Ending America’s Gun Violence

By Ajay K. Singh, MBBS, FRCP, MBA
November 7, 2017

…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries. – Faiz Gani

Gun violence is a leading cause of premature death in the US, killing approximately 30,000 people and causing about 60,000 injuries each year.

In the midst of writing an article about a blog post on gun violence by Faiz Gani, I heard breaking news about 26 people tragically killed in a Texas church.

Senator Chris Murphy (D-Conn) issued a statement after the Texas church mass shooting: “As my colleagues go to sleep tonight, they need to think about whether the political support of the gun industry is worth the blood that flows endlessly onto the floors of American churches, elementary schools, movie theaters, and city streets. Ask yourself—how can you claim that you respect human life while choosing fealty to weapons-makers over support for measures favored by the vast majority of your constituents.”

While the motive for the Texas mass shooting (or for that matter, the tragic mass shooting in Las Vegas) remains elusive, one factor that has been common among some earlier mass shootings is that the perpetrator(s) suffered from mental illness.

Besides the mental instability part of the problem, there is also the economic cost. The post by Faiz Gani in Health Affairs discusses the price of gun violence:

Thousands of individuals incur firearm-related injuries daily, leading to approximately 36,000 deaths each year from a firearm-related injury. The number of nonfatal injuries is estimated to be three times that number…we estimate that the annual financial burden associated with the ED and inpatient care for firearm-related injuries to be $2.8 billion in hospital charges. Taking into account the costs of rehabilitation, repeat admissions, and lost work, the CDC estimates that each year, approximately $46 billion are lost due to firearm-related injuries. This figure is comparable to the $49 billion spent to treat patients with chronic obstructive pulmonary disease, the third leading cause of death in the United States…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries.

Setting aside constitutional right issues around gun ownership and the huge and tragic human cost of gun violence, there is the economic cost. Isn’t it worth asking if better access to mental health services to perpetrator(s) would reduce the current rate and extent of mass shootings?

Gani’s post suggests that from a purely economic perspective, the government investing in more mental illness treatment (programs and facilities) might make the difference. Even if mental illness is not formally diagnosed, most of us would agree that this type of mindless, despicable violence has a component of mental instability.

Share your thoughts with Harvard Medical School in the comment section below.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Spirituality and Medicine

Ajay K. Singh, MBBS, FRCP, MBA
October 19, 2017

“Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.” —Christina Puchalski

An interview with Christina Puchalski on integrating spirituality into medicine in BigQuestionsOnline caught my eye. So I dug a bit more into this topic.

I came across a 2001 article by Puchalski titled, “The role of spirituality in health care” that I would strongly recommend to anyone who takes care of patients. In her article, Puchalski writes: “Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.”

According to Puchalski, physicians should incorporate spiritual practice into their interactions with patients. This could happen by physician’s being “fully present and attentive to their patients…actively listen and allow their patients to share “fears, hopes, pains and dreams.” She also recommends that physicians pay attention to “all dimensions of patients and their families: body, mind, and spirit.” Puchalski supports physician’s involving chaplains as members into the interdisciplinary health care team.

Puchalski is an advocate of “compassionate care,” which she defines as physicians walking “with people in the midst of their pain, to be partners with patients rather than experts dictating information to them.” Merriam-Webster defines compassion as “sympathetic consciousness of others’ distress together with a desire to alleviate it.”

Puchalski writes that compassion is important because:

While patients struggle with the physical aspects of their disease, they have other pain as well: pain related to mental and spiritual suffering, to an inability to engage the deepest questions of life. Patients may be asking questions such as the following: Why is this happening to me now? What will happen to me after I die? Will my family survive my loss? Will I be missed? Will I be remembered? Is there a God? If so, will he be there for me? Will I have time to finish my life’s work?

Studies support Puchalski’s contention that physicians generally underestimate patients’ spiritual needs. Ehman and colleagues performed a self-administered survey to 177 patients in a hospital-based pulmonary clinic: only 15% were asked about spiritual or religious beliefs. Nearly two-thirds of the patients said that they would welcome a question about whether they were spiritual from their doctors while they were taking the medical history. In another study, also a survey, but in primary care clinics of six academic medical centers in three states, MacLean and colleagues report that many patients want their physician to ask them about spiritual beliefs; indeed, this desire for inquiry about spiritual beliefs increases strongly with the severity of the illness. The MacLean study enrolled 456 patients who were dying. Seventy percent of these patients said that they would welcome physician inquiry into their religious beliefs, 55% said that they would appreciate silent prayer, and 50% believed their physician should pray with them.

