Click here to read about her talk  

Photo by Don O'Shea

The overarching message of Dr. Mar Sanchez's presentation was that parental care early in infancy is an important determinant of neurobehavioral development in mammals. During this period, the infant is attached strongly to the caregiver and depends upon the caregiver for all the needs for normal growth and development. This includes development of efficient coping strategies to environmental challenges. Poor maternal care, physical abuse, and rejection as well as low sensitivity/responsiveness to infant needs are stressful to the infant. The lack of maternal buffering leads to phenotypic plasticity, and altered physiological reactivity and behavioral make up. Dr. Sanchez corroborated this by presenting data collected by her and colleagues in rats and the Rhesus Monkey (Macaca mulatta or Rhesus Macaque). In rats, maltreatment needed to be induced, whereas in the Rhesus Monkey some mothers exhibit the tendency naturalistically. In both models, Dr. Sanchez carefully evaluated measures related to genetics, development, behavior, neuroendocrinology, neuroimaging, primatology, psychobiology, psychopathology, and stress neurobiology. Because of the multidisciplinary approach, her studies have a high degree of translational validity to humans.

In a parent-infant relationship, childhood maltreatment leads to reduced affiliation and social and cognitive deficits as well as increased risk of behavioral and psychiatric disorders. This includes anxiety and mood disorders, increased emotional reactivity, aggression, and impulsivity, and risk for substance abuse. These arrays of developmental outcomes are likely due to alterations in the development of the prefrontal cortex and its connections with limbic regions such as the amygdala, a brain region critical for emotional regulation and stress responsiveness. Adverse maternal caregiving critically affects the brain circuits that control these functions. Neurobiological alterations in the abused infants include elevated plasma cortisol, reduced brain serotonin, and activation of peripheral pro-inflammatory cytokines, parameters that are either associated with psychopathologies or greatly influence their development.

Epigenesis is a process that does not change the sequence of chromosomal DNA, but modifies the way the genes are expressed leading to variable phenotypes. This modification depends upon a reaction known as DNA methylation, with higher methylation leading to less functional gene expression. In abused infants, Dr. Sanchez observed increased DNA methylation and suggested a potential correlation of modification of genomic DNA with behavioral trait imprinting. This epigenetic reprogramming makes possible the transfer of altered psychopathological traits from one generation to another (epigenetic inheritance). At present, Dr. Sanchez is evaluating strategies to modify the behavior of abusive mothers in the monkey colony and make them good mothers.   

Photo by Don O'Shea

-- K. V. Thrivikraman (Thrivi)

Much of Mar Sanchez's work is done at the Yerkes field station in Lawrenceville.  During her talk she stated that she would be delighted to welcome us to a visit at the field station, a suggestion that was greeted enthusiastically by the audience.   Be on the lookout for details about such an excursion! 

May 15, 2015

Of our graduating class of 66 in 1959, we are now down to 35 survivors. Enclosed are the entering 1955 pictures of the 73 members of our freshman class for your review. Emory's entering medical school class now numbers 138, one-half female, a striking change from the two females in our entering class. Sixty years ago nursing, teaching, and secretarial jobs were the principal careers open to women. Now the entire career world is open to these busiest of people. What are the consequences of these changes in medicine?

I would like to toss a few pitches to my 34 classmates and umpires. Remember Ralph Nader and his effective crusade against unsafe automobiles and his book, Unsafe at any Speed, decades ago? As a professor of law at the University of Georgia, Nader formed GREENLAW to represent the disadvantaged in environmental matters, free of charge. He spoke in Atlanta this past week, a thoroughly informed and comfortable presence in his 81st year. The first law museum in the country, a Tort Museum, will open this fall in Winsted, CT, Nader's hometown. Nader is concerned about the controlling influence of Corporate America upon the legislative process through its lobbying and campaign contributions. Nader believes the influence of Corporate America could be reversed by the active involvement of 1% of the citizenry (three million), strategically placed throughout the country, leading informative campaigns on the issues. A sense of fair play would aid in overcoming the corporate influence. Remarkable!

