Genes: Masters of Health and Disease

The science of genetics has changed so much over the last 50 years that it is hardly recognizable to someone like me who took my last genetics course in medical school. At that time, we were taught that an individual’s basic characteristics are inherited from his/her parents by means of genes that are carried on 23 pairs of chromosomes, twisted strands of DNA that carries the code for life in the nucleus of all of our cells. Genes were thought to be immutable, fixed for life, except for the occasional mutation. Identical twins were thought to be exactly alike because they carried exactly the same set of genes. So your (phenotype), physical size, skin color, eye color, basic physical structure, susceptibility to various diseases etc. are determined by your genetic make-up (genotype), and this wasn’t thought to change. It was clear, however, that there were other influences on the development of a person. Even identical twins with the same genetic makeup (nature), particularly those raised separately, developed some differences in their characteristics, such as intelligence, athletic ability, health, preferences and accomplishments depending on influences from their environment (nurture).

It was recognized as far back as Aristotle that parents contributed “messages” that led to the formation of a new child. This was a big step from the earliest theories that the male contributes a tiny miniature person to the female who in turn nurtures it in her body until the time of birth. The state of knowledge about inheritance remained pretty much the same until the mid-1800s and the observations and experiments of Darwin and Mendel. The work of these two men began almost a century of observations and experiments to try to determine what accounted for the formation of new life and inheritance. It wasn’t 1944 until that DNA was recognized, through a series of imaginative and exhaustive studies, as the substance that carries the genetic code and that structurally similar RNA reads the DNA genetic template and carries the message from the nucleus to the mitochondria in the cells which in turn manufactures proteins that implement the structures and functions of the body.   What has followed is a deep understanding of the structure of DNA, how genes are arrayed on the various chromosomes and how it carries out its functions. We have also learned the effects of genes, far from being static, can be amplified, diminished, activated or turned off that this is the primary mechanism mediating changes in the body’s health and functioning throughout our life time from fetus to old age.

Humans have somewhere in the neighborhood of a billion genes. The numbers which are active at any point in time are a few thousand. In other words we have many sites on the genome that seemingly aren’t doing anything. A discovery of the last decade is that many of these seemingly blank spots are actually switches that turn on and off other genes largely as a result of challenges encountered from the environment. These are called epigenes. So we have many more genes than those that are active at any point in time. In fact, we have vast warehouses of inactive genes that can respond to new or different challenges. We don’t know what all of them are doing, but it has become clear that many of the functional changes that occur during our life times are mediated through epigenes switching on and off the genes that control functions. One example of a functional change that is turning out to be related to changes in gene function is the development of cancers. We have come to understand that many kinds of cancer (perhaps all) are related to genetic functional changes probably through the activation of genes that previously were silent. The development of the body’s many different kinds of cells (liver, blood, heart, etc.) is probably related to which genes have been activated. Since all cells of an individual have the identical gene complement at birth, something has to instruct the cell to become a liver cell or a blood cell, and this is likely to be mediated through epigene activation of the appropriate structures as the embryo develops.

There are many diseases that appear to have a genetic basis. Some genetic diseases show up at birth.   In these cases, if you have the causative genes in your cells, the disease develops soon after birth. The metabolic defects that cause sickle cells, cystic fibrosis and inherited immunodeficiency are present and manifest from the beginning. However, there are no apparent problems at birth for those who carry genes for type 1 diabetes (onset usually in childhood), schizophrenia (late adolescence), manic-depressive disorder (adulthood), depression or Parkinson’s disease (late life}. The gene or genes have been present from birth, but they apparently don’t have an effect until they are “turned on”. In some instances, as with the case with cancers, environmental factors interact with genes or epigenes to act as triggers for activation. So the exposure to chemicals, smoking, radiation, stress, nutrition and some habits may be, at least in part, mediated through the activation of genes by epigenes, rather than mutation. One can see how the effects of diet, exercise and a variety of other environmental factors can be mediated through activation or inactivation of genes. What this says is that genetic makeup is much more plastic than we imagined when genes were thought to be immutable, and it opens the door to therapy based on blocking or activating genes.

Genetic research has accelerated. Scientists are discovering ways of identifying specific gene abnormalities and of plucking out disease related genes and replacing them with normal versions. Cancer may turn out to be a genetic disease with a cure that can be achieved by manipulating the genetic code. It is also possible to generate stem cells, cells that are undifferentiated and can transform into anything (heart, liver, kidney, etc.). The hope is that it will be possible to infuse these cells and have them replace damaged or lost functions, like dopamine producing neurons in Parkinson’s Disease or heart cells in someone who has had a heart attack. We are still a long way from being able to turn these theories into active therapies, but it is an area where it seems there are almost an infinite number of possibilities.

For those who want to go from this cursory summary to a more detailed understanding, an excellent book written for the lay public is “The Gene, an Intimate History” by Siddhartha Mukherjee.

Reducing the cost of Care

Two months ago, I summarizing the main drivers of the health care costs in the United States, which make health progressively less affordable. I promised to write a subsequent post with some suggested changes to reduce costs or, at least, slow the rate of health care inflation. This is an enormously complicated and arcane subject about which volumes have been written, so my “solutions” will necessarily be simplified. My goal is to give the reader a sense of what might be necessary to slow the runaway costs that now consume 17.5 percent of our GDP.

History:   To briefly set the stage, it is important to understand the traditions of medical practice. Until the early 1940s, medical care was delivered overwhelmingly by solo practitioners or small groups of two and three physicians. There was no health insurance to speak of, and the government programs of Medicare and Medicaid didn’t exist. The technology of medicine was very limited and was largely what a doctor could do in his or her office. Doctors were closely tied to a community, and payment was negotiated between the doctor and patient, largely through the exchange of cash or “in-kind” services. There were few insurance payments, group practices, few specialists, and hospitals were largely for dying patients. The good things about this model were the strong personal relationship between doctor and patient and also doctor’s freedom to determine how he wanted to run his practice. It is what many seniors remember about the good old days of personalized attention from the family doctor.