So what’s the bottom-line? While most physicians focus on the physical aspects of illness, a more holistic approach may be what patients want. Arguably to be complete, physicians should consider discussing spirituality with patients. Christina Puchalski concludes: “I think we can be better physicians and true partners in our patients’ living and in their dying if we can be compassionate: if we truly listen to their hopes, their fears, and their beliefs, and incorporate these beliefs into their therapeutic plans.”


Harvard Medical School CME:
Lifestyle Medicine: Nutrition & The Metabollic Syndrome


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

Does Increasing Cigarette Prices Impact Consumption?

Ajay K. Singh
September 7, 2017

An interesting article by Nicholas Bakalar in the Aug 23, 2017 New York Times “Well” section caught my eye. It discusses a paper by Stephanie Mayne and colleagues accepted in Epidemiology that supports a relationship between the price of cigarettes and consumption. Quoting from the abstract:

$1 increase in price [of cigarettes] was associated with a 3% reduction in risk of current smoking (aRR: 0.97, 95% confidence interval [CI]: 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93, CI: 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR 1.2, CI: 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65, CI: 0.45%, 0.93%). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

A CDC Grand Rounds article titled Current Opportunities in Tobacco Control, which cites earlier work, supports the conclusions reached by Mayne et al. A 10% increase in the price reduces cigarette consumption by about 4%. The data from the chart below is pretty impressive. The progressive rise in the sales price of a pack of cigarette has resulted in a steady decline in cigarette sales.

The CDC article makes the following point: “Increasing the price of cigarettes discourages initiation among youths, prompts quit attempts, and reduces average cigarette consumption among those who continue to smoke.”

However, since early 2000 the price of cigarettes has remained relatively steady, but sales have continued to fall, suggesting that factors beyond price are also important.  These factors include tobacco control programs run by states, media campaigns, health warnings on tobacco packaging, changing attitudes about smoking and the tobacco industry, and reduced youth tobacco initiation.

An interesting article looking at the economics in the UK of increasing cigarette taxes makes two points:

  1. Nearly two-thirds of the price of a pack of cigarettes goes to taxes.
  2. Because people are addicted to cigarettes, demand price is inelastic and sales are unlikely to fall much.

The article also reaches some harsh observations: “Smokers already pay a lot of tax …[and] they do not cost the government much because they die early and save pension and health care spending. Higher taxes will increase inequality because the poor will pay a higher percentage of tax than the rich who are more likely to have given up. Higher taxes will encourage people to smuggle illegal cigarettes and avoid paying the tax.”

In the US, there is tremendous variability in the price of a pack of cigarettes. In New York State, the price currently is around $10.50 (and there is a proposal to raise it to $13 per pack). In contrast, price elsewhere is about half this amount (According to the website Fairreporters.net which lists the prices of cigarettes by state, $5.40 per pack in Kentucky and between $6 to $8 per pack in other states).

In summary, the jury is out on precisely how elastic demand is based on price, but it is a fair conclusion from published data that price does impact sales. Further, there seems to be ample room among many states in the US to increase cigarette taxes and, therefore, price.

But, at least one thing is indisputable: the benefits of not smoking.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Tort Reform and Health Care Costs

By Ajay K. Singh, MBBS, FRCP, MBA
August 31, 2017

The country gyrates and convolutes about whether Obamacare should be repealed and replaced, but the larger discussion should center on how to reduce health care costs.

One significant contributor to escalating health care costs is the impact of malpractice. An article published by Michelle Mello and colleagues in Health Affairs discusses the impact of medical malpractice on the US health care system. It estimates that in 2008, medical malpractice, including defensive medicine, cost $55.6 billion or about 2.4% of total health care spending.

Currently, having passed the House of Representatives, federal tort reform legislation is stuck in the US Senate . The nonpartisan Congressional Budget Office estimates that enacting federal tort reform would save approximately $14 billion over five years and $50 billion over 10 years. Some key features of the tort reform proposal languishing in Congress include a cap on non-economic damages, a three-year statute of limitations on medical liability suits from the date of injury, and a “fair-share” rule in which a defendant would be liable only for his or her share of responsibility for a medical injury.

