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Why Doctors Hate Science
theodp writes "A 2004 study found some 10 million women lacking a cervix were still getting Pap tests. Only problem is, a Pap test screens for cervical cancer — no cervix, no cancer. With this tale, Newsweek's Sharon Begley makes her case for comparative-effectiveness research (CER), which is receiving $1 billion under the stimulus bill for studies to determine which treatments, including drugs, are more medically sound and cost-effective than others for a given ailment. Physicians, Begley says, must stop treatments that are rooted more in local medical culture than in medical science, embrace practices that have been shown scientifically to be superior to others, and ignore critics who paint CER as government control of doctors' decision-making."
While I am all for people being able to make their own calls and decisions, this sort of research could very well help to streamline more basic medical procedures and help bring to light both new medicines and treatments that might not be able to afford the same advertising as the crap that gets shoved in front of consumers every ten minutes on tv, radio and internet.
The musings of just another geek and his junk.
I bet next they give mandatory prostate exams to women too!
"Infecting minds with my own memetic virus, one post at a time." Ultimape
Of course, its Newsweek, the famous liberal rag, and yes, the intent here is trying to persuade doctors that foolishly supported Obama into believing that they will somehow gain in the new regime. They won't.
This is my sig.
Obama's ppl are writing news for Slashdot already???
There are a lot of evidence-base guidelines already. The question to ask is why patient hates science and ask for hi-tech test (MRI, CT) and latest pills.
the assumption here is that wasteful procedures are due to the profit motives of physicians.
anyone who knows anything about health-care will tell you that the primary cause of most non-cost-effective procedures is fear of legal consequences.
want cheaper healthcare? reform the legal system and get the hmo's out of the game.
------ The best brain training is now totally free : )
Evidence-based medicine is not the norm in the US, but you can't necessarily blame the doctors for failing to consider it: the whole system is the problem. Consider the case of Dr. Daniel Merenstein, a family-medicine physician trained in evidence-based practice.
... there is little evidence that early detection makes a difference in whether treatment could save your life. As a result, the patient did not get a PSA test. Unfortunately, several years later, the patient was found to have a very aggressive and incurable prostate cancer. He sued Merenstein for not ordering a PSA test, and a jury agreed--despite the lack of evidence that it would have made a difference. Most doctors in the plaintiff's state, the lawyers showed, would have ignored the debate and simply ordered the test. Although Merenstein was found not liable, the residency program that trained him in evidence-based practice was--to the tune of $1 million.
In 1999 Merenstein examined a healthy 53-year-old man who showed no signs of prostate cancer. As he had been taught, Merenstein explained
This game will waste your life. Don't clicky!
... as the title of this entry suggest. Not all doctors are created equal, and lets get this straight - all human beings, no matter how educated are very fallible and human.
I had one young doctor think I should have my moles checked out that "looked cancerous" and another doctor whom I'm also freinds with that tells me "that doctor is full of shit". I also had my GP (general practitioner) suggest I had a part of my foot cut off after a series of infections after many an ingrown nail, needless to say I rejected his suggestion and did the work on the foot myself and still have everything all intact and normal as ever.
Just because someone suggests something who is in a position of recognized credentialed authority, does not mean it is a license to take their judgments and advice without scrutiny and a grain of salt.
Knowing how to do this and when is the hard part, but this is something that only people who've lived long enough and have the wherewithal to gain by experience - mankind is extremely fallible. Therefore critical skepticism must be employed when decisions can have significant consequences.
It's easy for experts to suggest something to someone else when they don't have to bear the risk and consequences of going through with it.
While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency". They may well make some things better. But they'll inevitably make more things worse.
I want to aid in better treatments, but I can also easily see some overreaching federal agency micromanaging physicians. Sorry, but find me one federal agency that never tried to expand their power exponentially, often in the name of "the public good".
Life is hard, and the world is cruel
Remedies has been around of thousands of years, we tested it all and the stuff which works was called "medicine"
The point I'm trying to make here is that these people that believe modern science is some how inferior to their new age hocus pocus need to be hit with the clue stick.
This goes especially for those idiots that believe in Homoeopathy.
Why do you folks think Big Pharma is so successful? One of the prongs of their attack on medical knowledge (and ultimately research also) is mis-education and indoctrination of physicians themselves, through both subtle whispering in their ears as well as brute-force constant bombardment. The knowledge of physicians is pretty much under attack from the day they toss that cap in the air, if not sooner.
BTW, I've heard from a family member who is a Kaiser HMO patient that Kaiser does not allow Big Pharma reps direct access to its staff phyicians, and instead funnels them to some sort of departmental liaison; if that's true, that is certainly one good thing that an HMO is doing.
I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.
I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Very dissatisfying to a lot of patients.
Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.
The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.
EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.
http://www.amazon.com/Critical-What-About-Health-Care-Crisis/dp/0312383010/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1235966206&sr=8-1
And modeled on the UK system where a review board develops a formula the determines if the cost-benefit is worth it or not.
Sounds all good and all, but basically this is what HMO's try to do now.
Only difference I can tell is that the government will be the ones telling you what treatments you can/cannot get instead of the HMO's.
"The problem with socialism is eventually you run out of other people's money" - Thatcher.
I hope the procedures investigated and shown to be useless, if not harmful, once and for all, is male circumcision, especially when it involves non-consenting infants.
This will completely flummox the fraction of doctors that aren't good physicians to begin with. For the rest, this will just impede their judgement.
please stop with the media whore titles. it only makes you look stupid.
If you mod me down, I will become more powerful than you can imagine....
Medicine is currently more or less based on science, but that only because science has taken such a large role in our brave new society.
Medicine has always been more art than science, famously so; a doctor is not a scientist, even if he researchs and publishes, he's a different animal from a clinical researcher.
Doctors make, and have always made, and will always make, medical decisions on far less verity than any scientist would accept, for obvious reasons. Thanks to modern science, you can almost count on him(or her- new times indeed) not to kill you with the treatment. Our modern doctor has a vast arsenal of sceince based medicine at his disposal, but you may trust that every decision he makes is grounded in nothing more or less than his own hubris, and if you're lucky, his brains and experience and his expertise. Nothing whatsoever to do with science. In point of fact, our medical educational system is mostly designed to weed out the unintelligent, the fools and the irresponsible- aside from basic scientific literacy, that is your guarantee that your doctor won't fuck you up even worse- a general merit system. Works pretty well, actually! Science? Nothing to do with it.
Thanks to, again, modern science, and medical institutions, he is right more often than not, or has the tools to attack a problem he may not be right about, but he is not a scientist. He is an artist.
Picasso has more in common with a doctor than Neil Bohrs by a large margin. Sleep on that before your next checkup, o my brothers.
The next decade of 'change' in the US will reduce doctors to government functionaries. Too bad you sunk $150k into that education... you will soon be making the equivalent of 4 year engineer wages, and you'll have less discretion while earning it.
You deserve it. All of my life I've listened as the grabbers made their claims; US infant mortality is higher than the socialists, US lifespan is short because of free market medicine. Claims that the majority of US doctors would prefer a collectivized system. It all went unanswered by you. It was fear of offending your international colleagues. Fear of revealing the truth about canukistan's medicine, for instance. It's hard to defend a free market system while arguing for more government *-cade dollars, isn't it?
You kept your mouth shut because controversy is unpleasant, and now the barbarians are at the door. Enjoy your ass raping. That's what CER is all about; determining the precise technique and quatity of lubrication necessary to fuck the doctors and hospitals right up the tailpipe.
And if you educrats out there think Uncle Sam is going to pay full retail to make higher education 'free' in this country... LOL.
the funny thing is, medical studies changes their conclusions all the time. one day low temperature won't worsen your cold, the next day it does. one says coffee will save your life, another says it will kill you.
glad that finally we'll have a single authority to give us one definitive answer for any question.
While I understand the need to have a catchy title, it's grossly mis-representative of the problem. Doctors don't hate science - doctors hate the misapplication of science and the failure to apply common sense. Hence, pap smears for patients without a cervix.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
Why didn't they speak up about the Pap test? Is it possible that the test still has a purpose even if you don't have cervix?
You bring to light a lot of good points and examples. Patients are belligerent. But I suppose thats to be expected in a country where a good portion of its populace are believing things that might as well amount to superstition.
"Infecting minds with my own memetic virus, one post at a time." Ultimape
????
"I'm aware of people getting rid of cancer homeopathically and therapeutically, yet are killed in good health by the court-ordered radiation therapy they were coerced into continuing."
Because we are talking about EVIDENCE-based medicine, not eye-of-newt, toe of frog nonsense and tinfoil hat paranoia. Let me guess, this is all orchestrated by the Jewish Illuminati Freemasons?
I bet that radio show was something like Alex Jones', which is why you didn't care to mention what radio show you heard it on. Some people will believe any form of bullshit--you are one of them.
The title is quite sensationalist. If this were an article on the iPhone it would garner a rebuttal 5 times the original article's length.
...when they're constrained by reality.
Six minute video, don't need to watch it all, but be sure to catch the last 45 seconds.
This sounds like the kind of old country doctor that Dr. McCoy would be on the USS Enterprise and argue against Mr. Spock's Science and Logic, all the while Dr. McCoy uses science in his medical bay to treat patients.
One can reason that the cervical cancer tests would reveal other sorts of cancer as well. It is like a woman who had hear breasts removed, died of breast cancer later anyway as the cancer came back after the breasts were surgically removed.
Why can't we just have one general "cancer test" developed for all kinds of cancer that exist, be it cervical, breast, lung, kidney, colon, etc? Our technology is as advanced as it can get for this day and age.
Instead of Dr. McCoy, we now have Dr. House who gets a patient with a "mystery illness" as many diseases and cancers, etc share symptoms. Then they have to run dozens of tests until they find the right one via logic and deduction and process of elimination. Until the heathcare insurance company or the government gets the bill for the dozens of tests run to solve the illness the patient had, and then treat it.
If a person's life is at stake, how many tests a doctor is allowed to make, could mean the difference between life and death.
Well Mr. Smith we'd like to run a series of tests to see what illness you have, but Obama and Congress passed a healthcare bill that limits us to run just one test. We ran it for lupis, but it came back negative, and since we ran one test, we cannot run another. I'm afraid we'll have to just release you from the hospital and write it up as "the flu" and give you a prescription for antibiotics. Sure hope it isn't cancer, AIDS, or even something that might kill you. Best of luck, Mr. Smith, we got other patients to help out now, they pile up a lot and we are really busy after that Universal healthcare bill got passed.
Remember, Slashdot does not have a -1 disagree moderation, and no, troll, flamebait, and overrated are not substitutes.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
I have considered it. I also consider the fact that every medicine I prescribe carries risks, even if those risks are low. If I don't know whether the risk outweigh the benefits, I don't prescribe, particularly for 'nuisance' illnesses.
I know many physicians who prescribe placebo treatments and tests. I have trouble doing this even though patients find it very satisfying. What I sometimes do instead is tell people what the evidence is and let them decide. I struggle with the ethics of prescribing a placebo.
I feel for you, I really do. I couldn't handle being in your profession, it would be way too frustrating for me.
This game will waste your life. Don't clicky!
While there is merit in placebo... For patients that don't have health-care plans, or those on fixed income, spending shit tons of money on what amounts to snake oil is quite a good reason to prescribe bullshit.
"Infecting minds with my own memetic virus, one post at a time." Ultimape
Couple that with having to do unnecessary tests many times just to CYA to fight off bloodsucking lawyers and malpractice cases....well, that explains a lot of it away.
Light travels faster than sound. This is why some people appear bright until you hear them speak.........
There is no scientific evidence at all that "a regular practice of PSA tests" is useful in any respect, or that it even does more good than harm. It's a medical custom that has no empirical basis.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
Say I'm a scientist, but not in the medical profession. So I can't treat myself, but I would like to be treated by someone who I have confidence is basing their decisions on solid evidence. That is, going to them should get me results that have better expected outcomes than doing my own damn PubMed searches and self-treating. It seems this often isn't the case; a lot of treatment is "rule of thumb" or "I don't like the look of that", and as you point out the patients are probably at least as responsible as the doctors in this.
But if I really do want a physician who's going to give me an honest summary of current scientific evidence, how do I find someone? Do people openly advertise as doing evidence-based medicine? I can see that a lot of people simply don't want EBM--- they want the old-fashioned village doctor who has a folk remedy and answer for everything. But it seems there ought to be some way to connect people who do with doctors who're willing to provide it.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
There is quite a lot of resistance in the medical community to evidence-based medicine, especially among older doctors. The "everything requires subjective judgment of the practitioner, damn what your numbers say" strain of doctoring didn't really die out in the 19th century. Most doctors, actually, probably operate more based on folk knowledge and rules of thumb than any solid empirical evidence, except in specialized areas.
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If you're not spending your own money on the actual health care, it's not the free market. It doesn't matter much whether the government or a giant faceless corporation is the payer, neither one really shares your interests.
The whole reason we even have health benefits "provided" by employers is because of government price controls. Wartime price controls on labour. Benefits were a way to entice workers where salaries were capped.
If you're going to bitch about free market failings, it might be a good idea to make sure the effect you're complaining about is the result of free market principles actually being applied.
I figure I might as well throw in my two cents:
Last summer, I hurt one of my shoulders bad. It was somehow dislocated before it slipped back into place. I'm well aware that this does a good job fucking up the joint. For the first week, it was a dull ache that got acute when I moved my right side at all. I couldn't swing my arm backwards past straight out, to say nothing of doing any pushups. It's been about 4 months now and I can finally just about lay down on my back arms-straight-up without any nagging pain.
We can't afford health insurance so I never even considered seeing a doctor. Why risk getting raped for half a semester's tuition just so they can either say "you'll get better" or recommend more things we can't afford?
Now go ahead, tell me it's my fault for not working hard enough to have insurance or that I'd have to wait in line in England. At least there someone will eventually take a look at it.
Will this help hospitals stop cutting the penis of babies? I know a few folks that want there foreskin back.
Can't you just give them something for their anxiety?
Please post your name and city; you may get a large number of /.ers beating down your door.
Are you in the Bay Area? Do you take Great West insurance? Are you accepting new patients?
The World Wide Web is dying. Soon, we shall have only the Internet.
The vast majority of procedures are highly constrained by insurance rules: either the government in the case of Medicare, or private industry in the case of various HMOs and insurance plans, have complex rules about what must be done in what order to get reimbursement. Doctors already have to follow that, so it'd at least be an improvement if those rules had some basis in scientific evidence indicating what treatments really are better.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
First, you CAN have cancer of the cervix after hysterectomy...not all hysterectomies involve removing the cervix. Second, if you have a hysterectomy for cervical cancer, you still need screening: See this PubMed Article Third, the literature for screening after hysterectomy for benign disease is still evolving. See this PubMed Article
OP is a troll, I would say, and the title is alarmist and misleading. Evidence based medicine has been around for a while, the trouble is it is very expensive and difficult to perform, and just as hard to implement.
1. Private insurance will not pay for a woman's well visit if they don't have a Pap smear. They don't care that the woman doesn't have a cervix. If you don't do it, you don't get paid, and it's just easier to do it no matter how nonsensical it is than it is to get on the phone with someone who is not medically trained and argue that, yes, you did do a well woman exam even though you didn't do a Pap smear.
