Category: medicine

When can you have sex after a heart attack? Most doctors do not talk about it.

On By Jalees RehmanIn cardiovascular, heart disease, medicine, patient safety, patients, psychiatry, sexuality1 Comment

Each year in the United States about 720,000 people have heart attacks and about 124,000 people in the UK and 55,000 people in Australia will have them as well. Since the 1980s, survival rates from heart attacks have improved – a lot of people get them, but more and more people are surviving. A recent study of patients in Denmark showed that in 1984-1988 31.4% of patients died within a month of having a heart attack. From 2004-2008 this was down to 14.8%.

Once a patient has made it through a heart attack and begins to recover, they get advice from their doctors on what to do to stay healthy and get back to normal. That includes a lot of things – when to go back to work, when they can start traveling again and what to eat. But there is an important item that a lot of doctors don’t talk about: sex.

There are no universal guidelines for getting back to ‘normal’

Providing advice about lifestyle can be more challenging than prescribing standardized medications or smoking cessation because “normal” life differs widely among patients and requires individualized counseling.

For instance, scientific evidence from large-scale clinical trials isn’t always available to help the cardiologist decide the ideal time for when an individual patient should return to work. A software engineer might get different advice than a butcher or construction worker who has to lift heavy objects all day long. Physicians have to carefully estimate the patient’s capacity for physical activity as well as the physical demands of the job and be pragmatic about how long a patient can take time off from work.

Sex also requires this kind individualized counseling. New research shows that patients want to talk about sexual activity with their doctors, but that all too often that conversation never takes place.

Time for a heart-to-heart with your doctor.
Heart via Syda Productions/Shutterstock

 

Let’s talk about sex

A recent study conducted in 127 hospitals in the United States and Spain suggests that doctors are not very good at broaching the topic of sexual activity after a heart attack.

Researchers studied 2,349 women and 1,152 men who had suffered from a myocardial infarction (the medical term for a heart attack). This study focused on younger heart attack patients (ages 18-55) and asked them whether they had discussed sexual activity with their doctors. With younger patients talking about life after a heart attack is especially important. The loss of sexual activity or function is a major quality of life issue, and can affect intimate relationships, reproduction and lead to depression.

In the month following the heart attack, only 12% of women and 19% of men had some discussion with a doctor about sex. In the US, most patients reported that they initiated the discussion, whereas in Spain, most discussions were initiated by the doctor. This means that more than 85% of patients received no advice from their doctors regarding if and when they could resume sexual activity.

The study found that the vast majority of patients were sexually active in the year before their heart attacks, and they valued sexuality as an important part of life. They also felt it was appropriate for physicians to initiate the discussion about having sex again.

It is interesting that in the US, patients were more likely to bring up sex and men were given more restrictive advice, while in Spain, physicians were more likely to bring up the topic and more restrictive recommendations were given to women.

The study did not specifically study the motivations of the physicians but these differences suggest that cultural differences and gender affect the counseling in regards to sexual activity. Future research could potentially also study the physicians and help uncover how culture and gender influence the counseling process.

This lack of communication between doctors and patients was not due to the patients’ unease: 84% of women and 91% of men said that they would feel comfortable talking to their doctors about sex. What is even more concerning is that the 15% or so of patients who received counseling often got inaccurate recommendations.

Sex is exercise. But doctors don’t talk about it that way

Two-thirds of those who talked about sex with their doctors were told that they could resume sexual activity with restrictions like limiting sex, taking a “passive role” or keeping their heart rate down during sex. But here’s the thing: sex is exercise. And after a heart attack doctors routinely ask patients whether they can tolerate mild to moderate physical activity such as mowing the lawn or climbing up two flights of stairs without chest pain or other major symptoms.

The Scientific Statement of the American Heart Association (AHA) on sexual activity states that it is reasonable to resume sexual activity as early as one week after an uncomplicated heart attack. If there are complications after the heart attack such as feeling out of breath or experiencing persistent chest pain then these problems need to be addressed first. And in the AHA guidelines there is no mention of “passive roles” or keeping heart rates down during sex. These restrictions are also quite impractical. How are patients supposed to monitor their heart rates and keep them down during sex?

The kind of restrictions recommended by doctors in the study – and presumably by medical practitioners who weren’t polled – are not backed up by science and place an unnecessary burden on a patient’s personal life. Hopefully, after reading the results of this study, doctors will take a more pro-active role and address the topic of sex with their heart attack patients with proper recommendations instead of leaving patients in a state of uncertainty. If a patient can handle moderate exercise, they can probably handle sex.

The Conversation

This article was originally published on The Conversation.
Read the original article.

 

New Study Shows Surgical Checklists In Operating Rooms Are Less Effective Than Assumed

On By Jalees RehmanIn decision-making, medicine, patient safety, patients, research, risk, scientific method, scientific methodology, surgery2 Comments

The patient has verified his or her identity, the surgical site, the type of procedure, and his or her consent. Check.

The surgical site is marked on a patient if such marking is appropriate for the procedure. Check.

The probe measuring blood oxygen content has been placed on the patient and is functioning. Check.

All members of the surgical and anesthesia team are aware of whether the patient has a known allergy? Check.

Surgeon
Surgeon – via Shutterstock

These were the first items on a nineteen-point World Health Organization (WHO) surgical safety checklist from an international research study to evaluate the impact of routinely using checklists in operating rooms. The research involved over 7,500 patients undergoing surgery in eight hospitals (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) and was published in the New England Journal of Medicine in 2009.

Some of the items on the checklist were already part of standard care at many of the enrolled hospitals, such as the use of oxygen monitoring probes. Other items, such as ensuring that there was a contingency plan for major blood loss prior to each surgical procedure, were not part of routine surgical practice. The impact of checklist implementation was quite impressive, showing that this simple safety measure nearly halved the rate of death in surgical patients from 1.6% to 0.8%.  The infection rate at the site of the surgical procedure also decreased from 6.2% in the months preceding the checklist introduction to a mere 3.4%.

Checklists as a Panacea?

The remarkable results of the 2009 study were met with widespread enthusiasm. This low-cost measure could be easily implemented in hospitals all over the world and could potentially lead to major improvements in patient outcomes. It also made intuitive sense that encouraging communication between surgical team members via checklists would reduce complications after surgery.

A few weeks after the study’s publication, the National Patient Safety Agency (NPSA) in the United Kingdom issued a patient safety alert, requiring National Health Service (NHS) organizations to use the WHO Surgical Safety Checklist for all patients undergoing surgical procedures. In 2010, Canada followed suit and also introduced regulations requiring the use of surgical safety checklists. However, the data for the efficacy of such lists had only been obtained in observational research studies conducted in selected hospitals. Would widespread mandatory implementation of such a system in “real world” community hospitals also lead to similar benefits?

