This really nails it

Sometimes you read something that nails it so good , that condenses so many killer insights into one long sentence that you go way past wishing you had said it (the important thing someone said it) that you just want to shout it out to whoever will listen.And that is what I will do now to my tiny band of regular readers and the more readers who wander in from a Google hit on whatever.

That something (I know I have quoted this before but I want everyone to read it) is from The Covert Rationing Blog by DrRich who said this:

These reverse incentives, we’ve seen (we being readers of this site), are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent
healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians are creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors have a realistic chance of attaining excellence under such a system, so as to service at least the rich, the connected and the quick-witted, is to abandon the system altogether.

The more I read and think about it and discuss it with colleagues (active and other retired docs) the more I agree with DrRich's analysis and his conclusion. One route to abandon the system may well be the various versions of a retainer system that are sprouting up and in that regard if you want to learn more go here to hear from Dr. Chis Ewin who does more than talk about it.

Off the grid or black market medicine

I have written before about the expected effects of rationing health care and listed the usual outcomes-shortages,poor quality etc. The rise of a black market is another well known outcome but I did not think that we had reached the point in the the U.S. where there was actually a black market. I had to rethink that position after reading this entry by DrRich in which he talks about the off the grid medical activities.

If you accept the classical economic definition of a black market (An illegal market, in which something is bought and sold outside of official government-sanctioned channels)
then it seems that what DrRich is discussing is not really black market because it is not illegal to do most of what he describes. But this is really pedantic quibbling over definitions ( I think black market activities is a sub set of off the grid) and the issue is that we have still another consequences of the de facto medical rationing about which DrRick speaks so eloquently. Here patients choose to spend their money for various reasons to buy medical care outside of the insurance hegemonic universe even though they have health insurance.

I should not have been the least bit surprised by tales of off the grid medicine.My son while "insured" with a large nameless HMO in California fractured his radius at the elbow, was pinned and then began his battle with the HMO. He couldn't get PT ( ok he did get a handout sheet ) and later the wires began to almost push through the skin when he flexed his arm. The docs at the HMO said they did not take out hardware in "older patients"- he was 24. They were adamant and refused to accept calls from me or my wife,also a physician.We were told that Dr. X, head of orthopedics, did not talk to physicians on the phone .I had him come back home to Texas and he had the hardware removed by an orthopedic friend who did not charge him and the hospital discounted the facility fees a bit as I was on staff at the time ( that type of professional courtesy is, of course,history now).

The retainer medicine movement could be considered an off the grid activity at least off the insurance grid but at least so far is not illegal in the U.S. However, as the movement grows- as it seems to be doing- I predict we will be hearing more arguments to limit it or restrict it entirely by legislation if necessary. The anti retainer practice propaganda mill is already at work . See DB for examples.The insurance industry will bray about it as will those who believe that social justice principles trump individual freedom and choice.

ACP recent comments of P4P-sounds more like it but ...

I have not been one to sing the praises of the American College of Physicians and usually have offered my share of criticism. However, their recent comments which are critical of P4P , at least the way it seems to be playing out, appears to me to be more on target but unfortunately stops short of complete categorical condemnation which is what the concept deserves.

Here is a quote as found on a recent Medscape article which quotes from a recent piece in the Annals of Internal Medicine.

"Current incentives could result in deselection of patients, 'playing to the measures' rather than focusing on the patient as a whole, loss of trust between physicians and patients, unnecessary care, reduced access to care and continuity of care, and worse care for patients with complex chronic conditions. These consequences are avoidable, but only if the architects of the health care system try to avoid them."

I agree with all of the above except the comment about the consequences being avoidable. I believe paying or bribing doctors to do their job is a bad plan on its face and cannot be fixed by modifying this or that aspect of it. I find it a bit hard to reconcile these comments with the recent editorial in the Annals of Internal Medicine which urged physicians (and appealed to their professionalism) to work with insurers who strive to make medical practice lean and efficient.

Stochastic and epistemic uncertainty and the ecological fallacy

A recent comment made to a posted essay by DB of DB's Medical Rants spoke of a term I had not heard before, namely aleatoric uncertainty. But with the web one can quickly learn that it is merely another term for our old friend- random or stochastic uncertainty or variation.

One can talk abut two types of uncertainty. Stochastic is the random or some would say inherent or irreducible uncertainty. The other is Epistemic uncertainty which is that related to incomplete or inadequate information.

At least some of the former type of uncertainty can disappear as knowledge becomes more complete and adequate.

This introduction  gives me a chance to quote one of my favorite insights borrowed from others namely the thought experiment described by Dr. Steve Goodman of Johns Hopkins which I have talked about before.

Here is my paraphrased version of it which is crafted to elucidate the difference between the stochastic and the deterministic:

Mr. Jones is faced with the need for surgery.The particular procedure is generally accepted to pose a 15% risk of death. Let us magically produce 100 clones of Mr. Jones. When they all undergo surgery, what will happen? In the random process model ( stochastic interpretation) , 15 will die but we cannot tell beforehand who they will be. In the deterministic model, either all 100 will live or all 100 will die depending on whether Mr. J. and all his clones have or do not have some biochemical or physiological condition(s) that is/are in fact what causes the mortality risk of the procedure.

If we learn the reason for the death some or all of the uncertainty vanishes.Before it was learned that about 1 out of 300 people have a single nucleotide polymorphism (leading to TMPT deficiency, and toxic accumulation of 6MP type drugs) no one could predict which child with ALL treated with 6MP would experience catastrophic bone marrow failure. Now with at least this mechanism in our knowledge base, patients can be tested for TMPT deficiency and those who are deficient can be safely treated with a lower dose. Knowledge of the mechanism shrinks the level of stochastic or random uncertainty. The more we know, the fewer are the circumstances that appear to be random. But even as we learn more "mechanisms" we still have the issue of how to apply aggregate data to the individual even though more and more we hear about genetic perturbations that strongly influence and sometimes apparently even determine the response of various tumors to chemotherapy.

The British physician- author, Kieran Sweeney, writes about this age old problem of "balancing the general with the particular" in his book "Complexity in Primary Care".

In this balancing act, a force that may push the clinician in the wrong direction is the lure of the "ecological fallacy". Sweeny writes"

With the advent of evidence-based medicine, clinicians were encouraged to interpolate from population data to individuals. In so doing, however, we were at the mercy of the ecological fallacy-assuming that any and all conclusions derived from population data could be applied to individuals in the data set.

No where did (does) this appear more glaring than in the large number of drug company driven, medical education company arranged "CMEoid" dinner experiences in which practitioners (docs and mid-levels alike) are exhorted to treat to goal, whether this be blood pressure or HbA1C or whatever else. Previously the big guns that were hyped to get the blood sugar down were the glitazones now less so and I see invitations coming in for drugs that are attempting to favorably harness the integrin family. For an interesting and thoughtful take on the basis ( or lack of same) for treating cholesterol to goal see this recent essay by Dr. Howard Body.


addendum: Minor spelling and syntax changes made 10/21/2014

Everyone agrees -hospitalists are here to stay

With the publication of a recent observational study published in the NEJM which seems to indicate that hospitalists save a little money ( read the latest by the Happy Hospitalist and you just might conclude it is more than a little money- see below for link) and do not seem to have proven harm to the patients,several prominent medical bloggers ( Dr. Wes, The Happy Hospitalist, and Dr. Wachter) all seem to agree that we have a win-win situation. It is win-win at least as far as the doctors now known as hospitalists ( and sometimes noturnists) and the hospitals are concerned and sometimes for the internists and family docs who now no longer manage their patient's care when they are hospitalized. There is always at least one sour note.