2. There is a case to be made for anal Pap smears, because HSV also causes anorectal cancer in people who participate in anal sex. Unfortunately, because it's not standard of care, private insurance won't pay for that either. (We don't even need to talk about Medicare or Medicaid because they don't pay for preventative visits.)
The path to hell is paved with good intentions. Few could argue that the government means well, initially, but when has the state managed anything better than the private sector? Medical costs can be substantially attributed to doctors who fear medical malpractice suits. Thus the meaningless pap tests. A better solution would be comprehensive tort reform. But nooo. Look at the top donors to the two parties. The trial lawyers. Tort reform will never happen. As for outmoded practices, another easy solution. Board certification should never be permanent. A combination of CME credits and re-certification by exam every five years for MDs will help ensure best practices are followed. ---- First, do no harm. That's Washington's job.
All I can say is that the stock market is down 7,000 points since Obama first overtook McCain in the polls. You can talk about how great he is, but as it is, everyone with half a brain knows that Obama just spend a trillion dollars on welfare, won't accomplish anything, and all this talk about the Bush budget deficits is just utterly dwarfed by Obama's spending spree.
And you just wait, until we make you Democrats defend free trade. WE'll take the blue collar vote away from you, and then what will you have left?
This is my sig.
Many patients want a test to be done to ease their mind about it, or a pill they can take that will make it better. Even a placebo effect is better than nothing. People don't just wander into doctor's offices - some physical condition prompts them to go, and they expect the doctor to "fix it".
A good practitioner of evidence-based medicine would probably need to present their patient with the same data they are using to make their decision not to treat in a more condensed and easy to understand form. When you go against expectations, it's important to have a rationale can be understood to back up your response. Otherwise it almost sounds like you're lazy and just don't want to do "your job", which is to "fix it".
Just because a trial failed to reach P<0.05 in testing efficacy does not mean the treatment has no benefit. As we learn more and more about patients, we realize that everyone really is unique. The problem is that to conduct a double blind prospective study with good statistical power to test a treatment gets harder and harder as we categorize patients into smaller and smaller groups. At some point, you need to use inference, i.e., doctors need to think hard about the available evidence and make a decision even though we have not had the luxury of accumulating a large cohort of patients to conduct and adequately powered clinical trial. Demanding that standard of care be restricted to only those treatments that have demonstrated efficacy in an adequately powered randomized clinical trial is going to leave anyone with a rare disorder out in the cold, and more importantly, untreated.
Second point. Conducting a randomized clinical trial takes years, sometimes decades. And then you need to replicate the result in an independent trial to be really sure. Restricting standard of care to only those treatments that have demonstrated efficacy is going to make the standard of care lag many years behind the current state of biomedical knowledge. Are you really willing to pass up your physician's best advice on care while you wait for it to work through the trials process?
Statesman
If you want my opinion, the article sounded suspiciously like insurance company propaganda. The doctor is the one person in the equation who basically has the same vested interest the patient has -- keeping the patient alive.
The cost effectiveness arguments she makes are bunk. E.g., if the old line drugs for schizophrenia are so great, why haven't they worked? And why is dehydrating someone the best way of treating high blood pressure? Give me a break.
Politicians may hate science, and certainly the health insurance companies hate science, and both like to think in terms of cost effectiveness, unless of course it's their own health that's at stake, in which case they want the best "science" available. And maybe some journalists hate science if they've absorbed enough behind the scenes insurance lobby propaganda.
But of all the groups mentioned in the article, it is the doctors who hate science least, and who are most about trying to find the right answer, the right answer meaning the one that is best for the patient's health, as opposed to the insurance company's bank account.
(And in case you're wondering, I'm not a doctor, and have never even had any relative or personal friend who is a doctor; but I do remember my first doctor, who had, under a large glass dome, a giant gold microscope, which occupied the central place of honor in his office... a clear homage to his love and reverence for Science. And in practice he cared for the lives of his patients as though they were his own. And I guess they were.).
Ray Beckerman +5 Insightful
Let bureaucrats decide your treatment not doctors!
Wow, this is great!
Instead of my doctor making medical decisions, we'll have a government panel of "experts" making decisions about my medical treatments.
What could go wrong?
I thought it was bad when healthcare companies (HMOs) used accountants to make medical decisions, but I guess letting government bureaucrats make medical decisions is A-OK.
That's change for you.
---
U.S. Senator Tom Coburn, M.D. (OK), a practicing physician, released the following statement today regarding ongoing negotiations between House and Senate over controversial and complex health care provisions in the stimulus bill.
"The health care provisions in the House stimulus bill represent ideological and partisan overreach of epic proportions. It is ludicrous to ask a body that can't track its own spending to determine which medical treatments are best for individual patients suffering from complex diseases. The only reason to fund this project now is to lay the groundwork for establishing a government board that will be empowered to make life and death medical decisions about health care treatments and cost," Dr. Coburn said.
Dr. Coburn explained that both the House and Senate version of the stimulus bill include $1.1 billion for comparative effectiveness research. Unfortunately, the House language overreaches by permitting the use of that money to make coverage decisions based on cost to the federal government.
"The practice of medicine is about 40 percent art and 60 percent science. A so-called 'comparative effectiveness' formula will replace the professional judgment of doctors and nurses, which is developed over many years, with the political judgments of politicians and bureaucrats. A comparative effectiveness formula will only save money by rationing care and ending lives. Congress is on the verge of enacting the same policy that Great Britain has used to decide, for example, that extending a patient's life for a year isn't worth more than $45,000," Dr. Coburn said.
"Trusting the government to ration care will take away choices and life-saving treatments from sick patients and deny families more time with their loved ones. Doctors and patients should be making decisions based on individual patient conditions and needs. Allowing government to make these decisions would set us on a dangerous path. The unelected staff and career politicians who are negotiating these details have almost zero real world experience in the health care sector. Congress should confess its limited capabilities in this area and debate this issue in the open, not rush through massive policy changes in secret," Dr. Coburn said.
There are also good and bad physicists, chemists, mathematicians... and so on.
I'm a physicist, and if I do something a chemist finds stupid (and I have), they let me know it in no uncertain terms (and they have) and what they think has real consequences for my career (and it has). I'm not sure it works that way for medicine. Who reviews them? Who determines what doctors get promotions?
The way it works for me, the "faceless bureaucrats" who are looking over my shoulder are real scientists sent by NSF, DOE, NASA, NIH... all the good acronyms. Their reports are judged by other real scientists (who I know and meet with) who then follow strict rules on what happens with my funding or review or whatever is going on. These people still make mistakes, and are not always honest, but it's hardly soviet style brainless leadership. I think the current system with insurance companies and hospital administrators doing the reviewing is closer to the "faceless bureaucracy." If I was a medical doctor, I would prefer the scientific oversight.
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
I, for one, would welcome being part of the process of deciding my own treatment in the way you describe here. I would hope there are others like me.
Seriously, where do you practice medicine, and are you accepting new patients?
If practicing medicine consisted of a video game or a board test, then yes, doctors could suspend their own judgement in favor of strict evidence-based medicine. Unfortunately, this is the Real World, and doctors frequently have to approach EBM with a healthy dose of skepticism.
The problem with EBM is threefold: the evidence record is necessarily incomplete; many real-world patients have very little in common to patients that make it through selection criteria into randomized clinical trials (RCTs); it is very easy to skew studies in minute ways through endpoints, study design, and a thousand other ways that are difficult for busy practicing physicians to catch.
Want some examples? A recent multicenter study (in worldwide sites) of blood pressure medications funded by the maker of Lotrel found that their combination ACE inhibitor/calcium channel antagonist (CCA) had slightly better morbidity/mortality outcomes over a given period of time than patients who were placed on a combination of the ACE inhibitor and a thiazide diuretic, with similar reductions in blood pressure. The data is fantastic, and the outcomes are probably real. But when you check closely into the outcomes criteria, one of the "bad" endpoints is "hospitalization for unstable angina" (new or worsening chest pain). One of the indications that CCAs have that diuretics do not is the treatment of angina. CCAs, through the mechanisms of its action, can prevent anginal episodes or make them better. A thiazide diuretic will not treat angina directly. Out of the room of ~20 doctors this study was being presented to, apparently I was the only one who thought of this. And since many of the patients involved in the study had prior cardiac history with ostensible angina, it made perfect sense why CCAs would perform better for these patients. But this study is not being billed as that - the study is being presented as evidence of the possible superiority of using one drug over another in the general population with high blood pressure.
And then there's the Nexium/Prilosec fiasco. Nexium was developed by the makers of Prilosec when patent protection for Prilosec began running out. (You can buy generic Prilosec (omeprazole) over the counter.) Nexium (ESomeprazole [emphasis mine]) is filtered Prilosec - the biologically active enantiomer of Prilosec's racemic mixture. Nexium is on average six times more expensive, mg for mg, than generic omeprazole. The only study I know of (and that is certainly being quoted in wide circulation) comparing the effectiveness of the two was funded by the makers of Prilosec and Nexium, comparing healing rates of acid-reflux esophagitis with "typical" doses of Prilosec and Nexium. Nexium outperformed Prilosec in healing the worst grades of esophagitis - grades C and D. The "typical" doses used were 20 mg of Prilosec and 40 mg of Nexium. As this is the evidence out there, many doctors consider Nexium to be a "stronger" or "better" acid suppressor than Prilosec. I'll let the reader make the logical conclusions.
And let's talk about "typical" patients and the dearth of them in the evidence record. On an inpatient service today, I saw a "typical" patient hospitalized for a hypertensive emergency. He was a type 2 diabetic (DM)(uncontrolled) who came in with a blood pressure of 180s/120s. He has diastolic congestive heart failure (CHF) from his long-term uncontrolled hypertension (HTN). He also has chronic kidney disease probably due to a combination of his smoking, his DM, and his HTN. He also has an exacerbation of his bad chronic obstructive pulmonary disease (COPD) from his smoking. Now the evidence suggests that I place him on a beta-blocker to treat his HTN and his CHF concurrently. But beta-blockers are relatively contraindicated in acute exacerbations of COPD. The evidence suggests that I place him on an ACE inhibitor to treat his DM and HTN, but that would decrease his kidney function, and he's already at the tipping point of needing dialysis so
Light a fire for a man and he'll be warm for a day. Light a man on fire and he'll be warm for the rest of his life.
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Very dissatisfying to a lot of patients.
That'd be the ol' "1 in 10 000 patients having this surgery may get sympathetic blindness" rule.
Can't find a link but there was a case in 80s or 90s. Woman with a major vision disorder in one eye, everything OK in the other eye. Surgeon said he could fix the wonky eye. Woman's operation went according to plan but she lost vision in the eye that was being operated on and got sympathetic blindness in the other eye. Doc said 'sorry, that's a risk of this op'. Woman said "WTF?" and sued. Judge said 'WTF?'. Woman said 'if I knew there was a 1 in 10 000 risk of sympatheric blindness, I never would have had the op." Judge said "OK, you win, sort of." Doc said "Ulp". Insurers said "Damn". Docs associations said "There's your cut-off, people. 1 in 10 000. Now we shall flood you with information, lectures, pamphlets and decisions." Patients said "WTF..." And the cycle continues.
When they came for the communists, I said "He's next door. Take him away. Goddam commies."
anything that corrodes Medical Authority is something that it is COUNTER to their establishment to permit.
( and the AMA pours more into deforming gov't/law than ANY other organization ).
I found out that Doc+SW ( "Expert System" we used to call the things ) was significantly more accurate than either-one on their own, either in New Scientist, or in PhysOrg.com.
( and PhysOrg.com has such a .. ineffective .. search system, NOT anywhere near as horrible as the "search" system of ScienceDaily, which uses inclusive-OR instead of AND, but .. oh, yeah, and they also disappear all history that AP owns, as per AP's orders: It's a Good Thing that history won't be known to humanity without
a) already knowing it ( so they know what to petition AP for ), and
b) petitioning Associated Press for a copy of an already published story that AP ordered disappeared, and
c) paying the license-fees to read old news...
bah! maybe humanity DESERVES a Darwin Award for the connipted dishonest ExtortionFirst paradigm humanity enforces against humanity's own survival? )
Anyone who thinks the medical establishment is going to PERMIT objectivity to threaten/corrode Medical Authority, ignores history.
Period.
It would cause their establishment LOSS of control/revenue/influence.
It Won't Happen.
If anyone is interested:
http://www.nytimes.com/2009/03/02/health/02scans.html?hp=&pagewanted=print
Hey, they did the same thing over here at Craigslist. Kinda scary.
Why? Many experiments, if held with both a placebo group and a control group that takes nothing, have come back with showing improved results for the placebo group. Therefore, the evidence shows that placebos have a non-negligable beneficial effect.
We don't really understand how or why, but if you're basing your treatment on evidence rather than theory, is that understanding really necessary? For evidence-based medicine, IMO the only thing that should matter is the results.
I'm not a medical practictioner of any sort, so my attempt to make a point comes with a grain of salt, but hopefully we laymen can make decent philosophical arguments even if our knowledge of the specifics are lacking.
Maybe doctors just like doing Pap smears.
The problem is that the test/x-ray/biopsy not only carries risks in itself, but is wasteful of society's resources. What we need is a specific placebo tablet, with no active ingredient; just don't tell the patient!
Dont take this the wrong way, but I've seen similar things in computer consulting, and I have a few recommendations for you. Mind me, but Im not a MD, and only thought about being one for about 10 seconds after realizing that no MD training is done until after Bachelors...
---I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.
Same here. I tell the idiot user that porn sites using Internet Explorer will get you viruses. The question will then be "How many probems", not "If problems".
I then end back on site de-virusing the machines yet again. I even set up firefox for him, but back to the porn he goes.
---I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
---When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
If they're dead set on gravol, then why not offer up the advice that the active ingredient in Gravol is the same as seen in OTC motion sickness drugs. Come across as the caring doctor, and that you're trying to help them save money by not pushing prescriptions. Just say that you should follow all the advice and dosing instructions on the box.
From what I've seen, people dont usually care, unless they think they know better. Then they'll argue till they're blue in the face regardless what you say. Instead, imply agreement, but do the favor and offer a similar track.. and wouldnt you know, it's as good as a sugar pill.
---I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
Oval? Is that another homeopathy quack cure? I've never even hard of that one.
---People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
That's a hard one. My mom had severe back pain (history went back to 5 yrs old). She went to many doctors, all of them telling her it was either in her head, or nothing they could do. One did feel pity and put her on demerol, which made her retch (turns out, Im sensitive to it too).
Well, after years of back pain, was when the glucosamine chrondrotin cures were coming out. In fact, we heard it from our vet. My dad found a dosing chart that he believed reliable. After that, we tested it on our arthritic pug. She's no longer arthritic. Then, my mom went on it. Over the course of the next 2 weeks, she regained full motion and lost all the pain. And for about 3 days, she forgot to take it, and the back pain came back. After restarting it, the pain went away again.
I can also tell a story about my whole family, but mainly my dad. He hates doctors in general, but prefers to solve health issues for himself. You can blame the "preexisting conditions" rules for why. His BP and cholesterol was rather high. Well, he (and the rest of us) did research on Linus Paulings idea of Vitamin C and cholesterol... After reading his many papers, including his nobel thesis, we decided to take C, L-Lysine, and Proline. In terms of dosage, I personally take 8g of C each day.
