Wednesday, January 28, 2009

JUPITER--A Big Deal or Just Lots of Hot Air?

That's my idea of being clever. Perhaps we should just move on...

One thing you can't fault clinical researchers on is a tin ear. They've come up with some doozies for names of various clinical trials, having jiggered the acronyms just so: ACME (Angioplasty Compared to MEdicine), AVERT (Atorvastatin Versus Revascularization Treatment), COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), and MAGIC (MAGnesium In Coronary Arteries) are but a few of the cleverly-named studies dotting the pages of medical journals. The latest big statin trial (the Covergirl of the November 20, 2008 New England Journal) places itself in this proud tradition, calling itself JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin). That rumbling you hear from Austria is nothing more than Mozart screaming from his grave, don't mind it at all.

Now, statins are very, very interesting drugs, among a small group that Doctor Rubin genuinely considers worthy of the title "wonder drug" (aside from aspirin--the ultimate wonder drug--he would include opiate narcotics, penicillins, antihistamines, and that's about it), and in this respect the JUPITER trial doesn't make any waves. For the non-specialists, statins are drugs that block one of the early steps of cholesterol production, and in trial after trial they have proven their worthiness in reducing the risk of dying from heart disease. They're not completely safe drugs, but they are mostly safe, so as long as you have an MD who's paying attention to your liver (for instance) they have a big impact on people who are at risk for serious cardiac problems.

Here's the thing: it's not fully clear why statins work. Oh, there's the cholesterol-lowering theory, which may well be right. But statins have other weird effects that don't appear to be directly related to what we know about cholesterol "pathways"; they seem to have anti-inflammatory effects and affect bone resorption. JUPITER's strategy, which seems to me to be fairly novel although I am not a specialist in this field, was to enroll people who had normal cholesterol levels but did have elevations in a chemical marker of inflammation called C-reactive protein, or just CRP. The trial, originally scheduled to last for 4 years, was stopped after about two because of the significant reductions in cardiovascular events (such as heart attacks). There is some dispute as to the magnitude of this benefit (as seen in an accompanying editorial here, see fourth paragraph about differences in relative vs. absolute risk), but it is hard not to find the data impressive.

My question--and the question of this entry--is: regardless of the success of the JUPITER trial and whether or not it has identified other groups of people who may benefit from statins, has JUPITER also popped the bubble on the idea that cholesterol is the key metabolic player in the drama that causes the MI? Perhaps cholesterol is really a surrogate marker and has only been the center of our focus because it's one thing that we could, in fact, focus on? We will see if the basic physiology labs have any thoughts on whether or not we have been searching for our lost car keys under the lamp-post because that's where we had some light.

Sunday, January 25, 2009

YIKES! Here Comes Ebola!

The main page of the NY Times website has three stories listed under its "Health" section:

--Vital Signs: Women Delayed While in Emergency Care
--Coffee Linked to Lower Dementia Risk
--Pig-to-Human Ebola Case Suspected in Phillipines

...and Doctor Rubin has nearly developed lockjaw from all the tongue-clucking he has been doing this Sunday morning. Of three stories to highlight on The Website Of Record, it seems irresponsible and mildly fear-mongering to have one such story focus on Ebola--particularly given that this is not a story about a large-scale Ebola outbreak. He has no problem with the first two articles--though he suspects the second story about coffee consumption to be, to put it nicely, silly--and thinks there are a plethora of other health stories published by the Times that would be useful & topical to showcase (e.g. "Students Still Getting Mono After All These Years"; "List of Tainted Peanut Butter Items Points to Complexity of Food Production"; and a personal favorite, "New Rules on Doctors and Medical Firms Amid Ethics Concerns").

The Pig-to-Human story isn't even that hair-raising when you go past the heartbeat-skipping title, as the person was infected six months ago with a strain of the Ebola virus that has thus far not been lethal to humans (it is the Ebola Reston strain, subject of Robert Preston's book The Hot Zone). Believe me, give me a needle, a couple of vials for blood collection, and enough time on pig or horse farms from Australia through southeast Asia to bleed some farmhands, and I will find for you evidence of prior infection with viruses like Nipah and Hendra, less well known than The Big E but equally as scary and about as lethal. Will that make the "link" page on the NY Times website? I think not.

I'm not implying that it should be forever verboten to write about subjects like Ebola. The Kikwit outbreak in 1995 and the Uganda outbreak in 2000 (among others) were certainly major stories as they had the chance of becoming very serious international health problems. But when you get caught up in publishing relatively minor stuff, which in theory should be trivial to everyone but the specialist, you only succeed in uselessly inducing stress, and you set the stage for future panic.

Thursday, January 22, 2009

Drug Company Funding of CME--Notes from the Family Fight

Over at Medscape (membership required), the white-coated brotherhood and sisterhood is talking about drug company funding of Continuing Medical Education--or "CME," as it's more commonly called, and as I predicted it ain't altogether pretty. This week they hosted a roundtable discussion entitled "Should We Eliminate Pharmaceutical Funding of CME?" and the comments, though small in number, shine a light on what I find a disturbing problem.

CME is the nationally-mandated method by which physicians keep themselves abreast of ongoing developments in their respective fields. CME can take the form of weekly local conferences such as Grand Rounds, or can include week-long seminars, symposia, conferences and whatnot. The length of each of these educational activities is commensurate with the number of CME credits, and each state has a specific number of CME credits that docs must accrue in order to be in good standing with their respective licensing boards.

Makes sense, yes? After all, you would want an infectious disease practitioner who finished fellowship in the early 80's, well before there was any treatment for HIV infection, to have learned something about the most important infectious disease in the US since finishing formal training, right? Especially in a field that changes as rapidly as medicine, where it is often said that half of what is currently known will be outdated or totally overhauled in about ten years, the need to stay current can literally make the difference between life and death.

So who would you want in charge of ensuring this education? You would think that professional societies, without any affiliations to for-profit companies, would arrange and direct the overwhelming majority of CME activities, but it just ain't so. As of 2001, drug companies paid over sixty percent of the costs of CME, and it does not appear the number is dramatically declining. Let's just pause to appreciate that for a moment: the groups that stand to benefit the most by altering the prescription habits of physicians are the very groups who sponsor the majority of educational activities for physicians in the US. Um, foxes guarding the henhouse, anyone?

