Friday, December 25, 2009

A Dose of Christmas Humbug

Today's Boston Globe reads, "Health Win in Hand." You can almost feel the exclamation point coming off the page. It follows with the caution, "Hurdles Ahead." Noting that the healthcare bill still faces the challenge of reconciling the two substantively different bills passed by both houses of Congress, not to mention Constitutional challenges and whatever other dirty tricks the Senate Republicans can muster between now and the passage of the reconciled bill, the Globe has a side article usefully informing its readers that this bill may still not become law because the coalition supporting the bill is so fragile it may come apart during the usually perfunctory reconciliation phase. That said, assuming that no 11th hour roadblocks are raised, universal health care is going to become law in the US. Our President has put a happy face on things, saying he got "95 percent of what I want."

On this Christmas Day, allow me to honor a ghost of Christmas past (and doing so as a virtually-atheist Jew, no less) by saying...HUMBUG!

Paul Krugman--not normally a man predisposed to cheery pronouncements just for the sake of feeling good--writes in the NYT that the bill, despite a number of flaws, really is a major accomplishment and will lead to improvement in the lives of Americans in the coming years. But he does provide an analysis of why so many people are so unhappy:

So why are so many people complaining? First, there’s the crazy right, the tea party and death panel people — a lunatic fringe that is no longer a fringe but has moved into the heart of the Republican Party. In the past, there was a general understanding, a sort of implicit clause in the rules of American politics, that major parties would at least pretend to distance themselves from irrational extremists. But those rules are no longer operative. No, Virginia, at this point there is no sanity clause...Finally, there has been opposition from some progressives who are unhappy with the bill’s limitations. Some would settle for nothing less than a full, Medicare-type, single-payer system. Others had their hearts set on the creation of a public option to compete with private insurers. And there are complaints that the subsidies are inadequate, that many families will still have trouble paying for medical care...Unlike the tea partiers and the humbuggers, disappointed progressives have valid complaints. But those complaints don’t add up to a reason to reject the bill. Yes, it’s a hackneyed phrase, but politics is the art of the possible. [my emphasis]

So what's a disappointed progressive to do?

Let me go out on a limb here--very, very far out on a limb--and suggest that maybe the nutso wing of the Republican party (which is now the de-facto leadership of the Republican party) has the right strategy, and maybe it is time for progressives to take a page from their playbook. The phrase that's been bandied about over the past year in relation to the tea-partiers is that they demand of their representatives that they "pass a political litmus test" demonstrating a level of ideological purity. We saw this most clearly in evidence in the New York 23rd Congressional race this November, where so-called "liberal" Republican Dede Scozzafava was abandoned by the Republican base in favor of 3rd-party candidate Douglas Hoffman, allowing Democrat Bill Owens to win in an overwhelmingly Republican district. The conventional wisdom of that election was that the far right had become so crazy that they would rather be out of power than have an electable candidate who wasn't absolutely ideologically pure. My own sense is that the Tea-Party choice, Hoffman, very nearly won the election (he lost by just over 3,000 votes out of 140,000 cast), and almost certainly would have won had he had an additional few months to gain momentum.

So while the strategy of demanding ideological purity failed the far right on the political equivalent of a broken play, I suspect it will pay long-term dividends. Even in marginal districts, potential Republican party candidates are going to be very careful not to run afoul of this very determined, apparently reasonably well-organized group. Yes, in the short run they may have some setbacks as they had in the NY 23rd. But next year I am willing to bet that Owens will be out and he will be replaced by someone approved of by "the base," maybe Hoffman himself.

Might it not be time to demand this from Democrats? Particularly Democrats running for Senate seats? Or even President of the United States? I am not suggesting that an ideological litmus test need to be applied to every single issue that faces us. But demanding support for the Public Option (which, after all, was the compromise position that progressives had decided to live with instead of a Medicare-For-All, single-payer system that would represent real change) would have been a starting point.

Anyway, perhaps Krugman is right and the reasons to be unhappy with the bill are not reasons enough to walk away from it. But I do note that Krugman's view is not universal among progressives, and I'm quite sympathetic to their viewpoint. Here is a great summary in an editorial for CNN online by the mightily courageous Congressional representative from the NY 28th district, Louise Slaughter. She has one line, nicely summarizing the critical difference between the House and Senate versions of the health care bill, that captures it all for me: "I do not want to subsidize the private insurance market; the whole point of creating a government option is to bring prices down." I have yet to hear anything from the leadership of the Democratic party that lucid. Perhaps it is time to think about withholding our support from leaders who do not speak or act as clearly as Congresswoman Slaughter.

Thursday, December 17, 2009

Do NOT Go Spelunking in Sub-Saharan Africa! (Plus Mammogram Stuff.)


PS--As a follow-up to the news on CT scans and people misoverestimating its dangers (as Bush 43 might say), a good comparison can be found in the recent brouhaha about the US Preventive Services Task Force revised recommendations about when women should obtain mammograms. In mid-November, the USPTS rolled back the recommendations for annual mammograms for women under 50, and for women over 50, they recommended mammograms every other year.

There was a firestorm, with outraged women calling up congressfolk and other government people howling about how women's lives are worth less than men's. Even prominent academics took to the airwaves and cyberspace to pile on, as this piece by the University of Pennsylvania's Center for Bioethics Arthur Caplan demonstrates. "Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease," Caplan wrote. Those are commendable and powerful virtues, and...more compelling than a pile of bland data...there is no reason to doubt the accuracy of the scientists' findings...but there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women." [my emphasis]

Ladies and gentlemen, a nominee for Most Cowardly Writing By An Academic For 2009! That little pile of bland data suggested that, whatever "ethical weight" pre-50 mammograms may have for women, it would lead to unnecessary amounts of radiation, agonizing trials for women awaiting biopsies of tissue that didn't need to be biopsied, and, in some cases, completely useless mastectomies. Could a guy like Caplan maybe have considered it his responsibility to use his status as Big Time Academic to try to help explain this data, and give it the proper context it deserved because the data indicate a better way to treat women? He will have to answer for that. In the meantime, a nice counter-example can be found in this NYT op-ed by the very awesome mathematician John Allen Paulos, who tried his best to explain to women the potential benefits of the USPTS recs, at least in terms of the mathematics of the probability of a "positive" mammogram being a "false-positive" due to the relatively low prevalence of breast cancer in the 40-50 group.

The US Senate, which has shown remarkable ineptitude thus far in getting even the most modest health care bill passed, rushed to include an amendment to cover the mammograms its own USPTS no longer recommends...pleasing wild-eyed constituents and providing just the kind of unnecessary radiation discussed in the cat scan studies that so freaked people out! (Though yes, a mammogram has far less radiation than a standard cat scan.)

So I say of this: you can't have it both ways!

Perhaps the USPTS might have been more media-savvy about announcing their new recs, and perhaps they might have more shrewdly thought out how to get this information out. But the notion--which seems to have been uncritically bandied about by people in positions of authority in both government and academia--that this is part of science's ongoing war against women is not merely short-sighted, it may well harm women! This may be the final irony of what medical historians in the coming years might call the "Radiation Flap of 2009." Too much radiation from CTs, not enough radiation for mammograms...and not enough people with a bully pulpit brave enough to try to help show people the way.

I do want to note that the issue gets stickier when one considers African-American women under 50. Please--for the few people who read this blog, pass this information on to African-American women! They are at higher risk of having breast cancer before age 50 compared to white women. The problem is that it's not fully clear that earlier mammography will put a dent in the excess mortality rate, because the most lethal types of breast cancer, and the kind that AA women are more likely to have, grow more rapidly than the kind of cancers that mammograms are good at detecting and thus "pop up" in between screens due to their rapid growth and can be found simply by feeling them. A good discussion of the problem can be found here at the Science-Based Medicine blog. In short, African-American women aged 40-50 need to take special care and not simply take the USPTS recs at face value. Not that anyone is, but still.

Tuesday, December 15, 2009

Cat Scans and Cancer

The recent news about the study indicating that about 30,000 extra cases of cancer may be caused by CT scans (audio version from WBUR here, silly shallow TV version below) didn't surprise me much. I have yet to read the study, so I cannot speak to its methods and whether I agree with its conclusions, but it certainly sounds plausible. After all, a CT scan provides a relatively large dose of radiation...I was told by a radiologist during my residency to think of it as the equivalent of 300 x-rays, although according to the news stories this number is at the high end of the estimate, noting that most scans are equivalent to about 100 x-rays. The sicker you are, the more likely you are to get more than one cat scan; some patients that I admit have had dozens of cat scans in a time span of only a few years. Because dividing cells are exquisitely sensitive to radiation and can more easily become cancerous, a few CT scans won't make much difference if the patient is 60 or 70 because most of the cells in their bodies don't actively replicate. But in a 30 year-old--or even one cat scan in a child, whose cells will divide multiple times over the span of their life--this dose of radiation is not without its risks.

So like I said, not a major surprise. Also not surprising is that a good number of these scans were unnecessary: the link above to Toronto's Globe and Mail is useful because it approaches the study from a Canadian perspective, and helpfully points out that Canadian MDs order about half the number of cat scans than their American counterparts, and even then Canadian health experts believe that about a third of those are unnecessary. From a systems perspective on how docs utilize these tests, it's a problem.

How big a problem is an open question. I don't want to sound like an apologist for radiation or to soft-peddle the serious problems raised by this study, but there has been a fair amount of context missing from the news stories and a not-insubstantial amount of fear-mongering to boot. Take a listen to WBUR's Robin Young as she practically jumps out of her seat from fear of getting cancer by just talking about the subject with radiologist Donald Frush of Duke:

"Well, let's get to some of these scary and startling statistics. We understand that some of the highest doses of radiation are routinely used for coronary angiography [to look for blocked arteries in the heart]...the Los Angeles Times writes that according to the [study]...1 in 270 women and 1 in 600 men, at the age of forty, just one [scan], might be at risk to develop cancer as a result. That's a pretty startling conclusion." [my emphasis]

Scary, startling...and Dr. Frush to his great credit gave some critical context to the statistic: that this looks at people who are getting very high levels of radiation, that not all experts agree with the calculations and that the risk may in fact be lower, and most importantly that it ignores the benefit derived from the patients who receive an accurate diagnosis as a result of such a test.

For instance: I admitted a patient recently and was told by the ER physician that "this guy's got community acquired pneumonia, couldn't hack it as an outpatient, he just needs pain control." The patient, a relatively young man in his 30s, had been feeling lousy for a few days and saw his primary care doc, who ordered some blood tests and a standard, low-radiation dose chest x-ray, which I could see in the ER clearly showed an "infiltrate"--a hazy spot on the film that certainly looked just like pneumonia. His blood test showed a high white count indicating an infection, and so before I even saw the patient it seemed like the diagnosis was gift-wrapped: game, set, match. Give the guy antibiotics and some morphine and move on to the next patient.

Only problem was that as soon as I started talking to the patient things weren't making sense in the nice, clear way the labs and film suggested. I found out that he had had these symptoms a few times in the last six months; the symptoms included coughing up blood and night sweats. Can regular old pneumonia cause someone to have night sweats and cough up blood? Sure, but in an otherwise healthy guy in his 30s who just recovered from a similar bout two months ago? That was weird. I mulled it over and after talking about other things like recent travel, his family background, and his job, I realized he could have one of many different things and "community acquired pneumonia" was now about the fifth or sixth most-likely diagnosis. I was worried that he might have had undiagnosed HIV, or tuberculosis, or a pulmonary embolism (a "PE," which is a blood clot in the lungs), or lymphoma, or even lung a few other more zebra-like diagnoses. To rule out each of these things would require different tests, but the first place to start was by getting a cat scan to rule out cancer and that blood clot. An hour later, I had my answer: he had several PEs in his lungs. The treatment he needed was blood thinners, not antibiotics. It wouldn't be too melodramatic to suggest that the cat scan--which delivered that radiation that so spooked Robin Young of WBUR--may well have saved his life.

It's that kind of nuance that requires emphasis every time one of these studies comes out. Indeed, the study estimated that unnecessary radiation from cat scans accounted for only 2 percent of all cancers. Will that be taken into account by every current cancer patient who has undergone a CT scan when they hear the story, or will they assume that their cancer was without doubt cause by a careless doc or hospital or CT scan manufacturer? Will she be like Connie Barton, the woman recently featured in the Sunday NYT who believes that her breast cancer diagnosis was, without question, due to the hormone replacement therapy that was prescribed by her doctor and made by Wyeth, Inc.? At least in the Barton case I'm sympathetic: Wyeth, as the Times notes, "oversold the benefits of menopausal hormones and failed to properly warn of [its] risks." But docs aren't cashing in on thousands of useless tests: if anything, the problem is often the reverse based on my experience, namely that we order tests defensively, fearing that if we don't get a cat scan for something we're pretty confident doesn't require one, we could find ourselves in court having to defend not ordering the test sometime down the line.

In other news, Season's Greetings! In the Rubin household this means "Happy Hanukkah." Billy notes this truly weird article in the Times about how the Very Mormon Senator Orrin Hatch (R) of Utah wrote a little Hanukkah jingle and even did a little bopping (ahem, the musical variety) in the studio. Quoth the Senator, "Anything I can do for the Jewish people, I will do." All Billy can say is: please don't do much! (Though thanks for the sentiment.) And, of course, Billy thanks the Lord that his last name is Rubin and not, say, Hatch. Hat Tip to the Professor of Rhode Island.

Wednesday, December 2, 2009

Flu Thoughts

Good news, team: this flu season's about to come to an end. Bad news is that the regular flu season is just getting underway.

It is hard to underscore just how much this virus tore through the population. The CDC reports higher-than-normal medical visits for influenza-like symptoms in every region of the country--a total of 51 of 54 epidemiologic jurisdictions. Now it doesn't tell you the total number of cases, which at this point could only be made with a guess as most cases are identified "clinically" and aren't even reported, much less confirmed. There are just too many cases to allow for that kind of precise measurement. However, the CDC's best guess is that, by the end of the epidemic, about 22 million Americans will have been infected. That's simply an awesome number of infections.

If you have gotten the flu thus far, it's overwhelmingly likely that you got the novel H1N1 virus. The CDC data indicates that only four out of nearly 2,500 strains are "seasonal" strains. ("Strains" are the molecular sub-type of the virus...think of different colors and years of Toyota Priuses, with one or two Camrys thrown in, and you've got a rough idea of strain differences.) And some further good news is that these strains remain almost universally sensitive to oseltamivir (Tamiflu). Even better is that this virus so far hasn't become really deadly. Shown below is the graph displaying pneumonia and influenza mortality (link above) and, except for a recent blip, the mortality is well within the expected level during
nearly all of the "Swine Flu" epidemic. The CDC estimates are for a total of 3900 deaths (540 of those occurring in people less than 18 years of age), which is considerably less than the average annual influenza mortality, which tops off at about 40,000. We owe our good fortune to the fact that this flu strain wasn't particularly virulent and thus far hasn't shown any predilection for mutating into a deadlier strain. There was some news coming out of Norway that there was a more virulent strain that had been recovered in two patients who had died and a third who had been critically ill, but subsequent samples from other patients haven't shown the same molecular signature. So, all in all, hard to say what's going on there.

