Saturday, March 31, 2012

More False Equivalencies of Shallow Journalists (Or: David Brooks Tries To Think, But Fails Again)

We love reading David Brooks for the occasional laugh. Unlike most other conservative political pundits, who are simply hypocrites and liars and not troubled by the truth, Brooks makes a twice-weekly earnest effort at squaring the circle of his conservative philosophy with what's actually happening in the world. He's the Grantland Rice of the political page, possessing a deft touch for the sentimental phrase, living in a mental state of divorce from harsher realities.

This week's case in point involves his observations about what can only be described as the far rightward drift of the Republican party since the election of Barack Obama to POTUS. Brooks's Thursday NYT column details the fading political fortunes of a Gulf War veteran/San Diego Republican, one Nathan Fletcher. As part of his candidacy for Mayor of San Diego, Fletcher has adopted a few positions that most liberals or lefties would find amusing but irrelevant (he supports bike paths, apparently, which Brooks considers to be of weighty importance). But for that and some moderate stances on immigration and "the environment" he has run afoul of the Tea Partyists, and the hard liners have backed City Councilman Carl DeMaio. As a consequence, Fletcher, who sounds like the classic "good guy with whom you might disagree on political stuff", is leaving the Republican tent.

Now any perceptive, or any sane, observer would note that this represents yet another demonstration of the quantum change in the radicalization of the Republican party from respectable-but-flawed to utterly-nutso. It doesn't take a genius to have seen that process--in which the most dangerous, racist, xenophobic, paranoid elements have chased away any voice of reason--has robbed the party of honorable moderates like Fletcher, Lincoln Chafee, and Michael Bloomberg among others in favor of a rabble of Know Nothings. It doesn't require a political mind like Henry Kissinger's to understand that the ideological progeny of Barry Goldwater and Joseph McCarthy are now firmly in control of the party's destiny, and that at most Barack Obama merely catalyzed an inexorable process that's been rolling since Ronald Reagan's ascendancy.

And what conclusion does the perspicacious David Brooks arrive at? That since it's happening on the right, the same thing must by definition be happening on the left.

No, really. In all his mental arithmetical glory, this is Brooks's last paragraph: "Fletcher...represents a nationally important test case. Can the Iraq and Afghanistan veterans, who were trained to be ruthlessly pragmatic, find a home in either party?...As the two parties become more insular, is it possible to mount an independent alternative?"

That's my emphasis, for he spends an entire column dissecting the far right lurch and then finishes wondering about where a moderate's to go when both parties become so rigidly orthodox. Brooks is apparently unaware, or has conveniently ignored, the political career of Tammy Duckworth, Gulf War veteran and still happily at home within the Democratic tent. Ms. Duckworth, who lost both legs during her tour, ran for Congress in the Illinois 6th district in 2006 and lost a close contest to the Republican candidate after a series of predictably scuzzy political maneuvers. As for other vets who drift Democrat but have been ousted by orthodox lefties, I'm waiting to hear a list of examples from Brooks. And I suspect I'll be waiting for quite a long time.

Yet the most amusing aspect of seeing this particular argument, that the Dems are headed toward as equally nutty a place as the Republicans, is that it took place as the Affordable Care Act's constitutionality was debated before the Supreme Court. The Billy Rubin Blog staff is too emotionally spent to contribute to any discussion regarding its legitimacy, political or legal; you can guess what we think.

But like the law or no, no matter how loudly Fox News attempts to tell you otherwise, this law was by no means the gem that hard lefties enforced on the moderates of the Democratic party. Rather, it was very much the other way around: a crappy rightward compromise that a small minority of centrists enforced on the vast majority of Democratic congressfolk who preferred either a single-payer system or the so-called "public option". Despite overwhelming support within the party for either of those approaches, the "individual mandate" being argued before the Court this week was one originally developed by the right-wing Heritage Foundation as a free-market solution to universal health care coverage.

The main reason why this took place is because of a weak and largely ineffectual President. Regardless, I think the Democratic party passing a health care law thought up in the war room of the Heritage Foundation hardly qualifies as evidence of the Dems becoming more insular, David Brooks's nonsense to the contrary notwithstanding.

Tuesday, March 27, 2012

The Origins of "ObamaCare"

From the blog today:

"Yesterday the Supreme Court took up the case of whether all or part of the Affordable Care Act passed by Congress 2 years ago is constitutional. Twenty six states, all with Republican Attorneys General or governors, have filed suit claiming it is unconstitutional. The great irony of these suits is that the whole idea was not invented by President Obama (ObamaCare) or even Mitt Romney (RomneyCare). It's origin goes back to President Richard Nixon, who saw that many people did not have adequate health care and wanted a solution, albeit a Republican solution. He asked the extremely conservative Heritage Foundation to think of a solution and they did: make everyone buy insurance from a private company, that is, an individual mandate. For decades, this was the Republican response to Democratic attempts to expand Medicare to cover everyone. Only after Obama pushed through NixonCare did the Republicans begin objecting to what was, in reality, their own plan."

