Instead I was a mid level medical lieutenant with faculty above me but also with a junior resident and medical students under my almost always goal oriented direction.  When students and interns would join me on rotation, immediately after our first morning teaching conference, I would explain our three main goals as a team: take care of patients, learn (aggressively) and try to have fun in the process.  Invariably making the “expectations talk” so short  quickly dispatched the worry of the overbearing upper level and always made everyone more at ease. Finally I would add one unofficial but not negligible goal: “get stuff done, and get out on time”.

In retrospect learning, enjoying the camaraderie of the neurology team and even working efficiently proved to be the easiest goals to define and attain. Treating stroke patients on the other hand was a lot more nuanced since the treatment of stroke is a lot more difficult.  The only rigorously studied acute treatment for “low blood supply” or ischemic stroke is IV TPA, a very potent clot busting drug. Unfortunately IV TPA can only be given safely within 3 hours of onset of symptoms, and in our center about 90% of patients are outside the window on arrival.

Even with IV TPA, only 12% of patients are one grade functionally better in 3 months. In other words for one patient to be better off from TPA, you have to give the drug to 8.33 stroke patients. Nonetheless the institutional dedication to the management of acute stroke in a typical large American hospital center is dramatic compared to other countries. In my hospital there is a neurology staff member in house 24/7, there are also CT scanners always on call, and finally an ICU bed will be made available for TPA patients whatever the circumstances.  The resource mobilization for these patients is not only extraordinary but it is also laudable. A skeptic might point out that TPA patients with their costly work-up and  mandatory ICU stay represent a highly lucrative revenue stream with its intrinsic motivations, but nonetheless it takes great organization and hard work to routinely care for these patients.

What about other medical therapies that make you better after a stroke? The overwhelming benefit comes form early and intensive physical and occupational therapy.  As from a neurology standpoint there is always a major effort to take steps to prevent another stroke such as taking an aspirin, quiting smoking and lowering blood pressure and among other things.

From my experience on our stroke unit, the relevance of secondary prevention is variable.  Recently, I saw a man in his mid 50 who had a small stroke in the setting of astronomic blood pressures and a heavy smoking history. For him the upside of quiting smoking and taking blood pressure medicine is significant. On the other hand I had also seen an octagenerian man, who had a new stroke after having an old stroke on the other side of the brain in the past. Because of the bilateral involvement of the brain his level of consciousness was limited. Yet after the stroke well meaning attendings would round and among other things would prescribe a statin. When I see this on the floor, I whole-heartedly agree with the motivation, but honestly believe its not reasonable medicine. To prevent a stroke with a statin you need to treat 50 patients for 5 years to prevent one stroke. Since statins do have side effects and of course are not free, I do not believe it helps the patient.

So if the treatment of stroke is not highly effective and fraught with grey areas,  what are we to do as the next generation of physians to address this large pubic health problem. Certainly funding of the most promising therapy research must be pursued. But we have been doing this and it has not been enough. Beyond more ICUs,  CT scanners, and hospital staff what is needed is a transformation and modernization in the way we approach stroke and vascular disease in our society.

Such movement in public perception is not without precedent both in public health and in the public policy arenas. Smoking was a lot more prevalent 20 years ago than it was today in the United States. Greater taxation of cigarettes and stricter marketing rules have been important public health victories. As we speak a palpable shift is occurring in the national consencus about energy policy with more people embracing the importance of conservation as well as the strategic centrality of energy independence.

For the prevention of vascular disease including stroke a similar shit in public opinion is needed. As Americans we need to improve the quality of school lunches, we need to promote and incentivize increased physical activity, and we need preventive care to become more routine and affordable. This tilt of public opinion to embrace prevention as a cornerstone of public health policy will not be easy. But the extraordinary stakes make this the defining challenge for physicians of our time.

The adds were slick and quite dramatic: critically ill patients, determined staff and a narrative of hope and conquest set amidst griping religiously themed music. So I was essentially looking at myself on TV, but clearly that is not what the hospital feels like both for patients and employees. This discrepancy between reality and its representation in marketing campaigns is all but expected in popular culture. But hospital advertising is relatively new. Should the same licence to embellish your product by granted by default to hospitals that also advertise. I don’t think so.

Physicians in addition to helping patients get better also have the less glamorous job of guiding people through illness, disability and severe loss. In this second mission, setting expectations to reality is so important it can not be under-emphasized. So what I struggled with, is that where society often tends to have already unrealistic expectations of physicians, here we have a multimillion dollar campaign that for the sake of name recognition and referrals is willing to further inflate expectations. That is not a responsible policy.

For example an add shows a mother looking at her sleeping child and asks, “what does it take to conquer the challenges that seem most unfair?”. Great diagnoses, team work and technology can make a difference, but not infrequently, and especially in a tertiary care centers, families bring their loved ones and there is nothing that can be done to conquer these excruciatingly unfair challenges. In fact, despite our best efforts much can be done to make these challenges worse through iatrogenic disease.

