Israel - Then and Now

Rhonda and I have just returned from a 10-day trip to Israel - a trip designed for "first-timers."  Now though Rhonda was a first-timer, I was actually a "third-timer," having visited Israel in 1966 and 1980.  When I visited as a "first-timer" I was in my late 20's and Israel was 18.   How did my sense of the country change over this 48-year span.

I still remember the words of our guide Max, in 1966, as he addressed our group on entering Tel Aviv after having landed at Lod Airport.  He pointed out to us (a group of US Military officers) that the people cleaning the streets were Jewish, even the criminals were Jewish and, yes, the prostitutes were also Jewish!  There was no West Bank. There was no East Jerusalem to visit. There was no Western Wall to approach  There were armed Jordanian soldiers readily visible in towers overlooking us as we walked the streets of Israeli Jerusalem.  Most of the Israelis we met were European by birth.  So many questioned why we were still part of the Diaspora and refused to emigrate to the State of Israel.  Israelis would accost us in the streets to lecture us, with a classically Israeli uninvited insistence, that the place for Jews was Israel - all Jews should feel an obligation to emigrate.   I felt disrespected as a Jewish-American.  I was made to feel less Jewish, made to feel that Israelis did not consider me a committed Jew unless I committed to an intention to emigrate.  I was clearly uncomfortable.

Fast forward to 2014.  I'm in my mid-70's and Israel is 66.  It's a different place - not only physically, but also in its sociologic and self-sustaining evolution.  I'm also a different "place" - not only physically but also in my sociologic and self-sustaining evolution.   Israeli "street cleaners" do not appear to be Jewish (I must admit, I did not knowingly meet any prostitutes, so can't be sure about their backgrounds) and  there are noticeably now people of color!  The cities seem much more cosmopolitan.

That sense of being a derided, uncommitted Diaspora Jew was no longer.  No one encouraged emigration.  No one even suggested it.  Diaspora Jews were Diaspora Jews and Israelis were Israelis!  We have a common history, but not necessarily a common commitment.  That's good.  A feeling of Israeli "dependency" no longer existed.  The word "miracle" is often used in describing this extraordinary, vibrant country.  "Miracle" is a word that I find hard to accept in describing anything, but somehow the word may apply here.  I venture to say that if there is such a thing as a "miracle," Israel may be the unique paradigm.

Israel - Mature, Modern, Madcap, Majestic, and - simply aMazing!

A Fetal Life in a Dead Mother

A woman who is legally dead, is being kept on "life support" in a Texas hospital against the wishes of her husband and parents.  She is being maintained on "life support" solely to sustain the viability of her 21-week old fetus.  Physicians have refused to honor the wishes of the family, arguing that Texas law prevents them from withholding "life-sustaining treatment" from a pregnant patient.  The family contends, however, that since the mother has been declared "brain-dead" she can no longer be considered a pregnant patient, since a "patient," by definition, is someone who is alive.  Physicians intend to continue the present regimen until the fetus has reached the age when a caesarian section can be performed.

This fetus is now approaching extra-uterine viability - a fact which makes this case difficult to morally adjudicate.  However, if the fetus were as little as 4 weeks of gestational age, or if the fetus were as much as 30 weeks gestational age, how one would feel about this tragic set of events might be quite different.

If the fetus is to be the sole consideration here, then perhaps a caesarian section should not even be considered, there being no question that a fetus has a far better chance of survival in-utero than ex-utero.  Assuming no complicating medical factors, would it be ethical to continue to maintain this "natural" form of fetal nurturing rather than proceeding with a C-section?  Would it be ethical at 4 weeks gestation?  Would it be ethical at 30 weeks gestation?

Whose Medical Record Is It Anyway!

A recent article in the prestigious New England Journal of Medicine discusses the usefulness of giving patients full access to their medical records, including the physicians "notes," which had previously remained inaccessible.

A medical record includes laboratory results, radiology results and pathology results - all of which I concur should be made available to a patient - after all, they are his lab results, his radiology results, and his pathology results.  However,  it had always been my feeling that what I entered into a medical record (my "notes") was only for my eyes and for other eyes to which I wished to show them.  And when I translated these notes into a formal letter, most commonly to a referring colleague, the letter was a private communication between my colleague and me.

Medical record "notes" often contained personal reflections on the patient, possibly his family, his attitude, and maybe even some quirky anecdotes to help recall a a previous encounter.  I never regarded my "notes" like those that would be part of a personnel record or subject to the Freedom of Information Act.

