Medical Error: 3rd leading cause of death in the USA
- Created on Thursday, 05 May 2016 15:22
Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published this month in the British Medical Journal.
As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland.
But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.
And it's not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator.
The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.
Cancer and Heart Disease Get the Attention
"Top-ranked causes of death as reported by the CDC inform our country's research funding and public health priorities," Dr Makary said in an university press release. "Right now, cancer and heart disease get a ton of attention, but since medical errors don't appear on the list, the problem doesn't get the funding and attention it deserves."
He adds: "Incidence rates for deaths directly attributable to medical care gone awry haven't been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used."
The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error.
That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease.
In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC.
The new estimates are considerably higher than those in the 1999 Institute of Medicine report "To Err Is Human." However, the authors note that the data used for that report "is limited and outdated."
Strategies for Change
The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department's morbidity and mortality conference.
Another is changing death certificates to include not just the cause of death, but an extra field asking whether a preventable complication stemming from the patient's care contributed to the death.
The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.
Standardized data collection and reporting are also needed to build an accurate national picture of the problem.
Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News he was not surprised the errors came in at number 3 and that even those calculations don't tell the whole story.
"That doesn't even include doctors' offices and ambulatory care centers," he notes. "That's only inpatient hospitalization resulting in errors."
"I think most people underestimate the risk of error when they seek medical care," he said.
He agrees that adding a field to death certificates to indicate medical error is likely the way to get medical errors the attention they deserve.
"It's public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider," he said.
However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform, he said.
Still, this study helps emphasize the prevalence of errors, he said.
Human error is inevitable, the authors acknowledge, but "we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences."
They add that most errors aren't caused by bad doctors but by systemic failures and should 'not be addressed with punishment or legal action.
Dr. Cinque: So, what do they mean by "systemic" errors as opposed to doctor error? Do they mean that the doctor followed the standard protocol but the protocol was wrong? That's what it sounds like to me.
First, note that this has been reported before that medical errors are killing people on a grand scale. I mean: it has been known for decades. And they said then that steps were going to be taken, etc. etc. to reduce the medical carnage, but obviously, it hasn't worked. Second, medical deaths are still being grossly underreported. Take heart disease, for instance, the leading killer. If a person dies from the adverse effects of medications for heart disease, such as calcium channel blockers which are dangerous because they can trigger heart attacks, it's likely to be called a death from heart disease rather than heart disease treatment.
I'll admit that my perspective is very bleak. I think that most of medical treatment is killative. Leastways, most of it is harmful. Most of it amounts to suppressive, symptomatic, pharmaceutical tinkering which adds a new abnormality to the ones you've already got- complicating your condition, even if in some ways it seems better or looks better. They are not making you healthier; they are just making your disease manifest differently as you continue going downhill.
A good example are diuretics which are very widely prescribed but rarely do anybody any good. You're better off living with whatever fluid retention you have than trying to get rid of it forcibly that way. Better yet, take some constructive actions with diet, salt restriction, weight loss, exercise, supplements, and perhaps fasting to see if you can get it to resolve naturally and spontaneously through actual biological improvement rather than forcing measures. What's so terrible about that? Remember, patience is a virtue. You start doing the right things, and then you give it time. There is no need to resort to anything reckless and drastic.
This whole thing is complicated by the fact that there are areas in Medicine in which they do do valuable and beneficial things, such as surgery for cataracts, giving Metformin to Type II diabetics, antibiotics when necessary, and hormone replacement when indicated, especially when they are bio-identical. And I have no doubt that great work is being done with stem cells, and more is to come. But, none of that changes the fact that most of modern medical treatment is just disruptive pharmaceutical tinkering, which is hurting people and sometimes killing them. As a percentage, there isn't that much good in Medicine, and most of it should be avoided.
Does that seem radical? Well, I'm sorry, but it's true.
More evidence of statin misuse
- Created on Sunday, 03 April 2016 17:22
Statin Drugs: They're just a superstition
- Created on Friday, 01 April 2016 21:20
I am republishing here the April newsletter of Dr. Uffe Ravnskov. Dr. Ravnskov is a Swedish physician, a nephrologist (kidney specialist) and internist. And for many years, he has been at war with the medical establishment over cholesterol and use of cholesterol-lowering drugs, particularly statins. The evidence is very strong that statins do no prolong life, and they may even shorten life. I'm sure that Dr. Ravnskov would say that statins are the biggest medical scam of all time- and I agree with him. So, here is his latest newsletter. Be glad to know about this extremely knowledgeable and immensely competent physician, Dr. Uffe Ravsnkov.
In a recent Danish paper published in European Heart Journal the authors claimed, that negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality. It was based on the fact, that early statin discontinuation by some of more than 800,000 Danish statin-treated people was associated with the number of negative statin-related news stories published in the media between 1995 and 2010., and that 1.1% more of those with early statin discontinuation had died after 10 years of follow-up compared with those who continued.
