Billy Rubin's Blog

Komen Update: Now It's Stem Cells

2012-02-03T11:36:00.002-05:00

At least my corner of the Facebook world is abuzz with the news about Komen's severed relationship with Planned Parenthood. The news keeps rolling in, though, and multiple websites of both left and right have now posted that Komen is also removing funding from medical centers that also sponsor research on Embryonic Stem Cells. If I'm reading the news correctly, Komen is cutting off the funding simply because other researchers in the institution are doing ESC research. That must come as one hell of a shock to some bench or clinical researcher whose funding is being taken away because some PhD in a different building who has never even seen her does some totally unrelated science. Again, maybe I'm reading this wrong, and the story is changing rapidly.

Regardless, it removes the fig leaf that the Komen spokespeople used earlier this week indicating that the only reason why they pulled funding to Planned Parenthood is because they're under congressional investigation. That was always pretty flimsy, as the "investigation" could be better described as "a witch hunt by a zealot". Johns Hopkins University, however, is not under congressional investigation, and they're getting dinged $3.75 million collectively from Komen. It's now quite clear to anyone looking objectively that Komen has become a highly partisan political organization.

One friend of mine on Facebook who has no objections to Komen's new found policies has engaged in a back-and-forth about the rationale and implications of the move. Despite having two very strongly adversarial stands, we're getting through the discussion so far with generally polite verbal punch-counterpunches. When I posted the latest Komen news about the ESCs, the friend took a moment to point out this article from USA Today that suggests that Adult Stem Cell research is outpacing that of ESCs, so the argument may be settled on the scientific gridiron and not require the machina ex deus, so to speak, of religious objection. But I'm not so sure.

I heard a similar talk at Grand Rounds here a few months back, which is fine and may resolve the dispute. But the key word there is "may". Science often goes in all kinds of weird and unanticipated directions, and technologies that look pro...missing at first can be rapidly outpaced by advances in other areas. At the beginning of the 4th graf of the USA Today article closely, you'll see a big red warning sign: "[this] isn't a rigorous study". Pilot projects often look rosy, as anyone who remembers the hullabaloo surrounding gene therapy can easily recall. So I wouldn't put my chips on adult stem cells as being scientifically superior to embryonic cells just yet, and if ESC opponents are relying on the superiority of ASCs to settle the issue, what will they do if the research winds blow in a different direction? They can't have it both ways.

I don't deny that there must be ethical rules and regulations regarding biomedical research (if you've read these blog entries, I hope that you'll see I passionately care about such issues). The question is where one draws the lines and by what basis does the line-drawing occur. Though my comparison of many anti-abortion groups to Hezbollah may have seemed to be purely outrageous and deliberately provocative, it truly is an apt comparison, for like fundamentalist Islamists, fundamentalist Christians approach the world with a narrow literalism about scripture that is ultimately wildly hostile to a scientific worldview. The most obvious example of this is the Theory of Evolution, about which fundamentalists of every stripe from Des Moines to Dubai reject out of hand because it threatens their justifications for the social order (though, obviously, two different social orders there). Likewise, doing research on microscopic cells that no Christian even believed existed two centuries ago somehow rises to the level of demonizing the researchers as taking a life. To me, this is profound nonsense and becomes increasingly absurd with every new scientific advance in the field.

It's not yet possible, but it's not hard to conceive of a time where we could -artificially- create human embryos. What would the Pope, or Michelle Bachmann for that matter, say about this? Would this fall under the proscription of taking a life? We're already generating proto-viruses called "Virus-Like Particles" that allow us to work with these organisms in a Tinkertoy-like fashion. What if we could do the same with a human stem cell? What if the research on virus manipulation would allow us to make some kind of a "human-like particle"? It's not so terribly science-fiction to suppose this. Does this mean we should now halt all research that might even lead in that direction? I'm confident that both Muktada Al-Sadr as well as Pat Robertson think we should.

--br

Those Not-So-Loveable Scamps At Susan Komen For The Cure

2012-02-01T20:50:00.002-05:00

Anti-abortion advocates are cheering a big huzzah this week over the decision by the advocacy group Susan Komen For The Cure to cut its ties with Planned Parenthood. As noted here and here, the Komen folks aren't always the friendliest of sorts when it comes to organizations that want to use the word "cure" as part of their fundraising campaigns. Moreover, their single-minded advocacy of mammography as the critical piece in reducing breast cancer mortality may be misguided due to increasing amounts of scientific evidence indicating otherwise, for which their response appears to be to ignore it. So their kow-towing to groups by-and-large hostile to the idea of women's freedom is only a marginal surprise. The only question is how many women will now be willing to march in all those lovely pink-ribboned Breast Cancer Awareness Walks in the springtime. In Boston, where the Billy Rubin Blog makes its home, I'm suddenly dubious that we're going to see the same level of enthusiasm as in previous years.

Amanda Marcotte nicely dissects the Komen action in Slate here. She notes: "No matter how much anti-choicers wish otherwise, it's not feasible to create an approach to women's health that separates good girl concerns from bad girl concerns. For instance, many women land in gynecologist's offices seeking contraceptive services and cervical-cancer screenings, and doctors use that opportunity to teach the art of breast self-exam." Well written, indeed.

The episode reminds us here at Billy Rubin Central of an old yarn from our med school days. It was supplied by an OB/GYN resident from Romania who had lived--indeed, survived--through Nicolae Ceausescu's regime, which, for those whose history isn't up to snuff, can be tersely summed up as "less cuddly than Josef Stalin". Anyway, Dr. Resident OB/GYN was in med school during the regime, and saw some unimaginable things. What kind of things? Watching women die from septic abortions, for starters. As abortions were illegal in Romania, they were performed much as they were in the US before Roe v. Wade, often by back-alley butchers with little or no medical training in nowhere-near-aseptic conditions.

"I used to see it all the time," my resident told me in the middle of the night while we were on call. "These women would roll in with sepsis from a botched abortion all the time, and the police would find out, and they wouldn't allow us to treat them until they gave up the name of the person who performed the abortion. So we'd see women die all the time, refusing to implicate anyone. This was bread-and-butter in my medical school." It nearly made me vomit all those years ago, but perhaps this would be music to Rick Santorum's ears.

True, it's not quite the same as Komen's move, though the downstream consequence--let's call it the cut-off-their-breasts-to-spite-their-vaginas policy--may well be the same: a heap of discarded ta-tas and mounds of dead women.

If you wish to make a donation to Planned Parenthood shortly, consider doing it in the name of Karen Handel, Komen's Senior Vice President for Public Policy since April 2011. Handel, an anti-abortion crusader and former candidate for Governor of Georgia (state, not country, lest the Romania reference mix anyone up) was overtly opposed to Planned Parenthood during her run, and may have been one of the critical players in forming Komen's new policy.

Various hat-tips to Facebook friends, the Point of Law blog, Amanda Marcotte of Slate, and TBogg of FireDogLake.
--br

The Problem Is Profit (At Least in Healthcare)

2012-01-31T11:32:00.000-05:00

If the vagaries of the medical system has you frustrated, look no further than today's New York Times opinion page for a little shot of optimism to your system. There you will find some government/academia heavy hitters (Ezekiel Emanuel and Jeffrey Liebman, both former advisers to the Obama administration) explaining how wunnerful healthcare is gonna be due to the impending extinction of health insurance companies. How's that possible, you ask? Well, the details are complicated, but the gist is that due to the changes wrought by the health care bill so stupidly referred to as "Obamacare" by the vast majority of Americans, a new system of apportioning dollars for healthcare will come into being in the next few years. This new system will have organizations known as "accountable care organizations", or ACOs, which "will increase coordination of patient’s care and shift the focus of medicine away from treating sickness and toward keeping people healthy". And, the authors contend, it's going to make everything better.

How that will take place is explained in two terse grafs midway through the article:

Because most physicians and hospitals today are paid on a fee-for-servicebasis, medical care is organized around treating a specific episode of illnessrather than the whole patient. This system encourages overtreatment and leadsto mistakes and miscommunication when patients are sent between their primarycare doctors, specialists and hospitals. Indeed, under today’s payment system,investments in providing better care are doubly penalized. If a hospital hiresa nurse to follow up with patients after they are discharged in order to reducereadmissions — for example, to help patients with diabetes improve blood sugarcontrol — it must pay for the nurse, which is typically not reimbursed byinsurance companies or Medicare, and it loses revenue by preventing thereadmission.

In contrast, accountable care organizations will typically be paid a fixed amount per patient, along with bonuses for achieving quality targets. The organizations will make money by keeping their patients healthy and out of the hospital and by avoiding unnecessary tests, drugs and procedures. Thus, they will actually have a financial incentive to hire that nurse for follow-ups.

To give some context, a major chunk of Zeke Emanuel's career has been defined by paying attention to the issue of "overutilization"--the overuse of extremely expensive resources by physicians and hospitals--and ACOs appear to constitute a solution to this problem. Stop overutilization, you drive costs down because you stop needless testing. Create incentives to limit spending, you stop overutilization. QED. Thus, the new rules of the healthcare act will massage this new model into place.

Now that all sounds very nice and well, but color me dubious for the most part. I don't dispute Emanuel's contention that we spend too much on healthcare (we spend twice the amount of any other country per capita), and I agree with much of his analysis of the root causes of overutilization. But Emmanuel and Liebman appear to think that the private sector is up to the task of doing this, and on this point I am skeptical. Oh, we'll have changes with this ACO model, I'm pretty confident, but several of them are going to take a system that already has huge problems and make at least some of them worse.

The problem is profit. Healthcare companies are like any other capitalist venture: the bottom line is that they are in business to make money, and make a lot of it. Companies exist to make shareholders wealthy, and they will engage in whatever practices are legal in order to do so. In healthcare, this means, on the whole, that corporations wishing to make money have to increase production (having doctors see more patients, not by having more sick people) and/or reduce costs (either by making people healthier, which is easier said than done, or by decreasing overutilization, or by having cheaper labor than doctors see patients, or just paying doctors less).

I'll let the economists wax eloquent on how this makes the world a better place in theoretical terms, but I want to give you some idea of what this means in the real world. Let's take Your Local Little Hospital. If you go there nowadays, you're as likely as not to be cared for by something called a "hospitalist", which is an internal medicine doctor whose sole job is to care for hospitalized patients, and thus this doctor has no "practice" in the traditional sense of having a group of patients for whom he or she cares for an extended period. These hospitalists often work for either the hospitals themselves, or for corporations involved in the profit business.

If you go to Your Local Little Hospital and your hospitalist works for a corporation, that corporation likely is putting an enormous pressure on Dr. Hospitalist to see as many patients as they possibly can in one day, upwards of 20 to 25 patients. If you have ever spent time in a hospital or been with a loved one or friend, you'll know that face-time with the doc can (one hopes at any rate) be a huge factor in understanding what's going on. Suppose a conversation with a doc takes just five minutes; most people would want more, especially if they're sick, but let's just be conservative for the sake of the numbers to make a point. If that doc spends just five minutes talking with each patient and/or family of the patient, the doc with a census of 25 would spend about two hours each day just doing that task. That leaves the tasks of reviewing data, interpreting the data, writing a note, calling consultants, examining the patient, placing orders, and then reviewing the new data from that day's tests and making plans as necessary. It takes a lot of time to take care of a patient, about an hour each day by my estimation, so you can see what happens when you have 25 patients on your census.

The difference between this world and the one where the hospitalist is employed by Your Local Little Hospital is that the hospital--assuming it is a non-profit hospital--is not driven to quite the same extent by raw money. Of course, even non-profit hospitals need to keep a positive cash flow, but they don't have to worry about creating huge amounts of cash so that their CEO and major shareholders can afford lovely getaway ski chalets. Their only real bottom line is to stay in business, so they can afford to let their hospitalists see, say, 12 to 15 patients a day--considered by most in the biz to be an entirely reasonable number and still do good medicine. That's nearly half the workload of the hypothetical hospitalist in the graf above, and while this is all hypothetical, it really is happening out there right now.

In the brave new world of ACOs, all of these numbers may eventually seem quaint. Here's an op-ed--from the CEO of the Society of Hospital Medicine, mind you--that blithely chirps about "new paradigms" in which a hospitalist can see up to forty patients in a day! I have no understanding of what such a new paradigm could be except for one in which mistakes will be made and families and patients will wonder who the hell is in charge of their care.

So when people write feel-good phrases like "the new system will encourage treatment of the whole patient instead of being organized around treating a specific episode of illness", and that the remedy for such problems is by bringing the magic of market-based solutions to bear on them, I think that such people have learned the high art of euphemism because they either don't understand, or don't care about, the realities of what caring for patients actually means. (Though Zeke Emanuel must--he's a doc himself! What happened to his rhetoric I can only guess.)

I make good money as a doc, but I'll never be CEO-rich doing it, which is fine with me since becoming rich wasn't my priority in going into medicine. Most of the docs I know could be described similarly. But for us, profit wasn't the primary motivation. It's true that most of us make enough for the occasional nice bottle of Cabernet, but for people who want to be rolling in it, being a doc is not the right way to go, as there are easier ways of making a buck. The same should be true, by and large, for the entire biz of healthcare as well.
--br

Taking the Right (Though Small) Steps in Conflict of Interest

2012-01-21T13:55:00.000-05:00

Amidst the braying and screeching of the Republican Presidential candidates in South Carolina came a small news bit that the Obama administration will institute new requirements that drug companies must disclose their payments to physicians for speaking, consulting, and research activities. As noted here, this has been backed in large measure by Republican Senator Chuck Grassley and Democratic Senator Herb Kohl, who have been at the forefront of conflict-of-interest issues in medicine for the past several years.

Two facts in the articles bear repeating: a) that physicians can be mightily influenced by the largesse of drug companies; and b) that "about a quarter of all doctors take some cash payments from drug or device makers and nearly two-thirds accept meals or food gifts" [my emphasis]. As you can find on the ProPublica website in the above link, companies invest millions of dollars in these little gifts. If you think that doctors can go to a fancy dinner sponsored by Drug Company X and not have their subsequent prescription patterns influenced in favor of Drug Company X, then you would wonder why the industry invests such resources in the first place.

Disclosure is a nice gesture, but it is mostly only a gesture. Like the disclosure of nutrition facts for food producers (something that industry likewise fought against tooth and nail), it is utilized only by a very small group of people. Similarly, the vast majority of patients won't have the determination and persistence to track down the disclosure information. And besides, when two-thirds of docs are on the take, what difference does the research make, anyway?

The only legitimate long-term solution is to tighten existing rules about doc-industry relationships. There are a few areas where docs have to work hand-in-hand with industry (surgical subspecialties are the main ones that leap to mind) and would need to be carefully thought out, but otherwise it's really not that difficult to create rules by which docs are supposed to operate with respect to drug companies. We already have such rules for scientific ethics in research; why there can't be a similar arrangement for the daily business of doctoring is quite beyond my understanding. In the meantime, the standards we have now would be regarded as appalling by most people if they understood the situation.
--br

One Patient, One Hour

2012-01-10T08:16:00.000-05:00

If the American principle of voting can best be described as "one man, one vote" (leaving aside that it ain't just men), I'd say there's a similar, though less well defined and understood, principle that applies to hospital medicine: one patient, one hour. That is, to do good medicine in a hospital-based setting, it takes a general internist, on average, about one hour to take care of a patient.

This may come as a surprise to anyone who has been hospitalized and seen a doc for about five minutes each day, but that hour applies to all the tasks required in caring for that patient. A doc's gotta review the vital signs, the med sheets, the nursing notes, the social worker and physical therapist's assessments, look up the daily labs, check the consultants' notes, and then come before the patient, examine them, answer their questions, talk to family members, set up a plan for them, and then write a note in the chart. Of course, individual styles may vary: I tend to enjoy spending time talking with patients and their families, but that slows me down, and I'm not highly efficient to begin with. Moreover, not every patient every day requires an hour, as the patient with uncomplicated cellulitis needs IV antibiotics, not a huge re-evaluation on a daily basis. But based on my experience and discussions with lots of hospital docs, the one-hour-one-patient "rule" is a pretty good predictor of the quality of medicine. Cut that amount substantially, and sooner or later a doc will make a mistake, whether it's an oversight in drug-drug interactions, a missed lab value, or a misunderstanding with a family about prognosis because a meeting between doc and family didn't take place.

So this past weekend, when I took to covering the "floor" patients as part of a moonlighting gig at a local community hospital, I was given a list of 14 patients at 7 am. I wasn't surprised very much when I left the hospital almost exactly 14 hours later. It took about a half-hour to divvy up the patients initially, and I took about ten minutes to wolf down a lunch, but the average time I spent was just under an hour for each patient, and by the time I headed home I felt I had a decent handle on what was going on with them.

Two particulars about this experience bear mention, however.

First is that a "census" of 14 is, based on what the full-time floor docs tell me, on the lower end of the spectrum, with typical numbers in the 18-20 range, sometimes higher. The reason for this is money, money, money. The docs at this particular hospital work for a for-profit company (as do I when I moonlight for them), a company whose stock is publicly traded and for whom profits are by definition their lifeblood. While I'm not making any comments on how the company is run and how they try to maximize profits and simultaneously provide high-quality care, I can give you an idea about the numbers.

In the northeast, where I work and where salaries are a little higher than in other parts of the country, a typical hospitalist (i.e. a hospital-based doc, though more on "doc" anon) costs a company around $250K per year when you add benefits, malpractice insurance, and administrative costs to the salary, which at least where I work is a touch under $200K. When you factor in reimbursements from patient care, all it takes is an accountant to figure out how many staff are needed to see so many patients on average and estimate the census size required for the company to make a profit at a given hospital. Since the company's reason for existence is profits, they are always trying to push the envelope with patient census, and shooting for a census of 20 (or higher!) keeps the company in the black. This article from KevinMD features the musings of a doc who once routinely had to care for forty patients a day--and he casually notes that he currently has a daily census of "maybe around 20".

Now, a non-profit hospital running its own hospitalist program also has a bottom line and still has to think about having its revenue stream cover its costs. But there's one difference, and it's a huge one: the need for profit. I haven't done a lit search to see if there are any articles looking at this, but I'd be willing to bet more than $5 that if you surveyed the average patient census of hospitalists working for non-profit hospitals versus for-profit companies, you would find a statistically significant larger census in the latter group. By how much, I don't know. But what I do know is that if you move an average census above 12-14, and if you ever move it above 18, you simply can't be a decent doctor. It can't be done.

(As this piece notes, two studies have shown that as census numbers increase, face-to-face patient time does not decrease, but the critical behind-the-scenes work of "documentation, writing order, and communicating with nurses and primary care physicians" does. For those interested in reading the primary academic literature on staffing requirements, you can see this article from 1999--it assumed an average census of about ten in making its calculations.)

The second item of note is that, while I was slogging away seeing my patients, I saw a brief verbal altercation between two of the younger hospitalists, neither of whom I knew. I ran this past one of the hospitalists with whom I've worked for many years and he shrugged. "Oh, X is mad because Y just left yesterday at noon and turned her pager off," he said. "Noon?!" I responded. To leave at noon, this doc saw fifteen patients in around five hours. That's twenty minutes per patient--and she was meeting all of these patients for the first time. That means she looked through the chart, reviewed the medications, saw the patient, wrote a note, and (a theoretical conjecture--I doubt it really happened) communicated with family members...all that in less than the length of a sitcom. Which is an appropriate comparison, since all one can do when confronted with such negligence is laugh. My heart goes out to this doc's patients and families. I hope she remains the exception in our profession.
--br

Is HuffPo Changing Its Science and Medicine Editorial Policy?

2012-01-06T17:14:00.000-05:00

Yesterday the Huffington Post ran a fascinating column in its Science section. Seth Mnookin, a science journalist and author of the book The Panic Virus (required reading for anyone looking for an introduction to the flim-flammy methods of the vaccine-causes-autism cult), commented on the role that responsible journalism has to play in educating its readers on science and medicine. "The fact that a specific story is controversial (or that it is promoted by a particularly outspoken celebrity) does not mean it deserves the oxygen it needs to survive", Mnookin wrote.

Such sentiments have been expressed before by Mnookin as well as other journalists and scientists. What made his dispatch so singularly stunning is that HuffPo has heretofore provided an electronic safe harbor for most well-known anti-vaccine cranks for the past several years. The website has granted a platform to an ongoing campaign of misdirection and misinformation about vaccines and its alleged link to autism, of which this article by Robert F. Kennedy Jr. is but one odious example.

As a consequence of this policy, Mnookin has, entirely appropriately, devoted much of his energy in recent years to hammering HuffPo for its irresponsibility and harm-inducing potential. (A terse encapsulation of his thoughts can be found in a brief blog entry where he notes, "Let me state very simply: HuffPo publishes dangerously ignorant dreck", and similar thoughts can be found here and here.) Thus, inviting Mnookin to hold forth on...well, basically anything constitutes a very profound shift in attitude.

Will this lead to wholesale changes at HuffPo? Hard to say. "It'll be interesting to see how this all plays out", says Mnookin, wondering if he was being played by the editors who could then claim that they were being "balanced" in their approach. If they are sincere, a good place to start would be to issue some form of retraction, as Salon did in its removal of a Kennedy-authored vaccine/autism piece, co-published with Rolling Stone, entitled Deadly Immunity. (Rolling Stone removed the story as well, but as noted here, they have not been as forthright in dealing with the criticism of their decision to publish Deadly Immunity as Salon.) We'll see what comes of it.

Also in the same vein, it appears that one of the main peddlers of nonsense about the vaccine-autism link, the now-thoroughly-discredited Andrew Wakefield, has decided to file a libel lawsuit in Texas against the authors of a British Medical Journal article published last year in which Wakefield was described as a "fraud". A similar type of lawsuit filed by Wakefield in the UK in 2005; Wakefield dropped the suit after the judge suggested that Wakefield was using the proceedings "for public relations purposes". As the linked article notes, a new law in Texas is supposed to discourage frivolous libel suits by placing a higher burden on the plaintiff than in years past, so the Wakefield suit should become something of a test case.
--br

Billy Rubin Blog Hero & Villain Of The Year (and Year-End Book Review)

2011-12-29T15:01:00.000-05:00

"It's an honor just to be nominated," crowed sex columnist Dan Savage in response to Andrew Sullivan's listing of Savage in his poll for the "Moore Award". Sullivan, in his Daily Beast blog "The Dish", has a variety of year-end awards, and his "Moore" award (named after the lefty agitpropster filmmaker Michael Moore) is for "divisive, bitter and intemperate left-wing rhetoric". Savage garnered a nomination this year, and has thus far worn that nomination like a badge. As of this writing, with just under 10,000 votes cast, Savage is comfortably in the lead with more than 58 percent of the vote in a field of ten candidates--a sum that Mitt Romney dreams about even more than Sugar Plum Fairies as we close in on the Iowa Caucuses. (What Simon Winchester, whose entire collected works I have nearly finished over the past few years, has said or written to be included in this group is unknown to me, but it must have been a doozy, since under normal circumstances one would not describe his utterances as remotely extreme.)

Savage's nomination came as a result of a dustup between him and soon-to-be-former-candidate-for-President Representative Michele Bachmann back in September during the Republican Presidential debates. At that time, Bachmann was indulging in one of her favorite political tactics in order to separate herself from her rivals and recover some of the mojo she had lost over the summer when she had been the darling of the party and led in the polls.

That tactic would involve departing entirely from reality and making up whatever stuff she deemed suitable to rile up sufficiently nitwitted partisans, as she did earlier in the campaign when she attacked Michelle Obama for advocating breastfeeding by supporting a tax break for breast pumps, turning the tax break into a right-wing fantasy that the government was "going out to buy my breast pump". In the September debate, Bachmann had decided to stake out the anti-vaccine territory to stick it to Texas Governor Rick Perry, who was then leading in the polls. In 2007, Perry had admirably issued an executive order mandating that Texas girls receive access to the HPV vaccine, a major cause of cervical cancer as well as other maladies. That order was later overturned by the Texas legislature, causing Perry to quip--correctly--that the bill's supporters were effectively killing women who would needlessly die from the cancer.

Not that he said it that bluntly, but he came close: "no lost lives will occupy the confines of their conscience, sacrificed on the altar of political expediency", was his rather eloquent retort at the time. Unfortunately, he may have wished he never uttered those words, as the HPV order came back to bite him rather fiercely as the primary season got more contentious and governmentophobic conservatives took a dim view of his actions. Bachmann, though, decided to go for the jugular, and took the almost-reasonable sounding "there are limits to government" argument and pushed much deeper into the Twilight Zone. At the debate, she merely parroted the usual lines about governments forcing people to do things against their will, but the following day, in an interview with the Today show's Matt Lauer, Bachmann noted that she had been approached by a mother who claimed that her daughter had "developed mental retardation" after receiving the vaccine, and asked the viewers to draw conclusions for themselves.

In response to this perceived bit of a politician's own mental retardation, advocacy groups rose up in unison to denounce Bachmann's position. "There is absolutely no scientific validity to this statement", wrote Dr. O. Marion Burton of the American Academy of Pediatrics. Doctors blogging on the subject blasted her, including one who chided Bachman for her "anti-vaccine porn". And a few bioethicists offered thousands of dollars to review the records searching for proof of the vaccine's harm. Bachmann, in the days to come, would disingenuously backtrack on the claim, noting that she herself never made a claim about the vaccine's harm, only that someone else had done so, in language and reasoning so slippery it invites comparison to any number of reptiles.

Enter Dan Savage.

Within two days of the blowup, Savage wrote a brief dispatch on the matter, noting that her "comments" on the HPV vaccine were much more accurately described as "lies". Then he let his savage pen loose, noting the following:

Bachmann and her ilk believe that woman [sic] who have sex—along with men who fail to purchase health insurance—deserve to die horrible deaths. That's why they hate the HPV vaccine, that's why they fought its introduction, that's why they tell lies about it now. Because they want women to die.

Presumably, Savage meant something more along the lines of "women who have premarital or extramarital sex". Regardless, Savage's characterization of Bachmann was unquestionably intemperate. It was obviously divisive. It was unambigously bitter. Thus, by Andrew Sullivan's criteria, an ideal nominee for his award!

Only one matter bears mention: Savage was almost certainly correct. And for that we name one of our favorite columnists, Dan Savage, for the Billy Rubin Blog Hero Of The Year, and his public foil, soon-to-be-just-Representative Michele Bachmann, for the Billy Rubin Blog Villain Of The Year. Happy 2011, y'all.
--br

PS--In other news, we've been catching up on our reading around here and want to give a special shout-out to the following books, most of which came out in 2010, but we're almost never that up to date on our reading until someone actually pays us to write this blog. Besides, these books will have a shelf life to come, so please do consider them if you want to read excellent books on medicine:

The Emperor of All Maladies--Siddhartha Mukherjee's phenomenal "biography" of cancer. Though the subject matter may seem intimidating and depressing, Mukherjee takes the reader along on a ride that is suffused with the insight of a great clinician, the wonder of a thoughtful scientist, and the humanity of a fine writer. For his work he won the Pulitzer Prize for general nonfiction, and appropriately so. (Readers wanting to delve further into cancer literature might consider watching a Japanese film that received almost zero attention in the US, 1778 Stories of Me and My Wife, detailing the struggles of a writer and his cancer-stricken spouse. Be forewarned, however, that it makes the phrase "gut-wrenching" seem inadequate. I watched it on a flight from Europe to the US, and by they end the Dutch people around me practically had to carry my sobbing ass out on a litter.)

The Panic Virus--Seth Mnookin's book about the vaccine-causes-autism movement. An excellent primer on vaccine hysteria, narrower in scope than Arthur Allen's Vaccine but no less important or readable.

Anatomy of an Epidemic--Robert Whittaker's compelling analysis of modern psychiatry, which I've written about before here.

Lipitor Goes Generic, and Everyone Wins...Theoretically

2011-12-01T07:37:00.001-05:00

I like to play a game with my med students, residents, and fellows--although really the game can only be played with residents and fellows as the students don't have enough medical mileage under their belts to fare well. I ask them this question: what do they think are the five greatest drugs of all time? After all, people routinely debate the greatest baseball player--I'm partial to Willie Mays--the greatest writer in the English language, the greatest movie, and the list goes on. Why not have a discussion about what makes a drug great?

So we talk about how drugs are used and what makes them good or not. I do this exercise to get them thinking about qualities that define particular drugs or entire classes of them, and why some may be preferable to others. Such qualities include "applicability" (i.e. how many people would benefit from its use, as Tysabri™ is an incredible drug that preserves quality of life, but only does so for people with advanced multiple sclerosis, a very small group), the magnitude of benefit (a drug that saves a life is more important than one that eases wrinkles, such as Botox™), ease of use, minimal side effects, and a proven track record (drugs that are new to the market often appear miraculous; most don't last, as the brief life of Xigris™ shows) among other things.

Lively debates ensue, but what I find most interesting is that the drugs that most housestaff end up agreeing on are ones that have been around a very long time and weren't developed by recent pharmaceutical company R&D programs. And by "recent" I mean the past 30 to 40 years. Aspirin may be the greatest drug of all, and has been around in its current form since the mid-19th century (and the active ingredient was found in folk remedies long before that); morphine and its narcotic siblings are likewise more than a century old; penicillin-class and sulfa antibiotics were developed before World War II; insulin was first used in the 1920's after decades of research; and beta-blockers were first developed in the 1960's.

That said, one class--relative teenagers compared to these elders--stands out, and one drug from that class stands out in particular.

The class of drugs are known as "statins", and the drug is Lipitor™, the signature product of Pfizer. Since its introduction in 1996, Lipitor has not only gone on to become a blockbuster drug--its total estimated gross is $100 billion--but has by any measure been proven to meet the definition of a wonder drug. It is reasonably safe, most people tolerate it, lots of people require it, and it saves lives. Lots of lives. It's usefulness has been proven over and over again in well-designed trials. Unlike so many other drugs, its initial promise has not begun to fade.

The biochemical pathway in which Lipitor and its fellow statins work disrupts cholesterol synthesis, but we're still learning about how it works its magic: other medications that lower cholesterol in different ways, such as ezetimibe (trade name of Zetia™), seem not to have the same benefit in terms of preventing heart attacks and death that the statins do. Moreover, while Lipitor wasn't the first statin to market, and there are six other members of the statin class, Lipitor has reigned supreme. This is due in part to a more profound reduction in "bad cholesterol" LDL and an elevation in "good cholesterol" HDL than others in the class, but also its "gentleness", as for instance rosuvastatin, whose trade name is Crestor™, lowers the LDL the most of any in the class, but does at the cost of more serious and more frequent side effects. (A useful consumer review on statins from Consumer Reports can be found here.)

Pfizer has seen an enormous windfall from Lipitor, and they have deserved every penny. It is, in other words, an "honest" drug: no ridiculous shenanigans, such as those seen in the marketing of the generally unimpressive drug Neurontin™ by the very same Pfizer corporation, or the introduction of the current #1 drug by sale, Nexium™, which is nothing more than a clever repackaging of Prilosec, whose patent was due to expire and would have deprived its maker Aztra Zeneca of billions of dollars. But today Lipitor is now open to the competition, as its patent expired on Wednesday, so generic atorvastatin can be made and marketed in the US, which should drop the price of atorvastatin considerably. Thus, although I make no claims to be an economist or an intellectual property law expert, it looks like the expiration on the patent of the greatest modern medical drug was a win-win for both consumers and the shareholders who brought the drug to market.

