The movement to reform medicine from within

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Lorima
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The movement to reform medicine from within

Post by Lorima » Sat 19 Jan 2013 17:10

There are people and groups working on reforming medicine. This topic is intended to report on that movement. Please add to it, if you see something relevant. 

A first entry: "The case for slow medicine", by Richard Smith, former editor of he BMJ, in the blogs of the British Medical Journal.

http://blogs.bmj.com/bmj/2012/12/17/ric ... -medicine/ 
Richard Smith: The case for slow medicine
December 17, 2012 at 3:05 pm by BMJ Group

The characteristics of health systems are complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. They are thus largely a black box and uncontrollable, said Gianfranco Domenighetti of the Università della Svizzera Italiana at a meeting in Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year. 

snip

Yet against this backcloth more than four fifths of people in most countries think medicine is an “exact or almost exact science.” In a study published in the Annals of Internal Medicine nearly 90% of patients undergoing percutaneous coronary intervention (PCI) thought that it would reduce their chances of having a heart attack, when it doesn’t. Asked about various scenarios almost half of cardiologists questioned would go ahead with a PCI even when they believed there was no benefit to the patient.

It is time, said Domenighetti, to open up the black box of healthcare. Encouraging “health literacy” seems to be a way to do this, but Domenighetti thought that this was “old wine in new bottles.” We need, he said, to encourage a healthy skepticism about the medical market and to help people understand that medicine is far from being an exact science. Data should be published exposing variations in practice, corruption, and conflicts of interest. We should explain that health depends mostly on exogenous factors not the healthcare system. And people should be given practical tools to promote their autonomy—tools like access to evidence based information. 

snip

We need to pull back from what Ivan Illich called the hubris of medicine.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.
"I have to understand the world, you see."
Richard Feynman

Lorima
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Joined: Mon 29 Oct 2007 20:47

Re: The movement to reform medicine from within

Post by Lorima » Sat 19 Jan 2013 18:45

Here's a blog with a few brave and outspoken souls keeping tabs on the big guys: 

"Health Care Renewal
Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care."

Here are highlights from their most recent post, from Roy Poses, MD: 

http://hcrenewal.blogspot.com/2013/01/s ... l.html?m=1
FRIDAY, JANUARY 18, 2013

"Slap on the Wrist" for a "Too Big to Fail" Hospital - Judge Rejects WakeMed Settlement
Maybe we are reaching an inflection point in how misbehavior by big health care organizations is handled in the US legal system. 

We have frequently discussed the march of legal settlements made by big health care organizations.  Many of these settlements indicated severely bad behavior, often behavior that seemed overtly dishonest, sometimes criminal, and had the potential to harm patients.  Yet most of these settlements involved only fines, and sometimes written agreements that pledge the organization will do better in the future, often in the form of deferred prosecution or corporate integrity agreements.  Yet the fines were often small compared to the amount the organization stood to make from the bad behavior.  It is not clear that any written agreements were enforced, or caused major penalties if the organization did not fulfill them.  And almost never did any individual within the accused organization suffer any negative consequences for authorizing, directing or implementing the bad behavior, even if such individuals may have personally profited from high compensation partially fueled by the bad behavior.

Now and then, though, there are cases that are different.  Perhaps one has just come along that may signal things are going to change.

The Basics of the Case

The case was first reported by the Raleigh (NC)  News & Observer in December, 2012.  Here are the basics: 
 

What follows is a readable, detailed summary of the issues of the case. 
It's interesting, and has a subplot of blame-shifting among the doctors, the nurses, and the management of the organization. 

Then there's a summary at the end: 
Deb Laughery, a WakeMed spokeswoman, said after the hearing that none attended because the board approved a resolution earlier in the week supporting the proposed settlement.

Summary

For years now the leadership of large health care organizations have grown rich while denying accountability for their actions that made this so.  This denial has been largely abetted by governmental regulators and law enforcers, who while often recognizing that corporate misbehavior has occurred, have seemed unable or unwilling to pursue anything but the most lenient resolutions of such cases.  These resolutions are often fines that might appear big to gullible members of the public, but are actually small in comparison to the money to be made; sometimes deferred prosecution and corporate integrity agreements that rarely are enforced; and almost never any negative consequences for the people who authorized, directed, or implemented the bad behavior.  Thus the leaders of health care organizations have enjoyed impunity, have become the new untouchables, and thus health care organizations become ever better at raking in money and ever worse at providing good health care. 

As I have said again and again, until the people responsible for the bad behavior experience negative consequences from that behavior, they will continue to perform, direct, and condone bad behavior. We will not achieve real health care reform in the US until we effectively deter unethical, self-serving behavior by leaders of health care organizations.
 

The authors of this blog don't often concern themselves with bad science in medicine, and they probably wouldn't be able to see through the Lyme disease establishment's scientific smokescreen, but I find their devotion to exposing and analyzing systemic bad behavior in the business of medicine, refreshing. 
"I have to understand the world, you see."
Richard Feynman

Lorima
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Re: The movement to reform medicine from within

Post by Lorima » Sat 19 Jan 2013 18:57

Here's another one from Roy Poses at Health Care Renewal blog, this one about a "key opinion leader" (KOL) who admitted he was wrong. 

This may be a good time to say, I don't believe in hero worship, because there's no one I always agree with. I respect Dr. Poses, and find him to be thoughtful, honest, and persuasive - but that doesn't mean we should automatically believe, or agree with, everything he says. For example, he may be over-optimistic about the capacity of "evidence-based medicine" to provide anything other than food for individual doctor's thought and judgment. It seems simplistic to hope for universal guidelines from EBM, because the complexity of most medical issues don't really lend themselves to a reductionist approach, and because it's almost impossible to do properly controlled experiments on people. And finally, because doctors' training seems to unfit most of them to assess evidence rigorously. How else can we explain what has happened in the Lyme disease field?

I don't have an opinion about the medical content of the specific issue (the use of narcotics long-term, for chronic pain due to a non-fatal condition), because I haven't studied the subject, nor do I have any personal experience with it. Nor can we know whether the motives of the seemingly mistaken but powerful KOLs were primarily financial, or mere misguided enthusiasm for their cause (they probably don't know, themselves.) I suspect the hunger is for influence, rather than for [yet more] money, which they already had in abundance, but maybe I underestimate the power of simple greed. Plus, money is used by many people as a status symbol, which brings us back to the hunger for influence and status among (or above) their peers. 

What I find most interesting is how a few people managed to sway a whole field of medicine to their way of thinking, by a focused, prolonged effort to make their view into a universal standard of care. (Maybe this is the real-world version of the movie super-villian motive of "world domination.") 

It's quite interesting that "These campaigns included production of clinical practice guidelines promoted as authoritative, and enlistment of accrediting organizations and government regulatory agencies." Sound familiar? 

http://hcrenewal.blogspot.com/2012/12/t ... l.html?m=1 
Poses says, 
In summary, it appears that the huge increase in the use of narcotics to treat chronic, non-malignant pain was never based on clear convincing evidence from well-designed studies.  At best it was based on irrational enthusiasm and wishful thinking by some very vocal and persuasive advocates.  These advocates seemed to become "key opinion leaders," that is, influential people who promoted the use of pharmaceuticals while they were being paid by pharmaceutical companies, and were likely involved in what appears to be systematic stealth marketing campaign by the pharmaceutical companies that make narcotics.  These campaigns included production of clinical practice guidelines promoted as authoritative, and enlistment of accrediting organizations and government regulatory agencies.

snip

So I would argue that the case of the legal narcotics pushers underlines the need for utmost transparency about conflicts of interest affecting people and organizations that advocate for particular approaches to health care, and to the management of individual patients; continuing movement to bar at least the most egregious conflicts, as per the Institute of Medicine report on the topic (look here); and the need for the very skeptical, rigorous application of true evidence-based medicine approaches.   

Finally, I must note that this seems to be the first time that a prominent, highly influential key opinion leader  has recanted. Maybe he will write an article entitled "Dr Drug Pusher?" - just joking, but at least one former key opinion leader did write the confessional  "Dr Drug Rep."  Maybe this is the beginning of a movement toward health care based on logic and evidence rather than wishful thinking, irrational enthusiasm, or ideology, or even worse, on deception or personal enrichment.
"I have to understand the world, you see."
Richard Feynman

Lorima
Posts: 914
Joined: Mon 29 Oct 2007 20:47

Re: The movement to reform medicine from within

Post by Lorima » Sat 26 Jan 2013 20:27

Scientific inbreeding and same-team replication

http://www.ncbi.nlm.nih.gov/pubmed/23148806 
J Psychosom Res. 2012 Dec;73(6):408-10. doi: 10.1016/j.jpsychores.2012.09.014. Epub 2012 Oct 6.
Scientific inbreeding and same-team replication: type D personality as an example.
Ioannidis JP.

Source
Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA. jioannid@stanford.edu

Abstract

Replication is essential for validating correct results, sorting out false-positive early discoveries, and improving the accuracy and precision of estimated effects. However, some types of seemingly successful replication may foster a spurious notion of increased credibility, if they are performed by the same team and propagate or extend the same errors made by the original discoveries. Besides same-team replication, replication by other teams may also succumb to inbreeding, if it cannot fiercely maintain its independence. These patterns include obedient replication and obliged replication. I discuss these replication patterns in the context of associations and effects in the psychological sciences, drawing from the criticism of Coyne and de Voogd of the proposed association between type D personality and cardiovascular mortality and other empirical examples.
Copyright © 2012. Published by Elsevier Inc.
PMID: 23148806 [PubMed - in process]
"I have to understand the world, you see."
Richard Feynman

Lorima
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Re: The movement to reform medicine from within

Post by Lorima » Sat 26 Jan 2013 21:03

Appropriate humility

http://wingofzock.org/2012/08/30/physic ... ealthcare/ 
“A disease and its treatment can be a series of humiliations, a chisel for humility” – Laurel Lee

“Fullness of knowledge always means some understanding of the depths of our ignorance, and that is always conducive to humility and reverence.” – Robert Millikan

“Humility is nothing less but a right judgment of ourselves.”- William Law

“Early in life I had to choose between honest arrogance and hypocritical humility.  I chose the former and have seen no reason to change.”  Frank Lloyd Wright

“Humility is the foundation of all the other virtues hence, in the soul in which this virtue does not exist there cannot be any other virtue except in mere appearance. – Saint Augustine

Three physicians got me thinking about humility.

At the health care innovations summit in Washington, DC earlier this year, I heard Atul Gawande, MD call for medical schools to do a better job at training physicians in humility, discipline, and teamwork. In a 2010 Stanford School of Medicine Commencement speech, Dr. Gawande said:

“And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had:  values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and perhaps above all, humility – for we need humility to recognize that, under conditions of complexity, no technology will be infallible.  No individual will be, either.”

Eric Van De Graaff, MD wrote a blog titled “Why Are So Many Doctors Complete Jerks?” Dr. Van De Graaff was chagrined when his own mother was disappointed when he became a physician; she “had a deep-seated disdain for doctors.”  Dr. Van De Graaff answered his own question with two theories. His first theory was that some physicians “let the glory of their careers go to their heads and begin to treat patients and underlings like chewing gum on a movie theater floor.”  His second theory was that physicians act like jerks when emergencies occur and they feel overwhelmed and frightened.

Dr. Van De Graaff offers two simple rules, which he admits he sometimes does not follow:

“Rule #1:  It is simply not allowable to be impolite, mean, nasty, or snippy with staff or patients even when you are in a stressful situation.

Rule #2:  Whatever is stressing you is probably stressing those around you as much or more. Under those circumstances you have to go out of your way to be kinder and more understanding.  As a doctor, you control the mood in the clinic and operating room even if you can’t control the situation.”


A physician left the following comment on the above Van De Graaff blog post:

“Frustrations and stress mount, yes. I think in medicine we should be aware that continuing bad behavior is partially the responsibility of us all. We have social standards and maybe should ask ourselves how much have we allowed these actions to continue? None of us function in a vacuum.  We all have the ability to affect change and reward positive communication.”

How do we as a community of physicians respond to these three physicians who are clearly calling for physicians to exhibit more humility in our practice of medicine?  Do we know how to affect this change in behavior in our colleagues and ourselves?  T. S. Eliot once wrote, “Humility is the most difficult of all virtues; nothing dies harder than the desire to think well of oneself.” (‪Shakespeare and the Stoicism of Seneca. ‪An address read before the Shakespeare Association 18th March, 1927).

The English words humility and humble are derived from the Latin noun humilitas and the adjective humilis which can be defined as grounded, from the earth, respectful, unassuming, modest, and low.  Humility is often contrasted with the terms pride, haughtiness, and arrogance (See the Frank Lloyd Wright quotation at the beginning of this post).  Humility has been held up as a virtue in both religious and ethical writings.

Pride and arrogance are commonplace among physicians and provide the punch line for the famous New Yorker cartoon where a physician goes to the front of the line in heaven “because he thinks he is God.” In the Christian tradition, part of humility is self-knowledge about the limits of one’s own skills, knowledge, and authority. When a professional like a physician or a teacher does have superior content knowledge when compared to the patient or the student, arrogance is an all too common attitude.  Bertrand Russell was talking about teaching, but his lesson applies to physicians as well:

“In the presence of a child [the teacher] feels an unaccountable humility – a humility not easily defensible on any rational ground, and yet somehow nearer to wisdom than the easy self-confidence of many parents and teachers.”

The Harvard psychiatrist Robert Coles thought the greatest achievement of his mentor physician/poet William Carlos Williams “was to teach doctors honest self-scrutiny, to show how ‘we become full of ourselves, self-preoccupied, so caught up in either our importance or our own affairs that we can’t listen and pay attention to other people, even our patients at times.’”  (Carlin Romano. America the Philosophical, New York:  Knopf, 2012).
snip

- Kent Bottles, MD, is a member of the Wing of Zock external advisory board and a guest contributor to the Wing of Zock as well as the medical blog, The Doctor Weighs In. He is the editor and author of Kent Bottles Private Views and can be reached at kentbottles@gmail.com
"I have to understand the world, you see."
Richard Feynman

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Muscle Car55
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Re: The movement to reform medicine from within

Post by Muscle Car55 » Sun 27 Jan 2013 15:24

It's hard to reform medicine, when at the core of our country is capitalism. Everything within the country is for profit, health insurance, drugs, doctors, patents etc... Problems arise when it's over embellishment of profit and I think it's safe to say we're well past that point when so many people are claiming bankruptcy because of medical bills.

Country and government needs to change first before health, hate to say it!

But hey I'm all for some change, even if it is a little.

Lorima
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Re: The movement to reform medicine from within

Post by Lorima » Mon 28 Jan 2013 4:07

Hi Muscle Car,
Did you read the whole thread? Most of the issues that were raised aren't related to government or money, but to habits of thought and behavior that are part of current Western medical culture, regardless of which country, or who is paying the bills. I don't think the Lyme disease problem is driven primarily by capitalism. I think it's driven by the hubris of a few people, whose errors have been amplified by some features of medical culture. Those things are hard to change. But they are easier than the whole government. And many people in medicine are aware of them, and working to change them. I want to call attention to those efforts, to give credit where credit is due, in the medical profession.
"I have to understand the world, you see."
Richard Feynman

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Muscle Car55
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Re: The movement to reform medicine from within

Post by Muscle Car55 » Mon 28 Jan 2013 8:33

Lorima wrote:Hi Muscle Car,
Did you read the whole thread? Most of the issues that were raised aren't related to government or money, but to habits of thought and behavior that are part of current Western medical culture, regardless of which country, or who is paying the bills. I don't think the Lyme disease problem is driven primarily by capitalism. I think it's driven by the hubris of a few people, whose errors have been amplified by some features of medical culture. Those things are hard to change. But they are easier than the whole government. And many people in medicine are aware of them, and working to change them. I want to call attention to those efforts, to give credit where credit is due, in the medical profession.
Yep you're right, capitalism is definitely not the only cause. But I think it can prevent medicine from moving forward.

