The Doctor Weighs In

Brian Klepper and David C. Kibbe

Until now, non-health care business has been noticeably absent from the health care reform proceedings, and quiet about the bill's impacts on their management of employee benefits, on cost, and on the larger issues of competitiveness globally. Where have the voices been of the powerful business leaders who will pick up much of the tab?

Keep in mind that, at this point, health care reform has been a series of power plays between Congress and the health care industry (meaning the professionals, firms and associations representing health care's four major sectors: the supply chain, HIT, care delivery and insurance/finance).

Until now, the health care industry - those who seek dollars - has dominated, lobbying Congress and contributing enormous sums to election campaign coffers to make sure that the legislation doesn't impede health care profiteering and sends new funds their way. Meanwhile it has held its breath, apparently hoping that other interests with clout won't notice. As the bills come down to the wire, the air waves have NOT burned with cautionary and righteously indignant health care industry messages opposing them. That's because organizations in the health industry are reasonably certain they've won. They have been sitting tight until the deals are done.

And with good reason. As they stand now, the reform bills are very generous to the health care industry, facilitating, through mandate and/or subsidy, millions of new customers but, as we've recently pointed out, doing pathetically little to rectify the health care crisis' structural drivers. For example, the health plan sector can raise rates without restraint, and a significant chunk of Medicare dollars will be transferred to private sector control. The biotech industry gets a 12 year moratorium on generic competition. With only token progress away from fee-for-service reimbursement and toward primary care re-empowerment, the system will continue to make specialist excesses lucrative. The American Medical Association (AMA) and Medical Group Management Association (MGMA) couldn't be more enthusiastic, though both are now campaigning for H.R. 3961, which would eliminate the 21.2% drop in Medicare physician reimbursements scheduled to go into effect January 1, 2010. There are many more examples.

Commercial purchasers have waited to see how all this would play out. But now they're stirring, and not a moment too soon. Non-health care business leaders finally appear to be mobilizing against the weak cost control provisions of the current proposals.

What is needed now is an orchestrated, mobilized, highly visible campaign effort that features the faces and voices of well-known American CEOs, and that leverages the full force of business' leadership across industries, not just for their own interests, but for those of all Americans. The places to start are in the structural areas we and others have recently discussed: primary care, fee-for-service reimbursement and cost/quality performance transparency. Properly implemented, reforms in these approaches throughout health care could have profoundly positive impacts on both cost and quality, empowering the market to make health care far more affordable for businesses and working families.

It is possible that the entire health care reform process just changed tone and direction. If it did not, then we're no worse off than before. But if it did, then the ramifications for how American policy works - not just for health care but for all our issues - could have just entered a new and profoundly important paradigm.

Brian Klepper and David C. Kibbe write together on health care market dynamics, health IT, innovation and policy.

By Dov Michaeli MD, Ph.D

Art history has always fascinated me. It encompasses the history of art since essentially the beginning of intelligent Homo sapiens. The astounding art in the Chauvet cave in France dates back to 32,000 years ago! Think of it: these ancient people manufactured their own pigments and were painting before they could communicate through writing. A painting, any painting, is a puzzle. What purpose did the paintings serve? What were they trying to convey? Art criticism is trying to decipher just that. What did the artist mean? Is she successful in evoking the desired emotion?

To me, one of the fascinating aspects of Picasso’s work is his depiction of the women in his life. I read and re-read works of art criticism, trying to understand the images of women pulled and gouged into tortured shapes, women cut in bits and reconfigured on the canvas. Yes, I intellectually know that he had a stormy relationship with his Russian ballet dancer wife, Olga Khokhlova. But why do the paintings of her image evoke such a viscerally uncomfortable feeling? Is it the fact that her nose, painted in two perspectives is reminiscent of a pig's nose? Or that the unnatuarally long fingers and sharp nails are talon-like? Is it  why are paintings of Dora Marr, his mistress and accomplished photographer, resemble more a human-like monster than a warm-blooded human being?

 A Possible Answer?

A recent paper in the Proceeding of the National Academy of Sciences titled Monkey visual behavior falls into the uncanny valley (October 12, 2009) struck a Aha! bell.

As the authors note, “it is natural to assume that, as synthetic agents (e.g. androids or computer-animated characters) come closer to resembling humans, they will be more likely to elicit behavioral responses similar to those elicited by real humans (namely, empathy; my addition). However, this intuition is only true up to a point. Increased realism does not necessarily lead to increased acceptance.”

And here is the amazing observation: “If agents become too realistic, people find them emotionally unsettling. This feeling of eeriness is known as the “uncanny valley” effect and is symptomatic of entities that elicit the concept of a human, but do not meet all the requirements of being one”.

We know it from our own experience. Haven’t you found it almost irresistible to avert your gaze from a person whose face has become horribly deformed by disease or accident? Would you feel comfortable touching his or her face?

These unsettling emotions are thought to have an evolutionary origin, but no evidence for that hypothesis have been available –that is, until now.

Would monkeys, for instance have this “uncanny valley” when shown pictures of monkeys that resemble, but not quite, a real monkey? To test their preference, researchers showed macaque monkeys real pictures, digital caricatures and realistic reconstructions of other monkey faces. To the latter, the macaques repeatedly averted their eyes.

“The visual behavior of the monkeys falls into the uncanny valley just the same as human visual behavior,” wrote Princeton University evolutionary biologists Shawn Steckinfinger and Asif Ghazanfar. The “uncanny valley” was identified in 1970 by Japanese roboticist Masahito Mori, who noticed that people presented with likenesses of increasing realism respond with increasing empathy, right up to the point where the likenesses are almost real. At that point, people are repulsed. The sudden dip in graphs describing their response gave the phenomenon its name.

Did Picasso know about the “uncanny valley”?

I am pretty sure he didn’t. But what I do suspect is that his genius was not restricted to painterly matters –he was intuitively a master of the human psyche. Picasso could be astoundingly brutal, to friends, lovers, even complete strangers. 'Women are machines for suffering," Picasso told his mistress Françoise Gilot in 1943. Indeed, as they embarked on their nine-year affair, the 61-year-old artist warned the 21-year-old student: "For me there are only two kinds of women, goddesses and doormats". Of the seven most important women in Picasso's life, two killed themselves and two went mad. Another died of natural causes only four years into their relationship. So is it far-fetched to suspect that the great wizard manipulated, may be unconsciously, us, merely mortal admirers of his paintings, into feelings of unease, even hostility, toward the women he brutalized emotionally in the service of his art?

By Dov Michaeli MD, PhD

So you thought you’ve heard enough about the deep fissures in our body politic; a map that is colored red for Republican states (last I checked this color connoted Socialism, God forbid) and blue for Democratic states (blue-blood Democrats? The ultimate oxymoron; who is the moron who devised this system, anyway?). Or noisy demonstrations against the “public option” (and don’t touch ‘my Medicare’ you dirty Socialists!) or angry commentators on MSNBC (does Keith Olbermann ever smile? Lighten up dude, you won!) who’d rather see no health care reform at all than cede one iota to the malevolent opposition. Well, scientists finally found what is at the root of this divide: TESTOSTERONE!

Background evidence

 As if we didn’t suspect that something primeval must be underlying the differences between D’s and R’s. Consider:

• More D’s are vegetarians, and conversely more veggies are D’s.
• Psychological studies have shown that D’s tend to show more empathy than R’s.
• Likewise for tendency to altruism.
• Maybe somewhat unrelated, but more college graduates are D’s, more professors are D’s, more journalists are D’s, and according to Pat Buchanan/Spiro Agnew D’s are “nabobs of negativism”, or simply put –a bunch of egghead wimps.

