“An interview with Sami Karam”

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I was interviewed by Sami Karam, editor of Populyst, a demographics and economics blog and podcast.  Sami lives in New York and became interested in my “early detection” approach to heart disease prevention.  Here is the link to our conversation.  We covered a lot of ground, contrasting a screening approach to the standard “risk-factor” approach for heart disease prevention.  I think you will find our dialogue informative.

A Deadly Choice for the Medical Profession

The (assisted) death of Socrates, by Jacques-Louis David.  Metropolitan Museum of Art, New York
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“Physician-assisted dying”

As part of the debate on physician-assisted suicide, the San Francisco Medical Society kindly invited me to write an article taking the “contra” position.  Below is the text of the article.  You can find the print version along with the article taking the “pro” position here.

When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about such wish?  The California legislature is considering that question, and physicians will soon be asked to weigh in on it.  Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors.  Currently, however, enthusiasm in its favor is growing.  What are the reasons given to justify this emerging practice?  Do they truly warrant legal sanction?  And do they justify an about-face from the medical profession’s long-held stance on this matter?

The Apostles of “Less is More”

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Gnosticism in medicine

Gnosticism describes a religious movement flourishing at the beginning of the current era, as Roman paganism was foundering but before Christianity became firmly established.

The main belief of the Gnostic sects was a doctrine of “Salvation by Knowledge (gnosis),” the idea that a privileged class of human beings can, by special insight, obtain possession of the mysteries of the Universe.

Gnostics held a deprecating view of the material world, and favored instead the spiritual realm.  Gnostic elites would profess a severely ascetic lifestyle as the path to enlightenment, although some have been accused of hypocrisy for shunning the austere discipline they would demand of their followers.

American medicine in the 21st century bears resemblance to the Gnostic movements of old.

Question from the board exam ABIM execs are required to take

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Board Question #21

Mark Cuban vs. Guideline Writers

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Who can do the most harm?

Celebrity Marc Cuban set off controversy a few days ago with a Tweet expressing his recommendation that people should get quarterly blood tests “for everything available.”  If you have not followed the story, you can quickly get up to speed by reading a couple of posts on Forbes.com written specifically about this opinion firestorm.

Apart from their disagreement with Cuban’s specific recommendation, many physicians seemed particularly concerned that he and other celebrities who express medical opinions exert undue influence on the public.  In my opinion, this concern is misplaced.

A&O Is Back On-Line!

After a hiatus of a couple of years, I am happy to be back on-line.  This is essentially a fresh start; I am keeping only a few of the older posts up (others may be dusted up and repackaged if the need arises).

Thank you for joining me and be sure to follow me on Twitter.

Is the government writing your next hypertension guidelines?

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The release of the latest report from the Joint National Committee on Hypertension (JNC-8) has been delayed for several years.  It’s already been a decade since the prior report was issued.

Until recently the reason for the delay was obscure, but in the March issue of Cardiology News inside information is provided by cardiologist Sidney Smith.  The UNC professor of medicine, who has made a career out of writing practice guidelines for the American Heart Association, is a senior writer on the JNC-8 panel and this is what he had to say:

The delay has been due in large part to an unprecedented degree of prerelease review by numerous government agencies at a multitude of levels. This extensive and time-consuming advance scrutiny was instituted mainly because many health officials felt blindsided by the publication of the U.S. Preventive Health Services Task Force controversial mammography guidelines, which kicked up a hornet’s nest of criticism in the breast cancer and public health communities. Government officials don’t ever want to be caught by surprise like that again, explained Dr. Smith, professor of medicine at the University of North Carolina, Chapel Hill.

That’s right.  There is nothing more frustrating for a government official than to be caught by surprise by a body of medical experts sifting through scientific data for the benefit of practitioners.  The report must first be approved by the authorities!

We suppose that when the government pays for so much of health care and medical research, it’s only natural it would try to ensure that scientists have the national interest in mind, No?

Box 4 of the ACP’s ethics manual

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My 2¢ on parsimony

There’s been a bit of a buzz following the release of the latest edition of the ACP’s Ethics Manual.  For the first time, it seems, the manual includes a section on “stewardship of resources” with directives summarized in Box 4.

The Left hailed the new change as “truly remarkable” and an important first step to “break the logjam” of health care deficits, while the Right was quick to denounce the set of instructions as an “ethical game-changer,” a surreptitious undermining of the doctor-patient relationship, or an overt step toward health care rationing.

The purges have begun

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Has cardiology entered the Reign of Terror?

The heart.org has the following news report about a Maryland doctor accused of overstenting:

Baltimore, MD – A malpractice lawyer is accusing Dr John Chung-Yee Wang (Union Memorial Hospital, Baltimore, MD), a member of the committee tasked with stopping improper stenting in Maryland, of improper stenting in his own practice [1].

The Baltimore Sun reports that medical malpractice attorney Jay Miller has filed complaints with the state health claims arbitration office against Wang. Miller alleges that Wang, Dr Mark Midei, and Dr Kourosh Mastali wrongfully stented patient John Bowers in 2005 and 2006, when the three interventionalists were partners in MidAtlantic Cardiovascular Associates, a practice that has since disbanded. Miller also charges that Wang overstated the extent of coronary disease in patient Lorie Skillman to justify implanting a stent (…)

As reported by heartwire, the Maryland Medical Board revoked Midei’s medical license after it determined he repeatedly violated the Medical Practice Act by implanting hundreds of unneeded stents while working at St Joseph Medical Center in Towson, MD. Midei is one of several high-profile cases of alleged overstenting in recent years.

Wang is part of the Technical Advisory Group on Oversight of Percutaneous Coronary Intervention Services, a group of experts tasked by the Maryland Health Care Commission (MHCC) to develop recommendations for legislative changes that would improve oversight of coronary intervention labs in the state. The committee is set to report its findings at a public meeting of the health commission today. “The allegations could cast a shadow over the work of the advisory committee,” the Sun reports. Wang was nominated for the committee by the Maryland chapter of the American College of Cardiology (ACC).

We may recall another period of time when committees played a prominent role in regulating safety and security.

In 1793, Georges-Francois Danton was given the task of leading the French Committee of Public Safety to ensure application of the ideals of Liberté, Egalité, Fraternité.  In the months that followed, the committee prescribed treatment with the “National Razor

What it means to be normal

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“The artifactual disease” is the phrase George Pickering coined to describe hypertension in the 1950’s and 60’s.  In those days, he dominated the debate about the nature of hypertension, arguing against those who thought hypertensive patients who developed complications comprised a distinct entity of subjects.  “The higher the pressure, the worse the prognosis,” he would repeatedly affirm.  To my knowledge, he did not expound on the J-curve phenomenon, but he surely made a convincing case that defining a disease on the basis of arbitrary cut-off numbers is most foolish indeed.

But since the 1970’s, after clinical trials established the success of anti-hypertensive therapy, and with the growing enthusiasm for “risk-factor modification” and the inexorable rise of population medicine, any attempt to expect rational nomenclature or clarity of thought has seemed increasingly futile.

Instead, we must be impressed by discussions of studies where “Patients were categorized by their mean SBP level over follow-up as very low normal (<120 mm Hg), low normal (120 to <130 mm Hg), high normal (130 to <140 mm Hg), high (140 to <150 mm Hg) and very high (>150 mm Hg). ”

I recently tested myself on a 24-h ambulatory blood pressure monitor.  My SBP varied from 90 to 142 mmHg.

No wonder I was feeling out of sorts.