California Medicine Man

Trouble at Domino's Pizza

2010-03-14T08:54:00.000-07:00

Via the Instapundit, people are complaining about Domino's online "Pizza Tracker". I for am appalled about the possibility that one of our most stalwart institutions may be attempting to deceive us. My 7-year-old loves keeping tabs of it when we order a pizza. How am I ever going to explain to her that maybe, maybe, this example of modern technology may be a fraud?

Well, at least I can console her that unlike big business, government would never engage in such duplicity.

Protecting the Lowly Pedestrian

2009-05-05T12:06:00.000-07:00

This article mentioned by the instapundit caught my eye. Apparently, Cranfield University in England has prototyped a novel airbag technology to protect pedestrians hit by cars.

From the photograph, it looks to have a somewhat Rube Goldberg flavor to it. To my unpracticed eye, it also looks to be somewhat expensive although a spokesman for the project reassures us that, "it would add little to the cost of the vehicle." Why does this seem unlikely to me?

There is essentially no limit to the features that can be added to automobiles to make them safer. The problem is of course figuring out how to pay for them. There is also obviously a difference between technologies designed to protect innocent third parties (e.g. pedestrians or people driving other cars) and the cars' occupants. This is why all cars must have brakes but not bulletproof windshields.

It's one thing for a consumer to be willing (or not) to pay for things that will directly benefit that consumer. On the other hand, it seems unlikely that he or she would be interested in voluntarily paying extra for something that will only be of very remote benefit to oneself. External airbags as described in the article seem destined to be a marketing and pricing nightmare.

I wonder though, in our current atmosphere of government regulation, how far might the White House and Congress might go in mandating technologies such as this one? I also wonder what actual public health benefits might be realized. I can easily imagine such a device having only a marginal benefit in terms of morbidity and mortality. We will study this in a meaningful manner before broadly demanding its application?

As an aside, I think it's ironic that this device was first tested on a Fiat Stilo. Fiat is of course a company soon to own 20% of Chrysler which is in the process of becoming nationalized by the U.S. How long before the powers that be declare that all Chryslers (and or Fiats) are required to have it installed?

Natasha Richardson and Problems with Canadian Health Care

2009-03-22T00:05:00.000-07:00

When any young person dies of an intracranial hemorrhage, it's obviously a very sad thing. However, many people were uniquely touched by the death of Natasha Richardson owing to her popularity. There are now questions being raised regarding the promptness of her care particularly regarding the lack of a Medevac helicopter system in Quebec.

Will we be able to count on the mainstream media to investigate such possible inadequacies in the Canadian health care system? Wouldn't such debate be apropos given the Obama administration's commitment to implementing Universal Health Care, a system remarkably similar to Canada's?

Taking Trust With a Grain of Sodium

2009-02-04T00:53:00.000-08:00

I was rather intrigued when a drug company representative showed up at my institution with some literature on a medication called Vaprisol manufactured by Astellas Pharma. This drug is one of a class of drugs called vasopressin receptor antagonists (VRA's) and is used to treat low blood sodium levels (also called hyponatremia).

I may be the worst philistine in academia but to me, Vaprisol is a so-so solution in search of a problem. Hyponatremia is typically treated by first identifying its underlying cause. Once that cause is determined, treating it generally makes the hyponatremia go away or at least improve. And guess what? Even if the problem can't be cured, the chronically low sodium that results rarely causes serious problems by itself.

That said, I can imagine rare scenarios whereby drugs such as Vaprisol may be useful. Obviously, attempting to be helpful, the rep left a reprint of a paper from the reputable American Journal of Medicine. It summarized some expert panel recommendations regarding the diagnosis and treatment of this condition.

I was surprised however to find that of the articles eight pages of text regarding the actual treatment of hyponatremia, half were devoted to VRA's. This may have been appropriate for a review of developments in the field but this was ostensibly a guideline for current management practice.

I encounter hyponatremia frequently but I've never seen nor known of a physician using this drug or any drugs in its class. I hardly think that the use of VRA's is generally accepted by the medical community. Which brings me to the title of my reportage. Are the recommendations of this guideline really trustworthy? Curious, I immediately flipped through the reprint to find the authors' financial relationships disclosure which had been dutifully reported.

I wasn't the least bit surprised that of the five authors, all five had financial ties to one or more of the companies selling VRA's:

Joseph G. Verbalis, MD, has served as a consultant and member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc.; as a consultant and member of advisory boards for sanofi-aventis, and as a consultant to Otsuka.

Stephen R. Goldsmith, MD, has served as a consultant and member of advisory boards for Astellas Pharma US, Inc.

Arthur Greenberg, MD, has served as a member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc., and as a consultant to sanofi-aventis.

Robert W. Schrier, MD, has served as a consultant to Otsuka.

Richard H. Sterns, MD, has served as a member of advisory boards and Speakers’ Bureau for Astellas Pharma US, Inc.

Now don't get me wrong. I myself haven't done an exhaustive search of the literature to determine whether or not these drugs are in fact any good. For all I know, they're magic bullets that should be put in the water supply to treat and prevent all current and future cases of hyponatremia.

But that's not my point. The problem is that even before checking out this particular drug's usefulness, I'm already starting from a position of mistrust. With such an undeniable "appearance of impropriety" how can I truly rely on these experts to give me the unvarnished truth? It's one thing to report hard facts. It's something entirely different to render an opinion which is what a guideline is.

Surveys of physicians have shown that most believe that the clinical judgment of other physicians can be influenced by financial encumbrances. However, those same doctors also believe that they themselves wouldn't be. What does this tell us?

Should any of us in medicine have unerring faith in the fairness and objectivity of our profession's opinion leaders and can we as patients trust that our doctors have access to the best information available? Perhaps we all need to read Dr. Daniel Carlat's 2007 New York Times article on his transformation from honest clinician to drug company shill (and back again).

It seems to me that we're getting to the point where we have to get away from the very concept of having clinical guidelines (not to mention FDA Advisory Committee reports) formulated by opinion leaders altogether. It may be far better to simply convene skilled but generic clinicians, epidemiologists, and statisticians with no ties to the pharmaceutical industry to create recommendations based only on a nonbiased, critical reading of the existing medical literature.

As drug reps are being increasingly isolated from prescribing physicians due to practice group and academic institution policies, pharmaceutical companies are shifting more of their advertising budgets towards cultivating (financial) relationships with academia's clinical gurus. No one can deny the moral hazard associated with this trend.

Understand that I am not impugning the integrity of the authors of the above-mentioned guideline but truthfully, I have no a priori reason to trust them either.

A Fresh Look at the US Airways Crash

2009-01-23T21:43:00.000-08:00

If you're at all like me, you may be a bit exhausted by the US Airways crash news coverage. OK. By now, I finally get that Chesley Sullenberger is a true hero.

Well if you still have the stomach for yet another fresh view of this oh-so-close air disaster, may I recommend Robert Wachter's take on it?

His observations are newsworthy because Wachter raises more far-reaching implications about the nature of Sullenberger's training and the important innovations made in commercial aviation since the tragic 1977 crash at Tenerife. He describes some of the well-known corollaries between this industry and that of health care delivery.

Well worth the time.

ER Docs Feel the Police Use Excessive Force

2008-12-24T10:18:00.000-08:00

To me, this story should be filed under the category of "There's less to this than meets the eye". Apparently a survey of emergency medicine physicians demonstrated their almost universal opinion that the police engage in excessive force.

While this result is interesting, it may lead to conclusions that, while appearing important and plausible, are not really informative. I can easily imagine this data being used to support the position of "criminal rights" activists appalled at low performance levels of the police and high levels of police brutality.

The opinions of ER docs would certainly be expected to carry great weight in discussions regarding health care as they should. However, the question of excessive use of force is most assuredly not a health care issue rather, it falls under the purview of criminal justice.

I don't recall a single course in either medical school or residency that addressed the issue of appropriate use of force by law enforcement. Guess what. It's not part of the medical education curriculum (93.7% even admitted not receiving such training). I don't care if every ER doc does feel this way. The fact is, such physicians are in no more of a position to assess appropriate force usage than are social workers or New York Times reporters. It's OK to have an opinion and maybe such testimony might be relevant in specific cases (more as witnesses to a possible crime) but they weren't there and cannot possibly have much insight to the actual events leading to a suspect's observed injuries.

In fact, the police have an extraordinarily difficult job dealing with some very dangerous people on a day-to-day basis.

Medical personnel do receive coursework regarding child, spousal, and elder abuse which does tend to qualify many of them to assess such cases. However, this is mainly to learn whether or not physical trauma actually occurred. In caring for an injured criminal suspect, there is little or no question that their condition is the result of violence. The question is whether such violence was justifiable and this is not something physicians having no knowledge of the events leading to it are in a position to assess.

The researchers apparently concluded that their results:

"suggest that national emergency medicine organizations in the USA should become involved, jointly developing and advocating for guidelines to manage this complex issue."

A nice inference but saying so doesn't make it true...or even logical.

Interesting Case of "Co-rumination"

2008-06-10T10:53:00.000-07:00

I haven't written much about actual medical cases I see here at my hospital but this one intrigued me. Some details have been altered of course.

A 30ish female showed up in our emergency department complaining of a sharp, stabbing pain in her left neck (10 out of 10 in intensity) for several days along with a palpable mass over the area. The pain had been present for two to three months but not nearly this intense nor had the mass been as large. She also complained of fatigue, shortness of breath, tactile fevers (felt hot but hadn't actually checked her temperature), and a range of other symptoms. The intern who presented this case to me found absolutely nothing on physical exam: normal vital signs, no mass, lungs clear, etc.

My impression just from the presentation was that this was unadulterated BS (medicalese for "move along, nothing to see here"). How wrong I was.

When I walked into the exam room there were two healthy-appearing women sitting, both with the same look of overwhelming dread. Usually I'm fairly insightful but in this case, it took several seconds to determine which one was the patient. Seeing an "older" attending, the patient's friend whom I'll call "Patient #2" immediately unloaded Patient #1's symptoms upon me.

Patient #2 related in great detail every ache, every sensation, every pain, every bowel movement, indeed every agonized breath of her friends over the past three months. Certainly, it is not unusual for a patient's friend or family to function as an advocate and relate observations about the patient that may be helpful to clinicians.

It's rare however for such advocates to give detailed subjective descriptions of how the patient is actually feeling (at least when the patient herself is articulate, not shy or embarrassed, and for whom English is her native language). Between Patient #1 and Patient #2, I was barraged with with a torrent of imagined symptoms.

In examining Patient #1, I agreed with my intern that there was no mass, nor any other physical findings of note. In my most professorial and reassuring manner and despite the fact that my skin was crawling in much the same way as when I walk into a room with a patient believed to have scabies, I told her her symptoms were nothing to worry about, that medical science can't always explain what patients are feeling, that her problems would undoubtedly resolve shortly, and that we were always here in case she didn't get better...

Our patients were greatly reassured and they both thanked me profusely. I walked out of the room feeling I'd done some good.

The diagnosis? This woman (and her friend) turned out to have a severe case of co-rumination, a topic I've written about before. The problem was that, like many females, they tend to "share" far too much. By doing so, their anxieties spiral upwards out of control as happened here. Men seem much less likely to engage in this maladaptive behavior. Certainly, we'll see more of this with men as society continues to encourage us to explore our "feminine side".

Perhaps if I had been more upfront with my convictions, I would have also recommended they stop co-ruminating regarding each other's maladies.

But that might not have been cool.

Google Commemorates Memorial Day

2008-05-26T04:06:00.000-07:00

Google generally makes special holiday modifications to their homepage logo. Here's Google's celebratory logo for Memorial Day:

What kind of statement are they making here? It seems that I'm far from the only one who's noticed the extent to which they honor the deaths of our nation's fallen warriors; the same dead who gave Google the ability to freely gather and disseminate information in a free society.

Google may be ignoring this day but at 10:30AM, my 5-year-old daughter, my wife, and I will be at the Los Angeles National Cemetery where we go every year...to remember.

Update:
In case anyone wants to send a message to Google telling them how they feel about this, here's how. My message to them:

"One of the ways I'll be celebrating Memorial Day is by not accessing your website for a week.

"Maybe next year you'll consider the pernicious effect of your decision to pointedly ignore one the United States' most solemn days."

A Practical Suggestion for President Bush and Congress

2008-05-20T21:27:00.000-07:00

I rarely write about non-medical issues but I have an important policy recommendation that I think will help the country.

Several days ago, the media lampooned President Bush for being "snubbed" by the Saudi's for refusing his request to significantly increase oil production. Bush's request was part of his plan to to ameliorate the problem of seriously rising oil prices. I wasn't there but I imagine that his plea was met with an admonition to "go pound sand".

Today, it was announced that the House of Representatives passed a bill allowing the U.S. to sue OPEC for their antitrust activity in arbitrarily limiting oil production. I may be wrong on this but I kind of doubt that the idea of being sued in an American federal court has the OPEC nations shaking in their boots right now.

So to these two Solomonesque solutions, I've decided to add one of my own: Let's have a bipartisan committee from Congress travel, along with the president, to India and China and ask them to stop buying so much oil. Most economists believe that their dramatically increased consumption (due to rising industrialization) is a principle reason for our current high prices at the pump.

Who could doubt that these two countries would willingly curtail their own drive for progress so that we Yanks can shave off a buck or two a gallon here in the states?

See? This policy stuff isn't so hard.

Those Crazy Politicians and University Endowments

2008-05-10T10:03:00.000-07:00

The Wall Street Journal is reporting that Massachusetts is contemplating a 2.5% state tax on university endowments in excess of $1 billion per university (via Greg Mankiw's Blog). Now personally, I could care less about Harvard's financial concerns. It's hard to worry about a school with a $34 billion endowment. I'd be happy if my net worth was half that amount.

Here's an idea that would take some of the wind out of these legislative proponents' sails. Harvard could take 2% of their endowment each year and give it to their 19,000 undergraduates and graduate students. This is surely a fraction of the annual interest Harvard makes on its investments each year.

This would amount to over $35,000 per year per student and would essentially give them free tuition. Of course the B-school students would still have to cough up about $7,000 more per year but well...they're B-school students. They'll be able to pay that off after their first few weeks of gainful employment.

Massachusetts would have an awfully hard time taxing such "good" citizens as the Harvard administrators for providing a world class education for free.

I don't know. 2.5% going to taxes vs. 2.0% going to their own students? Seems like a no brainer to me. Maybe the legislature is threatening the universities with this tax just to achieve this end. Either way, it seems like an abuse of their authority to me.

More on my thinking about government meddling in the affairs of private universities (non profit organizations) here.

The EMTALA and Inintended Consequences

2008-05-09T14:54:00.000-07:00

Edwin Leap wrote a revealing post about one of my personal pet peeves: the EMTALA laws (h/t KevinMD). Read the whole thing.

The EMTALA (Emergency Medical and Active Labor Act) mandates that essentially all patients must be seen regardless of ability to pay. Admittedly, this federal law states that people can be sent away without treatment after they've been properly evaluated. However, the penalties for being wrong are so severe that few hospitals are willing to take the chance. In effect, hospitals see and treat almost all E.R. patients even if they know that they won't be payed for doing so.

People will of course argue that some patients might die after having been mistriaged to home. Unfortunately, it is the nature of things that this is so. Triage nurses will always make mistakes on occasion and as sure as the sun rises in the east, some patients or their families will pay a tragic price.

Inevitably, such cases will become front page headlines, but rare as they may be, the victims will be "named" and therefore worthy of our sympathy and compassion. Consider though, that in California alone, at least 65 E.D.'s have closed in the last decade. Unreimbursed care is at the root of most or all of these closures.

How many more patients will die, however, because of a lack of nearby or conveniently located E.D.'s? Moreover, these patients will not be named but will instead be mere statistics in some as-yet-unperformed observational study.

Again, read Leap's article for more reasons why the EMTALA is a bad idea (as it's currently written).

From Dr. Jill Bolte Taylor: The Most Electrifying Lecture You'll Ever Hear

2008-03-29T23:55:00.000-07:00

I've heard a lot of lectures in my life but never one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.

Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.

It makes me never want to step up to a podium again.

Universities' Endowment Funds and the Federal Government

2008-02-07T10:29:00.000-08:00

Here's an idea I hate (via the instapundit). Congress is considering regulating the amount of university endowments that schools may keep for themselves and how much they have to pass on to students (in the form of tuition cuts, financial aid, or scholarships). Do these guys really have this much time on their hands?

Laws such as those being proposed give our legislature the bad name that it has. Why a private, non-profit organization such as a university endowment "needs" to be controlled by the federal government eludes me. Don't get me wrong. When I read that elite schools such as Harvard could pay the tuition of their entire student body on just the interest that their endowments earn, I find that reprehensible and a poor reflection of their governance. But that's their problem, not the fed's.

Surely people will make the argument that as tax-exempt organizations, some limitations on their behavior is appropriate. Really? Is the federal government really so much the paragon of efficiency and insight that they should decide where the Red Cross or Harvard should allocate the contributions they collect? Is that what we want?

Likewise, some will point out that many (most?) students receive some federal aid in the form of grants or federally insured student loans and as such, the government has an overriding interest. To me, this just strengthens the position that the fed should get out of higher education completely.

My guess is that such legislation will probably go nowhere (although some provision for more transparent reporting of where endowment money actually goes may pass). I think though, that the real intent of such debate is to put a chill in the minds of fund managers' minds. The mere threat of such laws may well be enough to "influence" behavior. In my opinion such saber rattling is an immoral use of federal power.

Bad law. It's contagious.

Gonzo Medical Blogging

2008-02-02T10:22:00.000-08:00

Periodically, I will add a new blog to my "blogroll". Unlike many bloggers that maintain such lists, I try to post only the ones I like to read frequently. Some bloggers maintain huge alphabetized lists of blogs, a practice I've never really understood. Perhaps these lists grow because of quid pro quo (you link to me and I'll link to you, a practice I hate) or perhaps some people just like the look of really unwieldy, completely unfiltered lists.

Personally, when I look at someone else's blog, I enjoy looking through their blogrolls to see just what they like to read. Being an avid reader, I'm always curious about such things. When my patients or their families have books with them in the hospital or exam room, I invariably ask what they're reading. Huge blogrolls don't really give me that kind of insight into the compiler's tastes.

At any rate, this post is to announce an addition to my blogroll. That we are judged by the company we keep concerns me as I add a link to Panda Bear MD but what can I say? The guy is hysterically funny and says things that many of us think but are unwilling to express in polite company. Panda is a resident in emergency medicine. I'm sure he is a bit older than his fellow residents as he's described a wide variety of prior life experiences.

This added age undoubtedly gives his writing a level of sophistication extremely unusual in someone the age of a typical resident. If I had to pigeonhole him, I guess I'd call him the Hunter S. Thompson of medical writing, an appellation I'm sure he'd understand as a compliment.

I enjoy his observations, his insights, and his style very much and have pointed colleagues, nurses, and residents towards selected posts to much hilarity.

Truthfully, I sometimes worry about Panda. My hope is that his posts are put-ons and that the darkness, even bitterness, imbued in his writing is more for shock value than anything else, sort of like Ann Coulter's subtle style. But I have my doubts. His writing is too authentic and fluid.

I think that while most of us will occasionally laugh at the peccadilloes of our patients and their families, most of us don't define such people by them. I hope he is happy in what he does and that if so, medicine continues to sustain him. Unfortunately, my suspicion is that his cynicism has been acquired at far too early a stage in his career. He has all the markings of someone headed for premature burn-out. Hopefully by turning others' attention to his writing, I'm not reaffirming his world view and somehow facilitating such burn-out.

One last point Panda, if you're reading this. You should give some serious thought to posting your name and your institution. Not because I want to know who you are but instead, to protect yourself. While I don't recall reading anything you've written that's frankly libelous or in violation of HIPAA or terribly likely to get you into trouble, some of your posts definitely push the envelope. I think that writing without the imagined security of anonymity helps ensure just enough caution to prevent saying things that can have tremendous legal or professional repercussions. Internet anonymity is fleeting. Just ask the Flea.

My two cents.

Service in Medicine, Has it become a quaint anachronism from a bygone era?

2008-01-31T03:13:00.000-08:00

Bob Wachter has posted some great points regarding the "service" of radiology.

The last paragraphs are priceless:

In my NEJM article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.

Or the country.

I feel the same way about so many aspects of modern medicine. If primary care physicians want better reimbursement, they need to "add value" to their interactions with patients. Otherwise, why not have a nurse practitioner or physician assistant grab their business at a discount (e.g. at CVS Pharmacies)? If emergency medicine docs want more respect from their colleagues and to not render themselves useless, then they have to do much more than act as glorified triage nurses. In the same way, if radiologists want to avoid having their jobs outsourced, let them raise their standards of service.

The list of examples could go on and on. Read Arnold Kling's recent article in tcsdaily to see one reason why quality has declined so frequently. Hint: imagine what happens to a service when the recipient pays for it rather than someone else like a third party payer.

Who says big government is inefficient?

2008-01-22T08:35:00.000-08:00

Courtesy of the InsureBlog: A little USA article on your government at work. So it seems that the NIH can't keep track of the potential conflicts of interest between grant recipients and the companies they ~~shill~~ consult for.

I was going to ask myself how the General Accounting Office (GAO) could allow this to happen and then I realized...

Of Mice and Men

2008-01-17T21:42:00.000-08:00

This caught my eye. It's an article in Yahoo News entitled Humans Crave Violence Just Like Sex. I'm thinking, this has to be noteworthy. Imagine my disappointment in reading the first few lines:

New research on mice shows the brain processes aggressive behavior as it does other rewards. Mice sought violence, in fact, picking fights for no apparent reason other than the rewarding feeling.

The mouse brain is thought to be analogous to the human brain in this study...(my italics)

Pardon me my skepticism.

From the Field to Angiogram.

