Category: Medicine

Bob Sullivan reports at MSNBC on the early developments of a medical privacy score by Fair Issac, the same company that invented the credit score for lenders. This is somewhat scary, because the entire point of credit scores is to make decision making easier, so easy that people very low on the totem pole can make decisions about you without really thinking, and because it is a number, it is imbued with an air of legitimacy. Credit scores arose after Congress forced consumer reporting agencies to open up their files; scoring allowed companies to put their analysis back into a black box so you can’t tell for sure what information they use to evaluate you.

Several published reports have described Healthcare Analytics product as a MedFICO score, computed in a way that would be familiar to those who’ve used credit scores. The firm is gathering payment history information from large hospitals around the country, according to a magazine called Inside ARM, aimed at “accounts receivable management” professionals. It will then analyze that data to predict how likely patients will be to pay future medical bills. As with credit reports and scores, patients who’ve failed to pay past bills will be deemed less likely to pay future bills.

[…]

Tim Hurley, a spokesman for Healthcare Analytics, said criticism of the firm’s work is purely speculative, as its product is still in development. Even the term MedFICO is inaccurate, he said

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Hurley did say, however, that hospitals will not use the Healthcare Analytics product before patients receive medical treatment, and it will have no impact on medical decisions.

[…]

The Healthcare Analytics tool will be used after patients receive care and after a bill is generated to help hospitals make better financial planning decisions, Hurley said. It will also help health care providers sort through patient records and potentially make it easier to write off some unpaid bills as charity cases, rather than delinquent accounts, which would offer the hospital some accounting benefits, he said.

The firm “is particularly focused on finding ways to help hospitals systematically allocate charitable resources, to make sure that patients who need financial assistance the most receive it on a consistent basis across the industry,” he said.

I guarantee you that this is not the primary function of medical credit scores, and that it will, one way or another, be used to get certain people out the door faster than others.

Despite the best attempts of the New York Times Wellness Blog to get me fired, I’m still here and doing fine. Somehow a post about how impressed I was with surgery, the professionals that practice it, and how many of my preconceptions about surgeons were incorrect, got all turned around into some “peak behind the curtain” into the secrets of the medical profession. This is terribly absurd and the article made a hash out of what I was trying to say. I was trying to relate some of the shock one experiences going from an academic setting into a clinical one for the first time, as a reminder to those who have done this before, and maybe preparation for those who have yet to make the jump. None of these things are secrets, and all could be culled from watching about 15 minutes of the Discovery channel or Scrubs.

But the confusion of some individuals over what I was trying to communicate is still my problem, even if I was quoted all out of context. Clearly the biggest issue is the change in audience, my sb audience includes a lot of scientists and doctors, and the way I write is somewhat geared to this group. Thus you’ll notice in my comments mostly positive responses – especially from medical professionals like Orac, PalMD and various others. When the NYT expands my audience to a group of people who don’t know my writing, my assumptions or my more egregious stylistic shortcuts, it is not surprising there was some confusion and hurt feelings, not to mention some people with absolutely no sense of humor.

This does not mean that there is no problem however, ultimately this is a sign that I need to remember that I am writing in a public arena and need to be more careful with the assumptions I make about my audience on any given day. Rather than clamming up for the next couple of decades until I’m tenured, instead I’m going to use this as an opportunity to broaden the appeal of the blog and help explain to a wider audience what evidence based medicine is, the process of learning it, and why I think medicine the best career in the world. Writing this way will help educate people about medicine and how its practiced, and at the same time improve my knowledge of medicine with the goal of making me a better doctor one day. So, back to basics.

First, an explanation of the role of a medical student in the arena of patient care. Medical students are being introduced into the profession of medicine. To accomplish this they take two years of some of the most arduous training imaginable, intensively learning about anatomy, physiology, pharmacology, biochemistry, genetics, pathology, microbiology, physical exam, history taking, and all the other knowledge that makes up the foundation of clinical knowledge. By the third year, which is what I am currently in, you have accumulated more knowledge in two years than you probably have in your entire life. You are tested, retested, observed, corrected, and tested again and after all this work you get the incredible privilege of participating in patient care in your second two years of med school. This does not mean your first week of patient care is any less of a shock to the system – it is very much different from the purely academic pursuit of medicine – it is more of an apprenticeship in which you learn by doing and is certainly the most important part of learning to be a clinician. At this point you are participating in patient care, usually at an academic setting, and you see patients, take histories and physicals, learn how medical decisions are made in the care of individual patients, and in the case of surgery, observe how operations are performed. While you are an important part of the patient care team, you are not responsible for clinical decisions at this point and are at the bottom of the proverbial totem pole. You work with interns, residents and attendings who are ultimately responsible for medical decisions. For the most part, you observe, participate, tell them what you would do, and then wait patiently as these more experienced clinicians explain why you are right or wrong and what is the correct course of action. It is training to develop clinical judgement and competence in patient care. Further, when I say that I “scrub in” to a surgery, it means that I am allowed into the sterile field (after scrubbing, gowning, gloving etc.) and am given the privilege of watching surgery up close. If you’re lucky you may get to participate, but in a very limited capacity, never beyond your abilities (usually just holding instruments, aiming a camera, applying traction, suction etc), always under the supervision of someone with between 5 and 40 years more experience than you, and in a very controlled environment. Always paramount is the patient’s well-being, and if it is ever in question you quickly find yourself shuffled back behind the doctors who are doing the very difficult and demanding work. Before you even step into the room one must remember the student has years of training to understand the pathology and anatomy of the case, the student has read up on the patients’ specific case, and has reviewed the surgical procedure, relevant pathology, anatomy etc. Before you work with patient on a medicine rotation you’ve done similar prep, and throughout the case are studying the patient’s case, lab results, textbooks of medicine, the scientific literature, etc., as part of your training. When you graduate from medical school and become an intern and then a resident you are still training for about 3-5 more years, you become directly responsible for patient care, and are under the supervision of an attending physician. This structure is ultimately very successful and academic medical centers provide the best medical treatment in the country, attract bright people, take all kinds of cases (the ones many other hospitals simply can’t handle), and constantly push the boundaries of medicine.

Now, onto the fun part. A clinical case. This is how we learn medicine, as being social animals, it’s almost always easier to remember medicine in the context of a person. You’ll always remember medical facts and treatments better if they are associated with an actual human being. And this is, of course, an artificial teaching case having nothing to do with an actual individual. I had a post all prepared describing a complicated procedure, but since we’re starting from basics, let’s begin with wounds.

The patient is a 52 year old construction worker who suffered from an open fracture (bones sticking out of the skin) of his left radius and ulna (bones of the forearm) from on-the-job accident. He was taken to the ER, his arm was evaluated with a plain X-ray film, and the break was cleaned, reduced, and set in the OR. He received prophylactic cephalosporin antibiotics before the surgery. 24 hours later he is on your floor, admitted to your service, and he complains of chills, and severe burning pain at the site of his incision. The patient is alert and oriented to time, place, and person, but is diaphoretic (sweating), pale and in some distress. He has a fever of 39.2, BP 140/90, and his heart rate 110 beats per minute. An examination of the arm reveals a brown, weeping wound at site of the repair, the arm is warm to the touch, and acutely painful. Physical exam and review of systems is otherwise unremarkable. Labs show an elevated white count. He has a history of type II diabetes and hypertension.

What do you do?
A) Treat empirically with a broad spectrum IV antibiotic like Cipro and culture the bacteria for a definitive diagnosis and sensitivity testing.
B) Clean and debride the wound.
C) Change the dressing and wait for the wound to heal naturally.
D) Send the patient back to surgery to debride (clean) the wound and start therapy with penicillin and clindamycin.
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One only has to be minimally involved in a surgical procedure to understand the appeal of this profession. It is instantly gratifying and very rewarding to be able to just fix something. That, working under time pressure and mixture of physical and mental skill make it a very exciting way to practice medicine.

So after a week of this, and just getting off call around 1:00 this AM after scrubbing in on a liver transplant I’ll tell you what has surprised me about surgery so far, and some of the things I didn’t realize going in.
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Eight hours standing in a single spot, how do surgeons do it? I’m hoping my endurance will build, especially knowing that some of the procedures I’m going to see in the next few weeks such as the “Whipple” or pancreaticoduodenectomy may take twice as long.

The good news is that I have lucked into working with great people – the misbehavior of surgeons is greatly exaggerated – and have learned lots of interesting things. The coolest yet was running the camera on a laparoscopic or “keyhole” surgery – it looked something like this.

Although what we did was more complicated (and harder to reach) it was both physically and mentally challenging. Basically, you are operating a camera in a 3 dimensional space, and the hand movements that will direct the position of the camera are reversed (usually). It’s a little bit like flying a plane, meanwhile, you’re standing for hours in a single spot, unable to lean on anything, maintaining a sterile field, and trying to track the position of the surgeon based on the movements of the instruments and a fair amount of mind-reading. It goes from exciting, to grueling pretty rapidly. Meanwhile the attending is standing in the same spot, running everything, not even bitching at me when I end up off target, perfectly content, like a stone wall, while my feet are killing me. How do they do it?

More soon.

This time the Ask a Scienceblogger Challenge is to explain why a male contraceptive pill does not exist.

Good question! It’s because medical researchers are all sexist bastards. Didn’t you know?

