Then and Now

I draw your attention to the official 200th anniversary essay in NEJM, which, yielding to the awesome power of Stayin' Alive, they have made available to the rabble.

As Drs. Fauci and Morens want you to know, listen up folks! You just have no idea how good you have it living in the 21st Century. Until people figured out what the deal was with pathogenic microorganisms, starting in the 18th Century and culminating with the genomic revolution of the late 20th through right now, life was really nasty, half the children died and if you were lucky enough to make it to puberty you were grateful for every day. They choose as their illustrative anecdote the guy on the dollar bill, who died of an infectious disease, probably a plain old sore throat as we would know it today; survived smallpox, malaria, and abscesses; watched his brother die of TB, and watched most of his government flee the capital in the midst of an epidemic of yellow fever.

Living in a world where you just assume you'll grow old is very strange. But what strikes me is how little we seem to appreciate it. There's a whole industry of people who deny the validity of medical science and make billions selling worthless concoctions and bizarre rituals to people who think they're being all progressive and wise because they know better than those high and mighty M.D.s. Also, too, they don't immunize their kids.

The only reason anybody has the luxury of acting so idiotically is precisely because they are wrong. The ocean of pathogens in which people once swam has been drained by science based public health and medicine, and you don't generally notice what's missing. Here's one really important suggestion. If you want to keep it that way, stop feeding antibiotics to livestock.

This post writes itself . . .

Because I already wrote it. Our new article is out in AIDS and Behavior. Believe me, I ain't happy that it's subscription only, but here's the abstract:

Provider-patient Adherence Dialogue in HIV Care: Results of a Multisite Study

M. Barton Laws, Mary Catherine Beach, Yoojin Lee, William H. Rogers, Somnath Saha, P. Todd Korthuis, Victoria Sharp and Ira B. Wilson

Few studies have analyzed physician–patient adherence dialogue about ARV treatment in detail. We comprehensively describe physician–patient visits in HIV care, focusing on ARV-related dialogue, using a system that assigns each utterance both a topic code and a speech act code. Observational study using audio recordings of routine outpatient visits by people with HIV at specialty clinics. Providers were 34 physicians and 11 non-M.D. practitioners. Of 415 patients, 66% were male, 59% African–American. 78% reported currently taking ARVs. About 10% of utterances concerned ARV treatment. Among those using ARVs, 15% had any adherence problem solving dialogue. ARV problem solving talk included significantly more directives and control parameter utterances by providers than other topics. Providers were verbally dominant, asked five times as many questions as patients, and made 21 times as many directive utterances. Providers asked few open questions, and rarely checked patients’ understanding. Physicians respond to the challenges of caring for patients with HIV by adopting a somewhat physician-centered approach which is particularly evident in discussions about ARV adherence.

Pocos estudios han analizado en detalle el diálogo entre médicos y pacientes sobre la adherencia del paciente al tratamiento con antirretrovirales (ARVs). Se describe globalmente encuentros entre médicos y pacientes en el tratamiento del VIH, con enfoque en el diálogo sobre ARVs, usando un sistema que aplica a cada enunciado un código para el tema, y para el acto de del habla.Estudio observaciónal con uso de grabaciones de consultas externas rutinarias de personas con VIH en clínicas especializadas.Los proveedores fueron 34 médicos y 11 proveedores de otras clases. De 415 pacientes, 66% fueron hombres, 59% Africano-Americanos. 78% informaron tomar ARVs actualmente.Aproximadamente 10% de los enunciados se refirieron al tratamiento con ARVs. Entres los que usaron ARVs, 15% tuvieron algún diálogo sobre la resolución de problemas de adherencia al tratamiento. El diálogo sobre la resolución de problemas incluyó significativamente más actos directivos y enunciados en la clase de control, comparado a otros temas. Los proveedores dominaron la conversación, hicieron 5 veces más preguntas que los pacientes, y 21 veces más enunciados directivos. Los proveedores hicieron pocas preguntas abiertas, y raras veces chequearon el entendimiento del paciente.Los médicos responden al reto de atender a los pacientes con VIH adoptando un acercamiento que se centra en el médico, lo que se evidencia particularmente en la discusión sobre la adherencia al tratamiento con ARVs.

Yep, you're probably nuts

My friend Gary G. discusses the upcoming, brand new, shiny DSM-V in the NYT. I believe I may have noted here once or twice that the psychiatric diagnoses aren't real entities. If a diagnostician makes the judgment that you have two from column A and three from column B of whatever subjectively rated symptoms are on the list, you get a disease label. But whether any two people with that label have the same disease, or any disease at all, is completely unknowable.

If Gary had more space, I expect he also would also have mentioned that applying disease labels to psychological traits or states is necessary in order to get insurance companies to pay for drugs, prescribers' time, and counselors. I will also extend his remarks (I'm sure he won't mind) to say that applying a disease framework has other important consequences.

Despite the complete lack of evidence (in fact plenty of evidence to the contrary) that psychiatric diseases are caused by "chemical imbalances" that are "corrected" by psychiatric medications, many people, including the psychiatrists who prescribe them, continue to believe that they are. And the disease framework is essential scaffolding to the deep cultural proclivity to respond to distress by finding a defect in the sufferer and trying to fix it by pumping in a chemical or some similar technical intervention. Perhaps we could look for the cause of suffering outside of the sufferer, and try to fix that; or decide that sometimes, it makes sense to suffer and that some good can come from it.

But no, all problems are medical.

Oh yeah -- Elsevier

I have spewed my malice at the greedy scientific publishing company a few days ago. My wrath has its response: A petition and boycott (to whatever extent you can manage) of Elsevier. I'm totally down with it.

Once again my passion to tread the boards is awakened

Believe it or not, I majored in theater (excuse me, theahtuh) in college and did quite a bit of acting in my youth. Got sidetracked by politics and science and whatnot but I do kind of miss it -- especially since I think I've figured it out and would be much better at it.

Anyway, I've been helping a colleague who is trying to train pharmacists to use Motivational Interviewing techniques to get people to take their pills. Actually it's more complicated than that but no sense getting into it. My mission is to role play a patient who is trying to control his blood pressure by losing weight and exercising and eating right and who believes he is succeeding based on his self-monitoring of his blood pressure at home.

Again, without going into further details or objections, this experience has driven home for me how very difficult it is for health care providers, of whatever particular stripe, to resist being Daddy. They typically see their job as getting us to do what they want us to do. That's okay, it's understandable, the whole point is they are experts and they're supposed to know what's good for us, otherwise why are they paid?

But there are major problems. If they don't actually know what's going on with us, they might just be wrong about what's good for us. However, if all they do is lecture us and threaten us with death if we don't carry out their orders, we are likely not to tell them what's actually going on because a) who wants to listen to that and b) nobody likes to be pushed around. In this case, the pharmacists saw it as their job to get me to take the pills, not to control my blood pressure. And they undermined my efforts to do it the natural way by insisting that hardly anybody could succeed at that so why don't I give up and take the pills? Having me not take the pills and keep losing weight would have been a defeat.

Now, admittedly, few people do succeed long term at weight loss and other behavioral risk modifications. That's why doctors give up very quickly and prescribe diabetes, hypertension, and cholesterol-lowering medications. On the other hand, half the people don't take the pills either. But they won't have an honest discussion with the doctor about that if all they'll get is flack.

Having played this part, I totally feel that way on behalf of my character. Supposedly the subjects have been trained and they're going to call me back and try again. I'll let you know how it goes.

I've never quite wanted to go there . . .

But, it looks like we're there anyway so let's talk about it. You may have heard tell of this new paper in Psychological Science, the essential point of which is that lower IQ is associated with prejudice and conservative ideology. I've sorta kinda danced around this in discussing the prevalence of liberalism in academia and the canard about "liberal elites," but it isn't really a very good debate strategy to accuse your interlocutors of not being the brightest bulbs on the tree.

So let's cut to the chase. The association of lower cognitive ability with social conservatism, endorsement of intergroup inequality, and authoritarianism is well known. It is not by any means a new discovery. This is a fact: people with higher measured IQs and better grades in school are more likely to be liberal, tolerant of difference, and open to social change. The authors of this study cite plenty of research going back a decade or more.

What this study adds is actually fairly modest. Using large, longitudinal data sets, they found that British children with lower cognitive ability were more likely to grow up to be adults to be racists; and that this can be explained in large part by their having more endorsement of right-wing authoritarian ideology. A separate analysis of U.S. children had similar findings with regard to anti-homosexual prejudice. "In psychological terms, the relation between g [a hypothesized general intelligence] and prejudice may stem from the propensity of individuals with lower cognitive ability to endorse more right-wing conservative ideologies because such ideologies offer a psychological sense of stability and order."

Put more simply, confronting the real complexity of the world is taxing for many individuals. It is easier for them to contemplate the world in simplistic terms, while they are disturbed by diversity, disorder and change.

While I have no doubt of this, it does not seem to be a finding that can usefully be imported into political discourse. Telling people that they are stupid, or that their beliefs are a marker of limited intelligence, won't win you very many arguments. So I'm not sure what we can really do with this information.

Slow Apocalypse Now

Our political system is determined to ignore the immense dangers of global climate change, but if James Murray and David King are right, they will have a harder time ignoring peak oil, because it's already here.

As they point out, in spite of the sharp jump in petroleum prices since 2005, global production has not increased. We're stuck at 75 million barrels a day globally, and the rate of production just doesn't respond to prices. Supply is totally inelastic, which is why the price has been so volatile. And forget about the Canadian tar sands and Brazilian offshore oil and all that saving us -- they can't even make up for the ongoing depletion of existing oil fields. To meet the The US Energy Information Administration projection of a 30% increase in production by 2030, they write:

If realistic declines of 5% per year continue, we would need new fields yielding more than 64 million barrels per day — roughly equivalent to today's total production. In our view, this is very unlikely to happen.

Non-conventional oil won't make up the difference. Production of oil derived from Canada's tar sands — sometimes called the 'oil junkie's last fix' — is expected to reach just 4.7 million barrels per day by 2035.

In fact, they don't think oil production will increase at all. It will likely decline. And the current bubble in natural gas production is almost over. Those fracking fields? They only last a few years.

The consequences for our civilization are, frankly, appalling. You might feel you can take some comfort that carbon emissions probably won't meet worse case scenarios, but they will continue, and the planet will continue to warm, even as struggles over petroleum resources grow more desperate and, quite likely, more violent. The reason is that we just aren't doing anything serious about this. The economy runs on fossil fuel and it can't grow or even keep going without it.

Taxes on billionaires, regulatory uncertainty, and Kenyan Muslim socialist health care aren't what's stopping us. It's peak oil.

Vocabulary

Reporters routinely refer to Mitt Romney as a "venture capitalist" and to Bain Capital as a "venture capital firm." Neither is correct. Venture capitalists underwrite high risk new enterprises, usually with innovative technology or business models. Most of their bets don't pay off but they hope to reap spectacular payoffs from the few that do, in other words they're looking for the next Google or Amazon. Romney has never been a venture capitalist. He and his pals bought existing companies, usually old and tired ones, and made money however they could -- sometimes by chopping them up and selling off the pieces, sometimes by breaking their existing deals with workers and suppliers, sometimes by shutting down less profitable parts and buffing up the balance sheets. That's not venture capital.

A headline on the CNN web site a few days ago said that six NATO "peacekeepers" had been killed in a helicopter crash in Afghanistan. There are no NATO peacekeepers in Afghanistan. The NATO forces in Afghanistan are combatants.

The NPR newsreader yesterday morning, referring to the prosecution of ex-CIA agent John Kiriakou for leaking classified information, said that the Obama administration has cracked down particularly hard on "breaches of national security." They've cracked down hard on leaks of information, alright, but whether those constitute breaches of "national security" is a matter of opinion, at best. Kiriakou revealed information about the torture of Abu Zubaydah. Is our national security harmed because we know that?

Of course, Politifact will never label any of these statements as lies, or even half truths. They're just the ordinary perversion of discourse.

Common Sense

You may feel that all taxation is theft, and that the nanny state should not be trying to influence us to do what's good for us, and that the corporations who sell us flavored sugar water are people. Okay, fine. But let's inject some facts into the discussion and see where that leads us.