After still not changing our eating habits, we have halved our cholesterol levels, brought our BP to "above normal" levels, and generally feel better. And we still dont know why
I guess we do, now.
The quote is from a very interesting article on the use of checklists in emergency rooms, how effective they are, and how much the medical culture resists them.
Your god may be dead, but mine aren't!
Well, you missed his point.
1) Modern employer paid health insurance came about because during WW-II the government froze the free market on labor and banned salary increases. As a compromise they allowed companies to increase their benefits, and health insurance went from something YOU paid out of your income to something THEY (your employer, your health insurance, etc.) paid.
Yes, the company effectively/indirectly gave you a raise by paying for something you normally would have paid for. But that was because the government stopped the labor free market by banning direct raises.
2) Unless you use an HSA plan (which are great BTW, wish my new employer had one), you don't get to choose what medical treatments you can receive. You are cut out (by your insurance company) of the supply/demand curve.
You don't get to choose how many times you see a doctor. You don't get to choose what procedures to pay for. (I once had a Dr. tell me that I would have 2 tests. Test A would tell use nothing helpful, but we'd do it anyhow because insurance would cover it. I couldn't say "no".)
You don't get to choose what treatment you get. The contract is between your doctor & the insurance company; you are just a 3rd party.
"Why Japan hates the iPhone", "Why doctors hate science".
What is with the generalisation and exaggeration of everything? Is kdawson trying to be inflammatory, or does he simple not know any better?
People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
Actually, I don't hate that. What I hate is when I get chronic, severe back pain at age 16 and I got to doctors for 11 years who try the same thing every time while rolling their eyes and insisting that no, this time it will work, you must just be imagining it, and you should just get over it anyway, because it doesn't show up on our tests so you're faking and fuck off.
And if you want drugs for it, you're an evil terrorist addict.
"Evidence-based medicine" would start with, "Wow, we really don't know what's going on with you, here's a research hospital you can go to." Heck, even without the research hospital would be a tremendous improvement.
Want to convince me that standard medicine is scientific? Get results! That's it! That's all you have to do!
Information theory is life. The rest is just the KL divergence.
Awesome. You're accidentally on-topic... Tom Coburn is a perfect example of a doctor who hates science.
The problem is that the market has come up with an awful solution to medical liability, which is pitting malpractice insurance against health insurance. Much of the cost of health care can be traced back to either. The other source of cost is that health care is sold as any other product on the free market, which is unfortunately very stupid. Deregulation of health care has led to the closure of hundreds of hospitals around the country, and pushed the costs out of the reach of much of the population. This is actually based on market principle, since the question moved from how much it costs to provide adequate health care, to how much people are willing to pay for it. Of course the upper sector of society is loving life with 3d pictures of their unborn child and access to obscure specialists at the drop of the hat, while the rest of the population struggles to pay for pills and basic care.
Now you have people dropping dead of overdoses and mixed prescriptions since the doctor is motivated to treat instead of heal, and billions of dollars are invested in figuring out how to sustain erections instead of preventing cancer. Hopefully the current economic situation will provide enough pressure to put an end to the ridiculous and unfounded belief that the market works for everything. Health care is no different than any other bit of infrastructure. You pay taxes and share risks for the benefit of the whole population.
While it may seem silly, the truth is that a woman can still develop dysplasia despite the lack of a cervix. The cervix is attached to the upper portion of the vagina, when a hysterectomy is performed it is possible that a portion of the cervix may be inadvertently left behind. Moreover, the transformation zone (the area on the cervix where most cancers develop) can extend onto the upper vagina in some women leaving them at risk despite a properly performed hysterectomy. Several times a year we will see a woman in our practice with dysplasia of her vaginal cuff picked up by one of these "silly-seeming" pap smears. If left untreated, these lesions could progress to cancer. The HPV virus which is responsible for cervical dysplasia and cancer is also highly implicated in vaginal and vulvar dysplasias and cancers. Now, admittedly, the development of a lesion in a woman who has had a hysterectomy is uncommon, but it does happen, and if you are the one it happens to..... If you are the doctor who decided that woman didn't need a pap - you are probably facing a lawsuit - despite all the evidence that in most situations the pap was not necessary. Evidence based medicine is great and I practice it whenever I can, but we all must realize that human physiology is highly variable and outcomes are based on likelihoods, odds ratios, and relative risk. Sometimes bad things happen to good people despite the evidence.
I guess I do sometimes prescribe and perform treatments that have little evidence behind them. The problem is that the placebo effect is not necessarily statistically significant. Is it worth taking the gravol to have one less barf over the course of the illness? Maybe...
It's hard for me to recommend anything that has potential to harm, unless I firmly believe that the benefits outweigh the harms. That's the crux of the issue for me.
Many people I see take a number of medications, prescription and non that I may not even know about. There are potential dangerous interactions there that I don't/can't/won't know about. Even non dangerous side effects can be problematic. There is also the fact that medications cost money. I don't want people to waste their money on a treatment that is no better than placebo.
I do prescribe things that are of nebulous benefit, when people are desperate to try something, or to cling to their experience that it works.
It's just not my style to prescribe unnecessarily (in my opinion). If you see me for your cold. I will tell you to rest, take some advil or tylenol, suggest a decongestant and give you a note for work if you need it. If you see my partner, you will get a prescription for cough syrup (most do nothing), painkillers and decongestants. He also has a very low threshold for prescribing antibiotics. The net result is that his patients are extremely satisfied and his visits are quicker. My patients leave somewhat disappointed, often come back (I'm STILL sick!!!) and I have to spend a lot more time educating my patients. The patient populations self select over time and the pill poppers go to him, and the pill averse come to me.
Stronger dose placebos cost more:
http://www.walgreens.com/library/finddrug/druginfo.jsp?pdid=1088&particularDrug=Cebocap
Cebocap #3 (a prescription placebo) costs more than Cebocap #1.
At first glance, I thought I saw an article referencing women's health... on Slashdot. First off, there are absolutely no women reading slashdot. Second off, At least half of slashdotters either do not or have not ever interacted with women, much less to the extent that the nature of the cervix is relevant to them. I might go so far as to say that no female has ever seen slashdot intentionally. Ever.
A primer:
"Study finds cure for cervical cancer" == irrelevant to slashdot
"Women's health problems caused by Micro$oft" == a valid slashdot article
And I am not going to bother RTFA, the example they gave was too non-slashdotty. This isn't digg... we don't have girls here. QED.
Well, for what it's worth, I think you should know that there are many out there (even if we're a minority) that are grateful for your approach to medicine. I tend to be a skeptic to many things, and medicine is one of them. I often get prescribed drugs I don't need, and I don't like to take drugs if it's not necessary. I wish more doctors would tell me "Honestly speaking, you're just gonna need to let your body get over it. It will take rest, and about a weeks time. In the mean time, you may be in serious pain. IF that happens, take these. If you can bear the pain, don't. If it starts to swell considerably, it may be something more serious, so come back. At this point in time, it's not possible to tell, but as long as you come back when it swells, it's not gonna make anything worse." More often than not it's just "OK, here's a week of medication, take it after each meal. NEXT!" And then I go home and lookup the medication and try and figure out if I should be on it, occasionally on it, or not on it at all.
I agree on the difficulty. What do you do when you know there's nothing to do but that the patient won't accept it and will shop around until they find someone pushing something?
The best for that deluded person might be to give them a real placebo (ie, not a prescription med you just think isn't going to be effective but a real "sugar pill" known to be safe) because nothing else they get will be any better, but it establishes a bad precedent.
I'm very against quack remedies. If I believed in one I'd want someone to point it out. I complain to pharmacies about selling homeopathic crap. But that's just it - the crap is everywhere, even places that sell "real" medicine. What's someone to do if they're clueless and don't know it? Especially as proponents of quack medicine are so vocal - and the remedies sound great because they're told there are never any side effects from anything natural. It's like they need to be de-programmed, like a cultist. Presented with the evidence and given time to think, then freed to make their own choice.
I'd like a doctor who would say no where reasonable, but explain themselves. Depending on who I end up with I can either get any test or med I want even if anatomically impossible, or end up with the silent inflexible type who may or may not have reasons for their decisions but are incapable of explaining them.
Can you fire a patient? When you get someone who demands placebo-antibiotics sit them down and explain why that is more likely to hurt them and more likely to hurt everyone. If they go off and get antibiotics or such elsewhere after this simply don't see them again. Perhaps you'd get patients you could really work with and do more good, have more fun...
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
That's easy to solve. Prescribe them a placebo.
there is no god but truth, and reality is its prophet
A compromise would be to require a written statement from a physician who wants to deviate from the standard. Don't forbid them from deviating, but make them clearly justify it. And add patient notification of deviation. Physicians who deviate too often get closer scrutiny.
Table-ized A.I.
Practicing medicine based on CEB doesn't seem
any different from doing Evidence-Based Medicine.
What good is there in changing the name to CEB?
EBM seems more likely to be acceptable to people,
ie, once they understand what it entails and how
it works.
Each sounds to me like Science having greater in-
put to the practice of medicine... not a bad idea!
Prescribing a placebo is a serious form of medical malpractice, even though a significant number of doctors routinely practice it. Perhaps our current perception of what is proper practice for a doctor needs to change... or perhaps not. But currently, you simply can't do that.
Prescribing a medication that will be ineffective, but DOES have side effects, is tantamount to "doing harm". The very antithesis at the basis of the modern medical profession.
Slashdot gets worse every day... Pipedot: News for nerds, without the corporate slant
The truth is doctors aren't geniuses. They sat next to you in high school. Some of them copied your answers on the math test. They are average everyday people that have been trained (hopefully well) to do a specific job.
MDs have a median IQ significantly higher than all other measured professions. That is to say, the average, everyday median MD IQ at ~125 is already halfway to official "genius" level.
The notion that "Doctors Hate Science" is absurd.
Da Blog
Therefore, the evidence shows that placebos have a non-negligable beneficial effect.
We don't really understand how or why,
Of course we know why. The mind has a significant effect on the body. There is enormous therapeutic value in going to see an authoritative person in a white coat, telling your story, getting looked at, getting some sympathy and TLC.
Which is why quacks like homeopaths, new-age herbalists and other kooks are so popular - they take the time to do all the above. On the other hand, real doctors & nurses are always being squeezed for time & money by the insurance companies and hospital management.
The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people — they are harder to corral.
Losing a job meant losing health-insurance, and switching employer often meant having to switch an insurer, along with the "network" of doctors. Why exactly the two completely unrelated things (job and health insurance) had to be bundled together by government regulation (employers were given a tax-credit for insuring the employees) remains unclear.
Last fall, however, during the elections, two alternatives were put forth. One of them, from Mr. Change, was the old and tried (elsewhere) "single-payer". He said, it is his top choice, but promised not to push for it, although health-related parts of the "stimulus" bill suggest the opposite.
The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.
The benefit would've been enormous, because the exelsior ("ever upwards" lat.) health care costs (and the associated evilness of health-insurers) are primarily explained by the fact, that consumers of care aren't the ones paying neither for the care itself, nor even for the insurance. This creates a lot of waste, and leads to — inefficient, but alienating — attempts to control it. Nobody is happy and we may end up with something worse (like government-provided health care), just because it will be different ("Change" is good, right?).
In closing I'd like to offer a real-life example... A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other). Here is the point, where different people would think different things:
As you could guess, my thoughts were 2 and 3. But you, likely, know quite a few people, who would think 1 — and, maybe, 2 as well, but angrily.
In Soviet Washington the swamp drains you.
Damn! Where do you practice? I would LOVE to have a doctor like you.
I guess I do sometimes prescribe and perform treatments that have little evidence behind them. The problem is that the placebo effect is not necessarily statistically significant. Is it worth taking the gravol to have one less barf over the course of the illness? Maybe...
It's hard for me to recommend anything that has potential to harm, unless I firmly believe that the benefits outweigh the harms. That's the crux of the issue for me.
Many people I see take a number of medications, prescription and non that I may not even know about. There are potential dangerous interactions there that I don't/can't/won't know about. Even non dangerous side effects can be problematic. There is also the fact that medications cost money. I don't want people to waste their money on a treatment that is no better than placebo.
I do prescribe things that are of nebulous benefit, when people are desperate to try something, or to cling to their experience that it works.
It's just not my style to prescribe unnecessarily (in my opinion). If you see me for your cold. I will tell you to rest, take some advil or tylenol, suggest a decongestant and give you a note for work if you need it. If you see my partner, you will get a prescription for cough syrup (most do nothing), painkillers and decongestants. He also has a very low threshold for prescribing antibiotics. The net result is that his patients are extremely satisfied and his visits are quicker. My patients leave somewhat disappointed, often come back (I'm STILL sick!!!) and I have to spend a lot more time educating my patients. The patient populations self select over time and the pill poppers go to him, and the pill averse come to me.
I think the placebo effect isn't worthwhile if there's any risk of a negative side effect from the placebo itself. I also worry that the side effects of many medications are rather poorly known.
You might enjoy reading In Defense of Food, which discusses many of the problems with the lack of evidence based nutritionism.
"I zero-index my hamsters" - Willtor (147206)
As one of the people that would MUCH prefer this style of practice:
Is there a good way to find Doctors that practice EBM, or will I have to call around and ask each one what their take is?
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
But perhaps his view is a little more long-term; the more often you prescribe a placebo, the more you you indoctrinate the patient into the way of thinking that "the doctor always has the answer and will always give me something to make it better", which may cause far more headaches down the road.
Sometimes it's better to educate people than to make them feel better.
Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...
I agree that the VA is underfunded relative to its size and patient population but, given its funding limitations, it's actually the best performing health system in the US when measured objectively in terms of patient outcomes.
Da Blog
I had one young doctor think I should have my moles checked out that "looked cancerous" and another doctor whom I'm also freinds with that tells me "that doctor is full of shit".
They get a lot of slagging, especially from other doctors, but this is a classic example of why dermatologists exist. They are not just for botox! The sad truth is that there are literally *hundreds* of disease processes that can manifest on the skin, but they manifest in only surprisingly small set of symptoms... many of which look very similar, if not alike. That is why pretty much every generalist or non-dermatologist would prefer to refer a patient with any kind of non-obvious skin lesion to a dermatologist. If it's something rare, you might never have seen it before, or you might have seen it once. But it's a safe bet that the derm person has seen it a few hundred times, along with thousands of similar-but-different lesions, and will have a much better chance of diagnosing it by rejecting false positives and ruling out false negatives.
Da Blog
I had a hysterectomy. Do I still need Pap tests?
It depends on the type of hysterectomy (surgery to remove the uterus) you had and your health history. Women who have had a hysterectomy should talk with their doctor about whether they need routine Pap tests.
Usually during a hysterectomy, the cervix is removed with the uterus. This is called a total hysterectomy. Women who have had a total hysterectomy for reasons other than cancer may not need regular Pap tests. Women who have had a total hysterectomy because of abnormal cells or cancer should be tested yearly for vaginal cancer until they have three normal test results. Women who have had only their uterus removed but still have a cervix need regular Pap tests. Even women who have had hysterectomies should see their doctors yearly for pelvic exams.
There are plenty of examples of doctors and hospitals choosing what's habitual, convenient, or more profitable than using good science (don't even get me started on c-section-happy obstetricians and hospitals) , but this PAP thing isn't as black and white as the article makes it out to be.
