Archive for the 'doctor logic' Category

Sleep and Depression: More Links

Friday, March 7th, 2014

In 1995, hoping to improve my sleep, I decided to watch TV early in the morning, for reasons explained here. One Monday morning I watched tapes of Jay Leno and David Letterman that I’d made. Nothing happened. On Tuesday, however, I woke up and felt great: cheerful, eager and yet somehow calm. I had never felt so good so early in the morning. Monday had been a normal day, I had slept a normal length of time. The good feeling was puzzling. Then I remembered the TV I had watched. It had seemed so innocuous. The notion that 20 minutes of ordinary TV Monday morning could make me feel better Tuesday but not Monday seemed preposterous. Absurd. Couldn’t possibly be true.

Except for one thing. I had done something to improve my sleep. Plenty of research connected sleep and depression. That research made it more plausible that something done to improve sleep would improve mood. I went on to confirm the morning faces/mood linkage in many ways. The research connecting sleep and depression had been the first signs of a hidden mechanism (we need to see morning faces for our mood regulatory system to work properly) I consider very important.

Two new studies further connect sleep and depression. One of them found that people who sleep normal amounts of time are less influenced by genes associated with depression than those who sleep longer or shorter lengths of time. The other found that teenagers who sleep less than usual are at greater risk of depression.

The theories that psychiatrists have used to justify anti-depressants (e.g., “chemical imbalance”) do not explain the many connections between sleep and depression. Depression is associated with lots of bad things, unsurprisingly, but the association with bad sleep is especially strong. It is not easily explained away. You might think that if you are depressed you are more tired than usual and therefore sleep more/better than usual. The opposite is true.  All this might have generated, among psychiatric researchers, a search for a better theory — an explanation of depression that can explain the sleep/depression connections — but it hasn’t.

 

Who Tests the Genetic Testers? And the Experts?

Wednesday, January 15th, 2014

In the New York Times, a writer named Kira Piekoff, a graduate student in Bioethics, tells how she sent her blood to three different companies, including 23andMe, for genetic analysis and got back results that differed greatly. As usual, none of the companies told her anything about the error of measurement in their reports, judging from what she wrote. So she’s naive and they’re naive (or dishonest). Fine.

I’m unsurprised that a graduate student in bioethics has no understanding of measurement error. What’s fascinating is that the experts she consulted didn’t either, judging by what they said.

A medical ethicist named Arthur L. Caplan weighed in. He said:

The ‘risk is in the eye of the beholder’ standard is not going to work.We need to get some kind of agreement on what is high risk, medium risk and low risk. [Irrelevant -- Seth] If you want to spend money wisely to protect your health and you have a few hundred dollars, buy a scale, stand on it, and act accordingly.

As if blood sugar and blood pressure measurements aren’t useful. A good scale costs $15.

A director of clinical genetics named Wendy Chung said:

Even if they are accurately looking at 5 percent of the attributable risk, they’ve ignored the vast majority of the other risk factors — the dark matter for genetics — because we as a scientific community haven’t yet identified those risk factors.

She changed the subject.

J. Craig Venter, the famous gene sequencer, does not understand the issue:

Your results are not the least bit surprising. Anything short of sequencing is going to be short on accuracy — and even then, there’s almost no comprehensive data sets to compare to.

The notion that “anything short of [complete] sequencing” cannot be helpful is absurd, if I understand what “short on accuracy” means. He reminds me of doctors who don’t understand that a t test corrects for sample size. They believe any study with less than 100 subjects cannot be trusted.

I told a friend recently that I have become very afraid of doctors. For exactly the reason illustrated in these quotes, from well-known experts who are presumably much more competent than any doctor I am likely to see. The experts were unable to comment usefully on something as basic as measurement error. Failing to understand basics makes them easy marks — for drug companies, for example — just as the writer of the article was an easy mark for the experts, who managed to be quoted in the Times, making them appear competent. Surely almost any doctor will be worse.

Man Beats Prostate Cancer Without Surgery

Friday, January 10th, 2014

This story by investment blogger Mish Shedlock about a prostate cancer diagnosis illustrates the bias of doctors toward dangerous expensive treatments:

The biopsy showed I had cancer. My “Gleason Score” was 6. The surgeon who performed the biopsy strongly recommended surgery. He gave me a cost of $20,000.

Bad recommendation. Shedlock got rid of his cancer, as measured by PSA (Prostate Specific Antigen) tests, without surgery or any other expensive or dangerous treatment.