In this posting, Dr. Rob expresses no little dissatisfaction that he can't find out in anything like a timely fashion what the heck the hospitalists et al did with his patient in the hospital.Further, I am becoming more and more of the opinion that patients tend to be in the win column as well except when they go back to their primary care doc to find out what happened to them in the hospital. I hasten to point out that this is not be case with every hospitalist-patient-PCP encounter set but obviously sometimes it does happen.

Dr. Wes points out that when we go to the hospital we now have the doctor rather than our doctor. That is ,the primary care doctor who attends the patient when he is not in the hospital hands off the patients to the hospitalist who in the course of the patient's stay in the hospital may himself hand off the patient a number of times. The recurrent discontinuity of care at least so far has not been proven to cost anything in terms of cost to the hospital or morbidity of mortality of the patients. One might argue that the loss of one aspect doctor-patient relationship could be lost but no dollar value is typically assigned to that. And as Dr. Happy Hospitalist points out , there was no shortage of hand offs on weekends between docs in the same group anyway, so what's different now.

As Dr. Wes states and as the Happy Hospitalist has explained clearly the current economics of medical care is such that the dichotomy of "officist" and hospitalist makes sense and the former practice of an internist playing both roles perhaps was only possible in a long gone economic environment.

I chafed against the concept of a hospitalist and mourned the apparent terminal condition of the type of internist that I enjoyed being for a number of years but now if I were just entering into a medical life as a general internist I believe I would have to take the road of either the hospitalist or the physician with a retainer practice. As pointed out by DB the retainer doc can have the time to do a good job in the office .We all know that the time pressured doc is a prefect recipe for missed diagnoses, poor judgment calls, pride and sometimes ethical damage to the physician and loss of respect of the patient. The retainer doctor has the time and the hospitalist practice -as least of the type that Dr Happy Hospitalist lives- does also.I think as far as general internists are concerned. Mr. Dylan's advice might be heeded.

..you better start swimming or you'll sink like a stone.For the times they are a changing

The high jacking or corruption of EBM

The following quote is taken from DBs Medical Rants which he quotes from a BMJ article which apparently requires a subscription so I can't access it but it so good I have to feature it here.

Evidence based care was never meant to be a substitute for clinical judgment but, combined with the inducements of the quality and outcomes framework, it becomes so. Mechanistic blanket management strategies, embedded into computer software, become fixed and static with the danger that innovation will be stifled. Interventions become routine, and practitioners are no longer required to grapple with the innate uncertainty of each different clinical situation. Most randomised trials systematically exclude patients’ symptoms, functional status, comorbidity, severity of illness, ideas, and preferences. Yet these are the factors which should fundamentally affect decisions about appropriate treatment.2 Within large study populations, there will be smaller populations sharing different characteristics whose response to a given treatment will differ from that of the larger group. Such groups could be systematically harmed by the intervention, and there are currently no robust systems in place to measure or monitor this.3

The "insight/word" ratio is that paragraph is about as high as it can get.

Not only will innovation be stifled, individualized, proper thoughtful patient care will be worse than stifled it could almost die out. Of course with blanket management strategies, or pathways or algorithms or recipes patients could be harmed. And the innate uncertainty of each different clinical situation is what it is all about.Two patients with chest pain often have different underlying diseases, two patient with the same disease label have different symptoms, two patients treated with the same dose of the same medication for the allegedly same disease have greatly different responses,two patients with the same disease label react differently to the suggestion that they even take a medication.In a given randomized clinical trial some patients get much better, some a little better, some not at all and some get worse.

The lure of the mantra of evidence based pathways or guidelines is exactly what third party payers can use in their rational quest to control physicians to control costs to control their profit stream. Control is the operative word. Recognition of this innate uncertainty is the last thing they want to admit to or deal with.

The lure of the mantra of evidence based pathways and guidelines works well for the academics and others who "partner" with the third party payers to control the working stiff docs in their rational quest to be members of the ruling class , to be first among equals , to be the animals that are more equal that the others or for whatever reason they have.

The lure of the mantra of evidence based medicine (EBM) fits nicely with those whose philosophical mind set includes the notion that medicine is too important to be left to the individual physician and the individual patient and that wiser heads must prevail so that people will do the right things for themselves.

The lure of evidence based medicine could not be better for some drug companies whose skilled epidemiologists and statisticians are able to stack the deck and cook the books to make the overworked, over regulated, over hassled physician in her quest to do the right thing for her patients believe that their latest entry into the medication market is clearly what she should prescribe yesterday whether that is true or not. It should be said that deck stacking and book cooking is not the monopoly of drug companies but are the seductive tools of anyone with an ax to grind.

The lure of evidence based medicine even offers apparent salvation for the over worked, over regulated, over hassled physician who sometimes thinks "Hell, just tell me what to do, give me the latest guidelines."

The lure of evidence based could not be better for the third payers who would decrease payments generally and then reward these compliant with the guidelines with part of the money they took away.

The lure of evidence based medicine could not be better for the newly minted MPH who can now crank out a meta analysis or a quick and dirty case-control study with software that is so much easier to run than to understand that can flash across the rapidly cycling news cycle, bag an interview and add to their CV, whether the study makes sense or not.

The lure of evidence based guidelines could not be better for those believe the way to go is the mid-level route. Arm a NP or PA with electronic access to the right guidelines for efficient, evidence based care and then only the complicated cases would need the physician's input and I suppose the guidelines would include guidance as to when a case is complicated.

The manipulative value of the evidence based medicine label has meant so much to so many that it has become harder and harder to separate the valuable contributions of valid, well done clinical trials and analytic thought from the hijacked, counterfeit versions that serve to control the narrative dialog and ultimately to control much more. Reference to EBM can serve as a talisman.To say that such and so is evidence based is to ignore the real question which is what is the nature of the evidence.

"Total responsiblity to our patients"

Dr. Robert Centor in his DB's Medical Rants hits a home run. Read his essay here. He reminds us that physicians have responsibility to patients and not to systems. When I am sick I want a physician who cares about his patient; I do not want to be embraced by an efficient,evidence based,EMR facilitated system that like a pig with lipstick calls itself my medical home.

He speaks of the crisis in internal medicine. Clearly there is one. The crisis is bigger than that though, all of U.S. medicine is in crisis or nearly so. The primary care folks are the ones currently most affected, but the radiologists and surgeons et al who are fairing relatively better might be as concerned as the forces battering primary care have their addresses as well and the big single payer (CMS) influences more than Medicare fees for the office visit.