There's a quick way to tell if someone has actually managed to motivate themselves enough to click, and that's if they epically fail to check a link to see the original source:
Figure 12 of Hauser, Robert M. 2002. "Meritocracy, cognitive ability, and the sources of occupational success." CDE Working Paper 98-07 (rev). Center for Demography and Ecology, The University of Wisconsin-Madison, Madison, Wisconsin. The figure is labelled "Wisconsin Men's Henmon-Nelson IQ Distributions for 1992-94 Occupation Groups with 30 Cases or More" and is found at http://www.ssc.wisc.edu/cde/cdewp/98-07.pdf
Why do you hate social science?
Da Blog
In the future, please remove penis from your mouth before posting.
The great thing about controlling doctor recommendations: it brings up minimum standards, which kill a lot of people every year.
The terrible thing: it brings down maximum standards, which saves a lot of people every year.
It also makes it harder for really good doctors to do things they know work if the studies don't show conclusively that it works. Studies of D2 lymphadenectomies for gastric cancer, for example, showed that they weren't helpful enough to justify the added mortality rate of the more complicated surgery. But if you have a good surgeon operating, the mortality rate is 0%.
But once I know that the pill my doctor is giving me might be a placebo, I lose the benefit of the placebo effect.
I was referring specifically to acute (new onset) back pain. I'm not advocating never investigating back pain.
I think that medicine and physiology is still in its infancy relatively speaking. When I get someone in your situation, I tell them that the tests look normal. That it's good news because it rules out a lot of bad things, but it still doesn't explain the problem. There is a vast range of human experience that we just don't understand or have a good solution for.
That type of thought lets homeopaths, chiropractors, and other quacks thrive. This has negative consequences:
- placebo effects wear off quickly; the patient will have to continuously seek new treatments
- the placebo treatments are seen by some to be on the same level, or greater (due to lack of side effects / cost) than legitimate treatments, the results of which are never good
- it generally helps to encourage the populous to be stupid and think magically
Yes, but maybe that is not "over-investigating". Maybe that is deliberately trying to make more money by being dishonest.
Fortunately, I've had relatively limited interactions with doctors, but the ones I have had left me somewhat surprised; perhaps I had had too idealistic view of scientific advances in medicine. Even things that seem like they're narrowly defined seem not to have much data around. For example, I got totally random suggestions from dermatologists about moles being removed vs. not vs. who knows. Obviously nobody wants to say "you shouldn't remove that mole" only to be sued when it turns cancerous. But it seems like a well-defined enough thing that there would be lookup tables giving cancer likelihood. Or something better than squinting and "eh, I don't really like the look of that one".
Heck, I bet if you collected enough photographs of moles, some basic demographic data on the people the photographs came from, and cancer vs. no-cancer labels, a computer could produce decent diagnoses.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
You are a flaming moron (with a +4 Interesting at this point).
Should we have doctors prescribe placebos with fancy names and high price tags just because people will be sure that they saw a difference? A placebo is, by definition, nothing, and any improvement seen while taking it (or any "alternative medicine" for that matter) was either imagined by the patient or would have happened if they did nothing!
When I've had friends and relatives in the hospital in the last decade or so, we have always had to bend over backwards to ensure that hospital staff did their jobs for our loved one. I mean, every single time they were supposed to get a dose of medicine at some particular time, we had to chase down a nurse. We have to make sure they actually dispense the correct drug. And the correct amount.
It's all part of a culture of incompetence that has sprung up in the American medical establishment, coinciding with massive increases in costs. Personally, I think the insurance companies have created a vicious cycle of "you scratch my back I'll scratch yours" with doctors, where both parties benefit from less work and more money being extracted from us. In this environment, there is no need to do your job well. It's as anti-competitive as Soviet Russia.
I don't know if it was intentional--but it's got to go. The private sector has failed failed failed, and I say that as someone who would like to be a Libertarian.
expandfairuse.org
There's levels of generalization between "treat all men over 75 as an identical class" and "every person must be treated as a unique individual". You could, for example, segregate outcomes by a few major factors, like reported levels of exercise, weight, smoking vs. not, amount of alcohol consumption, etc.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work.
Would it not make sense to try it once--assuming that it is not a risky experiment? I mean, is there evidence that it doesn not work for your baby?
Not a doctor, or a father. Don't know what Oval is...but I *do* know what cranky is.
I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
How do you diagnose the difference between a sinus infection and a cold on the first several visits? I had a sinus infection that probably would have responded to antibiotics, but the doctors I saw didn't give them because the symptoms looked like a cold - even after I kept coming back for months. When I was finally referred to an ENT who did a CT scan to diagnose it, it was bad enough to require 2 surgeries and months of heavy-duty antibiotics to clear up. Do you follow up with all those patients that you refuse antibiotics for to see that they did not continue to get worse or just take it on faith that you did the right thing. (I ask because no one every followed up with me and the initial doctors probably still think they did the right thing).
If doctors are upset by this and believe that their medicine works better, then they ought to use the circularity of the concept of "empirically supported treatment" to their benefit. In other words, if it is in fact the case that some other system of treatment works better than the "empirically supported treatment", then it should be able to be shown-- empirically-- and thus BECOME the empirically supported treatment.
----
"Those who quote others are more likely to one day be quoted" -Tom Planter
"It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Gods would I love it if any doctor I ever had did that!
It should really be the first question on the forms you fill out when signing up with a new doctor - "Would you like: a) Bullshit Feelgoodery or b) Rational explanation of available evidence (ie you are a grown-up who accepts that the world is not a perfect place)?" Seems like it would make life much easier for everybody.
sic transit gloria mundi
My father is a doctor-- a radiologist. He is definitely good at medicine, and chemistry, and a lot of the science related to his job.
We talked about the tedium of work (comparing engineering to medicine). He all but told me that 99% of the time it is reflex. And the remaining 1% of the time is actually interesting.
It kind of put it in perspective: Some doctors handle many cases a day, over decades of work, and the problems are fairly routine. I bet it would be difficult not to develop some sort of internal automation to handle the boredom.
Hell, I get bored working on the same system for more than a year. I can't imagine working on the same system (human) for my entire career.
Essentially what you are suggesting that physicians do is let their patients believe that sugar pills mixed with water work to cure disease X; or, at least, fail to re-educate patients with such notions.
It's a medical custom that makes money for doctors.
Comparative-effectiveness research doesn't have much to do with that scenario. Instead, the purpose of this bill is to fund research into, well, comparative effectiveness of treatments. Say you have some particular condition, and there are three possible treatments in reasonably common use. Which one should your doctor prefer? Is there any scientific reason to think one of them is the better treatment to try, or at least to try first? That's what CER aims to tell you.
The current, relatively poor, practice is that doctors get bombarded with information from pharmaceutical companies about how their patented drug is the treatment to prefer, which they can cite various studies backing up, which you probably don't have time to track down. A center for CER would, hopefully, track them down and summarize the results for you.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
I wish you were my doctor.
Thanks for your comments, I'm on my second Cardiologist, not that I was not satisfied with my first one; well actually, he probably saved my life when I drove into Er with chest pains. As a patient I can tell you it's all very confusing. Prescriptions, and symptoms etc.
I've worked in a large Med Center so I have a feel for the overwhelming information you have coming at you. I'm in the IT field (until I got laid off). But I still have the utmost respect for you. Cheers!
Get up!
At least those women, who do not have a cervix, can proudly proclaim that they do not have cervical cancer.
See, that's what early detection and repeated testing can get you!
Now if you'll excuse me, I'm off to get my own pap test.
-David
-David
I mispelled it. It's actually Ovol.
Sadly, physicians are often faced with the dilemma of choosing diagnostics and/or treatments based not on what would be best for the patient, but what can be billed with the least amount of overhead. I am not suggesting that frivolous procedures are performed, but merely that in order to perform a necessary test often times it must be done surreptitiously under the guise of another seemingly unnecessary test. Can we lay off a few bean counters and let the physicians do their jobs more efficiently?
Most of your post makes good sense (although simplistic, I'd guess) until
Try to check if you actually know something before opening mouth. Or did you think that the Slashdot crowd wouldn't understand the word "inflammation" and went for the car analogy: "lubrication"?
You are correct that corticosteroids do not directly aid the healing of the damage, but they are not helping because of their lubricating effect. They modulate the immune response, which is how they relieve the pain and inflammation. The "truth" here is probably more complicated than what we know about it. (Yes, I realize the linked research deals with muscles and not bone or connective tissue, it's just illustrative.)
An inflammatory and misleading headline from kdawson! What may be new is that it doesn't involve Microsoft.
First, I would like to applaud you. Very, very few doctors do what you do, and every one of them should - and for the sake of our health and the survival of health care must - do. Especially a proper differential. I suffered with an unusual illness for several years because my primary didn't do anything but rule out the common causes of my symptoms and then tell me to go home, because it must be 'stress'. Thank you, Sir; because of doctors like you, health care is cheaper, and others won't have to suffer like I did.
I can only offer one suggestion, which you have probably already thought of; have you considered prescribing placebo drugs and even (if it's possible) tests? It might solve the problems you're seeing in EBM's actual implementation.
A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other).
We had similar with our first baby. Its a common problem and many things may help. Did your doctor suggest anything else in addition to drugs? Antacids are cheap and over-the-counter, so the doc probably prescribed a PPI (proton pump inhibitor). The only reason it cost us a bit, was paying the pharmacy to make a suspension. The cost for the tablets was negligible, as they just ground up three adult tablets to make enough suspension to last the baby a month.
Better give them some vitamin or sugar pills. You get the placebo effect, do no harm and it's cheaper.
thegodmovie.com - watch it
Sensationalist headline: check!!
Posted by kdawson: check!!
Sounds like business as usual.
Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
No.
They use placebos in trials because in order for the control group to be valid, all factors have to be the same except that one factor being tested, including the belief that they're taking a medication.
A placebo is given in trials to *negate* the placebo effect on the trial. They are testing the difference *between* what might simply be a placebo effect and actual medicinal usage.
Have you considered that, although it's no better than placebo, it might be better than nothing?
Ecxpet that you can't just prescribe a sugar pill outside clinical trials because the patient will know, totally negating the placebo. Since, in that case, you needto use *real* medicine, there is a risk of problems *resulting* from taking the unneeded drugs, not to mention masking other real conditions, etc.
In short, your solution is foolhardy, short-sided, and quite possibly dangerous and your reasoning is flawed and unfounded not to mention uninformed of the actual reasons for decisions in clinical trials and use of the scientific method.
"goodbye and hello, as always" ~Prince Corwin, from Zelazny's Amber series
Yes, we all know that (arguably) most docs don't keep up with the literature. Or they choose a treatment and stick with that because it worked the best at one point and they like it because they trust it. Problem is, that research is ongoing and new things are found all the time. In fact, on one of my clicking adventures on-line, I found out that Lithium Carbonate was being used to treat refractory depression (as an adjunct), OCD, cluster headaches and even ALS (the one that Stephen Hawkins has) to name a few. All that in *low* doses. Yet, most docs still consider this a horrid drug refusing to realise that in low doses Lithium Carbonate does _not_ require close monitoring.
So, this sort of study could be very beneficial.
HOWEVER, it's things like this that HMO's really *really* like. They'll probably use it to force doctors into treatments that are cheaper alternatives regardless of that particular patient. Because, as with many things, certain disorders, etc, have different drugs to treat them. Different drugs for different sets of symptoms, different severity of symptoms, etc, etc, etc. So, patients will likely get cheated out of drugs that would be more effective for them simply because there HMO won't pay for the one that is best for them and the one that is best for them isn't in there price range. Especially, for the more complicated disorders.
And what happens when next week happens and this changes. How often is this list going to be updated? How often are the HMO's going to be updating from the research?
Quite frankly, while I fully believe that this thing is undertaken with the best of intentions, it is ripe for abuse. In the end, it is my opinion, that it'll likely lead to more harm than good.
While the points are relevant for women undergoing pap smear who don't have a cervix/uterus, the second part of the smear procedure is to collect cell samples from the vaginal wall to screen for vaginal cancer. There are still women at elevated risks of vaginal cancer, due to their mothers using DES, having a HPV (papilloma virus - aka "venereal warts"), and if the bimanual exam does not reveal any palpable mass, a microscopic vaginal wall smear (normal part of a pap smear collection) can be a worthwhile screening. Is it cost effective in the scenario of no cervix? Depends if you are one of the women with vaginal cancer detected or not. http://www.cancer.gov/cancertopics/pdq/treatment/vaginal/patient/
HMOs and federally mandated employer-based healthcare was proposed and signed into law by President Nixon. In fact, there is an infamous tape of Nixon and his adviser discussing the plan as proposed by Edgar Kaiser of Kaiser Permanente where they blatantly talked about how the emphasis would be on profit (for the HMO) and "providing less care."
What we have today wasn't the result of some master-plan hatched in a secret lair in the lower recesses of an evil University by bleeding heart liberals or whatever you've been told. No, our entire employer based healthcare system is the result of special interest pork legislation written by the industry and pushed upon the public by a Republican administration. It's the DMCA of 1971.
With regard to your child's heartburn, you need to start asserting yourself as a patient and parent. Take an active role in your child's health and specifically ASK your doctor for generic prescriptions. I'm going to go out on a limb and guess that your doctor prescribed Nexium or some other namebrand Proton Pump Inhibitor. The generic, Omeprazole, is available Over-The-Counter, costs a fraction of the price, and works virtually identically. Call your doctor and ask him or her if this is appropriate for your daughter. No doctor I've ever met would mind a call such as this. In fact, I think most would welcome it. Fifteen seconds of his or her time for one potentially satisfied, engaged patient is what you call a clinical no-brainer.
-Grym
As Paul Krugman said it, with the economy in this kind of state, you have to pay people to dig holes and fill them back up. If something good can be done instead of something useless, that's just a bonuns.
I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
You don't actually have three heads do you? Because maybe there's an alternative reason for the staring...
Hippocratic Oath.
Money
Michael Jackson
I've calculated my velocity with such exquisite precision that I have no idea where I am.
I'm surprised you choose not give people little bottles of sugary water: As I see it, there is not point in wasting the healing benefits of the placebo effect when that's all you have.
Wow, the parent post validates your comments 100%. I don't think he realized it.
I can honestly say that I actually moved over 100 miles so that my child would have a doctor that behaves as you describe. I have yet to find a doctor for myself and wife that I can feel is being 100% honest with me. I wish I could find a doctor for myself that behaves like my son's pediatrician. Give me 'what the studies show', give me what his personal experience has been, then ask me what I want to do, and accept my answer, even if it conflicts with both the 'studies' and his own opinion. Once I can trust the doctor, I am far more likely to take his advice.
You are reaching the point that every nerd will reach in his life. It's the realization that people prefer lies to the truth in almost any social situation.
I suggest that you prescribe them innocuous placebo's from a big jar saying 'PLACEBO - DOES NOT DO ANYTHING', with a friendly smile and say this has been shown to not work by those scientists.
People try to prove them wrong and will love you for the lack of adverse side-effects.
Absolutely not. When it comes to your own health, the buck stops with YOU, the patient.
Inappropriately prescribing antibiotics for education is no better than inappropriately prescribing for treatment. The bacteria certainly don't care why the prescription was made. Adverse side-effects are still a risk either way.
