The Big Sleep

This study by Daniel Kripke Robert Langer and Lawrence Kline in BMJ Open has gotten some publicity. But in case you haven't heard about it, it's time you did. They used data from electronic health records of Geisinger Health System, which serves a quarter of a million people in Pennsylvania.

They found that people who were prescribed sleeping pills had an excess mortality risk, over an average 2.5 years of observation, of more than 5 times for people prescribed the top third number of doses; but there was still a substantial risk for people prescribed fewer than 18 doses in a year. This pretty much applies to all kinds of sleeping pills, although the inference is strongest for the most commonly prescribed drugs, which are Ambien and similar chemicals. And it applies to all ages -- young and old. Oh yeah -- people who took sleeping pills also had an increased of being diagnosed with cancer after they got the prescriptions.

So, this just shows association, not causation, right? Technically yes, but they beat this data to death to try to rule out confounding. It is true that people who got prescriptions were more likely to have all sorts of pre-existing conditions, from asthma to heart disease to obesity. But they controlled for that. These risk ratios are for people who have the same comorbidity profile, same smoking status, and similar age. If taking sleeping pills isn't killing people, it's very hard to see what else could be.

They didn't just do this for the heck of it. There have been a lot of observations that seem to link sleeping pills with mortality but the evidence hasn't been of high quality. This is. And it isn't really all that hard to think of reasons. Sleeping pills have been associated with the onset of depression, with suicide, with accidental drug overdoses (e.g. mixing them with alcohol). Controlled trials show they cause impaired driving, more falls, bizarre behavior such as somnambulist binge eating, gastric reflux, and more infections. They may be directly carcinogenic. As these authors conclude:

The meager benefits of hypnotics, as critically reviewed by groups without financial interest, would not justify substantial risks. A consensus is developing that cognitive-behavioral therapy of chronic insomnia may be more successful than hypnotics. Against meager benefits, it is prudent to weigh the evidence from the current study and 24 previous reports, in order to reconsider whether even short-term use of hypnotics . . . is sufficiently safe.

Indeed. You will see these drugs heavily advertised on TV. I'm not a real doctor so I'm mustn't advice, but I sure as hell wouldn't take these and I really won't like it if you do. It's probably time to think about revoking approval.

Visionaries and fools

I have written here before about Galileo, in particular his Dialogue Concerning the Two Chief World Systems in which he inhabits intellectual territory hundreds of years ahead of his time. He was a foundational scientist because he was at the same time an adept constructor of apparatus, a clever experimenter, an accomplished mathematician, and an intuitively brilliant theoretician. Nowadays we generally have a division of labor among these roles. In that sense, perhaps, there will never be another Galileo.

Paula Findlen, in The Nation, reviews two new biographies of Galileo, by John L. Heilbron and David Wootton. The main difference in their evaluation of this person for the ages is the extent to which he may have abandoned faith. Of course he had no choice but to make an outward appearance of piety. The question is whether he ultimately concluded that religion was not consistent with reason. (His public statement on this question, in Letter to the Grand Duchess Christina, was very much like modern accomodationism: that they occupy separate realms and concern separate kinds of truth. Read Pharyngula [link in the side bar] if you want to hear this notion repudiated on a semi-daily basis.)

My feeling from the Dialogue is that he could not possibly have accepted Christian doctrine. He considered the universe to be infinite and to have no center; and he also demonstrated that he was aware of the earth's great antiquity, although no doubt he greatly underestimated it just as he underestimated the distance to the stars. But it is difficult even for us who have actual knowledge of the vastness and age of the universe to comprehend it. In any event, Galileo was rational enough to know that without the creation myth and the garden and the fall, indeed without there being anything special about the earth and humanity, Christian theology is nonsensical. Yet today, many people happily accept the doublethink needed to avoid this conclusion.

But all this is just by way of getting to real point, about Rick Santorum, who has recently compared himself to Galileo. Santorum's idea is that he, Rick Santorum, is sufficiently wise and courageous to recognize that anthropogenic global warming, which he sees as a religious doctrine, is false, and to say so publicly; and that like Galileo, he will be vindicated by history.

That is quite amusing. The theory of global warming is not, of course, a religious belief. It is a conclusion based on understanding of the climate system and an immense body of direct observation. And the scientists who study climate are not threatening to burn Rick Santorum at the stake, nor, unlike the Pope, do they have the power to do so. Galileo, in the end, had no taste for martyrdom, and not wanting to suffer the fate of Giordano Bruno, famously recanted. But the only fate Santorum will suffer for what he would like to think of as heresy is to see Texas made into a desert and Florida beneath the sea. That's a lot fewer Republican voters to pander to.

There's good news and bad news . . .

(I'm up to my eyeballs in proposal reviews, so limited blogging for another day or two.)

We've known for a while that people who have colonoscopies have a lower risk of colon cancer than people who don't have the procedure, because doctors can actually remove pre-cancerous lesions, called adenomatous polyps, in the process. This follow-up study find that, after almost 16 years, the death rate from colon cancer is also lower for people who have had polyps removed than it is for the general population. Specifically, out of 2,602 people who had polyps removed, 12 ultimately died from colorectal cancer, compared to an expected 25.

For various reasons, this number is not definitive. This is not a randomized controlled trial, so people who have colonoscopies may be different in any number of ways from people who don't. And the numbers of deaths are small so the confidence intervals are pretty wide. Still, it seems likely that yes, getting a colonoscopy will reduce your risk of dying from colorectal cancer.

Now for the bad news. According to my back of the envelope calculations, it cost about $200,000 per person to avert (or rather delay, since everybody dies) those deaths. (That's assuming a colonoscopy costs $1,000; I think the average is actually slightly more, but close enough for jazz.) And, during the follow-up period, 1,233 of those people died of other causes. So, we need to ask, what else could have been achieved with the total of $2.6 million that was spent on these colonoscopies?

That's always the question, I'm afraid. You may think that you can't put a price on a life, but you don't have infinite resources. So you're wrong about that. We have to make choices, like it or not.

Running on Empty

I'm referring to the Democrats, who inexplicably do not bother to take credit for, or even mention, their achievements. I'm ultra busy right now because I'm reviewing proposals for the Center for Medicare and Medicaid Innovation's (CMMI) innovation challenge grants. I'm also part of a group that applied for one of these, which is okay because I'm not reviewing any proposals that compete directly with ours. And, as I believe I have mentioned here before, we also applied for a grant from the Patient Centered Outcome Research Institute (PCORI).

Since I have a (long shot) chance to get funding from one or both of these agencies, it probably doesn't carry a lot of weight that I'm for them. But most voters would be for them, and would have a better understanding of the Patient Protection and Affordable Care Act, aka Obamacare, and would like it a lot better, if they had ever heard of either one of these, which they have not, because president Obama and the Democrats in Congress never mention them in public.

Briefly they are both important, and complementary initiatives to make health care in the United States better in three ways: better health outcomes; better patient experience of health care and more patient empowerment; and less costly, more efficient health care. PCORI sponsors research to figure out what health care interventions -- drugs, imaging, surgery, lifestyle changes, you name it -- work best for which people; and how people can get the information and power within the health care system to make the choices that are right for them. CMMI sponsors demonstrations of reforms in the organization, financing and delivery of health care that will enable us to actually deliver all that best health care to people.

This is what we need, desperately, if we are to catch up to the rest of the world in quality, outcomes and affordability. No, we don't have the best health care in the world, we have the worst among the wealthy countries. We need to fix it, and that's what the Obama administration is working on. In secret.

Ratz

It's difficult to think of any distinct group of people with less moral authority than the Catholic bishops. The Sinaloa drug cartel comes to mind, or the North American Man-Boy Love Association. Come to think of it, NAMBLA is much less hypocritical. Even the people who sit in the pews on Sunday and listen to them recite their meaningless mumbo-jumbo agree with me: 90% of them commit the mortal sin of contraception.

Why then have we spent the past couple of weeks trying to placate them and undertake obsequiously to deny that we would ever give them offense, because they claim that the almighty creator of the universe grants them the absolute right to disobey the law? Worse than that, the whole argument morphs into whether anybody should have access to contraceptives and whether anyone -- well, anyone who is an employer, that is -- should be able to disobey any law they wish if it offends their "moral conscience." Feeling the wave, the freak who is leading in the polls for the Republican presidential nomination starts running against the president's "theology," which he claims is not based in the Bible.

Fortunately, the scientific community is finally recognizing the mortal threat we face from the suddenly resurrected 13th Century, but you have to read a British newspaper to hear about the meeting of the American Association for the Advancement of Science, which happened unnoticed by Americans. Robin McKie of The Guardian reports that AAAS president Nina Federoff told the gathering:

"We are sliding back into a dark era, and there seems little we can do about it. I am profoundly depressed at just how difficult it has become merely to get a realistic conversation started on issues such as climate change or genetically modified organisms." . . .

As Fedoroff pointed out, university and government researchers are hounded for arguing that rising carbon dioxide levels in the atmosphere are changing the climate. Their emails are hacked while Facebook campaigns call for their dismissal from their posts, calls that are often backed by rightwing politicians. At the last Republican party debate in Florida, Rick Santorum insisted he should be the presidential nominee simply because he had cottoned on earlier than his rivals Newt Gingrich or Mitt Romney to the "hoax" of global warming.

