One epidemic, two problems

Last week, the New York Times reported on the current epidemic of Dengue fever in Key West, FL, so let’s back up a bit and get a larger view of this.

Dengue fever is caused by a virus transmitted by mosquitoes.  It’s the most common arthropod-borne illness in the world, but, like malaria, has been of only limited concern in the U.S. over the last half-century.   The illness is characterized by high fevers, rash, and terrible pain that gives it its nickname: Breakbone Fever.   As unpleasant as it can be, a case of Dengue usually passes and leaves the victim with nothing worse than bad memories.  For a typical American traveler, this can lead to an unpleasant vacation.

But for people who are repeatedly exposed to the virus, it can have much more devastating effects.  Exposure to a different strain of the virus can lead to Dengue hemorrhagic fever (DHF), an frightening illness that is rarely fatal when patients have access to good medical care.  But many areas where Dengue is endemic do not have access to good medical care.  People with DHF have high fevers, but also develop bleeding and vascular leak, causing fluid to accumulate in places it shouldn’t, such as the lungs, and can lead to shock and death.

While Dengue fever is a painful inconvenience to travelers, it can be deadly if it becomes a endemic in an area because of the risk of DHF when re-infected.  This is the primary reason surveillance and prevention are so important.  Which leads to problem number one (asie from the outbreak itself): according to the Times, the CDC is going to be cutting back the Division of Vector Borne Infectious Diseases, which is responsible for important emerging diseases such as Dengue, West Nile Fever, and Lyme disease.

The second problem is also economic, but in more human and less bureaucratic way.  The Times is reporting that residents of Key West, who are dependent on tourism, are reluctant to acknowledge and deal with the epidemic.  About five percent of the Key West population is believed to have been exposed to Dengue, a huge number considering that this part of the U.S. rarely sees the disease.  It is also a popular tourist destination, meaning that travelers can acquire it, and bring it home to their local mosquitoes, potentially leading to its establishment elsewhere.

The worst possible reaction to an epidemic is denial, but reactions in Key West from residents and officials has been disappointing.  One local health official called the CDCs report “alarmist”.  There are active mosquito eradication efforts ongoing, but as we saw with West Nile Fever in other parts of the country, it is possible to inform the public without panicking them.

Prevention of mosquito-borne diseases like West Nile and Dengue requires not only local control of populations, but personal protection.  Minimizing exposed skin, and applying a repellent containing DEET (usually at a concentration 20-30%) can provide protection from bites thereby minimizing the risk of acquiring mosquito-borne diseases.

Scotch Whiskey

I’m not going to lie, folks: today has been pretty horrid.  Around five this morning MrsPal and I found out that our friend had just died.  It wasn’t unexpected, but since when does that matter?  In the poor timing characteristic of real life, MrsPal and PalKid left town today on a long-ago-planned journey, leaving me with an empty house and memories of a good friend in better times.

And tonight my family gathered to remember a cousin who died last summer.  She was a remarkable woman, and her husband and children spoke eloquently and lovingly over drinks and excellent food, as she would have loved.  It gave me a chance to reflect on my cousin’s life, and my friend’s, and to take solace in the company of my parents and sisters, who rarely have the chance to be in the same place at the same time.  I only wish my wife could have been here to share in some of that comfort.

People who want to comfort you often tell you tomorrow is another day and other such nonsense.  People like platitudes.  But they’re right, I suppose.  Tomorrow morning I’ll sit down with my parents and my sister’s family over bagels and lox, and talk about the heat, our summer plans, and how remarkable our children are.

There’s nothing I can write about grief that hasn’t already been written, but since we are all destined to experience it, we all have to find our own way to understand it.  Grief can be a lens, one that magnifies fear and uncertainty, but can also bring into sharper focus that which is important—friendships, successes, failures, loves lost and gained.  We don’t get to choose a life without grief, unless we choose a life alone, or enough like alone that there is no real difference.

Speaking of the internets…

There was an interesting story on Tell Me More yesterday about the various digital divide(s).  African Americans are strongly represented on twitter, accounting for perhaps 25% of twitter users.  Also, minorities tend to make more complete use of mobile technology than whites/Anglos.

I find that fascinating.  Europe and Japan seem to have been ahead of us for a long time on these sorts of uses.  I’d love to find out what underlies these trends.  I have some ideas, but they are unsupported by data as far as I know.  I’d like to see a comparison of white lower income users and minority lower income users as well.

By the way, don’t miss Tell Me More.  It’s a great show.  If you can’t get it on your NPR station, write them and listen to the podcast.

Twenty years, another world

My family has always been quick to embrace new technology.  When my oldest sister went off to college in the early mid-70s, her university was unusual in that it had a computing center and apparently (I was a wee lad at the time) encouraged education in computing.  When I was slightly less wee, my middle school offered a computing class.  We learned to make flow charts and to program in BASIC.  Once we’d written our little programs, we would head over to the teletype machine in the closet in the back of the room, dial up the county mainframe, and if all went well, find out if our programs worked.

Around that time, my folks bought a computer.  I think the first one was an Apple II +, which was roughly shaped like a flattened typewriter on which you could perch a TV.  My parents took computer programming classes at the local community college, and we used the computer to play with programming, and even to do some very basic word processing. (For you young folks, the word processors were characters and markup—there was no WYSIWYG.)

Then the Macintosh came out.  It was beautiful.  And my parents got me one as a graduation present.  Always ahead of the curve, they were (and still are, mostly).  My computer served me and many others through my years in Ann Arbor.  During my time there, typed papers faded away, and computing centers (filled with Macs) opened up in central campus locations.  And one day, while sitting at one of those computing centers with a friend, I was told I could write a letter to a friend of ours overseas—on the computer.  It was called “electronic mail”, and it was instantaneous, and no, it didn’t cost anything.  Remarkable.  Of course our email addresses at the time were rather different as I recall.

This was an exciting time.  In high school we had learned how to use libraries to our advantage, searching card catalogs, reference indexes, and huge books full of citation indexes.   When I got to college, we continued with this system, with a little help form computer terminals that could help us find the huge books that helped us find smaller books and articles.  By the end of college, I’m not sure anyone used a card catalog or any of the heavy tomes, or even knew where they were.

All of that seems rather quaint now.  I can sit here at my computer and search for articles about, for example, direct current cardioversion, or murine models of MDMA tolerance.  Often enough, I can find the full text with citations, and the citations themselves are linked to their sources.

The technical aspects of science blogging aside, I don’t think we could have had science blogs twenty years ago.  There was no way to get up to date information on discoveries, no way to quickly find references, no way to produce a well-referenced post on breaking science news.  Writing a blog post without modern information science would be more like writing a term paper.  And who wants to read a blog that’s only updated a couple of times a year?

I hate orange urine

In recognition of real life and blogospheric insanity, here is a repost from last year.  Try it, you’ll like it.  –PalMD

Urinary tract infections (UTIs) are a very common problem, especially in women. The link provided offers some very good information, but briefly, women’s urethrae (the tube the urine comes out of), are closer to the rectum than those of men (who have a built-in “spacer”). This allows bacteria from the colon to creep over to the urinary tract and cause burning, pelvic pain, frequent urination, etc.