How then, does a profession with a high sense of commitment to serve its patients find this arrangement acceptable? How can they not see the potential for conflict-of-interest, even if the corporations that sponsor educational activities have only the purest of intentions?

I have a couple of thoughts on the matter but let's get back to the Medscape Roundtable. Medscape chose to invite four physicians to write about the matter. Each of the statements were brief (about 4-6 paragraphs each), and two of the writers were essentially in favor of ongoing pharmaceutical funding, while two were essentially against it. Three of the four appear to be private-practice physicians (a hospitalist and two family docs), while one has an academic affiliation as a full Professor of Medicine. One of the four (who wrote in favor of drug company funding) served as a sometime speaker for a drug company, while the other three had no reported financial conflicts of interest. None of the four appear to have any expertise in the matter, at least by what Medscape reported about them. Doctor Rubin has no particular problem with non-expert physicians airing their thoughts on medical matters--he is one such non-expert doing so right now--but he does have a problem when the authors are leading a roundtable discussion on a website read by thousands of physicians around the country. Can I huff and puff in my blog? Sure. But I might not be the best person to speak with authority in a more formal setting, unless I had done a good deal of homework beforehand.

And it's quite clear from reading the posts that nobody had done a great deal of homework, pro or con. Doc Rubin's personal favorite entry was from a private-practice physician in Arkansas whose bluster far exceeded his thoughtfulness. Before attempting to summarize said doctor's piece, I note that it's easy to get heated in such discussions and Doctor Rubin frowns on the kind of name-calling in which this physician engages out of the starting blocks. I would never, for instance, even dream of calling such a person a "chucklehead" for his poorly-reasoned, highly polemic rant. Wouldn't dream of it.

The Arkansas Doc starts out noting, fairly enough, that lifelong learning is the responsibility of the doctor, and that we as physicians are the best-suited to determine our own educational needs. Then comes the whammy:

The opportunities for continued learning are now better than ever due to the development of the Internet. Unfortunately, there is a movement afoot to limit those options. A growing McCarthyesque purge seeks to restrict our educational choices by banning industry support of continuing medical education (CME).

"McCarthyesque purge"?! Under the category-heading for inappropriate allusions, Doctor Rubin thinks that this statement may likely not be supplanted from its perch for the remainder of 2009. He would point out in detail the foolishness of the historical comparison, but prefers to think it speaks for itself and he has other fish to fry forthwith.

The remainder of his arguments go like this:
a. Because of the heavy money involved in CME, options for CME without such funding would be "severly limited," leading to situations where "nearly all high-quality educational conventions sponsored by professional societies would cease to exist."
b. There's just no evidence that it influences physician behavior in ways beneficial to drug companies!
c. Physicians just aren't that credulous!

With respect to his first point, that high-quality education would just disappear, does this imply that, without planning and forethought, it would be simply impossible to have professional gatherings? Billy thinks not, remembering his days at a conference while in graduate school in English lit, of no interest to any corporate sponsor of anything, and enjoying himself thoroughly at the decidedly-not-posh conference held on university grounds. Must physicians be forced to endure such sacrifices in the name of their profession? Billy thinks it will still be a step up from an English department conference, but yes, it must be so. It doesn't mean that educational activities have to grind to a halt, it just means that you might not be able to attend the next conference at the Ritz-Carlton, charming though such digs are.

As for there being no evidence that industry-sponsored CME results in no bias, Doctor Rubin finds this argument to be particularly rich. The evidence he cites is from the Accreditation Council for CME--the very body which has handed itself over to the industry funding in the first place! It's like asking Alberto Gonzales to investigate the Bush administration: not too likely you're going to get an impartial review. Any attempt at knocking down the argument about industry sponsorship of CME without at least mentioning Marcia Angell's must-read The Truth About Drug Companies (material on CME pages 138-141 for the google-booker's out there), Jerome Kassirer's On The Take, or even the milder tome by Jerry Avorn, Powerful Medicines--to say nothing of actually refuting their ample evidence--has not done due diligence. Mind you, this is Medscape's attempt at a serious discussion! You might as well invite Paula Abdul to air her opinions on the matter.

His last point, one that Doctor Rubin hears time and time again when he chooses to discuss this matter with various colleagues (though truth be told he has learned which colleagues are like-minded on this matter, and tends to avoid the remainder lest he lose his control in public), is perhaps the most precious of all: I'm not biased! Maybe everyone else is, but not...incredibly smart, skeptical me! The beauty of this argument is that one can smugly dismiss with the wave of a hand all the evidence that suggests that doctors as a group are in fact heavily biased by the industry tampering with CME (to say nothing of marketing), because one can just imply that it's those other docs who are unwitting dupes. And believe me when I tell you that this argument is the ultimate fallback. "IF you are 'dumb' enough to be indoctrinated by a drug rep with a bachelors degree then I AGREE you should not attend," says one MD in the ensuing discussion on Medscape. Skepticism? The skepticism of many physicians appears to be in force about everything except their opinions of their own, remarkable, infallible, skepticism.

Oddly--well, actually, not oddly at all--the real argument running beneath these rationalizations is virtually never spoken of. It's pretty simple, actually, and Doctor Rubin, despite his immense respect and affection for the vast majority of his colleagues, has heard that silent-yet-powerful argument since his early days in med school. The "argument," such as it is, is this: I am a physician and that entitles me to nice things. Trinkets, such as free hors d'oeuvres at the cocktail hour following the day's professional meetings, fancy dinners on the tab of the local drug rep, tax-deductible trips to "educational conferences" in the Bahamas--all this is part of the trappings of the lifestyle of a doc. Such is the mentality that resists seeing the obvious conflict-of-interest in industry sponsorship of CME; the defense of the indefensible rests on an emotional response, not a rational one. Until that mentality, that sense of entitlement changes, you can count on organized physician opposition to the meek suggestion that, you know, perhaps we might want to reconsider our relationship with groups whose job it is to make money, given that our job is theoretically to heal patients.

Tuesday, January 20, 2009

Thoughts on Obama's Inauguration

I am, for the most part, someone who does not believe in God, but I will nonetheless thank him for bringing us to this day.

