Monthly Archives: April 2011

Patient safety and corporate profits

Patient safety firstThe Supreme Court recently decided, in the case of Bruesewitz v. Wyeth, that Wyeth Pharmaceuticals could not be held liable for injury to the Bruesewitz’ daughter (following a vaccination) because Wyeth was protected by the National Childhood Vaccine Injury Act.

I was reading an article on this controversial issue in the NEJM when I was brought up short by the following sentence: (emphasis added)

Litigation such as the Bruesewitzes’ can help the FDA in its oversight function by revealing important and previously unknown information about product-related risks, especially during the postapproval period, and by deterring manufacturers from acting irresponsibly and engaging in business tactics aimed at increasing product sales at the expense of patient safety.

Now, I know corporations sometimes put profits before consumer safety (I once owned a Ford Pinto). And I know that, starting in the late 20th century, medicine became driven by corporate profits rather than traditional medical professionalism. (This is not to say that medical professionalism has disappeared. Merely that there has been a shift in values.) But it still troubles me to read a casual reference to profits being more important than patient safety. It’s an acknowledgment that such practices are an everyday occurrence, imperfectly dealt with by regulations and legislation, and are not a matter of what’s ethically right or wrong.

For-profit medicine drives increased use and costs

I believe medicine – which deals with life, death, pain, suffering, and disability – is not just another business like selling consumer goods. (See From MD to MBA: The business of primary care.) Other industries –automobiles, airlines — may need to consider life-threatening safety issues. But the primary focus of those industries is to sell a particular product or service, not to keep people alive and well. Read more

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The emotional burdens of patient care

The emotional pain of doctorsIn a recent issue of JAMA, Dr. Michael Stillman writes about the emotional pain of delivering bad news to a patient he has known through the best and worst of times.

Earlier in my career, delivering bad news seemed like a technical challenge. I would methodically seat patients and their family members facing one another, pause for a moment after reporting that there was an “unexpected finding” on a scan, and search for an opportunity to say that I “wish things were different” and that I would be there to help until the very end. This routine, though slightly stiff, helped anchor me in whatever emotional swell was to come.

Now, however, these conversations just make me sad. …

Patients suffer and die, and a physician must find the balance being feeling her own humanity and maintaining the professional stance that allows her to move on. There are no simple guidelines, although Dr. Stillman suggests remembering the good times his patients have had and focusing on those moments.

Emotional hazards of practicing medicine

I wonder just how aware patients are of the psychological burden of being a doctor. Dr. Stillman writes:

I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many “civilians” would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.

How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction? …

There is simply no way to be a good but distant physician.

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Guest post: A sound mind in a disintegrating body

Mens sana in corpore sanoIn an attempt to balance my very serious attitude towards the subject of healthism – the idea that individuals should be held personally responsible for their health; an idea promoted at a time of rising health care costs in the “Great Society” seventies, appealing to residual American sentiments of self-reliance and individualism, conveniently distracting attention from social and environmental determinants of health …

I could go on, but as I was saying, in an attempt to provide balance, I offer this guest post by Kate Gilderdale, a writer who valiantly resists healthism propaganda and whose approach to any subject is always liberally laced with humor. Kate blogs at The Jaundiced View (where this post first appeared), and I highly recommend a daily visit (laughter being the best medicine and all).

Mens sana in corpore sano is today’s mantra for many people, but a lot of us only manage to fulfil half the equation at best.

In order to attain the corpore sano required by today’s fanatical health and hotness community you have to devote two or three hours a day to honing the body beautiful so that it contains no lumps, bra overhang or bits that have to be sucked in when you walk past a mirror. This involves lunges, squats, curls, lat pulldowns, pushups, bench presses and eventual death from exhaustion unless you are of that rare elite who are truly in The Zone.

The rest of us get by by avoiding spandex and investing in Spanx, whilst using those three hours not spent at the gym to fill our brains with stuff that we hope will make us appear erudite without being unforgivably elitist.

When it comes to physical exertion, Joan Rivers said it best. “I don’t exercise. If God wanted me to bend over, he would have put diamonds on the floor.”

Any deviations from Americanized spelling (“fulfil”) may be attributed to Kate’s proper British education.

Kitten with barbell

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There’s more to life than the pursuit of health

Doctor with stethoscopeA few quotations on attitudes towards the pursuit health:

And do you not hold it disgraceful to require medical aid, unless it be for a wound, or an attack of illness incidental to the time of year, — to require it, I mean, owing to our laziness, and the life we lead, and to get ourselves so stuffed with humours and wind, like quagmires, so to compel the clever sons of Asclepius to call disease by such names as flatulence and catarrh.

– Plato, The Republic, 380 BC

Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the flattening out of human experience. I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living.

– Ivan Illich, Health as One’s Own Responsibility – No, Thank You!, (PDF) 1990

After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.

– Lewis E. Foxhall, M.D., The Tyranny of Health, 1994

Thinking that we can make death, illness, or privation easier to bear by preparing for them day and night is a sure way to poison our lives, to spoil the slightest pleasure by imagining its end.

– Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy, 2000

In the past, health was usually understood as the normal state of affairs, and taken for granted as [a] feature of life largely beyond the control of the person or the society. The proliferation of reflexive techniques which promise actually to improve one’s health has transformed the very meaning of the term ‘health’. The advent of such an immense range of popular ‘health-enhancement’ or ‘self-improvement’ techniques has meant that health is now seen more as a positive goal to be achieved rather than the normal state of a person without illness.

