Monthly Archives: March 2011

Are the most heavily marketed drugs the least beneficial?

Prescription drugs symbolIn a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.

For example, harmful effects (like death) may not show up during the limited time span of a trial. Data from trials may be selected – and other data ignored — to produce positive results. This is apt to happen when clinical trials are conducted by the pharmaceutical industry, rather than by economically disinterested parties, such as the NIH or independent academic institutions. Also, the participants in the trial may differ significantly (in age, gender, and health, e.g.) from patients who end up taking the drugs. As a recent article in JAMA put it, “most clinical trials fail to provide the evidence needed to inform medical decision making.”

The Inverse Benefit Law

If you follow pharma news, you will have noticed that many high profile, aggressively marketed drugs turn out to be either ineffective or positively dangerous (think Vioxx, widely prescribed for arthritis, which turned out to cause heart attacks and stroke). Howard Brody, MD, and Donald Light, PhD, have proposed an explanation for this phenomenon. They call it the Inverse Benefit Law: “The ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed.” Or (for those who feel fuzzy about inversion): The more aggressively a drug is marketed, the more likely the drug will cause harm, be ineffective, or deliver little by way of benefit. Read more


Down so low we dare not speak

Despair and pessimismDue to multiple, largely uncontrollable influences that include both nature and nurture, individual outlooks on the world are arrayed along a continuum from bright to dark. I tend to land on the dark side.

Three weeks ago I read a darkish blog post that made a strong impression on me. I was especially struck by its characterization of the current political/economic climate as so depressing one hesitates to speak of it. I understand that sentiment.

I couldn’t remember where I read it and recently tried in vain to locate it in all my usual web haunts. Then last night it popped up like an old friend. It’s called “The New American Pessimism,” and it’s written by the Serbian-American poet Charles Simic, a Pulitzer Prize winner, among other things. Here’s an excerpt. (emphasis added)

It must be difficult for any hostess nowadays to stop her dinner guests from reciting to each other over the course of an evening the endless examples of lies and stupidities they’ve come across in the press and on TV. As they get more and more wound up, they try to outdo each other, losing all interest in the food on their plates. I know that when I get together with friends, we make a conscious effort to change the subject and talk about grandchildren, reminisce about the past and the movies we’ve seen, though we can’t manage it for very long. We end up disheartening and demoralizing each other and saying goodnight, embarrassed and annoyed with ourselves, as if being upset about what is being done to us is not a subject fit for polite society. …

By the president’s calculation, telling the truth to the American people would doom his reelection campaign, since he would not be able to raise the billion dollars he needs this time around. The kind of people who have that kind of money and will agree to contribute to his campaign know very well what informed voters in a working democracy would to do to them once they understood just who has depleted the national treasury to line their own pockets. No doubt, he and his political party will do anything to avoid the truth and will propose outwardly attractive solutions—like the health care bill that not only expands coverage but greatly benefits insurance companies and does little to reduce healthcare costs. They hope that these kinds of measures will lure the majority of voters who won’t bother to learn the details, but they will also send a clear signal to the moneyed classes that they won’t be inconvenienced in the least. … Read more


Breaking the self-destructive meritocratic spell

A just societyIntelligent, thoughtful essay by Namit Arora on distributive economic justice: libertarian, meritocratic, egalitarian. (emphasis added)

In Rawlsian terms, the problem in America is not that a minority has grown super rich, but that for decades now, it has done so to the detriment of the lower social classes. The big question is: why does the majority in a seemingly free society tolerate this, and even happily vote against its own economic interests? A plausible answer is that it is under a self-destructive meritocratic spell that sees social outcomes as moral desert—a spell at least as old as the American frontier but long since repurposed by the corporate control of public institutions and the media: news, film, TV, publishing, etc. Rather than move towards greater fairness and egalitarianism, it promotes a libertarian gospel of the free market with minimal regulation, taxation, and public safety nets. What would it take to break this spell?

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What Wisconsin hath wrought

Wisconsin protestsFrom a long piece by John Nichols in The Nation on the spirit of Wisconsin, written early in March. (emphasis added)

One of the most popular signs on the streets, distributed by National Nurses United, said, Blame Wall Street. Instead of concessions, the nurses argued, it’s time to focus on the corporate CEOs and speculators; as they point out: “In U.S. states facing a budget shortfall, revenues from corporate taxes have declined $2.5 billion in the last year. In Wisconsin, two-thirds of corporations pay no taxes, and the share of state revenue from corporate taxes has fallen by half since 1981.” The same is true in other states. These facts must be stressed, repeatedly and aggressively, if the debate is going to shift from cuts in public services and education to demands for fair taxes and the revenues necessary for services and schools.