I say "looks like" only because Pfizer, as this article explains, still intends to protect Lipitor's brand name in some ways that defeat the entire purpose of the spirit of patent law. Some of their efforts, like direct mailings of "coupons" for lower copays for Lipitor, seem free-market legit. Others, however, have that unpleasant odor so frequently associated with Big Pharma these days. In particular, Pfizer appears to be cutting deals with so-called "Prescription Benefit Managers" to elbow out the competition. PBMs serve as third-party payers for insurance companies and administer drug formularies. Pfizer's goal in negotiating with the PBMs is to give Lipitor at a discounted price in exchange for the PBM not carrying other companies' generic atorvastatin, effectively cutting them out of large markets.

It is not an illegal practice, although I fail to understand how this benefits consumers tremendously. Nor does the CEO of Watson Pharmaceuticals, Paul Bisaro, who complained about Pfizer's tactics on CNBC's "Squawkbox"--not exactly the kind of haven for socialist ideologues. But the story is still in motion, the deals are taking place in the backrooms and boardrooms away from journalists, so time will have to tell about atorvastatin's future. Today, however, was a good day for medicine, for business, and ultimately, for patients.
--br

PS--we also note with great enthusiasm that Gary Schweitzer's Health News Review blog has adopted a new look. Go check out the makeover! It is among the most valuable resources on medicine, and comes awfully cheap.

Say It Ain't So, Joe

2011-11-09T20:15:00.000-05:00

The breathtaking arrogance of Coach Joe Paterno's statement that he would continue to coach the Nittany Lions football team can only be met with a dropped jaw. While confessing to being "absolutely devastated by the developments in this case", Paterno nevertheless states that he will soldier on as head coach until season's end. Astonishingly, he manages to shoot a specific barb at the Board of Trustees, presuming to offer advice that they "should not spend a single minute discussing my status. They have far more important matters to address."

No, they really don't, and for Paterno to even think to throw his weight around indicates, alas, his complete inability to comprehend the magnitude of his errors. At best a case can be made that Paterno acted within the legal boundaries of behavior when confronted with accusations that his longtime assistant coach, Jerry Sandusky, had forcibly sodomized a ten year-old child on Penn State University grounds. But no legitimate case can be made that Paterno behaved in any way that anyone with a moral compass would regard as humane or decent. How this man could possibly have the nerve to think about taking the sideline against Nebraska this weekend in light of the week's revelations about his appalling role in enabling Sandusky's predatory instincts, words cannot summon the outrage. He should be wearing sackcloth and ashes, begging anyone willing to listen for forgiveness for having allowed a monster to run amok for at least a decade. Instead, he swaddles himself in the cocoon of supporters who appear to think the Kool-Aid tastes quite fine, thanks, as he shoots off press releases without staring the disbelieving in the face.

Regardless of whether Paterno does indeed rally the Happy Valley faithful for one victory lap after having become the winningest college coach, this is an ignominious end for a fine man, one who was arguably the last of a special breed in big-time college football: the coach who saw his mission as shaping and educating the minds of young men as much as winning national titles. To distant admirers--and I count myself in that group--Paterno stood for something that I fear large Universities embody less and less with each passing year, namely, a commitment to principle. When the Jim Tressell scandal at Ohio State broke this year, nobody who had been paying any attention to the corrupt state of college football could really have been surprised, except that the ensnared head coach was one who wore sweaters and projected an image of integrity.

Like the rest of big-time college football, it was only an image, a fig leaf covering a morally bankrupt system. There was more than a hint of wink-wink nudge-nudge in the bouncy collegiate career of Cam Newton, who despite being involved in a cheating scandal at Florida nevertheless managed to finish his career leading the Auburn Tigers to the national championship. Somehow Newton managed to play for three colleges during his NCAA eligibility despite clear evidence to anyone willing to pay attention that he likely deserved expulsion from the first school, and behaved in a manner unbecoming any University in offering up his services to the highest bidder in what has since been called the "pay for play" scandal. (Two scandals for one college athlete--not bad!)

Compare this to the NCAA position thirty years earlier on running back phenom Marcus Dupree, who had left the University of Oklahoma in 1983 in an attempt to break with head coach Barry Switzer. The NCAA ruled him ineligible for two full seasons; Dupree's awkward attempted leap to the pros never panned out, and his claim to fame is being the subject of an ESPN documentary, The Best That Never Was. Such an action today, along with the so-called "death penalty" levied against Southern Methodist University, is inconceivable. Everyone is in on the joke, and most serious college football fans appear not to care terribly much. Even the Miami Hurricanes scandal, along with the shenanigans at Ohio State and the unsavory behavior of Newton, seems not to have made a blip on anyone's ethical radar screen. Yes, they get paid indirectly. Yes, a good chunk of them don't belong in college. So what? Let's talk about the injustice of the BCS rankings instead.

All of which is lamentable, but the Paterno scandal is different, as the look-the-other-way behavior (or, in the case of two senior Penn State officials, outright perjury) didn't enable some coddled athletes but instead led to little boys being raped. Several little boys--the count stands at nine who have come forward, and it seems reasonable to suppose that these are not the only nine. According to the Grand Jury report, Paterno had been told the explicit details of the rape of "Victim #2" when informed by grad student Mike McQueary in 2002. Moreover, one thinks that the Coach must have heard, at the least, rumors of some odd behavior of Sandusky in 1998 involving showering with a child. As Andrew Rosenthal notes while scratching his head, these are not the actions of a man who should be allowed to script his own exit, whatever sterling reputation he may have had previous to November 2011.

The ESPN columnist Rick Reilly argues that this story isn't really about Paterno, but I would beg to differ. Stories of pedophiles being caught, however grotesque, are not centrally important to the national news of the United States. But when powerful people in a revered institution give a free pass to a pedophile due to whatever inexplicable reasons tied to the success of a football team, that is a statement about not only the abuse of power by those people, but also the screwed-up priorities that gave such people that kind of power in the first place.
--br

PSA and the Embattled US Preventive Services Task Force

2011-10-10T08:34:00.000-04:00

The US Preventive Services Task Force is a teeny tiny little group of researchers, physicians and epidemiologists who can claim the privilege of issuing recommendations on a variety of health-related issues such as screening, counseling, and preventive medication use. They're meant to be independent of the Department of Health and Human Services so as to be as far from the taint of Washington politics as possible, but alas, they've had a habit of getting themselves into the spotlight in the past few years, most recently this past week with some new recommendations on the blood test that screens for prostate cancer known as the PSA (for "Prostate Specific Antigen").

I'm not blaming them for stirring the pot so much, mind you--the USPSTF's job is to evaluate the evidence for a given current health practice and decide whether that practice makes any sense. While that concept sounds simple in theory, it becomes exquisitely difficult to accomplish without wading into dangerous political waters in practice. It was just about two years ago that the USPSTF issued recommendations about mammography as a screening test for breast cancer: they advised that women between ages 50-74 should have mammograms every other year (unlike the then-current annual recommendation) and that women under 50 shouldn't have mammograms at all unless they were in a particularly high-risk group. This fairly understated document generated an enormous backlash (which I've described before here) and caught members of the Task Force by surprise.

But when you look at the numbers, the actual data that formed the basis of the recs, it's not hard to see that the Task Force was if anything being generous about mammography. I don't have the time to review all the data here but one stat may suffice. One typical mathematical model was used by the Task Force to estimate the number of lives saved versus the number of those who would go on to be diagnosed with possible breast cancer based on an erroneous read from a mammogram (these are known as "false positives"). In the model, if you annually screened 1000 women starting at age 40 and did so for 30 years, you would save eight lives. This came at the cost of one hundred fifty-eight false positive diagnoses, at least a group of which, presumably, would progress all the way to mastectomy and possibly even radiation or chemotherapy. If, however, you started the annual screen at age 50, you would save seven lives instead of eight, but you'd reduce the number of false positive mammograms from 158 to 95..."only" 95. (Again, the USPSTF advised against annual screens for women 50-74, and there are data that can be used showing a similar effect in the every-other-year scenario, but I thought these numbers were revealing.)

So when news came this past week of the new recommendations on the PSA screen, I wasn't completely surprised to learn that the panel--which, incidentally, is a different group of doctors than those who issued the mammography guidelines--advised against its use entirely. The evidence has been mounting for several years that PSA is a less than stellar test, and its interpretation can be especially slippery when the value of the test hovers just above the normal range. This leads to many false positive diagnoses with precisely the same problems found in the mammogram. Men with false positives sometimes undergo radical prostatectomy, a surgery that can leave one not only sexually debilitated but incontinent. The test works entirely differently than a mammogram but the principle of test interpretation and the problems of overdiagnosis remain the same.

Likewise I wasn't surprised to hear of a similar backlash against the Task Force and the exchanging of academic insult followed by counterinsult, or more heated comments outside the ivory tower walls. (One advocate for the PSA, the urologist Dr. James Mohler, described the chief medical officer of the American Cancer Society Dr. Otis Webb Brawley, a PSA skeptic, like this: "I have known Otis for over 20 years. He doesn't come off as being ignorant or stupid, but when it comes to prostate-cancer screening, he must not be as intelligent as he seems." That's about as close as one can get to saying, "hey, asshole, fuck you" in the subdued world of academia without actually doing so.) At the blog db's Medical Rants, a fairly innocuous post by db was met with at least one howl of indignation, with commenter Scott Orwig accusing db of being "irresponsible, unprofessional, and unethical". (db's follow-up post is here.)

Caveat emptor: I have not yet read the Task Force report so I don't want to take sides in this post. What I can say is that slogans impress me less than an explanation of complex data, and while the latter is less sexy and the former more emotionally comforting, it's usually an indicator of which argument is more likely to be right. In all the articles I've read so far, all I'm hearing from the advocates are slogans.
--br

When a Microbe "Eats" a Human

2011-08-19T16:48:00.000-04:00

There they go again. My guess is that the science & health "editors" at the major television media outlets felt a frisson of excitement when they heard of the deaths of some teenage kids exposed to pond or lakewater from an extremely rare amoeba known as Nagleria fowleri. Why? That's lot's of eyes of worried parents zooming in to their website and passing it along to other worried parents. It's good for the news business. ABC News's piece is here; CBS's story, with a link to a piece giving tips on staying safe, is here; MSNBC's take is here. Of the majors, only CNN appears to have taken a pass at the time I write this; at Fair & Balanced, the story is buried in the "Children's Health" tab here.

That the media Bigs love a good scare story, particularly with respect to some spooky infection, isn't saying anything new (and is discussed thoroughly in Marc Siegel's great book False Alarm: The Truth About the Epidemic of Fear). Suffice it to say that, depending on how you slice the numbers, thousands of American children die every year and that the three deaths so far due to Nagleria hardly indicates that we need to take all of our children out of the lake. Indeed, about a thousand kids die annually due to drowning, but this substantially larger problem isn't grabbing headlines and isn't even being mentioned as a comparison in the Nagleria stories to give some sense of proportion. Yes, lakes can be dangerous places: but mostly because teenagers drink alcohol and do stupid things on boats, not because a microscopic beast lurks underwater.

Which is actually what the Rubin blog is preoccupied with at the moment: the description of Nagleria. "Microscopic beast" is something of a contradiction in terms, right? Nagleria is smaller than a speck of dust and almost pretty to look at under a microscope. Beasts, by contrast, are big. They look scary! They have big, giant...teeth. And with those teeth, they eat. No surprise then, that a sensationalistic news item indulges in a little sensationalist imagery, as every one of the news stories above refer to Nagleria as a brain-eating amoeba.

But it's nonsense for the most part. Humans are, for Nagleria, what we call an accidental host: it makes its living by hanging out in the water feeding on tiny little bacteria. Yes, it does consume brain cells once it finds itself inside a human head, but to call it "brain-eating" just amps up the raise-the-hair-on-the-back-of-your-neck factor. Why not just call it "lethal", as it is almost universally so?

While we're on the subject, "flesh-eating bacteria" is--are you at all surprised?--likewise a misnomer. There is no particular species of flesh-eating bacteria, as it could be any number of bacteria. The most common bug to cause the condition of necrotizing fasciitis (the phenomenon that is caused by so-called flesh-eating bacteria) is from the family streptococcus, which lives harmlessly in the nasal passages, mouth and gut of humans. The problem isn't the bacteria per se; the real problem is when the bacteria manage to get deep into the soft tissues of the body (usually the legs, sometimes the arms, less commonly the trunk or face). In the upper layers toward the skin, bacteria have lots of physical impediments in their way to cause infection, and by the time they've lumbered along to a new patch of tissue, the immune system usually kicks in and clears the infection. We call that cellulitis.

In rare cases, though, these bacteria can dive deep and get down to an area called the fascia. Once there, there are no physical impediments, and the bacteria can move rapidly and make people incredibly sick very quickly, and typically the only "cure" is to filet the person's limb, take out the dead tissue, and hope that they survive. Often the affected limb needs to be amputated, and there's a high mortality rate. But there's nothing special about the bacteria themselves, although you wouldn't know that from seeing the news stories put out by the august organizations noted above.
--br

Media Overstatement on a Slow News Day

2011-08-18T11:36:00.001-04:00

Right now one of the lead stories at the NY Times website deals with a potential new "miracle drug" called SRT-1720. With heavy emphasis on the scare-quotes. The article's title, "Drug Is Found to Extend Lives of Obese Mice," might be generating a huge buzz on the obese mouse circuit, but beyond this, I'm puzzled as to why this story is given such prominence in the Paper of Record. You could even argue that the story is barely worth running at all, even if placed deep in the science section of the website.

Bottom line is that this is a very preliminary study of an experimental drug. Studies like this are a dime a dozen, and it turns out that lots of fascinating things can be done in mice, but most of the time those fascinating things either don't work in humans, or end up having unacceptable risks compared to the benefits. I don't mean to belittle the experiment--it sounds very exciting--but I'm not sure that it's ready for primetime among laypeople just yet. Could it be part of a bigger article talking about strides that science is making in the field of aging? Sure: that's what the TV show NOVA is about, among other forms of popular science media. But there ain't no miracle drug coming down the pike that's going to extend the lives of obese people by 44 percent. So time to bury the story.

I can't wait to see what Gary Schweitzer is going to do to this story in his HealthNewsReview Blog. Go get 'em!
--br

"Owning" a Patient & Other Quick Medical Thoughts

2011-08-06T22:16:00.000-04:00

a. The subspecialties of medicine each have their own slightly different personalities and subcultures, and although this is a gross overgeneralization I have long thought of surgeons--that is, general surgeons and their ilk, not orthopods or, say, urologists--as the Baddest Motherfuckers in the business. These guys & gals are the toughest & most reliable hombres: they work the longest hours and rightly take enormous pride in their work. When I was in medical school and a patient was admitted to surgery, the culture of the team was that nothing, absolutely nothing, would get in the way of caring for the patient--not sleep, not food, not any kind of distraction. Although I wandered down the internal medicine pathway, I have always admired the attitude with which surgeons owned their patients.

The word "ownership" is a term we use in medicine and while it sounds rather paternalistic, I have a fondness for it, as it signifies a kind of special level of responsibility. When you "own" a patient, it means that you consider yourself to be the most important of a team of doctors & nurses, that the buck stops with you. And as I've said, during my training I never saw a group that took ownership more seriously than general surgeons and their subspecialties such as cardiothoracic, colorectal, & vascular. At the risk of redundancy, these folks are tough.

Only I've seen some weird things happening at my academic medical center as well as at my little community hospital over the past year or two, and this week while attending as a consultant I witnessed something that I found quite surprising, and I'm wondering if that cast-iron sense of ownership is eroding amongst that hardcore group. I was asked to see a patient about a pre-operative infectious issue before the patient was due to get a mitral valve--should the patient be on antibiotics & if so how long, does the surgery have to go on hold, that sort of question. When I finished the consult I had my team get on the phone to talk to the intern, whom they dutifully paged. Only the intern who answered wasn't the surgical intern, it was the medicine intern.

"Wait, this lady's on the medicine team?" I said in frank astonishment. The patient had been admitted to the hospital specifically to get a valve replacement; that's purely a surgical issue. She didn't have a lot of medical problems that required an internist to be her primary doc in the hospital. And yet, somehow, she was sitting there on a medicine team with the cardiothoracic docs serving as consultants.

For laypeople out there this may be hard to grasp why this is a bad idea, but suffice it to say that you manage patients differently based on the kind of training you've had, as well as the kind of patients you care for. Surgeons are better taking care of patients undergoing surgery because, well, they do surgeries! And the surgical patient has a host of problems that internists don't encounter in the same way: fluid shift issues, mostly, which doesn't sound like much, but can be the difference between life and death if you misread the signals. This lady really did not belong on an internal medicine service, and search me as to why she was.

This isn't isolated, as I've seen pancreatitis patients, diverticulitis patients, cholecystitis patients all get turfed to medicine in the recent past. Some of these are borderline calls and could be taken care of adequately either way; some of these are what I would consider clear-cut surgical patients and I scratch my head when they are refused by the surgeon and sent to medicine (where I work, internal medicine does not have the luxury of refusing patients except in extreme circumstances).

Anyway, I'm happy to "own" such patients although I'm not sure that it's always in the patient's best interests for internal medicine doctors to be managing surgical cases. I'm also wondering if something's changed in the ethic of those surgeons whom I have held in such high esteem for so long.

b. Many months back I took my best shot at discussing a book before I had read it. The link, which can be found here, is a discussion about a book that had made a bit of a flap in the psychiatry community called Anatomy of An Epidemic by Robert Whitaker. Since I hadn't read the book, I did not venture to offer an opinion about it, but wondered about how the reviews framed what appeared to be a startling hypothesis: namely, that psychiatric drugs have, for at least a generation, made patients who suffer from psychiatric disease worse on the whole. Was the book worth reading? was my simple question, and I concluded it was and that I'd get around to it as soon as I could.

Well, I did, and my initial reaction is wow. Whitaker's book goes to the core of psychiatry and takes a sledgehammer to it, and he makes one hell of a powerful case that there's nothing behind the curtain. This is not the work of a pseudoscientific idiot who is raging against the machine; Whitaker supports his thesis by citing reputable scientific sources, and does so quite thoroughly. Unlike Celia Farber, an AIDS denialist who is short on facts and long on paranoia, Whitaker lays out his argument with the kind of precision and scientific grounding medical schools hope & pray they can impart to their students.

Whether Whitaker's contentions are completely right I cannot say; I just don't know the literature of psychiatry well enough. (A small quibble: I think he didn't portray Peter Kramer's excellent book Listenting to Prozac fairly, but it's been a long time since I read that book.) But he's without doubt persuasive, and has written a book that anyone who is seriously interested in the broad sweep of modern psychiatry should read. Next up on my reading list is Dr. Dan Carlat's Unhinged; the utterly awesome Dr. Marcia Angell, the former Editor In Chief of The New England Journal of Medicine and author of The Truth About Drug Companies, has a review about both books (as well as Irving Kirsch's The Emperor's New Drugs) in a recent New York Review of Books which can be found here.

Anyway, the point is simple: read this book.

c. Prior to her death, my only knowledge of Amy Winehouse was that she was a singer, and that her escapades with drug addiction were tabloid fodder. I had never listened to her music, but the comparison of her to Janis Joplin in the NYT obit, as well as the description of her as a jazz singer, caught my interest. I downloaded Frank and over the span of the next several days I heard her voice while driving to and from work, and suddenly shared in the collective frustration over a life that held such promise and exhibited such talent. I have not yet gotten around to listening to her signature album Back to Black, but I have become a fan.

Her place in music history is of course an open question, but even if I am blown away by Back to Black I think her troubles with addiction, which led to her decline and untimely death, will place her in that rank of singers whose talents we'll never really know. Joplin was the Times's point of comparison but I've spent some time thinking about Billie Holliday as I listen to her. Holliday gave more of her music to the world, surviving to 44 instead of Winehouse's 27, but she too represents the kind of talent that ventures too close to the flame. Match that against perhaps the greatest singer ever, Ella Fitzgerald, who kept care of herself her entire life (she died from diabetic complications, not drugs or alcohol), devoted it mostly to singing, and it's hard to listen to Holliday without some twinge of regret. Holliday in some way played the Charlie Parker to Fitzgerald's Dizzie Gillespie, the former dancing with demons on a nightly basis, the latter plugging away like a tortoise racing against a hare.

But Holliday, and Winehouse too, may have made the Faustian bargain of communing with the dark side in order to create their art, and it may not make sense at some level to shake our heads at their self-destructive recklessness. I love this clip of Holliday singing "My Man Don't Love Me" from a series that CBS television did called The Story of Jazz in 1957, two years before her death. (There's many things to love about this, actually: that one of the three major networks had a primetime series showcasing America's greatest and most serious artists; that Holliday is hardly the only important face in this ensemble, with a kind of Fania All Stars version of American jazz surrounding her like Coleman Hawkins, Lester Young, Gerry Mulligan and others; and that it's the last time Young & Holliday had a musical tete-a-tete before they both succumbed to their addictions.) The song is beautiful, but it's dark, jagged, and bloody; in short, it is the perfect song for Holliday at her peak. Would Winehouse have been able to step into that mix and take over for Lady Day? I think so. Would the First Lady of Song? I think not.

All of which is to say that Winehouse may have paid a price for her short-lived brilliance, but to judge that bargain as inherently wrong (or indeed, to understand it as anything other than a bargain) may be to fundamentally misunderstand her talents. I tell my med students when confonted with the peculiar vices of their patients: don't judge, just understand. Should we not do the same for Winehouse as her audience?
--br

Free-Market Capitalism and Death Panels: The Musical

2011-07-26T22:05:00.001-04:00

How long ago it seems. While we await the final negotiations in Washington to figure out some solution to the budgetary battles--which will likely produce a bill, endorsed by the President, that will be either "very right" or "extremely right" but will somehow be billed as "centrist"--we at the Billy Rubin Blog are feeling nostalgic tonight for those heady days of the summer of 2009, when a health care bill was slowly working its way through Congress.

Remember that? What passed for reasonable dialogue got hijacked by a very noisy rabble of Know Nothings, a group for whom the descriptions "willfully ignorant" and "anti-intellectual" are taken as praise, who screeched at town hall meetings and demanded that "government get its hands off my medicare". But the meme that took the cake at the time, the Chant Of Nitwits as it were, was that somehow the government was secretly planning to arrange "Death Panels," and the paranoia from the imbecilic mob sent the few remaining sensible Republican politicians running for cover and pandering to save their souls (as Chuck Grassley of Iowa did here).

Between the media, who largely buy into the myth of false equivalence that every story must have two equally valid sides and thus reported on the protests without pointing out the basic stupidity of the protesters, and the politicians, too many of whom were spineless in shouting down the nonsense, the silliness carried the day. The Obama administration backpedalled in the Public Relations game, giving up ground to its political foes (sound familiar?), and the consequence was that the country ended up with two presents. The first was a not especially progressive healthcare bill. The second was the Tea Party.

Which brings us up to the present, more or less. So what did ever happen to the Death Panels? Well, they never left, argues the massively awesome blog Health Care Renewal. HCR links Bloomberg News reporter Peter Waldman's investigation into the for-profit hospices now littering the landscape. It makes for grizzly reading. For instance, Waldman relates the story of former social worker Misty Wall, who alleges in a lawsuit against Gentiva Health Services, Inc. that she was "assigned to convince people who weren't dying that they were." (A spokesman for Gentiva said that the allegations predate Gentiva's ownership of the hospice at which Ms. Wall worked. She was fired from the hospice in 2005 for refusing to continue such practices.)

Perhaps even more troubling--and that is saying something--are the allegations that for-profit hospices gave "financial kickbacks" to "referral sources" (in English, that usually means money to doctors) and tied employee bonuses to "enrollment goals". This easily has the potential to induce some employees to move the goalposts a bit and encourage hospice for some patients inappropriately. How's that for a "Death Panel"?! No grim bureaucrats in Washington doling out the Number of The Beast, but rather a "Death for Dollars" in which the most successful recruiters walk home with a tidy cash sum at the end of the day, along with the corporation supervising it.

One notes more than a touch of righteous indignation as HCR writes,

There has been a lot of blather from politicians in the US about "death panels" in debates about health care reform. Many such politicians seem worried that the US government has or will have death panels under the new health care reform legislation. We have criticized that legislation for not addressing many important health care problems. No one, however, has convincingly demonstrated how its provisions would convene "death panels."

I couldn't agree more.

Lest I am misunderstood, hospice has been a tremendous step forward in American medicine. It allows people to die in greater comfort and with greater dignity than before. We need hospice, which is precisely why we shouldn't sully it by making it the object of some corporation's greed. But if people don't want their government involved in their health care, the business of dying will be overseen by for-profit businesses, and the Death Panels will be convened in elegant board rooms with oak tables, plush carpeting, and executives enjoying record salaries. Sound appealing?
--br

The Budget "Crisis" and Medical Residencies

2011-07-16T14:26:00.001-04:00

Among the more amusing tidbits of news that came out of the state government shutdown in Minnesota were pieces like this in which certain voters expressed outrage over the stalemate and demanded their elected officials to just "get things done". "They could have talked more, but they get their feelings hurt a little bit, and act like a bunch of little kids," said one frustrated citizen.

Umm....no. What we witnessed in Minnesota, and what the media is playing up in Washington at this moment, is not merely a bunch of squabbling children, even if there are some childish antics involved. The problem, in Minny as in Washington, is that you have genuinely, truly divided government, with huge blocs of both parties with irreconcilable views about the proper function and structure of government, and to expect them to arrive at agreements on operating costs totally misunderstands the ideology of these blocs. You can't simply expect them to "go and get it done" because there's no consensus on even the most basic roles of government.

Despite what some commentators have said about the current inter-party spats being just more of the same-old same-old, the different visions being fought over today really are much more substantive than any other political fight since the early 20th century. For instance, Richard Nixon and a Democratic-led Congress, while political foils, really did agree on the basics: yes, Nixon presided over some unpleasantries in Vietnam and Cambodia, and obviously sought to limit government in ways that Democrats didn't. But Nixon bought into the concept that government could play a role in preventing drag on the economy, so much so that he proposed a comprehensive health care bill not dramatically unlike the one the current President finally got passed, the hysteria over which led to the election of a House so radically different in philosophy from Nixon (Richard Nixon!) that he would have blushed. Given the budgetary concessions that President Obama has already put on the table, and his breathtaking capitulations since the arrival of the new Congress, the fact that the House "Hell No" caucus won't budge in the current debt-ceiling discussions is evidence enough that this is not just your ordinary political dust-up.

The point here is: if it really does come to pass that the US defaults because of the political stalemate, don't blame them--because the voters were the ones who put Obama into office, and then two years later not only seated an opposition party, but an opposition who would legislate against the sunrise if the President said, "the sun will come out tomorrow" in his increasingly grating Annie-like naiveté. It doesn't make any sense to elect a Democrat like Obama (even one as willing to adopt right-wing talking points as him) and then vote for Republicans further to the right than what even George W. Bush could have dreamed of. At least the voters of my home state of Ohio were consistent when they seated a right-wing executive and legislature in the most recent elections, and now have a new budget crafted by people with a very particular view of the role of government in the lives of its people. Let's see how that one works out for you guys in the years to come; as Chrissie Hynde of The Pretenders once lamented, "Hey, way to go Ohio."

Anyway, this blog is geared toward commenting on such political machinations in relation to the world of medicine (with a jaundiced eye befitting its name), and needless to say the world of medicine is going to undergo serious revisions if the Tea Party really does get its way and something resembling the Ryan medicare proposal (see here if you want to read warm fuzzies about it, and here if you prefer cold pricklies) becomes federal law. (Side note: I think there's a pretty good chance that our "Democratic" President is going to avert this "crisis" by eventually signing legislation that passes with either zero, or very few, Democratic party votes in the House.) And to that end, here are two stories (NYT and Boston radio station WBUR) discussing the huge impact that deep medicare cuts are going to have on teaching hospitals.

To help lay readers understand the structure, Medicare is the government-run health insurance program for senior citizens. While you almost certainly knew this (though obviously some people are not too quick on the uptake), what you may not have realized is that Medicare is also responsible for financing the postgraduate medical training in the US, which costs, give or take, a little over $6 billion per year, although a proposal that even Obama himself endorses would cut that amount by an estimated 60 percent. The feds don't pay residents directly, but rather pay the hospitals running the programs, which tend to be large, academic medical centers. These places may also get hit by a decreasing NIH budget to fund research at those medical centers, as this November 2010 article indicates current House Whip Eric Cantor's philosophy.

While places like New York and Boston are going to be hit disproportionally by major cuts to the residency training budget, you can bet that smaller places like Peoria, Illinois, with its 10 residencies affiliated with two local hospitals, will smart as well. In fact, as residency programs in smaller, more rural communities tend to serve as feeders of physicians who would otherwise not move to such places, the damage to residency training programs is going to reverberate well beyond the hospital parking lots, and have a good chance of doing so well into the future.

Perhaps this will all work itself out and the changes will benefit everyone; perhaps all that extra money from the taxes that nobody seems to be paying will give taxpayers more money to afford...well, afford something. We shall see, though hope (© Senator Barack Obama, 2008) is becoming as thin as gruel. Dickens would appreciate the consistency.

Republican Primary Maneuvering and Hypocrisy About Science, Writ Large

2011-07-11T17:45:00.001-04:00

I keep telling anyone who will listen that we all better get used to the phrase "President Bachmann" as the Republican candidate increasingly looks like a not-so-improbable contender for the nomination. Extreme though she may be, she doesn't come with Mitt Romney's troubling baggage of being both Mormon and the former governor of a liberal state whose signature legislation was the passage of a health care law remarkably similar to what nearly all conservatives refer to as "Obamacare"; she doesn't have to resort to a two-step to explain why she worked for President Obama's administration as John Huntsman does; she is a good deal more media savvy than former Alaska governor Sarah Palin; and she isn't Newt Gingrich. I'm no political expert, but in the age of the Tea Party dominated Republican primaries, I see her as having a legitimate shot, with her only substantive competition being former Minnesota Governor Tim Pawlenty, unless current Texas Governor Rick Perry gets into the mix. Maybe I'm misjudging Romney's chances, but I'd call Bachmann the favorite right now.

Representative Bachmann certainly has no fears about wading into controversy, and in doing so making herself a darling of the extreme right. Earlier in the week she became the first candidate to sign a pledge for the protection of marriage entitled "The Marriage Vow: A Declaration of Dependence on Marriage and Family," which as the NY Times noted in a blog post, puts her rivals--at least some of whom do not have such distinguished marital records themselves--into a tricky position. In a fairly short time, "The Marriage Vow" has managed to generate an uproar over whether or not it explicitly endorses banning pornography (it doesn't, as noted here); its not-so-subtle racism, as discussed here; and its religious fanaticism (see, for instance, here). In short, it highlights all of the qualities most commonly associated with the rightmost wing of the Republican Party, and quite possibly the group best positioned to put a candidate over the top for the 2012 nomination. And Bachmann got there first.