I would likely have felt this way regardless of who took the oath of office this afternoon, but knowing that a man like Barack Obama is now our President will enable me to sleep more soundly tonight. It is not merely that he appears to have attracted many of the best brains in government to work for him, that he has a generally inquisitive nature well suited for a complicated world, and that he has a steely evenness that one hopes will guide him through the crises to come--all traits lacking in the former model--but that Obama, more than any national politician that I can recall in my lifetime, seems to have a vision for the untapped potential of the country, for unrealized possibilities and concrete thoughts on how to achieve them. We are only at the beginning, and I don't wish to get too caught up in all the flowery prose that has been bestowed on Obama (and I've already had to pucker my face at some of the cabinet nominations), but I do feel better about our government today. A lot better.

One of those minds that Obama collected along the way was a guy named Mike Froman. Typical of the kinds of people with whom Obama has surrounded himself, Froman's resume reads like a where's where of elite institutions: Princeton, Oxford, Harvard, Citigroup. Among many other accomplishments he served as Robert Rubin's chief of staff in the final years of the Clinton administration. He was a classmate of Obama's at Harvard Law and the two have apparently been close friends since; he was one of the key players on the transition team and, given his background with Rubin, likely had a hand in some urgent policy discussions and decisions about the economy.

I bring this up because Froman has been balancing his sense of commitment to Obama's vision while simultaneously coping with his son Jacob's medulloblastoma, a rare brain cancer. On January 16, Jacob succumbed to the disease. I don't know the Froman family personally, but from the looks of Jacob's website they appear to have shown remarkable grace throughout their trials as a family, Jacob in particular.

For those who would like to commemorate President Obama's inauguration in a tangible and meaningful way, please consider a donation to Jacob Froman's foundation, Kids V Cancer. Their website is here, and the address is Kids V Cancer, c/o Jewish Communal Fund, 575 Madison Avenue Suite 703, NY NY 10022. Online contributions can be made here.

Friday, January 16, 2009

Flu Batters Europe

The staff here at Billy Rubin's Blog have taken as their creed something like this: the mass media warps people's perception of medicine, thriving on keeping their readers and viewers in a state of near-constant fear about the various little microbes and other health risks that can do them in at a moment's notice. Our goal is to bring a little perspective to this constant onslaught of scare-mongering, and as such we prefer not to talk about "scary diseases," finding such terms sensationalistic nonsense.

That said--and in a blog just two weeks old, no less--today's topic will be something that the Doctor considers to be genuinely scary: the influenza virus. Most people aren't as scared of flu as they are of, say, flesh-eating bacteria (the danger of which Doctor Rubin thinks is wildly inflated even in the best of circumstances), and yet they should be. Partly due to his own encounter with the bug in his mid-20s, when he endured a three-day stretch where death seemed like a preferable option to continued suffering, partly because as a physician he has seen people--young and old, healthy and ill--succumb with eerie speed to this virus, he maintains a healthy fear of influenza and recommends everyone else do the same. By "healthy fear", he means that everyone should get their flu shot, pure and simple.

Last year's flu season in the US was particularly disturbing. The CDC reported just under 40,000 confirmed cases from October through mid-May. Keep in mind, though, that that number represents only the cases where the patient came to medical attention, and that the test was performed accurately (the nasal swab to test for flu has to be inserted deep into the nose, which it often isn't, leading to a high false-negative rate), so the true number almost certainly is a good deal higher than 40K. Moreover, the sheer aggressiveness of the virus can be seen in this graphic supplied by the CDC in this report. The graph represents the deaths caused by influenza and pneumonia as a percentage of overall mortality; the red line shows the actual percent, while the black lines show the threshold at which the public health guys & gals declare an epidemic. You can see that 2004 and 2008 were bad years, while the intervening three seasons were fairly mild (the arrow in the middle notes the epidemic threshold line):
All of which is to say that this year, the flu is not nearly as bad. At least in the US. On the other side of the pond, Europe is getting slammed. Bloomberg has an article that does an admirable job of describing in detail the nuances of influenza infection, its complications, the various strains involved and how vaccines are made, and drug resistance, all within 1200 words. It's impressive. Would that every medical story be written this well. Then again, Doc Rubin would be out of a blog.

Tuesday, January 13, 2009

Billy's Dad's Drugs

Billy's father was just sprung from the hospital after a five-day stint for an acute GI bleed. First time he has ever experienced this, father Rubin came in after about four days of constant cajoling by his wife as he had looked pale and sick long before a stethoscope came within a mile of him. When he showed up at his primary care physician's office, his blood pressure was 80/40 and his hematocrit turned out to be 15.8. For the non-specialists out there, to give you an idea of just how low 15.8 is for a crit, think of it this way. A normal crit for an adult male runs about 39-45. For patients with coronary (heart) artery disease--which he has--physicians usually don't get worried or think about transfusing until the crit falls below 30. For anyone, doctors get nervous when a crit falls below 24 (actually, they get nervous a good deal before then, that's just the threshold at which they normally transfuse patients). Pop got down below sixteen! Way to ignore your wife there, big guy! As I told him once he recovered, I have never seen anyone get that low acutely and live to tell the tale. He's unbelievably lucky.

I mention this because my father's drug list prior to this episode was virtually medical poetry: a beta-blocker here, a little hydrochlorothiazide there, a nice TZD-class drug for his diabetes. Looking at the list I liked his physician's style, though I had never spoken with him until last week. The over-the-counter med he uses for his arthritis and that was at least partially responsible for his bleeding, naproxen, would have to be stopped. And to prevent a recurrence of bleeding in his stomach and duodenum, he would be given a medication called a proton-pump inhibitor to prevent his stomach from producing so much acid.

After my father's condition moved into calmer waters I headed back for home and a few days later mother Rubin called me on the phone and were discussing dad's discharge plans. What's the new med for dad, I asked.

"Nexium," says mom. "It cost us fifty dollars! The pharmacist says it costs four hundred overall." bet it's fifty dollars! Nexium is one of the great swindles perpetrated on an unsuspecting public that believes good things about the pharmaceutical industry. As the patent on Prilosec was running out, Astra-Zeneca needed another cash cow, and their solution was to take the molecule that made up Prilosec (which comes in two versions of the exact same molecular form, both mirror images of one another) and separate out just one of the two forms and test, patent and market it under a different name. Amazingly, this little scientific chicanery allows a company to keep on charging those insanely-high prices for which patented drugs are notorious. Nexium is really just the left-handed version of the two-handed Prilosec.

Mind you--Nexium is not a bad drug. Indeed it's a good one, as its parent, Prilosec, is as well. But it's a completely unnecessary drug! Prilosec does just fine in a situation like my father's. But how much does Prilosec cost? About 25 bucks, total. That's a lot less than Nexium's 400-dollar bill.

Now you tell me: is it the fault of the drug company to pull off this clever little piece of flim-flam to produce such a drug, or is it the fault of the physician who prescribed it? And what can you conclude about the system when you see something like this happen?

NYT Aces Its Editorial on FDA

Those who haven't yet become convinced that the medico-industrial complex has lotsa lotsa rotten goings-on would do well to look at the Times's analysis of the FDA and how big pharma has managed to turn it into a virtual rubber-stamp organization instead of one devoted to genuine oversight. There's plenty to chew on despite eight terse paragraphs, but the one that interests me the most is this one:

The inspector general found that fewer than 1 percent of the doctors who helped oversee clinical trials reported any financial conflicts — such as consulting payments, honoraria, grants, patents or stock options — that might influence their studies. That number seems unbelievably low given credible estimates that one-fifth to one-third of all doctors have such conflicts. [my emphasis]

Thus: if you expect your physician to be making unbiased judgements about the medications they administer or the surgical equipment they utilize, you have a one-in-five to one-in-three chance of being sorely disappointed. But it's much better than that, because the above paragraph is talking about the financial conflicts of interest of the physicians who participate in the studies that allow drugs to be brought to the marketplace--in other words, the people running the studies to evaluate the worthiness of a drug or device are themselves potentially biased, being favorably predisposed by receiving "honoraria" and whatnot. This means that, even if the other 66-80% of docs who try to maintain some disinterestedness carefully evaluate a new medication, they may be reading already-biased studies in the dozens of journals so chirpily-quoted by the local drug reps when they go to hand out their candy & pens & invitations to the local Bistro Foo-Foo for a "talk" on that very drug. And spending lots of time & energy trying to chase down the financial conflicts of interest by the people who publish a study showing the effectiveness of Drug X is not high on the priority list of most busy & harried private-practice physicians.

At professional gatherings Doc Rubin stays very quiet about his thoughts on the relationship between the pharmaceutical industry and physicians--and staying quiet for Doc Rubin is a challenge of immense proportions--because he has discovered through casual conversation that his views are considered to be radical to the point of loony-toonicity, such that he would be regarded by many of his professional peers as a red-loving fruitcake in their midst. Doc Rubin's crazy opinions? That physicians should never accept any gift or enticement whatsoever, and that they should never attend "dinner lectures" at fancy restaurants sponsored by pharmaceutical companies. That the only paycheck that is acceptable for a physician is that derived from caring for patients. That the moment one does any of these things I have proscribed against, one has in effect violated his or her Hippocratic Oath. In short, that there should be a firewall between companies aiming to profit from patient care, and the patients themselves.

I think such policies would cover about 90% of today's conflict issues (wouldn't cover what to do about grant money from drug companies, which is a tougher nut to crack and of which I don't necessarily disapprove), but don't expect any change on that anytime soon. If there is a shift in the policies, it will have to come externally; the medical establishment is far too comfortable with the current arrangement to agitate for change.

(Hospitals and departments, at least in the northeast where I work, are actually doing pretty well implementing conflict-of-interest changes. In many academic and private hospitals, for instance, drug reps cannot "sponsor" educational activities like Grand Rounds, and Conflict Disclosure forms--Doc Rubin himself had to fill one out when he gave a Grand Rounds talk at a community hospital--are becoming standard. But those yummy drug-rep dinners on a night after work, especially for those hard-working less-well-paid residents who are grateful for the bon-bons? Those will keep going, and as long as they are effective in shaping and changing physicians' prescribing habits, you can bet that the gravy train will continue, ad nauseam as it were.)

Keep in mind that Doctor Rubin considers himself persuaded by several principles of capitalism. He believes that those who bring innovative and new drugs to the market should be rewarded, and rewarded amply, for their ingenuity. Not only that, he has come to embrace many of the qualities of yuppiehood he sneered at in his youth: a love of good food and wine, life in the suburbs, a car with leather seats. (He'll never join a country club, but still this a dramatic depature from his collegiate days when he really did have a Marxist bent.) But the good doctor only wants to taste from the fruits of the good life by serving his patients or by living off his grant money, and he's highly skeptical about the puffed-up claims of the drug industry about how many wonderful medicines they've created in the past, oh, say, two decades. I'd guess that just under half of all docs share, in a vague way, those convictions. But nobody wants a family fight, so unless Congress gets involved, the current arrangement will remain the status quo.

Monday, January 12, 2009

Come Be a GI Doc, and one last thought on Gupta

The NY Times today has a quick piece about the coming shortage of gastroenterologists, which will lead to delays in screening colonoscopies. Medicine residents of the US, here is your future! Upsides: your income will be among the highest of internal medicine subspecialties (along with cardiologists and pulmonary-critical care docs), but typically with a less brutal schedule, as there are fewer middle-of-the-night GI emergencies. Downsides: scoping patients day-after-day has got to be one of the less exciting jobs in medicine, and managing GI bleeders can be raise-the-hair-on-the-back-of-your-neck scary.

As those residents who decide on pursuing GI instead of pulmonology like to say, "take shit over spit."

As for Gupta, I've just re-watched the 17-minute showdown between Gupta and Michael Moore on Larry King Live (I just love juxtaposing a serious topic with the words "Larry King"). To me it's a case study in making mountains out of molehills. On every major point Gupta not only concedes the general accuracy of Moore's facts, but states that he agrees with his overall bleak assessment of the US healthcare system! This is not the rhetoric of an apologist for the system, as some have alleged. They spend a few minutes going round each other on whether Cuba spends $229 or $251 annually on health care per person; they might as well debate about the number of angels that can dance on the head of a pin, as that wouldn't be any less relevant to the real issue at hand. They do have a scrape about the use of the term "free healthcare," with Gupta making the point that countries like France and the UK, despite having universal health care, still have to pay for their system in some way so it's a bit of a misnomer to call it "free," but Moore just won't concede the point even though he's wrong.

The one time when Gupta does go astray (and it's a biggie) is when he defends his choice of interviewing Paul Keckley as a "healthcare expert" to discuss Sicko. Gupta says that Keckley's only affiliation is with Vanderbilt University--but this is clearly wrong. The entire explanation is covered by Media Matters here, the gist of which is that Keckley is affiliated with Deloitte & Touche USA LLP (not just Vandy), and that Keckley personally has made contributions to Republican politicians. This isn't mentioned in the original three-minute piece that aired in Wolf Blitzer's "Situation Room" (snicker), and Gupta--wrongly--stands his ground on Larry King.

How Gupta ends up finding a Republican-connected "expert" to interview is the subject for another day, but my point is that's the rub, not whether or not Gupta was smug and arrogant (he doesn't seem so to me) and did a mugging on Sicko. A superficial analysis that missed the forest for the trees? Yes. A hatchet job? No.

Friday, January 9, 2009

What to make of the Gupta Kerfuffle?

Sanjay Gupta's nomination to the office of Surgeon General, and the resultant mini-tempest in some parts of the blogosphere (see here and here, for instance), may offer a glimpse of the coming relationship between President Barack Obama and the progressives who catapulted him to the presidency. At the moment it doesn't look altogether pretty, although of course Obama hasn't even taken office yet, making dire assessments a touch premature.

Those keeping score will recall that Gupta provided an assessment of filmmaker-puckster-agitpropster Michael Moore's documentary on US healthcare, Sicko, as a piece for Wolf Blitzer's CNN show "The Situation Room." (Hard to write the name of that show with a straight face.) Gupta gave a three-minute review of the film, pointing out some perceived inaccuracies, and ending with the near-hyperbolic statement that Moore had "fudged" some facts--in other words, consciously played fast-and-loose with the truth in order to support his view. Moore took umbrage, leading to a debate on Larry King Live (no, really--a debate on a serious issue on Larry King; you can't make this stuff up) in which Moore and Gupta defended their turf.

I don't want to re-create that debate here as the two links up top do an admirable job of laying out, with some precision, the problems that the Sicko smackdown has for Gupta's credibility as Our Nation's Doc. For my own part I think that this does not disqualify him for the job, that his appointment isn't really going to have much impact on healthcare policy, and that the original report that was the source of the fight wasn't nearly as lopsided as some bloggers (even Paul Krugman) suggest--though I do agree that it was most unfortunate for Gupta to use the phrase "fudged the facts." Gupta may not have wholly endorsed Moore's views, but he didn't exactly say a McCain-like the-fundamentals-of-our-healthcare-system-are-sound, either.

What I find much more troubling than the content of Gupta's piece (or, for that matter, the entire coverage in Blitzer's "Situation Room"), is the sheer length of it. Three minutes were given to analyze/rebut/celebrate Moore's argument--and Michael has two minutes to respond after we hear from these sponsors! How anyone can even begin to fathom the nature of the problem, let alone the solutions, in three minutes time is beyond me. And watching medical personnel waltz around in scrubs as part of the B-footage is not deeply edifying, either. If Gupta thinks that this is what constitutes a serious discussion about healthcare, then it doesn't bode well for his tenure as Surgeon General.

Wednesday, January 7, 2009

Why not to be afraid of residents, part I

I am often told by people, sometimes in a tone of pride, that when they require care at the hospital "I always have the attending see me, without the resident." Or else: "I don't want to have a resident operating on me, you know; I want someone with real experience." Sometimes these confidences were relayed to me when I was in the middle of my own residency; not exactly a shot in the arm in terms of confidence, I can tell you. The thinking behind this--so far as one can accurately label it as "thinking"--is that residents are inexperienced and attendings are seasoned, and you don't want to be practice material for some greenhorn, now do you? Let someone else be fodder for klutzy residents (as in: poor people in city hospitals).

Perhaps. I can't deny that residents do not possess the full complement of skills of a well-seasoned attending (at least in theory). I also can't deny that it takes years of day-in day-out work to attain that skill set. But while leafing through Malcolm Gladwell's very good new book Outliers I read a passage that sheds some light on the issue, starting with the same premise (more experienced people should be in command) and arrives at a strikingly different conclusion (that's not necessarily better for your health). Gladwell spends a chapter dissecting various plane crashes in recent history. He discusses "mitigation," the process of engaging in deferential speech toward a superior, hinting with various levels of subtlety when inferiors believe the superior is making an error, and makes the following remarkable observation:

"Mitigation explains one of the great anomalies of plane crashes. In commercial airlines, captains and first officers split the flying duties equally. But historically, crashes have been far more likely to happen when the captain is in the 'flying seat.' At first that seems to make no sense, since the captain is almost always the pilot with the most experience...planes are safer when the least experienced person is flying, because it means the second pilot [the superior] isn't going to be afraid to speak up." [my emphasis]

I do not know for certain if there is any way that medical errors can be tracked in such a manner (likely not). But I could see how you could substitute "attending" for "captain," and "resident" for "first officer," and arrive at similar conclusions. That holds especially true for the uber-deferential world of the operating room, with surgery's typically rigid hierarchical culture. Worth considering next time you think yourself above the care of a resident (and that it's the hoi polloi who deserve such scraps). Or rather, when one thinks oneself is above such considerations--because you wouldn't ever venture near such a thought, would you?

Sunday, January 4, 2009

Has medicine become "industrialized"? An intro to hospitalist medicine

Sorry in advance. This is going to be a long one.

In July 2007 on, a website for medical professionals, there appeared an article entitled “The Disappearing Doctors” (apologies in advance for the link, a subscription is required). Written by Jane Gilsdorf, a pediatric infectious disease specialist at the University of Michigan, the article discusses the complications that have arisen from recent changes in scheduling the work hours of residents—what is now almost universally called “the 80-hour workweek” based on the most important recommendation of one of the highest governing bodies in medicine. Mostly, the article is a lament about the current state of physician training wrought by the 80-hour workweek, where residents are often being shuffled between outpatient clinic and inpatient hospital coverage, covering for other residents who need to leave the hospital due to maxing out on hours, not fully understanding their patients’ conditions due to the cross-coverage. She argues, not without some justice, that this is not the optimal learning environment for an apprentice doc, noting:

“[Residents’] heads are crammed with the facts they've learned during medical school, but they can't see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.” [my emphasis]

For what it’s worth I don’t completely buy her argument. For starters, the contention that one must see the “entire” course of a given illness, when taken to its logical extent, should mean that residents should never leave the hospital. After all, until a patient is out the door and restored to health, the course of illness is running and should require constant observation. Many hospitalizations span days; complicated ones last for weeks or months. Why should residents be allowed to follow the course of a hot gallbladder, which usually can be followed in two or three days, but not be expected to stand watch to the full storm of, say, a patient who develops Acute Respiratory Distress Syndrome in the midst of an influenza infection, and could require three weeks of touch-and-go care? (Of course, the term “residents” comes from the fact that, in the early part of the 20th century, they didn’t go home; they “resided” on the hospital grounds.) But we live in theoretically more enlightened times, so physicians-in-training gotta have some time off. The question is how much, and how do you schedule coverage in the interim.

