The Rule of Experts: There's an interesting article in this week's New England Journal of Medicine about the rise of racial hygiene in Nazi Medicine (available only by subscription). It has the alluring title of In the Name of Public Health, and it points out that the Nazi's publid health philosophy didn't spring de novo from Hitler's brain, but was well-rooted in the opinions of medical experts of the day - across all nationalities. It was very easy for the experts to accomodate themselves to the more unsavory consequences of their theories:
Some physicians and biologists who supported eugenics had to accommodate themselves to Nazism's rabid anti-Semitism. But in return for accepting the persecution of Jews as a source of biologic degeneration, many in the medical community welcomed the new emphasis on biology and heredity, increased research funding, and new career opportunities — including openings created by the purge of Jews and leftists from the medical and public health fields.
Interesting choice, there, to describe the victims of Nazi purges as "leftists." While it's true that they purged communists (they hated and feared Stalin, as did most of Europe) the Nazi's themselves fell on the left of the political spectrum. They were socialists, after all. Mussolini, too, leaned left.
But that's the only jarring note in an otherwise excellent essay that serves as a useful reminder that we should always be on guard against abuses of the power of government in the name of public health.
Detecting Cancer: The news says that MRI's are a useful adjunct to detecting breast cancer, at least in women with genetic mutations that put them at high risk for cancer (a very small portion of the population):
MRI had a statistically significant better overall discriminating capacity than mammography. The sensitivity for detecting invasive breast cancer ranged from 18 percent for physical exam, 33.3 percent for mammography to 80 percent MRI. The corresponding specificities of the three procedures were 98 percent, 95 percent and 90 percent.
What does that mean? The sensitivity of a test is the likelihood that a test will detect a disease if it's present. So, the lower the sensitivity, the higher the false negative rate. (Amazing, isn't it, how low the sensitivity is for mammograms, yet every day radiologists get sued for "missing" breast cancers.) In this category, MRI certainly seems to be superior. If there's a cancer there, it's more likely to see it. And that makes sense, for it's a better imaging technique. However, there is a draw back, and that's in specificity, the likelihood of a person without the disease having a negative test. That's 90% for MRI's, which doesn't sound bad, either, until you realize that it also means that 10 percent of women without breast cancer would have a postive MRI. That's a fairly high false-positive rate, especially for a test with a four digit price tag. And that's in a population of women with a higher-than-normal incidence of breast cancer. Those numbers for specificity and sensitivity change when the incidence of a disease within a population changes. In the general population, where the incidence of breast cancer is much lower than the study group, there would be many more false positives. Which is why mammography is still the screening method of choice in the general population. posted by sydney on
7/31/2004 08:31:00 AM
Friday, July 30, 2004
Expanding Medicare: DB over at Medrants has already covered this story, but the expansion of Medicare benefits to cover one complete physical per enrollee deserves some comment.
At the moment, Medicare doesn't pay for physical exams, or for most screening tests. They pay for pap smears every two years, but they don't pay for the office visit that's required to collect the pap smear. (They only pay for the pathologist's fees.) They pay for mammograms yearly, and they pay for colonoscopies, and prostate cancer screening. They don't pay for screening blood sugar levels or for cholesterol levels. All of that will change in January, when each 65 year old will get a complete physical upon entering the program. They'll pay for blood sugar tests twice a year for "high risk" patients and for cholesterol screening every five years (The whole enchilada - cholesterol, LDL, HDL, Triglycerides, which is about $150 -$200). And they'll pay for a whole lot more - bone densitometries ($200), depression screening, functional ability screening, and counseling for any problems discovered during the exam.
Presumably, they'll be paying for the office visit in which all of these things are being done, too. At least that's what common sense would suggest. But with Medicare, never bet on common sense.
One other thing about this new benefit - the physical has to be done within the first six months of enrolling in Medicare. Most patients won't have met their Medicare deductible yet, so they'll probably end up footing more of the bill than first meets the eye.
posted by sydney on
7/30/2004 10:58:00 PM
Edwards and Me: Yesterday morning I awoke to the sound of John Edwards's voice on NPR. It was his convention speech. These were the first words I heard that morning:
Tonight, as we celebrate in this hall, somewhere in America, a mother sits at the kitchen table. She can't sleep. She's worried because she can't pay her bills. She's working hard to pay the rent and feed her kids. She's doing everything right, but she still can't get ahead.
When John Edwards was in that hall giving his speech, that mother was me. The next day, I was going to find out how much my malpractice insurance premium would be for the coming year. It's no exaggeration to say that I was every bit as worried as John Edwards's hypothetical mother, and certainly as sleepless. Lucky for me, and my family, my premium turned out to still be affordable. At least for this year. No thanks to John Edwards. posted by sydney on
7/30/2004 10:20:00 PM
Turf Wars: The French NGO humanitarian organization, Doctors Without Borders, is pulling out of Afghanistan. Some of their members have been killed there, so it's understandable that they no longer feel safe. They blame the U.S., however. Not for failing to protect them, but for doing humanitarian work, too:
'MSF denounces this attempt to co-opt humanitarian aid; to use humanitarian aid to win hearts and minds.'
Buissonniere said providing humanitarian aid is no longer viewed as a neutral and impartial act in Afghanistan
Evidently, the Taliban remnants and their terrorist allies can't tell the difference between an NGO and the U.S. Army. Well, actually, they probably can, which is why they target the unarmed NGO's. But does it really make sense to blame the Army's humanitarian aid efforts for the Taliban's disdain of all things good? They have a long record of hating all that's good. Remember, these are the people who once banned kite flying, who would not allow women needed medical care, and from whom their own nation's art treasures had to be hidden. Not for fear that they'd sell them. But for fear that they'd destroy them. No doubt, Afghanistan is a dangerous place to work. But if it's too dangerous for groups like Doctor's Without Borders, maybe the humanitarian work is best left to the armed forces.
posted by sydney on
7/30/2004 10:03:00 PM
Apologies: Sorry for the absence, I was sidelined yesterday by a migraine. Meant to blog on return from work, but just went to sleep instead.
posted by sydney on
7/30/2004 08:51:00 PM
KerryCare: John Kerry's healthcare plan gets proper scrutiny today at National Review Online by Michael Cannon of the Cato Institute. In addition to the points made here, there are these things to consider:
1)According to Rand, a nonpartisan think tank, up to half of those who enroll in Medicaid under such eligibility expansions already have private insurance but drop it — or are dropped by their employer — when they become eligible....this suggests that under the Kerry plan, taxpayers would spend $300 billion over 10 years to provide Medicaid coverage to as many as 18 million people who already have private coverage today. Draining 18 million paying, risk-spreading customers from private pools would make coverage even more expensive, causing even more workers to lose the coverage they now have.
2)Under the Kerry proposal, insurers would have to offer the same plans to both federal workers and those in the Kerry health alliance. Any plan that proves unprofitable in one would be taken away from the other, which could take away from federal workers the coverage they now enjoy
3)Like the Kerry proposal itself, Thorpe's widely cited cost estimate — $653 billion over ten years — does not withstand scrutiny. First, Thorpe's projections cover nine years, not ten. Second, they implausibly erase much of the cost by assuming the Kerry plan would so increase efficiency that taxpayers would get back 30 cents of every dollar spent. Ignoring savings projections and adding a tenth year, Thorpe's projections suggest the Kerry plan would cost $1.1 trillion over ten years, which most agree would require a broad-based tax increase.
The HealthGrades report used 16 of 20 'Patient Safety Indicators' developed by the federal Agency for Healthcare Research and Quality to screen hospital administrative data for safety-related incidents from 2000 through 2002.
In all, the report looked at 37 million Medicare patient records, representing about 45 percent of all hospital admissions in the United States -- not including obstetrics patients.
...There were about 1.14 million 'safety-related incidents' associated with 323,993 deaths in hospitals during the period reviewed by HealthGrades, which is based in Denver. Eighty-one percent of those deaths were directly attributable to the incident.
And one in every four Medicare patients who experienced an incident died, the report found.
'Failure to rescue' (which refers to failure to diagnose and treat conditions that develop in a hospital), bedsores, and postoperative sepsis accounted for almost 60 percent of all ' safety-related incidents,' according to the report.
The report's authors said these errors accounted for $8.54 billion in excess costs to the Medicare system over the three years studied. If that number were extrapolated to the entire United States, it would mean an extra $19 billion was spent and more than 575,000 preventable deaths occurred from 2000 to 2002, the authors concluded.
That sound horrible. Maybe we should fire all the doctors and close all the hospitals. Then no one will be harmed and we'll save billions of dollars.
But wait, the "study" leaves more questions than answers, as one of the authors of the report that started all of this, To Err is Human, by the Institute of Medicine, points out:
'Medicare patients have a higher adverse event rate because they have a lot more treatments, they're sicker, they have multiple diseases, so the mortality rate, the error rate, all these things are higher,' said Dr. Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health, and one of the authors of the IOM report.
Furthermore, he added, 'failure to rescue' is not normally used in calculating deaths from medical errors; it's not an accepted standard."
The problem is, these folks act as if we already live in a FuturePundit world where no one ages, no one gets sick, and no one dies. We have not reached that state, and until we do, people will continue to get sick and continue to die. Not every rescue attempt can be successful. And many times, especially in the very old whose bodies are worn out, our rescue attempts are like spitting in the wind.
So why would this HealthGrades company go to such lengths to exaggerate the dangers of modern medicine? Because, they make their money by giving error-reduction advice. Got to drum up business. And a perception of a problem is sometimes better than an actual problem at stirring up the market. Trouble is, unless they have the waters of the fountain of youth in their vaults, they can't correct these "failure to rescue" events, either.
UPDATE: A reader notes another problem with the study:
Not only are all your points well-taken but the software they used was designed to identify POTENTIAL preventable deaths, and these people treat them all as preventible. posted by sydney on
7/28/2004 07:58:00 AM
Tuesday, July 27, 2004
Blog Notes: I'll be guest-blogging this week at Overlawyered, where today Walter Olson has already covered the Kerry campaign sugar daddies - trial lawyers all.
(Sorry for the html slip up earlier. Failed to close a tag. It's fixed. Sentence makes sense now.)
Fire Under Fire: Teresa Heinz-Kerry and I had the same kind of day today. Heinz-Kerry was confronted by a reporter who asked her repeatedly to explain what she meant by "un-American tendencies." Her answer was that she didn't say that. And it's true, she didn't. She said "almost un-American tendencies." But under the reporters repeated badgering she erupted and told him to, "Shove it," or "Shut up," or something like that.
This is quite aptly called "pushing the right buttons." One person annoys another in just the right way to send them off the deep end. Some people are lucky. They have buttons that cannot be pushed. We say that they have grace under fire. It's a quality to be admired. But most of us don't have it. Confronted with someone who unreasonably badgers us, we're apt to fly off the handle or at the very least get cross. That's what happened to Dick Cheney recently. It happened to Barbara Bush when she encountered an annoying Al Franken on an airplane. "I'm through with you," she told him several times to no avail, a story he tells with mock shock in his most recent book. And it happened to me today with a patient. It isn't easy to sit in close quarters in an exam room with an angry, unreasonable person. The best thing is to walk away. But that leaves the angry, unreasonable person still in the office, taking up needed exam room space. And still making a fuss. When the right buttons are pushed I end up reacting somewhere between Barbara Bush and Teresa Heinz-Kerry. But afterwards, I always feel some bit of shame. Not for dismissing them. They surely deserve that. But for failing to find a gracious way to shut them up and send them on their way. On a good day, with the right patient, I can usually find the right words to deflect an escalation. But today wasn't a good day, and this certainly wasn't the right patient. My sympathies to Mrs. Kerry. posted by sydney on
7/26/2004 10:38:00 PM
20/20 Vision: I didn't see it, but this 20/20 segment on the social cost of litigation sounds like it was good. Many of the comments are worth reading, too. The best quote from the story comes from Richard "Dickie" Scruggs, who made a substantial fortune suing big tobacco:
Clearly, there are bad and careless doctors, but in certain specialties most doctors are being sued.
In fact, 76 percent of American obstetricians have been sued. Yet lawyers, like Scruggs, often say there are only a 'few' physicians who are causing all the problems.
Then how is it fair that three-fourths of the obstetricians get sued?
"Well, you know … that's why they have insurance," said Scruggs.
Yep, that's why we have insurance. To redistribute the wealth to attorneys.
I Know We Speak the Same Language but it took me a while to figure out what this is about. It doesn't take long to realize that "dummies" are pacifiers, but "cups"? I thought they might be modified bottles, but the article goes on to mention small medicine cups. Do they really make premature babies drink from tiny little cups in England (a skill most babies don't aquire until around twelve months of age)? Or is it just a confusion of language? Any input would be appreciated.
The Gynecology of Flowers: Flowers have long been popular subjects for painting, from still lifes to landscapes. But when Georgia O'Keeffe painted flowers, she caused a sensation. For O'Keeffe didn't paint flowers from a man's eye view, or even a woman's eye view. She painted flowers from a butterfly's eye view. Many of her flower canvases were huge (the largest was six by seven feet), with the flower in complete domination - a close-up view that even today gets closer to the essence of a flower than even a camera can.
Pink Sweet Peas, Georgia O'Keefe 1927
To many critics, that butterfly view was outrageously sexual, even pornographic. They looked at the luscious folds of petals, and dangling carpals and anthers in them and saw not plant genitalia, but female genitalia. It was the Jazz Age when Freud and his theories were all the rage, and so many of those theories got applied to O'Keeffe and her flowers. It didn't help that she already had a reputation for eroticism thanks to the photographs taken by her lover (later husband), Alfred Stieglitz.
But O'Keeffe always denied the gynecological metaphor, telling her critics: ".. you hung all your own associations with flowers on my flower and you write about my flower as if I think and see what you think and see of the flower - and I don't." She painted her flowers not to shock but to record the play of shapes, color, and light that she saw when she looked at a flower closely. Her brain didn't think in words so much as it did in patterns and colors:
The meaning of a word - to me - is not as exact as the meaning of a color. Colors and shapes make a more definite statement than words. I write this because such odd things have been done about me with words. I have often been told what to paint. I am often amazed at the spoken and written word telling me what I have painted.
Which is why her flower paintings transcend the label of flower porn. They are visual poetry. Keats' described the sweet pea flower as "wings of gentle flush o'er delicate white." O'Keeffe's vision of the flower is the same. She may have not have been able to express it in words, but she felt it just the same. Lucky for us, she could turn that vision into a picture worth more than a thousand words.