A Healthy Sense Of Urgency. (registration required)

This article should help everyone reevaluate their priorities.

Again I will use MQ's words to stimulate a rant:

It was the role of the docs' defense team to convince the jury (and I agree here) that not providing the CT scan was appropriate care.

The defense team failed. And you blame the plaintiff's lawyer for effectively arguing his case.

If only people who feel that they've been the victims of medical errors would hire incompetent lawyers! That's the solution to the malpractice.

So MQ, you agree that the physicians made the correct decision. Then you blame the defense lawyers.

This is my problem. Malpractice cases should not be a game between competing lawyer teams. My lawyer is better than your lawyer!

As original conceived, tort cases should arrive at truth. The goal of the law (not the practice unfortunately) is to provide justice.

I, and my physician readers, are interested in justice and equity. If I commit malpractice, the patient should receive a reasonable compensation.

Where we differ, and where I differ with the trial lawyer lobby, is in the venue for achieving justice. I shudder when I think of malpractice cases as a battle of wits between lawyers. They can become battlegrounds of sophistry, hyperbole, and obfuscation.

Trial lawyers who use these techniques can become rich, and even run for President. But I contend that the public suffers from this perversion of the tort philosophy.

We need a better method for judging claims. We need a method which looks at the data dispassionately, and seeks truth. We do not have that method in 2004.

Several readers have written asking for my opinion on the antibiotic breast cancer link. Here is the Washington Post article about the study - Antibiotics May Raise Risk for Breast Cancer

The first-of-its-kind study of more than 10,000 women in Washington state concluded that those who used the most antibiotics had double the chances of developing breast cancer, that the association was consistent for all forms of antibiotics and that the risk went up with the number of prescriptions, a powerful indication that the link was real.

A variety of experts quickly cautioned, however, that the findings should not stop women from taking the often lifesaving drugs when needed to treat infections. There could be other explanations for the association, and much more research is needed before scientists understand what the surprising results mean, they said.

"This is not saying that women should stop taking antibiotics. Women should take antibiotics for infections," said Stephen H. Taplin, a senior scientist at the National Cancer Institute who helped conduct the study. "We need to follow up and find out if this is a real association."

Nevertheless, the consistency of the findings in a study with such careful methodology could indicate that antibiotic use is an important, previously unrecognized risk factor for breast cancer, experts said.

Antibiotics could increase the risk for breast cancer by, for example, affecting bacteria in the digestive system in ways that interfere with the way the body uses foods that protect against cancer, experts said. Another possibility is that antibiotics increase the risk by affecting the immune system.

Even if it turns out that antibiotics do not increase the risk for breast cancer, the finding is likely to be important because it could lead to the discovery of whatever it is about women who use the drugs that appears to make them prone to the disease, researchers said. "This has opened up a picture that people had not been thinking about," Taplin said. "The important thing is more research and asking more questions about what it could be."

My thoughts:

• This study reports an epidemiologic association. Associations are statistical findings which suggest, but do not prove linkage.
• We should classify this article are hypothesis generating. We now require more studies to examine this new hypothesis.
• The hypothesis may persist in follow up studies. If so, then we need further investigations to understand why there is an association.
• The positive side of this article is that it should remind everyone that antibiotics have clear indications. We should use them for bacterial infections and not use them for viral infections.
• This article should not change how we treat patients, but it may make women more receptive to not having an antibiotic prescription. It may decrease the demand for antibiotics for viral upper respiratory infections.

Overall, this article is interesting, but should not be over interpreted. We do not know that antibiotics cause breast cancer. We only know that one epidemiologic study found an association.

