Saturday, February 28, 2009

A Parting Shot For Black History Month, Through the Medicine Lens

Readers here will no doubt be familiar with the ongoing debate, such as it is, about the appropriateness of the very concept of Black History Month. On the one hand, proponents view the exercise as an opportunity to have a specified time devoted to PR for accomplishments of Americans of African descent, which have been traditionally neglected or downplayed. The opposing view, largely and most vociferously argued by cultural conservatives, argues that Black History Month is something of a "cultural entitlement," with their reductio ad absurdum going something like: well, if there should be a Black History Month, then there should also be an Italian-American History Month, and a Korean-American History Month, and a Handicapped Women's History Month, et cetera. Obviously these are the boiled-down, oversimplified forms of the arguments, but that's the general gist.

Billy has no particular dog in this fight, regarding it with about the same low level of interest as he does other topics that once inspired fierce passion in him, such as whether or not the child of a Jewish father but not Jewish mother can be regarded as a "true" Jew. One particular reason that Billy cares not a whit for being neither a booster nor a detractor of Black History Month is that he remains fascinated by and committed to learning about the culture of African-Americans the whole year round. He considers many cultural monuments of America to be the product (or province) of "Black" America--among them the greatest novel (Song of Solomon) and its greatest writer (Toni Morrison), the greatest film (Do The Right Thing), arguably its greatest musician (John Coltrane), and the greatest television series to date (The Wire)--so arguing about whether or not there should be a Black History Month until one's face becomes blue seems a waste of precious time. He has no real objection to it, and as his interest in African-American culture is constituitive, he has no real enthusiasm for it either.

However, Black History Month does provide Billy with a convenient excuse to tell the story of one of his mini-heroes in medicine. As we leave February allow me to quickly sketch out the story of Hamilton Naki.

Naki (1926-2005) was born and raised in apartheid South Africa, about which no elaborations are needed. He was fortunate enough to be employed as a gardener at the University of Cape Town, where he toiled for ten years until he managed to change jobs tending the animals and performing other basic janitorial duties at the medical campus. According to a brief biographical sketch, he became directly involved with surgical procedures when one of the faculty, Dr. Robert Goetz, asked him to hold a giraffe while he operated, and given his reputation for industry and meticulousness he soon came to assist such procedures at more sophisticated levels. (Internet-info reliability warning: while most of the details of Dr. Naki's story are well-sourced and available in reliable publications such as the NY Times, Washington Post, and The Economist, the story about the giraffe is the one yarn that does seem to possess the odor of implausibility, and Billy recommends readers take it with a grain of salt.)

What is beyond dispute, however, is that he did indeed become increasingly involved in more complicated procedures, and over a period of years came to be the equivalent of a faculty member, training a generation of surgeons at the University as a lecturer and a hands-on mentor, teaching operating techniques. Given that this all took place in mid-century apartheid South Africa, and that his official status never rose beyond the title of "gardener," it's quite a story.

That story is known to posterity (and includes an unfortunate twist) because of his association with Dr. Christian Barnard, the surgeon who performed the first heart transplant in 1967. Although there is no evidence that Naki had any direct involvement in that procedure--see below--Barnard himself noted the critical importance that Naki had to the transplant program and his role in training surgeons. "He probably had more technical skill than I had," Barnard is supposed to have said before his own death (sorry, I don't have this sourced). If true, those in the biz know what a remarkable statement it is, given the generally non-magnanimous nature of cardio-thoracic surgeons, particularly one who made his bones, so to speak, in the 1960's.

Naki retired in 1991, and his accomplishments gradually became well-known in post-apartheid South Africa, such that he received an honorary doctorate from the University in 2003, two years before his death. By that time the story of Dr. Naki's accomplishments had become embellished to the point where he was described as being Dr. Barnard's primary assistant in that first heart transplant, such that Dr. Naki had publicly stated it was so. Initial obituaries of Naki repeated this yarn, and at least one subsequent correction in The Economist appears to have been rather over-the-top, in Billy's opinion, in its need to dis-entangle itself from the lie. Whether Naki came to believe the matter himself, or simply felt pressured to exaggerate his own incredible story, is lost to the ages, but Billy for one remains awestruck by the heights to which one man rose in about the least hospitable environment one can imagine, and will remember that that is his true legacy.

UPDATE: On the Provider Conscience Rule front, President Obama seems to be moving toward rescinding that noxious piece of legal work. We can only hope for a swift reversal. Details here.

Billy's got some article- and grant-writing to do in the coming weeks, so check back here by the ides of March and we promise to have more grist for the mill.

Friday, February 20, 2009

George Will and Global Warming: A Case Study in Dishonesty--or Just Willful Stupidity?

Prior to the Presidential election last November, those who were addicted to tracking all the polls and reading the long analyses of stats geeks may have numbered among their pet websites. Along with, Doctor Rubin checked these two sites usually daily to see whether the country had finally come to its senses or had chosen to drive itself off a cliff. Well, both websites churn along, continuing to turn out thoughtful commentary (the former website has expanded to discuss all number of political issues; the latter remains relatively focused on polls, elections and the balance of power between the two major parties).

Earlier this week Nate Silver of fivethirtyeight wrote about a remarkably wrongheaded essay in the Washington Post by George Will. The gist is that Will wanted to poke a mighty big hole in the entire notion that global warming is as big a threat as several of the leading world's climatologists have indicated. The problem with the essay is that he accomplished this by cherry-picking a few quotes and facts completely out of context. Nate lays the case out quite eloquently (and does so in a second follow-up post, as well) so I won't add much here, except to say that I have never been able to understand why Will, despite being more civilized in tone than some of his ideological family such as Rush Limbaugh and the ever-icky Ann Coulter, remains something of a darling of "centrists" and "liberals"--along with his tweedle-dum twin over at the New York Times, David Brooks (who did a little facts-out-of-context op-ed of his own this week while analyzing the results of a Pew Research Study about how & where Americans want to live).

Quick rules for journalists and opinion-makers with respect to interpreting science:

a. If you are not an expert on a scientific topic, generally defer to the experts, keeping in mind that what anyone says isn't absolute gospel.

b. When there is a scientific controversy where there is no consensus opinion, don't take sides unless you either are an expert or you are prepared to admit that you have no expertise in choosing one view over another.

c. When there is a scientific controversy where there is a general-but-not-absolute consensus, be prepared to explain this, especially before writing some glowing review of somebody who endorses theories of chronic Lyme disease, vaccines-cause-autism, homeopathy or the like.

d. Healthy skepticism is of course welcome, but snarky disrespect of the work of several generations of really, really smart people, as if scientists are just a group of touchy-feely idealists who set up experiments to confirm their pre-existing socio-political beliefs, is not.

From my viewpoint, Will managed in his op-ed to violate "a," "b," and "d." Let's give him a week or two to work on "c"!

Tuesday, February 17, 2009

The "Provider Conscience" Rule: Time for Obama's--and the Media's--Move

Earlier today on the NPR show Here and Now (WBUR) there was a piece on the "Provider Conscience" Rule, one of the final Presidential acts of the Bush administration. It's a gem. According to the piece, "[the rule] says a doctor or a pharmacist can legally refuse to provide not just abortions, but any services or advice they find morally objectionable, even birth control." Laura Meckler, the Wall Street Journal reporter who has written on the issue and interviewed for Here and Now, noted that the rule is written so broadly as to include much more than just physicians and pharmacists. She states,

"let's say a receptionist opposes abortion on moral grounds, and she does not want to make appointments for abortion, or she does not want to make referrals for abortion. Well, she can decline to do so--that's the kind of breadth we're talking with this rule."

As Doctor Rubin was hearing this he was ruminating over the Bush administration policies, returning to a well-worn thought that his brain has utilized these past eight years (to the effect of you gotta love these guys) but then a curious transition took place. The show's host, Robin Young, abruptly transitioned into a prolonged discussion (5 full minutes of a 9-minute segment) with a family physician in San Antonio named Michelle Phillips, a woman who resigned from a hospital because she felt uncomfortable prescribing contraceptive pills for unmarried women--not all cases of contraception, mind you, just specific cases in which she felt that her patients had no business asking for or receiving contraception according to her moral conscience, which she unapologetically noted was rooted in her interpretation of biblical scripture.

What followed was a somewhat tedious discussion about the sticky ethics of Dr. Phillips's position--tedious because the ever-polite Ms. Young, of whom Doc Rubin is something of a fan, absolutely refused to shred the frail logic of Dr. Phillips, which is so bald that hardly anything more need be said. (I recommend the listen; WBUR's website has no direct link so the piece, entitled "Overturn for Bush's Provider Conscience Rule?" will only stay "live" with a link for a few days.)

However, what does need further exploration is how Here and Now handled, or rather failed to handle, the overall story. Two immediate problems leap to mind: first, who the hell is Michelle Phillips and how did WBUR track her down? My own brief time devoted to internet sleuthing revealed nothing other than her practice's address (feel free to send obnoxious letters), so I am at a loss to explain how a radio station in Boston manages to track down a fairly anonymous physician in Texas. The second, more grave problem is that Here and Now devoted the entire back half of the piece to give Dr. Phillips a platform. What's troublesome about this is that Dr. Phillips, at least from this doctor's point of view, is so clearly violating all sorts of firmly-established medical ethical precepts and Here and Now never appeared to go to the trouble to point this out.