I've heard a lot of concerns from family and friends over the past several months about the safety of the flu vaccines. An amazing 72 percent of Americans are either very or somewhat concerned about the safety of the Swine Flu vaccine. Granted, it has been been confusing, given frequently changing recommendations from the CDC, the shortage of the vaccine, and the generally confusing issue that there are separate vaccines for the seasonal flu strains and the Swine Flu strain. Still, at least two points need to be kept in mind: first is that the technology used to make the flu vaccine hasn't changed in decades; the vaccine for the novel strain is no more "novel" than that of the seasonal strains, it's just that the strain of virus being grown in chick eggs--yes, that's how it's done--is different. The process of manufacture, however, is totally the same. The second point is that it's very safe. Keep in mind that there is the issue of "background noise" when you give out this many vaccinations: if you just watch 10 million people over the span of six weeks, nearly 17,000 women will have miscarriages, about 20 of them will come down with Guillan-Barre Syndrome (a potentially life-threatening condition sometimes associated with vaccines), and half a dozen will experience the joys of sudden death. So that means that you'd expect to see these kinds of numbers following a mass vaccination campaign. If you're trying to understand why you got Guillan-Barre solely from the perspective that you were vaccinated the week before, you can't really know just from your own experience whether the vaccine was the cause; you have to look at the incidence throughout the population. (The failure to grasp this point is what makes the anti-vaccine crowd so exasperating. Statistically, when you give millions of vaccine doses it's bound to happen that some kid is going to get sick after getting the shot...because the kid was going to get sick anyway!) Of the nearly 34 million doses of the Swine Flu vaccine given so far, there have been only 84 reported adverse events associated with the vaccine, including 6 deaths and 4 cases of GBS. That's a pretty good record.

If one must be in the vaccinophobic crowd, then at least pick the right thing over which to have an irrational fear. Like I said, the vaccine that you may or may not have gotten for your kid due to shortages is just an old-fashioned vaccine. You want truly different? The FDA just met and decided against a flu vaccine "manufactured" using caterpillars. The Protein Sciences Corporation in Meridien, CT had their application rejected on a 6-5 vote mainly because the data at this point in time are insufficient. But you can tell by the vote that it's close. Advantages of making flu vaccines in caterpillars? One, people who have egg allergies can be vaccinated, and two, the company claims that because the virus grows faster in caterpillars than in chick embryos it could ramp up production much quicker than in the traditional manner, no small consideration given the profound shortages of vaccine stocks this time around. (And keep in mind that it's still likely an irrational fear.)

My own sense of the mild hysteria surrounding the flu vaccine? An indicator of the extent to which Americans distrust authority. Having grown up with a marginally rebellious attitude in my younger years, I am not completely unsympathetic to the mindset that authority should be questioned (particularly as my high school Principal, Mr. Sertell, was practically begging to have his judgement held up for scrutiny). But there's a difference between a healthy skepticism of official pronouncements (take the President's recent Afghanistan Surge speech as an example) and outright paranoia, and I have the sense that we've been increasingly shifting towards the latter perspective over the past decade.

Wednesday, November 25, 2009

Thoughts on Cato, Thanksgiving, Capitalism and Public Safety

I returned to the northeast after a five-day stint in our nation's capital at the annual American Society of Tropical Medicine and Hygiene conference. Not much to say about that today except for one thing: Trop Med includes scientific symposia on all number of diseases, but the two biggest players are malaria (accounts for a bit less than half of all sessions in the conference) and my own field, flavivirues (dengue, West Nile Virus, Yellow Fever and a few others, which accounts for maybe 30 percent of the conference). You'd think, given that flavies are the second-biggest draw in terms of the sheer weight of presentations and amount of research that it represents, that they'd have rooms big enough to accomodate interested participants, right? You'd be wrong if you thought that. The rooms for the flavi presentations were wide enough but too shallowmaybe 7 or 8 rows deepand as a consequence there were maybe 40 or 50 people standing near the entrance milling about trying to catch the talks. Not so great in terms of crowd dynamics. It was hard to concentrate with all the movement, people were regularly walking in front of the speakers to try to find places to sit, those sitting felt bad for having a comfy seat while others stood around (or at least I did). In short, a mess.

Now, don't you think the organizers knew that there were going to be 400 versus 300 people coming to those sessions, and arrange for the appropriate room? It's not like this stuff has changed much in the past few years. Might there be some kind of bias against the virus people from the malaria crowd? Hmmm.

Anyway, I left the conference early (early) Sunday morning and caught a cab to Union Station. (As far as I'm concerned, in the northeast corridor the only civilized way to travel is by train. Takes a little longer, but it beats being publicly strip-searched after waiting an hour in line before being thrown into a flying tin can where you have exactly one inch of wiggle room and the passenger in the seat ahead of you leans their seat back, making comfort a complete impossibility. Gimme the train any day over that!) While winding through the streets of Washington, we drove by the offices of The Cato Institute. Say what you will about their politics, but they have a lovely building.

After we passed it, I began thinking about Cato's little YouTube clip that I wrote about last week. Recall, the title was "You Are
Not The Customer," and it went on to argue in various ways that government intervention in the healthcare system would only make matters worse. That's of course in keeping with Cato's philosophy, which is that free-market solutions are virtually always the best solutions. One odd thing about the clip is that they complain about the wacky computer situation in the current healthcare system (they are right to complain; it really is that bad), but imply that that's because government legislated it...only their overall argument is to prevent the encroachment of government into healthcare by opposing the current legislation. In other words, the lousy system we've got is mostly because of a free-market model. Another point they never mention is that other countriesand by "other countries" I mean "virtually all other countries with standards of living comparable to ours"manage to have perfectly functional health systems that are either run directly by the government (Great Britain) or have insurance systems mostly or entirely administered by the government (Western European countries, Canada). And these countries manage to spend, in all but two or three cases, less than half of what we spend on healthcare in the US. Remember this the next time we talk about the decline and fall of, say, American manufacturing and consider how much insurance premiums hurt the bottom line of so many corporations.

Cato's need to regard every political and social issue through the lens of free markets and the benefits they provide is actually neatly shown in the title of their piece: you are not the customer. Cruising by their offices at five in the morning, I was struck by the oddness of that title. For instance, they didn't say "the government will make you sicker," or "you're just another number to a bureaucrat," but they focus on your identity as a customer. But how is being a "customer" in healthcare related in any meaningful way to being a customer when you go food shopping, buy a cell phone, or look for a place to live? As a customer, you have a right to expect that the fridge you buy will function, at the very least, as long as the warranty applies...and if it doesn't last much beyond that warranty you'll probably heavily consider buying a different brand next time. (This is why the Rubin family will no longer be buying any products of the Magic Chef company, whose fridge lived a paltry 18 months, six months beyond its warranty.)

But how do you do that in health care? Do you march into the hospital and demand that the staff have Grandmawho in her prime smoked two packs a day and drank enough Bloody Marys to make Boris Yeltsin blush, and did this for forty yearsdoing the Lindy Hop in the next 24 hours, or else? Do you request a refund after you develop a wound infection after your gallbladder surgery (a known complication)? Do you pay your primary care physician only if the pills he or she gives you make you feel better?