The disadvantages were that there were no limits to physician hours, no oversight of quality, and no ability to scale up to the advanced technologic world of medical and hospital care. The entry of insurance into both the private and government worlds brought more reliable payment but also greater complexity and administrative costs to doctors’ offices. While physicians complained about the changes in medical practice, they began to slowly gravitate toward larger group practices often with others of the same specialty and sometimes in very large multispecialty practices. The other segments of the health delivery industry also had to scale up. Hospitals began to supply more than nursing care; they have become purveyors of vast technologic resources, sites of highly specialized care, and, in many instances, became owners of physician practices. The pharmaceutical industry had dramatically expanded with an array of drugs that were unimaginable in 1940. And so on with the rest of the health care establishment, the surgical centers, the device manufactures, the nursing care providers, the laboratories, the insurance industry, etc..

One of the problems with this growth is that it has been in silos, each segment independent of the others, each jealously guarding its prerogatives and income. It has resulted in inefficient practices, duplication of effort, incentives to do more or sell more even if it has no benefit to patients’ survival or well-being. I believe that most people in health care are ethical and well motivated, but they are imbedded in separate systems that have no incentives to organize, to be efficient, to do only what is proven by evidence to provide benefit or to be guardians of limited resources.


Absence of an organized system of care: It is difficult to contemplate solving other problems without solving this first. Integrating doctors practices into a system that includes hospital care, diagnostic testing, pharmaceuticals and the various types of needed ancillary care is, I think, the path is to develop systems that are not competing for the patient’s dollar and have incentives to work together to find efficiencies. The oldest, but not the only, integrated care system of care is Kaiser Permanente health system. The Kaiser Permanente Foundation owns the facilities within which the doctors practice. They control the hospitals, the technology, the insurance products, the information systems and most of the back-office administration. They negotiate a contract for services with Permanente Medical Group, the doctors who deliver the care. The two entities work closely together. Customers pay Kaiser a specified each month, and Kaiser must provide all of the needed services for that fee (prepayment). Freed from fee-for-service, they can plan their services any way that they deem most advantageous to the patient and the institution. They are a system of care that can design strategies to avoid overlapping and unnecessary services. For example, they can utilize nurse practitioners and other ancillary personal to perform tasks for which they are qualified without worrying about whether they will be denied payment. Kaiser physicians are paid a salary competitive with what they could earn in their own office, so that there is no reason to churn out extra visits to generate more income. Patient education is encouraged to avoid unnecessary illness and hospitalization.

Other medical groups are organized differently. There are administrative entities that contract with many medical groups in many different locations, giving doctors more freedom to design their practice. However, they generally share an information system and are still held to standards for quality and service. The Sutter Health System in California operates in this fashion. Whatever the mechanism, the goal is to assemble all of the resources (hospital, laboratory, radiologic, outpatient care) under one financial roof to encourage sharing of information and to design more efficient processes.

Most young doctors finishing their training are not interested in opening an office on their own. They desire a more reasonable life style, readily available resources, the stimulation of colleagues to and be freed from administrative hassles. The trend is obvious. Most medical care is going to be provided large entities, which, at least in theory, can deliver comprehensive, efficient care of high quality. There is a cost to this. Care will be far less personalized and will require the patient to learn how to work within what can be a bureaucratic system.

 The current system incentivizes overuse:  I have already written about the perverse incentives of the fee-for-service system.  It encourages churning, the overuse of procedures, and it stifles innovation.  Doctors have little incentive to spend time developing new streamlined methods, which may reduce the number of visits and services if they are being paid fee-for-service. That could, in fact, reduce their income.

Medicare is experimenting with the creation of Accountable Care Organizations (ACOs), entities made up of groups of physicians and hospitals that are responsible for providing all needed care for a for a fixed monthly payment. These are HMOs by another name, but with the difference that patients can choose any physician in the insurer’s network and that there are strict quality controls on the care delivered. HMOs in the 1990s got a bad reputation because of overly restrictive limitations on physician networks and, in some instances, skimping on care. The downside to prepayment is that it reverses the incentives, potentially incentivizing underuse. Quality and satisfaction must be closely monitored.

Expansion of the use of technology: The technologies that have been introduced in the last 50 to 60 years are truly amazing. Technology companies have been booming, and it is clear that there is a lot more to come. In some instances, new technology can save resources, for example doing a CT or MRI scan of the abdomen rather than exploratory surgery. The difficulty is the temptation to overuse these wonderful, but very expensive technologies rather than older but reliable technologies combined with clinical judgment and the passage of time.   In many instances, the new technology is used before it is proven to be better. New products should be studied to show when they are clinically effective and cost effective. Currently insurers have the unenviable task of deciding when a new technology is ready for prime time and should be covered.

Patient demand for services: As I noted in my earlier post, this factor is often cited as a cause of the riding cost of health care. It is unclear to me how much of the rising costs can be attributed to this. Because the payment for service is usually done by an insurer (private or government), out of sight of the patient, it is easy for some to abuse the system and demand excessive services. There is some evidence from a study from the Rand Corporation many years ago that people who had zero financial responsibility for their medical bills used services more readily than those who pay a co-payment and have a deductible. This seems less relevant now when most policies are sold with substantial patient co-pays as employers offload costs to their employees through greater co-payments and deductibles.

Patients’ demands can be increased by the introduction of marketing and advertising.  The pharmaceutical companies in particular have perfected so called “direct to consumer” advertising. There was a time when pharmaceutical companies were prohibited from advertising drugs on public media. That restriction no longer exists, and pharmaceutical companies spend untold amounts touting the benefits of their product on television.

I won’t discuss aging of the population, but it is very real and only going to accelerate in the future. We have visions of life spans getting to be 90 to 100 for the Millennials rather than 70 to 80 as it is now. We have dreams of curing cancer and developing custom drugs and therapies for each patient. That could make health care an impossible burden to carry unless we can figure out ways of making a more efficient and cost-effective system.

Aging As An Adventure

It is easy to assume that aging is not going to be a pleasant time of life. Many have heard the now famous quotes, “Aging is not for sissies,” (Bette Davis), and “Too old to work and too young to die (Unknown).” It does at times feel like a one-way road downhill without redeeming features.   As parts of your body start to fail, and your capabilities begin to diminish irreversibly, dying ceases to be an abstraction, and you know that it lurks in the not too distant future. I had my awakening at the relatively young age of 56, when I was admitted to the hospital with chest pains, which proved to be caused by a substantially blocked coronary artery. I had a procedure called an angioplasty where a long catheter is passed from an artery in my groin into my coronary artery and a balloon is inflated to expand the area of blockage and restore circulation.

