By Dov Michaeli

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Seriously, did you hear about the two guys bragging about their incredible memories despite their advanced age?

“I can remember every baseball statistic of the last decade”

“Big deal, I can remember every meal we ate at a restaurant in the last 10 years. By the way, last night we went to a fantastic restaurant “

“Really? What’s its name”?

“It’s called…it’s called… What do you call the colorful flower that has this great fragrance”?

“You mean a rose”?

“Ah, yea. Hey Rose, what’s the name of the restaurant we went to last night”?

Well, this guy probably had an incipient dementia. But most normal adults suffer from a certain degree of memory loss as they age. Nothing abnormal, just part of getting old.

What’s happening to our brain as we age?

In a word (or two): we lose neurons. During the normal maturation of the brain, we lose neurons almost from birth. This initial loss, lasting to the age of puberty, is actually very healthy. We are born with a great excess of neurons, and by dropping a large number of them the brain becomes better at filtering out extraneous “noise” and more efficient at transmitting and storing information. You have heard it said that the child and adolescent brain “is different”; less judgment, sometimes weird reasoning, and predilection for risky behavior. Part of the problem is that lack of well-defined brain structures which results from the surfeit of neurons. One theory of childhood autism is that the process of neuronal loss is somehow defective in these children, resulting in an inability to filter out the huge amount of external stimuli bombarding the brain. Hence their withdrawal from interaction with people.

Alas, once the sculpting of the brain attains its ultimate beauty, the “sculptor” does not call it quits. We continue losing neurons. Most of these losses are without much consequence, because they are not noticeable in daily life. We may have trouble learning a new language, or solving a mathematical problem; so who cares? But of a more daily consequence is that as we lose hair cells in the inner ear (these cells are neuronal), we start losing our auditory acuity. First go the high frequency sounds, and our ability to discriminate between certain consonants. Later on, we become prime targets of hearing aids ads.

The most disconcerting to most adults is the loss of memory through loss of neurons in the hippocampus, this sea-horse shaped brain structure, where different types of memory (visual, auditory) are integrated. The memory losses can be of varying severities –from the occasional forgetfulness (where did I leave my car keys?) to forgetting one’s wife name, if only for a split second.

Such loss of memory can be recreated in rats by disrupting the generation of new neurons in the hippocampus. But even more interesting, memory could be restored by allowing stem cells to generate new neurons. But rats are not human (although the opposite is not always true), and human memories are probably a much more complex affair than the rat’s. So the nagging question always lingered –can human memory be restored by neuronal stem cells?

In the latest online edition of the journal Brain scientists from the University of Florida tried to answer the question. The UF researchers, in collaboration with colleagues in Germany, studied 23 patients who had epilepsy and varying degrees of associated memory loss. They analyzed stem cells from brain tissue removed during epilepsy surgery, and evaluated the patients’ pre-surgery memory function.

In patients with low memory test scores, stem cells could not generate new nerve cells in laboratory cultures, but in patients with normal memory scores, stem cells were able to proliferate. That showed, for the first time, a clear correlation between patients’ memory and the ability of their stem cells to generate new nerve cells. The scientists said that the work is potentially applicable beyond epilepsy, but first more studies have to be done with larger numbers of patients and more detailed testing of related brain structures and function. In addition, researchers still need to figure out how exactly the newly generated nerve cells contribute to learning and memory.

Potential therapy

Obviously, even the guy who forgot his wife’s name is not going to get neuronal stem cell implanted into his brain any time soon. But there is a ray of hope. Extensive research is already being done to identify the natural substances, most likely growth factors peptides, which activate stem cells to form mature nerve cells, involving the use of fMRI and PET imaging techniques. One can envision the use of such peptides in stimulating the formation of new neurons. Better yet, drug developers could dream up (while sitting at their computers) drugs that would mimic the in actions of these peptides. I can already hear the drug commercial featuring an 80 year old memory whiz who could recite the restaurant menu of last night’s outing with…what’s her name?

by Gregory Shumer, Medical Student

Introduction by Margaret (Maggi) Cary, MD, MBA, MPH: I am a physician and writer. I teach “Personal Essay and Narrative Medicine: Writing to Make Sense of Medical School and Becoming a Physician” at Georgetown University School of Medicine. Medical school is an intense environment, filled with new experiences, feelings and thoughts. Personal essay is where writers intersect with our environment to make sense of the world around us with a personal, subjective view. Narrative medicine uses a story-essay to discover meaning and purpose in illness and healing. Writing can improve our ability to reflect, stay focused and interact with patients and colleagues.

At the core of the Doctoring Curriculum at Georgetown is the importance developing altruism and concern for each patient as a person, as well as the foundation for concern for the health of the population as a whole. One of the most significant outcomes of this class is my students’ realization they each experience doubt, elation, the thrill of discovery and humility. They are dedicated to becoming excellent and caring physicians. I am hopeful for the next generation of physicians and will be sharing their essays with you.