I don't mean to imply that they were obligated to have a second guest to argue with her, and thus set up the false dichotomy of pro-con that journalists love because it allows them to be intellectually lazy. But Dr. Phillips isn't just someone who could benefit from the Provider Conscience Rule because she has a controversial though consistent stand; she's a physician who has obviously unethical principles; she applies her biblical worldview to her patients willy-nilly, choosing which personal questions to ask of which patients and then deciding whether she wants to provide certain treatments. For instance, she indicates that, as a rule, she would probably provide married women with contraception, but fails to indicate if she would ask if they were having extramarital affairs and possibly deny contraception if her patients shared this with her. And Ms. Young never even touched on the very thorny subject of what she would do if approached by a closeted gay male--or female, for that matter--who required any form of help from Dr. Phillips.

All that needs some context--just a quick check-in from, say, the chairperson of the Disciplinary/Ethics Committee of the Texas Medical Board as to whether or not her views or actions could lead to disciplinary action. Or someone from any number of national groups: the AMA or the American Academy of Medical Ethics would be decent starting points. And in attempting to provide some much-needed context for the views of this fringe doctor, Here and Now failed, and did so badly.

Let us hope that other media outlets are not as sloppy should President Obama overturn this reprehensible policy.

Sunday, February 15, 2009

The Point-Source Epidemic in Facebook

Billy, being a touch behind the technology curve, came to Facebook at just about the same time that he began to blog (i.e. a bit less than two months ago). One or two friends had long advocated that he check it out, but he resisted, highly skeptical of what he considered an online exercise in frank narcissism, until he succumbed to peer pressure and joined. Since then he has been he has been mildly pleasantly surprised to see names and faces of long-gone friends from high school, college, medical school, residency, and other odds & ends of life and to find out what's going on in their lives, see pictures of their spouses and children, and exchange short notes about where life has taken us. Although I already spend far less time on it than I did one month ago, it's been unexpected fun.

But there are limits, and anyone familiar with the Facebook culture, particularly those who actively use the website, will not be surprised to know there is indeed a heavy element of navel-gazing that goes on. Facebook invites participants to tell their friends "What are you doing right now?" and several users appear to be delighted by noting that they are "about to go to sleep," "wondering what to drink tonight," or "loving Sudafed today"--apparently considering such pronouncements critical for posterity.

One such activity that has been making the rounds of late has been the Facebook equivalent of a chain letter. Dubbed "25 Random Things People Don't Know About Me," the game is to write little pieces of trivia as the title suggests, then "tag" 25 other Facebookers who are encouraged in turn to submit their own lists. While Billy has enjoyed perusing some of the lists, he has remained reticent to share the things people don't know about him as there is likely a good reason they don't know such things.

Nevertheless, "25 Things" has been a sensation of late, earning the attention of such trendspotters as Slate and NPR among others. The Slate article discusses the evolutionary origins of the concept; apparently, "25 Things" had several prior incarnations before the current version took off. Readers familiar with the concept of the cultural meme will find all of this familiar, but one fascinating observation about the popularity of the list concerns the kinetics of its spread. Earlier, Slate had asked its readers who had posted their own "25 Things" list to send in the date of when they were first "tagged," and when they subsequently posted their own lists. The curves (which I am having a terribly difficult time pasting here) look exactly like this:

This graphic describes what's known in the biz as a point source outbreak, and this particular graph shows cases of cholera after a population drinks a single source of contaminated water. The mathematical description goes like this: "the epidemic curve in a point source exposure commonly follows a log-normal distribution, in which the number of cases increases rapidly, reaches a peak, and then gradually tapers off, creating a right-skewed curve, or a curve in which the mode (or highest point of the curve) is shifted to the left of center."

The Facebook "outbreak" of "25 Things," therefore, appears to perfectly mimic a human infectious disease epidemic at a population level.

A certain caution needs to be applied in interpreting the Slate data. The participants were all, of course, Slate readers, which is pretty clearly a self-selected audience (I would guess older, more well-educated, and more likely to be white-collar relative to the average Facebooker) and could represent a serious confounder to the "study," such that there was no genuine point-source epidemic if you look at the overall Facebook population. Plus these are only voluntary respondents; we might not have heard from readers who decided to post their list either well before, or well after, the "outbreak" which occurred around January 30, and again that would change the kinetics of the epidemic and the curve might not match the one above. Still, at least for this subgroup, I find the data compelling. Art does imitate life!