One criticism of tort reform is whether it works, and in particular whether it could be implemented in the US. A recent article by Vishal Khetpal in Slate on reforming medical malpractice caught my eye.  The article makes two points:

  1. Tort reform that creates a no-fault compensation system has worked in several countries such as Sweden, Denmark and New Zealand.
  2. The US has implemented a system for patients harmed by the administration of a vaccine—the National Vaccine Injury Compensation Program. This system does seem to work.

The other criticism is that tort reform might reduce clinical quality and clinical outcomes. But the authors of an interesting article in the Journal of Public Economics disagree.

The President of the American Medical Association, Dr. David O. Barbe, MD, has been  quoted in Modern Healthcare by Mara Lee: “This legislation is an important step toward fixing that system—a step that reins in defensive medicine, reduces the growth of health care costs and strikes the correct balance by promoting speedier resolutions of disputes—while maintaining an injured patient’s access to just compensation.”

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Fake Medical News: When is Fake Really Fake?

By Ajay K. Singh, MBBS, FRCP, MBA
August 24, 2017

The use of the term “fake news” by President Trump and others raises the issue of whether medical news about disease and/or its treatment can be faked. Robert McNutt, in a provocative article in the Health Care Blog, asks the question: How Can I Tell if Medical News is Fake or Not?

Dr. McNutt recommends asking three questions in evaluating medical news:

  1. Is the item being reported measurable?
  2. What additional human traits or actions may cloud or confound the relationship between the item being studied and the outcome being touted?
  3. How was the study done?

McNutt uses the example of the purported health benefits of coffee. In a blog piece about one year ago, one of my Harvard colleagues, Dr. Sanjiv Chopra, wrote the following about the benefits of coffee drinking:

The facts are indisputable; coffee appears to offer a great variety of benefits, including substantial protection against liver cirrhosis, type 2 diabetes, heart disease, Parkinson’s disease, cognitive decline and dementia, gall stones, tooth decay and a host of common cancers, including prostate, colon, endometrial, and skin cancer. There also is a lower rate of suicide among coffee drinkers.”

Since I am not an expert on this, I will refrain from opining on the merits of coffee drinking, although I am very skeptical that the facts are “indisputable.” In McNutt’s example, he interrogates the benefit of coffee drinking using the three stated questions. More generally, he then states:

Observational comparison studies, rather than randomized studies, are nearly always fake, as observational studies cannot prove an independent contribution of the item being studied to the outcome of interest. In other words, if they happen to be true, we can’t prove it. Hence, they are fake.”

Of course, Dr. McNutt must realize that his statement goes too far. While confounding is an important issue in any association study, it is manifestly wrong to state that results from these studies are fake. Observational studies have limitations, but so do randomized trials.

Observational studies do not prove causation, but they can provide valuable data that, when examined by sophisticated statistical methods, might mimic randomized trials. Take the example of postmenopausal hormone therapy and coronary heart disease. Hernan and colleagues conceptualize observational data as a sequence of non-randomized trials to demonstrate the ability to arrive at conclusions that mimic those from a randomized trial on postmenopausal hormone therapy.

The early epidemiologic science around the association between smoking and lung cancer underscores the powerful impact that observational data can have in reducing the burden of disease and saving lives. Writing in Tobacco Control, Robert Proctor states:

“Scholars started noting the parallel rise in cigarette consumption and lung cancer, and by the 1930s had begun to investigate this relationship using the methods of case-control epidemiology. Franz Hermann Müller at Cologne Hospital in 1939 published the first such study, comparing 86 lung cancer ‘cases’ and a similar number of cancer-free controls. Müller was able to show that people with lung cancer were far more likely than non-cancer controls to have smoked, a fact confirmed by Eberhard Schairer and Eric Schöniger at the University of Jena in an even more ambitious study from 1943. These German results were subsequently verified and amplified by UK and American scholars: in 1950 alone, five separate epidemiological studies were published, including papers by Ernst Wynder and Evarts Graham in the USA and Richard Doll and A Bradford Hill in England. All confirmed this growing suspicion, that smokers of cigarettes were far more likely to contract lung cancer than non-smokers. Further confirmation came shortly thereafter from a series of prospective ‘cohort’ studies, conducted to eliminate the possibility of recall bias. The theory here was that by following two separate and initially healthy groups over time, one smoking and one non-smoking, matched by age, sex, occupation and other relevant traits, you could find out whether smoking was a factor in the genesis of lung disease. The results were unequivocal: Doll and Hill in 1954 concluded that smokers of 35 or more cigarettes per day increased their odds of dying from lung cancer by a factor of 40. Hammond and Horn, working with the American Cancer Society on another large cohort study, concluded that same year that the link had been proven ‘beyond a reasonable doubt’.

