"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
If Thy Heart Fails Thee: This past week’s study of the week appears to be the New England Journal of Medicine’s paper on genes and heart failure. Because the authors looked at the incidence of certain genes and heart failure in blacks compared to whites, a lot of newspapers included in their stories the slant that doctors harbor prejudice against their minority patients. CNN and The Washington Post both alluded to this now-accepted myth of racial bias in the medical field. The studies that purport to prove this bias all resort to the statistical dodge of reporting results in terms of odds ratios that exaggerated the differences. (A good debunking of this sort of data can be found in Damned Lies and Statistics by Joel Best.)
The media’s reporting of this particular study wasn’t much better. The Washington Postquoted the study’s lead researcher as saying, “The genetic combination plays a role in one-quarter of the cases of congestive heart failure diagnosed each year among blacks,” but the combination didn’t even count for one-quarter of congestive heart failure among the blacks in the study - it only accounted for 15 out of 78 cases, or almost one-fifth of cases.
The study looked at the expression of genes that code for two cell receptors that regulate the action of norepinephrine. One gene was for the alpha2c adrenergic receptor found at the ends of nerve cells. This receptor inhibits the release of norepinephrine from the nerve ending. A defect or deletion in the gene means that the nerve cells release more norepinephrine. The other gene was for a receptor found on the surfaces of heart muscle cells, the beta1 adrenergic receptor. This receptor enhances the heart cell’s response to norepinephrine. The particular defect in the gene involved in the study creates a receptor that is hyperfunctional, causing the heart cells to hyper-respond to norepinephrine. Norepinephrine is one of those chemicals that the body produces in its “flight or fight” response. It increases the heart rate, makes muscles contract more forcefully and enhances the general state of alertness. The theory is that a person having both defective genes would have a doubly hyperactive heart.
Now, heart failure can be caused by a number of diseases. The most common cause is damage from coronary artery disease. Other causes include viral infections, autoimmune disorders, alcoholism, hypertension, and the great umbrella category of idiopathic, which is a fancy way of saying “we have no idea.” In this particular study, the vast majority of the black patients (83%) had idiopathic heart failure. The majority of white patients (54%) had heart failure caused by coronary artery disease. Not surprisingly, more of the black patients than white patients had at least one of the gene mutations, since in the majority of cases they had no known cause for their heart failure, making it more likely to be caused by some malfunctioning of their cells. The double mutation occurred in only 2% of blacks and whites without congestive heart failure, but it occured in 19% of blacks with heart failure and only 4% of whites with heart failure. It hardly argues for a racial difference in genetic causes of heart failure, however. If the study had only included patients with idiopathic heart failure, regardless of race, the incidences of the mutations may have been the same.
The results are interesting, though, in their implication for the treatment of heart failure, especially idiopathic heart failure. A lot of our treatment is already focused on decreasing the effects of norepinphrine on the cardiac cells, but this gives us a basis for predicting how some people might respond better to those treatments than others. If someone has the mutation for the nerve cell receptor, then they might respond better to drugs that inhibit nerve cell release of norepinphrine. Another patient with the muscle cell receptor mutation might respond better to beta-blockers, and someone with both might do best with both medications. It’s exciting to think that someday soon we’ll be able to design our therapy to complement our patient’s unique body chemistry. This is the true import of the study, not what it says about race. posted by Sydney on
10/12/2002 11:35:00 AM
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Smallpox Update: The military is mulling plans to vaccinate the troops. This makes sense. They were the last to quit vaccinating. They should be the first to begin since they're the most at risk, and most vulnerable, to a biological attack. posted by Sydney on
10/12/2002 11:34:00 AM
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Friday, October 11, 2002
MedMal Crisis/Tort Reform Update:Overlawyered is all over this today, (I just put a campaign sign in my lawn on this evening for the State Supreme Court justice he quotes.) and RangelMD has even more to say on the topic. posted by Sydney on
10/11/2002 07:39:00 PM
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Good News/Bad News: Epidemiologists are in the process of revamping cancer survival statitistics. The good news is that the average survival of most cancers is longer than previously thought. The bad news is that the number is just an average and a statitistic, so it's application to reality is limited. Thus we have statements like this:
For example, Dr. Brenner said, a woman with ovarian cancer may have been told that she has a 35 percent chance of surviving 20 years; in fact, she probably has at least a 50 percent chance of living that long.