The surgeon said something else also highly misleading. He told Shedlock he was “10% cancerous”. When Shedlock repeated this to his oncologist,

The oncologist replied “That’s not correct. Of the 12 samples, only one had cancer and one was questionable. The cancerous sample was 10% cancerous.” Now that is a hell of a lot different than being 10% overall cancerous.

His oncologist seemed unfamiliar with data:

I informed the oncologist that I was going to have a PSA test every month. He commented something along the lines of “Why do you want to do that? Every six months is sufficient. The tests are not that reliable.”  . . . [I thought:] The more unreliable a test is, the more tests one should take to weed out erroneous outlier results.

This reminds me of the dermatologist I had in graduate school. After I tested the two medicines he had prescribed for my acne, and found that one of them didn’t work, and told him this, he said, “Why did you do that?” Haha.

The oncologist predicted that the cocktail that cured Shedlock “would not do [him] any good”.

I am sorry Shedlock does not name the doctors involved, as I did in a similar situation. I too avoided recommended surgery and my surgeon made highly misleading statements. Shedlock wrote about bad health care more generally here.

Thanks to Steve Hansen.

Dark Picture of Doctors

Monday, November 25th, 2013

A New York Times article about error in a risk calculator paints an unflattering picture of doctors:

1. The risk calculator supposedly tells you your risk of a heart attack, to help you decide if you should take statins. It overestimates risk by about 100%. The doctors in charge of it were told about the error a year ago. They failed to fix the problem.

2. The doctors in charge of the risk calculator are having trouble figuring out how to respond. The possibility of a simple retraction seems to not have occurred to them. As one commenter said, “That the researchers, once confronted with the evidence it was faulty, struggled with how to handle the issue is quite telling.”

3. In the comments, a retired doctor thinks the problem of causation of heart disease is very simple:

Statins . . . are only one component in the prevention and treatment of coronary artery disease. Item number one is to have a normal weight. Item two is never smoke. Item three is exercise. Four is to eat an intelligent diet. Five is to remove stress from your life as much as practical. If everybody did these five things (all of which are free), the incidence of coronary artery disease would plummet and many fewer would need statins.

This reminds me of a doctor who told me she knew why people are fat: They eat too much and exercise too little. She was sure.

4. In the comments, a former medical writer writes:

Several years ago, I wrote up, as internal reports, about two dozen transcripts recorded at meetings with local doctors that a major drug company held all around the country. The meetings concerned its statin. Two ideas presented at these meetings by the marketing team, and agreed with by the physician attendees, were: 1) the muscle pain reported by patients was almost never caused by the statin but was the result of excessive gardening, golfing, etc; 2) many children should be prescribed a statin and told that they would have to take the drug for life.

5. Another doctor, in the comments, says something perfectly reasonable, but even her comment makes doctors look bad:

I am a physician and I took statins for 2 years. Within the first 6 months, I developed five new serious medical problems, resulting in thousands of dollars spent on treatments, diagnostic tests, more prescription medications, and lost work. Neither I nor any of my 6 or 7 different specialists thought to suspect the statin as the source of my problems. I finally figured it out on my own. It took 3 more years for me to get back to my baseline state of health. I had been poisoned. I see this all the time now in my practice of dermatology. Elderly patients are on statins and feel lousy, some of whom are also on Alzheimer’s drugs, antidepressants, Neurontin for chronic pain, steroids for fibromyalgia. These poor people have their symptoms written off as “getting older” by their primary physicians, most of whom I imagine are harried but well intentioned, trying to follow guidelines such as these, and so focused on treating the numbers that they fail to see the person sitting in front of them. The new guidelines, with their de-emphasis on cholesterol targets, seem to tacitly acknowledge that cholesterol lowering has little to do with the beneficial actions of statins. The cholesterol hypothesis is dying. If statins “work” by exerting anti-inflammatory benefits, then perhaps we should seek safer alternative ways to accomplish this, without subjecting patients to metabolic derangement.

6. A patient:

My previous doctor saw an ultrasound of my Carotid Artery with a very small buildup and told me I needed to take crestor to make it go away. That was four years ago and I still suffer from some memory loss episodes as a result. The experience was terrible and he’s toast because he denied it could happen.

7. A bystander:

For the past couple of years my job has involved working with academic physicians at a major medical school. After watching them in action — more concerned with personal reputation, funding and internecine politics than with patients — it’s a wonder any of us are limping along. And their Mickey Mouse labs and admin organizations can barely organize the annual staff holiday potluck without confusion and strife. So these botched-up results don’t surprise me at all.

