Thursday, May 31, 2007

TB and Andrew Speaker

ABC News with what he is likely to go through:
Thursday, doctors at National Jewish planned to try two more antibiotics against the extensively drug-resistant disease -- one oral, the other an intravenous injection.

Dr. Henry Boom, director of the tuberculosis research unit at Case Western Reserve University School of Medicine, said such a "cocktail" is a common strategy for a resistant case like Speaker's.

"What's done in this situation is that you look at the drug-resistance pattern and try to come up with a cocktail of at least two or three drugs that have potential for treatment," he said.

Three more antibiotics may be on the way for Speaker this week, and doctors will continue to scrutinize an isolated sample of bacterium taken from Speaker's body to see if anything in the current arsenal of medicines can kill it.

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Gupta on the TB scare

CNN's Sanjay Gupta says it should be a wake-up call:
More than anything, I think this one case reflects deeper failings in our public health system. What if there were ten cases, instead of just the one? What if it were smallpox or a bioterrorism attack? Are we ready?

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Thanks for the link!

I appreciate the recent links to Kevin, M.D.:

Dr Flea Blogged His Malpractice Trial, Settles When Outed

How one physician blog may have cost him millions

Unmasked, Undone

Flea: Another Argument for Tort Reform?

More on Doctor "Flea" Being Outed On The Witness Stand

On Flea

Days of Fame

Ins and Outs

Doctor "Flea" Settles Malpractice Suit After Blog Exposed In Court

Glad I don’t

Flea Collared

This makes me so sad

Flea’s Case Outed

Health Care: What Single Thing Would You Change?

Details unfold about Flea’s day in court

Flea

Un(settling) End In The Case Of The Disappearing Flea

An attorney weighs in on Flea’s malpractice settlement

Flea's fall sobering for other bloggers

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Job board

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Together with The Health Care Blog, your job post will be viewed by readers of two prominent health care blogs, with a targeted audience of physicians, nurses, health IT, and other health professionals.

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Why health care is expensive

Panda Bear minces no words:
1. Patients are not encouraged or expected to take personal responsibility for their own health . . .

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions . . .

3. The legal environment makes it impossible for anyone in authority to exercise common sense . . .

4. Futile care, which is in no way discouraged . . .

5. Doctors don’t know how to say “no” or admit defeat.

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EHRs and real life

There is often a disconnect between what an EHR programmer anticipates and real life.

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Gawande on health reform: "It is not single-payer"

His most recent op-ed talks about the health reform possibilities:
This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.

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Brain surgery canceled six times

Due to "capacity" issues in Canada:
In March 2006, Mary Lou Frye had a seizure and drove off the Fraser Highway into a ditch.

A CAT scan revealed a golf ball-sized tumour behind her left eye. She had surgery in May 2006, but bleeding cut the operation short, leaving part of the tumour.

She now has two tumours in her brain, but since January Frye has had her surgery postponed six times, the latest last Friday when four other neurosurgery cases were also postponed.

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The most ethical pharmaceutical?

So far, Glaxo comes out ahead this year.

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Smoking and your penis

The NHS of all people, with some clever marketing:


(via PharmaGossip)

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Chest pain in the ER

The age-old question, how can you tell if it's cardiac or not? Scalpel writes from the ER perspective.

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GSK plays defense on Avandia

They are reaching out to the Lancet and WSJ.

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Flea

Stunning news. The Boston Globe on Flea, his trial and how his blogging ultimately led from a possible victory to settlement:
As Ivy League-educated pediatrician Robert P. Lindeman sat on the stand in Suffolk Superior Court this month, defending himself in a malpractice suit involving the death of a 12-year-old patient, the opposing counsel startled him with a question.

Was Lindeman Flea?

Flea, jurors in the case didn't know, was the screen name for a blogger who had written often and at length about a trial remarkably similar to the one that was going on in the courtroom that day.

