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Saturday, October 4, 2008
One of the nation's most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules, according to documents provided to Congressional investigators.
The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent figure to date in a series of disclosures that is shaking the world of academic medicine and seems likely to force broad changes in the relationships between doctors and drug makers.
In one telling example, Dr. Nemeroff signed a letter dated July 15, 2004, promising Emory administrators that he would earn less than $10,000 a year from GlaxoSmithKline to comply with federal rules. But on that day, he was at the Four Seasons Resort in Jackson Hole, Wyo., earning $3,000 of what would become $170,000 in income that year from that company — 17 times the figure he had agreed on.
The Congressional inquiry, led by Senator Charles E. Grassley, Republican of Iowa, is systematically asking some of the nation's leading researchers to provide their conflict-of-interest disclosures, and Mr. Grassley is comparing those documents with records of actual payments from drug companies. The records often conflict, sometimes starkly.
"After questioning about 20 doctors and research institutions, it looks like problems with transparency are everywhere," Mr. Grassley said. "The current system for tracking financial relationships isn't working."
The findings suggest that universities are all but incapable of policing their faculty's conflicts of interest. Almost every major medical school and medical society is now reassessing its relationships with drug and device makers.
Thursday, October 2, 2008
Wikis — collaborative websites — are powerful tools for education. The Efficient MD Wiki is designed to help healthcare professionals and medical students discover clinical pearls, useful resources, life hacks, and strategies to improve the practice of medicine.
Although this Wiki is currently in its infancy, it is growing rapidly and needs your help. Please post your ideas, mnemonics, best practices, tricks, timesavers, presentations, helpful links, or other advice you'd care to share. (Don't worry if your writing is disorganized. Someone will always edit it later.) Anonymous posting and editing is allowed.
Dr Wiki is a nonprofit 501(c)(3) educational web site made by physicians for physicians, medical students, and healthcare providers. Its purpose is to serve as a online repository of medical information that can be accessed by anyone.
Why do the vast majority of heroin users live in cities? In his provocative history of heroin in the United States, Eric C. Schneider explains what is distinctively urban about this undisputed king of underworld drugs.
During the twentieth century, New York City was the nation's heroin capital—over half of all known addicts lived there, and underworld bosses like Vito Genovese, Nicky Barnes, and Frank Lucas used their international networks to import and distribute the drug to cities throughout the country, generating vast sums of capital in return. Schneider uncovers how New York, as the principal distribution hub, organized the global trade in heroin and sustained the subcultures that supported its use.
Through interviews with former junkies and clinic workers and in-depth archival research, Schneider also chronicles the dramatically shifting demographic profile of heroin users. Originally popular among working-class whites in the 1920s, heroin became associated with jazz musicians and Beat writers in the 1940s. Musician Red Rodney called heroin the trademark of the bebop generation. "It was the thing that gave us membership in a unique club," he proclaimed. Smack takes readers through the typical haunts of heroin users—52nd Street jazz clubs, Times Square cafeterias, Chicago's South Side street corners—to explain how young people were initiated into the drug culture.
Smack recounts the explosion of heroin use among middle-class young people in the 1960s and 1970s. It became the drug of choice among a wide swath of youth, from hippies in Haight-Ashbury and soldiers in Vietnam to punks on the Lower East Side. Panics over the drug led to the passage of increasingly severe legislation that entrapped heroin users in the criminal justice system without addressing the issues that led to its use in the first place. The book ends with a meditation on the evolution of the war on drugs and addresses why efforts to solve the drug problem must go beyond eliminating supply.http://www.upenn.edu/pennpress/book/14532.html
Wednesday, October 1, 2008
We humans are such complex beasts. Why is it that we can be so wonderful and yet so awful, eccentric and prosaic, enigmatic and obvious, witty and dull, and all of these at once?
All in the Mind, presented by Natasha Mitchell, is Radio National's weekly foray into all things mental – a program about the mind, brain and behaviour. From dreaming to depression, addiction to artificial intelligence, consciousness to coma, psychoanalysis to psychopathy, free will to forgetting – All in the Mind explores the human condition through the mind's eye.
Our mental machinery remains one of the greatest mysteries of this or any other age, performing for us the most incredible feats of perception, cognition and coordination. Scientists, theologians, philosophers and armchair psychologists alike have long debated its form and function. And yet, the mind, in all its madness and brilliance, continues to elude us.
All in the Mind brings together unexpected voices, themes and ideas and engages with both leading thinkers and personal stories. Psychology and human behaviour are only part of the equation. The program's scope is considerably broader and explores themes in science, religion, health, philosophy, education, history and pop culture, with the mind as the key focus.
All in the Mind has been honoured with the Grand Award at 2008 New York Radio festivals for best entry across all categories, as well as a Gold World Medal in the Health/Medical category.
- cognitive behavioural therapy
- chronic pain management
- values-based therapy
- interdisciplinary teams
- using exposure therapy
- and more!!
On a massive sound stage at Hollywood's Raleigh Studios, a woman is dying of ovarian cancer. One doctor wants to treat her traditionally, by removing her uterus and ovaries. Another wants the patient to participate in a clinical trail that might preserve her ability to have children, but could have serious side effects.
On a different day, an obstetrician is conflicted about whether to deliver a premature baby she believes was conceived solely because the umbilical-cord blood could save the family's older, dying child. Another doctor struggles to do what's right when his teenage patient — who has HIV but doesn't know it — confides that he plans to have sex for the first time.
"We're telling stories ... that will provide a lot of moral debate among our doctors and maybe debate at home when you watch," said series creator Shonda Rhimes.
The issues they face cause plenty of drama for the doctors at the Oceanside Wellness Group, where Kate Walsh's character, Addison Montgomery, came to work after leaving "Grey's" Seattle Grace Hospital.
"They're all viable conflicts ... grounded in these medical stories," Walsh said. "It's topical but not so procedural that it's not a Shonda Rhimes show. You still have all the great dialogue and characters and stories and romance."
Like "Grey's Anatomy," ''Private Practice" features an ensemble cast of doctors whose personal lives are often far messier than their professional ones. They have affairs with one another and struggle with love as they overcome tough medical challenges and the financial realities of keeping their medical co-op alive.
The bioethical issues raised are based on real medical cases and community concerns, said researcher and writer Elizabeth Klaviter.
"We look at the things that have ourselves and our family members and friends buzzing — the issues that people are talking about in terms of right or wrong and the laws, ethics and social morays that are put on us in terms of how we conduct ourselves," said Klaviter, who also researches cases for "Grey's Anatomy."
"Doctors disagree," she said. "We're looking for cases where there are different courses of action or treatment."
This season, the doctors at Oceanside Wellness will have to decide what rights prostitutes have to medical care and whether to treat a sex offender at their child-friendly practice. They also engage in an abortion debate that surprised actor Tim Daly, who plays Dr. Pete Wilder.
"I never thought we'd be doing something like that on Disney," which owns ABC, he said. "It was just these characters discussing their opinions and they didn't agree and they were passionate about it, just like in the real world."
Daly and his castmates credit Rhimes and the show's writers for using the forum of a prime-time drama to inspire viewers to consider current bioethical issues.
"If you can make anybody think in this day and age, and entertain them at the same time, that's a dream come true," said KaDee Strickland, who plays Dr. Charlotte King, a physician at a rival hospital.
Making bioethics a theme of the show is "seductive," Walsh said, because it deepens the characters while raising important issues for viewers to ponder. Though she said it was a risk for her to leave "Grey's," she feels she landed in a good place.
"It was a risk but it wasn't like sex-without-a-condom risk. It was an offer I couldn't refuse," she said. "I'm hugely grateful that it did really well last fall... It's really a testament to Shonda and her gift for being able to tap into the culture and the big collective consciousness of what people really relate to."
History proves that viewers respond to medical shows: "We may never end up in a courtroom or never end up arrested, but sooner or later everybody's going to come through the doors of a doctor's office," Rhimes said. Exploring bioethics adds a new dimension to the already-beloved genre.
"It's something more and more doctors are facing these days," Rhimes said. "It's just a very different way of looking at medicine that I don't think we normally think about — the ethics of what you're doing."
Founded in 2004 by three MIT engineers whose collective experience spans from running the world's only non-profit biotechnology laboratory to large-scale online commerce applications, PatientsLikeMe is a privately funded company dedicated to making a difference in the lives of patients diagnosed with life-changing diseases. Our personal experiences with ALS (Lou Gehrig's disease) inspired us to create a community of patients, doctors, and organizations that inspires, informs, and empowers individuals. We're committed to providing patients with access to the tools, information, and experiences that they need to take control of their disease.
In 1998, a young carpenter named Stephen Heywood was diagnosed with ALS. The Heywood family began taking charge of Stephen's care, searching the world over for ideas that would extend his life and improve the way he lived. This set in motion a series of events that have led to PatientsLikeMe, a new system of medicine by patients for patients. We're here to give patients the power to control their disease and to share what they learn with others. We're here to help you.
Our goal is to enable people to share information that can improve the lives of patients diagnosed with life-changing diseases. To make this happen, we've created a platform for collecting and sharing real world, outcome-based patient data (patientslikeme.com) and are establishing data-sharing partnerships with doctors, pharmaceutical and medical device companies, research organizations, and non-profits.
KNOWLEDGE IS POWER
You're Sick. Now What?
GOOGLING YOUR HEALTH
The exploding online universe.
WHERE TO CLICK
Reviews of six popular health Web sites.
What does 'F.D.A. approved' mean?
BEYOND THE YELLOW PAGES
Finding the right doctor.
Denise Grady on self-diagnosis.
DOCTOR AND PATIENT
Dr. Pauline W. Chen on candor.
Testing claims for alternative medicine.
Jane E. Brody on the primary care crisis.
Late one recent Friday afternoon, doctors informed the father of a friend of mine that he had pancreatic cancer. When I heard the news from my friend's wife, it came as a complete surprise. I had met the father, a lifelong Democratic activist, just a few months earlier, and we had enjoyed a lively discussion about the candidates. Nothing led me to sense that cancer was lurking in this vibrant man's abdomen.
But even if I could have suspected it, I wonder if I would have shared my concern with him.
In the hours before the doctors came to the hospital room to deliver the pathologists' final report, my friend knew the gravity of his father's case. He knew the mass in his father's pancreas was a malignant tumor. And he knew not because the doctors in the hospital had shared their suspicions, but because they could not look at him in those hours before.
The diagnosis was in their body language.
"I understand that they needed to be sure before they could say anything definitive," my friend's wife later told me, "but they had strong suspicions. Why were we dancing around the issue?"
As a doctor, I know I have evaded the probing looks of patients and families. I have heard myself speaking carefully and measuring my words, fearful that hunches shared prematurely might worry or anger them, or even dash their hopes.
I am not alone in this dance of avoidance. But in trying to protect patients, doctors may be misjudging them and the consequences of not sharing our suspicions. We may be assuming that patients and families are more fragile than they really are and that keeping our hunches to ourselves will protect them, when in fact we may be making the situation worse.
No matter what our specialty, communication is at the heart of what doctors do. Since 2002, the Association of American Medical Colleges and the Accreditation Council of Graduate Medical Education have made interpersonal communication one of the six core skills taught in medical schools and residencies.
But many doctors can be woefully evasive in talking with their patients. In a 2007 study, for example, researchers monitored doctors in simulated office visits with actors trained to portray cancer patients in remission; the doctors were supposed to inform them that their cancer had recurred. Fewer than 20 percent of the doctors said the word "cancer."
Research in nonverbal communication is even scarcer than in other areas of the patient-doctor interaction, in part because of the challenge of measuring and assessing nonverbal behavior and personal qualities like "sensitivity." Nevertheless, investigators have repeatedly come up with one finding: doctors are not always good judges of their patients' emotions. In fact, we can be pretty bad when it comes to reading worry, anger and disappointment.
Does your doctor spend time talking to you? Do you see your doctor within 20 minutes of your appointment time? Are you getting the guidance you need to cope with a continuing health problem or multiple overlapping problems? Do you even have a personal physician who monitors your health and treats you promptly with skill and compassion?
A "no" answer to any of these questions — even to all of them — would not be surprising. Finding doctors who know their patients well and who deliver informed medical care with efficiency and empathy has become quite a challenge in America.
There is a crisis in medicine today, and it will not be fixed by any candidate's proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.
The crisis is a diminishing supply of primary care physicians, the doctors on the firing line — family physicians, internists, pediatricians, gerontologists and others — who practice the art and the science of medicine and who seek to put patients at least on a par with their pocketbooks.
According to a study published this month in The Journal of the American Medical Association, the number of medical students choosing to train in internal medicine is down, and young physicians are leaving the field. Other primary care specialties, including family medicine and gerontology, have also reported drops.
Primary care doctors spend far more time talking to patients and helping them avert health crises or cope with ailments that are chronic and incurable than they spend performing tests and procedures.
They are the doctors who ask pertinent questions, about health and also about life circumstances, and who listen carefully to how patients answer. They are the doctors who know their patients, and often the patients' families, and the circumstances and beliefs that can make health problems worse or impede effective treatment.
The problem is that in this era of managed care and reimbursements dictated by Medicare and other insurers, doctors don't get much compensation for talking to patients. They get paid primarily for procedures, from blood tests to surgery, and for the number of patients they see.
Most are burdened with paperwork and hours spent negotiating treatment options with insurers. And the payments they receive for services have not increased as the costs of running a modern medical practice have risen. To make ends meet and earn a reasonable income of, say, $150,000 a year, many primary care doctors have to squeeze more and more patients into the workday.
"If you have only six to eight minutes per patient, which is the average under managed care, you're forced to concentrate on the acute problem and ignore all the rest," said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.
Yet, he said in an interview, in a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other problems that warranted medical attention.
More than 80 million adults in the United States are estimated to use some form of alternative medicine, from herbs and megavitamins to yoga and acupuncture. But while sweeping claims are made for these treatments, the scientific evidence for them often lags far behind: studies and clinical trials, when they exist at all, can be shoddy in design and too small to yield reliable insights.
Now the federal government is working hard to raise the standards of evidence, seeking to distinguish between what is effective, useless and harmful or even dangerous.
"The research has been making steady progress," said Dr. Josephine P. Briggs, director of the National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health. "It's reasonably new that rigorous methods are being used to study these health practices."
The need for rigor can be striking. For instance, a 2004 Harvard study identified 181 research papers on yoga therapy reporting that it could be used to treat an impressive array of ailments — including asthma, heart disease, hypertension, depression, back pain, bronchitis, diabetes, cancer, arthritis, insomnia, lung disease and high blood pressure.
It turned out that only 40 percent of the studies used randomized controlled trials — the usual way of establishing reliable knowledge about whether a drug, diet or other intervention is really safe and effective. In such trials, scientists randomly assign patients to treatment or control groups with the aim of eliminating bias from clinician and patient decisions.
Sat Bir S. Khalsa, the study's author and a sleep researcher at the Harvard Medical School, said an added complication was that "the vast majority of these studies have been small," averaging 30 or fewer subjects per arm of the randomized trial. The smaller the sample size, he warned, the greater the risk of error, including false positives and false negatives.
Critics of alternative medicine have seized on that weakness. R. Barker Bausell, a senior research methodologist at the University of Maryland and the author of "Snake Oil Science" (Oxford, 2007), says small studies often have a built-in conflict of interest: they need to show positive results to win grants for larger investigations.
"All these things conspire to produce false positives," Dr. Bausell said in an interview. "They make the results extremely questionable."
That kind of fog is what Dr. Briggs and the National Center for Complementary and Alternative Medicine, with a budget of $122 million this year, are trying to eliminate. Their trials tend to be longer and larger. And if a treatment shows promise, the center extends the trials to many centers, further lowering the odds of false positives and investigator bias.
Doctors who treat themselves may have fools for patients, but they look like geniuses compared with a reporter who tried to diagnose herself via the Internet.
It seemed so simple. I Googled "foot pain," and up came two sites with neat little pictures of feet, arrows pointing to various parts and instructions to "click where it hurts." I clicked and, voila! both sites said my pain — on the top and side of the foot, around the big toe — was probably from a bunion or gout.
Gout? Hmmph. What came to mind was Henry VIII, the movie version, hugely fat and grotesque on his throne, bellowing about his toe. As for bunions, weren't they from pointy shoes, high heels, a family history? I had none of those. This wasn't quite adding up.
Onward I clicked. I took fleeting comfort from a slide slow of hideous foot diseases that I clearly didn't have. Lists of other ailments didn't match, either. I don't have diabetes or flat feet and I hadn't injured myself. One site mentioned leprosy, which had drama but seemed unlikely. I was baffled.
A podiatrist, recommended by a doctor friend, took about 37 seconds to figure out what was wrong. He shoved my big toe up and down, gave it a squeeze that made me shriek and said smugly, "We'll take some X-rays, and I'll show you what's causing your pain."
A few minutes later, there it was on his computer screen: a bone spur, sticking up like a tiny, evil spike where the big toe joins the rest of the foot. The cause was arthritis of the big toe, which sounds ridiculous even to me. But it's real, a wearing out of the cartilage that normally protects the bones from rubbing against each other. I've always walked a fair amount — at least three miles a day, often twice that or more in recent years — and at 56, I guess it's catching up with me. Without realizing it, I've been wearing out my feet.
The medical name for this condition is hallux limitus, which means "stiff toe." It's progressive, and can turn into hallux rigidus — a really stiff toe. It's humbling to be hobbled by such a comical-sounding ailment.
The podiatrist recommended shoes with stiff, rounded soles called rocker bottoms, to minimize bending of the joint. I figured out that I also needed lots of room in the toe, to avoid pressure on the spur. He said a cortisone shot into the joint might help. (It didn't.) He also suggested shoe inserts, orthotics, but I was skeptical because I've had knee surgery and I feared the inserts might throw my knees out of whack.
Finally, he said I would eventually need surgery to remove the spur and shorten a bone. He said he could perform it right there in his office, and the sooner the better. At that point, if I'd been able to run, I might have. Instead, I nodded politely and said I'd think about surgery. But it sounded drastic.
I retreated to the Internet. Self diagnosis had been a lost cause (I would have done better had I Googled "toe pain"), but at least it was noninvasive. And knowing the name of the ailment made a big difference. Among other things, the Web cheered me up by revealing that hallux limitus is also called winkle picker's disease (winkles are snails, and in England, winkle pickers used to be a nickname for pointy shoes, if that makes any sense). Unfortunately, I also found out that it can sometimes be disabling. Three of the more useful links were Arthritis Practitioner (www.arthritispractitioner.com, search for hallux limitus), eMedicine (www.emedicine.com/orthoped, click on foot and ankle) and Foot Physicians (www.footphysicians.com, foot and ankle information).
A Google search for "cancer" returns 299 million results; narrow that to, say, "prostate cancer" and you still get 12.7 million. It's a vast, bewildering world out there, but here's a look at six of the most interesting and potentially useful online health resources.