Flashback to a year ago: I’m a first-year medical student–a fledgling, a novice–trying to integrate countless facts into a coherent understanding of how the human body works. Professors slam me with two months’ worth of information inside of two weeks’ time. They tell us that this is a necessary process, one that all doctors must go through: we must first learn the science of medicine before we can master the art of healing.

My life revolves around tests, labs, deadlines, long hours in the library and very close relationships with the baristas at Starbucks.

In the midst of this chaos, I developed a crippling ankle condition that transformed me into a concerned patient for the first time in my life. The pain started as a dull ache that I experienced only during exercise. Then it gradually worsened, to the point where I could barely walk to school the day after I’d played a basketball game. A golf-ball-sized bulge stuck out from my right ankle, and my two months of medical education suggested no remedies.

It was at this point–worried, looking for answers and desperate to get back to normal–that I decided to see someone.

Dr. B, the orthopedist I consulted, had attended a prestigious medical school and had gone on to complete an illustrious residency program and a fellowship specializing in the foot and ankle. I waited thirty minutes in the exam room before he walked in, flanked by a second-year resident wearing a long white coat. Dr. B himself wore a gray sports jacket and tie. His hair was slicked back, and he radiated authority.

After introducing himself, he glanced at my x-rays and MRI and started examining my ankles.

“You see this,” he said to his resident. “I can fit my two fingers underneath his left foot, but none under his right. This patient has been running his arch into the ground.” Glancing back at me, he told me to walk in a straight line.

As I walked, he said to the resident, “Yup, look at that. He’s pronating way too much on his right side. Something’s off with the mechanics there.”

He went on talking to the resident, never addressing his comments to me, and using medical terms that I didn’t understand.

Finally, scribbling in my chart, he said, “Sit down.”

I sat, feeling confused.

“All right,” he said, “I’m going to order you some rehab, and I want you to get a pair of orthotics. Rest your ankle, and come back and see me in five months.”

He handed me the chart, stood up and turned to leave.

“When you say ‘rest my ankle,’ what does that mean exactly?” I asked his back. “I was hoping to play basketball in a few weeks, and I want to run a 5K a couple of months from now.”

Turning back and grinning wryly, he said, “I wouldn’t do any running until you see me again. The way your ankle looks, I’m more concerned with your walking normally at age thirty-five than running in a 5K next month. Any other questions?”

He seemed annoyed at being delayed. For my part, I felt panicky. What had seemed like a small problem now seemed like much, much more.

“Is surgery an option?” I asked.

He paused, then said it was risky and probably not the best idea.

My mind was racing. I couldn’t bear the thought of giving up physical activity–one of the few pleasures in my life of stress and studying. But I asked no more questions, for fear of irritating him further.

Dr. B turned again, opened the door and walked out.

My visit to Dr. B was the worst encounter I’d ever had with a physician. I’d gone in seeking answers, guidance and direction. I came out feeling scared, confused and worried that I would never be the same on my feet again.

I didn’t make a follow-up appointment .

I did start physical therapy, as he’d recommended, and I made an appointment with a podiatrist recommended by a friend.

The physical therapist was wonderful. And he was incredulous when I told him of Dr. B’s concerns about my ability to walk later in life.

“A doctor told you that?” he said. “I’ve seen people with worse problems than yours recover 100 percent. And you’re young! With rehab and stretching, we can have you running and playing basketball again. I’m confident of that.”

I left the session with a plan for my recovery, and feeling a lot more hopeful.

Then I saw the podiatrist, Dr. Stevenson. Podiatrists attend podiatry school instead of medical school and are trained in the diagnosis and treatment of foot and ankle conditions. When I repeated Dr. B’s words to him, he looked at me and said, “You know, I’ve seen hundreds of people with problems worse than yours, and you know how many I’ve told they would never run again?”

I shrugged.

“Zero,” he said, making a circle with his right hand.

After having me walk in several straight lines, he studied my feet and ankles for a long time. He showed me an anatomical model and explained what was going on: My arch had started to collapse and apply extra pressure on an already injured posterior tibialis tendon. With rest and the help of an orthotic device, the tendon could heal–and I could return to running and playing sports. He then sat down and answered all of my questions; I had plenty. I left feeling much more optimistic about my condition.

Being a patient and seeing three different professionals gave me valuable insights into the doctor-patient relationship. Although Dr. B had attended prestigious schools and on paper had more qualifications than the physical therapist or podiatrist, his lack of compassion and poor communication skills made him a far inferior clinician.

I promised myself at that point, while still a beginning medical student, that I’d never practice medicine like Dr. B. I want to be a caring physician who not only makes the correct diagnosis but also facilitates the healing process by listening to, reassuring and working with patients.