A more reasonable explanation is that the statin-treated individuals learned that their many unpleasant symptoms were caused by the statins, because most adverse effects do not appear immediately. Very often they develop several weeks or months after the start of the treatment. As the side effects of almost all drugs appear immediately, neither the “patient” or the doctor realize that the late statin side effects are caused by the drug. The muscular problems, the mental disturbances and the decrease of sexual potency, the most common side effects, are therefore seen as a result of of increasing age.
An interesting observation is that the heart mortality difference of 1.1% is what those who continued their treatment won after 10 years of treatment. This is much less than reported from the statin trials. In the first statin trial 4S for instance, the difference between the statin and then placebo group as regards heart mortality was 2.5% after about five years of treatment. Notary impressive, but more than four times as much as in this paper.
Furthermore, there was not a word about total mortality in the paper. The only reason for excluding this information is of course, that either there was no difference, or that those, who stopped statin treatment lived longer than those who continued. It was not possible either for a Canada Free Press journalist to get this information from Børge Nordestgaard, one of the authors and head of the department, where the study was performed. He just answered the following: We probably could have looked at all-cause mortality. What I thought would have meaning for people that are interested in this field was myocardial infarction and cardiovascular death. Those are the two major endpoints that you look for when trying to prevent cardiovascular disease.
Aren´t the main interest of people on preventive medicine to prolong their life?
In an interview in the Danish newspaper Politiken, Nordestgaard declared that people, who stop their statin treatment have a 26% increased risk of a heart attack and 18% higher risk to die from a cardiovascular disease compared with those, who continue the treatment.
What explains his misleading words may be that he has strong economical links to the drug industry. In the section Conflicts of interest you can read the following: B.G.N. has received consultancy fees and/or lecture honoraries from Astra Zeneca, Pfizer, Merck, Amgen, Sanofi, Regeneron, Omthera, Dezima, ISIS Pharmaceuticals, Aegerion, Fresenius, B. Braun, Kaneka, Lilly, Kowa, and Denka Seiden.
Much evidence has shown that there is little benefit from statin treatment, if any at all. In my previous newsletter for instance, I told you about the Danish study, where the authors had calculated how may years you are able to prolong your life by statin treatment. What they found was that on average you can only prolong it by a few days.
Recently a research group from Italy, the UK and Sweden published a study in BMJ Open about the trends of statin use and heart mortality between 2000 and 2012 in 12 European countries. In all of the countries statin treatment has increased and heart mortality had decreased, apparently a support of statin treatment. However, there was no association between the degree of statin increase and the degree of mortality lowering between the countries. In Germany, for instance, statin treatment had increased by 54% during these years and heart mortality had decreased by 85%, whereas in Portugal statin treatment had increased by102%, whereas heart disease had decreased by only 41%.
As I have told you before, the directors of the statin trial do not allow access to the primary data. This has raised much criticism and a campaign, backed by the British Queen´s former doctor Sir Richard Thompson calling for urgent public enquiry into drugs firms' 'murky' practices. You can read more about that in in Daily Mail, in Sunday Express and in The Western Australia
In 2005 new, stricter regulations were introduced in the conduct and publication of randomized controlled trials. Since then the results of all statin trials have been minimal compared to those published before 2005 You can read more about that in a paper published in Expert Review of Clinical Pharmacology by Professor Harumi Okuyama and his co-authors; in a paper in Journal of Controversies in Biomechanical Research by Michel de Lorgeril and Mikael Rabaeus, and in Sunday Express. The authors of the two scientific journals are no amateurs; most of them are members of THINCS and de Lorgeril was the first who demonstrated the benefits of the Mediterranean diet.
Uffe Ravnskov, MD, PhD, independent investigator
Avoiding the sun as dangerous as smoking
- Created on Wednesday, 30 March 2016 15:18
A new study out of Sweden and published on Medscape, which is an online magazine for doctors, reported that nonsmokers who stayed out of the sun had a life expectancy similar to that of smokers who soaked up the most rays. Hence, not getting sufficient sunlight is as dangerous and life-shortening as smoking. The study involved nearly 30,000 Swedish women over 20 years.
This indicates that avoiding the sun "is a risk factor for death of a similar magnitude as smoking," write the authors of the article, published March 21 in the Journal of Internal Medicine. Compared with those with the highest sun exposure, life expectancy for those who avoided sun dropped by 2.1 years.
Pelle Lindqvist, MD, of Karolinska University Hospital in Huddinge, Sweden, and colleagues found that women who seek out the sun were generally at lower risk for cardiovascular disease (CVD) and such diseases as diabetes, multiple sclerosis, and pulmonary diseases, than those who avoided sun exposure.
