Will Technology Keep Us From Thinking?

The New York Times quotes Plato’s play Phaedrus to make a point about Facebook’s use of data. They make the claim that “Technology promises to make easy things that, by their intrinsic nature, have to be hard”.

In the play, a wise king, Thamus, is offered the art of writing by the god Theuth.

The art of writing, Theuth said, “will make the Egyptians wiser and give them better memories; it is a specific both for the memory and for the wit.”

But Thamus rebuffed him. “O most ingenious Theuth,” he said, “the parent or inventor of an art is not always the best judge of the utility or inutility of his own inventions to the users of them.”

The king continued: “For this discovery of yours will create forgetfulness in the learners’ souls, because they will not use their memories; they will trust to the external written characters and not remember themselves.”

It struck me how this analogy is also perfectly applicable to the new technologies entering the field of medicine, from EMRs with “Decision Support” to Artificial Intelligence.

Just like there are store clerks who can’t make change (for customers who still pay with money) or school children who can’t multiply without a calculator, will the doctors of the future be helpless if dislocated from the propping up we are now starting to expect should they ever have to practice in a natural disaster, remote area or mass computer hacking situation?

Premortem Examination Can Help Decisions

This was an interesting read in the Sunday paper. Of course, the word “premortem” brought to mind “vivisection” in H.G. Wells’ “The Island of Dr. Moreau”, which I remember reading as a teenager:

Instead of weighing real or imagined pros and cons of two alternative courses of action, imagine the choice has already been made.

“The psychologist Gary Klein has developed a variation on this technique. He calls it a “premortem.” As the name suggests, the approach is a twist on the medical procedure of post-mortem analysis. In a post-mortem, the subject is dead, and the coroner’s job is to figure out the cause of death. In a premortem, the sequence is reversed: “Our exercise,” Dr. Klein explains, “is to ask planners to imagine that it is months into the future and that their plan has been carried out. And it has failed. That is all they know; they have to explain why they think it failed.”

Imagine having to make a difficult treatment decision. Then consider being fast forwarded into the future. Your patient’s surviving spouse says, in a faint voice:

“Doc, you made the wrong decision…”

Cold Showers: From Hippocrates to Neurobiology

The Father of medicine prescribed cold baths for many of his sick patients. The Romans and Turks built bath houses, where health seeking citizens would go from a hot sauna-like room to a tempered room where they gradually finished sweating and finally climb or dive into an ice cold swimming pool. Modern Scandinavians, presumably following Viking traditions, cut holes in the ice and more or less briefly immerse themselves in frigid midwinter waters, with or even without a preceding sauna.

I read an interesting interview in the Harvard Buisnesss Review in the seat behind the copilot of a very small Cessna on my way back to Bar Harbor from the #HarvardWriters2018 workshop.

Dutch researcher Dr. Geert A Buijze and colleagues demonstrated that a daily cold shower, even 30 seconds of ice cold water at the end of a more typically soothing warm one, decreased workers’ sick time by 29%.

The explanation, he speculates, could be that cold water induces shivering and raises cortisol levels, which in turn increases energy and stamina. It could also have something to do with activating brown fat, or maybe it’s even a placebo effect, but, as we now know, even the placebo effect is reasonably well explained by modern neurobiology.

Celiac Disease and the Gut-Brain Axis

Gluten free diets have become somewhat of a fad lately, and many people say that they are not offering any health benefits for most people. But, given the wide range of symptoms and conditions that seem to be associated with celiac disease, it makes you wonder.

I had been aware of the physical symptoms claimed to be triggered by gluten sensitivity, but an article in The New York Times by Moises Velasquez-Manoff describes several cases of neurological symptoms – “seizures, hallucinations, psychotic breaks and even, in one published case, what looked like regressive autism, all ultimately associated with celiac disease.”

The mechanism is at least partly understood:

“Scientists at the Royal Hallamshire Hospital in Sheffield, Britain, have identified an antibody that binds to a version of transglutaminase, called TG6, which occurs primarily in the brain. This antibody, they argue, may identify celiac patients at risk for neurological complications. When celiac patients with ataxia adopt a gluten-free diet.”

“Celiac disease differs from most other autoimmune diseases in one critical respect: The trigger, gluten, is known. And in most cases, removing gluten will turn off the autoimmune destruction in the gut. Around 10 percent of people with celiac disease, and possibly more, are thought to suffer neurological symptoms, ranging from headache and nerve pain, to ataxia and to epilepsy.”

Some researchers even claim that 25% of schizophrenics have anti-gliadin antibodies, compared to only 3% of the general public, but not all patients whither neurological symptoms associated with gluten intake carry this marker.

Certainly, food for thought…

Only Half a Physician

“You’re only half a physician if you’re just good at your craft. Unless it’s coupled with patient-centered care and humanism, it’s suboptimal care.”
– Arnold P. Gold, MD

I happened to read an obituary in The New York Times this morning about a pediatrician who started the tradition of introducing swearing of the Hippocratic Oath at white coat ceremonies early on in American medical schools instead of just at graduation.

I added him to my mental list of imaginary mentors.