Wednesday, February 11, 2009

CME Funding: Family Fight Redux

(UPDATE below.)

Thanks to all the folks who weighed in on my previous discussion of the pharmaceutical industry funding of CME (and a special thanks to Dan Carlat who sent most of the readers my way). I'm sure it's not the last time I will comment on the subject, but a few points of clarification are probably in order.

Leaving aside the anonymous soul who clearly misunderstood Nancy Frugé's point that the Medscape Roundtable in question wouldn't have passed muster in the Medscape Nursing section, the loudest objections came, not altogether surprisingly, from Dr. RW Donnell, in the comments section of both this blog and the Carlat Blog. Additionally, he devoted two entries in his own blog (here and here--the latter entry delightfully referring to my "unmitigated gall," apparently unaware of the irony that that adjective has for this blogger) to arguing that there is nothing inherently wrong with industry funding of CME. He also got some potshots in at Doctor Rubin, among other things for his use of third-person singular when referring to himself. (For those not completely clear, I referred to Doc Donnell as the "Arkansas doc" when discussing the Medscape Roundtable because I wanted to preserve his anonymity given that Medscape is a semi-private website and at the time was unaware of his blog. Given that I am shy, I will soldier on with my pseudonym, but am happy to use his real-world name henceforth.)

There are two broad issues about which Dr. Donnell complains, first with respect to the structure of the forum (he saw nothing wrong with it), second with respect to the specific points raised about CME. He states in his blog that I had failed to understand the informal nature of the forum by complaining about the qualifications of the four discussants. He then notes that

"...if Dr. Rubin wants to make an issue over whether a bunch of bloggers should huff and puff in front of Medscape’s larger audience, I suppose we can debate that some day."

Um, I think we should debate that today. That's my whole point: that it was irresponsible for Medscape to hold a Roundtable discussion with four doctors who do not appear to have any qualifications to air their opinions out on the matter in that kind of forum, which by its very nature is not informal. The Medscape audience doesn't view the site to engage in the cyber equivalent of a water-cooler chat, it does so to seek current medical knowledge from authorities in the various fields of medicine. Nowhere do I find any reference to "informal chit-chats about pertinent medical topics by groups of bloggers" in Medscape's description of itself, and this is appropriate. If I'm reading some article there I want to know that the author is qualified to talk about this, and I suspect that's true of the overwhelming majority of Medscape subscribers. The casual talk, to which I am not opposed, happens in the comments section. I say: give the experts the spotlight in the meantime.

Let's take a real-life example: every year at the Infectious Diseases Society of America there's a point-counterpoint session about current controversies in the field (and I am quite sure that other subspecialties have similar sessions at professional meetings). I particularly remember a showdown in San Diego over whether one should use metronidazole or oral vancomycin for treating Clostridium difficile infection. Now this is a clinical dilemma facing ID docs (and a good number of hospitalists like Doc Donnell!) on a weekly basis across the US. There were, I would guess, about 2,000 physicians at that session. And who represented both sides of the debate (one advocating metronidazole, the other advocating vanco)? It was not the ID equivalent of the Dr. Donnells--or for that matter the Dr. Rubins--of the world, but rather two docs who had published several articles on the subject, so their opinions carried genuine weight with a highly sophisticated audience. Why Medscape (or why anyone) shouldn't assume that their audience has similar expectations for a Roundtable is beyond me.

As to the substance of the argument about CME, though there is much to address I will try to keep it brief. The briefest of explanations would be, "read Marcia Angell's book, then read Jerome Kassirer's book, then get back to me," but that would take away the fun of blogging so I'll press on a bit.

The quick & dirty argument relies on pointing out the obvious potential for bias in educational activities sponsored by groups whose interests are not healing the sick, but making large profits for corporate shareholders. Medical and scientific journals go out of their way, standing on tippy-toes, to avoid publishing articles that have any obvious source of bias. The majority of the comments from reviewers of journal articles concern possible sources of bias, and a huge chunk of letters to those journals discuss potential bias that could affect outcomes. Modern medicine, and modern science as a whole, is built on the premise that actual working knowledge of the world can only be gleaned by stamping out every possible source of bias when conducting an experiment.

So, can you think of any reason why drug companies might want to influence the prescription patterns of physicians? let me struggle with this for a few seconds...hmmm...oh, wait, I can think of about two hundred billion reasons! That's the number of dollars currently involved in annual pharmaceutical sales. Now if you're the kind of physician that values unbiased information, how can you not consider drug-industry sponsored CME sessions anything other than friendly forums to turn doctors into mini-ATMs for the drug companies? Most CME activities, if presented in the form of a paper to a standard medical journal, wouldn't get past the front door, so to speak. (Granted, journals are also a target of industry, but let's save that matter for another day. And please, spare me the retort that this is a laughably naive description of CME because "drug companies don't control content." They don't need to control content, directly anyway. There are plenty of doctors willing to have their messages dovetail with Company X for the tidy speaker's fees that they earn at those charming and ubiquitous drug-rep dinners.)

