1 Boring Old Man

1. helping to learn; guiding in discovery or investigation
2. allowing pupils to learn things for themselves
3. a. using or obtained by exploration of possibilities rather than by following set rules

   b. computing: denoting a rule of thumb for solving a problem without the exhaustive application of an algorithm: a heuristic solution

^{Origins: from New Latin heuristicus, from Greekheuriskein to discover]}

1. a logical arithmetical or computational procedure that if correctly applied ensures the solution of a problem
2. logic, maths  a recursive procedure whereby an infinite sequence of terms can be generated

^{Origins: 1690s, from Fr. algorithme, refashioned (under mistaken connection with Gk. arithmos "number") from O.Fr. algorisme "the Arabic numeral system," from M.L. algorismus, a mangled transliteration of Arabic al-Khwarizmi "native of Khwarazm," surname of the mathematician whose works introduced sophisticated mathematics to the West (see algebra). The earlier form in M.E. was algorism (early 13c.), from O.Fr. Modern use of algorithmic to describe symbolic rules or language is from 1881.}

I thought of a story from the dawn of time. It was 1968 and I was a first year medical resident. One night, a patient we all knew was brought to the ER in extremis. Husher was a notorious alcoholic with alcoholic cardiomyopathy [heart muscle failure associated with his alcoholism]. He was in severe heart failure, swollen up like a pumpkin, unresponsive. He had a cardiac arrest in the ER and another when we got him to the ICU. We resuscitated him both times, but the situation was dire. He had life threatening acidosis [pH 7]. The heart just wasn’t pumping enough blood to oxygenate the cells. Unoxygenated cells make lactic acid, a sign that his demise was eminent. In those days, the only treatment for acidosis was Sodium Bicarbonate. The worst thing you can give a person in heart failure is sodium which causes fluid retention and overload, the very problem with heart failure in the first place. Cut to the chase – an impossible situation with no solution. In the moments I had to think about things, he arrested and was resuscitated yet again. So, we just started pouring in the Sodium Bicarbonate. There was a brand new diuretic [Etacrynic Acid] I’d read about, but never used or seen used. The literature said it was powerful, but very potent and unmanageable. I asked the nurse if we had any. She found some and we gave him the max dose. The logic? If you’re going to treat lethal acidosis and lethal heart failure with a lethal dose of Sodium Bicarbonate, use the most potent diuretic made and don’t worry about its unmanageability or your unfamiliarity hoping to outrun the sodium overload. My Intern and I sat at the bedside all night watching in awe as urine flowed from the catheter not in drops, but in an unending stream – a gushing hose. Husher lost 60+ pounds that night! Inconceivable! By the next morning, he was his irascible self, demanding to leave the ICU to smoke and pinching nurses. Inconceivable!

Those were heady times. My Intern friends from the year before were mostly off to Viet Nam. We were in Memphis where MLK had been killed and we had riots and Martial Law with tanks in the streets. The reason the story is still so vivid in my mind is that the day after that night, there was a sudden general hospital strike and we were left with a hospital full of patients and no staff of any kind. So we did the nursing, mopping, even cooking as we slowly emptied out the hospital. Husher told the reporter who snuck onto the ward that I was a hero and he uncharacteristically helped us with the mopping. But I didn’t feel heroic. I felt lucky. It was a heuristic solution that fortunately worked. Internal medicine is tidy. Usually, there’s a protocol, an algorithm, even for the direst emergency. But not this one, at least not one that I knew. Flying by the seat of your pants is the stuff of combat surgery, not Internal Medicine.

The story goes on. Towards the end of the year after the strike finally ended, I was on call one night and wandered to the cafeteria for a snack [a perk we got for staying up all night way too often]. There was my old Intern in line. He smiled and said, "Husher’s back. Same deal." He described a repeat of the situation we’d seen earlier in the year, then said, "No problem. I hung the Bicarb and shot him up with Etacrynic Acid just like we did before." What had been a flying by the seat of my pants heuristic solution for me was an algorithm for him – something that he’d seen work. Terminal Heart Failure; Fatal Lactic Acidosis; No problem. Just pour on the Bicarb and Etacrynic Acid – a formula for success – then go down for some grits and greasy bacon with soggy toast. I was horrified and went to the ICU, worried about the consequences. But he was right. Husher was doing just fine, already coming around [the hose was gushing].