Each time I find another of these cases I become more astonished. Thanks to Overlawyered for finding them. Doctors on hook for $5M

On December 4, 1998, 11-month old Jack Sprague, while with his babysitter, suffered a subdural hematoma that has left him disabled. A Maryland jury just awarded $5 million against three doctors who saw Jack a couple of weeks earlier--the theory being that if they had performed a CT scan on the infant, the parents would have discovered the babysitter's alleged abuse earlier, preventing the injury. .... Never mind that all three doctors diagnosed the asymptomatic infant as healthy: "What harm could it have done to do a CAT scan?" a juror asked. Well, even aside from the cost, and the risk of an anesthetic on an infant, doctors warn against unnecessary CAT scans to children because of the radiation exposure. How many healthy children will end up with cancer because of defensive medicine in response to this verdict?

Just another example of the problem of our tort system. This case makes no medical sense. The lawyer's argument defies evidence based medicine (the cry that I keep getting as to the solution to the malpractice problem). I use this case to point out that many cases having nothing to do with evidence as physicians define evidence. Outrageous!!!

No ranting - just a link - Pop That Pill This is how the article ends - the leadup is worthwhile also -

Is all of this bad? Not entirely. There is some notion of empowerment that goes along with being a medical consumer rather than a mere patient. Sure, drug companies are trying to persuade you, but that in itself means they are investing you with the power of decision-making. It means you are being emboldened to discuss alternatives with your doctor without being concerned that you will be patronized, as patients routinely were in the Marcus Welby era. But with empowerment comes increased responsibility. How many people have the insight or time to look at the published research before confronting their doctors with what they think is the drug they ought to be taking?

One doctor told me he's gotten tired of arguing with those of his patients who insist on an inferior or inappropriate drug because they liked the advertisement. "I don't make a case for or against individual treatments anymore," he said, "no matter how much I may disagree, It takes away time I need to deal with other patients. I just flat out give my opinion, and they can take it or leave it. But considering that I'm the one with the M.D., if I were the patient, I'd listen up."

Are there benefits to having a more informed patient base? "Informed is a loaded word," this doctor said, "Informed about what? The ads usually end off by saying, 'Ask your doctor,' but the message they're really conveying is, 'Tell your doctor.'"

Antibiotic resistance represents a significant threat now, and in the future. Giving antibiotics for non-bacterial infections causes much of the problem. Physicians have a dilemma when patients have bronchitis. We just do not know whether whether we should prescribe antibiotics.

A new study suggests that we may be able to use a blood test to help with that decision. New test shows promise at reducing unnecessary antibiotic use

After the blood test results were revealed, the researchers then advised the doctors to prescribe antibiotics only if the blood level of the chemical marker, called procalcitonin, was above a certain level.

The rate of antibiotic prescriptions foreseen by the doctor was similar in both groups before the blood test results were disclosed.

But once test results were known, antibiotic prescriptions dropped almost in half. A total of 99 patients in the comparison group got antibiotics, compared with 55 in the blood test group.

Antibiotics were given to 22 patients with a blood test showing low levels of the chemical marker. Doctors often prescribe antibiotics to people with severe viral infections because viruses can damage the airways enough to encourage a subsequent life-threatening bacterial infection.

"Importantly, withholding antibiotic treatment was safe and did not compromise clinical and laboratory outcome," said the study, led by Dr. Beat Muller at the University of Basel.

Dr. Marc Siegel, a professor of medicine at New York University School of Medicine, said the study convinced him the procalcitonin marker may help doctors, but larger studies are needed to determine if it is safe to withhold antibiotics from high-risk patients.

The danger of missing a severe or progressing bacterial infection is too great to rely solely on the blood test, Siegel said. "You worry about antibiotic resistance, but you also worry about patients dying," he said.

Interesting! I hope we do see more studies on this test.

Prognosis: Index for Heart Risk Shows Merit

Many commentors (and this author) wave the flag of evidence based medicine to marshall arguments. Often we wave this flag without really understanding what the phrase means. We have 2 levels of evidence - efficacy and effectiveness.

Efficacy and effectiveness reflect the success of an intervention when implemented according to intervention guidelines under optimal conditions or in real-world situations, respectively.

- RE-AIM Framework: Efficacy/Effectiveness of Health Behavior Interventionsl

In that context, investigators performed an important effectiveness study on the importance of following guidelines in ACS which derive from efficacy studies. Combined Medical Therapy Improves Survival After Acute Coronary Syndromes. This study is very important because sometimes efficacy does not translate to effectiveness. In this study it does!

Use of all evidence-based therapeutic agents, when indicated, greatly reduces 6-month mortality in patients with acute coronary syndromes, according to a report in the February 17th rapid access issue of Circulation: Journal of the American Heart Association.

Several pharmacological agents have been shown to reduce mortality in patients with acute coronary syndromes, the authors explain, but the impact of their combined administration on clinical outcomes has not been studied previously.

Dr. Debabrata Mukherjee and colleagues from the University of Michigan in Ann Arbor examined the impact on 6-month survival of combined antiplatelet drugs, beta-blockers, ACE inhibitors, and lipid-lowering agents in 1358 consecutive patients with acute coronary syndromes.

Patients who received all indicated medications had only 10% of the mortality risk of patients who received none of the indicated medications, the investigators report.

The mortality risk was reduced by 83% among patients who used 3 of 4 medications indicated, by 82% among patients who used 1 of 2 medications indicated (or 2 of 3 or 4 indicated medications), and by 64% among patients who used 1 of the 3 or 4 medications indicated, the results show.

"Patients presenting with ACS represent an important high-risk cohort, where secondary vascular disease prevention is likely to be particularly effective and cost-effective," Dr. Mukherjee told Reuters Health.

This is certainly an important study. As I have written previously, our research group is focusing on methods to help physicians adhere to well accepted guidelines. This article reinforces the importance of our research. When we see such dramatic effectiveness results, it emphasizes the importance of helping physicians follow rational guidelines.

"His tactics in winning cases using an unreliable tool in cerebral palsy cases demonstrate once more the triumph of junk science in the courtroom, and of how unreliable the jury system is in judging malpractice cases."

If the defense (the medical community) couldn't demonstrate that Edwards' methods were "junk" (and the patients weren't ahrmed), then the victim of the alleged malpractice deserved to win. Are you insinuating that juries are too stupid to make decisions in malpractice cases? What about murder cases?

With the current error rates in treatment decisions (~45% of the time) and with the needless death of tens of thousands of Amercans per year as a result of medical errors - and only a SMALL percentage of them ever seeing a court - the idea that docs are the helpless victims in this is myopic.

I just had to copy this comment - because it defines our problem exactly! Yes, I do believe that most juries are too unsophisticated to evaluate malpractice cases. These cases are often extremely technical, and require understanding scientific evidence.

Physicians are not receiving juries of their peers. The junk science which Edwards uses would not pass muster in any scientific medical journal. We (physicians) are taught to evaluate evidence carefully. Juries have no such training. Lawyers must disregard the scientific evidence in such cases, and replace it with emotional appeals and sophistry. That is exactly what distresses me.

I cannot speak about murder trials. My impression is that trial lawyers use evidence selectively in murder trials also (e.g., the jury ignoring the DNA evidence in the OJ trial).

When a physician's career is on the line (and sometimes malpractice cases are that serious), then we need a higher standard of judging than our current system.

Most critics of physicians quote the flawed medical errors study. But even if that study were true (and I believe it greatly exaggerated), our current malpractice system does nothing to address errors. The randomness of awards and suits does not change practice for the better.

Rather we need a system that makes physicians accountable and provides fair compensation to patients. We do not need lawyers raking in a high percentage of malpractice settlements.

The commentor and I clearly have fundamental differences in how we view malpractice. I believe that a better system would reward more patients and challenge more physicians to fix our current system. The problem is that for us to really fix the current system we would need dramatic changes in reimbursement for medical care.

