Denialism Blog

Author: denialism_bv2x6a

  • Who's your hospitalist?

    Me: Hi, I’m Dr. Pal and I’ll be taking care of you here in the hospital.
    Patient: Where the hell is my real doctor?
    Me: He’s at the office seeing patients. He doesn’t come to the hospital anymore.
    Patient: Why the hell not?
    Me: Well, it’s complicated, but it’s getting harder and harder for doctors to pay their overhead. They have to see more and more patients, and in the time it takes to come to the hospital and see one patient, he can see 5 or 6 in the office.
    Patient: What’s wrong with him just getting up earlier?

    OK, time for a brief lesson on modern medical practice. First of all, I’m an internist. In the old model, an internist sees patients both in the office and in the hospital. Over the last decade or so, there has been a shift in practice. Fewer and fewer outpatient primary care doctors see their own patients in the hospital. Most now use “hospitalists”, internists who specialize in taking care of hospitalized patients.

    There are several reasons for this.

    First, hospitalized patients are much sicker than they used to be. To meet the “severity of illness”, and “intensity of service” requirements, you have to be pretty darn sick. This means that hospital care is more complex and specialized. Still, it’s not impossible to keep up with both outpatient and inpatient medicine.

    Second, there are the financial pressures. Margins are very thin in small practices. Medicare pays me perhaps seventy bucks to see a patient. In the time it would take me to go to the hospital, I could have seen a whole lot of patients, and seeing a hospital patient doesn’t pay all that much more. Not only that, but to pay the bills, you have to see lots and lots and lots of patients, which leaves even less time for other things, such as family, eating, urinating.

    I’m in a unique situation, in that I need to be at the hospital every day to teach, so seeing my own patients is no big deal. But for most internists, it’s becoming impossible. Taking care of hospital patients is not just the 10 or 15 minutes at the bedside; it’s the paperwork, phone calls, and pages; the discharge planning, the specialists. Each hospital patient is more work than any 5 office patients, for the same pay.

    Where does that leave patients?
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  • Cancer 102

    In Cancer 101, I gave some basics to understanding cancer. A commenter asked a good question, and our next lesson will attempt a simple answer.

    The question regarded how a pathologist can tell if a cancer is “invasive” by looking at a specimen. Well, depending on the specimen, the answer changes, but let’s use the colon as an example. Most colon cancers start out as benign polyps. Eventually the cells in the polyp can become malignant, and after that, they can they can begin to grow through layers of normal cells.

    Here is a diagram of a cancer of the colon at various stages. As you can see, at a certain point, the cancer begins to grow through each layer. The ability to grow through, or invade, other layers is one of the things that makes cancers behave in a nasty manner.

    i-879e97c9f33a541f1465fb682da71e1e-cancermicro.jpgHere is a piece of colon cancer under the microscope. This could have been from a biopsy of a polyp, or from a tumor completely removed by a surgeon. The stripe of light purple cells labeled “normal muscle layer” should extend across uninterrupted. Instead, a glob of darker purple cells is growing through the muscle layer, destroying it. Once the cancer cells get to a blood vessel, they can go anywhere in the body (metastasize). That’s bad.

    I hope that’s helpful.

  • Ayurvedics Are Secretly Using Pb®

    Friends, many of you know the miraculous benefits of Hoofnagle Brand All-Natural Pb®. Well, I am writing to tell you that today I am filing a suit against a wide range of ayurvedic herbal supplements providers for using the active ingredient of Pb® and its sister product, As33® without licensing it from me.

    The New York Times reported yesterday on this widespread deception of consumers. You see, in order to make ayurvedic medicine appear efficacious, a large number of supplement providers are secretly including Pb® and As33® in their scammy supplement products:

    A report in the Aug. 27 issue of The Journal of the American Medical Association found that nearly 21 percent of 193 ayurvedic herbal supplements bought online, produced in both India and the United States, contained lead, mercury or arsenic.

    As you can see, the ayurvedic practitioners are riding off the all-natural, pure, elemental aspects of Pb®. I’m not going to allow this to continue, and you shouldn’t either–continue to buy your Pb® and As33® directly from Hoofnagle!

  • What makes these quacks different from all other quacks?

    These quacks are in a bit of trouble. The FTC and FDA have decided that they are sick of bogus cancer cures, and have sued a handful of companies.

