Tag Archives: clinical medicine

Academic medical centers: Education or profits?

ludmerer-let-me-heal

The quality of health care depends on many things, but certainly medical education is uniquely significant. Following four years of medical school, the additional years of internship, residency, and fellowship are not simply a time for acquiring the latest insights into the nature and treatment of disease. This is when fledgling doctors imbibe the values and priorities of the medical profession from the attending physicians who mentor them. If attendings have no time to mentor the doctors they are presumably training, the quality of doctors who emerge from such a system will suffer. And if the priority of an academic medical center is to increase profits rather than care for patients, patients will also suffer, first at the hospitals associated with these centers and later as patients of the doctors who trained there. The decline in the residency system for training doctors is the subject of Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.

From mentorship to profits

Sir William Osler established his ideal of medical training at Johns Hopkins Hospital in the 1890s. The guiding principle was that doctors should learn to care for patients under the close supervision of highly experienced attending physicians. Right up to WWII, the highest priority of teaching hospitals remained education. Faculty members formed intense mentorships with their students, often lasting a lifetime. Lara Goitein, in an essay/review of Let Me Heal, writes: Read more

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The Journal of Medicine & Philosophy – June 2014

cognitive-enhancement

The theme of the June issue of Medicine & Philosophy is disagreements among bioethicists. This is an interesting topic in its own right (see the extract from the Introduction to the issue below), plus there are a few articles that especially appealed to me. The discussion of cognitive enhancement appears to argue for a more tolerant attitude toward enhancement drugs based on an attitude of humility, plus toleration and transparency. There’s also an article that points out how we assume the art of clinical medicine is an innate skill and that, as a result, we fail to teach it.

Note that nothing is this journal is open access (and also that I have added the emphasis).

Introduction

Bioethics and Disagreement: Organ Markets, Abortion, Cognitive Enhancement, Double Effect, and Other Key Issues in Bioethics

Victor Saenz

I. BIOETHICS AND DISAGREEMENT

Bioethics was born in the 20th century out of an attempt to cope with rapidly and radically developing medical technologies, especially as they arose around the time of the Second World War. Albert R. Jonsen, one of the founders of bioethics, writes in reminiscence:

New techniques, from antibiotics to transplanted and artificial organs, genetic discoveries, and reproductive manipulations, together with the research that engendered them, presented the public, scientists, doctors, and politicians with questions which had never before been asked. (Jonsen, 2000, 115; cf. Jonsen, 1998)

But more importantly, bioethics arose as well due to major cultural changes that marginalized previous approaches to moral issues in health care and that brought into question medical ethics as an enterprise grounded in the medical profession. Read more

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The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

general-health-checkups

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling. Read more

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The misuse of health statistics by politicians

Rudolph Giuliani prostate cancer[This post contains links to the New York Times. If you position your mouse over a link, you can view the destination URL at the bottom of your browser.]

When former New York City mayor Rudy Giuliani was seeking the Republican presidential nomination in 2007, he used to give a campaign speech that referred to prostate cancer and health care. His sound bites were turned into a radio commercial and included the following:

I had prostate cancer five, six years ago. My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.

What’s wrong with this picture? Several things.

The numbers themselves – the 82 and 44 percent — were incorrect. Chances of survival are typically stated as the prospect of living another five years. According to the National Cancer Institute, the five-year survival rate for prostate cancer in the US is 98.4%. For England (according to the United Kingdom’s Office of National Statistics), the number is 74.4%.

Where did the lowly 44% for England come from? Giuliani’s health care adviser started with the number of people who have prostate cancer and the number who die (called incidence and mortality rates): how many people have the disease in a given year and how many die from the disease in that year. From those numbers he came up with a five-year survival rate. This is not possible. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” according to the Commonwealth Fund.

Comparing apples to oranges

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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

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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

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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

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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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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

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History of patient modesty part 1: How bodily exposure went from unacceptable to required

Patient in open-back gownEven doctors can be embarrassed when it comes time to expose their private parts to medical personnel. In an essay that appeared in The Journal of the American Medical Association, a doctor describes her discomfort as she arrives for a colonoscopy appointment.

[A]s a person not exactly looking forward to the morning’s adventure, I found the receptionist’s demeanor and lack of eye contact wrapped me tight within a cold, impersonal cocoon. I was a subject. Though I hadn’t shared my sentiments with anyone, I felt both vulnerable and completely sheepish about having a very human reaction to such a common procedure. But this was my bottom and I was not happy to share it with others. Here to be exposed and invaded, in truth I was embarrassed and sought compassion. As anyone else would, I wanted to know that my discomfort, self-consciousness, and loss of control were understood. Instead, she exuded efficiency and delivered transparent quality assurance and poise.