I'm trying to remember the last time I saw someone live twenty years after being diagnosed with ovarian cancer. I can't remember anyone. It depends, of course, on the type of cancer and how it was found. Most ovarian cancers aren't discovered until they're large and have spread. We simply have no good way to screen for them. Others might be found serendipitously during a hysterectomy or oophorectomy (removal of the ovaries) for other reasons. The latter group of patients can be expected to have quite long survival rates and no recurrence, thus skewing the average upward.
The reality is better expressed by the biostatistician from MD Anderson:
But Dr. Donald Berry, head of biostatistics at the M. D. Anderson Cancer Center in Houston, cautioned that the study might have little or no effect on what patients hear from their doctors.
"No clinician — well, almost no clinician," Dr. Berry said, would simply quote to a patient the overall survival numbers for a type of cancer. Any good doctor making a prognosis, he said, takes into account the size of a tumor, how far it has spread, the patient's age, success rates of new treatments and other factors. posted by Sydney on
10/11/2002 08:20:00 AM
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Get Ready for More Statin Hype: A trial in Britain that looked at heart attack rates in men with high blood pressure but normal cholesterol who were given Lipitor ( a cholesterol-lowering drug in the statin class) has been halted because the researchers felt the drug was so advantageous:
Among the 5,000 patients who took atorvastatin, the risk of heart attacks or stroke was cut by a third.
The story doesn't mention what the absolute numbers were. That could be a reduction from 3% to 1%, or it could be from 30% to 10%. The study hasn't been published yet, but I'm sure that we'll soon be urged to put everyone with high blood pressure on Lipitor, regardless of how great or small the magnitude of change actually is. Stay tuned.... posted by Sydney on
10/11/2002 08:05:00 AM
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Frozen Eggs: A British couple have a three month old daughter produced from a frozen egg, and apparently she's quite healthy. In the past, this was avoided out of fear that the resulting baby would suffer congential defects. It's good news that it works, because it saves women the pain of going through monthly egg-harvesting procedures when trying to conceive with assisted means:
The clinic attempted to meet the couple's wishes by producing just a couple of eggs to fertilise. But Mrs Perry produced far more than expected, and the clinic decided to try freezing them, using an "antifreeze" chemical to prevent damage.
They were stored, defrosted a few weeks later and fertilised by injecting Mr Perry's sperm directly into them. One developed successfully after being replaced in Mrs Perry's womb. Her daughter Emily is now three months old.
Using frozen eggs also eliminates the need to create multilple embryos at a time and the ethical dilemma that creates:
"We have really strong feelings that life starts at conception" Mrs Perry said. "We needed to know what would happen to the embryos that were actually produced from our treatment. And as it turns out, the way IVF is done at the moment, some embryos are discarded ... for want of a better word they are thrown away and we felt that as they're life we couldn't do that." posted by Sydney on
10/11/2002 07:53:00 AM
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Thursday, October 10, 2002
Quote of the Day: "When fascism comes to this country it will be wearing a white coat and a stethoscope"- New York City smoker interviewed today on NPR. posted by Sydney on
10/10/2002 08:29:00 AM
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Even the Wealthy: Elderly in the nation's tenth wealthiest county claim they can't afford their "life-saving" medication. I'm sure that a lot of that medication is expensive, but a lot of it probably isn't "life-saving," although doctors have come to paint just about every medication that way. Statins for cholesterol decrease the incidence of heart attacks by three percentage points, but they're sold to patients as drugs that will save their lives. When patients don't have to shoulder that cost, the truth about them gets glossed over. Physicians and patients would deal with these sorts of issues more honestly if they had to face their true costs. posted by Sydney on
10/10/2002 08:27:00 AM
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Preaching of Another Sort: The medical malpractice insurance crisis is tempting physicians to preach it in their practices. As strongly as I feel about the tort reform, this is just wrong. Politics don't belong in the exam room. That time should be devoted entirely to the patient's needs, with no distractions. If they want to campaign for tort reform, they should do it outside the office.