Well said.

Sunday, March 25, 2012

The Value of "DUH" in Political Discourse

At Billy Rubin central, we like snark just as much as the next guy or gal, but our amusement is dependent in part upon the wit used in the creation of said snark. And "duh" doesn't seem to rely on a great deal of wit--especially when written in all caps. To wit:

a. Though we don't share his political views, we're a fan of retired doc. Retired has been haranguing against the health care act for some time, and of late he has been pointing out what he believes is the erroneous use of data from the Dartmouth Atlas in forming public health policy. (Quick version: the atlas uses Medicare data to look at the distribution of medical resources across the country, and takes the editorial point of view that more care is not necessarily better care.) One of his blog posts tries to make the point that sometimes spending more on health care brings better outcomes, and then finishes off the title of the post with those piercing three letters d, u, and h.

Of course, it's the qualifiers that are critical: noting that more care is not necessarily better implies that it depends upon the comparisons. Health care in the US is undoubtedly better than Botswana (or, say, Cuba, a topic we've covered previously here) and the US spends much more as well. But within the US, regions that have a higher concentration of docs, facilities, and technology do not appear to benefit disproportionally on the whole. Even a cursory reading of the Dartmouth Atlas makes this clear.

As for whether sometimes spending more on health care brings better outcomes, one might as well say that sometimes it rains. I rather doubt that the researchers who put together the Dartmouth Atlas would quake in their boots at the evidence gathered in this post. As of now, the sole commenter on this post points out, "[it] shows that people don't read the caveats". We agree.

If one really needs to search for facts about health care which might be met with the chorus of "duh", one might simply look at our per capita expenditure on health care--which is twice that of any other nation of similar size in the world. We are most certainly not twice as healthy as other industrialized countries. We simply can't afford more care whether we want it or not. What's the difference between our health care system and those of comparable nations? The answer is nationalized health insurance (which, lest anyone misunderstand, is not the same as nationalized health care, for which the only comparison is Great Britain).

b. The clever folk at Gun Owners of America are circulating a cartoon on Facebook describing the "as yet unlearned lesson of 9-11-01". The lesson, helpfully illustrated by Ben Franklin, states that "disarming innocent people does not protect innocent people", with Ben usefully chiming in that "We Founders call this 'the theory of DUH'." Surely Trayvon Martin, innocent and unarmed as he was, would have appreciated this sentiment, were he not shot through the chest by a very much armed George Zimmerman. Though perhaps GOA believes that wearing a hoodie and being a black teenager disqualifies one from being 'innocent'. Stand your ground, Gun Owners of America!

(One also wonders why this is a lesson from 9/11. Does GOA believe that allowing passengers to carry firearms aboard flights is a good idea? It would seem that the hijackers would have been delighted by such a policy, but perhaps I'm too stupid to appreciate the subtleties of their point.)

The "duh" that forms the rider on these expressions serves only to indicate that no real dialogue is taking place. If one must say "duh" to make a point, it means that the truth of the point is so obvious that anyone not in agreement with said point is self-evidently an idiot. So why bother? The chuckle can be had among the elect, as they already know what's what and don't need to deal with the trivial details of constructing a plausible argument.

Saturday, March 24, 2012

WSJ Publishes Paranoid Rant on Organ Donation

I don't follow the financial news media closely enough to have an expert opinion, but I know enough about Rupert Murdoch to have assumed that it was at least possible that the quality of the Wall Street Journal would have been affected by his takeover of WSJ back in 2007 (I appear not to be the only one thinking this). And while it is hard to point to one single piddly article as evidence of a trend at WSJ or anywhere else, I can't help but think that this wild-eyed harangue against organ donation by Dick Teresi would have brought a smile to Murdoch's face. I'm also dubious that such a piece would have passed muster at Bloomberg or the Times--New York or LA, though it might have made the cut in the London version.

WSJ trend or no, it's deeply irresponsible fear-mongering. Teresi's argument against organ donation, insofar as there's any logic worthy of the term "argument", seems to revolve around three separate premises. The first is that, as an organ donor, you have no right to informed consent if you're brain dead. This is (marginally) true, although Teresi implies that physicians then swoop in on you, mad-scientist like, and perform unspeakable, ghoulish acts on your body. We'll get to that in a few paragraphs.

The second premise is that, if declared brain dead, you may not in fact be dead. As such, Teresi wins an award for being allowed to express his inner six year-old in the eminent pages of WSJ. That's pretty much the substance of this "argument". The "not really dead" shtick is a fear that reached its zenith in Germany in the late 19th century, where the fear of premature burial was so profound that "waiting mortuaries" were built, though no recorded accidentally-classified living people ever rose in the manner of Lazarus. Republican lawmakers, most infamously Senate Majority leader Bill Frist, were eager to whip up such anxieties in the case of Terri Schiavo, and Teresi's scribblings are of a piece with that.

