Monday, March 30, 2009

Lies, Damned Lies, and Statistics: Vol. 1

Mark Twain's famous quip probably has four hundred thousand instances prior to this one, but for the Billy Rubin Blog, this is Volume Number One.

Actually, the problem in this instance may not necessarily be in the statistics, just how the stats are portrayed. And the difference between one portrayal and another is the difference between a shrug and full-fledged panic.

In yesterday's New York Times there is a brief piece about a study of "near-term" infants, comparing them to those born full-term. The gospel when I was in medical school was that 32 weeks was something of a magic number--those babies who could make it to that time were believed to have no increased risk of abnormalities compared to babies who were not delivered until 40, i.e. the full term. The current study discussed by the Times article casts doubt upon that. The near-termers (born 3-6 weeks prior to due dates) were noted to have--and this is the key word--subtle differences in levels of disabilities or developmental delay. But before we get there let's trot the stats out. Assuming the research is good (which I do) both of these statements are true:

a. Near-term babies have a thirty six percent higher risk of having a disability or developmental delay.

b. Slightly more than four percent of near-term babies had these abnormalities, while just under three percent of full-term babies had them.

As you can see, statement "a" seems a good deal more troubling than statement "b," even though they utilize the same data. Interpretation is everything. And the Times does a nice job of explaining the nuance. Roni Caryn Rabin, the reporter, notes before laying down these two identical yet seemingly contradictory stats that "Over all [sic], the risk is small, and doctors emphasized that parents should not be alarmed."

The question is: will smaller print-news organizations that are likely to pick up the Times story, or the local TV media that have a habit of trying to tease viewers with the most sensational bit of a story to attract viewers to their local "Health Watch" sections of their news programs, relay the all-important subtlety that the overall risk of developmental delays and whatnot in near-term infants is still quite low?

I have my suspicions. Readers, help me--let's keep track of this story over the next week and see what play it gets, and if it becomes a sensational, 36 percent increased risk in abnormalities, New Threat To Civilization, or if it is described for what it really is. I hope to hear from you.

Saturday, March 28, 2009

Back In The Saddle

Thanks to the readers of this blog for their patience and forbearance during the past 2.5 weeks when no new entries came forth. I have been slammed by a vicious case of MRSA cellulitis, which happened to coincide with some nasty GI bug that claimed my entire family as victims, one by one. Only today, after nearly two solid weeks of being weak/feverish/nauseous, and in pain from the cellulitis, do I feel anything resembling the description "normal."

My illness led to two visits to the ER--two more than I have had in the past 15 years, at least when I was the patient. No, I don't have any dramatic revelations about How Different It Is To Be A Patient, and don't think I've learned anything valuable that will fundamentally alter how I approach patients as a doctor. There is one exception, however. I have long heard patients in the ER ask with some urgency when they will "go upstairs" to their hospital bed after I have completed their admission paperwork, because they can't stand staying put! I have usually shrugged, explaining that the bed situation is controlled by nurses and their staffing priorities. At least now I understand their complaint: those stretchers in the ER are unbelievably uncomfortable! Woe to those with low-back pain forced to endure a several-hour stint in an ER. My advice is to lower the stretcher as close to flat as possible and roll to one side. Not always so easy when you've got all those wires and IV lines and blood pressure cuffs attached, but your back will thank you for it.

Back in the next few days with something of substance to chew on. In the meantime, do feel free to leave "ER Horror Stories" if you wish in the Comments.

Tuesday, March 10, 2009

Stem-Cell Ban Lifted; Is The Justification Right?

There's a touch of slippery language in President Obama's prepared remarks on lifting the stem-cell ban that was put in place by President Bush:

"[I]n recent years, when it comes to stem cell research, rather than furthering discovery, our government has forced what I believe is a false choice between sound science and moral values...this Order is an important step in advancing the cause of science in America. But let’s be clear: promoting science isn’t just about providing resources -- it is also about protecting free and open inquiry. It is about letting scientists like those here today do their jobs, free from manipulation or coercion, and listening to what they tell us, even when it’s inconvenient -- especially when it’s inconvenient. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda -- and that we make scientific decisions based on facts, not ideology." (my emphasis)

Now to be clear: Billy does not disagree with President Obama's decision to lift the ban; indeed, like many of the moves of the President in recent weeks (after a very concerning sluggish start), he practically cheered himself hoarse when he heard the announcement of yet another rollback of the policies of the Bush administration.

That said, Billy isn't so sure that the metaphor of a scale of scientific knowledge on one side balanced by moral values on the other is a "false" one. Indeed, he thinks that a good number of troubling scientific research projects done are troubling precisely because they were not balanced by those very "moral values"--and many of these studies were done well into our own lives; indeed, in this decade! Billy is happy to cite such studies on request (including a doozie from a cancer journal published in 2002); in the meantime he assumes the shorthand is acceptable.

The issue, to Billy's mind, is not that there is a false dichotomy between the need for scientific knowledge and the moral values that restrict the access to such knowledge, but rather involves an argument about the moral values themselves. That is, it's not that scientists should just have their way and those with "moral values" should be trampled over in the quest for knowledge, but instead that we have to have a debate about which "moral values" will form the basis of ethical research. Billy has no desire to cede the "moral" high ground to what appear to him to be mostly religious fundamentalists. He does believe that moral values sometimes do have to put a halt to science. He just thinks that banning research on stem cells in the arcane belief that a collection of cells constitutes a human life is a poorly reasoned basis for such values.