I am not leaving out stuff that makes doctors look good. Maybe this is a biassed picture, maybe not. What I find curious is the wide range of bad behavior. I cannot explain it. Marty Makary argued that doctors behave badly due to lack of accountability but that doesn’t easily explain ignoring a big error when pointed out (#1), an immature response (#2), a simplistic view of heart disease (#3), extraordinary callousness (#4) and so on.  In her last book (Dark Age Ahead), Jane Jacobs wrote about failure of learned professions (such as doctors) to police themselves. Again, however, I don’t see why better policing would improve the situation.

Thanks to Alex Chernavsky.

Saturated Fat and Heart Attacks

Friday, October 25th, 2013

After I discovered that butter made me faster at arithmetic, I started eating half a stick (66 g) of butter per day. After a talk about it, a cardiologist in the audience said I was killing myself. I said that the evidence that butter improved my brain function was much clearer than the evidence that butter causes heart disease. The cardiologist couldn’t debate this; he seemed to have no idea of the evidence.

Shortly before I discovered the butter/arithmetic connection, I had a heart scan (a tomographic x-ray) from which is computed an Agaston score, a measure of calcification of your blood vessels. The Agaston score is a good predictor of whether you will have a heart attack. The higher your score, the greater the probability. My score put me close to the median for my age. A year later — after eating lots of butter every day during that year — I got a second scan. Most people get about 25% worse each year.  My second scan showed regression (= improvement). It was 40% better (less) than expected (a 25% increase). A big increase in butter consumption was the only aspect of my diet that I consciously changed between Scan 1 and Scan 2.

The improvement I observed, however surprising, was consistent with a 2004 study that measured narrowing of the arteries as a function of diet. About 200 women were studied for three years. There were three main findings. 1. The more saturated fat, the less narrowing. Women in the highest quartile of saturated fat intake didn’t have, on average, any narrowing. 2. The more polyunsaturated fat, the more narrowing. 3. The more carbohydrate, the more narrowing. Of all the nutrients examined, only saturated fat clearly reduced narrowing. Exactly the opposite of what we’ve been told.

As this article explains, the original idea that fat causes heart disease came from Ancel Keys, who omitted most of the available data from his data set. When all the data were considered, there was no connection between fat intake and heart disease. There has never been convincing evidence that saturated fat causes heart disease, but somehow this hasn’t stopped the vast majority of doctors and nutrition experts from repeating what they’ve been told.

Assorted Links

Monday, September 30th, 2013

Thanks to Alex Chernavsky.

Progress in Psychiatry and Psychotherapy: The Half-Full Glass

Saturday, September 28th, 2013

Here is an excellent introduction to cognitive-behavioral therapy (CBT) for depression, centering on a Stanford psychiatrist named David Burns. I was especially interested in this:

[Burns] currently draws from at least 15 schools of therapy, calling his methodology TEAM—for testing, empathy, agenda setting and methods. . . . Testing means requiring that patients complete a short mood survey before and after each therapy session. In Chicago, Burns asks how many of the therapists [in the audience] do this. Only three [out of 100] raise their hands. Then how can they know if their patients are making progress? Burns asks. How would they feel if their own doctors didn’t take their blood pressure during each check-up?

Burns says that in the 1970s at Penn [where he learned about CBT], “They didn’t measure because there was no expectation that there would be a significant change in a single session or even over a course of months.” Forty years later, it’s shocking that so little attention is paid to measuring whether therapy makes a difference. . . ”Therapists falsely believe that their impression or gut instinct about what the patient is feeling is accurate,” says May [a Stanford-educated Bay Area psychiatrist], when in fact their accuracy is very low.

When I was a graduate student, I started measuring my acne. One day I told my dermatologist what I’d found. “Why did you do that?” he asked. He really didn’t know. Many years later, an influential psychiatrist — Burns, whose Feeling Good book, a popularization of CBT, has sold millions of copies — tells therapists to give patients a mood survey. That’s progress.

But it is also a testament to the backward thinking of doctors and therapists that Burns didn’t tell his audience:

–have patients fill out a mood survey every day
–graph the results

Even more advanced:

–use the mood scores to measure the effects of different treatments

Three cheap safe things. It is obvious they would help patients. Apparently Burns doesn’t do these things with his own patients, even though his own therapy (TEAM) stresses “testing” and “methods”. It’s 2013. Not only do psychiatrists and therapists not do these things, they don’t even think of doing them. I seem to be the first to suggest them.