The third premise, which can only be described as "rich" as they come on the pages of the Wall Street Journal, is that organ transplantation is big business. "Average recipients are charged $750,000 per transplant," Teresi notes. He then reasons that maybe donors and their families can get a piece of that action: "It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal."

It's really quite amazing that WSJ allowed this bit of nonsense into its pages, for doctors and hospitals do not, under any circumstances, haggle with families over the lives of potential organ donors or "negotiate deals" with families. If there's a case of brain death where we might be able to harvest organs, and the patient in question does not have an organ donation status on their driver's license, members of an organ donation team, not the docs taking care of the patient, ask next of kin--once--if they would consider organ donation. If the answer is no, then it's no, and that's that.

Money is never discussed and certainly none ever changes hands. Teresi implies something sinister in the money involved in organ donation, which raises the question as to whether he is a fully functioning adult. What--does he think that medicine doesn't involve money? As to whether money affects organ donation the same way it does, say, the buying and selling of automobiles, it isn't the same at all. There aren't docs out there getting "finder's bonuses" for snatching the greatest number of bodies, though he barely stops short of implying this, and there aren't people out there trying to game the system, lurking the halls of hospitals, just waiting for the big payday when someone's EEG goes flat.

The actual process of harvesting organs from a body is, in its details, best left to be discussed among professionals or those with either the morbid curiosity or intestinal fortitude to sustain them. The same could be said of routine colectomies. In both cases the goal is to save the lives of the patients--and in organ transplantation, the medical teams often succeed mightily. In 2011, over 22,000 organs were harvested from ~6,000 patients declared brain dead: most of the organs donated were kidneys, livers, hearts and lungs. There are a lot of people alive today walking around because of those organs. I can't emphasize this enough: thousands of people wouldn't be alive were it not for organ donors and the process of organ donation. It's among the reasons why I'm in the biz (in medicine, that is: I have only passing involvement in transplants, mostly in infectious disease consultations on transplant patients). Two helpful fact sheets on organ donation can be found here and here.

Organ donation is one of the few true miracles of modern medicine. It is based on the clear calculation that one's body, when no longer of use to one's soul, might be able to benefit the souls of others by sustaining their bodies. If members of the Billy Rubin Blog staff went out to lunch (meaning: if I got into my car) and had an unfortunate mishap with an 18-wheeler, I would want to cry out, "TAKE EVERY DAMNED THING YOU WANT, FROM MY CORNEAS TO MY COLON!" Alas, I wouldn't be heard in such circumstances...which is why there's a little red heart at the bottom right corner of my driver's license. I highly recommend everyone else put that heart down there too, though Dick Teresi is welcome to have a special license that says in small type "I am a heartless, selfish bastard", which indeed he is.

Wednesday, March 21, 2012

Should a Chemo Drug That Doesn't Prolong Life Be Approved?

Being a touch late to the social media game, the Billy Rubin Blog just got its own Twitter page up and running this week (follow us!) and started happily chirping away about medical issues. Having never lived more than five minutes of my life according to Polonius's dictum that brevity is the soul of wit, I wasn't sure how Twitter and I were going to match up.

Yet lo, first day in, I see a very interesting tweet from USA Today Health dealing with the FDA approval of the GlaxoSmithKline drug pazopanib (trade name of Votrient™) for use as a "salvage" chemotherapy agent for people with a type of cancer known as a soft-tissue sarcoma. Votrient had already been approved for use in renal cell carcinoma, but in seeking approval for the sarcoma indication, GSK was seeking to expand Votrient's market: while any doc could legally prescribe Votrient for a sarcoma patient as an "off-label" medication, insurance companies would not be likely to pay its steep cost (as this cost analysis demonstrates for one health plan, Votrient can run up to $7,000 a month).

What made the article interesting and worthy of tweeting is that GSK was unable to demonstrate that Votrient actually prolonged the lives of the affected patients. GSK measured the drug's effectiveness in two ways: one by looking at survival, but two, by looking at something called "progression free survival"--or how long the tumors stay suppressed. The FDA summary notes: "median progression free survival was 4.6 months in the pazopanib arm and 1.6 months in the placebo arm...however, this improvement did not translate to an improvement in the overall survival...the median overall survival was 12.6 months in the pazopanib arm and 10.7 months in the placebo arm." [my emphasis]

So off I tweeted "FDA approves new GSK chemo med, but drug doesn't prolong life. Umm...then what good does it do?", which I thought a succinct summary that required not much further explanation. Later in the evening I felt my own twitter of delight when someone from parts unknown replied to my tweet, though delight morphed into mild disappointment when @JLM_drivel's reply was "r u joking? it says what it does, prolongs illness-free life. obv not grt drug bt may or may not be worth it". Such are the limitations of Twitter: hard to have a meaningful discussion in 140 characters or less. But no, I wasn't joking.