Tuesday, March 3, 2009

Is Pharmacology at Harvard Medical School Being Taught By Drug Companies, or Professors?

The good name of Harvard Medical School has been a bit sullied these days. The NY Times details the general ickitude in an article about a couple of bold medical students who came forward with the idea that perhaps it was not right to learn about drugs from people who made money--and one can only assume lots of it--moonlighting as speakers touting the wonders of the very drugs about which they were supposed to teach with disinterest. One choice tidbit: one of the students meekly asked a pharm professor about the side effects of cholesterol drugs, and apparently got "belittled" in reply. A fellow med student named Matt Zerden did some online checking afterward and discovered that said professor was a paid consultant to 10 drug companies, including five makers of cholesterol treatments. Bravo, future Doc Zerden and your fellow activists! The article notes that the American Medical Student Association has given Harvard an "F" for how poorly it monitors and controls the relationship between its faculty and big pharma, though its Ivy-league cousin the University of Pennsylvania got an "A." The silver lining may be that the new dean, Dr. Jeffrey S. Flier, wants to make some changes and has convened a committee to re-examine Harvard's policies. Billy's Blog promises to hope for the best and report on any changes should they become known to him.

Better still is that the Harvard student activists, while holding a demonstration to call attention to the problems inherent in such laissez-faire policies, were photographed by an employee of Pfizer in what appears to be a creepy kind of surveillance project. Senator Charles Grassley (R-Iowa), who is investigating the relationships between the pharmaceutical industry and physicians, is looking into the shenanigans. Go Chuck! (I have delivered my one endorsement for a Republican in the year 2009.)

One last recommendation for the truly interested is to check out the comments section to the main article (on Harvard's ethics issues, the first link above). The "Editor's Selections" include at least two hum-dingers, with a reasoning process that would bring a smile to Rush Limbaugh's face (see comment #11 from RichardN, Idaho, and #16 from Dr. O, Michigan). Apparently the Editors feel a need to represent letters both pro and con, regardless of how well the comments are written. The "Readers Recommendations" I find to be more telling of what a highly literate, sophisticated group like NYT readers think of the comments, and--no surprise, this--the above comments don't arouse much sympathy.

Women in Medicine

Okay, I said I was going to hold off for a few weeks pending some urgent work, but I couldn't resist.

Billy has of late become a fan of the Bioethics Discussion Blog, thoughtfully led by Dr. Maurice Bernstein. A long-standing blog, one can literally scroll through several hundred discussions on various ethical issues involving modern medicine. The most recent post concerns the shifting gender demographics in the medical profession and references an op-ed in the February 25 edition of JAMA ("The Feminization of Medicine and Population Health," by Dr. Susan Phillips and Emily Austin). Dr. Bernstein provides a long quote where the authors discuss matters such as the differences in proportion of women physicians in primary care fields versus subspecialties, and concludes that this may have an impact on overall health care given that primary care fields are much more likely to be "longitudinal" in nature. (For the lay-readers, that's fancy medical terminology for "you have a long-standing relationship with your physician.") The authors conclude:

"Either way, as women increasingly enter medicine and become generalists, rather than being a liability by not working excessively long hours or abandoning parenting, the quality of the care they provide may result in improved population health.”

Billy, being the good card-carrying let's-all-sing-kum-ba-ya liberal that he is, poses no objection to the massive influx of women into the ranks of physicians. However, he does want to take issue with the reasoning that the authors use here.

Though not quite explicit, they seem to imply an argument from utility: we should all be appreciative of the "feminization of medicine" since it may result in improved population health! And Billy disdains mixing arguments about moral rightness with those involving utility. To wit: "the government should be utilized to improve the genetic stock of its people." This was one of the most common refrains heard 100 years ago by prominent eugenicists, of both progressive and conservative political leanings, and that bedrock utilitarian notion formed the basis of mass-sterilization campaigns of people who at the time were thought to be "genetically inferior" but would now be described with one very simple word: "poor." Similar utilitarian arguments have formed the basis of many if not most of the mass slaughters perpetrated on various populations throughout the 19th and 20th centuries (slavery, the Holocaust, Stalinism, the Cultural Revolution, the Khmer Rouge...have I missed anything?). Of course, no such ugly intent can be imputed to the authors of this article; my point is that the rhetoric of utility is the wrong approach to take.

Additionally, the problem that a utility-based argument poses for their cause is if it turns out that large numbers of female physicians (whether primary-care or otherwise) do not improve overall population health. Assuming this could be studied at all (of which Billy is highly skeptical), should we abandon female applicants to medical schools if we discover in study after study that female physicians provide either no benefit or even a decline in care? (In the comments section of the link, "obdoctom" asserts the latter, arguing that the takeover of OB/GYN by women in the past decade has only made patient care worse.) Billy would argue "no," that the reason why you have just as many qualified women as men admitted to medical school is because it's the right thing, and not because of some possible population benefit down the road. There may well be positive effects wrought by the change--indeed, how could there not be?--but such changes are merely a happy consequence of, and not the reason for, that change.

UPDATE: A follow-up to the know-nothingness of George Will and his poorly-reasoned articles on global warming takes place over at The Daily Howler (March 2), but if you want the aw-shucks defense of the editorial staff as to how an influential columnist could be allowed to print pure fantasy, feel free to check out the WaPo's ombudsman's column.