The 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? Read more

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The downside of overly aggressive cancer screening

False positive mammogramOne more follow-up on overly aggressive cancer screening (see Screening for cancer and overdiagnosis and Creating an epidemic of cancer among the healthy). A recent study found that false-positive results of breast cancer screening create anxiety and undermine the patient’s quality of life for up to a year.

Here’s an excerpt from BusinessWeek:

“Common sense tells us that early detection of breast cancer is good, and most screening programs have been successful in reducing breast cancer deaths,” lead author Dr. Lideke van der Steeg, of the department of surgery at St. Elisabeth Hospital in Tilburg, said in a journal news release.

“However, while some women truly benefit from early detection, others experience harm and unnecessary anxiety. The women who received false-positives in our study experienced a significant reduction in their quality of life, especially if they were prone to anxiety, and the effects of this lasted at least a year.”

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Creating an epidemic of cancer among the healthy

Siddhartha Mukherjee Tthe emperor of all maladiesFollowing up on Dr. H. Gilbert Welch’s comments on the new blood test for cancer – that overdiagnosis may lead to an epidemic of individuals who mistakenly believe they have cancer – here’s a description of the climate that’s created when we try to scare people into believing they have cancer. It’s from a review of The Emperor of All Maladies, a new book on the history of cancer by Siddhartha Mukherjee.

Writing in The New Yorker, the author of the article, Steve Shapin, explains optimism surrounding the drug Gleevec, a new type of cancer drug that targets a known cancer gene. Gleevec has been quite successful in the treatment of leukemia. (emphasis added) Read more

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Screening for cancer and overdiagnosis

Screening for cancer: OverdiagnosisEarlier this month scientists announced a test that can detect a single cancer cell in a blood sample. Although some news reports were realistic – BusinessWeek commented that “researchers still aren’t sure what these circulating tumor cells (CTCs) actually mean” – most greeted the news as a revolution in the fight against cancer, promising early, non-invasive detection.

Dr. H Gilbert Welch offered a more sober opinion. Welch is the author of Should I Be Tested for Cancer?: Maybe Not and Here’s Why. While it’s commonly assumed that screening saves lives and that more screening is always better, Welch’s book helps patients (and the medical profession) understand that the implications of cancer screening are more complex.

More medical care leads to more screening

As Welch points out, medical care is a much more prominent part of our lives today than it was in the past. There are a number of reasons for this. Read more

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The physical exam and society’s regard for physicians: A history

Laennec examines patient with stethoscopeThe physical exam – looking into the eyes and throat, taking the blood pressure, sounding the chest – is part of the process of medical diagnosis. It’s one way a physician attempts to determine the cause of a patient’s complaint.

In recent times, doctors have asked themselves whether the physical exam is becoming a lost art. It’s been replaced by an array of laboratory tests and high tech machines that presumably provide greater accuracy than the eyes, ears, and touch of a mere human being. (Smell, of course, also provides clues, and device makers are inventing medical gadgets that detect scents. Doctors no longer taste urine for sugar, as they did from antiquity into the 19th century, nor do they taste perspiration to see if it’s sweet, salty, or acrid.)

The reasons for the current decline of the physical exam are many. Hospital stays used to be much longer, so students had more time to learn from patients. The modern resident’s work week is officially limited, so there’s less time to spend at the bedside. Office visits are now much shorter, and a hands-on exam uses precious time. Read more

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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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Health Culture Daily Dose #18

Baby ducks

Source: Wunderground

When did we start calling the whole day before Christmas “Christmas Eve?” I thought Christmas Eve was the evening before Christmas. But no. Senators voted on health care reform at 1:00 AM on Thursday December 24th. To me, that’s still Wednesday night, but it was widely reported as happening on Christmas Eve. Perhaps publishers want to save ink. Or we live in such fast times that it takes too long to say “The day before Christmas.”
Anyway, here’s a flock of interesting stories I’ve come across recently.

Aging, end-of-life, and death

The Breadth of Hope, Selling Hope, and More on Quelling Thanatophobia, (Pallimed: A Hospice & Palliative Medicine Blog)
One unspoken message behind the “sell hope for a cure” ads is “we will not only cure your cancer so that you can avoid death, but we’ll also make it so it’s a non-issue in your life so that you can return to the way things were before. It’ll kind of be like getting your car’s air conditioner recharged.”

