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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
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.
Yeah, those damn liberals. Here they come, trying to screw up the impeccable record the Republicans have accrued over the years... ... wait, nevermind. I was delusional for minute.
Still bitter about the election? Good. I can't tell you how rewarding it feels as an American to demoralize and frustrate the idiots on the right.
Next up:
Which conflates the argument that doctors sometimes do those (and other) stupid things. They don't have to....
And another gem:
What the fuck is wrong with this woman? Did somebody do a prostate exam on her? Yep, there is a problem - doctors don't necessarily do what sometimes iffy research describes as best practices. And there is the big issue of why medical practice varies so much from region to region. And doctors very definitely tend to do things that pay them money (i.e., procedures) when perhaps they are better off not doing so.
But this 'article' is just an idiotic rant. There are fairly large and well funded groups that find it in their best interest not to go along with this idea, but to paint everybody with the same brush and to dismiss detractors of CER is just immature. Unfortunately, for the vast majority of patients, we really don't know what is the best combination of treatment or not treatment. Most of the studies have been done for fairly short periods of time and on rather homogeneous populations. It's hard to know how those studies apply to the real world patient in your office.
Let's take the little issue of pap smears after hysterectomies. If you had a hysterectomy for actual cervical cancer, then you ARE supposed to keep getting pap smears (at some unknown frequency). That's because cancerous tissue doesn't necessarily stop growing the moment it wanders off it's initial tissue base. That's why it's a cancer.
Way to go Newsweek. Take an important, complicated issue and create a brain dead sound bite.
Roll up your sleeve and bend over.
Faster! Faster! Faster would be better!
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
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.
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....
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.
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.
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.........
The quote I like best is: "What do you call 'Alternative Medicine' that works?" "Medicine"
Awesome furniture, accessories and cabinetry in Santa Rosa, CA: http://humanity-home.com/
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.
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
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.)
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.
CANCERS DO NOT WORK THAT WAY!
They have the same general properties (a condition of abnormally frequent cellular reproduction), but the mechanism of how each one works is different. If we consider the biological definitions of the terms, they are analogues but not homologues.
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
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.
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!
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.
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.
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
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.
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
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
Let's take the little issue of pap smears after hysterectomies. If you had a hysterectomy for actual cervical cancer, then you ARE supposed to keep getting pap smears (at some unknown frequency). That's because cancerous tissue doesn't necessarily stop growing the moment it wanders off it's initial tissue base. That's why it's a cancer.
Thanks you for posting this. My wife had a hysterectomy after cervical cancer, and IS supposed to continue to get them (less frequently, of course). She knows much more about this than I do, but when I told her about this article, she said it was irresponsible to suggest after cancer is removed you no longer need to get paps. She was a surgical tech, worked in an OBGYN office and grew up around family working in medicine. She doesn't know everything, but she did her homework on this when we were dealing with it. Anyone out there who deals with this, your life is worth more than this sound-bite critique.
Yes, but maybe that is not "over-investigating". Maybe that is deliberately trying to make more money by being dishonest.
>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.
You're absolutely right. And these intermediate levels of generalization is what leads a physician to treat patients as individuals, not as numbers. The governmental guidelines do NOT say, "Don't test men over 75 for prostate cancer, unless they're relatively or absolutely healthy." Nope, they say, "Don't test. Period. There is no evidence of benefit." It doesn't matter if the lack of evidence is because they're right, or because no one has looked into doing the appropriate studies to determine if there are some men over 75 that would substantially benefit from getting checked for prostate cancer.
There is always a grey space between clinical judgement and EBM. (Those intermediate levels of generalization that you talked about, but haven't been studied in appropriate detail.) And I will always err on the side of treating a patient as an INDIVIDUAL, rather than treating a patient as a NUMBER.
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.
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.
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.
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.
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 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.
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.
Ahh yes. The classic broken window fallacy.
GDP is not the end-all of economic analysis. Just because an action or a policy increases GDP does not mean that the nation is better off for it. Paying workers to dig ditches and then fill them in again will likely displace workers from projects that are actually useful. By artificially increasing the demand for labor, the supply of labor available to useful projects is diminished. By increasing the cost of an important input (labor), the number of useful projects will be diminished. The country will be worse off as a result.
No one has ever tried anything like the spending bill on such a large scale before. The coming years will provide huge amounts of interesting data for macroeconomists. I don't appreciate being a labrat in the largest macroeconomic experiment in history, but part of me is very interested in seeing the eventual results.
If you had super powers, would you use them for good, or for awesome?
Well said.
Also this is a gigantic waste of money. They're spending 1 billion dollars so they can eliminate tests and save 100 million dollars in the future. That's bass-backwards. It would be like me spending 10 dollars so I can buy a "1 dollar off" coupon.
"I disapprove of what you say, but I will defend to the death your right to say it." - historian Evelyn Beatrice Hall
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.
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.
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.
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.