Monthly Archives: September 2010

We’re all on Prozac now

Doctors with pharma giftsThis entire poem is available online, so I hope JAMA won’t mind if I reproduce it here. The concept might seem simply clever at first, but in fact it’s quite thought provoking.

Side Effects May Include

Now available
over the counter, the phone, or the Internet—
even on the corner—
with or without a subscription.

Clinically proven to
counteract depressed mood,
soothe frazzled nerves,
decrease heart and respiratory rate,
lower the heart from the throat,
warm the heart,
coat the pit in the stomach,
moisten eyes with tears of joy,
motivate individuals to fulfill their potential, and
inspire groups of people to alter the very course of history,
including (but not limited to) putting a man on the moon and
casting off the shackles of racism and political oppression.

Side effects may include
malapropisms,
Freudian slips,
tears of sadness,
things said that can never be taken back,
false hopes,
and, in general, the exact opposite of what’s intended.

So,
talk to your loved one,
your neighbor, your doctor,
to everyone you can, about
Words.

(Words is a registered trademark of Language.)

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Why don’t hospital workers wash their hands?

Nurse washing handsHand washing reduces hospital-acquired infections. How do you motivate hospitals to comply with standards? How do you measure compliance? Turns out this is not a simple problem, according to an article in The Journal of the American Medical Association.

Hospitals may have good reasons for selecting an auditing method that will overestimate compliance. For example, audits may be delayed on poorly performing units to allow time to implement quality improvement or auditors may inform health care workers they are being auditing (sic) because they believe it is unethical to monitor covertly. However, as the pressure to perform increases, organizations seeking rapid improvement will be more likely to maintain or substitute methods that overestimate compliance than to use methods that measure true (ie, worse) compliance because doing so would make their hospitals appear to be underperforming relative to their peers.

Public reporting of hand hygiene compliance places clinicians in a position in which they must choose between protecting patients by striving for real hand-hygiene improvement or protecting their reputations by reporting high rates of hand hygiene compliance. The first path is difficult and often unsuccessful. To encourage progress along this path, it would be better to avoid public reporting before evidence-based improvement strategies are implemented and direct resources toward identifying better ways of measuring and improving hand hygiene. [emphasis added]

Am I missing something here or does this say we shouldn’t publicize information about hospitals with poor hygiene because they’ll just lie about the facts or be otherwise devious and dishonest? Plus, reputation – that is, the financial profits of medicine – is more important than the health and safety of patients? No, it couldn’t be saying that. Or maybe it is, and we should at least be grateful that someone has the courage to speak honestly in public.

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Michelle Chappel – No Place Like Home

Homeless

World Homeless Day is on October 10, 2010 — 10/10/10. My friend Michelle Chappel Millis has written a song and made a video to support this cause. It’s called “No Place Like Home.”

Michelle and I encourage all viewers to share the video – here’s the YouTube link – as a way to raise awareness of the problem of homelessness. If you’re so moved, please contribute to registered charities in your locality.

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Should psychiatrists go to med school?

Psychiatry and big pharmaWhat’s happened to psychiatry over the last 15 to 20 years? That’s a big subject, discussed in many recent and excellent books. One of those books is by Daniel Carlat, author of Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis.

One of the problems Carlat readily acknowledges is that psychiatry is excessively focused on psychopharmaceuticals at the expense of other effective treatments. Not only is there too much focus on drugs as treatment. There’s so much money flowing from the pharmaceutical industry to psychiatrists that it makes one wonder if the profession can be objective.

Evidence of financial ties was documented by clinical psychologist Lisa Cosgrove. She considered those psychiatric experts who were responsible for the diagnostic criteria in the DSM, the bible of psychiatric disorders. Of the 170 psychiatrists who contributed their expertise on mood and psychotic disorders, 100% had financial ties to drug companies.

Carlat asks: Why do psychiatrists take more money from the pharmaceutical industry than other doctors? His answer:

Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another. This makes us ideal prey for marketers who are happy to provide us with a false sense of therapeutic certainty, as long as that certainty results in their drug being prescribed. Furthermore, psychiatrists feel inferior and less ‘medical’ than other specialties. Working at high levels with drug companies gives us a sense of power and prestige that is otherwise missing.

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Should grief be labeled and treated as depression?

GrievingThe American Psychiatric Association (APA) is in the process of revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the psychiatrist’s bible. Its last incarnation — known as DSM IV — was published in 1994, with a “text revision” in 2000. The new version will be DSM V.

Psychiatrist Daniel Carlat described some of the initial arguments over revisions as a bar room brawl. Now that the APA has moved the publication date forward from 2011 to 2013, the number of publically traded insults appears to have died down.

One item in dispute is whether bereavement – the grieving process that follows the loss of a loved one – might qualify a patient for the DSM label Major Depressive Episode. Many symptoms of bereavement are similar to those of depression, such as feeling sad, poor appetite, weight loss, and insomnia.

Here’s one of the APA’s needlessly obscure arguments for including bereavement.

The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation [or] loss of loved one from other stressors.

In other words: Bereavement symptoms should be included because bereavement is a source of stress. Just as divorce, job loss, illness, and disability cause stress, so does the loss of a loved one. The assumption here is that stress can lead to depression. Read more

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Support the Fair Elections Now Act

Lobbying: Nobody tells me what doAmericans of all political persuasions can surely agree that Congress is currently dysfunctional. Much of the problem stems from the enormous influence of special interest groups – through lobbyists — on elected officials. The importance of this issue increased last January with the landmark Supreme Court decision, Citizens United v Federal Election Commission, which overturned a ban on political spending by corporations.

