Health Care Decision Making: The Freakonomics Option

With the emphasis today on patient centered care, many patients and their families struggle with the tough decisions of whether to treat or not, which treatment options may be the best choice etc. etc. It’s important to note, that while many times patients are told they have options, they often only receive detailed information about one approach, which is usually the one the provider prefers or uses. Research shows that when patients/families are given relevant information about all treatment options, they make very different choices than what providers would have predicted.  “The Cost of Assuming Doctors Know Best” 

I’ve written quite a bit about choices in care, because it’s something that people think about and worry about. Remember you always have at least two options-not doing anything is an option. The summary post Decision Making/Choices in Care includes a variety of resources, as well as what I now see is probably way more information than you might be interested in. However, the strategies and resources for decision-making are valid so check them out.

What if you’ve considered things from every possible angle and you still don’t know what to do? Should I have surgery? Should I get a second opinion?  Is my roommate part of my problem, so should I move? You’ve talked with your provider, your family and friends and quite frankly you just can’t make up your mind. So you might want to consider the FreakonomicExperiment. 

If you aren’t familiar with Freakonomics, this is the title of a book written by a New York Times Magazine journalist Steven D. Levitt Reporter and an award winning economist Stephen J. Dubner. The subtitle of their book, blog, website, and just about everything else they do is “The hidden side of everything.” 

Back in January,Freakonomics Experiments was launched- Sometimes in life you face a major decision, and you just don’t know what to do. You’ve considered the issue from every angle. But no matter how you look at it, no decision seems to be the right decision. 

In the end, whatever you choose will essentially be a flip of a coin. 

Help us by letting Freakonomics Experiments flip that coin for you. 

They provide preset questions for education (e.g. should I go to college), family, health, home, just for fun, and relationships. The seventh category allows you to create your own questions and pick what will be head and tails.

To help answer your questions about this approach to decision making, check out the Freakonomics Q and A section.

Several weeks ago, I wrote Ten Things to Learn from Diana Nyad’s Swim.  On Thursday, Nyad wrote a piece for the Huffington Post Cuba: 3 Weeks Later. It’s very interesting to read how she feels incredible relief “of not living with the unrelenting drive.” The contentment for me today does not come from "what I am getting," to paraphrase Thoreau. [What you get by achieving your goals is not as important as what you become by achieving your goals] I am profoundly happy to in fact be this person who is bold, who is fearless, who has no regrets, no matter how many failures piled up on the way to the final, dazed, magical moment on that beach.

Take A Break with David Sedaris

Rated as America’s top humorist and essayist,  I can’t decide if I find David Sedaris funniest when he reads his own work –you can hear him on This American Life-or if I’m curled up in bed with his latest collection of short stories. Sept. 20 was the opening of the movie C.O.G. based on one of Sedaris’s books, so what better time to enjoy a sampling of his work.

• The Santaland Diaries: His story about being an elf at Macy’s. His reading on National Public Radio help to launch his career. 

• Trailer for C.O.G. 

• Being interviewed by Jon Stewart on the DailyShow about his most recent book “Let’s Explore Diabetes with Owls.” 

• What’s Funny About America 

• David Sedaris at The Village Voice 

• Squirrel Seeks Chipmunk

• David’s Diary App 

• Books: By clicking on the various titles you can hear excerpts. 

Medical Marijuana: Separating Fact from Fiction

Medical Marijuana is a hot topic in my community at the moment. Vermont  legalized medical marijuana and has issued three of four licenses for dispensaries. With the 4^th one up for grabs, and an organization interested in locating a dispensary in the small town where I live, there has been a lot of discussion about medical marijuana and its usefulness.   

One of the first things I’ve noticed, in trying to understand more on this topic, is that there are a lot of personal stories about the effectiveness of medical marijuana. As discussed before on this blog, what works for you, may not work for someone else and vice versa. A lot of healing is individualized. That noted, I’ve been looking for well-designed studies as a means of trying to understand what may or may not be valid regarding medicinal marijuana.

Marijuana or cannabis, in the seed and seed oil form,  has been used medicinally for around 5,000 years. For recreational, cannabis is smoked or ingested and is the largest illegal drug used in the US.  A good overview of how cannabis has been used, and the legal issues surrounding it through history, is available on-line at the Medical Marijuana ProCon site. 

Currently, 20 of the 50 states and DC have legalized the medical use of marijuana. Those in favor argue that it’s safe and effective for treatment of a number of symptoms and conditions, while those opposed point out that it is addictive, could lead to harder drugs and that long term use leads to a variety of serious health issues.

