One of the sectors closely monitoring the debt debate in Washington is the medical world, where hospitals, physicians, and patients anxiously await the final agreement on cuts to Medicare and Medicaid. Of particular concern to academic medical centers [pdf] are proposed cuts to graduate medical education, funding used to pay the salary of residents and fellows who are both training as physicians and specialists and working on the front lines of patient care. In a time when a patient’s wait time to see a specialist grows longer and longer, squeezing the bottleneck of physicians-in-training even tighter could have long-term consequences.

This week, the Medical Center’s executive vice president for medical affairs and dean Kenneth Polonsky took to the newspapers to argue against these damaging cuts. In an op-ed letter published by the Chicago Tribune, he expressed concern that the proposed cuts would “would reduce access to doctors, multiply waiting times and do lasting harm to patients in Illinois and nationwide.”

No one questions the need to rein in spending on health care or the obligation of hospitals to do their part. But we need to maintain a high level of patient care, and to make certain that our country has enough physicians in the future. Policymakers in Washington must maintain their support for graduate medical education and find more equitable ways to distribute the budget-cut burden.

Elsewhere…

Speaking of Washington and health care policy, without the Patient Protection and Affordable Care Act, 63-year-old Glenn Bovard of Valparaiso would not have been able to receive life-saving gift this past Father’s Day: a new heart. The Post-Tribune profiled Bovard’s story and surgery, performed by the Medical Center’s Valluvan Jeevanadam and Jai Raman. “The surgery was a cakewalk compared to the heart attack,” Bovard told the paper.

As many as one-third of patients with epilepsy cannot control their seizures with medication. Local newsmagazine Chicago Tonight profiles efforts by Wim van Drongelen, technical and research director of our pediatric epilepsy center, to develop new ways of helping these patients by modeling how seizures begin and spread in the human brain.

At the end of a long, difficult week, many people like to unwind on a Friday evening with a drink? But does alcohol relieve stress, or prolong it? A new study by Emma Childs of the University of Chicago Behavioral Pharmacology Laboratory and written up by the Gannett News Service suggests a double-edged sword - stress reduces the positive effects of alcohol, while a drink may extend the tense feelings produced by a stressful event.

A cautionary tale about when newspapers twist the words of scientists for sensationalist ends - did paleozoologist Darren Naish really say that the Loch Ness Monster was “more fact than fiction?”

Evolution isn’t only a process that happened in the distant past. Carl Zimmer’s wonderful cover story in the Science Times this week follows New York evolutionary biologists as they hunt for signs of urban evolution in progress for mice, fish, ants, and other city-dwelling critters.

Being a parent these days is anxious business, with an onslaught of news reports telling you what might be good or bad for your child’s health and development. In many cases, these claims are based on scientific evidence that is preliminary at best, studied only in small subject pools or retrospectively. To comprehensively confirm a link between, say, breast-feeding and body weight or living near a smokestack and asthma, a large epidemiological study that tracks thousands of children from before birth to adulthood is necessary. But that kind of study is very expensive, thanks to costs associated with recruitment, data collection, and analysis over decades of time.

As such, it’s better to do one enormous study of many factors that potentially influence child health rather than several independent and costly experiments. Enter the $5 billion National Children’s Study, a federally-funded project that hopes to track over 100,000 American children from their mother’s womb to age 21 in order to test possible influences - genetic and environmental, positive and negative - to their health. Already 11 years in the making, the study is just completing its warm-up phase, hoping to start the main event in April 2012. But as Daniel Johnson and Angela DeBello presented at the University of Chicago Medical Center Pediatric Grand Rounds earlier this month, the study is already teaching researchers valuable lessons.

“We have a very ambitious agenda,” said Johnson, an associate professor of pediatrics at the Medical Center involved in the Chicago branch of the study. “We’re kind of learning how to do this as we’re going along.”

The Children’s Health Study was authorized as part of the Children’s Health Act of 2000, alongside improvements to child mental health care, anti-violence programs, and day care provider training. While many of the other initiatives have long been implemented, the CHS has taken more time to reach the launchpad due to the mind-boggling logistics involved. In order to break down the roughly 4 million U.S. births each year into a manageable study cohort, the project will collect medical and survey data on growing kids from 105 different counties reflecting almost every region of the country.

It’s a beautiful plan on paper, but executing the recruitment and retention of 100,000 children around the country is immensely difficult. Debello, the vice president and associate director of public health research at the National Opinion Research Center (one of the organizations charged with administering the CHS), said that pilot studies have revealed just how difficult it is to even find pregnant mothers eligible for the study. Researchers have tried surveying homes for women expecting children or trying to have children, working with medical providers who can direct eligible women to the study, and mailed surveys to try and find the right subjects. But the up-to-date numbers presented at grand rounds indicated the low hit rate of this full court press: of 28,000 households originally contacted in Cook County, only 67 women were found to be eligible for the study (and only 49 provided consent to participate).

“It’s pretty overwhelming…the numbers are going to get big very quickly as this study progresses,” DeBello said. “Not surprisingly, it was far more expensive than we expected it to be.”