If a doctor doesn't protect his Professional Integrity, he becomes no better than a glorified snakeoil salesman. Telling patients only what they want to hear or prescribing inappropriate tests or prescriptions may make patients (temporarily) happier but it doesn't help them, and it certainly isn't ethical.
P.S. You have a lot of anger. Can you show us on the doll where the bad doctor touched you?
If we'd begun using only proven medical treatments a hundred years ago we'd have saved billions. That's dollars, not lives, of course ...
A few facts first:
1) Pap smears still make sense in women after a hysterectomy. It is then called a vaginal vault smear. It is meaningful at the very least in women who had abnormal smears prior to hysterectomy, because abnormal cells can have spread to the surrounding vaginal wall
2) Some surgeons leave a stump of the cervix behind when they perform a subtotal hysterectomy. Not common practice any more, but used to be very common in many countries and can have some advantages for the stability of the pelvic floor. Not all women who had a hysterectomy know whether they still have a cervix stump or not.
3) When the hysterectomy was performed for malignancy, eg cancer of the uterus, the vaginal vault smear can be useful to detect early recurrence
Hence. some women may not need pap smears after a total hysterectomy - but in many women this is still a meaningful and cost effective procedure - which is why even public health systems are still happy to pay for them.
The article does not seem to take this properly into account - because most scientists have only a very limited insight into medical problems. I should know - I did a science degree first before becoming a MD.
The other day, my new thai girlfriend was tested for testicular cancer!
And I think the doc *knew* he was being ridiculous, because he kept grinning at me.
I mean, yeah, she has larger hands than most women. And a prominent Adam's apple...
Oh no.
As good as EBM is, there's a surprising list of interventions that have never been proven - and never will, because they came in before evidence-based medicine...
eg. there is no evidence that epinephrine is of benefit in cardiac arrest. (and by the way, no evidence vasopressin is any better except flimsy evidence in a small subgroup - worth mentioning since this forum is so US centric - I can't help wondering if you use vasopressin because it's better marketed because it's more expensive...)
That having been said, I think I'll keep using epinephrine. Insisting on EBM in *every* case suggests either a zealot or non-clinician is pushing the agenda.
The OP is nothing more than a ReThuglican Jew shill.
It's better if you can get them to build roads.
But it's better to pay them to dig hole and fill them up THAN doing nothing.
They exist: sugar pills.
Actually, while I _am_ for socialized healthcare for other reasons (cue the flame wars), when it comes to the actual topic of TFA, namely incompetent doctors, I can assure you first hand that socialized healthcare doesn't solve that at all. Here in Germany plenty of doctors still prescribe the wrong things, do the wrong tests, or make judgment calls like "he's probably just imagining it, let's give him a homeopathic placebo"... for something that later turns out to be a real disease when actual tests are performed.
Let's put it like this: according to one study, about 3 out of 4 programmers can't actually program, and according to another one about 2 in 3 don't really know the language they're paid to program in. (Or not above the knowing the basic syntax level.) What makes you think it's any different for doctors?
And the insurer, one way or the other, can't know the expected benefit for _your_ case. Only the doctor knows if it looks like disease X or disease Y. If the doctor says it's a bad hip, and you need tests and procedures X, Y, and Z, even if they would be the best ones for that hip case, they won't do jack shit if the real source of the pain are for example the kidneys. Or if like in the summary, the doctor says you need a PAP test, the insurance doesn't know that you don't actually have a cervix, and isn't qualified to really understand such things in the first place. The best thing the insurer can do is trust the doctor there anyway, because he just isn't qualified to say otherwise.
And socialized healthcare, for all it's good parts, has also created the following problems down here:
1. There are doctors prescribing very expensive, and sometimes dangerous tests, because they need the money to pay for those machines and the insurance pays anyway. Now if it just meant taking a couple of millilitres of blood and running it through the machine that goes "bing", that's just a waste of money, but won't kill you. But you can be sent to get an X-Ray for example, when you don't actually need one, and that carries a tiny risk of getting cancer.
2. There are a lot of placebo treatments and remedies prescribed, mostly because the insurance can't (for one reason or the other) say that it won't pay for that.
E.g., at the doctor I used to go to, she had posters on the walls for such things as "natural pulsing magnetic field therapy". As far as I understand, they put a wide coil around you and hook it to a very low frequency AC power supply. Exactly what's natural about a coil and a PSU with lots of transistors, or where the f-word would you find such a pulsing magnetic field in nature, is still baffling me.
E.g., one of the treatments she offers is basically this: they take a pint of your blood, expose it to UV-B, then inject it right back. It's supposed to be some naturist "optical activation" or such. The problem is that it doesn't do jack squat for your blood, except kill a bunch of cells there and maybe give nasty mutations to the survivors. But at any rate UV-B _kills_. It's used to kill germs in water, for example. So they just killed a bunch of your healthy blood cells, and injected the result back, with the only effect being that the liver will now have to metabolize the resulting bilirubin. And exactly how is that natural, anyway?
E.g., another poster on her walls is for holistic natural homeopathic plant extracts for various ailments ranging from being tired, to shock. Now shock is a very nasty, life-threatening emergency. Even if you survive it, the body cuts off blood supply to muscles and inner organs to try to keep the brain alive as long as possible. Basically the rest of the body starts dying pretty fast, and it costs years of your life. Prescribing some naturist placebo there, or even helping spread the idea that one could just take a few drops of a placebo in a life-threatening emergency, is _criminal_ in my book. Or should be.
Now she certainly hasn't prescribed any of that to me, so I'm willing to give her the benefit of the doubt. It's probably th
A polar bear is a cartesian bear after a coordinate transform.
...the real problem. Doctors won't use the best course of treatment as long as they are encouraged by big pharma and HMOs to do otherwise
my mom has copd, which is one of the biggest killers of u.s. citizens.
health declined steadily over past five years until i got involved - im a web designer, not a doctor.
within three months of MY care she breathes, better, has more energy, and has more hope than ive seen her have in years - what did I do? Took her off two drugs (the steroids she was on i wouldnt wish on my worst enemy) bought her a good air purifier, and adjusted her diet.
You might think, well if she was eating bad, thats her fault - you'd be right except none of her doctors stressed that diet was even important.
If its not a pill or surgery, u.s. doctors havent heard of it, and dont recommend it - its way past sad - it is infuriating
You are provided with access to a doctor in order to protect you from contracting something contagious and being both unable to work (and pay the government) AND pass this malaise on to others, multiplying your illness's effects.
I've experienced both systems first-hand -- I'm an American living in Britain. Government-provided health care is FAR superior to what I received in the USA. Easier to get, cheaper, and of equivalent quality. No comparison.
I piss off bigots.
I had a specialist prescribe me Paxil and I wanted to go off it - it was making me gain weight (40+ lbs and I run and swim!). To make a long story short, I had horrible withdrawal symptoms. The "specialist" said that doesn't happen. On his recommendation, I went to my internist to be tested for MS. She did and found nothing. She then said it was the Paxil. She sees it all the time! WTF?! It was like that with every SSRI I was on: I always got the very rare side effects.
And another thing, come to find out, my exercise was just as effective as the meds. I didn't need them. And I read more and more studies that come out the old and generically available ant-depressants are just as effective and in some cases more effective than the new ones that have come out over the last decade.
I'm now on a yoga, weights, running, swimming, sex with wife anti-depressant plan that working much better and is much much cheaper.
And yeah, tons of stuff are ototoxic (ears are seriously about the most fragile organ you can think of imho, it's as though they're really just a weak patch over touch :p )
Then there was the case of the "effectiveness" screen that denied coverage for a woman whose doctor was billing for a prostate ultrasound. Obviously unnecessary, right? WRONG. Transsexual. Still had her prostate intact from her former days as a male, still needed the prostate checked periodically.
Ok, so a someone who wants government funding says to ignore critics of the government... sounds like we should listen to her...
I had an unfortunate incident of that. I came in with depression/anxiety, and my doctor put me on Paxil. Not because it was the best choice, but because it was the NEWEST one, and the lovely dinner the pharamceutical company paid for had these nice salesmen who told all the doctors how safe and effective with it.
After one night on it, I stopped it and made another appointment with the doctor. To say I had a bad reaction would be an understatement. I'd describe it as extreme anxiety with hot sweats and other wonderful symptoms. Cut to a few years later, I start reading in the news about "unreported" side-effects of Paxil and the drug maker being forced to issue updated clinical notes. Now the warnings list all these things.
The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.
All of the marketing and nice dinners by the Paxil salesmen aside, reading this makes me wonder just exactly what the FDA did to approve this drug? One would think that SOME of the testing they would do would have revealed some of these side effects prior to it hitting the market.
Of course, with billions at stake, there's just no chance that pharm-grade palm grease wasn't applied between parties to gain approval, right? Riiiiight...Yeah, funny how things go "unreported" until absolutely necessary...
I want to throw in my support and agreement with the way you practice medicine.
I'd much rather live in a society where ALL of the facts are on the table, even if it means some people take it the wrong way. This includes the facts of "We simply don't know. Some people think this, other people think this. The margin of error is so high that it really could go either way. So the answer is maybe, maybe not."
People HATE that.
It makes them feel like there's nothing tangible to hold onto and they're floating around in the unknown. So they cling onto the best guess. If a study has a 50% margin of error, many people take the results in the same way as a study with a 1% margin of error.
This is why politicians, doctors, computer technicians, etc, have learned to give only half of the story when recommending something. It's quick, and the person would probably come to the same decision if they had all the facts. But it leads to misinformation. And when 'exceptions' come into play, the person given the one-sided information has no tools to make an informed decision.
a jury agreed--despite the lack of evidence
Why lawyers hate science?
You can't take the sky from me...
No, anecdote implies that the information is second-hand, can not be verified, and is therefore unreliable.
Actual scientific data is first-hand and verifiable.
No, it does not imply that.
An anecdote is a short tale narrating an interesting or amusing biographical incident. It may be as brief as the setting and provocation of a bon mot. An anecdote is always based on real life, an incident involving actual persons, whether famous or not, in real places.
People may embellish anecdotes, and they may falsify data, but it is not implied that all data is falsified and all anecdotes are embellished.
You can't take the sky from me...
Would you have trouble prescribing a placebo if you told the patient what it was? If I recall correctly, at least one study showed benefit from taking a placebo even when it was carefully explained that there were no active ingredients in the pills.
For more information, check out a pair of radio programmes called 'Placebo' by Dr Ben Goldacre. (They were on BBC Radio 4 last year.) In fact, I'm surprised no-one's mentioned him before; his blog (Bad Science), occasional radio programmes and other media appearances are an inspiration to anyone interested in evidence-based medicine or the media's blatant misrepresentation of science in general.
Ceterum censeo subscriptionem esse delendam.
The rule of thumb is: If you are African-American or you have a family history of some prostate cancer, you should get the PSA test starting at age 40. Else start testing at 50.
Said as one who just had treatment for prostate cancer. The treatment (www.rcog.com) was chosen from about 8 possibilities because the treatment was evidence based/proven and the Dr could tell me based on my PSA (blood test) and Gleeson (results of Biopsy) scores the statistical probability of my total cure measured 10 years from now with a .2 PSA as the measure of the cure rate. I wanted a cure, not someone who would treat me, did few treatments and didn't adjust his treatments based on the statistics of his success/failures with patients. I will be followed up every 6 months until I die as my results go into the 12k person data base the practice keeps.
Using the same treatment, early detection can change the cure rate from as high as over 97% to below 40%.
GET TESTED
(They do not know why AA men get cancer earlier and get a more aggressive form, just that they do and it needs to be caught earlier to have the same chance of successful treatment.)
My wife had a hysterectomy in 2002 for recurrent problems. She continued to get PAPs done on a yearly basis. In 2006 she came up positive for cancer, and it was classified as cervical because of the location and the likelyhood it was caused by cells missed during the hysterectomy. So no cervix, yes cancer.
All very good, except that medical science isn't up to the task of providing reliable diagnostic and treatment guidelines. We can see this because this is the kind of efficiency program the insurance companies try to impose.
For example, a family acquaintance has a fifth grader who is unusually athletic and physically mature for his age. He swims competitively and practices every day. If you look at him, he is obviously very lean and muscular, but because of his body mass index the insurance company insists he and his pediatrician implement a weight management plan.
Of course it is not beyond the capabilities of science to distinguish between lean body mass and fat. It's just extremely difficult for a committee to take scientific literature and come up with comprehensive, iron-clad guidelines for treatment. And that's what physicians need. When they have a patient, they need guidelines that are right for this patient, not 80% of patients or even 95% of patients.
I think a better approach would be to institute some kind of scientific peer review of treatment decisions between physicians. But of course health care is so damned expensive it has a hard time accommodating new mandates, even if they are good for long term cost control
Post may contain irony: discontinue use if experiencing mood swings, nausea or elevated blood pressure.
The fact that the medical system has struggled to implement evidence (ie, science) based medicine over the past 20 years is not evidence that physicians hate science. Its evidence that the science is poor, the process is hard and there are tremendous incentives against it. Its just damn difficult.
Think physicians hate "science"? Try explaining to a patient why they should take the drug that is 10% less effective than the competitor but half the price. Or explain why the diagnostic procedure that saved their best friends life is unlikely to find anything in their case, wouldn't hurt them -- but is "worthless" from a cost efficacy perspective. We all struggle with cost efficacy - no one wants to get something less than the best, patients even less than physicians.
Besides which, "doctor" means teacher, not medical practitioner. So exactly why does this journalist think that teachers hate science? And how does citing a Senator help? Yes, Coburn is a physician (albeit an obstetrician which is one of the fields that has struggled the most to integrate hard science appropriately due to the overwhelming malpractice issues), but Coburn doesn't believe in science in the first place - famously calling global warming a "bunch of crap."
Garbage.
+--------------------- You idiot! I told you we were facing the wrong way!
is that chronic condition obesity, cancer, or cirrhosis of the liver?
To take an example from my own extended family, let's say type 1 diabetes.
Was it Genetic or was it generally caused by you own choices?
Doctors still aren't sure. The going hypothesis implicates one or more of a gene, a virus, and failure to breastfeed.
And I'm talking evidence from peer reviewed studies of success rates and complications rates over thousands of patients. Early detection can result is very high cure rates, and late detection very low.
Biopsy is certainly something that you want someone well practiced in the art performing. But once you have had a repeatedly elevated PSA or a rapidly changing for the worse PSA, to not get a Biopsy invites what can be a painful demise.
Prostate cancer isn't just one kind of cancer, doesn't just affect the prostate and doesn't grow slowly in all men. There are types that originate in the prostate but then can spread outside the prostate capsule through the body and, when finally detected in late stages due to some complaint other than a urinary one, can have affected the bones or other organs. At this stage, surgery or radiation can do little for the man. Yes, there are people who are old enough or ill enough that something else will get them before the prostate cancer. But dying of an aggressive prostate cancer that has gone undetected and spread is a painful way to go.
I was treated with a lot of people of varying ages, some with young kids, some in their 80s. Truck drivers and physicians, IT workers and farmers. From all over the world. 16% of men will get it.
My prostate rectal exam always came back: smooth and normal. Only the Biopsy detected it and, by the time I had the Biopsy, my cancer was in several sites within the prostate. The Biopsey results in a Gleeson score which is a measure of the aggressiveness of the cancer.
