Trouble at Domino's Pizza

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

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

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

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

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

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"

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.