I've seen the way doctors treat disease with drugs, instead of cure. Think the way money, patents, and power controls ideals. It's all due to the type of government we live under. History Fact: One day the church was in control of science, turnout wasn't good.

Health insurance needs a major overhaul and not be driven by just profit. Obama care supposedly improved this, but I have my doubts. How do you cure disease when health insurance won't pay for most the drugs you need.

Lorima
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Re: The movement to reform medicine from within

Post by Lorima » Mon 28 Jan 2013 14:09

Hi MC,
Here's a good book about the US health insurance industry:
Deadly Spin by Wendell Potter.
Potter worked as the executive in charge of corporate PR for Humana, and then for CIGNA.
He has become a whistle-blower, testifying before Congress in 2009, and writing this book.
It's about how the insurance companies, both individually and as a group, have used PR to discredit critics of the insurance industry, campaigners for single-payer systems, and others who try to reform the system.
There's a great chapter about how they got together to neutralize the effect of Michael Moore's movie Sicko.
Incredibly crass stuff going on at all the huge corporations, I agree. And it's all supposedly justified by their duty to their shareholders, to increase profits, no matter what.

My biggest interest now, though, is in what it is about medical culture that prevented the errors in the science from being corrected. I did my PhD in a department of a big medical school; and I had several friends in med school. It changed their personalities. I have collaborated with MDs in my career; some of them were very good scientists, and they complained about medicine over a couple of beers. I think the acquired arrogance there is not just ugly, and hurtful to everyone's feelings, but is distorting medical science.

It's unlikely that once someone makes an aggressive, confident assertion, that they will be able to back down, or even modify their stance, when it turns out to be not quite right, or worse, completely wrong. There's a tendency to defend it to the death, and get even louder and more aggressive, instead of backing up and quietly looking at the new data, and correcting the model to incorporate it. The more they defend it, the more they believe it, and they end up writing editorials calling everyone who disagrees with them "antiscience" and "unethical". How ironic.

There are people in medicine who see this (along with other problems) and are thinking about how to modify the culture so that it can reliably perform in a trial-and-error, rather than a dogmatic, mode of thought. But there are practical considerations, like the need to hurry and treat patients now, the liability generated when it becomes clear that big errors are present in "standards of care", and the psychological needs both patients and doctors have, to be confident that the doctor knows what he's doing. These problems are avoidable in bench science; but they are kind of built-in, for medicine. There is much work to be done, on many levels, and in several disciplines.

I'd rather not oversimplify the issue, by assuming it's all about money. Though money certainly plays a role.
"I have to understand the world, you see."
Richard Feynman

Lorima
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Joined: Mon 29 Oct 2007 20:47

Re: The movement to reform medicine from within

Post by Lorima » Tue 29 Jan 2013 6:14

Bad Pharma, a new book by Ben Goldacre 

Ben Goldacre, MD, is well known for his column in the UK Guardian, and his book Bad Science. He has been popular among the "Skeptics". 

I'll probably start a thread about this book after I've finished and thought about it. Meanwhile, here's how it starts. 

From the Intro: 
Medicine is broken. And I genuinely believe that if patients and the public ever fully understand what has been done to them - what doctors, academics and regulators have permitted - they will be angry. On this, only you can judge. 

We like to imagine that medicine is based on evidence, and the results of fair tests. In reality, those tests are often profoundly flawed.
We like to imagine that doctors are familiar with the research literature, when in reality much of it is hidden from them by drug companies. We like to imagine that doctors are well-educated, when in reality much of their education is funded by industry. We like to imagine that regulators only let effective drugs onto the market, when in reality they approve hopeless drugs, with data on side effects casually withheld from doctors and patients.
snip
"I have to understand the world, you see."
Richard Feynman

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