2008-01-17T21:24:00.000-08:00

Here's an interesting study in the New England Journal of Medicine.

There have been several studies that fairly conclusively demonstrated that reducing the time from the symptoms of a particularly dangerous type of heart attack (the so-called ST-segment elevation myocardial infarct or STEMI) to the time of balloon angioplasty saves lives. Getting this symptom-to-balloon time down is of course partly a function of physician skill. But the biggest determinant has to do with the nature of the system that's in place to move the patient from initial transportation to assessment to cath lab team mobilization.

Getting this time down involves tremendous planning, resources, and careful thinking. This study looked at door-to-balloon time (the time the patient hits the hospital to the time the angioplasty balloon is inflated (thus opening a clogged artery). It seems to show that if paramedics in the field are taught and allowed to diagnose STEMI's, then patients can be transported directly from the street to the cath lab thus bypassing the emergency room.

Using this strategy, the door-to-balloon time was shaved from 123 to 69 minutes. Judging from morbidity/mortality results of previous studies, this is no small amount and probably has important clinical significance. In fact, inpatient mortality went from 5.7% down to 3.0% using direct transport.

This study was not randomized nor blinded and numerous confounders can be assumed and postulated. It is noteworthy however that the baseline characteristics between the direct transport and emergency room transport groups are surprisingly similar which suggests that these clinical benefits may be real and not explainable by such confounding variables.

These results are preliminary but definitely tantalizing. It seems unlikely to me however, that a randomized trial testing this approach will ever be done and this data may be the best that we get.

Might it be enough?

Physicians and Their Role in Executions

2008-01-11T08:01:00.000-08:00

The New England Journal of Medicine has published a provocative editorial on capital punishment and the physician's role in carrying it out.

Read my thoughts on this important editorial here.The New England Journal of Medicine has published a provocative editorial on capital punishment and the physician's role in carrying it out. In truth, the position taken, that no physician should agree to facilitate an execution is old and has been endorsed by many medical societies. However, in over 1,000 words, the closest thing to an argument in support of this are these words: "A professiondedicated to healing the sick has no place in the process ofexecution."

Yet even this statement is offered without proof or justification and is merely a recapitulation of the authors' opinion. Cannot the exact opposite position also be offered, that in a nation that condones the death penalty through its laws and courts (and incidentally in public opinion), medical science should be brought to bear to insure that all executions are administered with compassion and decency?

If that is the case, who better to supervise an execution than a physician; preferably one expert in pain management, anesthesiology, or critical care medicine? After all, the article cites several instances of botched executions that almost certainly increased the pain and suffering of the criminal.

The position that this editorial takes, that the medical community's canon of ethics forbids it from participating in executions may well be heartfelt. Yet consider revealing words such as these:

Injected drugs, now used in all but 1 ofthe 37 states in which capital punishment is legal, have beenpart of the increasing medicalization of executions and the enlistment of medical personnel to lend them apparent morallegitimacy" (my emphasis).

I can't help but think that something else is going on here. Could it be that these authors are simply opposed to capital punishment and that by promoting a policy forbidding physicians from facilitating it, they in effect render it an impossibility?

If that is truly their agenda then that should have been their thesis and they should be forthright about it. Pardon me for finding it intellectually dishonest however, to hide behind some vague, poorly established interpretation of the Hippocratic Oath (which they also cited). The Oath was never understood to forbid the palliating of pain and suffering when death was imminent due to disease. Why should it be any different here?

By the way, unless you know me well, don't presume to know where I stand on the death penalty. This post is more about being upfront than about capital punishment.

medGadget Posts a Cool One

2008-01-10T08:38:00.000-08:00

This is one cool post by medGadget!

Outsourcing the Day to Day Stressors of Life

2008-01-10T08:06:00.000-08:00

Here's some insight regarding life on the other side of those monuments to outsourcing, Indian call centers. It seems that operators in India are succumbing to the stress of dealing with European and American ire:

Miss Aggarwal, an English graduate, said she planned to quit, tired of wishing customers a good morning only to hear: "Oh, I'm through to India am I? Put me through to someone who can understand English, you f****** cow."

Yikes. These people are apparently suffering from various medical problems real and imagined from this sort of work.

I'm reminded of a patient I saw in my office many years ago, a young woman with a "positive review of systems" which is medicalese for having every complaint under the sun. After getting a detailed medical history and examining her thoroughly finding nothing wrong, I asked her if anything in her personal life was bothering her.

"Well gee doc, I hate my job. It's kind of...you know, stressful."

I asked her what she did (which I should have done in the first place). Her answer convinced me that she did in fact have one of the worst, most stressful jobs in the history of mankind.

She worked as a cashier at an impound garage. She had to take rather large payments from less than cheerful "clients" to retrieve their cars which had been towed. My advice: find another line of work.

Who says medicine has to be complex and arcane?

Disaster Preparedness and Emergency Out-Of-State Physician Licensing

2008-01-09T08:14:00.000-08:00

During Hurricane Katrina, I called our local Red Cross chapter to offer my services in Louisiana. I attended their training course to do just that but was then told that I wouldn't be able to volunteer as a physician. Louisiana was unwilling to temporarily grant licensing reciprocity to out-of-state doctors even though it had experienced a massive disaster.

Any such physician assisting there would be practicing without a license and I surely don't need to review the medicolegal implications of that. Their state legislature is obviously filled with a group of rocket scientists!

I instead opted to be placed on a list of physicians willing to respond to in-state disasters (California in case you missed the title of this blog).

An interesting letter was published in the latest issue of JAMA. Lori A. Boyajian-O'Neill et. al. surveyed each state in the U.S. to find out what their policies were regarding the licensing of physicians in the event of a disaster. The chart they compiled lists three possibilities: an "expedited" licensing procedure, waiver of licensing altogether in the event the physician has a license in another state (reciprocity), or my favorite -- none.

Louisiana belongs to the expedited procedure group. During Katrina, their governor wrote an executive order suspending the usual licensing procedures. Apparently this wasn't in place at the time I considered going with the Red Cross (who would only send docs with a valid Louisiana license).

I was surprised to see that 18 states opted for no emergency licensing at all. Talk about protecting your turf!

Maybe every states' lawmakers should be reviewing their own laws. To me, emergency reciprocity seems like the way to go. For most state medical boards, a physician's licensing status can be checked reliably and instantly on the internet. Why wouldn't a state want a physician in good standing in his home state to volunteer in the event of an emergency?

Are Medical Device Manufacturers About to Get a Truly Free Ride?

2008-01-08T01:17:00.000-08:00

If my reading of an article in the latest New England Journal of Medicine is accurate, then the Supreme Court is about to rule on a case of momentous implications.

The case is Riegel v. Medtronic and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.

Read more about this extremely important case here.I'm not a attorney and I don't play one on TV. But unless I'm facing the wrong end of a lawsuit (which has happened more than once), I do find the law fascinating and engaging. Every once in a while though, I encounter a legal case that truly cuts at the heart of our day-to-day lives. One such case was Kelo v. City of New London. This case ruled in 2005 by the U.S. Supreme Court gave local municipalities incredibly broad power in exercising eminent domain over private property owners.

Kelo sent shockwaves through society when a previously assumed fundamental right to be secure in one's property suddenly vaporized. A town could now take your home and give it to a real estate developer who could then commercialize it in such a way as to increase tax revenues to that town. People across the country (even people who were not owners but hoped one day to be) instantly felt less secure about their homes and their lives.

If my reading of this article in the latest New England Journal of Medicine is accurate, then the Supreme Court is about to rule on a case with similarly momentous implications.

The case is Riegel v. Medtronic and it's a big one. Charles Riegel is suing Medtronic over a balloon angioplasty device that malfunctioned necessitating emergency care and ultimately coronary bypass surgery. Medronic is arguing that because their product received premarketing approval by the FDA, it has effectively been "immunized" against lawsuits in any state court arising from the failure of that product and that the suit should be thrown out.

Their argument is based on an amendment to the FDA charter voted by Congress in 1976. This amendment granted authority to the FDA to certify the safety of medical devices, a power that had not previously been extended to them. In order to ensure that this new FDA mandate wasn't usurped by laws that individual states might create, a clause (360k(a)) was inserted in the amendment guaranteeing that FDA guidelines would supersede any such state laws.

It is this clause that Medtronic is attempting to exploit in this case. They are arguing that 360k(a) gives the FDA priority over state laws and that this includes state provisions allowing lawsuits against device manufacturers if the FDA certified a product before it went to market. Medtronic's argument then, is that Riegel's lawsuit against them should be completely thrown out.

If the Supreme Court rules for Medtronic, this would open the door to immunizing all medical device manufacturers from lawsuits. The article in the NEJM does an excellent job of describing the implications of such a ruling.

I hate lawsuits as much as the next guy but I'm not so militant that I don't recognize the important social good that they can serve. While lawsuits are a blunt, often misused weapon, they clearly help promote better medical product reliability and safety. To simply eliminate the public's right to sue a company making a faulty device would be extremely damaging to society.

I love medical device companies. I think the products they develop help incredible numbers of people. It is naive to think however, that getting FDA premarket approval is all that's necessary to insure product safety. It is the sword of Damocles in the form of a lawsuit that truly stimulates device manufacturers to "do the right thing".

I differ with the authors in one respect. They claim that the most compelling argument the Supreme Court should be guided by is whether a ruling for Medronic will truly benefit or hurt society. My understanding is that the role of the Supreme Court is simply to adjudicate the law and determine whether or not it conforms with the U.S. Constitution. It is not the Court's job to decide whether a law is stupid or not or whether it does or doesn't achieve a particular objective

In this case, I think that the Court needs to determine whether Congress ever intended clause 360k(a) to prevent product liability lawsuits against device manufacturers. For me, it's inconceivable that that was the case.

I can only hope that for my patients and for society as a whole, nine justices think long and hard about this one.

Any lawyers have an opinion on this?

Project Steve and Its Detractors

2008-01-07T14:08:00.000-08:00

A few days ago, I blogged about Project Steve. Predictably, I ruffled some pro-creationist feathers, particularly those of M. Mitchell who commented.

So M., I'm sorry if I've offended you but this is not a "petty squabble". The reason for Project Steve is to show that a larger and much more prestigious group of scientists can be compiled that discount rather than support creationism--even while limiting themselves to those named Steve. It's a whimsical idea but as a rhetorical tool, it also sheds light on exactly what's happening here.

Creationists compile lists of scientists to cause the illusion that there is scientific merit to their positions when in fact, the opposite is true. One of the most important features of a scientific theory is that it has to be testable, i.e. it has to lead to conclusions that can be disproven. Creationism does not meet that standard as attributing the known world to God (or some other "intelligent" designer) can NEVER be tested nor proven wrong.

People have looked at the fossil record and carbon dating evidence for evolution and simply said 'God created that these findings thus giving the "illusion" that evolution is a viable conclusion.' How can a scientist possibly respond to this? Such an idea is impervious to refutation.

For this reason, the vast majority of scientists refuse to endorse creationism as science. I have no problem with including such theories in classes on religion...just not in science class.

Even one like myself who unashamedly believes in God can recognize the difference. This is no petty squabble.

John Edwards Disgraces Himself With Regards to Nataline Sarkisyan

2008-01-07T01:57:00.000-08:00

The Wall Street Journal just published an article on the Nataline Sarkisyan case and how it has been exploited by presidential candidate John Edwards. I have never endorsed nor rejected a political candidate in this blog. Today, I'm making an exception. I think that Edwards' actions regarding this case are despicable. It is clear that by giving Sarkisyan's family voice at his political rallies, he has accepted the preposterous notion that CIGNA systematically killed their daughter for profit (which they claim).

It's bad enough when this family's lawyer makes such statements to the press. Malpractice attorneys have a rich and colorful history of trying their cases in the media. In law, this is thought of as mounting a "vigorous" advocacy for one's client. Edwards however wishes to be President of the United States.

In my eye, his actions have firmly established his status as a lightweight. Policy differences aside, I for one would never wish for a president with such a simplified world view.

By the way, I was quoted in this article but my title was mangled a bit. I'm sure that UCLA, my employer was quite surprised to find that I was promoted from assistant to associate professor.

Does the Drive for Equality Trump Absolute Benefit?

2008-01-06T08:55:00.000-08:00

I'm going to point to two, shall we say...divergent viewpoints as linked by KevinMD. Read them both.

My sense is that most people would choose Graham's perspective over Panda's. One survey of college students revealed that they would prefer two nations to experience the same growth in their standards of living over having both achieve improvement but one having significantly greater gains than the other. Equality seemed to trump absolute gains for both nations.

I believe the same finding would hold were the question to concern a wealthy and a poor group within the same country. The notion of equality has been imbued with biblical preeminence, even if its quest might exclude policies that improve the lot of the poorest but improve that of the wealthy even more.

I'd love to know what people think about this. Please comment or email me.

Political Correctness and the Elderly

2008-01-04T18:04:00.000-08:00

I REALLY want to be on the road at the same time as this guy: 85 years old and driving 100 MPH in snow and ice. Apparently they're pretty lax about such things in Canada. He only lost his license and the use of his car for one week.

My feeling is that while this may have been an appropriate punishment for a younger person, in this case, doesn't it suggest a blindness to the physical realities of getting old? Is it political correctness not to ask if the combination of this driver's age and actions alone betrayed a lack judgment and a decline in cognitive function?

Are such questions not to be asked even the face of an overriding public health interest? To me, this individual's "right" to drive should be terminated before someone else's life is.

Project Steve and Evolution

2008-01-04T08:19:00.000-08:00

This post assumes that the reader believes in evolution. It's not funny otherwise and is likely insulting. There. You've been warned so I cannot be held responsible for the indignation you may experience.

The National Center for Science Education (NCSE) has embarked on Project Steve to convince evolution deniers that their list of scientists endorsing such beliefs is shall we say...deficient. To counter their list, the NCSE has attempted to compile a similar list of evolution adherents.

To be a signatory, one must have a doctorate (can be an M.D.) and be willing to sign the following statement endorsing evolution:Evolution is a vital, well-supported, unifying principle of the biological sciences, and the scientific evidence is overwhelmingly in favor of the idea that all living things share a common ancestry. Although there are legitimate debates about the patterns and processes of evolution, there is no serious scientific doubt that evolution occurred or that natural selection is a major mechanism in its occurrence. It is scientifically inappropriate and pedagogically irresponsible for creationist pseudoscience, including but not limited to "intelligent design," to be introduced into the science curricula of our nation's public schools.
Oh, and you have to be named Steve or some variant thereof (Stephen, Stephanie, Esteban, etc.)

So far, Project Steve has 860 signatories the most recent of whom is Steve Vance. Within the U.S., this would correspond to almost 54,000 scientists (1.6% Steve variants according to census figures). Two thirds of them are biologists. This is a far higher proportion than is on any list of deniers. It is also a far more prestigious group. The majority are working scientists. Many on the denier lists are not.

The NCSE hopes that when anyone shows you a list of evolution deniers, your response should be "but how many Steves are on your list!?"

CIGNA Responds in More Detail to the Nataline Sarkisyan Case

2008-01-02T12:41:00.000-08:00

Today, I received an email from Wendell Potter of Corporate Communications, CIGNA Corporation. He directed me to an open letter from CIGNA's chief medical officer Jeffrey Kang, MD, MPH that expands on his previous public communication regarding Nataline Sarkisyan.

I think it's rather illuminating and adds credence to the notion that there's more than one side to this story. Of course for those who have made up their minds, this won't matter at all.

I've posted my feelings on this case here and here.

Words to Remember (When You're Not Forgetting)

2008-01-02T12:22:00.000-08:00

Here's one approach to eliminating fear (via the Instapundit). Just induce forgetfulness. Personally, I don't know if this is the ideal approach. It may sound crazy but sometimes our fears are justifiable and based on concerns better not forgotten.

It did remind me of some words of wisdom from my father:

"If you can keep your head when all about you are losing theirs...perhaps you don't have a clear understanding of the situation."

Apologies to Rudyard Kipling.

More Sexy Ways to Spend Your Health Care Dollars

2008-01-02T08:02:00.000-08:00

Dr. Wes, an electrophysiology cardiologist has posted on two remarkable implantable devices. They continually monitor the heart's pulmonary arterial and left atrial pressures. Normally, continuous monitoring of these parameters requires the insertion of a pulmonary artery catheter in the ICU. The patient doesn't get to take this invasive equipment home with them (fortunately).

These new devices however, are permanently implanted and may yield an early warning when a patient with congestive heart failure begins to "decompensate".

Read my thoughts on this here.Dr. Wes, an electrophysiology cardiologist has posted on two remarkable implantable devices. They continually monitor the heart's pulmonary arterial and left atrial pressures. Normally, continuous monitoring of these parameters requires the insertion of a pulmonary artery catheter in the ICU. The patient doesn't get to take this invasive equipment home with them (fortunately).

These new devices however, are permanently implanted and may yield an early warning when a patient with congestive heart failure begins to "decompensate". Such a warning may allow the patient's doctor to adjust his medications to reflect these alterations in cardiac function. This is analogous to asthmatics measuring their lung function with portable peak flow meters and adjusting their inhaler frequencies accordingly.

Of course the difference is that peak flow meters cost hardly anything. They're disposables that we give away in the E.D. all the time. The devices mentioned by Dr. Wes will undoubtedly cost a zillion dollars each and will certainly be associated with nasty complications.

It may seem quaint but there was once a time when we used to assess patients' cardiac function by listening to their hearts and lungs and looking at their feet. We even trusted patients to adjust their own meds by actually weighing themselves each morning!

Now we'll have these gadgets. Of course as Dr Wes points out, there won't be a market for them unless they can be shown to add significant benefit to these more arcane methods of assessment. Randomized clinical trials are no doubt on the way to see if they improve cardiac outcomes (MI, death, cardiovascular hospitalization).

Here's a little prediction: these upcoming studies will compare the use of the devices with "usual care" (physician assessments). They will NOT be going head-to-head against "that other" early warning system: serial monitoring of serum brain natriuretic peptide (BNP). BNP is a relatively cheap blood test that also appears to provide clinical information that augments that of the physical exam. Serial monitoring reduced heart failure-related death or hospitalization compared to usual care in some small studies and at least one big study (see here).

Why would the device manufacturers go looking for trouble by comparing themselves to another technology that also works and that is almost certainly cheaper?

I don't think I'll be pulling out my Vanguard S&P 500 cash for the these particular investment opportunities.

Making Hospital Discharges Safer

2007-12-31T09:04:00.000-08:00

Bob Wachter blogged about an uninteresting topic in an interesting way. The topic (medical errors made because of care transition "fumbles") is "uninteresting" because directing your patient's care elsewhere represents "closure". Who wants to dwell on the past? 'He's not my patient anymore. He's not my problem anymore.'

More on this critical issue here.Bob Wachter blogged about an uninteresting topic in an interesting way. The topic (medical errors made because of care transition "fumbles") is "uninteresting" because directing your patient's care elsewhere represents "closure". Who wants to dwell on the past? 'He's not my patient anymore. He's not my problem anymore.'

Of course this is the wrong attitude but call me a liar for proclaiming it a norm throughout our health care system. There was once a time when doctors coveted their patients like greedy misers. Woe to the doctor who stole a patient from his colleague! Woe to the specialist who usurped the PCP's hegemony! The psychology was different when fee-for-service medicine was the standard. With declining reimbursements caused by the rise of government and private third party payers as well as capitated medicine; this all changed years ago.

Medical residents weren't that covetous even back then but hospital care by the housestaff has always been the antithesis of fee-for-service medicine. Residents are paid the same regardless of their census. This led to the popular technique of "turfing" (transferring a patient to someone else's service). If these turf wars in reverse sound like a game, read the medical field's version of a cult novel, The House of God to get the full flavor.

Unfortunately, the health care system as a whole has adopted the medical resident "model". If the modern transfer is uninteresting, it's because the patient has just become someone else's problem.

With fractionation of care and lack of ownership comes patient dissatisfaction and worse, medical errors. Of course there are other reasons for the increase in disjointed care: the increased complexity of medicine, the greater acuity of hospital patients, the declining reliance on face-to-face or at least telephone communications in medicine. But, I think that this lack of ownership is way up there.

Wachter points out that no one is currently accountable for transition-related goofs. I think this is partially right. I don't think it explains everything. He points out the current lack of quality measures specifically related to determinining the integrity of the hand-off process. But I think we've always been aware of the problem. I believe that high readmission rates (which are measured) are generally attributed to poor post-discharge planning as a first approximation. Obviously there are other causes but this is usually what is blamed first. The principle culprit of this poor planning is frequently miscommunication.

He is right though that easily measured indicators that are more specific to the quality of hand-off procedures are required.

His discussion of "transition coaches" and his interview with Eric Coleman is fascinating. I'm quite surprised to read that such coaches were found to be cost-effective though. They seem to be extremely hands on, spending much time with patients, visiting them at home, etc. This seems very expensive to me. Clearly the patients eligible for this type of intervention need to be closely screened. I'd think that for such a program to work, only patients classified as being at very high risk of bad outcomes should be considered.

I once worked as a hospitalist for a large IPA that achieved good results with some relatively simple and inexpensive procedures. We immediately dictated detailed discharge summaries at the time of discharge. The IPA had a special contractural arrangement with the hospital to have these transcribed immediately and they were FAX'ed to the PCP (and relevant subspecialists) by the following morning. Our IPA discharge summaries had a standard format that was designed to be specifically helpful to the doctors participating in after-care (and that met the discharge summary standards for the hospital as well).

We also arranged for a full-time RN who called every single discharged patient the next day. She was often able to troubleshoot problems before they became problems. Of course one of the big advantages of such a nurse was that screw-ups became less serious and were more easily rectified. The transition coaches discussed above appear mainly geared at preventing screw-ups in the first place -- always a better though I believe costly solution.