With that in mind, consider the following:

• Marinol, a synthetic version of the active ingredient in marijuana- tetrahydrocannabinol (THC)- is available in pill form with a prescription. Its primary uses are for weight loss in patients with AIDS and nausea and vomiting associated with cancer chemotherapy in patients who failed to respond adequately to conventional antiemetic treatments.

• Marijuana can be addictive. It is estimated that nine percent of people who use marijuana will become dependent on it. Anthony, J.; Warner, L.A.; and Kessler, R.C. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol 2:244–268, 1994. The number increases to about 1 in 6 for those who start in their teens and to 25-50% in daily users. Hall, W.; and Degenhardt, L. Adverse health effects of non-medical cannabis use. Lancet 374:1383–1391, 2009. Hall, W. The adverse health effects of cannabis use: What are they, and what are their implications for policy? Int J of Drug Policy 20:458–466, 2009

Interestingly there is now Marijuana Anonymous. 

• The National Institute of Drug Abuse has identified the following health issues from smoking marijuana:

• -       Elevation of heart by 20-100% shortly after smoking. One study found a 4.8 fold increase in the risk of heart attack in the first hour after smoking the drug. Risk may be greater in older individuals or with cardiac histories.
• -       Mental illness: A series of large studies showed a link between marijuana and the development of psychosis.
• -       Use during pregnancy is associated with increased risk of neurobehavioral problems in babies.  This can include problems with attention, memory and problem solving.
• -       It has been linked in a few recent studies with an increased risk of an aggressive type of testicular cancer in young men.
• -       Long term marijuana users report lower life satisfaction, poorer mental and physical health, relationship problems, and less academic and career success compared to matched peers.
• -       Regular marijuana use among adolescents can have long-lasting negative impact on the structure and function of their brains.

• Marijuana can suppress the body’s immune system. Venkatesh L. Hegde, Mitzi Nagarkatti and Prakash S. Nagarkatti. Cannabinoid receptor activation leads to massive mobilization of myeloid-derived suppressor cells with potent immunosuppressive properties. European Journal of Immunology, 2010; 40 (12): 3358-3371 DOI: 10.1002/eji.201040667

• Smoking marijuana makes sperm less fertile-even if the woman is the one who smokes it. To learn more about the effects of marijuana on fertility read Smoking Marijuana Lowers Fertility: Sperm burn out, less potent when men-or women-smoke marijuana. 

• Pulmonary (lung) complications associated with the regular smoking of cannabis are “relatively small” and far lower than those associated with tobacco smoking. Marijuana does, however, "cause visible and microscopic injury to the large airways that is consistently associated with an increased likelihood of symptoms of chronic bronchitis that subside after cessation of use. Tashkin, Donald Annals of the American Thoracic Society June 2013.

• According to the National Cancer Institute, A number of studies have yielded conflicting evidence regarding the risks of various cancers associated with Cannabis use. 

• It is not clear if marijuana is a “gateway” drug. In other words, does using marijuana lead users to try cocaine, heroin etc.? It is known that those who use marijuana are more likely to try other drugs. Does this happen because these individuals are more prone to use other drugs or does smoking pot cause further drug use?

• Even though marijuana is widely thought to be helpful in people with glaucoma, the American College of Physicians noted in 2008 that large doses of cannabinoids are required to reduce eye pressure. This effect is short lived, and side effects, such as a reduction in blood supply to the optic nerve, may cancel out the benefit over the long term. Other medicines are generally more useful for people with glaucoma.

• In the 2008 American College of Physicians report Supporting Research into the Therapeutic Role of Marijuana and concludes Evidence not only supports the use of medical marijuana in certain conditions but also suggests numerous indications for cannabinoids. Additional research is needed to further clarify the therapeutic value of cannabinoids and determine optimal routes of administration. The science on medical marijuana should not be obscured or hindered by the debate surrounding the legalization of marijuana for general use.

• The Office of National Drug Control Policy commissioned the Institute of Medicine (IOM) to assess the potential health benefits and risks of marijuana. The IOM is an independent research body affiliated with the National Academy of Sciences. The IOM issued its final report in 1999 and offered several conclusions regarding marijuana's usefulness. It found that scientific data indicate that cannabinoids, particularly THC, have some potential to relieve pain, control nausea and vomiting, and stimulate appetite. American Cancer Society 

• The American Cancer Society has a very good review of medical marijuana, maybe among the best I’ve read so far,  and is worth taking the time to read. The medical use of marijuana is limited because different strains of the plant contain different amounts of various compounds, which makes effects hard to predict. Medical researchers have isolated substances from the plant (cannabinoids) that can be used in precise doses alone and in combinations with other medicines to achieve more predictable effects. .... Relying on this type of treatment alone and avoiding or delaying conventional medical care for cancer may have serious health consequences.