Doctors are very much like plumbers, electricians, and car mechanics: they have a specialized knowledge base that makes it difficult at best for a laypersona "customer"to judge their body of work. Unless you have specialized training, you pretty much have to trust them in their diagnoses. Of course, as anyone who has taken an Old Yeller-type automobile to a car shop knows, a mechanic can give you options: "if I just fix the fan belt, your '93 Chevy Celebrity can probably make it another six months...if we add a carburetor and an alternator to that, maybe you'll get another year beyond that." You as a customer can make some informed decisions based on that information. But is that really the system one would want in medicine? "Well, pay for these drugs now, and your chance of a massive heart attack and a long rehab costing your family $30,000 in five years will be cut in half. Or you can just start saving up for The Big One. Which would you prefer?" There's a reason why discussions about money are at something of a remove in healthcare. You couldn't imagine some doctors taking financial advantage of situations with stressed-out families terrified of losing a loved one? Is that really how everyone would benefit? David Goldhill, the CEO who critiques the current system in the Cato piece, does I think helpfully point out how peculiar the system of financing has become in medicine, where the actual value of an MRI is...well, it's totally unclear. But imposing a "customer" model onto that system without even beginning to consider some of the implications of that decision is, to my thinking, scarily naive.

One last thought on this theme. Happy Thanksgiving, everyone! I hope that you are all off to reunions with family and friends. Many of you will be traveling, especially by car. Some good news: car travel (at least on highways) has gotten remarkably safer over the past few years. We are at the lowest level of highway fatalities in the past 40 years. Some of this has to do with the recession as there are fewer people on the road, but a lot has to do with various engineering changes made both inside the car and out. This week NPR did a series on car and highway safety (which can be found here and here) and the stories are worth the listen, requiring less than 20 minutes of your time.

Highlights: one of the reasons why cars now have audio/radio controls on the wheel is to prevent you from taking your attention away from the road to change stations, adjust volume etc. Now you can keep your eyes on the road and flip stations to your heart's delight. Not bad, right? Capitalism in action, yes? Even more enlightening (to me, anyway) was this: you are also safer on the road because of some simple-yet-enlightened changes to the physical structure of the highway: rumble strips now can be found on the sides of most interstates to jolt into vigilance that person with a wandering (or sleepy) mind who has drifted out of the lane; caps on the end of roadside rails (instead of the older kind that "dove" into the ground) prevent cars from running up onto them and vaulting into the air; and cable guardrails have been installed increasingly to prevent cars from crossing medians.

Who is responsible for these changes to the road that keep people safer? Civil engineers! But how could such a thing be possible? After all, they don't work for profit, now do they? They're just merely government employees. And as well all know, because we've heard it for thirty solid years since Reagan became President, "government is not a solution to our problem, government is the problem." What say you, Ron?

Saturday, November 14, 2009

More Myths of the Healthcare System

Billy Rubin's Blog returns after a three-month hiatus (for professional reasons, largely), its slumber awakened by a link forwarded by a friend on Facebook. The link, entitled "You Are Not The Customer", is a nine-minute clip put out by The Cato Institute and featuring the commentary of Game Show Network CEO David Goldhill. It puts forth the argument that what has made American health care so bad is that there has not been enough free-market thinking guiding health insurance. That is, if we had even less government involvement and just let the system 'do its thing,' so to speak, we could eventually clean up this mess. Since the current system is mostly not overseen in any direct or even indirect way by the federal government, what could he be talking about? My best guess is that he's proposing that Medicare is what's screwing up all the pricing and keeping us in the dark ages, although he never explicitly says this. In a similar vein to Cato's free-market perspective, the libertarianish Gregg Easterbrook has been wondering why not simply apply standard pricing models to health care outside of catastrophic insuranceand doing this in football columns on ESPN! (Thus making it about the only football column worth reading.)

The tone of the whole clip is certainly an order of magnitude more intelligent than the more popular objections coming from that ideological end of the political spectrum, which as far as I have been able to tell has amounted to screaming "Socialism!" and "Death Panels!" and "Tyrrany!" and not much more. And while I don't share for the most part Goldhill's or Cato's perspective, I do agree, at least in theory, with some of the questions they raise. And (apparently) like them, I definitely believe that there are deep structural problems in American health care.

That said, Goldhill absolutely screws the pooch on one particular point, one that he appears to regard as the centerpiece of why anything other than a 'pure' laissez-faire capitalist model is doomed to failure. Here he tries to peddle a myth just as insidious as the Death Panel nonsense.

About two minutes in, he starts to complain about the shocking failure of hospitals to adopt computer technology. While his father was ill in the hospital, Goldhill says, "this hospital was less computerized than my dry dry cleaner is concerned enough about losing shirts that he's fully computerized, and the hospital's not as concerned about losing lives? Why is that? Why weren't those investments made? Why do they need to be made by the government?" Later (about 3 1/2 minutes in) he picks back up on the theme with his 'guy on the street knows more about this stuff than the healthcare pinheads' shtick:

"The reason my local sushi bar gave its waiters hand-held ordering devices was not because of the National Sashimi Act passed by Congress...its because they want to get the orders right and [do it] quickly. They capture some of that benefit--and by the way, the customer captures some of that benefit--from that fairly simple thing. The lack of information technology investment in health care is not the problem. It's a symptom."

I admire, from a rhetorical standpoint, his use of a well-grounded, easily visible example. And to a point, he's right: I work for a hospital on the weekends that uses a DOS program for its computerized order entry and electronic medical record. It's functional, I guess, but would laugh a product like that out of its board room if someone came in and tried to sell it as the model for ordering books. Everything else at this hospital is state of the art: MRIs, CT scans, remodeled ICU & Surgical wingsall the stuff one can think of in a fine community hospital, but the information technology is from about two decades ago. And the good news (for the hospital) and the bad news (for you) is that they're no different from any other hospitalif anything, their system may be a little better because it's not prone to crash by being DOS based.

There's only one problem with his analysis, one little fact that makes this apparently sensible criticism look like the canard that it really is. The fact is this: there is one computerized system that would fulfill Goldhill's wildest dreams. It's user-friendly, it combines the electronic medical record with computerized order entry, physicians love it. Even IT nerdy-types love it. And it's been around for more than a decade. What is this amazing piece of technology and why hasn't it revolutionized health care the way the home computer revolutionized small business?

Well, it's called "VistA" (not to be confused with the Microsoft operating system), and it was not developed by someone trying to get shirts dry cleaned or a sushi order rightmeaning it was designed without profit in mind. (I think that deserves an exclamation point: it was designed without profit in mind!) VistA is the computer system of the Veteran's Administration, was commissioned by the US Federal Government and began operating in 1997, and it was then and continues to be the Rolls Royce of healthcare information systems. Having worked at a VA during medical school, I can assure you that it was a joy to work with and I have yet to see its equal. As you can see here, VistA has a main page that has all the goodies a doc needs to retrieve the relevant info: a relevant medical history, a current medication list, links to scans, tests, notes, the whole shebangjust like having a chart in your hands only infinitely easier to deal with.