In his blog, Flea had ridiculed the plaintiff's case and the plaintiff's lawyer. He had revealed the defense strategy. He had accused members of the jury of dozing.

With the jury looking on in puzzlement, Lindeman admitted that he was, in fact, Flea.

The next morning, on May 15, he agreed to pay what members of Boston's tight-knit legal community describe as a substantial settlement -- case closed.
There is no anonymity on the web. If you blog under a pseudonym, people will find out who you are if they really wanted to. So with that in mind, blog as if the whole world is reading and knowing who you are.

It's unfortunate for all concerned. For Flea obviously. But also for the medical blogosphere. The strength of blogging is its inherent openness and allowing the curtain to be "pulled back". Now, every post will be filtered through this question: "Will this ever come up in a malpractice trial against me?"

Flea, we'll miss you and sorry to see things turn out this way.

Update:
Plaintiff attorney Eric Turkewitz called it correctly and has a roundup of the ordeal:
Finally, this case was a tragedy for two parents, and a nightmare for a doctor. If the parents had lost the trial, it would have added yet another layer of extraordinary emotional trauma. If Flea lost, it would no doubt been emotionally difficult for him. A settlement allows each to move on with their lives without the additional fallout of a jury's verdict. The parents might feel they had their day in court and that the settlement was based on the merits, while Flea might feel it was based on his own carelessness with his writing and the concerns a jury might not like the way his legal team was trying to manipulate the jury. Neither won and neither lost. And sometimes that is all for the best.
MetaFilter comment:
"But when I look at this case, I wonder what we've lost. Expert analysis of issues in the pediatric and medical community. Transparancy into the behind-the-scenes aspects of our legal proceedings. Eloquent and insightful content, now gone because your opinion can be a legal liability."

N=1:
"Bloggers have no real protections against the invasion of their privacy. The healthcare blogging community is the poorer for the loss of Flea’s insights, passions and wit."

Update 2 -
The Boston Globe with blogger reaction, including mine:
"'It's a little bit sad in a way. The whole purpose of blogging is to be open and pull back the curtain to talk about how it really is,' he said. 'So the question is, how realistic is that? I think that's what physicians and other health professionals are wrestling with right now. It's part of the growing pains of the medical blogosphere.'"

symtym:
"Arrogance, ignorance, or both? Dr. Lindeman’s most potent defense was his character—a character the Flea so thoroughly impeached—case over and settled. Hosea 8:7. For they sow the wind And they reap the whirlwind."

Mary Johnson:
"Anyway, a lot of people will be mulling this one over for a long time to come. The lawyers are already spinning it as a 'win-win' (I expect Flea doesn't feel that way). Doctor-bloggers are bemoaning 'the loss' of expert analysis, transparency, insight, passion, wit (it's a long list . . . for the physician known in the blogosphere as 'Flea' is a gifted writer)."

Althouse:
"Here's a tip. Don't blog anonymously unless you're ready to accept all the consequences that would come if everyone suddenly knew it was you. Congratulations to the lawyer who figured out that she should ask that question on cross. You know, I love to support bloggers, but this doctor totally deserved what he got."

Update 3 -
David Catron:
"Flea’s case wasn’t settled on the merits. It was settled because of a few intemperate posts on his blog. Now, there will be lawyers and paralegals all across the country trolling the web for blog posts by anyone connected with a medical defendant. Will they be doing so in states where tort reform has been enacted? I doubt it."

#1 Dinosaur:
"Flea -- and all of us -- have a right to blog anonymously. This also means we should have the right not to be compelled to renounce that anonymity. Anonymous blogging didn't have anything to do with the medical case at hand. What business did the attorney have bringing it up in court at all? Answer: she didn't. So I repeat, where the HELL was Flea's lawyer when that question was asked?"

OnThePharm:
"It saddens me when a case is settled not on the facts of the case, but rather on issues that are only tangentially related to the matter at hand, at best. That said, perhaps Flea was confident in his anonymity, but probably shouldn’t have been."