But most of my issues with Dr. Gilsdorf are quibbles, and I think her points are well taken (despite having been trained more-or-less at the beginning of the implementation of the 80-hour workweek). I bring up her essay here not to discuss the merits or drawbacks of the new work-hour system for residents (though I promise to do this down the road, as I think few people outside of even residency programs really understand the implications of the changes). I wanted to use her essay as an introduction because of the last portion of her statement above, where she worries that “the current system is creating a legion of shift-worker physicians.”

By my reckoning, her worries are somewhat out of date. The current system—and by that, I mean the medical system well beyond residency programs—has already created a legion of shift-worker physicians. The old system, which I will briefly sketch out below, is largely becoming a vestige of the past. We’re already well into the new age of medicine, at least in the hospital, where the sickest patients reside.

Michael Pollan’s influential book The Omnivore’s Dilemma was not the first but has become one of the most famous books to turn a critical eye on the system of food production and distribution in the United States. Those who have read Pollan will recognize a meme throughout his writing that can be summarized as: food has become highly industrialized, just like cars, televisions, trash collection, energy production, you name it. Pollan’s analysis is that such industrialization of food is, on the whole, bad for the country, and bad for its people. It’s a remarkably provocative argument, one which I won’t try to evaluate here.

The question that Pollan’s book raises with respect to my own profession, in terms of Dr. Gilsdorf’s observation that medicine is turning into shiftwork, is this: has medicine become industrialized? And is that, perhaps like industrialized food, bad for people?

It’s a big question and I’m not going to try to take on this whole issue in one gulp. But I will try to explain to people what is becoming the model of inpatient medical care. For the lay audience out there: this is more-or-less what you’re going to experience as a patient if you get admitted to a hospital today. Many hospitals these days have turned to a shiftwork model, similar to the kind of system that Dr. Gilsdorf decries. It falls under a new subspecialty called “hospitalist” medicine. While that term was only coined just over ten years ago, it’s now becoming the standard in medium-to-large hospitals throughout the country, and my guess is that within the next generation it will almost completely replace the old model of inpatient care.

Keep in mind, as I give an intro to this, that I am one of these hospitalist-shiftworkers, at least on a part-time basis. I am one of the cogs in this maybe-industrialized arrangement.

First, what was the “old” system? Let’s say it’s 1970 and you have some bad belly pain. Assuming you have a primary-care doctor (what in those days would have been called a “GP,” for general practitioner, or just “internist”), you call up the doctor’s office and explain what’s going on. At that point, you may be asked to come to the office for an evaluation, or sent straight to the hospital and admitted directly “under” that doctor’s care. The doc will call the admitting office, arrange for the bed, speak with the nurses and secretaries on the floor and “give orders”—the top-down command model in full force in those days—for what the doc wants done. You’ll get one or a few x-rays, maybe a surgeon will drop by to see you, you’ll have some blood drawn. There weren’t cat-scans or MRIs back then so you will spend much of the time lying in bed (unless of course you go to surgery for that hot appendix). Every morning your outpatient GP will drop by to see you, examine you, talk about your improvement or lack thereof, and then the GP will sit down and write a brief progress note and any new orders for the day. The only time you will ever see a physician that isn’t your GP is if a consultant, like that surgeon, is called in. In other words, your “outpatient” doctor is your “inpatient” doctor—there wasn’t even a distinction in those days. When you’re better and it’s time to go home, you schedule a follow-up with Doc GP and when you are seen, the doc knows exactly what went on during the admission, because the doc was there for the entire course.

Now fast-forward to 2009. You have another bout of belly pain—get that fixed, will you?—and call your internist. As before, you might get into the office for an outpatient eval. You also might be sent to the hospital directly and admitted under that old system. But what is also just as likely is that you may be admitted to a hospitalist, someone you’ve never met before, who hasn’t been your doc for 40 years, who is going to be responsible for your care. Doc Hospitalist takes care of strictly inpatients for his or her job, full-time. Depending on the hospital and the vagaries of the season, that doc may have as few as a handful or as many as 20-plus patients under his or her care. Throughout your hospitalization now, you are under the care of the hospitalist.

Okay—so far it doesn’t sound so industrialized, does it? You’re just replacing one doc for another. And it’s helpful to understand just why this is the new arrangement, due to some changes in medicine as well as shifting demographics in the US in the last 30 years. (This isn’t meant to be a definitive explanation but just give the broad brushstrokes.) First, medicine is a lot more technologically complicated than it was back in 1970, with many more procedures to be performed and analyzed. We do have cat-scans, MRIs, as well as let’s-look-with-a-camera procedures (colonoscopy, upper endoscopy, bronchoscopy), guided needle biopsies, nuclear medicine imaging, and other procedures which require much more intensive management than in days of yore. A ten-minute visit in the morning and daily orders typically won’t cut it anymore. You need to have boots on the ground to manage inpatients today, with a specialist’s knowledge of which tests to order, which consultants to seek, and how to “stack” all these procedures into the most efficient process—remember, as a consequence of managed care, hospitals and insurance companies want patients out the door in the minimum time possible. That’s very, very hard to manage from the distance of the outpatient clinic via telephone.

Second, unless you are one of the fortunate physicians whose office is attached to the hospital and you can just stop by the hospital to check in on a patient during some down time in the hospital, you’re at your outpatient office in a time when more and more people live in more and more densely-populated suburban areas, with plenty of traffic to slow you down and ruin your efficiency as you drive from office to hospital and back. And I haven’t even mentioned that primary-care docs may have patients at more than one hospital.

For these reasons, you can see why the old system is being replaced, especially in large, metropolitan areas, by hospitalist medicine. So where’s the “industrialization”?

