Beauty, chemistry, and natural philosophy

Summer reflections

Molecules? by Jori Samonen, via Flickr.  (CC BY 2.0)
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About a year ago, Theral Timpson interviewed Stanford chemist Carolyn Bertozzi on his Mendelspod podcast.  I only heard the show recently and enjoyed it.  The title caught my attention: “Is the future of biology a return to chemistry?”

Bertozzi made some interesting comments about her field, which she regards as “the central science,” and Timpson probed her about her expectations for the place of chemistry in what is otherwise expected to be “the century of biology.”

The discussion was of interest to me for two reasons.

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The mother of all medical errors

Iatrogenesis in perspective

Healing the sick, fresco by Domenico di Bartolo. Sala del Pellegrinaio (hall of the pilgrim), Hospital Santa Maria della Scala, Siena. Public Domain, via Wikimedia
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A study published a couple of months ago in the BMJ  made headlines for claiming that medical errors are the third leading cause of death.  As expected, the reactions were swift and polarized.

For some, the study confirmed that the self-serving healthcare system is utterly careless about the welfare of patients.  For others, the claim was complete hogwash, based on faulty methodology designed to justify further regulatory oversight.

The two positions are not necessarily mutually exclusive.

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Risk-factor medicine

An industry out of control

Image credit: NHLBI image gallery on Flickr, via CC-2.0
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If concepts could get awards, then “risk factor” would surely be a Nobel prize winner.  Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it.  Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept.  I will summarize here some of those points.

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Risk factors, causes, and the diet-lipid hypothesis

A conversation with a reader about medicine's Ptolemaic epicycles

Photo credit: By by jefras a.k.a Jo?o Est?v?o A. de Freitas. Public Domain,
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I shared with a reader an editorial I co-wrote in 2010 entitled “Risk-Factor Medicine: An Industry Out of Control?” Subsequently we had the following e-mail exchange, which I thought might be of interest to other readers of Alert and Oriented.  I was impressed by Robert’s comments and learned a few things from him and from the links he provided.

On April 29, 2016, Robert wrote:

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Interview on the Wake-Up Call podcast.

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I had the pleasure of being interviewed by Adam Camac and Daniel Laguros, hosts of the Wake-Up Call podcast.  We talked about the history of American healthcare.  The interview was broken down into 2 segmenst.  Here is part 1 and here is part 2.  I highly recommend this podcast.  Adam and Daniel are very good hosts and they have terrific guests, covering a wide range of topics.  You can subscribe on iTunes.

The pharma-fed doctor

And the foundation-fed healthcare journalist

Photo credit: Bobsama - Own work, CC BY 3.0, via Wikimedia
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In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

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In defense of the employed physician

Photo credit: Pixabay (public domain)
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I wish to make one clarification and one prediction regarding employed physicians.

The clarification is this:  There is a common misconception that if healthcare operated under free market conditions, it would primarily be a cottage industry of solo practices and of small physician-owned hospitals.  Such operations would not develop the capabilities of large healthcare entities that we commonly associate with central planning.

In reality, however, the opposite would be the case.

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Let’s be clear about transparency

And about the obfuscations of healthcare policy interventions

Image credit: Pixabay (public domain)
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Note: This article is jointly posted here and on The Health Care Blog.

Transparency—or its absence—continues to fascinate healthcare analysts and healthcare economists.  A study just published in the Annals of Internal Medicine addresses the effects of public reporting of hospital mortality rates on outcomes.  Its senior author, Dr. Ashish Jha, offered his perspective on the study results and on the topic of transparency in The Health Care Blog.

According to the study investigators, mandatory public reporting of hospital mortality is not improving outcomes.  The result of their analysis surprised them because “the notion behind transparency is straightforward” and the “logic [of public reporting] is sound.”  The conclusion, therefore, is to persist in the effort, but to do it better with better metrics, better methods, and better data. 

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Practicing medicine for the common good

Beware of the fallacies of Spaceship Earth ethics

By Forcastro - eigin skrá, Via Wikimedia Commons
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In a recent New England of Medicine article titled Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each which his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of one against those of the other.

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Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)