Long story, but with a point. Much of medicine is "protocolized’ – sequences of best approaches to situations based on experience – personal or collective. I don’t recall the word algorithm being used much, but it sort of fits loosely – some way of doing things that aims for success. It’s not a perfect choice of words, because success isn’t always guaranteed anywhere in medicine. But there are protocols in medicine for other reasons too. In the Clinic I work in, I see charity and Medicaid patients. There will be plenty of protocols, drugs that have been donated or generics, Medicaid approved drugs. Anything expensive will require pre-approval. National generic Adderall shortages will limit choices for treating ADHD. But the forces behind those protocols are things like cost containment, necessity, and availability – not medical reasons. Those aren’t algorithms. They’re rules.

The psychiatric algorithms in TMAP [Texas Medical Algorithm Project] weren’t algorithms either – as in medical protocols or recipes derived from science or successful experience. They weren’t even heuristics. In fact, on the face of things they were very odd indeed. The Schizophrenia version started life as Expert Guidelines [The Tri-University Expert Guidelines] compiled by questionnaire from a panel  in 1995 under a grant from J&J. They were adopted by TMAP [also funded by J&J] in Texas in toto. The first version recommended Risperdal or a first generation Neuroleptic, but within a few years, TMAP recommended the Atypicals over the first generation drugs. What was odd was that the expensive drugs were chosen over the generic drugs without any solid evidence of superior efficacy or safety. And the new ones were added as they came on the market above the first generation drugs.

We psychiatrists were a willing audience having lived with the neurologic toxicity of the neuroleptics for years, we welcomed the chance to treat our patients with less toxic medication. And like my Intern, we looked to presumed wiser mentors for guidance, for new algorithms I guess. The notion that those mentors were for sale would have been unheard of at the time – just a decade and a half ago. As it turned out, TMAP was a protocol that was driven by jury-rigged expertise, ghost-written literature, and cherry-picked research conducted by a biased research industry. TMAP wasn’t an algorithm as advertised, it was a rule, a protocol based on profitability that cost public institutions a mint. It insured that the [often involuntary] patients in Mental Hospitals, Clinics, and Prisons were exposed to adverse effects unknown by their treating physicians, but well known to the drugs’ manufacturers.

I told my Husher story for a reason. A lot of medical learning is on a case by case basis. That night I learned that if you needed a power-house diuretic in 1968, Etacrynic Acid was there for the using. But I also learned that it was a plenty dangerous drug, not to be played with. You could easily kill someone with a diuretic with that kind of power. I actually don’t think I ever used it again myself – maybe once at most. It was just too potent for the everyday cases of Heart Failure that we saw frequently back in those days when we were not yet able to routinely "fix" damaged heart valves and open up clogged coronary arteries. It’s hard to have that kind of hands on learning treating psychosis, because the adverse effects like weight gain, diabetes, tardive dyskinesia come much later in the game. Likewise, in public mental health and prison systems, there’s often limited patient continuity – multiple different on-call doctors seeing the patients over time. In those situations, up-front safety information is paramount.

The architects of TMAP at J&J operated with surgical precision with skillfully placed interventions – undermining traditional medical pathways of learning at many levels simultaneously. The phrase, "a crime in plain view" comes to mind. It only saw the light of day because of a diligent inspector half a continent away found a thin trail and followed it against a difficult gradient – a path that cost him his career. It has all the elements of the stealth invasion of psychiatry by the pharmaceutical industry: compromised academicians and public officials, ghost-written literature, biased research in refereed scientific journals, rampant but ignored and unreported conflicts of interest, gullible physicians in public mental health systems, a patient population with little voice, patient advocacy organizations with financial vulnerabilities, a State system that was traditionally anything but corruption averse, etc, etc. The target was scientific medical learning, and the mission was successful, at least for a time.