In my first year of medical school, when the focus had been on memorizing medical and anatomical facts, my own anatomy managed to teach me a pointed clinical lesson without any cramming at all.

A year later, many of the facts I stuffed into my head are lost to me, but that lesson has stayed. It had better–if I’m to be the kind of doctor that I myself would want to go to.

About the Author:

Gregory Shumer is a second-year medical student at Georgetown University School of Medicine. After graduating from the University of Michigan with a degree in Biology and Asian Studies, Gregory spent a year teaching English to middle-school students in rural Japan. He started writing essays, poems and short stories in high school and now continues to enjoy writing as a medical student. This article was initiatlly posted in Pulse Magazine, an online magazine that uses stories and poems from patients and health care professionals to talk honestly about giving and receiving medical care.

by Patricia Salber

Here is another good one from Fierce Healthcare, written by Dan Bowman.  It is so bizarre that, if you saw this in a movie, you would say, “Not believable!”

Misidentified patient allegedly beaten, held against will

by Dan Bowman

In a case that underscores the importance of one of the most basic patient safety requirements––a male car crash victim allegedly was misidentified as a female cancer patient by a Maryland hospital and beaten up by security guards after attempting to leave. The victim–46-year-old Joseph Wheeler–is suing Prince George’s Hospital for more than $12 million.

The incident occurred in June after Wheeler was taken to the Cheverly, Md., hospital for torso trauma from a car accident, ABC News reports. According to Courthouse News Services, Wheeler woke up hungry the day after the accident, but was told by a nurse who checked his ID bracelet that he wasn’t allowed to eat because he was scheduled for surgery to remove a cancerous mass from his chest. Wheeler then checked his bracelet, which allegedly bore the name of a female patient 13 years his junior.

When Wheeler tried to leave, a different nurse told him he wasn’t allowed to leave and called for security. Two security officers then unleashed an assault of physical and verbal abuse on Wheeler, a complaint filed in Prince George’s County Circuit Court details, shoving him into a metal railing, punching him in an elevator and shouting expletives. Wheeler then was taken to an unnamed “lieutenant” who questioned him and told him he was going to be taken back to his room and given a new ID bracelet. When Wheeler refused to give up his first bracelet, stating that he just wanted to leave, the lieutenant allegedly became angry, yelling, “You do not tell me when you want to leave! You will leave when I tell you you can leave!”

After another run-in with the security officers, Wheeler met with a hospital administrator, and eventually was granted permission to leave upon signing a release form stating he was leaving against medical advice. Wheeler immediately was treated at another facility–St. Mary’s Hospital–for broken ribs, a sprained shoulder, a ruptured spleen and a concussion.

Among the charges filed by the Wheeler’s lawyers are assault and battery and false imprisonment.

George Annas, chairman of Health Law, Bioethics and Human Rights at Boston University, told ABC News that the only time a patient is restrained is when they can’t make sound decisions because of delirium or intoxication, or if they are a potential danger to themselves or others.

“A hospital is not a prison, and usually a patient can always leave,” Annas said.

To learn more:
- here’s the actual 
- read this ABC News
- check out this Courthouse News Services

By Michael L. Millenson

The humble tonsillectomy has been at the center of controversies over practice variation, inappropriate surgery and avoidable harm for decades; indeed, well before the terms to describe those problems were formally articulated.  Now, thanks to the recently unearthed Tonsillectomy Riots of 1906, you can add “patient empowerment” and “informed consent” to that list.

Tablet, an online magazine of Jewish news and culture, rescued the Tonsillectomy Riots from historical obscurity. Piecing together old newspaper accounts in English and Yiddish, the magazine told what happened on New York’s heavily Jewish Lower East Side on a steamy day in June when “50,000 immigrant mothers descended on their local public schools demanding to see their children, having heard that there was a Board of Health-sanctioned child slaughter taking place.”

The article continues:

Greeted by locked doors, the screaming throngs surrounded the schools and began smashing windows and pounding on doors….During this rampage, gangs of immigrants cursed out principals, fought police, and attacked anyone in the street bearing the slightest resemblance to a doctor….Some of them raided vegetable pushcarts for ammunition while others, like one young man who pulled a revolver on a member of the Board of Health, used more serious weapons.

Word had spread among the Jews of the Lower East Side that uptown doctors were coming into downtown public schools and were, as described in the daily Varhayt, “cutting the throats of Jewish children!” After a two-hour assault, the rag-tag army achieved victory: Their kids were released early and alive, proving that no such slaughter had taken place.