A recently published study in the New England Journal of Medicine lead by Dr. David Urbach at the University of Toronto has now reviewed the surgery outcomes of hospitals in Ontario, Canada, comparing the rate of surgical complications during three-month periods before and after the implementation of the now mandatory checklists.  Nearly all the hospitals reported that they were adhering to the checklist requirements and the vast majority used either a checklist developed by the Canadian Patient Safety Institute, which is even more comprehensive than the WHO checklist or other similar checklists. After analyzing the results of more than 200,000 procedures at 101 hospitals, Urbach and colleagues found no significant change in the rate of death after surgery after the introduction of the checklists (0.71% versus 0.65% – not statistically significant). Even the overall complication rates or the infection rates in the Ontario hospitals did not change significantly after surgical teams were required to complete the checklists.

 

Check the Checklist

 

The discrepancy in the results between the two studies is striking. How can one study demonstrate such a profound benefit of introducing checklists while a second study shows no significant impact at all? The differences between the two studies may hold some important clues. The 2009 study had a pre-checklist death rate of 1.6%, which is more than double the pre-checklist death rate in the more recent Ontario study. This may reflect the nature and complexity of the surgeries surveyed in the first study and also the socioeconomic differences. A substantial proportion of the patients in the international study were enrolled in low-income or middle-income countries. The introduction of a checklist may have been of much greater benefit to patients and hospitals that were already struggling with higher complication rates.

Furthermore, as the accompanying editorial by Dr. Lucian Leape in the New England Journal of Medicine points out, assessment of checklist implementation in the recent study by Urbach and colleagues was based on a retrospective analysis of self-reports by surgical teams and hospitals. Items may have been marked as “checked” in an effort to rush through the list and start the surgical procedures without the necessary diligence and time required to carefully go through every single item on the checklist. In the 2009 WHO study, on the other hand, surgical teams were aware of the fact that they were actively participating in a research study and the participating surgeons may have therefore been more motivated to meticulously implement all the steps on a checklist.

One of the key benefits of checklists is that they introduce a systematic and standardized approach to patient care and improve communication between team members. It is possible that the awareness of surgical teams in the Ontario hospitals in regards to patient safety and the need for systematic communication was already raised to higher level even before the introduction of the mandatory checklists so that this mandate may have had less of an impact.

 

Looking Forward

The study by Urbach and colleagues does not prove that safety checklists are without benefit. It highlights that there is little scientific data supporting the use of mandatory checklists. Since the study could not obtain any data on how well the checklists were implemented in each hospital, it is possible that checklists are more effective when team members buy into their value and do not just view it as another piece of mandatory and bureaucratic paperwork.

Instead of mandating checklists, authorities should consider the benefits of allowing surgical teams to develop their own measures that improve patient safety and team communication. The safety measures will likely contain some form of physical or verbal checklists. By encouraging surgical teams to get involved in the development process and tailor the checklists according to the needs of individual patients, surgical teams and hospitals, they may be far more motivated to truly implement them.

Optimizing such tailored checklists, understanding why some studies indicate benefits of checklists whereas others do not and re-evaluating the efficacy of checklists in the non-academic setting will all require a substantial amount of future research before one can draw definitive conclusions about the efficacy of checklists. Regulatory agencies in Canada and the United Kingdom should reconsider their current mandates. Perhaps an even more important lesson to be learned is that health regulatory agencies should not rush to enforce new mandates based on limited scientific data.

 

ResearchBlogging.org

Urbach DR, Govindarajan A, Saskin R, Wilton AS, & Baxter NN (2014). Introduction of surgical safety checklists in Ontario, Canada. The New England Journal of Medicine, 370 (11), 1029-38 PMID: 24620866

Should Doctors ‘Google’ Their Patients?

On By Jalees RehmanIn Ethics, medicine, mental health, patients, personal, privacy, professionalism, psychiatry, psychology, social media, social networking, technology4 Comments

Here is an excerpt from my latest post on the 3Quarksdaily blog:

 

Beware of what you share. Employers now routinely utilize internet search engines or social network searches to obtain information about job applicants. A survey of 2,184 hiring managers and human resource professionals conducted by the online employment website CareerBuilder.com revealed that 39% use social networking sites to research job candidates. Of the group who used social networks to evaluate job applicants, 43% found content on a social networking site that caused them to not hire a candidate, whereas only 19% found information that that has caused them to hire a candidate. The top reasons for rejecting a candidate based on information gleaned from social networking sites were provocative or inappropriate photos/information, including information about the job applicants’ history of substance abuse. This should not come as a surprise to job applicants in the US. After all, it is not uncommon for employers to invade the privacy of job applicants by conducting extensive background searches, ranging from the applicant’s employment history and credit rating to checking up on any history of lawsuits or run-ins with law enforcement agencies. Some employers also require drug testing of job applicants. The internet and social networking websites merely offer employers an additional array of tools to scrutinize their applicants. But how do we feel about digital sleuthing when it comes to relationship that is very different than the employer-applicant relationship – one which is characterized by profound trust, intimacy and respect, such as the relationship between healthcare providers and their patients?


The Hastings Center Report is a peer-reviewed academic bioethics journal which discusses the ethics of “Googling a Patient” in its most recent issue. It first describes a specific case of a twenty-six year old patient who sees a surgeon and requests a prophylactic mastectomy of both breasts. She says that she does not have breast cancer yet, but that her family is at very high risk for cancer. Her mother, sister, aunts, and a cousin have all had breast cancer; a teenage cousin had ovarian cancer at the age of nineteen; and that her brother was treated for esophageal cancer at the age of fifteen. She also says that she herself has suffered from a form of skin cancer (melanoma) at the age of twenty-five and that she wants to undergo the removal of her breasts without further workup because she wants to avoid developing breast cancer. She says that her prior mammogram had already shown abnormalities and she had been told by another surgeon that she needed the mastectomy.

Such prophylactic mastectomies, i.e. removal of both breasts, are indeed performed if young women are considered to be at very high risk for breast cancer based on their genetic profile and family history. The patient’s family history – her mother, sister and aunts being diagnosed with breast cancer – are indicative of a very high risk, but other aspects of the history such as her brother developing esophageal cancer at the age of fifteen are rather unusual. The surgeon confers with the patient’s primary care physician prior to performing the mastectomy and is puzzled by the fact that the primary care physician cannot confirm many of the claims made by the patient regarding her prior medical history or her family history. The physicians find no evidence of the patient ever having been diagnosed with a melanoma and they also cannot find documentation of the prior workup. The surgeon then asks a genetic counselor to meet with the patient and help resolve the discrepancies. During the evaluation process, the genetic counselor decides to ‘google’ the patient.