I treat UTIs daily. Most are uncomplicated, but some are quite serious (usually in the elderly and chronically ill). As medical problems go, I love UTIs. When a healthy, young woman comes in with the usual symptoms, a quick test can confirm the diagnosis, and, usually, three days of inexpensive antibiotics fixes it. The patient is happy, I’m happy, everyone’s happy. But then there’s the orange stuff.

A few years back, a medication called “phenazopyridine” became more widely available as an over-the-counter drug. It is marketed to treat the symptoms of UTIs. It turns urine and other body fluids bright orange. This medication is useful for reducing the symptoms of UTIs, but does not cure them. The FDA does mandate certain labeling for the OTC preparations, but I can tell you from experience, the subtlety of this distinction is, well, subtle. Fortunately, you don’t have to rely on my experience. Someone bothered to study the question. Most patients do not realize the difference between treating the symptoms and treating the disease. This leads to delay of treatment, and the infection can become more serious. To add insult to injury, phenazopyridine’s orange pigment interferes with the most common tests we use to diagnose UTIs.

In discussions of medical ethics, the concepts of “paternalism” and “patient autonomy” are often thought of as being in opposition to each other. It is sometimes in the name of autonomy that medications are made more easily available to patients by skipping the physician prescribing process. (Also, over the counter meds are quite profitable). This can be very useful for medications such as ibuprofen, or Plan B (post-coital contraception), but any time you cut out the expert, certain risks accrue. Paternalism isn’t the opposite of autonomy. The two work together. Patients see me for my expertise. They don’t consult me about movies, art, or (thankfully) religion—just medicine. They do this because I’m the one with the training. Giving a patient knowledgeable advice is not paternalistic—it’s what they came here for. I don’t paternalistically command my patients to do anything. I dole out advice, and they are free to follow it or not.

Orange urine not only removes the expert, it fools the patient. It does not increase autonomy, it actually decreases it by deceiving the patient, perhaps causing them to become more ill.
<End of rant>

A few deep breaths

The whole ScienceBlogs debacle is, more or less, behind me, and for that I’m grateful. I’m looking forward to pursuing my writing with a bit less drama.

Or not.

But at least for today, I can share an interesting news item about Avastin, a chemotherapy drug made by Roche/Genetech. Avastin is a pretty remarkable drug. It inhibits angiogenesis, the process by which cancers develop a blood supply which both nurtures them and allows them to spread. It’s also been remarkably effective in the treatment of macular degeneration, an eye disease that can lead to blindness.

In 2008, an FDA advisory panel recommended against Avastin being approved for metastatic breast cancer. Despite this, the FDA approved the indication. Now, an FDA panel is recommending removing this indication.   The panel felt the data showed little benefit in progression free survival or overall survival, and an increase in adverse events.  Many oncologists would view any decrease in disease as a useful measure in treating advanced cancers, and see the “hope” as a worthy enough benefit.  But this is a costly drug, and at least according to the studies cited, not without harm.

This is somewhat—but only somewhat—reminiscent of the bone marrow transplant (BMT) controversy of the 1990′s and early 2000′s.  At the time, BMT was being used for the treatment of advanced breast cancer.  The idea behind BMT (and stem cell transplant) in this situation is relatively simple: one of the things that limits how much chemo you can give a patient is its effect on the bone marrow.  Since a little chemo often works, it was thought that if a larger, cancer-killing dose could be delivered without killing the patient, they’d have a much better chance of survival.

So bone marrow (or stem cells) were harvested from the patient, who was then subjected to otherwise-fatal doses of chemotherapy (BMP is used very differently in blood cancers).  If the patient survived the chemotherapy, they were re-infused with their marrow cells.  If they survived this process, then perhaps they would be more likely to survive their cancer.  Except they weren’t.

Bone marrow transplants are expensive and dangerous, and require a patient to go through a period in which their immune system is essentially absent.  Most transplants involve prolonged hospitalizations, time which, in a patient with advanced breast cancer, might be spent just about anywhere else.   The data eventually failed to show sufficient benefit from the procedure, and it was largely abandoned for this indication.

If the FDA goes with the panel recommendations, Avastin could still be used for breast cancer, but that use would be “off-label” and would not be covered by insurance.  In this case, despite its expense, some people will probably continue to use it while more data accumulate.  A marrow transplant is prohibitively expensive, but Avastin is only almost prohibitive.

I will be interested to see where the data finally lead us with this terrific (in many other indications) drug.   I hope that oncologists don’t use it solely for its “hope” value.  There are other ways to give hope than by a needle.

Book Review: Breakthrough

I envy writers of medical history, especially those who can create a really good read.  Someday, I would love to be able to write a good medical history, but this is not that day.  Today is one of the many days I get to tell you about another good book on medical history written by someone other than me.

The book is Breakthrough: Elizabeth Hughes, the Discovery of Insulin, and the Making of a Medical Miracle.^{(amzn/b&n/pwll)} When I read the preface, I had some reservations.

This book is based on a true story, and relies heavily on primary historical sources and documents.  With one exception, detailed in the section Notes and Sources, all characters are historical figures.  Most dialogue and incidents have been drawn from contemporaneous sources, but in some cases have been invented or augmented for narrative purposes.

This gave me pause, as there is something about authenticity that seems particularly important in both history and medicine.  We’ve all read histories, and we’ve all read historical fiction, and most of us have an idea of which is the better read.  One of my favorite authors in the genre, Rebecca Skloot, said in a recent interview:

When you write nonfiction in a way that will hopefully read like fiction, with scenes and dialog, there’s an assumption that you made it up or made some things up. When I do Q&As, people in the audience will ask, “So how much liberty did you have to take?” Not did you take any, but how much? There’s this assumption that it’s impossible to recreate history in a way that reads like a story.

[...]

I think it’s interesting that people assume that when they read dialogue that took place in the 1950s, it was made up, because I wasn’t there. But in fact there are ways you can recreate that accurately in reporting. It is absolutely possible to recreate nonfiction in a narrative way and still be factual. It takes a heck of a long time, but it’s worth it.

So it is possible to create compelling and accurate dialog.  But authors Thea Cooper and Arthur Ainsberg chose a particularly difficult protagonist around whom to build a story.

Elizabeth Hughes was the daughter of a powerful American politician in early 20th century America.  She was also one of the world’s first insulin patients.   At the time of her diagnosis, the most sophisticated treatment for diabetes involved controlled starvation, a horrific process described in some detail in the Breakthrough. Dr. Frederick Allen, the doctor behind the starvation protocol, believed that something like insulin was just around the corner, and that it was worth putting his patients through the misery of starvation to help them survive long enough to take advantage of this cure.

As we know, he was right.  The heroic and probably-insane Frederick Banting received much of the credit for this discovery, and he was hardly unsung.  Elizabeth Hughes, however, was intentionally unsung.  She hid her diabetes for the rest of her life, and her role as one of the first patients to receive it was buried in time.