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Health Culture Daily Dose #17

Additional stories related to health. Categories include: More articles on Health Care Reform, History of Medicine, Medical Journalism, Medical Technology, Medical News, Pharmaceuticals, Pop Culture, Social Media and the Internet, and The So-Called Obesity “Epidemic.”

HEALTH CARE REFORM

A ‘Common Sense’ American Health Reform Plan (The New York Times – Uwe Reinhardt)
After studying this nation’s perpetual “national conversation” on health reform for over three decades now, I am firmly convinced that any health reform that is the product of logical cerebral processes automatically misjudges what Americans appear to see as “simple common sense” in health care.
The Experts vs. The Public on Health Reform (Kaiser Family Foundation)
In repeated Kaiser polls, we see a divide between what experts believe and what the public believes about some of the key issues in health reform. There is a wide gulf on basic beliefs about what is behind the problems in the health care system and key elements of reform.

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Get thee glass eyes

Telescope in the eyeMy mother was decidedly vain her whole life. She’d been exceptionally good looking in her youth, which made it especially difficult to accept the slow physical decay of aging.

Surely it must be easier in our culture to accept the wrinkles, sags and bulges that come with advancing age if one has never thought of oneself as particularly attractive. Or if one has cared little about appearances. Admittedly, this is an increasingly rare point of view in contemporary Western societies.

My mother slept in her wig. She didn’t want anyone to see her bald spot, in case she died in her sleep. The bald spot was caused by the wig, which she wore because her hair had turned gray.

Scientists have not yet discovered that vanity is transmitted through the genes. Macular degeneration, on the other hand, is genetically transmitted. When my mother died of a heart attack at age 91, the doctor told her children she was about to be declared legally blind. She had macular degeneration and had never mentioned it to anyone.
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Will health care reform stop the rising cost of health care?

healthcare-costsAs we get into the nitty-gritty of health care reform, critcs from both left and right are asking whether current proposals will reduce costs. Here we have a historic opportunity to make major changes in health care, but it appears no one is willing to address the problem of escalating costs.

The public insurance option might reduce the cost of insurance by competing with for-profit insurers. But this doesn’t reduce the number of unnecessary procedures. As David Brooks points out in a NY Times column, the public option, as it’s currently formulated, would have no effect on the fundamental incentives that lead to higher costs. Read more

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HRT shrinks women's brains? What's wrong with this picture?

There was a widely reported story today about hormone replacement therapy (HRT) and a decrease in the size of women’s brains. The headlines were predictably but needlessly sensational. In fact, the study did not measure a decrease in the brain size of any individual woman.

Amsel Incredible shrinking woman

Source: Richard Amsel, The Movie Posters

First, the headlines. There were 27 stories listed when I checked Google news this afternoon. 19 of these (70 percent) used the word “shrink,” definitely a frightening choice of words when talking about one’s brain. Five stories (18.5 percent) used a less provocative descriptor: brain-tissue loss… reduced brain size… reduction in brain volume… affects brain mass… loss of brain tissue… You get the idea. Three stories (11 percent) elected not to refer to brain size in the headline. But two of those talked about brain “shrinkage” in the first paragraph, another waited until the third. So all of these stories led you to believe that the brains of women on HRT got smaller.
The rush of stories was based on two papers published in the January 13 issue of Neurology. The primary paper analyzed brain scans for abnormal tissue (lesions) in blood vessels. The second paper analyzed MRIs of the brain and reported:

Much to our surprise, we found a small but significant decrease in the hippocampal and frontal volumes, and a nonsignificant trend towards reduced total brain volume in women who had been randomized to hormone therapy.

I haven’t had an opportunity to see the original study, but none of the quotations I have seen use the word “shrink.”

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The first clinical trial: Eat your vegetables

The first ‘clinical’ trial may have been 2600 years ago. According to the Book of Daniel, King Nebuchadnezzar held Israelites in captivity in Babylon after the siege of Jerusalem in 597 BC. The king selected an elite group of prisoners to serve him in the future. They were to receive the same “choice” food and wine as the king.