Your Veterans benefit from this cost-effective, error-reducing system every single dayLord knows they shouldand they do it in a seamlessly linked nationwide system. If you're a Vet from the great town of Mansfield, Ohio and are on vacation in San Diego and you come down with appendicitis, the docs at the SD VA have your whole medical chart at their fingertips. Not bad considering how easy it is for patients to forget critical medications or allergiesassuming they are even consciouswhere the lack of such information can lead to life-threatening complications. Meanwhile "private" medicine continues to struggle with thousands of different systems all over the country, few of them integrated (as an east coaster, I cannot comment on Kaiser Permanente's system with which I have no firsthand experience), and none that I have seen best the VA's Little Information Engine That Could.

Best part? Since this is your tax dollars at work, the software for VistA is in the public domain. Oh yes, it's a free program just waiting to be plucked out for eager hospitals who want happy physicians and greater productivity. So why hasn't this magnificent, almost revolutionary system been snatched up by every profit-oriented hospital in the country? A variety of reasons (and indeed some hospitals have adopted it), but the most important is that because the VA is a government-run health system, it never needed to trouble itself with translating medical codes for billing. Adequate billing obsesses every hospital CEO because insurance and medicare reimbursement is the lifeblood of the private health system, so while VistA may be marvelous for, you know, patients and their providers, it's useless for generating money under the current system. So I would say that Mr. Goldhill has this particular argument about as completely upside-down as possible: not only has the free enterprise model been unable to develop information technology nearly as well as a not-for-profit government-run system, it additionally can't even make use of the blue-ribbon technology that the government is willing to give away gratis! (And in the ultimate irony, other countries who see the value of the VistA technology are adopting it, as this article notes about Mexico's VistA use even surpassing that of the VA itself. Just think about this: we taxpayers have funded a system that we can only have access to as Veterans, but civilian Mexicans can benefit from this technology?! What would Lou Dobbs say?)


PS--The blog is back! We took some time off, but are planning on weekly visits from now on. Please continue to drop in suggestions, questions, links and quibbles.

Thursday, August 13, 2009

Of Hillary Clinton, the Media, and Women's Health

One would be forgiven if one had no idea what it was precisely that Secretary of State Hillary Clinton was doing in Africa this past week. After all, in addition to her husband's splashy, headline-grabbing quasi-diplomatic mission to North Korea, there has been this small matter of town hall meetings where people were theoretically learning about the health care reform proposal(s) wending their way through Congress that were dominating the headlines of the US media outlets.

But if one did hear about the Secretary's trip, it would likely have been about her testy response to one seemingly inappropriate question from a Congolese student asking about her "husband's" views on a loan made by the Chinese government to Congo. Seemingly because this appears to have been a mistranslation of the student's actual question (more anon). "What does Mr. Clinton think through the mouth of Mrs. Clinton on this situation?" was the question that the Secretary received, and--not altogether surprisingly--"Mrs. Clinton" bristled at the apparent implication.

"Wait--you want me to tell you what my husband thinks?" she replied. "My husband is not the Secretary of State, I am. So you ask my opinion, I will tell you my opinion; I'm not going channeling my husband."

The flap may have been the result of a misunderstanding on part of the translator; the student claims he was trying to ask Secretary Clinton what President Obama's opinion was, and the translator, confusing the current president with a former one, made the slip between "President" and "husband." Mistranslation or no, Secretary Clinton's carefully-crafted trip to sub-Saharan Africa received virtually zero attention in the US...with the exception of this one, single, less than 20 second flare that she sent up while in Kinshasa. If you heard about her visit at all, odds are was that you heard about her tantrum. Video is below; a representative article from MSNBC is here.

Billy is not here to defend the behavior of the Secretary, a politician for whom he has generally not held much enthusiasm, although he thinks that a mulligan should be allowed for this one, given that this would be about the worst, most condescending question to ask of a female politician accomplished in her own right...and the question being asked of her during a foreign tour and while adhering to what sounds like a fairly brutal schedule. For what it's worth, the Secretary did lose her composure, and in a perfect world she would have kept her cool. She didn't. I for one think that it's not much of a big deal, though the mainstream media would beg to differ. The link below is to an interview with Andrea Mitchell at NBC (the "Today" show), but one could just as easily pluck up clips from CNN and Fox as well.

What's most contemptible about this little episode of media coverage is that her twenty second screed got play, while essentially nothing of the actual substance of Clinton's reason for going in the first place got discussed. As it turns out, Clinton's visit was directly related to issues pertaining to health and medicine, although again one would be forgiven if one didn't recognize that these issues were viewed as "health" through the lens of the US. For in many parts of sub-Saharan Africa, often caught in the grips of war, "health" refers to the mere avoidance of being gang-raped. For women, that is. The UN notes that the Congo has the highest rate of sexual violence in the world, and Clinton's visit was in part designed to be the US government's attempt at stemming the tide of the violence.

Again--if you weren't following this closely, you would be forgiven for not being aware of this.

You would be forgiven because your media has done such an unbelievably poor job of explaining her mission to Africa--but what a wonderful job they did of explaining her twenty seconds of pique! The article above, which explains in detail the purpose of Clinton's visit, showed up on page A8 of the New York Times; that got virtually no play at the TV news networks. Her tete-a-tete with the student and his hapless translator did, however. That you just might have caught.

As long as our major media outlets are obsessed with this kind of lunch-room gossip, we're doomed. Not surprisingly, one could be forgiven if one had failed to learn anything about healthcare reform by watching mainstream TV news stories about the Town Halls this past week. Sure, one would understand that there are groups of angry people out there, but precisely why they are angry and what is actually being proposed would not be explained very much, because...well, it's just doesn't make for interesting viewing! (Or reading.) So lots of nonsense reigns. Billy had originally hoped to discuss the truly idiotic "death panels" a few days ago, but he felt that women's health in Africa superseded it for a day, and so you have this. Perhaps we will return to the topic of death panels, and try to make a (very, soft,) case for death in the coming days. But for now, we only humbly beg that you read the Times article that actually reports the point of why Secretary Clinton went to Africa in the first place.

(Also: it is late August, which is the time that Billy takes to get away and spend with his family on what is theoretically vacation. We just might find some time to write about the government's plans to pull the plug on Grandma...and how Chuck Grassley let us down as one of only two Republicans for whom Billy maintains any affection...but we make no promises. If we don't get it in, check back in September. If nothing else, we promise to talk about the Flu. Get those shots, team! A bad moon is rising, and God only knows what the hell is coming our way in the fall.)

Tuesday, August 4, 2009

Health Care Reform Debate & Mind-Numbing Stoopidity: A Match Made in Heaven (or, Quite the Laffer)

What happens when a prominent conservative economist takes to the airwaves to debate healthcare reform on national television?

Well, let's just say that George Orwell would have a chuckle.

You will recall that Orwell authored that polemical novel 1984 about how governments deceive their citizens. Most of us had the book assigned to us in high school because of the seemingly obvious anti-commie streak the book had, despite Orwell's open embrace of socialism and scathing criticism of western European democracies, all of which was politely swept under the rug. Billy took a pass on reading it at that time though he caught up in college during an Orwell Phase where he consumed not only '84 but also Homage To Catalonia, Down and Out in Paris and London and various essays including probably his greatest work, Politics and The English Language. Among the central preoccupations of 1984, as well as the entirety of Politics, are the rhetorical methods by which governments achieve duplicitous aims. Sometimes it involves subtle tricks such as euphemism, as the phrase "enhanced interrogation techniques" in place of torture makes abundantly clear (and is an example where our own allegedly "independent" media have completely and uncritically bought the government's line, for more see here). But sometimes it's fairly bald and just involves a flat-out lie, though done with the perfect straight face.