    WHAT THE HELL TOOK THEM SO LONG?

    And more important, are they going to go after more snake oil salesmen? There is nothing special about the companies the FTC is going after. They make the usual bogus claims—“our particular magic herbs detoxify, boost immunity, and cure cancer.”

    Hopefully, ChrisH will weigh in on some of the legal issues, but one of the interesting facets of these cases bears directly on the Quack Miranda Warning. According to ABC News:

    In a May 27, 2008, the FDA acknowledged that Spohn had “attempted to disclaim” some of the statements about products sold by the company, Herbs for Cancer.

    The FDA noted that the site contained the message: “Disclaimer: The FTC and FDA require us to place this disclaimer here, please read. Herbs for cancer are not intended to cure, treat, or diagnose your illness.”

    In the letter, the FDA told Spohn, “However, untrue or misleading information in one part of your site will not be mitigated by inclusion of such a “disclaimer.’”

    Wow. I have regularly complained that snake oil salesmen are allowed to operate unmolested by simply giving the completely disingenuous disclaimer. Is this a sign that the Quack Miranda Warning may someday lose it’s magical power of protection?

    Another fun piece of the FTC complaint is “the letter”—the FTC is requiring the cancer herb quack to send “an exact copy” of a letter to all customers:
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  • Everyday, every day

    I love language, which I suppose is as good a reason as any for being a writer. I’m also terribly critical—I hate misuse of language, especially my own. I’m not talking about silly grammatical rules that real speech renders moot. I’m talking about the misuse of words that actually changes meaning.

    Every day I give bad news. I hate it. For me, it’s an everyday thing—not routine, exactly, and not rote, but profoundly normal. For patients, it’s the furthest thing from normal. Bad news doesn’t come every day. No matter how everyday it is to me, my words can deliver the worst news of a person’s life.

    Part of delivering bad news is helping guide people’s reactions. I can’t stop someone from being sad or angry, but I have to help them stay on course. If they find the news so devastating that they can’t function, the battle is lost. Thankfully, I have examples of survival to share with my patients.

    Several years ago, I diagnosed an acquaintance with metastatic lung cancer. It really was a horrid diagnosis, and most people with her diagnosis die—quickly. She didn’t (but she’s gone now, a story for another time, perhaps).

    One day, after her life had change completely, I ran into her in the hospital on her way to chemo. We sat in the lobby and chatted.
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  • I Can Haz Less Poison in My Drugs?

    The Journal reports this morning that:

    The U.S. Food and Drug Administration banned imports of more than 30 generic drugs made by India’s Ranbaxy Laboratories Ltd., citing concerns about the safety of the company’s production practices.

    The ban affects low-cost versions of popular medicines such as the anticholesterol drug Zocor; Acyclovir, which treats herpes; the heartburn pill Zantac; and AIDS drugs. Consumers shouldn’t be affected by a medicine shortage because the drugs can be supplied by other generics makers, the agency said.

    The agency said it acted because of concerns about the “seriousness and extent” of violations of manufacturing standards at two Ranbaxy plants in India. The agency said it hasn’t found safety problems in drugs in the U.S.

    There are a number of aspects of this story that are scary. First, I’m involved peripherally in the issues surrounding offshoring personal data to countries like India. The complexities of that should be reserved for another post, but a basic problem involves supervision and accountability. How can you tell that data has been misused or stolen? The complexities must be more severe in ensuring that drug makers have sound practices. I would imagine that US regulators cannot detect most violations of the rules.

    Second, for our government to take action against a drug maker means that things were really screwed up. And if things were really screwed up, why should we believe that Ranbaxy-made drugs in the US are unaffected?

    More broadly, is there any way for consumers to ensure that their generic or branded drugs are made in the US? I read every day about the Chinese Poison Train (next stop, you), and would like to limit my exposure to leaded or otherwise tainted foreign products.

    Here is the FDA’s release on the Ranbaxy action, and the list of affected drugs.

  • The Miracle that Failed

    Yesterday, I posted about the rabid, pro-free-market rhetoric present in Washington, DC over the past decade. When Congress had the opportunity to consider privacy laws that would limit marketing of financial products, it chose to side with bank lobbyists, who invoked the idea of the “miracle of instant credit.” Basically, they argued that any incursion on the free market would harm credit markets. They promised that this miracle would lower credit prices, make credit more convenient, and manage the risk involved in lending. Congress sided with the banks. As a result, many financial products were marketed to people who didn’t deserve mortgages. And now you’re paying for it. You’ll soon be paying their auto loans and credit card bills too.