Let’s start with familiarity: most hospitalists don’t “know” their patients, are meeting them for the first time, and often will never see them again. (This is not always true of the kind of patients we somewhat churlishly refer to as “frequent flyers”—patients who often cycle in-and-out of the hospital, usually ill nursing home patients or people with chronic medical problems—but that’s typically a minority of patients on a hospitalist census.) As a rule, as long as one is vigilant, it’s not terribly difficult to learn the critically relevant details about a patient’s medical history provided good documentation and knowledgeable patients, which is not always but often possible. So while the relative anonymity of the new system isn’t directly a problem in terms of medical care, subtle problems can creep in at the margins, problems which well-informed primary care physicians who thoroughly know their patients would avoid. Bad family dynamics? The patient’s tendency to minimize his alcohol consumption? The problems created by the hospitalization of a woman who is the primary caregiver for her son, who has severe cerebral palsy and developmental delay? These are the kinds of details that don’t make it onto the “Past Medical History” list, but can be as critical to the care of the patient as the history, and are often of much greater importance to patients and their families than whether or not the patient should be on Zocor.

Another issue is one that simply bedevils the system, and it’s the same problem I alluded to in discussing the residency work-hour problem: sooner or later the doc’s gotta get some time off. That’s to be expected, but it sets up another problem with inpatient care that’s at the heart of the description of medicine as potentially being “industrialized”: shiftwork. Some call it “musical doctors” and it works like this: patient X is admitted to the hospital on a Saturday morning. They were admitted from the ER at 6:30 a.m., and the word didn’t reach the hospitalists until 7:15, by which time there is a new hospitalist on shift, only when the hospitalist tries to discuss the case with the ER doc who did the initial eval, that doc can’t be found because her ER shift ended at seven. Not so big a deal, the hospitalist can re-create the details just by evaluating the patient themselves (sometimes difficult with demented patients sent by nursing homes, but no room to go on that tangent today; demented patients and their care need their own, and perhaps several, entries). During the day, that hospitalist is the doc of record. The evening comes and the hospitalist “hands off” the service of patients to the nighttime hospitalist. Typically the nighttime doc just handles what I refer to as “tylenol calls”—generally routine matters so that patients can have pain meds, sleeping pills, and the like—as well as true emergencies that occasionally crop up. Tomorrow’s Sunday, which is “change day” at the hospital so the hospitalists can have a few days off, so there’s a new hospitalist taking over the service. Mind you, this doc has just picked up, say, fifteen new patients; he’s not just meeting patient X for the first time, he’s meeting patients A through N and patient X for the first time. (Suppose ten of these patients have a fairly long list of medical problems and medications, and you can see how much of a challenge change day is to the average hospitalist, to say nothing of the challenge it poses for the patient.)

So, within the course of 36 hours, patient X—who three or four decades ago would generally be followed by just one physician (this being the weekend it’s either the GP or the cross-covering physician, but it’s still just one)—has had at least four different people in charge of X’s medical care, with a possible breakdown in communication on the initial handoff. You can now see how there’s something approaching a factory-like quality in the system.

As I said, I work for this system, and I would like to think I provide good medical care. I’m not so much trying to expose it as an evil as I am trying to illustrate some of its drawbacks. There are very good reasons why we’ve converted to the new system. I may have scared you with the above paragraphs but the alternative scenario, where your primary care physician, who is distracted by a thousand details at the office and has only five or ten minutes to observe you on a daily basis, perhaps ordering tests that weren’t even around when he was doing full-time hospital medicine as a resident, is fraught with just as many pitfalls. But they are different pitfalls. I’m going to try to explore some of these pitfalls as this blog progresses.

Some follow-ups and then I’m done. Anyone who has gotten this far is either very interested in the subject matter or humoring the hell out of me. At the moment, and as you can see, this is structured more like a “running essay” than the kind of short, link-filled quips seen in many other blogs (the most logical extreme of which is Mickey Kaus’s blog on Slate, which I find distasteful on a variety of levels, not least of which is aesthetic). Let me know if it’s working or needs to be culled. And I do promise to discuss the commercial aspects of medicine, which I’ve only touched on in the last two entries.

Saturday, January 3, 2009

Your death, cheerily explained

Oy. Doc Rubin has barely gotten blogging underway, and he’s already having issues with length. (He’s also referring to himself in the third person, which is never a good sign. Call it a weird homage of sorts to Roland Burris.) I’m working on an entry I’m calling “Has Medicine Become Industrialized?” but it’s becoming interminably long, so I’ve decided to put it on hold for the moment and provide something shorter and sweeter. At least I think it will be shorter and sweeter.

What are you going to die from? What are you worried about dying from?

Leaving aside the issue of ending questions with prepositions, the two are not altogether the same questions, as you could guess. For the moment, let’s just play with the first one so that we can have some sort of perspective on the second. Okay class, it’s quiz time:

First, how many people die every year in the US?
Second, what is the biggest killer, and how many people die from it?
Third, can you now list #2 through #5?
(Bonus question, round I: what were the top five causes of death 100 years ago?)
(Bonus question, round II: how many people are born in the US each year?)

Give yourself, I don’t know, say, five minutes. No cheating on google though.

Allright. You’re very on top of things (or you’re incredibly geeky) if you know that about 2.5 million people die every year in the US. That’s not really so important but I include the number as a reference point.

As to leading causes of death, feel proud of yourself; you got the first one right: heart disease. About 650,000 people—just about one-quarter—of people in the US die from this. Number two? Yes, most of you I imagine are still doing good: cancer (all forms combined), which clocks in at just over 550,000. I want to break the cancer numbers down in a bit but let’s put that on hold. Number three cause of death is stroke, at just under 150,000 (or, importantly, a big dropoff). Number four you’re not likely to get unless you’re involved in medicine in some way, shape or form: it’s “chronic lower respiratory diseases,” usually in the form of emphysema, which claims 130,000 victims annually. To round out our top five we encounter the grab-bag “accidents,” which covers car crashes and whatnot; just under 120,000 people fall into this unfortunate group. Thus, these top five causes of death account for about 65 percent of all deaths in the US.