Today, on CNN during a debate about healthcare reform, our subject, economist Arthur Laffer employed just this sort of rhetorical touch. As part of the Repbulican party mantra, or what I like to think of as the Reagan Credo ("Government is not the solution to our problem, government is the problem"), Laffer explained why the current "Public Option" proposal will lead to a complete disaster:

If you like the Post Office and the Department of Motor Vehicles and you think they're run well, just wait till you see Medicare, Medicaid and health care done by the government. [my emphasis]

Now, that right there is a gem, for Medicare and Medicaid is "health care done by the government"! And, moreover, they are popular programs--so popular, and apparently misunderstood, in fact, that at a recent town hall held by Congressman Bob Inglis (R-SC), a constituent demanded that the "government [keep its] hands off my Medicare." Former Senator John Breaux (D-LA) had a similar experience in 2005.

Such nitwits are merely given the right to vote; they are not, however, allowed onto national television and given substantial airtime to proclaim their nitwicity--and have their nitwittish assertions go unchallenged by anchors in the name of "fairness." But the same is not the case for Arthur Laffer, respected economist.

This, folks, is why health care reform is going down for the second time in less than two decades, and why we will continue to have the most expensive and least effective health care system in the developed world.

True that Laffer is not speaking for the government, while Orwell was describing a system in which the government is the group doing the lying. But since the debate centers around what government policy is going to be, it's a distinction without a difference, and I'm sure that Orwell would see Laffer as an ideological descendent of Le Big Brother.

The link is here (hat-tip to War Room and Media Matters):

Oh, and one other thing: I don't know about you but I like the Post Office!

Wednesday, July 29, 2009

Senate Hearings on Continuing Medical Education

Today the Senate Special Committee on Aging (chaired by Herb Kohl, D-WI) held hearings on conflict of interest in medical education and research. Several speakers provided testimony, and if I have spare time in the coming days I will review their statements and maybe find some time for a separate entry on them. But one witness caught my eye, and his statement I read, and that is the subject of today's entry.

Thomas Stossel is a senior physician (Hematology) at the Brigham and Women's Hospital and a professor at Harvard Medical School. As I wrote last week, Stossel was the prime mover & shaker in arranging a conference for a group dedicated to the proposition that industry collaboration with physicians has been much more beneficial than harmful to patients over the past several decades. The goal of the group (Association of Clinical Researchers and Educators, or ACRE) is to organize a pushback against what they see as a movement comprised of anti-industry "zealots" who are out to "infect...medical school ethics instruction with guilt." (NB: this is more a paraphrase than an exact quote, although every word in quotations comes directly from his testimony.)

I noted after perusing their website that they were long on hot rhetoric but short on facts, and after reading Dr. Stossel's statement to the Senate Special Committee I remain not terribly impressed. His thinking seems to rely on a characterization of industry-funded CME critics as Luddites, who have a reflexive hatred of the profit motive: the "oft-repeated mantra that 'companies have a fiduciary responsibility to shareholders whereas physicians' fiduciary responsibility is to patients'...[is an] opaque platitude imply[ing] that business has no social responsibility and that physicians only behave in a venal manner when contaminated by business." In other words, Stossel believes his opponents think that industry (or profit, or both) is always equivalent to evil, and that physicians must remain pure from the evil profit motive.

Of course, that notion itself is so facile it can only induce a sigh. The issue, at least from my perspective, has always been one of bias. Physicians are a bit like little siblings of scientists in that scientists try to discover "truth" and in doing so are constantly vigilant against anything that could bias their view, while physicians have more practical concerns (their ultimate goal is generally to heal patients) but still are, and should be, deeply preoccupied with bias. Well, if lucrative financial deals don't constitute a profound source of bias, then pray tell what does?! It's not about the good or evil that comes of the profit motive, and indeed, the absolutely abominable behavior of some of the drug companies has given a bad name to the many good corporate citizens who do churn out useful products and deserve to profit from them. But to pretend that such bad behavior doesn't exist is to stick one's head in the sand. Moreover, regardless of the extent of bad behavior that has gone on in the past several years (of which there are an ample number of examples), ignoring the potential bias that can result in a physician's mind from financial perks doesn't merely ignore common sense, it ignores a great deal of psychology research that would suggest otherwise.

One can get a yuk or two in (should one be inclined to get yuks out of reading congressional testimony) by glancing at the beginning of Dr. Stossel's statement, in which he alleges that even the use of the phrase "conflict of interest" is a ploy (his exact word! see shortly) designed by that coterie of critics who wish to create an uneven playing field in the public relations war designed to win the hearts and minds of the public, and that nobody has any business even bringing the phrase to the discussion. I'm not kidding. Here is the paragraph (which, as a former English teacher, induces a cringe in me for being the polar opposite of lucid, with all of its subordinate clauses piled on top of one another, but you be the judge):

"'Conflict of interest' is only a meaningful term in terms of regulatory implications in the context of self-dealing by persons in positions of political or judicial power--and physicians and researchers do not even come close to having such influence. Therefore, the intent of the phrase in the context of medicine is a ploy, used since the beginning of recorded history, of adversaries to invoke allegedly evil motives of an opponent--such as greed--as a weapon in an argument they cannot win on substance."

Got that? Only someone in a position of political or judicial power can have a conflict of interest. Alas, this very, very narrow reading of the term is not what most people think when they utter the phrase "conflict of interest." Take this very simple, workman-like definition from Webster's New World College Dictionary: "a conflict between one's obligation to the public good and one's self-interest." That's how lots of people would define it, although even "public good" seems a touch narrow, since teachers or lawyers or the clergy have obligations to students, clients, and parishioners respectively rather than the public good. You can see how this contention that "conflict of interest" is a manufactured phrase doesn't hold up under even cursory scrutiny.

More damning to Stossel's contention, however, is the definition provided by the National Institutes of Health. That is, this is the principal body in the US that defines the ethical behavior of medical research: "a conflict of interest occurs when individuals involved with the conduct, reporting, oversight, or review of research also have financial or other interests, from which they can benefit, depending on the results of the research." Their definition doesn't even trouble itself with the characters that Stossel wants to reserve for exclusive use--judges and politicians.

Ignoring such obvious interpretations of the term might be viewed as, you know, maybe, um, a weapon in an argument one cannot win on substance.

(If the former English teacher can also get in a teaching point here, it is this: please read out loud your statement to a Senate committee before you go to Washington! The phrase the intent of the phrase in the context of medicine is a ploy really should have been written the phrase is a ploy--an "intent" can't be a ploy. Eliminate useless words, class! If there is evidence in this blog entry to the contrary, keep in mind that this blog is pretty much a first-version essay each time out with no time for revisions, and I'm not testifying before Congress.)

It's quite tedious to have to respond to the more fanciful accusations riddling Dr. Stossel's remarks: that nobody wants industry to fail, that physicians can have collegial relations (or even productive collaborations) with medical industry corporate employees, that...oh, you get the picture. The point that has to be made, again and again apparently, is that physicians can be biased by pharmaceutical companies, and that pharmaceutical companies have a responsibility to make money while physicians have a responsibility to treat patients. It's good that there's a profit incentive for corporations. It's bad when physicians are given financial incentives to try to influence the prescription patterns of their colleagues--precisely because those financial incentives allow bias not merely to creep in, but rather knock down the door, barge in, put up its feet on the coffee table, pop open a beer (or, since were talking about physicians, uncork a nice bottle of cabernet) and watch TV. That's bad for patients.