The genetic counselor finds two Facebook pages that are linked to the patient. One page appears to be a personal profile of the patient, stating that in addition to battling stage four melanoma (a very advanced stage of skin cancer with very low survival rates), she has recently been diagnosed with breast cancer. She also provides a link to a website soliciting donations to attend a summit for young cancer patients. The other Facebook page shows multiple pictures of the patient with a bald head, suggesting that she is undergoing chemotherapy, which is obviously not true according to what the genetic counselor and the surgeon have observed. Once this information is forwarded to the surgeon, he decides to cancel the planned surgery. It is not clear why the patient was intent on having the mastectomy and what she would gain from it, but the obtained information from the Facebook pages and the previously noted discrepancies are reason enough for the surgeon to rebuff the patient’s request for the surgery.

 

If you want to learn more about how ethics experts analyzed the situation and how common it is for psychologists enrolled in doctoral programs to use search engines or social networking sites in order to obtain more information about their patients/clients, please read the complete article at 3Quarksdaily.com.  

Prescribing Male Contraceptives: Ethical Considerations

On By Jalees RehmanIn clinical trials, contraception, Ethics, medicineLeave a comment

There have been a series of interesting comments on Twitter about the ethical dilemma involved in prescribing male contraceptives, prompted by my recent essay for Aeon Magazine. Here is the relevant excerpt from the Aeon essay:

The discontinuation of the WHO/CONRAD trial was a major setback in bringing male contraceptives to the market. It also raised difficult ethical questions about how to evaluate side effects in male contraceptive trials. Since all medications are bound to exhibit some side effects, what side effects should be sufficient to halt a trial? Female contraceptives have been associated with breakthrough bleeding, mood changes, increased risk of blood-clot formation, as well as other side effects. Why should we set a different bar for male contraceptives?

The twist here is that female contraceptives prevent unintended pregnancies in the person actually taking the contraceptive. Since a pregnancy can cause some women significant health problems, the risk of contraceptive side effects can be offset by the benefit of avoiding an unintended pregnancy. However, men do not directly experience any of the health risks of pregnancy — their female partners do. Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men.

The usage of female hormonal contraceptives has been associated with a higher risk of blood clot formation, but pregnancies carry an even higher risk for blood clot formation and other medical complications. Doctors can make the reasonable argument that the benefits of a contraceptive outweighs the risks for their patient – and prescribe it.

The situation is a bit different when it comes to male contraceptives. I will try to illustrate this with a hypothetical scenario, in which there is a male contraceptive on the market.

Mr. Solo has an appointment with his family physician Dr. Crusher, who informs him that he is in perfect health. Mr. Solo then asks if he could receive a prescription for the newly approved male contraceptive. Dr. Crusher explains to him that this new male contraceptive has a 1% risk of causing side effects such as major depression.

Mr. Solo responds that he and his partner Ms. Amidala-Skywalker have decided not to get pregnant – at least not in the near future. Mr. Solo is very concerned about Ms. Amidala-Skywalker’s family history because her mother had a very difficult pregnancy and even died during childbirth. Ms. Amidala-Skywalker is not as worried about her pregnancy as Mr. Solo is and she does not want either of them to be permanently sterilized, but she and Mr. Solo have agreed to at least postpone having children for a few years. Ms. Amidala-Skywalker has been on an oral hormonal contraceptive for the past years.

Just prior to seeing Dr. Crusher, Mr. Solo was browsing some reading material in the waiting room and came across the magazine “Women’s Health” in which he read that women who regularly use hormonal contraceptives are at a higher risk for blood clot formations and maybe even strokes. All these years, his partner has been taking hormonal contraceptives and exposing herself to this higher risk. Since they both agreed not to have children at this point in time, Mr. Solo feels that it would only be fair if he now started using a male contraceptive and gave his partner a break. He does not mind the 1% risk of side effects, after all, she has been taking the “pill” for so many years and he believes that a true partnership is based on an equitable sharing of risks.

Dr. Crusher tries to dampen his enthusiasm. She says that she respects his desire to be fair towards his partner and she also wants to be supportive of their decision not to have a baby. She understands their concerns about the health risks that Ms. Amidala-Skywalker would face if she became pregnant.

However, Dr. Crusher explains to Mr. Solo that she has a doctor-patient relationship only with him – not with his partner. Dr. Crusher feels comfortable prescribing a medication for a patient when the patient derives a net health benefit from it. She agrees that Ms. Amidala-Skywalker’s well-being is important, but the health of Mr. Solo’s partner (or of any other family member) is not her primary concern. She does not see how she can justify subjecting him to a 1% risk of side effects and declines to prescribe it.

 

I am not suggesting that this is the best way or the only way to analyze the ethics of prescribing a male contraceptive pill which has some side effects. Not everyone has to agree with Dr. Crusher’s choice to focus only on the risks and benefits for her patient and to ignore the greater good or the medical benefits for his partner. These are the kinds of ethical dilemmas that physicians have to grapple with when it comes to addressing the issue of side effects associated with male contraceptives. Concerns about such ethical dilemmas and potential legal repercussions can act as deterrents for physicians and pharmaceutical companies.

But this does not mean that we should abandon the quest for male contraceptives. Doctors perform cosmetic surgeries without any medical benefits, despite the fact that some of the procedures can result in major complications. Physicians prescribe Viagra for men without a clearly defined medical indication even though Viagra can cause significant side effects.

If patients, healthcare professionals and the general public can find ways to ethically justify the risks of cosmetic surgery, it should be possible to resolve the dilemmas surrounding the prescription of male contraceptives. Instead of just maintaining the status quo in which women shoulder most of the burden and responsibility of contraception, we have to educate ourselves about alternatives and address the scientific, medical, ethical, political and cultural obstacles that prevent the development of newer male contraceptives.

//storify.com/jalees_rehman/ethics-of-male-contraception.js[View the story “The Ethics of Prescribing Male Contraceptives” on Storify]

Good Can Come From Bad: Genetic Testing For The BRCA Breast Cancer Genes

On By Jalees RehmanIn cancer, Ethics, medicine, patients, psychology3 Comments

Our ability to test for the presence of genetic mutations has become extremely cost-efficient and private companies, such as 23andMe now offer genetic testing for consumers who want to find out about their predisposition for genetic diseases. The results of such tests are sent directly to the consumers, without the involvement of genetic counselors or other healthcare providers. This has lead to a growing concern about how people will respond to finding out that they are carriers of mutations that predispose them to certain life-threatening diseases. Will the individuals be burdened by excessive anxiety? Will they tell their relatives and their healthcare providers that they carry mutations?