One of my original complaints of Dr. Donnell's prose involved his use of the phrase "McCarthyesque purge," and he explained his use of the term thus:

"...perhaps I started out on the wrong foot with Dr. Rubin in my choice of words. It was my characterization of the relentless hunt for corporate evil in every nook and cranny of medical education and the associated non-evidence based fear mongering as a McCarthyesque purge."

What I find amazing about this passage is the idea that those opposed to industry influence over physicians somehow have to hunt for evidence of corporate malfeasance. You don't even have to go to kwazy, left-wing nutjob blogs with the vitriolic prose of those like Doctor Rubin to read the ongoing horror story of an industry completely lacking in scruples and running amok, holding both physicians and their patients hostage. Think I'm kidding? Okay, let's take a peek at that well-known bastion for Communist propaganda, the Wall Street Journal, for its take on that fantastic antibiotic Ketek. Or here's the NY Times writing on one of Doctor Rubin's all-time favorite drugs, Neurontin, and its maker's attempts to manipulate data to boost its sales (the article title speaks for itself: "Experts Conclude Pfizer Manipulated Studies"). Remembering the halcyon days of Vioxx gives that warm feeling in the tummy, too. (Though watch out! That warm feeling is perhaps a GI bleeder! But not to worry, you can always benefit from a little Nexium, like Billy's Dad did.) It's not like you have to be on a "relentless hunt" for this kind of stuff; it practically whacks you in the head on a daily basis.

One last point I'll take up before calling it quits is that Dr. Donnell implies that advocates for a firewall between industry and docs are "medical thought police" (his words). He circles back on this point a few times, both in his blog and in the comments that he posted here and at Carlat's blog. It's paranoid, true, but also pretty clearly incorrect. I have never written that a doctor should, for instance, be punished in any professional way for consorting with drug reps or receiving educational materials from them. I do believe, however, that those doctors should not be entitled to CME credits for a night out on the town with said rep.

The idea that, by trying to eliminate the potential for industry bias in professional educational activities, a group of intellectual thugs are stamping out the God-given right to freedom seems to me pretty silly, but I'm only exaggerating Donnell's prose a bit. While it does have a nice rhetorical flourish, the "freedom" meme doesn't really hold up to scrutiny from my vantage point. He's free to get his information anywhere he wants it--there are, for instance, a few nutty people with all kinds of theories about chronic Lyme disease, and by all means read it!--but why he feels like he should be entitled to professional education credits is a different matter. And pretending that this is any different from any other aspect of professional conduct, where there are unambiguous regulations on how physicians prescribe medications for their patients (for instance, they aren't allowed to sell narcotics prescriptions), or how they relate to them after office hours (they aren't allowed to have sex with them), or how they study them (IRB approval required), is just nonsense.

Over the last 24 hours, Dr. Donnell and I engaged in a pas-de-deux in the comments section, which to me seems basically a continuation of the original post, so I have unilaterally decided to bring those five "letters" into the main page. I took the liberty to edit one piece of Dr. Donnell's remarks (excising a long list of corporate sponsors of the IDSA/ICAAC convention), the unedited version of which can be found in the comments section. Since Momma taught me to exhibit decent manners on occasion, I give Dr. D the last word here--although he still has my invitation to continue this in a more formal discussion as part of future blog entries, as I would be happy to reply to the points he raises at the end. I also would encourage readers to follow the link that Dr. Donnell posts below--he's making my points for me! It's a great view into the mechanisms of how this system works. I am in his debt.

Dr. Rubin,
I gather from your post you attend IDSA. How do you resolve their commercial bias? It appears they are calling for industry exhibitors for their 2009 meeting. Here’s a partial list of supporters of past meetings I copied and pasted from their web page. It appears the degree of support is substantial. How can you even go to their meetings with all that potentialfor bias?

"IDSA is grateful to the following companies that supported the Society’s mission through their participation at IDSA 2007 and the 2008 ICAAC/IDSA Joint Meeting*:" [Ed: what follows is an extensive list of sponsors, omitted here.]

You left your reply at 1:44 AM? We gotta get you out more. I finished the post at midnight and it nearly killed me. I guess this explains how you can come up with 30 posts just in February alone (and I mean that with genuine admiration--I certainly don't have the time or the energy to keep up with that pace).