Dr. Centor is referring to the fiduciary duty of the patient which I believe is in danger not only from the hegemonic strength of the third party payers but from the self destructive rhetoric of many of the professional organizations and academics who strongly influence the emerging generation of physicians.A glaring example is the "new professionalism" as pushed forward by the ABIM foundation and the ACP- and mindlessly or perhaps innocently accepted by many other professional organizations- which eviscerates the duty of the physician to the patient replacing it with some type of impossible balancing act where in physicians are cajoled into being instead stewards of the finite medical resources that seem to be owned by everyone and no one and advancing the cause of a nebulous social justice. Recently an editor of the Annals of Internal Medicine seems to equal professionalism with the imperative to meet the third party payers in their effort to improve "quality and efficiency." See if you can find a general internist in private practice who believes that the third party payer are interested in real quality.

Physicians take care of their patients and are responsible for them. Systems do what systems do and cannot care or be responsible for individuals.

A commentor writes DB asking to begin at the beginning and tell what is broken with internal medicine.

I offer this great summarizing quote from DrRich. which speaks of what is wrong in general and which I believe disproportionately impacts primary care folks including internists. The links are his.

These reverse incentives, we’ve seen (we being readers of this site), ( the reference here is to DrRich's website "Covert Rationing Blog")are aimed at actively stamping out, eradicating, and punishing any self-motivated physician who tries, despite all obstacles, to deliver excellent
healthcare. Among these are the mandate that primary care doctors spend only 7.5 minutes per patient encounter; invoking the magic of P4P to determine exactly what must and must not take place during that 7.5 minutes; grabbing the right to interpret clinical science in order to formulate the “guidelines” that inform P4P; coercing doctors to agree to egregious adhesion contracts that any sane person would find unconscionable; forcing doctors to practice under a set of coding “guidelines” that prevent good patient care and serve as traps for “fraud;” and in general, making every patient encounter subject to a web of regulatory speed traps that force doctors to concentrate on keeping the OIG ( Office of Inspector General)at bay rather than on what the patient needs. In short, in their efforts to gain control of physicians’ behavior in order to covertly ration healthcare, American Wonkonians (You will need to read more from Dr.Rich to learn what a Wonkonian is ) re creating insurmountable, systematic disincentives for excellence and penalties for non-mediocrity. They have placed doctors in the untenable position of being utterly unable to fulfill their professional, traditional, legal, and ethical obligations.

The only way doctors have a realistic chance of attaining excellence under such a system, so as to service at least the rich, the connected and the quick-witted, is to abandon the system altogether.

Is not gradually disabusing physicians of the notion that their prime duty is to the patient part of the package deal (the above mentioned disincentives plus watering down their fidelity to the patient) to control physicians?

Would internists be better off without the ABIM?

More and more I am beginning to think that is the case. Dr. Faith Fitzgerald,who I love to quote when she said regarding P4P doctors do not need to bribed to do their jobs (paraphrased), has criticized the ABIM recent moves regarding certification and re-certification.

Her essay can be found here.

She finds a disconnect between the notion of certifying a "comprehensive general internist" and their recent proposal to certify a type of cardiologist who treats severe heart failure and cardiac transplantation. OK transplant medicine is another world but has treatment of heart failure not been a regular activity of internists since forever.

She really nails it saying :

It is disingenuous of the ABIM, I think, to feign support for the so-called “comprehensive internist” while simultaneously depleting the general internist's portfolio of certified legitimacy in some of the more highly valued components of recognized expertise, such as management of heart failure and of hospitalized patients. This threatens to further shift the work of general internists to a support function not only for the classic subspecialists of medicine but also for the “certified modular” subspecialists. It potentially leaves the so-called comprehensive internist, already beset and underappreciated by payers and systems, to do predominantly triage, health information technology, social services, counseling, prevention, screening, and general organizational and secretarial functions for the “experts.” I doubt that many young internists in training will aspire to this role, especially because its many components can be done better and more efficiently by nonphysician personnel.

The good doctor worries about his patient

When I began private practice of pulmonary disease and internal medicine in the late 1970s I had spent the previous one year doing research at a medical school and before that two years in the army. The thing that impressed most in my first three weeks of work in a moderately large group of internists was how much my partners seem to really care about their patient and how they actually worried about them.

A recent essay by Dr. Philip R. Alper entitled "Being a good doctor" reminded me of those thoughts.He writes a regular column in the Internal Medicine World Report and I have quoted him before.

In this essay he is reminded of a comment made to him many years earlier by a colleague of his who said "You know good doctors worry about their patients".

Alpert continues:

Doctors who worry about their patients keep up-to-date, listen to their patients and think about not only what they say but also what they haven't said.They second guess their own impressions because they are aware of the potential for error. More than adherence to clinical guidelines or being paid for performance and recertification, the combination of good medical training and worrying abut one's patients is likely to lead to highest quality care.

Worrying about the patient puts the patient first not the doctor.

The 70s and early 80s were a time when we didn't worry about coding so much or E &M games. We spent more time talking about our patients and what was wrong with them medically and what we should do and attended no seminars on the best way to code. We did not use templates to treat the charts and we didn't worry abut how to game the system so as to get pay for performance. Being bribed to do our job was not a concept that in our universe of discourse or of thought. We could worry about our patient because the economic reality of time allowed us to do that.

I feel sure-or at least hope-that the good doctor still worries about their patients but it seems all the other worries -like how to keep the practice viable and not be audited by CMS and somehow be stewards of the limited medical resources , or if you prescribed the "wrong "drug according to the patient's prescription plan, or if you had enough patients with a low enough Hb A1 C to not be delisted by the patient's insurance plan-may well encroach on the available worry time and energy . You can only worry about so much.

The Medicare E & M System and enforcement is even worse than I thought

If recent posts by prominent medical bloggers ( see here and here) have not stirred up enough anger and fear and astonishment at the Medicare E & M system for coding clinical activities for payment, you should read the latest entry by DrRich .

Draconian is too mild a descriptor what the auditors can do and apparently actually do.DrRich correctly points out that it is a game the doc cannot win if he plays it at all. Opting out of the system seems to be the only way not to loose. It seems to be a world of Kafka inspired bureaucrats wherein if you consistently down code to avoid trouble with the man you can be accused of upcoding.

Read DrRich's essay and see what this powerful single-payer does and see if you still believe a single party payer for the country is the way to go.

Some docs opt to not "work on Maggie's farm no more"

Thanks to Kevin for this reference. Several groups California seem to be opting out of the third party payers hegemony.

Dr. Harold Sox in the Dec 4,2007 issue of the Annals of Internal medicine gives a brief history of the medical "guild" ending with this sentence:

"...by the mid-1960s the [medical] profession has become increasing subservient to the principal purchasers of health care;business and government."

In somewhat understated prose he nails it.

However, later he suggests that the third party payers have made an effort to make make medicine more lean and evidence based and he cajoles the internist readers of the Annals to meet "our partners"at least halfway. As expected he makes the obligatory genuflect to the concept of of the medical profession's obligation to work to conserve finite medical resources. For physicians to live up to the tenets of professionalism as defined by the ACP and the Annals folks private practice docs have to cooperate fully ( or at least halfway) with the altruistic efforts of third party payers to conserve resources and practice evidence based medicine.