Hence that large price tag, which Johnson admitted is high, while also suggesting that it could be a bargain in the end. Any costs spent on conducting the study should be weighed against the potential health care costs saved with the information it collects. There’s a lot of room to work with in child health costs, he pointed out - a study in the journal Health Affairs calculated that environmentally-mediated diseases caused by lead exposure, air pollution, and other toxins produced $76 billion in medical costs in 2008 alone. Johnson also pointed out that the results of a similarly large project, the Framingham Heart Study, has prevented an estimated 800,000 deaths despite only being 1/20th the size of the CHS.

“It’s still not clear how successful this study will be,” Johnson said. “But we think that the goals and aspirations are certainly strong reasons to drive us forward.”

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In a typical clinical trial, the results are reported in purely medical or biological terms. Did the patients in the treatment group live longer than those in the control group? Did the drug shrink the tumor or reduce symptoms? Were clinical measures such as blood pressure or cell counts affected? These are the details that the Food & Drug Association and the physician community look for when they decide to approve or prescribe new therapies. But looking at a new treatment’s effects in a medical vacuum might miss critical details about its actual usefulness out in the real world, where patients have different priorities and health care dollars are finite.

To create a more well-rounded and practical clinical trial, medical researchers need to reach outside of their discipline for expertise. Or, they can bring those experts into the hospital fold, as was recently done with the establishment of the University of Chicago Program in the Economics of Cancer. Led by Ya-Chen Tina Shih, an economist who specializes in the economic aspects of cancer care, the program has a unique premise: to study the economics of a disease that produces estimated yearly costs of $270 billion and rising in the United States. In a field where new treatments, devices, and procedures appear with startling frequency, Shih’s group aims to weigh the costs and benefits of these new technologies so that patients receive the best, most logical care rather than just the hot, new, often-pricey thing on the market.

“I see it as a place to bring researchers together to look at economic issues in cancer,” Shih said. “The issues to be addressed can be large policy issues or a cost-effectiveness analysis comparing two different treatments. What we would like to do is provide an environment where if there are oncologists who want to study those questions, they don’t have to try to learn everything themselves. They can team up with economists or people in operation research or health services research, and can work on issues together. Similarly, people with no medical training who are interested in exploring those questions can find their clinical collaborators here.”

Calculating the cost of cancer is harder than it might seem. A diligent researcher could, with much effort, simply total up all the money spent on drugs, procedures, doctor’s appointments, and devices, and calculate a price tag for cancer or cancer treatment. But one must also take into account the indirect cost of missing work, either temporarily due to illness, side effects, or surgery, or permanently due to death. Other factors are even harder to convert into dollars, such as quality of life under different treatments, while still others are politically fraught, such as cost-effective analysis to determine whether a new treatment is a significant enough improvement over the current standard of care to justify coverage by insurance companies.

Economists can estimate these figures retrospectively, after a given treatment has been out on the market for a few years or more, but at that point the horse is long out of the barn. If a new treatment is given to patients for three years, then found to be less cost-effective than the standard of care it replaced, it could unnecessarily cost society millions or billions of dollars. Shih hopes that the Program in the Economics of Cancer will help cancer researchers design clinical trials with such economic questions in mind, so that information about costs can be gathered before the widespread diffusion of a new technology that provides a very small benefit at substantial cost.

“You don’t at the conclusion of a trial say ‘let’s add a cost-effectiveness analysis to that.’ By then, it’s way too late,” Shih said. “The idea is to get more people interested in collecting this data at early timepoints, so by the time they really want to answer a question, they have the data to answer it.”

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Countless campaigns have been launched to steer schoolchildren toward healthy habits, and yet rates of childhood obesity and diabetes continue to soar. Celebrity endorsements, catchy catchphrases, and food pyramid redesigns have struggled to combat the allure of fast food and television in the battle for child health in the United States. But with childhood obesity rates tripling in the last 30 years and type 2 diabetes showing up earlier in life, there’s an urgent need for more effective programs to promote nutrition and exercise in kids. One strategy is to create more relevant programs, locally focused and tailored to the culture of the children the program is trying to help.

That approach inspired not one but two child diabetes prevention programs created by Medical Center researchers and tested with our neighbors on Chicago’s South Side. The two programs - called Reach-Out and Power-Up - are siblings, with similar designs, goals, and measures, but in slightly different populations and venues. The pilot studies, both published in recent months, demonstrate the challenges faced by researchers in creating effective, reproducible programs with a local focus…and also offer hope that a successful intervention is possible.

Before the programs could be designed, the first step was to listen. The research team, led by Deborah Burnet, professor of medicine and pediatrics, organized focus groups with overweight children and their parents to learn about their specific obstacles to improving health and gather ideas about the types of physical activity and classes that would appeal to them. For example, the African-American children said they would like to try martial arts and yoga, so instructors for those activities were recruited. The conversations laid the groundwork for programs that would take the unique circumstances of families on the South Side of Chicago into account.

“Nutrition and exercise are both behaviors we do in a social context; in a place, in a neighborhood, in the context of certain social mores and expectations and cultural factors,” Burnet said. “Food, especially - who cooks, where we learn how to cook, how do our tastes get shaped in what we like to eat - those occur in social and cultural contexts.”

While both programs were designed to improve the health and behavior of children, the targets were both the kids and their parents. In Reach-Out, families gathered at a local YMCA for 14 weeks, splitting into separate parent and child groups for the first part of each session and then reconvening for a combined activity. Sessions included grocery store tours, exercise training, cooking classes, and even a family basketball game. Scavenger hunts, relay races, and Family Feud-style review quizzes were used to keep the kids and their parents engaged. But addressing the family’s cooking and eating habits could also be a sensitive topic.

“Feeding is all bound up with caring and love, so it’s very complicated - if you tell grandma she’s not cooking for her grandchildren right, her feelings get hurt,” Burnet said. “So how do you do that in a constructive way so that grandma is valued, but also moves in this healthy direction?”

At the end of the Reach-Out pilot study, published in the Journal of the National Medical Association, the program earned glowing reviews from participants, who said that it helped reduce food intake, steered them toward new fruits and vegetables, and encouraged increased physical activity. However, the clinical improvements were modest, including slight dips in BMI z-score (which scales the measure to child age) and glucose-to-insulin ratio. The incremental changes might mean that very heavy kids need more help to get back to healthy habits, Burnet said: “Kids who are this big probably need a more intensive treatment and intervention than a weekly community-based program.”

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More and more Americans are working at least a portion of their jobs from home, facilitated by technological advances and encouraged by soaring gas prices. Even physicians, enabled by the spread of electronic health records (EHR), are increasingly able to perform some of their tasks at home, including updating patient records, checking lab results, and submitting orders for their patients. But for residents - the doctors-in-training who log the longest hours in the hospital - the ability to work at home can add even more burden to an already overstuffed schedule. In light of new national duty hour restrictions which limit residents to 80 hours a week, there could be increased pressure to push even more of their work to the home office.

However, few studies have looked at just how often these clinical activities already occur from home. To fill this gap, a team of Medical Center residents recently conducted a survey about the frequency of clinical and educational work done at home by their peers. The results of that study, published yesterday in the Archives of Internal Medicine, depict the double-edged sword of EHR home access: greater convenience and surveillance mixed with the potential for danger and abuse - especially as the new rules go into effect on July 1st.

“There are constantly new restrictions on duty hours but additions and new requirements in our training, which include more clinic time,” said Allison DeKosky, one of the study’s authors. “So we’re constantly logging in from home, not just to look up information for our research and education on our own time, but also to follow up on patient information that we simply couldn’t do in the hospital because we had to leave.”

The survey, conducted at two Chicago hospitals, found that performing clinical duties at home is commonplace. A majority of residents reported checking and ordering labs, reviewing records, e-mailing or paging staff at the hospital, and conducting clinic phone calls and orders at least once per month. Of more concern, significant numbers reported performing such activities at least once on their post-call day - when residents are supposed to be recovering from a grueling 30-hour hospital shift.

“Working from home is not necessarily always bad,” said Vineet Arora, associate professor of medicine and faculty advisor on the study. “After all, with electronic health records, working remotely is part of modern-day physician practice. The key question for residency programs is where do you have to draw the line and say that’s unsafe.”

The potential missteps are many: sleep deprivation could interfere with medical decision-making, the information received via EHR may be incomplete or out-of-date, and orders from the resident at home and the team working in the hospital could be redundant or conflicting. So why do residents have such a tough time leaving their work at work? DeKosky said that it’s a combination of responsibility, communication concerns, and looking out for their fellow residents. When shifts change after a call shift, the resident must turn their patients over to another resident to cover in addition to the incoming resident’s own patient load. Not wanting to over-burden the cross-cover resident or worried that an important test result or order might get lost in the shuffle, the post-call resident may feel compelled to check in via the EHR from home.

“It’s hard for us to relinquish responsibility for our patients, we all care very much about them,” DeKosky said. “It is a balance between getting out of the hospital and maintaining your ownership of the patient.”

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By Meghan Sullivan

That there even was a luncheon at Crerar library last week to welcome Nancy Hopkins was a sign of progress. Speaking of a committee formed at MIT in 1995 to explore gender discrimination among tenured faculty, she commented that their meetings were generally held off campus since “having that many women in one room at MIT was so unusual that we were afraid to be seen meeting on campus…it was sure to arouse suspicion.”

Fifteen years later, the packed luncheon in the middle of Crerar was hard to miss. A few dozen women - and a few men - had gathered to discuss her work uncovering and fighting gender discrimination at MIT. More than a relaxed opportunity to ask Hopkins questions before her afternoon lecture, the lunch was a chance for graduate students and post-docs to discuss their experiences and ask for advice. While the prevalence of gender discrimination in the sciences and elsewhere tends to incite strong emotion, Hopkins carried herself with sensibility and humor that was contagious.

Hopkins, a professor of biology at MIT and accomplished cancer biologist, is the first to admit that she never intended to be a feminist. It wasn’t until pervasive and arguably unconscious barriers at MIT began to impede her research in 1995 that she took action against the status quo. Science, she pointed out, has always been touted as a meritocracy, yet she saw her female colleagues repeatedly passed over for tenure, funding, even lab space. In the early stages of her work on gender discrimination, Hopkins perused the MIT staff listings looking for other women in science. She was shocked to learn that out of 274 faculty positions, only 22 were filled by women. “I said check the back of the catalog,” she laughed, “Perhaps they list them separately.”

But why was science losing women? By the nineties the percentages of male and female graduate students in the sciences were about equal, yet that equality failed to emerge in tenured faculty positions. To explain this, Hopkins described a well-established phenomenon known as “the Leaky Pipeline.” In essence, while the proportions of male and female students entering science are comparable, women are more likely to leave (or leak out of) the scientific career path due to issues which primarily affect women.

Like many, Hopkins believed the Civil Rights Act and affirmative action policies were the answer to getting more women in science. But over the next thirty years, less obvious issues proved serious barriers, including sexual harassment, connecting with an empowering mentor, and managing a successful family-work balance. The last was especially frustrating, as high level science can often require more than 70 hours of work a week, leaving little time for family and children. As Hopkins put it, many were required to be “nuns of science,” working in an environment where talking about family and children was far from the norm.

However, it wasn’t until one of the more insidious barriers to women in science began to interfere with Hopkins work that she got involved. Called unconscious gender bias, this subconscious undervaluation of work done by women has been studied for years by psychologists. For example, when people are shown work done by a man or a woman and asked to rate it, the panel will value the man’s work over the woman’s, even if the objective quality of both is identical. Such undervaluation of women’s work not only directly impedes their progress up the academic hierarchy, but also self-selects female researchers out of science, caving to feelings of inadequacy and disappointment. As Hopkins said, she felt that “no matter what I discovered, I wouldn’t be accepted in this field.”

Rather than give up a career she’d already sacrificed so much for, Hopkins and 16 other tenured female faculty members drafted a letter to MIT’s Dean of Science at the time, Robert Birgeneau, concerning the unfair gender biases prevalent in the MIT system. Birgeneau responded immediately and impressively to the committee’s report, instituting an aggressive hiring campaign designed to recruit top female researchers from around the world. The resulting increase in the percentage of women faculty was fondly called “the Birgeneau bump.” In addition to the hiring of more women, MIT set to work on increasing day care options and set up committees that would oversee equality in working conditions and institutional policy. These institutional changes would go on to become a standard in the academic world and be adopted by institutions throughout the country.

Yet problems remain.

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By John Easton

Are we flushing away cures? In the last few years, physicians have developed a new respect for what used to be considered waste. Led by a maverick Australian physician, many US doctors have begun to test the curative capacity, when appropriately acquired, prepared and administered, of human excrement.

For once, it’s not the fiber that interests these digestive specialists; it’s the creatures that live in it, the intestinal flora. These indwelling microbes, when compared cell-to-cell, outnumber their hosts by about 10 to one. More than 1,000 different strains of bacteria co-exist peacefully in the typical healthy bowel. But when the delicate balance is altered by antibiotics or other causes, a few strains can become dominant, leading to severe diarrhea, inflammation, tissue damage, even death.

Bacterial aggregates derived from fecal matter have been used sporadically to treat digestive disease for more than 50 years. These were often last-ditch efforts aimed at restoring microbial balance for patients with raging intestinal infections. Fecal microbiota transplantation (FMT) - also known as fecal bacteriotherapy, among other names - is designed to calm a troubled bowel by reintroducing the vast diversity of collaborative bowel inhabitants after the usual, collegial mix has been disturbed.

The first FMT cases, dating back to 1958, were used to treat life-threatening infections caused by aggressive bacteria that had overwhelmed the bowel and eradicated the competition. When antibiotics were unable to control the infection, physicians were able to restore balance by collecting fecal matter from a healthy donor and injecting it into the patient’s colon. It was like a massive dose of probiotics, but delivered bottom up, rather than top down.

More recently, the approach has produced lasting remissions for a small number of patients with a common disease: ulcerative colitis. In 2003, a team led by the Australian physician, Thomas Borody, published a report [pdf] on successful treatment with this approach of six patients who had longstanding ulcerative colitis (UC). “Complete reversal of UC was achieved in all 6 patients following the infusion of human fecal flora,” the authors reported. “These 6 cases document for the first time the total disappearance of chronic UC without the need for maintenance treatment.”

After interviewing Borody, the Freakonomics podcast summarized the expanding medical role of human feces like this: “To paint it with a very broad brush: it could be that many maladies - from intestinal problems to obesity to disorders like multiple sclerosis and Parkinson’s and Alzheimer’s and perhaps even cancer - are related to damaged or missing gut bacteria; the solution therefore may lie in transplanting healthy bacteria into a sick person.”

“This is a fascinating idea, and the early studies show great promise,” said University of Chicago gastroenterologist David Rubin, associate professor of medicine. The notion has also made headway among patients. “We are getting at least one phone call a week from patients asking about the treatment and when we are going to start treating patients,” said colleague Stacy Kahn, instructor of pediatrics at the University of Chicago.

Although fewer than a dozen case reports involving ulcerative colitis have been published, Rubin and Kahn realized that many more patients were getting treated, largely without supervision or medical oversight, a development they called “alarming.” Several websites now provide guidance, almost like recipes, on how to perform this relatively simple procedure.

“This morning I decided to try a fecal transplant,” begins the saga of “Lucky Lindy,” posted on HealingWell.com. “I’ve been reading about it for months, and figured I might as well try … and while the process was a little gross it was easier than I anticipated. For anyone who is interested (and not grossed out), below is the process I used.” He goes on to list his entire protocol, with daily progress updates and cost-cutting tips, such as using a fork to stir the broth instead of a difficult-to-clean blender. read more

The final question of the MacLean Center for Clinical Medical Ethics seminar series on health disparities was a seemingly obvious query that had gone unasked and unanswered the entire year: who is responsible for fixing the problem? For the self-selecting audience that had attended the lectures all year, the question may have seemed irrelevant - many in attendance are already working on research and interventions to reduce disparities at home and abroad. But for Dan Brock, the director of medical ethics at Harvard Medical School, the question was worth approaching from a philosophical perspective, if only for the purpose of preaching beyond the choir assembled each week at the seminar series.

The statistics about disparities between developed and undeveloped countries are not in question: the threefold difference in life expectancy, the millions of children who die each year from preventable disease and malnutrition, the large discrepancies in health care spending. But who has the moral responsibility to try and remedy these enormous global health gaps? Is it the obligation of rich individuals, or organizations and institutions, or governments, or (as a libertarian might say) of nobody at all? Brock said that philosophical theories of global justice are too new to offer answers for such questions. Arguments have been made for centuries about helping the unfortunate you can see, or even the unfortunate of your own tribe, city, state, or country. But stretched to a global scale, these theories have not yet matured, on issues such as how to take care of a nation’s own needy while still assisting the “foreign” needy thousands of miles away.

To address this shortcoming, Brock suggested three other scaffolds upon which an argument for fighting global disparities could be argued. The first was an economic proposition: as he stated, “if you can prevent great harms at little risk, you are obligated to do so.” Fifteen cents worth of rehydration salts can save a child from dying of dehydrating diarrhea, ten dollars (the cost of a movie) given to a charity can buy minimum essential medicines and more - an argument for sacrifice.

“One can’t make a plausible case that more good comes from me going to a movie then would be done in the world if I had gave that money to OxFam instead,” Brock said.

One obstacle to these small acts of charity is the “out of sight, out of mind” phenomenon - as Brock said, almost everyone would give part of their sandwich to a starving African child sitting next to them, but the concept of millions of starving African children is more abstract. But in a time of increased connectivity, where news organizations and social media can instantaneously spread images around the world from even the most remote locales, this detachment will no longer be an excuse, he said.

Brock’ s second argument that the well-off are obligated to help the needy was a harder pill to swallow: Guilt. The prosperity of the developed world is not independent from the poverty of the undeveloped, Brock argued; it was built upon a history of slavery and colonialism that has continued to handicap Africa and Asia long after such policies (officially) ceased. Even today, the exportation of natural resources such as oil from Africa and the Middle East to the developed world perpetuates oppressive governments, inequalities, and poverty in those countries. That complicity in the suffering of others gives the developed world a special responsibility to help, Brock said.

“Our failure to act isn’t just a failure of beneficence, a failure to help others that are needy, because we are in significant respects causally responsible for their need and in turn morally responsible for their suffering,” Brock said. “If I was the one who drove into your car and wrecked it, then I have a special obligation to help you, because I caused your need.”

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In Akira Kurosawa’s 1950 film Rashomon, the story of a crime is told three times from the perspective of three different witnesses/participants. Due to the biases of each storyteller, the details of the three accounts fail to align, ultimately leaving the film’s narrator - and the viewer - unsure about what truly happened in the central incident. Historians have their own version of the Rashomon effect, filtering past events and organizing historical narratives according to their own beliefs, whether the influence is subtle or overt.

In an attempt to offset any such potential bias in his Regis J. Fallon Lecture at the University of Chicago, health law expert Timothy Jost of Washington and Lee University School of Law chose to present three parallel narratives in his discussion of the history and future of American health insurance. Despite a relatively brief run as a major player in our country’s health care system (”there are many people alive today in Chicago who were born before modern health insurance arrived,” Jost said), health insurance has quickly risen to a place of great importance, as demonstrated by the industry’s role in last year’s passing of the Affordable Care Act. The goal of that legislation to make sure that all American citizens have health coverage will likely be a key turning point in the story of American health insurance. But to understand which direction health insurance will travel after the ACA is fully implemented, you need to understand how it got there in the first place, for which Jost offered three tales.

1. A Failure of Socialized Medicine

In this tale, the public’s push for universal government health care was repeatedly rebuffed by special interests and conservative politicians throughout the 20th century. Though incremental victories were achieved, from the push by labor unions for employer-provided health benefits to the passage of Medicare and Medicaid during the Johnson Administration, the century ended with a whimper for socialized medicine advocates thanks to the doomed health care reform of the Clintons. Opposition from organized medicine, small-government Republicans, and an increasingly powerful private insurance industry thwarted the push to join other developed countries who had switched over to government-run health care after World War II - “for two decades, we saw no progress,” Jost said.

2. A Failure of Market-Driven Medicine

But according to the second narrative, this lack of progress was good news. From this perspective, Americans are “overinsured…because of misguided government policies that have encouraged private insurance for routine as well as catastrophic medical costs,” Jost said. By placing the cost burden on employers and government programs, the American health insurance system has severed consumers from the true price of their own health care - the main culprit, many economists believe, for the exponential rise in medical spending over the last century. Under this narrative, the steering wheel of health care should be handed back to the market with a strategy of tax credits, vouchers, and the roll-back of Medicare - key components of the current Republican budget plan.

3. A Messy Compromise That Kind of Works

Mixing the two narratives together creates a third storyline, one that Jost seemed to prefer despite describing it as “muddling through to moderate success.” In this history of health insurance, the industry grew haphazardly over the 20th century, incorporating elements of both government- and market-driven approaches according to the fickle political winds of different eras. From the birth of modern health insurance as “health services plans” (guaranteeing coverage of hospital costs) in Dallas in 1929, through the expansion of coverage to all types of care including routine visits, pharmaceuticals, and even dental, the unlikely bedfellows of consumer demand and labor union pressure combined to nurture the explosive growth of the industry. And for a while, this worked, Jost said - 82.4 percent of the population held private heath insurance in 1980, the peak of such coverage.

“The United States seemed to have solved, through private initiative supplemented by public programs…the problem of health security that other nations had addressed through social insurance or public provision,” Jost said.

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In the Norman Rockwell past, patients had one doctor who followed them from home to clinic to hospital, managing their health care over a significant portion of their lives. That sort of doctor-patient relationship in today’s medical world seems about as outdated as a family gathered around the fireplace listening to the radio. Now, patients are growing used to unfamiliar people in white coats, seeing multiple doctors at their clinic and a parade of physicians from their hospital bed.

Part of this shift has been the move toward medical specialization, with more medical students choosing careers in surgery, cardiology, neurology or other specialties. The coincident decrease in primary care or family medicine doctors has reduced the ability of those who remain to visit their patients when they are hospitalized and monitor their care. Into this void has rushed the hospitalist, a physician who spends more than a quarter of their time on inpatient service.

Since the mid-90s, hospitals have increasingly relied on this new class of doctor to handle the work of the wards, and David Meltzer, associate professor of medicine, economics, and public policy, has studied the impact of this cultural change. In his talk for the MacLean Center for Clinical Medical Ethics seminar series, Meltzer detailed the impact of an increased role for hospitalists, for both patient health and the hospital’s bottom line. But with the Affordable Care Act rewriting the rules about how Americans receive and pay for their health care, a new kind of hands-on hospitalist may be a key player in the medical landscape of the future.

Meltzer started his research by looking in his own backyard: at the Medical Center’s hospitalist program that he himself directs. From 1997 to 1999, one of the four general medicine services at the Medical Center was run by two hospitalists rather than the rotating house staff and general internists who normally take in new patients. Time revealed the benefits of the more consistent care provided by the hospitalists - by the second year, patient stays were a half-day shorter in the hospitalist service, survival 30 and 60 days after discharge was higher, and costs per patient were nearly $800 lower.

Why would hospitalists show such a profound advantage? The answer may come down to repetition and experience with commonly encountered conditions, Meltzer said. He compared the improvements on the hospitalist service to the growing efficiency of shipbuilders during World War II as they built more ships.

“The total effect was explained by disease-specific experience,” Meltzer said. “Hospitalists seemed to have shorter length of stay and lower costs not because they spend so much time in the hospital, per se, or have so much more experience overall, but because they actually saw these diseases again and again.”

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The University of Chicago is the birthplace of nuclear energy. So like proud but concerned parents, UChicago has kept a close eye on the benefits and challenges of nuclear power over the years since the first self-sustained nuclear reaction under Stagg Field. Thus, the battle to manage the consequences of the damaged reactors at the Fukushima I Nuclear Power Plant in Japan has drawn the University’s interest, and the short-term and long-term effects of that ongoing situation were the subject of a unique panel held on campus yesterday, “Lessons from Fukushima.”

Though nuclear power was created by scientists, discussing its use requires input from political and economic spheres as well. So the panel, assembled by the University of Chicago Alumni Association, brought together nuclear technologists (Hussein Khalil, director of the nuclear energy division at Argonne National Laboratory, and Mark Peters, deputy director of Argonne), nuclear policy watchdogs (Kennette Benedict, executive director of the UChicago-based Bulletin of Atomic Scientists), and energy economics experts (Robert Topel, director of the University of Chicago Energy Initiative). With such different perspectives, it didn’t take long for the panelists to find points of debate, reflecting the tug-of-war over nuclear power that has gone on for several decades.

Nobody disputed the magnitude of the Fukushima incident, with workers at the plant still struggling to limit core meltdown in at least three of the reactors as well as re-cooling spent fuel rods at the site. As well, the panelists agreed that the incident was very relevant to nuclear power in the United States, where roughly one-fifth of electricity is provided by nuclear plants, many of which use the same model as the Fukushima reactors. But opinions differed on what those consequences would be.

Khalil pointed out that this was the first natural disaster to cause “grave damage” to a nuclear power plant in nearly 60 years of their use, and that a similar occurrence was very unlikely in the United States. But Benedict argued that “very unlikely” wasn’t good enough for “the most dangerous technology on Earth,” and that not every safety precaution possible had been taken at Fukushima. Topel agreed with the latter point - “why build generators on the ocean side in a country that coined the term ‘tsunami’?” he asked - and noted that the renewed attention to the long-term dangers of nuclear power would only make it more difficult to build new reactors.

In fact, no new nuclear reactor has come online in the United States in 32 years, Khalil said. So while Argonne continues to research new designs for nuclear plants and new strategies for containing nuclear waste, the economic (and possibly now public opinion) barriers are too large. The most likely rescue for nuclear power may come from an unlikely source: climate change.

“If other technologies turn out to be a bust, and if we really are serious about reducing our carbon footprint and carbon pricing becomes important, then there is a technology we have that can produce a lot of energy at relatively low cost compared to the alternatives,” Topel said. “Then, nuclear energy will prosper.”

By the end of the 90-minute discussion, the panelists came back to common ground on a hopeful note. If a thin silver lining could be found on a disaster that hasn’t yet been completely averted, it’s that the events at Fukushima have re-opened the international dialogue on nuclear power - its immense benefits and equally immense costs.

“One of the positive externalities of the Fukushima accident is that many more people are interested in nuclear energy, and I think that’s terrific,” Benedict said. “It’s unfortunate that it takes an accident to do it.”

Elsewhere…

The conversation about cancer is changing, from a single disease classified by the organ where it appears to multiple diseases grouped by genetic and biological similarities. As ScienceLife has written before, the Chicago Cancer Genome Project is our local contribution to this strategic shift against “the emperor of all maladies.” This week the Los Angeles Times examined that research effort and others like it, speaking with project leader Kevin White and many of the Medical Center’s cancer experts collaborating on this new vision of how to classify and battle cancer.

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There are many different stakeholders in fixing the runaway costs of the U.S. health care system, including patients, doctors, hospitals, and the federal government. Another interested party, heavily involved in recent debates over health care reform, is the health insurance industry. As the Patient Protection and Affordable Care Act rolls out in the coming years, insurance companies will need to adapt to many new rules and regulations on matters such as pre-existing conditions and insurance exchanges. But they also have their own ideas about how to reduce health care costs, focusing on two key components of PPACA: health disparities and quality improvement.

Aetna is the third largest insurance provider in the United States, providing medical insurance for more than 17 million people. The Aetna Foundation, their charity and grant-dispensing arm, is focused on promoting wellness, health, and access to high-quality health care. Addressing those goals will also make progress in reducing health disparities, said Anne Beal, president of the Aetna Foundation, in her presentation to the MacLean Center for Clinical Medical Ethics. The strategy she outlined showed how parties who have sometimes been at odds in the health care reform debate can find common ground for the benefit of patients.

Beal, formerly a faculty researcher at Massachusetts General Hospital and the co-author of a best-selling parenting book, made a case for health equity to the seminar series, which this year is themed “Health Disparities: Local, National, Global.” Beal presented now-familiar statistics about higher rates of infant mortality, diabetes, and more in minority communities, but added a new voice to the mix - the words of Martin Luther King, spoken in Chicago in 1966: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

But aside from social justice, there’s also a bottom-line argument to be made for reducing health disparities, Beal said. If you think of disparities as a form of inefficiency in the health care system, billions of dollars could be saved by narrowing those gaps.

“When you talk about health disparities, it is an important opportunity for us to really try to bend the cost curve,” Beal said. “Giving people the right care at the right time and preventing disease is an amazing way for us to really rein back a lot of these health care costs.”

Ensuring that people receive appropriate care falls under the domain of quality improvement (QI), the idea that health outcomes can benefit from fewer mistakes and more efficient delivery of care. Beal admitted that quality improvement was just one of many possible causes of health disparities, but argued that QI was a way to improve care for all patients and reduce health disparities at the same time - a win-win situation, if done right. Simple interventions such as making sure patients receive the right hemodialysis dose or even basic vaccination programs can help overall population health while narrowing the gap between white populations and minorities.

“This is not to say we shouldn’t do special interventions and targeted population efforts and things like that, but we need to stick to the basics,” Beal said. “If you can’t look at a population of children and say that they’re 100 percent vaccinated against measles, then any other intervention you do is just trying to put a band-aid on a bad situation. I would argue that we really need to focus on high quality care as the first step for addressing population health in communities of color.”

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It’s no big secret that one of the keys to good health is getting regular exercise. Yet good intentions are often thwarted by factors outside of one’s control. A person might decide to jog or bike several times a week, but if the neighborhood outside their door is not conducive to physical activity, it can be easier said than done. Whether you live out in the country or deep in the heart of the city, the design of the neighborhood around you can have an effect on your ability to exercise out of doors.

To clarify that relationship between neighborhood streets and physical activity, epidemiologist Ningqi Hou used data from one of the largest longitudinal studies of cardiovascular health in the United States, the CARDIA study. As a graduate student at the University of North Carolina, Hou and her colleagues analyzed the frequency of physical activity in over 5,000 CARDIA participants alongside characteristics of the “street networks” where they live. Hou, now a postdoctoral researcher in the Department of Health Studies at the Medical Center, looked at the density of intersections, the connectivity of streets, and the type of roads in each participant’s neighborhood.

Their hypothesis was that the “built environment,” the infrastructure surrounding a person’s home, has an invisible influence on their behavior that could conflict with their exercise plans.

“Although there are a lot of physical activity interventions, a lot of them don’t actually work. For example, you have an education program to tell people how beneficial physical activity could be, but over time, that effect is going to fade,” Hou said. “However, your built environment is really just existing there for you, and you are passively receiving its influences. To build a sustainable intervention, you need to know what works in that environment.”

The results of the analysis, published in December in Health & Place, were more complex than just “more roads, more exercise.” In areas of low urbanicity - rural and exurb regions with small, spread out populations - more connected street networks did indeed promote walking, jogging, and bicycling. Specifically, a higher density of intersections was associated with more outdoor exercise, suggesting that long, country roads are better suited to physical activity when they are connected instead of remote. That information could be valuable for civic planners looking to build “exurban” neighborhoods that promote health, instead of sprawling suburbs filled with meandering drives and cul de sacs.