When I read polling statistics, I get the impression Americans don’t hold corporations or the finance industry accountable. This article provides evidence to the contrary, at least in Wisconsin. Read more


It’s cheaper to let the sick die

Free health care clinic draws thousandsIn January, Atul Gawande published an article in the New Yorker called “The Hot Spotters.” It described medical pioneers who were engaged in a promising solution to both aspects of the health care crisis: rising costs and patients whom the current system fails. By concentrating on the sickest and most expensive patients – those with the most frequent visits to the emergency room, e.g. – and by assisting them as they return to health, the cost of care for these patients would be significantly reduced and the patients themselves could go on to live healthier and more productive lives. I wrote about the article here.

In February, the New Yorker published three letters to the editor in response to Gawande’s article. The first advocated use of the Medical-Legal Partnership network for those suffering from poor housing conditions or the denial of food stamps and disability status. The second letter both contradicted and supported Gawande’s case.

It’s the third letter that really caught my attention. (emphasis added)

Gawande makes a strong case for the cost-cutting benefits of comprehensive case management for the small minority of patients who utilize medical services most intensively. Unfortunately, he dismisses what, from the standpoint of reducing total health-care expenditures, is the single most serious drawback to such an approach; namely, the probability that effectively case-managed patients will survive longer than they would without intensive ambulatory care and will thereby offset their reduced frequency of hospitalization with an increase in their time at risk. If an intervention reduces a patient’s frequency of hospitalization from ten admissions annually to five, but simultaneously increases that patient’s survival from one year to two, the intervention is fully justified medically but is a wash from a cost perspective. If it increases that patient’s survival to two years and one month, it’s a net liability.
Aaron Walton Newtown, Australia

I don’t think there can be any misunderstanding as to what Mr. Walton is advocating here. This is rationing in its most naked form. Does it make me a bleeding-heart liberal to find this reasoning utterly objectionable? Surely even Sarah Palin wouldn’t support such a position.

Health care for the poor is a moral and ethical issue

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Complaints about pharma go way back … to ancient Rome

History of pharmacyOne hundred years ago, editors of The Journal of the American Medical Association voiced their complaints about “pharmaceutic” problems. In particular, they objected to proprietary remedies (compounds with secret formulas), the inappropriate substitution of one drug for another, counterfeit drugs, and flowery but meaningless names that served only to increase the popularity of a drug.

According to the anonymous editors, these practices were in fact nothing new, but could found in descriptions of the ancient Romans.

Pliny the elder (first century AD) complained that physicians of his time used remedies that had already been prepared, thus saving the time it would take to prepare them. A historian (Ludwig Friedlaender) writes of the Romans: “[O]ften the physicians did not know the exact ingredients of the compounds that they used and should they desire to make up written prescriptions, would be cheated by the salesmen.”

Pharma reps less than totally forthcoming? Hmmm.

In the second century AD, Galen also complained of physicians who used “ready-made” medicines. Both Galen and Pliny believed prescriptions should be carefully prepared by physician’s themselves, or at least under their close supervision. But no. Some doctors simply followed the line of least resistance and abdicated this most important function. Surely this brought harm to both patients and the physicians themselves. Read more


Don’t drink and judge: Bitter tastes and moral disgust

Tasting something bitterDisgust is an emotion experienced – either actually or in the imagination – through the senses. Charles Darwin, for example, wrote: “I am disgusted by the stench and sight of that rotting viscera.” Some anthropologists suggest that feeling disgust was an adaptive survival mechanism in the course of our evolution. It may be maladaptive today, however, as it can result in fears of those who are different from us, sexual prejudices, and other irrational behaviors. Says anthropologist Dan Fessler:

We often respond to today’s world with yesterday’s adaptations. … That’s why, for instance, we’re more afraid of snakes than cars, even though we’re much more likely to die today as a result of an encounter with a car than a reptile.

Do bitter tastes increase moral disgust

Psychologists have asked whether there’s a connection between feelings of physical disgust and a sense of moral disgust. In an experiment designed to explore that question, test subjects were given three different drinks – one sweet, one bitter, and water. They were then shown morally questionable scenarios (ranging from second cousins engaging in consensual sex to a man eating his dead dog) and asked to rate how morally questionable they found these scenarios. Participants were also asked about their political orientation.

The results? Those who drank something bitter rated the scenarios 27 per cent more disgusting than those who drank water. In addition, political conservatives were more strongly affected by bitter tastes than liberals.

The psychologists’ conclusion: “[E]mbodied gustatory experiences may affect moral processing more than previously thought.” Or, as New Scientist relates:

Although the mechanisms linking taste and behaviour are not yet clear, the authors [of the study] ask whether jurors should avoid bitter tastes and whether food preferences play a role in shaping political ideals.

Hmmm. Maybe we could create more political harmony by feeding conservatives more cake. Read more


Overdiagnosed and overprotected children

Helicopter parentsThere’s been much discussion for years now on whether children are overmedicated for behavioral problems. A very thoughtful report was just published by The Hastings Center: “Troubled Children: Diagnosing, Treating, and Attending to Context.” It asks the underlying question: Are increased rates of diagnosis and treatment with drugs appropriate or are healthily children simply being labeled as sick and given drugs to alter their moods and behavior? (The report is available online as a PDF file.)