The docs in California realize meeting them half way is worse than impossible it is probably suicidal.

Dylan wrote

"Well, he hands you a nickel ,he hands you a dime
he asks you with a grim if you're having a good time"

Many internists in private practice and their patients have long since stopped enjoying a good time.

Hats off to the physicians with the courage to say no.They have realized a simple fact.

The third party payers will not control medicine if the physicians do not contract with them.

The Avandia scrum and the art of war and narrative control

The Executive Physician (EP) has an excellent and interesting take on several aspects of what went on ( and maybe why) in regard to the Avandia saga. I say "scrum" as in rugby because , in a way, I am reminded of a bunch of strong forces all pushing in different directions for their own ends.

Drug companies are not unique in their desire to do things for their own self interest and explain their actions in terms other than the obvious. Researchers may write articles to further their own reputations and academic careers. Federal agencies actions, as so well explicated by Thomas Sowell, can be best understood and explained by looking at the incentives and constraints they are subject to and the feedback they receive. It seems that EP gives us a view of the Avandia narrative in terms of power relationships and natural incentives a knowledge of which he attributes in part to his reading of "The Art of War" and "The Prince".

After the publication of the bomb-shell meta-analysis in the NEJM we witnessed a battle of words,data manipulation or analysis-depending on how you look at it-to determine who would control the narrative.

EP tells us that actions of the various players in the Rosi saga are natural and that "indignation is laughable".

I continue to be impressed with how much influence an article in a high impact medical journal can have. Not only has Avandia suffered a major sales slump and a relative advantage accrued to Actos but I believe that the current recently revised diabetes guidelines reflect a growing disenchantment with the glitazone family not just with Avandia. The touring Joslin Clinic traveling dinner, diabetic CME roadshow was once described by one of my ex-partners as a glitazone love-fest.I doubt if it will seem so now. The glitazone advocates no longer control the narrative.

It has not gone unnoticed how quickly the "gliptins" move on the stage. The guidelines already include one of them,sitagliptin, band name Januvia as an alternative for second line treatment ( i.e after metformin and life sype changes are unable to drive the HbA1c to under 7.)With the glitazone story still playing out you have to wonder why the movers and shakers of the diabetic treatment world are so eager to latch on to another diabetic wonder drug. Could the manufacturers of that group of medications already be scurrying to control the narrative? Duh.

A blog entry that every doc and med student has to read and learn!

I have referenced essays by the Happy Hospitalist before.There are all good but there is one that is so full of insights and such an important description of how things are that everyone should read and learn what it says. That entry is found here.

In a few hundred words you will learn what the Relative value scale of physician payments is all about, a thumbnail description of how it works and more importantly of how conscientious physicians trying to do the right thing by their patients and not be charged with fraud are complicit with their own ultimate professional demise.

Everyone also needs to read this entry by HH and this commentary by DRRich to tie all the pieces together. As long as physicians simply play the government's game they cannot win.

Interesting take on the strategy behind drug company-doctor dinners

I have only recently stumbled on to a great blog, " Hooked: Ethics,Medicine and Pharma" written by Howard Brody, M.D., PhD . He is the director for the Institute for Medical Humanities at the University of Texas Medical Branch at Galveston.

In this entry Dr. Brody suggests that the fancy dinners at trendy eateries given by Big Pharma companies are more to reward the speaker than to influence the audience. He talks about what happened in Minnesota where legal constraints exist regarding how much can be spent per doctor per year by drug companies. Of course, if the docs in the audience pay any attention at all to the slides prepared by the "medical education" company or the words of the speaker, all the better. He suggests the talks are basically to reward ( bride) the speaker who is a high prescriber of the medication being lectured about at the talk.

I find it a bit hard to believe that this makes economic sense.Some speakers makes 75K or more per year. How much Lipitor ( or whatever) could one doc prescribe to make that worth while. I have noticed ( yes, I have accepted invitation to a few of these dinner) that many of the attendees are retired docs, nurses and pharmacists so Dr. Brody's comment that the room could be filled with cardboard cutouts and the sponsoring company would be as happy may not be too far off the mark.

Dr. Carlat's NYT's drug rep-md "expose"-must reading

Dr. Daniel Carlat has written an eye opening piece in the NYT Magazine describing his activities as a physician-drug detail man promoting Effexor. For regular medical blog readers there may not be many completely new revelations but his story is important for those who have not realized the ways that drug companies can influence drug sales and how physicians may be complicit and while I was well aware of the drug- dinner-drug promotional activities I had not heard that physicians paid by drug companies would actually go to individual doc's office and hawk their wares with over a free lunch and pocket a nice fee.

Carlat is a practicing psychiatrist who writes an excellent blog dealing largely with psychiatric medications and critically analyzes clinical trials with psychotropic drugs. (There are a number of blogs dealing with that general topic and if a small fraction of what they say is true, you would probably never prescribe or take psychotropic medications.) His NYT article deals with several issues that I tend to harp on time and again in my blog including:

1 The idea that meta-analysis MA) should not be placed on the same pedestal in the hall of evidence based medicine (EBM)that houses the randomized clinical trial. They should be considered "observational " studies in which the subjects are trials and can rise or fall based on what studies the author includes and what summary statistic(s) the author chooses to use. And, of course, if the RCTs that comprise the MA are flawed the MA will be mega-flawed. I have written about that issue before here. As illustrated in Carlat's article, a MA presented by someone with appropriate academic credentials can be quite persuasive and such a presentation at a company sponsored training program was one of the major elements in the argument that convinced ( at least for a while) Dr. Carlat that Effexor was superior to the SSRIs .

2.Drug companies (or anyone for that matter) can stack the deck and cook the books of RCTs so that the efficacy of a given drug is put in the best light and the adverse effects minimized.As time went on Dr. Carlat became more aware of the deficiencies in some of the RCT which were used to support the position that Effexor was superior to the SSRI family and became more concerned with the hypertension and withdrawal symptoms that are associated with Effexor use.

3.His article refers to events that provide examples of how the tenets of EBM and the desire of physicians to have better treatments can be and are perverted .

Dr. Carlat was recruited by Wyeth and invited to their training seminar replete with various perks and cash payments to learn how to promote Effexor by visiting practicing physicians offices and educating them about the medication's purported superiority in the treatment of depression.

His article describes his gradual disillusionment with the arguments supporting Effexor and his activities and his decision to quit. He deserves much credit for admitting what happened and I admire his courage.

There is so much in the article that makes one feel bad about the medical business and the role that physicians play (as drug salesmen and sometimes as those who should know better when a salesman comes to call, and the AMA whose role in making money by allowing drug companies to have access to physicians' prescribing patterns-that still boggles my mind). This is not what I thought being a physician was all about. I cannot believe-as the article claims-that 25% of physicians act as drug shills one way or another , but if the number is even one tenth of that, I feel ashamed. On the other hand if you read this post, maybe 25 % is not too far off.

In the interests of holiday cheer, let me interject a positive story ( at least positive in regard to the actions of some retinal specialists).Go here for the tale of two drugs and the treatment of wet retinal degeneration and how the eye docs seem to be doing the right thing while the drug company...