The authors’ narrative is more than readable, and from the available sources about this intensely private person, they created a complex and likable protagonist.  But some of the motivations attributed to her later silence were part of the “augmentation” of available historical documents.  At one point in the story, the powerful Charles Evans Hughes, Elizabeth’s father, is portrayed as betraying his instinctive reticence and sense of duty to call up  Banting and pull some strings to get his daughter the insulin that would save her life.  But this phone call never happened, or at least it’s never been documented.

And I can live with that.  The book successfully weaves together the personal struggles of the patients, doctors and scientists living and dying on the edge of one of medicine’s greatest discoveries.  It also captures the beginning of the modern pharmaceutical industry, and how Eli Lilly and Company was poised to take advantage of this new discovery.  The scientists in Toronto were working day and night to come up with a process to reliably isolate insulin, but once they did, Lilly was able to turn it into an industrial process, quickly supplying insulin to thousands of diabetics.   Cooper and Ainsberg create vivid images of the solo chemist sweating over borrowed equipment, the industrial might of a large corporation, and Lilly employees spreading across the Midwest to talk slaughterhouses into harvesting pancreases by the ton.

Breakthrough is to be published in Fall of 2010 by St. Martin’s Press, so it won’t be out in time for a summer read.  But it should be an interesting one to discuss with friends over apple cider, something that many diabetics can enjoy with caution thanks to the discoveries documented in  this book.

An advance proof of this book was provide to me at no cost by the publisher.

Still under construction

Please be patient. This place is full of cobwebs. I’m trying to get everything up and running, including features I hadn’t realized weren’t here. The blogroll is very , very old, and will be updated—I promise.

Old-new digs

So, welcome…or welcome back.  Either way, White Coat Underground is going to be hanging around here for a little bit while I prepare some other things.

My explanations for the move is basically one of ethics and credibility, and is documented back at the Scienceblogs site.  I enjoyed my time at Sb immeasurably, but it was time for a change.  Also, the version of Movable Type used at Sb is very difficult to work with.  It’s nice to stretch out a bit with wordpress.

So welcome back, and thanks for following me here.  Details to follow.

Ethics and goals: always a challenge

My formal ethical training began in medical school with an introduction to the basic concepts of medical ethics. This training continued as I encountered difficult cases and thought through them, often with the help of the hospital ethics committee. While I haven’t continued my formal education in ethics, I’ve continued my own reading, and I enjoy writing on ethical conundrums.

I’ve been blogging now for over three years, which, in internet time, is quite a while. During that time, I’ve begun to take the writing itself more and more seriously. I’ve begun to recognize the implications of the medium itself, especially in conversations with mainstream journalists. We bloggers are, for better or worse, part of “the media”.  So I’ve had to learn something about journalism ethics as well.

This has changed the way I write. When I look back at some of my earliest posts, I cringe. In many ways that’s a good thing; as it turns out, I have the ability to learn and improve. My commenters and my colleagues help keep me honest, and without them, I’d write just as poorly as I did five years ago. I’ve also expanded the type of writing I do. In addition to my always well-reasoned rantings and my discussions of science-based medicine, I’ve done some more investigative pieces, interviewing sources, and consulting other journalists about ethics and approaches.

Given that much of my writing is very critical of unethical medical practices, I don’t have a lot of wiggle room in my own public behavior.  This isn’t to say that to be ethical is to be perfect; far from it.  But behaving ethically is hard work that involves hard decisions, and frequent mistakes.

ScienceBlogs has not made such a mistake. With the mishandling of the launch of a commercial ad-blog, Seed Media Group showed incompetence and mismanagement.  They also showed that they do not consider themselves (or we bloggers) to be “media” or journalists.  Whether we like it or not, we are the media, and while we may enjoy a great deal more freedom in style and content than most mainstream media, we cannot claim immunity from their ethics.

It is for these reasons (and others, most of which have been eloquently and completely laid out by Bora Zivkovic) that I’m leaving ScienceBlogs, something I do with great regret.  I have gained immeasurably from my association with Sb and with the people here.  It has given me incredible opportunities.  But despite the advantages in exposure, the fit just isn’t good anymore.

This is a personal decision, not one that can be generalized to include anyone writing here.  The bloggers here are some of my favorite science writers, and always will be, whether they remain at Sb or go elsewhere.  I have nothing but respect and admiration for them.

As the science blogosphere has evolved, and as my own writing has, I feel that the risk of leaving is not what it might have been once.  I will continue to write White Coat Underground at my old wordpress site for now, and will announce further plans there.   And I will continue my occasional pieces at Forbes.com and Science-Based Medicine.

Reminder: Whooping cough is serious business

I shouldn’t see any cases of pertussis (“whooping cough”), but I do. We have a safe, effective and affordable vaccine. But still, people are getting this disease. In the age group I see (adults), immunity has often waned, and if they haven’t been revaccinated, they can get the disease and pass it on. In adults it often looks like a cold, but not in kids. Most properly vaccinated children are immune and remain so until there little airways are large enough to cope with the illness. But a certain percentage of kids either don’t get vaccinated or aren’t successfully vaccinated, leaving them vulnerable to a disease that shouldn’t even exist at a measurable rate.

In small children, with their little airways, pertussis often leads to hospitalization, and not infrequently kills. It kills children who should never have been put at risk, either because their parents refused to vaccinate them, or people around them did and gave them the disease.

Children and adults who should be vaccinated but are not represent a public health failure, and in the case of parents who deny their kids the vaccine, an ethical failure as well.

As a reminder, this is what pertussis looks like in little kids.

HuffPo blogger claims skin cancer is conspiracy

I was a bit torn when trying to figure out how to approach this piece.  A reader emailed me about an article in the Huffington Post, and there is so much wrong with it that I felt overwhelmed.  My solution is to focus on a few of the problems that can help illuminate broader points.

There is a small but vocal movement of people who refuse to believe that skin cancer caused by sunlight is a significant health risk.  These people tend to also believe that the risk is being purposely hyped by others, and that our current approach to skin cancer prevention is causing an epidemic of vitamin D deficiency. Leaving aside the seemingly insane denialism regarding sunlight and cancer, there are two broad problems with this article.  The first is pretty bad.

With the summer months upon us I wanted to find out firsthand what exactly the mantra is that dermatologists are telling patients. So I went undercover to several San Francisco dermatologists in order to see if there is legitimate concern about the sun-scare media hype. Are these doctors being sensible or going overboard when it comes to advice on sunscreen use and skin cancer prevention? Is the sky falling with dangerous UV rays or are we being induced into a media panic?
 

He goes on to give links to recorded conversations, and prints out partial transcripts.  He does not specify whether or not he received permission to record these conversations, as required by California law.  Whether or not the law requires it, the writer should have disclosed to his readers whether or not he had received permission.  This information is important in interpreting the conversations he reports to us.  

The next problem is broader, and deals with physicians’ willingness to lie on behalf of patients.  The author’s presumably-clandestine recordings of his deceptive visits to dermatologists (catching my breath—this is striking and requires a digression.  The act of deceiving these doctors is not only unethical, but can influence the outcome of the visit.  Doctors make the assumption that most patients are interacting with them out of good faith, and are not intentionally deceiving them.)