With that on my mind, I was struck by a comment from Tanya Byron, an English psychologist, writer, and child therapist,

[W]e have to really listen and think about why a child is telling us something. The behaviour of children and young people is fundamental to a well-functioning society, because they can tell us what is going on more honestly than we tell ourselves.

If there really is an increase in mental disorders among children, what does this tell us? If there isn’t, what does giving psychopharmaceuticals to four-year-olds tell us about ourselves? And could we be honest about what it says?

Stigma: We are afraid to lose the competition of life

Byron also made a good point about the stigma of mental health: (emphasis added in the following quotations)

[I]t would be helpful if we could accept that mental illness and physical illness all lie on a continuum, and sometimes bits of our physical body don’t work very well, and sometimes bits of our mental body don’t work very well – and that that’s OK, and it’s actually not an indication of failure. If you break your leg, you are not going to suddenly be seen as less successful than you were before you had broken your leg. So why do we have this stigma around mental health?

… We are scared of people seeing us as somehow not the person they thought we were, as if life is a competition and the only way that you win it is by being completely invincible and robust and never being fragile or vulnerable. That is just ludicrous. That is why I like kids: because they remind us that life really isn’t like that.

On not letting children be children

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Why do we feel bad about the way we look?

Laurie Essig’s new book, American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection, includes a chapter on how we learn to want cosmetic surgery. She quotes Joan Rivers, from her book Men Are Stupid . . . And They Like Big Boobs: A Woman’s Guide to Beauty Through Plastic Surgery:

My abiding life philosophy is plain: In our appearance-centric society, beauty is a huge factor in everyone’s professional and emotional success—for good or ill, it’s the way things are; accept it or go live under a rock.

Heidi Montag cultural texts promoting cosmetic surgery

Essig comments:

But Rivers is a TV star. TV and movie stars have always utilized the miracles of cosmetic surgery to look good in the two-dimensional spaces they inhabit. How did the rest of us learn to desire a perfectly plastic body? How did ordinary women and men with ordinary lives and ordinary bodies learn that they need plastic? The answer: the plastic ideological complex, a set of cultural texts that are both highly contested and yet tightly on message. It is itself so ubiquitous that it might even be described as hegemonic. In other words, the “need” for cosmetic procedures is impossible to avoid. Through advertising and TV shows, movies and magazines, we learn to want cosmetic intervention in our aging faces and imperfect bodies. This need is now so firmly implanted in our cultural psyche that it has become “common sense” to embrace cosmetic procedures. Why wouldn’t we want to look more beautiful, younger, thinner, more feminine, better? The question is no longer will you have plastic surgery, but when.

Accept plastic beauty or go live under a rock. Rivers isn’t just joking; she’s also doing the serious work of enacting the ideology of plastic, an ideology that we can no longer avoid. Even if we did live under a rock, whenever we crawled out from underneath it, we would be assaulted by images of perfectly plastic beauty on billboards and the sides of buses and on TV and in movies and even the nightly news. And then there are those damn magazine racks, an unavoidable gauntlet of Dos! and Don’ts! that must be passed through each and every time we buy our food.

A conspiracy of capital to make us feel bad

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Doctors eliminate the middle man: Insurance

Doctors practice outside insurance systemIn Seattle, Washington, a group of 12 physicians and nurse practitioners see patients at a clinic that doesn’t accept insurance. Instead, patients pay roughly $65 a month, every month. In return they get unlimited office visits (including evening and weekend office hours), e-mail and phone access to practitioners, and – my favorite part – appointments that last up to an hour.

There are some additional charges, such as for lab work and other outside services, but these are billed at or near cost, and many medications are available at a discount. Even if you add in the cost of catastrophic medical coverage – say, $225 a month – this is still a reasonable price to pay for health care, especially compared to the premiums charged these days by major health insurance companies.

The real beauty of the plan, however, is not only that it’s attractive to patients. It can be a way for struggling primary care physicians to maintain a financially viable practice. The average patient pays $700 to $800 a year for membership. According to a report from Kaiser Health News, this is three times more than a doctor makes for each patient in an insurance-based practice. Not to mention the extra time and the absence of aggravation that comes when doctors eliminate insurance companies.

Norm Wu, president and chief executive of Qliance Medical Management, the direct-pay practice in Seattle, comments:

“So we can have a third the number of patients and get the same revenue per clinician, but with much less overhead.” … The approach, he says, allows Qliance to funnel more money into the care itself — through longer office hours, for example, or better diagnostic equipment.

A patient at Qliance comments: “The doctors will sit there with you as long as you need them to. … They don’t rush in and out.”