And one of the strengths of the study was that results were dose-specific — sunshine benefits went up with the amount of exposure.
The researchers acknowledge that longer life expectancy for sunbathers seems paradoxical to the common thinking that sun exposure increases risk for skin cancer.
"We did find an increased risk of.skin cancer. However, the skin cancers that occurred in those exposing themselves to the sun had better prognosis," Dr Lindqvist said.
Some Daily Exposure Important for Health
Given these findings, he told Medscape Medical News, women should not overexpose themselves to sun, but underexposure may be even more dangerous.
"We know in our population, there are three big lifestyle factors that endanger health: smoking, being overweight, and inactivity," he said. "Now we know there is a fourth — avoiding sun exposure."
Sweden's restrictive guidance against sun exposure over the past 4 decades may be particularly ill-advised, the study finds, in a country where the maximum UV index is low (< 3) for up to 9 months out of the year.
Use of sunscreen is also widely misunderstood in the country and elsewhere, Dr Lindqvist said.
"If you're using it to be out longer in the sun, you're using it in the wrong manner," he said. However, "If you are stuck on a boat and have to be out, it's probably better to have sunscreen than not to have it."
Women with more pigmentation would be particularly well-served to stop avoiding sunshine, he said, adding that many people in India, for instance, follow guidelines like those in Sweden to avoid sun year round.
And because melanomas are rare among women with darker skin, benefit goes up in those populations when weighing sun exposure's risk against benefits, Dr Lindqvist said.
Age and Smoking Habits
The researchers studied sun exposure as a risk factor for all-cause mortality for 29,518 women with no history of malignancy in a prospective 20-year follow-up of the Melanoma in Southern Sweden cohort.
The women were recruited from 1990 to 1992 when they were 25 to 64 years old. Detailed information was available at baseline on sun-exposure habits and potential confounders such as marital status, education level, smoking, alcohol consumption, and number of births.
When smoking was factored in, even smokers at approximately 60 years of age with the most active sun-exposure habits had a 2-year longer life expectancy during the study period compared with smokers who avoided sun exposure, the researchers note.
.Role of Vitamin D Still in Question
The results add to the longstanding debate on the role of vitamin D in health and the amount of it people need, but this study doesn't resolve the question.
"Whether the positive effect of sun exposure demonstrated in this observational study is mediated by vitamin D, another mechanism related to ultraviolet radiation, or by unmeasured bias cannot be determined. Therefore, additional research is warranted," the authors write.
Dr. Cinque: Even the role of sunlight in causing skin cancer is not fully understood because it is not uncommon for people to develop skin cancers in areas which have not been over-exposed. Likewise, there are plenty of areas which, which for some people, are chronically over-exposed- say the arms of a fisherman- where the incidence of skin cancers doesn't correlate. Protecting the skin from too much sun exposure is definitely a good idea, apart from cancer, because we know it ages the skin and damages it. But, there are plenty of people who want to avoid the sun completely, and that is wrong. The sun's ultraviolet has a powerful anti-cancer effect which seems to work against every kind of cancer except skin cancer. And yes, skin cancer can be deadly, but caught early, it is about the easiest cancer to treat. Here's a good rule of thumb: if the sun exposure you are are getting is causing frank, visible tanning, then you're getting too much sun. The frank, visible tanning is a reaction to too much sun. And here's another good rule: if you want to protect your face all the time, it's fine. You are not going to suffer if that small part of your body doesn't get exposed to the sun. But, find large, broad areas of yourself that you can expose directly to effective sunlight for 10 or 15 minutes at a time. There is more danger if you don't than if you do.
Fasting triggers stem cell regeneration of immune system
- Created on Friday, 25 March 2016 13:25
From a new study out of USC, it was learned that in both mice and humans, fasting caused stem cell regeneration of the immune system, after damage was done by chemotherapy. Fasting was said to have "flipped a regenerative switch" activating the response of hemopoietic stem cells in the bone marrow which are responsible for building blood and immune cells.
“We are investigating the possibility that these effects are applicable to many different systems and organs, not just the immune system,” said Longo, whose lab is in the process of conducting further research on controlled dietary interventions and stem cell regeneration in both animal and human studies.
“We could not predict that prolonged fasting would have such a remarkable effect in promoting stem cell-based regeneration of the hematopoietic system,” said corresponding author Valter Longo, Edna M. Jones Professor of Gerontology and the Biological Sciences at the USC Davis School of Gerontology and director of the USC Longevity Institute.
The process involved the reduction in an enzyme known as PKA which is believed to suppress stem cell regeneration. “PKA is the key gene that needs to shut down in order for these stem cells to switch into regenerative mode. It gives the OK for stem cells to go ahead and begin proliferating and rebuild the entire system,” explained Longo, noting the potential of clinical applications that mimic the effects of prolonged fasting to rejuvenate the immune system. “And the good news is that the body got rid of the parts of the system that might be damaged or old, the inefficient parts, during the fasting. Now, if you start with a system heavily damaged by chemotherapy or aging, fasting cycles can generate, literally, a new immune system.”