A study published in the new open access journal PeerJ addressed these questions by contacting male and female individuals who has received genetic testing by 23andMe for mutations in the BRCA genes which are strongly associated with breast cancer. The study “Dealing with the unexpected: consumer responses to direct-access BRCA mutation testing” by Uta Francke and colleagues (who are all employees of 23andMe) surveyed 16 women and 16 men who had received the news that they were carriers of BRCA1 or BRCA2 mutations, as well as control subjects who received the fortunate news that they did not carry any of the common BRCA mutations. Among the 16 women who tested positive (i.e. found out that they had a significant likelihood of developing breast cancer), none were extremely upset and six were either mildly or moderately upset. Surprisingly, nine mutation-positive women reported that they felt “neutral”.

The majority of the mutation-positive participants shared the test results with their spouses / partners or their blood relatives. Importantly, 13 of the 16 mutation-positive women contacted their primary care physician, gynecologist or oncologist for medical advice. There were 11 mutation-positive women who received this information through 23andMe for the first time (the others had already been diagnosed with breast cancer or had previously undergone testing), and these women indicated that they were planning to either undergo surgeries or have further breast cancer work-up and regular exams. The majority of mutation-positive men, on the other hand, did not consult their physicians, but did indicate that they would participate in future cancer screening.

Nearly all the participants said that they would undergo the testing again and felt good about knowing the results, independent of whether they positive or negative for the BRCA mutations. Only one of the participants (a mutation positive man with a family history of breast cancer) said that he would have preferred not to know, because of the “emotional cost”. A significant proportion of the participants who tested positive also had their relatives tested. This lead to the identification of 13 additional carriers, many of whom received medical counseling and were planning to take risk-reducing measures.

These findings suggest that the identification of mutations that indicate a high risk for developing breast cancer did not lead to severe anxiety or panic, but actually resulted in pro-active steps and medical care to help reduce their risk of developing breast cancer. One has to bear in mind that the sample size is small and that the study and the salaries of the authors were all funded by 23andMe, a genetic testing company that would financially benefit from widespread genetic testing. Nevertheless, the presented data seem solid and the responses of the participants do suggest that such testing was on the whole very beneficial for the participants. Hopefully, we will see more data emerge in the future regarding the psychological impact of genetic testing and whether the findings of this small study hold up in larger cohorts and when it comes to other genetic diseases.

On a side note, there is a very intriguing aspect to this paper that will be of benefit to many readers. The PeerJ journal gives the authors of a manuscript the option of disclosing the peer review process to the public. The authors of this paper took advantage of this option and we can all have a close look at the peer reviewer comments as well as the rebuttal of the authors. For anyone who is not used to reviewing scientific manuscripts, this is an excellent opportunity to learn about the inner workings of the peer review process.

 

Image Credit: Cartoon representation of the molecular structure of BRCA1 by Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute, via Wikimedia Commons

ResearchBlogging.org

Francke, U., Dijamco, C., Kiefer, A., Eriksson, N., Moiseff, B., Tung, J., & Mountain, J. (2013). Dealing with the unexpected: consumer responses to direct-access BRCA mutation testing PeerJ, 1 DOI: 10.7717/peerj.8

Flipping the Switch: Using Optogenetics to Treat Seizures

On By Jalees RehmanIn cell biology, medicine, molecular biology, neurology, optogenetics, scientific method, scientific methodologyLeave a comment

Optogenetics is emerging as one of the most exciting new tools in biomedical research. This method is based on introducing genes that encode for light-sensitive proteins into cells. A laser beam can then be used to activate the light-sensitive proteins. Many of the currently used optogenetic proteins respond to the laser activation by changing the membrane voltage potential inside the cells. This is the reason why neurons and other cells that can be excited by electrical impulses, are ideally suited for studying optogenetic responses.

The recent paper “On-demand optogenetic control of spontaneous seizures in temporal lobe epilepsy” by Esther Krook-Magnuson and colleagues in Nature Communications (published online on January 22, 2013) applies the optogenetic approach to treat seizures in mice. The researchers used mice that had been genetically modified to express the inhibitory light sensitive protein halorhodopsin (normally only found in single cell organisms but not in mammals) in neurons. They placed an optical fiber to deliver the laser light to an area of the brain where they chemically induced a specific type of seizures (temporal lobe epilepsy or TLE) in the mice.

The results were quite remarkable. Activation of the laser light reduced the seizure duration by half within just five seconds. Krook-Magnuson and colleagues then also chose a second optogenetic approach to treat the seizures. Instead of using mice that contained the inhibitory light-sensitive protein halorhodopsin, they opted for mice with the excitatory (activating) light-sensitive protein channelrhodopsin (Chr2). This may seem a bit counter-intuitive, since the problem in epilepsy is that there is too much activation of neurons. One would not necessarily want to introduce activating light-sensitive proteins into neurons that are already too active. The key to understanding their strategy is the choice of the target: a subset of GABAergic cells, which can inhibit the seizure activity in neighboring neurons. This second approach was just as effective as the first approach, which used the halorhodopsin protein.

This means that one can substantially cut down seizure duration by more than half, either by directly inhibiting seizing neurons, or by activating inhibitory neurons. This research shows that there is tremendous potential for developing novel optogenetic treatments for epilepsy. Specifically targeting selected neurons that are involved in seizure activity would be preferable to generalized treatment with medications that affect global neuronal activity and could cause side effects (as is often the case with current epilepsy medications).

It is not yet clear whether this treatment can be easily applied to humans. The linchpin of the experiment was genetically introducing the light-sensitive proteins into selected neurons of the mice. This type of targeted neuronal gene therapy would be far more difficult in humans. The other obstacle is that the light activation in the mice required implantation of an optical fiber which directed the light into a specific area of the brain. Performing such an invasive procedure in patients could carry potential risks that would need to be carefully balanced with the risks and benefits of just continuing to use anti-seizure medications. Hopefully, future improvements in gene therapy methods and light stimulation will be able to help overcome these obstacles and pave the way for a whole new class of optogenetics-based therapies in patients with epilepsy and other neurological disorders.