Lower costs and no complaints

Direct-pay primary care was encouraged in Washington by a new state law in 2007. The law permits direct patient practices – also called retainer health care – to operate without some of the legal and financial requirements typically imposed on entities such as insurance companies and HMOs. The goal of the legislation was to provide more affordable care for patients, improve access to primary care, and reduce the use of emergency rooms for primary care purposes. Read more


Daniel T. Rodgers on equality and inequality

Paul Klee Framed - Age of FractureAge of Fracture is one of the most stimulating books I’ve read in a long time. But then I’m especially interested in its subject matter: What happened in the last quarter of the 20th century.

Rodgers is an intellectual and cultural historian at Princeton. In a series of chapters, he examines specific subjects in depth — the language of presidential speeches, the concept of power, economic theory, race relations, feminism, a sense of community, nostalgia for the past. In each case he finds a “fracturing” of society. You could also describe it as a transition from a sense of society that is coherent and holds common values to a concept of society that emphasizes the individual. In each of the areas Rodgers discusses, it’s clear that this transition serves a conservative political agenda. What’s especially exciting about the book is seeing the same intellectual transition occur in so many different areas of social, political, cultural, and economic change.

A Theory of Justice

Here is Rodgers’ concise summary of the premise of John Rawls’ A Theory of Justice, published in 1971. (“The closest thing to a book that people are ashamed to admit that they have not read.”) (emphasis added in the following quotations)

The question with which Rawls began was explicitly a thought experiment in the justice owed by each to all. Imagine men and women coming together to form a society. Imagine that they did not already know, or guess, the place in that society that would ultimately be theirs. Imagine them to be intensely self-interested but blocked, for the moment, from knowing anything specific about their talents, their property, or their social assets. What principles of justice would they choose?

Rodgers goes on to explain Rawls’ conclusions: Read more


Surgery at a deep discount

Tummy tuck and medicine as a for-profit businessMedicine is a profession. Economically, it’s sufficiently different from other marketplace transactions that it shouldn’t be run as a for-profit business. When I made that argument in a recent post, I mentioned: “The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.”

That may still be true of brain surgery, but it’s obviously not true of plastic surgery. Here’s an excerpt from a recent press release:

Though the recession is slowly lifting, desired cosmetic surgery is still out of reach for some. And with winter almost over, time is running short for those who want to receive plastic surgery in time for summer. That’s why Dr. Lapuerta of the Plastic Surgery Institute of Southeast Texas, sympathetic to both his patients’ time and finances, is offering a very special offer of $500 off the very popular surgery, tummy tucks.

Just to make sure you understand how sympathetic Dr. Lapuerta is, the release continues:

With cosmetic procedures slowly but surely on the rise, Dr. Lapuerta wants to ensure that those who desire the procedures are more able to attain it. He appreciates the present circumstances stating, “I know that a tummy tuck or any cosmetic surgery can seem out of reach of many. Even though the procedures are on a rise, a lot of people who want the surgery are unable to get it because of finances. I hope that offering this special deal will help.”

Guess he doesn’t offer financing. According to Laurie Essig’s American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection, 85% of cosmetic surgery is purchased on credit and over 70% of patients earn less than $60,000 a year. Read more


Ezra Klein on inequality

Economic inequalityAfter briefly reviewing (favorably) Jacob Hacker and Paul Pierson’s Winner-Take-All Politics: How Washington Made the Rich Richer–and Turned Its Back on the Middle Class, Ezra Klein proceeds to give his own assessment of the inequality dilemma. Why has income inequality in the US increased so dramatically since the 1970s, especially in comparison to other developed countries? His conclusion: despite extensive analysis and discussion of the issue, there have been no good answers. But he has some suggestions on where to look. Some excerpts: (emphasis added)

[W]e’re still having trouble saying just what, exactly, is causing all this. … [T]here are four good places to look for answers. One is where Hacker and Pierson focus their energies: Whatever our eventual conclusions on inequality, we’re going to have trouble acting on them if the political system can’t bring itself to care about the average American a little bit more. A second is the education system: Arguably the only persuasive explanation for what’s happened to median wages is that educational attainment leveled off in the 1970s, even as the demand for educated workers increased. Economists Claudia Goldin and Lawrence Katz estimate that this explains two-thirds of the rise in inequality, and importantly, explains it on the side of median-wage stagnation, which is what we’re most worried about. Even if that estimate is a bit high, boosting educational attainment would still be a good place to start.

Then there’s the financial system. Insofar as anything explains the run-up in the incomes of the very rich, it’s the increasing financialization of the economy. …

[T]he federal government and the Federal Reserve brought overwhelming force to their efforts to save the financial market and underwhelming force to their efforts to save the labor market. And so the rich are getting richer again, but unemployment remains above 9 percent. … [W]e at least need to recognize what it is that we keep doing: green-lighting the policies that make the rich richer or, in the case of the crisis, keep them rich, while dithering and drifting on the problems and needs of the vast middle. …

And finally, we need to recognize that Americans haven’t accepted the status quo. Rather, they’re unaware of it. … [M]ost Americans think wealth is distributed vastly more equally than it actually is. … The fact that we don’t quite know how to solve inequality and median-wage stagnation doesn’t make the situation any less urgent.