Anyway, thanks for the extensive list! I'm certain that without the complete version your point would have been totally misunderstood. My answer is that I go to such meetings fully aware of the heavy corporate underwriting and the potential influence it has on the physicians who attend meetings like IDSA or ICAAC, and would prefer to have the system minimize that influence. Several of those companies above offer "travel scholarships" so that medical and graduate students, fellows, and international physicians can attend; several others do no market pharmaceuticals. Others still might not have sponsored IDSA alone but were on board for the ICAAC component, which has a similar but slightly different audience and relationship to industry. (Without getting too technical for the non-specialists reading this, the ICAAC convention focuses heavily on drug discovery and development, so many who attend that conference either work for or have close ties to the pharmaceutical or diagnostics industries. This past year they merged the two conventions, which happens every so often so that participants don't have to choose which one they'd prefer given travel & conference costs.)

The point is that meetings of the size and magnitude of either IDSA (annual attendance usually 10,000), ICAAC (attendance usually 15,000) or the third large North American ID conference, CROI (Conference on Retroviruses and Opportunistic Infections, annual attendance ~5,000) can't easily be ignored by any ID specialist, regardless of the corporate sponsorship of the event. I'm not going to cut off my nose to spite my face because the system works the way it does right now. But aside from the genuinely helpful industry contributions like scholarships and fellowships, there are obvious and egregious attempts to get in drug advertisements, and these should clearly be eliminated.

A few examples: when I went to the ICAAC convention in San Francisco in 2006 my electronic hotel room key didn't bear the name of the hotel, but rather had the corporate logo of Sanofi-Aventis and advertised the then hot-new-macrolide Ketek. (Ketek didn't stay hot for long though, as it was withdrawn from the market for being associated with several cases of acute liver toxicity--cases which the FDA alleges were suppressed by the company in order to grease the rails for FDA approval.)

At a different convention, the bookbag I received to carry around convention materials had a big Novartis logo plastered across it. It's one thing to allow drug companies to advertise their products at a convention; it's a totally separate matter to FORCE physicians to advertise their products by just showing up to the convention. And yes, in case you were wondering, I refused to use that bag, thankfully having brought the previous year's edition along which does not sport any corporation's name.

The idea that one can avoid all possible sources of industry bias by refusing to participate in professional meetings is about as naive as supposing that one can find a way to read journal articles that are free of taint. As I noted in the post, even reputable journals have difficulty ferreting out studies where the data have been sufficiently massaged to ensure outcomes favorable to drug companies (file under: Vioxx, Celebrex, Neurontin, and the list goes on). And Medscape too, a website that I find very useful, has a lot of corporate sponsorship. So what am I going to do? Stop reading articles? No, of course not. I'm not a Luddite, though perhaps you believe it to be so. I'm simply proposing that our professional groups should try to minimize their involvement with groups whose job is something other than treating patients, and that if the corporations themselves behaved more responsibly perhaps we wouldn't be at this crossroads. But as a group they don't behave well--I mean, they really, really don't behave well--and you don't exactly have to get out a pair of binoculars to find evidence of it.

Dr. Rubin,
Thanks for your prompt reply. I promise not to make this an endless back-and-forth. We may reach a point where we have to agree to disagree. However, I hope you will be patient and indulge me in some questions, as I struggle to find the consistency in your position.

Let’s start with this. You’ve explained why you feel it important to attend IDSA. But my real question is that given the pervasive influence and huge potential for bias (see page 2 of the pdf below!) how do you deal with it? How do separate the wheat from the chaff to make it a worthwhile learning experience?

I think a mildly-prolonged back & forth is not a bad idea, actually; I'd be perfectly willing to have a point-counterpoint like we're having in the main post of both your blog and mine. (Shall we invite Dr. Carlat, too?) Seriously, I think there's more to explore about this issue, and I'm genuinely curious about how a physician of your obvious thoughtfulness about medical issues (I didn't read -all- of the February entries, but many--and thanks for the heads-up on fondiparinux!) manages to square the circle with respect to conflict-of-interest issues regarding the relationship between drug companies and docs. So from my point of view there's more to hash out, though I would appreciate laying off the hyperbole about thought-police & witch-hunting & whatnot.

Anyway--how do I deal with the pervasive bias at the premiere meeting for ID docs? The quick answer is: not very well. I suspect that a certain percentage of what I "know" as an internist and an ID physician is bunk. Some of it is bunk because we've just got the wrong scientific model (this was the topic of my post on the JUPITER study, which I think is genuinely interesting because the lower-your-cholesterol angle may be totally wrong, even though that's been the central model for atherosclerosis for over two decades); that's unavoidable and how science works. Some of the time it's because somebody's got some other agenda, and given the huge financial rewards for producing a blockbuster drug, that other agenda is most commonly associated with large pharmaceutical firms. These organizations are highly-organized and determined. Normally in business I think that's a -good- thing, but the evidence that the large, multinational firms try to game the system at every opportunity--via conventions, friendly chats at the office with drug reps, the cushy dinners, and yes, ensuring favorable articles in theoretically objective journals--is to me simply overwhelming. So I have no illusions that at least some of what I take as gospel may be either flawed or the product of manipulation by people who stand to gain lots of money by influencing which medications I prescribe. I have difficulty understanding how other physicians, including those capable of zeroing in on a potential confounder of a study with lighting-fast speed and the vengance of an archangel, can't see the obvious problem this poses. So how do I deal with it? Not well, but with what limited influence I have I can argue that perhaps we should consider doing what we can to create a firewall between Us & Them so that our objectives remain uncontaminated, and their objectives don't place us in any compromising positions (that is, the kind that you read about almost daily in the NYT, WaPost, WSJ, LAT and the rest).

For your second question--how do I separate the wheat from the chaff?--I have two replies. I make no pretense that I have some remarkable ability to divine which drugs are fabulous and which are stinkers, and as I noted above I would guess that some of my prescription patterns are directly influenced by the system or because I don't have the time to chase down all the articles on medications, particularly trivial ones.* That said, I have a few rules that I try to apply:

a. Be suspicious of fantastical claims of new drugs ("new" being vaguely defined as "approved by the FDA over the past 2 to 3 years").

b. Be HIGHLY suspicious of "me-too" drugs, i.e. newly patented drugs in the same class as some other previously-approved drug. I have seen nothing to indicate why Prevacid is better than Protonix is better than Nexium is better than Prilosec--and omeprazole, Prilosec's generic name, should in theory be made by generic companies at a theoretical substantial savings to the entire healthcare system. But you, Dr. Donnell, know as well as I that most hospital formularies carry no such drug--they've been wheeled & dealed by the makers of the patented drugs, often at substantial discounts, so that they can develop brand loyalty when they are discharged and can be customers-for-life as outpatients. So, if it isn't the original in its class, and especially a new one out, I think it has, as Desi Arnaz observed, a lotta 'splainin to do.

c. When possible (not always the case), be suspicious of brand-name claims when there is an equivalent generic available in its class. In ID, you see people (sometimes even ID docs! but usually unaware hospitalists and primary care folks) often inappropriately prescribing really important drugs like Invanz (generic name ertapenem) in place of the considerably-cheaper ceftriaxone or cefazolin because they got lazy and were told a some lunch how great Invanz was. Well--it IS an important drug, one of the most helpful for people with serious and/or resistant infections, but it sure as hell won't be if everyone prescribes it for routine cellulitis or community-acquired pneumonia!

d. I try to attend University clinical case conferences as often as possible. The University where I work, like many in this part of the country, has strict policies on whether drug reps are allowed to bring goodies and discuss their products (in brief, they're mostly not).

None of these are failsafes, and each have exceptions (e.g. I am a big big fan of Atripla for HIV, which came out about 2 years ago, is only a reformulation of previous drugs, and is a cash cow for its makers), but following these precepts certainly help. Or at least I hope they do.--br

*(For instance--is Zofran REALLY that much better than Compazine or Phenergan for non-oncologic cases of nausea? I know it's a lot more expensive, yet the hospital that I do my part-time work for has Zofran as the default anti-emetic in the automatic drop-down order menu in the computer. In other words, you have to go -out of your way- to order the cheaper drugs that for all I know have never been shown to be less effective. But then the nurse calls me later in the night because she's -heard- of Zofran, and why didn't I prescribe that? Sometimes it's not worth fighting the fight, and Zofran is of course a fine medication.)

Dr. Rubin,
You don’t avail yourself of the freebies at those meetings. That’s well and good, but you (or your medical group which pays your registration fees) do benefit from the largesse of the drug companies in terms of reduced fees. In one of the comments above you said “I'm not going to cut off my nose to spite my face…”

But, if you and others who advocate for a ban on industry support are successful, won’t you have done just that? IDSA meetings and others like it would cease to exist altogether, or in anything near their present form without support. That was one of the points I made in the Medscape piece under the category of unintended consequences. I didn’t want to cite personal communications in that piece (maybe I should have) but leaders of CME meetings have said that such meetings would not exist without support. I recently asked Bob Wachter, for example, if he could continue his UCSF hospital medicine course without support. His answer was, essentially, “no way.”

I’m still curious as to why you even bother to go to IDSA in view of your answer:“Anyway--how do I deal with the pervasive bias at the premiere meeting for ID docs? The quick answer is: not very well.” If that’s true wouldn’t you be better off, and save yourself considerable time away from practice and family, to get the same information from sources like Medical Letter, UptoDate, or independent literature searches?

In reference to some comments you made in your post, I want you to understand my position. I am not advocating for CME credit for a dinner meeting with a drug rep and a paid speaker. I thought it would be clear to readers that that type of activity is not on the table for this discussion. Such activities (at least in my state!) are no longer accredited, (haven’t been for some time) nor should they be. And if you can cite an example of accredited “CME” which promotes Nexium or Ketek over better alternatives I’ll be the first to agree that such activities should never have been accredited. That’s a far cry from a total ban of industry support.

Saturday, February 7, 2009

One Patient's Perspective

I want to comment at length on the remarks that folks have made about the Medscape roundtable on drug industry funding of CME, but that will have to wait for another day or two. In the meantime I wanted to share with you the delightfully impish humor of a 90+ year-old patient that I admitted to the hospital recently. Still living at home and reasonably independent, there was not a question she had all of her (razor-sharp) wits about her, and she had a gleeful sense of mischief. Just as I was finishing up taking her history and performing a physical exam, interspersed with asides and stories from her long life, she wanted to let me know about her perspective on passing the 90 mark.

She said, "this is my favorite quote:
I get up every morning and dust off my wits; I pick up the newspaper and read all the obits
Oh, my name is missing so guess I'm not dead; So, I gobble my breakfast and hop back into bed!"

It took me a little poking around to find it on the internet, but this appears to be a piece of a poem by a woman named Donna Mccay entitled "I'm Fine Just Growing Older," a cute piece in its entirety as well.

Monday, February 2, 2009

Who's That Doctor?

***FCC Language Warning, Internet Version***

I promise not to dwell excessively on political topics unless they should touch upon medicine and health care, but forgive this one digression. If someone could please explain to me what the fuck President Obama is doing right now, just over one week into his presidency, would you please send me an e-mail to explain it? I am dumbfounded, and deeply worried that we are experiencing the beginnings of Clinton Redux. What I have witnessed over the past seven days is not why I went to the trouble of explaining to virtually all of my friends, who were Hillarites to the nth degree, why she palled in comparison to The Real Deal. This in a state that Clinton crushed Obama 56-41 in the primaries, and my wife and I took heat for being politically-naive daydreamers by supporting The Big O. So, if you've got some understanding of how our President is savvily gaming the system for the greater good, please let me know.

Anyway, today's post is based off a little study done out of the University of Chicago Medical Center and reported in the Annals of Internal Medicine that finds that about 75 percent of patients admitted to their medical center could not name any physician involved in their care.

At some level, this is not altogether surprising, given the structure of an urban, academic, referral medical center: it's the nature of the beast at a place like U of Chicago to have multiple physicians, each from various subspecialites, taking care of a single patient. Plus, each of these physicians are usually in charge of a "team" of apprentice physicians, each with their own rank in a hierarchy well known to those involved in the system but undoubtedly byzantine to patients themselves. (After all, those who play the game know that, say, Fellow trumps Intern, but to a patient ignorant of hospital culture, the only way to find the correct answer would be to guess. I myself can't keep track of ranks within the military, with what little I do know derived from watching far too many reruns of M*A*S*H*.) All in all, not precisely an earthshattering revelation.

Why this study interested me is that I would be willing to guess that if you ran that study at a smaller, 200-bed community hospital where there's a hospitalist program, you'd probably obtain a similar result. That wouldn't have been true 20 years ago, when the vast majority of patients at local community hospitals would have known their doctors by name, because their inpatient doctors would have been their outpatient doctors as well.

At small-to-medium community hospitals there's often no connection between the inpatient docs and the primary care physicians in the community (speaking at least partly based on my experience observing the hospitalist group for which I moonlight), so patients may know their outpatient MDs but have no clue who's the one "in charge" of their care at the hospital. Even the PCPs may not know the hospitalists beyond anything but name, since the turnover rate for hospitalist work is fairly high, so cross-communication between docs behind-the-scenes doesn't take place.

There are some ways to blunt this effect: handing out business cards (the practice I work for encourages this, although I don't know how often the hospitalists follow through on it); taking a few minutes to explain the system and the primary/consultant concept; and the most important of all (though not necessarily easiest), frequent stops by the patient's bedside to communicate with said patient directly. These solutions, which are decidedly low-tech and easy to implement, will only have an impact if hospitalists and hospital administrators prioritize the problem, however, and I'm not sure that those groups are fully aware of how much impact this can have on a patient's sense of safety in the hospital.