Actually that’s only part of the reason. Research into hormonal or pharmaceutical contraception for men is a hot topic. Male hormonal contraception is actually fairly effective. Using a combination of testosterone and other hormones to suppress the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary you can, after several months, prevent men from making sperm. For the men that respond (not all do), this treatment is highly effective as a contraceptive method. But the problems are delivery and efficacy. If you first screen men to see if they respond, then it is highly effective. But it doesn’t work on everyone: unlike the pill, you have to inject these drugs, put in implants or use a patch for delivery. This makes it far less attractive than the oral contraceptive pill for women, which is 98% effective when usedcorrectly and works with few exceptions. In the future, researchers may develop a more effective delivery and screening system for men that would allow them to more reliably assess the efficacy of the treatment.

Sexism has played some role in the long delay in the development of male contraception. But these days the far more important issues are those of physiology and capitalism. Women produce one egg a month and have a biologically built-in mechanism for preventing ovulation. Men, on the other hand, are sperm machines, producing an overabundance of genetic delivery vehicles from adolescence until death–with no simple mechanism to interrupt production. That’s why barrier methods, such as condoms, will likely remain preferable even after the development of hormonal birth control for men as they are highly effective and also prevent STD transmission. And for women, the pill (especially in lower-dose modern formulations) is safe, effective, and very well tolerated.

The second problem, that of capitalism, refers to the difficulty in developing a market for male contraception and thus the limited incentive for their production. It will be difficult for drug companies to sell a formulation for men that alters their hormones, lowers their sperm count (a cultural barrier), and requires doctors visits, injections, sperm counts, etc., when highly effective alternatives already exist. Many women will also likely prefer to remain in control of contraception because it’s their body, their health, and because men are liars. The capitalist barrier may be even more significant than the physiological obstacles.

Male hormonal birth control options will probably be offered within a decade. But they will likely be a niche market, limited to people in committed monogamous relationships, or for the partners of women who can’t tolerate the pill, and thus, not widely adopted.

This new year is shaping up to be pretty exciting, and part of the changes in my life will be reflected in what I write about on the blog. First let me explain how the MD/PhD program I’m in works, and where I am in it.

The Medical Science Training Program (MSTP) or MD/PhD program is designed to promote bench-to-bedside or translational research. The idea is that if you take medical students and give them a PhD as part of their education they will be more likely to take science from the basic literature (bench research) and translate it to medical care (bedside research) or at least do research that is more applicable to clinical research. In practice this ideal is not always achieved, but we try. This program is funded by a grant from the NIH, and between 2-10 such positions exist at most medical schools.

The program starts with students doing two years of medical school, which at most U.S. universities consists of the basic science portion of the medical curriculum. In the first two years you learn biochemistry, physiology, anatomy, histology, pathology, microbiology, pharmacology, genetics, psychiatry, etc. and at the same time are introduced into clinical medicine, differential diagnosis, taking patient histories, physical exam, and all the other skills you need to become a medical doctor.

After you complete these two years, and take the first of the national standardized tests to check and make sure you’re not a total incompetent, MSTP students then go into graduate school. Yes, some intelligent people actually think this is a good idea and enter this program. Luckily, you get a good deal of credit to your graduate classes (or substitute some graduate classes in medical school) and for the most part go straight into lab work. Then it’s the standard grad school spiel which I explained previously. Briefly, you work in a lab, you struggle, eventually figure out what the hell you’re doing, and then write a thesis. Now the fun part, after being separated from the first two years of medical school by between 3 and 13 years you get tossed into patient care for the medical school third year.

The third and fourth years, referred to as “the wards”, is more like a medical apprenticeship. You spend between 4 and 8 weeks on a variety of wards learning the full breadth of medical practice. These consist of family practice, surgery, psychiatry, medicine (ICU, infectious disease, slumming around the hospital etc.), neurology, pediatrics and OB/GYN, and whatever electives you decide you are interested in. This is when you really learn medicine and how to apply your clinical knowledge to the actual treatment of sick human beings.

I’ve spent the last month studying, working with doctors to get my clinical skills back, and generally freaking out in preparation for tomorrow, my first day on the wards. And guess which I’m doing first!
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Except this time it’s from the right! Richard Dolinar of the Heartland Institute (a crank tank) writes in TCS Daily that evidence-based medicine (EBM) is bad for patients.

A new buzzword entered the medical lexicon in 1992 when the Evidence-Based Medicine Working Group published one of the first articles on the phenomenon in the Journal of the American Medical Association (JAMA). In the years since, the role that evidence-based medicine (EBM) plays in medical care has increased exponentially. Some now question whether it should play such a prominent role.

“[EBM is not] medicine based on evidence, but the equivalent in the field of medicine of a cult with its unique dogma, high priest … and fervent disciples,” says Dr. John Service, editor-in-chief of Endocrine Practice. Indeed, if a doctor questions EBM today, it seems he or she runs the risk of being branded an infidel or heretic, or worse.