The morning after the procedure, the catheter was removed and the artery almost immediately shut down. I developed severe chest pain, and I knew that I was having a heart attack. My call brought the cardiac team into the room, and there was the bustle that I was so familiar with, hooking up the EKG, taking blood pressures, starting IVs and calling out instructions. At some point, someone said the EKG showed 5 mm of S-T elevation, an indicator of a severe heart attack in process. While this was going on, I felt strangely detached, like I was watching this happen to someone else. Within minutes, I was rushed back to the catheterization lab, and the catheter was threaded back into my coronary artery, and it was reopened.

In retrospect, I realized how close I had come to a fatal heart attack. Had this occurred outside of the hospital, I might not have made it. It made me realize that dying wasn’t something theoretical   I was going to die, perhaps relatively soon. As it turns out, I’ve been very fortunate. That was 22 years ago. Since then, I have developed Parkinson’s Disease, another chink in the armor of perceived immortality. So, I write this from the perspective of how important it is to see the world as one of possibilities and to use my time well. I don’t know how much time I have, and I want to go out with the feeling that I have lived and grown as much as I can.

Several authors have written about the stages of life, from childhood through establishing a life’s work to finding a partner, raising children, reaching the peak of one’s career and retiring to a quieter life. However, there has been relatively little written about the last stage, after retirement. It is not surprising given that until 40 to 50 years ago, life expectancy was slightly north of 60 years, and the average person often worked until they were disabled or died. Improvements in life style, disease prevention and treatment have led to dramatic increases in longevity, and the creation of Social Security and Medicare has given many people the means to make a life beyond retirement age. Having the time and health to pursue new goals has only become common in the last few decades and has activated questions about what makes for a more fulfilling latter stage of life. Given the potential of 10 – 20 years after retirement, what does one do with the time? This is still only partially explored territory.

Interestingly, many seniors view their later years as the best time of their lives. With a little luck, one has lessening responsibility for producing, meeting goals, earning money and raising a family. I realize that is coming from someone who has been relatively privileged and blessed with the means to retire from work and to have free time. However, time can be the curse or the blessing of getting old.   Time can be a void that longs to be filled or an opportunity to create something new. Some people dread the prospect of retirement. I don’t begrudge anyone the opportunity to continue to do work that they love. However, it is my view that when one scales back on one’s career, there is an opportunity to discover neglected or unrecognized parts of oneself.

Work that we like and a fulfilling career are blessings to be appreciated, but I believe that work satisfies only certain aspects of one’s life and neglects others, by necessity. Work satisfies our ambition and needs for competence, skill, the sense of making a difference and the ability to maneuver in a particular world, but it suppresses other important domains. It is difficult to satisfy the demands of succeeding at work and, at the same time, explore our unfinished business and neglected opportunities. All of us have bruises and regrets from our past. They may be disappointments, relationships left untended, or there may be potential passions that we’ve left unexplored. In that sense our lives are incomplete. For most of my life, I didn’t think about my potential other aspirations or my unresolved questions, because I was busy with the necessities of working and maintaining a life. Work can substitute for dealing with our basic conflicts and desires, the unfinished business of life. It may sound sophomoric but we deserve time and the opportunity to explore our passions and our disappointments from the past.

So you might ask, “Who wants to explore the potentially painful and difficult aspects of their life when I am relatively satisfied doing what I am doing”? I would say, it’s not all painful. There are many satisfactions to be had, new worlds and interests to be explored and pleasant surprises to be gained. There is an opportunity for a new creativity and a chance to give back to the world in which we have been raised.

I’ve been impressed with the richness of peoples’ lives when they get off the work treadmill and start to explore. People become writers, musicians, artists, tutors, community activists, students, competitive athletes and volunteers of all kinds. You don’t need to be world class to get great pleasure from exploring new parts of yourself. But it takes courage to stop doing something that you are comfortable with and to take a chance on the unknown, and it is difficult to take the risk of doing something that you might not be good at. The blessing is that there is no penalty for trying something that you may not be great at. It’s not like your life depends on it. I’ve related before that I started out learning something about photography, and by habit, I immediately wanted to be professional grade. When I acknowledged that I wasn’t at that level, I enjoyed it more.

So I encourage people who ask me about retirement to think creatively and to take risks.   Let your interests lead you to something that you have never done before. This is an opportunity to explore worlds that are new to you. The good news is that you will bring to it all of the wisdom that you have acquired in a long life.

If any of this makes sense to you, there are two books that address the subject of the challenges and satisfactions of late life in more detail. One is “The Third Chapter, Passion, Risk and Adventure in the 25 Years After 50” by Sara Lawrence-Lightfoot.   For the more “new age” inclined, “The Second Half of Life” by Angeles Arrien is a good discussion of the successive challenges of aging.

Hospital Hazards for the Elderly

Most people know that being a patient in a hospital can be dangerous while, at the same time, providing critical care. This post catalogs the dangers of hospitalization, particularly for older people and recommends some ways of lessening the hazards. The next three paragraphs are a direct quote from an NPR report on the program “All Things Considered.”

“Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.

Doctors cared for her wounds and treated her for pneumonia, but Prochazka, who Is 75, didn’t sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.

Patients over 65 tend to be less resilient during a hospital stay than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that brought them there. One study, published in 2011, found that about a third of patients older than 70 and more than half of the patients over 85 left the hospital more disabled than when they came.”

The sobering case described is not unusual. In fact, hospitalization can be the beginning of a downward slide for an elderly person, followed by declining function, reduced quality of life, placement in a skilled nursing facility or nursing home, and death. This post shares some of the common factors that cause complications and how they can, where possible, be prevented.

Conceptually, all of us have physiologic reserves that we call into play when there are challenges to the body’s well being. However, reserves decline with age due to loss of muscle strength, heart and lung capacity, immune function, cognitive function and general physiologic resilience. At the extreme, there are the “frail elderly,” who are most likely to do poorly in the hospital. Add the challenges that greet people in a hospital to the underlying loss of reserves, and it is a recipe for disaster. What are those challenges?

Immobility: It is surprising how many complications can be caused by the inability to get out of bed and ambulate. In no particular order, immobility can lead to pressure sores, rapid development of muscle weakness (which in turn contributes to falls), under expansion of the lungs (contributing to pneumonia), blood clots that can break loose and go to the lungs and loss of orientation.

Hyper-stimulation: Patients in hospitals must endure the almost constant noise, lights, machines, waking to be checked and other interruptions to sleep and rest. This is particularly true for patients in an ICU. Adding this to an unfamiliar environment can cause disorientation or a delusional state complete with hallucinations. Over medication can be another contributor to this set of events.

Infections: Hospitals are associated with many factors that lead to infections. Breaking our first line of defense, the skin, and invading the body through surgery, bedsores or procedures that puncture, reduce the body’s natural defenses. Similarly, organisms can invade the body through catheters placed in the bladder and through the air that is breathed, particularly if tubes are used for ventilation. Urinary infections are very common in people who have catheters in their bladder for more than a couple of days. Recumbence, pain and loss of muscle strength can make it more difficult for a person to fully expand their lungs, and partially collapsed lungs are a setup for pneumonia to develop. Add to that the proliferation of “super bugs,” virulent and resistant to antibiotics, any of the above sites can be susceptible to life-threatening infection. These organisms are carried from patient to patient primarily by the hospital staff, such as physicians and nurses who don’t always wash or disinfect their hands when going from patient to patient.

Our bodies are home to literally billions of organisms with which we live in harmony. These organisms are kept in check through barriers to entry, the skin, the lining of the gut and respiratory tract, through secretions like saliva and mucous and by the immune system. Patients who are sick, and particularly the elderly, have depressed immune function and less able to fight off microbes. When they have a chance to invade through breaks in the normal defenses, even ordinary cohabitants can become the cause of serious infection.

Errors: Medical professionals are subject to errors. They are caring for a large number of very sick patients in a complex environment, and it is easy to become distracted, overlook something or make an outright mistake. Some mistakes are egregious, like removing the wrong limb. Some are easier to understand, like misreading a doctor’s order and giving the wrong dose of medication. The elderly generally cannot tolerate medication doses that are standard for younger patients. Many errors are preventable by using standardized procedures and protocols and by putting in safety checks. Quality hospitals are implementing the tools of modern industry in the hope that like modern industry, errors can be reduced to one in a million.

Accidents: Falls are the most common accident occurring in a hospital. A combination of weakness and disorientation are usually responsible. After that, accidents can be caused by equipment malfunctioning, by a medical procedure gone awry or by failure to adequately supervise a young professional.

So to what end this litany of medical woes associated with hospitalization? What can we do to lessen these dangers given that although they are best avoided, hospitals can be life saving and are absolutely necessary at some points? I would give the following advice to someone entering a hospital and to their significant others who may need to be on guard if the patient can’t be. It is easy to be passive and compliant in the confusing setting of a hospital, but it is important to be one’s own advocate.

Avoid immobility: Even seriously ill patients including patients with recent surgery or on a respirator can be gotten out of bed to sit in a chair for a while, and preferably to walk short distances. My wife was hospitalized in an ICU for several days after a biking accident. She complained bitterly about how uncomfortable she felt when she sat up in a chair, but the staff persisted in getting her out of bed for short periods.

Advocate for periods of uninterrupted rest: It is difficult to avoid the consultations and monitoring of vital functions, particularly with patients in an ICU. However, protecting some time to sleep quietly is essential to avoiding exhaustion and disorientation. Talking to the staff about scheduling events in bunches, leaving time for rest, can help the patient recover.

Understand what is being done and why: It is difficult to get physicians’ attention in the hospital. They are usually in a rush when making rounds, and getting them to stop and answer questions can be a challenge. When my wife was in the hospital, doctors seemed invisible. They made rounds at 6 or 7 am, and they were often in the operating room or somewhere else during the day. I had to be persistent to get someone to talk to us. Other than in an emergency, you should understand the rationale for major tests and treatments, the benefits and the risks.

Be your own (or family members’) best advocate: When things are going well, compliments go a long way. However, if you are concerned about something, respectfully speak up; it may be a clue that something is awry. Know what medications you are being given and what they look like. I’ve had nurses bring a medication to my bedside that was actually intended for another patient. In the extreme case, chemotherapy has been given to the wrong patient.

Don’t be intimidated by the technology or staff: At times, the hospital procedures seem bewildering, and the staff may seem busy and brusque. As a patient, it is your right to know what is happening and as a visitor, you provide an important function, namely, being a friendly point of reference reminding the patient of who they are outside. If a patient can’t be their own advocate, it is best if one person speaks for the family so that the staff is not getting repeated or conflicting questions. Hospital staffs are usually concerned human beings who want to do what’s best for the patient, but they are busy and working in a complex environment. It’s often best to begin your inquiry with the nurse, who can bring in the physician as needed.

Hospitals can do miraculous things, and at times they are absolutely essential, but they can be dangerous. It is best to know where the dangers lie and to take steps to prevent them.

Why does Health Care Cost So Much?

Health care costs in the US continue to rise at an unsustainable rate. I remember studying this subject when I was early in my career, when health care costs represented about 8 percent of GDP, and reading predictions of it rising to 15 percent over the coming decades.   It is now 18 percent of GDP and predicted to rise to 20 percent in the not too distant future. Make no mistake, rising costs are a problem throughout the world, but it is a uniquely American problem in that the US spends about double the amount per capita that other developed economies spend and has inferior outcome measures. It is clearly a problem that affects what we earn and can spend as well as the competitiveness of the country as a whole.

It is a problem that is getting surprisingly little attention in this crazy presidential campaign of 2016. Donald Trump promises to abolish Obamacare, and Hillary Clinton wants to expand coverage to more of the poor, neither of which will help to control the cost problem that is the driver of many economic concerns. This brief post will not contain all the answers to a tremendously complex problem, but I will try to summarize the main issues. First, I’ll focus on the principle drivers of increasing cost.

Aging of the population: It ‘s well known that providing health care for older people is much more expensive than the young. Our population is aging, and calculations project that this is some of the cost increase, but it is nowhere near the total problem. Besides, it doesn’t explain the US costs as compared to other developed countries, since their populations are aging too.

Expansion of the use of technology: In the last 30-40 years, there has been bonanza of new technologies that have vastly increased our capabilities and improved outcomes. Imaging (CT scanning, MRI, PET scan), minimally invasive surgery, new drugs for the treatment of cancer and other diseases, genetic diagnosis and improved treatment modalities (targeted radiation therapy, joint replacement, microsurgery) are some of the things that have improved what we do.   The problem is that each of these innovations is expensive, and once they are available, their usage expands to problems where they have no incremental value. It would be great if they substituted for other less effective, costly procedures, but they tend to be incremental. No one is going to suggest forgoing a valuable new tool, but our payment system (next section) encourages their overuse.

A system of payment that clearly incentivizes doing more: The following is complex but important. In fact, if I had one thing that I could do to control costs, I would change the reimbursement system. With some notable exceptions (such as Kaiser), health care in this country is paid for on a fee-for-service basis. In other words, a doctor or a hospital provides a service, and they are paid a fee, usually pre-negotiated, for that service or procedure. The main thing that insurance companies, Medicare and Medicaid negotiate are the fees, and providers of care are paid sharply discounted fees as compared to their “usual charges”. If you are unlucky enough to not have health insurance, you will be charged the full fee. In other words, you will be charged the retail price, not the wholesale that everyone else is paying.

The perverse problem with fee-for-service is that it controls unit price but not volume. So what has happened is that providers have increased the volume of services that they provide. By doing more procedures, providing more services and seeing patients more quickly, doctors, hospitals, laboratories, etc. have been abLe to maintain a high level of income. The effects of this are obvious to most. Visits tend to be brief and rushed. Unable to take the time for a careful history and physical exam, doctors send patients for multiple scattergun tests, and physicians have a strong incentive to do more procedures, such as surgery, because it pays well. Young physicians are gravitating to specialties that are more procedure oriented, in part for life-style reasons, but in part because procedures pay better and take less effort than talking to a patient. Consequently, there is a growing shortage of primary care physicians to coordinate care, because it is hard work that doesn’t pay well. It is difficult to make changes that might make healthcare more efficient and rational, because the payment system holds everything in place. There are no financial incentives to do it better, only to do more.

Patients’ demand for services: A colleague of mine, spent a year in Europe studying the health care systems, particularly the British National Health Care System. He said that one of the contrasts between there and here is that the British are much less demanding about their care and more accepting of limitations. The average American expects to have the latest care technology and care available immediately, and can be very impatient with advice that it may not be needed. Until recently, comprehensive health insurance shielded them from the cost of  care.  Health insurance was designed when the costs were an order of magnitude lower and was often given away by employers as a way of avoiding wage increases. It wasn’t unusual to total coverage with minimal to no co-pays and deductibles. That is changing with high deductible policies that don’t pay until the patient has paid a $3,000 – $5,000 deductible, thereby giving the patient a reason to hold down costs. It appears to have had some effect, but to a great extent, we are spoiled and expect to have access to the most expensive technology without having to pay for it. As a country, we have not had to balance the tradeoff between access and cost. That is true except for the poor and uninsured who have limited access.

Absence of a system of care: The fundamental problem is that we don’t have a system of care. We have many silos, physicians, nurses, hospitals, insurers, pharmaceutical companies, laboratories and the government each trying to optimize the care process to enhance their own incomes and leverage. There are no villains and no heroes. Each is trying to turn a profit within their own domain without considering the effect that it has on another silo or the overall product. No one is in charge of the quality, efficiency or the rationale of the enterprise as a whole. It makes it very difficult to assess what needs to be done no less bring about a fundamental change.

In a subsequent post, I’ll discuss solutions that have been suggested and my own ideas.

Can We Prevent Cancer?


A recent Op-Ed in the New York Times by a physician, Aaron E. Carroll asked the question, “Are we helpless to prevent cancer?” Although it causes fewer deaths than heart disease, cancer is the most feared affliction for most people. When and if cancer strikes seems like pure bad luck, putting aside the few people who have a known genetic predisposition. There has been so much progress in the prevention of heart disease that it feels more controllable whereas cancer seems like it strikes out of the blue.

Dr. Aaron’s message is that many forms of cancer can be significantly reduced or prevented by attention to the risk factors that contribute to its developing. Our medical system is very physician centered. Since most physicians are usually not focused on disease prevention, they pay most attention to testing for early detection of relatively few cancers for which there are effective screening tools and the treatment of already established disease. The public tends to mimic this medical model and puts off doing the things that can reduce its risk of cancer. Thus cancer is often discovered at a stage requiring treatment, resulting in much less chance of success in becoming disease free, much more arduous treatment with many more adverse effects on the patient. Obviously, it is far better, cheaper and less uncomfortable to prevent the disease if at all possible.

It is difficult to assess the impact of behaviors or the percent reduction of cancer risk. Most of these suggestions do not come from controlled studies where people are randomly assigned to implement the behavior or not. More often they are the result of observational studies that note the number of times a cancer is associated with a particular behavior. For example, 80 percent of people with esophageal cancer smoke, much higher than the general population. There are geographic locations where the incidence of a particular cancer is much elevated, and people from low risk areas acquire the elevated risk when they move into a high risk area. These observations strongly support the presence of extrinsic factors that influence how often cancer occurs, factors that can potentially be controlled.

The following lists the five behaviors for which the evidence is strongest that there are risks that we can reduce in the formation of cancer:

Avoid tobacco – Strongest evidence of risk. Cancer of the lung, esophagus, stomach, throat, larynx, kidney, pancreas, bladder. Substantial risk with second hand smoke, and risk of cancer of the mouth, tongue and throat with chewing tobacco

Protect skin from sun exposure – Skin cancer, melanoma, squamous cell, basal cell, particularly if fair skinned. Evidence well established

Drink alcohol in moderation – Cancer of the breast, colon, liver, mouth, throat, larynx . Moderation is 1-2 drinks per day.

Eat a healthy diet – Fruits and vegetables, 5 servings per day, is associated with reduction of many forms of cancer. There is some evidence that cooked red meat increases cancer incidence, but it is not yet strong enough to recommend. Healthy diet can help reduce obesity, which is independently associated with many kinds of cancer.

Exercise regularly – (150 minutes of active exercise per week) Aside from the many cardiovascular benefits, there is also linkage to lack of exercise to breast, colon and endometrial cancer as well as longevity.

I can’t vouch for the accuracy of the number, but it is estimated that 40 percent of the incidence of cancer can be reduced by following these five suggestions. Obviously, there is much that is unknown, such as the mechanisms of the effects and other risk factors as yet unproven or undiscovered. Of the thousands of chemicals to which we are exposed, there are undoubtedly many that are going to prove causative to developing cancer. For any who want to read more detail about the strength of evidence related to the above behavioral factors and some that are less proven, a reference on the Internet is . It is from the National Academy Press, “The Behaviors Contributing To The Burden of Cancer”.

So knowing all of this, why don’t we follow more healthy behaviors? Well there is some evidence that we have improved. The incidence of smoking is down substantially, exercise seems more common, and there is some evidence that people eat healthier diets (beef consumption has dropped dramatically in recent decades). However, most of us fall short of addressing all five behaviors. Unfortunately, there is no pill to take for any of these, and behavioral change is hard. As many times as I have reminded myself, I routinely forget to apply sunscreen. I recently had my first basal cell carcinoma removed.

There are also five screening tests that have been proven to be of benefit in finding cancer at an early enough stage to reduce mortality. Screening is tricky because it tests a large population most of whom do not have the of cancer being screened for. Even with a very good test, the result is often more false positives than true positives. (If a test is 98% specific, then 98 % of the time when the test indicates disease, it is, in fact, present. Obviously, 2% of the time, the test is a false positive.) If 1000 people are being screened for cancer that occurs in 1% of the population, then ideally 10 people will have a test result that indicates disease. However, false positive results will occur in 20 people, so that only one third of the people with positive results will have the disease. This results in a large number of follow-on tests or treatments that are not needed.

The U.S. Public Health Service Task Force (USPHSTF) has looked at all of the evidence on the benefits and risks of screening, and they recommend five screening tests to be promoted to the general population. Other tests may be indicated depending on a person’s unique situation, but these five have been proven to reduce mortality.

Pap Smear – For the early detection of cervical cancer in women, screening should begin at age 21 and continue to age 65. Screening should begin yearly but once there has been 2-3 negative tests, screening should proceed every 3 years.

Screening for Human Papilloma Virus (HPV) – Should be done in conjunction with Pap smear at age 30 to 65. HPV is the putative cause of most cervical cancer and genital war ts. It is more sensitive than Pap Smear in finding early stage changes, and, consequently, a positive test should be followed up with colposcopy. Negative results on both tests indicates that screening can be done every five years.

Mammography – for women between the ages of 50 to 74. Negative results mean that screening can be done every two years (This does not apply to women who are being followed for an abnormality or who have had previous breast cancer.) There is controversy over whether screening should begin at age 40, the USPHSTF has left the choice up to women and their doctors.

Colonoscopy – Recommend this being performed at age 50 and every 5 years thereafter until age 75 for the detection of colon cancer.

Skin Examinations – There is only fair evidence for the effectiveness of having a doctor survey your skin every year or two. The purpose is to look for skin cancers including melanoma. As I have gotten older and lesions are more common, I personally have seen a dermatologist every year for an examination.

Most of the guidelines recommend the cessation of screening at age 65 – 75. However, as people live to an older age, this will need to be re-evaluated. The question to ask yourself at that age is, “Would I do anything about it if I found an abnormality?” If you are healthy enough to say yes, then you and your doctor should consider continuing screening.


Falling into a New Age

The following post was written by Diana, reflecting on her experiences recovering from a bicycle accident and its physical and psychologic aftermath.

Two years ago, I had a bike accident that – literally and figuratively – threw me for a loop. I recovered physically and then found myself in a psychological quagmire that took me a much longer time to sort out. I was 68 years old and vigorously healthy at the time, and I wasn’t thinking of myself as anywhere near old. The accident changed all that.  I no longer felt sure of how to regard myself on axes of age or health.

Now I am turning 70, grateful to be alive and healthy, still enjoying my work although at a lesser pace than before, and I know for a certainty that although I am full of energy and gusto and knowledge, that I am a senior, and the future is uncertain. I have trained myself to enjoy the present, to do as much as I can, and not to look at the future as an inevitable downhill slide. (Of course it is an inevitable downhill slide, but I don’t have to focus my energy on it all the time.)

Four of my good friends or family members – all in their seventies and reasonably healthy – have each taken a fall within the last year. Fortunately, their physical injuries were relatively minor. But for each of them it has revealed a trajectory that I recognize only too well, and each of them has experienced a psychological reckoning. Each of them either tripped over some small ‘bump in the road’ or lost his/her balance. On getting up, each one felt embarrassed first and only gradually realized he/she was injured and needed medical care. Physical recovery has been smooth for all of them, but each has had a deeper reckoning as a consequence. Not everyone was willing to talk about his or her own recognition of frailty as a fact of life.

I too have tripped and fallen recently, fortunately without injury. But I know that my balance is imperfect, a factor of simple aging. The recognition that we can no longer take for granted navigation with our own feet is (forgive me) a first step. I can hike at least as far as I could ten years ago, but now I will happily use a walking stick on uneven ground. The second step is not to feel diminished by this.

I have eliminated from my life certain physical sports and risks I used to enjoy, with the conscious recognition that I don’t want to invite injury. And I enjoy, at least as much as before, all that I can see and do. I admire those of my peers who are more physically adventurous and adept than I, without wishing I could still compete with them. Losing the sense of competition is one of the under-celebrated blessings of this time of life. Another is abandoning any striving for perfection, a perennial frustration best left to the young.

This sense of wellbeing has been a gradual acquisition over the past two years. Each of us finds our own way through this labyrinth of growing older. It helps that my friends and I can laugh about our frailties of memory and balance. It helps immeasurably that we can share with each other the beauty that surrounds us, and the inspiration of the young people in our lives. My sense of dread has been replaced with these gifts.

Philosophy For Old Age

This wry look at aging was sent to me by a friend. It is circulating on the Internet, and I thought it was worth sharing. The only attribution is the name He Yan Jan. In its original form, it comes with lovely pictures of nature, but I couldn’t copy those.

Do you realize that the only time in our lives when we like to get old is when we are kids? If you are less than 10 years old, you are so excited about aging that you think in fractions.

‘How old are you?’ ‘I’m four and a half.’                                                                        You’re never thirty-six and a half. You are four and a half going on five.                          That is the key.

You get into your teens; now they can’t hold you back. You jump to the next number or even a few ahead.                                                                                                        ‘How old are you?                                                                                                          ‘I’m gonna be 16.’                                                                                                            You could be 13, but hey, your gonna be 16.

And then the greatest day of your life, you become 21!                                                   Even the words sound like a ceremony.

But then you turn 30. Oooohh, what happened there?                                               Makes it sound like bad milk!                                                                                            He TURNED; we had to throw him out.                                                                     There’s no fun now; you’re just a sour dumpling.                                                         What’s wrong; what changed?

You BECOME 21. You TURN 30. Then you’re PUSHING 40….                                   Whoa, put on the brakes. It’s all slipping away.                                                             Before you know it, you REACH 50,                                                                                 And your dreams are gone.

But wait!                                                                                                                         You MAKE IT to 60.                                                                                                         You didn’t think you would.                                                                                           So you BECOME 21, TURN 30, PUSH 40, REACH 50 and MAKE IT to 60.

You’ve built up so much speed that you HIT 70.                                                             After this, it’s a day-by-day thing.                                                                                     You HIT Thursday, June 23, 2016.

You get into your 80s, and every day is a complete cycle.                                                 You HIT lunch; you TURN 4:30,                                                                                       And you REACH bedtime.

And it isn’t done there.                                                                                                       Into the 90’s you start going backward.                                                                               I was just 92.

Then a strange thing happens.                                                                                             If you make it to 100, you become like a little kid again.                                                       I’m 100 and a half.

May you all make it to a healthy 100 and a half.

Tips for staying young:

  1. Throw out the nonessential.
  2. Keep cheerful friends.
  3. Keep learning.
  4. Enjoy the simple things.
  5. Don’t sweat the small stuff.
  6. Laugh long and loud.
  7. Let the tears happen.
  8. Surround yourself with what you love.
  9. Cherish your health. Take steps to preserve it.
  10. Don’t take guilt trips.
  11. Tell the people that you love……you love them.

Life is not measured in the number of breaths that we take, but in the moments that take our breath away.  Be Well

Redesigning Your Life

You may not think of it this way, but we redesign ourselves constantly throughout our lifetimes. The most obvious ways are the changes that occur at different ages.   We move from infancy to childhood, to teenager to young adult to mature adult to middle age to being a senior. Parenting fits in there somewhere as one of the most profound periods of change. With each of those time periods, we change roles, jobs, attitudes, perspectives, friendships, relationships and the way that we see ourselves. This evolution is much more true today that it was during our parents and certainly grandparents’ day, or at least the changes were more predictable then. People often grew up and lived in one geographic area, went to work in a job or company which could last throughout their work life, stayed married to the same person, for better or for worse and retired to a quieter life of hobbies and memories.

It’s very different today. We are much less rooted geographically. It is unusual for people to work in one job or one company for their lifetime. The best advice you can give to a Millennial is to be prepared to redesign yourself to another work role or occupation at least once in your life. Hopefully marriage is long term, but in a high percentage of cases, it is not.

Somehow, old age is seldom mentioned as a time where redefinition of oneself is necessary. Writers have treated old age as a “thing”. You are old and you are retired, out to pasture, quietly descending down hill. The one area where seniors are acknowledged as taking on a new role is as grandparents. At no age is the need for constant redesign more important than when we become seniors. Aging brings illness, disability and limited energy, all of which change what we are able to do, and that means that we must find our satisfaction in new places.

Many hang on to the roles that they are familiar with, sometimes work beyond their effectiveness, because it is too daunting to contemplate giving up the familiar. But, inevitability, change will occur that constricts what we are able to do, for some earlier than others. Father Time has a way of forcing adjustment whether we like it or not. Actually, changes in our status, such as retirement, can lead to the freedom to pursue other interests, which can be a very good thing. Some people blossom in their later years in unexpected ways. Today, we live longer, and often are capable of active physical and emotional lives into 70s, 80s and even 90s, so we have an opportunity to find roles that are personally satisfying, albeit different than what we did before. Some modification of one’s role is not only necessary, but healthy. It could mean cutting back on work and starting to develop new interests or pursuing a radically different set of goals for one’s life.

The question that is put to us is, can we continue to grow and explore during old age.   Can we begin new things? Can we remain vital and creative at a time when the common expectation is slowing down and withdrawing from life. I think that there are two things that most get in the way of people branching out in new directions. The first is fear, fear of incompetence, of looking stupid of having others think you are being foolish. The second is the concern that we will never be excellent at the new things that we try. Doing things for their own sake, because it gives pleasure is not something that most people are accustomed to. In our utilitarian, pragmatic world, there is a desire to do things that have a purpose and to use external standards of judging whether an activity is valuable or not. One of the first challenges in redesigning how you are going to spend time is letting go of the expectation that everything we do, we must be good at, and it should have a purpose.

When I retired, I decided to take up photography as an avocation. I took several workshops with professionals, and after a while, I became a reasonably competent photographer. I made slide shows and calendars for my friends, and received positive feedback for my work. Then I wanted to show it off more broadly, so I found a restaurant that would display my work and put on an art show at a local school. Now my old instincts kicked in. Could I sell my work? That seemed like the ultimate test of whether what I was doing was worthwhile, at first not realizing that I was taking something that I did for pleasure and making it into a job. Fortunately, when I looked more closely, I realized that commercial photography was a very competitive world. It takes substantial effort to take the best pictures with the right lighting and perspective. Photographers can work a whole day to get just the right vantage point. Then you have to be willing to hustle your pictures in a world with intense competition.   Fortunately, I realized that this isn’t the way that I wanted to be spending my time and energy.

Often when freed from work, people choose things that are spiritually pleasing and are emotionally satisfying. I know at that for most of my life, I worked with my intellect, and I found that retirement is a time to bring the other dimensions of being human into play. I think that is why many people in late life seek experiences in the arts and in serving others. It is a time that can bring deep emotional satisfaction if you are willing to seek just what makes you happy.

The bottom line is that change will come. Grieve what you are giving up and then embrace it. It can be an opportunity to explore different parts of yourself and to be creative about your life.


Diets – Do They Work?

There has been a spate of articles in the press recently claiming that weight loss diets don’t work. Many diet researchers have been saying this for a long time, but what has caught peoples’ attention is the longer-term outcomes of the contestants on the TV show, “The Big Loser”. The contestants started out grossly overweight and competed to see who could lose the most weight. Indeed, they did lose weight, an average of 129 pounds, some with even more dramatic results. Unfortunately, that’s not the end of the story. As it turns out, most of the contestants regained most or all of the weight that they lost, an average of 70 percent regained.

This has been the result of most of the scientific studies of weight loss. Dieters struggle to lose weight, but even those who are successful eventually see that weight regained. It appears that the body has a “set point”, a weight that it will fight to maintain. The level of the “set point” seems to be determined by genes and by life experience. For example, babies who are overfed will become obese setting up the likelihood that they will be obese throughout their lives. One comes into this world with a “set point”, but eating the wrong foods, eating too much, lack of exercise or stress can modify it. If one gains significant weight, the “set point” will be modified up, making it very difficult to take the excess weight off.

When one lowers weight below that point, the body interprets it as starvation, an emergency, and puts into effect a series of compensatory mechanisms to move the weight back up. First it slows down a person’s metabolism so that one burns as few as 500 calories a day, a level that is almost unsustainable by dieting. In addition, the body releases a series of hormones that increase hunger and make eating feel more rewarding. So, a person who is dieting must have tremendous will power and/or do a prodigious amount of exercise to take the weight off, levels that rarely can be sustained long term. Hence, the often seen yo-yoing between weight loss and weight gain.

Worse yet, according to Sandra Aamodt, a neuroscientist writing for the New York Times, dieting seems to predispose to weight gain. To quote her, “Long-term studies show that dieters are more likely than non-dieters to become obese over the next one to fifteen years. That is true among men and women, across ethnic groups, from childhood to middle age. The effect is strongest in those who started in the normal weight range, a group that includes almost half of the female dieters in the United States.” Without going into detail, there are several studies that indicate this relationship of dieting leading to long-term weight gain is causal.

Why would that be so?  According to Dr. Aamodt, dieting is stressful, and stress is one of the factors that lead to weight gain. Weight anxiety and dieting also predict later binge eating as well as weight gain. A study showed that teenage girls who dieted frequently were twelve times more likely than non-dieters to binge eat two years later. All in all, the evidence that dieting produces beneficial results, either in long-term weight loss or in health, is very sparse. I believe the evidence that dieting is beneficial for seniors is particularly scarce.  However, anecdotally, as a physician, I believe that some who start out obese, improve their blood pressure and control of their blood sugar by losing modest amounts of weight.

There are reasons why obesity is so common in Americans besides stress.  Many people have poor eating habits. Americans, in particular, eat large portions of food governed by what we are served rather than by a feeling of fullness. We are told not to leave food on our plates. We eat the wrong foods, sweet desserts, sugary drinks, junk food and starchy food. We are subject to the pervasive influence of marketing about food. It starts in childhood when kids see TV adds pushing McDonalds’ Big Macs, sugary cereals or fatty foods like nachos, and overweight kids often lead to overweight adults. Once the pattern is set, it tends to reinforce itself.

There are many reasons why people decide to diet. It is often to improve one’s body image, since obesity is viewed by many as self indulgent and unattractive. It might be a way of reducing stress on joints and muscles such as knees and hips or of lowering cholesterol, blood pressure or the propensity for Type 2 diabetes. Also, someone who is severely obese is in real danger of a wide variety of health side effects. The problem is that rapid weight loss is often followed by weight gain as the body fights to maintain its “set point.” Is there any way of changing or modifying the “set point”? That’s not clear. There aren’t good studies to prove that any method works long term.

So, are there any recommendations for people who are overweight? Yes.

1. Set a clear goal of how much you intend to lose, so that you have a target.

2, Don’t lose weight by crash dieting. If you take weight off fast, it’s likely to be gained back fast as the body adjusts to prevent weight loss. It is recommended that you slowly take the weight off, a pound or two per week, to about 10% of your desired weight loss and then stop and maintain. So if you want to lose 30 pounds, you try taking off 3 pounds and then try to maintain the new weight for a month or two. This is less of a challenge too your set point and gives it time to adjust. Then take off another 10 percent. This slow and steady approach requires more patience, but it builds the habits that are necessary to maintain your new weight.

3. Obviously, watch what you eat. Avoiding or minimizing very sweet, starchy and fatty foods is important. Eat more lean protein, salads and vegetables that tend to produce more filling meals and reduce hunger. The problem is not that people don’t know what to eat and avoid, but don’t consistently do it. Since all of us are tempted by “forbidden foods”, take a bite and then stop. If you really take the time to taste and savor the bite, it is surprising how satisfying that can be.

4. Eat at regular times if possible. Don’t skip meals and get so famished that you can’t control what you eat.

5. Eat slower. Gobbling down your food doesn’t give time for your body to register fullness. Stopping when you start to be full is more important than finishing your plate.

6. Exercise, in whatever forms you enjoy. Exercise alone won’t cause you to lose weight, but burning more calories helps to make the needed dietary restriction more moderate. It also reduces abdominal fat, which is associated with health problems.

To date this is the best information available. There is always the desire to find a quick painless way to do dieting, and everyone is aware of the various fad diets. However, following these principles seems more likely to build the habits necessary to prevent long term weight gain, if not loss.