So let me pile on here and point out that one of its additional hypocrisies involves science: as part of the rationale for why the "Institution of Marriage in America is in great crisis," the Vow argues that "[the debasement of marriage continues due to an] anti-scientific bias which holds, in complete absence of empirical proof, that non-heterosexual inclinations are genetically determined, irresistible, and akin to other traits...as well as an anti-scientific bias that holds, against all empirical evidence, that homosexual behavior in particular, and sexual promiscuity in general, optimizes individual or public health." [my emphasis]

There's a lot to unpack in that pile of nonsense but here's a start: whether "non-heterosexual inclinations" are indeed genetically determined is an open question, but to say that those who posit the theory are "anti-scientific" and are making such assertions "complete absence of empirical proof" is patently false. The neuroanatomist Simon LeVay (author of the fascinating tome Queer Science--it proclaims its allegiance right on the cover!) pioneered studies on differences in brain structures between heterosexual and homosexual men, and while I'm skeptical of the results or even the meaning of the findings, there's no question that LeVay's work constitutes science--the empirical testing of hypotheses about the mechanisms of the world. He's hardly the only example, and the literature of scientific publications is rife with tests, theories and arguments about the origin and nature of human sexuality. Nobody's got a definitive answer, but The Vow label of "anti-scientific" is really just tossing out a phrase to make itself seem respectable.

An additional yuck can be had from the fact that the author of The Vow, Bob Vander Plaats, is...well, typically anti-scientific in his fundamentalist Christianity! While running for the position of Lieutenant Governor of Iowa, Vander Plaats endorsed the teaching of "intelligent design" as an adjunct to evolution. As the redoubtable Tara Smith at the blog Aetiology points out, intelligent design isn't a scientific theory at all, something even some of its proponents realize. The casual disregard for critical thought appears to be part and parcel of the document, so a disregard for science shouldn't really be a surprise. Nor should it be a surprise that Bachmann immediately signed on to it.
--br

PS--today's Times has a fascinating article on how some schools (including Billy's medical alma mater, the University of Cincinnati!) have changed their admission interview strategies in the hopes of finding future doctors who are better team players than those who may have stellar grades but are arrogant & condescending (and who in being this way may foster poor communication leading to medical errors). I ran this past a senior colleague who works on a med school admissions committee and he seemed skeptical: "what you do in your life = what you say in a mini-interview; however, grades = long term commitment" was his quick response. Count me tentatively among those hopeful for the new system.

Jack Kevorkian: Goodbye, Good Riddance

2011-06-05T10:05:00.002-04:00

The news of Jack Kevorkian's death brought out a large number of laudatory comments in The New York Times (laudatory about the man rather than his death, natch). "I hope that one day the world will look back on the service Dr. Kevorkian provided and will be shocked and saddened to learn that he was ostracized and incarcerated for the practice of providing dignity and some control to those in the late stages of terminal illness," SteveBnh of Virginia wrote in a representative sample of the praise heaped on the crusader for physician-assisted suicide.

Count me among the ostracizers. As the warm comments from seemingly well-informed readers demonstrates, Kevorkian was widely perceived to be a fierce advocate for patient's rights, a promoter of death with dignity, and the victim of a hypocritical and vindictive profession hellbent on maintain its Godlike power over patients. His trial, conviction, and imprisonment in 1999 for second-degree murder has the flavor of martyrdom, reinforcing the admiration of his followers and inviting comparisons to various legendary civil-rights activists.

In reality, Kevorkian was none of these things, but rather a creepy zealot obsessed with death who knew nothing about actual patient care. (I am not using the word "creepy" lightly; read on.) Although he was trained at a bonafide medical school and thus was a "doctor" in the general sense of the term, his training and subsequent practice was in pathology, where his work involved autopsies and analysis of human tissues on slides rather than actually taking care of living, breathing souls with joys and fears--making his public persona as "doctor" a bit misleading, as if he were the same as Marcus Welby, M.D. Kevorkian's nickname, "Doctor Death", didn't come from the notoriety he generated in the 1980s and '90s, but rather from perplexed and amused housestaff during his early days in a wry observation about his peculiar fixation on photographing patients' eyes at the precise moment of death. (Various blogs and websites supportive of Kevorkian state that this is because he wanted the profession to be able to distinguish the moment so that resuscitation could be performed, or something to that effect. It's utter nonsense: even in the 1950's, which some might consider the Dark Ages by medical standards, there were EKGs, a considerably more precise tool to determine death than staring into people's eyes, which seems positively medieval. Whatever his stated justifications, his "death photography" was pure fetish.) Long before he took up physician-assisted suicide as his cause, he bounced from hospital to hospital, disturbing various medical staffs with his distinctly unconventional preoccupations.

He was praised for his compassion despite the fact that he had not only not taken care of living patients except during his internship, but had never received any training of any kind in treating patients with depression (common enough among the terminally ill), palliative care, or any of the diseases that he claimed to treat. His choices reflect this very poor training: among the 130 or more cases in which he was the prescriber of death, several had no terminal illnesses nor were suffering, such as the case of Janet Adkins, who had been recently diagnosed with Alzheimer's disease but aside from mild memory loss was in otherwise reasonably good health.

Even more disturbing were the reports of the death of Judith Curren, a 43 year-old woman who not only didn't have a clear-cut underlying disorder, she had reportedly been a victim of domestic violence. These are not the only cases, but even the inclusion of these two suggests at best a sloppiness in methods, and at worst a murderous instinct hidden under the guise of medical concern for suffering. ("How could I have known?" was Kevorkian's retort after being confronted with the news of the messy life of the Curren family. Perhaps if his only acquaintance with them had not been through a questionnaire, and had been based on caring for Judith Curren in a legitimate medical practice for several years, such surprises wouldn't have popped up.)

In short, Dr. Kevorkian-the-Caring was a total media fabrication. He was a murderer, and if anything was treated gently by the justice system.

Other, far more responsible doctors have spoken out in favor of physician-assisted suicide--doctors who personally knew and ministered to their patients before taking the terrifying power into their hands and helped patients end their lives, doctors who gave such power its proper due, only arriving at that moment after slow and careful deliberation, wholly unlike Dr. Kevorkian's quickie-in-a-Volkswagen butchery. Perhaps the most famous of these doctors is Timothy Quill, a practicing doc in New York who challenged the ban on physician-assisted suicide in the State of New York which was ultimately decided by the US Supreme Court; the court decided 9-0 against Dr. Quill. Even Quill, as forceful an advocate for physician-assisted suicide as could be, found Kevorkian's behavior troubling, saying that he "is very much on the edges of what ordinary doctors do."

I have heard Timothy Quill speak on two occasions and found him an eloquent man whose concerns are ultimately for the health and happiness of his patients. That said, I still believe that physician-assisted suicide is a terrible idea. Ironically, the two times I attended lectures by Dr. Quill mark dramatic shifts in opinion I have had on the subject: the first time happened before I started medical school and was strongly in favor of his ideas, while the second time was a few years ago, after I had undergone more than a decade of medical training, and my attitude had changed considerably.

Generally, the discussions about physician-assisted suicide revolve around two themes. The first is what bizzyblog refers to as "the euthanasia theme song," or having a life that is not worth living. The second deals with the scenario of unbearable and unremitting suffering, which the supporters of physician-assisted suicide regard as the ultimate justification for the practice. This is often where the accusations of "doctors playing God" come in--docs are so invested in keeping people alive that they consider it a personal affront to allow patients to die. (In general, my experience has been the opposite, not withstanding the rather regrettable final few days of my father's life, in which we attempted in vain for several days to have his life-support removed after an episode of sudden cardiac death. Based on what I've seen, it's usually the doctors, and not the families, who see little or no value and much suffering in store for families and patients with terminal illness requiring intubation, PEG tubes and the like, and often have difficulty explaining to families the benefits of "letting nature take its course.")

It turns out that, not unlike the public misperceptions of Dr. Kevorkian, the picture of frequent, unremitting suffering of the terminally ill is for the most part a fiction. Curiously, over the past 20 or so years attitudes about physician-assisted suicide and euthanasia haven't changed a great deal among the general public or physicians in general (those numbers are different from one another, but stable over time). However, one group in which attitudes have changed significantly is among oncologists, who have had a steep drop in approval for those practices.

Why? It's hard to say with complete certainty, but it's likely because oncologists are more aware of, and tuned into, the multiple ways in which terminally ill patients can remain pain-free and finish their lives with meaning and dignity, to paraphrase the article in the link. A telling statistic: among oncologists, surgical oncologists, who deal with the long-term care of their patients far less often, were twice as likely to support physician-assisted suicide as their medical oncologist colleagues. In other words, the further away one gets from the actual practice of death and dying, the greater the fear of pain and suffering among laypeople and physicians alike, and the corresponding increase in support of physician-assisted suicide.

As for judging whether a life is worth living, that's much more straightforward. Physician's have no business judging the worth of any of their patients' lives. That is playing God.

It is not hard to kill onself in the US: over 30,000 people do it each year, and do it in a multiplicity of ways ranging from relatively peaceful to gruesome. And while there are technically laws on the books against suicide and no Supreme Court recognition of a "right to suicide," the practice is tacitly accepted. Suicides are allowed to be buried with everyone else, and the state does not seize their assets. So given the ease by which people can commit suicide, the debate around physicians being involved in the taking of lives has increasingly for me had an odd ring about it. Why must physicians be present to sanctify this process? It has the feel of approval-seeking, and docs shouldn't be in the business of approving or disapproving anything about a patient's lifestyle, except maybe smoking. Even then: maybe.

Doctors cannot take lives; it's not our job and should never be so. If we administer comfort medications that may hasten death to a suffering patient as a side effect, that is more than acceptable. If doctors withdraw tubes or machines that "artificially" keep patients alive, that's fine as well. But there's a big difference between maintaining a morphine drip and injecting a bolus of potassium chloride into a patient. The former is a drug with legitimate medical uses; the latter is never used under any conditions except to kill. Morphine is an everyday drug in hospices across the US; the potassium bolus was a "medication" unique to Dr. Kevorkian. May there never be another one like him again.
--br

Racism--The Gift That Keeps On Giving

2011-05-05T22:44:00.017-04:00

My philosophy of bedside medicine is founded on trying to be aware of how patients view the world well before I bring that quarter million-dollar scientific education to bear upon their problems. I've met docs who can form a differential diagnosis with greater length, and in faster time, than me, but I've also observed a lot of docs of that ilk who don't have a clue about how to use their stellar clinical acumen to explain to patients what they are thinking. This inability frequently leads to all sorts of problems for patients and their families, either because they are anxious and don't understand what is being told to them, or because they don't understand instructions and are afraid to ask out of a desire not to appear stupid. Being simultaneously intimidating and clueless can have lethal consequences, even when a doc is just as smart as House.

Put yourself into their shoes, I tell my med students, think about how they're feeling when you're talking to them before you start with the technical talk. Imagine, I say to them, how it feels to be lying there, usually half-naked, while an army of White Coats is standing there at your bedside, looking down at you, speaking in a language that sounds vaguely like English but makes no sense at all. (See this clip here, for instance, from the British TV miniseries The Singing Detective, which illustrates this in simultaneous hilarious and exquisitely painful detail. I mean it--follow that link, team! Not only is it a fantastic, biting satire of academic medical culture, it features a much younger Michael "Dumbledore 2" Gambon as well as Imelda "Dolores Umbridge" Staunton. And though made in the 1980s, the medical language--indeed, the medications!--hasn't changed much.) One thing Billy always does when seeing his hospitalized patients is to sit in a chair at patient's-eye level, and if no chair is present, then he gets down on his knees to communicate. It's symbolic, but I think it means a lot.

Being exposed and vulnerable is a universal condition of patienthood, but there are other factors that influence the physician-patient interaction as well, and race is one of the biggies. I don't believe that every interaction between black and white Americans has to "devolve" to race by necessity, but I sure's hell think that it's something to be aware of when you step into a room as a white doc with an African-American patient. I, nor any of my ancestors, were ever involved in any overtly racist act, but that doesn't mean that I shouldn't at least be cognizant of the fact that African-Americans often are leery of white docs, and not unjustifiably so (more on this in a moment).

Race was on my mind today as I listened to a fascinating lecture about blood transfusions. Most Americans have at least a vague understanding that there are 4 major blood types (A, B, AB, and O) each of which can be described as "Rh positive" or "Rh negative"--thus 8 blood types in total. In order to have a blood transfusion safely, these types must be matched to prevent immune responses. The blood types are distributed across all races making "universal" transfusion a generally easy process. (Though some readers may recall an episode of M*A*S*H* taking the topic of race and blood head-on, when a white GI needing surgery tells the surgeons not to give him "any of that black blood"--no doubt reflecting the attitudes of real people in the 50's, when the scene was set, as well as the early 70's, when the episode was filmed. Plus there's the cultural convention in many Asian communities, especially in Japan, that the ABO blood types correlate with personality, and Japanese are even more keenly aware of their blood types than Americans are of, say, our zodiac signs. So we haven't eliminated this brand of nonsense from humanity just yet, but we're getting there.)

It turns out that the ABO and Rh+/- system is just the beginning, and the immune response to blood is a good deal more complicated than this. But in the majority of cases the model of eight blood types is sufficient to save people with the magic of transfusions. (This assumes that people have ready access to blood, which they often don't, for instance, in many northern Mexican communities, as described here, but in the US that's almost never a problem.) The exceptions to this, where patients have to have a host of other blood cross-typing done, are frequently found among patients of African ancestry, in particular among those who suffer from that quintessentially African disease, Sickle Cell Anemia. Whether this is due to the inherent genetic variation in Africans, or whether it's a process of sickle cell disease, is not fully clear to me, but from a clinician's standpoint it hardly makes any difference. Patients who have requirements beyond the eight common types need to be cross-matched for special blood, sometimes very rare blood indeed. One patient under discussion in the lecture today essentially had only one person who was known to have blood that she could accept--in the entire world. And since that patient's donor (a close relative) was still a child, not so much a help.

Anyway, the likelihood that you'll get a match for that special blood is increased if you have a large pool of donors who more closely resemble you genetically. Meaning: from your ethnic or racial group. So Africans and African-Americans--who constitute a major if not the major group of people with these rare reactions to blood transfusion--are the ones most in need of blood donors of African ancestry. And there's the rub, because African-Americans are far less likely to donate their blood, at the rate of 25 to 50 percent the rate of blood donation among whites. This is very much unlike the situation in a group of transfusion-dependent diseases called thalassemias, which sometimes afflict people of African descent, but more often are seen in Caucasians, who have a much larger pool of donors from which adequate matches can be found, and so there are far fewer transfusion crises and dilemmas.

Why is this? Well, if you don't think that American history, filled with its pernicious racism, is grasping with its fetid hands our modern system of blood donation, then you're missing just as much as the brilliant-but-clueless docs I've described above. Leave aside slavery and all of its ill consequences alone for a moment--just consider the treatment of African-Americans at the hands of doctors, some of whom were employed by the Federal Government of the United States, as they were prevented from being cured of syphilis or bombarded with radiation without awareness or consent. Or the story of Henrietta Lacks, whose ultimately fatal cancer cells became the first human cells cultured outside of the body, remaining the workhorse cells for biomedical scientists to this day, a major source of commerce in the scientific world, worth billions of dollars, while her descendants struggle to afford health insurance.

Think about that while you swallow the statistic on the poor rates of blood donation among African Americans when your next sickler needs a transfusion. Does blood donation cause syphilis? No, of course not--but would you trust a system that had treated your brothers and sisters like this for generations? As the Tuskegee Syphilis Study Legacy Committee Report wrote in 1996: "the [study] continues to cast its long shadow on the contemporary relationship between African Americans and the biomedical community."

Indeed. It has not only done that; it has cruelly deprived some members of its own community the lifeblood it so desperately needs. This is why doctors need to be as aware of history as they are of science.
--br

Government and Medicine: Legislative and Judicial Follies

2011-04-27T21:52:00.000-04:00

I try--I repeat, I try--to construct eloquent blog posts as often as I write them, taking care to choose my words as I tiptoe through the minefields of cyberspastic hyperbole and vitriol. That said, I could do little more than utter "blech" at this news piece that the Massachusetts State House has voted overwhelmingly, as part of an "economic development" bill, to repeal a ban on gift-giving from pharmaceutical companies to physicians that had passed in 2008. For those who have been trapped in solid ice since, say, the mid-1930s and the heyday of the Henry Cabot Lodges and William Morgan Butlers, in Massachusetts, the House belongs to the Democratic party. So how does such a law that seems to once again encourage the wink-wink nudge-nudge relationship between docs and the pill-pushers--particularly when the same legislative body clamps down on labor's bargaining rights in an effort to rein in spending costs--get passed?

Amazingly, the answer appears to lie in...the dining & entertainment lobby. According to Garrett Bradley (D) of Hingham, the sponsor of the measure, the ban stifles business, hurting convention centers and "restaurants where companies typically hosted physician events and dinners." (NB--the quote is from the article, not a direct of Mr. Bradley, though I doubt he'd quibble if the line were attributed to him.) Never mind the fact that this sector of the Massachusetts economy appears to be doing reasonably well, with an increase in overall revenue compared to last year, the measure's backers appear to be saying that it's perfectly fine if a payola-style arrangement is in place, as long as the palms continue to be greased and the filet mignon gets served with the Cabernet.

Blogger-doc Dan Carlat has already staked out the Swiftian rhetorical territory with a delightful skewering of the follies, leaving me and others to play the straight guy. So here goes my best effort: no self-respecting physician compromises the health of his or her patients by allowing themselves to be manipulated by claptrap. There is ample evidence that gift-giving induces an attitude of reciprocation, lucidly-but-luridly described in such books as The Truth About Drug Companies and White Coat, Black Hat, regardless of the actual quality of the product, and that drug reps know this and seize on the vanity of physicians to play them for dupes. Drug companies, however beneficial their societal effects may (or may not always) be, have a responsibility to shareholders, whose primary or sole interest is in the generation of wealth. To anyone in any state of mind other than that of abject denial, this is a primary objective that is in direct conflict with the caring of patients. Thus, doctors cannot accept gifts of any kind from those whose job it is to sell drugs.

A related theme is being played out in the judicial branch of government, as the US Supreme Court is hearing arguments on a Vermont law that bars the commercial use of physician prescription patterns. Based on the early returns, and noting previous Court decisions that take a fairly broad view of "free-speech" rights (at least if you are a corporation), it appears that the law is destined for being overturned. I can't claim to be a legal expert and thus won't even begin to take a crack at the wrangling over the First Amendment, other than to note a certain puzzlement at what passes for "free speech" these days among the Court's "strict constructionist" wing. Did the Founding Fathers really have the selling of a doctor's prescription habits in mind when crafting the First Amendment? I'm thinking not, but I await the peals of derision from my philosophico-legal foils (and loyal readers!) such as Ted Frank, a conservative maverick (I'm not sure if "conservative" is the right word for him; I'm certain that "maverick" is) and who ranks as the second smartest person I have ever had the pleasure of knowing in my life. (And in case anyone might misunderstand, I'm not implying that I occupy the top spot; I doubt I crack even the top 75, and I don't have that many friends.)

Regardless of the legal principles at stake, Chief Justice John Roberts made his contribution to the follies by appearing to frame this as an argument of "restricting the flow of information to doctors," as silly a line that can be uttered in such an august house as SCOTUS. How would withholding prescription info from drug companies prevent them from making their pitch for their drug? How does this even remotely "restrict the flow of information"? The naivete exhibited by the Chief Justice is pretty remarkable (and shared, without surprise, by Justices Scalia and Kennedy). The "it's all data, it's all protected by the First Amendment" argument seems to only work when big business benefits, but not the other way around. The recipe to Coke is just data, too; somehow I don't think the Coca-Cola Corporation considers that to be something that your local Joe can just barge on in and demand. Pray tell, what's the difference?

A hat-tip to Carey Goldberg at WBUR's Common Health Blog, especially for her humoring me in my response of "blech"!
--br

Fukushima Daiichi, and the Perception of Radiation Risk

2011-03-23T21:21:00.003-04:00

Evolutionarily speaking, we are as a species hardwired to analyze risk based off of information that's directly in front of us--immediately accessible to our five senses. We're designed not to trust food that smells funny, can instantly calculate how far away we should stay from large cats capable of having us for a snack, and do a host of other things that were very useful for us to eke out a living in Olduvai Gorge.

But we live in the 21st century, and nowadays our ability to perceive and estimate risk is hampered by the fact that many of today's risks are abstract, and require a resonably sophisticated understanding of statistics. Take, for example, a recent discussion found in the Paper Of Record about income distribution in the United States. True--it's not really a round table about "risk" per se, unless you consider radically unequal wealth distribution to be a risk to democracy, as Supreme Court Justice Louis Brandeis did when he said that "we can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can't have both." Still, the NY Times roundtable was remarkable in that all of the contributors, whether approaching the issue from a left or right viewpoint, agreed that most Americans had vastly underestimated how much wealth is held by relatively few. In particular, a study by Michael Norton and Dan Ariely found that not only do Americans think that wealth distribution to be significantly more equitable than it actually is, but that they would prefer it to be even more equitable than what they (wrongly) perceive.

If this isn't a classic example of what George W. Bush would call "misunderestimation" then it's not clear what is, and moreover, it highlights the difficulties people have in making accurate estimates about things like the distribution of wealth in a hugely complex society: the information simply cannot be found by opening your eyes and looking around. In medicine, we see this all the time: people are often terrified of exotic diseases that pose little threat to them, while being utterly blithe to the daily assaults on their bodies--frequently self-inflicted--that are much more likely to send them six feet under. To wit: drinking, smoking, eating poorly and not exercising.

The recent events at the Fukushima Daiichi nuclear power plant have been a case study in this process of risk assessment, and not altogether surprisingly, we haven't done well collectively in harmonizing our level of panic to the actual threat that the reactors pose. Despite a good number of depressing news stories, some cataloging evasive action by non-Japanese governments, it is far from clear how huge an impact the nuclear accident is going to have. While it is already comparable to the Three Mile Island accident in 1979, and is not (yet) as catastrophic as the Chernobyl accident of 1986, the question still remains: just how dangerous is it? Though the story is far from over there with events taking dramatic swings in short periods, the short answer is something like dangerous, but not as dangerous as you think. Not nearly as dangerous as you think.

That point is neatly illustrated, both in sound and visual format, in this news story from Adam Ragusea of WBUR (Boston), and is described as the "Dread-to-Risk ratio" by Andrew Revkin of the Dot Earth blog at NYT. Both pieces have the same useful graphic to give you some sense of the relative levels of radiation that we're talking about. Live within 50 miles of a nuclear power plant for one full year? That will give you about 0.1 microSieverts (uSv) of radiation. (What a Sievert is, is a longer discussion, but we'll just shorthand it here and say that it's some relative value of radiation, and that the higher the number, the more dangerous it gets.) One flight from New York to LA buys you about 400 times that amount (40 uSv). That's not even the round trip! A standard chest x-ray, meanwhile, is worth about 20 uSv. But a mammogram is a whopper, clocking in at 3 milliSieverts--thus about 150 "standard" x-rays and just under forty roundtrip flights from NY to LA. A CT scan can be worth almost twice the amount of the mammogram (5.8 mSv).

(In case I've lost some people on this micro/milli distinction, you need 1000 "micros" to make 1 "milli." I'm going to flip back and forth but will point it out when I do.)

So how do these numbers stack up to the nuclear disasters? If you lived within 10 miles of the Three Mile Island plant during the accident and didn't make a run for it, the total dose of radiation you received was 80 microSieverts--far less than one mammogram. By contrast, one area near the Fukushima plant recorded a total dose in one day of 3.6 milliSieverts: less than a CT but more than a mammogram, though of course we're only talking about one day's worth of radiation. With Chernobyl, the radiation levels fluctuated wildly both in time and place so making a general statement about the radiation is essentially impossible, but had you been moved by some weird spirit to take a stroll on the grounds just last year, about 25 years after the accident, you would have gotten two mammograms' worth of radiation for your troubles: 6 milliSieverts. I won't reproduce the pic here out of respect for copyright but highly recommend it to anyone with the time; Ragusea of WBUR translates this into a tone equivalent, and the radiation from TMI is a blip, while the sound for "mammogram" is substantially longer.

I draw two conclusions from all of this. First, while the troubles at Fukushima are by no means trivial, and for that matter aren't yet finished, I think it's a bit premature to write the obituary for nuclear power. In terms of accidents, it's not nearly as dangerous as most people suppose. The problem with nukes, in the TMI and Chernobyl age as well as today, is what to do with the radioactive waste generated by the plants rather than the risks they pose viz. accidents. Second is that we should try to minimize mammograms! Do only the amount that will help save lives, and not one more after that. This was the logic behind the recently revised US Preventative Services Task Force, which recommended no mammograms to women under 50, and biannual ones to those over. Despite this entirely sensible approach--based on good research with a careful eye toward the risk/benefit ratio of the radiation, it should be noted--there were howls of indignation from people purportedly speaking for women, accusing the very bureaucrats who issued the new recs to be female-hostile, or something like that.
--br

(NB--the first draft of this version, which snuck out prematurely, posted some incorrect calculations with respect to x-rays, mammograms, and NY-LA flights. The corrected version is now present.)

The "Back-Door CD4" and Its Ethics, or Lack Thereof

2011-03-21T20:28:00.002-04:00

Every year, virtually every first-year medical student gets introduced to medical ethics by learning about the quirky religious beliefs of a small Christian sect: Jehovah’s Witnesses. Based on their interpretation of a passage from Leviticus, Jehovah’s Witnesses consider blood transfusion to be against God’s word, and will thus not accept them, even if their life depends on it. Medical students are introduced to this situation as the classic example of how an American physician is supposed to behave: it don’t matter what your personal beliefs are with respect to the Witnesses, only that you accept their right to their beliefs and, if need be, protect them, defend them, and do whatever else is necessary to let them decide what to do with their bodies. We call that concept informed consent, and it’s the basis of most serious discussions about life-saving medical care in this country. (Of course, I'm talking about adults here; with kids, the situation gets stickier, and with adolescents, stickier still.)

In theory, informed consent is the process by which patients take the reins and make all the genuinely important medical decisions for themselves, while docs serve as something like advisors. Needless to say I’m not talking about the minutiae of medical decision making, like whether to switch a patient from amlodipine to atenolol, but rather the stuff that most patients worry about when they (or their loved ones) walk through the hospital doors: do I want to be resuscitated? do I want to have “everything” done for me? can I refuse some procedures the doctor recommends? These are precisely the kinds of questions where we, as physicians, have an obligation to help patients and their families figure out what they want—that is, not impose on them what we want—and guide them as best we can, even if, indeed, especially if they make decisions that we find shortsighted or wrongheaded or both.

That’s the theory. Fortunately, in terms of practice, most of the time I think we physicians do a pretty admirable job of supporting our patients. You would be hard pressed to find a doctor who thinks it’s acceptable to override the beliefs of a Jehovah’s Witness and force-feed them blood to save their lives. That said, while the core of that philosophy is wholly adopted by the profession, precisely where the boundaries lay can be contentious. And last week I was again reminded that we don’t all agree on what constitutes honoring our patients’ wishes.

It happened when I was hearing about a case of a patient in the Intensive Care Unit fit for an episode of House, M.D. The patient was older without being elderly, and had a respiratory illness that had defied diagnosis despite the best intentions of cardiologists, pulmonologists, infectious disease specialists, and a few other medical professionals to boot. The ID docs, though unsure of what was going on, thought that this was most likely some infection seen in the setting of underlying AIDS, and I, being an ID guy, shared their point of view while hearing the details. Like my colleagues, the question to which I wanted to know the answer was: what was the result of the HIV test? But the patient had adamantly refused HIV testing. And that’s within his right: a doctor can order most blood tests without having to discuss them with a patient, but an HIV test—just like a blood transfusion—is special, and requires a signed form saying that the patient agrees to it. In this case, where a diagnosis of HIV infection might be helpful (more on this later), such a refusal can be maddening. But that is how the rules are set up right now, and once the patient says no, then that’s all she wrote.

However, in this case, that wasn’t all she wrote. HIV is a virus that infects, and destroys, a special kind of white blood cell called a CD4 cell. In general, the further your CD4 cell count drops, the more you are at risk of being infected by the weird organisms that are the sine qua non of AIDS, things like toxoplasmosis, cryptococcosis, penicillium marneffei and a host of other parasites, bacteria and fungi that people with healthy immune systems never develop. A person with a healthy immune system typically has a CD4 count that runs from 500 to 1500, give or take; the definition of AIDS is someone with HIV infection and a CD4 count less than 200.

One of the loopholes of informed consent for HIV testing is that it does not cover CD4 counts.

You can see where this is going. Some doc tried to do an end run around the refusal and checked the patient’s CD4 count. Surprise! It was low, less than 200, although the pattern of the CD4 cells didn’t really look like AIDS (skipping some technical detail here). So then what do you do? You have gotten no closer to the diagnosis, and you have put yourself into the uncomfortable situation where you may be tempted to take action. Sometimes the treatment for some of those weird “opportunistic infections” in AIDS is to just give a person medications for HIV, but you wouldn’t give those meds to a patient without a diagnosis of HIV. In this situation, that wasn’t the case, but what if it were? Would you throw antiretrovirals at the person because his CD4 count was suggestive of HIV—even though the patient unambiguously refused the test? To me, this smells exactly like giving blood to a Jehovah’s Witness: doing what I call a “Back-Door CD4” might seem clever, but it pretty obviously violates the spirit of the patient’s wishes, if not the letter.

Some would argue that the very need to consent people for HIV is outdated. HIV consent was established at a time when the diagnosis was severely stigmatizing, and “positives” could lose jobs, insurance premiums and in general face ostracism from their communities; it also happened at a time when treatment wasn’t exactly effective. Today, the latter is definitely not true, and as I tell my HIV patients all the time, there is no reason to suppose that, should they take their meds every day faithfully, they should live as long as anyone else. Whether the former is true I am a touch skeptical, but I acknowledge that the level of stigma nowhere near approaches where it was twenty years ago. Thus, proponents of the Back-Door CD4 would say that the time for HIV consent has come and gone. Way back in 2004 a doc named LA Jansen wrote in the Journal of Medical Ethics and supposed that the Back-Door CD4 was a form of “conscientious subversion,” something akin to conscientious objection, where a physician acknowledged the existing legal landscape but did his or her own thing based on their personal ethics.

Jansen dresses the term up in calling it “conscientious subversion”; I prefer using simpler language and think of it as a bad idea. By my compass, patients have rights to refuse tests, medications, procedures, and any attempt at thwarting those desires defeats not only the entire point of informed consent, it belies the idea that we are advocates for our patients. Don’t get cute, is what I’d say: we are better than most professions at standing by those we serve. Let’s not mess things up by thinking we know better than they do.

—br

PS—the Jehovah’s Witness example has, for me, not been entirely academic. Twice I have cared for Witnesses who were in situations where transfusion was definitely worth considering, and in one of the cases it was pretty clearly indicated. Like most of my profession, it never entered my mind to try to push the idea on them once I learned of their religious beliefs. For more on Jehovah’s Witnesses and their philosophy behind their refusal of blood transfusions, see here, here and/or here.

Profile in Courage, Writ Small, But Still

2011-03-10T18:29:00.001-05:00

Today was Grand Rounds at my academic medical center. The subject was diabetes and how we--"we" being the medical system as opposed to "we" the individual doctors--can improve outcomes in this disease, which is a killer, and which we (pick whichever "we" you like) stink at treating successfully. The view of the speakers, with which I'm sympathetic, is that we require less gee-whiz bioscience breakthroughs than we do a comprehensive, systematic plan for identifying, following, and ensuring affected patients stay on their meds. None of their suggestions were particularly sexy and didn't involve lots of fancy technology except for using a personal computer. I was persuaded by their assertion that sometimes it's simple but labor-intensive solutions in medicine that are the ones with the best chance of success.

Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.

I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.

So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.

She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)

It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.

BRB Link Dump

2011-03-02T21:48:00.001-05:00

My spiritual and theological leanings are probably just enough to drive everyone concerned totally nuts: I am intellectually atheist, though functionally Jewish, plus I'm fond of various other religions (or at least certain aspects of them). We have a new Rabbi at our Synagogue and while he appears to be a very charismatic man, my own religious leanings are such that I do not look to him for spiritual leadership in any capacity, and I remain a member partly because I like going to synagogue, but mostly because I really like peace between me and my wife.

The point of this rambling being that although I long ago decided to follow my own path and look toward no other man or woman as my spiritual leader, if I had to choose a person, I quite possibly could have chosen Peter Gomes, whose life ended just a little too soon for my tastes earlier this week. Gomes was about the most polar opposite person you could pick for me to follow: he was African-American; I was white. He was Christian; I, an agnostic Jew. He was gay; I, not so much, thanks, though as Jerry Seinfeld noted, not that there's anything wrong with that. He was, for most of his life, a Republican, and I have mostly not been a Democrat because I regarded them as too far to the right. He was something of a dandy with something of a pompous manner of speaking at the most Establishment university in the United States; I am a well-educated though frequently unspeakably crude dude who went to Abbie Hoffman's school and often sneers at The Establishment. On the surface, thus, not my kind of guy.

But once you peel away his formal and sometimes antiquated mannerisms and really listen to Peter Gomes, there is aught but beauty, truth, and light. Here is a brief comment on gay marriage, while here a longer talk with Charlie Rose. He opens the conversation with Rose with a line that elegantly encapsulates why I find him so admirable: "I like the notion that there is much yet to be revealed about the Christian faith; it's not all over yet. It's not a complete story, and we're moving into it. There is much yet to be revealed, and I think our best theological days are ahead of us." If that ain't a bare-bones summary of the philosophy of the great Talmudic masters (that is, the part of the Talmudic masters that I find worthy of attention), then I don't know what is. I have not read any of his books, and my acquaintance with him is largely through talks & other coverage he's received in that peculiar Harvardo-centric fishbowl of Boston media (you could catch his sermons on Sunday morning on WHRB, the Harvard radio station). It may be a tough pill for me to swallow to read a book about Jesus, but in the coming months I may peruse one of his books to stay connected with this eminently decent and astonishingly eloquent man.

More immediate concerns that nobody else in the vicinity of Harvard Yard prematurely join the Reverend Gomes are very much on the minds of Massachusetts public health officials as they scramble to contain a measles outbreak inflicted on the city by an unvaccinated French woman working for the French consulate downtown. What a mess: the super-contagious virus may have spread to a professor at UMass Boston, and thus his students are bearing the brunt of some public health measures, but fortunately seem not to be too bothered by the whole fuss. Though make no mistake, a fuss this is: measles spreads like wildfire and--while not overwhelmingly lethal by Andromeda-strain standards--kills simply by the fact that so many can become infected so quickly. Even a low mortality rate of, say, three percent can be a lot of bodies if tens of thousands become infected. And while the vaccine for measles (the "MMR") is good, it's not perfect, so even vaccinated people are at risk of infection, especially if they haven't been vaccinated in decades. As I noted in a previous entry: this virus is a killer. How this gal got into the US and was allowed to work without having a documented MMR is not fully clear to me, but many are paying the price for her folly.
--br

Doctors in Wisconsin Sign Fake Sick Notes for Protesters; Civilization to Collapse Shortly

2011-02-22T14:08:00.003-05:00

Whenever I begin to think that I have Sold Out in life and have embraced respectable living and taken an establishment career track, something will happen to remind me that, whatever desires I might nurture in the bosom of my soul to be acceptable and thus accepted, I am in fact a person with a fringe philosophy that most in my profession would consider dangerously radical.

A long sentence, that, but a good summary of my reactions to recent blog posts by my medical blog siblings. Their scorn was directed at physicians (several, apparently, from the Department of Family Medicine at the University of Wisconsin School of Medicine) writing fake sick notes for the protesters hunkered down for the political fight in Madison, Wisconsin, in which Governor Scott Walker is attempting to rewrite, and effectively strip, the collective bargaining power of public-sector workers. Health Care Renewal led the charge, calling it "the face of postmodern medicine: lying," while Happy Hospitalist danced a little jig after having 10,000 hits after Instapundit's shout-out on his post calling these docs "an embarrassment to their profession." db's Medical Rants piled on, saying much of the same.

I'd be so much more impressed by these sermons if they weren't so over-the-top in both their collective tone and in their historical comparisons. Based on their posts, you'd think that because of this little stunt, which is equal parts civil disobedience and wink-wink chicanery, the world was coming to an end or thereabouts. Happy uses the event to scream with a certain incoherence at Democratic pols involved in the fight, and HCR compares the sick-note signing to doctors who enabled the legal claims of minor car accident victims by medically legitimizing their fake symptoms. (Is this really the same thing? If so, do tell me what is in it for the docs this time around; accident-injury fakery yields a financial benefit for the doc, which is, to my moral compass, considerably more troubling.) db uses lots of words heard at White Coat Ceremonies and the like, intoning about the "sacred trust [between physician and] society."

Curiously, back in 2003, db (of whom I am normally a fan) not only chose not to utter so much as a peep about the potential dissolution of that sacred trust when doctors in New Jersey refused to see patients as a protest about malpractice insurance rates, he wrote several entries that were sympathetic toward them (such as here and here--the latter entry explicitly entreating us to understand the motivations of the physicians, while never wondering if it's maybe unbecoming for a physician--as well as a violation of that supposedly precious "sacred trust"--to tell a patient to go Shove It). Last year, when urologist Jack Cassell thought it a good idea to notify patients that, had any of them voted for Obama, they should seek care elsewhere, db did not see fit to call this man to account for what I would define as deeply unethical behavior (from what I could find on db's archives, at any rate), though perhaps he was unaware.

To be clear: I'm not so sure I'm supportive of these docs, and I do think they've gotten themselves into swift waters without, it appears, thinking carefully about the consequences of their actions (at the very least, they didn't take into account the political consequences, if not the moral ones). But this isn't the beginning of some fake sick-note movement, and none of these people are doing it for personal gain. I don't have qualms with raising doubts about the ethical wisdom of their actions, but the smell of sulfur coming from these heavy-handed judgements is a bit much for me.
--br

UPDATE: So far I appear to stand alone among doc blogs in not jumping up and down in blistering condemnation of the sick note scandal: GruntDoc's quick take is here and Retired Doc shakes his head here. RW Donnell, who against all expectations manages to once again defend the status quo, airs his thoughts here among various entries.

Michele Bachmann, the First Lady, Breast Milk, and Much Ado About Nothing

2011-02-21T20:34:00.000-05:00

It makes for a very intriguing headline: could some political spat somehow realign self-identified liberals with Michele Bachmann, and conservatives with Michelle Obama?

At first, while glancing at the NYT headline, "A Breast Feeding Plan Mixes Partisan Reactions," I thought that perhaps the moon was indeed in the Seventh House, and Jupiter had aligned with Mars.

But as much as NYT and some other outlets would like to have you believe that we've reached the Age Of Aquarius, I'm thinking more that we've reached the Age of Same-Old, Same-Old, with a page from the Mountains Out Of Molehills playbook.

To recount the mini-saga, last week Representative Bachmann fired a broadside at the First Lady during an interview with radio host Laura Ingraham for "the government's role in breastfeeding," as Ingraham's website proudly chirps. Ms. Obama has been promoting breastfeeding for almost a year now, from what I can find on the WhiteHouse.gov website, but Bachmann was reacting to the latest news that the IRS had announced that breast pumps, which can cost up to several hundred dollars, would be available for a tax break. Bachmann first complained about the tax break--something very un-Republican like--by complaining that "government is the answer to everything." She then added, "to think that government has to go out and buy my breast pump—you want to talk about nanny state, I think we just got a new definition,” in classically Bachmannian rhetoric which is either exasperatingly stupid or chillingly cynical, since a tax break in no way implies that the government is going to purchase breast pumps for the mothers of America.

[That's my emphasis, by the way. Also, I have been unable to find the link to the actual IRS announcement, though many outlets report on it, as TIME does here, or ABC News does here--the ABC News link is dead.Typing in "breast pumps" into the IRS search engine turns up nothing, and searching IRS.gov on "breasts" does turn up a lengthy document released in August, though I could find no breast pump references while perusing it. Nor could I find a press release on tax breaks for devices designed for the liberation of boob juice. Needless to say, I am having an enormous amount of fun tonight.]

Anyway, the story received attention from media outlets in search of culture-war fodder or some such, and lots of outlets, even including ones across the Pond, ran with it. Which, no doubt, is precisely what Representative Bachmann had hoped for, even if the attack made no real sense: she's in the headlines. Maybe this is part of a coordinated effort to put her name in the mix for the 2012 Republican Presidential primaries, and chip into the Republican/conservative gal-appeal of Sarah Palin, who, perhaps sensing a missed opportunity, got in a shot in at the First Lady in a speech in Long Island.

Who knows? Who cares? But the Times article tried a new slant: the reactions from party loyalists were flipped. "On blogs and in interviews, some liberal Democrats found themselves agreeing with Representative Bachmann...some conservatives, meanwhile, stood up for Mrs. Obama for promoting what they said was a healthier choice," the Times reporter, Kate Zernike, observed.

Which is technically correct, as the article goes on to quote some self-described liberals siding with the utter nonsense of Ms. Bachmann, and conservatives siding with Ms. Obama. But as numbers go--and after a not-exhaustive and not-scientific but well-intentioned reading of comments at the soft-left Times, the soft-right WaPo, the harder-left Salon and a few other places to boot--I found no evidence of massive political realignment. I found a small number of comments from self-described conservatives supporting the First Lady, a good many more criticizing her, and more than half of those totally missing the point...but no comments from liberals defending Bachmann.

(As a side note, I read the Salon comments with a certain horror--the comments section has become a den of lefty sleaze. On many topics I am of one mind with Salon's editorial staff, and I share in their righteous fury at the various injustices of the world, but reading the comments section of pretty much any Salon political article these days is chilling. Civility is considered quaint as commenters attempt to outvulgarize each other, and the menacing allusions to violence would make you think you had just walked into a Tea Party rally. It's disturbing.)

I was feeling quite proud of this analysis until I discovered this article from HuffPo that explains how Zernike used one anonymous commenter, and a second equally anonymous "progressive mother in Brooklynite" as a source to gin up what amounts to a fake article. NYT should be a bit embarrassed; if it isn't Billy is on their behalf.
--br

PS--The Billy Rubin Blog is up to four--yes, count 'em, four!--followers! Please feel free to get on board, or get an RSS feed so that new entries will be sent directly to your e-mail and you won't have to check back every so often for updates. We appreciate it!

Will Doctors Be Relevant in the World of Watson?

2011-02-18T21:39:00.000-05:00

Like so many other people, I watched Jeopardy this week with rapt attention as I saw IBM's uber-computer Watson clean the clocks of Jeopardy's two greatest champions, Ken Jennings and Brad Rutter. My reaction--that of fascination bordering on the point of awe simultaneously mixed with a not insignificant amount of apprehension--was probably also shared by a good number of viewers. Did we witness the creation of something worthy of comparison to the Brandenburg Concertos, or Frankenstein? No way to know at the moment. Check back with the Billy Rubin Blog in about four or five decades. I promise to do a follow-up entry at that time.

While watching the informational clips during the Jeopardy show in the first round, where various Big Bluers explained the mission and the challenges of developing Watson, I was struck by how Watson could be used in medicine. Give it a patient who explains their symptoms, then feed Watson with basic lab or other clinical data, and you could easily produce a computer doc that would rival the best in the biz. IBM seems to have had the same thought, as Carey Goldberg of the CommonHealth blog notes, as they have partnered with Nuance Communications of Burlington, MA to set up computer systems built on the advances gained from the making of Watson.

Leave aside the rather terrifying fact that this could deprive me of a job in the decades to come, it's not hard to see the ways in which a Doc Watson could outperform a flesh-and-blood physician. Take, for instance, the news story this week about the neurologic event of TV anchor Serene Branson, which earned speculation from ER physicians as well as a Happy Hospitalist as to the diagnosis (for a prescient discussion of the media portrayal, see Gary Schweitzer's HealthNewsReview entry here). Leave aside the dramatic videotape of Ms. Branson for a moment. What's the diagnosis?

The immediate speculation was that Branson suffered a Transient Ischemic Attack or "mini-stroke." To me, this never quite made sense for the simple fact that Branson is young, and TIAs are typically a disease of people in their 6th decade and beyond. Of course, there are outliers, as demonstrated by the sad story of professional baseball pitcher Darryl Kile, who died in his sleep in midseason at age 33 and was found at autopsy to have obstruction of two major coronary arteries, which is extremely unusual for one so young. So although a TIA seemed possible, I thought that the list of possible diagnoses included things like Multiple Sclerosis, and since I'm an ID doc I immediately thought of neurologic diseases associated with HIV. Other docs weighed in on the blogs and several proposed the possibility that this was a complex migraine headache This is now the official diagnosis of the authorities who have cared for her at the UCLA medical center (though, as Happy notes, this pronouncement came from a neurosurgeon, which from a medical standpoint is very odd and not entirely appropriate).

The diagnosis might be spot-on but it's a tough one to make. What could a Doc Watson do that we couldn't? Watson would be able to take the patient's age, take the information from all the data generated by her care (vital signs, physical exam findings, the history of garbled speech, any pertinent information from her family and social history, labs and radiologic tests) and arrive at a mathematically precise risk assessment for each of these various diagnoses, just as it did in trying to answer Alex Trebek's questions. (Yes, I know, it's the other way around in Jeopardy. Let's just move on.)

That is, I can note in a vague way based on my learning in medicine that TIAs are less likely to occur in younger people, but I have no idea the precise numbers; for Watson, I would assume that it would be a small matter to incorporate hundreds of epidemiologic studies allowing it to calculate multiple probabilities for all sorts of diseases. It's not that Watson would be doing anything different than what we do every day when we form differential diagnoses on patients, it's just that Watson would have three huge advantages: it could access considerably more information than we can (we are limited by how much we can read, and then remember, while for Watson that's just a download), it can then take that information and process it orders of magnitude more quickly, and it can describe the likelihood of an uncertain diagnosis with a precision that is virtually impossible for a lone human physician to do in live time while seeing a patient.

I'm not a computer specialist and don't know the inner workings of Watson, but I don't think this is wild speculation on my part. I suspect that we're not far away from being able to feed information into Watson-like programs that will help our diagnostic accuracy increase tremendously in the years to come. I also suspect that there will come a point where Watson-like programs will obviate the need for physicians. Hope I'm retired by that point!

Hat tips to Grunt Doc, Gary Schweitzer, Happy Hospitalist, CommonHealth.
--br

Another Milestone

2011-02-14T22:47:00.000-05:00

Among various items for which it is tedious to be Jewish, the adherence to the lunar calendar must rank relatively high. We're talking about a people who have won Nobel prizes in every field, far out of proportion to their actual numbers on this earth, leading the world in physicists, mathematicians, and astronomers. And they can't use a modern calendar? Leap months every few years? Please.

Its tediousness bothers me at this hour because tonight marks the end of my first year on earth without my father. That is, by the Christian, or Solar, calendar, call it what you will. And herein lies the problem: the official mourning period ended for me some several weeks back. But even then that wasn't the completion of a Jewish, lunar year, because for reasons which I am not especially curious, the mourning period ends at 11 months in Jewish tradition. Then there was the Jewish year marking...yet another date. And I am ignoring the two or three other periods of Jewish mourning, which include shiva (the seven days following the burial) or shloshim (the thirty days), each of which has its own particular rites & obligations. Fortunately, as I am just a hair shy of atheist, the specifics didn't trouble me a great deal, with the sole exception of the prohibition against shaving during the shloshim, to which I adhered, in what is perhaps a term not used in jest, religiously.

But in my spiritual clock, as it were, I always measured Dad's death by the date of February 15th. To hell with this lunar nonsense, I thought--I don't pay attention to the Jewish calendar in any other part of my life except to show up for High Holidays or Passover when I'm told. The truth is that I have not taken Jewish chronology into my bones, and the 11 months came and went without any reflection, without making a point to go to the synagogue to say kaddish (Pops could have cared less, which helps assuage my guilt in this respect), without any reckoning of any sort. But in my quiet moments over the past few weeks, I see his face in my mind's eye, I think about how much of my father's son I have become--against even my own expectations and understanding--and how this past year would have been had he been part of it.

Paradoxically (or, for those who know me, likely not paradoxically at all) I have found myself in these moments taking comfort in about the least respectful of ways, saying to myself things like it's almost been a year since Dad bit it or yep, he sure bought the farm when he went to get the mail. I have giggled with a certain childish giddiness of the magnificent tribute paid to Graham Chapman by his Monty Python alum and longtime collaborator, John Cleese: "he's kicked the bucket, hopped the twig, bit the dust, snuffed it, breathed his last, and gone to meet the great Head of Light Entertainment in the sky." On New Year's Eve, a friend asked a truly loving and caring question about how my mother has fared since father's death, and perhaps a bit too mischievously I immediately flipped back, "actually she's been doing really well. She's really risen to the occasion. Dad should have died more often."

I'm glad I said it as I not only think the line is funny, but I think Dad would have laughed at it. And I'm glad to have a laugh when I think about him even in death, as I loved to tease him in life, especially after I overcame my fears of this man whose quiet thoughtfulness intimidated the oft-loquacious-and-not-nearly-as-thoughtful-me for many years. But the mirth is short-lived, and the truth undeniable: my heart is broken. I do miss him, and doubly so as I tried to make up for lost time once I figured out exactly how to be his son, as well as the fact that I am as much my father's son as I am my mother's--something much easier to spot, for me as well as everyone else. For nearly four decades our similarities had escaped my notice; now I ruminate upon them often.

I write this tonight not to excessively hash over these details (though readers will kindly forgive for the little bit of hashing I have done above), but rather to write about the toughest reckoning of all surrounding his death. To wit: I experienced his death both as a son and as a doctor, and I remain undecided as to whether I've screwed the pooch. But let me explain a little.

My father had reasonably clear instructions in his "living will" that he did not want what we in the biz would call "heroic measures." That is, if, say, his heart stopped beating, he would not want anyone to start CPR or shock him or do much anything else. For an in-hospital strategy, that works fine, but Dad's heart chose to stop beating out by the mailbox for the condo association. A neighbor, who of course knew nothing of that living will, called 911. The EMTs arrived and were able to resuscitate him. I can't and don't blame anybody for "saving" Dad's life at that point. But after that things get murky.

The blow-by-blow of the next ten days is unnecessary to recount, but the gist is that he underwent a series of maneuvers designed to give him the best chance of not only surviving "the event," as we call it (it was almost certainly something known as Sudden Cardiac Death, though even that's a loose term), but surviving it "neurologically intact." My sense from the start was that we needed to get the tube out of my father and let him die. It wasn't that I didn't want him to pull through. It wasn't--or at least I think it wasn't--that I had seen enough cases of patients like this to know the steep odds he faced in having anything approaching a "meaningful" recovery. Rather, it was the knowledge that a ventilator isn't what he wanted! Yet despite this we had doctor after doctor, from the ICU attending to the PCP, continue to tell us to stay the course.

Several days of back-and-forth passed until I finally said that he would be extubated or I would leave, and my mother agreed. We approached the hospital and explained our position, said that we understood the recommendations of the doctors, but were no longer in agreement with them. The following morning my father's primary care internist relented and acquiesced to our demands--though not without a subtle parting shot where he said, after acknowledging our position, that "it's not something I would do for one of my family members." Dad was extubated that morning, and died a few days later.

And there's the rub for me. I spent a week trying to be such a good doctor and seeing the reasonableness of their point of view, as well as their medical management, that I may have forgotten how to be a good son in the process and fight for what my father wanted, which was to be left alone. (For what it is worth, I have no qualms with their medical management; as far as I am aware all of the doctors involved in his case made fine medical judgements.) In particular, I have spent much of the past year unclear if I have been furious with the loose ethics of Dad's PCP, who imposed his own ethics onto the situation without regard for Dad's wishes (which might be shorthanded as live at all costs), or if I am just disappointed with him and understand that he made a tough call with which I might disagree but hardly one that deserves scorn. And, since my identity is split between son and doc, I have vacillated on even whether I am angry, flinging myself into meta-analysis upon meta-analysis, or am just trying to manufacture anger on my father's behalf, since I see the quandary of the PCP, who pushed, pushed, pushed for us to keep him, and hope, alive. Not how I'd play it but totally justifiable from a medical standpoint. So am I a furious son, or a distant doc? Search me.

What fills me with dread is that I may be bringing that shit into a room when I admit patients on Friday nights. I am not Sir William Osler--while I think I am a very competent doc I have never quite been able to make medicine sing like a few of my fellow residents--but I do pride myself on my ability to communicate with patients and their families. If I have a strength, it is in helping families through the kinds of moments that my family went through one (solar) year ago. But I can't tell at the moment whether I bring that damned baggage into those rooms, and I don't know when I'll be able to sleep soundly knowing that I haven't let my own experiences get in the way of what I do very well, at least in my own opinion. Thus I am being tested but have no way of knowing the grade.

Until I can find some internal method of ascertaining my own emotional and intellectual response, a one-year anniversary can't serve as a marker for some kind of closure for me. Pops may rest in peace, but his son the doc continues to cope in the aftermath, wondering how he did as a son, wondering what it has done to him as a doctor.
--br

Industrialization Comes to a Small Hospital

2011-02-13T15:27:00.001-05:00

If the relationship I have with the University Medical Center where I work is like a spousal relationship (substantial, committed, long-term, serious), then the hospital where I moonlight is more like a friends-with-privileges arrangement. I 've been moonlighting at this small hospital (about 200 beds) for the past five years now, and my feelings for the place are unquestionably fond, but my emotional and spiritual investment in it is minor. I use her for a little extra sustenance, not merely financial, as I like the people there and they--shockingly and inscrutably--appear to like me back in turn. In short, I like her but I do not love her. I want her to thrive but my heart will not be broken if she doesn't.

That said, my heart did a little breaking this weekend when I strolled in for an evening shift, ready to enjoy the give and take with patients and staff alike, and emerged 10 hours later having bade farewell to five employees (four docs and one secretary) that I had come to respect. They are all headed out the door, and while each has some particular reasons for departing, they all share one common motivation: the hospital is "industrializing" its hospitalist work force (using it for lack of a better word, I am definitely open to suggestions), and about 40 percent of the current hospitalist group has decided nearly en banc to look for greener pastures. Amazingly, after these departures are complete and the new crop of docs comes in, I am going to end up being one of the graybeards of the group, either the second or third most senior of the hospitalists...perhaps apropos since my actual beard has been sprouting grays & whites more insistently these past few months. What I find somewhat sad and slightly disconcerting about this is that I am, among the medicine physicians at least, becoming the one with the longest institutional memory.

But let's backup a moment and explain how we got here.

This hospital used to operate on the old model: if a patient was admitted to the hospital under the medicine service (i.e. not for a surgical procedure), the patient was usually under the care of that patient's primary care physician. I'm oversimplifying things here, but since internal medicine had begun to get significantly more complicated in the '80s and '90s, that old model, where the outpatient doc doing rounds and writing orders at 7 a.m. on the way into office hours, became increasingly impractical. The "hospitalist" movement sprang up as a consequence, and a new specialty was created: full-time inpatient internal medicine doctors whose sole job was to take care of internal medicine patients during a hospitalization.

At my hospital, about 10 or so years ago a few physicians began hospitalist work, and they would contract with particular medical groups to take care of that group's patients when they were admitted. When I first came to moonlight there that first hospitalist group was small, covering perhaps a third of all the patients admitted to the hospital. If a patient was admitted, the ER doc would call us, and we were supposed to check to see whether the patient belonged to our contracting medical group, and if they didn't we were supposed to inform the ER that such a patient was the "responsibility" of some other group. Since I found spending 15-20 minutes figuring out who "owned" such-and-such a patient rather tedious, and since I was moonlighting at least in part to maintain my hard-earned internal medicine skills, I just admitted everyone they told me to without concern for the primary physician, and accepted the frequent lectures from some of the full-time hospitalists the following morning when I found out that 5 of the 8 patients I admitted didn't "belong" to the group. (Their group still made money off those admissions since they could bill for them, while then as now I was paid to work by the hour, so I don't feel so bad about the whole thing.)

Anyway, once the primary care physicians saw how much contracting with hospitalists relieved their work burdens, a clamor arose to expand the hospitalist group, and the hospital started placing direct pressure to achieve this, because if the PCPs could find hospitalists at the other nearby small community hospital, then my hospital's revenue stream would start to dry up. The problem was (and I say this from the perspective of an outsider who watched from afar, so take my observations both with a grain of salt and at your own risk) the group couldn't expand fast enough to keep up with the demand. This led directly to a major problem, which was that the hospitalists who had been recruited had to shoulder larger and larger amounts of work, and see more and more patients, in order to keep up with the demand. The hospital, feeling perilously close to losing its patient base, mandated that within 6-9 months the hospitalist group be prepared take on all of the patients previously seen by the PCPs. But there weren't enough boots on the ground: each individual hospitalist was seeing more than 20 patients a day, which is far too many to do good medicine on a daily basis, and so morale sank. A few people departed, making matters worse, since larger amounts of work had to be shouldered by even fewer hospitalists.

Long story short, the hospital became concerned enough to take the program over and administer it directly. They promised to recruit more physicians and resolve the morale problem by lowering the patient census for each doc. I was skeptical and on the verge of hanging up my spurs, wondering in particular how the hospital thought it was better situated to recruit nearly a dozen physicians where the private group had failed, but over the next several months I was pleasantly surprised to see the administration deliver on pretty much all of its promises. I stayed on and met several new colleagues with whom I was proud to work. I thought that this little community hospital had solved the riddle of creating a stable hospitalist group, with at least some of the docs serving for years to come, becoming part of the fabric of not only the hospital, but of the community as well. And what better way for a community hospital to achieve its mission than by effecting this change?

Alas--that happy arrangement lasted about 18 months. While the hospital managed to succeed in a stellar manner in creating and sustaining a decent group of physicians devoted solely to the hospital and its patients, it came at a high cost. Literally. I have no idea of the numbers involved but by the summer of last year the administration began discussions with various companies who would take over the hospitalist group and administer them. The one they chose to take to the prom is a for-profit company, listed on the NYSE I am told, who must have promised huge savings for the hospital. Whence my term "industrialization": I remain uncertain as to whether this is the optimal word. Either way, the affairs of a major chunk of how this hospital runs was going to be dictated by a company run from far away, with its primary concern for the economic welfare of its shareholders rather than the health of the community who live and sometimes die within the hospital walls.

The administration found the pitch so irresistible that within the span of a few months, they went from trying to "explore options" with the hospitalist group, to submitting a take-it-or-leave-it offer to each individual physician that they become employees of this "hospitalist corporation" or submit their resignations. (To digress briefly, from my own narrow standpoint their offer seemed quite handsome, as the corporation would cover my malpractice insurance, which costs me nearly $10 thousand per year--that covers several nice bottles of zinfandel, I can assure you--and I was not required to work a minimum number of shifts for coverage.)

So over the past 3-4 months I watched with dismay the hospital re-create the exact situation it was trying to solve when it first took over the group, and this weekend I saw off some colleagues that not only will I miss, but much more importantly my "girlfriend" the hospital will as well. And this was just a quirky night where my schedules intersected with theirs: there are several other physicians who also chose to call it quits whom I haven't seen.

What kind of financial alchemy does this company perform to both make a profit for itself and save money at this not-for-profit hospital? After all, they can't increase the revenue stream unless they have a plan to make everyone in Small New England Town sicker, or unless they plan to blow up Other Local Community Hospital. Cutting costs may be part of it but I haven't read anything in the documents I signed that rewarded physicians by limiting test utilization, an approach that's totally reasonable in concept and very difficult to execute in reality.

Again, because of my very part-time status, my answer is far from definitive, but my suspicion is that they're not giving us a new wheel so much as repackaging the old one. Which is to say that the way they will generate more revenue by increasing the individual doc's workload. Overhead for hospitalists is relatively small (depending on how a hospital would charge a practice for things like office space and computer access), but salary is huge. Cut the size of the group by a third and you've found a lot of previously missing money--I'm thinking something approaching $2 million based on my back-of-the-napkin calculation for this particular hospital. I have no experience with hospital budgets, but for a hospital of that size, I'm guessing that's a serious amount of cash. Some of that, of course, will go directly to the pockets of the shareholders of Hospitalist Corporation, but the hospital stands to benefit from this arrangement.

As to whether the whole venture will succeed, I have no idea. My nature is to be suspicious of anything tied to the term "for-profit," and doubly so when it applies to entities involved in healthcare. But that is--to appropriate a term from RW Donnell--a bias, and it may well prove to be a faulty one in this instance. At this particular moment in the life of this particular hospital, its influence cannot be described as anything other than destructive, but I remain open to the idea that this new, industrialized relationship might benefit everyone by the time we next sing Auld Lang Syne. To say that I am optimistic, however, may be saying too much. We will see, and barring an unforeseen event, I'll be around at least long enough to see the immediate effects of the transition, which takes place in less than a month.
--br

Readmission Rates as a Means to Measure Hospital Quality

2011-02-08T20:29:00.001-05:00

My alarm is set to let loose the soothing tones of NPR at 6:15 each weekday morning, and I spend the first seven of those minutes in the pleasant haze before actually rising (which is less pleasant). This usually coincides with the final story before the news headlines, and this morning's piece brought news that the Massachusetts state government is planning to "stop paying hospitals where the re-admission rate is higher than the statewide average." This is expected to save the Commonwealth roughly $8 million annually in a budget that, like most of the states in the Union, is strapped for cash.

Let's leave aside the most egregious part of this policy: namely, that half of all hospitals should be made to take a financial hit, even if every hospital in Massachusetts improves its readmission rates, since by definition half of any defined group is always above the average. There's a cruel logic at work there, or rather more likely, none at all. But for the sake of argument let's assume that some clever legislator thought of this and worked out some model to adjust for this problem, measuring hospitals against some baseline of expected performance rather than against each other. Is it still a good idea?

Maybe, but to expect politicians and/or bureaucrats to get this right just now is...well, color me skeptical.

Measuring a given hospital's performance isn't very difficult: you just collect data on the number of admissions, the kind of admissions, the length of those admissions, how many people die in the hospital, how many have surgical complications, and the like. With computerized databases this takes only the amount of time that one wants to spend querying the data, and it's equally easy to cross-check the admissions to see how many patients are re-admitted to the hospital within one month (the typical measuring stick) with the same problem. What is difficult is knowing the standard to which that hospital's performance should be compared.

Wait, you say--why not compare all the hospitals against each other? You can actually do this via this news piece from USA Today; the slightly more tedious, and less user-friendly, version put out by the federal government is here. What if the re-admission rate for, say, pneumonia at Hospital A is 15.9 percent, while at Hospital B it is a stunning 22.5? (The national average, as illustrated here, is 18.3 percent.) Should we punish Hospital B, deprive its operating budget of potentially hundreds of thousands of dollars, and maybe send some of that cash over to Hospital A, a gleaming example of the finest medicine practiced in the US?

It's not such a hypothetical: I took the data from two actual hospitals here in Massachusetts. Hospital A is a small, regional center about an hour or so outside of Boston, while Hospital B is an academic medical center in the heart of the city. I'm sure "A" is a fine hospital with good doctors, but for my money, send me to "B" any day of the week! But why would I think such a thing given those stats (which, I'm confident, would be similar for virtually any medical condition such as heart attacks and asthma)?

The answer is that "B" is a large urban, tertiary-care center. Why is this relevant? Because of their size, they have many different ethnic groups passing through their doors, including at least two major immigrant populations: more opportunities for misunderstandings--both cultural and linguistic--that can lead to readmission. Because "B" is urban, it has the kinds of patients that "A" rarely sees, who happen to be the kinds of patients at highest risk for readmission: single mothers working two jobs who can't find time for follow-up appointments, working poor who can't afford meds, semi-literate patients who only partially understand the bizarre language of doctors and nurses, drug addicts. Because they are a tertiary-care center, they take referrals of the sickest patients in town--precisely the kind of patients that make many nurses and doctors from Hospital A pee in their pants when so confronted. For all of these reasons, Hospital B is very far from being on a level playing field, and while I'd probably be fine being taken care of at either place for routine stuff, I would very much rather be at Hospital B for even the slightest setback.

With the fancy computerization has come significantly increased access to data, and the arguments and counterarguments about how to use hospital outcomes data have been circulating for a few years. Take, for instance, the discussion about hospital mortality statistics, as evidenced by this editorial in the British Medical Journal last April, or very recent news stub by Harvard University here. Contrast this with a warm account in 2009 of Baylor University's lower readmission rates for heart failure, and its emphasis of defining the admission rates relative to the national average. Baylor may well be a model for how all hospitals should construct their programs; I'm not a heart failure specialist so I can't comment. The story, however, plants the idea that everything better than the mean signifies a better hospital, and everything worse, worse--an idea that can be misinterpreted with potentially disastrous consequences for certain patients.

My fears about how this is going to play out in the years to come is that hospitals will continue to feel budgetary pressures from government agencies and insurance companies alike, and those that care for the sickest and most vulnerable patients (read: often not white, frequently the poorest, sometimes immigrants who do not speak English well or at all, just to name a few attributes) are going to suffer the brunt of this well-meaning but so far not-ready-for-prime-time approach to measuring a given hospital's quality.
--br

A Journal Declines Drug-Industry Advertising

2011-02-05T22:34:00.001-05:00

It's not The New England Journal of Medicine, but it's a start. Word today from Gary Schweitzer's Health News Review Blog, passed along from the Croakley Blog, that the journal Emergency Medicine Australasia has decided to eliminate advertisements from drug companies. A brief excerpt from their editorial (full editorial available here):

Doctors need to stop being used as agents of the drug industry in the complex financial arrangement between drug companies and consumers. It is time to show leadership and make a stand, and medical journals have a critical role to play in this. At EMA we have therefore drawn a line in the sand, and have stopped all drug advertising forthwith. We invite other journals to show their support and follow suit, by declaring their hand and doing the same.

Now that's some writing that would make George Orwell proud!
--br

The Mathematics of Residency Interviews

2011-02-02T22:37:00.001-05:00

This year I have just completed my first season of interviewing applicants to the internal medicine residency program at my University hospital-based program. It's something I always wanted to do, and after living through the interview process on the other side of the coin I'm inclined to help out in the years to come. My guess is that it's more fun than medical school interviews, where the stakes are higher and the candidates more nervous by virtue of the fact that everyone applying for residency is going to get in somewhere, it's just a question of where. In internal medicine especially (and doubly so since I don't work at a Hospital whose first name is "Massachusetts General"), we're trying to vie for their love as much as the other way around. So I put on a little salesman schtick at the same time I'm trying to appraise the person before me. And most of the time it's quite fun.

That said, my impressions count for about two percent of where soon-to-be-Doctor so-and-so is going to end up on the rank list. Bob Seger may have complained that he felt like a number, but we'll assume that he wasn't singing about the process of becoming a doctor, however accurate his assessment would have been. In order to become a doctor in this country, one must become a number. The only question is: how high is it? The answer to that determines whether you will become a dermatologist or family practice resident, or whether you will cruise the halls in your snappy white coat at Johns Hopkins, or at Southern Podunk Community Health Center.

The Number for our residency program is, I suspect, calculated in a manner similar to other programs of its ilk around the country. For example, you get a certain number of points for having certain kinds of grades. In most medical schools there are three grades for the "clinical rotations," that is, when you actually see patients: "honors," which is like an "A"; "high pass," which is like a "B"; and "Pass," which is like a "C." (It is rare to fail once you've gotten that far in med school; for more on this feel free to read Blind Eye by James Stewart, but have a bottle of booze at the ready.) So, if you had, say, honors for your internal medicine grade, you'd get a 3, but if you got a high pass, you'd get a 2, and so on. Since our program is internal medicine, we have a category for the general internal medicine rotation, a category for the more intensive internal medicine rotation known as a sub-internship, and a category for all the other clinical rotations put together. Thus, if you had honors in both internal medicine and in the sub-I, but only a spotty showing in all your other classes, you'd end up with an 8...not too shabby, in fact.

Anyway, we have other scoring categories for things like research and leadership positions, how well you did on the nationalized standardized medical examinations, and so on, and the total number of points one can have, if they were a perfect candidate in our system, is somewhere in the high thirties. The interview accounts for four of these points, and each candidate interviews with two different faculty members. Thus, you might make a killer impression, but it won't save you if you didn't do so well in those other categories; your number is more or less fixed before you've even shaken my hand. (On the other hand, if you interview badly it will count against you in a most unpleasant way: say or do something offensive and there's a special category marked "Red Flags," reserved for people who do something socially inappropriate during the interview day. Red Flags will pretty much put you at the bottom of the rank list, or remove you from it entirely. Don't make ethnic jokes, students!)

Much could be said about this process but in the interests of time I will say that, in general, it appears that it works for the majority of candidates in determining who's going to be a decent match for a program. It won't really help you learn who is going to be very good, nor will it help you identify who is going to drive the medicine faculty bananas, but it will do just fine for the average, solid resident. (The truly stellar, as well as the truly awful, are pretty easy to spot; I'm talking about the residents who come in with the same grades as their classmates and turn out to be future Chief Residents. These guys & gals are hard to find in this kind of application process, and I'm not sure how you'd spot them in a time-efficient manner regardless.)

But grades can translate to interesting numbers, and the interpretation of the former can very much influence the assignation of the latter, which in turn can make the difference between whether a given candidate will end up at Man's Greatest Hospital or McGrungy State City Hospital. Let's take, for example, the grades of this (anonymous) student: high passes in most clinical rotations (internal medicine, surgery, psychiatry, and family medicine) and passes in two (OB/GYN and pediatrics). The student's "overall" recommendation by the medical school is "strongly recommend," which means that they regard this student as being in the second highest of four categories ("enthusiastically recommend," "strongly recommend," "recommend with confidence," and finally, with what approximates a straight face in medical school bureaucratise, "recommend").

Let's take a closer look at this student, though. When you consider this student's grade in relation to those of the student's classmates (I would like to show the chart, but have privacy concerns for the student, and have altered the classes to maintain that privacy), you discover that in some cases the numbers are damning, and in others they provide no useful information at all. For instance, this student got a "high pass" in psychiatry, but roughly two-thirds of the students got a high pass, and virtually nobody got a mere "pass." Thus an "honors" is useful information (top third of class), as is a "pass" (this student stinks), but not so much for the middle category. All of this students high pass grades have a similar flavor; they tell you that the student was competent, but don't really indicate if he or she was a cut above--the original intent of the high pass designation. The distribution of the OB/GYN grades is about what it should be: top 10-ish percent got honors, a bit less than 30 percent got high pass (a bit too large, but closer to the mark), and the rest got pass...so this student is average, what you'd expect of a "pass" grade. The pediatric grade, by contrast, indicates something more concerning: due to the grade inflation only twenty percent got a pass--that is, the bottom twenty percent, more like a "D" than a "C". Not so hot! Now that overall "strongly recommend" status looks a touch fishy to me and seems inflated. And sure enough, almost half of this class is given this label. If I were a better than average but not outstanding med student, I'd feel ripped off by this school.

Balancing these variables is part of the art of ranking, but no matter how you slice the bread, someone's going to end up higher on a given program's rank list due to some medical school's grade inflation, while others will inadvertently get dinged. I see no easy way around this except to give greater weight to national standardized tests. Unfortunately, they only speak to how well a person knows how to take tests, and perhaps how much "book medicine" they know. It won't tell you a lick about how good a doc they'll be.

The rank list meeting, where faculty try to jockey position for certain pet candidates (though my understanding is that the bumps are very minimal and most people's rank order is pretty well fixed), is taking place in a few weeks. Maybe sometime in July or August, after I've had a chance to make a survey of the new bunch, I'll drop a line about how things turned out.
--br

Is Robert Whitaker's book Anatomy of an Epidemic acceptable heresy, or dangerous nonsense?

2011-01-30T15:24:00.000-05:00

Over the past year in the world of psychiatry there has been a small hubbub about a book that was released last April entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Its author is Robert Whitaker, a science journalist who has an expertise in issues involving psychiatry, having written a previous book entitled Mad In America: Bad Science, Bad Medicine, and The Enduring Mistreatment of the Mentally Ill. The gist of Whitaker's book is that the very treatments used for psychiatric illness (that is, drugs) for the past generation may, in fact, be driving the epidemic in the first place, prolonging and worsening psychiatric symptoms.

Needless to say it is a provocative hypothesis, but for the most part it has not yet taken hold in the collective consciousness in the manner of Rachel Carson's Silent Spring, to which vague comparisons could be made. As of now it ranks only 19th in the amazon.com category for "Mental Illness," being edged out by such books as Will I Ever Be Good Enough? Healing the Daughters of Narcissistic Mothers as well as The Sociopath Next Door (which particularly sounds like a remarkably silly book). Part of its modest showing has to do with the media coverage, mostly limited to smaller outlets such as Salon and New Scientist; a local NPR station in Boston covered Whitaker's address to the department of psychiatry at Harvard earlier this month. Time had a brief dispatch, and The Boston Globe published a review, somewhat oddly, by a pediatrician specializing in lung and sleep disorders. Without the media flap, the book's sales appear to have faltered.

This last review by Dr. Daniel Rosen is particularly interesting because he finishes his review, which roundly criticizes Whitaker's contentions, by making a dark allusion to the dangers of agreeing with Whitaker's thinking. "Thabo Mbeki [the president of South Africa at the turn of the century] refused to accept that AIDS was caused by the HIV virus, believing instead that it was a side effect of malnutrition and the medications used to treat AIDS itself," Rosen noted. "Those who would seize the opportunity to cast psychiatry as a discipline into the rubbish heap without consideration for the benefits it has brought to so many would do well to remember how Mbeki’s inability to distinguish between theory and fact exacted such an enormous toll in human life and suffering."

It's an interesting little maneuver because, without explicitly saying so, Rosen essentially proclaimed that Whitaker's book belongs to a completely different class of book than the kind a reader would naturally assume he was discussing, which is to say that Rosen was accusing Whitaker of writing dangerous nonsense rather than acceptable heresy. And the two categories are as different as they could be in the world of science and medicine.

The typical mechanism of scientific progress relies on the establishment of heresies. Let's say we have some model about how stomach ulcers come into being: people think that it's related to stress, and doctors who read the literature prescribe a bland diet and tell people to chill out. Then along comes someone who's been doing biopsies of patients with ulcers and reports a new bacteria that's pretty much impossible to grow, but is clearly there, and thinks that it's this weird new bacteria, and not a stressful lifestyle, that is the cause of ulcers. This someone--after doing further research on his little bacterium--writes papers, gives talks at various conferences, and essentially argues with the scientific establishment that he's right and the old way of thinking about ulcers is wrong. Eventually, enough people are convinced by his data and adopt the new model. What I've just described actually happened and involves the discovery of the bug Helicobacter pylori by Dr. Barry Marshall in Australia in the early 1980's; by the late 1990's the H. pylori model was universally accepted. It's what you'd call standard, acceptable heresy, and science thrives on such a process.

The problem that very simple-minded people frequently are unable to appreciate, however, is that just because science works by overturning conventional beliefs, it doesn't mean that anything goes, or that just because some theory isn't shared by mainstream scientists, it must by definition have some merit. So a lot of writers and thinkers of science distinguish this form of thinking from "acceptable heresy" by regarding it as "dangerous nonsense." In the world of science, the two most dangerous forms of nonsense is that a) evolution isn't really true, and b) man-made global warming doesn't exist. In the world of medicine, the two would be a) vaccines cause autism, and b) HIV is not the cause of AIDS.

Which brings us back to Dr. Rosen's comparison of Robert Whitaker and AIDS denialists: it's Rosen's way of telling people that they shouldn't even bother, that Whitaker's work is not acceptable heresy, but rather dangerous nonsense. And Whitaker got the point of that right away: he posted a same-day reply in his blog at Psychology Today decrying that particular rhetorical trick, calling it "a bit over the top" in what wins points for remarkable restraint.

The question is: who is right? Should we agree with Dr. Rosen, think of Whitaker as a purveyor of dangerous nonsense, and throw it on the ash heap of silly attacks on medicine, or should we give Whitaker's argument a wide berth and read his book with care? For me, this is not an idle question as I haven't read the book, and I've been wondering whether I should put it on my reading list, and if so, how high should it go?

The answer is that I think Whitaker's probably solidly in the camp of acceptable heresy (which doesn't mean I think he's right, only that I am taking his contentions quite seriously). Anatomy Of An Epidemic is going on my reading list, and may go pretty high, for at least three reasons:

a. Whitaker clearly did his homework. One doesn't need to have a Ph.D. in statistics, or be a psychiatrist, to see that Whitaker researched his subject thoroughly, and for me that counts a great deal. Far too often people hostile to science rely on clinging to single studies as proof of their rightness. Whitaker sought to undertake what appears to be a comprehensive survey of the literature and ask the singularly heretical question is all of our modern therapy making a difference for the better? But even a causal glance at the reviews makes clear that he has done due diligence in trying to assess what the entire field knows. It's entirely possible that his interpretation of the data is flawed, as psychiatrist-blogger Dan Carlat thinks (part 1 here and part 2 here), but he isn't cherry picking data in order to further his pet theory, an intellectual strategy that drives me nuts.

b. Studying outcomes in psychiatry is a tricky business. One of the reasons why AIDS denialism is dangerous nonsense is because it's really not that hard to follow the progression of HIV viral load through sickness and death. In other words, outcomes are pretty clear. I have personally witnessed what happens to some patients who have stopped taking their antiretrovirals (small, nonstandardized nonexperimental data to be sure, but persuasive data nonetheless). In other fields, like cardiology, studying the effect of this-or-that drug is comparatively easy, because you are often measuring death as the main outcome, which as outcomes go is pretty fixed. In psychiatry, by contrast, outcomes are much more slippery: "feelings" are notoriously hard to standardize, and even in more severe cases such as schizophrenia, I remain skeptical that you can easily and cleanly reproduce results in clinical trials. As a consequence, I'm inclined to listen to multiple interpretations of effectiveness data, including those that question the value of the entire enterprise--and I'm inclined to listen to it in a way that I wouldn't if I hear an attack on HIV meds, for which there is far too much data to suggest anything other than their effectiveness.

c. Other people whose opinions I respect think highly of him. It's of course the weakest of the three reasons, but still counts for something. Particularly when one has to deal with sorting garbage from gems, it helps to have a trusted figure offer their two cents. E.g. Carlat: "[Anatomy Of An Epidemic] is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment. Put it on your reading list, and join the debate."

It is, and I will.
--br

HIPAA, Medical Writing, and the Problem of Disclosure

2011-01-22T13:47:00.001-05:00

Recently I saw a patient whose case I very much wished to write about, but as far as I was concerned she was off limits. The problem was that the particulars of her case could allow readers to figure out her identity without too much effort. Although "Billy Rubin" is a pseudonym, I don't zealously guard my pseudonymity, and an intrepid reader could figure out not only my actual name, but the hospitals where I work, and if anyone in the area of that hospital happens to read about a patient whose story is unusual, it won't be hard to connect the dots, and voilá, I have just casually violated this patient's privacy. Without discussing the particulars of her case, there was nothing to discuss, so I shelved the idea.

My own policy about writing about patients follow these rules:

Never write about a patient where the particulars of the story could lead a reader to suspect with a high degree of confidence the actual identity of the patient;
If I write about a patient with some idiosyncratic quirk, I change the details of the patient's description enough to preserve their anonymity--details like where they are from, what they do for a living, even their sex; and
I let people know that in advance.

Thus, when I wrote about last week about a woman whose hip replacement had gone wrong, there was nothing in the story that could lead anyone to identify her. There are lots of patients with hip replacements in your typical community hospital, and about 5 to 10 percent of them have some kind of postoperative complication, so it's hardly a narrow group. I felt comfortable writing about that, because I gave no detail other than that she was a she. Earlier in my professional life I wrote a book about my experiences as a medical student (feel free to follow link and buy it!), and said up front in the introduction to the book that I had changed around details such that nobody would be able to know whom I was writing about.

Jerome Groopman is one of medicine's more famous writers, and his most recent book is How Doctors Think, a book that delivers on its title as an explanation of the kind of reasoning that drives medical decision making from the doctor's perspective. I have a few quibbles about the book but it's a very good read for both physicians and laypeople. That said, he starts out the book by illustrating a case of a woman (whom he refers to as "Anne Dodge") who lives in western Massachusetts. She had been progressively losing weight and given the psychiatric diagnosis of anorexia and bulimia by her physicians, but her boyfriend suspected a missed diagnosis and urged her to see Groopman's colleague, Dr. Myron Falchuk at Beth Israel-Deaconness Medical Center in Boston. He proceeds to find the correct diagnosis, celiac disease, possibly saving "Anne's" life as a result.

Nowhere does Groopman tip us off that any of these details are altered so we can't identify this woman, and the medical particulars, when combined with her personal history, could easily lead someone to identify this patient. Groopman likewise doesn't let us know that "Anne" gave permission for him to write about her so that he doesn't have to hide her identity. From my perspective, you've gotta do one or the other, and in the age of rapidly decreasing privacy, you have to do it every time you discuss a patient with "the public." Either make it clear that nobody could figure out the identity of the actual person, or make it clear that it was okay with the patient to write about them, or include so few details that it's effectively an anonymous affair. (I still think the book is worth the read and don't mean to imply that Groopman is a careless doc--anyone who reads his work knows this ain't true. But I did, and still do, find it troubling about the book.)

If anyone out there has encountered similar issues where they have felt squeamish when reading a medical professional's discussion of a given patient, or is familiar with any formal considerations about the ethics of medical writing and the problem of disclosure, do let me know.
--br

Salon's Retraction on Vaccines, and Blog Revamp

2011-01-19T23:14:00.001-05:00

I just returned from a symposium sponsored by the New England Science Writers on science and medicine blogging; it was truly invigorating to listen to some tips from some fellow travelers, all of whom have a good deal of experience and heavy-hitting credentials as they blog on issues dear to my heart. Their thoughts have inspired me to do the blogging equivalent of a facelift, so there will be some changes in the coming days. An important change will be that I will revamp the links, adding some and losing others.

One of the additions is Retraction Watch written by Adam Marcus and Ivan Oransky (Ivan spoke eloquently and humorously at tonight's symposium), a blog devoted to tracking the retractions taking place in scientific literature "as a window into the scientific process," as they say. It is a fascinating blog and makes for a kind-of scientist's version of The National Enquirer. Though behind the tawdry headlines (and reading some of the scientific shenanigans really does require a strong stomach) lies a journalist's concern for the accuracy in scientific research, and more broadly a serious concern for transparency--both critical elements in a healthy, functioning democracy. The Billy Rubin Blog is officially a fan! (And, with blogs like this, he is wondering what his own purpose in blogdom is.)

One of the pieces Retraction Watch discusses is a piece I've linked to on Facebook but not on the Billy Rubin Blog: the recent retraction by Salon of their own anti-vaccine article of 2005. Salon gets huge credit for coming clean on its past mistakes, not just in admitting the specific errors of the piece, but in saying that it was wrong to the core. The link in Retraction Watch notes how Rolling Stone, which wrote a similar piece entitled "Deadly Immunity" also in 2005, has removed the article from its website without ever owning up to its general wrongheadedness, even issuing a "correction" that acknowledged they were wrong on some specifics, but with a generally defiant tone that most lay readers would assume meant that Rolling Stone wasn't really disowning it.

This all reminded me of the 2006 article by "journalist" Celia Farber in Harper's Magazine essentially contending that AIDS wasn't actually caused by HIV after all, and which led me to cancel my 12-year subscription to the magazine. (Please don't actually follow the link unless you plan to read this point-by-point rebuttal here, or get a general introduction to AIDS denialists here.) It was a depressing, though relatively little noted, episode in the history of American intellectualism and a huge blot on one of America's great magazines of ideas.

Retraction Watch includes Salon's retraction alongside periodicals more commonly thought of as "journals"--that is, "magazines" written on technical matters by and large for specialists. But Salon reaches not only more readers than these specialized publications, but is writing about science and staking claims about the validity of science just like all these other organizations whose collective feet are held to the fire when faulty or, much worse, fabricated data grace their pages. Yet the errors of a publication like Salon, just because they are written by lay writers, are no less excusable, and Salon should be commended for coming clean. (To my knowledge, Harper's has never issued a retraction of the Celia Farber piece, as far as I am aware, for instance.)
--br

Billy Rubin To Orthopods: Man Up or Drop Dead

2011-01-18T21:36:00.000-05:00

A rant:

In the pecking order of physicians, both in terms of salary and status, I'm not especially high up there. As an infectious disease doc, I make a bit more than primary care docs, a bit less than hospitalists, a lot less than some of my fellow internal medicine subspecialists such as gastroenterologists and cardiologists, and a whole lot less than general and plastic surgeons. All of which is fine with me, as salary wasn't the main reason I got into medicine in the first place, and I have always put very little stock in status. Moreover, I have always maintained a huge level of respect for the vast majority of cardiologists and surgeons, most of whom are not only consummate physicians but incredibly hard workers as well. I'm content to play the bottom-feeding catfish to their swordfish (cardiologists, in this somewhat strained analogy) or shark (general surgeons, of course).

Also in this metaphorical fishbowl of American medicine are the clownfishes: small but beautiful, always the envy of the other fish in that they draw the admiring stares from people while flitting through the tank. Orthopedic surgeons are the clownfishes. They're not a big subspecialty: of the roughly 22,000 residency positions available last year, only 641 were for orthopedics. But oh, do they do well: the median income of an orthopod is estimated to be over $400,000 (!). Hence, a lot of very good medical students in med schools in the US work very, very hard as they pine for the joys of knee arthroscopy, laminectomy, and hip replacements, to say nothing of the Cabernet Sauvignon or trips to Bermuda that await.

One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.

Again, bone surgery is not what interests me so I'm not trying to rain on their parade, and I'm not trying to cry about unequal compensation. I do think, however, that with all that compensation comes a few obligations.

Take, for instance, the patient that I saw this weekend while covering for the local ID physician at the nearby community hospital. My pager chirped early Saturday morning and I got one of the hospitalists on the line. "Billy, I'm not sure what's going on with this lady, and she's not even 'mine'," said the hospitalist, meaning that he wasn't the attending of record, but just a consultant managing the medical issues. The attending of record was an orthopedic surgeon from one of those "Sports Medicine Associates"-type groups (not the real name). It turned out that the patient had gotten a new hip eleven days before, and her postoperative course was complicated by a fever that never seemed to go away, even though cultures, x-rays, a CT scan of the hip, and a few other tests turned up nothing. Plus her white count was normal.

I relate this story not because of its "House"-like interest (though MDs out there are welcome to take a crack at the diagnosis), but because during those eleven days she was not once seen by the orthopedic surgeon who put the new hip in. Nor was she seen by the surgeon's partners who were on call; she got visits from three different Physicians Assistants, all of whom assured her that she was on the mend (she wasn't) and would be discharged the next day. Eleven days!

You know what? I don't care that the clownfishes make the big bucks until I see a patient not merely suffering (sometimes that's unavoidable), but feeling abandoned, which is inexcusable! I know that they're just doctors of bones and not real doctors at this stage of their careers, and that they can't manage anything other than deciding between a press-fit stem and a cement-stem, but the patients don't know that! It's fine, let me and the other consultants who actually know how to be doctors of people do the real work of taking care of the patient--I'm handsomely compensated as far as I'm concerned, even if it's a third of what they make. Just try to make the patient feel like you care! So Man Up, you asshole, and see your fucking patient! She's sick!

Lest you think I'm overstating the case, take a look here at this 2007 NYT article about "specialty" hospitals not being able to handle sick patients. Not all of these specialty hospitals are completely orthopedics, but a lot of them are. You know what's really rich about this? These hospitals are often built by the physicians themselves because they want to cut out "traditional" hospitals so that they can receive even higher levels of compensation. Amazing! (And yes, "rich" was an intentional pun.) Physician salaries are often a delicate matter to discuss, because docs want to be well paid, but this isn't just your typical societal working-out of a doc's salary. This is greed! Good grief.

When I signed off for the weekend to the regular ID doc, I related this story. He sighed. "Yeah, we have really had problems with that group over the years," he said. "The amazing thing is that when something goes wrong and the patient doesn't just recover in three days like normal, they tend to get mad at the patients for sticking around."
--br

Billy Rubin, The Patient

2011-01-12T17:56:00.001-05:00

Over the past year I have been having increasing difficulty with my breathing, having frequent episodes of wheezing and chest tightness, to the point where over the summer I could no longer exercise. I had never had such a problem before, but knew enough to know that albuterol would temporarily halt the symptoms. I stole some of my son's albuterol nebs, and the incredible relief they brought made me realize that I shouldn't be self-medicating and so I arranged an appointment with my doc. His take (after noting my room air pulse oxygenation of 93%--abnormally low for a 40 year-old with no major medical problems) was that I had new-onset asthma probably due to reflux, and while I was skeptical, I duly arranged to take a battery of medications, including the acid suppressor protonix, a steroid nasal spray, a steroid inhaler, and most importantly at that time, a two-week tapering course of prednisone, which by the end had me feeling like a million bucks and allowed me to get back on my bike again.

Two months later, though, despite being nearly completely faithful to the medications, I was tightening up again. Each week exercise became harder and harder, and I got more and more reliant on the albuterol (which helps symptoms but doesn't fix the problem). I went to see an ENT doc and he found nothing. My doc shrugged and suggested that I see a pulmonologist. When I called to make an appointment, though, the first opening they had was in mid-February, and I was getting worse by the day. Finally, by last week I had reached the end of my rope and decided to prescribe myself a steroid taper. Treating yourself as a doctor is definitely not considered smart, but I felt I had little option. When the pulmonologist had a cancellation a few days later, I came in and sought to apologize for the self-medication. After she listened to both my story and my lungs, though, she looked me straight in the eye. "You sound terrible, even now, a few days after you've started the prednisone," she said. "You absolutely did the right thing; I just can't believe you waited as long as you did." Well, how about that, I thought, Billy Rubin, model patient!

Then came the conversation about cats.

I knew it was coming. Anyone who suffers from asthma is advised to minimize exposure to a variety of allergens known to (or at least suspected of) drive the pathology in the first place. So my pulmonologist asked me if I had cats. I replied I had three. She paused, then said, "you may need to consider placing them somewhere." (Disclosure--I can't remember if those are her precise words but it's damn close.) Place them somewhere?

Doc, you seem nice and all, but I ain't getting rid of the cats.

A story leaps to mind. Back in med school I had a classmate whose wife had just delivered. She had two cats who had lived with her for about ten years and regarded them as "her kids," but the process of having human-based children had a profound effect on her. "I just came home from the hospital and looked at them," she told us, "and I said, 'Oh my God, they're just cats!' It was like I never really realized it until I had my own."

The family joke around the Rubin household is a bit different: I'm fond of saying that I have two and a half children and two and a half cats, the third cat being a good deal more than just some friendly fur that eats food and wants its box cleaned. This little feller sleeps with us, cries when we leave, comes right to the door as soon as we walk in and jumps straight to my shoulder. The other two are your basic cats, and while I'm very partial to them I suppose that I could banish them if my life were threatened. But this third cat? My baby? Oh, you must be kidding.

During my infectious disease fellowship, I had a clinic with a few patients who had advanced HIV and owned cats. Cats, especially the outdoor ones, carry a parasite called toxoplasmosis that's harmless to them and is in general harmless to us. However, those with compromised immune systems have to be careful--thus warnings against changing your cat's litter box if you are pregnant, are a transplant recipient, or you have advanced HIV. Usually there's some easily found solution so that the person at risk doesn't have to change the box, but twice I had patients who simply didn't have options: it was change the cat's boxes themselves or get rid of the cat. Both times I suggested they consider getting rid of the cat.

I remember both of these moments because I remember the looks I got in response to my suggestion. It was the same look I gave Doctor Pulmonologist last week.

In medicine, sometimes the equations are simple and so is the advice. But the solutions (and the docs that give them) have to take into account the whole of the person: knowing what's adjustable and what's non-negotiable. I don't blame my doc for her advice--it is, after all, the right initial advice to give--nor do I have any trouble with the clinical detachment that she delivered it. She's supposed to be detached! As we continue to visit, though, I'm hoping that she'll come to appreciate how very un-simple the equation of getting rid of some cats would be for Billy Rubin, The Patient.
--br

The Whitewashing of Mark Twain

2011-01-05T22:24:00.002-05:00

The most appalling tidbit in this story about an English professor who has redacted the word "nigger" from Mark Twain's novels The Adventures of Huckleberry Finn and The Adventures of Tom Sawyer is not the preciously childlike logic motivating his actions, thoroughly childlike though it is. The professor, one Alan Gribben of Auburn University, Montgomery--more thoughts on the Auburn connection anon--said that he felt that the more polite term "slave" should be put in "nigger"s stead, in part, because he was approached by a number of local teachers who said they would love to teach the book, but can't because "in the new classroom, it's not really acceptable." No, what is truly, deeply appalling, even beyond this triumph of bowdlerizing stupidity is that Gribben actually justifies his decision in the wake of critical e-mails he has received. "None of them mentions the word. They dance around it," he says, and one can hear a certain tone of schoolmarmish pride.