The longest fast involved was 4 days, and it resulted in the removal of old, damaged immune cells and their replacement with new ones.
I have been involved in conducting fasts for people most of my adult life, and I have seen fasts much longer than 4 days. The longest fast I have ever done is 28 days. That's water-only for 28 days. And the longest fast I have ever supervised is 40 days. However, we know beyond doubt that there have been fasts much longer than that- longer than 100 days.
To many people, not eating for an extended period may seem drastic, but in practice, it's not as hard as it seems. For one thing, hunger disappears after a day or two. The ketosis of fasting, in which the body switches from burning glucose to burning fat, takes away the appetite. Most people feel quite indifferent to food while they are fasting. In fact, the biggest complaint we hear from fasters is not that they are hungry but that they are bored. And that's why we keep a lot of books and movies around to help them pass the time. Freeing the body from having to process food from scratch, saves the body a tremendous amount of energy and work. And, the process of living on one's reserves, forces the kind of cleaning-out of old damaged cells that we are looking for. The breakdown of tissues during fasting (in search of food) is a rigidly controlled process, and it results in discarding the bad and hoarding the good. You can compare it to peeling back the layers of an onion to get to younger, fresher tissue.
I am proud to say that I am one of the most experienced fasting practitioners in the world. And, I know that under the right environment and with the right conditions, fasting is one of the most healing and regenerative things that a person can do, as it aids and benefits a broad array of health issues. It would be great if the medical world became more aware of fasting and its potential to enhance human lives.
With aging, zinc nutrition suffers
- Created on Monday, 29 February 2016 04:32
A new study has shown that aging mice lose the ability to absorb and utilize zinc. For a long time, that has been suspected in humans as well. Dr. Walter Pierpaoli, who is responsible for introducing the world to melatonin, believes that the failure of zinc nutrition is responsible for much of the frailty and decrepitude of old age. And, he is very interested in preventing it. He discovered that melatonin tends to reverse the effect. Yes, melatonin enhances your body's ability to absorb and utilize zinc. And that is why he puts a little zinc in his melatonin supplement- so that it will be there at the same time as the melatonin, so that it can work on it.
Zinc absorption is a dicey situation even in the young. Are you aware that the essentiality of zinc in human nutrition wasn't discovered until the 1960s? And I'll tell you how it was discovered. It involved some growth-retarded boys in Iran. It was found that their diet was heavily weighted in unleavened bread made of wheat- which was high in phytic acid. Phytic acid, which is a form of phosphorus, binds minerals, rendering them unabsorbable, including zinc. Raising bread with yeast breaks down some of the phytic acid- so it is less of a problem. Even though I do not avoid wheat completely, I'm willing to admit that it's a food we should go light on, and some people shouldn't eat it at all.
But, phytic acid occurs in much more than wheat. It occurs in virtually all grains, nuts, and legumes, and also vegetables to some extent. Phytic acid is so widespread in plant foods, that's why they call it phytic acid, which means plant acid.
But, there is also oxalic acid which is also widely distributed in plants, including, fruits, vegetables, sesame seeds- even coffee beans. Oxalic acid combines with minerals forming insoluble oxalates which cannot be absorbed. The spinach family vegetables, including chard and beets, are high I oxalic acid, but there is some in just about every fruit and vegetable.
Because of these digestive antagonists, we only absorb a small portion of the zinc we consume. The recommended daily quota is 12 mg, but that is based on the idea that we will absorb just 20% of it. So, that means that only 2.4 mgs of zinc actually gets through. But, there may be times and conditions in which even less than that gets absorbed.
I should also mention that the fiber in plant foods- wonderful as it is- can also interfere with zinc absorption.
So, getting some supplemental zinc each day isn't a bad idea no matter who you are. But, if you are older, then it is especially important. Zinc is one of the top reasons why taking a good multi is a good idea.
By the way, an excellent source of zinc are pecans. They really are loaded, and pecan growers in Texas have to use a foliar spray of zinc or else the nuts won't fill out properly. I have a pecan tree at my health retreat that is not starting its 3rd year, and I give it foliar zinc as well. And, pecans are relatively low in phytic acid and oxalic acid, compared to other nuts. And what a tasty way to get your zinc.
So, the fact is that zinc is one of the weakest links in the modern diet, and the damage it is doing is probably incalculable. Making sure you are supplied with optimal zinc is one of the best things you can do for your health.
Mark Twain: A Man of His Time and of All Time
- Created on Thursday, 11 February 2016 02:49
My dear cousin Maria gave me The Autobiography of Mark Twain for Christmas. His life story is fascinating, and so is the history of his autobiography.
