Wednesday, September 30, 2015

Doctors Leaving The UK

The Economist discusses the growing problem of unhappy UK physicians, "Some junior doctors consider a strike, while others pack their bags".

One possible "canary in the coal mine" indicator:
Like workers in any public service, doctors always say that morale has never been lower. But this time many are threatening to vote with their feet and practise overseas. Normally the General Medical Council, which regulates the profession, gets 20-25 requests a day for certificates of professional status, which make it easier to work abroad. From September 16th-18th it received a staggering 1,644 requests.

Monday, September 28, 2015

Hsieh Forbes Column on Bad Science Reporting

My latest Forbes piece is now out: "How To Protect Yourself Against Bad Science Reporting".

I discuss some sources of error and bias that lead to bad science reporting, including:
1) Many publicly reported science results are still provisional
2) Beware of sloppy statistics
3) Beware of the bias towards positive dramatic results
This latest piece is relatively non-political. But it is uncompromisingly pro-bacon.

For more details, read the full text of "How To Protect Yourself Against Bad Science Reporting".

Thursday, September 24, 2015

Preventing Medical Errors

Medical errors will happen. As Arlene Weintraub notes in Forbes, "Doctors Are Screwing Up Diagnoses -- And Patients Should Speak Out".

An excerpt:
The authors of the IOM report identify several possible methods for encouraging patients to get more involved in their diagnoses. First, they suggest that the act of diagnosis should no longer be treated as a solitary task that takes place mostly inside a single clinician’s brain—but rather as a team effort that includes patients and their families. To achieve that, the authors admit, the entire culture of the healthcare system needs to change to one that welcomes patient feedback...
I personally think that patient should obtain their own personal copies any important medical records (including radiology studies on CT, pathology reports, etc.) in case they wish to review them at home or in consultation with an independent physician.

And overall, patients should treat physicians as advisors -- but not infallible authorities.

Tuesday, September 22, 2015

Adalja on Pyrimethamine and The Market

Dr. Amesh Adalja discusses "Pyrimethamine and the Market".  An excerpt:
While I have no understanding of how the new price was determined, it will eventually have to withstand the scrutiny of the market. If the price is set higher than the market will bear, because it is no longer under patent, other manufacturers will enter the market lowering prices. Ideally this would happen near instantaneously but, because of legislative barriers to entry, which include a multi-step approval process, it will take some time. Better alternatives to the current regimen may also appear in time as well.

Overall, however, infectious disease products have become less attractive to pharmaceutical companies and this, at root, is why we are left with just one manufacturer for many important non-patented products. The disincentives to enter this market are myriad and the ultimate answer to this scenario is not more intervention but to remove artificial barriers to entry, inviting the appearance of competitors in the market...

Monday, September 21, 2015

Speed Bumps And Appendicitis

From the British Medical Journal, "Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study":
Our results confirm that an increase in pain while travelling over speed bumps is associated with an increased likelihood of acute appendicitis. Absence of pain over speed bumps is associated with a significantly decreased likelihood of appendicitis. Although the specificity was relatively low, as a diagnostic variable pain over speed bumps compared favourably with other features commonly used in diagnostic assessment, with a better sensitivity and negative likelihood ratio than all other features assessed.

Moreover, some patients who were “speed bump positive” but did not have appendicitis had other important abdominal diagnoses, such as a ruptured ovarian cyst, diverticulitis, or pelvic inflammatory disease...
And some comparison data with other clinical signs (Table 2 in the article, click on image to see full-sized version):

Which indicates how poor a clinical exam is for diagnosing appendicitis.  And why the CT scanner has made such an important difference.  (BMJ link via Slate.)

Wednesday, September 16, 2015

More Anti-MOC Backlash

Kurt Eichenwald at Newsweek has an update: "To the Barricades! The Doctor’s Revolt Against ABIM is Underway".