At the Billy Rubin Blog, while we unquestionably react viscerally and angrily to the casual use of such words, we do not shy away from mentioning words that have real power to broadly offend in American society (of which we would only list two: the aforementioned "nigger," and "cunt") simply because such words are deemed impolite.

[A digression: "bitch" used to be in this category but has attained a certain level of acceptability, with restrictions: noting that you've had a "bitch of a day" in polite chit-chat with colleagues won't raise eyebrows, but referring to one of the female SCOTUS Justices as a "bitch" certainly would. And obviously people immediately think of various words that in part helped launch the career of comedian George Carlin--"shit," "fuck," "motherfucker," "twat," "cocksucker," et cetera--words which might induce a scowl by others at work or play for their overall rudeness, but have basically become accepted at all but the most austere gatherings of the D.A.R. or Focus On The Family. Indeed, some of Carlin's words that couldn't be mentioned on television in 1978 are considered fully acceptable, if perhaps vaguely crude: "piss," "turd," and "fart" (this being a favorite word of Benjamin Franklin's...Billy delights in having selected writings of Franklin sit in his bathroom with the large title "FART PROUDLY!" referring to an essay of the same name). Such words, while having perhaps the power to titillate, almost never except in the most tight-wadded communities have the power to immediately and thoroughly offend. "Nigger" and "cunt," however, maintain an absolutely-out-of-bounds status in more social situations than any other words currently in use in the US. And we are, of course, ignoring the fascinating-but-complicated appropriation of the word "nigger" by African-Americans themselves. Suffice it to say that no sane white person would utter the word except among like-minded racists.]

Professor Gribben's exultation of prissiness (and the similarly comic reactions of at least some mainstream media outlets such as USA Today, who refused to actually write the word "nigger" since their policy prohibits it, admirable though such misguided intentions are) ironically misinterprets Twain in more than one way. The clear error, as explained by Jonathan Turley, who delicately tries to avoid the direct use of the word himself, invokes the notion that "to truly appreciate great works of fiction, such books must be read with an understanding of the mores and lexicon of its time." (The blog Rightpundits.com--we can safely assume that the Billy Rubin Blog concurring with such a site is rare if not unprecedented--merely decries the nonsense but doesn't bother to take the time to argue the point since it seems obviously ludicrous, an attitude toward which I am not entirely unsympathetic.) That said, Gribben's logic is not merely embarrassing because it fig-leafs Twain's equivalent of David (though my favorite has always been Pudd'nhead Wilson), but because it seems to operate on the logic that since Twain's work is great, Twain therefore is a Great American, and Great Americans by definition could not have possibly meant to use "nigger" the way most white people actually meant "nigger" until only 20 years ago, and it goes without saying, still used as the butt of jokes in a good many social circles, though much more discreetly.

But the reality is a good deal more complicated, and Gribben's attempt to anoint Twain as saintlike in his pursuit of racial equality ignores the fact of Twain's actual, explicit racism, and astonishingly manages to undervalue his incredible contributions to the American discussion about race (at least from this white Jewish kid's late-20th century perspective). Take, for example, Twain's love of the minstrel show, which without question would make Gribben blush himself into oblivion: "If I could have the nigger show back again in its pristine purity and perfection I should have but little further use for opera," he waxed nostalgic in his Autobiography published in 1906 [my emphasis]. How does Whitewasher-In-Chief, Professor Gribben account for such an unguarded and honest remark from his hero? Could the autoclaved Twain ever have uttered such ugliness?

Illustrating Twain's contradictions, though, should never be used to create the shibboleth that Twain was just another white racist who used the word "nigger" without care or concern for the people it referred to or those who used it. Twain unequivocally maintained a palpable disgust at slavery and the inequalities between whites and blacks, and did so quite vocally throughout his adult life. If one can read Pudd'nhead Wilson and not feel the rage against racism fly off page after every page, then one perhaps belongs in Professor Gribben's little Sam Clemens picnic of decorum, where the finer aspects of human cruelty are swept under the rug in the attempt to tell comforting bedtime stories, where nobody curses and all are treated with respect.

The actual Mark Twain, though, wrote about the real world, and he unleashed his vehemence at the peculiar racial injustices of America over the course of decades. Before he became the affable, wry man as portrayed by Hal Holbrook--Mark Twain! Utterer of Witticisms! Large Mustache and Pre-Einstein Hair!--he was a guy willing to skewer existing attitudes at great personal risk. The following is an essay that Twain wrote while living in Buffalo entitled Only A Nigger, commenting with acidity in the newspaper The Buffalo Express (of which Twain was part owner) on the lynching of an innocent man in 1869, and deliberately emphasizing the word "nigger" by putting it in quotation marks. Twain himself calls deliberate attention to the word--it's no accident! How would Professor Gribben even begin to try to teach this essay to his innocents, sunk as it is in the mire of foul language?

A dispatch from Memphis mentions that, of two negroes lately sentenced to death for murder inthat vicinity, one named Woods has just confessed to having ravished a young lady during the war, for which deed another negro was hung at the time by an avenging mob, the evidence that doomed the guiltless wretch being a hat which Woods now relates that he stole from its owner

and left behind, for the purpose of misleading.

Ah, well! Too bad, to be sure! A little blunder in the administration of justice by Southern mob-law; but nothing to speak of.

Only "a nigger" killed by mistake -- that is all. Of course, every high toned gentleman whose chivalric impulses were so unfortunately misled in this affair, by the cunning of the miscreant Woods, is as sorry about it as a high toned gentleman can be expected to be sorry about the unlucky fate of "a nigger." But mistakes will happen, even in the conduct of the best regulated and most high toned mobs, and surely there is no good reason why Southern gentlemen should worry themselves with useless regrets, so long as only an innocent "nigger" is hanged, or roasted or knouted to death, now and then. What if the blunder of lynching the wrong man does happen once in four or five cases! Is that any fair argument against the cultivation and indulgence of those fine chivalric passions and that noble Southern spirit which will not brook the slow and cold formalities of regular law, when outraged white womanhood appeals for vengeance? Perish the thought so unworthy of a Southern soul! Leave it to the sentimentalism and humanitarianism of a cold-blooded Yankee civilization! What are the lives of a few "niggers" in comparison with the preservation of the impetuous instincts of a proud and fiery race? Keep ready the halter, therefore, oh chivalry of Memphis! Keep the lash knotted; keep the brand and the faggots in waiting, for prompt work with the next "nigger" who may be suspected of any damnable crime! Wreak a swift vengeance upon

him, for the satisfaction of the noble impulses that animate knightly hearts, and then leave time

and accident to discover, if they will, whether he was guilty or no.

At the Rubin Blog, we consider ourselves to be at one with Twain's rage, though of course the issues have changed (but see the following paragraphs) and we do not believe that Professor Alan Gribben's Dolores-Umbridge-inspired prettyfying of American history does anyone any good as it generally short-circuits the justifiable rage that one could muster about any number of political issues. Such is the dismaying attitude not only of a silly professor in Alabama, but of the vast majority of political pundits and various television celebrities, all of whom would assiduously avoid saying "nigger" but who would be loath to remark on racial matters with anything approaching honesty.

Case in point: as one final note, I can't help but relish the irony that such a rationale is being dished out by an employee of Auburn University, which if you haven't been paying attention, is about to play for the national championship. Look at their webpage, which as of this writing has a gleaming picture of their star quarterback Cam Newton! Cam has been at the center of a number of stories detailing inappropriate transactions between various schools and his father in a "pay-for-play" arrangement.

How badly does this story stink? It depends on whether you choose to point the finger at Newton and his family, or rather the system which blithely chews up and spits out players, the vast majority of whom do not have a future in the NFL. This system does this, moreover, with generally little regard for a given player's education (or indeed, their eligibility to attend such schools), but rather in the quest for tens of millions of dollars in advertising revenue as funneled through ESPN and other major networks. Most of the colleges of the major conferences such as the SEC, Big-10, ACC, Pac-10 and former Big-12 have large numbers of football players, a good many of whom are African-American and frequently are descended from the very people that Twain wrote about; these players are being systematically exploited in ways that any impartial observer would at least find vaguely similar to the economic system of slavery that every Serious Thinker publicly declares as a thing of the dark ages. And what is the skin color of most of the boosters and coaches and University students that come to the stadium on Saturday ready for the rah-rah-rah! as long as their players are winners, damned be everything else? I'm thinking they're mostly white.

Go team!

Sometime soon: Billy Rubin, The Patient.
--br

Dumb Science + Politics = Media Fascination!

2010-12-29T20:16:00.000-05:00

The recipe is pretty simple: take some current topic of theoretical interest to many people (e.g. coffee drinking, organic food consumption, political views, amount of daydreaming, or some such), then pick some biological outcome to measure (e.g. death, prostate cancer, brain size, happiness, or some such) and try to see whether they correlate. Then, after you have made the fascinating finding (study finds that coffee drinkers less likely to develop constipation as octogenarians!), you get interviewed by "science journalists" and end up on TV and radio shows, even though most of these "journalists" appear to understand very little about science and have dismally low standards as journalists.

Case in point today comes from Salon as it references an article from the British paper The Telegraph about how different political views correlate with differences in the size of certain parts of the brain. The gist: "conservatives" appear to have larger sized amygdalas; the amygdala plays a central role in the processing of emotional reactions, which The Telegraph article describes as "often associated with anxiety and emotions." Moreover, conservatives have smaller anterior cingulates--a part of the brain the articles describe as "responsible for courage and optimism."

The reality? It's likely nonsense. The study hasn't been published yet (indeed, one very big red flag is the fact that the study findings are being released to the media before going through the theoretically rigorous process of peer review) so I can't comment with great precision on its validity. But it sure doesn't smell right: they took the "brain scans" (unclear from either story whether they were MRIs or CT scans) of two, yes, two Members of Parliament, one from Labour, the other a Conservative, and then reviewed the brain scans of 90 "students" (again, unclear if college-aged or not) and matched the sizes of the brain structures against a questionnaire designed to elicit political views. Again, the questions weren't made available, so it's really hard to know how they measured political values. Even so, the study design doesn't seem especially impressive. Students? Isn't the point of being a student to create one's worldview, meaning that some students will surely drift further toward the right in life, some further left, and some change not much at all? So how can this population be used to measure political attitudes? Is the distribution equal between men and women? Between whites and blacks? Immigrants and natives? Students and non-students? Well, we already know the answer to that question--and couldn't that bias the results all by itself?

Even more concerning is the whopper unloaded by the researcher himself when he said that he and his team were "very surprised to find that there was an area of the brain that...could predict political attitude." But his study predicted nothing at all! They took scans, administered a questionnaire, and then after the fact compared the two. Prediction would entail administering the scan and guessing what the responses would be before they were given. That's a freshman-level mistake and sure doesn't boost my overall confidence in the sophistication of this guy.

But the most odious part of this sorry little news flare is found in the first line of The Telegraph article, which begins, "Scientists have found that people with conservative views have brains with larger amygdalas." What's so singularly frustrating about this opener is that it quite possibly leaves less eagle-eyed readers with the impression that this is both a) unquestionably true because it was "found" like a little fact in the forest, and b) "scientists" are all agreed as to its truth--both of which seem dubious at best. At least in Salon, they change the passive verb formulation "scientists have found" to a more-cautious note of "a study to be published next year suggests."

It's still quite likely prattling nonsense, careful phrasing or no. And as the links supplied in the Salon piece make clear, political bloggers (apparently from both sides of the aisle) have seized on the findings and spun their own theories, each sounding as silly as the study probably is. People want scientific literacy? Find some journalists who have a sense of what constitutes good science and have them leave the junk to languish in throwaway journals, that's one place to start.
--br

A Tale of Two Values

2010-12-28T08:54:00.000-05:00

On Christmas Day, the NY Times ran a story whose title really does give readers most of the necessary information in the article: "In Budget Crunch, Science Fairs Struggle to Survive." The article goes on to quote various educators worried about the impact of these cutbacks, but there aren't any real surprises.

But while the story is accurate in collecting and relaying the details, I'd argue that it is narrowly telling the story (granted, as good journalism often should). Even without a strained economy, science education--or indeed, education of any sort--has long played second fiddle to that Great American Obsession, sports. For much of the 20th century the two were able to coexist in something approaching harmony since there was plenty of money to go around. But even before the Great Recession of recent years, public schools have been faced with cutback after cutback, while both amateur and professional sports have gotten fatter and fatter, budgetarily speaking. I recall as a kid growing up in northern Ohio and listening to the radio on election nights as my family listened to the majority of school levies, most of which were asking for a pittance, go down to defeat.

Not so the public financing of stadiums, which the public seems to adopt with a certain slobberingly stupid zeal, as witnessed in these articles on the financing of the Florida Marlins baseball stadium, an attempt to finance a professional soccer team stadium in Portland, Oregon, a brief take on the return-on-investment for Paul Brown Stadium in Cincinnati, and details and an opinion about the huge tax subsidies the city of New York granted in the construction of the new Yankees stadium. Comparing the amounts of public money that these businesses receive to the amount that school boards meekly request is akin to comparing the size of an NFL lineman to that of a Pop Warner player: you're not in the same, um, ballpark.

And we're surprised at the decline in educational standards in this country? Right.
--br

No, There Is Not a Cure For HIV

2010-12-16T23:44:00.000-05:00

One of the guiding principles of the Billy Rubin Blog is quite simple: namely, that mass media in the US provides grossly distorted and exaggerated "news" to a largely uncritical public that appears to be not only more interested in ESPN, but only interested in said network. This blog's major concern is the distortion of scientific and medical news, and this week provided an example of just how irresponsible "journalists" can become in pursuit of a sexy headline.

"German doctors declare 'cure' in HIV patient," the Reuters headline proclaimed Wednesday. The story got legs immediately, and was picked up by nearly all of the outlets one would consider mainstream: the Fox coverage can be found here, CNN's article can be found here (more on CNN shortly), Yahoo's article is here, the US News & World Report brief is here. Once the stories showed up on the respective websites, it rapidly rocketed onto the "most viewed" and "most e-mailed" lists: at the time of this writing, the CNN site lists just over 10,000 Facebook "shares" and 413 comments--easily among the top 5 health stories for that website over the past week; over at Fair & Balanced, the numbers were almost identical.

One small problem: it's not really true. Oh, sure, the facts of the story, as reported, are correct: there was a patient infected with HIV, and this same patient now does not appear to have HIV due to a bizarre quirk of cell biology and transplant medicine (more on this shortly). But the truth of the matter is that one patient with HIV became improbably, almost impossibly, lucky, and aside from the scientific curiosity that the case has for the physicians and scientists who study and treat HIV, there's nothing so hugely important in this story that merits a splashy shout-out in the health sections of major news outlets.

The headline does most of the damage: doctors declare cure. The online dictionary Your Dictionary has three separate relevant definitions for the word "cure," which are: a) restoration to health or a sound condition; b) a medicine or treatment for restoring health, remedy; c) a system, method, or course of treating a disease, ailment, etc. In declaring "cure," the German doctors were using the first definition. Technically, it is a perfectly adequate definition. But the reason why the news media ran with the story, and the reason why it's gotten flashed all over the internet in very little time, is because they understood the word "cure" in the latter two senses--that there was some new magical treatment on the horizon for the tens of millions of people infected with the virus. And that is, quite simply, a dream: there's no cure at all. One guy just got very lucky.

This reality did not stop major networks from jumping on the "cure" bandwagon, when its science and health "correspondents" should have known better. Here is CNN's Elizabeth Cohen barely containing her enthusiasm for the story:

It's important to note that the anchor, in framing the story, asks his audience to "listen up" and says that "doctors in Germany claim they may have found a cure for HIV"--which isn't what they claimed at all, and again wildly exaggerates the importance of the story based on that misreading of the word "cure." This is followed by Cohen performing the two-step of noting the facts, but ignoring the meaning those facts have, which is that this is a whole lotta ado about nothing. "This is so fascinating that, even if this isn't the cure for HIV, which it's not, it's still amazing what these doctors in Germany did," she gushes [my emphasis]. What ensues is a lot of back-and-forth graphics reminiscent of Ross Perot's presidential bid. There are, indeed, caveats that lace their way through the discussion, but the overall tone of excitement and optimism is unmistakable.

What makes such enthusiasm unfortunate is that it's a lie. Whether Cohen has deceived herself is unclear, but nevertheless the amount of fake hope generated by such a story is corrosive in at least two ways: it oversells what medicine is capable of, and in doing so helps to promote a backlash against the genuinely amazing things that modern medicine can accomplish.

CNN, to their credit, does make an attempt to contextualize the finding with an opinion piece stressing extreme caution when reading the story. But even here they screw the pooch a bit by throwing up the title "Why HIV advance is not a universal cure." Again, this is remarkably misleading--it's a cure only for one lucky person! A better title might have been, "Why HIV advance is not a cure at all."

What happened with this patient? You can read the articles for details but the quick version is that HIV lives in special immune cells, and this HIV-infected man had a cancer of the immune system. One of the principal ways we treat immune cell cancers is by completely destroying the patient's immune system and transplanting a different person's immune system into the patient (we also sometimes harvest the patient's own immune cells, get rid of the cancerous ones, and transplant them back in after "nuking" the patient's body, which is called an autologous transplant). The person who donated the immune cells to the patient had a special mutation in his immune cells that prevent HIV from entering the cell and setting up house; this donor is literally immune from HIV--part of a very, very small number of people on earth who cannot be infected by the virus.

Anyway, this is the Cliff's Notes explanation. What it misses (and what the news stories largely ignored as well) is that the bone marrow transplant that led to this patient's "cure" is basically a game of Russian roulette, with a high one-year mortality rate, a not-especially-impressive remission rate (it varies depending on the type of immune cell cancer, but they have nearly universally horrible prognoses), and causes unimaginable pain and suffering for the few months before and after the transplant. Even if there were an abundance of similar donors, we'd kill tens of thousands for the iffy chance of having "cured" an equal number. In the age of perfectly adequate HIV drugs--which keep the virus at bay but do not produce "cure" and thus need to be taken for life--this seems like a mad scientist's dream.

Where was the breakdown? Part of it lies at the feet of the German physicians, who might have thought more carefully about the implications of touting cures that simply aren't practical and thus don't really, truly exist. But I'd direct my venom at the health and science editors of the news outlets I've mentioned; there just doesn't seem to be any care taken in investigating this story, and in the case of Elizabeth Cohen's CNN piece, it's worse than that, as she runs away from the more sober implications of the story, even though she is fully aware of such implications, swept up as she is in the wonder of the Modern Medical Miracle. It's tremendously irresponsible journalism. This is a story that nobody should have touched.

Curiously, after seeing the article in a Reuters link at The New York Times, I have been unable to find any other mention of it at the Times website. Here is their page devoted to news on HIV. As of this evening (December 16), they appear not to think of it as worthy of their attention or their readers' attention. I not only concur with them, I applaud their restraint!
--br

Evolution Ain't a Ladder, and We Ain't at the Top

2010-12-15T19:15:00.000-05:00

The idea that we humans are the most privileged, most developed, most special creatures on earth has been around, of course, a very long time, further back than when the Bible creation stories came into being, further back than Gilgamesh, probably further back than when some guys took to painting on a wall at Lascaux. Since Darwin, though, we've known better: humans are just another species trying to make its way in the world, quite intelligent to be sure, but no more or less special than, say, a bacterium happily living in the soil.

But thinking of ourselves as the Most Special Species--where evolution is a ladder and the top rung is occupied by humans, who preside over all life much like Adam on the Seventh Day--has been hard to root out. Even intelligent and thoughtful people can fall into the metaphor in the midst of an otherwise lucid discussion about science. Such a thing happened today when Gina Kolata, the science writer for the New York Times, was writing about some new research on the killer bug Staph aureus.

Ironically, when I saw the article I thought that it would make a great blog entry from the perspective of how warped laypersons' perceptions are about the relative dangers of various microbes. Even those only with a nodding acquaintance with science often have heard of Ebola, no matter that Ebola is a very rare disease and no human case has ever occurred in the US (not from the lethal strains, anyway). Staph, meanwhile, which is an outright killer, was barely known outside of medical circles until the past decade, when the drug-resistant staph strain MRSA was the culprit in various outbreaks, including a famous outbreak among the St. Louis Rams football team. I often feel like I could have summarized the major clinical take-home point of my fellowship in Infectious Diseases in two words: "Staph kills."

Alas--a more in-depth discussion about the warped perception the public has about various diseases will have to wait, because Kolata fell into the we're-on-top ditch midway through the article. While discussing the predilection that Staph has for human blood over other animal species, Kolata wrote, "Staph definitely preferred human blood...but there also was a definite trend, the higher up the evolutionary scale an animal was, the more the bacteria liked its blood" [my emphasis]. But Gina, it just ain't so! Those creatures whose blood was more liked by Staph were more closely related to humans on the evolutionary tree, but not higher on a scale, not more "advanced", not more worthy of the description "living thing." Evolution allows for adaption to particular living conditions, and the creatures that occupy each niche are all equal. The best way to visually think of the web of life is as a two-dimensional non-vertical tree (the vertical version, with "man" at the top, can be found in an exemplary drawing from the early 20th century below). We're just hanging out at the end of a branch like every other living thing.

Tomorrow, a brief commentary about this Reuters piece announcing a "cure" in an HIV patient. While the facts are true, the message is deeply misleading.
--br

The Dearth of Republican Scientists

2010-12-08T20:31:00.001-05:00

There's an essay in Slate today that wins points for turning arguments completely upside-down. In "Lab Politics," author Daniel Sarewitz encapsulates pretty much his entire point in the subtitle: "most scientists in this country are Democrats, and that's a problem."

So far, so good--although my own politics aren't likely to turn Red anytime soon, I don't disagree with his observation. Problem is that he seems to think that the fault of this imbalance lies largely with the scientists themselves, rather than a Republican Party whose unequivocal anti-scientific, anti-intellectual rhetoric has driven the vast majority of scientists away.

Sarewitz spends most of his time discussing the climate change debate, and making the very slippery contention that "disagreements over climate change are essentially political--and that science is just carried along for the ride." To be fair, he doesn't quite assert this: rather, he asks it rhetorically, implying that there's more than a grain of truth to it. He explains:

For 20 years, evidence about global warming has been directly and explicitly linked to a set of policy responses demanding international governance regimes, large-scale social engineering, and the redistribution of wealth. These are the sort of things that most Democrats welcome, and most Republicans hate. No wonder the Republicans are suspicious of the science.

There are at least two misconceptions here. First is that "evidence" about global warming is directly linked to a political program by the scientists themselves--implying that scientists are working in lock-step with the Democratic political establishment to bring about policy change. This is largely nonsense, and ironically describes fairly accurately how the other party operates. Second, nobody "welcomed" climate change as an excuse to legislate "large-scale social engineering,"--whatever that means--so his whole analysis sounds like a daydream to me.

Climate change is a fact. It's extent can be debated, but not its existence. To pretend that "Republicans are suspicious of the science" is to give the Republicans far too much credit: they simply deny that there's any scientific validity to anything with which they disagree a priori. No wonder the Republicans are suspicious of the science--good grief! The Republicans don't believe in evolution! How could you expect them to believe in anything that requires scientific literacy? No Republican politician in this country can reasonably expect to gain the presidential nomination if they support the teaching of evolution in public schools. How could you expect scientists to willingly join such ranks?

There are thinkers on the public scene who are vocal enthusiasts for science and who simultaneously hold beliefs that don't dovetail with the Democratic party: author and football columnist Gregg Easterbrook is one such voice of whom Billy is fond. A generation ago, his politics would have put him squarely in the center of the Republican party. But the Republicans sold their soul to the devil around that time, and decided that the best way to deal with the fallout of unpleasant scientific facts was to attack science itself. Those intellectuals are in search of a home, neither comfortable with the Democratic party (Billy sympathizes, though he no longer finds his home there because he's fallen off the other edge) for political reasons, nor with the Republicans because of their hate-mongering anti-intellecutalism.

So please, Mr. Sarewitz, spare me the false equivalencies.
--br

It's Not Nice To Fool Mother Nature

2010-11-16T16:35:00.000-05:00

The AP reported this week about an unusual method of battling dengue fever. Dengue, a virus that's transmitted by the bite of the Aedes aegypti mosquito, causes hundreds of millions of infections worldwide and accounts for about 20,000 deaths each year, the vast majority in children. Since early in the 20th century there have been only occasional cases of home-grown dengue in the states along the Texas-Mexico border, though in the past year there appears to have been a full-scale outbreak in Key West, Florida, and a case of dengue in a man who never traveled out of Miami was just reported by that city's newspaper.

While dengue has been a known disease for centuries, serious researcher on the disease dates to about World War II, when Albert Sabin (famed father of the polio vaccine) did experiments with US Army recruits, actively infecting them with the virus and studying their immune response. (It's not an exceptionally lethal virus, killing only a tiny fraction of those who are infected, but still. Times have changed.) Despite the 60+ years of work, a successful vaccine remains elusive, although there are many different groups hard at work on vaccines in various stages of clinical testing. So far, the leader is the company sanofi aventis (no caps is correct, don't ask), whose Sanofi Pasteur division has its candidate vaccine in what is called Phase 3 clinical trials, the final stage before receiving governmental approvals. Their vaccine is based on a very cool concept. They've taken the Yellow Fever vaccine, called 17D, which has been around seemingly forever--it's the first true modern vaccine--and is quite safe and very well tolerated, and spliced a piece of dengue's genetic code into the YF 17D genetic code. Since Yellow Fever and dengue are closely related viruses, this is, in concept, simple to do, and the genes that are swapped are those that encode for the surface proteins, so the human immune system "sees" a virus that looks like dengue, but the vaccine still uses the 17D proteins to replicate itself. We still need to see the results of the Phase III trial but it looks very promising at this point in time.

That said, it makes perfect sense to look for other solutions to the dengue problem, and one approach has been to control the mosquito populations. Olivia Judson of the NY Times speculated about this in her blog over two years ago. The AP report this week indicates that the company Oxitec Ltd has figured out a way to genetically engineer male mosquitoes so that they are sterile. After the science of gene manipulation, the concept is simple: release enough sterile males into the environment so that they mate with females who proceed not to reproduce, and just like that your mosquito population is lowered. The AP story notes that they've released 3 million of the critters in a small area on the Cayman Islands as a pilot project. The story also goes on to quote some worry-warts who fear that the company is jumping into an ecological experiment without having considered all of the variables. The story quotes Pete Riley, the founder of GM Freeze, a British group that opposes genetic modification. "If we remove an insect like the mosquito from the ecosystem, we don't know what the impact will be," says Riley.

Count me among the worry-warts this time. "Teaching" our immune system to recognize pathogens has been a wildly successful strategy at keeping people alive and healthy for over two centuries; messing with the environment as a means to control disease has occasionally worked, but equally as often has spectacularly failed. In the 50s and 60s, there were wholescale "malaria eradication" programs in the western hemisphere where DDT and other insecticides were used in an effort to stamp out mosquito populations, and we know how that solution worked out. One point Riley makes is that a collapse of the mosquito population will have unknown effects in the food chain, and could possibly lead to some other disease being introduced by an insect predator stepping into the breach. I'm a little skeptical about this, only because Aedes aegypti populations have taken off precisely because of human development over the past 150-200 years. These critters are as domestic and reliant on civilization as we are, as we constitute their happy hunting grounds--unlike other mosquito species, who live quite placidly in the wild. That said, I do agree that you never know what's gonna happen when you do a large-scale ecological experiment, and our these kinds of projects almost always, forgive the pun, come back to bite us.

Oxitec notes that they aren't trying to bring about permanent change since the genetically sterile males can only hang around for a generation, although to me that begs the question: what's the long-run solution? Are we going to keep introducing genetically sterile males, generation after generation, to keep mosquito populations low? And how will we define "low," anyway? Leave aside the ecological implications, which has the possibility of bringing about unintended consequences (in a way that a new vaccine almost certainly doesn't), it's an incredibly costly, top-heavy solution. And the last time I checked, a huge number of the countries that really suffer from the burden of dengue don't have the kind of cash or infrastructure that would make this kind of an approach feasible. You'd get a lot more bang for your buck if you just hired people to come visit houses and identify and eliminate all areas of still water where mosquitoes lay their eggs. Do that, and watch your skeeter population drop just as much as with the fancy genetic experiment.
--br

Truth, Found in Football

2010-11-10T21:17:00.001-05:00

Killing a bit of time earlier this evening, and I happened upon an article in Slate--don't ask me why, I'm still trying to figure that out myself--by the sportswriter Stefan Fatsis. Stefan, who parlayed his weekend warrior soccer talents into a Paper Lion-style project as a placekicker for the Denver Broncos, has been a keen commentator on NFL issues given his insider experiences. I usually hear him on NPR, but since he had an article in Slate writing about the narcissism of Brett Favre, I figured I'd take a look with a few spare minutes.

Much as I'd like to talk about Favre, what caught my eye was an assertion that Fatsis made about another NFL primadonnish narcissist, Dallas Cowboys owner Jerry Jones. For those who don't follow the sport, Jones is regarded as something of a football equivalent of Yankees former owner George Steinbrenner: megalomanical, autocratic, a man who interferes with his coaches and management because he thinks that he knows everything about everything. Fatsis describes him like this:

...the meddling owner who considers himself a businessman, promoter, player personnel expert, general manager, entrepreneur, public speaker, draft guru, and coach.

This description is couched as part of a larger point, which is the link between Jones's personality and the Cowboys' rather spectacularly bad 1-7 record so far this season. Leave aside the devastating injury to Tony Romo, the star quarterback of the team, thus utterly preventing easy wins for the past several weeks, the Cowboys were still a bad team this year, despite being picked to be a contender to play in their very own stadium for this year's Super Bowl. The question is why they're so bad. Here's Fatsis's analysis:

It is hard to pinpoint exactly how and why an NFL team falls to pieces. There are so many moving parts. But a hefty share of the blame should go to the meddling owner...That ego seeps into every nook and cranny of that organization and clogs up the machinery. The result is a 1-7 team: uninspired and looking forward to Jan. 3, the first day of the offseason.

Truth can be found in a discussion of football, and the truth is this: it's not hard, especially in an age of easily procured data, to fact-check one's arguments, yet people often seem to rely on lazy assertions as long as it fits in with the prevailing narrative. Fatsis, in writing about Jones, makes not only a specious argument, but makes one while the facts are sitting quietly like Christmas presents, eagerly waiting to be opened and used by their owners.

You see, Jerry Jones has owned the Cowboys for over twenty years...there's a very long track record to establish if his ego does indeed "clog up the machinery." And to judge by his record--or rather, his team's record--it does nothing of the sort. I googled "Cowboys record by season" and within four minutes learned that, since 1989, when Jones bought the team, the Cowboys have a record of 185-159 for a winning percentage of .538, plus three Super Bowl victories. That's not too shabby, especially from the point of view of this long-suffering Cleveland Browns fan. Take away his one true lemon season, his first (which one could argue was a perfect storm of new owner combined with the departure of a legendary coach in Tom Landry), and his record is 184-144, with an even more impressive .560 winning percentage. So if Jones's megalomania is really responsible for their failure, why have they had so many successes during his ownership?

