Different Strokes for Different Folks

The latest Medscape Roundtable, featuring Robert Centor, Graham Walker, Theresa Polick and me writing about the 'VIP' treatment, has been posted.

Special thanks to our editor, Christine Wiebe, for getting this idea off the ground... and for mercifully, tactfully killing my attempts at VIPoma humor.

The Stroke's The Word

In May, when the new ASA stroke guidelines came out, this table's title caught my eye. Now I'm copyediting a piece on stroke management in the ED, and this phrasing is probably the clumsiest part of the manuscript:

Suggested Recommended Guidelines For Treating Elevated Blood Pressure In Spontaneous Intracerebral Hemorrhage

My issue is with the unecessary hedging built into the title -- "Suggested Recommended Guidelines."

Why not just call it, "Some Ideas You Might Want to Consider, if That's OK -- I Know You've Got Strong Opinions About This" ?

He Helps You To Understand

Lifehacker.com recently linked to a WikiHow post, about maximizing the efficiency of a patient's time with his or her doctor. The article is pretty good, with tips like:

Describe your basic reasons for the visit in one or two sentences.

Recall the onset and timing of your symptoms. Include starts, stops and frequency.

Explain what makes the pain better or worse.

...Do not wait till the end of the meeting to say "...and, by the way, I have this other pain".

Good advice. I never really knew this, before medical school -- I was naive enough to think my physician would love to hear a pre-med's theories about his ear pain. But now I can't believe we don't hand this out, pamphlet-style, in the waiting room.

The one item on the list that Lifehacker should have paid closer attention to was this one:

Start talking to the doctor about your symptoms, not what you think your diagnosis is...

Because a few days ago they linked to WebMD's symptom checker, which is an arbitrary mix of commonsense medicine and diseases lifted from the Hypochondriac Hall of Fame (that back pain could be a muscle strain... or dermatomyositis... or kidney cancer! Ask your doctor about starting chemo).

What'd be great is if Lifehacker editors read each other's posts, or, better yet, web-based symptom checkers were based on the same cardinal questions doctors ask patients (the Revolution Health checker is a step in that direction).

That's What Makes Our Town the Best

Yet another boost to New Yorkers' sense of superiority:

Americans have gained an extraordinary 33 years in average life span over the past century. A baby born today can expect to live an average of 78 years, compared with 45 years back in 1900. But those gains have not been uniform across the nation. Columbia University economist Frank Lichtenberg reports in a new study that, while average life expectancy increased by 2.33 years nationwide from 1991 to 2004, the increase varied widely among states. Residents of New York gained 4.3 years, the most of any state, during the 13-year period studied and can expect to live 79.2 years. Oklahomans, however, gained only 0.3 years over the same period, to 75.4. (For a table listing all the states, click here.)

(He's talking about NY state, but recent data on the city is equally encouraging. With the drop in gun violence and AIDS mortality, and, I suspect, before the diabetes epidemic starts cutting into life expectancy, Gotham dwellers are among the longest-lived in the country. Even the smoking prohibitions and revolutionary trans-fat ban aren't yet reflected in this data).

So what's our secret? I had some theories:

1. Franklin said that death and taxes are the only certainties in life. But what if more taxes can stave off death? Then New Yorkers would approach immortality.

2. With so many hospital emergency rooms close by, maybe the nonchalant, inappropriate use of emergency medical services has actually led to some benefit.

3. Greed is good for you. Also, rudeness and narcissism function like vitamins and fiber, respectively.

4. We walk everywhere. We walk our way to fitness, and indeed, we walk faster than ever. Even in the dog days of July, when you'd expect others to slow down, the heat just causes New Yorkers to pound the pavement faster. Maybe it's because of the unlocked odors hovering in the air. But it's dramatic.

Alas, Lichtenberg's work supported other conclusions:

Lichtenberg measured a number of variants that might explain this gap, including obesity, smoking, income, health insurance coverage, and the incidence of AIDS. He discovered that a primary reason for greater gains in life span is access to new drugs and other medical innovations. For each state, he determined the year that commonly prescribed drugs won Food & Drug Administration approval, and found that those states that skewed toward newer drugs tended to have above-average increases in longevity, when adjusted for other factors.

Frankly, I'm skeptical. Lichtenberg is an economist, not an epidemiologist (dammit, Jim). He has previously dismissed some fundamental tenets of public health in favor of his theories. According to his recent WaPo op-ed, he's using econometric models to explain mortality, which is (I like to think) ultimately a medical question.

His work has been funded through the pharmaceutical industry, and a longtime collaboration with a free-market advocacy group called the Manhattan Institute (when I put it that way, it's no surprise he concluded free-market pharmaceutical innovations benefit New Yorkers).

Also in the WaPo piece, Lichtenberg states that the biggest gains in life expectancy came in NY, NJ, DC, and California -- can it be that other factors he didn't account for, such as health initiatives for immigrants, improvements in infant mortality, or the introduction of more robust state-level health plans -- increased lifespan more than, say, the rapid adoption of the latest statin?

And if there's merit to Lichtenberg's underlying hypothesis (that access to medical innovations drives changes in life expectancy) then why has the US fallen behind 44 other countries? Has Andorra shot to the top because their drug-approval process is more laissez-faire?

BusinessWeek said full study should be available at the Manhattan Institute site, but it doesn't seem to be there. So, without true stats or methodology to pour over, I'll do a very New York thing, and trust my gut: The activity level and disposition of New Yorkers (and the strong civic services in the community) has more to do with our longevity than the fact our doctors were prescribing Zocor a year or two before docs elsewhere.

*The title of this post, as with most of my posts lately, is lifted from pop music lyrics. In this particular song, the noted longevity expert Mick Jagger listed other attributes of Manhattan that he found redeeming, besides the access to cutting-edge medical care.