He discusses the growing backlash against the "Maintenance of Certification" (MOC) requirements by the American Board of Internal Medicine (ABIM). In theory, a private agency that certifies that doctors are keeping up on important clinical knowledge is good. But his series of articles on the ABIM's process shows serious problem with the specific methods chosen.

From the article:
Dr. Jones can’t manage his practice, care for his family and study for the certification exams administered by the American Board of Internal Medicine. The tests purportedly insure doctors’ competence, but, like many physicians, Dr. Jones says the questions often have nothing to with what he sees in his practice and are little more than a game of medical Trivial Pursuit. Dr. Jones can’t afford the thousands of dollars for study guides and classes to learn obscure, often irrelevant information, and has no time to review the material every night for months. He failed the test, so his hospital will no longer allow him to admit patients because he couldn’t answer questions about diseases he will never encounter....

This medical protection racket has made millionaires of ABIM top officers, financed a ritzy condominium, limousines and first-class travel, all while sucking huge sums of cash out of the health care system. But now, after decades of unchecked rule by ABIM, cracks are appearing in the organization’s facade of power. Thousands of doctors began a widespread revolt months ago and, in the last few weeks, evidence that their efforts are succeeding has started rolling in...

[A recent study in the Annals of Internal Medicine] concluded that internists incur an average of $23,607 in MOC costs over 10 years—with doctors who specialize in cancers and blood diseases out $40,495. All told, the study concluded, MOC will suck $5.7 billion out of the health care system over 10 years, including $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs. And remember—all that time and expense is for a program that has not been proven to accomplish anything.
The article also describes how other specialties (such as the anesthesiologists certification board) are adopting other methods to ensure physician quality through tests and quizzes that are more relevant to clinical practice.

Let's hope the ABIM learns from their example.

And kudos to Kurt Eichenwald for continuing to report on this developing issue.

(Link via Dr. Megan Edison and Dr. Matthew Bowdish.)

Thursday, September 10, 2015

Quick Links: Anti-MOC Backlash, Google, Apple

The Washington Post reports how anti-MOC (Maintenance of Certification) forces are gaining momentum, "Doctors' group will scrap 10-year re-certification exam":
The professional group that represents anesthesiologists will become the first medical board to scrap a widely criticized test that most physicians take every 10 years to demonstrate that they are up to date in their specialties, officials said Wednesday.
(For more background on the MOC controversy, see these earlier Newsweek pieces "The Ugly Civil War in American Medicine" and "A Certified Medical Controversy".)

Time magazine discusses the new Google health initiative in "Here's What 6 Doctors Really Think of Dr. Google". Personally, I think this will a tremendous value for patients and doctors in the long run.

The new Apple iPad Pro could help physicians better communicate important anatomy concepts to patients.  The discussion of medical applications starts at 42:00 in this video.  (Link via Ari Armstrong.)

Tuesday, September 1, 2015

Market for "Perfect Poop"

From CNN: "One man's poop is another's medicine".

Donors who qualify can earn $40 per sample of "perfect poop", to be used for fecal transplantation to treat patients with C. difficile infection:
To donate, Eric had to pass a 109-point clinical assessment. There is a laundry list of factors that would disqualify a donor: obesity, illicit drug use, antibiotic use, travel to regions with high risk of contracting diseases, even recent tattoos. His stools and blood also had to clear a battery of laboratory screenings to make sure he didn't have any infections. 

After all that screening, only 3% of prospective donors are healthy enough to give. "I had no idea," he says about his poop. "It turns out that it's fairly close to perfect."

And that, unlike most people's poop, makes Eric's worth money. OpenBiome pays its 22 active donors $40 per sample. They're encouraged to donate often, every day if they can. Eric has earned about $1,000.
Prospective donors are told, "It's easier to get into MIT and Harvard than it is to get enrolled as one of our donors."

The poop also has to have the acceptable texture, either types 3, 4, or 5, on the Bristol Stool Chart: