health and Medicine. In other words, today's science of medicine is based on a model that reduces every aspect of health to a process that can be isolated and understood, and from there we can develop specific therapeutics to fix those processes that are "broken." The problem is, this model doesn't fully explain why some people get sick and others do not. It doesn't fully explain why some people respond well to treatment and others don't.

Environment, genes, and psychological and social stressors do explain, to some extent, some of these differences, but not reliably so. When Tony Robbins urges one to "Change your physiology" he's taking some liberties with the scientific meaning of "physiology" but what he means is essential, since he is arguing that changing the way you think and feel about being physically, mentally, and spiritually in the world will change the way you are in the world.

I've tried this. It mostly works.

My wife had an uncle who was a Hindu monk for many years, and it was told that he developed a tumor in his neck. I was further told that he meditated it away.

Now I've never been able to fully verify this story as medical fact, but it doesn't matter, because there are literally thousands of other stories out there like it. Some people believe that their god will heal them, and he does, or so they believe. Whether it is their belief or not is beside the point, since at its most basic, whether it comes from within or is thought to come from without really rests upon the idea that everything comes from within. To will away a tumor, or to believe that God will do so is, essentially, a belief that there's a force that overcomes the destiny of matter.

I have also seen this not work, plenty of times. There was the Christian Scientist I was asked to see several years ago. CS is a school of religious thought that argues that all failures of the material of our bodies is mere failure of belief. Unwilling to accept any form of "regular" medicine, her home care nurses asked me to see her in her home because they felt that perhaps someone in alternative medicine might be able to accomplish what all the exhortations of the nurses and doctor couldn't. I saw her, tried homeopathy, suggested some simple ways to address the ulcers she was suffering from, yet her belief was firm: God would provide. She died within two months of my seeing her.

Was this a failure of belief or a conflict of beliefs? After all, she could hold a belief in the healing power of God and her belief that she would be received into the afterlife with Him.

In 1978, novelist and essayist Susan Sontag argued that metaphors for illness are unhealthy, and that they impose a kind of guilt trip on the ill person, much in the way that Christian Science implicates the faith (or lack of faith) of the ill. She further argued that to impose such an implication was itself a kind of social punishment: After all, it must be you who failed if despite your will, you died of cancer anyway!

This theme has been repeated by many others writing about their cancer (or other disease) experience. Coincidentally, writer and professor Norman Cousins published Anatomy of an Illness: As Perceived by the Patient, in 1979. After being diagnosed with ankylosing spondylitis (a usually-crippling disease) he fired his doctor and undertook a regimen of vitamin C, healthier eating, and laughter, reportedly checking into a hotel and watching comic movies to improve his mood. He was said to have "laughed his illness away" and outlived his doctor's dire prognosis by more than 2 decades.

In 1992, researcher Lydia Temoshok published The Type C Connection in which she shared her research about the connections between emotional self-repression and risk for cancer development--diametrically opposite to Sontag's attempt to relieve the sick of their "guilt" for having gotten sick in the first place. Research in psychoneuroimmunology has demonstrated that the minds of laboratory animals can be conditioned to make themselves sick, by directly manipulating their immune systems.

A comprehensive review of the research and philosophy surrounding this question is beyond the scope of an online blog. But what I have here is enough to establish a few important points:

1. The mind definitely influences what happens to the body, whether we mean risk for illness or hope for recovery and cure.
2. We don't really understand how this works or what its limits are.
3. Assigning blame to an ill person because of these facts is both unkind and a failure to admit how little we know about consciousness and its influence on health.

It's possible that thought itself may be less controllable than we believe. We are taught that there is the world of the body and the world of the mind. So we have medicine and biology to address the former, and psychology and theology to address the latter. This dualism is, I believe, a fundamental failure of today's medical philosophy.

In homeopathic medicine, the state of imbalance of the "vital force" described by homeopaths itself leads to behavioral abnormalities and disturbances. In short, "mental" illness is both material and energetic and not fully amenable to "self" control. Interestingly this squares with the work of today's neuroscientists, who postulate that those things we believe are our "thoughts" that are under our "control" themselves arise before we could possibly "think" of them. In other words, brain science suggests that volition is illusory: we have a thought before we think we thought the thought!

In nursing science, the late Martha Rogers argued that there was no separation between the body and the mind, that they are co-located in a perceivable body, but also extensive beyond the border defined by the body itself. Nurse researcher Elizabeth Barrett writes about the "simultaneity model" of human existence (and one could ask, of all life forms?) in that what we think, and what we are, materially, in the world, are inseparable, and that a full understanding of human health and disease will elude us until we reconcile ourselves with this fact.

Of course, that makes ordinary medical treatment of our day to day sufferings in The Factory problematic. It also makes our social construction of health and illness difficult for ordinary people to navigate. To say someone "bravely fought" against cancer (and lost), as I read often in the local obituaries could say they didn't "fight" hard enough, or that their aim was untrue, or that they harbored a hidden death wish. But to say that their will doesn't (or didn't) matter seems to contradict our observations and a growing body of scientific research that that suggests it does matter.

How do we understand that? How do we unlock its potential? And how do we do so without condemning those who get sick to guilt and those who do die to posthumous humiliation?

I'll write about this more in upcoming blogs. Happy new year.