As these folks point out in Health Affairs, Americans consume on average 45 gallons of sugary beverages every year. (That's soda, sugar sweetened tea, fruit punch (with minimal fruit, of course) "sports" drinks -- which are nothing of the sort -- all of that. It's all the same. Sugar, water and flavoring.) A 20 ounce drink contains 17 teaspoons of sugar. Those 45 gallons add up to 70,000 empty calories per person. So what, you say? Women who consume just one of these per day have been found to have an 83-98% increased risk of diabetes. It's partly because it makes them fat, and it's partly because it causes a glycemic spike. Put another way: that shit is poison.

So, these people figured out, based on estimates of how price would affect demand, that putting a one penny per ounce tax on these drinks nationwide would result in a reduction in the obesity rate of 1.5%, which means 867,000 fewer obese adults. It would reduce the incidence of diabetes over 10 years by 2.6%. This is even assuming that people would make up 40% of the calories by eating or drinking other stuff. If they didn't do that, we'd save $20 billion in medical costs. That would also mean 95,000 fewer cases of heart disease, 8,000 fewer strokes, and more than $17 billion in medical expenses averted.

Now, there are all sorts of caveats and reservations and what ifs behind all this, but the basic conclusion is clear. The price of these beverages does not reflect their cost to society -- the "externalities" of the transaction. We haven't even mentioned the cost to individuals of poor health, disability, and premature death. But those medical expenses are mostly paid by Medicare, which means you are paying.

So under which situation do you have more freedom? The situation where you can still choose not to poison yourself and save the extra 20 cents on a drink, while not having to pay as much for other people's health care not to mention your own? Or the situation we have now, where corporations are aggressively marketing poison to children and nobody is doing anything about it, but you have to pay the cost?

Freedom. It doesn't mean what Ron Paul thinks it means.

False consciousness

It's not exactly a news flash that we're living in a new gilded age. As human civilization reaches ever greater heights of accumulated wealth and power, it concentrates in fewer and fewer hands. This essay in the NYT by Chrystia Freeland puts our present plight in the perspective of economic history. The technological revolution in the developed world eliminates many of the white collar and pink collar jobs that kept the middle class afloat despite de-industrialization. At the same time, the industrial revolution in the formerly poor countries, combined with the rise of global transportation and information infrastructure, has allowed many of the remaining jobs that would have been stuck here to move to those emerging economies.

While our working and professional classes have suffered from this double whammy, our politics has turned in precisely the wrong direction. Market forces have created the decline of the middle class and the grotesque inequality we now endure; yet the public has turned against the activist government it desperately needs to correct the problem. The wealthy don't care about "creating jobs," and certainly not for people in the United States. On the contrary, it is precisely their decisions over the past 30 years which are to blame.

I won't go into the whole argument here about the fiction of the Free Market, I've been there before. But assuming readers are with me on this -- that we need to tax the rich and invest the money so as to give our people, not to mention our planet, a future -- the question is why so many Americans of modest means have been convinced to vote against their own interests and to direct their rage and precisely the wrong targets.

Or I might better say, non-existent targets. Who or what are the "liberal elites"? Elites are not liberal. Mitt Romney, Newt Gingrich, and the Koch brothers are elites. They are also not liberal. But they are the very people who are screwing you.

College professors do tend to be more liberal than average -- I maintain that's because reality has a liberal bias -- and we are kind of elite in that it takes a lot of luck and effort to get one of these jobs and keep it, but believe me we a) aren't rich and b) aren't running things. All we do is blather. You can dislike my philosophy and values if you like, but I'm not causing you any problems and I certainly don't have any way of forcing you to think the way I do.

I don't know if doctors and lawyers and other professionals particularly tend to be liberal but again, they only way they get to be elites in any sense other than a bit of social status is if they become fabulously wealthy, and those examples, I'm pretty sure, are not generally liberal. (Viz. Bill Frist.)

Nevertheless, the right wing propaganda machine has managed to channel people's cultural resentments and insecurities against this mythical "establishment," and thereby insulate the real establishment from popular wrath. That Newt Gingrich, the ultimate Washington insider and wealthy grifter could become a populist champion is truly bizarre. But there you have it -- the real, shadowy establishment will spend a billion dollars this year on television advertising to drive that transparently ludicrous lie deep into the collective consciousness. They just might succeed.

The most corrupt Congress ever?

I don't know for sure, Mark Twain famously said that "It could probably be shown by facts and figures that there is no distinctly native American criminal class except Congress." But this latest attempt to sell us out to our corporate overlords particularly frosts my pumpkin because, as long-time readers know, I'm obsessed with open access publishing.

Science, especially science that is funded by the taxpayers, as most basic medical research is, belongs to all humanity. But right now, subscriptions to scientific journals cost hundreds of dollars which means that people without library privileges at universities can't read them. Universities in the poor countries can't afford them which means nobody there can read them. Even here in the U.S., academic libraries -- including the library at my institution which is one of the wealthiest universities on earth -- are being forced to prune their subscriptions. And guess what? The biggest academic publishers are for-profit corporations.

So, in 2008, NIH made it mandatory that research it financed become free to access through the National Library of Medicine 12 months after publication. Remember -- you paid for it. So comes now the Research Works Act, heavily promoted by the Association of American Publishers -- the scholarly and professional publisher's lobby -- to reverse the policy and put government funded research back behind the paywall. Elsevier, the biggest academic publisher, and the AAP have spent $6.3 million lobbying over the past three years, writes Keith Epstein in the new BMJ. (Ironically, behind the paywall -- they make their research articles open access, but not their news and commentary. Yeah, I have a beef with that.) By the way, Elsevier is highly profitable -- their profit margin, even in the recession, is 36%. And the publishers have, of course, contributed heavily to the campaigns of the Act's sponsors, Darell Issa (natch, one of the worst tools in congress) and Carolyn Maloney of New York, who really ought to know better.

You know what to do -- let your Congresscritter know that you oppose the Research Works Act. The scientific knowledge that you pay for belongs to you.

They aren't in business for their health . . .

. . . or yours, necessarily. Mike Mitka, in the new JAMA, discusses recent findings on what happens when physicians have a financial interest in medical imaging services. (I think you aren't allowed to read it because you are mere commoners, so I've linked to the extract.)

It is common for orthopedists to invest in MRI scanners and such, and it has long been observed based on insurance data (what we in the biz call "claims" data) that they tend to send more of their patients to have pictures taken of their insides when they get a piece of the action. However, the docs who do this claim that their patients just happen to be sicker or in more pain than other doctors' patients. I agree that doesn't seem highly plausible, but they say it anyway. Mitka reports on research done at Duke that finds a group of orthopedic surgeons who had an interest in MRI scanners had 86% more negative scans than a group with no such interest. Put another way, 42% of patients from the financial interest group had negative scans compared with 23% from the group without a financial interest.

A meta-analysis (pooling data from various studies) of claims data finds that physicians who do such "self-referral" do more than twice as many imaging tests as physicians who refer out to an independent radiologist, in all sorts of conditions.

I tell you all this because it is just one more way in which the mythical "free market" does not work in health care. It is what we call provider induced demand. Patients don't decide whether they need an MRI, doctors do. And if doctors are getting paid to do them, they'll do more of them, whether you really need it or not. And no, it wouldn't work to have you pay out of pocket because you have no idea whether you need an MRI or not and chances are, you wouldn't get one if you really did need it.

The solution is to make sure that doctors make these decisions untainted by financial interest, one way or the other. In other words, this just doesn't work as a market transaction. There are lots of other reasons why it doesn't but this one ought to be obvious even to Ron Paul (although I doubt that it is).

The most straightforward, best and smartest solution is universal, comprehensive, single payer national health care. That's what we need.

Here we go again

Yet another prominent, highly productive "scientist" has been caught making it all up. This time it's Dipak Das, who was director of the Cardiovascular Research Center at UCONN. His research focused on resveratrol, which you have probably heard of -- it's a compound found in red wine that has been thought to have anti-aging properties, although unfortunately it's not looking so great lately. This doesn't help, so if you have been using the whole resveratrol thing to rationalize getting schlozzed every afternoon, you'll need another excuse.

Anyhow, if you're interested (and you probably aren't), you can look at the university's investigative report here. The whole thing is (literally) 60,000 pages long but it's summarized up front. Basically, the university concludes that he was photoshopping his western blots. (That's a method for detecting specific proteins in samples.) His entire program of research was evidently fraudulent. They're stripping him of tenure and firing him. Oh yeah, they're giving up $890,000 in NIH funding. And there are more than 100 published papers which are now either shown to be fraudulent or suspect.

This and other recent cases are not starving post-docs desperately trying to compete for the few available faculty spots. You could understand that even if it's sad and bad. (Plenty of Ph.D.s are driving cabs these days.) These are very senior people with fancy titles and big time salaries, and plenty of money with which to do honest science. The moral depravity of this conduct is just astonishing. It's not just stealing money, and obstructing scientific progress. It's harming patients, maybe even killing people; and it's potentially ruining the careers of the students, fellows, post-docs and junior faculty who worked under him, not to mention the more diffuse damage to the institution and everyone connected with it. The swath of destruction is just incredible. I simply cannot believe that anything like that could happen where I work but I'm sure that's what people thought in all the places where this has happened.

So, comes now the obvious question. Why? I honestly cannot tell you. Sure, when you set out on an investigation you may have hypotheses that you cherish, that if proven true will open up a road you really want to go down. But it's nonsensical to think of a rejected hypothesis as a failure. You hear that language all the time -- the experiment "failed" -- but that's completely wrong. The experiment showed what it showed. Ruling out a hypothesis is just as much a contribution to knowledge as confirming it. Okay, that didn't work, try something else.

One problem that probably does contribute is publication bias. For reasons which are not entirely clear to me, it's usually harder to get negative results published. That never made any sense, and it is starting to change, but it's still there. Another problem is that it may be harder to get the next round of funding if you can't build directly on previous work. Proposal reviewers like it if your work so far leads logically to the proposal they are seeing now, and that may be harder to argue if you've had negative results. However, in my own work at least, I've had no problem making lemonade out of my negative results, it just takes the imagination to see their implications.

So I can only conclude that this behavior must have started way back, before the guy made it big, and it's actually been the basis of his whole career. It came to be the thing to do, in for a dime, in for a dollar. Think Bernie Madoff. Anyway, it is just enraging.

Oh yeah, I forgot to mention the damage to the reputation of science itself. With one of the two major political parties in the U.S. running against science as an institution and a philosophy of knowledge, we really can't afford that.

All the roots grow deeper when it's dry

I grew up in the Sixties -- which lasted from 1964 to 1974. To place myself more precisely, I graduated from high school in 1972, so I missed the SDS and the stolen FBI files and all that stuff at Swarthmore but still got swept up in enough momentum to spend my 20s and early 30s as a full time activist. Yeah, I was an ACORN organizer, among other $80 a week movement jobs. Poor people voting and demanding decent services in their neighborhoods and jobs and housing is not actually contrary to American values, by the way. Martin Luther King and the civil rights and poor people's movements were obviously a major inspiration for me.

In spite of the inexplicably popular presidency of Ronald Reagan, we still maintained that vision of a more just and humane future. It was just going to take a little longer than we had expected.

So looking back on the past 40 years this MLK day, what do I see? That the fundamental trajectory of the era would be plutocratic ascendancy, reactionary religious revival and resurgent militarism is astonishing, preposterous, nearly inexplicable. Here we are trying desperately to hold on to the basic social infrastructure forged over 50 years, from FDR to LBJ. Even voting rights and basic values of secularism are in retreat; and the hardest times and greatest economic inequality since the Great Depression have produced, not a mass movement for justice and equality, but an uprising of moderate income people on behalf of wealth and privilege. Our hard won scientific understanding of the biosphere and our relationship with it has been simply rejected, by political consensus, and we are destroying the very world that enables our existence to satisfy the immediate greed of the wealthiest.

The title of this post is a song by David Wilcox.

It looked so easy, we change the weather
We would turn this world ourselves, our world so small.
But slower rhythms still unheard of
Said that every blessed summer someday has to fall.

Prosperity will have its seasons
Even when it's here it's going by.
When it's gone we pretend we know the reasons,
And all the roots grow deeper when it's dry.

Sympathy for the devil

Or rather, for some minor demons who might prefer to be cherubs but they are what they are. That would be our modern class of journalists.

Yes,it seems utterly ridiculous for the purported representative of the readership at the New York Times to be asking whether reporters should bother to point it out when politicians lie. But it compels us to ask how the culture of journalism could end up in a place where that actually seems problematic to its practitioners.

They must inhabit and transmit the political culture, and the fundamental problem of our age is that we have had a breakdown of epistemological consensus. To me, it is a fact that burning fossil fuel increases the atmospheric concentration of CO2 and makes the climate warmer; it is a fact that increased federal deficit spending counteracts recessions and that the stimulus package of 2009, however inadequate, saved millions of jobs; it is a fact that Barack Obama has never "apologized for the United States" and that he has not "slashed military spending" but increased it; it is a fact that taxes have been cut, not raised, under the Obama administration; the health care reform act is not a "government takeover" of health care. And so on.

But conservatives repeatedly, relentlessly, say otherwise. Just about everything they say is objectively false (except for normative statements such as "abortion is murder," which are another category). So, if you are a reporter covering the Romney campaign, for example, every story would have the headline "Mitt Romney lies about X, Y and Z." I believe that would be objective and balanced, but half the country would see it as advocacy journalism and confirmation that the New York Times has a liberal bias. The Times doesn't want to be perceived that way, so what can they do?

Satire is obsolete

I caught this via Atrios. The New York Times "Public Editor" asks readers to weigh in on whether reporters should point out when politicians tell lies, instead of just transcribing the lies as they normally do.

Apparently he finds that an odd concept -- of course that isn't their job -- but he's been getting all this puzzling mail complaining that they don't do it, so please explain it to him.

I'll retire to Bedlam.

Where was I yesterday?

Answer: I was transferring my driver's license and motor vehicle registration from Massachusetts to Connecticut. It turns out this is approximately like getting a top security clearance. Because my passport gives my name as Cervantes, Jr., and my birth certificate lacks the "Jr." it became a federal case. I was there for 3 1/2 hours before I finally managed to avoid getting sent to Gitmo. After all that I didn't feel like doing a blog post.

Anyhow, I owe the world one so here are two essays in the new JAMA that have something to do with each other, one on patients who request interventions their physicians believe are useless or potentially harmful, the other on court involvement in disputes about end-of-life care, focusing mostly on families who refuse to pull the plug when their doctors want to (the other category being disputes between family members, a la Terry Schiavo, but that's another kettle of fish).

What both of these discussions highlight is the evolving conception of the physician's ethical obligations and the physician-patient relationship. We have experienced a major shift in cultural expectations since I first studied medical sociology some 20 years ago. On the one hand, from Talcott Parons's conception of the "sick role," in which one of the obligations of the sick person was to obey "doctor's orders," we have moved to an ideal of "patient centered" medicine in which patients make informed choices on their own behalf. (I said that's the ideal -- it isn't so much the reality. I will have a good deal to say about that down the road.)

On the other hand, while we once presumed that the physician's sole ethical responsibility was to the individual patient, given the unsustainable growth in medical spending, physicians are increasingly expected to be stewards of society's, or at least the health plan's resources. They are expected, and in some cases paid, to limit medical spending. Now, that doesn't necessarily conflict with the individual patient's interest. In fact, it's generally maintained that the obligation is to maximize both efficiency and patient welfare, and that there is no paradox because right now, much medical intervention is not justified by the balance of risk and benefit.

This is certainly true, but as these essays indicate, conflict does often arise between the ideal of appropriately limited medicine and patient autonomy. Whether they are husbanding society's resources or interpreting patients' interests according to their own calculus, physicians may conclude that beneficence conflicts with patient choice. This puts them in an uncomfortable position. Many simply acquiesce, as by prescribing antibiotics for cold symptoms or ordering imaging or other tests that patients demand, but for which no benefit is expected.

While the authors of both pieces say that physicians should take the time to have better discussions of these issues with patients and families, they don't address the reasons why this doesn't happen. There are at least two. One, they don't get paid to do it. They get paid a standard (and inadequate) amount for an office visit, whether they take extra time for a discussion or not; and they get paid to do procedures -- which is exactly the wrong incentive. Second, they don't know how to do it. Physicians are taught the biological science of medicine, but the interpersonal art gets short shrift.

We can't solve this problem just by writing about it and exhortation. We need basic change in both the organizing and financing of medicine; and the culture of medical training and practice. That's like sweeping the beach. But we must do it.