Still more reasons to throw out P4P

The following is a quote appearing in DB MEDICAL RANTs, in turn taken from a recent BMJ article about the P4P misadventure in England, complete with words spelled in British English.

The whole initiative is based on reductive linear reasoning that views the body as a machine and assumes that a standardised treatment will produce an equally standard unit of beneficial outcome. However, any practising clinician knows that the same treatment applied to two people with the same diagnosis can produce very different outcomes. Complexity theory suggests that the body is more usefully regarded as a complex adaptive system, characterised by rich interactions between multiple components that produce unpredictable outcomes. This analogy makes much more sense of clinical experience. Psychological states and social contexts exert measurable effects on the functioning of the body. Standardised treatments ignore all of this.

The purveyors and apologists of P4P will not, for the most part, be convinced either by cogent arguments or empirical data showing the harm in such programs.They are not about doing good or really promoting "quality" -in the good care sense of the word- They are about control and the purpose of controls is to spend less money and/or make more money or as Dr. Fogoros puts it, it is about covert rationing.

Kick backs for switching to generics

Three years ago,my brother-in-law was started on a brand name lipid lowering medications. He complained that he had about 80$ per month out of pocket expense. He believed that the physician received some type of kickback for prescribing the medication. I assured him that could not be case.

Now we see this news item in which we learn that physicians were paid to switch from a brand name drug to the cheaper generic. According to the news report some doctors in Michigan were paid $100 by Blue Cross for each patient they switched from Lipitor to a generic drug. A news release from the AMA warns physicians that this or similar activities is illegal.

More and more we witness the downward spiral of physician's ethics and pride.

The pathophysiology of primary care dwindels

There are two recently published sources of important information regarding a major cause of the primary care exodus. One is in JAMA ( JAMA,November 21, 2007) Vol.298,no.19, pg 2308, " The Unintended consequences of Resourced-Based Relative Value Scale reimbursement", Goodson, J.D.) and unfortunately as important as this is, you need a subscription to read it. The other source is free and we can thank The Happy Hospitalist for his insight.

The major cause is decreasing take home pay. This plus increasing third party requirements and mandates and the threat of malpractice and the perceived greener pastures of the non primary care branches of medicine add up to the perfect storm.

And the cause of the decreasing take home pay is the system of CMS payment fee schedule. What follows is a description of how the price controls on physician's fees are implemented. In 1992 the RBRVS was put into place allegedly to mitigate the payment gap between procedure type docs and those who just see patients. Over the past 15 years it seems to have had just the opposite effect.

These price controls seems to have disproportionately impacted the income of the primary care sector. Until recently I was not ware of the role the AMA and a group known as the RUC played in this story. The AMA web site give a rather sterile and uninteresting rendition of who and what the RUC is. It is a group that gives advice to CMS about the details of the price controls.According to the JAMA commentary, their "advice" is put into motion about 80 % of the time by CMS. The committee is disproportionately represented by surgical and other non-primary care physicians. Of the 30 members, 27 have no term limits and the meeting are not made public.The proceedings are said to be proprietary (the AMA owns the CPT (current Procedures and Terminology to which the RVU ( Relative Value Unit) systems is linked.)

"All animals are equal but some animals are more equal that others."

So the story seems to be that the "remedy" set up in 1992 to make more equitable the payments from CMS to procedure and non procedure physicians has been largely controlled by a group of physicians who do procedures and the gap between the two broad groups has now so widened that there is now much scurrying to leave a sinking ship.

To summarize and embellish. There are wage controls on physicians fees. These are implemented by CMS with advice and consent from a procedurist dominated, AMA sanctioned group, the RUC. The third party payers follow suit. Wage controls lead to shortages (of primary care docs who are disproportionately impacted ),poorer quality and increased waiting times. Every year the AMA goes to Congress to plead, beg and weakly threaten them to not cut the overall CMS funding by as much as proposed. This dysfunction "system" is not going to correct itself.

I make no claim to the "answer". One approach that resonates in my libertarian consciousness is that made by the American Association of Physicians and Surgeons. The following is copied from their website. It is basically an escape route away from the wage controls and favors individual choice over the current command and control arrangement.

“FREEDOM FOR PATIENT AND DOCTORS WILL MAKE A DIFFERENCE.

H.R. 580 Seniors”Health Care Freedom Act of 2005, and

Say “NO” to Government Cookbook Medicine

“We oppose the various bills playing with the Sustainable Growth Rates (SGR), such as HR 3617, HR 2356, HR 1162 and S. 1574. Instead of changing the SGR, we support H.R. 580, the Seniors’ Health Care Freedom Act of 2005” that would allow the use of private contracts under the Medicare program. This is a win for patients, doctors and taxpayers as well.

“Our survey shows that 63% of doctors would be more willing to treat Medicare patients if unrestricted private contracts were allowed. Patients could pay doctors more than Medicare allows if they think the service is worth it. It would be up to the patient.”

I know ,the chances of something like that passing have to be slim to none and as Dan Rather was fond of saying, "slim just left town."Still it is good to dream of the day when physicians could join the other professions (lawyers,accountants, dentists, veterinarians,etc) who do not go to Congress every year to beg for crumbs.

The Massachusetts Plan for health Insurance, Success is what you say it is

I have mentioned the Massachusetts plan to solve the health care "crisis" by making everyone who can afford insurance buy it. This news report indicates that more people have have signed up for subsidized insurance than the state planed to have funds for. No problem , since they are using taxpayers' money , they will just get some more. This is a news item of the dog bites man type and would attract little interest.

What interested me and the author of the blog Health Care BS was that this is labeled a success. Labels are important and they have been used expertly in the medical care universe of discourse. The label "managed care" was a PR and propaganda home run. Who could be against care that is managed? The accurate label "rationed care" would not have flown.

The term "Medical home" cannot but evoke mom and apple pie. However, the version of managed care/P4P/control-what-the-doc-does that United Health Care has kicked off is anything but that. I have fumed about that before.

It seems that in Massachusetts, not everyone who is mandated to buy insurance has and many people who cannot afford insurance have signed up for a free health care program. I am not sure what part of this is a success.

Health Care BS quotes George Orwell. Here is another quote from Orwell.

Political language... is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

There is hope for medical research yet

I have been accused of going over board in my rants about meta-analysis that are often contradicted by randomized clinical and meta-analysis (MAs) that are critically dependent of the choice of the summary statistics and the choice of studies to include trials and are contradicted by other MAs, and observational studies that link everything to everything else only to be contradicted by other observational trials that fail to do so.

But from time to time my cynicism of the medicine business ( I remember when it was a profession) fades away at the sight of a thing of beauty - a mind boggling piece of clinical research that I can appreciate all the more after years of grueling study and practice . Here is reference to a project that demonstrated that nursing home patients who have trouble seeing do better when they get glasses that help them see. Who would have thought?

And- in the same week, we are treated to a research paper that demonstrated that when clinical trials are done and/or sponsored by a drug company, sometimes the materials is presented in such a way as to put the drug in question in a favorable light. Here is a review of that publication.