Read more


Are hospitals too chaotic to be safe?

Hospital operating theaterWhen I read JAMA, I’m often thankful I haven’t needed to be in a hospital. The March 2 issue included a commentary on why “academic health science centers” (teaching hospitals, often associated with prestigious medical schools) lack incentives to provide quality care.

In the same issue was a thoughtful piece on how hospitals need to coordinate the many things they do and how the profit-driven nature of health care makes this difficult. (emphasis added in the following quotations)

On the lack of integration:

[T]rue integration of disparate data streams and clinical workflows into a single smart system, although technically possible, does not exist. Accordingly, clinicians are presented with ever-increasing amounts of raw data, often in chaotic environments, with the expectation of filtering data, prioritizing risks, and making informed treatment decisions. Consequently, safety has not improved. Ironically, the overall signal-to-noise ratio in complex health care settings may be worsening despite advances in technology and computing power.

On the profit motives that prevent integration:

The broader fragmentation of medicine extends to hospital units and even to individual patient rooms. Industry vendors depend on and promote this fragmentation with each vendor working alone trying to maximize market share. Although single-solution equipment providers exist, they still reside within isolated domains … and do not integrate with other technologies. Hospitals have largely stood on the sidelines in shaping the landscape of technology, equipment, and infrastructure in health care. They are perceived as the battleground in which vendors claim victories and admit defeats, but not as a driving force behind integration to which the market responds.

Who can make the loudest, most annoying noise?

And this was downright frightening: Read more


Robots dispense drugs and remove prostates

UCSF robot pharmacyEric Schmidt, chairman of Google, speaks of the “age of augmented humanity.” If we let computers do the things they do well, this will free up humans to be better at the things they do well. “The computer and the human each does something better because the other is helping.”

A win-win use of automation appears to be dispensing drugs in hospitals. The University of California, San Francisco (UCSF) has a team of robots that fills prescriptions for its medical center. Orders are submitted electronically. The drugs are retrieved from a secure, sterile environment. The dosage is as exact as a computer is logical. Medications are packaged for each patient – even assembled into 12-hour packets for the day. This eliminates possible errors by both pharmacists and nurses.

According to UCSF:

By using robots instead of people for previous manual tasks, pharmacists and nurses will have more time to work with physicians to determine the best drug therapy for a patient, and to monitor patients for clinical response and adverse drug reactions.

The dean of UCSF’s School of Pharmacy concurs:

The beauty of this robotic pharmacy system is that the pharmacist is taken out of that mechanical aspect of pharmacy practice, and they can use their intellect to be sure that the patients at the bedside are getting absolutely the right medicine.

It’s sort of like using scanners to buy groceries or to check out books at the library. It may put some people out of work, but hey. That’s the price we pay for the age of augmented humanity.

This video of the robots in action is actually quite good. Read more


Baby RB, Baby Isaiah, Baby Joseph

Baby Joseph MaraachliThese days, both the oldest and the youngest die in hospitals.

Baby RB suffered from a rare subtype of a genetic neuromuscular condition, congenital myasthenic syndrome, and spent his entire life – he was not yet two – on a respirator. After a protracted legal dispute between his health care providers in the UK and his parents (who disagreed on what should be done), he was allowed to die

Baby Isaiah was born with his umbilical cord wrapped around his neck after 40 hours of labor. He suffered severe and irreversible brain damage. He was kept alive for four and a half months. Following a legal dispute with health care providers in Canada, his parents agreed to allow their child to die.

The current case in the spotlight is Baby Joseph Maraachli. He suffers from a “progressively deteriorating neurological condition” of unknown origin and is in a permanent vegetative state. He is 13 months old. A court in Ontario ruled that the health center treating Baby Joseph could remove the breathing tube keeping him alive. The parents have transferred the child to a hospital in St. Louis, where he will receive a tracheotomy. The story has received extensive coverage in Canada and is just beginning to show up in the US press.

According to Reuters:

Rebecca Dresser, a professor of law and medical ethics at Washington University in St. Louis, said U.S. courts generally side with families in such cases that want to continue treatment for loved ones even in seemingly hopeless medical cases.

Dresser said similar end-of-life cases will likely become more common.

“Because of the growing concerns about costs, we’re going to see more of this,” she said.

Read more


Never Let Me Go: Exploitation of the young by the old

Movies in which life is all the more precious because the main character has a fatal disease are common Hollywood fare. Love Story and Terms of Endearment come to mind. Jenny (Ali MacGraw), in Love Story, appears to have leukemia. Emma (Debra Winger), in Terms of Endearment, has an incurable cancer.

