"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
Medical Complicity: A couple of readers have sent me links to this New England Journal of Medicine essay on torture (available in full without registration or subscription.) It's from the July 29 issue, but appears to be making the internet rounds just now. Evidently the Democratic convention distracted everyone, including the mainstream media, from noticing it.
I should have known it would be a topic of interest when I found my husband reading the essay in my dead-wood copy of the Journal. He never touches my medical journals, having zero interest in all things medical and a tendency toward squeamishness. But he saw the title "Doctors and Tortures" on the cover and couldn't resist. And, though I've touched on the subject before, it's worth revisiting, especially since one of my most prolific correspondents sent the link with the comment, "Ahhh, Germany 1936....."
Here's the essay in a nutshell:
There is increasing evidence that U.S. doctors, nurses, and medics have been complicit in torture and other illegal procedures in Iraq, Afghanistan, and Guantanamo Bay. Such medical complicity suggests still another disturbing dimension of this broadening scandal.
...American doctors at Abu Ghraib and elsewhere have undoubtedly been aware of their medical responsibility to document injuries and raise questions about their possible source in abuse. But those doctors and other medical personnel were part of a command structure that permitted, encouraged, and sometimes orchestrated torture to a degree that it became the norm — with which they were expected to comply — in the immediate prison environment.
The doctors thus brought a medical component to what I call an "atrocity-producing situation" — one so structured, psychologically and militarily, that ordinary people can readily engage in atrocities. Even without directly participating in the abuse, doctors may have become socialized to an environment of torture and by virtue of their medical authority helped sustain it. In studying various forms of medical abuse, I have found that the participation of doctors can confer an aura of legitimacy and can even create an illusion of therapy and healing.
The first is a New York Times story that mentions two doctors, two medics, and a nurse who noted suspicious injuries and did nothing at Abu Ghraib. The story makes it seem as if the entire prison medical staff was complicit in the torture, just as most of the media coverage has made it seem that torture was more wide-spread than it was at the prison. Other first hand accounts suggest this isn't true. No doubt, there were some doctors and medics who noticed suspicious injuries - and the sum total of them were mentioned in the New York Times article. Abu Ghraib was a very big place. Torture happened in a small portion of it, under the command of some very bad apples. Bad apples, it should be pointed out, who are now facing the possibility of a life in prison themselves - up to 38 years in prison for Lynndie England.
The second source is a story from the Washington Post that says that interrogators were allowed access to Guantanomo prisoners' medical records. The implication is that they could use information from the records to gain leverage in their interrogations. This may come as a surprise to most people, but even here in the United States, law enforcement officials have access to medical records. This particular issue isn't a clear-cut example of complicity in torture on the part of U.S. military doctors. For one thing, there's no torture involved, only interrogating. For another, whether or not captors should have access to captives' medical records is a matter of some controversy.
The third is a story from USA Today on deaths of Iraqi prisoners which a medical examiner ruled were due to cardiovascular causes, but which may - or may not - have been heat-related. The deaths are all under investigation by the military. The medical examiners in each case but one, listed the cause of death as "cardiovacular related" rather than heat related. Lifton accuses them of falsifying death certificates, but there's a good chance that those medical examiners believed the cause to be cardiovascular and did not suspect the heat. There would be no way to tell the difference, not even with an autopsy. The medical examiners would have to rely on the history given by the dead man's keepers. And they, too, may have not credited the heat. The cases are still under investigation, in any case. It's a stretch, and a libelous one at that, to accuse the medical examiners of falsifying death certificates at this stage of the game.
To his credit, Lifton acknowledges that the U.S. military doctors in the press stories are far from the Nazis he interviewed for his book. But still, he makes too many sweeping generalizations about U.S. military medical personnel and torture. The majority of doctors, medics, and nurses in the military, and the military in general, I believe, hold themselves to a higher standard than those five whose stories made it to the New York Times.
Race and Medicine: I was going to post something about this study showing that racial disparaties in medical care are due to geography and poverty, not racism, but Sally Satel beat me to it:
It is important to recognize that many of the physicians working in black communities are hardworking, committed individuals who make considerable financial sacrifices to serve their patients. As Dr. Bach's team notes, they deliver more charity care than doctors who mostly treat white patients and derive a higher volume of their practice revenue from Medicaid, a program whose fees are notoriously low. They are often solo practitioners who scramble to make good referrals for their patients but who are stymied by a dearth of well-trained colleagues and by limited entrée to professional networks with advanced diagnostic techniques.
It is long past time to put aside the incendiary claim that racism plays a meaningful role in the health status of African-Americans. The health gap is assuredly real. But growing evidence suggests that the most promising course is to get well-trained doctors into low-income and rural neighborhoods and enable them to provide the best care for their patients--something they will do, it somehow needs to be said, without prejudice.
She's right. If a similar study were done comparing doctors who practiced in rural communities with those who practiced in suburbs, the findings would likely be the same. Sometimes, you've got to do the best with what you've got.
UPDATE: Some thoughts from a radiologist:
I cannot echo the sentiments described on your site regarding this issue enough. Yes, there are physicians who cater only to well paying customers, and frankly those physicians are color blind except for one color, green. They will treat anybody who pays.
The rest of us, for the most part, are color blind except where the color of the skin may have clinical significance. Practicing in a large radiology group which covers a wide geographic area which encompasses the complete spectrum of American society from urban to suburban to rural, we see it all. Yes, we do have a facility to cater to the needs and comforts of the well insured, this is a necessity because we must survive and if we don't do it, somebody else will . I practiced in a practice in Cleveland where we were prohibited from doing this and we eventually had to fold, because we could not survive, though, we had plenty of work, but NONE of it paid. Our jobs were picked up by the Cleveland Clinic, and I am now aware that they have been named in that lawsuit regarding their tax exempt status and their questionable level of charity care, and my former hospital is named in this suit.
The majority of our present professional staff sits smack down in the middle of urban neighborhoods, close to everyone. We serve all, no questions asked. I do not know or care abour insurance information when I interpret or perform a study. Most of what I do is very expensive and everyone gets the service if needed whether they can pay or not. If we are so busy downtown that people cannot be served right away, we send them over to our swanky private office so we can take care of them right away. The amount of medicaid and charity care we provide is staggering. If we didn't have those who can pay or are well insured, we could not provide this service, because it COSTS us money to see every patient. If we get nothing back we cannot stay in business.
That said, we can not be responsible for the behavior and lifestyles of any ethnic subsector of the American population. I cannot force them to show up for appointments, see the doctor when needed, take their medication, or make the correct lifestyle choices. This is America. People may choose freely to live, to die, or how they choose to live.
Sullivan doesn't have to think hard anymore about doing something; he simply does it the way he always did. 'I feel my hand when I want to pick something up, then I just close my hand,' he said. When he wants to grab a bottle of water, for instance, the computerized arm moves forward, the elbow bends and the mechanical hand grasps the bottle, bringing it to his lips, as his natural arm once did.
It has its drawbacks, though:
It feels so natural, in fact, that Sullivan forgot himself this summer and yanked off the mechanical hand trying to start a lawn mower. The arm had to be sent back to the Rehabilitation Institute for repairs.
What Do We Know: A study out today in the New England Journal of Medicine suggests that doctors may have been too hasty and careless in their adoption of a previous study regarding the treatment of heart failure. In 1999, the Journal published a study known by the too-cute acronym RALES (It stands for "Randomized Aldactone Evaluation Study", but "rales" is also the name for the sound we hear when we listen to lungs full of fluid from congestive heart failure), which suggested that the drug spironolactone is the better choice among diuretics for severe heart failure. But spironolactone has the side effect of raising potassium levels as do several other drugs commonly used for congestive heart failure. One of those other drugs is the class of drugs known as ACE inhibitors, a class which is also especially prone to raising potassium levels. Not surprisingly, using the two of them in combination has taken its toll :
The Canadian researchers examined whether the use of spironolactone had increased after the 1999 research, and what impact it was having on patients who take a standard ACE inhibitor and had been sick enough to be recently hospitalized. ACE inhibitors relax the blood vessels and lower blood pressure but can contribute to high potassium when combined with spironolactone.
The researchers tracked prescription and hospital records from 1994-2001 for about 1.3 million residents of the province of Ontario who were over 65.
``We found when the drug took off in mid-1999, so did rates of hospitalization for high potassium and deaths in hospital associated with that,'' said Juurlink.
Prescription rates for spironolactone increased fivefold, and hospitalizations and deaths from high potassium tripled. The number of heart patients hospitalized jumped from 4 to 11 per 1,000; deaths rose from 0.7 to 2 per 1,000.
In Ontario alone, researchers estimated that broader use of spironolactone resulted in 73 additional hospital deaths and 560 more hospitalizations in 2001 than would have been expected.
One of the RALES researchers told the AP:
``This reflects the lack of education of doctors, I think, and that's what worries me most,'' said Remme, director of the Sticares Cardiovascular Research Institute in the Netherlands.
What it may actually reflect is the overeducation of doctors. It's true that as a group we are often too quick to embrace treatment recommendations that come out in studies without considering the likely long-term consequences. The studies get quoted and promulgated via educational conferences and practice guidelines, and before you know it, they become the standard of care. Doctors don't like to buck the standard of care. It makes us look like we're behind the times or worse, stupid. So no one ever stops to question the wisdom of piling all of these new treatment recommendations onto one patient.
