Prohibition: Then and now

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[The following editorial was first published in September 2014 on the blog of the San Francisco Medical Society. At the time, a ‘soda tax’ was on the ballot for voters to consider. The measure was defeated but the debate continues, as seen in these recent BMJ editorials. Note: the version below is slightly modified from the original.]

Nearly one hundred years ago, the eighteenth amendment to the United States Constitution made it illegal to produce, transport, or sell alcoholic drinks. The prohibition was the culminating action of a “temperance movement,” a century-long grassroots effort aimed at curbing the consumption of alcohol. The movement arose in response to an epidemic of alcoholism and was guided by the compelling argument that alcohol is toxic and that alcoholism brings along serious social evils: chronic unemployment and family neglect or abuse.

Today, a similar movement is taking shape in response to the obesity epidemic. Excessive consumption of sucrose and fructose in ubiquitous “sugary” drinks has been identified as a main cause and found to be responsible for the high prevalence of diabetes and its associated health and socioeconomic complications: cardiovascular and renal disease, blindness, premature death, and exploding health care costs. The new temperance movement decries the excessive use of sweet beverages and calls for restricting their sale. These restrictions can come in the form of taxes or outright bans.

But is resorting to taxation and to the strong arm of government always a wise move? I propose some arguments to ponder:Continue reading “Prohibition: Then and now”

Canadian medicosclerosis and American medicomania

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I follow several physicians from Canada on Twitter.  Since I do not have first hand experience of that health care system, I find their accounts instructive. Shawn Whatley, a Canadian physician I follow, wrote in a recent blog post entitled “Medicine resists change” that:

Canadians took a bold, progressive move in the 1960s and created Medicare. And we’ve blocked change ever since.

Sure, we dribble in new technology. Embarrassment demands we buy at least a few PET scanners and robotic surgical assists. But our core system is unchanged.

Government and Organized Medicine insist that basic clinical services work the same as in the 1960s. Patients see their family doctor. Doctors send patients for ‘high-tech’ X-Rays, ultrasounds or blood tests. Patients drive to licensed and controlled lab facilities. Then they trudge back for results days later.

That sounds grim.Continue reading “Canadian medicosclerosis and American medicomania”

Overdiagnosis: The disease that cannot be diagnosed

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Some say mammograms don’t save lives, and we order too many of them. That may be true, but which ones should we eliminate? The answer is not so easy after all.

Today’s post will deal with overdiagnosis, a concept preoccupying health care analysts, academics, and policy makers, and one whose importance is confirmed by the distinction of having its own dedicated Twitter hashtag.

And if you follow the #overdiagnosis hashtag these days, you will surely encounter the following chart, excerpted from a recent JAMA Internal Medicine paper:Continue reading “Overdiagnosis: The disease that cannot be diagnosed”

A documentary about doctors and widowmakers

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[Note: A slightly modified version of this article was just published in the Feb/Mar 2016 issue of San Francisco Medicine, the magazine of the San Francisco Medical Society (MA 03/23/2016).]

An award-winning documentary entitled The Widowmaker was just released on Netflix.  It shouldn’t leave viewers indifferent, and doctors in particular are likely to be thoroughly captivated.

Cardiologists can identify the title as the nickname commonly given to a threatening plaque near the origin of the left anterior descending artery, the major of the coronary arteries of the heart.  A clot forming at that site is frequently fatal.  Since middle-aged men are more prone to heart attacks than middle-aged women, such a clot often leaves behind a widow and fatherless children, hence the name for the plaque.

Cardiologists who watch this movie will also recognize some familiar figures:  Drs. Steve Nissen, Matthew Budoff, Bruce Brundage, Martin Leon, Arthur Agaston, Shamin Sharma, Joseph Loscalzo, Julio Palmaz, Douglas Boyd, Harvey Hecht, and many other high profile clinicians, innovators, and academics are featured in a suspenseful tale of heroes and villains.Continue reading “A documentary about doctors and widowmakers”

Reasons to MOC®: Board certification revisited

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Bob Wachter has written a lengthy defense of the American Board of Internal Medicine (ABIM) and its Maintenance of Certification (MOC®) program, addressing contentions that the ABIM may have engaged in questionable financial practices, and that MOC® is irrelevant, time consuming, and onerous.

These allegations, however, are not the only questions board organizations may need to confront.  Along with several recent articles devoted to the topic of professionalism, Wachter’s piece provides us with an opportunity to examine three foundational arguments that board leaders invariably bring forth to justify the commerce of certification.Continue reading “Reasons to MOC®: Board certification revisited”

The Institute of Medicine and the doctrine of perpetual conflict.

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The Institute of Medicine’s 2009 report on Conflict of Interest in Medical Research, Education, and Practice aims to encourage institutions to develop conflict of interest (COI) policies to safeguard against circumstances in which individual members of the institution, or the institution itself, could risk neglecting primary professional interests (e.g., the welfare of patients or the integrity of medical research) in favor of secondary interests, such as financial gain.

As the IOM correctly notes, the means by which COI leads to a failure of professional responsibility is through bias, conscious or unconscious.  Conflict of interest policies, then, are codes of conducts erected to prevent bias from unduly influencing one’s professional actions.

I have no objection to the aim of the report or to the way in which the IOM defines COI (p. 46).  But given that the overwhelming bulk of the document’s analysis and recommendations serve to specifically guard against conflicts of interest arising from financial relationships and, furthermore, from financial relationships with commercial rather than non-commercial entities, it is worth examining whether this emphasis does not itself reveal a bias or prejudice against private enterprise.Continue reading “The Institute of Medicine and the doctrine of perpetual conflict.”

Austin Frakt’s conflict of interest disclosure

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Austin Frakt is a health care economist, creator of The Incidental Economist website, and a regular contributor at the New York Times’ Upshot.  A few days ago, he published a great piece about the best evidence for the treatment of insomnia.  I enjoyed reading it, learned from it, and passed it on to personal connections who suffer from insomnia.  As of now, this article is still at the top of the “most emailed” list for the NYT, and I will keep it as a reference for my patients.

In that piece, Frakt presented to the reader the objective information comparing different treatments for insomnia.  To do so, he reviewed the medical literature about clinical trials where drug treatment was tested against a form of psychotherapy (cognitive behavioral therapy).  The results Frakt reported seem to clearly favor behavioral therapy over drugs.

Yet, for all his claim to simply present objective data, Frakt disclosed a number of personal biases that could very well have influenced his interpretation of the medical literature and put him in conflict with his stated goal.Continue reading “Austin Frakt’s conflict of interest disclosure”

Is medicine a scientific enterprise?

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I was recently involved in a Twitter tiff triggered by the following Mayo clinic announcement:

Readers were promptly outraged:Continue reading “Is medicine a scientific enterprise?”

The murky call for transparency

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Yesterday, Bill Gardner weighed in on the conflict of interest firestorm set-off by Lisa Rosenbaum.  On the surface, his New Republic article seemed to offer a middle-of-the-road and nuanced counterpoint to the vigorous—and at times spiteful—counterattacks to Rosenbaum’s NEJM series.  But despite his efforts to achieve a balanced perspective, Gardner failed to resolve the question with clarity.

While he conceded that Rosenbaum made valid points, Gardner advanced the standard and seemingly indisputable 3-part argument in favor of COI disclosureContinue reading “The murky call for transparency”

Three questions for the Missionaries of Quality

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Two thoughtful healthcare analysts (a physician and an economist) wonder about health care quality:

They are not alone.  Even though the Institute of Medicine’s 2001 epic poem mobilized legions of missionaries of quality, it is far from obvious that we have clarity about the overall aim of the crusade.

Our eyes may have been opened to the sins of medical errors, the shame of healthcare disparities, the wastefulness of therapeutic inefficiencies, and the guilt of runaway costs, but if quality care is in fact the goal, and not a pretext for bureaucratic do-goodism, agreement on its meaning seems to be of the essence lest the campaign to “cross the chasm” turn instead into a crossing of the Styx.Continue reading “Three questions for the Missionaries of Quality”