(www.rcog.com is a good reference site)
We spend TWICE what England and Canada do per capita on health care.
And as a Canadian, I would *love* to see the US come up with a nationalized health plan. Why? Because there are *tons* of doctors here who get out of med school and skip the border to make bigger paychecks. This more-or-less totally screws our own health-care system as the US get-rich-quick system leaves our own understaffed.
Not that I really want to have a doctor who's in it solely for getting rich, but it seems to me that if both countries had equalized healthcare then the only ones going through med school would be the ones that want to become part of a healthcare system (and make a decent living, but not make themselves filthy rich).
The days when an MD was a royal road to riches are long over. Medical care is not getting cheaper, but most of the money is now going to the insurance companies rather than the doctors. It is still a well-paid profession, on the average, but keep in mind that doctors start making real money fairly late in their careers, often with perhaps a quarter million dollars in debt from educational and other expenses.
On the positive side, my experience with medical students suggests that now that an MD is no longer a guarantee of wealth, the medical profession is once again actually attracting people who feel a genuine calling to relieve suffering and heal the sick.
Especially considering the sedative effects of Gravol. (Even though I prefer pure diphenydramine)
EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.
In theory, practice and theory are the same. In practice, it's different.
how long until
The basis of this article is patently absurd: taking a 'dictionary-like' definition of 'cervical cancer and applying it to the issue as the article does is a grotesque misapplication of science, of logic, and of medical knowledge. Get this: 'cervical cancer' refers to cancer that BEGINS IN THE CERVIX!!!! get it?? Many patients who have HAD cervical cancer and have been appropriately treated by a cervectomy STILL can experience cervical cancer!! The operation might not have removed all the cancerous tissue! These people, in the judgement of their doctor(s) deserve to have their lives protected by continued PAP smears. The article is garbage, on its face! j. anderson, md (ret.) tkjtkj@gmail.com
"There are 11 kinds of people: those who know binary, those who don't, and those who could not care less!"
http://pandasthumb.org/archives/2007/03/egnorance-combo-arrogance.html
That particular criticism is well worth reading. I'm not sure that his dietary recommendations are on the mark: clearly there have been many healthy diets pursued by many different cultures. It is equally clear that the "Western" diet (as he labels it) is quite unhealthy. Beyond that, his conclusions as to specific diet are debatable.
The companion book should be Good Calories, Bad Calories, with an eye to the merits of each book, and a healthy dose of skepticism.
Those who advocate genocide deserve every protection afforded by law, and none afforded by common human decency.
There are some types of injuries to the back that an X-ray will not show.
That's true but that does not change the fact that the xray (properly called a radiograph or roentgenograph by the way) is likely the correct thing to try first. A xray is a screening test in this case. It's relatively cheap and the strengths and weaknesses are well understood and quantified. If it discovers the problem there is no reason to do a much more expensive MRI. If the doctor has reason to suspect from clinical indications that the xray wouldn't show anything he certainly can go straight to the MRI when appropriate.
Screening tests are standard and appropriate practice for a a huge variety of conditions. Use an inexpensive and well understood screening test which will catch most of the problems and then move to more complicated/expensive/accurate tests when needed. Thoughtlessly using a gold standard test right off the bat is very often wasteful and unnecessary and probably fraudulent as well. An MRI doesn't diagnose a broken bone any better than an xray and any doctor who orders such unnecessarily expensive tests is committing insurance fraud.
Another key question when ordering a test is whether the test results could result in a difference in treatment. There is no point in ordering a more complicated and expensive test if the patient will receive the same treatment in the end anyway.
In this day and age, you should already know about weight and diet.
Should, yes I agree. But if you've ever actually worked with the general public you should realize how foolish the general public can be. Even if they know, they might be unwilling/unable to take action. Furthermore physicians often run into patients (especially older patients) who are, often through no fault of their own, mentally incompetent, psychologically damaged, or just not very bright. You're absolutely right that diet and exercise matter but even motivated high functioning people struggle with controlling their diet and getting to the gym.
BTW, there already is a sort of best practices book out there. It lists all the generally accepted treatments for a variety of injuries.
Ha! I'm married to a physician and I've done statistical studies of medical data and there is FAR more debate about what constitutes "best practices" than you could possibly imagine. Insurance companies and medicare have their version of it but have NO illusion that there is any kind of universal consensus for many, many, many conditions. Very often there simply is insufficient or conflicting data on what exactly results in the best patient outcomes. Many court cases are precisely because of this fact - we often have to rely on professional judgment, experience and intuition because the standard of care isn't always agreed upon.
Even agreeing on diagnostic criteria can be a difficult process - never mind treatment options. Pathology involves far more judgment and educated guesses than you probably would be comfortable knowing about. Medicine is a science but there is a LOT we still don't know.
But is it reasonable for a patient to pay money for a placebo? And since placebos probably work best if the patient believes they are effective treatment, the doctor is in the awkward position of deceiving (or at least acquiescing to the deceit of his patients). Do you really want your doctor lying to you? Moreover, the fact that a drug or treatment is not better than a placebo does not necessarily mean that it is without harmful side effects.
Some doctors try to have it both ways; they'll prescribe something ineffective, but cheap and relatively harmless (perhaps a "homeopathic" treatment, which is really just water), and tell the patient, "Some patients say this helps them, although medical science can't explain why it should work. You might try it and see if it works for you." All of which is absolutely true, but a little less baldly stated than "This is worthless crap, but if I hadn't told you that, it might have made you feel better by the placebo effect."
The article is about outdated treatment and diagnostic procedure being used, not doctors and why they "hate science". Be less inflammatory.
I wish non-scientific journalists would not attempt to comment on scientific matters. "No cervix, no cancer," writes this journalist.
Perhaps she should consider the scenario where a woman had a radical hysterectomy for cervical cancer. In this scenario, this patient would remain at risk for vaginal and vulvar carcinoma. Perhaps the cancer is incompletely excised and a few cancer cells remain in the vaginal vault. A Papanicolau smear would pick that up. That is a completely justifiable Pap smear.
Consider further the scenario where a patient reports to you, her doctor, that she had her uterus removed. Only she didn't tell you that her that it was just her uterus that was removed, not her cervix -- a subtotal, not a total hysterectomy. I have found that clinicians are sometimes careless with their terminology. Such a woman might be lumped in under the category of 'woman with hysterectomy' without further thought. But she would still have a cervix and still require screening
The devil is in the details. Outsiders to the profession often have false expectations, or do not realize that the reality more granular and confusing than it first appears to be.
Coming from a country with socialized medicine, I find the US health care system mind-boggling. I used to think that the amount of paperwork in my country was bad, but I can hardly understand why anyone would choose to put up with endless reams of paperwork and contracts and co-pays and deductibles, plus the anxiety all of this must entail, for the luxury of 'choice' in health care. Yes, there are issues with socialized health care, but if you need investigations done on an urgent basis, they generally get done here on an urgent basis.
Your post was not worth the time it took to read it.
You are not only arrogant in trying to teach someone else their profession and deride them for acting in a way that harms no one and is clearly motivated by morality, but you are incredibly abrasive and foul in doing so.
I have frequently noted your contributions to discussions here on slashdot, and generally found them to be lucid and insightful. This sort of bile is shameful, and reflects poorly on both yourself and this community as a whole.
Those who advocate genocide deserve every protection afforded by law, and none afforded by common human decency.
A recent law (ruling?) requiring drug companies to register any study they intended to publish *before* they started the study revealed that about 19/20 studies go unpublished.
So only science that supports the desired goal of the drug or insurance company will be published. A little bit of bias there.
She was like chocolate when she drank... semi-sweet at first and then increasingly bitter.
Interesting. Incidentally, is it possible to overdose on placebo?
> The mind has a significant effect on the body.
That's not an explanation. What does the mind do that affects the body, and what makes it do it?
Interesting. Incidentally, is it possible to overdose on placebo?
Of course. Even if it's just water, about six liters will kill you.
to weight a few weeks
Scary!
Please tell me you are a few pounds short of being American.
ID: the nose did not occur naturally, how would we wear glasses otherwise? (apologies to Voltaire)
It might be time to give up listening to late night talk radio.
Ah, I see, I'm sorry. I misunderstood what you were referring to. Usually, when people are dumping on "socialized" health care in the US, they point to the VA first, and then Medicare next. I didn't know you meant Tricare. I'm afraid I don't know that much about it.
Da Blog
I'm a gyn pathologist. The implication in beginning of the summary is that a doctor is an idiot for screening for cervical cancer in a patient without a cervix. I would like to point out that HPV does indeed like to infect the cervical transformation zone preferentially, which is the target for the pap smear. *However*, the vaginal vault of a patient is still at risk from HPV infection, and I have personally seen pre-cancerous changes in the vaginal mucosa - changes that would be picked up on pap smear. A little bit of knowledge is a dangerous thing...
I think these are very valid points, but in the end, I'd also think you're in a position where your patient is your customer.
If he/she is essentially telling you, "Look doc, I know you're advising me I probably don't need an x-ray -- but I'd feel better seeing the proof."?
It sounds to me like you have no reason to be surprised when they run off to the chiropractor and get those x-rays, if you still refused.
These days, people have a lot of access to medical information. If I think something's wrong with me, I can get online and read all about the symptoms and possible causes on sites like webmd or the Mayo clinic's web site. Heck, I could probably get a lot of useful info off Wikipedia - as long as I understand it's just more possibly useful info, and not the "last word" on what's wrong with me.
Therefore, I'm not usually going to see a doctor because something's wrong and I have no clue. I'm going in, informed, and looking for a professional to confirm what I already suspect, or perhaps make a strong case to dissuade me from my initial opinion. A big part of my going is because I know he/she has access to the equipment necessary to do the tests or take the x-rays....
Another issue is that from the standpoint of evidence-based medicine, nobody really knows just how much of the placebo effect is due to power of suggestion. The placebo effect also includes such factors as regression toward the mean--which is another way of saying, "A lot of things get better over time on their own."
The older medical literature suggests that the suggestion component is quite strong, but some modern studies indicate that except for subjective complaints such as pain, placebos don't really do much. But placebo studies are not conducted the way they once were. At one time, it was considered OK to lie to a study subject. Modern ethical standards require that the subject be fully informed of the possibility that they may receive a placebo. So were the older studies wrong, or is the placebo weaker when a patient suspects that they may be receiving a placebo?
But placebos aren't ineffective. They are so surprising effective that we have, wait for it, an 'effect' named for that.
And, as someone else here pointed out, there actually are prescription placebos with no side effects, like Cebocap and Obecalp, which are actually sugar pills. (And right now someone who just read this is staring in shock at a pill bottle that they thought had medication in it.)
If corporations are people, aren't stockholders guilty of slavery?
Considering how many people think that they can diagnose themselves, I can actually see a huge market for doctors who actually explain things. Which is sorta the halfway step to trying to figure things out yourself.
All the doctors around here prescribe antibiotics for colds. I actually went to one when I had bronchitis, and he prescribed me some, and I had to stop him and ask 'Are you doing this because you think I have a bacterial infection, or you are doing this because fools often demand antibiotics when they have viral infections? Because I'm not one of those fools, and I'd rather not pay for antibiotics to inanely fight a virus.'.
He stared at me for a second and laughed, and said, yes, he actually did suspect it was bacterial, for a reason that I've forgotten. And then he admitted that, yes, that if there was any chance it wasn't a virus, and the patient wanted it, he'd give them antibiotics.
I don't pretend to be a doctor, I can't diagnose myself beyond a few emergency things like 'This is a symptom of heart attack, I better call 911 now.' But I like to think I'm intelligence enough to understand what's wrong with me when a doctor figures it out and tells me. Likewise, I can deal with the idea that the doctor doesn't know 100% what's wrong with me, and just has a set of possibilities.
If corporations are people, aren't stockholders guilty of slavery?
How strange,
In your country if you're accused of a crime you consider it a natural right to have access to a free lawyer and access to free legal advice is enshrined in the highest law of the land. The spirit of socialism at its finest! But oddly there's no "socialism" conflict in that area, even from the "libertarians".
That's probably because there is not Socialism involved at all. Public Defenders are only supplied in Criminal Cases because they are in opposition to Public Prosecutors. In contrast, the state does not hire you a lawyer so you can sue someone.
The system is set up that way to limit the power of the State. Instead of using the public coffers to bludgeon the individual into submission (as happens in most exercises of Socialism) the State must pay for both sides of it adversarial trials so as not to exert undue influence and marginalize the rights of its citizens. Similarly, evidence discovered by State employees and officers (such as the police) must be disclosed equally to both sides whether it helps or harms the State's prosecution of its case.
You sound like my kind of doctor. I certainly wouldn't describe myself as the type to go for unnecessary treatments. One time, I broke my toe - I think. I took it to the urgent care hospital (the not-quite-emergency ward), and the nurse said "It's either sprained or broken, but we can't tell for sure without an X-ray, which will take about half an hour." I responded with, "What's the treatment if it's sprained?" She said, "Well, we tape it to the toe next to it and tell you to take it easy." "And for the broken toe?" "We tape it to the toe next to it and tell you to take it easy." So I took the faster route, assumed it was broken (or sprained), and had them deal with it. I don't need to waste my time or money on a test that isn't going to change the outcome.
Now my friend who thought she might have broken her toe went through the hassle of confirming it was just sprained. So I see where you're coming from.
Sure I'm paranoid, but am I paranoid enough?
If some of the examples given in the article are representative, I have to side with the doctors on this one.
The glaring one to me: "A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones."
Uh, yeah. Perhaps even more effective. The main problem with those old-line antipsychotics isn't their effectiveness, it's their side effects.
Others have pointed out that testing for cervical cancer is still useful after total hysterectomy (especially if the hysterectomy was for cervical cancer), despite what the author thinks.
It's not about science or common sense--it's all about billing the insurance companies. That's how hospitals and clinic "businesses" make money. Doctors order tests because they are told to do so as often as they write prescriptions because they get "incentives" to do so from pharmaceutical companies.
It's all about money.
I might know what I'm talkin' about, but then again, this is Slashdot...
Hell, it isn't so much the Dr's making the decisions now...for the past decades, we've had the beancounters in HMO's
In the UK the problem has been the government. Several years ago before my dad retired they introduced a target percentage for all women to have pap smears (something like 95%). The problem was that the idiots in charge did not make any exceptions for women who had had hysterectomies i.e. had no cervix. Additionally they penalized the doctors, by paying them less, if they did not screen the target percentage of their patients. The result was that patients without a cervix were screened and patients who refused to have the procedure were threatened with being dropped as patients (not in my dad's practice but elsewhere this certainly happened) because otherwise the doctors got penalized. I think this has all been fixed now but usually I find that the doctors do actually know what they are doing (at least in the UK) but have medically unqualified and politically motivated idiots messing the system up for them.
Yeah, but if you get the generic placebos, they are a lot cheaper!
I've abandoned my search for truth; now I'm just looking for some useful delusions.
Other countries pay less per person for health care, and they cover everybody. Higher taxes are for other reasons (I will not even guess what). The US could lower taxes by going single payer.
You got me into this! You were the ideologue! I'm only a poor assassin! - Twenty evocations, Bruce Sterling
Americans ought to be delighted with that deal. You can find ways to cut back on your gasoline usage. It's a lot harder to ensure that you won't be hit by an uninsured drunk driver and need several thousand dollars worth of treatment.