Now there is a bad sign. When someone calls medicine a cult, you know you’re about to hear some real nonsense, usually from an altie. But hey, I’ll give them a chance. Why exactly is it that I’m supposedly studying to be a priest in this cult?

Proponents of EBM assume it will improve the quality of health care by basing medical decisions primarily on statistically valid clinical trials; therefore, information gained from randomized clinical trials (RCT) preempts information from all other sources. Yet, isn’t it ironic that a review of the literature by this author and others turns up no evidence as defined by EBM to validate this assumption?

Holy FSM! He searched the entire medical literature and found that there aren’t any articles scientifically showing that science works! Wait what? That can’t be right.

“The failure to conduct a randomized controlled trial, the recognized best form of evidence according to EBM, and reliance on expert opinion, namely theirs (the worst form of evidence according to them), hoist EBM by its own petard,” notes Service. EBM purports to provide “statistical proof” when in fact what it provides is “statistical data.” Data does not necessarily equate to proof. Data is open to interpretation, which can change over time or vary depending upon one’s perspective.

Page epistemiology! We have an emergency – our patient is having a crank attack! I guess they have a point, we’re clearly ignoring all those other methods of acquiring medical knowledge besides the RCT. I mean, we don’t really know they work. All they do is provide highly replicable data showing the efficacy of various medical interventions in different patient populations. That’s just data, not “truth”. Now divining, that must be how you find truth. I also think that he’s not just being cranky, he’s also just completely wrong. As I’ve pointed out many times John Ioannidis does just this kind of work (note the presentation, not the PLoS paper, is more relevant to RCTs).

It gets worse, and I mean, much much worse. And I’m left wondering what the hell kind of denialism the Heartland Institute is up to now?

Continued…

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Speaking of libertarians, reading the JCI this week I came across this wonderful review of Richard Epstein’s new book, “Overdose: How excessive government regulation stifles pharmaceutical innovation”.

We’ve discussed Epstein, and his ilk before. The libertarians that routinely attack the FDA as some kind of bogeyman, killing kids, eating babies, blah blah blah, when the market could be making all these drug decisions for us. David Ross, writing for JCI, sees through the nonsense.

Although Epstein terms Overdose a study, it’s really a legal polemic that could be subtitled “What’s good for pharma is good for America,” his title for a 2006 newspaper opinion piece (1). Overdose raises questions but fails to persuade, largely because Epstein consistently fails to mention evidence that might inconvenience his argument.

First, he ignores the reality that patients and health care providers cannot acquire on their own the information they need to make rational choices about drugs. Without complete information, drug market failures, in the form of poor patient outcomes, are inevitable. Epstein dismisses this problem, proposing, for instance, surfing the Internet as a replacement for FDA-required information on drug efficacy and safety.

Second, Epstein seems unconcerned about the effects of market failure. He notes the Elixir Sulfanilamide disaster of 1937, which cost over a hundred lives, without explaining how his proposals would prevent such catastrophes. He posits the effects of safety issues on companies’ reputations as a deterrent to the knowing marketing of unsafe drugs, ignoring repeated examples of manufacturers doing just that. He concedes that the average patient does not have the ability to tell whether a drug is contaminated yet assumes that judging clinical trial results is a simple matter.

Finally, Epstein repeatedly distorts clinical trial science. The most peculiar section of Overdose is Epstein’s attack on randomized controlled trials (RCTs). Epstein seizes on the heterogeneity of responses to any therapeutic intervention as evidence that reliance on RCTs is flawed. He contends that drugs that are equivalent to (or even inferior to) placebo should still be approved, arguing that patient responses in the experimental arm that are greater than the placebo mean imply efficacy for the drug in those patients — committing the blunder of rejecting the null hypothesis for a post-hoc subgroup. Epstein appears unaware, or indifferent, to the role of variations in natural history, drug response, and assessment, and the role of type 1 error. Under his scheme, patent medicine nostrums would be legal again.

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Epstein’s hidden agenda appears to be opposing more FDA-mandated information on drug efficacy and safety that might level the playing field between drug manufacturers and consumers.

I don’t have much hope that we’ll be able to keep these arguments out of the debate over the FDA forever. People have such a poor understanding of history (and everyone from that period is dead or soon will be – the drugs didn’t help), that they may actually be convinced of this nonsense. But I can think of few suggestions more profoundly stupid and intellectually dishonest than to suggest that we can create this ideal market system in which omniscient consumers navigate through the vagaries of pharmacologic science and RCTs to find the best drug for their condition, or that the market will magically provide information to consumers when the evidence is that companies have already shown they are disinclined to do so.

The argument over whether or not we should have validation of safety and efficacy of drugs by non-partial government scientists is over. The only way one can argue for a return to a pre-FDA market regime is to argue dishonestly.