Another spot asks “what does it take to make a child believe everything will be OK?” when showing a pediatric patient without hair due to chemotherapy. There are types of pediatric leukemia that can be curred, and in these occasions I would tell the family that the chances of cure are good. However, when I saw a child in the pediatric ICU a few weeks ago, with recurrent leukemia after chemotherapy and 2 stem cell transplants that was now unresponsive from a large stroke, I am not sure there is anything that make the child or the family believe that everything is going to be ok.

A more recent add touches on a disease I deal with a lot as a neurology trainee and asks “what does it take to keep a stroke from stealing away your life?” The hard facts about stroke is that while there is excellent prevention, there are no proven outstanding treatments right now. Even with the most high technology clot busting medicines, only 12% of patient are better in 3 months, while 6% get bleeding in the brain as a drug related complication. Commercials like this invariably make it harder for me to tell families that after the stroke in addition to lifestyle and medication changes the only treatment is rehabilitation.

Finally an add asks “what does it take to give the whole world, brand news reason for hope?”. Well maybe our stem cell researchers are on the way, and I certainly hope so, but on a day to day basis from my medical intern year I will tell you that many residents felt that they shuffled sick patients from one ICU to another, to the OR and then on. Sorry for the cynicism, but that job did not feel like giving the whole world, brand new reasons for hope. If you go work at an average ICU in the United States,  you will probably not feel like a beacon of hope.

So what do you do in today’s market conditions where there is competition for patients. Well how about constructing an add campaign that is less emotionally driven and focuses on telling the truth? For example adds can promote name recognition but also focus on health statistics, services offered or specific achievements attained recently such as a vaccine that was recently discovered at our center. Ideally a better brand of adds, instead of promising cures that do not exist yet, would ask more substantively what does it take to prevent a stroke, or what does it take to prevent a prevent a cardiac catheterization as opposed to delivering one.

For an academic medical center that promises to deliver medicine of the highest order, adds should be elevated to the highest order of social responsibility. It is odd but apparently acceptable to advertise next to Taco Bell, and Victoria’s Secret. This is a market based society. What should not be acceptable is advertising that distorts what physicians can do and is not in keeping with physician professional goals of truthfulness and social responsibility.

• One story dominates for Palin: she easily exceeded expectations. This pauses the the string of negatives for the McCain camp and is an opportunity to try to relaunch the campaign on firmer footing.
• Palin was more aggressive than expected in trying to discredit Biden’s credibility. She has some success when repeating although factually incorrectly her traditional mantras about big government and taxes, and whiffed completely when she attempted to correct the senator on how to chant about oil drilling.

On Biden, with a more complicated mission in hand, a couple more comments:

• Biden also avoided a humiliating gaffe. He looked authoritative, in great command of the facts, while also showing a human, and open side of him.  His opening up when talking about his son after the car crash, is probably the most memorable moment of the debate.
• Biden’sdiscipline was inconsistent although given his reputation he could have done much worse.  Early on he was right on message talking about the middle class and the economy, but then inexplicably got bogged down talking at length about issues voters are not likely to connect with like Bosnia and Darfur. Early on he brought up Obama on message but later in the debate he seemed to get carried away off message. 
• While the idea of Biden as advisor and witness to Obama’s character was credible after the debate, it is not clear that Palin will convince America of her role as partner in reform. Her folksiness probably will reinforce doubts about her.
• Biden just dropped the ball on explaining that domestic hydrocarbons supply is an insufficient answer to energy independence. He started using basic numbers but then got got lost instead of making the basic case that new exploration will not soon enough will be a drop in the bucket. This was a missed teachable moment for are the viewers. Instead we heard catch phrases like “all of the above”. Given the centrality of energy in the country future, this was a large omission.
• Finally Biden showed great elegance in the way he handled debating a young, attractive, folksy and fiery woman. This was was delicate task, but was handled confidently and will not be a source of distraction in the post debate analysis. I think women viewers will be reassured and comforted by it, and men will be all too ready to identify with the way Joe Biden handled himself.

The first reason is that expectations for Palin could not be any lower. Last week was quite possibly one of the worst weeks for an American politician in recent history(money and sex scandals excluded). If Palin manages to come off as a credible on stage she gets back some legitimacy as a candidate. The media that loves a good story let alone Republican operatives will jump on this as a triumph and “I told you so moment”. You can see the headlines already “Palin avoids mistakes, ready to be VPOTUS”.

Biden could also struggle to hit the right tone when he faces  a fresh faced mother of five that despite her hard edged political views still inspires empathy and identification among women around the country. A heavy handed jab by Biden might be grounds for a rebuke on stage reminiscent of Geraldine Ferraro’s accusation of G H.W Bush of condescension in 1984.

