Brain Mets or Psych?

An advanced cancer patient refusing treatment, presents all sorts of problems for family and providers. Compound this with bizarre psychiatric symptoms and contrary behavior and you have legal and ethical challenges as well. The first thing one does is order a psych consult, a tenuous diagnosis, even commitment, in the extreme, restraints. This Perspective Articlre in NEJM describes such a dilemma. Dec 8 375 2220-2221 DOI 10.1056/NEJp 1612129

My first rotation as a junior medical student -- UMichMed '60 in "Old Main," a 2000 bed hospital with 20 bed wards -- was "Blue Female" 2nd floor east, exclusively advanced breast cancer. Each ward had its own personality, largely driven by the nursing staff and the patients themselves. Blue. Female's was one of mutual support and suprising spirit; they shared in one another's condition, complications, prognosis and listened through the curtains to one another's daily rounds. Despite turnover and a frequent empty bed, you could feel the strength and moral.

Not infrequently, however one or two would become recalcitrant, atgumentive and display bizarre ideation. Residents and young professors, new to Blue Female, would invariably order a psych consult and speculate over which psych diagnosis. We did not have MRI, but everyone in the ward knew the problem was metastice to brain, even the ward clerk who did not rotate. We did not need an MRI or for that matter a psychiatrist who usually failed to figure it out.

Not long ago, I listened to an ethicist presentation of an almost identical case to the one in the NEJ. The case involved court orders for treatment and, early on, a court ordered confinement for psychiatric care and family guilt. No one thought to order an MRI.

Sadly we have losst the beauty of bedside teaching, supportive wards when support is needed the most and that's not to mention autopsy which would indeed figure it out, without the family having to say, she went crazy in the end.

Patient Care

Historical evidence suggests that the three measures of quality patient care we're infant mortality, bedside teaching and autopsy rate. We once ranked hospitals on these three considerations. We can blame politics/greed, misplaced confidentiality and stupidity respectively for their decline. Thr Global Burden of Disease statistics confirms, with the US at near the bottom in every category. Some of the poor outcome is behavioral and environmental, but dumbing down medical education to met the lower standards is not a solution. Furthermore, where we once lead in compulsive public health, today it's hard to find.

Infant Mortality

5.8 / CIA World Fact Book

56th or 58th depending on the listing of the Organization for Economically Cooperation and Developement 

GDP China 19.8 t

        EU.     19.4

        USs.    17.8

Are things really, "ok and getting better"?

The Cadusus vs. the Rod of Asclepius

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The Cadusus characterized by a rod with two snakes wrapped around it with wings, originates from ancient Greece, the winged herald’s winged staff, carried by Hermes, the messenger of the gods, also viewed as a protector of herdsmen, merchants, travelers and thieves.

The Roman adaptation, associated with Mercury, became the certification of fair trade, commerce and balanced exchange, the wings denoting protection by Roman law.

The Rod of Asclepius, on the other hand, stood for healing; from Asclepius a physician lost in pre written history but so venerated he became a god and his daughters, gods of hygiene, healing and health. By 4,500 BCE Asclepiads were of a school or guild of ethical and scientific physicians, physics as they were called then, later medicine (Greek, mindfulness) as taught in Greek medical schools by Hippocrates and his successors. The rod of Asclepius symbolized a concept of ethics, art and science that persists to this day despite epic periods of religious and political interference.

In North America, the Winged Cadusus comes to represent much the same as under Roman law, a symbol of protected trade, the commerce of healthcare, directed by politics and law.

DNA

One might be curious as to the structure of the most primitive, oldest DNA and from what it evolved. Also, what might be the uniqueness in Leonard Bernstein's or Einstein's genome. Evolutional pressure appears to no longer favor Inteligence, rather the opposit. Is such a healthcare issue? If so?? One fears to ask.

Evidence Based Medicine

If evidence based medicine were a stock market entity, it would be time to sell as a post mature overhyped entity. There is nothing wrong with the concept, needed in many ways, a handy reference but now a medical cliche. 

Despite the rigorous academic basis, the statistical validation, the scientific approach, which it is, the resulting best evidence protocol stifles the imagination, the trial and error, the inductive reasoning of the scientific method and the focus on individual patients. Medical-legally, best evidence tends to overshadow, well documented past studies, antidotal wisdom and individualized imaginative initiatives - progress itself and time - focusing instead on education reform, and training young physicians to a rigid structured algorithm, physicians who will follow the rules. Furthermore, mass studies of distant populations, fail to account for the environment, DNA, local epidemiology or personal concerns. It may even codify some highly profitable practices contributing gladly to the terms of best evidence.

Considering the cost, the dismal status of EHRs, professional communication and continuity of care, one might "sell short" and look beyond best evidence for the next higher level of academic and professional excellence, perhaps the genome and quantum biology, requiring a PhD MD rather than a Feldsher.

Victor McKusick 1921-2008 Genitic Disorders

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