There are programs being studied that assign roving physicians to do housecalls on frequent flyer patients (often old, tenuous patients with multiple medical problems). Such programs appear to be cost-effective but are treating a somewhat different problem i.e. trying to prevent admissions in the first place.

One thing that really used to disturb me was the response of PCP's to phonecalls. If I was discharging a particularly challenging patient, I would call the PCP to give him a heads up. Surprisingly, the most common response was "Don't bother. Just FAX the D/C summary." They didn't even want to take the two minutes to discuss it.

Now if there's just a way of financially incentivizing doctors to take ownership (in ways that don't lead to overutilization) then we'd really have something!

Everyone be sure and have a great new year!

Regarding My Curriculum Vitae

2007-12-28T07:22:00.001-08:00

People have recently pointed out to me that I've never been published in a peer-reviewed journal. For the record, it's not that I haven't tried.

Seven Health Myths Even Doctors Get Wrong

2007-12-28T06:55:00.000-08:00

Here's an amusing article from Newsweek on seven health myths that even physicians continue to believe. Only one of them fooled me but they are interesting.

I remember thinking as a kid that the statement "You only use ten percent of your brain," had to be wrong. My reasoning was that I couldn't imagine a way to even quantify such a nebulous assertion. I was an empiricist at an early age!

Also as a child, I knew that the stories about strangers tainting Halloween candy had to be BS. Of course I never minded that my parents wouldn't allow us to eat unpackaged candy or fruit. I guess my strength of conviction wasn't absolute.

As for the one that fooled me: Health professionals. Admit it, you still think that reading in dim light ruins your vision don't you?

More On Nataline Sarkisyan and CIGNA

2007-12-27T10:12:00.000-08:00

More thoughts on the Nataline Sarkisyan/CIGNA case here.I recently blogged about the teenager who died waiting for a liver transplant that never materialized. I ambled through the blogosphere looking for what other people have also written on the subject. While I'm not surprised at the intensity of emotion that has arisen from this case, the utterly inflammatory and often mindless rhetoric being propagated is sobering. It seems that nuance has taken a hike, never to reveal itself.

CIGNA is in a public relations morass from which it can never emerge regardless of what details may later be revealed. A lawsuit against them over this issue will be perceived as all but indefensible and will surely result in a settlement with many zeros. There is no way that such a lawsuit's merits will ever be tested. Unlike CIGNA, this family's attorney has very little to lose from a courtroom battle.

People's minds are made up and will in most cases be impervious to change. The facts of this case are unquestionably grim but can those advocating the public hangings at least imagine the possibility that some technologies may in fact be futile or at best experimental? And if such is the case, can these individuals not recognize the grotesque opportunity costs such expenses represent?

Every dollar spent represents a dollar that could have been spent elsewhere. Everything in medicine and economics is a tradeoff.

For a more reasoned perspective on this case, check out InsureBlog's assessment.

Personally, I think one of the biggest mistakes CIGNA may have made was giving in to the public relations consequences and actually approving the procedure (belatedly). I saw an internal memo posted publicly by a single blog and was hesitant to cite it (being unable to find it elsewhere). Apparently however, it has now been posted by CIGNA itself and it is rather revealing. A quote:

Based on the unique circumstances of this situation, and although it was outside the scope of the plan’s coverage and despite the lack of medical evidence regarding the effectiveness of such treatment, CIGNA decided to make an exception. CIGNA did not reverse the clinical determination that the member’s plan did not cover the transplant.

To me, this is very telling and the implication is that families capable of mobilizing public support will fare better before CIGNA than those not so savy regardless of medical realities. They've all but admitted that the decision to capitulate was based not on science but on emotion.

It's very sad what this says to other CIGNA subscribers who may in the future have their requests for expensive interventions rejected.

Notice To Would-Be Advertisers On My Comment Areas

2007-12-26T11:51:00.000-08:00

In the past, I've had automated programs insert advertisements in my comment areas. Blogger comment authentication software has been fairly successful at eliminating that.

Recently however, I've noticed a fair number of comments to my posts that add nothing substantive to the discussion. Rather, they are instead mere excuses to insert a link to a commercial website. They have an outward facade of contributing but in fact do not. Just to let commenters of that ilk know, I summarily remove them and I would urge all bloggers to do the same at their blogs.

On the other hand, I have no problem with a commenter that does choose to add to the discussion yet "happens" to insert a commercial link. I don't remove such comments. I'm not anti-commercial, I'm just anti-wasting-everyone's-time-for-the-sake-of-an-advertisement.

More Random Thoughts on Futile Therapy and Euthanasia

2007-12-26T07:43:00.000-08:00

Last week, I wrote about a sad end-of-life case brewing in Canada. Today, I'd like to add a few more thoughts on it.

You can read them here.Last week, I wrote about a sad end-of-life case brewing in Canada. Today, I'd like to add a few more thoughts on it.

This case is about a critically ill, elderly man and his family who are orthodox Jews. The family's orthodoxy is one of the reasons they are reluctant to allow the heroic life support measures currently being employed to be withdrawn. Their position is that it is against basic tenets of their religion to do so. They have an attorney whose position is that such withdrawal of care is no less than assault and battery. The family goes a step further calling it murder.

I myself am Jewish though far from orthodox. While I don't profess to be an expert on Jewish law (halacha), one thing i do know is that like secular law, much of it is in the eye of the beholder. There is very little under halacha that is truly, irrevocably settled.

Jewish law is based upon the Torah, the first five books of the Jewish Bible (what non-Jews call the Old Testament). The Torah, like all things biblical, is so shrouded in mystery that Jewish scholars have engaged in centuries of debate as to its meaning. By "meaning" is meant the Torah's relevance both spiritually but also as a code of ethics and behavior. This debate was transcribed and codified as a commentary to the Torah known as the Talmud.

Halacha is based on rabbinical scholars' understanding and interpretation of the Torah and the Talmud and is always changing to meet current ethical and legal dilemmas. There is no shortage of thought directed to end-of-life issues in halachic law.

Like so many issues of Jewish law, the orthodox position on withdrawal of life support is far from settled. That being the case, it may be simplistic or a misinterpretation to call such withdrawal murder as the family described in the link above is apparently doing.

In fact, there is a reference in the Talmud (B. Ab Zarah 17b-18a) regarding the execution of Rabbi Chanina ben Teradyon. When he was burned to death by the Romans, they wrapped him in a moist blanket to prolong his suffering. Responding to an appeal for compassion from his family, the executioner was permitted to remove the blanket thus hastening his death. This reference has been invoked in halachic arguments to justify the withdrawal of life support when its use will only prolong patient suffering.

I thought this might interest some readers both as providing an insight into some of the views Jews hold on this topic but also as an example of how halachic arguments are set up. The whole subject is fascinating though again, I'm no expert but merely a dilettante.

I'd also like to mention that when I was a medical student in my preclinical years, I read an article in the New England Journal of Medicine called Must We Always Use CPR?. Leslie Blackhall, the author posed the title question, the answer of which I had always taken for granted: one always offers a patient or his surrogate the option of CPR. In other words, the decision to be a "full code" or not always resides with the patient.

Blackhall questioned the wisdom of this approach theorizing that if CPR was futile for a given patient (she studied situations in which it surely was) then it shouldn't be offered or even discussed. This argument had a profound impact on me because it filled me with revulsion. I couldn't believe that a physician would write such a thing. To me, patient autonomy was a given.

Then, I began my clinical rotations and actually started working in the hospital. On the medicine wards for the first time, I started to see the incredibly ill, cancer infested, old, demented, zero-quality-of-life patients that we were going through the motions with and performing full codes. Almost none of these patients survived and the few that did had devastating loss of function and disability that made their quality of life even worse. All we ended up doing was delaying the inevitable...and causing unnecessary suffering on the way.

It came to me during these times that coding such patients was indeed futile. Only then did I understand that Dr. Blackhall was right.

The Realities of Health Care Economics Meet Personal Tragedy

2007-12-24T09:50:00.000-08:00

I suspect that we'll be hearing more about the tragic case of Nataline Sarkisyan, a 16-year-old girl who died of liver failure following a reportedly successful bone marrow transplant for leukemia. CIGNA, her insurer, denied coverage for a liver transplant until just before life support was withdrawn. They claimed that such surgery was experimental and therefore not a covered benefit.

A few observations here.I suspect that we'll be hearing more about this tragic case in the weeks and months ahead. It's about Nataline Sarkisyan, the 16-year-old girl who died of liver failure following a reportedly successful bone marrow transplant for leukemia. CIGNA, her insurer denied coverage for a liver transplant until just before life support was withdrawn. They claimed that such surgery was experimental and therefore not a covered benefit.

A few observations:

The LAT article I linked doesn't go into many of the medical details but other articles I've seen suggested that her liver failure was a "known complication" of bone marrow transplants. This leads me to wonder if it arose from hepatic veno-occlusive disease. If this is true (which I have no proof of) then there may have been some justification for attempting a liver transplant. I found several reports in the medical literature of successful liver transplants in this setting. Of course there may have been even more failed operations that went unreported (a death in such a grave setting might not warrant a journal article).

Whether such successes elevate the status of liver transplant for this indication from experimental to accepted therapy is questionable but certainly open for discussion. Of course the grave nature of the patient's condition may have also figured in assessing the futility of the surgery.
I was very surprised that the family's physicians claimed a 65% six month survival with the transplant. It seems highly unlikely that such data, if it exists at all, has any degree of reliability. These are rare cases. I think it's interesting that these doctors are now refusing to speak to the press and I wonder how excited they'd be at having to defend those numbers publicly.
Insurance companies don't do surgery or practice medicine. Doctors and hospitals do. Why didn't UCLA, the patient's hospital, simply perform the surgery and defer payment from the family or CIGNA until later? If it was such a great idea, why didn't they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA's assessment?

Surely an institution of this size could have absorbed these costs at least until the finances could later be sorted out. This is all the more true given that most such costs are fixed costs that the hospital would incur regardless of whether this particular operation was performed or not.

How is it that the hospital and the doctors' moral standing in this disaster has escaped media attention? My prediction is that eventually, it won't.
Predictably, the family has hired an attorney to sue CIGNA for wrongful death. He says that CIGNA "literally and maliciously killed" Sarkosin. I suppose that lawyers can and will say anything they want in order to sell their case to the media and the public but comments like this seem dangerously close to slander.
I think that CIGNA's attorneys are going to regret that they approved the transplant at the last moment. To me, this makes their decision appear capricious. I would have been willing to give CIGNA's utilization review process the benefit of the doubt; but by reversing themselves for no other apparent reason than the strident protest occurring outside their offices, they betrayed a sense of arbitrariness.

Believe me, this girl's family will surely capitalize on that.
In some circles, this case is already being touted as reason for moving to a universal health care system. This is a curious argument. I looked at some data and did some rudimentary (though not robust enough for publication) calculations that suggest the opposite. Canada appears to do 32% fewer liver transplants than the U.S. on a per capita basis and the U.K. does 42% fewer.

It seems to me that if it's more liver transplants you want, you'd do better to come to the U.S. than a country with socialized medicine.

This case isn't going away anytime soon.

CPR Meets Evidence-Based Medicine Revisited

2007-12-21T11:05:00.000-08:00

Big changes are brewing. Two articles were published in the most recent issue of Circulation. Both tend to support the notion that Continuous Chest Compression Cardiopulmonary Rescusitation (CCC CPR) using chest compressions only may be as effective as using both chest compressions and breathing.

Read more about why this is important here.Big changes are brewing. Two articles were just published in Circulation (here and here). Both tend to support the notion that Continuous Chest Compression Cardiopulmonary Rescusitation (CCC CPR) using chest compressions only may be as effective as with both chest compressions and breathing.

I wrote about Dr. Gordon Ewy's long struggle to convince the medical community of this possibility several years ago. I'm impressed that it looks like he may be vindicated.

CPR done immediately, prior to the arrival of paramedics, and by trained lay people has the potential for saving many lives and even for preventing the terrible consequences of cardiac arrest those who survive. The standard protocol (for adults) is to give the patient two breaths and then thirty chest compressions then alternating back and forth. The question is whether this is the best way. There is now increasing evidence that it is not.

Ewy, who wrote a previous review article on the subject was struck some years ago by a fascinating observation. A woman was attempting to resuscitate her husband using CPR as coached by an emergency

"Why is it that every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?"

This phenomenon has also been noted by previously by paramedics and among other things, caused Ewy to speculate that perhaps the breathing part of CPR isn't that important. Moreover, he questioned whether it was in fact harmful given that it prevented chest compressions from being done continuously.

Animal studies had suggested that the oxygenation during the breathing phase was not nearly as important as maintaining perfusion which only happens during chest compressions. In fact, it takes some "momentum" to maintain that perfusion which is lost when they are not done continuously.

The two studies linked above were observational studies but the first demonstrated that outcomes were similar in one month regardless of which type of CPR was done in the field (over 11,000 patients). The second showed that neurological outcome a year post-event was similar for the CCC CPR vs. conventional CPR.

For prolonged cases (resuscitations greater than 15 minutes), the second study showed a slight advantage for conventional CPR. This may represent what statisticians refer to as an alpha-error though (also known as a fake finding due to bad luck). The reason I say that is that even no CPR did better in those patients which to me doesn't make biological sense.

The big question and one that Ewy himself raises in the accompanying editorial, is whether there is now enough data to warrant a change in the general CPR guidelines given to perhaps millions of lay people worldwide eliminating the breathing portion. Certainly both of these new studies have enough holes in them to drive a semi through; but whether writing new guidelines on this issue has enormous implications for a simple reason.

One of the biggest barriers to people performing CPR on strangers is the "mouth-to-mouth" part. One survey Ewy did in the past showed that only 15% of lay people would be willing to do this. Eliminating this requirement could cause many people who would otherwise walk away to actually be willing to do CCC CPR. The public health consequences of such a change could be extraordinary.

The question is now becoming not so much whether there's enough evidence to recommend the change but rather whether there's enough evidence to continue teaching what may be a futile, deleterious practice.

Again, see my previous post for more information about this.

Patient Privacy, Gratuitous Nastiness, and the Ubiquitous Tort Lawyers

2007-12-20T06:26:00.000-08:00

KevinMD has posted about a news article dealing with a privacy issue that doesn't come up too often. A chief resident of general surgery took a picture of a patient's penis while he was under general anesthesia.

There were three problems with this incident:

The patient did not consent to or know about the photograph (he was unconscious).

The photograph was not used for the purposes of medical education but rather for its "check this out!" factor.

Federal privacy regulations (the Health Insurance Portability and Accountability Act or HIPAA) have surely been violated. It is acceptable to disclose a patient's medical data (including photographs) if the patient's data is "de-identified" or the patient's consent is obtained; and the information is used for academic purposes.

De-identified means that the information is stripped of 18 parameters defined by HIPAA such as name, address, etc. The 18th is, "Any other unique identifying number, characteristic, or code..." (emphasis mine). The man had a tattoo on his penis that said "Hot Rod" and unless I'm seriously unhip, it's fair to say that his tattoo would be considered uniquely characteristic.

In addition, the photograph was not taken for medical education or research but rather to be passed around the campfire for its "entertainment" value.

This resident is in a LOT of trouble. He violated federal law and surely his hospital's formal bylaws. More importantly, he violated standards of basic human decency. Apparently however, he did try to make amends. He apologized to the patient and also appeared to form a close bond with him. The patient in fact "had been terrified about the impending surgery and said he had formed a 'bond' with Hansen (the resident), who helped him stay calm."

The resident's institution suffered a public relations nightmare and an expensive one. HIPAA violation fines can be quite expensive. I also assume there'll be a major lawsuit or a large settlement. The victim has obviously been coached by an attorney and is using the "correct" language with the press:

"But now I feel violated, betrayed and disgusted. I've never been in a hospital and (my) first experience is the worst thing ever."

There was once a time when such a act would have been handled with an apology and some form of disciplinary action, possibly getting fired. Such times now seem a quaint anachronism. Frankly, I hope his young physician has learned a serious lesson. To be honest though, I hope this example of emotionally retarded behavior doesn't end his career.

Update: The Blog That Ate Manhattan has a more insightful post than mine. Of course the "whistle blower" committed a more egregious HIPAA violation than the resident by going directly to the press (HT Kevin MD)

Why Insurance Companies Don't Pay For Hearing Aids

2007-12-19T07:41:00.000-08:00

Toni Brayer MD of EverythingHealth asks the question, Why won't insurance companies pay for hearing aids? It's a good question and its implications are more far-reaching than you might think.

Click here for my feelings on this.Toni Brayer MD of EverythingHealth asks the question, Why won't insurance companies pay for hearing aids? It's a good question and its answer has implications more far-reaching than you might think.

The obvious response would be unadulterated avarice. But if that were the case, then insurance companies wouldn't pay for anything related to health. They'd just collect your premiums. While insurance companies may try to minimize the amounts they pay out, we all know that they must pay for something to maintain credibility (and not be sued for fraud). So something else must be happening here. And it has to do with the very essence of what "insurance" actually is.

There's nothing magical about how the insurance industry works. Its raison d'être has always been to spread the expenses of a rare, known risk from a small number of people to many people. This way, everyone pays a manageable amount so that no one person has to pay a huge amount.

If my house burns down, I don't want to face the catastrophic expense of paying for a new house and its contents (and going broke in the process). So I buy homeowners insurance. I'll probably never make a claim because my house probably won't ever burn down. However, I sleep better knowing I'm insured for that unlikely event (also my mortgage lender makes me do it but that's another issue).

This is insurance in its classic sense. There are other issues involved but this is the basic concept. I'll leave it as an exercise for the reader to guess why policies exclude "acts of war" from their coverage for example.

Because having my house burn down is a rare event, fire is an insurable risk. Likewise, getting seriously ill occurs relatively infrequently rendering this an insurable event.

Compare this with getting "home improvement" insurance. Have you ever seen it? No, and the reason is that if you purchased some, the likelihood of you using it is virtually 100%. Who wouldn't opt to replace the kitchen cabinetry if your insurance paid for it? No one. So from the point of view of the insurer, the chance of a policy holder sending in a claim for a home improvement doesn't represent a risk so much as a certainty.

So a home improvement, in contrast with a home fire, is not an insurable risk. For the company to be able to pay off such claims, the premiums would have to equal the average cost of home improvements plus administrative costs plus the additional cost of a profit. No customer would want to pay for such a policy and no insurance company would therefore offer it.

Now we come to the issue of hearing aids. Let's divide hearing loss victims into two groups: the elderly and the young. First, let's discuss seniors.

Approximately 30% of all Americans 65 and older and 40 to 50% of those older than 75 suffer from hearing loss (NIH statistics). These prevalence rates are so high that no insurance company can rationally consider hearing loss an insurable event. The risk is simply too high to make it financially viable.

Of course the insurance company could choose to spread the risk of paying for hearing aids to younger patients thus enlarging the risk pool. The problem with this is that the younger people are then paying substantially for coverage they have very little likelihood of ultimately requiring. It wouldn't be so much insurance as a simple gift to the older-aged risk pool.

Sure, Congress can step in and write laws that force insurance companies to pay for such benefits. That would be the simple solution and the morality of such laws is certainly open for discussion. But make no mistake, the end result of this approach would simply be to mandate such gift-giving from the young to the old.

Insurance companies want to be able to compete with each other for young people's premiums. Those that refuse to force younger policy holders to foot the bill for older ones will clearly have a competitive advantage. The end result? Insurance companies won't cover hearing aids in the elderly unless the government forces them to.

This really gets at the heart of one of the biggest problems with health insurance. Insurance was originally conceived to cover so-called catastrophic events like a major surgery or a lengthy hospitalization. These are extremely expensive, though relatively uncommon events like having your house burn down or totaling your car. Unfortunately for complex reasons, people demand insulation from all health care expenses. I've had patients complain to me that they spent hours on the telephone with claims people and they bombard me with "doctor's forms" to fill out so they could get their insurer to pay for a thirty dollar quad cane. Also, patients resent even minimal co-payments for office visits.

The problem is that when health plans cover the smaller (and decidedly un-rare) events such as minor equipment like quad canes and office visits, insurance ceases to be insurance and more like pre-payment instead. So when you add to these completely expected expenses things like administrative costs and a profit mark-up, premiums become needlessly high. With this extra overhead, it would be like buying a gift coupon for yourself at a store and paying more for it than its face value. Who would do that?

This is why many people concerned about health care finance (myself included) advocate moving back towards true catastrophic health insurance and away from insular insurance.

Regardless, this still leaves the question of why insurance won't cover the cost of hearing aids in young patients. To me, this is a very interesting problem. Hearing loss is much less common in young people. For this reason, one would think this risk to be quite insurable and easily distributed. It doesn't make sense that it's not covered unless something else is going on here.

My guess? Age discrimination laws. I believe the insurance companies would rather not cover hearing aids for anyone than have to explain to older policy holders and various regulatory bodies why they provide them for the young but exclude seniors. Trust me, no one relishes the thought of going toe-to-toe against AARP and trying to justify a bias against older patients!

How would I like to see this handled? At the risk of being politically incorrect, I'd like to see a law specifically excluding the insurance companies from age discrimination regulation and lawsuits regarding their coverage of hearing aids. The likely result of such a law would be to permit the industry to cover hearing aids for the young (insurable) and continue to exclude seniors (noninsurable).

Sounds harsh and I hope my mother doesn't try to run me over when she reads this; but I think things will still be better than the way they are now. If anyone has other ideas about this I'd love to hear about them.

Abandoning All Pretense of Being a Serious Medical Blogger

2007-12-18T07:26:00.000-08:00

I offer a heartfelt apology to anyone who came to my blog in search of serious commentary and instead found the following youtube video:

Who knows what demons lurk deep within my psyche that compelled me to post this piece of cinéma vérité?