He started writing it in 1870- which was 40 years before he died. And before he began, he decided that he didn’t want it to be published until after he was dead. But, he was ambivalent about how many years after, ranging from as few as 50 to as many as 500. Yes, he actually contemplated having his autobiography held for half a millennium before being published. But, he wound up stipulating a 100 year wait. Yet, somehow, the first edition came out in 1958, which was 48 years after he died. Go figure.
Anyway, I think it’s pretty darn arrogant to assume that 100 years after you’re dead that people will want to read about your life- let alone 500 years. And all the more so when you consider that in 1870 when he started, he hadn’t even completed Tom Sawyer yet. So, he was very far from the pinnacle of his fame. However, on the other hand, he turned out to be correct in his prediction.
Another weird thing about the autobiography is that it was not written in chronological order. Randomly, he wrote about different times in his life, as the mood struck him, and he expected the book to be published that way, in this “stream of consciousness” style. But, the version that Maria got for me, which was edited by Charles Neider, is arranged mostly, although not completely, chronologically.
Mark Twain, whose real name was Samuel Clemens, was born in Florida, Missouri in 1835. Florida, by the way, means “land of flowers.” But, at age 8, his family moved to the larger town of Hannibal, Missouri to live with his uncle who owned a large farm there. And, since it was before the Civil War, the work on this farm was done by slaves. He told a very touching story about a slave boy named Sandy. Sandy liked to sing and hum. He did it all day long while he was working. But, Samuel didn’t like it, and he asked his mother to make Sandy stop. But fervently, his mother explained to him that Sandy had been torn away from his family in Virginia, and he was never going to see them again- all the people he loved. And if singing and humming provides him some relief from his sorrow, then she is glad for it, and she hopes he will continue, and Samuel should too. That had a huge effect on Samuel, and it changed his attitude towards Sandy and towards black people in general. He was never again bothered by Sandy’s singing. And, he wound up including Sandy as a character in Tom Sawyer. You recall the famous scene in which Tom finagles the other boys to paint the fence for him. Well, Sandy was one of the other boys, except that he doesn’t fall for it.
Both Tom Sawyer and Huckleberry Finn were based on Mark Twain’s childhood experiences in Missouri. And, another character from Tom Sawyer who was real is the second-most important character in the book: Injun Joe. There really was an Injun Joe; except that in the book, Injun Joe got trapped in a cave and starved to death, whereas in real life, Injun Joe got trapped in a cave but didn’t starve; after many weeks, he was rescued, having survived all that time on the flesh of bats.
Mark Twain had very little education. He never went to college. He just attended a little country school in Missouri, and it was 3 miles from his home. Year-round, he had to walk to school, and remember, they get some pretty serious winter in Missouri. Can you imagine a little kid having to wake up in the morning and then trudge through snow for 3 miles to get to school? And return home the same way? I’m thinking that there wasn’t too much childhood obesity back then.
Oh, and that reminds me: he wrote a lot about the food they ate on the farm, and he raved about it, all the incredible edibles they had. And he began by listing all the animals that they ate, including a lot of uncommon ones for our time, such as squirrels, possums, rabbits, ducks, geese, wild turkeys, wild hogs, deer, elk, even bears. It seems that the modern meat supply has contracted quite a lot in variety compared to back then, although being a vegetarian, I am unaffected.
I got the impression that Mark Twain was a real epicurean; he enjoyed his food and drink. He wrote this in the book:
“There are people who strictly deprive themselves of each and every eatable, drinkable, and smokable, which has in any way acquired a shady reputation. They pay this price for health. And health is all they get for it. How strange it is! It is like paying out your whole fortune for a cow that has gone dry.”
Now, that’s what I call a bad attitude about healthy living. Personally, I think there can be plenty of enjoyment in life even when one tries to live it healthily.
But, speaking of smoking, Mark Twain really loved his tobacco. He smoked like a fiend. Tobacco is what his uncle raised on the farm. Samuel started smoking at the age of 9. He became famous for brandishing his pipe, but he also smoked cigarettes and cigars. He also chewed tobacco. So, the fact that he lived to the age of 74, dying in 1910 of a heart attack, is quite amazing when you consider that average lifespan for men in 1910 was 50.
If you are wondering how Mark Twain got started writing, it’s simple. His older brother Orion had bought the local newspaper in Hannibal, and he got Samuel to come work for him. So, Samuel learned the ins and outs of newspaper printing, including typesetting and everything else. But, sometimes, they would be laying out the paper and realize that they needed another third of a page to fill it up. So, his brother would say, “write something” and Samuel did. And that is how he got started writing.
Eventually, the newspaper failed, not because it wasn’t popular but because his brother Orion was a lousy businessman who couldn’t balance the books and turn a profit. So, he sold it and moved to Iowa, and that’s when Samuel moved to St. Louis and got a job as a reporter for a newspaper. And that became his bread and butter, being a newspaper reporter.