Look--GSK has what seems to be a very intriguing and promising drug on its hands. That it appears to have decreased tumor size indicate it has potential to be a useful adjunct chemo agent, or even with some molecular tweaking to be a beneficial drug in its own right. But a salvage chemotherapeutic drug that doesn't prolong life can't be described as "may or may not be worth it". It's not worth it! It isn't worth it at any price, but it most certainly isn't worth it at $7000 a month for 11 months.

If every patient annually diagnosed with soft-tissue sarcoma (about 10,000) took Votrient for that length of time, GSK would gross $770 million. Not a bad day's work for a drug that doesn't prolong life.

Not only is this not worth it, it has the potential to erode patient confidence in the system that's working to treat and maybe one day cure them. As this Bloomberg news piece notes in quoting doc Gary Schwartz, the head of the sarcoma service at Memorial Sloan-Kettering in New York, "if the patient comes to the oncologist with cancer, they want to be cured...but with sarcoma, they aren't cured, they want to live longer." They want to live longer. Votrient cannot deliver that, and if these very vulnerable patients take this drug without getting that in return, they and their loved ones will feel cheated by taking it.

That was what I meant when I asked "what good does it do?"--and until GSK can show that Votrient can prolong the life of these sarcoma patients, the answer will be "not much, progression-free survival be damned."

Tuesday, March 20, 2012

Abby Zuger's Two Rather Contradictory Pieces on NEJM

Yesterday two articles written by Doc-journalist Abigail Zuger came out in the Paper Of Record dealing with The New England Journal of Medicine and its ongoing influence as, well, the Journal Of Record for all things medical. These pieces, however, highlight two very different aspects of NEJM. The first is a warm birthday card of sorts as the Journal celebrates its 200th year of publication: a quick meditation on why it has remained at the top of the heap and continues to be equated with excellence not only among physicians but in the public mind as well. "It is an antique that outperforms all the newer models," Zuger writes, and she's right, which even a casual perusal of their website or a listen to their podcast makes clear. It remains the standard of excellence in clinical medicine, the venue where everyone with serious career aspirations wants to be published. (We're no different, often dreaming about seeing the name "Billy Rubin" in its pages.)

But also in the Times yesterday Dr. Zuger has a longer piece detailing the lives of two former editors of NEJM, Drs. Arnold Relman and Marcia Angell, and their relationship with the august journal is less chummy. Suffice it to say that Relman and Angell aren't likely to be brought back for the 200th anniversary party like an equivalent of former baseball players returning to the field for an Old Timer's game. Details can be found in the article, but the quick version is that Angell took a dim view of the increasing "contaminating influence of money, especially industry money" in the affairs of the Journal, and was eventually dumped from the Journal in 2001.

"Many physicians believed that the degree of separation the top editors demanded for the journal, and for its expert authors, was unrealistic and counterproductive," writes Zuger, although why these physicians believed that Angell was being unrealistic is not made fully clear. I can't claim to be an expert on the Journal's finances, but pretty much every doctor who reads medical journals with any regularity reads NEJM. Their subscription income should be more than enough to sustain its staff. Yet the Journal is rife with advertising and there has been ample evidence for years that industry ties create scientific bias.

So I can't quite figure out why Angell and her ilk are portrayed as being so rigid, and there's more than a touch of "oh, they're just crazy old bats" in the piece. Zuger doesn't say this herself, but quotes several hostile sources. Whether she feels that way personally I can't tell, but the chorus of criticism of Angell and Relman so clearly evident in the article is nowhere to be found in the "NEJM at 200" postcard.

The fact remains that, sterling reputation or no, NEJM is a multimillion dollar operation heavily subsidized by industry money--and at its 200th birthday, that creates grave problems for its editors, its readership, and ultimately the patients served by such a publication. Count me in as a fan, but likewise count me in as someone who's down with the Relman/Angell critique of how business gets done.

Sunday, March 18, 2012

Mike Daisey, This American Life, and The Public Theater: The Show Must Go On, At Least For One More Day

As part of a meditation on plagiarism in a link to the intrepid journalists at Retraction Watch, I opened with a brief quip about an episode of the radio program This American Life that aired in January and became the most downloaded podcast ever for TAL. That episode was essentially an adapted version of a one-man stage show called "The Agony and Ecstasy of Steve Jobs" featuring the work of one Mike Daisey. In both the stage piece and in TAL, Daisey describes horrific working conditions in the Chinese factories that produce the Apple products that so many American consumers love.

"Dickensian" would be the adjective of choice to describe the monologue, and Daisey walks you through a landscape where beautiful iPads emerge pristine from a landscape littered with mangled hands destroyed by the machines used during the manufacture of products, 12 year-old girls working at the plant, workers gone mad from neurotoxic chemicals used on the production lines, and armed guards posted outside the plant to ensure the workers don't get any strange ideas. "These guys looked pissssed", Daisey hisses in an audio clip from his play. It is very hard not to form a picture from this, and have a very unflattering view of Apple by the end.

But the touch about the armed guards didn't seem to jive with business reporters covering the Apple beat in China. Rob Schmitz, working for American Public Media's radio show Marketplace, started discussing the Daisey TAL piece with a colleague, who in turn didn't buy the story, due to the armed guards (only the military and police in China are allowed to carry weapons) and details like this:

Daisey [claiming to speak with members of an illegal union]: "I say, 'how do you guys organize?' And they look at each other bashfully, and they say, "Well...we talk a lot, we have lots of meetings, and...we meet at different coffee houses and we meet at Starbucks in Guangzho..."

Schmitz said this of such meetings: "Wait, hold on. Rewind. Factory workers making fifteen, twenty dollars a day, are sipping coffee at Starbucks?! Starbucks is even pricier in China than in the US."

After checking out many more details, Schmitz came to TAL highlighting the problems, which led to host Ira Glass auditing the entire story and discussing the discrepancies with Daisey. Over the past few days Schmitz published his piece on the Marketplace website here, and TAL spent an hour explaining and discussing its retraction of Daisey's work here. If "Agony and Ecstasy" made for gripping drama, the episode watching him squirm under the weight of people confronting him with his lies easily tops that. Listening to his very slippery replies to direct questions reminds us of another pathological liar, Stephen Glass (no relation to Ira that I know of), who is dramatically--i.e. not factually--portrayed in the movie Shattered Glass by Hayden Christensen, a good clip of which can be found here.

It bears mentioning that at least some of the details of Daisey's description are, in fact, real. The neurotoxin n-hexane really did poison some people at an Apple-associated factory 1000 miles away from where Daisey went on his trip, while a few underage workers have been found in Apple audits and workers often put in substantial overtime and live in crowded dorms, as documented here in the New York Times. Because of Daisey's overwhelming disregard for the truth, much of that will now get lost in the wake of the right-wing attacks which are sure to come in torrents against National Public Radio and any other media organizations that the followers of Newt Gingrich would just as happily label as "traitors".

The epilogue to this unfortunate episode is that Daisey's one-man monologue continued its run in New York at The Public Theater, although it now appears that its final date of today, March 18, will not be extended. The theater released the following statement that expresses its regret that Daisey had not been more forthcoming: understatement of the week, surely.

An elegant summary of Daisey's transgressions can be found in the comments section of the Retraction Watch piece, where "DefendSmallScience" says this:

As I listened to the NPR piece last night, it occurred to me that the similarities between Daisey’s fabrication and several well-publicized cases of scientific fraud are readily apparent. Ultimately, Daisey is guilty of both fraud and extreme laziness. Journalistic laziness is not dissimilar from scientific laziness. Reading the NYTimes piece by David Barboza on Apple manufacturing practices (also reviewed on ATC last night), it’s clear that there is more than a kernel of truth to the notion that severe working conditions are intrinsic to the manufacturing of iPhones, iPads, etc. However, rather than taking the more costly and time-consuming steps to properly research and expose these conditions for what they really were, Daisey decided to create his own evidence for the sake of his own convenience and the snappiest presentation. This reminds me of the stories of exposed scientific fraudsters, who massage their data (by dropping contradictory results or outright fabrication) to create the easiest or sexiest story possible, rather than spending additional time and effort to get closer to the truth. I have no doubt that transcriptional profiles of tumors can be used to predict their responsiveness, to a degree, to different therapies. Anil Potti surely knew he was on to something, but he chose the easy way to quick, high profile publications – fabricate data to fit the conclusions you want to make rather than reveal the limits of the existing evidence.

Well said.

Saturday, March 17, 2012

Being Honest In Science Really Ain't That Hard

Two quick media pieces involving truth-telling caught my attention this week. Some friends on Facebook circulated this Marketplace story about utterly false claims about working conditions Apple's factories in China which appeared on the public radio show This American Life (retraction here). In short: blech.

The other story dealt with issues of scientific integrity and generated interest only among a small group of specialists, but it's no less disturbing. The details, which can be found here on the awesome Retraction Watch blog, describe the story of Marya Zilberberg, a physician health services researcher at UMass Amherst whose review paper on ventilator-associated pneumonia was plagiarized in the Journal of Clinical Monitoring and Computing. As you read the details, it's pretty obvious that there's no way the authors could innocently explain away a borrowed sentence here or there: whole paragraphs are lifted verbatim, and Doc Zilberberg's work is never cited. It's theft, pure and simple.