Why am I going over these numbers? Because you can lower your risk of dying from these diseases in every category, and do so without any fancy-shmancy whiz-gidget medical tools or reading Deepak Chopra’s latest literary flatulence. Stop smoking: that reduces four risks (heart disease, lung cancer among others, stroke, and respiratory disease). Lose weight, be more active, and eat less: that takes care of at least two (heart disease and stroke), and possibly drops your risk of cancer. Don’t speed: don’t think I need to explain that one, or outline any of the other risky behaviors that can get you killed. You get the idea.

My point: you are not just more likely to die from fairly run-of-the-mill diseases than you are from anything exotic, you are overwhelmingly more likely to do so, and you can actually take steps to prevent or delay dying from such diseases.

Here’s what you’re not going to die from, even though you might have been worried (or at least you saw some piece on the local or national news) about it at some point in the last few years: bird flu, MRSA, “flesh-eating” bacteria, Ebola, Marburg, Eastern Equine Encephalitis, West Nile Virus, et cetera. I really can go on for a while with this list. Almost all of these diseases are beyond your control, and you stand the proverbial snowball’s chance in hell of dying from these things. So, unless you have an academic interest in flesh-eating bacteria (a goofy name anyway, but that’s a subject for another day), quit worrying about it. If you see a story that’s going to work you up about one case of someone who just died in their prime from West Nile, just stop reading or watching—um, don’t go near the dead birds, however.

About cancer: so, what’s the biggest cancer killer? “Breast cancer” is not the right answer. Again, it’s something that we could dramatically decrease if we just stopped smoking: about 165,000 people die every year from lung cancer. Colon cancer, which also may be linked to smoking though it’s less clear, is second at about 55,000. Breast cancer is third at about 40,000, followed by cancers of the pancreas and prostate, both of which claim about 30,000 lives per year. (I hope I’m not sounding anti-breast cancer awareness, I’m just trying to point out how the media can easily warp our sense of the relative risks of various diseases.)

One caveat: diabetes is probably markedly under-represented in these statistics. I’m not an epi-stats guru but the official total of deaths caused by diabetes (75,000) seems a huge undercount. Keep in mind that when someone dies of a heart attack, they might have had diabetes as an underlying cause; so too for strokes, and even a few car accidents might have been caused by people with super-low blood sugars caused by overshooting on the insulin, or super-high sugars causing ketoacidosis. Another major disease that’s fairly easily avoidable!

One last thought: I’m always amazed at the flu. I hear people say all the time, “yeah, I had the flu” in a sort of casual, I-just-toughed-it-out manner. Sometimes, of course, people knowingly use the word “flu” without really meaning “infection with the influenza virus,” but rather they mean something like they had a nondescript viral infection. But respect this virus, please! It is a killer: along with pneumonia it comes in at #8 on the mortality list (63,000 victims). And once again, you can do something about it. Get that flu shot! 2008-9 has been pretty mild (so far) but last year was scary.

All the data above unless otherwise noted is from 2005. For the geeks who want to peruse all the 2005 mortality data, here is the link: Happy reading!

Thursday, January 1, 2009

Welcome to Billy's Blog

How does one start a blog, anyway? (Other than begin by writing on January 1?)

I suppose I should just jump in feet-first. "Billy Rubin's Blog" is going to be my attempt to offer thoughts on medicine, commerce and politics and how they all work, or fail to work, together. If that sounds a bit too vague, here are some particulars that interest me and I think are worthy of comment:

1. Have you noticed all the TV commercials for drugs? And that these commercials frequently have, not humans, but inanimate objects prancing around extolling the virtues of their elixirs--cheerful water balloons, satisfied water pipes, dancing livers & spleens, emboldened lung cells watching clots of mucus scurrying for cover? I am interested not only in the abundance of pop advertisement of pharmaceuticals, but in how so many of these advertisements look the same.

2. Why do so many people fear dying from avian influenza, when they are orders of magnitude more likely to die from good old-fashioned routine human influenza? About two years ago when there were a few dozen cases of avian flu, I was asked constantly at parties & other gatherings whether people should stock Tamiflu in case there was an outbreak of avian flu in the US. I wondered why they weren't talking about stocking up supplies for nuclear war, for all the good it would have done.

3. Similarly, why do so many people fear dying from MRSA (methicillin-resistant staphylococcus aureus) when they're much more likely to die of a heart attack--and they can usually decrease their risk of dying from heart attack but often do not do so? I work in infectious disease, and MRSA is genuinely scary. That said, your average person--let's call him "Joe, The Plumber," shall we?--is pretty much going to die of a heart attack or cancer; every other cause is a footnote. Yet MRSA grabs the headlines and scares the be-jeepers out of people, including friends of mine whom I would otherwise consider to be well-informed and thoughtful. I got an e-mail from a friend once who asked me about her kids risk of MRSA after the kid scraped her knee after falling from her bike. I replied that she was more likely to die in an auto accident on a routine trip to the supermarket than she was of developing a serious staph infection. But nobody ever bothers to think about the fact that putting one's kid in a car (or putting oneself in a car, for that matter) is putting them in mortal danger. True, it's not that dangerous, but we all recognize that a fatal car crash is a risk, right? Yet MRSA is what keeps people up at night.

4. Will global warming lead to the spread of tropical diseases? This is more than just a sci-fi consideration: scientists are talking about it in professional meetings. In my own field of arboviral hemorrhagic fevers, one of the gurus has come out publicly against this kind of rhetoric. As far as I can tell, it's not because he doesn't believe that global warming theoretically could induce such a spread of disease, but I'll have to flesh that out further in a separate entry.

These are the kind of subjects that interest me, and I'd like to think that I bring some sort of expertise to the subject: I work as an infectious disease doc, doing research on mosquito-borne viruses like dengue. I also work at a local hospital as a part-part time internist and sometime ID consultant, so I see medicine from both the big University Hospital and Local Community Hospital perspectives. I love both, and wouldn't trade either right now for anything. Hopefully my employers will be down with that.

I don't promise to keep this blog strictly focused on medicine. Lots of things interest me, things ranging from the NBA to jazz to English 14th century history to beer brewing (and consumption!) to other scientific topics. So you (and indeed I hope there is a "you") will forgive me in advance for the occasional departure in topic. But I do promise to keep the focus on the one subject where I have a mild amount of authority, and hopefully something interesting to say.

As to the title, suffice it to say that my name is not Billy Rubin. Call it a little medical humor. I figure that some of my writing will include some pointed critiques of our medical system, but I will endeavor not to be too bilious.