Withdrawal of Futile Care vs. Euthanasia Revisited

2007-12-17T06:50:00.000-08:00

There is a medical case brewing in Canada that's about patient autonomy, medical paternalism, futile care, euthanasia, and of course religion. Have I left anything out? It's apparently turned into a bioethical "perfect storm".

Being the opinionated guy that I am, I have some thoughts on this here.Think this can't happen in the US? Guess what. It has.

I've written about the distinction between futile therapy and euthanasia before but this case brewing in Canada warrants another look.

I've often thought about this distinction because it's an important one. A great source of controversy and conflict can arise when these two entities are confused. This confusion often stems from the fact that medical professionals may define euthanasia and more frequently, "futile" therapy differently than the general public.

A therapy is futile when it offers no reasonable chance of helping a patient. Euthanasia on the other hand is the active use of an intervention deliberately employed to hasten a patient's demise i.e. the use of a lethal drug.

Most lay people would include as futile, unproven and potentially harmful therapies such as the sham cancer treatment laetrile. Medical professionals however, have often broadened the definition to include conventional treatments that have no real chance of meaningfully altering the natural history of disease for a given patient.

Under this more expansive definition, interventions such as ventilators, dialysis, or more dramatic, or more dramatically ECMO, would qualify as futile therapy in many settings. When a patient is hopelessly ill, has severe comorbid conditions, and is generally felt to be "poor protoplasm", such treatments may well be virtually no benefit.

A problem can easily arise when patients or their families can't be made to understand that in those utterly hopeless settings, medical interventions like ventilators or advanced cardiac life support (ACLS), are no different than laetrile. This is likely to be the situation described in the first link.

When this happens, withdrawal of life support will necessarily be seen as euthanasia. It is in these cases where serious conflicts between patients (and their families) and hospitals and doctors occur. Some of them make it to hospital bioethics committees and occasionally the press like this one.

Unfortunately, no doctor has absolute knowledge. No doctor can definitively predict the future and all outcomes. Those rare cases in which the unexpected occasionally happens can shake the faith of the most hardened physician in his ability to assess futility. But for the most part; when patients are old, demented, with multi-system failure, and other serious problems, the likelihood that aggressive so-called heroic medical care will cause more damage than good is very high.

In such instances, it is incumbent upon the physician to educate the family regarding this reality. If he is able to do so, then withdrawal of care is seen as a clear act of mercy. If he's not, such action will take on the appearance of euthanasia which for a majority of people is an anathema.

The situation in Canada has happened here and undoubtedly led to recriminations, guilt, and who knows what other deep, tragic feelings. The best that can be hoped for with this case is that some degree of understanding will emerge between the patient's medical providers and his family.

When the family conceives the withdrawal of life support tantamount to murder, it's already too late for that.

More on this case in a future post.

Update: Read more of my thoughts on this case here.

Patient Internet Use Revisited

2007-12-14T13:29:00.000-08:00

Trisha Torrey left a thoughtful comment to my post The Patient Who Knew Too Much and her point is well-taken. The title of my post was intentionally a bit glib. Certainly, patients need to be proactive in understanding their illnesses and can't actually know "too much".

She's quite right that the problem is not really too much information but rather too much bad information. In fact, there are things patients can do to dramatically increase the quality of information they get from the internet. One simple thing is to limit their searches to government or academic sites. This can easily be done by adding this to your (google) search term(s):

"search term(s)" site:gov OR site:edu

The "OR" needs to be capitalized. For example check out this search for information on the common cold. It filters the 2.3 million hits on the common cold down to 62,000 hits exclusively from government or university sites.

This is not to say that information from government or universities is always correct or unbiased but you definitely up the odds of getting better information this way.

Computerized Psychotherapy

2007-12-14T10:24:00.000-08:00

Ever wondered whether a psychiatrist could be replaced by a computer? Check out my latest piece in TCSDaily to find out if it's happening.

Scary stuff if you believe the "personal" touch makes a difference!

The Top 10 Questions Patients Should Ask Their Docs (And That Docs Should Be Asking Themselves)

2007-12-13T18:11:00.000-08:00

There's a very good article in MSN.com that's worth talking about. It lists 10 key questions to ask your doctor. Some are right on and some are problematic.

Click here for my scintillating observations!Here is a very good article on MSN.com entitled 10 Questions You Must Ask Your Doctor. The questions proposed are pretty good but I would like to throw my 2 cents in. It is MY blog after all!

First of all, I rather like the tone of the article. It recommends a reasonable, nonadversarial approach for patients to take with their physicians. Always a nice change from the usual How to Tell If Your Doctor is Screwing You Over pieces that I seem to run across.

So here we go:

1) Do I really need this test? Great question but the author is preaching not to the choir, but to the tree stump. It's pretty well documented that as far as the patient is concerned: "Nothing is too good for my health...as long as someone else is footing the bill." My feeling is that it's the patient that is the main driver to more extensive test-ordering. This is really a question the doctor should be asking until such time as patients are required to assume a greater personal responsibility for their routine medical expenses.

2) Where would you send your wife or children? Another great question. In fact, this is a version of a question I try to ask myself and that I try to teach housestaff to ask on their patients' behalf: "What would I do if this patient was my mother-father-child-etc.? Nothing focuses the mind like putting yourself in your patient's place.

3) How many surgeries do you perform each year? I would rephrase this as "How many of this type of operation do you perform each year?" As the article notes, There's an substantial body of literature that supports the notion that practice does indeed make perfect. This is true for both surgeons and for the hospitals in which they operate.

4) Can I schedule my surgery in the morning? I wasn't aware that outcomes for first procedures of the day were better but it seems plausible. The surgeons I know are mostly morning people. I'm ashamed to say that when I was a medical student, I definitely saw surgical cases rushed through because they were the last ones of the day.

5) If I get sick, will you see me in the hospital? Uh oh. And the author was doing so well. The fact of the matter is that hospital medicine has become so specialized that its best practitioners are those that do it the most. In fact, I point out (with some irony) his suggestion of the ideal response to question 3. In fact there's a large body of evidence to support the notion that hospitalists have better outcomes, shorter lengths of stay, and more cost-effective care than non-hospitalists. If a GP isn't admitting large numbers of patients per year, his skills are going to get a bit atrophied.

6) Do you earn bonuses based on performance? This is a tough one. The premise of this question is that, "Many hospitals pay their physicians bonuses based on how quickly they move patients out the door." First of all, there are very few settings where hospitals pay bonuses directly to hospitalists. That said, there are many situations in which hospitalist performance is evaluated at least in part on patients' average length of stay (ALOS). I don't know that many hospitalist groups are so crass as to pay a straight bonus on this basis but it can pretty much be guaranteed that ALOS is definitely looked at in reviewing their salaries. However, other quality measures are definitely examined as well: outcomes, bounce-backs, patient satisfaction, etc.

Should you refuse care from any physician whose income is in some way affected by the ALOS? If so, you may find yourself being cared for by the guy delivering the meal trays.

7) When did you graduate from medical school? The author cites a review suggesting that doctors more than 20 years out of medical school are 48% less likely to be on top of current developments in their fields. Like everything in medicine, the key question is whether your doctor is representative of the population studied. If you have confidence in your doctor, he explains things well in an easy-to-understand manner, and has a personality that clicks with your own; I wouldn't put too much weight on this finding.

Of course as one who will shortly approach that 20 year mark myself, this piece of commentary may appear curiously self-serving.

8) What the hell does that say? The point here is that "neatness counts" when penmanship is the issue. There have been countless cases of serious badness (as my infinitely more hip residents like to say) due to poorly written prescriptions and hospital orders. Reviewing your prescription with your doctor and making sure it's legible is obviously a good idea.

9) Will you remove that wedding ring? Hmm. The idea is that the risk of transmitting an infection to the patient is greater if his care providers are wearing rings. I don't know if this has ever been formally studied.

I pubmed'd "wedding ring" and found papers in the field of dermatology (eczema, allergic reactions to metals), emergency medicine and orthopedics (how to remove stuck rings, ring-associated injuries), and urology (don't even ask).

I also found a rather intriguing article in the journal Nature entitled Earth Science: The Extraterrestrial Wedding Ring. I'll definitely have to check out that one out.

The point is that I don't know if the evidence supports asking your nurse or doctor to remove his wedding ring. The study cited by the author didn't examine infection rates, only bacteria counts which in this setting may or may not have clinical relevance. Personally, I'd feel a little funny asking someone taking care of me to remove their wedding ring, particularly a woman. Who knows what she'd think!

10) What else can I do to treat my condition? It's true that physicians often lag in their familiarity with medical interventions if they don't involve man-made chemicals or sharp instruments. In fact there are studies that demonstrate the benefits of diet, nutrition, and exercise. Unfortunately, the data supporting them may not be as dramatic or as robust as you might hope. However, I've encountered many physicians who market their practices by emphasizing these more natural treatments.

I have no problem with that at all. Just make sure your doctor also knows about man-made chemicals and procedures involving sharp instruments.

All in all, I give this piece an 8.5. And some of that score has to be because the author raises compelling points that all of us, patients and doctors, should be asking ourselves.

A Self-Centered Act of Cruelty

2007-12-12T07:52:00.000-08:00

This (via Michelle Malkin) is a story that has nothing to do with medicine but is important enough to be publicized widely .

A dutch couple who adopted a South Korean girl at age four months has decided that at age seven, she didn't "'fit in' with their lifestyle." They apparently came to this realization after finally being able to have two biological children of their own.

One really has to marvel at the hubris, the self-absorption, not to mention the cruelty of these "parents". Maybe there's more to the story than was made public but that's hard to believe...and I'm not feeling very charitable or understanding right now.

I can't speak to the sensation of having a biological child but I will say that I can't imagine life without the wonderful daughter my wife and I adopted from China. How it's possible that a couple feeling the tug of parenthood strongly enough to adopt but weren't able to form the same connection with their child eludes me completely.

The father gave as his reason the fact that their daughter was "struggling to adapt to their culture, including food." This of course is preposterous as a moment's reflection would demonstrate. Our daughter was adopted at sixteen months and has absolutely no affinity for Chinese food or culture. She's about as American a gal as you'll ever meet. She certainly doesn't have an affinity for Chinese politics. Contrary to the wishes and knowledge of her staunch liberal mother, I've supplemented her Doctor Seuss readings with selections from Milton Friedman.

My thoughts and prayers are with this girl. I have no doubt that many couples will volunteer to adopt her into their families. My wife and I would take her in a heartbeat.

It's noteworthy that the father spoke to reporters only under conditions of anonymity. I suspect that he and his wife will be "outed" in the near future.

But I don't blame him for trying.

Update: Read this blog post by a Danish citizen who was adopted from South Korea. Also, read this press release from Global Overseas Adoptee's Link (G.O.A.'L). They raise questions about the legality of this "relinquishment". The first post makes the presumably obvious point that:

"A child is not a returnable product: Adoption is a lifelong commitment."

You'd think.

"Behind the Counter Drugs"

2007-12-11T07:32:00.000-08:00

You learn something new everyday. Today, I learned about "behind the counter" drugs (BTC). It seems that the FDA is contemplating a new class of drugs to be added to the traditional dichotomy of prescription vs. over the counter (OTC).

Learn more about them here.You learn something new everyday. Today, I learned about "behind the counter" drugs (BTC). It seems that the FDA is contemplating a new class of drugs to be added to the traditional dichotomy of prescription vs. over the counter (OTC).

BTC drugs will be halfway in between. They won't require a doctor's prescription but a patient can't simply purchase them on his own. A pharmacist can dispense them though, after questioning the patient and making a clinical judgment (presumably without performing a physical exam). I suppose that if this gives patients added access to health care, this may be a good thing.

But in all honesty, I have mixed feelings about it. Unfortunately it'll be difficult to voice them without giving the appearance of "protecting my turf". But here goes.

First of all, I can't believe that pharmacists will be willing to assume the role of clinician with its added liability without charging significantly for their services. Clearly, this marks them as direct competitors of physicians (particularly primary care physicians).

Will they then be objective about when a patient's problems are out of his range of expertise and be as willing to refer as previously?

Also, the pharmacist is in the same position that people often chide physicians about, namely having a vested interest in the treatment. When a pharmacist prescribes a BTC treatment, is he doing it out of purely clinical consideration or because in addition to collecting his counseling fee, he's also selling the drug as well?

Another obvious problem that would have to be worked out is the issue of malpractice. Will a pharmacist be held to the same standard as a physician? More to the point, will he be held to the same standard as a physician who diagnoses and treats without performing a physical exam?

Ultimately, I can't really think of a medication that I could imagine putting into this category. The dearth of potential candidates may in fact be the ultimate coup de grâce for such a policy. The article I linked failed to list a single example of such a drug.

On the other hand, perhaps there might be one exception.

Late one night, I was at a pharmacy picking up a prescription for my wife. I overheard the pharmacist talking to the customer next to me. The customer, a young woman, wanted to know which OTC could help her with the two days of terrible burning on urination she was suffering. The pharmacist told her that she'd have to see a doctor about that problem and that there wasn't anything she could recommend.

I came very close to ordering three days of Bactrim for her right then and there. Maybe a question about fevers and drug allergies...it would have been so easy.

I passed. Maybe the pharmacist had she been allowed to, wouldn't have.

Medical Schools Struggle to Integrate "Integrative Medicine"

2007-12-10T14:32:00.000-08:00

Medscape posted a thought-provoking essay on how medical schools are integrating "integrative medicine" into their curriculae. Its take home message: bad idea.

I agree. Find our why here.Medscape posted a thought-provoking essay on how medical schools are integrating "integrative medicine" into their curriculae. Its take home message: bad idea.

I agree.

The article discusses the Flexner Report which was indeed a remarkable document in its day. The authors make the point that it is no less relevant now. The original report published in 1910 covered a lot of ground but a central point was that medical education needed to be based on data-driven scientific knowledge. Flexner eschewed hokey, unproven, unquestioned dogma and established that modern medical education needed to do better than that.

While I have not studied the extent to which medical schools of today are getting away from that paradigm, it seems that we are to some degree. Integrative medicine is the new big thing. Traditional western medicine is increasingly being viewed as dogmatic, uncreative, and narrow-minded. Alternative modes of healing are seen as more holistic and somehow more natural.

I don't object to anyone following the call of their own belief system. But it is becoming less politically correct to argue against the incorporation of nonwestern therapies in modern medical practice.

Don't get me wrong. I would whole-heartedly embrace the most bizarre witchcraft imaginable...if it made people better and alleviated suffering. I wouldn't even demand that such therapies actually cured anyone. Unfortunately, so many of these treatments (herbology, accupuncture, magnets, crystals, magical incantations, channeling through my neighbor's beagle, etc.) have not been proven effective.

So why give these treatments the prestige that explicit support by allopathic medical schools engenders? It would be one thing if the principles of integrative medicine were being presented simply as information med students need to be aware of. It can be argued that such knowledge will facilitate communication with their patients (many of whom are using or considering such therapies). But that's only part of it. As the article discusses, fewer and fewer judgments are being made as to their validity and they're being presented as legitimate alternatives to standard treatments.

I remember a committee meeting of one of the two major private hospitals in a community where I used to practice (a highly regarded institution with a solid medical staff). A family practitioner on staff outlined a marketing push to promote our institution's support of alternative medicine (it wasn't called integrative medicine at the time). Some of us on staff were stunned that this hospital would risk its reputation on something so obviously non-evidence-based.

When she was asked about this, her response was simply, "Well, everyone is doing it and if we don't get on the train now, we'll be left behind." What an inadequate, wishy-washy excuse. Ultimately, the hospital caved. It's disturbing to read that (as documented in the article) these same changes are happening in our nation's medical schools as well.

And now, a personal anecdote. I once tried to learn accupuncture. I signed up for a very sophisticated, very rigorous course (that involved many hours of training). I read the textbooks, memorized the meridians and the accupuncture points (it was harder than gross anatomy). I learned the different diagnostic protocols, the personality types, etc. I practiced "feeling the Qi" when placing the needles in my classmates.

I failed miserably. I simply couldn't do it. I've asked myself many times why this discipline so thoroughly eluded me. The bottom line was that I just couldn't "let go". I just couldn't get away from the ludicrous silliness. It was like watching a movie where the characters were so poorly drawn, the storyline so utterly absurd that I couldn't achieve the suspension of belief needed to enjoy it.

I am an integrative medicine failure. I am a philistine.

Update: Read this post by Orac.

The Patient Who Knew Too Much

2007-12-07T08:43:00.000-08:00

Dr. Jay Parkinson is unimpressed with the ready availability of medical information on the internet for patients (courtesy of Kevin, MD. I myself have to agree. However, there have been times when a patient by virtue of his or her own net-surfing has brought useful info to me about their case.

But on balance, these situations are vastly outnumbered by those where a little knowledge is a time-consuming and occasionally dangerous thing. For example, I couldn't possibly count the times when patients have stopped taking drugs I recommended because they "read" that they had side-effects.

Sometimes concerns are raised by what a patient (or his well-meaning family) has found that just has to make me smile. One time, I was rounding on an elderly man I'd admitted to the hospital the day before. He did quite well overnight.

From his bed, he handed me a sheet of paper with the words hemolytic uremic syndrome on it. "What's this?" I asked.

"Well, my granddaughter got onto the internet..."

My heart fell. "And?"

"She said I need to be sure and ask you if I don't have hemolytic uremic syndrome."

I smiled benevolently. "Mr. Stevenson, that's a very good thought but I have a few problems with that diagnosis. First, you're not hemolyzing. Second, you're not uremic. Other than that..."

"Well then what DO I have doctor?"

"Pneumonia and you're going home tomorrow."

More "What Drug Reps Think of Us"

2007-12-07T07:54:00.000-08:00

CafePharma is a website for drug reps. that I've written about before. The best part are the message boards. In fact, I have posted a link to them on my blogroll because they are fascinating to read. While I can't say whether those that post there are truly representative of all drug reps, reading them is an eye opener. It is amazing how deeply some of them loathe physicians.

Recently, a psychiatrist named Daniel Carlat wrote a stunning mea culpa piece in the NYT Magazine. In it, he documents his less than savory "career" pushing the drug Effexor for Wyeth Pharmaceuticals. Read the article to get your bearings then read some of threads in the Wyeth board and see what the reps say about him and doctors in general. Another approach to finding choice quotes about him would be to google Carlat or his piece within the website like this.

Lovely.

A Novel Application of the Eye in the Sky

2007-12-07T07:35:00.000-08:00

Brent Eric Finley was unable to convince a federal court that he really COULD diagnose medical conditions remotely via satellite imaging. He'll be doing four years in the pen because of his detractors' paucity of imagination.

Bob Wachter has written about teleradiology before. I wonder what he'd say about this?

File Under "Cooking the Data"

2007-12-06T06:12:00.000-08:00

Heavens! JAMA published a study suggesting that there may be some shenanigans in the way scientific papers are cited by those with an ax to grind. The article implies that "true believers" may be, shall we say...selective in their arguments when promoting their pet theories.

Click here for more.This is demoralizing. JAMA published a study suggesting that there may be some shenanigans in the way scientific papers are cited by those with an ax to grind. This article implies that "true believers" may be, shall we say...selective in their arguments when promoting their pet theories.

The authors looked at two observational studies published by the New England Journal of Medicine in 1993 suggesting that high vitamin E intake was associated with marked reductions in cardiac events. In 2000, an RCT was performed that showed no benefit (and possibly some deleterious effects). They then looked at how frequently the two "disproven" studies were cited later in the medical literature.

One would have expected a rapid fall-off in the citation curve after the RCT. In fact there was a fall-off but not nearly as precipitous as one might have expected. Even as late as 2005 (the last year they looked) 50% of the papers citing the original articles were still favorable towards vitamin E. Many authors were persisting in promoting vitamin A on the basis of two non-RCT's despite markedly better contradictory evidence that became available later.

This is rather damning against either the thoroughness of the citing authors (who perhaps missed the RCT in their literature searches) or against their honesty (in perhaps ignoring and not citing it). The researchers of the JAMA article did something rather slick that suggests dishonesty.

They looked at a possible correlation with how favorable towards vitamin E the citing articles were with whether or not they also cited the RCT. This is what's a bit disappointing. They found that 35% of the articles unfavorable or equivocal to vitamin E failed to cite the RCT but 83% of the pro-vitamin E failed to. Of course the erroneous conclusions could be because of sloppy research but it seems much more likely that true believers simply choose to ignore data that doesn't support their beliefs.

As my five-year-old likes to say when she doesn't get her way: "How sad".

Recollections from an Old Blog Post

2007-12-02T16:25:00.000-08:00

A few years ago, I wrote about my response to an email I received from a patient. She was experiencing chronic pain yet her doctors were unable to diagnose her illness. I detailed the thoughts her email engendered in me. That post generated a great deal of email from many patients. Recently, a similar patient commented on that post anonymously.

If you're reading this, I just want to let you know that I read your comment and was just as affected by it as by the others I received. Good luck in your quest for health, relief, hopefully one day a cure!

John

Drug Companies and Their Big Marketing Budgets

2007-12-02T15:40:00.000-08:00

A recent post of mine was pretty down on the drug companies (or at least GlaxoSmithKline). Now I'm back to defending them.

Amy Tenderich, was diagnosed with Type I diabetes several years ago and was galvanized to start my favorite patient blog, Diabetes Mine. She recently blogged about the big marketing budgets of pharmaceutical companies and the relative paucity of money they spend on R & D. As usual, I have some thoughts on this.

Click here for more.A recent post of mine was pretty down on the drug companies (or at least GlaxoSmithKline). Now I'm back to defending them.

But first, a disclaimer. The subject is an extremely complex one and an attempt to arrive at a truly informed opinion would require a great deal of time which given my regular gig, hanging with the wife and kid, and watching old Picket Fences reruns is in precious short supply. But ignorance won't stop me from pontificating on this topic because I believe it is important and engaging. The bottom line is, if you've got a more solid viewpoint than mine, I'm happy to be educated!