Never Let Me Go, a novel by Kazuo Ishiguro, has been turned into a film that’s a variation on this theme. The director, Mark Romanek, asserts he was making a love story. In the final scene, the surviving character, Kathy H. (Carey Mulligan), says: “Maybe none of us really understands what we’ve lived through, or feels we’ve had enough time.” Romanek comments: “Since our lives are so short, it makes you change perspective about what’s important.”

The movie trailer (below) has a voice-over that says “Love made them human.” But there’s nothing about the characters that suggests they’re anything less than human. They don’t need a love story for that. The premise of the film is so much more than a character’s brief life and death. (If you haven’t seen the film or read the book, insert spoiler alert here.)

Romanek: “I wasn’t making a sci-fi”

The story takes place in the recent past, but Ishiguro has reimagined a few things. Medical breakthroughs have increased the average lifespan to 100 years, creating a huge demand for body parts that can be transplanted from the young and healthy. A segment of the population – their parentage only vaguely alluded to – has been designated from birth to become organ donors.

The reality of the donors’ lives – the truncated future they face – is revealed only gradually to them (and to the viewer) as they mature from child to adult. The film is so visually and acoustically lush – and the plot so concentrated on the love story – that one can easily fail to register moral repulsion at the premise. That would be a lost opportunity in the face of current organ shortages, rationing (kidneys for the young, not the old), and – more important – the immorality of exploitation.

Never let me go
The donors as children at their boarding school, Hailsham
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From MD to MBA: The business of primary care

Business of primary care physicianYou could argue that medicine was never meant to become a for-profit business the way selling cars, cosmetics, and fast food are businesses. Among the differences between being a patient and being a consumer of non-medical goods and services:

  • There’s an asymmetry in the knowledge available to patients and doctors – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.
  • Patients can’t predict when they’ll need medical care and often seek care when their health is threatened and when decisions must be made quickly.
  • It’s the supplier – the doctor – who determines what the patient needs.
  • There’s an ethic that assumes doctors will not sacrifice the medical needs of a patient to make a profit.
  • There’s a very steep entry cost to becoming a doctor.
  • The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.
  • What’s at stake in health care – the consequences of making a mistake – is death and disability, not simply a case of buyer’s remorse.

And yet, in the United States, health care has become a for-profit business. The story of how this happened is complex, but decisive elements include the advent of Medicaid and Medicare in 1966 and the widespread availability of employer-sponsored health insurance, which got a boost during the wage freeze of World War II. Once patients no longer needed to know the true cost of health care, business interests were free to create what Dr. Arnold Relman called the “medical-industrial complex.”

Regardless of how and why it happened, we now accept that medicine in the US is a profit-generating business, where many segments of the “industry” aim to reward investors, not patients. As a result, health care has become too expensive for many patients, for employers, and for the government. Everyone agrees that costs are out of control, but – with so many competing economic interests — the solution is extremely elusive.

Doctors caught in the middle

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Even dictators need a facelift

Muammar GaddafiPopular uprisings in the Middle East and North Africa are happening in countries with youthful populations. The percentages of residents under age 25 are, in descending order:

  • 55.3% in Syria
  • 52.3% in Egypt
  • 50.8% in Saudi Arabia
  • 47.4% in Libya
  • 43.9% in Bahrain
  • 42.1% in Tunisia.

(The percentage in the US is 34%.) The inability of these countries to employ so many young people, including the college educated, contributes to dissatisfaction and unrest.

It’s not surprising then that Colonel Muammar Gaddafi of Libya would want to maintain a youthful appearance. His Brazilian plastic surgeon, Dr. Liacyr Ribeiro, has just released the details. Ribeiro – who has also performed cosmetic surgery on Italian Prime Minister Silvio Berlusconi — told a Brazillian weekly that he operated on Gaddafi in 1995. According to Ribeiro:

He [Gaddafi] said he had been in power for several years and that he didn’t want young people to see him as old.

What about doctor/patient confidentiality, Dr. Ribeiro? The surgeon decided to reveal Gaddafi’s secret in order to “contribute to understanding this historic figure around whom there is much speculation but little information.”

The surgery removed fat from Gaddafi’s abdomen and injected it into his cheeks to remove wrinkles. The Libyan ruler also received surgery on his eyelids (presumably blepharoplasty), and a scar on the right side of his forehead received attention. Dr. Ribeiro was accompanied on his trip to Libya by a Brazilian colleague, Fabio Nakkash, a specialist in hair implants. Read more


Daylight saving time and heart attacks

Congress passes daylight savings bill1.6 billion people – almost a quarter of the world’s population – observe the biannual shifts between standard and daylight saving time. Does the loss of an hour’s sleep in the spring affect their health? According to a study published in The New England Journal of Medicine, there’s a statistically significant increase in the number of heart attacks (myocardial infarctions) in the week after we shift to daylight saving time.