One of the coolest things about universal health care is that it drives down the cost of so many other things as well. Car insurance is cheaper because it doesn't have to cover huge treatment costs. Health insurance (yes, it's available in the UK for those who want extra protection) is cheaper because so few people actually make claims. Doctors don't have to pay colossal malpractice insurance fees.
Mind you, as in every country, there are a lot of dumb Americans who would rather save a small amount at the gas pump and take their chances about later. It's a bad bet. EVERYBODY is going to get old and need health care, unless they're killed outright early on.
I piss off bigots.
You have to wait quite a long time if you are not very sick, but I was offered same-day knee surgery, and ended up having it in about 10 days after I tried to avoid it. Life-threatening cases get immediate treatment as well, no waits.
Admittedly here in Quebec the equipment is not as good as in, say, Ontario, where just about everything in major hospitals, from the machinery to the restroom stall doors, has a "donated by" plaque, but hospital care is still pretty good.
Of course things are privatizing here too. If you really need an MRI you had better have private insurance because without it you will wait 6-8 weeks instead of 0-2. I'm all for private companies providing care, but I disagree with getting away from single payer. For profit companies just can't leave the "but they'll pay anything" bit alone and care goes down while prices go up.
You got me into this! You were the ideologue! I'm only a poor assassin! - Twenty evocations, Bruce Sterling
I've yet to see a really top-notch person in EE or CS who wasn't actually interested in it, often from a fairly young age. The people who decide at 18 that they're going to do EE, and treat it as if it were a pre-med-style major, may get good grades, but aren't good at it.
10 PRINT CHR$(205.5+RND(1)); : GOTO 10
And on a site that has kdawson on it, that's saying a lot.
I agree. That's why I chose to use the adverb+verb form, rather than the simplistic (and more popular) adjective+noun form. The latter implies a single, time-constrained event of dubious provenance, whereas the former implies a continued, non-time-bound state of failure. I note that you apparently favour the adjective+noun form, which is epically weak.
Da Blog
I struggle with the ethics of prescribing a placebo.
From the rest of your posts, I think you're the type of doctor I would be proud to have. However, even though I agree you shouldn't go all willy-nilly on the placebos, I thought I'd re-post something to give you some anecdotal evidence in favor of them, under some circumstances.
Basically, for those patients who are so freaked out that will actually seek out other doctors because you didn't give anything, the problem isn't just that they'll think of you as a bad doctor for not helping them. You might actually be helping them out if the placebo serves to calm them down.
Here's an idea....how abut we stop the shitty treatments and start CURING ailments.
Thank you for your comments. I'd love to have a doctor like you (in fact I do - your attitudes are the sorts of things I look for if I need to find a new doctor). I also realize that if your practice depended solely on finding patients like me then you would be out of a practice...
I've thought about the ethics of placebos. If we're talking about an actual drug or a test, then you're exposing your patients to risks, and at the very least to cost. You're also directing their care without divulging your reasoning to your patient, which I think is also questionable. On the other hand, the placebo effect clearly works - there is a far greater difference between no treatment and placebo than there is between placebo and active ingredient in many classes of drugs.
I think the danger of placebos isn't that they're not effective - but rather that they're a step in the wrong direction. People need to get MORE involved in their health. I'd rather see a patient harmed because they interfered with their own care than see a patient "coerced" into a line of therapy they would rather not take part in. If it were up to me you wouldn't be required to have a prescription to take any drug (though I can see there being validity in insurers requireing them for reimbursement).
I think the real problem with EBM, or any kind of medicine, is that there is so little evidence out there. Real clinical data is hard to come by, and it is often in conflict. I think this just reflects the difficulty in working with humans. If we were talking about rats we could feed them bacon and count how many die of heart attacks, and then take those bacon-fed rats, give half of them bypass surgery, and then chop them all up and see the results a year later. Medical ethics (though clearly ESSENTIAL) really does tend to harm scientific progress. Ironically we might be able to save more people (statistically) if we just treated people like lab rats and sacrificed them for science from time to time. However, when you're talking about real human beings the needs of the individual clearly are at least as important as the needs of the statistical population.
As for my attitude - I'm going to die some day. It might be in 10 years, might be in 50 years, or even 200 years if somebody comes up with some fountain of youth. For me quality of life is certainly as important a consideration as quantity of life. I'd rather see people treated with dignity even if it does lower the average life expectancy a little.
You sound like a really good doctor - genuinely concerned about your patients well being. I wish you the best of luck!
Sorry I was a bit harsh, probably deserved the Troll moderation.
But next time you probably should put the words back into the third party's mouth, like "my doc said that ....".
I inherited a mistrust of doctors from my father, but I approach it as an opportunity to learn about something which is both interesting and useful to me personally, yet not directly connected with my profession. I understand that approach isn't for everyone.
Church hospitals routinely make massive profits and refuse to do the community work they are supposed to do to maintain their tax free "non-profit" status. The problem with the US system is that it is designed to make huge money available to the dishonest, and few resist the temptation. Of course the system is supposed to look like it provides medical care.
Most other countries do not have a mechanism for paying people not to provide medical services (though some do have bonuses based on people not needing medical services, i.e. doctors get paid extra if their patients are healthy).
You got me into this! You were the ideologue! I'm only a poor assassin! - Twenty evocations, Bruce Sterling
Honestly I don't know that they do but considering that they seem to want to cast that net based on the evidence they give. It seems like the title is equally appropriate.
For example: Pap smears sounds like a no-brainer but there are a couple of things that could easily account for this. Incomplete history and incomplete clinical agreement.
Incomplete history, so someone walks into your clinic and wants a physical (Ok, I mean makes an appointment and then after a while attends said appointment). Someone has taken a history but left out the hysterectomy. Doc doesn't see that and decides that they might as well do the test or perhaps they ask: "So have you had a hysterectomy" and the person answers "Yes". Doc responds with "Full or partial?". Person isn't sure. Doc does the test anyway.
Incomplete clinical agreement. Possibly the Mayo clinic is part of the problem but according to them: http://www.mayoclinic.com/health/pap-smear/AN00013
Just having no cervix is not the only criterion.
The overarching point is that people like Sharon Begley and publications like Newsweek are obsolete. They are come from a place and time where the mildly informed feel like they can lecture the less informed.
The real problem is that CER, while a useful instrument, is threatening to become the quant copula function of the insurance industry: non-technical people trying to turn a useful tool they don't really understand into a simple calculation that can be done in Excel. This is already happening, and yes it does end up being used for simple cost-benefit analysis, because that's what actuaries know. Of course they will plug whatever CER results they can find to reduce costs into their rates and payments schedules. This happens regardless of who provides the coverage, because that's the nature of the folks who make the money decisions.
The article really ought to be titled, "How Insurers Use Science They Don't Understand".
The stimulus package is not about growing the economy. It's not about the efficient use of resources. It's about getting the engine running. The alternative is having the economy grind to a halt.
In the broken window fallacy, the cost of replacing the window goes displaces other more useful investments. In the current situation, if no window is broken, the money will just sit here because the shop owner is too scared of the future and keeps his money instead of spending it, while the glass maker has no business going on, either for fixing broken glasses or supplying materials for new building that no one is financing.
You know, the Princeton prof who writes a column in the NYT and just got a Nobel prize?
And yes, take the god damn money from whoever has it and get it rolling, that's the idea, because if the gov't doesn't get it going, nobody is going to spend its own money willingly because they fear (rightly, rationally) that they won't make any in the near future.
In other word, it's about breaking a self-fulfilling prophecy. Everybody's predicting that things are getting worse, and as long as everybody thinks so, things will get worse, automatically.
Doing this in the long term would be a waste.
That's not the point.
The point is to jumpstart the engine of the economy.
Krugman's position, and that of all the economist that weren't accomplices in the friedmanian mindset that brought us where we are, is that the stronger the kickstart, the faster the recovery.
The mid-term danger is not inflation, it's deflation, whereby prices get lower and lower because no one's buying, driving wages down and then prices down again in a vicious circle.
That's a depression. That's bad.
The "digging hole and filling it" is an image used by Krugman to drive his point home. The point is getting money flowing.
As an ER Doc and a Chemical Engineer Undergrad I must say the data available to physicians is abysmal compared to that of the hard sciences. We don't hate science but we fundamentally distrust most studies. Lord Kelvin elucidated the principle that we know more about anything one can measure. That's true but much of medicine is very difficult to measure. We fear mandated standards because many past touted best practices have been subsequently discredited. Defensive medicine, patient expectations, marketing by drug and appliance companies, and profit motive all play a part in our practice patterns but mostly we just don't know. Bruce
Do you -
A. say, "we made the right choice, but the odds went against us."
B. say, "that doctor led us down the wrong path to save the insurance company a few bucks. We're suing for $5M."
In many cases, dealing with the grief of loss through anger and retribution are the response of choice. Especially when an attorney says, "I'll take the case on contingency; it won't cost you a thing. I'll take care of everything." Then, in court, with a picture of the child in the background, the grieving parents sitting there, the attorney says, "Three questions, Doctor. First, did you have access to a CT scanner? Second, wouldn a CT scan have shown this? Third, what's more important - saving this child or saving a few bucks?"
Since it's "malpractice insurance" that pays the bill, the jury awards $10M.
The doctor's malpractice insurance premiums go up because he's had a judgment against him.
The doctor starts CTing every child because of the suit.
The insurance premiums go up for all of the insurance company's members to cover "medical inflation."
The doctor's reputations is hurt, and he is more at risk in future suits. Attorney,"Doctor, has any other person died in the past because of your medical decisions? Just a simple yes or no, sir."
The fundamental problem is that people expect medicine to be perfect because the media and legal profession have set that expectation and anything less is "malpractice or negligence," even good decisions with bad outcomes.
Doctors get many kickbacks in the profession. They just come in many shapes and forms. Let me tell you about some stories I've witnessed first-hand:
I don't know about the USA, but in my country some pathology clinics will give a surgeon a certain monthly pay so all his patients' biopsies are sent to a certain clinic. Some of the most successful pathology clinics play this game. This I've heard from the owner of a successful clinic (you know, Sunday barbecues...) In fact, it's possible that all successful clinics play this game in a certain town.
Or how about that money-loaded orthopedic surgeon, known to his colleagues as "Dr. Screw", because his always so very keen on using special orthopedic screws in each and every patient - for which he gets a little side money from the company making them - which makes him run around town in a very cool car. Way cooler than Dr. Honesty's.
Or how about Mr. Bigshot Cardiologist, who gets a nice vacation in a 5-star hotel in the Bahamas or some such place for their nice job in multicentric clinical trials, etc., courtesy of Big Pharma? Do you think that's a kickback? I think so. For sure.
Also, you'd might like to know: some physicians do own clinics with their CT scans. When you own a clinic, you got bills to pay: city taxes, staff salaries, etc. It's a business. What do you do when your clinic needs money? To be fair, some clinics are so well-established they probably don't resort to dirty tricks. Or maybe, they do, I don't know. Or maybe they became well-established in a competitive environment because they weren't fair with the competition? All I know is that some doctors are well off, but not exactly rich. And some doctors run their practice like it's a business.
Academia, OTOH, pays horribly. But at least it's an honest job...
The unfortunate fact is medicine is a profession in which most people are in it for the money, not because the are fascinated with the human animal or are full of compassion. TV has epitomized such characters, as in Nip/Tuck, etc.
From what I see and hear in the news, I don't think US physicians are a bunch of holy saints either.
Main difference between the BSD license and the GPL license: one is from California and the other is from Massachusetts
So this is probably a stupid question, but as I understand things, a PAP smear is actually a test for HPV which a woman can (I assume) contract with or without her cervex. While it is true that HPV is very much the leading cause of cervical cancer, they are not one and the same. If all the above is true, then doesn't a PAP smear still make sense no matter the state of a woman's cervex? And for that matter, I do believe that men can catch HPV also, why is it that we test woman twice a year and men never?
Indeed I do get it. Universal anything is a utopian argument for those who still don't understand that the Wilsonian theories either failed, or got us into more trouble than they were worth. Universal means having to say you're sorry in perpetuity. Again, keep the damn lawyers off the backs of those who actually got in to medical school (you know who you are), and legislate strict tort reform. I remember what medical costs were like before the legal feeding frenzy started, and those costs were on a par with other professions. Doctor's are taught to do no harm. Lawyers are taught to harm everyone, and if possible, to eat their own. Ever see the US commercials which ask, "Have you been hurt by anything?" Doctors ARE scientists, though I'm not so sure about these slashdot commentators. If you want universal health care, let's go for it, but don't fail to include the tech community, developers, engineers, research scientists, etc., many of whom work to further the advancement of medicine. Next time you write a computational neurobiology application, better check with the government to be certain it follows the model, and accept "reasonable" compensation for your work. "To each according to his contribution..." Now where have I heard that before. Lastly, who would you rather see at the bottom of the ocean, a hundred doctors or a hundred lawyers?
Your observation about 30%-plus profit margins also doesn't stand up to the data. In general, hospitals run net operating margins of 5-15%, which is the money they use to replace aging equipment, build and repair buildings, and other "luxuries."
This is not a sob story to pity the poor doctor, but your generalization doesn't match the data. In particular, your shot at people going into medicine because of the lack of vacancies in B-school is cute, but there's no data to that point.
There is data to support the fact that the most health care dollars are spent in the last two years of life. Preventive care may delay those last two years, but everyone's still going to have them. Our bodies don't come with a warranty and replacement parts aren't cheap.
The ultimate choice is how the money can best be spent to provide quality of life.
At least, I've met very few doctors who would ever do any out-side research into what was ailing me. If they didn't know right-off what it was that was bothering me, they would send me away untreated. Or they would prescribe drugs that were inappropriate or superficially purported to treat symptoms.
It wasn't until I went to see a clinical nutritionist who wasn't afraid of doing some off-hours research that I was able to make any headway into the causes of my CFIDS. Turns out that the root cause of all of my problems was an intestinal parasite. On reflection, I had all the classic symptoms, both in terms of GI symtoms and other side-effects (energy problems, alergies, etc.), but every GI doctor I went to just treated my IBS symptoms and completely ignored the fatigue and never considered doing certain basic tests. Infectious disease doctors never found anything either. One doctor did a endoscopy, looking for anything mechanically wrong, but that wouldn't identify a protozoan.
Similar things happened with my wife. They wanted to treat her with antidepressants, when it turned out that she had a helmenth that caused mood problems as a symptom. When the nutritionist's ordered tests found that, some flagyl cleared it right up, and voila.
This is a problem with MD's especially. DO's are a little better, coming from a traditionally more open-minded discipline, but even they tend to operate a revolving door.
As a counter point, I also had strabismus. (My eyes crossed, and an in unusual pattern.) I had to get more than one opinion, but I found this one eye doctor who specialized in correcting pediatric eye alignment problems. He was absolutely fantastic. Other doctors told me that correcting my problem wasn't even possible. This guy knew exactly what to do, did it, and the results have been brilliant.
This leads me to differentiate between surgeons and medical doctors, and I have come to respect the surgeons a hell of a lot more. (But this is just due to my relatively small statistical sample.) Modern medicine seems to be good at treating COMMON illnesses and physical problems that are easy to measure. Anything else, and you're out of luck.