Thanks to Alex Chernavsky.

Eric Kandel Sheds Light On Who Wins Nobel Prizes

Saturday, September 14th, 2013

The most interesting thing about the Nobel Prize in Medicine is its predictable irrelevance to major health problems. Year after year, the prize-winning work has failed to reduce heart disease, cancer, depression, stroke, diabetes, schizophrenia, and so on. Another interesting thing about the Nobel Prize in Medicine is that Eric Kandel, a Columbia Medical School professor, managed to win one. In 1986, a book called Explorers of the Black Box: The Search for the Cellular Basis of Memory by Susan Allport told how Kandel tried to take credit for other people’s discoveries. Not a pretty picture. Yet in 2000 he won a Nobel Prize for those or very similar discoveries. Did Allport exaggerate? Did her sources deceive her? Did Kandel — contrary to what Allport’s book seems to say — deserve a Nobel Prize?

I can’t answer these questions. However, a recent article by Kandel (“A New Science of Mind”) in the New York Times sheds light on how well he understands medicine and neuroscience. Not well, it turns out. He writes:

We are nowhere near understanding [psychiatric disorders] as well as we understand disorders of the liver or the heart.

Actually, our understanding of liver and heart disorders is close to zero, matching our understanding of psychiatric disorders. If we had some understanding of heart disease, for example, we would know why heart disease is much rarer in Japan than in the United States. (more…)

“The Cause of Ulcers is Bacteria” Makes as Much Sense as “The Cause of Car Accidents is Cars”

Wednesday, September 11th, 2013

If I were to look at you, and say, in a serious tone of voice, “The cause of car accidents is cars”, you’d think I’m nuts. It’s not a useful statement. Yet many medical and science experts — including the people who award the Nobel Prize in Physiology or Medicine — believe it is helpful to say “the cause of ulcers is bacteria”. The two statements are similar because only a small percentage of cars get in accidents and only a small percentage of people infected with H. pylori, the bacterium that supposedly “causes ulcers”, get ulcers. A helpful investigation of what causes ulcers would figure out the crucial difference(s) between those infected with H. pylori who don’t get ulcers (almost all) and those who do (very few).

I recently encountered the “the cause of ulcers is bacteria” twice in one day. Once in a book review by John Timpane:

Barry Marshall, who discovered what causes stomach ulcers, played fast, loose, and messy with his methods and data. He was right, and got the right answer, and now we know.

(Timpane is right about the “fast, loose, and messy” part. Marshall ingested a large number of H. pylori. He failed get an ulcer — and claimed the outcome supported his view that H. pylori causes ulcers.) And once in The New Yorker, in a long article about the benefits of microbes, especially H. pylori, by Michael Specter:

In 1982, to the astonishment of the medical world, two scientists, Barry Marshall and J. Robin Warren, discovered that H. pylori is the principal cause of gastritis and peptic ulcers.

Should I expect science journalists to understand causality? Maybe not. But it is interesting that the people who award the Nobel Prize in Medicine and “the medical world” do not understand it.

How to Detect Dementia

Friday, July 19th, 2013

Dementia is common. You might think that doctors and neuropsychologists would have a good understanding of how to detect it. Judging from a recent New York Times article, they don’t. The article is based on a study that found that people who report memory problems not detected by a standard test turn out to be more likely to end up with dementia (measured by a standard test) than those that don’t. This isn’t surprising; what’s more revealing is how people who report memory problems have been treated in the past: their complaints have been dismissed. For example:

Patients like this have long been called “the worried well,” said Creighton Phelps, acting chief of the dementias of aging branch of the National Institute on Aging. “People would complain, and we didn’t really think it was very valid to take that into account.”

Doctors had no idea whether these complaints were valid but rather than admit this ignorance they . . . confabulated. They claimed, based on nothing, that the complaints were not valid. It reminds me of a surgeon telling me that research supported her claim that I needed surgery (for a hard-to-notice hernia). No such research existed. When I asked her what research? she said she would find it. She was bluffing, in other words. That’s just one doctor making up evidence. Here it has been a whole group of doctors.

The problem isn’t just confabulation. Apparently doctors in this area fail to understand basic principles of measurement. When Patient Y visits Doctor X and complains of memory problems, Doctor X gives Patient Y a series of memory tests. Only if Patient Y scores below normal range does Doctor X think that Patient Y’s complaint is “real”. For example:

The man complained of memory problems but seemed perfectly normal. No specialist he visited detected any decline. “He insisted that things were changing, but he aced all of our tests,” said Rebecca Amariglio, a neuropsychologist at Brigham and Women’s Hospital in Boston. 