Now, as a quick perusal of Retraction Watch will show, plagiarism and other intellectually dishonest shenanigans ain't such a rare occurrence in the world of scientific research. But what makes this story stand out in terms of its flabbergasticity is that the editors of Journal of Clinical Monitoring and Computing seem not to have been bothered by the plagiarism one bit. Indeed, as of this writing the link to the offending paper is still live here, i.e. the editors did not feel it necessary to retract the paper for its clear-cut offenses. That's astonishing! Does Springer, Inc. the parent company that publishes JCM&C and does nearly one billion Euro in business annually really want to sanction this kind of behavior? If so, wow indeed.

Except for the Bircher wing of the Republican party (i.e. that lovable group so often referred to as "the base"), most people still trust physicians and scientists because these professions are built on integrity and honesty. We look the other way at cases like the plagiarism of Dr. Zilberberg's work at our peril.

UPDATE: Eagle-eyed readers of BRB noted that the story uncovering the lies of Mike Daisey in his coverage of Apple Inc. came from Marketplace, not Media Matters, as I had written in the original. The correct attribution appears above.

Friday, March 16, 2012

Newt Gingrich Faces the Punditry, Who Substitute As Professional Psychologists

There's just enough seriousness in this otherwise tongue-in-cheek post about Gingrich's irrational exuberance to further corrode what is already pretty cheap political discourse about the Presidential primaries. Granted, The Atlantic's Robert Wright is mostly trying to have a chuckle in wondering aloud why the Newtster is still in the game. (Jacob Weisberg of Slate offered a similar assessment of Gingrich here in December.) After all, for what justifiable reason would Gingrich want to keep his name in the hat, now that he's given up the game in his own backyard of Mississippi and Alabama? Wright's conclusion: vengeance, egomania...and a lil' bipolar disorder mixed in. Robert--the ICD 9 code for chronic hypomanic disorder is 301.11: bill for that baby!

Not surprisingly, we've seen this before, not long after the 2008 election when Sarah Palin had her own "Personality Disorder Problem"--that is, having a psychiatric diagnosis applied by lazy journalists who seem to think that just because they don't like someone it gives them carte blanche to label them as mentally ill. Sorry, we at the Billy Rubin Blog just ain't amused.

From my vantage point, Gingrich seems like a kind-of non-felonious Republican version of Rod Blagojevich. He certainly seems to be an egomaniac. I suppose that he's pursuing a political vendetta against Romney and could thus be described as "vengeful", though he surely was goaded into that by Romney's attack ads, no? ("Vengeance" is a word I'm more inclined to immediately associate with that sweet Texan with the cuddly nickname "The Hammer", former US Representative Tom DeLay, but that's just me.)

But manic? Or even, since Wright tried to cover his tuchus a bit, hypomanic? Umm...most likely no. Key features of hypomania include pressured speech (Gingrich's speech is fairly slow and deliberate), easy distractibility, hyperactivity or "psychomotor agitation", and flight of ideas (a semi-technical term indicating a total inability to stay on topic even briefly). While there's more than a bit of grandiosity in Gingrich's speeches (yes, I've been listening to them the past few Tuesday nights), there's really nothing else in the clinical definition to indicate that Newt needs lithium.

Now, if you want to see agitated replies to questions or some pressured speech, you may want to find recent clips of Mitt Romney speaking.

Surprisingly, despite guffawing at Gingrich's tilt at the windmill, Wright himself offers up a perfectly rational analysis, however remote, of why Gingrich should stay in the race: in the 1920 Republican primaries, a man named Leonard Wood had the most delegates coming into the convention, though the nominee turned out to be Warren Harding, who was in a measly sixth at the outset of the horse trading. So, wildly improbable though such chances are, Gingrich has a shot.

There's no doubt that a heavy dose of ego is required to run for President of the United States, and Newt Gingrich possesses grandiosity in sufficiently hefty amounts. I don't object to a bit of snark to his silliness; I do object to turning that snark into a joke about the mentally ill--who, lest we forget, often have very real difficulty functioning in the world and don't live the charmed life of a pampered former lobbyist gunning to live in a pretty big mansion in Washington.

Wednesday, March 14, 2012

How Do You Rate Your Doctor?--Part Two

In keeping with the theme of ratings, US News and World Report just released its annual rankings of "Best US Medical Schools". Shock of shocks, Harvard University ranks at the top--at least in the "research schools" category. For best schools specializing in primary care the list is utterly different: the University of Washington occupies the top spot, and only one school, UCSF, makes both top-10 lists.

I wouldn't call these lists "nonsense" but my sentiments aren't too far off that mark. I see two major problems here. The first is that the concept of ranking one-through-whatever seems dubious at best: does putting the University of Nebraska (#6 in primary care) above UMass (#7, a school near and dear to the heart of the Billy Rubin Blog) or for that matter University of North Texas (#35) really mean that a Cornhusker grad who's now a doc in primary care is qualitatively better than a Minuteman or a Texan doc? I'm thinking not. Or does it really mean something to the average medical student that Harvard is a better research school than, say, Baylor (#21) if there's essentially no difference in the number of research opportunities at Baylor?

