Fear

I’m not afraid of getting Covid-19. This is partly because, knowing how the disease is contracted and that its prevalence is relatively low in my county, it’s unlikely that I’d get it. That’s my rational brain at work. My lack of fear also seems hard-wired. I can’t help it.

The degree to which we experience fear has a genetic component. Researchers have developed lines of mice in which all members are fearful. A newborn mouse from a fearful line who is reared by a fearless step-mother will still be fearful as an adult. Studies of adopted children as well as identical and fraternal twins reared either together or apart have also shown that fearfulness has a clear genetic component.

Multiple genes and multiple processes are involved in fearful responses. For one thing, if you lack functional nerve cell receptors for a certain chemical (gamma-amino butyric acid), you will be more fearful. That’s because the higher regions of our brains use the chemical to tone down our lower brain’s initial impulses, which could result in an overly fearful response to stimuli. (The “lower brain" is the amygdala and is involved in fight or flight impulses.) Genes also affect our bodies’ uses of serotonin, which regulates anxiety, as well as stress hormones.

Some researchers have figured out a treatment to lessen the power of fear. It’s called “eye movement desensitization and reprocessing” (EMDR). Therapists use it to treat PTSD and other fear-related problems. The technique includes having patients move their eyes in specific ways while either recalling traumatic events or being exposed to a fear stimulus. Scientists don’t know exactly how it works, but it has to do with tamping down the amygdala’s fear response while activating brain pathways involved in controlling emotion. Researchers can test the efficacy of these methods using fMRI scans and by measuring electrical skin conductance, which is a measure of fear. The methods seem to work.

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The seven sins of medicine

Below is a story I read in the New England Journal of Medicine as an illustration of the seven sins of medicine. The seven sins were put forth by Dr. Richard Asher in 1949. Asher, a Brit, was regarded as "one of the foremost medical thinkers of our times" who emphasized the need "to be increasingly critical of our own and other people's thinking.” His list of the seven sins of medicine is still relevant today.

Here’s the story: A guy has a dizzy spell. He goes to the emergency room, which, it turns out, is just the beginning of his medical misadventures which included the following: electrocardiogram, blood tests, x-rays, CTs of his head and neck, an MRI of his brain, treadmill stress test, “pharmacologic stress test,” two angiograms, ultrasound, audiogram, and, finally, a recommendation that he see a neurologist “because I can’t rule out a problem with your central nervous system.” At that point, the guy stops with the tests and goes with the suggestion of his niece, a young internist who has told him that he has BPPV (benign paroxysmal positional vertigo), a common condition that I and many of the people I know have experienced.

The seven sins are the following: 

1. Obscurity. "If you don't know, don't admit it. Instead, try to confuse your listeners."
2. Cruelty. Not following the Golden Rule.
3. Bad manners. Being rude.
4. Over specialization. Undervaluing generalists.
5. Love of the rare. In hearing hoofbeats, thinking zebras instead of horses.
6. Common stupidity. The opposite of common sense.
7. Sloth. For example, ordering excessive tests instead of taking the time to take an adequate history.

The guy in the story is particularly furious at what he calls “mental laziness.” “Where’s the science?” he says. “I’ve got this fleck of calcium tumbling around in my inner ear, and they tell me maybe it’s a heart attack!” The bills for all of this amounted to $74,542.

In researching Richard Asher, I was flabbergasted to learn that we knew his son Peter, a music producer. Peter lived down the street from us in Los Angeles. Our son, Rob, recently met up with Peter in Manhattan.

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Unregulated implants

I’m talking here about devices such as artificial joints, pacemakers, stents, surgical mesh, vein filters, insulin pumps and the like. In 2015 the FDA received around sixteen thousand reports of deaths associated with such medical devices. But the number is surely higher: 99 percent of “adverse events” are not reported. The more serious the event, the less likely it is to be reported. The true number of those deaths could be as high as 1.6 million, making them one of the leading causes of death in the US. About 1,100 of these devices are recalled annually. In 2013, 33,000 inferior vena cava filters were recalled. Instead of stopping blood clots from reaching the heart, the filters actually caused clots to form.

Regulation of these devices is lax. Depending on the level of risk, manufacturers can simply register them with the FDA prior to putting them on the market or provide “reasonable assurance” of their safety and efficacy. Clinical testing is the exception rather than the rule. Since 1976, the FDA had approved more than a thousand high-risk devices, such as pacemakers. Of those, only sixteen percent had gone through rigorous clinical testing before sale. Of the four hundred moderate-to high-risk implants approved for market between 2008 and 2012, no clinical testing was required. These devices included stents, replacement hips, surgical mesh, and similar implants.

Of course, device makers make huge profits from their products. In 2014, the industry’s estimated revenue was more than $136 billion. To increase sales, they strive to constantly innovate. Thus, more untested devices come onto the market.

Unlike Canada, Australia, Japan, New Zealand and several European countries, the US has no registry of implants that would provide the FDA, doctors, and patients with the risks and benefits of implants over time. Repeated efforts to implement a registry system in the US have failed, thanks to the implant industries’ powerful lobby.

   

As it is, people with implants are participants in a large uncontrolled experiment.

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Hospitals are hurting. Boo hoo

Our health care system is market driven. Every player—insurers, hospitals, pharmaceutical companies, doctors—must have a profitable, self-sustaining, business model. Like hotels, hospitals aim to keep their beds full with well-paying customers in need of knee replacements or heart procedures. Even though, in 2017, the CDC warned of the need to stockpile supplies such as ventilators and protective gear, the warning was ignored. Because stockpiling offers no return on investment, hospitals have zero incentive to do so. That’s the reason for the shortage of these items.  There's no money in being prepared for a pandemic.

Because they’ve had to postpone lucrative elective surgeries, hospitals will receive tens of billions of dollars as part of the coronavirus relief package. But get this: at least half of the top 10 recipients have paid millions in penalties for improper billing and other shady practices. For example, the Florida Cancer Specialists and Research Institute, one of the nation’s largest oncology practices, recently received a $100 million penalty for engaging in a nearly two-decade-long antitrust scheme to suppress competition. Nevertheless, it received more than $67 million in bailout funds. Dignity Health, the hospital conglomerate in my area, received $180.3 million in bailout funds despite having submitted false claims to Medicare and TriCare, the military health care program.

Many of the big hospital conglomerates have huge cash reserves, but receive bailout money anyway. The Providence Health System, which received $509 million, is sitting on nearly $12 billion cash, which, when invested, yields $1 billion in profits. Mayo Clinic has also lost money. Things are so bad it had to dip into its $10.6 billion cash reserves and investments. Boo hoo.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.