Amariglio apparently fails to understand that a series of measurements on one person — which is what the man’s complaint was based on, comparing himself now to himself in the past — is going to be vastly more sensitive to change than a comparison of one person to other people. A reasonable response to a complaint of memory loss would be: This is hard to detect with a one visit. Let’s give you a sensitive test and have you come back in six months to see if you decline more than normal. Judging from the Times article, doctors still haven’t figured this out.

Speaking of memory decline, Posit Science still hasn’t sent me the data they promised to send me.

Thanks to Alex Chernavsky.

The Rise and Fall of Heart Disease

Friday, June 7th, 2013

Heart disease was once the number one killer in rich countries. Maybe it still is. Huge amounts of time and money have gone into trying to reduce it — statins, risk factor measurement (e.g., cholesterol measurement), telling people to “eat healthy” and exercise more, and so on. Unfortunately for the poor souls who follow the advice (e.g., take statins), the advice givers, such as doctors, never make clear how little they know about what causes heart disease. Maybe they don’t realize how little they know. (more…)

Hospitals and Their Employees: Stuck in the 1800s

Thursday, May 30th, 2013

An article in the New York Times describes how difficult it has been for hospital administrators to get their employees to wash their hands. Hospital-acquired infections are an enormous problem and cause many deaths, yet “studies [in the last 10 years] have shown that without encouragement, hospital workers wash their hands as little as 30 percent of the time that they interact with patients.” Hospitals are now — just now — trying all sorts of things to increase the hand-washing rate. The germ theory of disease dates from the 1800s. Ignasz Semmelweis did his pioneering work, showing that hand-washing dramatically reduced death rate (from 18% to 2%), in 1847.

So hospitals are only now (in the last few years) grasping the implications of facts and a well-established theory from the 1800s. What goes unsaid in the usual discussion of how awful this is — how dare doctors refuse to wash their hands!, a sentiment with which I agree — is how backward both sides of the discussion are. A discussion in which many lives are at stake.

The Times article now has 209 comments, many by doctors and nurses. The doctors, of course, went to medical school and passed a rigorous test about medicine (“board-certified”). Yet they don’t know basic things about infection. (One doctor, in the comments, calls hand-washing “this current fad“.) They appear to have no idea that it is possible to improve the body’s ability to resist infection. I read all the comments. Not one mentioned two easy cheap low-tech ways to reduce hospital infections:

1. Allow patients to sleep well. The body fights off infection during sleep, but hospitals are notoriously bad places to sleep. Patients are woken up by nurses, for example. You might think that everyone knows sleep helps fight infection . . . but apparently not hospital administrators nor the doctors and nurses who commented on the Times article. It was in the interest of these doctors and nurses to suggest alternative solutions because they dislike washing their hands.

2. Feed patients fermented foods (or probiotics). Fermented foods help you fight off infections. I believe this is because the bacteria on fermented food are perfectly safe yet  successfully compete with dangerous bacteria. In any case, plenty of studies show that probiotics and fermented foods reduce hospital infections. In one study, “use of probiotics reduced the new cases of C. difficile-associated diarrhea by two thirds (66 per cent), with no serious adverse events attributable to probiotics.” Maybe this just-published article (Probiotics: a new frontier for infection control”) will bring a few people who work in hospitals into the 21st century.

That hospital administrators and their doctors and nurses — and, in this discussion, their critics — are stuck in the 1800s is clear enough. What is slightly less clear is that our understanding is better now than it was in the 1800s and some of the new knowledge is useful.

Thanks to Bryan Castañeda.

Oral Rehydration Therapy For Diarrhea

Monday, April 22nd, 2013

Oral rehydration therapy (ORT) is given to people (usually children) suffering from diarrhea, which before ORT was often fatal. It is very simple: The sufferer drinks water with sugar and salt ad libitum (as much as they want). You probably haven’t heard of ORT — at least, I hadn’t. Everyone has heard of antibiotics. Yet “in 10 years [ORT] saved more lives than penicillin had in 40.” Infant diarrhea was once (and may still be) the main cause of death in poor countries.