Researchers in Sweden extracted statistics from 20 years worth of data on heart attacks. They compared the incidence of heart attacks during each day of the week after we change the clocks (both spring and fall) with the number of heart attacks two weeks prior to and two weeks after the time change.

There are always more heart attacks on Mondays, presumably connected to the stress of going back to work. But the number of Monday heart attacks was significantly lower following an extra hour of sleep in the fall. In fact, except for Fridays, the number of heart attacks was lower for the rest of the week. Following the loss of an hour’s sleep in the spring, heart attacks were up for the entire week, and the increase was especially significant on Tuesday.

Here’s the data displayed graphically.

Monday heart attacks and sleeping in on the weekend

These findings, of course, do not mean that losing an hour’s sleep causes a heart attack, but they do suggest that individuals who are vulnerable to heart problems might want to make the transition to daylight savings time gradual rather than abrupt. Read more


JAMA announces new editor-in-chief

The Journal of the American Medical AssociationThe American Medical Association (AMA) was founded in 1847, a time of significant change in the practice of medicine and of intense competition among practitioners. It began publishing its peer-reviewed medical journal, The Journal of the American Medical Association or JAMA in 1883. The AMA has just named a new editor-in-chief for that journal, Howard C. Bauchner, a pediatrician from Boston University School of Medicine.

The two medical journals in the US that cover general medicine — as opposed to specialties — are JAMA and The New England Journal of Medicine (NEJM, founded in 1812). Both have their strong points. JAMA preserves the humanistic tradition of medicine. Each issue includes poetry, a personal essay, book reviews, and artwork on the cover that’s thoughtfully discussed.

It’s much more stodgy than NEJM, however, at least in my opinion. During the presidential election and then during the debate over health care reform, NEJM published timely commentaries on the issues and made them available online to non-subscribers. It continues to cover topics such as the legal challenges to the health care bill. Not only does JAMA give less space to these issues. Articles in JAMA are not available online without a subscription ($165 for 48 issues).

Reaching the general public in an online world

That may change with the new editor-in-chief. Dr. Rita Redberg, editor-in-chief of the Archives of Internal Medicine (also published by the AMA) told Reuters that JAMA faces the same issues that confront newspapers and magazines these days: “how to live and flourish in this online world.” Read more


The tipping point for motor car casualties

From The Journal of the American Medical Association one hundred years ago:

An alarming increase in the number of street accidents from the recent development of motor traffic is shown by the report issued by the Highways Protection League. In 1905, thirty-five persons were killed and 1,557 injured by accidents due to motor traffic, while 118 were killed and 6,323 injured by horse traffic. In 1909, 163 persons were killed and 6,579 were injured by motor traffic, while 123 were killed and 5,589 were injured by horse traffic.

Horse carriage traffic Easter parade
Easter Parade on Fifth Avenue in 1900. There are at least two motor cars.
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History of patient modesty part 2: Convincing patients to disrobe

Pelvic exam patient modestyIn part one of this post I explained how a new anatomical understanding of disease in the 19th century changed the practice of medicine. Prior to this insight, there was no need to expose the naked body to observation or to touch parts of the body that were normally clothed. In order to apply the anatomical theory of disease, doctors needed to discover what was happening inside the body. This required a new type of physical exam, with much greater exposure and invasion of the body. The new exam was an abrupt and significant change in the tradition of patient privacy and modesty.

Making patients blush

Doctors welcomed both the new understanding of disease and new techniques, such as the stethoscope, that gave them useful information about the interior of the body. Understanding and technique alone did nothing to improve the ability to treat disease, by the way. That came much later. What doctors could do was provide a better prognosis, thus avoiding futile and painful treatment of the terminally ill.

How did patients react to this change in medical practice? Unfortunately, we have very little direct information. Most of the evidence we have comes from doctors, not patients. Doctors tend not to record the routine and taken-for-granted nature of a patient encounter. The private diaries of patients undoubtedly recorded reactions to the more invasive physical exam, but historians of medicine have typically been more interested in uncovering evidence of new medical discoveries than in noting patient experiences.

There is every reason to believe that women found the new physical exam deeply embarrassing. For example, a woman’s diary entry from 1803 reads: “Doctor Williams called and made me undergo a blushing examination.” In 1881, Conan Doyle recorded that a female patient would not let him examine her chest. “Young doctors take such liberties, you know my dear,” she told him.

The indirect evidence we have comes from efforts of the medical profession to convince patients that the new physical exam was necessary and proper. This took two forms: Emphasizing the professionalism of doctors and arguing for the scientific nature of medicine. These 19th century changes in the image of medicine contain the seeds of a new relationship between doctor and patient. They led to a style of medical practice today that increases rather than eases patient concerns about privacy and modesty. Read more


Why are there so many cosmetic surgeons?