But, very much like my cousin Gary, Mark Twain decided early in life that he wanted to travel; he wanted to see the world. And he did; he traveled to every continent except Antarctica. And often he got newspapers and magazines to pay for his trips with the understanding that he would write about it, and they would get to publish it. He told an interesting story about something that happened to him in India.
But first, let me say that he wrote a lot about all these girls and young ladies that he pined for in his youth. And from reading it, you get the impression that he wasn’t too successful with them, overall. There was this one, whom he called Mary although he admitted that it was not her real name, who was gorgeous, a real siren. She was a little older than he was, but he fell head over heels for her. She did not return the sentiment. But, decades later, when he was traveling in India, he was at a hotel, and he saw her. Well, he thought he saw her. He knew he couldn’t be seeing her because this was an attractive young girl he saw, probably in her teens. And he was in his mid-40s at the time. But, he thought there had to be a connection. So, he approached this girl and asked her about the girl he knew. Well, it turned out that this young girl was the granddaughter of the girl he knew, and that her grandmother was there, staying at the hotel. So, he went to see the grandmother, now a grey-haired old woman in her 50s, and they had a wonderful reunion. What were the chances of that?
He didn’t get married until 1870 at the age of 35. His wife, Olivia Langdon, was 22. Yet, he outlived her. He said that she was frail and beautiful. Their first child, a son named Langdon, lived just 22 months. Mark Twain held himself responsible for the boy’s death. It was winter, and he took him out for a carriage ride, but the boy was inadequately dressed for the cold, and he got sick and died. Actually, according to Mark Twain, the boy's leg actually froze. So, maybe he died of sepsis. Perhaps the boy needed an amputation.
Mark Twain never forgave himself, and he suffered a severe depression. And I had read elsewhere that he had long bouts of depression in his life. Don’t you find it ironic that a humorist should suffer with depression? Shades of Robin Williams? Or perhaps I should say that Robin Williams was a shade of Mark Twain. And I think the following passage is evidence of his depression. He was talking about the “maddening repetition of the stock incidents of our race’s fleeting sojourn here, which has oppressed human minds from the beginning.”
“A myriad of men are born; they labor and sweat and struggle for bread; they squabble and scold and fight; they scramble for little mean advantages over each other. Age creeps upon them; infirmities follow; shames and humiliations bring down their prides and their vanities. Those they love are taken from them. Misery grows heavier, year by year. At length, ambition is dead; pride is dead; vanity is dead; longing for release is in their place. It comes at least- the only unpoisoned gift Earth ever had for them- and they vanish from a world where they were of no consequence; where they achieved nothing; where they were a mistake and a failure and a foolishness; where they have left no sign that they have existed- a world that will lament them for one day and then forget them forever. Then, another myriad takes their place and copies all they did and goes along the same profitless road and vanishes as they vanished- to make room for another and another, and a million other myriads to follow the same arid path through the same desert and accomplish what the first myriad and all the myriads that came after it accomplished- nothing!”
Now, that’s what I call depressed.
His wife Olivia went on to bear three more children, all daughters, the first of whom was Suzy. Oh, did he love Suzy. He wrote so much about her and practically nothing about his wife. He would just mention that his wife went with him somewhere, but he had little to say about her otherwise, and little to say about his other two daughters either. But, he went on and on about Suzy. She was bright, observant, and sharp as a tack. At the age of 15, she took to writing her own biography of her father, and he included an excerpt of it in the book. And, it was very good writing too, and I mean for anybody, let alone a 15 year old.
Oh, but tragedy struck again. While he and his wife were in England where he was receiving some award, they got word by telegraph that Suzy had fallen ill. Then, meningitis set it. And remember: there were no antibiotics in those days. And at the tender age of 22, Suzy gave up the mortal coil. He and his wife weren’t even there to be with her, though her sisters were and other relatives. Mark Twain really turned a phrase when he wrote of Suzy: “She was our wonder and our worship.”
There is a lot in the book about his friendships with famous people, including General Ulysses S. Grant. He explained that even after he was President, that Grant preferred the title of “General” to “President.” And, I learned an interesting fact: that Mark Twain handled the publication of Grant’s memoirs. Grant was racing to finish them before he died, and he knew he was dying. He had all kinds of ailments- he was such an alcoholic. And, he actually finished it barely in time and promptly died. But, Mark Twain got it published, and he delivered the royalties to Grant’s widow, which came to half a million dollars. Now try to think about what half a million was worth in 1870s dollars. How many millions would it be today? I'm thinking maybe ten million.