Amy Tenderich, was diagnosed with Type I diabetes several years ago and was galvanized to start my favorite patient blog, Diabetes Mine. Her writing is passionate, engaging, and represents the informed work of an advocate seeking to better both her life and the lives of others affected by this disease.

She blogged recently about an article in Newsweek decrying the lack of progress the drug companies are making at bringing new and innovative products to market. In the article she cites, ex-Intel CEO Andrew S. Grove skewers the industry. Grove has Parkinsons disease and is understandably upset at the lack of progress being made by pharma as is Tenderich for diabetes.

He notes the incredible progress the computer industry has made compared with that of the drug trade. In the years he worked at Intel, integrated circuits went from 1,000 transistors per chip to 10 billion transistors per chip. For the treatment of Parkinson's in that same period, "we have gone from levodopa to levodopa" (not entirely true but a not unreasonable first approximation).

Tenderich too is concerned about the same thing. She points out that the drug industry spends a third of its revenues on marketing but only a fifth on R & D. I assume she pointed out this lack of priority as a reason for why the pharmaceutical industry lags the computer industry.

Well guess what. I looked up Intel's 2006 financials (see page 33). With revenues of $35 billion, they spent $6 billion on R & D which comes to only 17%. This is less than Pharma. I can't calculate the percent spent on marketing because Intel doesn't break their expenses down that way (it will certainly be less than a third though because marketing, general, and administrative were lumped together and were around $6 billion as well).

Let's assume for argument's sake that Intel is representative of its industry as a whole. We then note three things:

The semiconductor industry spends the same (or even a lower) percentage of revenues on R & D than pharma.
The semiconductor industry seems to be accomplishing far more with its research dollars than pharma.
Pharma probably spends a higher percentage on marketing

Taken together, these facts raise several questions. First of all, why is the semiconductor/computer industry progressing in leaps and bounds while pharma is languishing in the doldrums?

Truthfully, there is an implicit assumption that hasn't been proven and is likely unprovable, namely that the progress made in medical interventions isn't as extraordinary as that made in computer science.

Sure, we can measure the strides made in IC chip technology with CPU cycle times and transistor densities. However, medical science doesn't lend itself to such simple benchmarks. Ask yourself: does the 10 million-fold increase in transistor density described above really outstrip say the dramatic reduction in mortality in AIDS or in some cancers? Who can say?

If age-specific breast cancer mortality rates have fallen by only a percentage point or two, that doesn't sound nearly as sexy as the strides companies like Intel can boast. Let me remind you however that the former corresponds to a few thousand lives saved each year. These patients and their family members are probably more impressed with that than with having fancier Gameboys.

So just because the semiconductor industry can cite some cute statistics doesn't mean we should discount medical advances over the same period.

I'd also like to point out as though we really need to be reminded of this: human biochemisty, physiology, and pathology is almost unimaginably complex. Diseases such as Parkinson's and diabetes are tough nuts to crack. Getting to the moon was comparatively easy and was accomplished back in the sixties with computers less powerful than the one driving your $10 throw-away watch. Don't downplay either the complexity of these or other diseases nor the vast array of factors that have to be taken into account to ensure drug efficacy and safety.

The second question that I would raise is why aren't drug company R & D budgets significantly bigger than their marketing budgets? This is equivalent to asking why pharma doesn't shift more of its revenue from marketing towards R & D. I think the reason is straightforward and has to do with risk.

R & D money by definition is money spent on speculation. Marketing money is "safe". As the venture in question becomes more risky, the safer thing is to partition capital towards marketing (safe) and away from R & D (risky). The fact of the matter is that there are few high-stake risks more threatening than those assumed by drug companies.

Consider that it costs over $800 million dollars to bring a new drug to market (in 2000 dollars). This number includes the presumably less risky "me too" drugs that are relatively simple modifications of existing drugs. One can only imagine the cost of bringing a completely novel drug class to market.

Then one must figure in the post-market risks. Pfizer just took a $2.8 billion write-off for their inhaled insulin technology, Exubera. It was a lousy performer in the marketplace. Merck is going to spend untold billions settling their Vioxx lawsuits.

And there's something else that drug companies are having to deal with that's relatively new. This is something that can dramatically increase the risk of development thus causing CEO's to flee even further in the direction of marketing and away from R & D: evidence-based access.

It used to be that to get your drug covered by a health plan all you needed was to show that it was incrementally better than the old drug. If your new drug only needs to be taken once a day rather than twice like the old drug, that was enough for it to be added to the authorized formulary of the insurance companies. No more.

With evidence-based access, not only does your drug have to be better, it has to be demonstrably better at improving outcomes. It may get past the FDA but if you want your drug to get on the insurance companies' formularies, you have to also show an economic advantage. For example, if your antibiotic can be taken just once a day compared to twice a day, will patient compliance be better with demonstrably better outcomes (i.e. eradication of infections)? Obviously this is much harder to prove and this increases the risk of bringing that drug to market. So you can see, many factors and many risks are involved in the drug industry that make comparisons with companies like Intel unfair.

In the best of all worlds, companies developing medical technologies would spend the bulk of their non-operational costs on R & D and none on marketing. If the technologies they produce are so great, shouldn't they just sell themselves? Unfortunately that's not how the world works. You can bet that your competitors are investing in marketing like crazy. It would be corporate malpractice for a CEO to not do the same thing.

In the final analysis, it's the competition between companies for increased market share that drives American pharmaceutical companies to be the most innovative and productive in the world. Not that either Grove or Tenderich were advocating this, but government regulation of R & D budgets or in some other way interfering with managements' drive to maximizing shareholder return will surely cause us to lose that edge.

Of course for those with serious medical conditions such as Parkinson's or diabetes, this is small consolation. What is really necessary is for advocates like Grove and Tenderich to continue to speak out as they are doing. If the drug companies can be convinced that there's a big enough market from a demanding enough constituency, they will seek to fill that vacuum.

Body Dysmorphic Disorder and Cosmetic Surgery

2007-11-29T06:11:00.000-08:00

Here's some news on the always popular body dysmorphic disorder (BDD) front. The journal European Psychiatry published an article suggesting that...cosmetic surgery doesn't help patients with this problem. In other words, if you have a pathological sense that you're ugly, surgery to correct a "minimal defect" will not improve self-esteem or happiness. This despite the fact that most such patients report that they're satisfied with their results.

Not terribly shocking.

The authors speculate that:

Patients' declared satisfaction with surgery may contribute to explain why some plastic surgeons may not fully adhere to the contraindication of cosmetic surgery in BDD.

That's one interpretation. How about the fact that surgeons get hugely compensated for such operations and they don't have to bill insurance companies? It's cash on the barrelhead.

Rapid Response Teams: Still Wondering After Allllllllll These Years

2007-11-27T16:24:00.000-08:00

Bob Wachter blogged about Rapid Response Teams (RRT's) today. His observations about this often misunderstood hospital safety intervention are quite helpful.

Click here for my thoughts on this.Bob Wachter blogged about Rapid Response Teams (RRT's) today. His observations about this often misunderstood hospital safety intervention are quite helpful.

RRT's are teams of personnel that can be summoned when a hospital patient isn't critically ill but is starting to just look bad. Dr. Wachter describes them as a Code Blue team in drag. I choose to think of them as a Code Blue team minus the adrenalin. Nurses are more willing to call them than call a Code Blue team because they're smaller and just...not as big a deal.

He is quite right that the empirical evidence supporting RRT's is lacking. Some relatively small studies (see here and here) did show benefit in terms of reduced mortality but these were not well "controlled" and their results can be easily refuted. The one large, multi-center trial, the Australian MERIT trial, failed to demonstrate benefit.

As Dr Wachter reports, the Institute of Healthcare Improvement (IHI) was so wedded to the RRT concept, that they elected to promote it as a national standard. Clearly, they were disturbed by the less then stellar performances RRT's exhibited in the MERIT trial and felt compelled to publish a specific critique of that study.

This critique struck me as quite reasonable. They noted that both the control and RRT groups demonstrated a reduction in mortality during the study period. IHI suggested that this could be explained by noting that in Australia, RRT's were already being adopted in various incarnations throughout the country. This probably tended to make the control and study groups look more alike and therefore lowered the likelihood of demonstrating a difference.

The IHI also made the point that the actual implementation of the RRT's in the study groups may have been suboptimal (and gave examples of this). Had the study groups RRT's been better executed, again, true benefits may well have been realized.

Arguments were also made that the hospitals studied were largely academic institutions and as such, the results may not have been generalizable. Likewise, they raised arguments that the study as a whole may have been too small and may not have had the statistical power to show a true difference.

For myself, I tend to think that there is some benefit to these programs even if the proof is hard to arrive at. The key, I think, is appropriate implementation.

I've seen situations where the RRT begins to look very much like a Code Blue team. This doesn't strike me as cost-effective. Too many people, too many doctors, too big a deal. I much prefer simpler concepts such as the version that Dr. Wachter eventually organized in his institution which seems to mainly be run by ICU nurses and respiratory technicians used to assessing very ill patients.

That such teams can be helpful in the event of a "pre-emergency" makes sense to me. In the second study I cited above, there is a very interesting table that documents the types of interventions the RRT's used. The leaders of the hit parade were:

Nasopharyngeal suctioning with additional oxygen
A simple IV fluid bolus
A dose of IV Frusemide (the diuretic Lasix for those of us on this side of the Atlantic)
Noninvasive positive pressure ventilation by mask
Nebulizer treatments
Temporary manual ventilation
Trach tub suctioning
IV Glyceryl trinitrate drip (which I had to look up to convince myself was just good ol' nitroglycerin)

With the exception of 8. and possibly 4. (which has some subtleties to it that can cause damage), these are all simple and relatively harmless interventions whose decision to initiate can easily be made by an experienced nurse. We're not talking major stuff here; just some simple things that can make all the difference in the world to a patient that's not quite critical but whose condition is worsening.

It's hard to argue with the utility of such an approach. I agree with Dr. Wachter that (at least given what we "know" at this time), individual institutions should be allowed to decide for themselves and later assess how well they work and whether they should be continued.

One additional point. I've heard a number of hospital nursing directors say that RRT's are a very useful nursing recruitment tool. It seems quite clear that nurses are very happy with RRT's and probably see them as helping to alleviate the anxiety of taking care of potentially deteriorating patients.

That has to be good!

The Latest Advance in "Hands-Off" Medicine

2007-11-25T15:59:00.000-08:00

The medical website medGadget.com reports on a new device approved by the FDA.

It is apparently able to sense pulse and respiratory rate without making contact with the patient. If I understand it correctly, it is also capable of alerting the medical staff when the vital signs change significantly.

I don't think that this technology really addresses any major medical issues but it is interesting for what it represents.

Note the comparison:

Now if we can just get one of those tricorders...

Is GlaxoSmithKline Engaged in Extortion?

2007-11-23T13:57:00.000-08:00

This is truly pathetic. Professor John Buse was apparently "intimidated" by GlaxoSmithKline (GSK), the drug company that produces Avandia (generic name rosiglitazone). Dr. Buse was one of the earliest researchers to speculate publicly on the possibility that this drug causes increased adverse cardiovascular events.

This charge, and it is stunning, was raised in a report by the U.S. Senate Committee on Finance. I would urge interested readers to take a look at it as it is quite eye-opening. The report stated, "The effect of silencing this criticism is, in our opinion, extremely serious."

GSK sent emails to Buse's superiors complaining about him and threatening a lawsuit. Subsequently, Buse was made to sign a letter drafted by GSK stating he was no longer worried about cardiovascular risks associated with Avandia. The report documents Buse's regret at caving in to GSK's intimidation.

As one who often defends drug companies for the good they do for society, I find this maddening. Attempting to silence a scientist for expressing a scientific viewpoint is an abomination. This is especially true when the public safety is involved.

I personally feel that the question of whether Avandia does or doesn't increase the risk of heart attack or stroke is still up in the air. The principal data used to support this hypothesis is a meta-analysis that has important methodological problems. But to stifle the discussion is wrong. Whether GSK's tactics are illegal is something that's beyond my pay grade, but in my mind, this constitutes extortion. There's no question that they're immoral They make a mockery of the concept of academic freedom and of John Stuart Mills' notion of the greatest good for the greatest number.

Their actions are a slap in the face to anyone such as myself who would defend pharmaceutical companies' right to maximize shareholder return (to make a profit). When a company such as GSK violates basic standards of morality and decency, it doesn't deserve my support.

Rather, its reprehensible behavior should be proclaimed loudly and widely.

Setting Paul Krugman Straight

2007-11-21T08:45:00.000-08:00

Paul Krugman wrote a recent column in which he "debunks" some popular responses to health care statistics. You might wish to read my debunking of his debunking at TCSDaily.

He may be canceling my Thanksgiving invitation.

Statistics and the Medical Residents Who Misunderstand Them

2007-11-20T08:01:00.000-08:00

Dr. Helen recently blogged on a study showing that medical residents aren't too good at statistics. This of course raises the possibility that they won't be able to critically read the medical literature and that their patients will ultimately be shortchanged.

Click here for more.Dr. Helen recently blogged on a study showing that medical residents aren't too good at statistics. This of course raises the possibility that they won't be able to critically read the medical literature and that their patients will ultimately be shortchanged.

As one who teaches residents, I have a couple of points to make about this.

First of all, the study's results seem quite plausible to me. I like to think however, that our residents at Harbor-UCLA do a little better since we run a weekly Journal Club (which I occasionally lead). It's fairly well-attended because there's usually a free drug company lunch...I know. That's another blog topic altogether.

In Journal Club, we take one article with important clinical implications and dissect it in all of its gory details. We pay particular attention to the biostatistics and methodologies involved. The purpose of such discussions is to understand the study and its potential biases. We also try to determine whether its results are valid and its conclusions generalizable to the patients we actually treat. The bottom line is that I think we make a fairly reasonable attempt to teach this stuff.

I will concede however, that my belief that our residents are not typical of those studied may be wishful thinking on my part.

But there are some larger issues here. While I agree that an understanding of basic biostatistics is essential to putting the articles comprising the medical literature in their proper perspective, many of the methodologies currently employed are extremely complex. Without a very strong background, rigorous understanding of a lot of these articles is all but impossible.

Even for those papers that don't use esoteric statistical methods (stochastic modeling, complex applications of logistic regression, nonlinear correlation methods, etc.) the amount of time necessary to digest them just isn't there most of the time; not for residents, not for most clinicians. That being the case, many doctors rely on clinical guidelines for basic decision-making. The idea is that a bunch of top experts in a particular specialty get together in Zurich for a week or so and discuss the world's literature between ski runs. They then hammer out a set of recommendations that summarize their collective knowledge.

These guidelines are generally quite readable and have the advantage of representing a consensus of these supposedly great minds.

Admittedly, such position statements have many disadvantages. There are all kinds of biases that can creep into them especially given the substantial conflicts of interest that top opinion leaders accumulate over their careers. The reality is that few other solutions are that well embraced at present and no one is going to read every significant study that comes out on his own.

My point is, don't come down too hard on the poor resident with his or her suboptimal understanding of basic statistics. I bet Sir William Osler wasn't that mathematically inclined either.

Here is a whimsical piece of irony: Dr. Donna Windish, the first author of the study mentioned above points out that many residents only read the abstract of journal articles rather than the body itself. She goes on to say that there is data to suggest that abstracts don't accurately reflect the implications of their studies. I then noticed the following in the abstract of her paper:

"Residency programs should include more effective biostatistics training in their curricula to successfully prepare residents for this important lifelong learning skill."

For this statement to be true, the authors would have to be able to cite data that establishes that

Such training does in fact "successfully prepare residents for this important lifelong learning skill."
That this learning skill makes them demonstrably better clinicians (or why develop it?)

I seriously doubt that either of these points has been firmly proven in the literature...which more or less justifies Dr. Windish's point that abstracts don't accurately state the implications of their studies.

Finally, if my discussion of this study seems a bit superficial, it's probably because I only read the abstract.

Terri Schiavo Revisited

2007-11-19T21:39:00.000-08:00

Today, Michelle Malkin linked an article by the pro-life website LifeNews. The article chastised both ABC News and the NYT for mischaracterizing Terri Schiavo's condition as "brain-dead" during her final years of life. As it turns out, the NYT did correct their article. which now states:

"...ultimately, an autopsy showed she had severe, irreversible brain damage."

Although google doesn't generally store cached versions of copyrighted news articles, the google link does quote this line as using the completely erroneous term brain-dead.
As down as I am on the NYT, I believe this was an honest mistake by a reporter who was clearly not well-versed in the science.

Brain-death is one standard for defining death (there are several). It generally implies that an electroencephalogram (EEG) shows no brain activity. As such, it is a rather objective definition which Schiavo clearly did not fulfill until she in fact died. I can't say how ABC News responded to this mistake but the NYT certainly rectified it.

My concern is that the revised version will still not be acceptable to Terri Schiavo's family. This, despite the fact that everything known about this woman's clinical condition points to its being factually correct.

Schiavo's sister, Suzanne Vitadamo apparently believes the following:

"If the media took the time to research Terri's case, perhaps they would understand that she was simply a woman living with a disability, just like the 50 million persons living with a disability in our country today."

Terri Schiavo was living in a persistent vegetative state. To call it a mere "disability" is to minimize the grave and essentially irreversible state of her condition. She was not a sentient being. If you'd like more information, try this link for an in depth discussion I wrote on the subject.

Vitadamo also described the withholding of nasogastric feedings as "killing" her. She sidesteps the fact that countless judicial rulings on multiple levels concluded both that this was Schiavo's wish as interpreted by her husband and that it was a legal one. Similar decisions are made by families on behalf of their gravely ill loved ones every hour of every day of the year.

Terri Schiavo was not killed. Nature was finally allowed to take its course.

Grease Fires As a Metaphor For Growing Up

2007-11-18T12:07:00.000-08:00

Today I'm pondering the link to a video emailed by a reader. It's about what to do during a kitchen grease fire and it raises some important issues about personal responsibility and safety.

Click here for more.Here I am sitting in my office on a Sunday morning waiting for my team of residents to get bombed with admissions. I'm attending on the wards this month, we're on "long call" today, and our hits will begin at noon.

So during these lazy moments before the storm, I'm pondering the link to a video emailed by a reader. It's about what to do during a kitchen grease fire (this is actually a link I found on youtube.com and it loads more reliably):

As a public service announcement, it's a truly riveting 30 second piece of footage. I've found this video on various sites on the internet but can't seem to determine who produced it.

It suggests:

Turning off the heat under the flaming pan.
Putting a soaked towel on top to smother it.
And as it dramatically demonstrates, do NOT pour water over it as this will cause the fire to explode.

I've looked at a number of websites such as this one by the United States Fire Administration (part of the Department of Homeland Security) to confirm the above. The message is pretty much as outlined in the video although each of the sites I looked at recommended just covering the pan with a lid rather than the towel.

This makes more sense to me because it's faster and obviously avoids the problem of dripping water into the pan. The point is also made that in the event of a microwave or oven fire, the best thing to do is simply close the door rather than try to extinguish it. This should put put it out rather quickly.

So why would I post a safety tip on this blog having never been interested enough to do so before? Two reasons.

One, the video itself is incredible.

Two, it raises the very important issue of personal safety. In my life, I've always been rather lackadaisical about such things. In fact, I used to be annoyed by "commercials" such as this one. I've also been more or less amused by people who assemble "survival kits" for their home which seemed to me to be a quaint and anachronistic holdover from the cold war.

I no longer feel this way. While I'm no "survivalist" and don't anticipate heading for the mountains to live off of berries and bugs, I definitely have come to see self-protection as part of the responsibility that comes with adulthood. The cause of these changes in my life is probably multifactorial.

Maybe part of it is spillover from the deep psychic wound all Americans suffered from 9/11. Perhaps a lot of it is the change that comes with fatherhood (which occured unusually late for me). Some of it may have even arisen from my experiences as an academic hospitalist and being immersed in the problem of inpatient safety.

In fact, videos such as the one above are important because when they are this well-made they tend to jar us from our apathy. I'm not one to dwell on how dangerous the world is and how fragile life can be; some perspective is definitely in order or we'll drive ourselves crazy.

But we should all engage at least the easy fixes in life such as knowing what to do during a kitchen grease fire. When there's an emergency, brain-lock is something we're all susceptable to. The more we think about the simple things in advance, the faster (and more correctly) we'll respond when it happens. Isn't that why those of us in health care periodically get recertified in ACLS (Advanced Cardiac Life Support) and dutifully drill in those obnoxious "mega-codes"?

Maybe the next time we fly, we should all pay a little more attention when the flight attendants bore us with where the nearest exits are and how to get those doors open.

Al Jazeera looking for Port of Olympia protest video. Is this a hoax?

2007-11-16T17:58:00.000-08:00

I saw this post on Michelle Malkin's blog. It suggests that an apparently "liberal" group called the Riseup Collective is hitting up its like-minded citizens for video footage of the recent Port of Olympia protest in Washington state. (The protesters are trying to block military supplies heading out to Iraq.) What is the video for? It's to be forwarded on to of all channels, Al Jazeera English.

Normally I don't blog about politics but would ANY liberal group be so depraved as to help Al Jazeera plant stories portraying America in an unfavorable light? It boggles the mind if true but I'm thinking this has to be a hoax.

Say it ain't so Joe.

MRI's and Demons of the Night

2007-11-16T06:41:00.000-08:00

The Underwear Drawer (one of the first medical blogs I started reading) has an amusing drive-by post on the hazards of accompanying patients into the MRI machine: "The magnet is always on."

I have a few MRI stories of my own.

When I was an intern, I basked in the unforgiving emanations of The Magnet with a patient while administering conscious sedation. Due to some not very swift carelessness, my credit cards and ATM card were summarily purged of whatever bits and bytes their magnetic strips were supposed to contain.

