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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Tuesday, January 07, 2003

    E-Medicine: More and more tertiary care centers are offering online consultations, sight unseen, as in the case of this woman who wanted a second opinion about a CT scan result:

    In Warner's case, she recently grew frustrated by the long waiting lists to get appointments with the nation's top neurosurgeons.

    ``This could be a tumor, and I didn't want to let that sit around,'' she said. ``I was worried sick.''

    When she logged onto the Cleveland Clinic's Web site in search of information, she found a link to an online second opinion service...

    She immediately gave her credit card number, filled out her medical history online and sent all her films and records to the Cleveland Clinic for review.

    Five days and $565 later, a Cleveland Clinic neurosurgeon sent her a report via e-mail confirming what her local physician suspected: The mass was a harmless, non-cancerous cyst.

    That might be fine for a second opinion radiology report, but caution should reign when applying it to most diseases. E-medicine provides only part of the equation that a doctor needs to assess a disease or a condition adequately. The physical exam plays a large part in wise medical decision making:

    `Physicians who cannot examine a patient miss out on a lot of important information that isn't in a written or electronic record,'' she said. ``They can't see the person in front of them, so you lose all those personal things, from tone to body language -- the types of things you develop as a physician.''

    For that reason, some hospitals won't provide online consultations or only offer them to international patients who can't get to the United States.

    ``By and large, I think the feeling of our physicians is if they're going to give a second opinion, they want to see the patient here,'' said Gary Stephenson, spokesman for Johns Hopkins Hospital in Baltimore.

    Sometimes it's something as simple as a gesture, or a faint rash, or the feel of the skin, or the odor of the breath that can cinch a diagnosis. There's just no substitute for sight and touch.


    posted by Sydney on 1/07/2003 01:21:00 PM 0 comments

    Doctoring: DB's Medical Rants has an excellent post on just exactly what "primary care doctor" means.
    posted by Sydney on 1/07/2003 01:07:00 PM 0 comments

    What We Have Done and What We Have Failed to Do: A plastic surgeon argues that reducing medical errors is a better solution to the malpractice insurance crisis than tort reform:

    In some states doctors in the more high-risk specialities like neurosurgery and obstetrics pay as much as $200,000 a year for malpractice insurance. I have not been sued for malpractice (yet). But my insurance premiums increase each year anyway, forcing me to raise my rates, too. If I'm a good doctor, why do I - and you - have to pay for the errors of others?

    Making it more difficult to file malpractice suits and imposing caps on excessive awards for pain and suffering, as the surgeons in West Virginia are demanding, is a start. But this won't get to the deeper problem: Mistakes do happen, and they have consequences, sometimes dire ones. Rather than focusing on rewarding victims and their lawyers, we should concentrate on creating fewer victims - that means changing how we train doctors, track and correct errors and mete out punishment.

    While reducing error rates is a commendable and worthy goal, there’s no reason to think that this would lower malpractice insurance premiums, nor the rate at which doctors are sued. Data already exists that show that most true cases of malpractice and error don’t result in lawsuits, and that many malpractice cases are of dubious worth. Lawsuits are a necessary evil. They provide us with a civil means of settling our disputes. No relationship is perfect. The doctor-patient relationship is no exception. Bad outcomes are sometimes inevitable. Even when all the decisions and actions were right and no errors occurred. And when things go wrong, we look for a place to cast blame. Even when no blame can justly be cast. It’s human nature. So, even in an error free system, we would still have lawsuits.

    In fact, I’m not sure that the goal should be to reduce the number of lawsuits filed. People should have a right to file suit if they feel they’ve been wronged, no matter how misconceived that notion might be. Better to have the evidence out in an impartial court of law to settle the dispute once and for all than to have the misunderstanding fester forever. What should be curtailed are the unrestrained actions of lawyers who chase after cases of dubious merit to make a buck, who file suit against doctors without checking for culpability (as when they name every doctor whose name appears in a hospital chart), and who milk the jury system for sympathetic juries in the hope of hitting million dollar jackpots. That’s why tort reform is much more crucial to solving the malpractice crisis.
    posted by Sydney on 1/07/2003 08:26:00 AM 0 comments

    Resistance is Futile: Is there a new movement within medicine to save money at the expense of patients? National Review Online says “yes,” and it isn’t the brain child of insurance companies, but of hospitals and doctors and bioethicists:

    As you read these words, quietly, slowly, inexorably, mostly behind the closed doors of hospital ethics committees, "futile care" or "inappropriate care" protocols are being put into place in hospitals throughout the country. The first time most patients and their families become aware that doctors are being given the right to say "no" to wanted medical treatment (other than comfort care) is during a medical crisis when they are at their most defenseless and vulnerable.

    The article is about the trend among hospitals to put policies in place for dealing with the issue of futile care - care that’s not necessarily in the best interest of the patient. The article goes on to characterize futile care policies of hospitals as cost-saving measures, a means of rationing healthcare. This isn’t necessarily so. Nor is it a “stealth movement.” Futile care policies exist to help mediate disagreements between families and physicians. There are times when care is futile, and even harmful. But, for whatever reason, the family can’t accept that. (Sometimes it’s just too hard to let go.) Consider, for example this hypothetical (and admittedly overly optimistic) case of a child with a terminal illness. Or this very real, and much messier, instance of a family that can’t agree on treatment. Without futile care policies, there would be no forum for the family to express their view - outside the courts.

    As in any system, there is the danger of abuse. A committee made up overwhelmingly of hospital employees, for example, could conceivably have the hospital’s best interest at heart rather than the patient’s or the family’s. (The constant references to wanting to free up a hospital bed for more acutely ill people with better hopes of survival in the second case above is an example.) But, the purpose and intent of the futile care policies truly isn’t to deny care. It’s to mediate. (Thanks to J. Bowen)
    posted by Sydney on 1/07/2003 08:15:00 AM 0 comments

    Monday, January 06, 2003

    Libretto: An opera inspired by the NIH: Il Destino di Grant Application. (Tip provided by a valued reader.)

    posted by Sydney on 1/06/2003 08:32:00 AM 0 comments

    Paging Dr. Ben Casey: This love letter to politician doctors was more than a little surprising, especially coming from The New York Times:

    Good doctors understand how affordable housing, a good education and secure jobs actually contribute to our physical health. I would rather trust a doctor to make a decision about war than I would a businessman or a lawyer; a doctor is more likely to remember the value of the lives he would be sacrificing.