ANOTHER OPINION: From a reader - "I believe patients should hear from their physicians the difficulty and potential consequences to their health care from the medical malpractice crisis. Patients may hear these things on TV or read them in the papers and never think that it will affect them or their doctor. Look at how the lawyers get their messages out. Example: hospital employees are placed on retainers by lawyers for funneling so called injured patients in their directions. Have you looked at the phone book lately that's placed in every room throughout our hospital at least where there is a phone? I will bet you that there are ads on the outside for personal injury attorneys. The last one that I saw had a full page front cover ad attached with a light glue( for easy removal) on every copy. This is not a fair fight." posted by Sydney on
10/10/2002 08:17:00 AM
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..and Patience Worketh Endurance: Yesterday, Maureen Dowd attacked the candidate being considered for the job of running the FDA panel on women’s health policy. At first glance, I was horrified. Having an advocate of faith healing at the FDA would be like having an alternative medicine department at the NIH. But, as I read on, I realized that Ms. Dowd is indulging in hystrionics. He's not a faith healer. She sees quotes from the scriptures and the word “Jesus” and immediately gets a bad case of the vapors. Citing his nonmedical books, As Jesus Cared for Women, Stress and the Woman's Body, and The Reproduction Revolution: A Christian Appraisal of Sexuality, Reproductive Technologies, and the Family, she makes him out to be a whacko evangelical who’s out to put women back in reproductive shackles where they belong. But, the quotes she uses aren’t very convincing:
"Jesus stood up for women at a time when women were second-class citizens," Dr. Hager says. "I often say, if you are liberated, a woman's libber, you can thank Jesus for that."
And so we can. We can also thank Him for the end of slavery. It was Christianity that gave birth to the Enlightenment that in turn gave birth to the freedom and rights we take for granted in this modern world.
She goes on to quote a comparison he makes in one of his books between a patient and the Samaritan woman at the well:
He writes about a young patient named Sparkle who gets a job at a strip joint in Kentucky and becomes promiscuous and gets several sexually transmitted diseases. Sparkle reminds him of "a woman Jesus met who was generally known in her town as a sinner, but whom Jesus saw through eyes of love."
I still can’t figure out what’s wrong with this, other than it’s written for a Christian audience and has the words “Jesus” and “love” . What would MoDo rather the doctor do? Denounce his patient as a whore unworthy of his attention? Ignore the fact that her chosen lifestyle is harming her health? Presumably, he was using the comparison to illustrate that we are all worthy of God’s love and therefore each other’s love and regard, no matter what our pasts may hold.
She does cite a kind of creepy suggestion in one of the books for avoiding the temptation of lust - imagine Christ as a lover. I admit that the “Jesus as lover” thing is over the top, but there’s a long tradition in Christianity of portraying Christ as a metaphysical lover, so it isn’t as creepy as it initially appears. It’s just that it’s couched in the simple language of evangelical theology rather than the grand phrases of mainstream theology.
After disparaging him for his Christianity, she delivers her fatal thrust, alluding to an essay that appeared in his third book. It’s an essay that suggests that it’s unethical to use oral contraceptives because of their abortifacient properties. There’s only one problem. Dr. Hager didn’t write it. He doesn’t even agree with it. In fact, he prescribes birth control pills in his practice, although he doesn’t perform abortions, insert IUDs, or use RU-486. Apparently, the pro-choice litmus test is to be extended beyond judicial appointments, to scientific panel appointments as well.
It’s his position on RU-486 that really bothers MoDo. She sees his appointment as a Machiavellian move by Bush to abolish RU-486, and to extend the recent hormone replacement study to taint oral contraceptives. The pure and pristine scientific reputation of the FDA is at stake! It doesn’t seem to have dawned on her that RU-486 was approved by the previous adminstration in response to interest group pressure, or that the recent hormone replacement therapy trial that has scared everyone off hormones, and by her extension the pill, was initiated under Clinton.
Reading her column, you can’t help but get the distinct impression that Maureen Dowd is acutely uncomfortable with anyone who lives by their religious convictions. That’s the main thrust of her argument against Dr. Hager - that he doesn’t separate his life into secular and religious components the way Cuomo Catholics do. (Cuomo Catholics are people, usually prominent politicians from New York, who use their religion only for reputation enhancement and ignore all of its moral precepts whenever it’s politically convenient to do so.) It’s just not hip to live life honestly - it’s medeival. Yet, who could be so cold and uncaring as to treat sexually transmitted diseases day in and day out, as Dr. Hager does, and not advise their patients to avoid promiscuity?
By concentrating on books that Dr. Hager wrote for a popular audience as spiritual aides rather than medical treatises, Dowd ignores his professional work:
- “Comparative study of mezlocillin versus cefotaxime single dose prophylaxis in patients undergoing vaginal hysterectomy”
- “The choice of an antibiotic for women undergoing non-elective cesarean section.”
- “Nonimmune hydrops fetalis associated with maternal infection with syphilis.”
- “Modes of practice in OB-GYN infections.”
- “ The treatment of sporadic acute puerperal mastitis.”
Their titles aren’t as catchy, or as scary, and I’m sure they aren’t as fun to read as his works for lay audiences, but they are a more accurate reflection of his professional qualifications for the job. They don’t serve MoDo’s purpose, though. You can’t scare people with words like “hydrops fetalis” or “puerperal mastitis” half as much as you can scare them with the word “Jesus.” posted by Sydney on
10/10/2002 07:39:00 AM
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Wednesday, October 09, 2002
Amazing Sound:The Eyes Have It has a post with an amazing image of a 4D fetal ultrasound. I don''t know how accurate they are, either, but if they become commonplace, I bet abortion rates will go down even further. posted by Sydney on
10/09/2002 09:35:00 AM
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Pain and Profit: A reader sent this inside view of the influence pharmaceutical companies wield within academia, especially among the lecture circuit crowd:
I lecture on pain and the issue of the use of opiates is quite contentious. If you organize a conference and have someone lecture on why writing opiates may not always be appropriate you are deluged with drug companies offering money. The offer is to have a lecturer sponsored by them to tell the "other" side. The money offer goes up until you can't refuse it. Even a minor conference can get 6 figure grants. If you are willing to lecture on why narcotics are good(whatever the question) you will be sponsered around the country. No one sponsors speakers who suggest that narcotics can be a problem.
Pain as a specialty actually started with the realization that chronic narcotics are not appropriate for most patients with pain. Pain is a multifocal disease with a large suffering component. Narcotics have severe side effects including endocrine suppression from suppression of ACTH. The issue of narcotics is difficult to disuss at the APS and AAPM due to the membership you addressed. The leadership is mostly academics who are on the narcotic speaking circuit and academic nurses. There is little practicing pain physician input.
I’ve heard this sort of thing before from physicians who lecture, and it isn’t just limited to opiates and pain. It happens with drugs used to treat incontinence, cholesterol, diabetes and dementia, too. (The list could go on and on.) The dissenting voices are increasingly being silenced by financial pressures from drug companies - they can't get their results published and they can’t speak at conferences. posted by Sydney on
10/09/2002 08:27:00 AM
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Contractual Muzzles: Researchers, and anyone who may take over their projects, are often barred by their contracts with their pharmaceutical company benefactors from releasing negative data. An example:
The findings stemmed out of research into the contract signed by Nancy Olivieri, a University of Toronto hematologist at the Hospital for Sick Children. In 1996, when Olivieri was conducting clinical trails on the effectiveness of a drug forthalassemia patients, she discovered the drug was not effective in some patients and might even cause liver damage.
Apotex, the company which manufactured the drug and sponsored Olivieri's work, terminated the trials and issued a legal warning to prevent Dr. Olivieri from disclosing the risks to patients or publishing her findings.
Yet another reason why publishing favors positive outcomes and why authors of papers put the best possible spin on the most marginal of findings. (And why you can't assume that papers speak the unadulterated truth, even if they appear in prestigious journals.) posted by Sydney on
10/09/2002 08:23:00 AM
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Of Little Brain: Research suggests that hyperactive kids might have smaller than normal brains. It was a small study - only 152 kids were measured; and the differences in size were small - only 3 to 4%. There are definitely kids with ADD who have something wrong with their wiring. The problem is that a lot of kids get labeled with that diagnosis who aren’t really ADD. It would be nice to have an objective way to diagnosis the disorder, but I don’t think we’ll be measuring kids brains to do it anytime soon:
``The first thought people have is that this is a product of bad parenting'' or that it is environmental, said Dr. Daniel Coury, a professor of clinical pediatrics at the Ohio State University College of Medicine, who was not involved in the research. ``Having clear biological findings that this is something beyond the control of parents or the child themselves helps to remove that stigma.''
First Hand Account: A reader sent in this account of his group’s experience with a coy insurance company:
When our practice found itself working harder and harder and our compensation kept spiraling out of control, we decided to take a long hard look at reimbursements from our payers, when we received a letter from our major insurer that we owed them some ridiculous amount of money in supposed overpayments. The first step in our process was to collect information. Frankly, we never got much further than this. As naive as we may have been, we thought that it would be educational to know whether what an insurance company had agreed to pay us, they were indeed paying us. At this point we realized that our fee schedules were woefully outdated. We attempted to obtain updated fee schedules from the insurance companies. Our largest insurer, basically refused to release their fee schedule. We had no way to know whether we were getting paid what we were owed. It took us about 10 months of legal action, tens of thousands of dollars, which we really couldn't afford, and lots of meeting time with lawyers and insurers, before they agreed to release the fee schedule in piecemeal fashion. They would only release 20 codes at a time. We also asked them for a detailed list of all the supposed overpayments that we owed them. They were unable to supply this.
When we finally found out how little we were being paid for most of our procedures, significantly lower than Medicare in most circumstances, we attempted to renegotiate the contract. Basically, they then refused, stating that what we had been given was their fee schedule and they didn't negotiate. Take it or leave it! When our revenues finally equaled our expenses, and there was little left to take home for our families, we left it. posted by Sydney on
10/09/2002 08:19:00 AM
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Persuasion:The Bloviator is upset with me again. He always gets upset when I write about lawyers or public health. Hits too close to home. The issue this time is my TechCentralStation column on bioterror preparedness. He says its hearsay and not based on fact, and that I would castigate any research paper of the same ilk. I certainly would. Research papers should never be written as opinion pieces. The column is an op/ed, not a research paper, and not investigative journalism. Even then, my points aren’t based on hearsay. They’re based on what reporters from around the country have written about their state and local health department efforts, what the HHS has made public about funding, and what those in the field have said about public health attitudes.
On the smallpox vaccine issue, we’re just going to have to agree to disagree. He doesn’t consider it much of a threat. I do, and I feel strongly that everyone should be given the opportunity to protect themselves from it if they desire. Even Ross admits that the logistics of giving mass vaccinations after an attack would be horrendous and llikely to tax the public health system beyond their means. This is certainly true, and all the more reason we should be offering pre-attack voluntary vaccination.
Online Exhibit Watch: The National Library of Medicine has an exhibit of anatomical art. They neglected, however, the very strange and disturbing eighteenth century art form of wax modeling. posted by Sydney on
10/08/2002 07:06:00 AM
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The Better Part of Valor? The nation's medical societies are going public with their reservations about voluntary smallpox vaccination. I had my say about the American Academy of Pediatrics and their stance yesterday. It’s really disingenuous of these organizations to make public statements when they’ve made no effort to debate or examine the issue themselves. They’ve only done what they always do, and that is to accept the recommendations of the Advisory Panel on Immunization Practices indiscriminately. These groups, the AMA, the American Academy of Family Physicians, and the American Academy of Pediatrics made their positions known in June when the Advisory Panel announced its decision. The people who head up the academies’ own committees also sit on the Advisory Panel. It’s unfortunate for all of us that they’ve decided to take a public stance without actually considering the issue and its implications for their physician members and the patients they treat.
And Another Thing:: It just amazes me that one year after the anthrax attack these officials can't expand their imaginations to accept the very real threat of bioterrorism. Yes, smallpox vaccination isn't as benign as our current immunizations, but its risks are lower than the disease by a factor of 300,000. Smallpox kills one in three of the people it infects. Smallpox vaccination would be expected to kill only one in a million. posted by Sydney on
10/08/2002 06:54:00 AM
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Malaria Update: Officials think the recent Virginia outbreak might be from migrant workers:
Wirtz said it's likely that people who picked up malaria overseas are in the area and that they had infected the mosquitoes. Some of them might not have symptoms of the disease, he said. Also, while it is rare to see so many malaria-carrying mosquitoes in one place in the United States, it could happen, he added.
"They've got a lot of migrant workers in the area," Wirtz said. "It just might be, like an alignment of the stars, a lot of things are just coming together."
Cost of Health Care From the Frontlines: A reader sent me the following email on trial lawyers, health insurance, and the cost of medicine:
...the bureaucratic inertia and slow paying you described so well in a recent medpundit piece indict the health insurance industry. I have seen the forms processing from the inside as a computer consultant, and I can assure you that the 15-30% administrative overhead the insurance companies add to health care is primarily a paper shuffling waste of time.
Efforts to make the trial lawyers the primary cause of health cost inflation have one essential fault. The argument just isn't true. I think the case about health care is made most eloquently with a simple pie chart. Everyone who I have ever talked to about these issues is stunned to find that physicians only make 20 cents out of every health care dollar. When they realize that insurance companies take an equivalent amount that represents pure overhead, they begin to see the shape of the problem more clearly.
I agree. The malpractice insurance crisis isn’t driving up the cost of healthcare. It’s doing something much worse - limiting the access to health care. Doctors can’t raise their fees to make up for their increased malpractice insurance rates. Our system won’t let them. Fees are determined by Medicare and the by the insurance companies. So, when the overhead becomes too expensive, as it has with the malpractice insurance premiums, doctors have no choice but to go out of business. When it comes to the high cost of healthcare, it’s the insurance companies and our indiscriminate use of drugs that have cost us so much.