– Christopher Ziguras, Self-care: Embodiment, Personal Autonomy and the Shaping of Health Consciousness, 2004 (emphasis in the original)

There have always been individuals willing to point out that the constant pursuit of health is not the be-all-and-end-all of life. This eminently reasonable attitude, however, is increasingly rare among both doctors and patients. We have been educated to believe – primarily by what Ziguras calls “commodified and mediated health advice,” but also by the medical and public health professions – that feeling good and assuming we’re healthy could all too easily be a delusion. How can we be certain some fatal disease doesn’t lurk in the unreliable interior of the body?

We choose to pursue health or to pursue disease

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From healthism to overdiagnosis

H Gilbert Welch OverdiagnosedIn his new book, Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch enumerates how the cutoff points that determine whether a patient should be treated for a disease – diseases such as high blood pressure, diabetes, osteoporosis — have been creeping inexorably lower over the years.

Take diabetes. The cutoff point used to be a fasting blood sugar level of greater than 140. In 1997, the number was lowered to 126. This immediately created 1.7 million new diabetes patients.

In a highly publicized study that began in 2003, one group of patients with type 2 diabetes received “intensive therapy” to make their blood sugar “normal.” The control group – the other half of over 10,000 patients – received treatment to lower their blood sugar, but not to the new normal level. The trial was stopped in 2008 when it became clear that there was about a 25% increased risk of dying for the intensive therapy group.

Dr. Welch’s comment on this: “If it’s not good to make diabetics have near normal blood sugars, then it’s not good to label those with near normal blood sugar diabetics. Why? Because doctors will treat them. People with mild blood sugar elevations are the least likely to gain from treatment – and arguably the most likely to be harmed.”

High blood pressure (hypertension) was also redefined in 1997. Instead of the cutoff points being 160 systolic over 100 diastolic, the numbers dropped to 140 over 90. This created 13.5 million new patients.

The definition of high cholesterol (hyperlipidemia) changed following a 1998 clinical trial. The definition of “abnormal” total cholesterol fell from 240 to 200. This created 42.6 million new patients, an increase of 86% over the previous number of patients.

It’s the same with the definition of osteoporosis. A bone mineral density X-ray produces a T score. It’s a way to compare an individual’s bone density to what’s considered “normal.” For women, normal is defined as the bone density of an average white woman aged 20 to 29 (a T score of zero.) If your T score is less than zero, it’s assumed you have an increased risk of fracture.

In 2003 the definition of osteoporosis changed from having a T score less than -2.5 to less than -2.0 (i.e., closer to normal). This created 6.8 million new patients, an 85% increase in those now eligible for treatment with drugs that turned out to have significant side effects – as virtually all drugs do. Read more

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Megan McArdle: Why are there no new antibiotics?

Approached by the Antibiotic ResistanceMegan McArdle spoke on antibiotic resistance at the Economic Bloggers Forum yesterday. McArdle is a journalists who writes for the The Atlantic, primarily on economics, finance, and government policy.

Her presentation, “Antibiotics: The world’s most broken market,” was interesting. Notice (in the video below) that she never questions the market-driven premise of pharmaceuticals – and by extension, the for-profit nature of medicine and health care. That’s not her politica/economic persuasion.

Here’s an excerpt from the talk where she discusses the patient/doctor end of the antibiotic resistance problem. What she says is already quite familiar. What’s interesting is her frank description of how doctors behave and how patients in turn regard doctors.

People love to get antibiotics. They go to their doctor and they’re like, “My kid has an earache. Give him antibiotics.” Now the doctor could say, “No we shouldn’t. We should wait and find out if it’s bacterial. Almost all ear infections are bacterial. Due to throat infections. Due to almost anything you can name. But to do that, the doctor has to sit down and deal with an angry patient who may pick up and leave their practice.

If you look at the way that the current insurance industry is organized, right, what do doctors need? They need volume. They get paid by volume. Reimbursements for primary care physicians, who are where a lot – by no means all – but where a lot these vaccines go through, are very low. They’ve made up for that, and you all know this, right. You go into your doctor, and the minute you start talking, your doctor exudes an almost visible — like — desire for you to leave now. So that they can go on to the next patient. So what do they do? They give antibiotics to patients to shut them up. It takes too much time to explain and the risk of losing the patient is high.

Where have all the unattractive people gone?

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Joseph Stiglitz on inequality

Income inequality waiting onlineGreat essay by Joseph Stiglitz on income inequality: “Of the 1%, by the 1%, for the 1%” in Vanity Fair.

As we gaze out at the popular fervor in the streets [of the Middle East/North Africa], one question to ask ourselves is this: When will it come to America? In important ways, our own country has become like one of these distant, troubled places.

Alexis de Tocqueville once described what he saw as a chief part of the peculiar genius of American society—something he called “self-interest properly understood.” The last two words were the key. Everyone possesses self-interest in a narrow sense: I want what’s good for me right now! Self-interest “properly understood” is different. It means appreciating that paying attention to everyone else’s self-interest—in other words, the common welfare—is in fact a precondition for one’s own ultimate well-being. Tocqueville was not suggesting that there was anything noble or idealistic about this outlook—in fact, he was suggesting the opposite. It was a mark of American pragmatism. Those canny Americans understood a basic fact: looking out for the other guy isn’t just good for the soul—it’s good for business.

The top 1 percent have the best houses, the best educations, the best doctors, and the best lifestyles, but there is one thing that money doesn’t seem to have bought: an understanding that their fate is bound up with how the other 99 percent live. Throughout history, this is something that the top 1 percent eventually do learn. Too late.

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