But then, these issues occupy a central theme of this blog almost daily. Daily readers know my positions. I am just so frustrated about the damage that malpractice attorneys do to health care that my fingers are obliged to type and type. Posted by at 12:42 PM | Comments (16) | TrackBack (0)

Must I Have Another Glass of Water? Maybe Not, a New Report Says

We have previously discussed this issue, but this report does a nice job of putting the recommendations into perspective.

Pricing Drugs

WITH THE MEDICARE prescription drug program projected to cost $134 billion more than originally planned, it's hardly surprising that Congress is talking price controls. Rep. Nancy Pelosi (D-Calif.), the House minority leader, and Thomas A. Daschle (D-S.D.), her Senate counterpart, have already called for the government to negotiate prices on behalf of the private companies that will be buying drugs for Medicare recipients. Others have revived the idea of reimporting drugs from Canada. Pharmaceutical executives are braced for a price-control movement that may take off -- and succeed -- at any time.

Drug pricing remains an easy target for politicians. I agree that many drugs carry prices that I consider outrageous. When we prescribe drugs for patients in our clinics, I generally consider price as part of the decision making. Several examples are relevant here:

• I almost never allow Nexium, because other cheaper PPIs work just as well - at much lower cost
• We use captopril bid for hypertension rather than a more expensive ACE inhibitor
• We use ACE inhibitors rather than ARBs for price considerations

We are handicapped often by inadequate information. The Washington Post understands!

Finally, markets don't work well without correct information. If Congress really cares about making sure drugs are used in the most effective and most economical ways possible, it should put more effort into ensuring that doctors and patients know enough about the drugs they are taking. Recent studies have shown that some older drugs may be just as effective as newer, more expensive drugs -- drugs for high blood pressure, most famously, but also some antibiotics and antidepressants. Indeed, the vast majority of new and more expensive drugs -- two-thirds, according to the FDA -- use active ingredients already on the market. Yet there is no systematic testing to measure their comparative effectiveness. Although Congress, in the Medicare legislation, authorized $50 million for the tiny Agency for Healthcare Research and Quality to do exactly that, the figure has disappeared from the budget. Before Congress starts setting prices, more should be done to ensure that the public and medical professions have access to good information and that older and generic drugs are used whenever possible.

This is a great quote. The reference is tangential - I was just reading a review of a book on greatness. But I love this quote, and will add it to my quote section.

One of Murray’s favorite ideas is contained in a quip he credits to his late colleague Richard J. Herrnstein: “It is easy to lie with statistics, but it’s a lot easier to lie without them.”

Or how inconsistent our politicians are. This column documents the Democrats' inconsistency on Medicare. I am not implying that the Republicans are any better when it comes to the political process. Patient welfare will always remain secondary to political gain. Medicare hypocrisy

What's wrong with the new Medicare bill? Nothing that a little honesty couldn't cure. A recent Wall Street Journal article suggests that the problem is not so much the substance but the failure of Republicans to rise up in defense of the measure. Since the day the bill was passed, Democrats, labor unions and seniors from retirement villages have been holding rallies and press conferences to scream about how the law is either "scamming" seniors or cheating them out of more generous private-sector coverage in order to pay off "Big Pharma and insurance companies."

They are also annoyed that the drug benefit only pays for half of all drug costs and begins two years from now — not immediately. They want the pharmacy benefit management companies in the law to be replaced by Medicare price controls and a national drug list. Some disgruntled Republicans aren't helping matters much by saying "I told you so" after learning that the Bush administration's estimate of adding a drug benefit to Medicare exceeded the Congressional Budget Office (CBO) number by more than 25 percent.

To paraphrase Mark Twain, let's get the facts straight and then distort them as we please. As an article in Health Affairs reports, the president "proposed an outpatient prescription drug benefit to be offered under a new voluntary Part D of Medicare ... Medicare would pay half the cost of covered drugs ? The drug benefit would be administered by a [private] pharmacy benefit manager." To help seniors maintain more generous private-sector coverage, "the president's proposal had incentives for employers to keep [drug coverage]. Medicare would pay employers 67 percent of the premium subsidy costs it would have incurred if retirees had enrolled in Part D instead."