Dr. Stossel also implies that critics of my ilk are clamoring for governmental oversight into every nook and cranny of the industry-physician relationship. For my part I would prefer that government not have to legislate on such matters. Honestly. But here's the rub: I would likewise prefer that my professional brethren and sistren regard the baubles offered by the pharmaceutical industry with contempt, for after all, if the drugs the company makes are good, they will surely flourish under a peer-reviewed system in which no conflict of interest exists, right? I would hope that this would be the prevailing attitude among medical students, for instance. But--good God!--it's not even the majority position among the faculty! And if we can't get the house in order, and further and further evidence of abuses mounts, leading any sane person to conclude that there's a systemic problem out there, well...that's when you get Congress to take note. And as we have found in so many recent episodes in our country, it's not necessarily a good thing when Congress gets involved. But if it does, the fault will lie at the doorstep of the physicians who have abused the goodwill of their patients, as well as their apologists like Dr. Thomas Stossel.

Dr. Stossel's statement can be found here. It takes some time to get through but for those interested in the CME issue it's worth the time investment. In the coming days I hope to have more to offer on some of the other witnesses (or even some of the Senators!).

Hat-tip to the Carlat Blog for the link as well as his attendance. I wanted to make it to the conference as it's down the road from my house, but pressing research issues (including a meeting with the boss) took precedence.

Tuesday, July 28, 2009

Fresh Air on Health Care Reform

Although I try to make my blog entries more than just a link to a "read/watch/hear this," today I just heard a discussion so lucid and crisp that I feel like extensive commentary would not add greatly to it. On NPR's Fresh Air, host Terri Gross invited two economists involved in health care reform to discuss the basics of the economics of health insurance, and for those who have found the news about the legislation working its way through Congress a bit confusing, this is the show for you. It only costs about forty minutes of your time, and is well worth the listen.

The economists are rather philosophical adversaries: Stuart Butler serves as the vice president for domestic and economic policy studies for the conservative think tank The Heritage Foundation, and Paul Krugman (a favorite of Billy's) recently won the Nobel Prize in Economics, writes a column for the NY Times and is a champion of political liberalism. As always, such terms as "conservative" and "liberal" get a little slippery and often aren't helpful, although in this case I use the labels since they indicate their general attitude toward their faith in "free markets" and whether they believe government involvement can improve or worsen a more laissez-faire system. Both men are highly articulate and offer a much more in-depth discussion than that found on cable network news. Moreover, given their divergent perspectives, it is astonishing listening to how much they agree about in terms of how ridiculous, wasteful, expensive and ultimately ruinous the current system is.


Tuesday, July 21, 2009

ACRE: Physicians Who Wish To Maintain Status Quo Fight Back

This Thursday, at Harvard Medical School, there will be a one-day conference that amounts to a new front in an ongoing war within the medical community. Probably no more than one or two hundred people will attend. I doubt it will get much play in large media outlets, but its agenda, and whether or not it wins the hearts and minds of the next generation of physicians, could have a major impact on determining the quality of care for patients for the next several decades, possibly just as important as the health-insurance reform bill working its way through Congress.

So what's the conference and why such a big deal?

First, some background and a little explanation of the "war." Over the past decade or so, an increasingly vocal but small minority of physicians have begun to publicly question the relationship that physicians have with for-profit companies involved in medicine, primarily pharmaceutical companies. They have noted that many physicians have become wealthy, for instance, by serving as "professional experts" earning honoraria speaking to audiences of physicians who are fed free dinners (compliments of the company sponsoring the event) and who receive credit for "continuing medical education." They have questioned the structure of postgraduate medical education, which can be heavily influenced by the pharmaceutical industry in the form of Medical Education and Communication Companies, or "MECCs," allowing pharm companies to sidestep sticky conflict-of-interest issues by paying physicians directly for teaching, instead using the MECC as a third-party payer. Indeed, they have highlighted the problems of medical school education as well, since many of these doctors who serve as paid speakers for drug companies also teach medical students without ever revealing that they do so.

Many docs have become involved in this critique of the current relationship between physicians and industry--and I count myself among these people--but probably none is more important than Marcia Angell, whose book The Truth About Drug Companies: How They Deceive Us and What to Do About It lays out in just over 300 pages, and in fairly lurid detail, the tactics used by the pharmaceutical industry to deceive physicians and patients alike in order to boost sales and profits. It is an excellent and highly readable book, and remains the best overview of the critical problems in this often overlooked area of medicine.

There is a lot of pushback by the industry and those physicians already co-opted by them. One small, precious example can be found here, where one Jonathan Leo, professor of Neuroanatomy at Lincoln Memorial University in Tennessee, tried to point out to the Journal of the American Medical Association, one of the premier medical journals in the US, that one of the lead authors of a paper had not properly disclosed a serious conflict-of-interest to the journal. The study involved giving antidepressants to stroke victims prior to developing depression in an attempt to prevent it (depression being a common condition following stroke); the lead author had been a paid consultant by the very company whose drug was being studied. When Dr. Leo questioned the conflict, he never received a reply from the JAMA editors, so nearly six months later he had his letter published in the British Medical Journal, which was met with howling outrage by the JAMA editors who not only verbally threatened Dr. Leo, but also told reporters at the Wall Street Journal that Leo was a "nobody and a nothing," and that "he is trying to make a name for himself." (Question: isn't that what you're supposed to do in academics? And he sure did! And for the right reasons!) Best part: while the study showed that treatment with the study drug (Lexapro, generic name escitalopram) was significantly better than placebo, it failed to show that it was significantly better than psychotherapy. The mainstream media who picked up the piece, however, quoted the study authors as saying that they believed all stroke patients should be given antidepressants--no quotes could be found about the fact that the drug was no better than therapy.

Anyway, Thursday's get-together at Harvard is the inaugural meeting of a group called the Association of Clinical Researchers and Educators. They state that "ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration." Seems entirely innocuous, no? After all, who isn't for "balanced policies," whatever that is?

More specifics can be found elsewhere in the website, where they state that "ACRE is to be a forum for what we believe is a hitherto silent majority of individuals engaged in clinical service, medical education and medical innovation ready to oppose (but not debate) a small but well organized and well-funded coterie responsible for an anti-industry movement. This movement has inverted reality by extrapolating from an astonishingly small number of adverse events related to industry compared to the incontrovertible evidence of social good that has eventuated from thousands of industry actions over my lifetime in medicine. The movement particularly demonizes industry marketing, despite the lack of any evidence that, on balance, such marketing impacts anything but positively on patient care."

What the writer--who appears to be Dr. Thomas Stossel of Harvard, but not fully clear--means by "oppose but not debate" is unclear to me although it sounds vaguely undemocratic, but the idea that there is a "well organized and well-funded coterie responsible for an anti-industry movement" is so remarkably laughable that it must rank as one of the great overestimations in recent American history. (I particularly like the use of the word "coterie," as if somehow I've been sitting around in a parlor sipping tea with Doc Angell snarling about the bad guys of big pharma.) If critics like Dr. Angell, or the bloggers Dr. Dan Carlat, Dr. Doug Bremner or Allison Bass are so well-funded yet so anti-industry, who has the money to fund them? The local chapter of the American Communist Party?