In the long run, most people would be better off if they paid their every-day outpatient medical expenses themselves, as my correspondent has discovered:
We ran the figures for my wife, a Type II diabetic. Between her quarterly doctor visits, quarterly lab tests, six medications, and disposable supplies, her care costs about 300 bucks a month. Her school district is paying $800 a month for both of us and we are now paying co-pays of about 150 per month. She would qualify as a reasonably high risk patient, but the insurance company is still making 450 a month on our little family. Something is wrong with this picture, and until we have a widespread national debate, nothing is going to change.
Yup. Like all middlemen, the insurance companies don’t offer much except increased administrative and cost burdens.
The same reader also sent along this link about a bill introduced yesterday by Senators Wyden and Hatch that proposes a national dialogue on health care costs and how best to approach them. I’m not sure if Congress is the right venue to answer this question.Their other foray into healthcare, Medicare, isn’t much better than private health insurance. In fact, it’s a lot worse. posted by Sydney on
10/08/2002 06:11:00 AM
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To Boldly Go... The New York Times has an interesting profile of one of the men who recieved an artificial heart. He was dying, and chose to be part of an experiment, but throughout the account you get the feeling that he never realized the full extent of what he was getting into. There are references to his expressed hope of going home eventually after the procedure, but the doctor and biotech executives make it sound as if that was never a realistic expectation. It’s as if everyone was focused on their own hopes and aspirations with little regard to the patient’s. Accounts like this one, from his surgeon, only reinforce that impression:
By Thanksgiving, Mr. Quinn was not only walking, but also riding a stationary bike. "We were astonished," Mr. Berger said. Elena Holmes, the nurse practitioner who supervised Mr. Quinn's care and rarely left his side, cooked a big turkey. Dr. Samuels wrote the couple a note, thanking them for changing his life.
On Dec. 6, Dr. Samuels introduced his patient to the press. In the middle of the news conference, Mr. Quinn's young grandson ran onstage to give his grandfather a hug. "I couldn't have staged it better if I was a Hollywood producer," Dr. Samuels said. "It was just so beautiful. And he looked fantastic."
Mr. Quinn never made it home. He died of complications. The doctor asked to give a eulogy at his funeral. Mrs. Quinn turned him down. I don’t blame her. It probably would have been more about the heart and the surgeon than the man. posted by Sydney on
10/08/2002 06:05:00 AM
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Give Me Your Tired, Your Poor, But Not Your Old: The field of geriatrics is having a hard time finding recruits:
Warshaw, who studied geriatric medical training, said today's medical students are attracted to almost every other specialty but geriatrics.
I have to confess, I’ve never found the idea of treating one particular age group over others very attractive, either. I once wanted to be a pediatrician. Then I did a rotation in a private pediatrician’s office during medical school and realized that if I spent all day listening to children screaming and crying, I’d soon lose my mind. At least in pediatrics the patients are predominantly healthy; in geriatrics they’re predominantly ill. In pediatrics there's the satisfaction of watching your patients grow and mature, but in geriatrics there's only approaching death. It takes a very special person to be able to endure that kind of strain and still find enjoyment in the job. It’s much more satisfying to see a diverse patient population. But, then, that’s why I’m a family physician. posted by Sydney on
10/08/2002 06:00:00 AM
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Monday, October 07, 2002
Fresh Air on Smallpox: Terri Gross interviews Richard Preston, author of The Demon in the Freezer: A True Story, a book about smallpox and anthrax. Good interview. He mentions that in his round of interviews with experts, he found the CDC scientists the most non-chalant about smallpox, and the military doctors most anxious about its potential threat. He's also in favor of voluntary mass vaccination, and does an excellent job of explaining the short-comings of the ring vaccination theory.
UPDATE: DB's MedRants pointed out this article from the New York Times about the American Academy of Pediatrics position on smallpox vaccine. They favor the ring vaccination technique of days of yore when immunity was high. Their reason:
Potential side effects are too severe, and available vaccines have not been tested on children, who may be at higher risk for bad reactions, the academy said in a policy statement released Monday.
``We're talking about a disease that hasn't existed in the world since the 1970s and a vaccine that we know can cause death,'' said Dr. Julia McMillan, a Johns Hopkins School of Medicine pediatrics professor and co-author of the policy.
Smallpox vaccine was used in children for years. It used to be a mandatory childhood vaccine. We know perfectly well how children respond to it. Smallpox does exist in the world, that's the problem. It's sitting in labs here and in the Soviet Union, and God knows where else. (Listen to the above Fresh Air interview to hear the details on why there's a good possibility Iraq might have it.) I've discussed the AAP's position on smallpox vaccination in detail before, but the bottomline is that a lot of their own committee members were the same ones who were on the CDC's Advisory Panel on Immunization Practices, so it's no surprise that they're clinging to the discredited ring vaccination. That's a shame. They're putting the nation's children at risk. Children have no immunity, and they have higher mortality rates. I wouldn't hesitate to have my own children vaccinated if it were offered tomorrow. posted by Sydney on
10/07/2002 07:41:00 PM
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Malpractice Crisis Update: As usual, Overlawyered has an excellent round-up of the current state of affairs of the malpractice crisis. posted by Sydney on
10/07/2002 08:23:00 AM
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More Smallpox: The shift in thought toward voluntary pre-attack vaccination continues:
"We live in a society that values individual choice," said Julie L. Gerberding, director of the Centers for Disease Control and Prevention. "If we have vaccine and we have data to accurately assess the safety, one school of thought is that informed people may want to have the choice of getting vaccine or not."
Anguish Hath Taken Hold of Us, and Pain: Pain is all the rage these days. Doctors have been told that they undertreat it, the public have been told that they suffer too much from it, and its assessment has been raised to the status of a vital sign. It’s no longer adequate to record in our records that the patient was in “no acute distress” or that he was “writhing in pain,” we have to assign it a number from 1 to 10. We’ve been told that we must eliminate every pain if we are to practice good medicine, even if it takes hefty doses of narcotics. There’s a lot wrong with this approach. Pain, especially chronic pain, is an extremely complicated entity. There is pain caused by physical wounds. That kind is easy to recognize and to treat. There is pain caused by purely emotional wounds - more difficult to recognize and much more difficult to treat. Then, there’s the most difficult of all - pain caused by both. There’s also a “pity-wanting pain” that makes us complain of pain for the sake of the pity it will gain us. Pain isn’t a vital sign. It can’t be adequately represented by a simple numerical scale. And, in some cases, it can’t be eliminated with all the morphine in the world.
Vital signs are just what their name implies - objectively measured signs of life. There are four of them: pulse, respiratory rate, blood pressure, and temperature. If any of them are a zero, the patient is dead. Pain is a symptom not a sign. I have had patients amble into my office with pleasant smiles and nimbly jump up on my exam table and tell me their pain level is a ten. On the other hand, I’ve had patients hobble in with a grimace and tell me their pain level is a two. Pain cannot be measured. It’s purely subjective. And the absence of pain, unlike true vital signs, does not equate with death.
So, how did pain come to be considered and accepted as a vital sign? That was the work of the American Pain Society, a group founded in the 1970’s by pain researchers, some of whom worked in the pharmaceutical industry. In the past several years, the APS has branched out from research into making treatment recommendations and lobbying Congress to keep narcotics freely available. At first glance there may seem to be nothing wrong with this, they’re an organization of pain experts, after all. But how expert are they? And at what are they experts? The greatest percentage of their membership come from specialties that don’t treat patients in on-going relationships, such as anesthesiology (30%), or who have no background in treating patients pharmacologically, such as nursing (12%), and psychology (15%). Membership also includes those wholly employed by the pharmaceutical industry: clinical pharmacy (3%) and clinical research (2%). They may be experts on treating pain within their fields, but none of them have any experience in dealing with the long term consequences of the liberal use of narcotics.
It’s even worse when you look at the list of their corporate donors. It’s chock full of companies with a vested interest in promoting narcotic use:
- Purdue Pharma, makers of OxyContin and all its "oxy" brethern
- Roxane Laboratories, makers of acetaminophen with codeine, just plain old codeine, methadone, hydromorphone, meperidine hydrochloride (generic demerol), morphine, various oxycodone products, and Roxanol (concentrated morphine) to name just a few.
- Whitehall-Robbins owned by Wyeth, makers of the muscle relaxer Robaxin, as well as other non-narcotic pain medication.
It’s not unusual for medical societies to get funding from drug companies, but it is unusual, as the American Pain Society has, to earmark some of the donations specifically for the financing of a clinical treatment guideline. These companies pay at least $5,000 a year (warning: pdf file) to be corporate members, some of them pay even more for special status, and some are identified as donors who support the APS works in progress, Pain Management for the Primary Care Clinician, and Clinical Practice Guidelines. No doubt they expect some influence in what those guidelines will say.
UPDATE: Lest you think that the American Pain Society is alone in its reliance on narcotics manufacturers for funds, here’s a list of donors to the American Academy of Pain Medicine.
posted by Sydney on
10/07/2002 07:22:00 AM
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Sunday, October 06, 2002
Conjoined Siblings Successfully Separated: Separation of conjoined twins is nothing compared to this. posted by Sydney on
10/06/2002 10:39:00 AM
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Mosquito Menace: Thanks to Moira Breen for pointing the way to this fount of malaria information. And here’s more, complete with microphotographs.
Bloviator Response Part II: I’ve been considering Ross’s challenge regarding the issue of physician self-regulation. He’s wrong that we make no effort to regulate ourselves, but he’s right that it could be a lot better. Something’s wrong with a system when a doctor who loses his license in one state resurfaces in another without even taking the effort to change his name.
Self-regulation within medicine varies greatly from state to state and from specialty to specialty. State’s have different requirements for continuing medical education to maintain licensing, and specialties have different requirements to maintain board certification. A physician doesn’t have to be board certified to practice medicine, or even to be a member of a specialty. To be a “general practioner” he need only complete one year of internship and pass the national medical boards, the licensing exam we all take during medical school and again at the end of our internships (or first year of residency.) There was talk some years ago of changing this, of requiring that everyone be certified by a specialty board to practice, but at that time it would have left a lot of very competent, experienced older physicians out in the cold. They entered the field before the dawn of specialty training. So, the measure wasn’t adopted. As time goes on, that objection becomes less and less compelling, so in a few more years we may see certification become necessary to practice.
To be board certified, a physician has to complete a residency in his field and then pass an exam. For family physicians, the residency is three years, for surgeons it can be as long as six years. Some specialties (family practice, pediatrics, emergency medicine, and internal medicine as far as I know. There could be more), require members to take re-certifying exams every seven years to remain board certified. Failure to pass the exams doesn’t limit the ability of a physician to practice medicine, but it does make it harder to stay credentialed by insurance companies and to remain on hospital staffs (unless they’re hard up for staff), as well as to get good malpractice insurance. Many would argue that passing an exam is no indication of one’s worth as a doctor, in some cases they’re right. How can you assess a surgeon’s skill with a written exam? He could have all the smarts in the world and pass a test with flying colors but be a total klutz in the operating room. But still, the tests at least provide a basis for judging basic medical knowledge.
Most states require doctors to attend a certain number of hours of continuing medical education (CME) programs each year to maintain their licenses. Specialty boards also require this to maintain certification, at least the ones with re-certification programs do. All CME programs are not created equally, however. Some are little more than drug company junkets, and the states often make no distinction between those and the more reliable programs sponsored by the national professional societies, or at least accredited by them. The certifying boards, however, do make a distinction, and they require that the majority of CME hours come from accredited programs.
I think what really bothers Ross, however, is our failure to come down hard on physicians who practice outside the pale of what most of us consider good medical practice. He was very upset about the over-sympathetic physicians described in my post and in the New York Times last week. This is always a very difficult issue, because a good deal of medical practice is more art than science, and our responses to our individual patients can’t be made in cook-book fashion. Sometimes, our colleagues don’t do things the same way we would, but our way isn’t necessarily the only way, or the infallibly right way to do things. Case in point is the issue of pain treatment. As recently as five years ago, the standard of care was to move with caution when treating chronic benign pain because it is so often complicated by emotional factors. Now, the standard of care has become to treat pain as the “fifth vital sign” (that’s a topic for a whole ‘nother rant) and to use narctotics liberally to alleviate it. I happen to think that approach does more harm than good, as do a lot of other physicians, so I continue to take the cautious approach and avoid addiction and dependence in my chronic benign pain patients. But, someone who believes strongly that all pain must be completely alleviated could accuse me of practicing bad medicine. Whether their accusation sticks or not would just depend on the political environment at the time. Personally, I’d rather not go about censuring physicians based on so-called “quality of care standards” because the standards themselves are always changing, even when they aren’t adopted under the influence of lobbyists.
In the absence of harm, it’s also difficult to restrict a physician’s ability to practice without violating their civil rights; especially if that restriction is based only on style. A surgeon in my hospital had his privileges suspended because of quality concerns a few years ago. He sued both the hospital and the chief of surgery, winning over a million dollars in damages. That sort of judgement makes everyone wary of pointing fingers. posted by Sydney on
10/06/2002 10:28:00 AM
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