A history of its discovery supports several things I’ve said on this blog. One is Thorstein Veblen’s point about the disdain among professional scientists for useful research:

ORT might also have been developed long before 1968 but for the attitudes of the dominant medical establishment toward practical experimentation, which the Cholera Research Laboratory and the National Institutes for Health shared. Nalin believes that “the people at the lab … got kudos for the extent to which [their] work was not practical. As soon as it became practical it was discarded like a soiled towel–it was too common, too hands-on… so the prestige went to people who measured trans-intestinal fluxes or electrical currents”.

No one who has attended an elite law school, medical school, or graduate program in education will be surprised by this.

Another is the great resistance among the medical establishment to cheap and effective solutions:

The formidable and persistent ignorance of the Western medical establishment, which continues over twenty-five years after the discovery of ORT, is phenomenal. While its refusal to advocate ORT may be due in part to the notion that ORT is only necessary for people in the developing world, its actions appear to be driven also by financial considerations. Most hospitals do not train physicians in the use of ORT since they have no financial reason to do so. [I think "since" overstates what is known -- Seth] The use of intravenous therapy, which often involves keeping a dehydrated child overnight, assures [greater] insurance reimbursement. Sending children home with ORT would [reduce] profits. Furthermore, recent studies show that diarrhoeal illness among the elderly may incur even greater health care costs that could also be reduced by the use of ORT. At a time of heated discussion about cost-containment in health care, it seems all the more ironic and egregious that a superior, cheap, and proven therapy [fails to replace] a far more expensive one. Estimates based on the cost of hospitalizations and physician visits suggest that ORT could save billions of dollars annually.

As an example of the resistance of American doctors to a better therapy, an ORT researcher, who had used it on Apache reservations in America, told this story:

I had an anthropologist friend who adopted an Apache child from the [Arizona] reservation where we were working. He used to be the anthropologist on the reservation. And then he [left the reservation and] went to Arkansas to teach and the Apache child came down with severe diarrhea and he called me up and he said desperately, “Look, my son’s in the hospital and they’re giving him all sorts of intravenous fluids. The diarrhea’s not stopping, he’s losing weight, they’re not feeding him. I know that you did this work in Arizona [on the reservation] and it didn’t look like that. . . . Would you call this professor of pediatrics and just collegiately talk to him?” So I called up the professor and told him that in our experience with Apache children this is what we found and here’s the publication and so on. And he said to me, “Doctor, doctor, our [Arkansas] children are not the same as your [reservation] children”. He was treating an Apache child from the same reservation.

Shades of Downton Abbey (where Lady Sybil died because a London doctor was listened to instead of a rural doctor).

End-of-Life Medicine: Enormous Lack of Informed Consent

Friday, February 1st, 2013

A few weeks ago I blogged about undisclosed risks of medical treatments. Undisclosed risks are common. They might be the norm. The situation would be even worse — in some sense, much worse — if doctors knew of these risks and failed to tell their patients. It was unclear if doctors knew of the undisclosed risks I wrote about.

Recently Tyler Cowen quoted a newspaper story about Israeli doctors giving birth control injections to Ethiopian women immigrants ”without their knowledge or consent.” Every commenter thought this was repugnant.

The latest RadioLab podcast (“The Bitter End”) is about the dramatic difference between how doctors want to be treated when they are near death (they want no CPR, no ventilator, no dialysis, no surgery, no chemotherapy, no feeding tube, no antibiotics, nothing except pain medicine) and how the general public wants to be treated (most people want CPR, ventilator, dialysis, surgery, chemotherapy, feeding tube, antibiotics, and so on).

The RadioLab guys were puzzled by the difference.   (more…)

Guest Post: What Makes a Good Clinician?

Thursday, January 31st, 2013

This post is by Adam Clemans.

Marco Arruda, an MD and PhD in the Department of Pediatric Neurology at the Glia Institute (São Paulo, Brazil) is the author of a recent editorial in JAMA Pediatrics about the use of Triptan for headaches in children. There’s a lot of controversy because placebos work very well for headache — so much so that they often have to use some tricky methods to actually show a treatment effect with the real drugs.

In a recent article on Medscape, Dr. Arruda is quoted as saying: “Although placebo is the enemy of great clinical trials, it is likely the best friend of good clinicians.”

This makes me wonder what he thinks makes a good clinician. If Triptan and a placebo are equally effective, it is curious that anyone would skip the placebo and prescribe the drug, which has listed as side effects:

Anaphylactic shock, angina, angioedema, breast pain, colitis, coronary artery vasospasm, hemiplegia, hypertension, myocardial ischemia, MI, neuropathy, rash, seizure, syncope, tachycardia, ventricular fibrillation, ventricular tachycardia

Why does putting patients in harm’s way make one a good clinician?