In the first conversation the author has with a doctor, the interviewer makes it clear that he wants a mole removed, and the doctor essentially leads him to say “the right thing” so that insurance will cover the procedure.  One thing the author seems to miss is that the dermatologist is going to be paid whether or not insurance covers the procedure.  If the insurance company says “no”, the patient will be billed.  The doctor is lying for the patient, not for herself.  

Data have shown that physicians are willing to lie on behalf of patients. There are a number of reasons that this poses ethical problems.  It could be argued that the doctor is lying to help get the patient something that they need, and that lying is a peccadillo compared to the benefit.  This can backfire in a number of ways, not least of which is that both the doctor and the patient can probably be prosecuted for fraud, something that is unlikely to be of benefit to either one.  

But there is a fine line between a lie and a truth, one that anyone familiar with the intimacies of the exam room will often experience.  As a doctor, your overall impression may be that the patient is at high risk for coronary artery disease, but perhaps the patient doesn’t quite meet the insurance company’s criteria.  You can then lay out the cost of the test and the risks and benefits for the patient, but I wouldn’t be surprised if some doctors took the short cut of asking, “are you sure you’ve never had any chest pain or difficulty breathing?”  

He begins his second dermatology visit by telling the doctor that he has a family history of melanoma, and finds fault in the doctor’s description of the statistics of the disease.  The problem of properly rendering statistics is a common one, and he links to an excellent piece by Ivan Oransky explaining the difference between relative risk and absolute risk.  Unfortunately, he uses this to spin a tale of some sort of dermatology conspiracy to inflate cancer numbers.  Skin cancers (including melanomas and non-melanoma skin cancers) are very, very common, and though many are not fatal, their diagnosis and treatment can be expensive and disfiguring.

His visit continues and the doctor tells him that insurance won’t cover his mole removal because it’s not necessary, and refuses to lie in the medical record. The doc then gives some sound medical advice about how to prevent skin cancers.

I then ask what measures I should take to prevent skin cancer. I’m told to apply sunscreen 24/7, wear a hat and sunglasses, as well as avoid the sun as much as possible. (The only thing she doesn’t mention is to live underground with the mole people.)

“Mole people”?  He asked the doc how to prevent skin cancer, the doc gave the correct answer.  It’s up to the patient to decide if the application of sunscreen is too onerous for the potential benefit.

This article shows a misunderstanding of journalistic ethics, medical ethics, and medical science.  It’s a disaster.  And it’s no surprise that it’s in the Huffington Post.

Would this work in Kansas?

Catherine Shoichet, a reporter at CNN, is reporting on a unique (as far as I know) public health intervention. For a few bucks, a randy Switzer can have a three pack of condoms delivered by bike in one hour.

How cool is that?

Update on Pepsipocalypse

The crack SEED management team has made some significant changes on the new Pepsi nutrition blog. They have placed a small, grey band on the banner that says “Advertorial” (a word I abhor, but whatever). They have also placed the Pepsi logo everywhere and made it fairly clear that it is Pepsi content.

This is a move in the right direction as far as transparency and ethics are concerned. As I read the extensive comments being left across the blogosphere I see some that show a misunderstanding of the problem here.

The problem is not that Pepsi is “corporate” or “commercial”. This is not about “selling out to The Man.” What Pepsi produces and how it does is ironic but beside the point. The main problems are:

1. Lack of transparency, which is somewhat improved
2. Visual appearance, despite caveats, very similar to “real” science blogs
3. Content produced by and for the benefit of the company that bought the space

These create all sorts of ethical problems.  It also erodes the credibility of some of us in a couple of ways, but I’ll speak only for myself.

I have spent a bit of time and energy building a little credibility with mainstream journalists, engaging them online and in person, and have started writing for a more mainstream outlet, Forbes.com.  I enjoy my role as both a writer and a physician; the more I read about journalism, the more I find myself questioning the best way to do what I do.  Given the multiple ethical challenges to what I do, I don’t appreciate being dragged into a new one with no warning.

One of the more fortunate things at ScienceBlogs has been the recruitment of experienced science writers such as Maryn McKenna, David Dobbs, Rebecca Skloot, and Deborah Blum (yes, I left some of you out, but it’s busy here tonight).  This gives me additional opportunities to learn the craft, but if they all run away from here, I lose out (as do our readers).

I have relied on a reputation (even if I were my only reader) of independence.  Ads are inevitable and not undesirable, but deceptive advertising that looks very much like my own content poses special problems for me (and for other medical bloggers).

Unlike a number of my most respected colleagues, I’m not making a decision to jump ship just yet.  If I do, it wouldn’t be to “punish” ScienceBlogs, as the real numbers I bring in aren’t huge.  It would be to satisfy my own sense of what it is to behave ethically.

So for now, I’m going to wait and see.  This isn’t the first time ScienceBlogs has had significant problems (not “issues”, “challenges”, or “opportunities”—problems).  It isn’t the first time we’ve lost top notch writers.  So I’m willing to watch a bit and see where this goes—but not for too long.

Ironic nostalgia

Rethinking blog networks and ethics

One of the wonderful things about blogs is their independence. Most are hosted by wordpress or blogger and there isn’t much advertising or sponsorship. Notable exceptions are blog collectives, such as ScienceBlogs and the Discover Magazine blog network. These networks have significant advantages, including technical support, increased reach, and collegiality (your results may vary).

One of the potential disadvantages is advertising and sponsorship. Here at Sb, we’ve been very fortunate in that our content is completely independent. We control anything in the center column. The top and right however belong to Sb, and they use this space to keep the place running. There have been several times when the advertising has been less-than-appropriate, and SEED has responded by altering it, but in this economy, it pays to be flexible. Ad content can serve as blog fodder. There’s nothing preventing those of us who blog here from critiquing the ad content as vigorously as we wish to.

While the various bloggers under the ScienceBlogs banner are independent of Sb and of each other, there is certainly a penumbra of association. We all may benefit from good publicity, and we may be harmed by bad publicity, even if it comes from other blogs in the network. Given that we may benefit from good publicity generated by the network, it could be argued that we bear some responsibility when we don’t speak out against bad practices on the network.

All that is my way of justifying what I am about to write: ScienceBlogs is launching a new blog, and in doing so they are making a spectacularly foolish decision. Today they announced a new blog called Food Frontiers, and I think a few simple quotes will allow you to see why I’m concerned.

On behalf of the team here at ScienceBlogs, I’d like to welcome you to Food Frontiers, a new project presented by PepsiCo.
As part of this partnership, we’ll hear from a wide range of experts on how the company is developing products rooted in rigorous, science-based nutrition standards to offer consumers more wholesome and enjoyable foods and beverages. The focus will be on innovations in science, nutrition and health policy. In addition to learning more about the transformation of PepsiCo’s product portfolio, we’ll be seeing some of the innovative ways it is planning to reduce its use of energy, water and packaging.