It wouldn’t surprise me if some anthropologist came upon skeletal remains which clearly demonstrated that ancient R’s were hunters and ancient D’s were gatherers. That’s no joke; just consider: anthropologists do tell us that men were the hunters and women were the gatherers. And guess what: more men are R’s and more women are D’s; ergo it begs the conclusion that R is likely to have been a hunter, D - a gatherer. Do you suspect that testosterone may have something to do with it?

Yes, it does!

An article titled “Dominance, Politics, and Physiology: Voters’ Testosterone Changes on the Night of the 2008 United States Presidential Election.” By Steven J. Stanton, Jacinta C. Beehner, Ekjyot K. Saini, Cynthia M. Kuhn, Kevin S. LaBar.was published in PLoS ONE, October 21, 2009. Mind you, PLoS ONE (Public Library of Science) is a first tier scientific journal: it is peer reviewed, highly regarded for the quality of its papers, and as the name implies – does not accept advertisement of any sort so as to safeguard its independence of any commercial or political bias. Now that I biased you sufficiently to accept the findings, read on.

The study investigated voters' testosterone responses to the outcome of the 2008 United States Presidential election. They note that “Dominance contests are a critical component of determining the leadership of social hierarchies across a wide range of species. In modern human societies, this dominance contest can take the form of a democratic election. Across mammalian species, testosterone is critically linked to dominance competition for hierarchical advancement in males. When males win a dominance contest, their testosterone levels rise or remain stable to resist a circadian decline, and when they lose, their testosterone levels fall”. A word of interpretation: “remain stable to resist a circadian decline” means an actual rise, in the same way that stable temperature in the morning, when it is supposed to drop from the evening levels, is in effect a rise.

Testosterone Levels: 183 participants provided multiple saliva samples before and after the winner was announced on Election Night.

Right wing Authoritarianism: The researchers also measured individuals' endorsement of authoritarian ideals using the right-wing authoritarianism (RWA) scale. The RWA scale includes items assaying individuals' values on issues such as religion, homosexuality, abortion, marriage, feminism, moral tradition, and strong leadership.

 The results show that male Barack Obama voters (winners) had stable post-outcome testosterone levels, whereas testosterone levels dropped in male John McCain and Robert Barr voters (losers). There were no significant effects in female voters.

The results also showed a high correlation between the RWA (right  wing authoritarianism) scale and declared political affiliation.

 In a typically professional understatement, the authors conclude: “The findings indicate that male voters exhibit biological responses to the realignment of a country's dominance hierarchy as if they participated in an interpersonal dominance contest”.

What does it all mean?

It may have many political/societal implications, but some of them are almost self evident.

• The losing party is in a funk, especially its male members, no pun intended.
• As many psychological studies have shown, the normative response to loss is final acceptance. But a non-normative (i.e. pathological) response could be denial, or worse – rage. Any evidence for that on recent TV images? Did the Secret Service take notice?
• Societal trends in the U.S. tend toward the less authoritarian, more inclusive attitudes. Did the GOP leaders take notice?

And finally: isn’t science fun when you are a D, and sort of a drag when you are an R? Just witness the difference in attitude toward science between W’s White House and O's.

By Dov Michaeli MD, Ph.D

We all have memories; some are pleasant, some less so, some have emotional content (my first date), some have none (I am not going to dip my hand in boiling water because I got scalded when I was young and didn’t listen to my mom). But did it ever occur to you that we really don’t know how we remember? Yes, I know, everybody knows that there is a special area in the brain called the hippocampus where memories reside. But that only tells us about the anatomical location of memories, not how they are made. A recent amazing experiment, using our distant cousin the fruit fly took a first stab at this problem. The results of the Oxford University-led study are published in the journal Cell. 

Scientists have used light to program the memories of fruit flies. Think about it: light to program memories!  The research team genetically engineered the fruit flies so that a small set of nerve cells in the brains would ‘fire’ in response to a flash of laser light. This showed which cells are involved in how a fruit fly learns and remembers what to avoid, and offers an exciting new opportunity to investigate how memories are formed.

‘Remote-controlling these cells and turning them on using light creates an illusion in the brain of the fly that it is experiencing something bad. The fly learns from the “mistake” it never really made and improves its actions the next time,’ explains Professor Gero Miesenböck of the Department of Physiology, Anatomy and Genetics at Oxford University, who led the work.

The Oxford scientists, with colleagues at the University of Virginia, Charlottesville, demonstrated that they could use flashes of laser light to train flies to dislike a certain odor.

They tracked the flies using a video camera as they moved around a small chamber while two different odors were fed into the chamber from either end. They found that they could implant a lasting preference for one odor over the other by remotely activating a specific set of brain cells each time a fly strayed into a particular odor. Using this method, the researchers were able to pinpoint the precise nerve cells that are responsible for telling the flies that they’ve done wrong, narrowing down the search from the 100,000 cells in the brain of a fruit fly to a set of just 12 neurons.

This puts them in position to follow this up and start to characterize the process by which memories are formed and organized.

 Surprisingly, the source of these signals is in a limited number of cells – just twelve. These cells send the signals that train the fly to associate the odor with something bad, so wherever their signals go must be the seat of memory.They can now follow this up and start to characterize the process by which memories are formed and organized.

While this work has been done in fruit flies, general lessons about how actions are learned and memories are stored should hold true for humans.

What is the relevance of fruit flies memories to our infinitely more complex brain? Biology teaches us that fundamental mechanisms tend to be conserved. Learning about the storage of memories from brain cells in flies should tell us a lot about how they are stored in humans. Professor Miesenböck has pioneered this method of genetic engineering to remote control the action of specific cells within tissues, or whole organisms like worms, fruit flies, fish and mice, using light from the outside. These efforts have given rise to a new field sometimes called ‘optogenetics’, to indicate that sensitivity to light is encoded genetically.

 As the ability to write memories directly to the brains of fruit flies demonstrates, optogenetic techniques have particular power in neuroscience. Why?

Because we are no longer just passive observers of processes in the brain. In the past, neuroscientists had to be content with recording the chatter of brain cells and trying to infer what it all meant. The ability to talk back and influence behavior directly is a game changer.

But do you get the vaguely discomfiting feeling as I do, that such techniques in the wrong hands can be abused? After all, genetically engineering human beings is already in clinical trials as a way to treat certain diseases. Once we master the technique, what would prevent a rogue scientist or a malevolent government from using it to control thoughts and behavior by shining a laser light? Sounds like the stuff sci fi is made of. Am I becoming a paranoid conspiracy theorist? At the dawn of the molecular biology era concerned scientists saw the potential for mischief in the misuse of DNA genetic engineering. They convened in Asilomar, a conference site in Northern California, and hammered out a code of scientific conduct that has served scientists and society exceedingly well. It is time for neuroscientists to do the same.

Check this out:  Piano Stairs

By Dov Michaeli MD, Ph.D

Go to the ant, you sluggard; consider its ways and be wise!

King Solomon, Proverbs 6:6

An item in the October 12 issue of Current Biology is really cool. Scientists from the University of Arizona and Brandeis University described the first known vegetarian spider. In fact, the aforementioned creature has gone a step further: he is a vegan, eating only uncooked veggies. They discovered this species (B.kiplingi) in Mexico and Costa Rica. But that's not all - the story gets even more interesting.

The Evolution of Vegetarianism

Spiders normally spin webs to better catch unwary insects for their daily “bread”. But this spider had a great insight: acacia plants are normally swarming with ants; this is a well-known example of mutualism — the insects provide protection for the plant and in return the acacia produces nutritious leaf tips (Beltian bodies, for the more scientifically inclined) for the ants to eat. So what does our clever spider do? He learned to jump to avoid the ants, and when the opportunity presents itself –he feeds on those very nutritious leaf tips. Speaking of rigorous science, the authors documented that this is indeed the major nutritional source of this veggie-spider by analyzing the chemical composition of its body, and demonstrating that its source is none other than those Beltian bodies.