Sound familiar? This proposal was supported by virtually every Democrat. But it wasn't President Bush's plan; it was Bill Clinton's. And it had three big differences. First, it was scheduled to kick in four years after it was to pass in 1999, not in two as the Bush plan anticipates. Second, it covered a lot fewer people. And third, the Clinton plan didn't cover catastrophic drug spending; it capped government spending at about $2,500 per senior with some adjustment for inflation. The Bush plan covers all drug costs over $3,000 a year.

I hope you read that excerpt and the remainder of the article. The Medicare bill is flawed. Virtually every bill passed by Congress is flawed. We can always find and exploit the flaws.

What we should (and apparently never will) do is to evaluate the pros and cons and weigh them to decide on whether a bill is worthwhile. I believe that on the whole (the forest view) this is a good bill. If I focus on trees, of course I see some that should be cut down.

I rant so often about this topic. But it is important, and a great dilemma. U.S. Is Working to Make Painkillers Harder to Obtain

Top DEA officials confirm that the agency is eager to change the official listing of the narcotic hydrocodone -- which was prescribed more than 100 million times last year -- to the highly restricted Schedule II category of the Controlled Substances Act. A painkiller and cough suppressant sold as Lortab, Vicodin and 200 generic brands, hydrocodone combined with other medications has long been available under the less stringent rules of Schedule II

The DEA effort is part of a broad campaign to address the problem of prescription drug abuse, which the agency says is growing quickly around the nation. But the initiative has repeatedly pitted the agency against doctors, pharmacists and pain sufferers, and it is doing so again with the hydrocodone proposal.

Pain specialists and pharmacy representatives say that the new restrictions would be a burden on the millions of Americans who need the drug to treat serious pain from arthritis, AIDS, cancer and chronic injuries, and that many sufferers are likely to be prescribed other, less effective drugs as a result.

If the change is made, millions of patients, doctors and pharmacists will be affected, some substantially. Patients, for instance, would have to visit their doctors more often for hydrocodone prescriptions, because they could not be refilled; doctors could no longer phone in prescriptions; and pharmacists would have to fill out significantly more paperwork and keep the drugs in a safe. Improper prescribing would carry potentially greater penalties.

This issue has no easy solution. Patients will suffer under the new rules. Abusers will figure out ways to obtain drugs. Physicians will get caught in the middle. But you know the story.

The entire article is well done, and describes both sides of the issue. I particularly like this quote:

Susan Winkler of the American Pharmacists Association said her organization is concerned that the "ripple effects" would be substantial and negative.

"Our members and doctors would have increased liability if [hydrocodones] are rescheduled, and that will inevitably reduce prescribing," she said. "We urge the DEA to make sure their decision is based on science and will make the situation better, not worse."

And rarely are these decisions based solely on science.

Eat Your Salmon

Staying out of the sun and quitting smoking are both good ideas. But now some scaremongers want to add salmon to the list of things we all should avoid to reduce our risk of cancer.

Yes, salmon. The heart-healthy fish that's also supposed to make you smarter stands accused of causing cancer. A study published in Science magazine last month says that salmon raised on farms in the U.S. and Europe has higher levels of pollutants than salmon caught in the wild. It recommends eating farmed salmon just once a month.

There are a number of fishy things about this study, starting with the fact that the proven health benefits of eating salmon far outweigh the risk of cancer. In response to the report, the Food and Drug Administration says that "consumers need not alter consumption of farmed or wild salmon at this point in time." Britain's food watchdog agency also rose to salmon's defense, saying the levels of pollutants reported in the study are within internationally recognized safety limits.

Sometimes scientists perform solid studies but have unreasonable extrapolations of the data. From this report, we can surmise that to be the case here. I will not stop eating salmon!