From the viewpoint of the befuddled Board of Health, this debacle was likely filed under the heading, “No good deed goes unpunished.” After tonsillitis reportedly kept scores of Jewish students out of school, the principal recommended the children have tonsillectomies. (The idea of a contagious sore throat was apparently not part of folk wisdom at the time.) When mothers complained they couldn’t afford either the doctor’s fee or taking time off to go see one, physicians were asked to perform tonsillectomies at the schools. Days before the riot, doctors had performed 83 tonsillectomies at one elementary school. That’s when the trouble began.

The English-language press reported that the operations all had parental consent. But the Yiddish press told of children sent home with slips of paper their parents couldn’t read using terms they couldn’t understand even when translated.

“All they knew was that when the children returned home from school after their procedures, they did so drooling mouthfuls of blood, barely able to speak,” Tablet related. “Shocked, their parents asked what happened. ‘Doctors cut our throats,’ the children replied.’ Rumors of a wholesale slaughter leapt like wildfire throughout the tenements and shops…and street-corner orators got into the act, screaming about the massacres in the schools, comparing them to the pogroms in Russian-ruled Poland.”

The riots quickly fizzled, but the police maintained a heavy presence until the end of the school year.

What might we take away from this story, apart from nostalgia for a time when false rumors could quickly spread without any help from the Internet?

To begin with, it reminds us how strong and durable physician paternalism has been. It was only the year before the riots that the Supreme Court ruled that a doctor had to tell a patient in advance what procedure he was doing. It was not until the 1950s that doctors were required to disclose risks and benefits in advance and not until the 1970s – seven decades after the Tonsillectomy Riots – that doctors had to disclose them in layman’s language.

As the physician ethicist Jay Katz wrote doctors, acting as “rational agents” on the patient’s behalf, intuitively believed that sharing information with patients was “inimical to good patient care.”

Even today, how often do physicians engage in genuine shared decision-making? And how well is even basic information conveyed to those who have scant education and even less familiarity with English?

The Tonsillectomy Riots also remind us about the durability of profitable medical procedures even in the face of evidence against them. By the mid-1930s, fully one-third of all operations performed under anesthesia in the United States were tonsillectomies. Around that same time, research that included a pioneering study of New York City schoolchildren began to show that the tonsillectomy rate was more dependent on physician preference than on objective indicators. Nonetheless, the growing medical literature on inappropriate and even dangerous tonsillectomies had little effect on actual practice until Congressional hearings in the 1970s spotlighted parents whose children had been harmed or killed. Only then did the profession react.

On the other hand, the Tonsillectomy Riots also illustrate the dangers of putting consumerism on a pedestal. In medicine the customer is not always right. The mob hysteria and irresponsible rhetoric of a hundred years ago are not so dissimilar from the shrill cries from our own time that vaccines are causing autism in the young while the government is plotting death panels for the old.

Finally, the fact that the Tonsillectomy Riots vanished for so long reminds us that the history of medicine is largely written as a chronicle of physician actions. Putting patients into that picture adds a perspective that is far too often absent.



by Patricia Salber

Hoarding is definitely out of the closet now that the syndrome has its own TV show and an Emmy award winning movie (Grey Gardens).  Nevertheless, fatal cases of hoarding  still grab headlines, such as this one:

“Missing Vegas woman found under garbage pile in her own home

Las Vegas police spent four months searching for Billie Jean James, but it was her husband who finally found the 67-year-old woman’s body last week — under a pile of garbage in their home. Billie Jean was something of a hoarder, it seems. The mess was bad enough that it hid James’ remains from search dogs when they went through the house.  Las Vegas police spent four months searching for Billie Jean James, but it was her husband who finally found the 67-year-old woman’s body last week — under a pile of garbage in their home. Billie Jean was something of a hoarder, it seems. The mess was bad enough that it hid James’ remains from search dogs when they went through the house.  The Clark County Coroner’s office said Friday the corpse found in the clutter-filled home belongs to 67-year-old Billie Jean James. A spokeswoman says it could take weeks to determine when and how she died. (AP Photo/Julie Jacobson).  Read more: http://blogs.kansascity.com/crime_scene/2010/08/missing-vegas-woman-found-under-garbage-pile-in-her-own-home.html#ixzz0y8VLAGxk“

Reading this story on the internet yesterday led me to hunt down and now resurrect one of TDWI’s most popular posts:  Diogenes Syndrome: self-neglect and hoarding –  not a pretty picture.  Click on the link to learn more about this unusual, but potentially fatal condition.

by Michael Millenson  )

(Thanks to Michael for sending this post, originally published on The Health Care Blog, along for posting on TDWI)

A recent contributor to The Health Care Blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.

The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.

Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medicalcare driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”

Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.

The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”

A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.

Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.

So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.

When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.

At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.

The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.

However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AH CPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”

Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.

Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.

I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.

Michael Millenson is president of Health Quality Advisors LLC, a principal in Health 2.0 Advisors and author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.”