Cosmetic surgery Dr. 90210Well, one reason is that primary care physicians are being financially squeezed out of practicing their profession. There’s a good post at KevinMD on how physicians are responding, along with an acknowledgment of this sad truth in the comments. The post is called “Primary care physicians are rebelling against the system.”

Here’s one comment that explains why more doctors are doing cosmetic surgery:

Great article, I agree this is a quiet and insidious rebellion. I found myself dropping one insurance after another, adding more and more cash based ancillaries, until my practice is now 99% cosmetic (botox, laser, etc.) and 1% internal medicine. My next decision is whether to bother spending the time and money to recertify in internal medicine this year. I probably will not. Sad situation for medicine in America, but the reality for most of us.

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What the Internet does to the mind and self

Internet addictionOne of the best things I’ve read on the subject of what the Internet does to our mental processing and social interactions is Adam Gopnik’s The information, How the Internet gets inside us. It was published in The New Yorker and is currently not behind a pay-wall.

Gopnik discusses the work of a number of writers, including the books Cognitive Surplus, Is the Internet Changing the Way You Think?, The Shallows, Hamlet’s BlackBerry, Alone Together, and Too Much to Know. He divides the thinking of these writers into three categories: Never-Better, Better-Never, and Ever-Waser.

The Never-Betters believe that we’re on the brink of a new utopia, where information will be free and democratic, news will be made from the bottom up, love will reign, and cookies will bake themselves. The Better-Nevers think that we would have been better off if the whole thing had never happened, that the world that is coming to an end is superior to the one that is taking its place, and that, at a minimum, books and magazines create private space for minds in ways that twenty-second bursts of information don’t. The Ever-Wasers insist that at any moment in modernity something like this is going on, and that a new way of organizing data and connecting users is always thrilling to some and chilling to others—that something like this is going on is exactly what makes it a modern moment.

Gopnik’s writing is inspired, as in the end of this passage:

[T]he Ever Wasers smile condescendingly at the Better-Nevers and say, “Of course, some new machine is always ruining everything. We’ve all been here before.” But the Better-Nevers can say, in return, “What if the Internet is actually doing it?” The hypochondriac frets about this bump or that suspicious freckle and we laugh—but sooner or later one small bump, one jagged-edge freckle, will be the thing for certain. Worlds really do decline. “Oh, they always say that about the barbarians, but every generation has its barbarians, and every generation assimilates them,” one Roman reassured another when the Vandals were at the gates, and next thing you knew there wasn’t a hot bath or a good book for another thousand years.

I found this next observation insightful. It relates to the offensive behavior so common on the Internet. Read more


Links: Implants & cancer/Ageism & healthism/Psychiatry/Climate change/War/Inequality

Breast implants and cancerWhen Is Breast Cancer Not “Cancer”? When You’re Funded by Breast-Implant Makers (Bnet)
Plastic surgery trade groups advised doctors on what to tell women worried by new link between breast implants and anaplastic large cell lymphoma (ALCL). Say it’s a “condition,” not cancer.

It Gets Worse (NYT)
Robert Crawford’s healthism is alive and well. Review of Susan Jacoby’s Never Say Die: The Myth and Marketing of the New Old Age. Jacoby sees a new ageism that doesn’t just stigmatize old people for their years, but blames them for physical ills that no lifestyle adjustments or medicine could have prevented. Read more


Cosmetic surgery for your pet

Neuticals to replace testicles in neutered dogsMy vet said my dog wont [sic] know that he’s missing anything. Is that true?
People know their beloved pet. Their pet can tell them when they are hungry, want to play, don’t feel well, hide when approaching the vet’s office or will get excited when driving by or going to the park – why wouldn’t the pet know a familiar body part is missing? Would he know if his foot was cut off? Of course he would – its [sic] only common sense.

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Links: Vampire facelifts/Happiness/Neuroenhancers/Climate change/…

Vampire facelifts‘Vampire Face-Lifts’: Smooth at First Bite (NYT)
Plumping out nasiolabial folds with your own blood platelets. Not tested. Not FDA approved. “This is another gimmick that people are using to make themselves stand out on the Internet in a real dog-eat-dog part of medicine.”

The Corporate Pursuit of Happiness (Fast Company)
Stanford business school teaches students the virtues of marketing products with the promise of happiness. Happiness is just “another commodity deployed to sell something.”
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History of patient modesty part 1: How bodily exposure went from unacceptable to required

Patient in open-back gownThe need to reveal private and intimate parts of our bodies is a routine occurrence in medical practice today. Though it may offend our modesty, we take it for granted that the embarrassing moments of a colonoscopy, a Pap test, or a prostate exam are necessary for our health. Has it always been so? Have doctors always expected patients to disrobe? Have young male technicians always exposed the chests of female patients in need of a routine EKG? Have patients always been willing to allow doctors and their staff to view parts of the body normally seen by only the most intimate of partners? The answer is a resounding no. Read more