So PepsiCo’s PR flacks basically own a the center column content on one of our blogs.  This is not only a fundamental conflict of interest, it’s also deceptive.  If PepsiCo is providing the content, it should, in my opinion, be clearly labelled as advertising.  It could be argued that since it is clearly announced that the content is PepsiCo’s, that transparency is maintained, but it’s not.  Readers of the other 70-odd blogs at Sb expect independent content in the center column.  What’s more, Sb is indexed by Google News.  As a news outlet, we should be held to a high standard.  If the SEED management can’t see what’s wrong with this, this may be an insoluble problem.

Quack-busting is dangerous work

First, I’d like to thank you all on commenting on the weekend’s de-lurking post. I really appreciate your taking the time to leave a note. While I write what I feel like, it’s nice to get an idea about what sort of things people are reading. For various reasons, I’ve preferred to write on diverse topics, and it turns out that this attracts readers with diverse interests.
Now down to some serious business. I’m sure that many of you remember the Simon Singh case. Simon is a well-known and well-respected science journalist in England. Last year, the British Chiropractic Association sued him for libel. They weren’t too happy when a story of his pointed out that many of their practices are bogus. This was a terribly expensive and presumably traumatic event for Simon, but against all odds (at least those set by English libel laws), he prevailed.
Here in the U.S. we like to think that our saner libel laws give us a bit more protection, and they do, but only to a point. It is still very expensive to mount a defense against a bogus libel allegation. Dr. Paul Offit, one of the leading experts on vaccination, was sued earlier this year by a seemingly unhinged antivaccination activist. This infectious disease promoter, Barbara Loe Fisher, felt that a single phrase he uttered about her during an interview—”She lies”—was terribly damaging to her. Given that she spends an inordinate amount of time making a fool of herself, it’s hard to see how anyone else can make her look worse, but she was upset and sued. Her case was thrown out, but I can only imagine what Paul went through.
Last week I learned of similar bad news that hits close to home. Dr. Stephen Barrett has been a tireless crusader against quackery. He has for years maintained the website Quackwatch, which along with several associated websites serves as a remarkably comprehensive repository for data on various medical scams and illegitimate practices. In a series of articles, Dr. Barrett (who is vice president of the Institute for Science in Medicine, of an organization that I am also involved with) explained the trouble with urine toxic metals tests. Doctors Data Labs was mentioned in some of these stories and in a vaguely worded bizarre set of letters, essentially demanded that Barrett not publish anything negative about them. When he asked them to point out specific content to which they objected, they declined and instead sued him. This suit is unlikely to be successful, unless they outspend him enough to break him. Barrett is taking donations for his legal defense. The more cases like this that succeed at trial or by default, the less safe all of us are to combat health fraud.
But what’s the big deal about this lab? They offer, among other things, urine toxic metals tests. These tests are promoted as a way to find “toxins” hidden in the body, and are a common tool by those offering chelation therapy. Chelation is an unethical use of dangerous medications, and is used frequently by so-called alternative practitioners to treat nearly anything.
Here’s what Doctors Data says about their test:

Urine toxic and essential elements analysis is an invaluable tool for the assessment of retention of toxic metals in the body and the status of essential nutrient elements. Toxic metals do not have any useful physiological function, adversely affect virtually every organ system and disrupt the homeostasis of nutrient elements.

Among the flaws pointed out by Barrett is that this test measures urine metal levels after the patient takes a chelating agent, a drug which scavenges any heavy metal molecules it can find and drags them to the urine. And as a reference range, they use urine levels that are considered high in people who aren’t chelated. In other words, the test purposely boosts urine metal levels and them calls the levels “toxic”.
The company offers many more tests not offered by labs with more (in my opinion) legitimate reputations. For example, Quest Diagnositics offers several different urine metal tests, none of which are “chelation-provoked”.
This is a nuisance lawsuit, but it may be enough of a nuisance to have a significant chilling effect on those of us who are using ethical, science-based practices to help people. To offer unconventional and at best unproven diagnostics or therapeutics, and then sue people who criticize you is unethical, immoral, and dangerous.

In Congress, July 4th, 1776

It’s worth re-reading this remarkable document from time to time, especially given that it says something very different from what many on the Right and in the Tea Party seem to think. It does, for example, give special importance to representative government; that is, in fact, one of the main purposes of the document. It does not call for a “right” to toss away any government someone disapproves of but lays out specific grievances and makes its declaration through the representatives of the people, not by mob action.
The document’s wording was very carefully developed and has specific meaning to those who wrote it at the time and their descendants. If you’ve never read it, or haven’t for a long time, give it a try.
The unanimous Declaration of the thirteen united States of America
When in the Course of human events it becomes necessary for one people to dissolve the political bands which have connected them with another and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, — That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn that mankind are more disposed to suffer, while evils are sufferable than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. — Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

Who are you again?

DrugMonkey has revived a blog meme that originated with uber science writer Ed Yong. It is basically a request for readers to “de-lurk”. On any blog, the majority of readers never comment, and the people who do comment tend to so over and over again.
Writers are inherently narcissistic. As bloggers we can get an idea of how many people are reading us, but not that much else.
So for the sake of the community, I’d like to ask you all, without revealing any important identifying information, who you are. Just leave a comment, even if you never have before. Don’t worry about the email address requirement. That isn’t visible publicly and you can always use a dummy address, such as none@none.com. Be anonymous or not.
I’d be interested to know many of the same things that DrugMonkey and Ed want to know. Do I know you IRL? Why do you read this blog? Do you have an interest in medicine, writing, journalism, or nothing in particular?
Throw me a bone here.

Cowpox as a sexually transmitted disease?

In February, a young woman visited an urgent care clinic complaining of painful vaginal ulcers.  The differential diagnosis of genital ulcers is interesting.  Common sexually transmitted infections such as gonorrhea and chlamydia don’t cause ulcers, but syphilis, herpes, chanchroid do (as do other diseases, but they are not common in the U.S.).  Syphilis is typically painless, so most painful genital ulcers turn out to be herpes, and sometimes chanchroid.  She revealed to the doctors that she had recently had sex with her boyfriend, a soldier who had just been vaccinated against smallpox.  The clinic treated her for chanchoid and herpes, as well as gonorrhea and chlamydia, and perhaps cellulitis.  She didn’t get better.  

The Great Zombie Hoax

ZombiePal, thanks to Ataraxia Theatre

Scene: Harpo Studios, Chicago, IL, under heavy guard

Dramatis personae: Oprah Winfrey, talk show host; Jenny McCarthy, famous person; Erica Turner, un-dead North Sider

Oprah: Jenny, you have been such a maverick. It takes a brave person, one with great inner strength, to say things that are unpopular. How is that adorable boy of yours?

Jenny: Well, he’s just great! I have him on a new diet and it’s done wonders!

Oprah: That’s great! I need to ask you all about it, but first, what do you say to those folks out there who say such negative things about you? I mean, does it get you down?

Jenny: Of course not, Oprah!

(applause)

Jenny: You know, Oprah, it’s all about money.  The drug companies want us to be scared, they want us to depend on what they sell.  