The shocking revelations continue.We are also informed that (see here for a review of the research involved) that college students engage in binge drinking, participate in sex that is often unprotected, spend much time on the computer not doing homework and often stay up late. A likely future project is rumored to be investigating if college students call home for money.

I was not the only one taken back by comments on the beta-blocker peri-operative mortality morbidity issue

Here the Happy Hospitalist had the same reaction I did to recent comments made in Dr. Robert Wachter's blog regarding the disappointing results of a clinical trial with beta-blockers ( the Poise trial). The Happy Hospitalist sums up Wachter's entry by saying "Oh Well".

Wachter enlisted the comments of his colleague, Dr. Andrew Auerbach who, in regard to the study that demonstrated increased risk of stroke from peri-operative use of beta-blockers said in part"

"So I agree with Bob – it wasn’t unreasonable to include them as a quality measure at the time. We were wrong, but at least we are in good company (can anybody say estrogen replacement therapy?). "

That comment may appear to be more flip and radiates more hubris than was intended . There is nothing flip about a stroke. Being in good company will do little to improve a hemiplegia or aphasia and I am sure Drs. Wachter and Auerback would not belittle the seriousness of the unfortunate events that seemed to be more common in the beta-blocker treated group.

Quality measures to a greater or lesser extent often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further when an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof or efficacy; when you are in the prevention mode, you had better be more sure.

The individual docs not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. The individual physician strives to do what it the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not.

Will making people buy health insurance really work?

There were voices singing out early on that Massachusetts plan to mandate health insurance might not be the simple panacea that some heralded it to be.

The push-come-to-shove-day is almost on us and this report indicates there are about 100,000 souls still uninsured. About one half may have incomes too high to qualify for state subsidies, but at this point no one is really sure of the numbers. More details can be found here. It seems that there is a contingent of healthy young men who don't want to spend there money on health insurance. It is time for the health insurance police to mobilize and make these people get insurance. We know how effective the state is in making people have insurance.

I have lived in two states with mandatory auto insurance. I was involved in two minor accidents , one in each state. As luck would have it, in both instances the other party did not have the mandatory insurance. Fortunately, I had on my policy a provision known as "coverage for uninsured motorists". Now why would such coverage be offered?

The insurance mandate idea reminded this Business Week contributor of the story of King Canute who tried to stop the rising waters by commanding the water to roll back.

More on "quality movement can be hazardous to your health"

I have mentioned before the danger of the "four-hour"pneumonia rule and the ill advised rush to quality rules about peri-operative beta blocker use and those likely only touch on the tippy top of the iceberg.

I have seen so many Journal supplements that are poorly disguised promotions for certain medications or classes of medications that when I see a supplement I cringe, but the April 2007, volume 120 Supplement of the American Journal of Medicine seems to be different( although I don't rule out the possibility that the issue is promoting something or other since a major drug company sponsored it.) I have become very cynical over the last two years.

This is on a topic near to my heart, the heterogeneity of treatment effects (HTE) which I have written about before,highly recommending a landmark article in the Millbank Quarterly,which I think is no longer available on line.

The editor of the issue is Dr. Sheldon Greenfield from UC-Irvine School of Medicine. He presents an important editorial and co-authors an article with Dr. Richard Kravitz, also from UC-Irvine, who was the lead author on the above referenced Milbank article. I believe if you go to www.amjmed.com and register you can obtain the AJM supplements for free.

The major points made by Greenfield in his editorial are:

He asserts that there are 2 evolving phenomena that "impair the ability to develop guidelines, payment rules and quality of care measures based on randomized clinical trials (RCTs)." They are:

First,there is now a broader spectrum of illness severity included in trials . That is, more patients with less severe illness who will be less likely to favorably respond to an agent than the more seriously ill patients.This results in less ability of the trial to detect a true difference.

Secondly, RCTS typically exclude patients with multiple chronic diseases,

" Only to have findings subsequently generalized from young trial-eligible patients to these older,complex patients whose mortality from comorbid conditions reduces treatment effectiveness."

So, on the one hand more false negative trials and on the other hand, trials with less external validity which may be used anyway to make quality rules for groups of patients who may differ markedly and in important ways from those patients who took part in the trial.

More and more decisions are taken out of the hands and minds of the individual physician and the individual patient and determined by third party rules which in turn are increasingly "enforced" by the devilish P4P system. The work of Kravitz, Greenfield and others make it clear how flawed RCTs can be and it follows that rules and rule-derived payments to physicians based on these RCTs can result in clinical mismanagement and harm to patients.

So we can look forward to more quality rules that , in one sense, backfire and which will be enforced by the powers inherent in the economic hegemony that third party payers enjoy over physicians.

I have written about physician's spiraling downward pride and ethics (now known as professionalism) before as have others. Many hospitalists and emergency physicians are either employees of a hospital or are contracted with a hospital. When such things as the four hour rule and give almost everyone peri-operative beta-blockers become institutionalized as quality indicators it is not difficult to imagine the position a physician find herself if she dare object or worse refuse to play by those rules.Accusations of being a disruptive physician may be hurled and what happens to employees who do not play by the boss's rule.Of course, it is not just ED docs and hospitalist impacted by these rules and their enforcement mechanisms and not just those whose pay checks comes directly from a hospital. I still believe that physicians still want to act primarily in the best interest of their patients and many times still do but it gets hard and harder to continue to do so.

I am reminded of the old saw version of the Golden Rule (He who holds the gold makes the rules) . The economic reality of today's medical practice makes it harder and harder for the physician to act in the fiduciary interest of the patient and this is all the more bitter as we become more aware and educated in the foibles and weaknesses of the "knowledge" base on many of the quality rules allegedly derive from.

The blogger, The Happy Hospitalist, in his recent entry "Dr. Government Vs Littol Sally" and those who posted comments all sound the note that the good physician is the one who can determine when it is appropriate and in the patient's interest and when it is not to go with the guidelines. The constraints, incentives and feedback that physicians face constitute a practice environment that could not be less conducive to "dong the right thing".

cause of elite marathoner death not revealed by autopsy

It was a perfect weather day in New York for an Olympic marathon trial. At 5 1/2 miles into the race, world class runner Ryan Shay collapsed and died.

The preliminary autopsy findings did not reveal a cause.

According to a very good web site on sudden death in athletes which is actually entitled "Sudden Death In Athletes",The top three causes are Hypertrophic Cardiomyopathy (HCM)-26%, Commotio Cordis 20% and Congenital coronary artery abnormalities 14%. He was not struck in the chest and Anomalous coronary artery would have been noted on a gross autopsy but according to Dr. Douglas Zipes, a spokesman for the American College of Cardiology, differentiation between HCM and a very hypertrophied "runner's heart" can be difficult. At 5 miles into the race on a cool day there would be no reason to consider hyponatremia in an elite seasoned distance runner. I assume a cranial exam was done and no cerebral aneurysm was detected. So what is the answer? In some well publicized cases of athlete's death the answer was never made clear.

Two well known cases of sudden death during an athletic event,both leading to legal complications and controversy, were the deaths of Celtic basketball player,Reggie Lewis, and college basketball player Hank Gathers in Los Angeles. Apparently neither HCM nor anomalous coronary artery were the cause in either death which were surrounded with charges and counter-charges regarding how early symptoms were handled in these very "valuable"athletes.