After reading a variety of research and position papers, it would seem that medical marijuana may be beneficial in certain situations. While it may have been used for thousands of years, there are now many medications on the market that effectively target a particular condition or symptom, thereby making marijuana less useful then it was in previous generations.  Case in point- marijuana does help with glaucoma, but eye specialists aren’t routinely recommending it because current medications are far more effective. This also maybe true for Parkinson’s Disease (PD), where it appears marijuana may be helpful with tremors. However, it can impact memory in a negative way, potentially compounding instead of alleviating issues for a person with PD.

If you are living with a chronic condition and wonder if marijuana might be helpful for you consider the following:

• Contact the condition specific organization (e.g. Parkinson’s Disease Foundation) and ask them for information about whether medical marijuana could be helpful.  

• Discuss this with your medical provider as marijuana can negatively react to medications you may be taking.

• Know the rules in the state where you live.

•  Medical marijuana can be expensive so check for clinical trials that you might be eligible for. Check Clinical Trials.gov

• If you want to use marijuana as a way to reduce stress and chill out, consider mindfulness based stress reduction.  It’s legal, free and has a proven track record.

Take a Break: Celebrate Agatha Christie Week

It’s Agatha Christie week in England from Sept 15 to Sept. 22. She’s afforded zillions of hours of escapism be it from reading one of her books, seeing her famous play “Mouse Trap,” or watching one of the many movies that have been made from her books. And of course there is her inspiring quote, “I like living. I have sometimes been wildly, despairingly, acutely miserable, racked with sorrow, but through it all I still know quite certainly that just to be alive is a grand thing.

If you can’t make it to the English Riviera to celebrate Christie’s special week, try some of the following.

• Check out her website http://agathachristie.com

• The festival website offers lots of interesting peaks into Christie’s world.

• Read one of her books. If you haven’t read her autobiography, it’s very interesting and much different than her mysteries.

• Solve 5 minute mysteries. 

• Watch one of the  movies made from her book on-line

- The Sittaford Mystery (featuring Miss Marple) 

- Lord Edgware Dies (featuring Poirot) 

- Murder on the Orient Express (featuring Poirot) 

• Plan a Murder Mystery Party. Check out your local library for books on this topic. Lots of websites offer scripts for a fee, depending on the number of players. 

Ten Things to Learn from Diana Nyad’s Swim

The media coverage of Diana Nyad’s amazing 110-mile swim from Cuba to Florida received extensive media coverage. Chances are good you’ve probably already heard her three messages-“One is, we should never, ever give up. Two is, you are never too old to chase your dream. And three is, it looks like a solitary sport but it takes a team."

At 64, living with asthma, Nyad knows a few things about “living well” with a chronic condition. Below are my thoughts on what we can learn from this incredible adventure and historic swim.

• With age and experience-both the good and the bad-comes an ability to understand how to survive and thrive. In many ways, Nyad was probably better prepared mentally at 64 for this type of endurance swim then she was in her late 20’s. Embrace your age and various experiences as they are what shape you and make you the person you are today. Your Best isMore than Good Enough 

• With each swim attempt, she made modifications so she would be better prepared for the next one. Learn from the past-the negative lessons are just as helpful as the positive ones- to be better prepared for the future.

• There are people who are questioning Nyad’s swim-did she rest for a while on a boat, was she truly unassisted etc.   No matter what you do, there will be those people who are skeptical. We have to live with ourselves, so be true to your self.

• Some critics said she wasn’t true to her sport because she used a special facemask to protect herself from the jelly fish stings. Nyad’s comment was "I don't mean to fly in the face of your rules, but for my own life's safety, a literal life-and-death measure, that's the way we did it.” Play and dream as big as you can, but don’t endanger yourself or others in the process.

•  Nyad did not follow the English Channel rules for her open swim. Why? Because she wasn’t swimming the English Channel and so needed to make modifications accordingly. We are each unique and one size doesn’t fit all, whether it’s clothes, medications, spiritual beliefs or your approach to healing. Do what feels right for you and the situation you are in.

• Live your dream not someone else’s.

• As Nyad noted, it takes a team. We aren’t meant to be solitary creatures. Be there for others and allow them to be there for you.

• Nyad credits her team as much as herself for achieving the swim. Surround yourself with people that are supportive and believe in you.

• Now that this marathon swim is behind her, Nyad is moving on to other projects, with a special emphasis on helping raise funds for communities who have been struck by disasters. Having purpose is key to living a long and fulfilling life. Power of Purpose 

• Nyad was unaware of the controversy around her swimming methods until it made national news. “First of All, I was trying to feel some joy.” "No one's going to take our joy and our moment that the world was inspired by away from us. Nobody." And what better way to end this post then with that quote and the goal of looking for the joy in all that you do.