Oprah: And what is it they are selling?  It seems to me they want to help us.  I mean…

Jenny: That’s exactly it!  They want us to think that, and when they give it away free like they are, that’s the most evil part.  It gets us hooked!

Oprah (turning to face camera): We’re talking of course about Zombievax.  This unprecedented collaboration between pharmaceutical companies and governments which the CDC says has slowed the current pandemic.

Jenny: The CDC!  They are the worst!  They’re the ones who invented this [air quotes] pandemic.  These so-called zombies are just like you and me.  It’s not an illness at all! 

Oprah (turning to camera again): Folks, I don’t know how my producer Jill pulled this off.  We have the former Mrs. Erica Turner, a native Chicagoan from the North Side…

(applause)

Oprah: Erica is one of these so-called zombies, although I think it’s kinder to refer to them, in the words of my dear friend Deepak Chopra, “life-force challenged”, don’t you, Erica?

Erica: (Incoherent grunting)

(applause)

Oprah: Now, Jenny, you were telling us how this isn’t really a disease, is that right?  Cause (turning to Erica) no offense, Sister, but you ain’t lookin’ too good (turning to audience), right folks?

(applause)

Oprah: I mean, I’m all into the natural look, but you put the stressed in distressed, girl!  I mean, I can get on the phone in two seconds, or Jill can, and we can do a makeover, and do something about those teeth.  Would you like that?

Erica: (Incoherent grunting)

Oprah: I’ll take that as a “yes”.  What do you think, people?  Should we make her over?

(cheers)

Jenny: And I think my diet could really help her too! And I brought a copy of it! 

Jenny hands book to Erica. Erica latches on to Jenny’s hand and bites off her left index finger.

Jenny (giggling): Girlfriend, fingers are not on the diet. They just wreck the immune system!  That’s why you have to read my book!

Oprah (turning to audience): I want each of you to look under your seat.  See that?  (points at various audience members) You get a book!  And you get a book! And you get a book!

(thunderous applause)

Jenny (shouting over applause, holding up her book): I know…(raising voice)  I know you all think this is some horrible diet where you eat gluten-free bread and raw carrots.  But this diet lets you eat stuff we all like!

Jenny (leaning toward Erica, but not too close):  This diet will keep you healthy, and you won’t need any Big Pharma vaccines, vaccines that will kill you!  And you only have to remember one thing.  Do you know what that one thing is,  Erica?

Erica (lumbering away from Jenny): BRAAINNSS!!!!!

Signs of life in medical social media

Many of us who are involved in social media have bemoaned the sluggishness of our own professions in adopting new media. There are two notable developments in my own field that seem to be holding up.
The first is the twitter stream for the American Medical News. This is an online and print newsletter put out by the American Medical Association, but in true social media fashion, the feed is not simply a conduit for their own articles. The feed retweets frequently and tweets stories from other media outlets and blogs.
The second is a blog from my own specialty organization, the American College of Medicine. It has a “QD” (medicalese for “daily”) news feature, and also features content from well-known medical bloggers.
This sort of online presence is a great start. I’m not an AMA member, but I occasionally read the American Medical News, and now that they tweet, I’m even more likely to check them out. Their willingness to link outside their own organization is critical.
So, folks, what other examples have you got for me? What am I missing out there?

“A state of institutional denialism”

Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents’ work hours. This was driven largely by Zion’s father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.

“You don’t need kindergarten,” he wrote in a New York Times op-ed piece, “to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-and-death.”

It was largely thanks to Zion’s tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.

Medical residents have traditionally worked long hours, especially in their first (“intern”) year. In fact, they used to “reside” in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn’t changed much, which sort of surprised me).   The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts.  During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night,  which has long been typical for internal medicine residencies.  

In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run.  Hospitals can only support a certain number of residents, and they count on these residents and the care they provide.  Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners).  And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints.  

Many of these changes involved a more toward “shift work” and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift.  This creates its own problems for both patients and residents.  There are concerns that shift work may lead to a disruption in continuity of care, since patients are being “handed off” potentially several times a day.  Also, residents are not supposed to be performing functions that are primarily “service” rather than educational.  During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.

These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies.   While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.

Resident Safety

As medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects.  The 2009 IOM report summarizes some of the evidence for fatigue-related injury.  Much of this evidence is readily available through PubMed.  Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue.  There is also good evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents.  And these data are not new.

Patient Safety

Data on patient safety isn’t new either.  A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones.  That’s just one good study of many.

Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes.  One of these fixes is the implementation of reasonable resident work hours.

Denialism?

Responses in the literature and in doctors’ lounges have been tangential and almost intentionally obtuse. A colleague of mine at another institution has opined that the medical profession is in a state of “institutional denialism” about the effect of long hours on safety and performance.  I don’t think that is unfair.  The evidence on this has existed for years, yet we’ve made only cosmetic adjustments to our training programs.  Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem.  The work hour limitations they mandate will very likely help, but there is a larger systemic problem.  Medical training is lengthy and expensive.  If we’re going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs.  If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt.    Quick fixes, even smart ones, aren’t going to do the trick.  

The Libby Zion case that eventually led to the new work rules was over a quarter century ago.  How long will it take us to create real, comprehensive solutions?

Science journalism pet peeve

I frequently read about the latest medical and scientific “breakthroughs” in the mainstream media, and in modern media such as sciencedaily.com. One commonality is lack of citations. If I’m lucky, they may cite the source journal or meeting. If I’m really, really lucky, they may even give a general date (e.g., “JAMA in June”). But I never see an actual citation. That would be one simple way to improve science journalism. A standard citation would give readers the tools to evaluate the primary source. In science, we consider that pretty important.

The vaccine problem: are we doing it wrong?

Author Chris Mooney has a provocative piece up at the Washington Post today. He argues that scientists are misunderstanding the dynamics of science-policy debates. Because, he argues, ideology often trumps scientific fact in the minds of the public, we (scientists) need to work harder to engage the public to win their hearts before we win their minds (please forgive me, Chris, if I didn’t get this quite spot on).
While I appreciate Chris’s general point—that we can’t just “fact” people into submission—I think some of his arguments beg for a more critical analysis. Point one, scientists are missing an important piece of data:

One the one hand, the nonscientists appear almost entirely impervious to scientific data that undermine their opinions and prone to arguing back with technical claims that are of dubious merit. In response, the scientists shake their heads and lament that if only the public weren’t so ignorant, these kinds of misunderstandings wouldn’t occur.

I’m not so sure Chris is right about this. Those of us who fight against the anti-vaccine movement have known for years that it behaves like a cult, making the members nearly impervious to reason. Many of us realize that the core of the anti-vaccine movement are not our primary audience. Our real audience is fellow activists (igniting the core) and those who have not committed themselves (nearly everyone). Chris’s argument is most valid when applied to this latter group who may or may not be turned off by the aggressive rhetoric of both sides.
But as Chris argues later, their minds may be more or less made up. They may choose a side based on their basic ideology rather than rational argument. If we can’t sway the cultists, and their ideologic fellow travelers are already spoken for, what are we doing?
We are also speaking to policy makers. The public health establishment is science-based but susceptible to politics. We are arguing for them to hold fast, not to bow to the vagaries of politics and ideology. And we are bringing our own inflamed base into the fight.
Chris argues—admirably—for a more democratic approach to swaying the public on scientific issues, giving as an example Canadian nuclear waste disposal. In Canada, the government has worked to involve the public and other interested parties.