More disturbing is a complete lack of data on the website; as far as I can tell ACRE does not marshal one fact to support their hypothesis. There are no references on the website, although there is a "link" page which includes several articles complaining about the critics, nearly half of those articles written by Dr. Stossel. Given that this is a website whose leadership consists of academic medical researchers, one would figure there would be at least a modicum of references and facts marshaled in order to make a convincing argument. But from what I can see, there's a lot of hemming and hawwing but no argument based in evidence. Ironically, the statement above notes that "the movement demonizes industry marketing despite the lack of any evidence that...such marketing impacts anything but positively on patient care" [my emphasis], which makes one wonder whether or not the authors have taken the time to even glance at the first page of The Truth About Drug Companies. Or Jerome Kassirer's book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health. Or Jerry Avorn's book Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. Might ACRE disagree with their conclusions? Perhaps. But to me it seems fairly ludicrous to suggest that this whole critique has been generated of whole cloth. Meanwhile, ACRE has not generated one shred of evidence to support their claim on the website.

My suspicion is that they can't rely on evidence because it's not on their side, and they require strawmen to knock down so that they can look reasonable. I myself cannot speak for the other critics, but my main objection is that some doctors are allowed to generate large sums of money in the service of pharmaceutical companies in a variety of ways, and do not consider this inappropriate. Well, I consider this inappropriate, and I believe the overwhelming majority of patients consider it equally so. And I consider it inappropriate because drug companies exist primarily to make money while doctors exist primarily to serve their patients. Anyone who refuses to see that a physician cannot serve both ends hasn't been reading about what's been happening in medicine for the past two decades.

One last link: don't say docs don't have a sense of humor! Here is a link to a satirical twin of the ACRE website: "Academics Craving Reimbursement for Everything." One juicy quote: "ACRE is to be a forum for a hitherto silent majority of doctors which believes that a small but well organized coterie of do-gooders are conspiring to prevent them from buying that third home on the lake." They even get that coterie word in. Love that.

As a quick post-script, I note that one of the featured speakers at the event will be Dr. Jeffrey Flier, who is the current Dean of Harvard Medical School. A few months ago I had written about the Harvard medical students who launched a protest about the conflict-of-interest issues in the pharmacology course, and noted that Dr. Flier had made noises that he wanted to change the policies at HMS. While those changes have partially taken place (following the lead of Johns Hopkins, although this new policy is through the hospitals affiliated with HMS, not the medical school itself), I can't say I am especially encouraged by Dr. Flier's acceptance to speak at this gathering, though we will have to see what he will say.

Monday, July 13, 2009

Effects of the Anti-Vaccine Campaign

Anyone out there thinking about going to merry old England for a summer excursion? Well, think carefully before you go--especially if you head to the northeast of that storied country, where they are experiencing the largest measles outbreak in nearly 20 years. A local public health official noted that "the majority of these cases could have been prevented as most were in children who were not fully protected with MMR." MMR is the acronym for the measles, mumps, and rubella vaccine, which has been around for decades and is one of the safest vaccines known to man.

The vaccine rate for MMR was quite high in England until 1998, when a gastroenterologist named Andrew Wakefield held a press conference where he presented research that indicated the MMR vaccine was linked with autism. The "findings" were trumpeted by the British press, and the vaccination rate fell over the next several years from 92 percent to below 80 percent. Alas, Dr. Wakefield's research was later found to have massive financial conflicts of interest; by March 2004 a dozen of Wakefield's co-authors, including some of the preeminent names in medical research in the UK, withdrew their names from the paper. But by that time the horses were out of that particular barn, and the effects are still being felt there today. And the problem has spread to our shores as well, with any number of otherwise educated people spouting about the vaccines-autism connection as if it were fact. Newsweek magazine provides the whole story in all its sordid details here. They did a commendable job of providing crucial context and essential details; would that mainstream journalism produce this kind of work more often.

Since most Americans--or for that matter most anyone who lives in a relatively developed country--hardly give it a thought, a couple of facts about the measles might be worth sharing. It is one of the most highly contagious viruses known to humans; consequences of infection can range from mild (a few days of generalized illness and the famous facial rash) to serious (among other things, a slowly progressive brain disorder called subacute sclerosing panencephalitis, which is as ugly as it sounds), to death. In fact, in countries where the MMR vaccine is not available due to adequate funds, refrigeration, or trained personnel to administer the vaccine, it is an all-out killer: in 1999 it had killed 873,000 children (and a smaller number of adults) in just one year. As part of a massive vaccination campaign in the areas where the children are not immunized or given boosters (mostly India, Indonesia, Pakistan, Somalia, Sudan and the distant rural provinces of China), the World Health Organization has been trying to get the number under control, with the annual mortality down to under 250,000 children in recent years. To give you some sense of perspective, in any given year just a bit over 10,000 children younger than age 14 die in the US each year. So this is by no means a trivial problem.

For further reading, you can peruse the information here (a guide to the studies about vaccines and autism) and here (stuff about vaccine ingredients), among other places. Also, Dr. Paul Offit, one of vaccine's greatest and most lucid proponents has written a book about the whole controversy entitled Autism's False Prophets, which I have not read but it is on my reading list. I am, however, working my way through journalist Arthur Allen's tome Vaccine: The Controversial Story of Medicine's Greatest Lifesaver, and it's been a very good read thus far.

Wednesday, July 8, 2009

Scientific Dialogue on Fox News

Something pretty incredible happened on Fox News today. Really. Given that Fox has managed to take the practice of using racial euphemism to the point of high art (no real surprise that, given that the whole shebang is run by master propagandist Roger Ailes), one would not expect one of their employees to depart from polished rhetoric and just go on a baldly racist rant, but one would have been quite surprised tuning into this morning's Fox offerings, if of course one wanted to torture oneself by sitting in front of such mind-numbing nonsense (like all television news networks, it must be said in fairness). And what a surprise it would have been.

On Fox & Friends a little chat was taking place over what under any sane conditions would be a study that would receive approximately zero attention by any serious science or health journalist, though nobody would confuse any of the three hosts of this show with such a beast. The study under discussion involved Scandanavian seniors, among whom those who had remained married appeared to be less likely to have Alzheimer's dementia.

Much could be said about the generally minimal worth of such a study, but that is merely a sideshow to the main attraction, which came when co-host Brian Kilmeade explained why he thought the results of such a study did not apply in the US. His reasoning? "We are...we keep marrying other species and other ethnics and other..." was his first foray into the thickets of reason.

Immediately--and to her great credit--his fair-haired co-host Gretchen Carlson tried to cut him off with a not-so-subtle rebuke: "You're sure you're not suffering from some of the causes of dementia right now?" Say what you will about the formulaic arrangement of a pretty blonde chatting with two guys on the morning news; she understood the potential for ugly consequences within milliseconds of hearing the sounds that issued from Kilmeade's mouth.

Undaunted, Kilmeade pressed on, saying, "See, the problem is the Swedes have pure genes. Because they marry other Swedes .... Finns marry other Finns, so they have a pure society." Again, Carlson responded with a look of puzzlement worthy of an Emmy, and third co-host Dave Briggs appeared to try to find middle ground with a half-question half-exclamation of "Huh?!" in response. You really have to see this thing to believe it.

The nakedly racist bent of Kilmeade's "analysis" is really only half the point (and requires no further commentary). At least as important though is the idea that this man--who reveals himself through this short little piece to be a woefully uninformed and deeply unsophisticated anchor--has been chosen by a major television news network to hold forth on the latest in medical research. Moreover, said anchor is spouting off on this inconsequential study, chosen by some superior, instead of any number of other medical or scientific topics that might be of some actual use to its viewers. Lastly, the size & reach of Fox News relative to, say, the "Health & Medicine" section of the New York Times is of course considerably larger, so the impact of such vapidity is amplified.

Video is here: