Sunday, May 24, 2015

Henry Marsh’s “Do No Harm” - The New Yorker

For the schoolteacher, the changes had come slowly. First, his walking had grown unsteady; then his hearing had worsened. He had become stooped, and had begun walking with a cane, even though he was only in his late fifties. Now he sat with his wife and son in the consulting room of Henry Marsh, a London neurosurgeon, looking at a scan of his brain, which showed a tumor growing near the base of his skull. The question was whether it could, or should, be removed. Marsh, who had been practicing neurosurgery for only a few years, was unsure. The tumor was massive—he was startled by its size—and it was situated in the brain stem, a vital area. Left to itself, it would destroy the schoolteacher's hearing, rob him of his ability to walk, and, eventually, kill him. But, Marsh explained, surgery could leave him paralyzed, or worse. The family faced a difficult choice, between the certainty of a slow, predictable decline and the possibility of an immediate cure—or catastrophe.

They decided to seek a second opinion from an older, eminent neurosurgeon. A few days later, the surgeon phoned Marsh. "It's a young man's operation," he said. "I've told them you should do it." Flattered, Marsh agreed to go ahead. The surgery began at nine in the morning and continued late into the night. Brain surgery is slow and dangerous, and removing a tumor can be like defusing a bomb. Often, surgeons look through a microscope and use long-handled, fine-tipped instruments to pull the tumor away from the brain before removing it with a sucker. A quarter of the body's blood courses through the veins and arteries of the brain; if one of them is torn, bleeding and stroke can result. It's also possible to remove important parts of the brain by accident, because brain tissue and tumor tissue look pretty much the same. Unlike the rest of the body, the brain and the spinal cord rarely heal. If a neurosurgeon makes a mistake, the damage is often permanent.

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Friday, May 22, 2015

How Yoshitaka Fujii, the Biggest Fabricator in Science, Got Caught

In April of 2000, the journal Anesthesia & Analgesia published a letter to its editor from Peter Kranke and two colleagues that was fairly dripping with sarcasm. The trio of academic anesthesiologists took aim at an article published by a Japanese colleague named Yoshitaka Fujii, whose data on a drug to prevent nausea and vomiting after surgery were, they wrote, "incredibly nice."

In the language of science, calling results "incredibly nice" is not a compliment—it's tantamount to accusing a researcher of being cavalier, or even of fabricating findings. But rather than heed the warning, the journal, Anesthesia & Analgesia, punted. It published the letter to the editor, together with an explanation from Fujii, which asked, among other things, "how much evidence is required to provide adequate proof?" In other words, "Don't believe me? Tough." Anesthesia & Analgesia went on to publish 11 more of Fujii's papers. One of the co-authors of the letter, Christian Apfel, then of the University of W├╝rzburg, in Germany, went to the United States Food and Drug Administration to alert them to the issues he and his colleagues had raised. He never heard back.

Fujii, perhaps recognizing his good luck at being spared more scrutiny, mostly stopped publishing in the anesthesia literature in the mid-2000s. Instead, he focused on ophthalmology and otolaryngology, fields in which his near miss would be less likely to draw attention. By 2011, he had published more than 200 studies in total, a very healthy output for someone in his field. In December of that year, he published a paper in the Journal of Anesthesia. It was to be his last.

Over the next two years, it became clear that he had fabricated much of his research—most of it, in fact. Today he stands alone as the record-holder for most retractions by a single author, at a breathtaking 183, representing roughly 7 percent of all retracted papers between 1980 and 2011. His story represents a dramatic fall from grace, but also the arrival of a new dimension to scholarly publishing: Statistical tools that can sniff out fraud, and the "cops" that are willing to use them.

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Robotic Butt Offers Prostate Exam Training For Medical Students: How ‘Patrick’ Teaches Empathy, Proper Technique

Medical students, meet Patrick.

The latest in training technology, Patrick is a simulated patient that talks to medical students while offering real-time feedback about the virtual prostate exam he's receiving. While a perplexing site to behold — users actually check the mock prostate of a dummy's rear end — doctors have praised the technology for allowing students to familiarize themselves with intimate exams before they ever encounter a live patient.

Patrick serves a dual purpose: personal and professional. Personally, he comes equipped with software that enables him to interact emotionally with the student and voice any concerns he has about the procedure. Dr. Benjamin Lok, one of the program's designers, says the interpersonal relationship Patrick helps foster is invaluable from a practicing perspective. "This virtual human patient can talk to the learner, expresses fears and concerns about the prostate exam, and presents a realistic patient encounter," Lok told Geekosystem.

The other purpose he serves is functional. Patrick is endowed with force sensors, which can alert the student when he or she is being too aggressive, and can report how thorough the student was in his or her examination.

"Consider this," Lok said, "how would a medical student know if they are doing a good prostate exam? Currently it is impossible for the educator to gauge performance. This simulation provides performance, feedback, and an opportunity to learn and lower anxiety."

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Saturday, May 16, 2015

NYTimes: The Case for Black Doctors

IN virtually every field of medicine, black patients as a group fare the worst. This was one of my first and most painful lessons as a medical student nearly 20 years ago.
The statistics that made my stomach cramp back then are largely the same today: The infant mortality rate in the black population is twice that of whites. Black men are seven times more likely than white men to receive a diagnosis of H.I.V. and more than twice as likely to die of prostate cancer. Black women have nearly double the obesity rate of white women and are 40 percent more likely to die from breast cancer. Black people experience much higher rates of hypertension, diabetes and stroke. The list goes on and on.
The usual explanations for these health disparities — poverty, poor access to medical care and unhealthy lifestyle choices, to name a few — are certainly valid, but the longer I've practiced medicine, the more I've come to appreciate a factor that is less obvious: the dearth of black doctors. Only around 5 percent of practicing physicians are black, compared with more than 13 percent of Americans overall.
As a general rule, black patients are more likely to feel comfortable with black doctors. Studies have shown that they are more likely to seek them out for treatment, and to report higher satisfaction with their care. In addition, more black doctors practice in high-poverty communities of color, where physicians are relatively scarce.

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Tuesday, May 12, 2015

New machine could one day replace anesthesiologists - The Washington Post

 The new machine that could one day replace anesthesiologists sat quietly next to a hospital gurney occupied by Nancy Youssef-Ringle. She was nervous. In a few minutes, a machine — not a doctor — would sedate the 59-year-old for a colon cancer screening called a colonoscopy.

But she had done her research. She had even asked a family friend, an anesthesiologist, what he thought of the device. He was blunt: "That's going to replace me."

One day, maybe. For now, the Sedasys anesthesiology machine is only getting started, the leading lip of an automation wave that could transform hospitals just as technology changed automobile factories. But this machine doesn't seek to replace only hospital shift workers. It's targeting one of the best-paid medical specialties, making it all the more intriguing — or alarming, depending on your point of view.

Today, just four U.S. hospitals are using the machines, including here at ProMedica Toledo Hospital. Device maker Johnson & Johnson only recently deployed the first-of-its-kind machine despite winning U.S. Food and Drug Administration approval in 2013. The rollout has been deliberately cautious for a device that hints at the future of health care, when machines take on tasks once assumed beyond their reach.

Everyone is watching to see how this goes.

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Thursday, May 7, 2015

America’s Epidemic of Unnecessary Care - The New Yorker

It was lunchtime before my afternoon surgery clinic, which meant that I was at my desk, eating a ham-and-cheese sandwich and clicking through medical articles. Among those which caught my eye: a British case report on the first 3-D-printed hip implanted in a human being, a Canadian analysis of the rising volume of emergency-room visits by children who have ingested magnets, and a Colorado study finding that the percentage of fatal motor-vehicle accidents involving marijuana had doubled since its commercial distribution became legal. The one that got me thinking, however, was a study of more than a million Medicare patients. It suggested that a huge proportion had received care that was simply a waste.

The researchers called it "low-value care." But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

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NYTimes: Company Creates Bioethics Panel on Trial Drugs

Johnson & Johnson has appointed a nationally known bioethicist to create a panel that will make decisions about patients' requests for lifesaving medicine, responding to an emotional debate over whether companies should allow desperately ill people to have access to the drugs before they are approved.

The move, to be announced by the company on Thursday, is believed to be the first of its kind in the industry and, given the size and influence of the drug maker, could inspire other companies to follow suit. It comes as a small but growing number of patients with terminal illnesses have sought the right to obtain drugs still in the testing phase that show promise for treating their diseases.

Some of the requests have become highly publicized cases on social media, where family members and advocates have lobbied the companies on patients' behalf — often to no avail because drug makers fear that doing so would interfere with clinical trials, or, in the case of the Ebola outbreak, that they have too little available. The issue, which involves fundamental questions of fairness and equal access to care, has become so intense that more than a dozen states have taken up legislation to speed the process.

Johnson & Johnson said the bioethicist, Arthur L. Caplan of New York University, who has written extensively about the issue of experimental drug availability — known as "compassionate use" — would oversee an independent panel of doctors, ethicists and patient advocates that will review requests for access to a limited array of experimental medicines and decide how Johnson & Johnson should respond.

The pilot program will be funded by the company but will have no influence on the panel's decisions, Johnson & Johnson said, adding that payments will go directly to the university. Dr. Caplan will not be paid in his work in the program.

Dr. Caplan, who has argued that the industry needs a fairer, more consistent system for deciding whose requests should be granted, said he was intrigued when company executives approached him about the idea. "If we could structure this right, this would be a chance to not just complain about what's wrong, but maybe to suggest a way forward," he said in an interview.

Drug companies have been granting emergency access to their unapproved drugs since the AIDS epidemic of the 1980s, when the Food and Drug Administration set up a process to help desperate patients get experimental treatments. The F.D.A. typically signs off on use of unapproved drugs, but not until the company agrees.

But saying yes is not so simple: Manufacturers often have a limited supply of such treatments, leading to anguished decisions over who should be given the products. The unproved drugs also might not work, or could even cause harm. And the time and resources involved in granting access to such drugs could delay efforts to get them approved for a much wider population of needy patients, especially at smaller companies. In the case of the Ebola epidemic, last year the F.D.A. allowed the makers of ZMapp, an experimental treatment, to be used on a handful of patients, but the company quickly exhausted its limited supply.

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Johnson & Johnson named the bioethicist Arthur L. Caplan to create a panel to decide on patients' requests for lifesaving medicines before they are approved.

Wednesday, May 6, 2015

Despite numerous risk factors that should shorten their lives, Hispanics in the United States are generally healthier than non-Hispanic whites, the Centers for Disease Control and Prevention reported Tuesday in its first comprehensive report on the health of that large and growing ethnic group.

Despite being poorer and having less access to health insurance and health care, Hispanics suffer 35 percent less heart disease and 49 percent less cancer than whites, and according to another study cited in Tuesday's report, live about two years longer. They also have lower rates of Alzheimer's disease, cerebrovascular disease, flu, pneumonia and other common killers of Americans.

"For many years there has been a description of the Hispanic Paradox, that despite … lower socioeconomic status they live longer," Tom Frieden, director of the CDC, said at a telephone news conference Tuesday. "Recent data corroborates that most of that may relate to smoking rates." In surveys, just 13.5 percent of Hispanics said they smoked, compared with 23.8 percent of whites.

Another possible factor, according to the report, is that the healthier members of Hispanic countries tend to be the ones who immigrate to the United States. And on average, Hispanics here are 15 years younger than whites.

But Hispanics' health advantages are not universal. Hispanics have higher death rates from diabetes, chronic liver disease and cirrhosis of the liver, hypertension and homicide than whites. More of them are obese and have diabetes when compared to whites.

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Sunday, May 3, 2015

NYTimes: The Medical Bill Mystery

I CONFESS I filed this column several weeks late in large part because I had hoped first to figure out a medical bill whose serial iterations have been arriving monthly like clockwork for half a year.

As medical bills go, it's not very big: $225, from a laboratory. But I don't really want to pay it until I understand what it's for. It's not that the bill contains no information — there is lots of it. Test codes: 105, 127, 164, to name a few. CPT codes: 87481, 87491, 87798 and others. It tells me I'm being billed $29.90 for each of nine things, but there is an "adjustment" to one of $14.20.

At first, I left messages on the lab's billing office voice mail asking for an explanation. A few months ago, when someone finally called back, she said she could not tell me what the codes were for because that would violate patient privacy. After I pointed out that I was the patient in question, she said, politely: "I'm sorry, this is what I'm told, and I don't want to lose my job."

I have spent the last two and a half years reporting and writing about medical costs, and during that time I have pored over hundreds of patients' bills. And while I've become pretty adept at medical bill exegesis, I continue to be baffled by how we've come to tolerate the Kafkaesque stream of nonexplanations that follow health encounters.

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Thursday, April 30, 2015

Video Is About to Become the Way We All Visit the Doctor | WIRED

The country's largest health insurer is putting telemedicine on par with a regular trip to the doctor's office, effectively saying a video visit is as good as brick-and-mortar medicine. 

UnitedHealthcare today is announcing a partnership with three telemedicine companies to cover video-based doctor visits just as it covers in-person visits. The tech set has for decades predicted that we would one day get our medical care via video chat, but it wasn't until recently that forward-thinking physicians started taking the promise of telemedicine seriously. The decision by so influential a player in the healthcare industry to telemedicine is the strongest sign yet that the technology is entering the mainstream.

United says it will cover virtual doctor visits offered through NowClinic, Doctor on Demand, and American Well. These platforms connect patients with thousands of doctors—albeit not the patient's usual doctor—via video chat. These consultations typically cost $40 to $50 a pop, but now that United is covering these visits, members will only have to pay their usual co-pay, making virtual medicine much more affordable for more people. For now, these virtual visits will be available only to UnitedHealth's self-funded customers, but the feature will expand to most members by next year.

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