And now for the final surprise: the males of B.kiplingi take care and protect its young larval offspring, a phenomenon unheard of in the spider world.

More Questions

Like every good piece of research, this one raises more questions than answers. Here are a few:

1. How did this adaptation occur? Enzymes required to digest an insect meal are quite different form the ones required for digesting plant material. Obviously, mutations had to occur. Did they change the function of pre-existing digestive enzymes, or did they occur in non-digestive proteins acquiring the function of plant-digesting enzymes?If it turns out to be the latter it would be absolutely astounding. But I wouldn't dismiss anything concocted by this non-conformist spider.
2. Is there a functional relationship between the unconventional diet and the equally unconventional behavioral change of rearing the young? Did one inevitably lead to the other? And if so, what came first, the diet or the “socially conscious” behavior?
3. Finally, like everything else nowadays, we should consider the profound political implications. Numerous studies have demonstrated that liberals are more likely than conservatives to be vegeterians, while conservatives are more prone to feast on red meat. Furthermore, progressive fathers assume more responsibility in performing child rearing and other domestic duties. And finally, a respectable poll showed that more educated people tend to vote Democratic rather than Republican. Caveat: these are only "tendencies", not absolute distinctions. Having said that, is it possible that the political equivalent of "women are from Venus, men are from Mars" is "progressives eat veggies, conservatives eat bugs"?

I think I’d better quit now before I incur the wrath some fire-breathing, flesh-eating commentators.    

Bill Bestermann, TDWI blogger and physician extraordinaire, appeared on the front page of the October 7, 2009 USA Today.  Way to go, Bill!....

Doctors join fight against obesity

A patient's weight is often the white elephant in the examining room. Both patient and doctor know it's a problem, but often neither party wants to talk about it, says internist William Bestermann Jr., 62, medical director of a cardiovascular treatment program for the Holston Medical Group in Kingsport, Tenn.

But "if doctors are serious about keeping patients from having heart attacks and strokes, they have to have this conversation, and they have to help their patients lose weight," he says.

Bestermann is helping develop recommendations for physicians on how to guide and treat overweight patients on a committee for the STOP Obesity Alliance, a coalition of professional groups, businesses, unions, insurers and health care providers whose goal is to figure out how to best attack obesity.

"He has been a phenomenal advocate to convince patients and physicians that they are a team attacking this problem together," says Christine Ferguson, director of the alliance.

Debra Horne, 52, of Dungannon, Va., says Bestermann "gave me my life back" by addressing her weight.

In July 2007, she went to see him for the first time. "I'll never forget that day," she says. "Dr. Bestermann walked into the examining room and sat down and introduced himself. He said, 'I see you have a lot of medical problems,' but he never mentioned my weight."

At the time, Horne, who is 5-foot-9, weighed 298 pounds and had type 2 diabetes, high blood pressure, high cholesterol and high triglycerides. She had suffered from depression. She had had foot and back surgeries and was getting around on a motorized scooter. When she got down on the floor to play with her grandchildren, she couldn't get back up on her own.

Bestermann asked Horne to read The South Beach Diet. "He said: 'I'm not asking you to go on a diet or lose weight. I just want you to get the knowledge that is in there,'" she says.  (click to continue)

By Dov Michaeli MD, Ph.D

I must admit that when I read about Prof. Bernard Gesch’s experiment on the relation between nutrition and violence, I had a mental reaction that probably approximated something like an intellectual sneer.

Bernard Gesch is a psychologist and an Oxford University professor, an impressive credential.Bernard Gesch. Senior Research Scientist His study was a double-blind, placebo-controlled, randomized trial, the gold standard in biological and clinical research. So what’s there not to like? I would say right off: a deep suspicion of nutritional claims, most of them either products of junk science, or no pretense of science at all –just claims.

Polmont Prison

The Experiment

In 2002 Gesh and colleagues published a report in the July issue of British Journal of Psychiatry about an experiment conducted in a prison in Aylesbury, England. In a double-blind, placebo-controlled, randomized experiment, Gesch et al. recruited 231 young adult prisoners, assigning half to receive dietary supplements and the other half to receive a placebo. The placebo and active-treatment groups were matched according to their number of disciplinary incidents and their progress through the prison system. There were no significant differences between the two groups in IQ, verbal ability, anger, anxiety, or depression.

Subjects remained on the supplements, which contained vitamins, minerals, and essential fatty acids, for an average of 142 days. Compared to the placebo group, the researchers report, prisoners taking the active supplements committed an average of 26.3 percent fewer offenses. Compared to baseline rates, there was a 35.1 percent reduction in offenses in the supplemented group. "The greatest reduction occurred for the most serious incidents including violence," the researchers note, with a 37 percent drop seen in such incidents. No side effects were seen in subjects taking the supplements.

This is truly impressive! And believable. The methodology of the study is beyond reproach, the statistical analysis is persuasive. And the societal implications are profound.

The September 25 2009 issue of Science reports that a much larger and more detailed study is now under way in one of the most violent prison in the U.K (Polmont, Scotland). The 3-year trial, which started this spring, includes blood chemistry analysis and a battery of computer-based behavioral and cognitive tests designed to address the question that the earlier study could not: If a balanced diet does stem violence, how exactly does it do so?

Other studies have shown a connection between diet and violence, the latest one in the Dutch prison system. Similar findings were reported by Richard Carlton et al. (Alternative Therapies, Vol. 6, No. 3, May 2000, pp. 85-91.) who found that supplements improved mood, behavior, and school performance in learning disabled children. And to close the loop: several studies have shown a connection between learning disabilities and violent behavior.

What can be done right now?

So what are we waiting for? Here is an inexpensive and scientifically- based intervention that promises to deal with a scourge afflicting our society. Anybody who watched the clip of the young student beaten to death by violent gang members on the streets of Chicago while onlookers did not interfere (and haven’t come forward to give evidence) cannot escape but wonder: why?! And why not try something as inexpensive and as promising as dietary supplements in our prisons and schools?

Part of the answer, criminologists and researchers say, is political: we have an ethos of “get tough” on prisoners. I can hear the hue and cry in certain circles that we are coddling criminals.

Of course this is not a panacea. Of course there are deep and complex causes of violence in America. But if there is a real chance of mitigating the problem, if we could save even a few lives –why not try it now?

Radical idea: Publish doctors’ outcome data and watch costs fall

There was a rabble rouser in the house at The Palm Beach County Medical Society’s “Future of Medicine” summit held at The Scripps Research Institute in Jupiter on Friday.

But it wasn’t featured speaker Dr. Jeremy Lazarus, who was there from Colorado to explain the American Medical Association’s unprecedented support for health reform.

The radical in the auditorium was Brian Klepper, a health care consultant whose firm is pushing for higher fees for primary care doctors, lower fees for specialists, and publication of physicians’
outcome data based on Medicare information – positions in conflict with the AMA’s official stance.

Klepper argued convincingly that nothing would improve health outcomes and lower costs more quickly than to make public doctors’ names alongside their success rates. That information exists in the federal Medicare database. It also exists in the computers of Cigna, Aetna and United Healthcare. But the public can’t see it.

Under the current system, the same knee surgery can cost between $2,727 or $9,383 depending on the doctor, yet the amount spent has little or no bearing on the quality of the outcome, Klepper argued.

Publishing doctors’ outcomes has been done by one health system in Kentucky, he said, and that system saw costs curtailed by 30 percent in two years.