Hard to Say Whether Medicine Does More Good Than Harm

Saturday, January 12th, 2013

A draft article by Spyros Makridakis about blood pressure and iatrogenics takes issue with the statement that “The treatment of hypertension has been one of medicine’s major successes of the past half-century.” Over the last half-century, the article says, the death rate for people with high blood pressure decreased by almost exactly the same amount as the death rate for people without high blood pressure. Apparently “one of medicine’s major successes” is a case where the health benefit no more than equaled the health cost — leaving aside what the treatment cost in time and money.

Because very high blood pressure (systolic > 180 mm Hg) is quite dangerous and blood pressure drugs really work, this is a surprising outcome. Makridakis points out that doctors start treating high blood pressure when it rises above  systolic = 140 mm Hg, a point when there is little or no increase in death rate. This article tells doctors to immediately prescribe drugs when systolic blood pressure is above 160. Yet death rate clearly increases only when systolic blood pressure is above 180. Makridakis concludes (as do I) that blood pressure drugs have significant health costs as well as benefits. The drugs are so often prescribed when they do no good and the costs are so high that the overall health costs of blood pressure treatment have managed to be as high as the overall benefits. Even when handed a relatively easy-to-measure problem (high blood pressure) and a relatively simple solution (blood pressure drugs), our health care system managed to achieve no clear gain. If this is “one of medicine’s major successes”, medicine is in bad shape.

The last paragraph of Makridakis’s article makes a surprising statement: “We strongly believe that medicine is extremely useful.” It does not explain this belief, which is contradicted by the rest of the article. I was puzzled. I wrote to the author: (more…)

Never Be Alone in a Hospital

Sunday, December 30th, 2012

The Health Care Blog post titled “The Empowered Patient”  by Maggie Mahar exists, as far as I can tell, because much hospital care has considerable room for improvement and many mistakes are made — for example, patients are given the wrong drug. One commenter (MD as Hell) said he has worked in hospitals more than 30 years and has some advice, including

  1. Never be alone in a hospital
  2. Never go to a hospital unless you have no alternative
  3. Do not let fear motivate you to be a consumer of any part of healthcare

In the comments, several doctors expressed their dislike of the whole idea of “patient participation”. For example,

Patients manage the process. Really? I’m sure your plumber or mechanic love you and this philosophy so much they hug you when you greet them.

Plumber and mechanic errors are not the #3 cause of death in America, as Marty Makary says about medical errors.

Here is another argument against patient participation:

The huge problem that barely anyone wants to talk about is [the assumption] that patient (and family ) participation are always (or even just mostly) beneficial. This is a completely unfounded assumption. Please read Dr. Brawley’s book “How we do harm” to read 2 long and IMHO representative anecdotes of patient/family centeredness resulting in net harm. . . . Lack of patient involvement and medical errors are hardly on top of the list of pressing flaws of the US health care system . . . Profit centeredness resulting in overtreatment of the insured and undertreatment of the underinsured are the main issues.

If medical errors are the #3 cause of death in America, they are one of the most serious flaws of the US health care system. The doctors who dislike patient participation in this comment section do not propose a better way to reduce mistakes, a better way to spend the time and mental energy required by patient participation. Maybe their annoyance is a good thing. Maybe they will be so annoyed they will reduce errors in other ways.

It is bizarre that patient involvement cannot be easily dismissed. I cannot think of another profession (accountants, bus drivers, carpenters, dentists, elementary school teachers, and so on) where anyone says never be alone with them. Sure, hospital patients are highly vulnerable but that vulnerability is no secret. It could have led to a system, similar to flying (airplane passengers are highly vulnerable), with an extremely low rate of fatal error. My own experience supports patient involvement. The biggest motivation for my self-experimentation, at least at first, was my self-experimental discovery that a powerful acne medicine my dermatologist had prescribed (tetracycline, an antibiotic) was no help. My dermatologist had shown no signs of considering this a possibility. When I told him about my experiment (varying the dose of the antibiotic) and the results (no change in acne), he said, “Why did you do that?” Later a surgeon I consulted about a tiny hernia was completely misleading about the evidence for her recommendation that I have surgery for it.

Few Doctors Understand Statistics?

Wednesday, December 12th, 2012

A few days ago I wrote about a study that suggested that people who’d had bariatric surgery were at much higher risk of liver poisoning from acetaminophen than everyone else. I learned about the study from an article by Erin Allday in the San Francisco Chronicle. The article included this:

At this time, there is no reason for bariatric surgery patients to be alarmed, and they should continue using acetaminophen if that’s their preferred pain medication or their doctor has prescribed it.