    Ah, that's sweet. And such a compliment to doctors. Unfortunately, it's an inaccurate assessment. While Doctors Dean and Frist may be very commendable and worthy men, you can't judge all doctors by them. Just sit through a few minutes of any hospital staff meeting and you'll soon realize that the the medical profession has more than its fair share of insufferable, arrogant asses. By the same token, there are many lawyers and businessmen out there who are men (and women) of great integrity. Better to judge our politicians by their actions and their ideas than by their professions.
    posted by Sydney on 1/06/2003 08:24:00 AM 0 comments

    Stop Me Before I Reproduce Again: CRACK, Children Requiring a Caring Kommunity, a birth control advocacy group for drug addicts has some controversial promotional techniques:

    A flier hanging on a pole in Brooklyn looks, at first glance, as if it might offer a room for rent or a job. There are phone numbers, dollar signs and tabs for people to tear off and take with them.

    But the offer is intended for a specific group: drug-addicted men and women. "Get birth control, get cash," the flier reads. "If you are addicted to drugs and/or alcohol then this offer is for you."

    While offers of birth control to drug addicts are common — distribution of condoms in particular, as a means not only for birth control but also to stem the spread of AIDS — this offer is much more radical. It offers men and women $200 to be sterilized or put on long-term birth control.

    There is something a little creepy about offering to pay people, especially the poor and disadvantaged, to stop reproducing. Yet, it isn't much different than the stance that many people think our country should take internationally by paying poor and disadvantaged countries to stop reproducing; a stance which the current Adminstration has rejected, and for which it was criticized.
    posted by Sydney on 1/06/2003 08:19:00 AM 0 comments

    Smoke and Mirrors: The Bush Administration is coming under attack again for the composition of its scientific panels. This time it's the Secretary's Advisory Committee on Human Research Protections. Critics say that it is overwhelmingly composed of industry leaders, with no patient advocates. At first blush, it would seem that the Bush Administration cares not a whit about people, and that they're sacrificing the health of volunteers to industry inteterests. But, a closer look proves otherwise. The real issue is what sort of life is deserving of protection. The Bush Administration includes embryos and fetuses in the category of life, and that is what has stirred the ire of the critics.

    One of the patient advocates who served on the Clinton version of this committee, but is not on the Bush version, is the president of the National Organization of Rare Disorders. NORD does a lot of good work. It’s a tremendous resource for people with rare diseases. It also happens to count among its hopes for some of those rare disorders, research on embryonic stem cells.

    Then, there’s the guy who resigned immediately upon learning of his appointment. He wasn’t an industry leader, but a bioethicist, and also a former Clinton appointee. His reason for resigning:

    .... he has no intention of joining, he said, given the committee's new embryo-oriented charter and its research industry-heavy membership, which includes the heads of research from several public and private for-profit research institutions.

    It would have been less tilted toward industry if he had stayed on board, but evidently he’s too offended by the audacity of the Administration to consider embryos and fetuses as human life. Protesting the inclusion of embryos in the category of human life is evidently more important to him than protecting the interests of adult research subjects against industry.
    posted by Sydney on 1/06/2003 08:15:00 AM 0 comments

    The More Things Change: A musing on the death of Joe Strummer by the London Times had this observation:

    The National Portrait Gallery has displayed a photograph of Mick Jagger close to an almost life-sized, and idealised, painting of Byron on his deathbed. The message was plain. The Byronic tradition of - mad, bad and dangerous to know - is alive and being maintained by present-day pop stars, in this case a young Mick Jagger.

    Young? (Must be an old photograph)
    posted by Sydney on 1/06/2003 08:15:00 AM 0 comments

    The Plot Thickens: Looks like the "independent journalist" who was to verify the Raelian cloning claim may not be so independent after all. You know something's up when all of the major networks say "no thanks" to a story being pitched by one of their own:

    His most ambitious proposal, for a reality-based program on the cloning effort, was made to Fox Entertainment several months ago, an executive at the company said. He said Dr. Guillen offered to produce the program and to be its host on the air. The program, Fox was told, would begin before the births of the clones and continue beyond, according to the executive.

    Fox, which is not known for squeamishness — the network has produced "When Animals Attack" and "Who Wants to Marry a Multimillionaire?" — declined, in large part because the project seemed "loaded with ethical questions" as an entertainment program, the executive said.

    posted by Sydney on 1/06/2003 08:10:00 AM 0 comments

    More of the Same: Yet another story about how expensive it will be for public health departments to vaccinate healthcare workers:

    In Syracuse, health officials estimated that they would need $475,000 to vaccinate about 600 health workers at five hospitals in Onondaga County.

    That's almost $800 a person. Come, come. There's no reason administering a vaccine that has been supplied for free by the government would cost such an exorbitant amount.

    What the public health community is really saying is that they don't want to do this. Having proven themselves unequal to the task of assessing the need for the vaccine in the first place, they are now proving themselves unequal to the task of administering it. Perhaps the task should be delegated to others. There's really no reason that the vaccine would have to be given through public health departments. Hospitals have employee health services that provide such services as hepatits B immunizations. Why not train the community physicians and hospital staff to adminster the vaccine and let it be done on site? And as for administering it to the public, again, that doesn't have to be done by public health departments. Community physicians are just as capable of learning to administer a smallpox vaccine as public health nurses.

    These stories also do absolutely nothing to bolster confidence in the public health system's ability to respond to a smallpox attack. If they can't find the will to administer vaccine at a leisurely pace, how on earth would they administer it in the seven day window after a smallpox outbreak?
    posted by Sydney on 1/06/2003 08:08:00 AM 0 comments

    Sunday, January 05, 2003

    Hiatus: My husband just dropped the New York Times on the table, and I see some tempting stories, but I’ve been up since 3AM when I had to go in to evaluate a hospitalized patient with the sudden onset of severe abdominal pain. (It turned out to be a rectus sheath hematoma.) My adrenaline rush has left me. Blogging will have to wait. I’m going back to bed.

    posted by Sydney on 1/05/2003 10:04:00 AM 0 comments

    Med Mal Circuit: The medical malpractice insurance problem continues to be a thorn in the side of doctors everywhere. In Tampa hospitals are letting neurosurgeons practice without insurance (The surgeons must be terribly dedicated to take that risk. One bad case could be your ruin):

    Four doctors at the hospital quit practicing there recently because they cannot get malpractice insurance or do not want to pay the increased costs. The loss of those doctors, and possibly more, could affect patient care, hospital Chief Executive Officer Alan Levine said Friday.

    To maintain neurosurgery service, Levine recommended waivers for two neurosurgeons so they could work without malpractice insurance, which is known in medical circles as ``going bare.'' The hospital board approved the waivers.

    At least two other hospitals in the area, Tampa General and University Community, have faced similar problems and recently changed regulations to allow staff doctors to work without malpractice insurance.

    Interestingly, Florida prohibits insurance companies from investing more than 15% of their profits in the stock market, yet they still have the same malpractice insurance problems that everyone else has. So much for the trial lawyer argument that the problem is caused by bad investments.

    And in a small community in Illinois, doctors are leaving for greener pastures:

    Some notable departures from the staffs at Alton Memorial and Saint Anthony's Health Center are Dr. Robert Hamilton, a general surgeon, who retired at 63 a year ago after 29 years of service in the area; Dr. Bryan Lohrbach, an orthopedist, who moved to Appleton, Wis.; and Dr. Nick Lorens, a gastroenterologist, who moved to Columbia, Mo. Lohrbach saved more than $50,000 a year in malpractice insurance premiums with the move to Wisconsin. Lorens' malpractice premiums were half as much in Columbia.

    Meanwhile, lawyers and healthcare insurance providers are protesting the reforms proposed in Pennsylvania. The lawyers' complaints are typical, and of not much merit. Here's one lawyer's comments on the proposal to require certificates of merit from independent physicians before a case can be filed :

    Ambrose said he doubts that Rendell's proposal to require certificates of merit in medical malpractice cases would dramatically lower the number of cases filed each year. Rendell's Medical Malpractice Liability Task Force estimated it would reduce the number of cases filed by 25 percent.

    "In Pennsylvania, you can't file an action until you have an opinion from a board-certified physician who practices in the area," Ambrose said. "That opinion must state that the doctor in question deviated from the standard of care and caused injury or death to occur."

    Yes, but how independent is that board-certified physician? Is he on the law firm's payroll to provide them with just that sort of statement? An independent physician would be much more trustworthy than one hired by either party, and it's difficult to see what would be so objectionable about that. Unless of course, you're afraid it'll cut into your income by curtailing the number of suits you can file.

    The healthcare insurance companies, however, have a legitimate gripe. The plan calls for them to cover some of the costs of doctor's malpractice insurance premiums. That makes no sense at all, and in the end could do far more harm than good. Forced to pay for malpractice insurance, healthcare insurers surely would decrease reimbursements to physicians and increase rates to consumers. Far better to keep the malpractice issue where it belongs: among doctors, lawyers, malpractice insurance companies, and the tort system.
    posted by Sydney on 1/05/2003 09:15:00 AM 0 comments

    Mending Hearts: There’s been another advancement in the use of adult stem cells to treat disease. A team of researchers has coaxed bone marrow stem cells into growing into heart muscle:

    Stem cells come from the patient's own marrow so there is no risk of rejectionIf the patient survives, s/he usually suffers disabling symptoms because of tissue damage that affects blood flow to the heart. These include chest pain and breathlessness, which can result in poor quality of life.

    The new procedure involves harvesting stem cells - types of cells present in bone marrow capable of developing into different kinds of tissue and muscle - from the patient and then transplanting them directly into the damaged heart tissue via a special catheter.

    The researchers claim all the patients who took part in the study failed to respond to traditional methods and surgical procedures. After the stem cell transplant, all had strikingly improved blood flow to the heart and heart functions.

    There’s a lot to hope for from adult stem cell research, and it avoids the ethical dilemmas of embryonic stem cell research.
    posted by Sydney on 1/05/2003 08:56:00 AM 0 comments

    Happiness is Self-Determination: According to a recent survey in the BMJ 22% of British physicians would like to quit. The British Medical Association says it’s because:

    ...a lot of treatment which used to be carried out in hospitals is now handled at GPs surgeries, where doctors feel they have lost control over the way they work.

    The Guardian says not to worry, the discontent is only among the older set, who are more prone to burn-out. But, a look at the results reveals that the percentage of that group who wants to quit has increased significantly since 1998. It’s also true that this is the group that’s more likely to act on those wishes, since they have fewer financial responsibilities. Their houses are more likely to be paid for, their education loans paid off, their children finished with schooling. The NHS should pay attention. The dissatisfaction isn’t just the middle-age career crisis of an aging baby-boomer generation. It’s much deeper and more systemic than that.
    posted by Sydney on 1/05/2003 08:50:00 AM 0 comments

    Vanity Press: There's an organization called the Public Library of Science that's planning to publish two free on-line journals, one in biology and one in medicine. They will be free to the readers, but not to the authors. They will have to pay $1500 to have a paper published. So much for peer review, huh? Have cash, can publish.

    Here's a better idea. Established journals could make their content available online for free and finance it with a pledge-week like Andrew Sullivan recently did. There's a lot to be said for having a journal in hand sometimes, so they can still get the majority of their money through their traditional mail-based subscriptions, but at the same time make a their content available to the wider public. And maintain the integrity of the publishing process.
    posted by Sydney on 1/05/2003 08:21:00 AM 0 comments

    Saturday, January 04, 2003

    Plague Times: Cronaca says that once upon a time, villages had plague stones where, in times of plague, farmers left food in exchange for vinegar-soaked money, to avoid the plague-infested villages.

    posted by Sydney on 1/04/2003 10:45:00 PM 0 comments

    Clone Update: The Raelians say that they've produced another clone:

    Boisselier, who heads the Clonaid firm that claims to have produced the first human clone, said the baby was born in northern Europe late yesterday to a couple from the Netherlands, but she did not specify the particular country in which the baby was born.

    "It is a little girl. She is very well," Boisselier said.

    "She is smaller than the first, at 2.7 kilograms," Boisselier said, adding: "It was a natural birth. Her parents are two lesbians from the Netherlands."

    It remains to be seen whether they'll let this one be tested and examined. The first one, after all the hoopla, is now off limits.
    posted by Sydney on 1/04/2003 03:37:00 PM 0 comments

    Measure for Measure: Yesterday, the London Times had a Q&A with their health editor about the trend for drug companies to take an active role in disease definition. The article was prompted by this essay in the British Medical Journal on efforts to define normal sexual behavior as dysfunctional. Here’s the Times’ editor on the various diseases whose definitions have been expanded lately:

    More often these days the development of disease descriptions come from "consensus conferences" where a group of experts, often with financial links to drug companies, meet to produce guidance for others. Once a diagnosis exists, the tendency is for doctors to employ it.

    The most obvious example of this is in autistic spectrum disorder - a wide-ranging diagnosis now used for many children who would previously have been diagnosed as subnormal. Another example is ADHD - attention deficit hyperactivity disorder. As soon as many patients are being diagnosed, it becomes possible to market treatments - such as Prozac for ADHD. So facilitating such conferences is a good way for drug companies to promote their wares.

    And to expand their markets. And it isn’t just psychological diseases whose definitions have been broadened lately. Obesity is more broadly defined now, hence the epidemic. So is diabetes, another disease that’s often labeled as an “epidemic.”

    These expansions can’t all be blamed on drug companies, though. In some cases, it’s a legitimate effort to improve health outcomes. This is the case with diabetes. By setting lower blood sugar levels for the diagnosis, the hope is that earlier treatment will delay even longer the complications of the disease, such as heart disease and kidney failure, and blindness. The same can be said of obesity, although the case is less clear-cut. Sometimes, as in autism, it’s the work of activists. The more people who can be counted as suffering from a disease, the more likely the government is to increase research funding, and other state-funded help for those suffering from it. Whether instigated by doctors, drug companies, or political activisits, however, the outcome is the same. As the BMJ article pointed out, we risk narrowing the definition of normal to such a degree that even the healthy are labeled sick.

    For Example: A good example of just that phenomenon is what has happened with autism in the past ten to twenty years. Once upon a time, autism meant a severe developmental disorder that rendered its victims completely unable to communicate or interact with other people in any way. Now, the definition has been substantially broadened. But even that broad definition wasn’t enough for the recent survey of the prevalence of autism published in JAMA. Not content with the DSM-IV criteria that are generally now used for the diagnosis, the authors included more general, less debilitating disorders:

    Throughout this article, the terms autism and autism spectrum disorders (ASDs) refer to autistic disorder, Asperger disorder, and pervasive developmental disorder - not otherwise specified (PDD-NOS).

    Pervasive developmental disorder, not otherwise specified is a waste-basket term, used to classify those who don’t fit into any of the other categories. Asperger's disorder, sometimes called “high functiong autism,” was only defined in the 1990’s. Before that, we called such people “eccentric” or ‘geeky.” Of course, “eccentric” and “geeky” aren’t the sort of labels that get schools special education funds, but Asperger syndrome, having the blessing of the medical profession, does. It’s no surprise that it has caught on as a diagnosis .

    Derek Lowe does a fine job of dissecting the media’s response to the JAMA article. In truth, the paper does not prove that autism itself has increased, only that the diagnosis of autism has increased, and it does that largely by including disorders that aren’t what most people think of as autism - that is the severe and disabling form of it. An accompanying editorial, although generally supportive of the claims that autism has increased, expresses reservations about them, nonetheless. One of those reservations is the way in which the classification of disabilities has changed:

    .... during 1987 to 1994, diagnostic substitution occurred; thus, while the prevalence of autism increased from 5.8 to 14.9 per 10,000, the prevalence for mental retardation decreased from 28.8 to 19.5 per 10,000. These trends then cancel each other. According to the authors, new federal legislation (Individuals with Disabilities Education Act15) mandating that states provide early intervention programs for toddlers with developmental delays played a role in the increasing use of the diagnosis of autism.

    The editorial also points out that there has been a disproportionate increase in spending on autism in relation to the scientific evidence of its prevalence:

    Although claims about an epidemic of autism and about its putative causes have the most weak empirical support, the subsequent controversy has put autism on the public agenda. In recent years, children with autism, their families, and professionals involved in their care and in research have seen welcome and legitimate increases in public funding. Yet, ironically, what has triggered substantial social policy changes in autism appears to have little connection with the state of the science. Whether this will continue to be the case in the future remains to be seen, but further consideration should be given to how and to why the least evidence-based claims have achieved such impressive changes in funding policy.

    Yes, indeed, we should give consideration to how and why claims of little evidence result in such impressive changes in public policy. Serious consideration.
    posted by Sydney on 1/04/2003 03:26:00 PM 0 comments

    Malpractice Extremis: The Bloviator has the latest on the West Virginia surgeon work-stoppage. He says the surgeons are angling to get the state to pressure insurance companies to pay them better. That's too bad. They weaken their cause. It would be far better for them to just cancel contracts with insurance companies they have problems with, rather than bringing the state into it. They have that option with health insurance companies. They don't have it with malpractice insurance companies.
    posted by Sydney on 1/04/2003 03:25:00 PM 0 comments

    Friday, January 03, 2003

    Clone World: Several months ago I posted an excerpt from a newspaper article about people who were seeking to have themselves cloned. One of those people was a man with cystic fibrosis. This was the original post:

    Then there is the man who thinks that cloning himself will give him a second chance at life:

    He was born with cystic fibrosis, an inherited lung disease that could easily kill him within the next decade. There is no cure, but by adding a healthy version of the gene that's defective in CF, scientists have been able to "cure" individual cells taken from patients with the disease. Now Colvin wants scientists to do just that, and a little bit more: Take one of the trillions of cells in his body, fix the tiny molecular mutation that causes the disease, and then clone that single repaired cell to grow a new and literally improved copy of himself -- a newborn Jonathan Colvin who would be free of the disease.

    "In some respect, it would give me a second chance at life without CF," Colvin said. "It wouldn't be me, but it would be very similar to me."

    I hate to break it to him, but it won‚t be his brain in that clone’s body, and it won’t be his life it’s living.

    Recently, Mr. Colvin emailed me:

    well duh, that's what I said ....."It won't be me, but it will be very similar to me".

    The point is precisely that it won't be "my" life the clone is living; it will be a life that I might have lived had I not had CF.

    What would be the point of living the same life again? I suppose this is why you are med-pundit, and not philosophy-pundit :)

    Mr. Colvin also suggested in a subsequent email that if Steven Hawking could clone himself, then maybe the world would be graced with another physics genius. Or maybe not. That’s the point about cloning. Even though the baby has the same genes as its parent, it is still its own unique person. Just as identical twins are unique people, not the same person split in two. Our genes aren’t our destinies. Throughout our lives, we’re influenced by things beyond the control of our genes. Even our genes are influenced by factors outside our control, and can be expressed differently in different situations. That’s one reason identical twins differ from one another. There’s no reason to expect a cloned baby to live your life for you anymore than you should expect a traditionally conceived child to do so. (Many a parent has been disappointed in that expectation, and many a child made miserable.) And as for Stephen Hawking, there’s a good chance his clone wouldn’t even like physics, let alone be adept at it.

    posted by Sydney on 1/03/2003 08:43:00 AM 0 comments

    Double Duty: A new drug aimed at treating inflammation at the cellular level, got not one, but two, papers in this week’s New England Journal of Medicine. The drug, Antegren, is an antibody that blocks receptors on cell surfaces that are involved in mediating inflammation. The two papers look at the responses of two diseases that are of an inflammatory nature,Crohn’s disease and multiple sclerosis:

    In the MS study, 213 patients in the United States, Canada and the United Kingdom were given six monthly infusions of one of two Antegren doses or a dummy drug. Patients who received the dummy drug had about 10 new brain lesions, compared to about one new lesion in those getting Antegren, a reduction of about 90 percent.

    The frequency of relapses was cut in half in the Antegren groups, to 19 percent from 38 percent in the comparison group.

    However, once treatment was stopped, there were no differences in the rates of relapses and new brain lesions between the two groups. The drug looks more promising for Crohn’s disease:

    The 248 patients in the Crohn's study in Europe received two infusions a month apart of either of two Antegren doses, a dummy drug or a combination of Antegren and the dummy drug. A scoring system measured their response over 12 weeks.

    Overall, the patients who received only Antegren had higher remission rates and response rates. The highest remission rate was 44 percent at six weeks in the low dose Antegren group, compared with 27 percent in the dummy drug group.

    In both studies, there were few serious side effects and there was no difference in side effects between the treatment groups.

    The Crohn’s disease study, however, didn’t look at relapse rates beyond the twelve week treatment period. As the author’s conclude, “the longer-term benefit and safety of this treatment...remain to be defined.”
    posted by Sydney on 1/03/2003 08:25:00 AM 0 comments

    Dehumanizing Medicine: The New England Journal of Medicine considers the legacy of Nazi medicine in this week's issue. They first appear in the discussion section of a research paper on the genetic characteristics of a neurological disorder called Hallervorden-Spatz Syndrome. Drs. Hallervorden and Spatz were distinguished German physicians - and committed Nazis. The authors suggest in their closing paragraph that the eponym be disgarded, as it has “fallen into disfavor”:

    The eponymous term "Hallervorden–Spatz syndrome" has fallen into disfavor in view of the unethical activities of the German neuropathologists Hallervorden and Spatz during World War II. We encourage the use of the term "pantothenate kinase–associated neurodegeneration" for the majority of patients with Hallervorden–Spatz syndrome who have proved or suspected mutations in PANK2. For the remainder, we propose the term "neurodegeneration with brain iron accumulation."

    In an accompanying essay, Michael Shevell argues the same. An eponym is an honor, and these two men are not worthy. Here’s a description of Hallervorden’s work:

    At the outbreak of World War II, Hallervorden was the pathologist of the Brandenburg State Hospital, which included the chronic care institution at Brandenburg-Görden. This would be one of the six elimination centers established under the Aktion T-4 adult-euthanasia program. The program effected the transfer of institutionalized patients from all parts of Germany after a secret review of questionnaires based on their medical files by a central committee of physicians. After their transfer and a brief period of observation to verify the underlying diagnosis, patients were killed by gassing with carbon monoxide in disguised shower facilities. The operation was never legally mandated and was rife with deception of the affected families. A memorandum signed by Adolf Hitler, dated the opening day of the war, empowered physicians "to grant a mercy death to those judged to be incurably ill." In operation for less than two years (during the period from 1939 to 1941), the Aktion T-4 program resulted in the deaths of 70,273 persons.

    To an academically oriented pathologist such as Hallervorden, Aktion T-4 provided an opportunity for the study of rare specimens on a previously unimaginable scale. Hallervorden's reports to the German Association for Scientific Research and the German Research Council detail his use of specimens derived from the Brandenburg-Görden killing center. Dissatisfied by the quality of medical information in the patients' dossiers for a funded project entitled "Inherited Feeble-Mindedness," Hallervorden himself selected and examined a number of living patients before personally removing their brains at the killing center. On the basis of these materials (and others he obtained through the child-euthanasia program and the Jewish Hospitals of Warsaw and Lublin in Poland), Hallervorden published 12 scientific articles (7 as sole author) in the postwar era on a variety of topics, including the effect of carbon monoxide exposure on the fetal brain.

    Note those publications were after the war. In fact, Hallervorden was still very much admired and respected as late as ten years after the war. Here’s an interview with a prominent American neurologist who worked with him in 1955 in Germany:

    Could you tell us more about Julius Hallervorden?

    Well, I had great respect and fondness for him. However, I had no idea then about what had happened in the past. I wrote a small biography about him in a little book that I have right here, entitled The Founders of Child Neurology, edited by Stephen Ashwal, a pediatric neurologist. I said in the final paragraph: "He was of a quiet, reserved nature, wholly devoted to science and to neuropathology, and, at the same time, warm, friendly, and an inspiring teacher. He was one of the last great figures of the classic period of German neuropathology."

    In recent years, his use of the brains of children that had been killed under the Nazis' euthanasia program has been heavily criticized.

    When, in 1938, Spatz became Director of the recently established and well financed Kaiser Wilhelm Institute for Brain Research in Berlin, he invited his old friend Hallervorden to become head of the Neuropathological Division. Meanwhile, during the Nazi regime in Germany during the war, a systematic program of euthanasia was carried out on individuals officially not considered suitable for the kind of society the leaders were trying to create. In addition, there were the now well known horrors of the Holocaust. There is compelling evidence that Julius Hallervorden knowingly carried out examinations on anatomical materials from victims of these massacres, thus becoming part of a dehumanized regime that denied respect and dignity to those members of the society which, within the framework of its perverted ideology, were judged unworthy of living.

    And here’s Hallervorden’s own account of the events:

    "I heard that they were going to do that, and so I went up to them and told them, `Look here now, boys. If you are going to kill all those people, at least take the brains out so that the material can be utilized'"; "There was wonderful material among those brains, beautiful mental defectives, malformations and early infantile disease"; "They asked me: `How many can you examine?' And so I told them an unlimited number — the more the better"; and "I accepted the brains, of course. Where they came from and how they came to me was really none of my business."

    Those were just brains and nervous systems to him, not human beings. And, since the people who owned them had already been deemed unworthy of life, what was it to him? Might as well make some use of all that discarded human tissue. It was for the advancement of science, after all. It was for the good of humanity.

    Sound familiar? It should. The same argument is made today for fetal stem cell research, and for therapuetic cloning. Those aborted embryos (whether aborted surgically from a womb, or aborted during their growth and development in a petri dish) aren’t human, or if they are, they aren’t human in the full sense of the word, so the argument goes. They’ve already been denied the chance to develop fully, so why not use them for the benefit of humanity?

    And if you think I’m stretching the analogy, consider this statement from pro-therapeutic cloning (yet also supposedly pro-life) Senator Orrin Hatch: (via Charles Murtaugh):

    Sen. Orrin Hatch, R-Utah, is one of four sponsors of a bill that would allow the creation of cloned human embryos but would ban their implantation in a womb. On Feb. 5, 2002, Hatch testified, "No doubt somewhere, some, such as the Raelians - are busy trying to apply the techniques that gave us Dolly the Sheep to human beings. Frankly, I am not sure that human being would even be the correct term for such an individual heretofore unknown in nature." [emphasis mine]

    Sieg Heil.
    posted by Sydney on 1/03/2003 07:31:00 AM 0 comments

    See One, Do One, Teach One: The Wheeling, West Virginia doctor walk-out might be catching on with other West Virginia doctors, in other specialties:

    Parkersburg-area doctors will consider a walkout during a meeting of the state medical association next week, said Dr. David Avery, a Parkersburg family practitioner and former association president.

    "I'm afraid this is just the first bit," Avery said. "If the governor and the Legislature don't act, this will be spread quickly across the state -- and it will be all physicians, not just surgeons."

    Michael Roberts, a surgeon at two Parkersburg hospitals, said Thursday there was "a good chance" the five surgeons at those facilities would stage a walkout in two weeks.

    "We are basically in the same situation as the people in Wheeling," he said, adding that his malpractice insurance rates have jumped 140 percent. "We just can't keep up with the rising costs."

    Meanwhile... at least one obstetrician had to close her doors in Huntington, West Virginia, because of the crisis:

    Smith said she received notice from the state Board of Risk and Insurance Management Dec. 19 that she would have to pay four times her current premium for medical malpractice insurance. The increase was from $24,000 to $96,000, she said.

    Smith appealed the increase and only decided Tuesday that she had to close, she said. The closure will be permanent unless she finds an affordable option for coverage, she said. Smith took a 30-day leave of absence, which would allow her to reopen if she finds a solution.

    In March, Smith decided to give up obstetrics, hoping that it would reduce her premium. But coverage for practicing gynecology alone was still unaffordable, she said. Smith also gave up obstetrics because she couldn’t recruit a partner to share the workload, a problem she said was related to the medical malpractice climate in West Virginia.

    Smith, like the surgeons who walked out in Wheeling, is insured by a state run malpractice program:

    "The state developed this program; however, it’s not affordable," Smith said. "In my situation, I have never lost a lawsuit, but I have had suits filed against me that I had to defend against. The suits were dropped, but it still counted against me, which I think is unfair."

    So, what’s a West Virginia doctor to do? Become a Virginia doctor:

    "I can get insurance in all the surrounding states," Smith said. "I looked at North Carolina and Virginia, and they will insure me at half the cost, but I have no other alternative in this area."

    ..."You have one choice," Smith said. "You put your house up for sale, and you move."

    As if West Virginia can afford to lose doctors.
    posted by Sydney on 1/03/2003 07:30:00 AM 0 comments

    Bluegrass Malpractice: In Kentucky, the state had to step in to keep the obstetricians at the University of Louisville insured:

    A California company recently notified University Hospital late last year of plans to drop malpractice insurance for the hospital's Obstetrics Department. Then the state stepped in, preventing the company from dropping coverage.

    Listening to the sound of an unborn heart, Dr. Daniel Edelstone breathes a sigh of relief after a near flatline for the Obstetrics Department at UofL. Edelstone is chairman of th department He says that without malpractice insurance, "we literally would have had to stop providing health care."

    Once the state stepped in, "They were forced to provide us insurance," Edelstone is chairman of the department, and he says the company is providing coverage, but at a much higher rate. "They weren't forced to provide it at a reasonable rate -- our rates went up about 65 percent."

    Costs for malpractice insurance have increased from $900,000 a year to one $1.5 million annually. The skyrocketing costs of malpractice insurance a dangerous threat.

    "What you have is a system that is just running away with itself," Edelstone says.

    And what happens next year when the rates go up even further? West Virginia redux.
    posted by Sydney on 1/03/2003 07:27:00 AM 0 comments

    Illinois Malpractice: They aren't striking yet in Illinois, but the malpractice situation is beginning to strain the system:

    Because Illinois law holds hospitals liable for actions taken by physicians affiliated with them, hospitals and especially academic medical centers have borne the brunt of an escalation in malpractice awards from juries in the past few years, the center's Max Brown said.

    Last year Rush was self-insured for the first $4 million in liabilities, but this year, it must cover the first $15 million itself, with insurance companies only stepping in to cover awards that exceed $15 million.

    "The London insurers have told us that no one is going to insure anything under $15 million and that will probably go to $20 million next year," Brown said. "Academic medical centers must set aside reserve funds to cover this liability, and that money has to come from other programs - from education and research."

    And at least one malpractice insurance company says it can't afford to cover anymore doctors:

    The agency that provides physicians with malpractice insurance in Illinois, ISMIE Mutual Insurance Co., has put a freeze on accepting new doctors for coverage. Rising malpractice awards could threaten ISMIE's reserves if it accepts more physicians, said the organization, which is an affiliate of the Illinois State Medical Society.
    posted by Sydney on 1/03/2003 07:23:00 AM 0 comments

    Thursday, January 02, 2003

    Crypto Fest: The festival that wasn't.

    posted by Sydney on 1/02/2003 08:31:00 AM 0 comments

    Pins and Needles: Howard Fienberg inspects the state of acupuncture research, and finds it wanting.
    posted by Sydney on 1/02/2003 08:29:00 AM 0 comments

    Defining Moments: Two “epidemics” in the news - obesity and diabetes:

    More than 44 million Americans were obese and 16.7 million people had diagnosed diabetes in 2001, according to the study by the Centers for Disease Control and Prevention.

    The researchers found the nation's obesity rate climbed to 20.9 percent in 2001 from 19.8 percent the year before, and the rate of diagnosed diabetes rose to 7.9 percent from 7.3 percent.

    Of course, the population is getting older, too. Age is a factor in both weight gain and in diabetes. And then there's the matter of our prosperity. We do such a good job of providing food to the poor that the poorest states are no longer starving, but suffering from diseases of affluence:

    The study confirmed previous findings that Mississippi is the state with the highest rate of obesity and Colorado the lowest. The highest rate of diagnosed diabetes was in Alabama; the lowest was in Minnesota.

    I can’t dissect the study, since I haven’t received my issue of JAMA yet, and I don’t have online access to the full articles, but the journal does have an insightful look at the problem by an economist that’s available for free.
    posted by Sydney on 1/02/2003 07:41:00 AM 0 comments

    Strike: Surgeons went on strike, but not in Pennsylvania, as feared. It was across the border, in West Virginia:

    At least 39 surgeons walked off the job at four hospitals in West Virginia on Wednesday to protest rising medical malpractice insurance costs, officials said.

    The hospitals are all in Wheeling, in the northern part of the state sandwiched between Ohio and Pennsylvania. They now must transfer emergency surgeries elsewhere and cancel planned procedures until the doctors end the strike, which they have scheduled to do at the end of the month, officials said.

    The surgeons are of all types - general, orthopedic, and cardiac. They all asked for leaves of absences for thirty days from their hospital duties. No word on who's looking after their patients already in the hospital, but a West Virginia newspaper has these details about the walk-out:

    Wheeling Hospital, Ohio Valley Medical Center, Weirton Medical Center and Reynolds Memorial Hospital all have surgeons who have requested leaves of absence to start the new year.

    Eighteen surgeons at Wheeling Hospital, 12 from OVMC, seven at Reynolds and four at Weirton Medical Center have requested 30-day leaves of absence. The exact number of surgeons protesting is not known, as many doctors have privileges at more than one facility.

    Wheeling Hospital has lost all but one surgeon, as three general surgeons requested leave on Monday. Unless something changes, the hospital will not offer any surgery after Wednesday.

    You know, this kind of thing would have been unthinkable as recently as a year ago. Doctors in the United States just didn’t go on strike. Who would we strike against, after all? Most of us are self-employed. But, the malpractice insurance premiums have gotten so untenable, that there’s no choice for some of the high risk specialties. It’s ironic that a lot of the West Virginia surgeons are still doing surgery across the river in Ohio, where malpractice insurance premiums are also considered exorbitant.
    posted by Sydney on 1/02/2003 07:29:00 AM 0 comments

    Desk Cleaning: While cleaning my desk of the latest unread journals, I came across this essay (requires a paid subscription) that reflects on the changes in healthcare over the past ten years:

    The cumulative effect of the public-policy and marketplace changes of the 1990s has been the near-elimination of the system's reserve capacity and the exhaustion of available compensatory mechanisms. Each part of the health care system used strategies to maintain its own stability. Hospitals closed beds and tried to increase the productivity of their workers, particularly nurses. Physicians added staff and worked harder to maintain their income in the face of managed care. Employers passed on some health insurance cost increases to employees, with the average worker's single-coverage contribution rising from 11 percent of the premium in 1988 to 15 percent in 2001, and with even greater cost sharing envisioned in the future.

    ...Even the Federal Employees Health Benefits Program and the California Public Employees' Retirement System, two of the best-managed and most aggressive purchasers, faced premium increases of 13 percent and 25 percent, respectively, in 2002.

    Use of emergency departments increased 14 percent between 1997 and 2000, and many emergency departments are reaching capacity, prompting diversions of critically ill patients to other facilities.

    Over the 1990s, the number of students entering nursing school declined by 25 percent, and the age of the average nurse increased from 37.7 to 45.2 years.

    ...medical-school applications have decreased 15 percent over the past four years.

    He paints a picture of a healthcare system straining under the burden. Overworked, dispirited doctors and nurses; hospitals with limited capacity, both in the sense of physical space and staffing levels, unable to handle any unexpected surge in patient loads, and patients being forced to use their retirement savings to pay for healthcare insurance. It isn’t pretty.
    posted by Sydney on 1/02/2003 07:28:00 AM 0 comments

    Bias: Speculation on why women died by the Chicago health department of 100 years ago:

    The abnormal preponderance of deaths among females, 305, to 293 males, in the week ended December 27, is accounted for by the health department by "the defective street car service, with its frequent breakdowns at a season of the year when thousands of women, at a high pitch of nervous tension over the holiday shopping, have been kept waiting for hours exposed to the inclemencies of the weather.
    posted by Sydney on 1/02/2003 07:23:00 AM 0 comments

    Busy Bloggers: richard[WINTERS]md was busy with a bunch of excellent posts this past week. Posts on breaking bad news, on responding to lawsuits, and "Arse or Elbow?" are particularly recommended.