So, after the nutritionist found our problems, we went to a DO, and he happily wrote scrips. Because we had certified medical test results from respected laboratories. Which he himself would never have thought to suggest we get.
This problem with the medical system tends to lead to a catch 22. If you have a problem and don't know anything about it, they won't treat you because they don't want to investigate. You have to learn all about the medicine yourself. But when you do that and discuss symptoms and potential causes with them and even use the right terminology and talk about "differential diagnosis", they label you a hypocondriac and send you away untreated. We were just lucky enough to get a nutritionist with the right credentials who herself was willing to do the research and arm us with hard test results that we could use to get the MDs to do what we needed.
Now, while MDs won't argue with you about hard test results, they WILL argue about treatment. I have a friend who got lyme disease, having been bit by a tick. Classic bulls-eye shape. The doctor gave her the WRONG TREATMENT (one that is specifically cited as being ineffective against this disease). When it didn't work and the disease started to enter some late stage that's dangerous, my wife had to go into the doctor's office with her WITH THE MEDICAL TEXT that lists the appropriate treatments before the doctor would prescribe the right medicine. And lo and behold, the treatment worked. Fucking moron doctor.
It implies that it is second-hand, cannot be verified, and is therefore unreliable. As this is an implication, and thus a connotation, it is not in the dictionary. Its denotation, however is in the dictionary.
That anecdotes are able to be embellished, or even completely fabricated while not being falsifiable is just such an indication that it does not qualify as scientific data.
WARNING! This girl exceeds the MAXIMUM SAFE standards established by the FDA for BRATTINESS
Almost. The perception is that doctors should be like doctors were before a medical license became a ticket to becoming a millionaire. There was really a time when a successful doctor might have the nicest house on the block, but not also a nice house in St. Lucia and a nice house in Aspen and a nice apartment on the Gulf Coast.
You think so? A general practitioner might be earning as little as $80,000 per year after expenses because we don't pay doctors much for preventative care. And that is while working 70-90 hour weeks doing it. Add in the 8-10 years of medical school and residency and the fact that you don't really get to start practicing until you are in your thirties, long after most people have had a career and it starts to look not so attractive. Try working 60-100 hour weeks for a decade straight for little pay, a mountain of debt and see how idealistic you are afterward.
Yes some physicians earn a lot more but I'm around them and they earn every penny of it. Hardly anyone becomes a doctor strictly for the money. Most of the doctors I know will tell you that if you can imagine yourself doing anything else, you probably should do the something else. It's just too hard otherwise.
So now doctors fear that if we have universal health care in the US, they might have to go back to being part of the community in which they serve.
We already have something close to it and it's called Medicare. It's a huge part of the compensation for the majority of doctors. And frankly doctor compensation is not the big driver of health care expenses. The real drivers are problems of adverse selection and/or moral hazard to use economics terms. Look at ANY analysis of drivers of health care costs and physician compensation will be at the bottom of the list if it is even on the list at all. Don't take my word for it.
The people who are going into medicine these days are doing so because there were no more spots left at Northwestern's B-school.
Ha! You don't know a lot of doctors personally do you? I'm married to one and as a result I know lots of them. Most of them are among the smartest people I know and most of them got into medicine for reasons other than money. It's only after they get to med school that they have the honorable notions figuratively "beaten" out of them. Most of them could get into even the top B-schools easily and yet they choose not to. If your goal is to make a lot of money there are a lot easier ways to do it than being a doctor.
Dr. Simoncini, an accomplished surgeon, stopped using surgery and chemotherapy to remove cancer. He found that cancer is a fungus that would be remedied, removed, and cured by using Baking Soda (sodium bicarbonate). If you read the AMA journals elluding to, and prior thus durring the events of Raymond Royal Rife, it is found that all virus is created by a fungus' immune system to attack it's host's cells.
It's all fungus, and plants have been fighting the war against fungus alot longer than Pharmaceutical companies and their accompanying corporations. That's why the word "doctor" is french, defined as meaning (and I am paraphrasing) "one that applies leaves" because an herbalist can use a plant's immune system to remove an infection from a man's body simply by laying it on the skin for the wound to absorb it.
Alex Jones is a psy-op for the Secret Society of Jesuits for Jesus, of which is infiltrated itself by "Illuminati" because if you researched everything he said then you'ld know it's half truth and half hysterical analysis or entertained; it's just like all radio "shows", eventually more critics listen then supporters. John Phelps exposed Alex Jones a long time ago, consider his book (a U$400 hardback limited print to under 300 available) and website on all occults and their peerage violating you and my side of the country Vatican Assassins. Yet If you want a true radial/radio'd ministry, try World Wide First Amendment Radio, American Voice Radio Network, and Republic Broadcasting Network. You want to throw stones, well you should know I work for a glass shop from time to time and I got plenty of glass to persue you for libel and slander of my good and lawful character.
If you do indeed get it, I don't understand why you refer to things as universal which aren't. Its almost as if you are looking for something to bolster your jaded view. As for lawyers or doctors; neither. Maybe 100 frothing zealots, but they would probably survive on regurgitated bile for a generation.
he decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.
Keep dreaming.
As of July 2007 there are about 600 HMOs [1], there's plenty of competition. Part of the issue is that the overhead that medical practitioners have to deal with to file all the various paper work forces them to hire a number of back-end office staff--the cost of which is passed on.
[1] http://www.statehealthfacts.org/profileind.jsp?ind=347&cat=7&rgn=1
Nice to see a Doctor who really applies the "First do no harm part of the oath!
I mean, seriously, how would that plan you propose actually work? If the healthy people are paying very little for insurance, where is the money going to come from to pay for the health care costs of the ones that get sick? (And when I say, "get sick," think of something along the lines of discovering at around age 30 that they have a congenital problem that requires periodic, costly attention for the rest of their lives.)
Basically, the choice you're expressing here is a form of adverse selection, where all the "healthy" people try to keep their health insurance costs to a bare minimum. This is a recipe for health "insurance" that doesn't actually cover you when you get sick. If the only people who opted for comprehensive coverage are the people who need it, then there won't be money to insure against risks that require you to get need comprehensive coverage, period.
Make sure to remember this: you shouldn't be trying to insure yourself only against "big emergencies," as you put it: one-time events that require a relatively brief period of very expensive coverage, but which you recover from thereafter. You also need to insure yourself against the risk that you may end up needing moderately expensive care for a chronic condition over 30-40 years. This is the reason why the cheap insurance you would like to have is broken, because it cannot protect you from many very significant health risks that you face.
Are you adequate?
How does a woman not have a cervix?
Yeah, but painkillers and cough syrups usually have mild opiates in them, which make the patient feel better until their body naturally recovers.
"That which does not kill us makes us stranger." -Trevor Goodchild
Wave a magic wand and make you better?
Give you completely free meds?
At the end of the day your health care will cost you money.
Get into a group not related to work (professional organization?) and pay for your own insurance. That way you get to dump part of the cost of your meds onto the healthy group members.
If it costs $10K per year to stay alive I'd think you'd be glad to pay it. Beats the alternative.
You've got ways to game the system so you don't even need to pay your own way. Quit bitching.
John McAfee 'It was like that time I hired that Bangkok prostitute; to do my taxes, while I fucked my accountant'
Ha ha ha ha ha
Homeopathy
Ha ha ha ha ha.
You guys crack me up.
Just want to point out that the above post corrects the GP about on the effects of a steriod and as of the time of this post is sitting at -1 Troll. Perhaps the post was not polite, but it isn't trolling. It's informative.
There is no "Informative but rude" mod. Troll is not a substitute.
That's absolutely correct, there are many reasons for performing a "pap smear" on patient's without a cervix, the most cogent is a history of dysplasia/cancer to assess the surrounding tissue for spread. The vaginal "cuff" as it's called (the area at the top of the vagina that was closed when the cervix was removed) is "scraped" very much like a pap smear. The ordering of the pap smear test using a lab slip is required to specify the specimen site (ie, cervix, vaginal cuff, etc).
As an ob/gyn, I don't relish the idea of ill-informed beaurecrats telling me how to practice medicine. The beaurecrats want to automate the practice of medicine so they can pigeonhole all diagnosis and treatments into cubby holes and check boxes in order to analyze and arrive at such statistics as pap smears per hour and state--as if it means something--"Dr B does a pap smear for $3.97 while Dr C charges $3.99." Therefor, we're only going to pay $3.97 for any and all pap smears. Think it sounds funny? That's exactly how Medicare pays, without regard to how easy or difficult it may be to perform a pap smear on various patients. You might just as well say you can reduce all of programming to a universal automated system, plug in a description of inputs and desired outputs and some algorithm generates perfect code. There are many aspects of programming that could be considered an "art form". The same is true with medicine, law, research and a host of other disciplines.
No man's an island, unless he's had too much to drink and wets the bed.
He wants insurance products or services that protect you against the risk that you may need expensive care over the long term. His problem is that by allowing people who believe they won't end up in this category to opt out of paying for that, it becomes impossible to insure against that risk.
Are you adequate?
Even if you suscribe to the pro tax cut creed in a normal environment where the economy is working fine, here they are absolutely counter productive. People are rightly afraid of the near future situation. In this situation, most companies / individuals expect their revenues to decline, so they resp. cut wages expenditures and cut spending, which results in people having less money to spend, therefore companies make even less money and cut jobs even further.
It's a vicious circle and you have to break it. If you give people tax cuts, they will just hoard it, because it's the rational thing to do for each economic actor, individually, even if it's negative as a whole.
One must ask what will be even considered as treatment options under this scheme : ... can you spell "multiple function coding", unlike the supposedly "scientific" research ?)
- accupuncture, shown to be effective since at least FIVE millennia in eastern countries ?
- light therapy (now called phototherapy), discovered in the 14th century by Avicenna, father of modern scientific medecine ?
- phytotherapy, which is basically the live version of what is sold in little pills at the pharmacy ?
- yoga, taiji quan & meditation, whose effect where proven to increase mood & cognitive functions by both the AMA and PubMed reports ?
- OR, will it only be the heavily priced pills sold by pharmaceutical companies ? (as a reminder of the "benefits" of gene therapy, please count both the genes and the number of cells in Humans
And all that is even without considering the financial impacts on ethics of nifty "study seminars" in sunny beaches ...
Women who have had total hysterectomies because of cervical cancer or history of HPV still require regular pap smears (http://www.med.umich.edu/opm/newspage/2003/skippap.htm) there is always a risk of recurrence of cancer locally in the vaginal cuff. in addition, many women may not know about exposure to hpv and the risk of vaginal cancer. is this cost efective--probably not, but one needs to define cost effective--one in 100 or 10,000. what would you do personally or advise your mom, wife, sister if her doctor explained that the "system" would not cover the $100 dollar test. what would you do if you could not afford it. what would you do if you had to decide how to pay for childhood immunizations but the budget was strained by thousands of $100 dollar tests and you could not provide for childhood immunizations. the devil is in the details, and it depends on where you stand. these blanket assertions do no one any good. we all are going to have to decide what level of treatment is acceptable. of course, if you are the one with the cancer, you always have recourse to the tort system. so much for the savings.
the anonymous idiot looks at the finger.
Doctors don't have to pay huge malpractice insurance fees not because it's illegal to sue them, but because as employees of the NHS, they're covered by the NHS. If you're the victim of malpractice, you sue the NHS, not the doctor.
Secondly, in the UK the courts are not nearly as willing to award huge punitive damages or damages for intangibles like pain and suffering. Charging the NHS money is charging the taxpayer money, and it takes money away from patient care.
Finally, there simply isn't the lawsuit culture. People are justly proud of the NHS as one of Britain's great postwar achievements, and while they keep a close eye on its performance, they don't like to see it attacked for no good reason. Judges take a dim view of frivolous lawsuits -- and so do juries. You can't just file a lawsuit any time you like -- you have to ask permission and demonstrate that you have a case to answer before it goes anywhere at all.
As for your final point -- I acknowledged that there were plenty of dumb Americans (as in all countries) who can't reason soundly about actuarial realities. I'd take free-at-point-of-service healthcare for life and $8 a gallon gas without hesitation, but then I can do math.
I piss off bigots.
Here your basically saying that savings is more important then treatment or quality of life.
Screening tests are about maximizing quality of life for as many people as possible, not you in particular. While you may only care about you, your doctor has a responsibility to many people and if he orders an unnecessary test for you, your doctor is necessarily taking resources away somewhere else. I'm talking about maximizing the treatment and quality of life for as many people as possible.
We can't fund everything for everybody. There is a finite amount of money and manpower available for heath care. It is economically impossible to provide unlimited health care for everyone. This is an indisputable fact. The question is how to spend the resources we do have most effectively. I realize this makes people uncomfortable (you included apparently) but it is reality.
A certain amount of money and manpower is allocated in each society for health care and within that allocation it is a zero sum game. Spend more money and manpower on your MRI and there is less money and manpower available to spend elsewhere. A given test might be an appropriate use of resources but there are very good reasons why we use screening tests.
Many conditions that can be detected on an X-ray or MRI can also include other injuries that the other won't pick up.
That is true and physicians are actually pretty good about knowing when to use one or the other. Sometimes they make mistakes but it is a better use of our finite resources to let them use their judgment in determine which test to use than to simply mandate an MRI and xray for every patient that comes in the door.
And yes, I do agree that pathology is perhaps more challenging then other areas. But that's in the diagnostic section of the treatment. Once they lay claim to a condition or disease, the accepted ways or guidelines to treating it will be printed in the codes.
Pathology was just an example. The same issues apply to ALL areas of medicine. Internal medicine, radiology, surgery, physical therapy, and on and on. Radiologists are masters of the differential diagnosis because imagining technologies can only tell you a finite amount about any given condition. Internal medicine doctors are frequently working with incomplete information. I'm married to a pathologist and they will tell you that it is very common for people to die and we have no idea why. There is SO much that we just don't know. If you can get some doctors to speak frankly with you (not always easy I know) they will admit that they are shooting in the dark a LOT of the time. Some are arrogant and won't admit it (surgeons are notorious for this) but they will be the first to tell you that for many, many, many conditions there is no consensus.
Let me give an example. I know a lot of dermatologists. The number one litigated condition in dermatology/dermatopathology is melanoma. Melanoma can mimic many other conditions and there are no tests that are even close to 100% accurate in determining the condition. It is usually diagnosed via morphology and sometimes with the help of some special stains or genetic markers. Eventually there probably will be some definitive genetic tests but they don't exist yet. Worse there is no consistent definition of exactly when a melanocytic lesion becomes a melanoma. You could ask 10 different doctors and have just as many different opinions. It is quite impossible to have a definitive best practice because there isn't one - the diagnosis has too many variables and unknowns.
The point is that there are SOME things that are agreed upon but many more that aren't and the ones that aren't matter greatly. Specialists in these fields are well aware of the issues but it is quite impossible to produce a book with a definitive best practice for many many conditions. I respect your desire for such a compilation of best practices but it's not as easy a problem as you make it out to be.
http://slashdot.org/comments.pl?sid=1147437&cid=27056793
Read all about it and realize he is a punk. A stupid one no less as he admits this here after the pressure of being caught doing so here this week exposed him in it.
Where are you, and are you taking new patients? ;)
I'm a she-slashdotter... but I make up for it by living with my folks.