In Italy, where the cardiology community is quite involved in screening athletes for potentially lethal cardiac conditions,an entity uncommon in the U.S. is said to be much more common namely, arrhythmogenic right ventricular cardiomyopathy (ARVC), a good discussion of which can be found here. The most common EKG finding is inverted right sided t waves, but this is also commonly seen with the benign incomplete RBBB pattern.A notch on the downstroke of the right precordial QRS complex is sometimes the tip off. In Italy, routine EKGs are recommended but that is not the consensus in the U.S. The Italian cardiologists have offered evidence that their evaluation which include EKGs have saved lives.

Shay's father has talked to the press and indicated his son had a history of "enlarged heart" as early as age 14 but he had been evaluated in the past and more recently and was given the OK to compete .

Peri-operative beta-blockers- A quality indicator or a bad idea?

The November 9,2007 edition of Med Page Today features a report of a paper given at the AHA meeting that casts serious doubt on a major recommendation of the AHA and a widely used "quality" measure.

There have been rumblings for some time that the rush to use beta-blockers to reduce cardio-vascular mortality and morbidity during and after surgery was ill advised.The rumblers now have a more convincing argument.

Dr. P.J.Devereaux reported the results of the POISE trial, which was an drug company randomized trial of over 8,000 patients, aged 45 or over undergoing noncardiac surgery and who had or were at risk for arteriosclerotic disease. The treatment arm received metoprolol 2 to 4 hours pre-op and had the medication continued for one month after surgery.

There was a decrease in nonfatal MI ( 3.6% versus 5.1%) but there were more strokes in the beta-blocker group ( 1.0% versus 0.5%) and a greater total mortality in the treatment arm (3.1 % versus 2.3 %),

I have suggested before that quality measures may be hazardous to your health in regard to the four hour pneumonia rule. This may be an even more glaring example. I submit that in the rush to infuse "quality" into medical practice we may have codified a practice, that may generate more harm than good, (I am sure folks will argue over that) based on far less than convincing evidence.

Current issue of Mayo Clnic Proceedings critical of ED docs handling of vertigo and current diagnostic paradigm

Ever since I heard Dr. Martin Samuel's classic lecture on vertigo, I took his advice and tried to become fairly knowable about vertigo so I could really look forward to seeing my "next dizzy patient".

Part of his approach is incorporation of the widely used classification proposed in 1972 by Drachman and Hart in which four categories are outlined.

vertigo
presyncope
disquilibrium
non-specific, or lightheadedness ( what Samuels calls "true vertigo")

In the Nov. 2007 issue of the Mayo Clinic Proceedings, several authors are rather critical of the manner in which ED docs approach and manage vertigo patients. (Full text is available after registration on their site).

The editorialist comments that ED doc training seems lacking in neurological matters and in his analysis of a number of missed diagnosis of cerebellar infarction that histories were incomplete, neurological exams were inadequate and there was undue reliance on CT scans. I would like to hear what ED docs think of that ( if any read this).

One article suggested that the emphasize on "quality of symptoms" ( which is basically over emphasizing the above mentioned classification) may lead to missing diagnoses, the most important of which is cerebellar hemorrhage which in some instance is treatable by surgery. So not only are ED docs (just ED docs?) accused of screwing up, the paradigm taught for years and used by many is also under attack by this multi-institutional cadre of authors.

In a rather complicated article based on a survey of 505 ED attendings and residents the authors ( it seeemed to require 12 authors to interprete the results) concluded that "the dominant paradigm...is the quality of symptoms approach ....the standard approach ..suggests a potential link to misdiagnosis".

I think they are saying that over reliance on a simplified approach to vertigo/dizziness may lead to missed diagnosis of brain stem strokes and cerebellar infarcts or hemorrhages. The simplified approach they think is being used involves the following thought chain: vertigo--->vestibular--->otolaryngology type cause. The reasoning I thought was applicable was vertigo--->vestibular or central (brain stem or cerebellar cause.) In other words, one has to differentiate between peripheral and central causes of vertigo.

What always bothered me was "Don't miss cerebellar hemorrhage" and to that end I think the following points are valid and helpful,some of which the Proceeding's authors make.

Vertical nystagmus within a single bout of prolonged vertigo almost always means a central cause.

Head motion or positional trigger of vertigo usually means peripheral BUT cerebellar stroke related vertigo can also be made worse by head movement.

The typical head CT done in ED does not rule out a cerebellar hemorrhage and MR may be needed.

If the patient is so vertiginous or disqulibrated ( probably not really a word) that he cannot walk you had better really worry about a cerebellar stroke.

Absence of headache does not exclude a cerebellar hemorrhage.

You really need to do a history and a neurological exam. Brain stem strokes almost always have other neurological findings-diplopia,cranial nerve palsies ,dysarthria, etc-but midline cerebellar disease may only have vertigo, nausea and inability to walk so intense is the disequilibrium.So absence of cerebellar signs-upper extremity- dysmetria,past-pointing etc-does not exclude a cerebellar stroke.

I blogged about cerebellar hemorrhage before here.

In that posting I referenced an article written by an ED physician who missed a cerebellar hemorrhage and with more than a little courage discussed in detail how it happened.

The Proceeding authors' thesis is, in part, that more emphasis should be place on the timing or duration of the symptom(s) and on the triggers. Perhaps so but whether or not their survey indicates a major and widespread defect in diagnostic reasoning is unclear. David Drachman in a 2000 Annals of Internal Medicine editorial said that the physician needs to evaluate vision,vestibular function,motor function and search specifically for certain conditions. In other words, evaluate the patient,try and make sense of clinical findings and search particularly for potentially serious and treatable conditions. Rigid adherence to his categories was never intended.

Drachman's decades old outline is just that, an outline, a reasonable broad category checklist to consider in the evaluation of the dizzy patient not a rigid algorithm that would use a patient's description of symptoms as a mechanism for premature closure.

Consultant fees ,bribes or kick-backs to academic othro surgeons?

Medical ethics news seems to get worse and worse. Health Care Renewal refers to articles on orthopedic device manufacturers paying-in some instances-unbelievably large fees to orthopedic surgeons. The nature of what they did to earn such fees is let to the imagination but four orthopedic device manufacturers were charged with violating federal anti-kickback laws by paying orthopedic surgeons to use their products.

Sites that list in detail the physician recipients can be found on the Health Care Renewal blog. Perhaps the most striking payment was for over six million dollars to the head of orthopedics at Brighams and Women's Hospital. There were 21 instances of physicians receiving one million dollars or more from one manufacturer.

Certainly, physicians can perform various legitimate consultative activities for drug and device manufacturing companies and we do not know what the fees were for but the accusations of receiving kick-backs delivers still another blow to the prestige and reputation of physicians in general.