“Those with the best outcomes gloated, and those with the worst outcomes got on the phones and asked ‘hey, what are you doing for those patients,’” Klepper said.

“If Medicare physician data were released, we would easily be able to see how doctors performed compared to their peers,” he said.

Klepper slapped the AMA for its protectionist stance on Medicare reimbursements to specialists. Primary care doctors are paid a fraction of what specialists are paid, yet they have the best chance of changing the behaviors - overeating, smoking, lack of exercise, drug abuse – that are most likely to lead to costly chronic diseases, he said.

Given that health care and other special interest lobbyists have showered Congressional leaders with half a billion dollars to influence what’s in the health reform bill, Klepper predicted that it would ultimately flop when it came to controlling spiraling health costs.

Ultimately, Klepper said, it will be large employers who force the system to change. And they’ve got the data to make sure it happens.

We are talking a modified "osteo-odonto-keratoprosthesis" (aka MOOK) procedure here.  Great concept, right?  This could be a very good thing to know if you are ever on "Jeopardy" or "Who Wants to be a Millionaire," don't you think?

Let's break it down into manageable bites: 

• Osteo means bone. 
• Odonto refers to teeth. 
• Kerato in this case refers to the cornea. 
• And prosthesis according to Wikipedia is "an artificial extension that replaces a missing body part." 

The procedure is used for people who have lost their sight because of corneal scarring. 

Here is what happens:

1.  The person who has a scarred cornea has one of their canine (eye) teeth removed together with the underlying bone (thus, osteo-odonto). 

2.  The operator drills a hole in the tooth and inserts a cylindrical artificial lens.

3.  The tooth, with the lens, is inserted under the patient's skin for a number of weeks so that it can "bio-integrate" - encourage the patient's tissue ito grow into the synthetic cornea.

4.  The surface of the damaged eye is then cleaned and repaired using skin from inside the patient's mouth.

5.  Finally, the osteo-odonto-keratoprosthesis is implanted in the center of the eye.

Results so far have been very encouraging for some these previously blind or severely visually impaired people.  How cool is that?

When I was in medical school many moons ago, a fellow UCSF student and close friend, Diane S. and I had the priviledge of accompanying a boy sent to Shriner's hospital in San Francisco back to Mexico to be reunited with his family.  He had severe corneal scarring because of a herpes viral infection.  He was not a candidate for corneal transplantation because he still had an active infection.  His parents were devastated when their son returned with the same problem he had before the "big trip" north.  They nevertheless graciously invited Diane and me to stay and celebrate the Christmas holidays with them.

I have often wondered whether the boy ever got his corneal transplant.  And, I wonder now if an an "osteo-odonto-keratoprosthesis" procedure would have been an additional option.

In the field of medicine, some of the most creative advances have come from the field of opthamology (e.g., online glaucoma screening and other advanced technologies that restore sight.  Blindless and decreased visual acuity are game-changers for people with these conditions.  Could it be possible that, in my lifetime, blindness is eradicated? 

By Dov Michaeli MD, Ph.D

Who amongst us hasn’t experienced the exasperation and heartbreak of suffering through punishing diets and staring at the unmoving dial on the bathroom scale? Gina Kolata, the eminent New York Times science journalist has been looking for evidence for throwing in the towel: the body’s composition, especially the proportion of fat, is just out of our control. Don’t blame the overweight and obese for lack of self-control; brain and metabolic regulatory mechanisms are just too powerful to resist over the long term. But wait, before you feel free to stuff your face with this juicy super-size hamburger, consider this.

The Neurobiology Self-Control

Behavioral studies have shown that self-control is exhaustible in the short term (explaining the phenomenon of dieting failures), can be enhanced by cognitive strategies (so no reason to declare defeat), and is correlated with measures of intelligence (aha! is that’s why physicians and scientists are rarely obese?). But hard-headed scientists insist on “hard” evidence; behavioral studies are susceptible to many “confounding factors”, which make unequivocal interpretation very difficult. Now we have this rock-solid evidence.

The May issue of Science magazine reported on research out of Caltech which identified the anatomical location of self-control in decision-making. They went about it in a clever way. They scanned the brains (using fMRI) of a group of 37 dieting volunteers while they performed two tasks: first, they rated 50 different food items for taste and health separately. On the basis of these rating, the investigators could select a reference item for each subject that was rated neutral in both taste and health. For the second task the subject were asked to choose between each of the foods and the reference item. Participants also indicated the strength of their decision by using a five-point scale (strong no, no, neutral, yes, and strong yes), which provided a measure of the relative value, or the amount of expected reward associated with consuming the food, instead of the reference item. Based on their decisions 19 of the participants were classified as self-controllers (SC), and 18 as non-self-controllers (NSC). There was a stark difference between the two: SC made decisions based on both health and taste, rejecting most- liked-but unhealthy items, whereas the NSC group made decisions on the basis of taste alone.

What did the scans show? It is well known that the prefrontal cortex (PFC) is the seat of the “executive center” –the site where emotional and cognitive signals come in, get processed, and a decision is then made. This study refined the picture quite a bit. A specific area in the PFC, called the ventromedial (or lower middle) prefrontal cortex (vmPFC) lit up in the fMRI scans. Activity in this area correlated with participants’ expectations of reward regardless of whether or not they exercised self-control. Furthermore, the activity in the vmPFC reflected the health ratings of the SC group but not of the NSC group. But, you may rightly observe, this still does not add up to self-control. Indeed, another area in the PFC, the dorsolateral (or upper outer) prefrontal cortex (DLPFC) became significantly more active during successful self-control than failed self-control trials. In other words, the vmPFC made a decision regarding the choice of food, but the DLPC modulated this decision by exerting self-control. It is the stern parent telling us not to eat the chocolate cream cake because it’s “not good for you”.

But if the DLPFC exerts functional control over the  vmPFC, there should be some functional connectivity between the two. Indeed, during successful self-control trials (i.e. high DLPFC activity) the activity of the vmPFC was reduced. You might say that in situations of successful self-control, the DLPC becomes predominant and the vmPFC assumes a diminished role. Interestingly, the same observation was made in gamblers who chose not to gamble in losing conditions.

The implications of this elegant study are wide and deep. The DLPFC areas identified in this study are similar to areas that are involved in cognitive control and in emotional regulation. But lest we absolve ourselves of any responsibility, these findings don’t mean that the DLPFC is immutable; thanks to the plasticity of the brain it is susceptible to behavioral strategies that can enhance or reduce its activity. So this brings us back to the argument that dieting is futile; that biology will defeat our most valiant efforts. We now know that “the devil made me do it” is simply not acceptable even on biological grounds.

This study is focused on dieters’ self-control. But the implications for drug addicts are obvious. In fact, many behavioral and neurobiological attributes of drug addiction are shared by compulsive eaters. And the many strategies offered to control both can now be evaluated by their effect on the activity of the DLPC.

Finally, one cannot ignore the implications of this study on the current political climate. We have more than our share of nut cases who would act impulsively on their political convictions. In a New York Times column today, Tom Friedman compared the super-heated atmosphere surrounding the our President with the atmosphere in Israel preceding the assassination of prime minister Rabin by a right wing religious fanatic. How discouraging it is to see Republican leaders (Michael Steele and Bill Bennet the morals czar) jumping to the defense of these nuts and labeling, I’m not making that up, Tom Friedman as nutty. My guess is that if anybody bothered to run an fMRI on the nuts that are pushing a military coup on Facebook and are running a poll whether or not President Obama should be assassinated, they will find them totally lacking in self-control and with an atrophied DLPFC. Where are the supposedly enlightened leaders who are expected to modulate rather than exploit this outrageous out of control behavior?