    To get a flavor for the atmosphere, check out this Congressional testimony by John Dugan. It was delivered on behalf of the Financial Services Coordinating Council, American Bankers Association, and the American Insurance Association. Dugan was listing the various benefits of having a federal standard for information sharing, unfettered by state privacy laws:

    Better risk management. Risk management is a crucial factor in every decision that a financial institution makes, including determining what types of products and services to offer. Undercutting this decision-making process has important implications. For example, if a lender cannot depend on credit files that are truly complete, loans may not be extended or may become more expensive in order to account for the higher level of risk. Moreover, Cate and Staten find that robust, national credit reporting has made it possible for more people to have access to more credit without significant increases in defaults.

    Oops. That risk management apparently wasn’t good enough. So, you didn’t get privacy protections or good risk management. And who’s John Dugan, you ask? Well, he’s now one of the principal regulators of banks–he is the Comptroller of the Currency and a director of the FDIC.

  • Cancer 101

    Cancer is the second leading cause of death in the U.S., and at any moment directly affects almost 4% of the population, or about 10.8 million Americans. A diagnosis of cancer can be one of the most frightening moments in someone’s life, and yet most people understand little about the disease. I hear the same questions about cancer over and over again, so it’s well past time to give a bit of an explanation of this set of diseases.
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  • [Updated] Free Markets and the Credit Crisis Freefall

    [Update: The WSJ reports that you’re now bailing out AIG.]

    For years working in Washington, I listened to libertarian tripe about how privacy law would prevent free markets from operating, and how banks should be able to freely trade personal information to assign risk and create new credit products. The “Miracle of Instant Credit” was invoked as a positive force that would allow banks to move smartly into the subprime market and make more Americans homeowners. They won that battle with the 2003 passage of the Fair and Accurate Credit Transaction Act, which largely superseded state law attempts to rein in the trade of personal information in the financial context. Prior to this, banks also lobbied to remove barriers in place (but weakened) since the 1930s that limited joint ownership of banks, brokerage houses, and insurance companies. Allowing these mergers caused banks to become behemoths that could not be beaten because of their political power.

    Frustration with the ideology of the free market radicals, and their blind faith in the market solving problems (if it didn’t solve a problem, the market wasn’t free enough, or the problem wasn’t actually a problem) motivated me to write the Denialist Deck of Cards. These same guys totally missed the housing blowup, or somehow thought they could manage the risk of it. Do you remember the news articles written about mortgages granted to people who didn’t even need to prove their income? Or the huge housing projects being built farther and farther into nowhere?

    Well, it’s all coming down on us now. It’s not just the subprime area where the miracle of instant credit fueled the crisis. Prime mortgages, auto loans, and soon, credit card debt will all be in trouble. Meanwhile, the bankers made tons of money and many were just in denial about the crisis. As Credit Slips points out, Lehman Brothers paid out $5.7 BILLION in bonuses in December 2007, overall, compensation was up 9.5% for the year!

    I’m happy that the feds taxpayers didn’t bail out Lehman. But other firms are going to fail, and you’re going to be left holding the bag for their denialism and their banal greed. Ultimately, the bailouts may be a good economic decision. But a few years from now when things have changed, let us remember how these people totally abandoned the rhetoric of personal responsibility, free markets, etc, when it was their interests on the line.

  • A very confused pharmacist

    I’ve written often about the ethics of doctors and pharmacists imposing their own morals on their patients and customers. Our Sb pharmacologist has as well. And even though all of our legitimate professional organizations recognize this line, Bush’s Department of Health and Human Services has jumped into the ring to join a fight that should never have started. And just to demonstrate how single-mindedly idiotic an evangelical (small “e”) mindset can be when applied to medicine, PZ Myers, uber-atheist, received an interesting solicitation (please, don’t quote-mine that).

    To remind you of the issue at hand, there are a number of doctors and pharmacists out there who think that their own religious beliefs should trump the standards of good medical care and the needs of their patients. This is why I write of “evangelism”: professionals who are trying to teach the Good Word (any Good Word) to their patients have stepped very far over an ethical line.
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