There will be a vote in the House of Representatives this week on a bill that addresses the problem of campaign financing. It’s a bipartisan bill called the Fair Elections Now Act. Basically, it provides a way to finance the election campaigns of congressional candidates with contributions from individual citizens rather than special interests.

There is an explanation of how the bill works on the Fair Elections Now website. There’s a difference, for example, between how funds are raised for Senate races and House campaigns.

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Lobbying against formula for babies

Baby drinking from bottleHere’s one small example of what lobbyists can accomplish in Washington.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides formula and food to low-income mothers of small children. Unlike food stamps, WIC is not an entitement. Congress grants WIC a finite amount of money. When that money runs out, the cupboard is bare.

Formula makers are increasingly adding “functional ingredients” – omega-3s, antioxidants, probiotics – to their products. This allows them to charge more. For WIC, that increased cost means formula will cost almost $100 million more.

The budget for WIC is already inadequate. In the past, there’s only been enough money for about half the number of eligible mothers and children. If the cost of infant formula increases, that budget will buy even less, which means even fewer mothers can participate.

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Century-old kerfuffle over the “syrup” in corn syrup

Pecan pie without corn syrupI see that the Corn Refiners Association is petitioning the FDA to change the name of their ingredient – as it appears on food labels — from corn “syrup” to corn “sugar.” There’s an amusing footnote to this story. A hundred years ago, Karo Corn Syrup – a product still on the market – was fighting to be listed as “syrup,” not glucose (a simple sugar), on its label.

To appreciate this story, I first need to explain a few things.

• Fructose is the sugar in fruits. Glucose is the sugar in corn, sugar beets, sugar cane, rice, and many other sources of starch. Dextrose is simply another name for naturally occurring glucose . (There’s another type of glucose that can be synthesized.)

• Corn syrup is what you get when you process corn with water. 100 years ago, the process involved hydrochloric acid, heat, and pressure. Today manufacturers use enzymes to break down the corn starch so it’s soluble. Corn syrup is glucose.

• High-fructose corn syrup (HFCS) is not the same as corn syrup. It’s produced by adding yet another enzyme to corn syrup, which changes most of the glucose to fructose. Manufacturers produce HFCS with different ratios of fructose to glucose. For example, 55 percent fructose and 42 percent glucose, which is about the same as the ratio in honey

• The Pure Food and Drug Act was passed in 1906. The skirmish in 1910 over Karo Corn Syrup’s label was an early example of the federal government’s regulation of food labels. Read more

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Merchants of Doubt

Merchants of DoubtIt’s easy to understand – if not condone – the behavior of politicians who are financed by tobacco and oil companies. They oppose the regulation of smoking or pollution because they benefit from the financial contributions of those industries.

But what motivates certain scientists to relentlessly cast doubt on peer-reviewed scientific evidence that’s inconveniently contrary to financial interests? A new book, Merchants of Doubt by Naomi Oreskes and Erik M. Conway, attempts to answer this question.

To some extent, the motivation for certain scientists is the same as that of politicians. Those who opposed the issues covered by this book – nuclear winter (could we survive a nuclear war), Star Wars, acid rain, the ozone hole, global warming, DDT, cigarette smoking and second-hand smoke – are frequently members of “institutes” or think tanks heavily funded by tobacco and “dirty” energy donations.

The answer is much more complex than money, however. And much more interesting. Read more

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Childhood obesity and will power

Childhood obesity socioeconomic classAn article in the Journal of the American Medical Association reports that the rate at which obesity is increasing has slowed down and may actually have plateaued. Is this good news? It would be if obesity was descreasing for everyone, at both ends of the economic spectrum. But what if obesity is decreasing for those who can afford healthy food and still increasing for those who can’t?

Research presented at the recent International Congress on Obesity showed that childhood obesity has stabilized or decreased in many countries over the last ten years. Rates are up in China, Vietnam and Germany, but have decreased or stabilized in Australia, Denmark, England, France, Greece, Japan, the Netherlands, Norway, Russia, Scotland, Sweden, Switzerland, and the US. In India, rates have stabilized for boys, but are still rising for girls.

When you dig a little deeper into the numbers, however, there’s a difference between the children of the rich and the children of the poor. An English study, for example, found that obesity was decreasing for 5-to-10-year-olds from higher socioeconomic groups, but was still increasing in lower socioeconomic groups. When the two sets of data balance each other out, it creates the appearance of a plateau.

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The art and science of medicine

Ars longa, vita brevisOne of my posts was featured today on KevinMD, Are physicians today active in the arts?.

While browsing the KevinMD site, I came across a post by “A Country Doctor,” Evidence based medicine at the expense of the art of medicine. My post was on the tradition of doctors as ”humanists” – educated professionals who contribute to the “fine” arts as writers, visual artists, and musicians. There’s a connection, however, between that tradition and the “art” of medicine.

What happens to doctors when the latest scientific methods of clinical decision making — as well as a reimbursement system that determines how medicine is practiced — encourage doctors to be little more than scientific technicians? Will their insight into the humanity and individuality of patients suffer? What happens to the physician’s art of addressing the uniqueness of each patient’s illness?

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