At best--at absolute best, if you're trying to put a happy spin on these lists--you might reasonably break these rankings out into "tiers" where you acknowledge that it's meaningless to rank one school above another within a given rank, but that you can make some broad statements about how groups of schools compare to one another. The difference between Duke (#9 research) and Vandy (#14) doesn't really exist, but I'd be willing to believe that there's a real qualitative difference, however small, between either of those schools and, say, University of Missouri (#74).

The second problem is that the criteria by which these schools are judged play to the strengths of schools with fancy pedigrees. As this page helpfully explains, there are several criteria that USN&WR take into account, but one of the most important factors is a school's reputation. In other words, a huge chunk of where you find your spot on this list is determined not by truly objective criteria, but simply by what other people think about you. So Harvard gets an A+ for being, well, Harvard--even slackers from the hills of Idaho have heard that Harvard is a good school, despite knowing nothing about how Harvard actually functions in the real world.

Thus, one of the major reasons why a given school lands where it does is essentially the equivalent of lunch room gossip: the popular kids are popular because, well, they're popular! There are objective portions to the score, to be sure: they factor in how much research money comes flowing in (Harvard really is a mammoth institution in this regard), what percentage of med school grads go into primary care, the average GPA and MCAT scores of the students, and so on.

Although with all of that, I still don't think it will tell you anything about the quality of the doctors being produced from those institutions. The University of North Dakota (#77 in primary care) is a school built for students who were, for the most part, born in the Upper Midwest and want to stay there. There's no particular reason to suppose that their training is any more or less better than pretty much anywhere else. Plus there are some weird discrepancies in the list: Cornell, a school with a very high reputation, is not surprisingly ranked as #16 in research but is #57 in primary care. Does that mean that New York-based prospective students interested in primary care should drop Cornell and head to the University of Rochester (#15)? Maybe yes, maybe no. Either way, they're likely to become pretty much the same kind of doc no matter which they choose.

US News is in the business of selling copy, and they seem to make an honest--though per above, I believe seriously flawed--effort at honestly assessing these institutions. The bone I have to pick is that people read these numbers without really understanding what they mean or where they come from, and suddenly attach great importance to them--and they just ain't that important. But mark my words, the haughty attitudes that get ingrained into many of these students once they get accepted to such-and-such a high-ranked school (or for that matter, the chips on the shoulders of those that get into the lower-ranked ones...though I'm not sure what a Cornell medical student should think) invariably will find their way into how they approach their colleagues, or much more importantly, their patients, in the years to come.

Tuesday, March 13, 2012

NPR Coverage of Cholera in Haiti

NPR reporter Richard Harris is one of the best science journalists around, and this week's series on the cholera epidemic in Haiti promises to be another entry in his stellar oeuvre. This morning's "teaser" piece documents the difficulties aid organizations are having in getting a cholera vaccine to Haitians, noting that there are political barriers well beyond the "simple" operations issues of getting the lifesaving vaccine into the mouths of people (the vaccine is oral). As I wrote in some brief thoughts immediately following the earthquake, understanding its horror and the aftermath in Haiti is best not merely understood as a natural disaster hitting an impoverished place: the problems run much deeper, and we're seeing some indications of why in Harris's reporting.

Given the GOP primaries, the possibility of a regional war in the Middle East (beyond the current violence, of course), and the recent tragedy in Afghanistan, the story of the Haiti cholera epidemic is not likely to be noticed by all but the most ardent news junkies--or at least commuters who listen to NPR. But it really is big news: since the outbreak began in late 2010, more than 7,000 people have died and hundreds of thousands have been affected (the CDC numbers need some updating, but otherwise a useful link). Keep in mind that of the various Ebola or Marburg virus outbreaks that have occurred in Africa where they received weeks of breathless front-page coverage here in the US, the largest number of deaths from any single outbreak was never larger than about 300. By any measure this is a tragedy on an epic scale.

Sunday, March 11, 2012

How Do You Rate Your Doctor?

Great pair of articles in the Paper Of Record (in the Business, not Health, section) on Friday looking at websites that rate doctors (here and here). The gist: you can get a wealth of reviews on pretty much any restaurant you live near through various sites, but very few docs have multiple reviews of them online. The first link goes into some depth as to why this is so, and concludes with the thought that the only way to get more accurate info about the doctors is to have more people put up more reviews. Which is true, although since many people already put up Tolstoy-length reviews of their local coffee shop, it stands to reason that people are still a bit uncomfortable about doing the same with docs.

The only guess I can hazard is that most people still put docs into a different category of job than those that are both clearly customer-service oriented and, for lack of a better word, capitalist. Hairdressers, auto mechanics, electricians and the like exchange services out of a specialized knowledge for cash; priests, teachers, and docs also do that but are in some sense responsible for our souls. Rating a priest seems like an exceedingly odd thing to do, and I suspect that doc ratings haven't caught on for a similarish reason.

That said, it seems reasonable to assume that sites like and the doc section on Angie's List will inexorably gain adherents and the practice will become more widespread. Not every physician--based on the comments in the second NYT article--is delighted about this. "The biggest problem is that it is the patient point of view which is often emotionally charged and not fully informed. If I tell a patient they have cancer and they don't like the diagnosis, am I rated poorly because 'that's not what I wanted to hear'?...I often ask the complaining patient 'Did you get better?', 'Is your loved one still alive?' and then which was more important to you, staff friendliness or the outcome?" wrote Doc Matt. (A delightful reply came from Miriam in Queens, who wrote, "You mean I can't have both?" One does wonder about Doc Matt's bedside manner when he explains that he "often asks the complaining patient" about their critiques: how many complaints does he get?!)

Such condescending attitudes weren't the only ones in evidence, but these and other comments do highlight the anxiety ratings are capable of promoting. From my own experience in professional chit-chat with colleagues, many more of us are worried about getting a malpractice lawsuit than a bad online review, but that could just as easily reflect the kind of doctoring I do (that is, not outpatient clinic-based) than it does the general mood of practicing docs.

One good point made in the comments that surprisingly didn't find its way into the articles dealt with the lopsided rules by which docs and reviewers can approach the online rating system. Patients can say whatever they wish in a review, but docs are bound by confidentiality, and are unable to respond if they feel they have a misleading review. However I'm not sure that any but the most thin-skinned docs would respond to bad reviews anyway, since it would likely make matters worse from a marketing standpoint, and just might indicate an underlying problem with feedback that lots of patients associate with certain kinds of docs in the first place.

The articles are good and informative, though journalist Ron Lieber does include one unintentional howler by noting that "the American Medical Association speaks for most doctors". While undoubtedly an important organization to reckon with, the AMA ain't all that, a topic we've previously covered here. But in terms of the overall ointment, it's a pretty small fly.

UPDATE: I received a comment from a reader who feels as if a doctor was responsible for their spouse's death. The reader named this physician and the medical group for whom the physician works. I won't publish the remark: I cannot verify the information and thus can't in good conscience allow a direct attack on a particular physician onto my blog. The reader is more than welcome to circulate the story on the websites above, but here I can't sanction specific accusations without the ability to verify the veracity of the claims. I tried to send an e-mail to this person directly but no address comes up on the link. If you wish to discuss further, please leave another comment with your address. I'm happy to entertain thoughts about tough times with physicians but my rule is to keep names out of it (as I wrote about experiences with one of my father's physicians here). I am sorry for your loss. Best, Billy

Saturday, March 3, 2012

New Jersey Fights Over Water Fluoridation: We Really Are Living In the 19th Century

That is, back when the Theory of Evolution was still hotly debated. Oh, wait.

From the Paper Of Record: news that a bill, which requires all public water supplies fluoridate their water, is causing a political stir as it works its way through the state legislature in Jersey. The most shocking fact trottted out in the opening grafs is that only 14 percent of NJ residents have access to fluoridated water, placing it next to last place, only in front of Hawaii. Yet despite this appalling statistic, it is not clear whether the bill will even pass, and if it does, it is equally unclear whether Governor Chris Christie (R) will sign it.

Why is such an obviously beneficial bill having a hard time mustering sufficient support to come into law? It's the usual recipe: misinformation fueled by anti-intellectualism encouraged by demagogues. The article notes that opponents cite websites such as the Fluoride Action Network, whose citation of papers and studies is selective at best in making claims that it is linked to bone cancer and lower IQ among other scourges. The website is sleek and impressive, which no doubt must play a role in convincing people that the anti-fluoridaters are legit and not merely cranks. Like the global warming deniers, the internet has become a powerful tool to disseminate nonsense.

What about all those public health officials and their claims as to the safety and benefits of fluoridate water? Well, they're part of the vast government machinery which conspires to "[medicate] us without our consent," as one insane woman, Ms. Jennifer DiOrio, states. A high school teacher, DiOrio is responsible for the intellectual welfare of her teenage charges, a chilling thought.

Just speculating here, but Governor Christie's current hedge on this issue is likely due in part to his national political ambitions and not wishing to provoke the ire of the far-right constituency currently proving such an irritation to the Romney campaign. As Governor Rick Perry discovered after having supported--in what was unquestionably good policy--a mandate for girls in Texas to receive the HPV vaccine, the road to the Republican nomination is very difficult if one runs afoul of these voters. Since their world-view is utterly cocooned from reality, as they do not believe any scientific data that undermines their preconceived notions, trying to explain to them that there's abundant data supporting the safety and benefits of such a policy is vastly riskier for an aspiring presidential candidate than just vetoing the bill and offering up some cheap fart about government overreach.