Now Daniel determined not to contaminate himself by touching the food and wine assigned to him by the king, and he begged the master of the eunuchs not to make him do so. … [T]he master … said to him, ‘I am afraid of my lord the king: he has assigned you your food and drink, and if he sees you looking dejected, unlike the other young men of your own age, it will cost me my head.’ Then Daniel said to the guard … ‘Submit us to this test for ten days. Give us only vegetables to eat and water to drink; then compare our looks with those of the young men who have lived on the food assigned by the king, and be guided in your treatment of us by what you see.’ The guard … tested them for ten days. At the end of ten days they looked healthier and were better nourished than all the young men who had lived on the food assigned them by the king. Daniel 1: 8-16

This was not a blind, randomized trial, so we can’t rule out the placebo effect. Also, there were only four subjects. But evidently the idea of a test group and a control group has been around a long time.

The word for ‘vegetable’ in this passage is sometimes translated as ‘pulse.’ Pulses are things like beans, peas, lentils, and chickpeas. They contain 20 to 25% protein by weight. So Daniel knew a healthy diet when he saw one. An early example of a “healthy lifestyle.”

I came across this story not by reading the Bible, but by reading Ben Goldacre’s Bad Science, an excellent book. It’s not yet available in the US, but you can get a like-new, paperback copy from Amazon (USA) through a third party reseller.

Sources:

(Hover over book titles for more info. Links will open in a separate window or tab.)

Ben Goldacre, Bad Science

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EBM provider Bazian uses Scrubs to make a point

A few more things about Bazian, the company that provides the evidence-based medicine (EBM) analysis used by Behind the Headlines. (Bazian, BTW, is named after the 18th century mathematician Thomas Bayes, as in Bayesian probability.) Those who work at Bazian call themselves evidologists. “Evidology aggregates, filters and synthesizes the entire universe of research about a given question into one odds-based answer.” Hmmm. Well at least they’re the first to admit this sounds grandiose. But they insist it’s not: “If you’re not using evidology then necessarily you are basing decisions on opinion or individual studies, and these routinely turn out to have been wrong.”
Bazian has a colorful, casual, good-natured presentation on their website about EBM and what the company does. (See Sources below.) There’s even a slide of Doctors Kelso and Cox from Scrubs.

Scrubs doctors

Ahh yes, the change in the doctor/patient relationship. That’s a subject for numerous future posts.

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Get your health news here

As promised in the last post, I have a recommendation for a source of health news. It’s a site called Behind the Headlines. It comes from the National Health Service (NHS), the publicly funded health care system of the United Kingdom, and it’s available on the Internet at Behind the Headlines.
The information in Behind the Headlines articles comes from Bazian, a company that provides evidence-based information to publications and healthcare systems. I won’t go into all the pros and cons of evidence-based medicine (EBM) in this post. Just a brief overview, and why it’s useful in analyzing the news. (EBM has a poor reputation in the US because some insurance companies have used it to deny benefits to patients.)

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Are Americans naive about medicine?

There was a follow-up letter to “The Last Well Person” (see previous post) from a doctor in Spain. He pointed out that the “extinction of well people” was anticipated in the 1920s by the French comedy, Knock, by Jules Romains. Dr. Knock purchased the unprofitable practice of a country physician and proceeded to diagnose everyone in the village with an illness. He prescribed cures commensurate with the patient’s income. (This is really quite considerate compared to the reality of bankruptcy caused by medical costs in the US.)

Just as Dr. Meador used the quotation “A well person is a patient who has not been completely worked up,” Dr. Knock was known to say “The healthy are ill people who are unaware they are ill.” Meador’s response to the letter mentions further explanations for the “The Last Well Person” phenomenon: insurance coverage that requires a specific diagnosis even when there is none, disability insurance, worker’s compensation, Medicare, and television advertisements.
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The last well person

last-well-personIn 1994, Dr. C. K. Meador published a now classic, tongue-in-cheek essay called “The Last Well Person.” It appeared in The New England Journal of Medicine and starts with a great anecdote.

A supervising doctor asks a medical resident “What is a well person?” With a straight face — evidently — the resident confidently replies: “A well person is a patient who has not been completely worked up.”

Fortunately, we can recognize the humor in this, but it does give one pause.

Technological advances in diagnostic testing give modern medicine the ability to detect disease. Testing is also used to measure health “markers” that may indicate risk for diseases we do not yet have. Along with this comes an enormous increase in

  • the number of things a healthy individual can worry about
  • a health regimen of lifestyle options that presumably prevent disease
  • the obligation to continually monitor one’s health.

The compulsive pursuit of wellness

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