In Canada, for instance, the national Nuclear Waste Management Organization spent three years listening to the public’s views about how to handle nuclear waste disposal and promised that no dump or repository would be sprung on a community without its consent. Throughout the process, even critics of waste storage efforts remained engaged and supportive of attempts to come up with the best possible solution.

There is a fundamental problem with science policy decisions. As a nation, we are a democracy, yet science is not. Not every community has the appropriate natural resources to serve as a nuclear waste repository. What happens when, as in Nevada, a good scientific choice is a bad political choice? Is the community really open to persuasion? And are anti-nuclear activists (who, as Mooney implies, are moved more by ideology than reason) really going to ever be persuaded that any site is adequate?
Those of us arguing for sound science policy are not ignorant of ideologies and of our own inabilities to sway true believers. We get that. But neither do most of us believe we can simply open up science policy to a vote. When the public “votes” that vaccines cause autism, what are we to do, halt proper vaccination until we can convince everyone, just to go through the same cycle in another few years?
This is a representative democracy. We must convince policy makers to isolate, as much as is possible, science policy decisions from the election cycle. And we must be loud advocates of sound science policy, realizing that we are fighting ideology. The more we isolate the Jenny McCarthy’s, the more our own voices will affect policy.

I miss you!

When you walk into a good coffee shop, you can smell it. It’s a smell nothing like the smell of the old, sour coffee sitting in a carafe at the office. It’s the smell of dark, dark beans, cracked open, releasing complex odors of fruit and of heat. And as much as I enjoy sitting in a coffee shop reading and writing, I don’t get much time for that these days. But I can bring it home.
I love opening a new bag of beans. They have that shine to them, a shine that is lost very quickly. And when you pour those fresh beans with their volatile sheen into the grinder, they jostle and release just a bit of their aroma. That intensifies the moment the grinder blades cuts into the beans. Sometimes I use a drip coffee maker, sometimes a press, and rarely an old copper Turkish coffee pot. I think the press is my favorite. I warm it up first, and then dry it and pour in the course grounds. I pour the hot water over them, give it a stir, put on the press, and set a timer for three-and-a-half minutes. The smell in the kitchen isn’t as intense as when using a drip pot, but when you press the coffee and pour it, there is a small crema in the cup, and the coffee has real texture.
I usually wait a few minutes for it to cool comfortably, then sip it, taking in the smell, taste, feel. I love to read and I love to write with a cup next to me. I rarely finish a cup, because it gets cold, so I pour a bit out and freshen it up. And I feel, in the most subtle of ways, the little boost as the caffeine hits.
The weekend is a great time for me to enjoy coffee. I love to sit around and sip it doing something completely relaxing. But when one of my 14 hour days is dragging on, I want to have a cup to get that extra little something. And I love to sip it when I’m bored.
Now that my coffee is nearly devoid of caffeine, I’m developing a new relationship to it. I took a small amount of regular this morning, as medicine really to ward off the withdrawal symptoms that have been pestering me. That sip, and a half a cup of half-caf today was it. I’d love a cup now, but I’m not sure; the caffeine in it apparently meant more to me than I thought.
But I’ll be content with good decaf. There’s plenty of good decaf beans out there, and once the worst of the withdrawal is done, I’ll be happy.
It’s a good thing I’m not an addict or something. I can’t even imagine what that must be like.

We need to fix Medicare NOW!

Medicare is the government health care program for the elderly. For internists such as me, Medicare patients make up around half our practice. Because of historical budget tools, every year Congress goes through the motion of watching our reimbursement cut, and quickly fixing it. It’s a terrible system. As a small business, my costs are pretty much fixed: rent, employee pay, health insurance, supplies, etc. Every year, a Medicare pay cut goes into effect, and then our checks are held while Congress puts together a temporary fix.
This year, the pay cut is 21%. That means that I will have to try to pay my rent, my employees and my suppliers and myself on somewhere around 10-12% less pay. We work on very narrow margins to begin with, so this means that we may not be able to pay our bills. This week, the Senate managed to pass a fix that would have stopped the pay cut. They did this by stripping away other legislation it was attached to. When it went to the House, Speaker Pelosi added back a bunch of unrelated legislation, which essentially insures that the fix won’t pass, or if it does, it won’t be for a long time. We’ve been informed that our checks, which were being held by Medicare until the fix, are now being mailed out with the 21% pay cut.
This may seem boring, this may seem like whining from someone in a higher income bracket, but providing medical care to our seniors is expensive. When these checks hit our accounts, we’re going to have to make big cuts just to pay the rent. These cuts may mean we have to try to run the office with fewer employees, we may need to cut our health insurance for our employees, and we will definitely need to stop taking Medicare patients.
This is not something that can wait. There are fewer and fewer primary care doctors taking Medicare patients every day. With more Americans reaching Medicare age, it will rapidly become nearly impossible for them to find doctors.
This cannot wait. Please call or write your representative now. Currently the House is the body holding up the “doc fix”. Doctors and their elderly patients need your help immediately.
Here’s how you can find your Representative’s contact info.
I’ve also started a twitter hastag #FixMedicare to help brainstorm ideas and connect people who care about this issue.

ACGME moves to limit resident work hours

When it comes to medical blogging, no one has been as consistently good, fresh, and snarky as Orac. Respectful Insolence sets the standard for all other medical blogs, and though Orac may not be a media star like some other med bloggers, his writing has had a significant impact on some important medical issues such as vaccination. The fact that he is often the target of vicious attacks by anti-vaccination activists and other quacks and wackos shows just how good a job he is doing.
Though he has been criticized for being a bit loquacious, his thoroughness is one of the traits that makes him so effective. So I was very happy to see his post on the so-called “July Effect”, the idea that hospitals are more dangerous in July when the new interns start. I love July, as difficult as it sometimes is. I always call the new interns “Doctor” and it always makes them do a double-take. Orac’s takes a very detailed look at a new study of the July Effect, and the data still aren’t clear as to whether and how July may be more dangerous to patients.
Another question regarding resident training and safety is resident duty hours. The data are not at all clear as to the effect of these hours on residents and patients, but despite a paucity of data there are reasons to believe that some parts of medical training may not be great for young doctors or their patients. In their continuing effort to address these concerns, the Accreditation Council on Graduate Medical Education (ACGME) today released a new set of standards for medical resident supervision and duty hours.
Before I explain these changes, which residencies will be expected to adopt, let me explain the traditional schedule. It’s no secret that residents work some crazy hours, although over the last ten years there have been some efforts to control this. Residents have been known to have fatigue-related auto accidents, and as stated above there may be patient safety issues related to fatigue. Different specialties have different schedules, with internal medicine (my specialty) being neither the worst nor the best (surgery and OB/GYN tend to be the worst). Classically, internal medicine interns take call “q4″, meaning that every fourth night they stay in the hospital. This means that on Monday, for example, they may come in at 0530 to pre-round, stay all night, finish all their work by Tuesday evening and go home to roll out of bed early again the next morning. It’s usually pretty easy to identify the “post-call” residents: they are wearing scrubs, unshaven (if relevant), rumple-haired, and they look tired.
The ACGME has decided to focus on first year residents (interns) in their new standards, as these are the residents who have the least experience, and the data indicate they may—maybe—be at higher risk for committing preventable errors.
The new standards set a limit of 80 hours of work per week. They also limit interns to no more than 16 hours of work at a stretch, with at least 8 hours between shifts. This is going to have a significant impact on the design of medical residencies. One of the advantages to the more torturous schedule was continuity-of-care. When I admitted a patient on Monday afternoon, I would be with them during the critical first day of their admission, seeing the patient through the whole initial work up. The new standard will essentially mandate a shift-work model, in which an intern will admit the patient, then hand her off to another intern to go get the mandated rest break. The ACGME recognizes the potential problems of “hand-offs” and allows some time “off the clock” for them.
One of the shifts likely to be implemented is “night float”, where a few residents will take admissions and keep an eye on the house. Many programs already have night floats, but the new system will make them nearly unavoidable. When I was a resident, we generally did 14 nights in a row (if I recall correctly) from 11 pm to 7 am. The new standards will limit these shifts to six in a row.
Residency spots are limited in number. Institutions can only afford so many residents per year, and with further work limits, hospitals that depend on these doctors are going to have to rely increasingly on other clinicians to care for patients. Physicians assistants and nurse practitioners are already being used extensively to care for patients in hospitals, and this role will probably increase as a direct result of these changes.
As valuable as my “in the old days” training was, these changes are probably positive in the long run. It’s not good to over-fatigue our young doctors, who may be risking their lives driving home after 30 hours at work, and if it has a positive effect on patient care, great.^* But we still must remind our young doctors that when they get out into the real world, there is no ACGME, no limit on work hours.
______________________________
^*DrugMonkey pointed out the implication of this statement. Upon self-examination, a few things underly this. First, I have a responsibility to both my patients and my trainees. The evidence of benefit to patients of these changes is not strong, but I do anticipate benefits to trainees. I am also biased by my own post-call traffic accident.

Summer reading list

I’m looking forward to having some time to read this summer. I’ve planned a total of two weeks away from work, and if all goes well, I’ll get some time to plow through a few good reads. My first trip away will be my usual gig as a camp doctor in Ontario. Last year I brought up The Great Influenza by John Barry, which was ironic, given I landed at flu central. My second week off will be up in northern Michigan. Here’s my list, which is heavily biased in subject matter (I’m far too lazy to give a three-source bookstore link, so you’ll have to google them):

1. Breakthrough: Elizabeth Hughes, the Discovery of Insulin, and the Making of a Medical Miracle, by Thea Cooper and Arthur Ainsberg.  Actually, I just finished this one, and I’ll have a review up by the end of the summer.  It’s a great read about the discovery of insulin, but not available until the fall.
2. Newton and the Counterfeiter: The Unknown Detective Career of the World’s Greatest Scientist, by Thomas Levenson.  I’ve been dying to read this one.
3. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, by Tracy Kidder.  A friend sent me this one a while back, and I finally started it.  The first sentence contains the word “beheading”.  It’s about a doctor, and I love it.
4. The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York, by scibling Deborah Blum.  I’ve been dying to read this (heh…)
5.  Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service, by Mark Pendergrast.  Hopefully it will be as good as The Medical Detectives, one of the first medical books I read, a couple of decades ago.
6. & 7. Superbug, by Maryn McKenna, another scibling.  It’s about bacteria, resistance, and all sorts of geeky things that affect what I do on a daily basis, and that may affect you, especially if you are ever in a hospital or nursing home.  Oops, and one more from Maryn, Beating Back the Devil.

I really wish people would stop writing such interesting books—I don’t know when I’ll read everything I want to.   Now if award-winning science writer Ed Yong would just crank out a new one, I’ll never get anything done.

Another Fathers’ Day—so soon…

I visited a physician this week as a patient. The details of the meeting are in the TMI category, but the long a short of it was he gave me advice that the altmed folks wouldn’t believe. Surrounded by the most advanced diagnostic technology, armed with a nearly infinite pharmacopoeia, he made a single recommendation: stop caffeine.
Stop caffeine. Ugh. He said, “Stopping caffeine often solves the problem you’re having. You know, it’s a drug. You don’t need it. It’s like speed. Stop it, and I’ll see you in a month.”
Caffeine is my friend. In college I always wrote my papers in one, long sitting, drinking tea the whole time. I started drinking coffee just after college. My life doesn’t always include enough sleep, and my good friend caffeine lets me pretend I living a normal, healthy life.
Except when it doesn’t.
Recent literature suggests that much like other addictive drugs, once one is tolerant of caffeine, the boost one feels is really just the mitigation of the withdrawal syndrome. Caffeine, taken occasionally, increases alertness. Taken chronically, it simply helps prevent withdrawal.
And withdrawal sucks. I had some decaf today—my plan is to have a bit of caffeine for the next few days and then just enjoy decaf coffee, which is not completely devoid of caffeine, but the amount is pretty minimal. I love my coffee rituals—buying beans, grinding them, stirring them to evenly extract them. And I hate the lethargy and headache.
But I do enjoy even decaf, and I know the withdrawal syndrome will be over in a couple of days. Despite the fact that coffee does not appear to have serious risk in most people, it is definitely causing me some trouble, and I look forward to mitigating that.
And while I wait for the positive effects of quitting caffeine, I’m enjoying some of the benefits of being a dad on Fathers’ Day. This morning, in addition to my decaf, we had fresh bagels (because any other kind are useless), hand-sliced Nova lox, and the usual additions such as Muenster cheese, sliced onion, and of course hand-packed cream cheese. And I stayed up late last night making lockshen kugel and despite not having a recipe, it didn’t come out too bad. I’m stuffed. Another advantage to decaf: my dad usually drinks it, and there are few things I enjoy more than coffee with my dad.
And I’m with my kiddo. We’re being decadent. We’re hanging out in the guest room watching Disney while she snacks on edamame and I eat some leftover kugel. She has a room full of toys, and yet has entertained herself for the last hour-and-a-half playing with a pile of balloons and a couple pieces of styrofoam packing.
PalKid finished kindergarten last week, and we had to cut off four inches of her hair (which doesn’t really look any shorter). Tomorrow she starts day camp, which means our morning routine together is over for now. But I have time planned for us this summer, if all works out. I’m taking her up to Canada for my usual gig as a camp doctor, and we’ve talked my folks into going up north with us for a week. By the end, she’ll be good and tired of her daddy. And she’ll be a first-grader. Everyone says kids grow up fast, but you never believe it changing a diaper in the middle of the night.
But one of the advantages of decaf is that tonight, after I tuck her in, I can pour myself a cup of coffee, look at pictures of my family, and think about what is past, or passing, or to come.