A few years ago, I had an unfortunate surfing accident that necessitated an MRI scan of my knee. While chatting it up with the tech, I asked the rather open question of just "how strong is that thing?" He took my shoe which has metal tacks inside and held it in the middle of the magnet and then let go. Believe me when I tell you that it was surrealistic to see it completely suspended in midair.

He then told me how one night at around midnight, one of the custodians, an unsophisticated man from rural Guatemala started to mop near the machine. The tech tried to tell him not to, that that was his job and that he used special nonferrous janitorial equipment. But language difficulties being what they were, the message didn't get through.

The man had started mopping again and the mop shot out of his hand and hung suspended in the magnet. Terrified, he ran out of the room screaming. The tech saw him in another part of the near empty hospital and asked him what the problem was. The custodian was yelling about "spirits" and was utterly inconsolable. He quit right then and there and returned to Guatemala.

Yes, the magnet is always on to which I would add, the magnet is stronger than you are.

Emergency Medicine, Stress, and the Pleasures of a Few Days Off

2007-11-15T22:19:00.000-08:00

The GruntDoc describes how strangely relaxing it is to have a few days off from his job as an emergency medicine (EM) physician. In his moment of clarity, he associates that bliss with the fact that he's no longer juggling multiple, simultaneous, urgent demands on his time.

The feelings he's describing are pretty well-known among time management experts. Engaging in multitasking is a major stressor (not to mention an impediment to efficiency). Given his field, he probably understands this better than most people.

He should be glad that when he IS on duty, his days aren't consistently like those depicted in the TV show E.R. I've had many nonmedical friends ask if working in an ER is really that stressful. I'm not an EM doc but as a hospitalist working at a large, busy county hospital, when teaching on the wards, I spend much of my day in ER's and ICU's and my sense is this: the show seems to concentrate a month or so of excitement in one eight hour shift.

I tell my friends that at that pace, the average mortal wouldn't be able to drag him or herself out of bed for the next shift after a month or so, that there'd be a run on the Valium market, that alcohol would become a nutritional supplement, and that becoming the caretaker of a national park in Alaska would become a viable career move.

Four Transplant Recipients Positive For HIV and Hepatitis C

2007-11-14T12:52:00.000-08:00

This is truly a tragic case with widespread implications. A single organ donor has apparently transmitted the HIV virus AND the hepatitis C virus to four organ recipients.

The nation's blood supply is quite safe because very accurate PCR testing detects almost unimaginably low levels of the HIV virus. However this test is NOT used for organ transplants and the ELISA test is used instead. The ELISA is not nearly as sensitive and can miss early infections (i.e. infections only a few weeks old).

This may seem crazy but, and I don't have more information about this yet, my sense is that the PCR test takes much longer to do and the added time may be unacceptable in the setting of transplant surgery. If this is the case, it would appear that this cannot be held against the transplant team(s).

However, the University of Chicago which performed the transplants does not appear blameless in this. The CDC has a policy advising that "high risk" donors (those who engage in behaviors strongly associated with HIV or hepatitis infection such as male/male homosexuality, unprotected promiscuous sex, intravenous drug use, etc.) should NOT be considered unless the recipients are gravely ill. Apparently the preliminary paperwork suggests that this donor did indeed fall into one or more of these categories. This will surely be looked at in more detail soon along with the recipients' actual acuity.

The assay for the hepatitis C virus has similar constraints as that for HIV. The more accurate quantatative test takes much longer to do than the relatively rapid antibody test.

My guess is that this event is going to open up a tremendous market for PCR or other gene amplification assays for both HIV and hepatitis viruses that are fast enough to be used for transplants. Development efforts should be immediately spurred by this.

Rightly so, and to everyone's benefit.

What Drug Reps Think Of Doctors

2007-11-13T13:15:00.000-08:00

Per KevinMD, here's a very "illuminating" thread on the CafePharma forum (a forum for drug reps). I admit that every once in a while, I'll check this website out just to see what the other side is thinking of.

In this particular thread the reps speculate on the ethics and presumably the personal satisfaction engendered by tainting the food they provide for docs and their staffs. Techniques described seem to focus on sneezing on food although others are also described and their relative pros and cons analyzed.

If it were only one or two "trolls" engaging this discussion, I wouldn't think much of it. But surfing through it, this actually seems to be quite a free-for-all. Whether threads like this are charactoristic of drug reps as a whole is obviously unclear although the tenor of the site in general is pretty down on docs.

Pandabearmd, an emergency medicine resident posted his rather understandable comment and was quoted in the following erudite and measured response (my italics):

Anonymous
Re: Do you ever mess with the food before lunch?

Quote:
Originally Posted by Anonymous

Man, as if I needed another reason not to accept gifts from drug reps you guys have provided it.
pandabearmd.com

Get lost! Why cruise rep boards if you hate pharma so much. Get back to your ivory ER tower u piece of crap primadonna. Put this shit on your blog too

Well whether pandabearmd does or doesn't, I just did.

Zyrtec-D Approved For OTC Use By the FDA

2007-11-13T07:24:00.000-08:00

Medscape reports that he FDA has just approved Zyrtec-D for over-the-counter (OTC) use.

Anyone who knows me or my writing knows that I'm very much in favor of free markets. I strongly believe that most economic environments serve people better when government regulation is low or minimal.

In fact at Harbor-UCLA, situated as it is in southern California and having a largely poor and minority patient base, I'm surrounded by very idealistic housestaff and faculty who think I'm an apologist for big pharma, big corporations, and every other "big" thing with negative connotations.

But am I really? Am I a libertarian? No. And here's why.

I see classic libertarians as being almost completely averse to all government functions except for a few things such as minting money, protecting our borders, maintaining a military, and I believe maintaining a civil and criminal judicial system. My attitude is far too hands-on to support such a laissez-faire approach.

Call me hypocritical but there are many government intrusions I whole-heartedly embrace. I don't think, for example, that people should be allowed to lie or make unsubstantiated claims in advertising and I applaud laws preventing such transgressions. But truthfully, such a stance puts me at odds with many"true believers". Likewise, I'm perfectly content to have the government oversee things generally helpful to communities as a whole, such as street cleaning. Why should I pay for street cleaning like most of my neighbors but allow the occasional cheapskate on the block ride for free yet enjoy its benefits? Does that make me a hypocrite? I yam what I yam.

Likewise, I'm also in favor of government intervention when it comes to public safety. Rather than accept a purely libertarian position, I recognize the existence of circumstances in which the government has an overiding public interest.

So what does this all have to do with OTC Zyrtec-D?

I admit that I haven't done a complete review of the world literature on the subtleties of the different non-sedating antihistamines/decongestants on the market. However, no one has ever demonstrated to me (or even suggested) that cetirizine is any better than the others. So why do we need yet another "me too" drug to be approved for OTC use? Why should the FDA want to clog up the market with Zyrtec-D when there are other drugs already out there that do the exact same thing?

Now a true libertarian would welcome the added patient autonomy that OTC's provide (I've heard libertarians argue that there shouldn't be such a thing as the FDA in the first place). To me however, keeping the pharmacy lean and mean and not allowing medications that solve no new clinical problems is beneficial to society and falls under the category of the overiding public concern I mentioned above.

When the market for a particular clinical purpose is fractionated among several different drugs, there is an unfortunate consequence. Adverse reactions and serious side-effects become much harder to monitor. It will be harder to detect truly harmful drugs and remove them from the market. This is so because when smaller numbers of patients are taking them, bad outcomes are more likely to make it under the radar than with more commonly used drugs.

For this reason, I would vote for a more active FDA that demands improved efficacy before approving (or in the case of Zyrtec-D, simply expanding its market to OTC).

I do understand that when more companies are allowed to compete, prices inevitably come down and obviously, this benefits the consumer. But in an era where there are tremendous pressures on the FDA to act on drug applications faster and faster, after-market monitoring becomes increasingly important for safety. To me this concern should take precedent and me-too drugs shouldn't be allowed to expand their markets without real demonstrated advantages over what's already out there.

The one caveat to this would be if a company would formally agree to market a new drug at a substantial discount compared to existing drugs performing the same function. Again, this would result in a substantial benefit to the consumer.

I realize that my positioning of the dividing line that separates the public interest from unfettered free trade is arbitrary and derives from my own personal opinion. I'm willing to live with a certain degree of inconsistency.

And if I were emperor of the world, you would have to as well.

Expanding Your Vocabulary With HotForWords

2007-11-11T12:51:00.000-08:00

I love words and have always enjoyed expanding my vocabulary whenever possible. I confess a certain pleasure in being facile with medical terminology especially when it puts most laypersons completely in the dark. It's that whole belonging to a secret club thing I guess. But despite that guilty pleasure, knowing mainstream English words that no one else knows holds far more interest for me.

When I was faced with the daunting task of increasing my vocabulary for the Graduate Record Examination (required for applying to a master's program in public health), I took a rather unusual approach. Rather than study one of the many GRE prep books, I read Francis Bacon's Advancement of Learning. This rather deep book on epistemology (the science of knowledge for those with smaller vocabularies than mine) was so dense, that I had to look up at least one word in the dictionary on virtually every page. By the time I was finished, there was NO way that I wasn't going to excel on at least the verbal part of that test.

Well, I may have found a better way and her name is Marina also known as HotForWords.

I frankly don't recall how I came across her on the internet but I did. Marina is a philologist, one who studies etymology and linguistics. She has taken it upon herself to convey her passion for words to us neophytes and her approach to education is...refreshing? Marina's style is perhaps most effective at stimulating male enthusiasts of the English language but certainly women will have much to learn from her as well. For kids...I think I'd go with more traditional methods.

She has posted some 58 videos on youtube, each one a short seminar on the etymology of a different word. I can't help but think that if I'd had her help so many years ago, I would have done even better on my test. The complete collection can be found here. I warn you though; they push the envelope on being "workplace safe".

I invite you to partake of this video where Professor Marina explains the origin of one of my favorite words, pusillanimous.

Also try out this very informative one on irony.

Pay attention.

Bottled Water Increasingly Available in School Vending Machines Over the Past 5 Years

2007-11-10T16:20:00.000-08:00

AMNews reports that the school vending machines are stocking increasingly healthy selections. Survey Results published in the Journal of School Health reveal that schools are doing significantly better in curtailing the junk food than in previous years and promoting nutritionally sound options to students.

However, of all the gains, the article specifically singles out the fact that schools in 2006 were 46% likely to offer bottled water compared to 30% in 2000. This is presumably a good thing when bottled water is compared to Coca Cola (which is incidentally my FAVORITE beverage of all time).

I do wonder though about the wisdom of selling bottled water in vending machines considering that it is generally the same and sometimes worse than tap water. Do kids even use drinking fountains anymore?

Of course bottled water is a bargain at only 2,900 times more expensive than tap. Marketing departments really earned their keep when they pulled that one off.

Finnish School Shooter Was Misunderstood

2007-11-08T09:37:00.000-08:00

Here's an article where the headline tells us more about ourselves than about the actual story:

Finnish School Shooter Was Bullied

As if being bullied was a major cause of this 18-year-old highschooler's ignominious rampage killing eight human beings before committing suicide.

Those lives could have been saved if only we'd do something about this.

My recommendations for preventing such tragedies here in the states?

Establish a bipartisan congressional committee to study the pernicious effects of bullying on today's youth.
Institute anti-bullying seminars to our schools and not waste so much time teaching the three R's.
Have the government do something, anything that will serve to wrestle the drive for solutions to this problem away from local jurisdictions and into the lap of the feds.
Hire more grief counselors.
Blame the school for not "reading the signs".
Do something about all those guns.

Don't laugh. Each of this reactions are either in the works or have been for some time already.

Perhaps a more appropriate headline would redirect our thinking on the subject:

Finnish School Shooter
Was a Depraved and Evil Person

Doesn't have the same nonjudgemental ring to it does it?

The Herpes Test: In a Doctor's Office Near You!

2007-11-08T07:57:00.000-08:00

I recently linked to a Medscape article on some new technologies approved by the FDA. I wrote a rather unenthusiastic review of one of them (a device for measuring the white blood cell count in the doctor's office) and now I want to briefly discuss another one.

Focus Diagnostics has developed a point-of-care (POC) test for the herpes simplex 2 virus which causes the majority of genital herpes. POC means it can be done at a doctor's office. It takes less than 15 minutes, can be done from a blood sample, presumably doesn't require the patient to have active lesions, and is more accurate than previous blood tests.

Ordinarily, I'm not big on most POC tests because they don't really solve any major diagnostic or therapeutic conundrums. Some such as blood sugar tests are helpful because patients' diabetes medications can be immediately adjusted depending on what the test shows. Coumadin clinics that monitor patients who are taking blood thinners use POC tests that tell how thin the patients' blood really is. Again, this information is helpful immediately because the blood thinner drug's dosage can then be adjusted accordingly.

Having a rapid, accurate test for genital herpes that doesn't require visible sores may very well be helpful because of the counseling that may result because of it. A patient may be reassured with his negative results or...he may have to be educated on the nuances of this life-long and contagious disease as well as the implications for any sexual partners the patient may have.

I think that a test such as this one can strongly alter the dynamics involved in treating herpes. First of all, I can easily imagine patients being brought in by their significant others (not to mention prospective significant others) for "screening". Previously, there was no reliable way to do this.

Also, I believe that there are many people, who for whatever reasons, suspect that they might have herpes but don't really want to know. Being in a condition of ignorant bliss perhaps helps them avoid unpleasant ethical dilemmas such as sidestepping concerns of spreading the disease to unknowing partners. I think a test such as this one will make the perpetuation of such bliss more problematic because again, the patient can be tested even in the absence of lesions.

Some patients have only one outbreak of the disease and can in theory go through life without having to confront the fact that they may despite the lack of active lesions, still be able to spread it. As long as it can't be proven that the patient "knew" he was infected, he can't be held civilly liable for infecting someone else. A test such as this one makes it far more difficult to maintain plausible deniability.

Doctors using this test will have to be very thorough in consenting their patients I would think. Patients would have to be completely informed of the medical, ethical, and even legal implications of its results because they may not be well-understood by many of them.

Just some things to ponder.

By the way, the test's name is HerpeSelectExpress. To me this name connotes a shipping company...with decidedly undesirable cargo.

Should the law "recognize" friendship?

2007-11-07T07:30:00.000-08:00

And if they ever put a bullet through your brain, I'll complain.
It's friendship, friendship. Just a perfect blendship.

Cole Porter

This is rich. I have to say that when I read this article in the journal Policy Review, I scratched my head wondering if I'd stumbled onto their April Fool's Day issue.

The article is entitled Friends and the Law and is by Hastings law professor Ethan J. Leib. I've always been interested in law but I do not pretend to understand its myriad subtleties. In fact, I am often completely confounded by the intricacies of complex (I would say convoluted) legal arguments that I've attempted to apply my meager logic skills to. This has not stopped me from trying though and when came across this paper, I thought, what the heck.

Leib's basic thesis, if I understand it correctly is that 'friends matter'. He spends the first half of his paper firmly establishing this decidedly noncontroversial point. But he goes further. He believes that the law should recognize friendship as a fundamental relationship deserving of legal gravitas in the same way that family ties do.

To argue this point, he points out some of the many ways that the law singles out familial relationships for special treatment.

Spousal privilege, for example, prevents one marriage partner from having to testify against another. Family ties are taken into account in sentencing hearings. Issues of family leave, laws of inheritance and numerous parenting issues also demonstrate the accommodations for family made by the judicial system.

Why then, he asks, doesn't friendship enjoy similar recognition? This apparently rhetorical question then leads him to the following recommendations:

Tax deductions for "friend expenditures" such as the cost of driving a buddy home after his colonoscopy.
The ability of a friend to sue for loss of companionship in wrongful death cases.
The institution of "Friend Leave" acts granting time off work to take care of friends.
Government mandates requiring municipalities to design and establish congenial public spaces that facilitate friendships.
Incentivize foot as opposed to car traffic to promote face-to-face interactions.
Although there is no legal requirement to rescue a stranger, Leib advocates creating such a requirement to rescue a friend.
My favorite: post signs encouraging citizens to smile at one another.

Leib admits that his last suggestion reminds him of a particularly silly Seinfeld episode. Despite this embarrassing association, he still advocates the signs.

I can only hope that neither legislators nor trial attorneys read the Policy Review. If either of these parties get wind of this article, courts will get a lot more clogged up, malpractice insurance will get a lot more expensive, the dead and dismembered will have a lot more friends than they ever knew existed, and life will get a lot more tedious.

At the risk of being thought a curmudgeon (or worse) I confess that I hope never to see a "Have a Happy Day" sign posted with taxpayer dollars...It might make me want to hit someone.

Now your doctor can check your white blood cell count at his office in just 3 minutes!!!

2007-11-06T11:13:00.000-08:00

Today, Medscape reported that the FDA has granted three new 510(k) clearances. This means that the companies involved will be allowed to market and sell their respective technologies. One of them, a gadget for surgically stabilizing the cervical spine (the neck), I'll defer to my orthopedic and neurosurgical colleagues to comment on.

The other two are worthy of comments by an internist.

The first one is a point-of-care (POC) assay of a patient's white blood cell count (WBC). This means that this test, which is normally done in a fancy lab will be possible at the doctor's office and the results will be available within three minutes.

WBC's are useful in a variety of clinical settings but I really question whether they need to be available as a POC study. When WBC's are high or low, that usually means infection of some sort or perhaps a malignancy. It's a very nonspecific test because so many things (including some non-disease states) can cause changes.

It is very rare however, that a doctor will need to know a patient's WBC immediately in his office to render a clinical decision. Truthfully, it'll take a doctor more imaginative than me to think of such a situation. If a patient is really sick, I'm going to admit him to the hospital; I don't need a WBC to tell me that. Some of us actually make clinical decisions based on talking to the patient and even examining them if you can believe it!

Don't get me wrong, WBC's are important. I order them all the time from clinic. I just don't need to know the results immediately. A day or two won't make a difference. On the other hand, if I have a sick patient in the emergency room, a "stat" WBC is often essential but hospital labs already are set up to do these quickly. In fact these results are far more useful because then, the WBC is part of a complete blood count which gives me more complete information. But in the E.R., I'm not ordering it to tell me that the patient is sick. I'm getting it because I need to know which diagnostic pathway to travel down next and I need to move fast.

Now there are some useful POC tests. I like getting blood sugar tests right then and there. They help me make immediate decisions on how to modify someone's diabetic care. The same is true with HemoCues (a POC test for anemia). This is sometimes helpful in managing certain problems such as iron deficiency because it allows me to know if therapy is adequate and if I need to modify treatment. There are other examples.

Unfortunately, I don't think WBC's fall into that category. I seriously doubt that most primary care providers (PCP's) will pick up on this subtlety. A lot of them will probably purchase this technology, a lot of them will make money running the test, and a lot more useless WBC's will be performed. Guess what? This will become one more factor in rising healthcare costs and with very little to show for it.

Also, more useless WBC's being ordered means a higher percentage of falsely abnormal test results. This inevitably leads to more clinical testing, more diagnostic dead-ends, more needless patient anxiety, and more wasted healthcare dollars.

Who knows, maybe I'm wrong. Maybe insurance companies will balk at paying for it and when patients are told they'll have to pay out-of-pocket, they'll ask the hard questions that should be asked of all forms of medical technology: "How much does it cost and what will this really do for me?"

I can dream can't I?

I'll try to blog about the third technology approved by the FDA another time (a POC blood test for the virus that causes genital herpes).

New York Times Gets It Right About Healthcare

2007-11-05T11:12:00.000-08:00

The Instapundit linked a remarkable article that I'd never have expected to see in the New York Times.

Harvard economist N. Gregory Mankiw gives a rather thorough explanation of the origins of three healthcare statistics seen everyday in the press. The issues he discusses are often invoked to prove how superior the Canadian system of a single government payer is superior to the "system" we have in the states.

He demonstrates that:

The longer life expectancies enjoyed by the Canadians compared to those in the U.S. have more to do with social factors outside the influence of medical care than with actual healthcare delivery.
That although 47 million people in the United States are without insurance, this includes 10 million or more illegal aliens, millions of people who are Medicaid eligible but who simply won't sign up until they get sick, many millions whose employers offer them insurance but who decline to save money, and millions of people who make enough money to afford private insurance but who again elect not to purchase it.
That the increased percent of our incomes (and our GDP) spent on healthcare do not necessarily reflect overpricing (gouging) but are instead more of a consequence of the wider range of expensive services medicine now has to offer patients.

Reporting on the misinterpretation of these facts is a very good thing. I would have also mentioned that the 47 million number discussed in point 2, did not represent people who won't ever be insured. In fact, around half of these people will have insurance within six months. Many people are without insurance only for the brief time they may be between jobs. In fact, very few of these 47 million people are the so-called "chronically uninsured" (see chapter five of The Cure).

I would have also added a fourth statistic seen often in the press but generally without the context that would have made it more meaningful. To demonstrate the deleterious impact of high healthcare costs, I often read that over 50% of all bankruptcies are due to the costs of medical illness.

This statistic came from a paper published in the journal Health Affairs in 2005. The result is probably true (although it was derived from survey data for which there was barely a 50% response rate) if you accept the researchers' definition of "medical bankruptcy". However most of us would be surprised to see exactly what that definition was.

They included anyone who:

Went bankrupt and had uncovered medical expenses of $1,000 or more.
Anyone who missed work two or more weeks due to medical illness.
Bankruptcies due to the economic impact of the addition of a new family member (i.e. a new birth).
The death of a family member.
Alcohol, drug addiction, or uncontrolled gambling.
Anyone who simply told the surveyor that their bankruptcy was due to medical illness.