Ami Chopine:
"It is you and it will sadly be the general public, who do not understand the nature of Flea’s blogging. He was anonymous. We could not check. But Flea’s articles, sharp as they’d sometimes been, had always consisted of sound science. Moreso, the frustration he often expressed was a mark of his compassion for the children under his care. In the blogging world, he was a model of integrity and compassion.

If you accuse of bloggers who defended him of ’not having the whole picture’, you must accuse yourself of the same thing.

To the lawyer, Mulvey, who claims to have read his entire blog: where is your integrity? Is it truth or power that you love? Is it compassion or money?"

Update 4 -
Kinohi Nishikawa:
". . . the prosecution was able to cast doubt on the Lindeman's character -- precisely because 'Flea' and 'the real 3-D doctor' turned out to be the same person, the same 'cocky bastard.' Here Lindeman's metacommentary doesn't realize its own ironic condition of possibility: that forcefully stating the difference between Flea and the 'real' doctor only serves to underscore their inextricability. (You know the type: 'Really, I'm not like that -- in fact, I did it just to remind myself how different I really am!') This rhetorical move amounts to Lindeman denying his very real investment in Flea as both a cathartic release and an agent, however modest, of public opinion."

Eric Turkewitz:
"Saltzman informed me during our conversation yesterday that Flea's attorneys were unaware of the blog, which means of course, that Flea didn't tell them and he wasn't prepped by his attorneys on the subject on how to deal with it if it should come up."

David Harlow:
"This takes the questions about propriety of physician blogging to a whole new level."

Update 5 -
Orac:
"My bottom line on this is simple. The case of Flea is not the dire signal about the demise of the medical blogosphere that some have been making it into and that I briefly fell for. Rather, it's a wake-up call about reality. The First Amendment guarantees us freedom of speech and allows us to speak with anonymity. However, just as it does not insulate us from being offended by other people's speech, it also does not insulate us from the consequences of what we say publicly."

Notes of an Anesthesioboist:
"The discovery process can't stay the same after this - it hasn't been the norm to request blogs, myspace pages, and such, but attorneys are now clearly going to have to take various types of records into account and adapt to the Internet age."

#1 Dinosaur:
"Although a doctor's personality, appearance and demeanor on a witness stand are seen as proxies for behavior with patients, I fail to see how actions (or writings) outside the courtroom or exam room have any relevance to the questions that come up in a malpractice trial. I know that's how the world *does* work. My question is, should it? I say no."

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Wednesday, May 30, 2007

Blogging physician corruption

A Greek blogger writes about physician corruption during her last few years with terminal cancer.

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Is the pressure getting to Steven Nissen?

An anonymous blog posting has got him riled up:
Arbesfeld included in his e-mail a comment on a blog posting, originally published in the Wall Street Journal, that accuses Nissen of primarily criticizing manufacturers that do not support drug trials at the Cleveland Clinic: "Wake up, pharmaceutical companies … if you don't hire the Cleveland Clinic for your big trials then you face the firing squad from Nissen and Company." The comment's author is identified only as "Brian A."

Nissen calls the anonymous blogger's accusation an example of "the big lie." "The idea that I would somehow be selective in my criticism to those companies that don't bring clinical trials [to the Cleveland Clinic] is … extremely offensive … and absolutely untrue."

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Thanks for the link!

I appreciate the recent links to Kevin, M.D.:

Ins and Outs

Doctors: take control of your online presence

A Hospital Death in Florida

Linkfest: "Frivolous, "Oppressive" or Just "Weird"?

Sermo becomes official AMA social network

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Hypnosis show volunteer sues over psychological damage

There is no precedent for a case like this:
Johnson, then a senior at Hercules High School, volunteered with several other students to be hypnotized by Cady. But he and his mother allege in a negligence suit filed earlier this month that toward the end of the performance, "while still in a hypnotic trance, [he] proceeded to run out of the building, jump two flights of stairs and continued running through the campus in an incoherent state."