Let's take a brief look at current healthcare in the US. It is our country's largest business, at 17% of our GDP, three times the cost of our national defense budget. Thirty-seven million of our citizens remain uninsured, down from 48 million before OBAMACARE ("The Patient Protection and Affordable Care Act"). Thirty percent of US healthcare provides no benefit (Institute of Medicine, 2013). US healthcare is based on profit and the fee­ for-service -- not UNIVERSAL CARE -- as is the case in other technically advanced democracies. The US is poorly ranked internationally. Yet there is a paradox: US healthcare provides some of the best care in the world, but sometimes too much care, even inappropriate care. The poor have difficult access to good care. A look at several cost centers:

HEALTH INSURANCE: There are more employees in the for-profit health insurance industry than there are doctors in the country. These companies answer to their Wall Street stockholders and reject 30% of all claims. Billing adds some 20% to the healthcare dollar. There are no bills and no health insurance in the British healthcare system, established in 1946 after WWII, to care for all citizens (UNIVERSAL CARE). It now costs 11% of its GDP. A SINGLE PAYER system is less expensive. Medicare spends only $3.70 to pay each bill. The for-profit health insurance industry is expert in political spin (Deadly Spin, W. Potter [5]).

DRUGS: Most technically advanced democracies purchase medications through a national bidding process. Legislation under George W. Bush promised full retail price for Medicare drugs, a bonus for big Pharma, a huge expense for the citizen. Hospitals mark up the cost of medications. New combinations of drugs must show only benefit, not increased effectiveness. Medications are far less expensive in Canada. European drug firms make higher profit margins on drugs sold in the US than in Europe. In Positive [8], Saag points out that when doctors, drug firms, and the government worked together to defeat AIDS -- without regard to patient income -- positive things are accomplished. Treatment for AIDS has diminished from 10 pills a day to one. Saag states that at age 20 he would prefer to have AIDS than diabetes, for life expectancy at age 70 is better with AIDS.

HOSPITALS: Non-profit hospitals average 12% profit and are more profitable than the for-profit hospitals that pay taxes. There is a lack of hospital transparency. A Princeton medical economist has likened hospital care to going into a department store blindfolded, selecting several items, and getting a bill three months later that reads, "You owe...." Hospitals are now large businesses favoring expansion into even larger corporations. With monopolies, prices usually go up. Hospitals have a CHARGE MASTER LIST [6] which spells out charges -- little based on costs -- used to negotiate prices with Medicare/Medicaid and the for-profit health insurance industry. The more national the organization, the better the bargaining position: Medicare, Aetna, United Healthcare, and CIGNA have stronger bargaining power than small health insurance firms. Small community hospitals are in a poor bargaining position. If the individual citizen is UNINSURED (unrepresented), he or she may be charged the full Charge Master rates. There are 700,000 medical bankruptcies a year, most in the middle and upper-middle income group, because of health insurance payment caps. Medical bankruptcies are two-thirds of all bankruptcies. Hospitals have a 2% profit margin. Hospital outpatient services have a 35% profit margin. The majority of a patient's varicose veins can be removed by a procedurist in 45 minutes in a profitable outpatient setting. Vein clinics advertise on billboards. How informed are their patients? Children's hospitals are often great money­ raisers. Some countries post both outpatient and hospital prices. Thirty percent of medical care in this country provides no benefit, some medical care even leads to unnecessary harm. When hospitals are financially stressed, they first cut back on nursing, an austerity measure hazardous to patient care. Records of Medicare and national insurance companies demonstrate varying standards of patient care and medical charges throughout the country.

DEVICE MAKERS: Your hip prosthesis, wheelchair, CT scanner, walking cane, MRI, pacemaker -- all have high profit margins. Hospital markups increase the costs. Device makers have the highest profit margin of all sectors.

DOCTORS: Doctors are paid based on fee-for-service. This leads to overuse of "tests, drugs, imaging, and operations that won't make them better, may cause harm, and cost billions" (Gawande, Overkill [12]). There is a shortage of primary care doctors and an abundance of specialists that drive up costs. Guy Clifton in Flatlined [10] documents that the quality of care is better and less expensive in states with more primary care doctors. The quality of care falls off in states where there are more specialists who order more tests and treatment at greater expense, but do not provide the disease prevention of the primary care doctors. (There is no denying that specifically indicated procedures are most beneficial, as in cardioversion for paroxysmal atrial fibrillation.) In Miami, where there are more specialists, charges are higher and the outcomes are not as good compared to Minneapolis, where there are fewer specialists, the charges are less, and the outcomes are better. New Accountable Care Organizations (ACO) are providing better patient care at lower cost to Medicare, sharing the savings with the ACO. Brawley, in How We Do Harm [11], states patient TRUST should be substantiated with FACTS. This is most important in surgical procedures, chemotherapy, and radiation therapy because of the unknown costs, outcomes, and risk-benefit.

INFORMATIVE PATIENT DOCUMENT (IPD) between the doctor and his patient, accomplished days before elective surgery: signed, witnessed, dated, and copied to the patient for his or her records. Such a document should include the SPECIFIC INDICATIONS for the proposed procedure, its CONTRAINDICATIONS, COMPLICATIONS, OUTCOMES, and OPTIONS. Specific facts are most important, for then the educated and informed patient can make a rational decision about a proposed procedure in the context of his or her own health. Specific forms should be developed for most surgical and expensive diagnostic studies for the enlightenment of patients, doctors, staff, and institution. "An informed patient is a medical TRUST. An uninformed patient is a body and a fee. In which patient camp would you rather be?" Specific IPDs can be readily developed, promoting an educated and informed patient rather than simply expediting the flow to surgery of a trusting patient. Should such educational documents not come from within, they may come from without in the form of APPS available to every patient­ citizen. Such an IPD would foster Transparency and Accountability within medicine.

MEDICAL RECORDS: In this digital age a patient should be entitled to a copy of his or her medical records promptly, if requested. The patient and his or her taxes pay for it.

STANDARDS OF CARE: High practice standards, guidelines, and fair pricing are integral to the consistent practice of medicine throughout the country.

ADVERTISING: Early in our careers there was no medical advertising. Now advertising abounds on radio, TV (Cialis), internet, billboards, and on the hoods of stock cars (Viagra). Advertising costs money. Is the purpose sales or medical care? What are the standards of medical advertising? The British and Canadian healthcare systems do not permit medical advertising.

MEDICO-LEGAL COSTS: It is often posed that many tests and imaging studies are performed out of fear of legal action (DEFENSIVE MEDICINE). Far more studies are obtained which are of little benefit (30%) but increase income in the fee-for-service world. Inappropriate procedures have their own complications [9, 11, 12]. When medical errors occur, should they be acknowledged to the patient and dealt with directly, or countered with denial and misinformation to delay the possibility of a suit within the two year medical statute of limitations dating from time of discovery? Which choices lower the frequency of legal action? Error conferences and confidential Morbidity and Mortality (M&M) conferences are most helpful. Is not a thoroughly informed patient, informed well beforehand, in writing listing Indications, Contraindications, Complications, Outcomes, and Options, not a factual prelude to the truly informed patient? Is not legal action a consequence of preventable medical and surgical mismanagement of a patient who feels poorly treated and no longer trusts the system? A Communication/resolution program was adopted by the University of Michigan Health System for its patients in 2001. Malpractice claims fell by 36% and patient compensation costs dropped by 60%. User-friendly decision aids (such as the IPD) led to a better informed patient and more conservative care (Kachalia and Saint [13]).

"If this is a medical emergency, hang up and dial 911 immediately."

THE HEALTH OF THE PLANET EARTH:

In 1800 our world population was 1 billion (B), 2B in 1930, 3B in 1960, 4B in 1975, now 7B and rising. The world's population has increased by 5 billion since our birth. Our EARTH is 70% water, only 1% fresh water. With the burning of fossil fuels in the industrial age the atmospheric C02 has increased from 280 ppm to over 400 ppm. C02 sits in the atmosphere for 100+ years. We are deeper into the greenhouse of a warmer planet. Our glaciers are melting and our seas warming, absorbing more C02 and turning more acidic. When land-based glaciers melt, the seas rise. Low level countries are in trouble. In global warming, dry areas become drier (California is in its fifth year of drought), and wet areas become wetter. Water will be the prime natural resource of this century. 350 ppm is thought to be the upper limit of acceptable C02 in the atmosphere. We have exceeded that level since the 1950's.

What will be the threats to the flora and fauna and health of our planet in the next 50 years? Will scientific fact and reason prevail over short-term profit? The scary thing is the threats to the health of the planet. Political spin will not solve the problem.