“For the ongoing projects we can still influence that process and hopefully help planners to build a more physical activity-friendly environment,” Hou said. “Sometimes when I see the cookie-cutter communities, they have a very suburban style of being spread out, and it kind of worries me. But I think our result may do some good in informing policymakers to change the design for new communities.”

But in more densely packed areas of high urbanicity, the street network effect reversed for women. The higher the density of local roads, the less often female residents biked, jogged, or walked on average (men were unaffected). This unexpected result suggested that other factors associated with high population and street density - such as crime, or socioeconomics - could counteract the exercise benefits of a more connected neighborhood, Hou said. It also suggests that changing urban neighborhoods to promote physical activity may be more complex than adding intersections.

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The benefits of measuring body mass index (BMI) are clear: a physician who knows a patient’s BMI is more likely to counsel her on lifestyle changes, and people are more likely to try diet and exercise on a doctor’s advice. But in the often-rushed environment of the clinic, even the quick calculations required to know a patient’s BMI can get lost in the shuffle.

Internal medicine residents at the Medical Center noticed that almost none of their patients had a BMI recorded on their charts, but many of their patients seemed overweight and obese.

“They initially wanted to improve obesity rates in patients,” said Vineet Arora, MD, who participates in teaching a quality improvement curriculum to residents and is senior author of a study. “But we needed something feasible. Recording and calculating most patients’ BMI was something they could change.”

Their quality improvement initiative and a study about it, published online in March in the American Journal of Medical Quality, grew out of the quality improvement education that all residents now receive at the University of Chicago.

Neda Laiteerapong, MD, was an internal medicine resident at the University of Chicago Medical Center when she decided that measuring BMI was vital to improving patient care. “We couldn’t even identify who was obese in our clinic. If you don’t identify it, you’re not going to treat it on a patient-by-patient basis,” she said.

Laiteerapong and nine of her fellow residents looked at the triage of patients in the clinic, and decided that they could easily make a few small changes to the vital signs that nurses record when a patient is checked in. “Most clinics weigh people, but they don’t measure height,” Laiteerapong said, noting that the combination of height and weight is usually only measured in children. She also said that asking a patient his height isn’t an accurate way to calculate BMI, since people often overestimate how tall they are.

The residents added rulers in the clinics, height and weight charts in the patient rooms, and a slot on the patient intake form for BMI. The nurses took the measurements, and the residents were responsible for calculating BMI. Within a month, the number of patients with a recorded BMI jumped from 4% to 80%.

Julie Oyler, MD, assistant professor of medicine and associate program director for the internal medicine residency, implemented the quality improvement curriculum for residents in 2006. “I would consider this a successful project,” she said. “Instead of complaining about poor practices in a clinic, the residents are getting experience changing and fixing the clinics.”

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In physics, there’s nothing better than an unexpected result. Wednesday, Fermilab scientists unveiled the graph at left and caused figurative rioting in the streets of the physics community, confirming months of rumors about an exciting new result from the suburban Chicago facility (You can watch video of the presentation here). It’s a big score in the final days of Fermilab’s Tevatron accelerator, which is due to close later this year due to budget cuts and the ascendancy of the more powerful CERN Large Hadron Collider in Switzerland.

The buzzworthy peak was the result of collision experiments where Fermilab scientists expected to see a W boson and two quarks, elementary particles that are part of the Standard Model of physics. But the experiments produced something additional, something unexpected, something unusual: a bump. Particle physicists spend their whole life chasing bumps, as Sean Carroll of Fermilab explains at his Discover Magazine blog, because they are “often a signature of a new particle that has been produced and then quickly decayed.” The anomaly could thus be a previously undiscovered particle that is not predicted by the Standard Model (apparently it is too large to be the elusive Higgs boson), forcing a re-write of the core theory of modern physics. Even if it’s not a new particle, some say an incorrect prediction like this one could mean that some of the rules of the Standard Model may need to be tweaked.

But despite the excitement, caution still reigns - as Dennis Overbye wrote in the New York Times, “The key phrase, everyone agrees, is ‘if it holds up.’” The chance that it is just a statistical anomaly is less than 1 in 1375, the researchers said. With that kind of data, biologists (whose 1 in 20 standards were lampooned effectively by the science comic xkcd this week) would already be popping champagne, but it’s not good enough for physicists - past findings of that strength have disappeared with further scrutiny. If additional experiments still being analyzed push the chance of error to 1 in a million, the true celebration will begin, and the finding could be the most important piece of new physics in decades.

Scientific Shutdown

Fortunately, that analysis will continue even in the face of a threatened government shutdown, the Fermilab website assures. But if a budget agreement isn’t reached by midnight tonight, business won’t continue as usual for many scientists, beginning with the 6,000 employees of the National Institutes of Health. As for extramural research that relies upon federal dollars, most ongoing clinical trials will be unperturbed, experts said. But Johns Hopkins researchers said that no new clinical trials will be able to start during the shutdown, and the Medical Center’s Richard Schilsky told MedPageToday that he’s concerned about obtaining experimental drugs from the National Cancer Institute.

“The biggest issue for us would be studies of investigational drugs being supplied by the National Cancer Institute,” he said in an email. “Many times we have to order drugs for each unique patient to be treated, and if NCI shuts down and can’t ship the drug, then we can’t treat the patient!”

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