Earlier I wrote about the accusation of renal doctors receiving rebates for the use (and some would say the overuse) of erythropoesis stimulating agents in patients with renal failure. I have also commented on the accusation that oncologists were profiting from the in-office administration of chemo drugs and that such profit may have lead to the inappropriate use of such drugs. From my positive personal associations with renal docs and oncologists I had no reason to believe those accusations and did not want to believe them but some who commented to my blog believed otherwise. No doubt many in the lay community will apply the adage "where there's smoke, there's fire" to this most current revelation about money exchanging hands.

Several years ago my brother-in-law after paying $90 for his first month supply of Zocor commented that his physician was probably getting a kick-back from the drug company. I self-righteously told him that sort of thing doesn't happen. I am not sure what I would say now.

The old time "peripheral brain" of house officers is now the external universal mind

Returning home from a vacation in Europe I read a delightful and insightful piece by David Brooks in the International Herald tribune entitled "The External Brain". It can be found here.

I actually still have my little black book which was a lab coat pocket sized binder notebook in which house officers in the day wrote things that they thought they needed to know and no, I don't use it anymore. That and the Washington Therapeutic Manual were our "peripheral brains." I find an 40 year old entry under CHF which talks about how to slowly "digitalize" a patient with congestive heart failure and another on how to do the "Ivy bleeding time, both of which are medical museum pieces.

Brooks, in what I believe to be at least in part a tongue in cheek essay talks about how by becoming progressively reliant and dependent on his GPS system he was discovering the "Sacred order of the External Mind." He could now out-source mental tasks to a satellite brain, an external Mind. He says he may now no longer need a memory because with a few key-board strokes he can get what he needs on Google or Yahoo and the drudgery of having to remember so much stuff is eliminated or for more personal material open up his Blackberry.

He writes that he discovered that the magic of the information age was not we could now know more but that it "allowed us to know less."

The clunky,relative information-poor little black book of yesterday's intern has morphed into the powerful PDA through the mystery and magic of the silicon chip animated by the unforgiving logic of the algorithm.This can not only hold a PDR, one of the available antibiotic guides and five Minute Clinical Consultations,etc,etc but when Internet-enabled the entire universe of the external brain can be accessed.

Brooks continues " I have relinquished control of my decisions to the universal mind...Life is a math problem and I had a calculator"

One possibly disturbing counterpoint is noted in Brooks' reference to a piece by Clive Thompson in Wired which claims that one third of folks under age 30 can't remember their own telephone number.

Of course, physicians cannot really relinquish control to the universal medical mind. However, when you have the background and the context of experience, access to the "outboard brain" is unbelievably empowering and having tasted of it you never want to do without it. But as Clive Thompson said in his closing, I would like to still remember my own phone number.

There are no average patients

Dr. Robert Centor has an important entry in his blog, DB's Medical Rants, dealing with a issue dear to my heart. He refers to an article in American Scientist by Drs. Rodney Haywood and David Kent. These are the same docs who published a recent article in JAMA that I talked about here.

The basic notion here is that averages hide individual differences and Haywood and Kent emphasize the need for risk stratification to be included in randomized clinical trials.


Earlier on I had been able to access a full text version of a classic article on this same general topic but now my attempts to link to that have been met with the realization that now a subscription is required. This is a real shame as it is an article every med student and physician should read and digest.
The Journal is

Milbank Quarterly ( 82(4),661-687, Dec. 2004 and the article is " Evidence-based Medicine;Heterogeneity of treatment effects and the trouble with averages" by Kravitz,RL,Duan N, and Braslow J.

Here is the abstract ( apparently all you can get without a paid subscription now) with my addition of the highlighting of certain phrases.

"Evidence-based medicine is the application of scientific evidence to clinical practice. This article discusses the difficulties of applying global evidence ("average effects" measured as population means) to local problems (individual patients or groups who might depart from the population average). It argues that the benefit or harm of most treatments in clinical trials can be misleading and fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few. Heterogeneity of treatment effects reflects patient diversity in risk of disease, responsiveness to treatment, vulnerability to adverse effects, and utility for different outcomes. Recognizing these factors, researchers can design studies that better characterize who will benefit from medical treatments, and clinicians and policymakers can make better use of the results."

Guidelines are based-ideally-on evidence.The highest rung on the evidence ladder is generally said to be the randomized clinical trial(RCT).The conclusions of RCTs are expressed in terms of averages and the problem is averages are abstractions of data and there are no average patients.

I am glad that DB is pushing on with this topic. He is widely read and a prominent educator and at least his students will benefit from discussion of averages and the madness of guidelines. Also be sure and read the insightful comments to DB's entry by Dr. Richard Fogoros

More on "Is there no end to the wonders that statins will bring about?"

Here is a link to one more in the ever growing list of the wonderful things that statins can do for us all. We now learn that the rate of loss of lung function is lessened in statin users with COPD.

Earlier I had listed some of the other benefits attributed to statins . These included

decreased risk of death from COPD and heart failure
decreased risk of advanced cancer of the prostate
decreased risk of pneumonia in diabetic patients

I also previously commented a study that seemed to show a decreased risk of sepsis in dialysis patients who took a statin. I cynically wondered aloud if some or all of these observational studies on the benefits of statins were not a big push by the statin manufacturers to generate more evidence that the value of the statins extend far beyond the LDL lowering effects and include the nebulous effects "pleotrophic" effects. Such a effort could well be triggered by the market success of Zetia.

There was also the issue of the dueling case-control studies that dealt with the question "do statins decrease the risk of colon cancer" with various studies reaching opposite conclusions. That saga seemed to prove once again you should not bet the farm based on the results of a case-control study.

I certainly do not rule out that some or all of the statins may bring about some type of benefit apart from the cholesterol lowering but the fact is the studies mentioned above are observational studies and are a hotbed of all the potential biases that we learned about in doctor school and basically cannot prove causation. and we need to particularly be wary of the healthy user effect.

changing mind set in medicine

Kevin MD references a posting on what life is like for a hospitalist at Kaiser that tells the readers more than what life is like for a hospitalist at that particular HMO.The blog that Kevin refers to is EM Physician-Back Stage Pass and here is the essay.

I believe it tells a great deal about what may be a major paradigm shift in the self image or mind set of physicians in this new culture of managed care.

Here is a quote:

Medical students and residents are seeking a better lifestyle for themselves. I guess we're finally coming to realization as a group that medicine isn't worth your happiness and sanity. That it's hardly admirable to subject yourself to abuse (by CMS, by DHA, by joint commissions,by society by medicine) and be absent in the lives of your loved one. Maybe when doctors were respected,autonomous and paid well...but now,not as much. when this happens, when docs start seeing themselves as employees with jobs,continuity of care sounds like crazy talk. Think how crazy it would sound if we suggested that nurse (or anyone else on the 'healthcare team' were made to "feel guilty" about going home at night....Everyone has a job these days..which is what government created and physicians (at least the professional societies) have allowed to happen.

The loss of pride that DrRich and I have blogged about seems evident in this doctor's view. It seems the doctor author sees himself as 'only" an employee. I re-read his piece and I go back and re-read the an early entry I submitted for this blog which dealt with the transformation of a lay person to a physician and at first conclude that our views are miles and ages apart.Or maybe my views are what I was taught a physician should be and his/hers are what the reality of the current economic medical landscape are turning physicians into.