Six police officers were required to handcuff him and strap him onto a gurney for the ride to the hospital, where a psychiatrist “'reversed' the effects of the hypnosis and brought Louis Johnson out of the hypnotic state.”

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Stroke and tPA: A journalist seeks an anonymous commenter

The recent NY Times' piece on stroke has generated some controversy. A journalist for a national magazine is interested in talking to the authors of some of the anonymous comments that the post generated:
I am a freelance medical investigative journalist and I will be examining how medical studies are misinterpreted for a feature article in a national magazine. Would those of you who posted on tPA for stroke who are willing to talk to me please contact me at jeanne.lenzer@gmail.com.

I have a special request for one of the "Anonymous" commenters who have posted on this topic. I especially want to talk to you and I can guarantee your anonymity if desired.

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USMLE Clinical Skills exam

What is motive behind this test that almost everyone passes anyways? There are 17 million reasons.

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Pink cupcakes and AstraZeneca

The brouhaha about pink cupcakes has come to an end as AstraZeneca has banned them. Peter Rost and John Mack with more.

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Nurses as the latest drug reps

Big Pharma is employing nurses to review charts, a precursor to pushing brand name medications:
One recent 18-month program sponsored by Pfizer and the National Health Service added nurses to hospitals to discuss management of chronic health conditions with patients. Sanofi-Aventis is paying nurses to train doctors’ office staffs how to identify patients at risk for cardiovascular disease and diabetes. Last fall, the British drug trade group temporarily suspended Merck after ruling that a company program in which nurses paid by Merck reviewed patients’ charts inappropriately promoted Merck’s blood pressure drug Cozaar.

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Ritalin to boost exam scores

Just confirming what has always been suspected:
Parents are giving their children internet-bought "smart drugs" to boost their performance in the exam room, a psychologist has claimed.

Anti-hyperactivity medicines like Ritalin are being used as a "study aid", says Leicester University's director of education Paul Cooper.

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Quarantine of a TB patient

He has drug-resistant TB and willfully disobeyed advice not to travel:
Federal and international officials are tracking down passengers and crew members on two trans-Atlantic flights earlier this month who may have been exposed to a man infected with an exceptionally dangerous form of tuberculosis.

The male passenger flew to Paris from his home in Atlanta on May 12 on Air France 385 and arrived in Paris on May 13. He returned to the United States on May 24 after taking Czech Air 104 to Montreal from Prague. The man drove into the United States that day and entered a hospital in New York City on May 25.

The man is now in an Atlanta hospital under federally enforced isolation after he was flown there from New York City on Monday in a plane owned by the Centers for Disease Control and Prevention in Atlanta.

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VistA

An op-ed in the NY Times extolling the virtues of the VA's EHR. I agree, it is the most redeeming entity of the Veterans' health system. Matthew Holt says it's not ready for prime time yet.

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Attacking Michael Moore

Rich Tucker and Benjamin Pugh take their shots.

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Raising HDL

Now that Pfizer's torcetrapib was DOA, how can you raise HDL? Well, there's plain old exercise for starters:
A regular aerobic exercise program of at least two hours a week produced a small but significant increase in HDLs, according to a meta-analysis.

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Stroke and tPA: ER perspective

GruntDoc on the recent NY Times' piece on stroke and use of tPA:
It’s a tour-de-force in obfuscation of fact, presentation of tragedy as preventable, and the presentation of TPA as an ignored wonder-drug, MRI should be the standard of care for new strokes, and frankly there’s no redeeming value within.

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"The MGH habit will be hard to break"

Expansion of Massachusetts General Hospital is causing some worry:
Slavin is right that the people of Massachusetts expect much from the hospital: the best of care no matter how difficult the case, the training of physicians, and advances in medical research. But government, business, and consumers in the state can only afford so much. The long-term cost trends at MGH will be evident in a year or two, when private insurers negotiate their rates with the hospitals. If rates don't moderate, more and more people could find themselves priced out of the splendid new facilities approved last week.
(via Running a hospital)

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The AMA and Sermo

The AMA decides to join to 21st century and partners with Web 2.0 upstart Sermo. Pharmalot shares some concerns about the deal.

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Tuesday, May 29, 2007

Whistle-blowing = bad outcomes

Heart attacks, anxiety, depression and suicide often contribute to the high mortality rate in whistle-blowers. (via Health Care Renewal)

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Arrested for hypoglycemia

An ignorant DA is continuing with charges against diabetic Doug Burns, who was arrested during a hypoglycemic episode:
. . . the authorities pressing charges are publicly chastising Doug for negligence in his diabetes care, on the basis that he was temporarily on injections rather than his usual Animas pump at the time of the incident. This was because he had run out of infusion sets during recent conference travel and was awaiting a new box.

"If life were perfect, this would never have happened... but they need to understand that anyone with type 1 diabetes is pretty much at risk for hypoglycemia at any time," Doug says.

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Health insurers' worst nightmare

Is potentially happening in the Czech Republic.

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Thanks for the link!

I appreciate the recent links to Kevin, M.D.:

The $33 million window

Heart congestion - share the revenue, better healthcare for the patients

War on Drugs marching north?

Journalistic malpractice?

Doctor Doofus

Linkfest: Sunday Updates

Funny Medical Student video

$30M verdict against doctor for saving patient's life?

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Obama's health plan

It's not single-payer and doesn't have a "doctor tax", so label me cautiously optimistic on Mr. Obama's proposal right now.

Kate Phillips, John McCormick, and Ezra Klein with the requisite analysis.

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Should you test cholesterol in children?

This pediatrician says no:
My advice is to forget about obtaining your kids' cholesterol level. More importantly, don't burden them with an explanation of the genesis of adult diseases, like atherosclerosis and its discontents. All a kid needs to know is that some things are "healthy" and some are not.
(via White Coat Notes)

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Universal health and primary care

Will there be enough primary care physicians to go around? At least I'll have some job security.

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Pharma gifts at physician conferences

An observer at a recent GI conference notes the pharma influence:
The Shire Pharmaceuticals’ booth offered weary physicians a park-like atmosphere complete with gently rolling grassy hills, stone paths, park benches, and free hot dogs. The Abbott booth contained a mini-movie theater. On every aisle, companies provided free slushies, gourmet espressos, coffee, tea, sweets, hot dogs, and fresh pretzels. They also offered beach towels, blankets, movies, free internet access, and, the most popular gift of all, a comfortable place to sit and chat with colleagues or the model-like sales representatives who prowled the convention floor.
Sounds similar to my visit to Pri-Med last year.

The flip side is that without pharma sponsorship, these conferences would be prohibitively expensive for physicians to attend.

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Avandia: Nissen and the media gets taken apart

David Phillips rips major media, Steven Nissen and the NEJM in this scathing entry:
Like the yellow journalism that set us on a collision course to war with Spain in 1898, many journalists are sensationalizing Nissen’s opinions to sell newspapers and/or magazines—with little regard for those most likely to be impacted by the findings—type 2 diabetes mellitus patients currently taking Avandia (and who might make unilateral decisions to stop taking a drug controlling there blood sugars, without notifying their doctors) . . .

. . . The 10Q Detective argues that the Avandia controversy epitomizes why circulation continues to decline at national dailies—like The New York Times, LA Times, and The Washington Post. Trust issues and lazy reporting are the corrosive causes of subscription losses—not reader flight to the Internet.
(via PharmaGossip)

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Mirapex and restless leg syndrome

Peter Rost further stirs the pot on Pfizer promoting the off-label use of Mirapex for restless leg syndrome (RLS). The thing is, Mirapex really is recommended as first-line treatment for RLS (via UptoDate):
Begin with pramipexole [Mirapex] (0.125 mg) or ropinirole (1.0 mg) approximately one hour before the usual time of symptom onset; the dose is titrated upward according to response. These drugs are effective and well tolerated by most patients
Off-topic, I like how the Pfizer drug rep described Neurontin:
Neurontin - Christ! Pick a disease. Any disease! Although, much of this off-label use was physician-driven. I recall one of my Neurologists describing Neurontin as the ‘Swiss Army Knife’ of pharmaceuticals.

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Codes for paramedics

Hilarious codes for things EMTs may encounter in the field. I like 20-301, "Overdose on normal dose of Ambien (also known as sleep)."

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Waiting Canadians = Uninsured Americans?

Brett Skinner: "Canada's public health insurance monopoly is failing and millions of Canadian patients wait so long for treatment that they are no better off than uninsured Americans."

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The war on drugs going to spread up north?

Canada is planning a US-style war on drugs. Don't, says this op-ed:
Instead, there are signs -- such as the Conservative distaste for safe-injection sites that are a key component of the "harm-reduction strategy" -- that Ottawa is tilting toward a more aggressive, U.S.-style war on drugs. If that is the case, it would be an unfortunate mistake with predictable and very disappointing outcomes.

While Washington from time to time trumpets bravely that it has scored a victory in the war on drugs, by all empirical measures it has been an abject failure.
(via The Health Care Blog)

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Grand rounds is up

From Medskool hosts this week. Come get the weekly best of the medical blogosphere.

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The link between golf and health

How you play golf can point to a variety of health problems:
You ride the golf cart. If a golf cart is essential, you probably need to improve your fitness . . .

Short drives. If your drives aren't going very far, it's often a sign of a flexibility problem in your lower body, particularly your hip muscles. . .

Accuracy problems. If the ball is consistently bending to the right or left, you may have posture, strength and flexibility problems in your upper body. . .

Inconsistent swing. If your swing is all over the place, it may be a sign that you lack strength in your "core" muscles. . .

Your game falls apart after a bad shot. How you react to a bogey or a birdie can also be a sign of how you manage stress every day.

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The NEJM as a tabloid

The WSJ jumps on the bandwagon against the NEJM, as discussed in the blogosphere last week:
At what cost do political machinations of the medical journals come? NEJM editors have long favored more drug regulation. But medical journals have also historically played a special role in helping to define medical practice standards. Even decisions they make on how prominently to place a study, let alone how they editorialize about it, are seen as strong signals to clinicians on how doctors should weigh the evidence. So when editors pursue a political agenda, it's public health that pays a price. Degrading an institution that doctors depend on for balanced analysis and fair-minded editorial judgments isn't good for anyone.

In the case of the Avandia study, NEJM editors gave short shrift to the study's flaws. The paper, which re-analyzed the results of 42 earlier studies of the drug found on the Internet, revealed that Avandia might cause a small increase in the absolute risk of a heart attack. But the study that the authors did, called a "meta-analysis" because it aggregates results from lots of studies to generate a larger sample, contained a number of serious limitations.

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"The customer is always right": Does it apply in medicine?

Edwin Leap thinks not:
Attention patients and families of patients, regulators, government officials, commentators, angry bloggers and reporters: I am the physician. That makes me the expert. I realize that we live in the age of polls, surveys, empowerment and self-help. I realize that the opinion of the masses generally matters more than the opinion of the educated. But as one of the educated, as one of those who considers his opinion more valid than many others, let me say what most physicians are too nice to say. Medicine is not a democracy. I appreciate your opinion, and you may accept or refuse anything I offer. You may even tell me what you think, and what has worked before. But I get the final vote. I have earned that vote through years of caring for the sick, and I am accountable for my mistakes, as is evident by my very expensive malpractice insurance. You may refer me to any one of your resources or family members, but in the end, like it or not, one unassailable fact remains: I’m the doctor, not you. Deal with it.
(via GruntDoc)

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