I seriously doubt most people believe that owing only $1,000 or missing two weeks of work would be a serious enough problem to by itself trigger very many bankruptcies. I also doubt that bankruptcies due to the addition of a new family member or a death of a wage earner really constitute a medical bankruptcy in most peoples' eyes. Likewise, when alcohol, drugs or gambling leads to bankruptcy, most people don't think of that as a medical bankruptcy. They tend to attribute it to, you know...alcohol, drugs, or gambling.

As for criteria #6 I have this to say: At the risk of being politically incorrect, I'd suggest that many people look to factors outside their control to explain their personal misfortunes. Might some of these subjective assessments not be reflective of reality?

By using a definition of medical bankruptcy much broader than one most of us would use, it's almost as if the researchers were trying to support a specific narrative about the inequity of our healthcare system. It's almost eerie...

At any rate, I'm delighted that this article was published by the Times but I'm frankly puzzled as to why it's taken this long. Every element of Mankiw's analysis has been common knowledge in the healthcare economics field for several years and strictly speaking, none of this is really news.

I hope I'm wrong but I believe that Mankiw is tilting at windmills and that we will see the same misconceptions repeated over and over again in the run-up to the '08 elections.

Drinking, Driving, and Little Kids

2007-11-01T09:26:00.000-07:00

It's hard to be a kid in school today and if I'm right about this, it's going to become even harder. A study published in the latest edition of Accident; Analysis and Prevention reveals that the problem of impaired driving may be bigger in middle school children than was previously thought.

17% of 290 middle school children surveyed admitted to driving after drinking. Maybe I'm just out of the loop but I thought that ten to thirteen-year-olds weren't supposed to drink OR drive.

If this study is accurate and generalizable, (it was limited to one Mississippi school in a rural area) there will be repercussions.

I can easily imagine a referendum to mandate teaching about the burdens of DUI's to young school kids. Such instruction will almost surely be useless and ineffective. It will also undoubtedly sidestep the issue of parental responsibility.

Given the fatalistic approach we've taken towards sex education (don't have sex but if you do, here's how...) I'm pretty sure I know what form this will take.

Class time is going to be set aside for lectures on the perils of mixing gin with your kool-aid and how doing so will degrade one's ability to negotiate freeway onramps. I can just picture the "role-playing" scenarios where the independent-minded little tyke has to learn to demand the car keys from her inebriated tetherball partner.

I'm just worried about when there'll be any time at all to study reading, writing, and arithmetic. Maybe in the interest of efficiency, they can have a session of interpreting blood alcohol levels incorporated into their math classes?

Romance in Primary Care

2007-10-26T22:08:00.000-07:00

A rather peculiar letter was published in the most recent issue of The Lancet. A psychiatrist named Brendan Kelly has perhaps more time on his hands than is healthy. He did an informal analysis of the portrayal of various specialties in a sample of romance novels with medical settings. He presents the following conclusions:

Most were set in primary care or emergency medicine settings.
The most common pairing was between a male doctor and a female doctor followed by a male doctor and a female nurse.
There was a "marked preponderance of brilliant, tall, muscular, male doctors with chiselled features" and "skilled, beautiful and determined, but still compassionate" female doctors and nurses.
"Protagonists of both sexes had frequently neglected their personal lives to care better for their patients..."

As one who works daily in an academic, medical setting, I was astounded by the almost eery accuracy and realism these novels attained.

I did find two significant departures from reality however. First of all, anyone who's following the cataclysmic fall in physicians continuing on in primary care, point number four seemed a bit overplayed. More physicians seem to be neglecting their practices to better live their personal lives than the reverse.

Second, I wouldn't describe my features as "chiselled".

The California Medicine Man hits the big time!

2007-10-22T09:31:00.000-07:00

Am I ever swelling with pride! Someone hit an article I posted having to do with the New England Journal of Medicine. I was curious about which site referred it to my reader.

What I discovered filled me with an overwhelming sense of self-importance. It seems that if one uses the search terms "New England Journal of Medicine" in the Nigerian version of Google, the California Medicine Man will be only the 162nd listing.

Oh happy days.

The FDA, Puffer Fish , and Homer Simpson

2007-10-21T22:39:00.000-07:00

This may not be important to anyone that's not a sushi lover such as myself. The FDA is worried about establishing a safe source for the lowly puffer fish. Why? Properly prepared puffer fish, or fugu, is a delicacy among sushi aficionados. I myself do not eat it because of its unfortunate association with a very funny Simpson's episode.

In it, Homer is cajoled by Lisa to take the family to a sushi restaurant in an attempt to get out of the "meatloaf rut". Homer discovers that he loves it and even becomes adventurous enough to try fugu.

Because the master chef was otherwise romantically "involved" with Miss Crabapple, his inexperienced protege had to prepare the potentially poisonous dish. Hilarity ensues as Homer is rushed to Dr. Hibbert's office.

There, he is told he has 24 hours to live (actually 22 hours because Dr. Hibbert kept him waiting two hours).

It's nice to know that the FDA is overseeing my gastronomic needs. Who knows? The next time I'm eating sushi, I may, like Homer, demand the waitress to "Fugu me!"

Religion, Philosophy, and Vaccinations

2007-10-18T22:39:00.000-07:00

Who would have thought that parents would contrive religious "convictions" to exempt their kids from vaccinations?

When one considers the medical advances with the most dramatic impacts on health, it is hard not to rank childhood vaccines and their mandatory use among the top. The resulting decline of life-threatening infections in the developed world has truly been a public health miracle.

Unfortunately many parents refuse to vaccinate their kids because some "experts" and the inevitable lawyers that give them voice have convinced many people that it is dangerous to do so. Their assertions are largely derived from junk science. The use of virtually every modern vaccine has been excoriated by these people despite an near absolute lack of supporting data.

Large studies, for example, have failed to document a link between vaccinations and autism (see here and here) yet still, many parents are terrified enough to opt out of them.

Such refusals are not without consequences. Great Britain had a vaccine scare in the late 1970's that caused pertussis vaccination rates to fall precipitously. This triggered the worst pertussis epidemic they'd had since the 1950's. Many children died.

The reason that vaccinations are made compulsory is that they not only protect the children taking the vaccine but by reducing the pool of susceptible individuals, they even protect unvaccinated children from getting infected. When enough people are vaccinated, the "critical mass" required to sustain an epidemic can't be achieved (a phenomenon referred to as herd immunity).

That said, virtually all states allow parents to opt out based on purely medical reasons i.e. allergic reactions to previous vaccinations. But in modern society, there is also a substantial aversion to forcing citizens to take medications particularly those for whom to do so would violate their basic religious principles. For this reason, most states allow religious exemptions, undoubtedly to avoid running afoul of the first amendment's freedom of religion clause.

Some states, though not all, allow similar exemptions for purely philosophical reasons (read: reasons based on junk science). Therefore, as the above article reports, many parents are lying about their religious convictions and the state is de facto designating them criminals.

To me, this is unfair. If we're going to allow parents to refuse the vaccines for their children for any nonmedical reason, it shouldn't matter why they refuse. Patient autonomy is patient autonomy.

There is no way to get into a person's mind to know why they want the things they want. To allow the state to evaluate religious vs. philosophical beliefs seems like governmental over-reaching to me and it brings Big Brother a little too close for comfort. The article does suggest that no one has actually been charged with lying but this doesn't mean that these distinctions between philosophical and religious motives are justifiable.

Parents should either be allowed to refrain from the vaccinations for nonmedical reasons or not. If we decide that the decision can be left up to the citizenry then it shouldn't be up to the state to decide if the belief system from which the decision arose is appropriate or not.

I understand that there is precedent for requiring the law to reach into people's minds. For example, prosecutors must frequently prove "intent" since it is a critical element of many crimes for example. However this seems qualitatively different from what we're discussing here.

There will always be conflict between the needs of the state and the rights of the individual. Having to prove to the state where my motivation for wanting something comes from is simply too obtrusive for my taste.

Breast Massage as Dental Therapy

2007-10-17T12:05:00.000-07:00

KevinMD alerts us to this rather provocative story about Mark Anderson DDS, a dentist with a novel approach to treating temporomandibular joint (TMJ) disease. He's incorporated breast massage in his therapy. Unfortunately for him, the courts aren't so progressive. He has had his dental license revoked and is facing charges of sexual battery. He stands accused of fondling the breasts of 27 female patients.

Two questions.

1) Do only his female patients benefit from this "treatment" or is he doing this with men as well?

2) What's with this?

Deputy Attorney General Jeffrey Phillips gave Lew (the judge) three new complaints, including one from a 31-year-old woman who said Anderson fondled her at least six times over two years.

Is she just a slow learner?

Narcotics and Appropriate Pain Management

2007-10-15T08:38:00.000-07:00

File these stories (story 1 and story 2) under A for Ambivalence; that is the medical community's schizophrenic ambivalence regarding pain management. Medscape is running two typically contradictory stories on this issue at the same time.

The first one describes a review article on noncancer pain management suggesting the broader use of narcotics (opiods) in this setting. Most primary care providers have become increasingly comfortable using such drugs for many chronic pain conditions (back pain, arthritis, chronic pelvic pain, fibromyalgia, and many others). For them, this article is probably old news.

The second story was also reported by Medscape. It is about a survey of members of state medical boards indicating that state and federal regulators may be increasing the number of prosecutions for prescribing these same drugs.

Great. As the appropriate indications for narcotics are expanding, more doctors may be going to jail for offering such progressive care. Given the modern recognition of pain as the "fifth vital sign" not to mention the increasing medical liability assumed by not controlling it, prosecuting more doctors doesn't seem the way to go.

Medical boards and regulators need to catch up with medical science.

Female Genital Mutilation in the United Kingdom

2007-10-12T16:45:00.000-07:00

As is generally known, female genital mutilation (FGM) is the mutilation of either the labia minora, labia majora, the clitoris or some other aspect of the female genitalia for religious or cultural reasons. While most of us are aware of this practice and consider it a barbaric human rights violation, I've not thought it to be a significant public health issue in the developed world. This may not be correct.

Medical News Today reported that in the United Kingdom, over 21,000 girls age 15 and under are "at risk" of being subjected to FGM. The risk these girls face is a consequence of the primative views of their parents, extended family and social peers. This surprisingly large number was derived from a study funded by the United Kingdom Department of Health.

If the study cited is correct, this corresponds to more than one out of every 300 girls in the UK (see my calculation below). From a more parochial perspective, one wonders how many girls in the United States face similar risks.

The majority of cases of FGM occur in African as well as many Muslim nations (although the Koran does not formally mention FGM). Certainly immigrants to the west bring to us their belief systems along with themselves. While the promotion of cultural diversity in our enlightened society may be a good thing in the abstract, its realization shall not be without limits. There comes a time when any civilized society simply has to declare an evil for what it is. This is not an issue where "moral relativism" can be tolerated.

Certainly, the study does not suggest that 21,000 girls in the UK will succumb to this fate at any given time. However, we should be filled with revulsion, anger and sorrow that so many who have come to the west continue to live under the specter of such an abomination.

There is a lesson here if we choose to face it.

Calculation of Prevalence of Risk of FGM
Statistics from England and Wales suggest that in 2005, their population was 19.3% children 15 and under. Half of these are presumably girls for a total of 9.7%. Assuming this ratio holds for the United Kingdom population as a whole (61 million in 2007), that would be 5.9 million girls. 5.9 million/21,000 girls at risk corresponds to one out of every 279 girls in the UK at risk of this brand of barbarism.

Health.com's Suz Redfearn is advocating insurance fraud

2007-10-05T00:54:00.000-07:00

A website called Health.com has posted an article by Suz Redfearn that openly advocates insurance fraud:

Your insurer doesn’t want to pay for a colonoscopy if it’s not necessary. But if your best friend is diagnosed with colon cancer and you want the $675 test to put your mind at ease, here’s how to get one covered: Mention to your doctor that you’ve had some blood in your stool and a lot of gas lately—or simply that your bowel habits have changed. Your plan has to pay for the test if you have gastro complaints, health experts say.

This is beyond irresponsible journalism and has moved into the realm of promoting a crime. Such duplicity also undermines the integrity of the doctor-patient relationship. My own thought is that anyone concerned about such a piece should blog about it. Be sure to include the name of this author in your post heading for the benefit of the search engines. That's: SUZ REDFEARN. Also include the website's contact URL.

Thanks to KevinMD for flagging this story.

UPDATE:
Here's another "classy" article written by this same author. I wonder if she's as proud of this piece of journalism as the one mentioned above?

Regarding Oscar the Cat

2007-09-07T21:34:00.003-07:00

The recent New England Journal of Medicine perspective on "A Day in the Life of Oscar the Cat" prompted me to write a letter to that most august of medical journals. Surely we all recall the poignant story about the cat that, anticipating death amongst nursing home patients, would cuddle up with them just prior to their shuffling off this mortal coil.

Imagine my disappointment at discovering today that their editors rejected my contribution. However, still believing my message to be both sound and relevant, I shall post it here:

To the Editor,

Dosa’s Perspective on Oscar the cat¹ suggests that Oscar is a gifted clinician with an aptitude for predicting patients' imminent demise. Of course, science must guard itself from spurious results and alternative explanations for his behavior will no doubt be raised by others.

Yet, as painful as it is to consider, someone must speak to the possibility that Oscar is not the benevolent care provider he appears to be. Given my predisposition towards insomnia combined with a gift for putting off more important priorities, I choose to accept this role. To wit, is Oscar truly a harbinger of death...or might he instead be its cause?

Concern that this cat is in fact a vector for a virulent agent leading to untimely demise cannot be discounted. At worse, and the thought itself leaves me bereft; Oscar may be a serial killer, a possibility for which there is precedent.²

1. Dosa DM. A Day in the Life of Oscar the Cat. N Engl J Med 2007;357:328-9.

2. Yorker BC, Kizer KW, Lampe P, Forrest AR, Lannan JM, Russell DA. Serial Murder by Healthcare Professionals. J Forensic Sci 2006;51(6):1362-71.

We should all strive to support clarity of thought within the medical community.

Electronic Medical Record May be Cost-Effective

2007-07-19T16:30:00.000-07:00

Given the lack of evidence that an electronic medical record (EMR) either prevents medical errors or is not prohibitively expensive, anyone purchasing such a system may sweat bullets until his or her organization can decide whether it was worth it (see what I've written about this here).

Well, this is news that may gladden such a person’s heart. The Journal of the American College of Surgeons recently published a paper suggesting that for some facilities, an EMR may in fact be cost-effective. Apparently, when one factors the costs of creating new patient charts, pulling
and refiling charts, transcription costs and clerical salaries; an EMR actually recovers its cost in an average of 16 months.

Five ambulatory offices with 28 providers participated in the study. The average annual savings per provider was $9,983 which for most of us is serious money. Other measures of improvement:

A reduction of 4.5 clerical staff despite the addition of six care providers.

A $27,872 reduction in the costs of creating new patient charts.

A 96% reduction in chart pulls at two years.

The average number of items (i.e. labs) filed per minute went from 3.4 to 1.0 (annual savings of $25,000).

A $35,560 reduction in annual transcription costs (for offices paying for transcription).

An increase in billing revenues per visit of $0.17 when compared with control offices.

A 13.8% reduction in the number of days an account is in accounts receivable.

Patient flow also appears to have been speeded up by 5% although this difference wasn’t statistically significant.

So what can one conclude from this work? At least for these offices (three primary care internal medicine practices, one dermatology office and one pediatric endocrinology office), some real benefits may have accrued.

Clearly, there are intangibles that weren't measured. For example, EMR's encourage the use of progress note templates which can easily result in uninformative "cookie-cutter" notes that are cut and pasted from visit to visit. This can degrade progress note quality and usefulness.

One also needs to question the quality of a patient-physician interaction in which the doctor spends his or her time staring at a computer screen rather than actually making eye-contact with the patient.

On the balance however, medical office managers and software venders everywhere may have cause to rest a little easier.

The Hazards of Talking About Your Problems

2007-07-17T04:52:00.000-07:00

I haven't read the original study discussed in this article but it doesn't strike me as news.

The latest issue of the journal Developmental Psychology published a paper suggesting that for adolescent girls, discussing one's problems amongst themselves ad nauseam can actually increase the likelihood of depression.

I particularly love the researchers' evocative term for this phenomenon, "co-ruminate" which connotes digesting the same stuff over and over again.

Although I can imagine numerous methodological problems associated with this kind of study, its results resonate with me. Pundits frequently suggest that men need to get more in touch with their feminine side; to be more demonstrative and discuss their problems more fully...like women do. While I recognize that there may be some benefit, on the balance this is more likely to fill a desire for gossip than a need for therapy.

Perhaps denial, suppression and just getting "over it" has gotten an undeservedly bad rap? Is it possible that in this instance, the girls might have something to learn from the boys? Maybe the endless co-ruminating fostered by many psychologists, social workers and school counselors will one day be seen, at least in part, as counter-productive. I hope so.

In the politically problematic song Why Can't a Woman be More Like a Man?, Henry Higgins asks:

"Would you be slighted if I didn't speak for hours?"

Sounds like he was onto something!

The end of a hot dog-eating dynasty

2007-07-05T03:23:00.000-07:00

People who know me are often surprised at my almost complete apathy to virtually all forms of spectator sports. That said, I must confess a virtually morbid fascination with the annual Fourth of July Nathan's Hot dog Competition.

I've long followed the magnificent exploits of Takeru Kobayashi, the six-time world champion of this august event. Kobayashi both dazzles and inspires. Although he's gained weight over the past few years, part of the miracle of his performances is his relatively diminutive size. The ease with which he consumes hot dog after hot dog (buns included) is breathtaking. I am almost moved to learn Japanese so as to ingest the words of his blog in the original.

This is not to say that his career has been unmarred by controversy. As in all elite athletic endeavors, allegations of "doping" have been raised. Why should hot dog-eating contests be free of such peccadillos?

It has been alleged, though to my knowledge never proven, that he has augmented his athletic prowess with the performance-enhancing drug Reglan, a gastric motility agent. Certainly my world-view would be shaken were incontrovertible evidence to this effect made public. Until such time however, my respect for this man is thus far undiminished.

Sadly, it now appears that his lengthy reign as hot dog-eating champion of the world has come to an end. Despite a blistering exhibition of 63 hot dogs consumed in a 12 minute period, Kobayashi was bested by one Joey Chestnut who, and I'm dizzy actually relating this, ate 69 hot dogs. Oh to have witnessed this event live! The rarefied air of Coney Island must have swelled with electricity as these titans worked their magic at the very threshold of human capacity:

The two gustatory gladiators quickly distanced themselves from the rest of the 17 competitors, processing more beef than a slaughterhouse within the first few minutes. The two had each downed 60 hot dogs with 60 seconds to go when Chestnut - the veins on his forehead extended - put away the final franks to end Kobayashi's reign.

The veins on my forehead are extended just imagining this. Perhaps I shall now have to engage Mr. Chestnut as my new model of athleticism yet it would be with great reluctance.

I can never so easily relinquish my regard for the great Takeru Kobayashi.

Physicians Upset About Nurse Anesthetist Incomes

2007-04-01T10:20:00.000-07:00

KevinMD blogged about the high incomes of Certified Registered Nurse Anesthetists (CRNA's). It seems that salary estimates vary significantly depending on the source.

One survey performed by a website gives a range of salaries broken down by work setting. They run anywhere from $88,000 in a private practice/office setting to $116,000 in "other" (whatever that is).

The American Medical Group Association survey notes an average salary of over $143,000 for 2006. No information is given the distribution of salaries.

This data for 2006 comes from a survey performed by a locum tenens company. It suggests that the average income is over $164,000. Notably, 6% of respondents claimed an salary between $230,000 and $250,000 and another 6% earned over $250,000. These number don't include bonuses. The survey participants are apparently all locum tenens practitioners (temporary workers). These numbers may be higher than might be expected among all CRNA's many of whom presumably trade job security for lower incomes.

The reason I'm writing about this is that some doctors are apparently upset with these numbers noting that many CRNA's appear to make more than the average primary care physician (PCP) and have much less formal education.

In fact, Kevin's blog mistakenly states that only two years of college are required to be a CRNA. However, according to the American Association of Nurse Anesthetists, a 24 to 36 month training program is required at a Master's level (which requires the equivalent of a Bachelor's degree). The total training therefore requires six to seven years of college/graduate school. Obviously, this is still significantly less than the eleven or so years required to be an internist, family practitioner or pediatrician.

It is understandable that physicians might be upset to discover these numbers and some have even asked 'what can be done about this inequity?' However, this perceived "disparity" is really a reflection of an often misunderstood concept of economics. The price of labor (or of any good or service) is arrived at by a balance of supply and demand in a free market. If supply is low or demand is high, the price rises. As supply rises or demand falls, the price falls.

That's just the way it is! In a free market, buyer and seller both freely enter into an transaction the price of which is determined by the above interplay.

What people don't get is that the price of something is independent of the expense and effort that went into creating that thing (except to the extent that greater expense and effort tends to lower the supply of that thing). The result of this often painful reality is that great effort may be expended in producing something but if no one wants it, its price will inevitably be low.

This explains why movie stars make more than teachers: extraordinarily high demand, relatively low supply of talented stars. It also explains why some products fail despite extraordinary labor, capital and effort that may have been required to develop them. Supply may be tight, but if demand (perceived desirability) is low, the producer won't be able to sell them at a price that is high enough to recover the expense of producing it.

And it seems to explain why CRNA's may make more money than some doctors notably primary care doctors. The number of years of training is essentially irrelevent to price determination. If the value of a PCP is unappreciated by the consumer (and indirectly by third party payers) then his or her reimbursement will be low compared to the value of a CRNA. From the point of view of the physician, this may not seem fair. Unfortunately for them, in this setting it's the public who decides how high to value the PCP.

I think that there's pretty good empiric evidence that although patients in general like their PCP's, they don't want to pay them much. Even minimal increases in co-payments for primary care doctors dramatically reduce doctor visits. I've personally seen this in reverse when I worked in an office setting. A managed care insurer unilaterally dropped PCP co-pays from five dollars to zero. Amazingly, that small difference caused utilization in our office to explode for members of that health plan.