“Dr. Gold, who treated patients and taught for more than 50 years at the Vagelos College of Physicians and Surgeons, part of Columbia University Medical Center, had a cheerful but authoritative demeanor. On rounds, he wanted to know about the life of the patient, not just his vital signs. He talked face to face with his young patients, often sitting on the floor and playing with them.
“He enjoyed kids and he dealt with them in a wondrous way,” Dr. David Mandelbaum, a former student of Dr. Gold’s at Columbia who is a professor of neurology and pediatrics at the Brown University Alpert Medical School, said in a telephone interview. “He always sensed what a kid was able to do, not what he couldn’t do.”
He was also concerned with the patients’ parents, spending time, for example, to understand the effects that a neurologically damaged child’s condition had on their marriage and finances. And if he could not give them hope, he gave them answers.”

Race in the Age of Personalized Medicine

On one hand, it may seem that physicians should consider their patients’ racial background when making diagnostic or treatment considerations. For example, certain blood pressure medications work better than others in African-American patients. But on the other hand, not only are racial boundaries fluid; features we have thought of as racial are often not. For example, sickle cell trait is more common in the Greek town of Orchomenos than it is among African-Americans.

Today’s The New York Times has an interesting essay about the need to go deeper and move beyond racial thinking when it comes to genetics, but to perhaps keep racial awareness when it comes to considering social or cultural risk factors for disease.

“Science seeks to categorize nature, to sort it into discrete groupings to better understand it. That is one way to comprehend the race concept: as an honest scientific attempt at understanding human variation. The problem is, the concept is imprecise. It has repeatedly slid toward pseudoscience and has become a major divider of humanity. Now, at a time when we desperately need ways to come together, there are scientists — intellectual descendants of the very people who helped give us the race concept — who want to retire it.”

Friendly Dogs and Human Genetics

The reason dogs are friendlier than wolves appears to be a genetic one, according to an article in The New York Times:

“A group of scientists from Princeton, Oregon State University and other institutions combined behavioral and genetic studies of 16 dogs and eight captive, socialized wolves to pin down changes in two genes on a region of one chromosome that were associated with hyperfriendliness in dogs. The two genes, GTF2I and GTF2IRD1, are also associated with Williams-Beuren syndrome in humans.”

I found this interesting, because of my general love for dogs and my heartfelt memories of the three extremely affable beagles I have lived with over the years. Also, I know a boy, now in his early teens, with Williams Syndrome. I wrote about him in my first year of blogging in a peace called “All God’s Children”:

“Joey didn’t reach his developmental milestones; his eyes didn’t seem right and he had an unusual, broad grin, which he always flashed. By age two he was diagnosed with Williams Syndrome, a rare genetic disorder that affects one in 7,500 newborns.

Joey, in typical fashion for Williams Syndrome children, is extremely gregarious, even with strangers. He is a favorite with the nurses. He isn’t potty trained, cannot make three word sentences, and cannot make age-appropriate drawings.

His parents elected to give him the 4-6 year-old shots yesterday, and he protested loudly. Immediately afterward, he wanted to kiss the nurses.”

My 2008 piece concludes:

“We must all remember that our children are only loaned to us. We have a natural desire to see them grow up to be healthy and happy, and more often than not I think we hope they will be a lot like us. Our task and privilege as their parents is to see them for who they are, and help them reach their potential.

A youngster with Down’s or Williams Syndrome can be more capable of receiving and returning the love of their parents than a child without genetic challenges, and a healthy child can be killed in a freak accident in the matter of seconds. The wisest parents cannot protect their children from making their own mistakes, and even the elderly often have to grieve the loss of a child.”

Single Dose Propranolol and Reexposure to Phobia or PTSD Triggers Brings Cure

After one round of treatment, the arachnophobes held the spiders in their bare hands.

http://www.nytimes.com/2016/01/24/opinion/sunday/a-drug-to-cure-fear.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

When Hospital Paperwork Crowds Out Hospital Care

A FRIEND was recently hospitalized after a bicycle accident. At one point a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.
She mumbled, “4 to 5.” The student put 5 into the computer — and then they left, without further inquiring about, or relieving, my friend’s pain.

http://www.nytimes.com/2015/12/20/opinion/sunday/when-hospital-paperwork-crowds-out-hospital-care.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Fish Oil May Have More Benefits for the Inuit than for Westerners

I have heard many people advocate eating local foods, and avoiding things from far away. Human metabolism, some say, isn’t the same everywhere. Now there is new evidence that whale blubber may be better for the Inuit than for westerners.

In the 1970s, Danish researchers studying Inuit metabolism proposed that omega-3 fatty acids found in fish were protective. Those conclusions eventually led to the recommendation that Westerners eat more fish to help prevent heart disease and sent tens of millions scrambling for fish oil pills.

Today, at least 10 percent of Americans regularly take fish oil supplements. But recent trials have failed to confirm that the pills prevent heart attacks or stroke. And now the story has an intriguing new twist.

A study published on Thursday in the journal Science reported that the ancestors of the Inuit evolved unique genetic adaptations for metabolizing omega-3s and other fatty acids. Those gene variants had drastic effects on Inuit’s bodies, reducing their heights and weights.

Rasmus Nielsen, a geneticist at the University of California, Berkeley, and an author of the new study, said that the discovery raised questions about whether omega-3 fats really were protective for everyone, despite decades of health advice. “The same diet may have different effects on different people,” he said.

http://www.nytimes.com/2015/09/22/science/inuit-study-adds-twist-to-omega-3-fatty-acids-health-story.html?smprod=nytcore-ipad&smid=nytcore-ipad-share