COMPARISONS

CONCLUSIONS:

The US medical-industrial complex is the most expensive healthcare system in the world, costing over 17% of our GDP, some three times more than our defense budget, yet failing to insure 37 million citizens. France, generally ranked number one in health care in the world, provides universal care for all its citizens at 12% of its GDP. The US system is based on profit rather than universal coverage. Most countries establish their health care based upon coverage for all. Lord Beveridge, an economist/ educator/socialist, and Earnest Bevin, a brilliant British labor leader who grew up in poverty, were instrumental in establishing the British healthcare system (the Beveridge System) in 1946 after WWII. The CAPITATION British system pays the doctor on the number of patients he or she cares for, not the number of tests and procedures he or she orders. Preventive medicine is built into the system. It currently costs 11% of the British GDP.

The young American doctors of today, men and women, will mature into a more informative medical world, caring for all its citizens with better outcomes at lower costs, improving life expectancy from its current 47th rank. What will become of the doctors of today over the next 50 years? Will they be salaried physicians, instructed to increase their "productivity"? Or will they be thoughtful men and women, educating and caring for their patients in a more medically transparent and accountable world, positioning the U.S. as a world medical leader in a more polluted, warmer, and more populous world?

Sixty years ago we entered Emory Medical School. All of our experiences are different. What are your thoughts and reflections on the practice of medicine in your retirement years?

My best,

Stewart R. Roberts, Jr., M.D.   

scoutrob@bellsouth.net 

P.S. In a nation that is obese (BM1>30) (46%) and sedentary (26%), what is the citizen's responsibility for his or her own health and its cost to the national treasury? A NATIONAL HEALTH CARE CORE CORRICULUM for schools, colleges, and universities and their employees would be beneficial. A one year national service program (20% military) for ages 18 to 22, men and women, could provide remedial education, technical training, nutritional, physical, environmental, individual and planetary health education and discipline for the youth of the nation, establishing a shared national service experience and esprit de corps.                 S.R.

1. UNSTOPPABLE. The Emerging Left-Right Alliance to Dismantle the

Corporate State, by Ralph Nader. Nation Books. 2014.

2. Return to Sender- Unanswered Letters to the President, 2001-2015, by

Ralph Nader. Seven Stories Press. 2015.

*3. The Healing of America. A Global Ouest for Better, Cheaper, and Fairer Health Care, by T.R. Reid. Penguin Books. 2009. NYT bestseller. Healthcare compared by country.

4. THE ECONOMIST. Pocket World Figures. 2014 Edition.

*5. Deadly SPIN. An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans, by Wendell Potter. Bloomsbury Press. 2010. Former PR Director/Journalist.

*6. TIME. Bitter Pill: Why Medical Bills are Killing Us, by Steven Brill. Feb.2013. Yale-educated lawyer turned investigative reporter and author.

7. America's Bitter Pill. Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System, by Steven Brill. Random House. 2015.

8. Positive. One Doctor's Personal Encounters with Death, Life, and the US Healthcare System, by Michael Saag, M.D. Greenleaf Press. 2014. An Infectious Disease doctor worked with AIDS patients from the very beginning of the mystery.

**9. UNACCOUNTABLE. What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care, by Marty Makary, M.D. Bloomsbury Press. 2012. Makary is an endoscopic pancreatic cancer surgeon with an MAin Public Health. In TIME, WSJ, CNN commentator.

**10. Flatlined. Resuscitating American Medicine, by Guy L. Clifton, M.D. Rutgers University Press. 2009. Neurosurgeon. Administrator. Health Policy Reformer. A ton of health care research attractively presented.

**11. How We Do Harm. A Doctor Breaks Ranks About Being Sick in America, by Otis Webb Brawley, M.D. St. Martin's Grittin. 2011. Brawley, an Emory-Grady oncologist, now V-P and Chief Medical Officer of the American Cancer Society, believes in strict scientific standards for medical care, extended to all citizens. Doctors should do no harm. Medical facts should replace patient trust. A captivating speaker.

**12. THE NEW YORKER. Overkill. An avalanche of unnecessary medical care is harming patients physically and financially. What can be done about it? Gawande, Atul, M.D. May 11, 2015.