The third item is a wild card. The McCain camp has been trying to play the refs like its nobody’s business. They have also found a way to play the ref of todays debate, Gwen Ifill, by accusing her of being in the tank for Obama for writting a book on black politicians and implicitly for being black. Palin did not blink and vowed, that this flap will just make her try harder.

So maybe if Biden can’t win, then the alternate scenario is that Palin cedes by continuing her self inflicted political suicide.

This does not seem likely. First of all Palin is much brighter than recent appearances have suggested. With study and practice her performance will improve perhaps dramatically. Also Couric’s softly delivered dagger follow-up questions will not be pat of of the format and limited opportunity for sparring is likely to also insulate Palin from tough probing.

At last the biggest question of the night is what will be Palin’s strategy for the debate. Will she aggressively go for the kill, at the risk of getting killed, or will she play it safe, get out unscathed and go for the triumph narrative. Despite the fact the McCain has shown a penchant for risk, having Palin torpedo his campaign is a risk he can not afford.  In my view Palin plays it safe.

More answers today at 9pm as the Gaffomatics face-off.

Our department has been one of the few in our medical center that because of robust NIH funding, publications and educational programs has international reputation and prestige. Therefore the Dean has a lot at stake in choosing new leadership. Specifically, if things do not go well, there goes one of the best departments in a hospital that is pushing hard to break through the ceiling of national prominence.

Days ago, our new chair was introduced and on day one layed out his vision for the department. The new strategic plan calls for comprehensive changes in inpatient services, outpatient services, integration with allied surgical services, and aggressive recruitment of basic science oriented faculty. Wow! Did you get that. That is pretty much everything that we do!

As with any  ambitious restructuring it is hard to project the outcome. I suspect a lot will depend on whether the changes makes sense in light of broader strategic goals, as opposed to change for the sake of change. I also suspect, that since recruiting is so central to the plan, the new chair will need to be very good at it. Charisma and prior relationships are a foundation but to close the deal you need three more things: money, space, and jobs for spouses.

From a resident standpoint there are reasons for optimism and reasons for reservation. Perhaps we will get exposure to sub-specialty ICU training, although this could come at a cost of elective time and quality of life. Perhaps the new chair will be just as supportive and also be a excellent research mentor as he is a prominent basic scientist. On the other hand, there are some things in our residency that our outstanding. Changing them without legitimate goals and consultation would be very disappointing no less to our outstanding program director.

This brings me to my last topic. What is it that made neurologists like our previous chair such masterful well rouded clinicians? A couple of things: he and his peers did 3 years of internal medicine and then did neurology. Now we only do one year of medicine before moving on. They also trained in an era when high tech neuroimaging did not exist. Therefore their history and physical exam skills were much more developed. Finally the previous generation of neurologists sub-specialized less. They saw much more broad groups of patients even after residency and therefore were  more well rounded. It is not atypical nor unreasonable today for MS neurologists to hesitate when treating stroke, and stroke neurologists to hesitate when treating MS.

The beauty in all of this is that while our professors move on, part of their practice continues through us. We are lucky to have worked with them. Me and my resident colleagues are already starting to look back at this generation of neurologists, perhaps neurology’s greatest generation.

In Mexico a government campaign appears to be doing exactly that.  Of course the proof is in the pudding, but if in the United States 25, 000,000 folks lost 4lbs each this could be a 100 million lb of cumulative weight loss. As we speak, the epidemiologic trends of obesity and related diabetes, vascular disease and kidney disease are marching on, and our generation of physicians will need to find ways to reverse these trends.

• The John McCain that showed up is decidedly better than the John McCain that has been campaigning the previous week. As a physician, after witnessing such consistent inconsistence, I was expecting to hear even the slightest signs of early cognitive decline.  Not at all. Despite limited preparation time, McCain was fluent on all the issues, agile, and mostly on the offensive.
• Barack Obama legitimately shared the stage and held his own against a former POW, and 20 year veteran of the senate. This was a basic yet crucial test. Consistency in the next two debates along with a spiraling economic crisis would seemingly have Obama in a strong position to close the race.
•  Now all the attention shifts to Gov. Palin. If McCain had a bad week, she had a catastrophic week. Defying conventional wisdom, instead of getting better with each interview, Palin completely tanked on her sit down with Couric. Several senior republican commentators broke ranks and withdrew support from Palin. This must be excruciatingly painful for the McCain camp. The only upside is that debate expectations for her will be very low, just like they were for G.W Bush in 2000. The downside is that if she fails as badly as she did last week, baring a big foreign crisis, it will be the beginning of the end of for McCain/Palin.