I don't have time write much tonite.  Tomorrow is a big day.  The company I work for, Universal American - a senior focused healthcare company, is sponsoring a Wii Bowling Tournament for seniors in Houston. You can google the event "Texan Plus Wii Bowling Tournament" or I can just tell you that we think that close to 3000 seniors are going to converge on the local stadium (Reliant Stadium) to virtually bowl to their heart's delight.

We think the event is a big deal.  The Guiness Book of World Records is coming to determine if we are sponsoring the biggest Wii Bowling Tournament in the world.  Can you believe that? 

I googled Wii Bowling the other night and found out that this is a cultural phenomenon.  This is what folks are doing in their spare (pun) time.  And it is great.  So much better than sedentarily (word?) munching on chips while watching the soaps.

It turns out that Wii is rapidly becoming an exercise vehicle of choice for young, old and everyone else (who I guess are the "middle-aged"). 

Wii is a very cool way to get exercise.  You all trying it?  Folks with kids still at home evidently already have a Wii, but even us "middle-agers" are eyeing the Wii as it goes on sale this month.  I would really like to improve my tennis game.  I hear Wii can help me get a power serve (or at least get the ball in the right place). 

From the Atlantic:  PLEASE READ:

The following article

by David Goldhill

Almost two years ago, my father was killed by a hospital-borne infection in the intensive-care unit of a well-regarded nonprofit hospital in New York City. Dad had just turned 83, and he had a variety of the ailments common to men of his age. But he was still working on the day he walked into the hospital with pneumonia. Within 36 hours, he had developed sepsis. Over the next five weeks in the ICU, a wave of secondary infections, also acquired in the hospital, overwhelmed his defenses. My dad became a statistic—merely one of the roughly 100,000 Americans whose deaths are caused or influenced by infections picked up in hospitals. One hundred thousand deaths: more than double the number of people killed in car crashes, five times the number killed in homicides, 20 times the total number of our armed forces killed in Iraq and Afghanistan. Another victim in a building American tragedy.

About a week after my father’s death, The New Yorker ran an article by Atul Gawande profiling the efforts of Dr. Peter Pronovost to reduce the incidence of fatal hospital-borne infections. Pronovost’s solution? A simple checklist of ICU protocols governing physician hand-washing and other basic sterilization procedures. Hospitals implementing Pronovost’s checklist had enjoyed almost instantaneous success, reducing hospital-infection rates by two-thirds within the first three months of its adoption. But many physicians rejected the checklist as an unnecessary and belittling bureaucratic intrusion, and many hospital executives were reluctant to push it on them. The story chronicled Pronovost’s travels around the country as he struggled to persuade hospitals to embrace his reform.

It was a heroic story, but to me, it was also deeply unsettling. How was it possible that Pronovost needed to beg hospitals to adopt an essentially cost-free idea that saved so many lives? Here’s an industry that loudly protests the high cost of liability insurance and the injustice of our tort system and yet needs extensive lobbying to embrace a simple technique to save up to 100,000 people.

And what about us—the patients? How does a nation that might close down a business for a single illness from a suspicious hamburger tolerate the carnage inflicted by our hospitals? And not just those 100,000 deaths. In April, a Wall Street Journal story suggested that blood clots following surgery or illness, the leading cause of preventable hospital deaths in the U.S., may kill nearly 200,000 patients per year. How did Americans learn to accept hundreds of thousands of deaths from minor medical mistakes as an inevitability?

My survivor’s grief has taken the form of an obsession with our health-care system. For more than a year, I’ve been reading as much as I can get my hands on, talking to doctors and patients, and asking a lot of questions.

Keeping Dad company in the hospital for five weeks had left me befuddled. How can a facility featuring state-of-the-art diagnostic equipment use less-sophisticated information technology than my local sushi bar? How can the ICU stress the importance of sterility when its trash is picked up once daily, and only after flowing onto the floor of a patient’s room? Considering the importance of a patient’s frame of mind to recovery, why are the rooms so cheerless and uncomfortable? In whose interest is the bizarre scheduling of hospital shifts, so that a five-week stay brings an endless string of new personnel assigned to a patient’s care? Why, in other words, has this technologically advanced hospital missed out on the revolution in quality control and customer service that has swept all other consumer-facing industries in the past two generations?

I’m a businessman, and in no sense a health-care expert. But the persistence of bad industry practices—from long lines at the doctor’s office to ever-rising prices to astonishing numbers of preventable deaths—seems beyond all normal logic, and must have an underlying cause. There needs to be a business reason why an industry, year in and year out, would be able to get away with poor customer service, unaffordable prices, and uneven results—a reason my father and so many others are unnecessarily killed.

Like every grieving family member, I looked for someone to blame for my father’s death. But my dad’s doctors weren’t incompetent—on the contrary, his hospital physicians were smart, thoughtful, and hard-working. Nor is he dead because of indifferent nursing—without exception, his nurses were dedicated and compassionate. Nor from financial limitations—he was a Medicare patient, and the issue of expense was never once raised. There were no greedy pharmaceutical companies, evil health insurers, or other popular villains in his particular tragedy.

Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.

These are the impersonal forces, I’ve come to believe, that explain why things have gone so badly wrong in health care, producing the national dilemma of runaway costs and poorly covered millions. The problems I’ve explored in the past year hardly count as breakthrough discoveries—health-care experts undoubtedly view all of them as old news. But some experts, it seems, have come to see many of these problems as inevitable in any health-care system—as conditions to be patched up, papered over, or worked around, but not problems to be solved.

That’s the premise behind today’s incremental approach to health-care reform. Though details of the legislation are still being negotiated, its principles are a reprise of previous reforms—addressing access to health care by expanding government aid to those without adequate insurance, while attempting to control rising costs through centrally administered initiatives. Some of the ideas now on the table may well be sensible in the context of our current system. But fundamentally, the “comprehensive” reform being contemplated merely cements in place the current system—insurance-based, employment-centered, administratively complex. It addresses the underlying causes of our health-care crisis only obliquely, if at all; indeed, by extending the current system to more people, it will likely increase the ultimate cost of true reform.

I’m a Democrat, and have long been concerned about America’s lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system—largely problems of incentives—our reforms won’t do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand, the role of insurance; focus the government’s role exclusively on things that only government can do (protect the poor, cover us against true catastrophe, enforce safety standards, and ensure provider competition); overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices, and sensible trade-offs between health-care spending and spending on all the other good things money can buy.

These ideas stand well outside the emerging political consensus about reform. So before exploring alternative policies, let’s reexamine our basic assumptions about health care—what it actually is, how it’s financed, its accountability to patients, and finally its relationship to the eternal laws of supply and demand. Everyone I know has at least one personal story about how screwed up our health-care system is; before spending (another) $1trillion or so on reform, we need a much clearer understanding of the causes of the problems we all experience.  (Click here to continue with this story)

Ashoka’s Changemakers and The Global Alliance for Improved Nutrition (GAIN) are seeking the most innovative entrepreneurial ideas for improving global nutrition for their online competition, Improved Nutrition: Solutions through Innovation (www.changemakers.com/nutrition).  Ashoka is a partner in the Clinton Global Initiative.

 
“GAIN is proud to partner with Ashoka’s Changemakers as both organizations are committed to business-like innovation with a social mission,” said Marc Van Ameringen, Executive Director of GAIN.
 
Good nutrition for everyone is within our reach. The question is how to make this a reality for communities currently lacking access to nutritious food or unaware of its benefits.
 
“Malnutrition is a solvable problem. Changemakers is looking forward to highlighting the solutions that will reach previously unreached populations,” said Charlie Brown, Executive Director of Changemakers. “It is of utmost importance that we identify
creative models that will directly and positively change the lives of millions most at risk of malnutrition,” Van Ameringen added. “Each year, 3.5 million children die because they are malnourished.”
 
