Bad Medicine

Finally getting around to reading Prescription for a Healthy Nation by Tom Farley and Deborah Cohen. The first chapter details how we overspend on healthcare, while confusing ourselves that we are spending on health. The two are not synonymous, as many, many, many others make clear. Farley and Cohen cite estimates that medical errors kill 50-100,000 persons per year, whereas iatrogenic deaths that result from appropriate medical care kill upwards of 250,000. Amongst these statistics are fun anecdotes like this one:

One of the more heavily publicized studies on this followed doctors’ strikes in 1976. Over five weeks, in a dispute about malpractice insurance, about half of the doctors in Los Angeles County cut back on services, and because anesthesiologists were the most militant, hospitals cancelled most elective surgery. For those five weeks no surgeons were doing non-emergency hysterectomies, tubal ligations, knee repairs, or face-lifts. As much as the strike must have caused panic in people who could not see their doctors, researchers afterward found that it actually prevented more deaths than it caused.

To some degree, the medical community has reacted to this information by moving towards evidence-based medicine; furthermore, physicians are coming around to the idea that price-transparent rationing is necessary for any rational health care system, universal or not. Nevertheless, while questions like this are batted around amongst economists and doctors with an interest in policy, my informal sense (talking to fellow students, and judging by the hubris of most of the doctors I’ve actually met) is that most physicians grossly overestimate the amount of good that they do (even if we ignore any one doctor’s place at the margin).

Why is this? One reason is that it’s easy for us to remember the patients we help, the ones for whom prospects were grim but recovery was profound, or even those whose life was never in danger but we helped recover more quickly or pass the illness more comfortably. On the other hand, amongst those 250,000 who died due to iatrogenic causes, a great many would have died anyways, and it’s easy to use that fact to elide those patients from our consideration. And as Farley and Cohen point out, it’s not just the memory of doctors that is so biased:

The newspapers trumpet the uplifting victories–such as Lance Armstrong’s beating testicular cancer before dominating the Tour de France–but muffle the losses in small obituaries.

Over at medrants, DB asks how we can improve the learning climate in teaching hospitals. I suspect this crap is not what he had in mind. Spillover at KevinMD, where I get into things old-school fray style, even (hi Dawn, and a hat tip to Moloch).

I admit a morbid fascination with this type of injury. The idea that someone could shove a reasonably sized foreign object into their own brain, with massive bleeding but no external trauma, seems just . . . bizarre. Here’s this week’s New England Journal image of the week, a fifteen year old boy assaulted with a pencil:

1. I don’t have much to say on it, but a nice paper in the NEJM looks at publication bias in antidepressant trials — most negative trials get squashed or spun into positive results, positive trials almost all get published. Robin Hanson is unsurprised, and Scott Aberegg gives helpful hints for the skeptical clinician.

2. Elsewhere in the Journal, a nice piece on foreign medical graduates, who face tremendous discrimination without much evidence supporting the usual attitude that they’re worse doctors than the rest of us.

3. I missed that Slate had taken on the forced rectal exam lawsuit last week. Here’s GruntDoc on the same, plus real world experience (HT: KevinMD).

4. One thing I don’t understand is the so-called primary care crisis. If people want it, they’ll pay for it. If they don’t they won’t. It’s only a crisis if you think you should be payed to do something nobody wants to pay you to do.

5. Now reading The Logic of Life. Interesting bit from ch. 1 — men who have a family member with HIV/AIDS are less likely to report attraction to or sex with other men. Why wasn’t this bigger news?

Much gnashing of teeth after a man who was forcibly given a rectal exam in the trauma bay (then intubated, then arrested) decided to sue the system. Even the New York Times gets in on the action, though they don’t say much other than that in general, patients have a right to refuse care, but in emergency situations this right needs to be balanced about other concerns (mostly the need to make snappy triage decisions with uncertain information about the patients rational capacity). (more…)

A recent piece in Pharyngula mocks gullible Michigan students falling for the positive power of prayer. Loads of people have jumped on this, pointing out that if prayer worked, surely Michigan’s football season wouldn’t have been so disastrous (it’s a triteness to point out that by battling great melancholy and social ill, we’ll not lessen the quantity of suffering, but merely increase the triviality of it).

Anyways I give you Genesis 50:20: “As for you, ye devised against me evil — God devised it for good, in order to do as [at] this day, to keep alive a numerous people.”

When he was only nine years old, his father fell from his horse and died the next day. A few years later, his mother was diagnosed with tuberculosis. Though Keats nursed her assiduously, sitting up with her all hours of the night, cooking for her, reading to her, she died in 1810, during Keats’s 15th year. Keats was assigned to a guardian and soon after taken from a beloved boarding school and required to apprentice as an apothecary. He found the work tedious, for during these years, his late teens, he was awakening to the grandeurs of poetry, especially the verse of Spenser and Shakespeare. To complete his training, Keats had to learn surgery. Day after day, he toiled in a hospital, malodorous and bloody, where he witnessed nothing but suffering. As he was turning from surgery to poetry, his first substantial poem, “Endymion,” was published in 1818. Two of the leading literary magazines of the time attacked the poem for not making sense.

Around this time, Keats’s brother Tom died after a long and painful illness. While attending Tom, Keats met the love of his life, Fanny Brawne, and became engaged to her. However, he soon realized that he would never be able to marry her because he himself was doomed to fall prey to the same disease that killed his family members. He knew he would die without ever consummating his ardent love.

One would think that Keats’s life would have fostered bitterness in him, but he remained generous in the face of his difficulties. He didn’t flee to the usual 19th-century escapes: Christianity or opium, drink or dreaming. Though he unsurprisingly underwent pangs of serious melancholia (who wouldn’t, faced with his disasters?), he nonetheless never fell into self-pity or self-indulgent sorrow. In fact, he consistently transformed his gloom, grown primarily from his experiences with death, into a vital source of beauty. Things are gorgeous, he often claimed, because they die. The porcelain rose is not as pretty as the one that decays. Melancholia over time’s passing is the proper stance for beholding beauty.

So writes Eric Wilson in the Chronicle, part of a longer article questioning whether we are medicating away “good” melancholy along with “bad” depression. I don’t particularly want to address that question, but rather to focus on a specific tradeoff implied above. I suspect that the return on scenarios where a child must lose his father to accident, and then mother and sibling to the same illness that will sap his strength and claim his life before he is able to consummate his love is relatively low in terms of producing great poets, therefore I’d be willing to trade Keats — of whom I am fond — for an assurance that children don’t have to go through that ever again. But I think many people would disagree.

From the Archives of Internal Medicine

Most respondents agreed that reporting errors improves the quality of care for future patients (84.3%) and would likely report a hypothetical error resulting in minor (73%) or major (92%) harm to a patient. However, only 17.8% of respondents had reported an actual minor error (resulting in prolonged treatment or discomfort), and only 3.8% had reported an actual major error (resulting in disability or death). Moreover, 16.9% acknowledged not reporting an actual minor error, and 3.8% acknowledged not reporting an actual major error. Only 54.8% of respondents knew how to report errors, and only 39.5% knew what kind of errors to report. Multivariate analyses of answers to hypothetical vignettes showed that willingness to report was positively associated with believing that reporting improves the quality of care, knowing how to report errors, believing in forgiveness, and being a faculty physician (vs a resident).

(more…)

Over at Respectful Insolence, which by the way is one of my favorite blogs in the known universe, Orac tells of a pathologist who, overcome with guilt over the autism of her three year old son (and her role in allowing that child to be vaccinated), and in the throes of mental illness, suffocated the child with a trash bag. He writes:

Even so, her case is illustrative of the real “evidence of harm” that comes from the rhetoric of equating autism with “mercury poisoning” or “vaccine injury.” It’s not just the fear of vaccines that such rhetoric produces, fear that leads parents to avoid vaccination even if they have to lie about their religion to do it. It’s not just the problem of the vaccination rate plummeting below the level necessary for herd immunity in response to this sort of rhetoric, leading to the return of previously controlled diseases, as the measles have returned in the U.K. in the nine years since Andrew Wakefield unleashed trial lawyer-backed pseudoscience claiming that the MMR vaccine causes autism and autistic enterocolitis. Rather, it’s the guilt that racks each and every parent who comes to believe that vaccines caused their child’s autism.

I think this is wrong. (more…)

Here’s the NYTimes:

There were a number of times when patients brought up emotional content and it went right by the doctors.” For instance, a patient would say, “I’m scared,” and the doctor would go off on a “scientific riff” about the disease, Dr. Tulsky said, adding, “We saw that a lot.”

Is it surprising that my medical school pays lip-service to encouraging humaneness (we sit through some classes on empathy, and play-act tough situations with a couple of patient-actors in classroom settings; no grades). But excellence in that domain is not directly rewarded in any objective fashion (unlike, say, the ability to go on a scientific riff about any particular disease).

Another reason you should prefer a robot doctor.