It’s ironic that Twain and Grant should have become close friends when you consider that Mark Twain fought briefly for the Confederate Army in the Civil War. But actually, he was never in battle, and actually, he only served briefly. He essentially deserted- although he didn't use that term. And what he did was head west, first to Virginia City, Nevada, where he got a job as a reporter, and then on to San Francisco, where he did the same thing. And that’s where he came up with one of his most famous lines, “The coldest winter I ever spent was a summer in San Francisco.”
He also had close friendships with other prominent authors, such as Rudyard Kipling and Robert Louis Stevenson.
Another close friendship was with the Serbian electrical genius and inventor, Nikola Tesla. Twain was fascinated with science and technology, and he spent much time with Tesla in his laboratory.
Twain’s wife Olivia died in Florence, Italy in 1904, and again, he blamed himself because he was the one who was dragging this delicate woman of frail constitution all around the world because of his yen to travel.
And then, in 1909, the year before he died, his youngest daughter Jean died of typhoid fever. Therefore, his wife and all his children except for one, his daughter Clara, died before he did. Oh, the grief that that man must have suffered.
And towards the end of 1909, he announced to his remaining family and friends that he would be dying himself the next year, in 1910. But, he made an amusing story out of it. He said that he was born in 1835, which was the year of Haley’s Comet. And astronomers were predicting that Haley’s Comet would revisit Earth’s skies again in 1910, and they were right. So, Mark Twain said that it’s fitting for two freaks of Nature to come and go together. He died of a fatal heart attack on April 21, 1910.
Mark Twain is considered the greatest American humorist of the 19th century, but William Faulkner took it further. He said that Twain was “the father of American literature.” His best-loved books are The Adventures of Tom Sawyer, The Adventures of Huckleberry Finn, The Prince and the Pauper, and A Connecticut Yankee in King Arthur’s Court.
It is quite amazing that he made it to 74, considering how heavily he smoked. But, I don’t think he had any regrets about that.
In Cancer Screening, why not tell the truth?
- Created on Tuesday, 19 January 2016 21:13
This is an article by John Mandrola, MD which was published in Medscape on January 18, 2016. I am reproducing it here in whole. He argues that if you really look at the evidence that there is no increased life expectancy from all the cancer screening that is being done. That includes mammography for breast cancer, colonoscopy for colon cancer, chest x-rays for lung cancer, etc. His conclusion is based partly on the recognition that the only thing that really matters is overall mortality, not disease-specific mortality. And it makes sense because staying alive is the thing; it's the goal; it's the reason for doing anything. If the whole medical process which begins with screening and then goes on to definitive testing and then treatment, often radical treatment, is not going to result in you staying alive longer, what's the point? If a man can live just as long with untreated prostate cancer as he can by having it treated and going through the trauma, the pain, the disability, and often the impotence that results from treatment, why not just leave it be? Even just ignore it, although I'm not really recommending that. I think there are nutritional and lifestyle measures that can influence the course of prostate cancer a lot. But, let me put it this way: for a man my age or older (65) who is feeling fine, who is urinating fine, who has good sexual function, and is not in any pain, I certainly wouldn't let anyone cut on my prostate. What for? I am going to die anyway, but if there is no evidence that I am likely to live one day longer by operating, why do it? They say that 80% of men get some cancer in their prostate before they die anyway, and that if a man lives long enough, he's almost sure to get it. But, prostate cancer is usually very slow-growing and non-invasive. Operating just for good measure isn't necessarily a good measure.
So, read this article by Dr. Mandrola. I salute him because it took a lot of guts to write this.
Dr. John Mandrola:
An unpleasant emotion caused by the belief that something is dangerous. This is fear. This is cancer.
The motivation to screen for cancer, therefore, is easy to understand.
The problem: cancer screening has not worked. Recent reviews of the evidence show that current-day screening techniques do not save lives. Worse, in many cases, these good-intentioned searches bring harm to previously healthy people.
I realize this sounds shocking. It did to me, too. Millions of women and men have had their breasts squished, veins poked, lungs irradiated, and bowels invaded in the name of "health" maintenance. I've been scolded for forgoing PSA tests and colonoscopy — "you should know better, John."
I know what you may be thinking. We have all heard the anecdotes — cases that are often celebrated in local news reports and hospital marketing material. People saved by early detection, and the opposite: the unscreened felled by late-stage disease.
Anecdotes, however compelling, are not evidence. When you pull up a chair, open your computer, take a breath, suspend past beliefs, and look for the evidence that screening saves lives, it simply isn't there.
One reason that this many people (doctors and patients alike) have been misled about screening has been our collective attachment to the belief that if screening lowers disease-specific death rates, that would translate to lower overall mortality. That is: breast, lung, and colon cancer are bad diseases, so it makes sense that lowering death from those three types of cancer would extend life.
It is not so.