• In the economy portion of the event, McCain just did not have a central narrative, or overall strategy to present to voters. All he did to rebut Obama was to bring up polar bear DNA, and small peanut earmarks, to essential divert and distract attention. While he did put Obama on the defensive with some accusations, he still did not sound like someone who had a philosophy and a plan for the economy that viewers can take away. This is the major failing of his campaign so far. With 5 weeks to go it will be extremely hard to catch up on this issue.
• Obama whiffed on the Iran segment.  On the first opportunity McCain looked directly into the camera and crisply guaranteed the security of Israel. Obama beaten to the punch, tried to do the same thing, but fumbled his words somewhat. This took away from the intended effect. Under normal circumstances you do not want to repeat yourself. But when it comes to some elderly Jewish quasi-one issue voters in Florida, he should have repeated and emphasized his support to Israel. Given all the chain emails circulating alleging the Obama is Muslim, the hesitation he displayed may worsen his problems with that important group of swing voters.
• Finally McCain appeared to not look at Obama for the entire 90 minutes of the debate. He also had this grin whenever Obama spoke that seemed to barely mask condescension towards a much inferior candidate. This was unwarranted and unfortunate. Obama by any metric is extremely bright and highly accomplished for his age. He won the democratic nomination in one of the most hard fought primaries ever. He also represents the very best of the next generation of Americans somewhat like McCain represents the best of a previous generation. McCain’s dismissive demeanor just did not look right on the stage. To a younger viewer and non-native born American like me, it made him look white, angry and mean.

His history started 7 years ago with worsening frontal headaches that given a strong family history, visuals aura and chronic non progressive nature were most consistent with transformed headache due to mild medication overuse. Some more questions revealed a positive depression screen and stress from work and family as a major precipitant of these headaches. This was enough to take a different approach than Mr. X’s previous physicians.

After flashing back to him the list of 20 medications that had failed in the past, I told him that I don’t have a medication that would likely help. In fact since medications have consistently not worked, a new medication would be more likely to bring on side effects. I also told him that what appears like depression and life stress is making his headaches worse.  I recommended stopping the Ultram to break the cycle of rebound headache, strongly consider starting therapy to learn how to  manage the stressors and finally learning  a little about living wit headache. I told him his sister has headaches and she seems to be doing a little better. Given that he had told me that he has no functional limitation from the headache, I told him point blank that “its not only what you got, but its also how you deal with it”. He was pleased to have a diagnosis and preferred not taking medications. He was willing to give it a try.

As this patient encounter suggests, in modern American medicine, we sometimes continue to use medications even in the face of strong evidence that they do not work. This pill pushing can result in medicalization of one’s life and over time the nurturing of a somewhat dependent patient. The verdict is not in yet, but I tried to cut Mr. X loose from the cycle of fruitless neurology visits. His diagnosis is now depression, medication overuse and migraine. The therapy is ultimately more behavioral. As I told the patient the time horizon is months, not days,  but that probably this is the only way to improve quality of life in the long term.

This is a long time staple of the Cretan Mediterranean diet. This particular kind is made with  whole grain barley and wheat flour, salt and yeast. Yes that is it! The result is a golden,  fiber filled rusk that has an incredible earthy stone aroma. Bread does not usually smell like that.

Finally when ready to eat, rehydrate with good old H20, add fresh tomatoes, feta, oregano and olive oil and you are there. In my humble opinion, there are not many places to go.

The irony here is that since this is a rusk, ie a re-baked bread that is completely dehydrated, its shelf life is months. So it competes with bionic Pepridge Farms bread, without an ounce of preservatives. Respect brother, respect.

The results are scary. In the stroke wards we are seeing the usually geriatric illness of stroke transform into a disease that often strikes the young. In the ICUs I have seen a few patients that have accumulated so much fat around their chest that they have difficulty exchanging oxygen for CO2 and thus get into a sleepy state called CO2 narcosis. These patients would require long term ventilation or surgery to produce an opening in the neck from where its easier to breath.

The point of this, is that I do not understand why as a society we are letting this happen. Why is Coca Cola so acceptable? Why can McDonald’s use perfectly sculpted Olympic athletes to market new “death on a plate” breakfast items during the Beijing Summer Games? Why are there significant amounts of sugar in most mass produced breads and buns at your local supermarket? Why is there corn syrup sprinkled just about everywhere in this country?

I’ll tell you what, in America we cherish individual freedom like few other places in the world, but our freedom to chose is killing us.

Here is what to do. Don’t take away anyone’s rights but correct market failure by adjusting prices to reflect not only the cost of bacon but also the additional public health cost of early vascular disease. In other words, fast food may appear cheap, but its real cost are much more expesive. So then add a medicare tax that will adjust the Big Mac to its real price of 8 dollars.

If you don’t agree with the above suggestion above, that is fine, but please help come up with others to help change the way we eat.