And, there are many other examples in the arena of public health and delivery science.

Dr. McNutt’s summary condemnation of the value of epidemiologic research, however well meaning, demonstrates a fundamental lack of understanding of the value of this science. Indeed, epidemiologic studies done well not only provide the foundation to develop hypotheses that can be tested in randomized trials, but have in themselves had tremendous impact on public health.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Dr. Singh teaches the online CME course: Developing Essential Skills in Clinical Research

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

 

Kissing Bugs and Heart Disease: Identifying Chagas’ Patients

By Ajay K. Singh, MBBS, FRCP, MBA
April 18, 2017

In managing patients with heart disease, most of us do not think about the possibility of Chagas’ disease (CD). CD is estimated to affect 5 million people worldwide and according to CDC seroprevalence estimates, affects about 300,000 people. CD accounts for nearly five times as many disability-adjusted life years lost as malaria. CD is estimated to cause approximately 7000 deaths annually.

A recent study by Sheba and colleagues of a convenience cohort of 4,755 Latin American-born residents of Los Angeles County reports that 1.24% tested positive for CD.

Bern and colleagues provide a comprehensive review of CD.  The disease was discovered in 1909 and is named after the Brazilian physician Carlos Chagas; Chagas’ is also known as American trypanosomiasis.

The protozoan parasite Trypanosoma cruzi (T. cruzi) is the cause of CD. It is thought that immigrants from Latin American countries acquire the trypanosomal infection from transmission by insect vectors (carried in the gastrointestinal tract of triatomine bugs) found in impoverished rural areas of Latin America. Triatomine bugs are also known as “kissing bugs”  because they bite while a person is asleep around the thin skin of the face around the eyes and mouth. T. cruzi transmission occurs when infected bug feces contaminate the bite site or intact mucous membranes, but it can also be transmitted through transfusion, via a transplanted organ, and congenitally.

CD has both an acute and chronic phase of disease. The acute phase is either asymptomatic, or associated with fever in a subset of patients with a chagoma. These chagomas contain the parasite and present with swelling and inflammation at the site of inoculation. Acute CD can rarely also present with more severe myocardial and central nervous manifestations.

[Review HMS lectures on Current Trends in Cardiology.]

The chronic phase manifests either with cardiac or digestive disease. Cardiac CD is a cardiomyopathy characterized by a chronic inflammatory process involving all chambers, conduction system damage, and a progressive dilated cardiomyopathy with congestive heart failure. Patients may also present with thromboembolism due to thrombus formation in the dilated left ventricle or aneurysm. Gastrointestinal CD disease is less common than cardiac CD and geographically distinct (mostly detected in Argentina, Bolivia, Chile, Paraguay, Southern Peru, Uruguay, and parts of Brazil rather than northern Latin America, Central America, or Mexico) and usually affects the esophagus and/or colon, resulting from damage to intramural neurons.

So what are the implications from the Sheba study? Sheba and colleagues make several recommendations. First, the prevalence of CD in the US has been underestimated and more awareness is necessary. Indeed, the US Center of Disease Control (CDC) considers CD, along with as cysticercosis, toxocariasis, toxoplasmosis and trichomoniasis, as a neglected parasitic infection.  Second, earlier diagnosis and treatment of CD might significantly impact the morbidity and mortality of the disease. And, third screening strategies should be considered for individuals at high risk: Latin American immigrants from endemic areas would be at the top of the list for screening. Indeed, screening tests are available for CD. Besides these, while CD is more common among immigrants, it has been detected in native-born Americans underscoring the importance of considering CD in the differential diagnosis of a cardiomyopathy.

Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Understanding Regret Leads to Clinical Empathy

By Ajay K. Singh, MBBS, FRCP, MBA
April 4, 2017

“There is a tide in the affairs of men
Which taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries”
William Shakespeare: Julius Caesar, Act 4 Scene 3

This idea of opportunity versus regret from Shakespeare was recently addressed by Anjana Ahuja a science writer for the Financial Times as she discusses the conflicting emotions generated around Brexit: opportunity in the minds of some and regret among others.

Ahuja writes: “Regret is a powerful emotion, and a universal one. Who among us has not felt a pang, even a churn in the stomach… that, in retrospect, was the wrong one?” Continue reading “Understanding Regret Leads to Clinical Empathy”