Facts, Not Fear
In a comprehensive review of the literature published in the BMJ, Drs Vinay Prasad (Oregon Health Sciences University, Portland) and David Newman (School of Medicine at Mount Sinai, New York), along with journalist Jeanne Lenzer, find that disease-specific mortality is a lousy surrogate for overall mortality. They report that when a screening technique does lower disease-specific death rates, which is both uncommon and of modest degree, there are no differences in overall mortality.
The authors cite three reasons why cancer screening might not reduce overall mortality:
Screening trials were underpowered to detect differences. I'm no statistician, but doesn't the fact that a trial requires millions of subjects to show a difference, mean there is little, if any, difference?
"Downstream effects of screening may negate any disease-specific gains." My translation: harm. Dr Peter Gøtzsche (Nordic Cochrane Center, Copenhagen) wrote in a commentary that "screening always causes harm. Sometimes it also leads to benefits, and sometimes these benefits outweigh the harms." To understand harm resulting from screening, one need only to consider that a prostate biopsy entails sticking a needle through the rectum, or that some drugs used to treat breast cancer damage the heart.
Screening might not reduce overall mortality because of "off-target deaths." An illustration of this point is provided by a cohort studythat found a possible increased risk of suicide and cardiovascular death in men in the year after being diagnosed with prostate cancer. People die — of all sorts of causes, not just cancer.
Let's also be clear that this one paper is not an outlier. A group of Stanford researchers performed a systematic review and meta-analyses of randomized trials of screening tests for 19 diseases (39 tests) where mortality is a common outcome. They found reductions in disease-specific mortality were uncommon and reductions in overall mortality were rare or nonexistent.
Drs Archie Bleyer and H Gilbert Welch (St Charles Health System, Central Oregon, Portland) reviewed Surveillance, Epidemiology, and End Results (SEER) data from 1976 through 2008 and concluded that "screening mammography has only marginally reduced the rate at which women present with advanced cancer and that overdiagnosis may account for nearly a third of all new breast cancer cases." Likewise, a Cochrane Database Systematic review of eight trials and 600,000 women did not find an effect of screening on either breast cancer mortality or all-cause mortality. This evidence caused the Swiss medical board to abolish screening mammography.
These are the data. It's now clear to me that mass cancer screening does not save lives. But I'm still trying to understand how this practice became entrenched as public-health gospel. It has to be more than fear.
How We Say It Matters
Dr Gerd Gigerenzer (Max Planck Institute, Berlin, Germany) offered a clue in his editorial accompanying the recently published literature review and analysis by Prasad and colleagues. He pointed to language and the ability of words to persuade. Instead of saying "early detection," advocates might use the term "prevention." This, Dr Gigerenzer says, wrongly suggests screening reduces the odds of getting cancer. Doesn't looking for cancer increase the odds of getting the diagnosis of cancer?
Gigerenzer noted two other ways language is used to emphasize screening benefits over harms:
The reporting of benefits in relative, not absolute terms.
The equating of increases in 5-year survival rates with decreases in mortality.
I would add to this list of word misuse, the practice of referring to women sent to mammography screening as patients. They are not patients; they are well people.
Dr Gigerenzer agreed with the commonsense notion that overall mortality should be reported along with cancer-specific mortality. His editorial included a fact box on breast cancer early detection using mammography provided by the Harding Center for Risk Literacy. I challenge you to tell me why such text boxes should not be shown to people before they undergo screening,
Fixing a Public-Health Problem
Given these revelations, I conclude that we have a massive public-health problem. Any expert in problem solving will tell you the first step of getting out of hole is to stop digging. I see three obvious next steps:
The first action healthcare experts should take is to spread the word that there is nothing about the mass screening of healthy people for cancer that equates to health maintenance. Embrace clear language. Saying or implying that screening saves lives when there are no data to support it and lots to refute it undermines trust in the medical profession.
The second action healthcare experts should take is to stop wasting money on screening. If the evidence shows no difference in overall mortality, why pay for it? I'm not naive to the fact that use of clear language will decrease the number of billable procedures. I am not saying this will be easy. One first move that would be less painful would be to get rid of quality measures or incentives that promote screening.
I want to be clear; I'm not saying all cancer screening is worthless. People at higher baseline risk for cancer, such as those with a family history of cancer or environmental exposures, might derive more benefit than harm from screening. Prasad, Lenzer, and Newman say this group of patients would be a good place to spend future research dollars. That sounds reasonable. I also acknowledge that some people, even when presented with the evidence, will want to proceed with screening. We can argue about who should pay for non–evidence-based medical procedures.
The most important action that all of us (patients, nurses, doctors, and healthcare writers) should take is to learn from this revelation. There's nothing bad about the fact that current-day screening tests don't save lives. Cancer is a tough disease, and in some ways, it may be the natural order of cell biology. What's bad about this medical reversal has been our blindness to the evidence.
We let what we believe become what we know. In clinical medicine, that should be a never event.