Instead, Fatsis cherry-picks the data, musing on the awful 1-7 record of this season, completely ignoring the rest of the data set. As a result, what we get is a tale of an owner run amok, and a moral lesson about the proper role of humility: don't think you're a genius at everything--just look at what Jerry Jones did to the Cowboys! Never mind that this reasoning is totally at odds with Steinbrenner's success as an owner, nor does it explain the perennially bad showing of the LA Clippers, owned by the hands-off Donald Sterling, who appears to take little interest in his team and almost never bids high for a player's services. Indeed, one reading of Jones's stewardship could be the polar opposite of the Slate article: if you are confident in yourself and trust your judgement, provided your judgement is good, sometimes that will pay off even if you don't rely on (or even overrule!) so-called "experts." (The Cowboys' record, it should be noted, is more erratic than consistently good, as the winning percentage only gives an average of the 20+ years and is misleading. They were the best team in football in the early-mid 90s, while from 2000-2003 they were positively mediocre. So Jones isn't always right, but sometimes he appears to have been as right as one could get.)

I don't care a great deal about Jones, and I care even less for the Cowboys, but what I found singularly irritating about Fatsis's assertion is that it could easily have been checked. Why he didn't is a mystery, since he normally is an intelligent writer. What is much more disturbing is that such lazy baseless assertions are not at all confined to the trivial world of sports commentary. And the assertions that people are going to make in the next few years may--I only say "may"--have a huge impact on how we fare locally and internationally for many more years still.

Sometime soon: cat scans, mammography, and lung cancer, and the media coverage thereof.
--br

NPR Reveals How Big Pharma Influences Your Doc, and Fires Juan Williams, Too

2010-10-21T18:21:00.002-04:00

This entire week, National Public Radio--that known haven of insane Marxist-Socialists--has aired a series of reports illustrating in lurid detail the extent to which physicians are manipulated by pharmaceutical companies into becoming unwitting accomplices in their efforts to generate profits. When you see how the game is played (or more accurately, how doctors are played in the game) you can't help but a) cringe, and b) wonder about the amount to which your own doctor is manipulated. I am a doctor and these stories (along with other books and articles I've been reading) are making me question just how much my own prescription practices have been influenced by these tactics, and that's in spite of the fact that I have assiduously avoided drug reps since I was a fourth-year medical student. How many times have I heard lectures from senior physicians--even those from within the academic medical centers where I was trained--where some large corporation's money had influenced the speaker, who may have been unknowingly acting as a shill? How many times have I taken these lectures at face value, assuming they were given by disinterested academics who took only the best evidence into account when preparing their slides? The more I learn about these practices, the more I realize I have no idea. Just follow the link, listen to the stories, and have some scotch at the ready. It ain't pretty.

Today's installment on All Things Considered brought a new twist to the game. I have long known that the cozy little dinners at nice restaurants sponsored by drug companies were not likely to be places where one could get unbiased information. Today's story, however, explains that sometimes the drug reps target not the audience, but the speaker in order to generate revenues. The recipe: find a practicing physician with a large patient base and prescribes a large volume of drugs. (Companies have access to the prescriptions made by doctors because of arrangements they have with pharmacies. It's perfectly legal and any doctor's prescription habits, down to the last valium tablet, can be tracked.) Approach the physician and explain that he or she is a "thought leader" and welcome them to come give these dinner talks. Provide them with slides about your wonderful drug. Watch them speak. Follow that doctor's prescription patterns--not the ones who come for the cabernet and prime rib, but Dr. Thought Leader Himself/Herself--and watch the money roll in as your company's drug sales shoot through the roof for the month or two after the gig.

Mind you, this is all above board: there's no quid pro quo as part of these speaking gigs. There doesn't have to be one. Beyond the speaking fee (which is typically around one grand: very nice money to be sure) there is no explicit arrangement as to the content of the talks. Indeed, the overwhelming majority of docs would be seriously indignant if there were any implication that they should explicitly endorse drug X at someone's instruction before a talk. No, the key to the scam (let's call it what it is) is that such docs are manipulated through a psychological trick that allows them to succumb to influence precisely because they think they're above influence. "[Doctors] come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious," says Dr. David Switzer, a doc who blogs about the interactions between drug reps and physicians. "I don't think that we're as good at that as we think that we are."

According to one former drug rep quoted in the story, a $1500 investment in the speaker's fee plus, undoubtedly, a whole ton of flattery to a high-prescribing doctor could result in a bump of $100,000 to $200,000 for the drug in question--all from just the speaker. One can't draw too many conclusions from just one example, but the yarn is enough to make me believe that various drug companies would make it part of their marketing arsenal. Indeed, if it's legal and other companies are out there doing it, they'd be fools not to.

One of the only humorous moments of the story was when one of the drug reps had to explain what to do with some of the less stellar "thought leaders." Recall, the game is to try to target the doctor who prescribes a lot. Such a doc might not be charismatic, might be unattractive, might not even be a very good doctor, but all of that is beside the point. If they are all of the above, that's clearly a bonus and you want to have the added benefit of that speaker's influence on the audience. But if those qualities are not in play and all you are trying to do is to get the doc to push your drug, you want to limit the damage, and you book the gig at a fast-food style restaurant to ensure low attendance. (Doc Rubin, no doubt, would do no better than top billing at a parking lot outside the local coffee & donut shop!)

If you are a political junkie, you may also have seen how NPR got Big Media to pay attention to it briefly, for firing Juan Williams, their longtime news analyst. Williams, who lived the weird double-life as a commentator for both NPR and Fox News, has slowly and inexorably been moving toward this moment for some years probably. I have been unimpressed by Williams's thoughts on NPR for a very long time (not unlike its other major political commentator, the even more vapid Cokie Roberts), but his stellar performance on Fox was a piece of work, and NPR couldn't abide by it, leading to a he-said-she-said (literally) trading of accusations documented at NPR.

In case you hadn't followed all this, the brouhaha started when Bill O'Reilly opined in a guest spot on The View that "Muslims killed us on 9/11," causing the usual media flap (to say nothing of hosts Joy Behar and Whoopi Goldberg's emphatic reaction of walking off the set, bless their hearts). Part of said flap was Fox News guy Brian Kilmeade defending O'Reilly's nonsense by asserting that "not all Muslims are terrorists, but all terrorists are Muslims," causing all teachers of Symbolic Logic to have one simultaneous nationwide seizure. Williams got into the act as something resembling the Dumb House Liberal, a role he apparently plays on Fox, by noting with an aw-shucks statement conceding that Bill-O was right: "I mean, look, Bill, I'm not a bigot. You know the kind of books I've written about the civil rights movement in this country. But when I get on the plane, I got to tell you, if I see people who are in Muslim garb and I think, you know, they are identifying themselves first and foremost as Muslims, I get worried. I get nervous." NPR, saying that the remarks were "inconsistent with our editorial standards and practices," fired him.

Whether or not NPR meted out an unjust punishment is, I suppose, up for debate. But what isn't really up for debate is that Juan Williams said something completely idiotic and, yes, of course, bigoted. The defense that Williams was just speaking his mind and should be praised for his honesty holds about as much water as Carl Paladino's insistence that forwarding ha-ha e-mails of a jungle-bunnyish Barack Obama doing a tribal dance wasn't racist, which is to say not at all. Let's try this one out:

You know, when I get on the plane, I got to tell you, if I see people who are black and wearing baggy pants and bandanas, and I think, you know, they are identifying themselves first and foremost as black people, I get worried. I get nervous.

How's that sound? Umm...bigoted, maybe? So Mr. Williams lost his job at NPR. This appears to have been a boon to both Fox and Williams, though, who seems to have gotten a raise in the wake of the whole matter. Boo Hoo Hoo.
--br

The Dark Side of Medicine, in Corporate Form

2010-10-11T13:16:00.000-04:00

Carl Elliot, a physician by training and currently a medical ethicist at the University of Minnesota, might have been pleased, in a twisted way, to hear the recent revelations about the US government's research project in Guatemala in the 1940's where physicians deliberately attempted to infect prison inmates, patients in mental institutions as well as soldiers with syphilis. After all, when you're writing a book about how the machinery of medicine can be used for unethical behavior, how much better can you do than by getting some free publicity from a news story about truly outrageous behavior by doctors employed by the feds?

There is one major difference between Elliot's thoroughly-researched book and the Guatemala Syphilis Experiment story, however: most of what Elliot documents is corporate-driven malfeasance, while the Syphilis study was done at the behest of government and, however wildly misguided its aims, with national security in mind. The bad behavior that goes on today in the medical research world is done in the name of the almighty dollar.
Elliot's title might seem a bit misleading--at first glance, I thought it was the memoir of a Chasidic Jew in the world of secular medicine--but White Coat, Black Hat more than makes up for it by painting a picture of just how the system of medical research, in particular pharmaceutical research, can be gamed by savvy corporations whose bottom line often doesn't overlap with patient needs. And a pretty picture it ain't. Elliot acknowledges in the introduction that he is not trying to paint a balanced picture of how the entire system works, and that he assumes there are many corporate-employed researchers as well as executives who really do want to succeed in business by making better drugs for patients ("There are still plenty of honest doctors out there. But honesty is getting harder all the time."). He does, however, aim to review the known abuses to give readers a sense of how patients and doctors alike can be conned, sometimes with lethal consequences.

The book dissects the system from the standpoint of the various players within it: he looks at "guinea pigs" (research study volunteers who have turned being a serial study subject into a most unusual professional career), "ghosts" (writers who author medical manuscripts), "detail men" (drug reps), "thought leaders" (MDs who have turned into shills for the companies), "flacks" (the corporate execs) and "ethicists." Throughout every step he recounts the half-truths and highly iffy behavior of pretty much everyone involved, and what happens to the careers of those whose ethical misgivings finally override their desire for wealth and admiration, leading them to speak out. The short version is that while it's not wise to mess with these entities, but it's decidedly highly unwise to mess with them after you've sucked at their teat for a few years.

For those who follow the New York Times regularly many of these stories won't come as much of a surprise, but when collected together the portrait does have a rather compelling effect, a bit like the difference between the distate one experiences when seeing one cockroach compared to watching the scene with Harrison Ford in Indiana Jones and the Temple of Doom when he discovers that the walls are enitrely covered with creepy-crawlies. Yes, the bugs probably aren't going to kill you, but the more you shine a light on them and discover how abundant they are, you can't escape the overwhelming sense of contamination.
--br

PS--On the subject of Chasidic Jews and good timing--bravo to Carl Paladino! The Republican candidate for the Governorship of the State of New York couldn't have timed his ranting anti-gay speech better. In an address to members of the Sha'arei Chaim congregation (that's "Gates of Life" for non-Tribe members out there) that was greeted by applause, Paladino said, "I just think my children and your children would be much better off and much more successful getting married and raising a family, and I don’t want them brainwashed into thinking that homosexuality is an equally valid and successful option — it isn’t." Nicely done, Carl! Especially within days of the ugly revelations of the targeted assaults of gay men in the Bronx. Carl, you may be aware, is a fine example of the G-rated squeaky-clean right wing candidate who likes to decry the sexual lewdness of a permissive culture, until it turns out that he's not so squeaky-clean, as the revelations of e-mails containing bestiality and racism surfaced earlier this year. In Paladino's case, the revelations came months before the anti-gay speech. I'm not following the NY Gov's race close enough, but it smacks of someone trying to change the subject. Ladies and Gentlemen, the Tea Party!

The HIV Epidemic Rolls On

2010-09-28T20:02:00.001-04:00

"Shocking" is a word I prefer not to use much--to me, it smacks simultaneously of Leave-It-To-Beaver-era naivete and reality-TV-let's-outdo-ourselves-era behavior--but I'm hard pressed to come up with a better word to describe this week's report from the CDC about the prevalence and awareness of HIV infection among Men who have Sex with Men. Most laypeople would describe these people as "homosexual" or "gay," but the clinical term has trended toward using the acronym "MSM." This is because some men, whether for reasons owing to homophobia in their communities or to a bisexual lifestyle or both, may not define themselves as "gay" but still fit into that epidemiologic group. It's not a trivial distinction, as the act of having unprotected sex with a man who has sex with other men is, no matter what he calls himself, statistically, a much more risky proposition than having sex with one who doesn't.

Thirty years into the HIV epidemic, that shouldn't be. There should be no group more painfully aware of the ravages of this virus than gay men. An entire generation was, if not destroyed, at least pummeled by HIV. And as Randy Shilts's excellent book And The Band Played On laments, it wasn't just the kind of dark paranoia of Ronald Reagan's administration that fanned the flames of the epidemic in New York and San Fransisco in the early 1980's: the patrons and owners of gay bars and sex clubs were equally interested in ignoring early compelling evidence that something wicked was coming. Tens of thousands of people--again, mostly gay men--died as a consequence.

So if any group should be hypersensitive to the need for basic Sex Ed and the usefulness of protective sex, or at least the value in frequent HIV testing in the absence of safe sex, it should be gay men. Alas, the CDC reports this week that such is not the case. The numbers can be a bit overwhelming when you examine all of them in detail, but the bottom line is actually quite simple: nearly half of all men actively having sex with other men that are HIV-positive are totally unaware that they are infected. (Of the roughly 8,000 men who were tested, 19% were infected, which means that approximately 10 percent of men who have sex with men are both HIV-positive and unaware of this. Russian roulette, anyone?)

These stats probably represent a slight overestimate of the true number of gay men who are infected and unaware, since the men were recruited to the study were found at "appropriate venues," such as bars, organizations, and street locations where gay men were known to congregate. Thus, this group is probably more sexually active and potentially more promiscuous than the larger community. That said, it's still cold comfort: the seroprevalence in this community, despite all that has happened to them and all the suffering they have gone through over the past three decades, is basically that of sub-Saharan Africa.

If you sift through the numbers, you will see that it's even worse for MSMs in minority communities, especially blacks, where the HIV prevalence was just under one in three (the prevalence for Latinos, at 18 percent, was only slightly higher than that for whites, at 16 percent).

I would like to think that I'm not shocked by much, but this leaves my jaw in a state of drop.

You might wonder why, in an age of effective medical therapy for HIV, I'm making such a big deal out of this study. After all, once they find out they're infected, can't they just take medications and everything will be okay?

Well, no. There's two major problems with this analysis. First is that there is abundant evidence that people whose HIV infection is treated earlier tend to live longer and suffer fewer complications from the disease (such as cancer, among many other things). Second, and even more importantly from a public health standpoint, is that people who are HIV-positive but on treatment are far less likely to spread the virus. When half of one of the largest groups of people infected with the virus are unaware of their infection, controlling it is a pipe dream. And because this group still does have sex with others outside its "own group," everyone remains at risk.

--br

PS--Apropos of nothing much, I continue to be annoyed, like many, at the infantile way in which the modern media seems to have constructed political debate, where apparently only two positions seem tenable: that of laissez-faire capitalism or Stalinist/Maoist/Marxist (choose your favorite!) communism. Today, Paul Krugman of The New York Times has one of the more eloquent rejoinders to this kind of diatribing,

The market economy is a system for organizing activity — a pretty good system most of the time, though not always — with no special moral significance. The rich don’t necessarily deserve their wealth, and the poor certainly don’t deserve their poverty; nonetheless, we accept a system with considerable inequality because systems without any inequality don’t work. And before the trolls jump in to say aha, Krugman concedes the truth of supply-side economics, that’s not an argument against progressive taxation and the welfare state; it’s just an argument that says that there are limits. Cuba doesn’t work; Sweden works pretty well.

His point was actually tangential to his main post, where he was commenting on the fact that a conservative blogger had accused him of advocating full-out war as a way of stimulating the economy during economic depressions. More than anything else, my sense of despair for the politics of this country is less of a concern for left/right division than the fact that so many people make so little effort to actually understand anything at all. It is true of medicine, it is true of science, and it is no less true of economics and politics.

Ethics After an HIV Trial

2010-07-26T21:50:00.000-04:00

Today the New York Times has an article about what appears to be the first successful "microbicide" that protects against HIV infection in women. Many hosannahs have been said in the medical & scientific research circles following the release of this data. No less an authority than Anthony Fauci, the head of the National Institute of Allergic and Infectious Diseases (and someone Billy thinks of as a patron saint of the profession), noted, "there’s a certain feeling of ease and pleasure for me as a scientist that any way you slice the data, it’s statistically significant." That may not sound like much, but in doctor-speak that's a pretty excited endorsement.

The "microbicide" is a vaginal gel that the woman applies both before and after having sex, and it provided protection between about 40 and 50 percent of the time (the amount varies because the researchers broke down the cohort into sub-groups based on how faithfully they applied the gel; the more faithful users, not altogether surprisingly, were better protected). That's it--the gel hardly constitutes complete protection, but previous studies have shown dismal results.

You might be tempted to ask about condoms: why not just use them? Aren't they much more effective? This depends on how you mean "effective." If you actually use a condom, then yes, it's in fact a very effective means of protection for both partners. The problem is most men, whether they're having sex with other men or with women, don't like condoms and try to avoid using them at all costs. (I'm certainly no fan of them.) So out in the real world, where the vast majority of people aren't enrolled in a clinical trial, a condom isn't actually especially effective, because it often remains on the shelf, or in the purse, or in someone's back pocket, sometimes with the owner having the best of intentions, or as the case may be, because one partner persuaded the other not to use it (regardless if the sex is "gay" or "straight"). So the gel can provide extra protection for a woman who has a partner or partners unwilling to wear The Sock. (There's some very preliminary data suggesting the gel may be protective for men in anal intercourse, but this study looked exclusively at women.)

The trial enrolled nearly 900 African women. Now, however, the trial is over. The study was funded largely by the US Government. The question is, what is the obligation that the researchers, backed by the US, have to the patients? Is it ethical to simply walk away from these patients and allow them to be at "baseline" risk of acquiring the virus--which is still largely a death sentence in Africa? Or are the researchers only obliged to enter into an agreement which ceases to be at the end of the trial? These women, after all, would mostly have become infected had they not enrolled in the trial. On the other hand, what if a microbicide is developed as a result of this trial and becomes available outside of Africa first? Does that seem fair? Shouldn't the women who "put their bodies on the line for this study" (in the words of AIDS activist Mark Harrington, quoted in the article) have first dibs on the gel?

These are not idle questions and such situations have occurred many times throughout the past 60-70 years in US medical research. Most readers will be familiar with the infamous Tuskeegee Experiment, but many other similar experiments have taken place precisely because nobody designing the trial took the kind of questions above into account. I don't mean to imply that these researchers didn't; I can only say I am concerned by the Times report. In my own field, the "intervention" we study is almost always a vaccine, and if that works you don't need to come back for more; this situation is different.

Typically, the Billy Rubin Blog tries to leave you with an opinion. Tonight I only have questions--those questions two paragraphs above, in addition to more in that vein running through my head right now--and can leave you only with a troubled shrug of my shoulders.
--br

Rambling Reintroduction

2010-07-21T22:12:00.000-04:00

My most recent post, alas, dates back to the election of Scott Brown to the US Senate, with a fairly prolonged harangue at President Obama and my various frustrations with him (frustrations which, I am sad to say, have if anything only increased).

Not long after that entry my father collapsed on a winter's afternoon in Columbus, Ohio while walking out to his mailbox. Though the cause is unclear, he was in cardiac arrest by the time the EMTs arrived about five to ten minutes later on the scene after a neighbor witnessed the collapse and called 911. My father would not have wanted this, though of course the neighbor could not have known that. The EMTs were able to revive him and brought him back up the street to the local hospital to "stabilize" him. My mother, needless to say, was in total shock; I was seven hundred miles away, while my older sister was twice that distance in the opposite direction--in short, not the best situation to be in for a reasonably loving & mutually supportive family to make difficult medical decisions.

There are some details which at this very moment seem tedious to recount--tedious only in that retelling them in a blog (whose readers I cannot see and may not know) ain't really why I'm writing this. Suffice it to say that my father passed away ten days after he collapsed, although as far as I am concerned, in what some readers may regard as complete heartlessness, he finished his just-too-brief stint on earth that early February day he went ambling out to peruse his bills & other ephemera.

He had just turned 76. I would have loved ten more years with him, I would have settled for five, but I have no gnawing regrets losing him when I did. And while I didn't much enjoy the ten days we spent watching the corporeal shell of what used to be my father stop functioning, overall I don't have many complaints. Pops went from being a fully functioning guy, totally independent and in control of every aspect of his life, to dead, and made that transition quickly and without prolonged suffering. As a son, I think "ah, couldn't I have just a little more time?" As a doc, all I can think is "Bravo!"

I haven't written over the past six months for a variety of reasons, but I would be a fool if I said that his death wasn't the major factor. My father hasn't been a major part of my day-to-day life for many years now, and I have not been depressed about his loss, though I have been sad to be sure. The act of writing, and writing about medicine in particular, has always served to connect me with my father. I think he was proud of me as a son for a variety of things in the general way that parents are (hopefully, anyway) proud of their children, but my father looked at my writing as something different entirely. He was my greatest reader. He loved it when I put pen to paper, so to speak, and I think he was a bit disappointed in me when I chose to pursue medicine as a career in my mid-twenties, hoping that I would become a professional writer.

Instead, I went my own way, although the writing bug has always remained with me. Since medical school nearly everything I have written has dealt with medicine, and I believe reading this work was more complicated and ambiguous for him: he really did love to read my stuff, but just never quite believed that I thought of myself as a doc, thinking I was pulling the wool over everyone's eyes. For a very long while I agreed with that assessment, but for many years I have considered myself to be at one with the stethoscope, part of the brotherhood and sisterhood as it were, and have made my peace with those decisions I made nearly half a lifetime ago. But to pick back up and blog on the issues that mean so much to me as a doc was just not something I could find the motivation to do until this evening.

Nothing special or magical has taken place tonight; this has been gestating for awhile (an odd metaphor for a son writing about his father, but still) and I've been considering getting back in the saddle for the past few weeks. I do not know how many readers I had when I was trying to get thoughts out weekly, and I assume that if I will continue again I will be starting back from nothing. But the time seems right for a stab at it.

I have spent the past month as a "teaching attending"--a somewhat odd practice at my medical school where the attending responsible for the education of the residents and students is frequently not the same doctor as the one responsible for the welfare of the patients. Regardless, I've thoroughly enjoyed the month and gotten a real kick out of observing younger physicians at a time of their professional lives that I haven't witnessed up close for many years. As the month got close I had a blank wall on my office (that I had just recently inherited) so I was eager to put up pictures, so that my students and residents could see what was important to me as a doc. Some docs like to display their diplomas and accolades, which is definitely not my speed. Others coat their walls in family pictures, also something I'm not eager to do. (A few visual reminders of one's kids? Sure. I'm just not looking to completely morph my personal and professional life to that degree.)

No, I wanted something like a "hall of fame," a sampling of the people whose stories in medicine have been important to me as I've grown up, my way of saying, "these are the models I hold up as exemplary, I hope you find your own too." There's Edward Jenner, of course--a pompous addition, perhaps, but after all the father of vaccinology (my field of work); he resides next to a pic of Henrietta Lacks, the African-American woman whose cervical cancer was "harvested" to become one of the first, and to this day most important, cell lines in modern medicine, the "HeLa" cells (and the subject of Rebecca Skloot's great book The Immortal Life of Henrietta Lacks); sharing the triptych with them is the granddad of modern dengue research, Albert Sabin (most people know Sabin for his work on polio, but that's not why he's on the Rubin wall). Over there on his own is Hamilton Naki, as triumphant a story in medicine as can be told, in my opinion, and he hangs out in the vicinity of Gerhardt Domagk (one of the "discoverers" of sulfa, who refused to join the Nazi Party during World War II even though all of his scientific colleagues jumped on that bandwagon) and Oswald Avery (one of the pioneers of influenza research).

I'm planning on adding some faces as time goes on but I think that's a good start for my hall of fame. However--and I pray that this doesn't come across as too smarmy--these impersonal heroes and heroines of mine all share wall space with my father, who never quite knew what to make of my later-in-life interest in medicine but never failed in being supportive (very much along with my mother, lest anyone misunderstand). It's a picture of him that was taken when he was a young man and I had never seen it before; it popped up when mom sent me some tributes about him. I don't regard myself as one easily given over to sentimentality, but frankly I think he belongs there up on that wall, not simply because he was my father but because he shaped me as a doctor--willingly, eagerly talking to me about what mattered to me in medicine, probing my ideas, challenging my perspectives, all the while not quite believing that his son chose such a path, but satisfied with the choice nevertheless.

I can't say for certain at this point if the Billy Rubin Blog is "back," but I can say the itch has returned. See you back sometime, perhaps.
--br

A Progressive's View of Senator Brown's Election

2010-01-20T22:14:00.008-05:00

That is, the other Senator Brown. This is about the new guy, not the one from my homestate (and indeed, hometown of Mansfield!) Ohio. But you already knew that. Unless you were living under a rock the past 24 hours, you were almost certainly aware that the voters of Massachusetts elected to the US Senate a little-known local politician instead of the Commonwealth's Attorney General. And as you probably heard since that fairly dramatic upset, this represents real trouble for both President Obama and the Democratic party as a whole, which is fairly astonishing given that Obama and his party swept into power with enormous popularity only one year ago. What seemed inconceivable only a few months ago now seems within the realm of possibility: that the Republican party, who gave us eight straight years of George W. Bush and some of the most odious policies in the history of the Republic, might return to power in the House (it is statistically impossible in the Senate, which has only 17 Democratic seats up for grabs; even if all were lost to Republicans the majority would drop to 52).

So who is responsible for this and what lessons can be drawn? First, one should dispense with some of the nonsense uttered by some of the Democratic party establishment in Massachusetts. "Any analysis of this that does anything but celebrate Martha Coakley--her service and the efforts of this campaign--misses the boat," says Dem state party chairman John Walsh, in what has to be one of the more spectacular expressions of denial in recent years. Walsh may be trying to protect some turf in his self-serving foolishness, but nearly everyone else recognizes that this was a debacle: Brown's victory occurred in a state where the majority philosophy leans toward the Democratic party, and strongly so. That Brown could have achieved such a large margin of victory, even with a fairly large turnout (2.2 million people voted yesterday), speaks to the complete disintegration of the Coakley campaign. Making pleasant sounds about Coakley in the aftermath, as Walsh suggests, is like putting a cherry on top of a pile of dung and declaring it a sundae.

There are to my mind three major reasons for Coakley's loss: her breathtaking arrogance; the perception that Obama is in the pocket of Wall Street; and the Democratic party's handling of healthcare reform. The first item about Coakley's ineptitude and political tin ear is a relatively local affair and I won't discuss much further, except to note that her fall from grace has been tremendously precipitous. It's not merely that she was nearly 30 points up only a few weeks ago; she was a very popular and well-liked politician in this state, second only to John Kerry, even more popular than the Governor, Duval Patrick. That she could lose by such a large margin speaks to her ability to alienate people, and I suspect she has permanently damaged her brand among the Massachusetts electorate, which is quite a pity since she is a highly competent Attorney General. Simply put, Scott Brown never took one vote for granted and never condescended to the people of Massachusetts. Neither of those are compelling reasons to have voted for the man, but he deserves immense credit for his hustle.

More important for the President are the second two reasons, and Coakley can't really be blamed for either. Leave aside Obama's troublingly cozy relationship with the financial industry for a moment, the question is: with regard to healthcare reform, what should Obama have done differently? To me, the answer lies in two separate flaws in the plan, the first a tactical mistake that is only clear in hindsight, the second--which is much more concerning--lies in a major character flaw of the President.

The tactical mistake was created in the wake of the failure of the Clinton plan in 1993, which was perceived by Congress as being imposing and top-down in structure, with the Clinton White House (and, in particular, its soon-to-be-unpopular first lady) dictating terms to congressional leaders. Obama, hoping to avoid this problem, only created another by "leaving the bill writing to Congress while it tries to charm an industry that controls nearly one-fifth of the US economy," as Ceci Connolly aptly put in the pages of the Washington Post last June. Consequently Obama tended to other duties--which, one grants, are not insubstantial with two ongoing wars, problems with the banking industry, staggering unemployment and a host of other, minor problems such as global warming.

But the tactic backfired: congressional leaders squabbled, "centrists" like Max Baucus and Joe Lieberman suddenly were extracting pounds of political flesh (an apt simile in this case) to a cowed Senate majority leader, while Republicans congealed together a host of exaggerations and outright lies to drag down the popularity of a once-popular notion. By the fall, it was clear the process had run amok, and Obama's hands-off approach in retrospect had failed miserably. Had Obama merely tried to nudge the legislation along, using his formidable powers as an orator to advocate for what he wanted, filling up auditoriums around the country as an out-front advocate for healthcare reform, explaining to the American people his vision for the legislation, a good deal of pressure might have been brought to bear on several senators and representatives who probably intentionally dithered for reasons ranging from humbuggery to outright corruption. Instead, for more than six months there was mostly a vacuum of advocacy, and worse, the White House never really found its footing, saying on one day that the public option was non-negotiable, followed by the exact opposite indicator a few days later. Is it any wonder that Congress couldn't move the proverbial ball past the goal line?

The second reason underlying Obama's failure to shepherd along a meaningful or decent healthcare bill lies in who President Obama is, and that is, namely, one whose primary aim is to achieve consensus rather than to advocate for a given belief. We have seen what such consensus-seeking did for the Clinton presidency: after the 1994 congressional drubbing that landed the Republicans in control of both the House and Senate, Democratic party faithful were given a moderate Republican president in all but name, who stood before that congress proudly declaring that "the era of big government is over," who happily signed the Defense of Marriage Act, who sought to further enable the kinds of financial shenanigans that led to the economic crisis we find ourselves in right now. It only took a small sliver of disaffected Democrats to turn away from Clinton's successor and hand the Presidency to George W. Bush. Against all odds President Obama has followed Clinton's script. Contrary to the mildly insane claims of some pundits and politicians, President Obama has given his left-leaning base precisely nothing of what it has asked for. Glenn Greenwald pointed out quite accurately today:

In what universe must someone be living to believe that the Democratic Party is controlled by "the Left," let alone "the furthest left elements" of the Party? As Ezra Klein says, the Left "ha[s] gotten exactly nothing they wanted in recent months." The Left wanted a single-payer system, then settled for a public option, then an opt-out public option, then Medicare expansion -- only to get none of it, instead being handed a bill that forces every American to buy health insurance from the private insurance industry. Nor was it "the Left" -- but rather corporatist Democrats like Evan Bayh and Lanny Davis -- who cheered for the hated Wall Street bailout; blocked drug re-importation; are stopping genuine reform of the financial industry; prevented a larger stimulus package to lower unemployment; refuse to allow programs to help Americans with foreclosures; supported escalation in Afghanistan (twice); and favor the same Bush/Cheney terrorism policies of indefinite detention, military commissions, and state secrets.