Five lousy dollars had such an impact in patients' willingness to see us!

Of course the arguments I've made assume a free market. This is of course a question open for discussion in the healthcare setting. But right now, the current market we have is closer to being "free" then the healthcare system almost anywhere in the developed world.

ONLY when patients decide that they value their PCP's more will PCP reimbursement and incomes rise. Until then, nurse anesthetists who facilitate lucrative surgeries will have greater value in the open marketplace.

So if you want to pull down a huge income, work on your jump shot or your singing or your airway management technique until you've established a skill people REALLY value.

More on this topic here.

Regarding Subversive Children's Books

2007-02-08T09:33:00.000-08:00

Here's a blog entry by Dr. Helen that triggered some memories. It's her mention of a work called The Dangerous Book for Boys.

My "bible" as a youngster was The Modern Handy Book For Boys written in 1933. The copy which I'm looking at fondly as I write, was given to me by my clearly irresponsible father. The author, Jack Bechdolt, would no doubt have been prosecuted for his subversive ideas were he to have brought his manuscript to a publisher today.

True, this thick book has relatively benign chapters on puppet making, magic tricks, insect collecting and other fun, harmless things (unless you consider braving the hazards of the great outdoors, necessary for locating bugs, dangerous).

But far more intriguing for boys (at least before they were encouraged to get in touch with their feminine sides) were the sections devoting to the construction of zip guns, darts and something called a whip bow. There is a chapter on building an attic shooting gallery, and sections on whittling and using an ax.

There are detailed plans for building various boats and an ice yacht with wheels. Although I never built the latter, it seemed perfect for riding in the middle of the street.

The book contains an unending list of activities guaranteed to induce various levels of mayhem, death and destruction. It's a miracle that I or any of my friends survived childhood. Yet we somehow overcame our youth before the relentless stampede of product liability attorneys that have become so dear a part of our social fabric.

One would think that such a book would never again be published for boys. First of all, the mere suggestion that boys and girls might have separate interests is a virtually taboo topic in today's proper social circles.

Second, after endless billable hours, the lawyers would have whitewashed this handbook until it was unrecognizable in its mediocrity and blandness. All references to things dangerous and any depictions of gender stereotypes would be expunged.

It is nice to know that at least someone is trying to resurrect the "Book for Boys" genre as Dr. Helen brings to our attention. I seriously doubt however, that the Dangerous Book for Boys can even approach the reckless hazards promoted by Bechdolt.

Pity. I had a lot of fun shooting my homemade zip gun as a kid. And I never used it to attack girls. And I never put out anyone's eye.

When you just HAVE to exercise au natural.

2007-02-02T22:41:00.000-08:00

Physicians are always looking for ways of getting people to exercise and I guess this one is as promising as any. Fitworld Gym in Heteren, Netherlands has announced that it will be promoting "Naked Sunday". The Dutch are so cutting edge!

Yes I'm afraid so. Fitworld will be offering its customers the option of performing their work-outs in the nude every Sunday. The gym's owner, possessed of the improbable name of Patrick de Man, performed a survey which determined that the majority of his members actually preferred to wear clothes while exercising (how parochial!). Despite this, the intrepid Mr. de Man was undeterred and will proceed anyway. I wonder if they have one of those big picture windows facing the sidewalk?

The first Naked Sunday will be on March 4. Step aerobics will never be the same.

As an aside, do you think a google search on this entry's title will have me sharing hits with porno sites?

In the workplace, the futile workplace, the Fre--ench sleep today

2007-01-31T19:27:00.000-08:00

It's nice to know that the U.S. isn't the only country whose government officials have too much spare time. In a news article entitled French health minister seeks nap study, we learn that France will be spending $9 million to determine whether or not the great tradition of sleeping on the job should be institutionalized.

Surely this study will be the first step towards a mandate further reaffirming France's endless quest for mediocrity. I'm no expert on national attitudes regarding sleep, but I suspect that the emerging economies of China, India and the rest of the Asian Pacific Rim aren't concerned with ensuring that their employees fill their work hours with more sleep.

Clearly, the problem of sleepiness in the workplace is an important one. As a general rule, I prefer my airline pilot, my brain surgeon and my accountant to be well-rested. Add to that list, anyone involved in sewage treatment. On the more altruistic side, I'd also prefer that anyone working with things that are extremely sharp, hot or radioactive be equally well-rested.

It worries me that in a country not known for its phenomenal worker productivity, designated sleep time will not provide much of an enhancement to their economy. Knowing how the French generally do things, I sincerely doubt that the time allotted for required naps will be added to their already taxing 35-hour work weeks (or subtracted from their annual five to seven week vacations).

At what point do employees have to assume responsibility for their own health and welfare (which necessarily includes getting enough sleep)? Is it too much to expect workers to arrive at their work site well-rested?

In suggesting a need for the study of sleep and possible workplace napping, the French Ministry of Health points to a survey suggesting that 56% of their people report that a poor night's sleep has affected their work performance. Of course most of us can relate to this. I know that when I've slept poorly, I wish that the patient's whose care I'm involved with would simply disappear (as well as the medical residents I'm supposed to be teaching).

However, to me, the solution is to promote better nights of sleep rather than deal with the consequences after the fact. Instruct workers in better "sleep hygiene" and discourage late night carousing and other such nocturnal activities before a work day. I say send them home without pay if they show up too fatigued for work. Perhaps next time they'll have the foresight to leave the Folies Bergère a few hours earlier on weeknights.

The Ministry has published a Passeport pour le Sommiel (Passport to Sleep) document (for those of you who read French). In it they've made suggestions that may actually facilitate sleep. These are the things we generally recommend to all of our patients who have sleep disturbances i.e. avoid caffeinated products and refrain from exercise immediately before bedtime. One suggestion that I didn't see was avoiding alcohol (which alters the sleep-wake cycle). Could it be that the French don't want to make a policy recommendation that could curtail wine industry profits?

My point is that sleep is something that we all have to take responsibility for. Why burden our employers (or the government) with our inability to set aside personal time for sleep?

Looming larger among my concerns regarding sleep patterns and their impact on the legendary French work ethic is the fear that some "progressive" American legislator will come across this new approach and the next thing you know, we have the birth of an inalienable right to nap at the workplace...right alongside free speech, trial by jury and the writ of habeas corpus.

Frankly, I'm hoping that our politicians don't read the news.

Choking on Caution

2007-01-30T01:31:00.000-08:00

You may be interested in my latest article in TCSDaily.com.

When I was a kid, forced silence is school was considered a punishment for when we were bad. The times they are a changing.

Economic Implications of Doggy Radiation Therapy

2006-10-30T15:14:00.000-08:00

Kevin, MD posted a rather provocative story regarding radiation therapy (XRT) for pets. It seems that Ipswich Hospital in England wants to capitalize on its underutilized XRT facilities to treat animals -- presumably on a fee-for-service basis. The hospital believes it can capture the equivalent of $95,000 U.S. in revenue per year.

While I can understand that some patient advocates in England are finding the whole idea of sharing medical technology with animals rather distasteful, I personally think it's great. As long as humans aren't obligated to face reduced access because of the new plans, I don't see anything morally wrong with it. In addition, cleanliness routines can easily be adopted that should eliminate any problems in this area as well. And sad to say, there are many pets I know of with more impeccable hygiene standards than some patients I've been in contact with.

What I think is most intriguing about the whole idea are the healthcare finance implications. It will be pretty interesting to see what kind of fee differential there will be for XRT services between humans and pets.

In a way, this is a perfect example of what epidemiologists refer to as an "ecological experiment". Such an experiment is a study that is based on a constellation of fortuitous circumstances in the real world that can be analyzed in such a way as to answer questions of academic importance.

If one wishes to know the impact of third party payers on price in a healthcare system, this is one great model with which to study it. The equipment is the same and one would therefore expect the capital costs to be about the same. The technician salaries are most likely no different. Certainly the record-keeping, privacy provisions and malpractice overhead is higher for humans than for pets but one would think that a rigorous analysis could easily factor those differences out. Likewise, any differences between physician and veterinarian fees can be isolated from the analysis as well.

So it would appear that unless the NHS has started covering pets, the only thing that'll be significantly different will be the lack of a third party payer!

I'm thinking that the calculated price per unit treatment will be less for the pets because the hospital will be limited to charging only what pet owners will be willing to pay out of pocket. For humans there is virtually unlimited demand because someone else will be footing the bill. I for one will be very interested in seeing how the price structure of this little fiscal adventure plays itself out.

Of course my guess presupposes that people care more about their own health than about the health of their pets. This must be considered an unproven assumption!

Why I'm Not a Hunter

2006-10-25T06:00:00.000-07:00

Yesterday, I added the blog Tundra Medicine Dreams to my blogroll. I have been reading more of it and came upon this description of the killing of a moose. It seemed quite sad to me and inspired me to share some of my views on hunting.

Please understand, that the Tundra PA's post in no way changes the way I view her excellent writing, her passion towards her patients and her community or the frequency with which I plan to continue reading her outstanding blog.

Though I'll never be able to justify for the needless killing of an animal for sport, I am in no way deriding her. I don't believe that my feelings represent a personal failing on my part nor that that lack of acceptance is based on a narrow-minded world view. I do sense however, from what I've read of her, that the Tundra PA, though not embracing my opinion, would not believe so either. I merely wish to reflect personally on how her post affected me.

As an urbanite who has never experienced hunting as a part of my culture her description was chilling. It also struck me as inexplicable.

Don't get me wrong, I'm a confirmed carnivore and harbor no illusions of where my meat comes from. I also understand the need for hunting for food. But hunting for recreation? I'll never "get" that. I'd never interfere with anyone's right to engage in this legal pastime and I thoroughly accept the enormous historical and cultural significance hunting plays in the measure of just who we are as Americans. I also understand and accept the importance that guns play in the psyche of American values. I'm not one to seek limitations on the populace's right to keep weapons for hunting or for the protection of oneself and one's family.

But killing animals for some type of aesthetic rush will always be an alien notion to me. I found the explanation of the Yupik Eskimo's approach to hunting convincing given the context in which it undoubtedly arose. However to invoke it now, in this modern age, to justify purely recreational hunting strikes me as both self-serving and even self-deluding:

When the animal stands facing the hunter, it is offering itself to be taken for the hunter’s needs; it knows this and makes the offer willingly. The hunter must be worthy of the offer, seeking the animal with an attitude of respect and gratitude.

To believe this explanation is to project one's internalizing of desires upon a less than sentient being. This is no more rational than Ahab's attribution of towering malevolence to Moby Dick.

"...makes the offer willingly"? How can the moose's behavior be explained in any conceivable manner other than that it simply didn't perceive the threat before it? To imagine that it was in some way offering up its life is fanciful and even repulsive. Do modern students of nature find the notion of an animal committing suicide while assisting the hunter to realize some aesthetic ideal in any way plausible?

Moreover, my sense is that the apparently self-evident notion (at least to those other than myself) that "the hunter must be worthy of the offer," is equally self-serving. To me, this is a concept that is derived mainly from the desire to avoid cognitive dissonance. In other words, 'if my mind and heart are pure, then the commission of this otherwise questionable act will maintain its moral basis.'

Again, I'm not trying to take away anyone's right to hunt. Nor am I even seeking to discourage those inclined towards this activity from continuing to pursue it. I only wish to portray my personal response to an act that I find incomprehensible.

This excerpt made me particularly queasy:

...she felt deeply the respect and gratitude that were the animal’s due; but even these were surmounted completely by her awe at the magnificent beauty of the animal. He stood facing her head on, six feet tall at the shoulder, displaying the full width of his chest and his mighty eight-point rack, calmly chewing on young willow shoots. Perfectly still, he looked at her.

“Thank you,” she whispered, as she gently pulled the trigger.

I can't believe that the "thanks" her friend uttered before her kill were for a gift willingly surrendered.

Regarding Tundra Medicine Dreams

2006-10-24T14:30:00.000-07:00

I'm definitely behind the eight ball on this one as everyone seems to have discovered Tundra Medicine Dreams but me. Oh well, better late than never.

I have read extensively from the blog of this southwest Alaskan-based physician assistant. She is a incredibly authentic writer and has an amazing story to tell. Her descriptions of "tundra medicine" and her beautiful, evocative photographs are captivating. She writes about a lifestyle and a manner of healthcare delivery that for most of us is as foreign and remote as the country doc of the turn of the twentieth century. There is romance and caring and personality in her writing that I haven't seen in many blogs. I am grateful for that.

For this reason, I've put her on my blogroll as someone I'll be reading frequently and of whom I encourage others to do the same.

Lester Crawford and a Major Disappointment in the FDA

2006-10-20T22:13:00.000-07:00

I actually gasped when I read this.

Lester Crawford was the previous commissioner of the Food and Drug Administration (FDA) before he abruptly and without explanation stepped down late last year after serving only two months.

His resignation at that time was puzzling as he had just weathered a difficult and lengthy confirmation process after he was appointed by President Bush. An FDA insider colleague of mine had no idea why Crawford had left at that time. Now, a logical explanation has become apparent.

Several days ago, he pleaded guilty to conflict of interest and to false reporting of financial holdings. The particular holdings involved were of companies whose products were under the aegis of his agency. Both of these offenses carry extensive fines and can lead to prison sentences of up to a year each.

The FDA is charged with the extremely complex and difficult job of insuring the safety of our food and drug supply. The commissioner of this agency is in charged of a decision process regarding the approval and licensing of most important foods, medications and devices that we as citizens consume and use.

Several factors make the FDA's mandate so difficult. Literally reams of data regarding the safety and efficacy of these products must be reviewed in making each of these complex decisions. The available evidence that can be brought to bear in any one decision is rarely clear-cut. It is virtually axiomatic that the conclusions drawn will be based on incomplete and often conflicting information subject to a multitude of interpretations.

And yet the final outcomes of these imperfect analyses affect the health and safety of millions of people. Because other countries will sometimes look to the FDA's reviews to base their decisions about these products, it is possible that billions of people may be affected. A misstep in either direction can obviously have widespread implications. When a dangerous product is wrongly approved, it can obviously injure many people. Likewise, when a safe and efficacious product is rejected, people can suffer needlessly as well.

At the same time, rejecting applications for products can result in the loss of billions of dollars in revenues for some of the most powerful companies in the world. Clearly, this can have enormous political ramifications.

The inherent subjectivity of many key controversies that the FDA must adjudicate simply reconfirms the importance of maintaining an administrative environment as free of potential bias as possible. Weighing the safety and health of our citizens against the economic concerns of massive, multinational corporations requires scrupulous transparency and integrity throughout the entire breadth of the FDA. Nowhere should this integrity be more unequivocal than in its commissioner.

Despite this, since 2002, while Crawford was working at for the agency, he filed seven incorrect reports with the government ethics office overseeing the FDA as well as to Congress (presumably as part of his confirmation hearings). The stock and options he held but did not accurately report were in a variety of companies under the jurisdiction of the agency. In effect he lied to both his agency and more importantly to Congress.

Even the appearance of impropriety can cause a devastating loss of faith in as essential and as politically sensitive an institution as the FDA. With the legion of questions that have been raised about conflicts of interest, hidden agendas and behind the scenes lobbying over the last few years, no one should better understand this than Lester M. Crawford.

His selfishness and his dishonesty was both shameful and destructive. His assertion that "Nothing that I have done, I hope, can be construed to affect the integrity of the FDA," is both self-serving and a manifestation of wishful thinking.

Crawford's cynical acts have lowered the credibility of a government agency that has at least the potential of improving countless lives. He deserves far more than a slap on the wrist.

Let's help the tobacco companies!

2006-09-03T08:51:00.000-07:00

Despite my general aversion to, and lack of respect for most conspiracy theories...I'd like to share conspiracy theory (here and here). The Massachusetts Department of Public Health (MDPH) has published the results of a study they commissioned suggesting that the level of nicotine has increased in American cigarettes by ten percent over the six year period between 1998 and 2004. The actual report is online here.

Not being a smoker myself nor an expert on the methodologies used to assay nicotine content in tobacco products, I can't fully assess the merits of the approach the MDPH used. Their claims however seem quite plausible.

In the past, cigarette nicotine content was assessed by a metric called the "nicotine yield". This was done using a machine that generates cigarette smoke and then measures the content of the smoke. The reason for this approach was that measuring the absolute nicotine content in a batch of cigarettes doesn't reflect how much nicotine actually gets into the body. The physical structure of the cigarette itself also determines nicotine exposure.

Unfortunately, these smoking machines don't really simulate actual smoking practices very well. Air holes on the side of the cigarette allow air to be mixed in with the smoke during each breath thus diluting the actual nicotine dose received. However, most smokers occlude those holes with their fingers when they inhale. This causes less air to be entrained in the smoke stream and therefore raises the nicotine dose inhaled compared to that received by the machine (which doesn't occlude the holes).

It turns out that when the MDPH modified this measurment technique to take this effect into account, nicotine levels in American cigarettes have actually risen during the period studied. For example, Kool (manufactured by RJ Reynolds) has seen its level rise twenty percent rise during the study period. Nicotine levels as measured by this methodology have risen for Marlboro, Newport and Camel, the largest brands and others (ten percent across the industry).

Being the rather credulous person that I am, as I've mentioned, I don't much care for conspiracy theories . However, that these actions were inadvertent pushes the "benefit of the doubt" envelope more than seems appropriate.

In general, I'm a strong advocate of free markets. But I also believe that our capitalistic system is not an economic suicide pact. I also refuse to accept that businesses should necessarily be completely devoid of all remnants of morality in their quest to maximize shareholder return.

If the findings of the MDPH are true then this strikes me as shameful and incredibly cynical behavior of some of the largest corporations in the world.

According to the NYT article linked above, the largest tobacco manufacturers, Philip Morris and Reynolds American "declined to comment". Perhaps they never suspected that their actions would ever be discovered or suspected and they never imagined that they'd have to answer to them. I have no doubt that their public relations departments are now scrambling to come up with some palatable responses.

In the interest of helping these much-beleagered tobacco company lackeys, I propose that we assist them in coming up with excuses for their inevitable press releases. I suggest the following:

There's no proof that increased nicotine content leads to increased tobacco consumption. -- this may convince the occasional die-hard empiricist so wedded to evidence-based medicine that he's turned off his nonsense detector. As an aside, this may actually be true. However, the tobacco companies would be hard-pressed to get such a study approved by a human subjects review committee and then use the data to make a dangerous practice even more dangerous.

This was totally unintentional. -- We had NO IDEA that the changes we made to our cigarette designs would increase nicotine ingestion. (Said with fingers crossed hoping that no one will notice that such changes were made in multiple brands by multiple companies.)

We are very concerned and will be looking into this immediately. -- The last refuge of the (corporate) scoundrel: bury concerns in massive bureaucracy. They can always wait until Brittany Spears forgets to buckle up her kid again to bump this rather inconvenient story off the headlines. This is also a variant of the Claude Rains, Casablanca approach ("I'm shocked, SHOCKED to discover gambling going on here!")

We forgot! -- the classic Steve Martin approach as in "We forgot our responsibilities to promote the health and welfare of our fellow man and to not plant our customers in the ground.

I'm sure there are others that more imaginative and fanciful readers can come up with!

The tobacco companies have to be concerned that these irresponsible and reprehensible actions, if intentional and true, will result in a new round of tobacco lawsuits. I for one will be very interested to see the company memos regarding this issue that may one day be discovered.

How to Prevent Drug Reps From Seeing Your Personal Prescribing Records

2006-08-08T12:58:00.000-07:00

Since July 1 of this year, the AMA has permitted physicians (both members and nonmembers) to "opt out" of having their personal medication prescribing records provided to pharmaceutical companies. Actually the AMA will still continue to send the information but if one opts out, the pharmaceutical companies "promise" they will keep it away from their drug reps and only use it for "research purposes".

Many physicians oppose the release of such information as they consider it a breach of their personal privacy. However, one survey demonstrated that only 34% of physicians are even aware that such information is compiled by the AMA (thanks to Dr. Kevin).

This new opt out plan is the result of outrage from physicians upon discovering this violation. The AMA apparently makes a great deal of money from selling this database to a company called IMS Health, a data-mining company that in turn sells it to drug companies for strictly marketing purposes.

Clearly, despite the AMA's constituency's stated opposition to this violation of basic privacy, they wish to maintain this revenue stream. Otherwise, 1) they would have instead instituted an "opt IN" policy and 2) they would have gone to greater lengths to advertise this new program and make it easier to execute. I would therefore like to take this opportunity to explain to interested physicians how this is actually done.

Certainly the AMA doesn't want you to know!

Go to the appropriate page on the AMA website.
Go to the bottom of this page and click on the link with this name: "Set up a log-in account to access the Prescribing Data Information Center" (I'm not including the URL within the link because you can't bypass step 1).
Set up a log-in account by following the directions (you don't have to be an AMA member).
Click on "continue to the page you requested." This will bring you to a page entitled "Prescribing Data Information Center".
Read the annoying attempt to dissuade you from your decision. Then click "Accept" followed by "Submit Form".
Check off your reasons for being angry at the AMA from the choices provided.
Leave a suitably nasty comment in the box provided. Mine was "I think it is reprehensible that the AMA should be committing such an obvious privacy violation and in such a surreptitious manner. The AMA's management should be ashamed of itself." Have fun! Be creative! Then click "Submit Form".
Read and understand the following disclosure:

"Pharmaceutical manufacturers will be required to check the Prescribing Data Restriction Program database quarterly. Once they check the database, due to various pharmaceutical data cycles, it may take up to an additional 90 days for a pharmaceutical company to restrict sales representatives from having access to your individual prescribing data."

Ponder why we have to trust the drug companies to keep the data from their sales reps since the AMA will continue to send it to them (via IMS Health).

Have a nice day.