 

Image credit: Confocal image of an eGFP filled striatal medium spiny neuron, National Institutes of Health (NIH), Margaret I. Davis

ResearchBlogging.org
Krook-Magnuson, E., Armstrong, C., Oijala, M., & Soltesz, I. (2013). On-demand optogenetic control of spontaneous seizures in temporal lobe epilepsy Nature Communications, 4 DOI: 10.1038/ncomms2376

Immune Cells Can Remember Past Lives

On By Jalees RehmanIn aging, cancer, cell biology, hiv, immunology, induced Pluripotent stem cells, lymphocytes, medicine, molecular biology, senescence, Stem CellsLeave a comment

The generation of induced pluripotent stem cells (iPSCs) is one of the most fascinating discoveries in the history of stem cell biology. John Gurdon and Shinya Yamanaka received the 2012 Nobel Prize for showing that adult cells could be induced to become embryonic-like stem cells (iPSCs). Many stem cell laboratories now routinely convert skin cells or blood cells from an adult patient into iPSCs. The stem cell properties of the generated iPSCs then allow researchers to convert them into a desired cell type, such as heart cells (cardiomyocytes) or brain cells (neurons), which can then be used for cell-based therapies or for the screening of novel drugs. The initial conversion of adult cells to iPSCs is referred to as “reprogramming” and is thought to represent a form of rejuvenation, because the adult cell appears to lose its adult cell identity and reverts to an immature embryonic-like state. However, we know surprisingly little about the specific mechanisms that allow adult cells to become embryonic-like. For example, how does a blood immune cell such as a lymphocyte lose its lymphocyte characteristics during the reprogramming process? Does the lymphocyte that is converted into an immature iPSC state “remember” that it used to be a lymphocyte? If yes, does this memory affect what types of cells the newly generated iPSCs can be converted into, i.e. are iPSCs derived from lymphocytes very different from iPSCs that are derived from skin cells?

There have been a number of recent studies that have tried to address the question of the “memory” in iPSCs, but two recent papers published in the January 3, 2013 issue of the journal Cell Stem Cell provide some of the most compelling proofs of an iPSC “memory” and also show that this “memory” could be used for therapeutic purposes. In the paper “Regeneration of Human Tumor Antigen-Specific T Cells from iPSCs Derived from Mature CD8+ T Cells“, Vizcardo and colleagues studied the reprogramming of T-lymphocytes derived from the tumor of a melanoma patient. Mature T-lymphocytes are immune cells that can recognize specific targets, depending on what antigen they have been exposed to. The tumor infiltrating cells used by Vizcardo and colleagues have been previously shown to recognize the melanoma tumor antigen MART-1. The researchers were able to successfully generate iPSCs from the T-lymphocytes, and they then converted the iPSCs back to T-lymphocytes. What they found was that the newly generated T-lymphocytes expressed a receptor that was specific for the MART tumor antigen. Even though the newly generated T-lymphocytes had not been exposed to the tumor, they had retained their capacity to respond to the melanoma antigen. The most likely explanation for this is that the generated iPSCs “remembered” their previous exposure to the tumor in their past lives as T-lymphocytes before they had been converted to embryonic-like iPSCs and then “reborn” as new T-lymphocytes. The iPSC reprogramming apparently did not wipe out their “memory”.

This finding has important therapeutic implications. One key problem that the immune system faces when fighting a malignant tumor is that the demand for immune cells outpaces their availability. The new study suggests that one can take activated immune cells from a cancer patient, convert them to the iPSC state, differentiate them back into rejuvenated immune cells, expand them and inject them back into the patient. The expanded and rejuvenated immune cells would retain their prior anti-tumor memory, be primed to fight the tumor and thus significantly augment the ability of the immune system to slow down the tumor growth.

The paper by Vizcardo and colleagues did not actually show the rejuvenation and anti-tumor efficacy of the iPSC-derived T-lymphocytes and this needs to be addressed in future studies. However, the paper “Generation of Rejuvenated Antigen-Specific T Cells by Reprogramming to Pluripotency and Redifferentiation” by Nishimura and colleagues in the same issue of Cell Stem Cell, did address the rejuvenation question, albeit in a slightly different context. This group of researchers obtained T-lymphocytes from a patient with HIV, then generated iPSC and re-differentiated the iPSCs back into T-lymphocytes. Similar to what Vizcardo and colleagues had observed, Nishimura and colleagues found that their iPSC derived T-lymphocytes retained an immunological memory against HIV antigens. Importantly, the newly derived T-lymphocytes were highly proliferative and had longer telomeres. The telomeres are chunks of DNA that become shorter as cells age, so the lengthening of telomeres and the high growth rate of the iPSC derived T-lymphocytes were both indicators that the iPSC reprogramming process had made the cells younger while also retaining their “memory” or ability to respond to HIV.

Further studies are now needed to test whether adding the rejuvenated cells back into the body does actually help prevent tumor growth and can treat HIV infections. There is also a need to ensure that the cells are safe and the rejuvenation process itself did not cause any harmful genetic changes. Long telomeres have been associated with the formation of tumors and one has to make sure that the iPSC-derived lymphocytes do not become malignant. These two studies represent an exciting new development in iPSC research. They not only clearly document that iPSCs retain a memory of the original adult cell type they are derived from but they also show that this memory can be put to good use. This is especially true for immune cells, because retaining an immunological memory allows rejuvenated iPSC-derived immune cells to resume the fight against a tumor or a virus.

 

Image credit: “Surface of HIV infected macrophage” by Sriram Subramaniam at the National Cancer Institute (NCI) via National Institutes of Health Image Bank

Armchair Psychiatry and Violence

On By Jalees RehmanIn journalism, medicine, mental health, mental illness, patients, professionalism, psychiatry, psychology, science journalism, science writing, violence3 Comments

Following tragic mass shootings such as the one that unfolded in Newtown, Connecticut, it is natural to try to “make sense” of the events. The process of “making sense” and understanding the underlying causes is part of the healing process. It also gives hope to society that if we were able to address the causes of the tragedy, we could prevent future tragedies. It is not unexpected that mental illness is often invoked as a possible reason for mass shootings. After all, the slaying of fellow human beings seems so far removed from what we consider normal human behavior. Since mental illness directly affects human behavior, it seems like the most straightforward explanation for a mass shooting. It is surmised that the mental illness severely impairs the decision-making capacity and perceptions of the afflicted person so that he or she is prone to acting out in a violent manner and causing great harm to others. Once evidence for “mental illness” in a shooter is found, one may also be tempted to stop looking for other factors that may have caused the tragedy. The nebulous expression “mental illness” can appear like a convenient catch-all explanation that requires no further investigation, because the behavior of a “mentally ill” person might be beyond comprehension.

The problem with this convenient explanation is that “mental illness” is not a homogeneous entity. There are many different types of mental illness, and specific psychiatric disorders, such as major depression, anxiety disorder or schizophrenia represent a broad spectrum of disease. These illnesses do not only vary in their severity from patient to patient, but even within a single patient, mental illnesses vary over time in severity. Just because someone carries the diagnosis of schizophrenia does not mean that the patient will continuously have severe manifestations of the disease. Some patients may show signs of withdrawal and introversion, others may act out with aggressive behavior. Making a direct causal link between a person’s diagnosis of mental illness and their violent behavior requires a careful psychiatric examination of that individual patient, as well as other circumstances, such as recent events in their lives or possible substance abuse.