This was nonsense. The evidence for a correlation between bariatric surgery and risk of acetaminophen poisoning was very strong. Liver poisoning is very serious. Anyone who’s had bariatric surgery should reduce their acetaminophen intake.

Who had told Allday this nonsense? The article attributed it to “the researchers” and “weight-loss surgeons”. I wrote Allday to ask.

She replied that everyone she’d spoken to for the article had told her that people with bariatric surgery shouldn’t be alarmed. She did not understand why I considered the statement (“no need for alarm”) puzzling. I replied:

The statement is puzzling because it is absurd. The evidence that acetaminophen is linked to liver damage in people with bariatric surgery is very strong. Perhaps the people you spoke to didn’t understand that. The size of the sample (“small”) is irrelevant. Statisticians have worked hard to be able to measure the strength of the evidence independent of sample size. In this case, their work reveals that the evidence is very strong.

If the experts you spoke to (a) didn’t understand statistics and (b) were being cautious, that would be forgivable. That’s not the case here. They (a) don’t understand statistics and (b) are being reckless. With other people’s health. It’s fascinating, and very disturbing, that all the experts you spoke to were like this.

I have no reason to think that the people Allday talked to were more ignorant than typical doctors. I expect researchers to be better at statistics than average doctors. One possible explanation of what Allday was told is that most doctors, given a test of basic statistical concepts, would flunk. Not only do they fail to understand statistics, they don’t understand that they don’t understand. Another possible explanation is that most doctors have a strong “doctors do everything right” bias, even when it endangers patients. Either way, bad news.

Thirty Years of Breast Cancer Screening May Have Done More Harm Than Good

Sunday, November 25th, 2012

A recent op-ed in the New York Times by H. Gilbert Welch, a co-author of Overdiagnosis, describes a tragedy of ignorance and overconfidence. The current emphasis on regular mammograms began thirty years ago. They will prevent breast cancer, doctors and health experts told hundreds of millions of women. They will allow early detection of cancers that, if not caught early, would become life-threatening. The campaign was very successful. According to the paper cited by Welch, about 70% of American women report getting such screening.

It is now abundantly clear this was a mistake. If screening worked perfectly — if all of the cancers it detected were dangerous — the rate of late-stage breast cancer should have gone down by the amount that the rate of early-stage breast cancer went up. Over the thirty years of screening, the rate of (detected) early-stage breast cancers among women over 40 doubled, no doubt because of  screening. (Over the same period the rate of early-stage breast cancers among women under 40 barely changed.) In spite of all this early detection and treatment, the rate of late-stage breast cancer among women over 40 stayed essentially the same. All that screening (billions of mammograms), all that chemo and surgery and radiation, all that worry and time and misery — and no clear benefit to the women screened and those who paid for the screening, treatment, and so on. Roughly all of the “cancers” detected by screening and then, at great cost, removed, aren’t dangerous, it turns out.

Quite apart from the staggering size of the mistake and the long time needed to notice it, screening has been promoted with specious logic.

Proponents have used the most misleading screening statistic there is: survival rates. A recent Komen Foundation campaign typifies the approach: “Early detection saves lives. The five-year survival rate for breast cancer when caught early is 98 percent. When it’s not? It decreases to 23 percent.” Survival rates always go up with early diagnosis: people who get a diagnosis earlier in life will live longer with their diagnosis, even if it doesn’t change their time of death by one iota.

Did those making the 98% vs. 23% argument not understand this?

I applaud Welch’s research, but his op-ed has gaps. A unbiased assessment of breast cancer screening would include not only the (lack of) benefits but also the (full) costs. Treatment for a harmless “cancer” may cause worse health than no treatment. Maybe chemotherapy and radiation and surgery increase other cancers, for example. What about the effect of all those mammograms on overall cancer rate? Welch fails to consider this.

Welch also fails to make the most basic and important point of all. To reduce breast cancer, it would be a good idea to learn what environmental factors cause it. (For example, maybe poor sleep causes breast cancer.) Then it could be actually prevented. Much more cheaply and effectively.  Yet the Komen Foundation and the Canadian Breast Cancer Foundation say “race for the cure” instead of trying to improve prevention.

 

Assorted Links

Saturday, November 24th, 2012

Thanks to Paul Nash, Grace Liu and Anne Weiss.