That's what has happened here. The ACE inhbitors are so strongly recommended for patients with heart failure, that their use has become a standard of quality against which physician performance is measured by insurance companies. Add to that the spironolactone and you have a recipe for disaster. What's even more alarming is that for some doctors, meeting those standards is more important than what's going on with the patient. The insurance companies will audit their charts for ACE inhibitor prescriptions, but not for hyperkalemia or other side effects. Case in point - one of my patients developed hyperkalemia as well as early signs that her kidneys were stressed while on an ACE inhibitor and spironolactone. I stopped them both, but her cardiologist told her to restart the ACE inhibitor. When I questioned him he said that he would rather she have a slighlty higher potassium level and mild renal insufficiency and stay on the ACE. He felt the benefits outweighed the side-effects. I thought he wanted his treatment record to look nice. I ended up admitting her for acute renal failure a week later, caused by her ACE inhibitor. Only then would he admit the drug wasn't a good choice for her.
The treatment of congestive heart failure is only one example in which the adoption of treatment guidelines are outstripping our knowledge of the consequences of that treatment. Diabetics are routinely on several different classes of medications to meet standards of care in everything from their blood sugar control to cholesterol to the functional capacity of their kidneys. And each of those medications has the potential to interact with one another. The more medications any one person takes, the more likely there will be drug interactions.
This used to be a cornerstone of good medical therapy - avoiding what we call polypharmacy. But in the past ten or so years, that cornerstone has been neglected as we rush to adopt the best and latest drug therapy to reduce every conceivable risk. No one has bothered to study whether or not we might be doing more harm by prescribing all those drugs to meet our guidelines. Until now. Let's hope this kind of study catches on.
Kerry MedMal Tort Reform: The Kerry campaign let go a trial balloon of their tort reform intentions, including a proposal to do away with punitive damages in all but the most egregious cases. But, the professional liability law blog DeclarationsandExclusions points out there's probably not a whole lot of "there" there:
In many states, the proposed changes to punitive damage law would be no change at all, while in others a "gross negligence" standard would actually expand punitive damage claims. Under current California law, for instance, "negligence" no matter how gross will not support a claim for punitive damages, which are permitted almost exclusively in cases of intentional wrongdoing and "despicable" conduct.
It's a therapy quietly championed since the early 1990s by a California physician who's earned the nickname Dr. Maggot. But Dr. Ronald Sherman's maggots are getting more attention since, in January, they became the first live animals to win Food and Drug Administration approval as a medical device to clean out wounds.
A medical device? They remove the dead tissue that impedes healing 'mechanically,' FDA determined. It's called chewing.
But maggots do more than that, says Sherman, who raises the tiny, wormlike fly larvae in a laboratory at the University of California, Irvine. His research shows that in the mere two to three days they live in a wound, maggots also produce substances that kill bacteria and stimulate growth of healthy tissue.
Researchers found that women with the lowest levels of 'Good' HDL cholesterol showed a risk of developing breast cancer up to three times greater than women with the highest levels of HDL.
'Low HDL-C, as part of the metabolic syndrome, is associated with increased postmenopausal breast cancer risk,' conclude the authors.
The study isn't completely available online, only the abstract is. And the data are only presented as "relative risk," a method favored by medical researchers to exaggerate the claims of their data. But don't expect that to stop drug companies from hyping their cholesterol lowering products as preventives for breast cancer. posted by Sydney on
8/04/2004 08:21:00 AM
0 comments
In a report released in St. John's yesterday, the task force recommended the provincial cabinet authorize health officials to release to police information on individuals suspected of criminal activity to feed their drug habit.
'Currently the police are limited in their ability to initiate investigations and access information,' said Newfoundland Justice Minister Tom Marshall.
If approved, the unusual move would allow health officials to release information only if there is evidence of criminal activity, Marshall said.
The Newfoundland government will consider the recommendation this fall, Health Minister Elizabeth Marshall said. 'There's a concern with respect to people's right to privacy and we're trying to balance that against the public good.'
Sure and that will be a fertile ground for lawyers, deciding what constitutes "evidence of criminal activity." A good argument could be made for allowing access to pharmacy sales records in cases like this, but not to hospital or doctor records. There's often a lot of other, unrelated information in doctors' treatment notes that would have nothing to do with the crime at hand and which would be nobody's business. Even drug abusers see doctors for legitimate reasons now and then, after all. And they don't usually schedule separate appointments for their genuine medical problems and their drug-seeking ones. posted by Sydney on
8/04/2004 07:58:00 AM
0 comments
Tuesday, August 03, 2004
Scanning for Alzheimer's: The state of the art of brain imaging is not yet ready for prime time when it comes to detecting Alzheimer's disease, but that isn't stopping some intrepid entrepeneurs:
Alzheimer's researchers said commercial firms already have begun advertising brain scans to detect Alzheimer's, a practice they said had little value for most people and may even been detrimental.
'People are going to make money on these PET scans; there's no question about it,' said Michael Weiner, chairman of the neuroimaging working group of the Alzheimer's Association and a professor of medicine at the University of California, San Francisco.
In the last two years, positron emission tomography (PET) has developed to the point where it can detect the so-called plaques and tangles of proteins that accumulate in the brains of people with Alzheimer's disease. There also have been advances in magnetic resonance imaging.
Still, except for research applications and very limited other uses, the technology has little value to the general public, according to several scientists who presented research here at the Ninth International Conference on Alzheimer's Disease and Related Disorders.
'I have reservations about everybody jumping on the bandwagon,' said Shi-Jiang Li, a professor of biophysics at the Medical College of Wisconsin who is developing MRI scans to detect Alzheimer's. 'I think abuse is the right word.'
Li noted that many healthy people in their 50s may have some plaques and tangles in their brains, but at the moment there is no way to determine if they will develop Alzheimer's disease.
Caveat Surfer: Internet sites that sell cancer cures are not the best sources of advice, according to a recent study in the Annals of Oncology:
The study examined 32 of the most popular cancer treatment websites, each of which received tens of thousands of visits every day from around the world, and analysed their claims. It found that not one of the multitude of treatments or medications advocated could be proven to cure or prevent the onset of cancer.
..."We found that between these 30-odd sites, 118 different cancer 'cures' were recommended," said Professor Ernst. "None of these can be demonstrated to cure cancer. A significant proportion recommends not using conventional treatments, which implies a significant risk to patients."
Dr. Lieberman's Diagnosis: Senator Joseph Lieberman on Howard Dean, who told CNN that this week's raised terrorism alert was politically motivated:
"I don't think anybody who has any fairness or is in their right mind would think the president or the secretary of homeland security would raise an alert level and scare people for political reasons," said Lieberman, who also sought the Democratic nomination for president. "That's outrageous." posted by Sydney on
8/03/2004 08:20:00 AM
0 comments
Monday, August 02, 2004
Can't Get No Respect: Activists for the calorically challenged say the current anti-obesity crusade is like a witch hunt. The overweight truly can't get a break, not even in the court room, where justice is supposedly blind:
Walter Lindstrom, a San Diego attorney specializing in weight-discrimination cases, said overweight plaintiffs usually must prove that acts of bias against them are covered by federal laws prohibiting discrimination against disabled people.
'These cases are more difficult from a proof standpoint, and also because you're dealing with a very unpopular class of clients,' Lindstrom said. 'Juries are generally disgusted with your average size-related plaintiff. You have to get past that, and have them see the plaintiff as someone with a true medical problem.' posted by Sydney on
8/02/2004 10:31:00 PM
0 comments
Reminder: Today at Overlawyered, I look at Edwards's money men, trial lawyer money in North Carolina, and the plight of one North Carolina family doctor. posted by Sydney on
8/02/2004 08:55:00 AM
0 comments
Granting Wishes: Once upon a time, when a child had short legs (or one leg shorter than the other), the only way to treat it was a very Frankensteinian surgery that involved metal devices, bone breakage, and stretching. Today, in Britain, bones can be lengthened electromagnetically:
The 'revolutionary' bionic prosthesis, which was six years in the making, enables the extension to take place at an out-patient appointment.
During the procedure, which takes about 15 minutes, the leg is placed through a special electromagnetic device.
The device is activated and the implant is extended by a specified amount.
The procedure takes about 15 minutes and the patient experiences no pain or discomfort and is free to go home immediately after the treatment.
Incestuous Amplification: Jerome B. Kassirer, former editor of the New England Journal of Medicine has an op-ed in today's Washington Post that takes the authors of the new cholesterol lowering guidelines to task. Kassirer has long been a vocal critic of the incestuous relationship between the pharmaceutical industry and medicine, and he makes a good point in his op-ed:
Better still, we should dissuade leading physicians from doing non-scientific work for pharmaceutical makers. Doctors who want to be respected as independent authorities should not become paid speakers for drug companies or consult with the industry on marketing issues. These arrangements do not benefit medicine or improve patient care; they only promote the profit goals of the companies. We should save the prized task of preparing clinical practice guidelines for experts without such conflicts. After all, having a financial conflict is voluntary; physicians can either take it or leave it. We must convince them to leave it.
Virtual Education: Free streaming videos of surgical procedures to educate surgeons. The "normal anatomy" video under Gyn Laparoscopy is a particularly nice view of the uterus, ovaries, and fallopian tubes. posted by Sydney on
8/01/2004 08:34:00 AM
0 comments