The competition is open to innovators with new ideas to expand and improve nutrition – to make sure all people have access to the vital nutrients and the critical information that will help them thrive. Solutions with the potential for growth and scale are likely to come from creative community members from all corners of the globe and local, grassroots organizations. 
 
“The best ideas may lie in the creative use of technology, innovative public education programs groundbreaking nutrition products, or other entrepreneurial approaches not yet broadly implemented,” Brown said. “We expect, through this competition, to discover and support the future of global nutritional health.”
 
Three winners will receive USD $5000 each and media exposure; they will be prominently featured on Changemakers.com and recognized for the endorsement they have received from  the world’s most vigorous and engaged online social change community. 
 
Winners are chosen by the Changemakers community after a panel of expert judges reviews all the entries and shortlists finalists. Anyone is welcome to join Changemakers, to nominate innovations, submit great ideas, vote for the top finalists, and interact with a network of supporters committed to social change.
 
In addition, five entrants will be chosen by GAIN to attend, all-expenses paid, the GAIN Business Alliance Global Forum in May 2010, where they will have the opportunity to present their solutions to investors.
 
###
 
About the Global Alliance for Improved Nutrition (GAIN) The Global Alliance for Improved Nutrition (GAIN) is an alliance driven by the vision of a world without malnutrition. GAIN mobilizes public-private partnerships and provides financial and technical support to deliver healthier foods and supplements to those people most at risk of malnutrition. Our innovative partnership projects in more than 25 countries are improving the lives of nearly 200 million people. Our project portfolio is growing and our goal is to reach one billion people.
 
About Ashoka’s Changemakers
Changemakers is an initiative of Ashoka, an organization with over three decades of finding, funding, and expanding the work of social entrepreneurs across the globe. It is a global online community of action that connects people to share ideas, inspire and mentor each other, and find and support the best ideas in social innovation. The Changemakers online community builds on this history and expands the Ashoka vision by creating an “Everyone a Changemaker” world through networking, relationship-building, and the
sourcing of funding opportunities.
 
Through its collaborative competitions and open-source process, Changemakers’ has created one of the world’s most robust laboratories for launching, refining, and scaling ideas for solving the world’s most pressing social problems.

For more information contact:
Delyse Sylvester
Director of Community 
Ashoka’s Changemakers
Tel: 250-352-0616
Cell: 250-551-0570
Email: dsylvester@ashoka.org
 

I think this is an article about health.  It is about mental health, anyway.  And even though health care professionals have done their best to separate mental from physical health, the last time I looked in the mirror, my head (where my brain resides) was attached to the rest of my body by a lot of flesh, bones, nerves and blood vessels.

Anyway, what I really want to write about today is how much fun it is to spend time with people who are different from me – in a variety of ways.  I started my day going to Dim Sum here in Houston.  Dim Sum, for those of you not familiar with it is a high-calorie, highly tasty communal Chinese-style brunch.

The restaurant staff wheel little carts around the diners’ tables offering such tasty morsels as siu mai (small steamed dumplings with either pork, prawns or both inside a thin wheat flour wrapper), bau (baked or steamed, fluffy buns made from rice flour filled with food items ranging from meat to vegetables to sweet bean pastes, exotic veggies), fried chicken feet, and very sweet Chinese dessert pastries.  Yum yum, dim sum (my attempt at poetry).   [No, I am not going to get into how greasy and high calorie dim sum is, this is a piece about joy and happiness].

Folks attending our Dim Sum feast were as diverse as the food.  I sat next to a woman originally from El Salvador who has been an accountant in Houston for many years; a young man from Cambodia who told me he couldn’t understand why his parents would ever want to go back to visit a country from which they had barely escaped with their lives in 1975; a couple born in Puerto Rico, part of a large close knit family here in Houston; and an “ordinary” white woman who lived in San Miguel de Allende, Mexico for seven years and later taught English as a second language in Northern China (near Mongolia) and then traveled by herself throughout China.

Later on the same day, I went to a Spanish Language “Meet-up” to watch an old Cantiflas movie in Spanish (no subtitles).  I loved it for about two hours or so and then had to leave because my head was reeling after trying to understand rapid fire Spanish and the slapstick humor of Cantiflas.

My husband and I have traveled all over the world and we have loved (almost) every minute.  But recently, here in Houston, I have had the chance to really get to know people different from me.  This week, my long time personal trainer (KW), told me a black joke about white people.  He mimicked a black guy hearing gun shots and coolly, but quickly, walking away from the area.  He then showed me what he thinks white people do when they hear gun shots.  Waving his arms in the air and running towards  the shots, he yells, “Hey, what’s going on, I think I heard shots, we ought to see what is going on.”  It was so funny, I had to put down my weights and laugh out loud.

We all know that laughter is good for our health.  And that is how come I am making this a blog about health.  Our world is now so small that we can come in contact every day with people different from ourselves.  Different color, shape, size, religion, sexual preference, interests, language, abilities and disabilities, and on and on and on.  It is very cool and very fun to meet people different from me.

I hate it that there are some talk shows and some politicians that want to make us fearful of our differences (BTW, I think hate is bad for our health). Relishing in the diversity of mankind can turn on our brains, help us laugh at ourselves, and open us up to new ideas, challenges, and most importantly, new people.

I am reading a great book:  The Little Giant of Aberdeen County. 

The heroine of the book, Truly, is a giant (she most likely has a pituitary tumor that is secreting growth hormone).  In one of the early chapters, the town's folk (the men) are betting on how big a baby her mother will deliver.  They all believe this big baby will be a boy... and will weigh 10 or 11 pounds.  But, Truly surprises them by being a 12 pound girl.

Now we see how puny the imaginations of the Aberdeen County men really were.  A woman named Ani in Jakarta, Indonesia recently delivered a 19.2-pound, 2-foot-long child via Caesarean section.

Oh me oh my.  19.2 pounds.  Glad it wasn't me carrying this "ginormous" infant to term.  How did the mom even get out of her chair to get to the hospital to deliver this big, big baby?

The "Little Giant" has been named Akbar ("the Great").  Believe it or not, Akbar doesn't hold the world record for biggest baby ever born.  That belongs to a baby born in 1879 who weighed in at 23 pounds (ouch).  

We can all enjoy this story, but what are the challenges this newborn is facing as he grows up enormous:

• Riducule from "normal" sized peers.  Sad, but a well documented truth
• Diabetes.  Large babies are often the "product" of diabetic moms and they are highly likely to become diabetic themselves
• Other endocrine disorders.  The Little Giant in the book I am reading suffers from gigantism (excess growth hormone in children/youth) associated in some cases with shortened lifespan and numerous uncomfortable complications.

Let's hope that little Akbar grows up with the ability to weather these challenges. 

Ok. so we took a break.  It turned out to be a year.  But, we're baaack. 

By way of reintroduction, TDWI writers like to write about health related topics, although sometimes we stray into other areas.  Not sure we will be posting daily, but we will be posting.

What is on our minds?  Health care reform.  Are we for it, yes?  Why?  Because our "health care system" is not working for many people.  Not all, mind you, but let's face it, lot's of folks are not getting the basics.

Did anyone watch the PBS special on health care last night?  If so, I have to ask the question, even if you love your doctor and love your plan (i.e., the system is working for YOU), do you want an American health care system that forces folks to get divorced in order to be poor enough to qualify for Medicaid?  How about having to sell your house and give away the few valuables that you have so that you are poor enough to get assistance when you have to "relocate" into a nursing home?  If we really have the "best healthcare system in the world" doesn't it have to work for most folks, not just the lucky ones who have employer-sponsored care or are wealthy enough that they can buy what they want?

We (TDWI) are agnostic about the health reform proposals making their way through Congress.  But we do feel strongly that certain elements of reform are essential:

1.  Get everyone in the insurance pool -  mandate coverage.  Failure to do that means that the insured continue to subsidize the uninsured

2.  Support Comparative Effectiveness Research:  we ought to be making health care coverage decisions based, whenever possible, on what has been demonstrated to work, bring value, improve outcomes

3.  We cannot pay for everything that everybody wants to be paid for by insurance:  I work for a health plan.  There are people in our plan who think we ought to pay to put in a swimming pool in their backyard because their doctor told them they need exercise.  There have to be some rules of engagement.  This is what managed care is all about.  Too bad the media maligned managed care in the 80's, we might not be in as bad a shape as we are now if we had supported good managed care.

4.  We need to recognize that health doesn't equal health care.  Good food policy, smoking cessation programs/legislation, exercise programs at work/school, safe car designs, etc. impact health every bit as much as world class ERs and world class cancer care.  We need to be holistic in our approach to health and embrace a national culture of health.  It may make some people gag when I say this, but my fru-fru county of record (Marin, California) leads the way when it comes a healthy culture.  Folks exercise, work out, and are amongst the best weighted, most fit folks in the country.  (No smoking here).

Well that's it for the inaugural return to TDWI.  As always, we welcome you comments (good, bad or ugly).

G'night

As Wikipedia has so effectively demonstrated, Wikis can become go-to authorities on nearly every topic.  However, accuracy and credibility problems may arise when topics are not moderated by subject matter experts. The possibility that information may be less than optimal is a fatal flaw for sites that would presume to offer information that can drive clinical decisions.

So these new health care sites address the accuracy issue with expert panels from every discipline who jury the content creation. Using this model, any professional (and conceivably, non-professional) who brings sufficiently strong arguments, backed by evidence (literature or data), should be allowed to contribute to or modify content.

What makes these efforts particularly interesting is that, through a collaborative Web-based process, they attempt to distill and document the current best knowledge about any topic. In health care, the goal is easily accessible state-of-the-science information, the equivalent of on-going medical/scientific review articles that detail what we know and don’t know about life and care processes.

MedPedia and Knol are merely two in a line of health care wikis. The Joint Commission established WikiHealthCare, an interactive forum for health care professionals. Clinfowiki is devoted to clinical informatics. And of course this blog’s readers will be familiar with the Health 2.0 wiki, which has assembled information about that burgeoning sector.

While Health 2.0 generally uses Web-based collaboration to achieve some health care objective, I see it in terms of two broad trends. The first are knowledge, product and service exchanges. Patients Like Me, Sermo, and Carol all fall into this category. They offer platforms that facilitate the organized aggregation of information. People can learn about a topic, or can contribute information that deepens the information readily available. In their present forms, Knol and MedPedia also can be understood as information exchanges.

But the second type of Health 2.0 platform will be stronger and more utilitarian, because it will assemble knowledge or data, and then analyze and reformulate it, presenting the results in ways that support decision-making. For example, Oncology Metrics aggregates clinical and administrative data across oncology practices, feeding the results back to the contributing practices to help them better understand and manage the clinical, operational and financial decisions that are part of everyday practice. Other organizations are bringing together subject matter experts to describe the rules that govern specific complex systems, or are aggregating health system quality data to put together a “Travelocity-type” site for medical tourism. The possibilities are endless.

MedPedia, Knol and other health care wikis are exciting developments, because they will help us organize and maintain a unified knowledge base of the best current medical and health care information.

But a related and more thrilling advance is just over the horizon. We’ll soon be able to use both knowledge and data to understand and accurately describe the rules that define complex systems in health care. The rules and data sets will simply be more action-oriented and experiential versions of the descriptions already contained in the expert-juried wikis. But the rules also will be translatable into readily accessible decision-support tools, built on the best collective knowledge and experience of clinicians and patients and accessible by any clinician.

The trick then will be to encourage clinicians to access these tools. That will require some form of pay-for-performance, with rewards for hitting clinical and financial targets.

All this is a work in progress. But the possibilities and the potential for dramatically improving care and driving down cost, in the US and globally, are clear. And, for those of us who have watched the mechanics of the crisis up close for the entirety of our careers, breathtaking.

Brian Klepper is a health care analyst and commentator based in tropical, breezy Atlantic Beach, FL.

Brian Klepper

Those who wait, ever hopefully, for real health reform might want to take a deep breath and take stock of a few realities.

First, think about the fact that when the Democrats retook Congress, they tweaked but did not fundamentally change the lobbying rules that trade money for influence over policy. In fact, most contributors have now adjusted their contributions to favor the current, rather than the past, majority party. As it turns out, Democrats, like Republicans, are only too eager to allow special interests to trump the common interest, so long as the transactions fetch a good price.

Take a long hard look at the chart below, taken from an April 15th report published by OpenSecrets, which tracks the impacts money has on politics and policy, put together by the Center for Responsive Politics. In 2007, the health care industry spent $445 million lobbying Congress, providing 16 percent of the total $2.8 billion spent to sway Congressional actions, more than any other economic sector for two years running.

$227 million, or 51% of that $445 million, came from the drug, device and medical products sector. General Electric alone spent almost $24 million courting our Senators and Representatives. PhRMA, the drug industry association, contributed another $22.1 million. The AMA also spent $22.1 million.

These dollars are spent to obtain specific results. David Beier, Amgen's head lobbyist and, formerly, Vice President Al Gore's chief domestic policy advisor, explained his company's 2007 $16.3 million lobbying expense very nicely in a Washington Post article last April. "We face a lot of legislative and regulatory issues. We resourced our advocacy to match our challenges."

Anyone watching the lobbying frenzy leading up to last week's vote, the President's veto, and Congress' rejection of that veto, pitting funding for Medicare Advantage plans against funding for physician reimbursement - the blow-by-blow was eloquently described by Bob Laszewski - could only marvel at the resources that can be brought to bear when money or other perceived interests are on the line.

Of course, there's nothing new here. For decades, the health care industry has leveraged its money and influence, shaping policy to its own ends. Last December I recounted that, upon hearing that the US Department of Health and Human Services had appealed a court ruling calling for CMS to release Medicare physician data, American Medical News quoted the AMA's Board Chair Ed Langston MD, "The Association is pleased that HHS is taking its advice." (This quote has since been expunged from the online version of the article.)

Or remember when the Employers' Coalition on Medicare, a powerful business interest group, teamed with PhRMA and the Republican Congress to pass Medicare D? The resulting legislation provided for a significant portion of the largess to be allocated to large firms (in the form of retiree prescription subsidies) in exchange for their support for the program. Retirees and taxpayers, of course, didn't fare quite as well in the deal.

Then there is the longstanding sole-advisor relationship between CMS and the AMA on the issue of physician reimbursement, in which the specialist-heavy society has continually called for, and CMS has continually delivered, increased reimbursements to specialists at the expense of America's primary care physicians, who are now in deep crisis as a result.

There are endless examples, all of which beg a couple important questions. Let's take the health care question first:

In a policy-making environment that is so clearly and openly influenced by money, how likely is it that Congress will pass be able to achieve health care reforms that are in the public interest?

There is broad expert consensus that one-third to one-half of all health care expenditure is waste. Talk privately with most health care professionals - physicians, hospital execs, health plan administrators, benefits managers, supply chain execs - and there is reasonable agreement on critical principles that are necessary to re-establish the system's stability and sustainability: some form of universal coverage for at least basic health services; a comprehensive and compatible IT infrastructure; a transition from fee-for-service to some form of performance-based reimbursement; pricing and performance transparency; and much more.

Such changes could drive tremendous savings for individual, corporate and governmental purchasers, but at significant cost to health care firms and professionals. Revenues and profitability would plummet. As the struggles over health care resources intensify, the efforts to protect and enhance each interest's position through policy will intensify as well.

It isn't as as though there aren't credible and influential people sounding the alarm. Take this comment from Peter Orszag, Director of the Congressional Budget Office, while testifying to the US Senate Finance Committee in June 2007.

“If [Medicare and Medicaid’s] costs continue growing at the same rate over the next four decades [as they have over the last four decades, at 2.5%/year higher than per capita GDP], federal spending on those two programs alone would rise from 4.5% of GDP today to about 20% by 2050. That amount would represent roughly the same share of the economy as the entire federal budget does today.”

Alarming? Sure. But that kind of "let's not burn the house down" warning tends to get lost against arguments for more dollars, backed by the nearly half-billion dollars the industry spent last year - an average of about $832,000 for each Senator and Representative!

Pass real reforms? I'd be surprised. Delighted! But surprised.

But that brings us to the biggest question.

America has a slew of important problems that cry out to be addressed: the obesity epidemic, energy, education, the environment, poverty, infrastructure replacement. What will it take for Congress to mount serious, public interest efforts that focus on these issues?

To a one, these problems are structurally identical to those we face in health care. Congress' current lobbying system means that money-for-influence relationships with lawmakers continually spin policy to favor special interests rather than the common interest.

Take the obesity epidemic. Here's a wonderful graphic I show in all my presentations. It shows that 31% of adult Americans are obese, with a body mass index of greater than 30. We're the leaders among developing countries on this problem. Mexico and England are a distant 2nd and 3rd, at 24% and 23%. The ridiculously industrious Japanese and Koreans are at 3%. I have two arguments here.

First, we have the worst obesity of any country because agribusiness and the fast, prepared and junk food industries have convinced Congress to provide concessions, ranging from corn subsidies to open-field running with advertising techniques that seduce our children. Sure, individual choices by parents factor into this, but whatever your philosophical position on that point, it is important to acknowledge that the current approach isn't working and we're losing the battle. And nationally, we HAVEN'T drawn a line in the sand as, for example, the Japanese recently did in deciding to mount an effort that measures waistlines. From their perspective, that effort is undoubtedly an investment in their national future.

Second, since weight is important to fitness, fitness is important to overall health, health is an important component of productivity, and productivity drives competitiveness, the US' future prospects are already lousy and headed south. In terms of our health AND our competitiveness, we're committing slow suicide.

And we can't seem to mount approaches like the Japanese seemingly did so easily. We're stymied due to policies that thwart the common interest in favor of the special interest. We wouldn't want to reduce choice for our consumers or our vendors, or be forced to reinvest in exercise programming, or compromise the profitability of agribusiness or the prepared food sectors.

And so we are paralyzed in our ability to problem-solve in virtually every area of societal endeavor.

As far as I can tell, there are two - and only two - solutions here. Both are highly improbable.

One is for America's largest corporations, the organizations that drive national policy through lobbying now, to galvanize to preserve the common interest. This is tough. Currently, most organizations focus their lobbying within their own core competency areas. Microsoft lobbies on IT, but not health. Marriott lobbies on hospitality policy, but not education.

What's needed is a national business coalition that collaboratively focuses on what's good public policy for the country - what's in our common short- and long-term interest. It could both support democratic institutions and, equally important, place sanctions on rogue organizations, like Enron, that would hurt the system through excesses or very poor performance at public expense. (By the way, I'm not advocating for government run by corporations - the formal definition of fascism. I'm simply explaining how things appear to already work, and how they might be redirected.)

They might do this because they realize that, if the components of the fabric that has made America strong - a focus on education and an informed populace, fairness and social justice, creativity, financial independence, productivity - are lost, then it will be more and more difficult to successfully pursue the special interest, at least from here.

The other solution would require a new Congress, under new leadership, to resolve to rid itself of its lobbying cancer, and to do so in a way that is highly visible and publicized. There would be ferocious opposition from industry. Hence the need for visible, articulate leadership from key political and business leaders.

Like I said, both are improbable. But they're also key our ability to turn the nation around.

In the meantime, we're all health care people. Go to the New York Times Health Page, and you'll see five sub-sections. The center one is "Money and Policy." Think that's clever, or simply precise?

By Dov Michaeli MD, Ph.D

We all heard this refrain; drug addicts kicking the habit, only to go through a lifetime of a constant battle to stay clean.

Why is it so hard? Why is it getting progressively harder within days after quitting? Who is the “devil that made them do it”?

The received wisdom for many years was that the reward system in the brain, which is the seat of all manners of addiction, is driven exclusively by dopamine receptors. But frankly, this belief had some problems. Here is a big one: the dopamine system is geared to maintaining homeostasis, which is the property of a living organism to regulate its internal environment so as to maintain a stable, constant condition. For example, exposure of dopaminergic neurons to increased concentrations of cocaine results in increased effects inside the cells. To maintain a constant internal environment inside the cell, the neuron responds by reducing the number of dopamine receptors. However, when the drug effect wanes, the addict feels depressed, and to get the same “high” in the face of reduced density of receptors he’d have to take an even higher dose of the drug, which would, in turn, result in yet another lowering of receptor density on the cell membrane. This is the basis of addiction; progressively elevated doses of the stimulus needed to obtain the same effect. Dopaminergic neurons respond in the same fashion to cessation of the stimulus, only in the opposite direction – the density of receptors increases back to the normal level. If the dopamine neurons were the sole ones involved, then this should be the end of addiction syndrome. But we know that this is not true.

We know that recovered addicts have to constantly battle the urge to go back on the drug. The dopamine receptor system does not explain this behavior.

The neurobiological basis of faltering resistance

Marina Wolff wanted to see if the neurons bearing the glutamate receptor have something to do with the difficulties addicts encounter after withdrawing from the drug. So she and her colleagues examined the glutamate neurons in the nucleus accumbens, which is part of the reward system and is involved in motivation and learning. They trained rats to self-administer cocaine by poking their noses into a hole when given a cue. As expected, the rats’ cocaine-seeking beahvior was more pronounced 45 days after the cocaine supply was cut off than after the first day. Examining the rats’ nucleus accumbens, they found something totally unexpected. Compared with rats in early withdrawal, rats deprived of cocaine for 45 days had incredibly high levels of a glutamate receptor of an unusual composition (called GluR2-lacking AMPA receptors). This unusual receptor promotes an inordinately strong response to glutamate. Indeed, if the new glutamate receptors were blocked in rats 45 days after cocaine withdrawal, their response to drug cues was cut by almost 50%. The conclusion according to Marina Wolff is obvious: the neurons were making new receptors in response to withdrawal, which explains the increased response to cocaine cues.

The implications

The obvious implication is that this receptor should be a powerful target for drugs designed to help in withdrawal from drug addiction.

But did you notice that this craving after withdrawal and the increasing difficulty in resisting cues is also an affliction of serial dieters? Indeed, eating stimulates the reward system just like any recreational drug; and overeating has all the hallmarks of addictive behavior. So, the obvious next step is to examine the levels of this unusual glutamate receptor in animals trained to overeat. It may be the answer to the losing battles millions of people wage every day in a desparate attempt to avoid re-gaining the weight they had lost.

Lastly, one more thought. Until only very few years ago it was believed that complex behaviors could never be explained by “simple”chemistry. Books and articles were written about the uniqueness of the brain, as if it obeyed different laws of physics. Here we have a receptor of a known composition, whose level in the brain controls a complex behavioral pattern. Can the day be far when we would be speaking of all human behavior in molecular terms?