    While over at RangelMD, Rangel is musing on life - its meaning and its origin.
    posted by Sydney on 1/02/2003 07:21:00 AM 0 comments

    Wednesday, January 01, 2003

    Happy New Year

    posted by Sydney on 1/01/2003 10:29:00 AM 0 comments

    The Other Pox: The New York Times reviews a book about the role of syphilis in history:

    Whatever its precise origins, syphilis reached plague proportions worldwide by the 16th century, when, Ms. Hayden writes, "each country blamed its neighbor for the malevolent import," the Russians calling it the Polish sickness, the Germans cursing it as the Spanish itch. The name syphilis comes from a poem written by the physician Girolamo Fracastoro in 1530, about a shepherd named Syphilus who offended the god Apollo and was punished with the world's first case of the pox.

    The disease remained a pox on many houses for centuries to come, as it spread from person to person by sexual contact or other exposure to ulcerating sores, or congenitally, from mother to child. Treatments, like the consumption of high doses of mercury, were harsh, dangerous and only minimally effective. By the turn of the 20th century, perhaps 15 percent of the adult population in major cities like Paris and London had syphilis, though often the diagnosis was spoken of in the most euphemistic and obfuscatory terms.

    The 16th century anatomist, Gabriele Falloppio described how syphilis may have been introduced to Europe. It was biowarfare. This is his description of the actions of a group of Spaniards holed up in a fortess in Naples while fighting the French army of Charles VIII in 1494 (his father was in the same fortress), as quoted in Combat Surgeons by John Laffin:

    ...under the pretext that food was short, they expelled from the fortress the whores and women, especially the attractive ones whom they knew were infected with the disease. The French, seized with compassion for the women and attracted by their beauty, gave them asylum.

    And, presumably, some loving attention. The tides of war turned when others joined the fight, and a month later the French and their allies beat a retreat, carrying syphillis out of Italy to the rest of Europe.

    At first, syphilis causes a painful ulcer at the site of infection, either in the vagina or the penis, but then that resolves and it manifests itself as a generalized rash, hence its name “The Great Pox.” Then, it gets tricky and hides in other parts of the body, quietly wreaking havoc. In the brain, it can cause dementia, in the aorta, an aneurysm, and in the heart, it can destroy the valves and cause narrowing of the coronary arteries. Understandably, it can be confused with many other diseases, hence its other name, “The Great Imitator.” The problem is, since its manifestations are so protean, many other diseases can be confused with it as well, making it all the more harder to accurately blame it for the erratic behavior of so many historical personages.
    posted by Sydney on 1/01/2003 10:23:00 AM 0 comments

    Hope In Sight? Pennsylvania officials have come up with a temporary plan to help doctors pinched by the malpractice insurance crisis:

    The first aspect of the plan is to reduce 2003 MCARE premiums. MCARE, or Medical Care Availability and Reduction of Error Act, was passed earlier this year. Rendell estimated that doctors will see at least a 30 percent reduction in their total insurance premium. The MCARE relief, estimated to cost about $220 million, will be funded through a one-time emergency assessment on surpluses held by all companies writing health insurance in Pennsylvania.

    Rendell said he will also support the reintroduction of legislation that would compensate trauma centers for the higher costs of trauma care. Two eastern Pennsylvania trauma centers -- at Abington Hospital in Montgomery County and at the Community Medical Center in Scranton -- closed recently because they lost their staff neurosurgeons, a requirement for certification. The trauma center legislation would cost between $18 million and $22 million, Rendell said.

    Reimbursement rates to doctors from insurance carriers should be increased, Rendell said. That, along with expected increased in Medicare and Medicaid reimbursements, will aid physicians' financial situations, he said.
    [Medicare payments are slated to decrease in 2003, not increase -ed.]

    The last element of Rendell's plan is a new court rule that will be recommended to the state Supreme Court in early 2003. The rule would require every malpractice suit to have a certificate of merit. Tort reform experts predict such a rule could reduce the number of malpractice claims by more than 25 percent.

    And it isn’t just the surgeons who are having problems:

    In a further worsening of the insurance crisis, many insurance companies are no longer writing medical malpractice policies and will cease coverage beginning Jan. 1, Rovito said. About 60 percent of the state's 35,000 doctors will be without coverage as of Wednesday, Rovito said. Those physicians are either not taking new patients, not performing high-risk procedures or simply closing their practices, said Chuck Moran, spokesman for the Pennsylvania Medical Society.

    "Doctors are really being caught between what their ethics tell them to do and what the law requires them to do," Moran said. State law requires doctors to have $1 million in malpractice insurance in order to be licensed to practice in Pennsylvania.

    Meanwhile, the work stoppage is still a go:

    Scranton neurosurgeon Shripathi Holla said he will not work the first week of January, a move that would temporarily close Community Medical Center's trauma center.

    Another Scranton surgeon said he'll temporarily stop work in protest of rising medical malpractice premiums, but he has no intention of closing his practice.

    "I think it's foolish for people to say we're going to close if they truly do not mean it," said Dr. William Auriemma, a colorectal specialist.

    "There should be no idle threats."
    posted by Sydney on 1/01/2003 10:21:00 AM 0 comments

    Other FDA News: The Red Cross is in trouble for ignoring FDA rules and passing out hepatitis infected blood as a result. That’s pretty bad. If you can’t trust the Red Cross, who can you trust?
    posted by Sydney on 1/01/2003 10:20:00 AM 0 comments

    Smear Campaign Fails: The campaign to stop the appointment of Dr. David Hager to an FDA committee on reproductive drugs based on his religious beliefs has failed. The FDA announced the new members of the committee last week, and Dr. Hager is included.
    posted by Sydney on 1/01/2003 10:17:00 AM 0 comments

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