This is not the approach of a robust advocate for traditional Democratic policies. This is the winning-is-more-important-than-fighting stance of a neoliberal, like Clinton before him; it is the pose, it pains me to say, of a wuss. And said wuss has fought for very little--indeed, nothing--he promised his base, the very people who catapulted him over the Hillary Clinton juggernaut one year ago. As I recall, this man, who offered such a thoughtful critique of the Iraq war (when it was far from politically expedient to do so), came to us with the promise of hope and change. Since the election we have been given hollow platitudes by a man unwilling to capitalize on his success, proceeding far too cautiously on the national stage (both links to Paul Krugman's column/blog in NYT).

Contrast Obama's lack of full-throated advocacy over the summer with George Bush's re-election in 2004. Bush, you will recall, had just managed to eke out a narrow victory, as a sitting war President, over another Massachusetts politician with a tin ear. Still, despite Bush's underwhelming performance (he garnered 50.7% of the vote and won by 2.4 points) he came before the American people the following day and confidently declared, "I have political capital, and I intend to spend it." Whether or not one finds that statement astonishing in its chutzpah, Bush immediately proceeded to campaign, election-style, for the privatization of Social Security, and did so in the face of enormous uncertainty, given Social Security's popularity. Bush of course did lose that fight, but as I see it the lesson here was that Bush was willing to fight for his party's beliefs at all.

President Obama? I have not only not seen such boldness on the whole, I have seen its opposite. You see, as I write this, the New York Times is leading with a headline that can only be described as dumbfounding. It reads, "Obama Weighs Shift In Health Plan, Seeking G.O.P. Backing." In the first graf: "President Obama on Wednesday signaled that he might be willing to set aside his goal of achieving near-universal health coverage for all Americans in favor of a stripped-down measure with bipartisan support." He has 59 votes in the Senate, and he might be willing to set aside his goal? Would the last President have asked for progressive input had he held a 59-seat majority in the upper chamber? I'm thinking not.

As a progressive, I think there is now only one option, and that is to declare war. On the Obama Presidency. He has not merely lost my support, he has lost my vote. Whether another politician will try to wrest control of the party from him in the coming few years remains to be seen, but barring a total turnaround, I am finished with him.
--br

Update #1: I have some additional thoughts which I can't write until later today, but in the meantime there was one error in the original post: in 1994 the Democrats lost control of both chambers, not just the House. The text above is corrected.

Update #2: Several thoughts.
One reader on Facebook asks: "[Obama's lack of courage] doesn't explain why MA voted for Brown. If voters thought the country so badly needs healthcare reform (and were frustrated for lack of progress), how is electing Brown going to help?" In the short run, of course, it won't--although to my mind even when Kennedy/Kirk was Senator and the Dems did have that supposedly precious filibuster-proof majority, the best the Senate could produce was a handsome subsidy for the private insurance industry. The House in all likelihood would not accept the Senate bill--after all, they still could, and rightly have given no indication that they want to pass it. In the upper chamber, politicians like Baucus, Lieberman, and Ben Nelson to name only a few have made it clear that if even a hair of their version of the legislation is tampered with, there won't be enough votes for cloture. Thus, Brown's presence on the political scene makes only a modest amount of difference. This is President Obama's fault. This is entirely President Obama's fault.

Also, it should be noted that (obviously) elections have binary outcomes even though the motivations of the voters run the gamut. (Technically there were three outcomes, not two given the Libertarian party candidate Joseph Kennedy--no laughing out there--but you get the point.) My back-of-the-napkin calculation goes something like this: of Scott Brown's majority of 52%, something like just under 15% represented the hard-core social conservative or ideological libertarian vote, who were not only in the bag but energized to vote. Another 20% represented the moderate members of the Republican base, socially progressive but friendly to business interests, and who generally determine what Republicans are viable for statewide office (Brown slipped by because everyone had left him for dead and no moderate Republican cared to lose to Coakley). About another, say, 13% represent mostly blue-collar workers in the suburbs who usually vote Democrat but were either alienated by Coakley's arrogance or charmed by Brown's little-engine-that-could shtick or both. Now all Brown's gotta do to win is pick off a fairly small percentage of disenchanted voters who are disgusted with "what's going on in Washington," regardless of whether or not they could offer a cogent critique, and wanted "to send a message." Add to that a lower voter turnout than usual due to the off-off cycle (turnout was 40 percent; turnout at Obama's election was a near-record 72 percent; typically in a non-Presidential but regular cycle it would be closer to 50 percent) and a disillusioned base, and bing! You have the making of a stunning upset. Basically, Coakley was able to count on urban voters and lefties (several Republicans in MA are also "liberals," so not the best term even though the two are almost interchangeable outside New England). That got her to 47 percent--actually an impressive number given how small lefty blocs are in other states--but it wasn't nearly enough. There is some question as to whether the other highly qualified candidate, congressional representative Mike Capuano, would have done better in the working class suburbs, but for me that's useless second-guessing. Though I'm glad I didn't wake up Wednesday morning being Capuano, wondering what could have been. Still, one might think that Capuano is actually now the odds-on favorite to win the Senate seat back in 2012, even though Brown just won!

As I said, Brown's ascension to Senator does not help Democrats' goals in the short run. But in the case of Republicans, neither did the wildcat candidacy of Douglas Hoffman in the NY 23rd district, whose tea party run (technically he was the "Conservative Party" candidate) against Republican Dede Scozzafava led to the election of Democrat Bill Owens in a reliably Red district. There, the conservative base found Scozzafava so unpalatable that they would rather have lost the election than vote for her. What did they get in return? In the short run, Owens. But less than two years from now, they are almost certainly going to get "their" candidate, whomever that is (and quite possibly Hoffman himself), on the ticket, and Owens will be playing defense. I think the political views of most of these people are totally nuts, but I deeply admire their resolve, and more importantly, I recognize that their strategy is almost certain to succeed. Incredibly, that strategy may well succeed not only in the NY-23 but in swing districts across the country, returning the Republican party to power only two years after the most disastrous defeat they have suffered in decades.

President Obama, on the whole, bears responsibility for this, and, although I am aware that I am opening myself to the charge of "left-wing nutcase" by suggesting this, he needs to be succeeded by another leader. He seemed like a highly thoughtful, extremely articulate, bold and confident leader. He continues to have the first two qualities but lacks the latter two, and we need the latter two. We have needed them for two generations. Think about this for a moment--here is the list of our national party leaders since our last truly effective leader, Lyndon Johnson (that could start a fight, but I'll stand by it): Humphrey, McGovern, Carter, Mondale, Dukakis, Clinton (blech!), Gore, Kerry, and Obama. With the exception of the current Prez, just look at that list! What a sorry collection of milquetoasts! And, alas, Obama's missteps have shown him to be of a piece with them. Yes, he has three years left and I do realize it sounds insane to write off his presidency. But I've seen not one shred of evidence to suggest that he's capable of even understanding his errors over the past several months, let alone attempt a course correction (or succeed at it). He needs to go, and if party loyalists stick by their man, they're going to go down.

Healthcare reform is quite probably dead for another generation. As I see it, there is only one way to avoid such a mess in the future: take a page from the Republican playbook, and refuse to vote for candidates who do not meet a litmus test, even if it means losing elections for a cycle or two...or more. I am not advocating a wide-ranging litmus test: I have mildly strong opinions about abortion, I have stronger ones about gun control, and stronger ones still about gay rights, but I recognize that the party needs to allow for minority views as part of a successful coalition. But healthcare reform and bank regulation? These seem to me pretty easy issues where Democrats can say, "Look, this party stands for federal government-backed health insurance, period. If you don't agree with that principle, you do not belong here, and we will not vote for you even if it means that we will lose a House or Senate district, or the Presidency itself." Then when you finally do win big, like the Dems did only one brief year ago, you won't squander the golden opportunity that dropped into your lap.

Another friend linked to a piece analyzing the structural peculiarities of the Democratic party. It has a slightly different take from my own, but I don't have any qualms about his writing except for the fact that Republicans, too, have their own structural issues, harmonizing the desires of libertarians, social conservatives, religious fundamentalists, and corporate interests, and they seem to have done a fairly good job of things since Ronald Reagan's election. And while I interpret Obama's motivations differently than Anonymous #1, I certainly see where he or she is coming from.

Update #3: How could the President redeem himself? Here's a thought: the radically right-wing Supreme Court just ruled today in a 5-4 vote that "corporations cannot be banned from using their general funds to pay for political advertising." As Andrew Leonard of "How the World Works" points out, this is going to profoundly influence Wall Street's reaction to the President's come-to-Jesus moment on banking reform, with the likely scenario being a huge influx of money supporting candidates who will block reform at every turn. So what can be done given a demoralized base and a surly electorate? How about a Constitutional Amendment barring such contributions? I'd like to see Joe Lieberman explain his vote against that. I'd also love to see Obama breathe fire on the campaign trail in, say August of this year--setting up a Constitutional Amendment vote just in time for the elections. Make that the story of the campaign. After all, the Republicans thought flag burning and gay marriage were such critical issues that they didn't hesitate to introduce CA's banning them; surely the Dems could do the same, especially as they (theoretically) oppose the Supremes' decision. Will we see the President adopt such aggressive tactics? I'm not holding my breath.

Update #4: I know I'm rambling, but just thought I'd add that the only person on the national stage that I can think of in my lifetime who was a politically viable Dem who simultaneously appeared to show genuine resolve was Howard Dean.

Various Thoughts on Haiti

2010-01-14T16:34:00.002-05:00

a. Before starting, if anyone has decided that they would like to make a donation but do not know which group to donate to, please consider making a donation to Hopital Albert Schweitzer in Deschapelles (about 3 hours northeast of Port-au-Prince). I worked there for a brief stretch during my residency. Their website notes that areas outside Port were affected, and the hospital has been swamped with patients and the doctors, nurses and support staff are stretched very thin. I don't want to divert money from the Red Cross but this is a more "tangible" donation, so if you have not yet contributed please do take a look at their website.

Pat Robertson's insane monologue yesterday is perhaps remarkable only for its particularly twisted form of logic. After all, religious fanatics have been in the business of interpreting natural disasters as divine retribution for millenia; what makes Robertson's thoughts on the matter so singularly flabbergasting is that he believes that Haitians, who had received a century of the most brutal treatment endured by humans at the hands of Christians, somehow made a "pact with the devil" ("true story!" the Reverend adds helpfully, as if he had found it in Wikipedia just before going on air) by not turning to Christianity. Assuming that he was trying to make any sense at all, I would guess that he's referring to the Haitian practice of voodoo. Even if one ignores his thoroughly peculiar logic, the vast majority of Haitians regard themselves as Christians. If Robertson thinks their particular brand of Christianity, with its African animistic influences, isn't up to Godly snuff, then why hasn't such a calamity befallen Rome? And why did God wait more than 200 years to get around to a punishment like this? No, what is most amazing about a raving lunatic like Pat Robertson--who, it must be remembered, made these comments on a show trying to raise money for the relief effort--is that his network, CBN, reaches millions of viewers in the US and millions more worldwide. "He's not like David Koresh," a colleague of mine quipped today, referring to the religious cult leader at the center of the Waco, Texas tragedy. "I mean, Robertson's got followers."

The irony is that because of their Christianity, a good many Haitians don't disagree with Robertson's assessment, although again I'm not sure they would concur with Robertson's underlying thought process. The quote of note from the writer in the above link: "If God exists, he's really got it in for Haiti."

c. Haiti was not an easy place to spend a month, and I continue to have conflicted feelings about the country. (And it goes without saying that spending one month in Haiti hardly makes me an expert. What observations I have are tentative, and what thoughts I have I myself regard with skepticism.) The story of the Haitian revolution and throwing off the yoke of bondage by the French at the outset of the 19th century has to rank as one of the greatest stories of self-determination in the history of humanity. Based off the very principles that defined the American and French revolutions, Haitian independence was a logical response to French oppression. It should be no surprise that politicians in the United States (Southern or Northern) or anywhere else had absolutely no interest in fostering this nascent state, and so, denied the ability to engage in trade like any other free nation (and Haiti was a country of vast resources at that time, and would have made a powerful trading partner for molasses and rum which were critical parts of the early American economy, to say nothing of the Spanish colonies), nor allowed to develop a navy for basic defense (attacks by the US prevented this), Haiti turned inward and began a two-centuries long process of auto-cannibalism that has been more-or-less uninterrupted. The US was heavily involved in Haiti in the early 20th century, occupying the country from 1915-34 (my jaw dropped when I saw WPA-style bridges there while riding through the countryside, as I had been totally ignorant of my country's involvement in Haiti); the Soviets also added to the infrastructure a bit during the 50s and 60s while Papa Doc Duvalier cleverly played the superpowers against one another. But besides these relatively short-term relationships, few nations have generally cared much about Haiti except for it to serve as a cautionary tale. Paul Farmer, now the famous doctor and subject of the bestseller Mountains Beyond Mountains, wrote about the history of Haiti's relationship to other independent nations over the past two centuries in his book The Uses of Haiti. It is worth the read. To have any hope of understanding the magnitude of the disaster that has just befallen Haiti, one needs to read a book such as this. This earthquake really couldn't have happened to a less prepared country.

d. You will read multiple descriptions of Haiti in the coming days as a place of "tremendous poverty." While that is undoubtedly true, describing Haiti as "impoverished" doesn't really give one the full scope of the core problems that its people face. For instance, when compared to an African nation of roughly equal population and area, Haiti (168th) outranks Rwanda (179th) in per capita GDP, and by a fairly sizeable amount ($1300 vs. $900; the US ranks 8th at $47,500, while Zimbabwe is last in 194th with a per capita GDP of $200). Rwanda's infant mortality ratio (17th highest in the world) is higher than Haiti's (37th), with similar data for life expectancy at birth (50.5 years versus 60.8). But Rwanda is a considerably more stable country than Haiti, with a government responding to the needs of its people, and there is a general sense among the people that their lives are improving. This is all the more remarkable given Rwanda's recent genocide; Rwanda's near-miraculous turnaround is the subject of New York Times reporter Stephen Kinzer's book A Thousand Hills, which has gotten some airplay in the US. In Rwanda, despite its recent horrors, the people have a sense of hope and of common purpose. In Haiti, where its leaders have been either uninterested or unable to help its citizens, there is no similar attitude--or at least, if it is, it is hidden well underneath the surface. I saw no evidence of it when I was there. Instead I often felt a sense of foreboding--especially in Port, where it was impossible for me to walk the streets without being accosted by people wanting my money. By contrast, when my wife worked in Kigali for a few weeks while building a high school there a few years ago, she was a magnet not for money, but for her camera--kids were constantly asking her simply to take their pictures. This in a place that, by the numbers, is even more impoverished than Haiti. So poverty is only a chunk of the problem. I don't want to imply that this is a fault of Haitians, and I don't want to sound callous to the needs of those people who came up to me on the streets of Port. Rather, my point is that if one only thinks about the earthquake without making some attempt to understand a little of Haiti's history, and if one also regards this as "earthquake hits impoverished place," one won't have understood anything about what's going on there. The earthquake hit a place that most of the nations of the world (including and often especially the US) have used as a punching bag for two centuries, and the people aren't merely impoverished, they are desperate, which to me is a critical difference.

e. At the risk of sounding pedantic, one final point about the scope of the disaster is that Haiti has no real "government" in the sense that we--so far, anyway--think of as "government." Despite some bad apples and assorted pockets of corruption, most Americans tend to think of their police as being there to protect them; there is no equivalent in Haiti. Here we take some of the most important functions of a government for granted, two of which are conspicuously absent in Haiti: garbage removal and a clean public water supply. I can't say how disheartened I feel here when I see families choose brand-name bottled water in their own homes while perfectly potable water taps in their kitchen sinks sit unmolested. Haitians right now would die for such a privilege. And because of the lack of potable water, many more may.
--br

ps--Now at the risk of sounding ridiculous, one small way to continue to make a contribution to Haitian GNP in the coming years, for those of you who like to drink alcohol, is to buy Haitian rum, one of their few true exports widely available in the US. I am a fan of Rhum Barbancourt, and recommend that you check it out the next time you are at the liquor store.

Ross Douthat, Professional Yutz

2010-01-11T14:59:00.001-05:00

Ah, the New York Times Editorial Page. Though I am not certain, I suspect that the Times readership is overwhelmingly socially liberal--not just by a modest amount but a huge one (say, 70/30 or 75/25, and note that I'm only talking here about views on social rather than financial policy). Nevertheless the Times seems to try mightily to avoid the accusation that it has a "liberal bias," and so retains among its staff a few house conservatives, the ideological descendants of William Safire, just to prove otherwise. Recently this included Bill Kristol contributing op-eds, although mercifully that experiment came to an end. Some centristy readers (among them my mother) find David Brooks intermittently enlightening; for my part I regard him as a harmless ninny. But Kristol's spiritual replacement--that representing the nutter wing of conservatism--was Ross Douthat, and ironically, Douthat's column yesterday centered around a situation in which Kristol The Younger found himself: Brit Hume's indefensible comments about Buddhism. And Douthat, consistent with being a nutter, tried to defend those very comments.

If you weren't glued to Fox a week ago Sunday, what Hume said, in an offhand remark at the end of a panel discussion, was this: "The extent to which [Woods] can recover seems to me depends on his faith. He is said to be a Buddhist. I don't think that kind of faith offers the kind of forgiveness and redemption that is offered by the Christian faith. So my message to Tiger is, 'Tiger, turn to the Christian faith and you can make a total recovery and be a great example to the world.'" [my emphasis]

(The comments--clip below--are followed after a cut by Kristol, a Jew, shifting in his seat just a touch uncomfortably, for a split second, as he tries to finesse Hume's remark. Makes for amusing theater.)

Hume's statement caused the usual mini-media tempest--and I even made my own brief contribution to it at the end of a recent entry. Douthat's editorial yesterday took on that tempest with the goal of lecturing "liberals" on "liberalism." Said Douthat: "In practice, the admirable theory that nobody should be persecuted for their beliefs often blurs into the more illiberal idea that nobody should ever publicly criticize another religion. Or champion one's own faith as an alternative. Or say anything whatsoever about religion, outside the privacy of the church, synagogue, or home."

(Um...are the words "mosque" and "temple" deliberately missing there?)

Ever since college I have regularly encountered this hide-behind-free-speech argument and I remain unimpressed by it. Those who advance it, like Douthat, appear to willfully confuse criticism of some person for their ideas with persecution of that same person, and then try to bask in a little feelgood (and consequence-free!) martyrdom. Did anyone suggest Brit be imprisoned for his ideas, or be punished by some legal means? No. All Jon Stewart did was laugh at him because of Hume's perfect arrogance that Douthat seems to be incapable of understanding. (It's instructive to watch the clip particularly because it reveals Fox News's hypocrisy with respect to their own obviously obnoxious pronouncements on Islam.)

Douthat notes that "the debate [about the value of religion in peoples' lives] kicked off by Brit Hume a week ago is still worth having." That may be so. But the outrage, which Douthat condescendingly describes as "knee-jerk," centers around how poorly Hume chose to frame the debate--not necessarily the debate itself, and Douthat has missed this point entirely. For instance, did Brit Hume make this conclusion based off of his expansive knowledge of Buddhism? Did he, for instance, do a survey of Buddhist teachings and conclude that there would be no chance that Woods would find redemption through that faith? I'm thinking, um, not. So if he knows little about Buddhism, what's he doing singling out Woods when he seems to have not made a peep about current Christians with issues astonishingly similar to Woods, such as Mark Sanford (R-SC), John Ensign (R-Nev), David Vitter (R-LA), and that great miscegenist in the sky, Jesse Helms (R-NC)? No, it's something much more simple than all of this, and is the reason why so many thoughtful people, Christians and non-Christians, believers and non-believers alike, were outraged: Hume was talking smack.

Honest public discussions about religion, race, sex and sexuality should not be mere free-for-alls where anything goes, and Douthat knows this. He blathers on about how America should be a marketplace of ideas where open competition between different perspectives is welcome. I agree with him--but that doesn't mean that major TV networks have a responsibility to allow airtime to racists and bigots! We give Nazis and their ilk the right to say what they want as a matter of law, but that's not the same as giving them a platform. There is such a notion as "polite" discourse where some kinds of talk (that is, racist and/or bigoted dialogue) are deemed out-of-bounds, and where there are consequences to violating that etiquette. And Hume (who has only appeared to gain status on Fox, getting a cushy interview from Bill O'Reilly, allowing him to defend himself without having to actually face a critic), clearly violated that etiquette. In discussions about race we've grown sensitive enough as a culture to punish people who step out of line, as in the case of Jimmy The Greek's racial theories on the origin of the black athlete or Rush Limbaugh's goofy thoughts on Eagles' quarterback Donovan McNabb. But because Hume took a shot at Buddhism and not, say, black people, he has only had to suffer minor ridicule at most.

What might a thoughtful Christian have said? Not being Christian I cannot fully presume, but I have some ideas about a reasonable way to inject religion into such a conversation. Hume might have said, "I have been following the Tiger Woods saga. For me, Christianity has provided the possibility for redemption and forgiveness." That way it's really a discussion about Hume's own experience and is not a judgement on the inadequacy of some other faith. Hume has had his share of tragedy, as his son commited suicide in 1998, which triggered his religious awakening (he is described in Wikipedia as being Episcopalian), and has given interviews to which I have no objection, where he describes the role his renewed faith has played in his life.

But even with this possible more gentle comment that could have been hypothetically posed by Hume, I still have to hold my nose a bit because it's really not a piece of advice to an actual person but rather a bland pronouncement. Tiger Woods isn't some guy that Brit Hume is on intimate terms with, I am nearly certain. Instead Woods is just really just a concept in Hume's diatribe rather than an actual person to whom he is giving genuine advice. Is that what Hume has learned from his faith--to use people as props in an attempt to evangelize? And is that what Douthat considers worth defending?
--br

Mike Leach Debacle Wrap-Up

2010-01-06T17:03:00.005-05:00

I grew up as a boy in the 1970s and '80s in a small industrial town in northern Ohio, which is another way of saying that I grew up a rabid fan of football in general, and of the Cleveland Browns in particular. After owner Art Modell moved the Browns to Baltimore because the taxpayers of Cuyahoga county declined to build him a new stadium (so that he could go from being merely wildly rich to uber-rich), I gave up following professional football. At that point I turned my attentions exclusively to my "other" team in the collegiate ranks, the Ohio State Buckeyes. But over the past ten years even following college football has left rather a sour taste in my mouth. College football is deeply corrupt--huge amounts of cash slosh around the system, coaches get millions while their players get, at best, a free education typically valued at something like $15,000 per year, and a huge number of these boys are duped because they aren't equipped for college and can't make the NFL--and is only surpassed in ickiness by (men's) college basketball.

And then comes Mike Leach.

Leach, for the non-football fans reading this who aren't aware, was the coach of the Texas Tech Red Raiders. He had just finished a successful season and was one year into a five-year, $12-million stint as the boss. Alas, reports began to surface before their bowl game that he had locked a player in a confined area because he had complained about suffering the effects of a concussion. In the sports media, there was an amazing attention to what to me seemed fairly unimportant details: the player (Adam James) was the son of an ESPN analyst so there was a question of the boy using his father's leverage to exact revenge against the coach; James was described by Leach as "lazy" and not having a solid work ethic; James was placed in an unlit space with no room to move...or maybe not, and maybe was well-lit, or remarkably dark. Yet despite multiple stories combing over these details, the essential fact never was in dispute: Coach Leach took one of his players and locked him away as punishment for some infraction. Does anything else really matter, like whether he was in a dark or lit room? I say no. I call this a sadistic act of a megalomaniac--and any waffling about the particulars ignores this reality.

Suppose, for one moment, that Adam James was lazy and had no work ethic. So what? The coach has the option of benching the player in the hopes of motivating him (cf Nate Robinson's 41-point return to the Knicks after being benched for a month). He can exclude him from practice. He can, as an extreme, drop the player from the team. But locking a kid in any kind of closet is assault. I am glad his ass got canned, and pray that his work as a head coach in the college ranks is over. (I noted that a quick blurb on espn.com says he might be up for the head coach job at the Oakland Raiders for next year. Let's see you try those motivational tactics out with professionals, Mike!)

But Leach's story is really only the most disgusting in a year where some exceptionally ugly facts about all levels of football have come into sharp relief. The columnist Gregg Easterbrook has a really good discussion about the significance of Leach's firing. His main point:

You don't need to be a bully to be an effective football coach -- you can treat players in a respectful manner, while holding your own ego in check. But bullies are drawn to football coaching, and the fact that so many coaches get away with little-god behavior is an indictment both of the sport's culture and of the lack of supervision by the schools coaches work for.

At the Rubin blog, we agree. And the Leach incident is trivial by comparison to death by heatstroke, with one of the most recent episodes happening to a 16 year-old kid in Maryland this past July. Of the 39 heat-related football deaths since 1995, 29 have occurred at the high school level. Normally this is exactly the kind of statistic that drives me bananas--40 kids dying over a 15-year period is a remarkably small number compared to the overall number of total deaths of kids under 18 for that time span (roughly the number would be something like just under 200,000). But these are, in theory, totally unnecessary deaths, and appear to occur because some small-time coach with a big-time Napoleon complex thought that a kid asking for water on a 90-degree day while running drills was only something a sissy would ask for. Think I'm kidding? Follow this link to learn of Coach David Jason Stinson of Louisville, KY, who was charged with reckless homicide and wanton endangerment after a player died of heatstroke in 2008. Coach Stinson "ordered [wind sprints] as punishment for lack of effort on a day where the temperature...[was] 94 degrees." Despite such compelling facts, it took the jury 90 minutes to acquit Stinson. Stories like these make Billy wish he did have conventional religious beliefs about the afterlife, because then he would rest more comfortably in the knowledge that Coach Stinson would roast in hell for eternity. Alas.

To cap things off, the NFL has been dealing with the problem of concussions, and doing it rather poorly. Despite mounting, compelling data suggesting that frequent hits to the head in football dramatically increase the risk of later neurologic problems including dementia, NFL Commissioner Roger Goodell dragged his feet until the season was nearly over before issuing an allegedly "stringent" new concussion policy in December. Again, the small number of NFL players affected does not make this a public health problem. But as the above article notes, "the culture of playing through brain injuries in the NFL has also influenced younger players...because the governing bodies at the college and high school levels do not have rules regarding concussion management, amateur players routinely return after concussions, even after they are evaluated by a doctor or athletic trainer." [my emphasis]

Now that's a public health problem.

--br

Harvard on "Consultant" Pay--a Step in the Right Direction

2010-01-04T15:06:00.004-05:00

It took some time, and, while "Harvard" (see further as to why the quotes) isn't the first institution to institute new and considerably more sane policies about conflict-of-interest in medical academia, it is the most renowned.

The story appeared in the Saturday NYT and I noticed a similar one in the Boston Sunday Globe. They note that Partners HealthCare, the parent corporation of two of the largest of the hospitals affiliated with Harvard Medical School, Massachusetts General Hospital and the Brigham and Women's Hospital (thus technically not the medical school itself), have established a set of rules intended to minimize conflict-of-interest and draw a sharper line at the boundary between industry and academia.

I say, "Bravo!" This is a huge step in the right direction. And because of the cachet that the name "Harvard" carries, other academic medical institutions are sure to follow suit. There are two main restrictions on academic physicians. First (and, to my mind, most important) is that docs affiliated with Harvard can no longer accept "speaking fees" from drug companies. For those unaware, these "talks" frequently come in the form of an after-dinner lecture where the drug company in question pays for dinner for the audience. These dinners aren't held at Burger King, it should be said. Officially, the editorial policy of drug companies is completely hands-off with respect to the content of the talk except for the general topic (like, say, emphysema). That said, only a fool would believe that there isn't an implicit plug-our-product directive, and that the audience isn't in on the arrangement. These speaking fees can net a doc who's willing to hustle a very nice little side income: say, $40 or 50 grand annually for two or three talks a month. That little gravy train is over at the Partners hospitals now.

The second restriction is on senior faculty who sit on the boards of various pharm companies. These policies apply to a much smaller group of physicians, and because of Harvard's privileged status, there's a disproportionate number of Harvard faculty on such corporate boards. The limits are still quite generous: they are allowed compensation for corporate board work, but now set the limit at "a level befitting an academic role," which the article states should be no more than $5,000 per day (!). The article further helpfully notes, just in case you're startled by this seemingly large amount, that "some [faculty] had been receiving more than $200,000 per year." There is also a great line by one Dr. Dennis Ausiello, who was compensated by Pfizer to the tune of $220K per year, about how he'll continue in his role on the Pfizer board with less cash in hand. "I think I should be compensated fairly...but if my institution rules otherwise, I will continue to work on the board." Apparently he thinks that five large a day isn't "fair compensation." Poor Dennis!

There are some quotes in the article from some academics expressing outrage at the leniency of the new policy, but for my part I am heartened. The problem of the relationship governing the most highly placed senior faculty making beaucoup bucks on the boards of Big Pharma seems to me to be minor compared to speaker's fees. The lecture circuit is widespread, obviously corrupt to anyone willing to think for more than two or three seconds, and virtually everyone's in on the joke. When medical faculty play along, they are sending an explicit message of "not to worry--you deserve these freebies that the drug companies toss out to us. You get the free fancy dinners, I get a thousand or two dollars. After all, aren't we entitled to this because we work so hard?" Needless to say, as much as I like nice dinners and making money, I don't think this is a good message to be sending in the medical community. And Harvard just took a definitive step toward shutting that message down. The battle ain't over, but I think that we just witnessed the turning of the tide.

--br

Other stuff:

a. I had, of course, meant to write about some great books that I read in 2009 (a short list includes the fantastic book by Steven Johnson The Ghost Map about the cholera outbreak in London and the genius who solved the question of cholera's cause, John Snow; John Barry's classic book of a few years back but no more relevant than in 2009 The Great Influenza; The Wine Trials--don't ask as to why I think that belongs in a blog about medicine; Adam Gopnik's quirky little book about Darwin and Abraham Lincoln--a great book for the sesquicentennial of the publication of Origin of Species--called Angels and Ages). That got swept under the rug due to time and family constraints. But for those who are fans of Malcolm Gladwell, he has a new book that is a collection of his writings during his past 10+ years at The New Yorker, called What the Dog Saw. In it there is a gem of an essay about the development of the pill, women's menstrual cycles and its relationship to "female" cancers, and living in the industrial age. You will get your money's worth if you read nothing other than this essay. That said, the rest of his writing is equally riveting. For those who have the time for audiobooks, Gladwell reads his own work, and he's an exceptionally powerful reader. Leave aside his talent as a writer, I would say his reading ability is second only to that of the immortal Scott Brick. But this may be getting too far afield except for the die-hard audiobookers.

b. Did Brit Hume really say that? You gotta love the guy. Oh, wait. No, you don't. The skinny is that Brit took a potshot at Buddhism while discussing the recent troubles of a fairly well-known golfer who, according to Hume, "is said to be a Buddhist." Hume then explained that turning to the Christian faith would far outstrip whatever Buddhism had to offer. One of the comments at the website above notes, "I've said it before: there was a very good reason why Rome threw them to the lions." Billy couldn't help but chuckle.

c. Also in the "I wanted to write about this but no time to give it its proper due" category was this excellent discussion of the difficulty surrounding the use of sedation in end-of-life care. It's a Sunday NYT piece so it takes some time, but I recommend it highly.