When shooters kill themselves after the murders they commit, it is impossible to perform such a psychiatric examination and all that one can go by are prior medical records, but it becomes extremely difficult to retrospectively construct cause-effect relationships. In the case of Adam Lanza, the media and the public do not have access to his medical records. However, soon after the shooting, there was frequent mention in the media that Lanza had been diagnosed with either Asperger syndrome, autism or a personality disorder and potential links between these diagnoses and the shooting were implied. Without carefully perusing his medical records, it is difficult to assess whether these diagnoses were accurate, how severe his symptoms were and how they were being treated. To make matters worse, some newspapers and websites have resorted to generating narratives about Adam Lanza’s behavior and mental health based on subjective and anecdotal experiences of class-mates, family friends and in perhaps the most ridiculous case, Lanza’s hair stylist. Snippets of subjective information regarding odd behaviors exhibited by Lanza have been offered to readers and viewers so that they can perform an armchair evaluation of Lanza’s mental health from afar and search for potential clues in his past that might point to why he went on a shooting rampage. Needless to say, this form of armchair analysis is fraught with error.

It is difficult enough to diagnose a patient during a face-to-face evaluation and then try to make causal links between the symptoms and the observed pathology. In the setting of cardiovascular disease, for example, the healthcare professional has access to blood tests which accurately measure cholesterol levels or biomarkers of heart disease, angiograms that generate images of the coronary arteries and even ultrasound images of the heart (echocardiograms) that can rather accurately assess the strength of the heart. Despite all of these objective measurements, it requires a careful and extensive discussion with the patient to understand whether his shortness of breath is truly linked to his heart disease or whether it might be related to other factors. Someone might have mild heart disease by objective testing, but the shortness of breath he experiences when trying to walk up the stairs may be due to months of physical inactivity and not due to his mild heart disease.

In psychiatry, making diagnoses and causally linking symptoms and signs to mental illness is even more difficult, because there are fewer objective tests available. There are, as of now, no CT-Scans or blood tests that can accurately and consistently diagnose a mental illness such as depression. There are numerous reports of documented abnormalities of brain imaging observed in patients with mental illness, but their reliability and their ability to predict specific outcomes of the respective diseases remains unclear. The mental health professional has to primarily rely on subjective reports of the patient and the patient’s caregivers or family members in order to arrive at a diagnosis. In the case of Adam Lanza, who killed himself as well as his mother, all one can go by are his most recent mental health evaluations, which could provide a diagnosis, but may still not reliably explain his killing spree. Retrospective evaluations of his mental health by former class-mates, hair stylists or family members are of little help. Comments on the past behavior of a mass shooter will invariably present a biased and subjective view of the past, colored by the knowledge of the terrible shooting. Incidents of “odd behaviors” will be remembered, without objectively assessing how common these behaviors were in other people who did not go on to become mass shooters.

An article written by Liza Long with the sensationalist title “I Am Adam Lanza’s Mother” was widely circulated after the shooting. Long was obviously not the mother of Adam Lanza, and merely took advantage of the opportunity to describe her frustration with the mental health care system and her heart-wrenching struggles with the mental health of her son who was prone to violent outbursts. In addition to violating the privacy of her son and making him a likely target of future prejudice and humiliation, Long implied that the observed violent outbursts she had seen in her son indicated that he might become a mass shooter like Adam Lanza. Long, like the rest of the public, had no access to Lanza’s medical records, did not know whether Lanza had been diagnosed with the same illnesses as her own son and whether Lanza had exhibited the same behaviors. Nevertheless, Long’s emotional story and the sensationalist title of her article caught on, and many readers may have accepted her story as a proof of the link between certain forms of mental illness and predisposition to becoming a mass shooter.

Instead of relying on retrospective analyses and anecdotes, it may be more helpful to review the scientific literature on the purported link between mental illness and violence.

 

The link between mental illness and violence

There is a widespread notion that mental illness causes violent behavior, but the scientific evidence for this presumed link is not that solid.  “Mental illness” is a very heterogeneous term, comprising a wide range of disorders and degrees of severity for each disorder, so many studies that have tried to establish a link between “mental illness” and violence have focused on the more severe manifestations of mental illness. The 1998 land-mark study “Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods” by Henry Steadman and colleagues was published in the highly cited psychiatry journal Archives of General Psychiatry and focused on patients whose mental illness was severe enough to require hospitalization. The study followed patients for one year after they were released from the acute psychiatric inpatient units, and assessed how likely they were to engage in violence. At one of the sites (Pittsburgh), the researchers also compared the likelihood of the psychiatric patients to engage in violence with that of other residents of the same neighborhood.  Steadman and colleagues found that there was a higher rate of violence observed in psychiatric patients, this was associated with the higher rate of substance abuse. Psychiatric patients without substance abuse had the same rate of violence as other residents of the neighborhood without substance abuse.

The recent large-scale study “The Intricate Link Between Violence and Mental Disorder” was published in the Archives of General Psychiatry by Elbogen and Johnson in 2009 and also found that severe mental illness by itself was not a strong predictor of violence. Instead, future violence was more closely associated with a history of past violence, substance abuse or contextual factors, such as unemployment or a recent divorce. A 2009 meta-analysis by Fazel and colleagues was published in PLOS Medicine and reviewed major studies that had investigated the potential link between schizophrenia and violence. The authors found an increased risk of violence and homicide in patients with schizophrenia, but this was again primarily due to the higher rates of substance abuse in the patient population. The risk of homicide in individuals with schizophrenia was 0.3%, and the risk of homicide was also 0.3% in people with a history of substance abuse. All of the studies noted a great degree of variability in terms of violence, again reminding us that mental illnesses are very heterogeneous diseases. An individual diagnosed with “schizophrenia” is not necessarily at higher risk for engaging in violent behavior. One also has to assess their specific context, their past history of violence, their social circumstances and especially their degree of substance abuse, which can refer to alcohol abuse or alcohol dependence as well as the abuse of illegal substances such as cocaine. The data on whether Asperger syndrome, one of the conditions that Adam Lanza is said to have been diagnosed with, is far sparser. Stål Bjørkly recently reviewed the studies in this area and found that there has been no systematic research in this field. The hypothesized link between Asperger syndrome and violence is based on just a few studies, mostly dealing with case reports of selected incidents.

It is quite noteworthy that multiple large-scale studies investigating the association between mental illness and violence have come up with the same conclusion: Patients with mental illnesses may be at greater risk for engaging in violence, but this appears to be primarily linked to concomitant substance abuse. In the absence of substance abuse, mental illness by itself does not significantly increase the likelihood of engaging in violence. Richard Friedman summarized it best in an article for the New England Journal of Medicine:

The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.

Human behavior and mental illness

One rarely encounters armchair diagnoses in cardiovascular disease, neurologic disease or cancer. Journalists do not usually interview relatives or friends of cancer patients to ascertain whether there had been early signs of the cancer that had been missed before the definitive diagnosis was made or a patient died of cancer. If medical details about public persona are disclosed, such as for example the heart disease in the case of former vice-president Cheney, journalists and TV viewers or readers without medical expertise rarely offer their own opinion whether the diagnosis of cardiovascular disease was correct and how the patient should be treated. There were no interviews with other cardiovascular patients regarding their own personal history of heart disease and they were also not asked to comment on how they felt Cheney was being treated. In the case of the 2012 US meningitis outbreak, which resulted in the death of at least 35 people, many questions were raised in the media regarding the underlying causes and there was understandable concern about how to contain the outbreak and address underlying causes, but the advice was usually sought from experts in infectious disease.

When it comes to mental illness, on the other hand, nearly everyone with access to the media seems to think they are an expert on mental health and one finds a multitude of opinions on the efficacy of psychoactive medications, whether or not psychiatric patients should be institutionalized and warning signs that lead up to violent behavior. There are many potential reasons for why non-experts feel justified in commenting on mental illness, but remain reticent to offer their opinion on cardiovascular disease, cancer or infectious disease.  One reason is the subject matter of psychiatry. As humans, we often define ourselves by our thoughts, emotions and behaviors – and psychiatry primarily concerns itself with thoughts, emotions and behaviors. Our personal experiences may embolden us to offer our opinions on mental health, even though we have not had any formal training in mental health.

The psychiatric profession itself may have also contributed to this phenomenon by blurring the boundaries between true mental illness and the broad spectrum of human behavior. The criteria for mental illness have been broadened to such an extent that according to recent studies, nearly half of all Americans will meet the criteria for a mental illness by the time they have reached the age of 75. There is considerable debate among psychiatrists about the potential for over-diagnosis of mental illness and what the consequences of such over-diagnoses might be. The labeling of mildly “abnormal” behaviors as mental illnesses not only results in the over-prescription of psychoactive medications, but it may also take away mental health resources from patients with truly disabling forms of mental illness. For example, the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM – which establishes the diagnostic criteria for each mental disorder) will remove the bereavement exemption for the diagnosis of depression. This means that people suffering from severe grief after the death of their loved ones, such as the parents of the children that were murdered in Newtown, could conceivably be diagnosed with the mental disorder “Major Depression”. 

Romanticizing and vilifying mental illness

The topic of mental illness also lends itself to sensationalism. Occasionally, mental illness is romanticized, such as the idea that mental illness somehow fosters creativity for which there is little scientific evidence. More often, however, patients with mental illness are vilified. Broad generalizations are made and violent tendencies or criminal behaviors are ascribed to patients, without taking into account the heterogeneity of mental illness. Wayne LaPierre of the National Rifle Association (NRA) recently called for the creation of an “active national database of the mentally ill” and on a subsequent event, LaPierre referred to mentally ill patients as “monsters” and “lunatics”. Such sensationalist rants may make for good publicity, but they also help further undermine an objective discussion about mental health. Especially the call for a national database of mentally ill people comes seems somewhat counter-intuitive since the NRA has often portrayed itself as a defender of personal liberty and privacy. Are organizations such as the NRA aware of the fact that nearly half of all Americans will at some point in their life qualify for mental illness diagnoses and would have to be registered in such a database? Who would have access to such a database? For what purposes would the database be used? Would everyone listed in the database be barred from buying guns? How about household members living with a patient who has been diagnosed with a mental illness? Would these household members also be barred from buying guns?  If indeed all patients with at least one psychiatric diagnosis were registered in a national database and if they and their household members were barred from owning guns, nearly all US households would probably become gun-free. If one were to follow along the logic of the NRA, one might even have to generate a national database of people with a history of substance abuse or a past history of violence, since the above-mentioned research showed that substance abuse and past history of violence may be even stronger predictors of future violence than mental illness.

When it comes to reporting about mental illness it is especially important to avoid the pitfalls of sensationalism. Mental illness should be neither romanticized nor vilified. Potential links between mental illness and behaviors such as violence should always be made in the context of the existing medical and scientific literature and one should avoid generalizations and pronouncements based on occasional anecdotes. Journalists and mental health professionals need to help ensure the accuracy and objectivity of analyses regarding the mental health of individuals as well as specific mental illnesses. It never hurts to have a discussion about mental health. There is clearly a need for the improvement of the mental health infrastructure and for the development of better therapies for psychiatric disease, but this discussion should be based on facts and not on myths.

 

Image Credit: Brain of MRI scan data for child onset schizophrenia showing areas of brain growth and loss of tissue via NIMH

 

“It Is An Opportunity For Great Joy”

On By Jalees RehmanIn medicine, patients, personal4 Comments

I was about 12 years old when I found out that my grandfather was born on 12/12/12. If he were alive, he would be exactly 100 years old today. I found out about his birthday, when he came to stay with us in Munich for an eye surgery. He was a diabetic and had been experiencing deterioration in his vision. At that time, it was very difficult to find an eye surgeon in Pakistan who would be able to perform the surgery. My grandfather spoke many languages, such as Punjabi, Urdu, Persian, English, Arabic and some Sanskrit, but he could not speak German. His visit occurred during my school holidays, so I was designated to be his official translator for the doctor visits and his hospital stay.


On the afternoon before his surgery, we went to the hospital and I was filling out the registration forms, when I asked my grandfather about his birthday and he said 12/12/12. I was quite surprised to find out that he had such a wonderful combination of numbers, when the lady at the registration desk saw the date and asked me whether he was absolutely sure this was the correct date. I translated this for my grandfather and he smiled and said something along the lines of, “It is more or less the correct date. Nobody is exactly sure, but it is definitely very easy to remember”. I knew that I was supposed be a translator, but this required a bit more finesse than a straightforward translation. One cannot tell a German civil servant that a date is more or less correct. If we introduced uncertainty at this juncture, who knows what the consequences would be.

I therefore paraphrased my grandfather’s response as, “Yes, it is absolutely correct!”

She then said, “Eine Schnapszahl!”

My grandfather wanted me to translate this, and I was again at a loss for words. Schnapszahl literally means Schnapsnumber and is a German expression for repeated digits, such as 33 or 555. The origin of the word probably lies in either the fact that a drunken person may have transient double vision or in a drinking game where one drinks Schnaps after reaching repeated digits when adding up numbers. I was not quite sure how to translate this into Urdu without having to go into the whole background of how German idioms often jokingly refer to alcohol.

I decided to translate her comment as “What a memorable date”, and my grandfather nodded.

