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Demystifying Medicine One Month at a Time

Tag: NEJM

Medical Revolution(s)?

9780465050642This week an essay in the New England Journal of Medicine asks if our collective learning to handle uncertainty should be ‘the next medical revolution.’ It caught my eye because many of the medical educators I follow on social networks were abuzz about it.

Coincidentally, I’m reading a fuller-length exploration of medical uncertainty, a book called “Snowball in a Blizzard,” by Steven Hatch, an infectious diseases doc at UMass.

Both the essay and the book remind us to have humility: though medical technology and scientific knowledge have leapt ahead and continue to hurtle forward, our profession’s abilities to diagnose, treat, or predict future health outcomes with precision remain stubbornly elusive.

The metaphor of the ‘snowball in a blizzard’ comes from the world of radiology–in particular mammograms. That’s what radiologists who read mammograms are looking for on the images they see. It’s challenging and inexact work. Often they miss tumors that are cancerous; to correct for this, it’s natural that radiologists need to be extra cautious and have women with anything even remotely suspicious follow up for more images and possibly biopsies. [With negative biopsies, such mammograms become known as ‘false positives.’]

I agree with the thesis that we should all become more comfortable with uncertainty. But it will be challenging.

As patients, we want our doctors and scientists to be able to give us predictions that are accurate.

  • Is this the right diagnosis?
  • Will this treatment work?
  • How long have I got?

As doctors, we wish we had greater ability to answer these questions.

As ‘consumers,’ we are fed an unending stream of media that tell us what we ‘should’ do, what we ‘need’ to be healthy, and what will make us live longer. Much of it never offers the necessary caveats about the inexactness of the science. This will be an uphill battle.

I was pleased to see a chapter in Hatch’s book devoted to health media, featuring Gary Schwitzer and his website HealthNewsReview.org. Gary has devoted his latter career to debunking medical hype. His site is well worth perusing.

Doctors and Industry [Updated]

Update: The column is here.

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I’m working on a column about doctors and conflicts of interest. This is a perennial topic in the field of medicine, but it’s been on people’s minds recently because of a set of three essays that appeared in successive May issues of the New England Journal of Medicine, America’s oldest and most esteemed medical journal. You can read the essays if you like — here, here, and here. The Journal’s editor-in-chief also weighed in with an editorial introducing the three-part series.

doctor-money-300Academic doctors have long had relationships with industry — and the history is complicated. Many of us in academe are trained to be very skeptical of our colleagues that take funding from pharmaceutical manufacturers (aka ‘drug companies’) and device makers (think hips, heart valves, pacemakers, surgical robots, etc.). We are skeptical because we feel that these colleagues have ‘sold out’ or that they are shills for the companies that have them on the payroll. Though seldom admitted, envy plays a role in our skepticism, also.

There’s no doubt that the skepticism originates from a good place — after all, those of us in academics prize objective truth and scientific advancement. The idea that researchers and clinicians are beholden to a commercial interest raises red flags for us about integrity. And there have been many reported examples of harm done by folks in thrall to commercial interests.

The outgrowth of all the skepticism is a set of rules and practices that center around transparency in our daily business. We must disclose any potential conflicts to the universities for whom we work. If we speak at a conference or submit an article to a journal, the same principles apply.

We’ve reached a point where we evaluate information based on the ‘moral purity’ of who is presenting it (and of course, the purported purity of the information itself — i.e. if it’s funded by industry, it’s automatically suspect). Moral purity is equated here with meaning no ties to any commercial interests.

The correspondent who wrote the three essays for the Journal is asking if perhaps we’ve gone too far to the extreme — suggesting that when we engage in morality litmus tests for the sake of convenience, we are likely overlooking opportunities to do good work that can have mutual and societal benefit.

Predictably, the response to her pieces has been pretty fierce. Two former editors and a former correspondent for the Journal lambasted their former workplace for even mentioning a reconsideration of academic-industry relations in a retort in the British Medical Journal (now know as just ‘BMJ’). The gloves are off! Another commentator opined about “Why [NEJM author] Lisa Rosenbaum Gets Conflict of Interest Policies Wrong.” Ouch.

When poking at sacred cows, you inevitably become a target yourself. The fact is that government (i.e. taxpayer) funded research is a zero sum game: the NIH budget has remained flat for several years, making the most high-minded, “pure” way of funding research harder and harder for young and mid-career scientists. Many of us see collaborating with industry as the only real possibility of moving progress forward. It’s OK to have rules about conduct of industry relationships — but to squelch it all as immoral benefits no one except those mandarins in charge of the litmus tests.

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coda: NPR ran an interesting piece on “Dollars for Docs,” a searchable database by the non-profit investigative news source ProPublica that reveals how much your doctor takes from drug companies as part of the Physician Payment Sunshine Act. Apparently I received $24 in 2014. I have no recollection of these inducements. My best guess is that some foodstuffs were brought to our nursing staff to encourage them to administer vaccines against shingles and cervical cancer. I can live with that.

Barefoot Doctors

DSC_4075The venerable New England Journal of Medicine published an opinion piece about why it’s important for us to learn about the history and current practices of health care in China.

Since the Communist Party declared victory in the Chinese civil war in 1949, health care in the People’s Republic has undergone rapid cyclical change, mirroring the various emphases the single-party government has proffered to its people — from collectivism to free market capitalism and then somewhat back again when >90% of Chinese were left uninsured — in what the authors of the piece describe as a movement to create professional norms for a medical profession that have not heretofore existed in China.

A good summary of the piece describing some of the implications can be found here. Other sources report that China is planning to double the number of primary care doctors in the country by the year 2020.

One concept worth learning about if you’ve never heard of it: “Barefoot Doctors.” Founding Premier Mao Zedong unleashed these “paramedical” folks into the countryside in the 1960s to offer help with prevention and primary care. One result: a stunning drop in infant mortality. The analogue in our own age is the concept of the community health worker, something that has garnered press and continues to be an alluring possible solution to our own problems of translating medical knowledge gains out into our communities.

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