But I guess those are bygone days.  Now, were I to enter information into a patient's record - it would be limited to "the facts." Any "color" would have to be withheld from the written record and restricted to some non-written form of communication (if deemed necessary).

Progress - onward and upward.

Some Issues About Evaluating Blood Pressure

A new report by an expert "guidelines committee" has shifted blood pressure norms for people over 60 years of age up to 150/90 from the previously accepted level of 140/90.  This has huge implications for many individuals presently taking anti-hypertensive medications, many of which have decidedly negative side effects.

This blog is not meant to evaluate the validity of this conclusion but to educate individuals about possible errors in blood pressure measurement.

Blood pressure is most often measured by using an inflatable cuff wrapped around the upper arm, a manometer (either a column of mercury, or a clock-face dial with a needle) and a stethoscope with which the examiner listens for the appearance and disappearance of pulse sounds in the crease of the elbow.  The blood pressure can vary based on a number of factors that affect these elements. Techniques used to record blood pressure in a doctor's office are "indirect."  The only true,"direct" method of measuring the pressure in a blood vessel is to attach a measuring device to the blood vessel directly - a procedure normally performed only in emergency rooms and hospital settings.

There is room for variability and some differences when the indirect measure of blood pressure is used. For instance:

1. The cuff may not be appropriately sized for the circumference and length of the upper arm - cuffs that are to short, or do not comfortably fit around the arm are apt to give falsely high pressures.  The reverse is true of cuffs that are too loose or to large.  The cuff must also be properly applied to the arm so that the bladder inside the cuff covers the brachial artery (the large artery in the upper arm.)
2.  Blood pressures are determined by the appearance and disappearance of sounds the blood makes as it moves under the stethoscope for which the examiner listens.  Clearly the auditory acuity of the examiner means something here. The ability to hear the initial and final sound depends not just on the examiner's ears, but also on the rate at which the air is released from the inflated cuff.
3.  Blood pressure may vary with body position.  It may also differ from one arm to the other.

Given the variables involved in the indirect recording of blood pressures, using absolute numbers as guidelines is fraught with the potential for error.  A blood pressure recorded as 154/90 could easily be an inaccurate reading of a pressure which may actually be 148/86, or even 158/94.

It would be more helpful to provide a "range" of normal (or abnormal) rather than an absolute number, given the variables discussed above.  And remember, one blood pressure recording is never enough to make a diagnosis of hypertension - there should be at least three such recordings over a period of a few weeks before a diagnosis is confirmed.

Children with Down Syndrome - How Times Have Changed

Susannah Meadows's book review in the Dec. 17 NY Times Science Section (Raising Henry, by Rachel Adams) discusses how the attitude towards children with Down Syndrome (also known as Trisomy-21) has changed.  Ms. Adams, a professor of English and American studies at Columbia University declined the amniocentesis which would have made a pre-natal diagnosis.  In describing Henry, who is now six years old, she makes the following heartwarming comment about what is described as Henry's essence:  "I couldn't have ever known about his great sense of humor or the sound of his infectious laugh.  Or the smell of his hair.  The delight he gets from singing along with music or pouring bathwater from one cup to another."  Her son is "separate from the diagnosis," she writes.

Ms. Adams goes on to describe the "abysmal" bedside manner of her physicians - the OB-GYN resident who "sewed her up"then "sprints out of the room," the pediatric geneticist who used Henry as a "teaching prop," without a word to Ms. Adams, and her obstetrician who assured her that "I wanted to make sure I didn't miss anything so I showed your records to my colleagues, and everyone agreed there was nothing."  So many doctors remain poorly trained in "people skills."  Medical schools must begin to realize that their job is to graduate not just physician-scientists, but physician-healers - doctors adept not just in the science of medicine, but in the art of healing as well.

When I was a young pediatric resident, Down Syndrome was often termed "mongolism" because of the "Asian" appearance of these children.  My chief of pediatrics routinely advised all parents of such children to institutionalize them immediately lest they adversely affect the family dynamic.  His "advice" frequently sounded more like a requirement and was, to the best of my recollection, most often followed.

Statistically 50% of children with Down Syndrome have congenital heart deformities, often rather severe forms, unfortunately.  When I was a trainee in pediatric cardiology, our team routinely declined to offer cardiac corrective surgery to these children, feeling that such treatment was far too involved for patients with Down Syndrome and that their lack of co-operation during the post-operative recovery period would add greatly to the risk and preclude a satisfactory outcome.

Attitudes have clearly changed.  No one is routinely institutionalized.  Surgery is no longer denied, and outcomes are excellent.  It has been a lifetime of change for me, especially as a pediatric cardiologist.

But one must remember that not all children with Down Syndrome have Henry's essence.  Some are extremely difficult to manage and very delayed developmentally - but so are some children without Down Syndrome.  And, finally, one needs to remember that children with Down Syndrome will become adults with Down Syndrome - and that is another issue altogether.

Should We Mess With Aging

Studies on aging are primarily concerned with controlling the process rather than coping with the process.  A recent article discussed the frequent features of the aging male - namely the development of the "pot belly," loss of muscle mass and a decrease in sexual desire.  These processes of growing older are mediated in large part by a fall in the level of testosterone.

Articles describing research in the field of aging refer to this change in testosterone level as a "decrease in the normal level of testosterone."  But it is not a decrease in the normal level of testosterone -  it, in fact, is a normal level of testosterone commensurate with the aging male.

Studies directed towards reversing the aging process by abnormally increasing a level of a hormone, be it testosterone, estrogen, or some other such agent, are concentrating on converting us from the normal aging process to an abnormal one.

Anti-aging research continues.  Why?  Are we truly interested in extending life expectancy to 150, or perhaps even further?   Is government expense for research to provide us with the proverbial "fountain of youth," - to control the aging process whereby we will live far longer, but at a great human and economic cost to society -  treasure well spent?

As Daniel Callahan (age 83), emeritus president of the Hastings Center, recently wrote in a NY Times Op-Ed article (Dec 1):  "We may properly hope that scientific advances help ensure……that young people manage to become old people.  We are not, however, obliged to help the old become indefinitely older.  Indeed, our duty may be just the reverse: to let death have its day."

The Three Considerations in Medical Care

Your health care requires three significant considerations and decisions on your part (not in any particular order).

1.  Cost and availability
2.  Expertise of providers
3.  Whether treatment is really required.

The Affordable Care Act is primarily, if not solely, concerned with the first of these.  It's intent is directed at making health care "affordable," as is clearly stated in its title.  I am not getting into the pluses and minuses of the act, except to say that I feel very strongly that everyone is entitled to basic health care, and it is the responsibility of a government to insure that such care is available to all citizens - as it is for the availability of a citizen's personal security (police and military "care") or the security and safety of his body and property (fire and safety "care").  Though military, police, and fire services are expensive, the cost is not borne by the individual directly, but indirectly via the tax structure.  Therefore the expense is not "felt" as is the case in medical care.  For the record, I am in favor of a form of single payer system, so common in most other developed countries, but available in our country only for people who have reached a certain age, or are below a certain income level.

The Affordable Care Act does not help you determine the expertise of the providers.  Medicine, is a provider-based service, not a product.  Various agencies, governmental or private seem to regard it as a product and wish to furnish you with the "product" at the lowest possible cost.  But there is variability in the expertise of the medical providers, which is just as important, if not more important than cost and availability.   Is your physician skilled at recording your medical history and performing your physical examination?  Does he know which tests to order and, perhaps more importantly, which tests not to order?  Is your surgeon skilled at the surgical procedures he may be advocating?  Additionally, much of medical practice today is guided by evidence-based medicine - recommendations for management of sundry medical diagnoses after evaluation by committees of universally regarded experts.  Physicians should be aware of, and should be following these recommendations, which are based on numerous well-researched published studies.

Lastly, and perhaps most importantly, is the question of whether or not the advocated treatment is really necessary?  A patient should be properly informed of the risks and benefits of the advocated therapy as well as the risks and benefits of no therapy.  Not everyone who is referred for heart surgery actually requires it.  Not everyone who is told to have a colonoscopy really needs it.  Not everyone is informed that surgery is not always the solution to a back problem.  Be aware that medical errors leading to death may befall some 400,000 patients a year,  according to a recent study in the Journal of Patient Safety.

Get all the information you can about cost, expertise and necessity.  If you feel uncertain, find someone to guide you.  Provide yourself with some basic knowledge of medical statistics to help you ask the appropriate questions when visiting your physician.  And try to have someone accompany you to help you understand what you are being advised to do and why.