We were then seen by a medical resident who also pointed out the unique birthday.

His comment was “Darauf sollten wir einen trinken!”, which is another German idiom and translates to „we should all have a drink to celebrate this”, but really just means “Hooray!”  or “Great!”

My grandfather wanted to know what the doctor had said and I was again in a quandary. Should I give him accurate translation and explain that this is just another German idiom and is not intended as a cultural insult to a Pakistani Muslim? Or should I just skip the whole alcohol bit? Translation between languages is tough enough, but translating and showing cultural sensitivity was more than I could handle. My Urdu was not very good to begin with, and all I could come up with the rather silly Urdu translation “It is an opportunity for great joy”. My grandfather gave me a puzzled look, but did not ask any questions.

 

*****

On the day after my grand-father’s eye surgery, the ophthalmologist and the residents came by for morning rounds.  They removed his eye-patch, inspected the eye and told me that everything looked great. He just needed a few more days of recovery and would soon be able to go home. After putting the gauze and eye-patch back on, the doctors moved on to the next patient.

 

Once the doctors had completed rounds, I made the acquaintance of the head nurse. She seemed to think that the eye ward was her military regiment and was running it like a drill-sergeant. She walked into every room and ordered all the patients to get out of bed and walk to the common area. Only lazy people stayed in bed, she said. The best way to recuperate was to move about.

 

I told her that I did not think my grandfather was ready to get up.

“Did any doctor forbid him to get up?”

“No, not really”, I replied.

“If he has two legs, he can walk to the common room. If not, we will provide a wheelchair.”

“He just had surgery yesterday and needs to rest”, I protested and pointed to my grandfather’s eye-patch.

“Yesterday was yesterday and today is today!” was the response from the drill-sergeant.

This statement did not seem very profound to me and I was waiting for a further explanation, but the drill-sergeant had already moved on, ordering the patients from the neighboring rooms to get up.

My grandfather and I did not have much of a choice, so we joined the procession of one-eyed men who looked like retired, frail pirates. They were slowly shuffling out of their rooms towards the common area.

The common area consisted of chairs and sofas as well as a couple of tables. I sat down in a corner with my grandfather, and we started talking. He told me stories from his life, including vivid descriptions of how he and his friends proudly defied the British colonialists. My grandfather recited poems from the Gulistan of the Persian poet Saadi for me in Persian and translated them into Urdu. He wanted to know about German history and what I was learning at school. He asked me if I knew any poems by Goethe, because the Indian poet Iqbal had been such a great admirer of Goethe’s poetry.

We talked for hours. Like most children, I did not realize how much I enjoyed the conversations. It was only years later when my grandfather passed away that I wished I had taken notes of my conversations with him. All I currently have are fragmented memories of our conversations, but I treasure these few fragments.

I then pulled out a tiny travel chess set that I had brought along, and we started playing chess. I knew that he had trouble distinguishing some of the pieces because of his eye surgery. I took advantage of his visual disability and won every game. During my conversations with my grandfather and our chess games, I noticed that some of the other men were staring at us. Perhaps they were irritated by having a child around. Maybe they did not like our continuous chatting or perhaps they just did not like us foreign-looking folks. I tried to ignore their stares, but they still made me quite uncomfortable.

On the next day, we went through the same procedure. Morning rounds, drill sergeant ordering everyone to the common area, conversations with my grandfather and our chess games. The stares of the other patients were now really bothering me. I was wondering whether I should walk up to one of the men and ask him whether they had a problem with me and my grandfather. Before I could muster the courage, one of the men got up and walked towards us. I was a bit worried, not knowing what the man was going to do or say to us.

 

“Can you ask your grandfather, if I can borrow you?”

“Borrow me?”, I asked, taken aback.

“He gets to tell you all these stories and play chess with you for hours and hours, and I also want to have someone to talk to.”

Once he had said that, another patient who was silently observing us chimed in and said that he would like to know if he could “borrow” me for a game of chess. I felt really stupid. The other patients who had been staring at me and my grandfather were not at all racist or angry towards us, they were simply envious of the fact that my grandfather had someone who would listen to him.

I tried to translate this for my grandfather, but I did not know how to translate “borrow”. My grandfather smiled and understood immediately what the men wanted, and told me that I should talk to as many of the patients as possible. He told me that the opportunity to listen to others was a mutual blessing, both for the narrator as well as the listener.

On that day and the next few days that my grandfather spent in the hospital, I spoke to many of the men and listened to their stories about their lives, their health, their work and even stories about World War 2 and life in post-war Germany. I also remember how I agreed to play chess, but when I pulled out my puny little travel chess set, my opponent laughed and brought a huge chess set from a cupboard in the common area. He beat me and so did my grandfather who then also played chess with me on this giant-size chess board which obliterated the visual advantage that my travel set had offered.

***********

Since that time I spent with my grandfather and the other patients on the eye ward, I have associated medicine with narration. All humans want to be narrators, but many have difficulties finding listeners. Illness is often a time of vulnerability and loneliness. Narrating stories during this time of vulnerability is a way to connect to fellow human beings, which helps overcome the loneliness. The listeners can be family members, friends or even strangers. Unfortunately, many people who are ill do not have access to family members or friends who are willing to listen. This is the reason why healthcare professionals such as nurses or physicians can serve a very important role. We listen to patients so that we can obtain clues about their health, searching for symptoms that can lead to a diagnosis. However, sometimes the process of listening itself can be therapeutic in the sense that it provides comfort to the patient.

Even though I mostly work as a cell biologist, I still devote some time to the practice of medicine. What I like about being a physician is the opportunity to listen to patients or their family members. I prescribe all the necessary medications and tests according to the cardiology guidelines, but I have noticed that my listening to the patients and giving them an opportunity to narrate their story provides an immediate relief.

It is an indeed an  “an opportunity for great joy”, when the patient experiences the joy of having an audience and the healthcare provider experiences the joy of connecting with the patient. I have often wondered whether there is any good surrogate for listening to the patient. Medicine is moving towards reducing face-to-face time between healthcare providers and patients in order to cut costs or maximize profits. The telemedicine approach in which patients are assessed by physicians who are in other geographic locations is gaining ground. Patients now often fill out checklists about their history instead of narrating it to the physicians or nurses. All of these developments are reducing the opportunity for the narrator-listener interaction between patients and healthcare providers. However, social networks, blogs and online discussion groups may provide patients the opportunities to narrate their stories (those directly related to their health as well as other stories) and find an audience. I personally prefer the old-fashioned style of narration. The listener can give instant feedback and the facial expressions and subtle nuances can help reassure the narrator. The key is to respect the narrative process in medicine and to help the patients find ways to narrate their stories in a manner that they are comfortable with.