McKie goes on to discuss how immense business corporations such as Exxon-Mobile, and billionaires such as the Koch brothers, are financing the campaign to destroy the cause of science in pursuit of nothing more than their infinite greed. Now, the Supreme Court has removed all restraints on their activities. Unless these evil bastards are stopped - exposed, disgraced, forever more ignored - and very soon, we are doomed. Rick Santorum? Really?

Another Democratic "Compromise" . . .

. . .that's a total cave. Yeah, Congress is apparently going to pass an extension of the payroll tax cut -- which was a terrible idea in the first place but it's the only economic stimulus Obama could get through Congress. And they're going to pass the so-called "doc fix" without threatening to shut down the government first. This has to do with an arcane statutory provision called the Medicare Sustainable Growth Rate, which basically requires a periodic vote to prevent reimbursement to physicians from being deeply slashed, kind of like the debt limit problem. What really needs to happen is that reimbursement rates for specialists should indeed be reduced, and more support should go to primary care, but that's a fight for another day.

But how are they going to pay for this? Funny you should ask. They're going to rip $5 billion out of the Prevention and Public Health Fund, one of the signature achievements of the health care reform act. We spend about 5% as much on preventing disease as we do on treating it once it's already happened. That makes no sense. But Republicans hate the idea of preventing disease -- they call the PPHF a "slush fund," whatever the heck they mean by that.

Why do they hate the idea of preventing disease? I'm not entirely sure, but maybe it's partly because a major way of doing that is to counteract corporate marketing of tobacco and junk food. Anyway, here's how Pennsylvania, for example, is spending its share.

It is not a win to slash spending on public health and give the money to highly paid medical specialists to try to fix the damage that could have been prevented. It's a massive surrender.

We need better Democrats.

We get e-mails

I'm not a real doctor, I'm a doctor of philosophy. But I publish in medical journals and consequently get a lot of interesting mail. Allow me to share:

Hi,

The American Society of Plastic Surgeons (ASPS) released their 2011 statistics on the increase in cosmetic surgery procedures just last Thursday. 13.8 million cosmetic plastic surgery procedures were performed in 2011, up 5% from 2010 and 5.5 million reconstructive plastic surgery procedures were performed last year, up 5%. This statistic proves that cosmetic surgery is an industry on the rise, however with the increase in procedures comes an increased risk of complications. Financial protection during cosmetic surgery is key and important to cosmetic surgeons all around the world especially for CosmetAssure founder and plastic surgeon Dr. James Grotting.

Endorsed by the ASPS, CosmetAssure is an affordable solution that helps patients of elective cosmetic surgery avoid the financial burden of unexpected post-surgery complications. CosmetAssure is offered in 45 states nationwide including DC and boasts over 500 participating surgeons. Dr. Grotting is available for an interview to speak to the new statistics and the importance of having CosmetAssure when embarking on an elective procedure.

WHY THIS IS IMPORTANT:

· Traditional health insurance policies refrain from covering costs incurred from complications that arise from plastic surgery. Most people who go in for cosmetic surgery have no idea that if they were to have a medical complication following surgery, their own health insurance most-likely would not pay.

· The average cost of treating medical complications following cosmetic procedures is $5,500+.

What people will endure, and risk, for the sake of vanity, is a sad commentary on the human condition. Anyway, if you're going in for a bubble butt, giant plastic boobs, or phony Batman biceps, do consider getting insurance.

Okay, lots of politicians flip-flop . . .

But in consecutive sentences?! Willard M. Romney:

By Shira Schoenberg, Globe Correspondent

Republican presidential candidate Mitt Romney is already attacking President Obama’s 2013 budget, which is being released today.

The Associated Press reported that Obama’s budget would reduce the deficit by $4 trillion over 10 years by cutting spending and raising taxes on the wealthy. House Republicans are already preparing their own budget that would make more cuts in entitlement programs like Medicare but would not increase taxes.

In line with the Republican view, Romney criticized Obama this morning for doing nothing to reform entitlements. “This week, President Obama will release a budget that won’t take any meaningful steps toward solving our entitlement crisis,” Romney said in a statement e-mailed to reporters. “The president has failed to offer a single serious idea to save Social Security and is the only president in modern history to cut Medicare benefits for seniors. I believe we can save Social Security and Medicare with a few common-sense reforms, and – unlike President Obama – I’m not afraid to put them on the table.”

So Romney is criticizing Obama for "cutting Medicare benefits," and for not cutting them enough. Actually, as usual, he's not only contradicting himself, he's lying. Obama has not cut Medicare benefits; he has reduced payments to so-called "Medicare Advantage" plans, for-profit managed care plans that were basically bilking the government by charging more than it costs to provide standard Medicare. It's Romney and the Republicans who want to cut Medicare benefits. Those are the "common sense" reforms he's referring to, specifically turning Medicare into a voucher program.

What is truly sad about this is that the Republicans successfully ran in 2010 by accusing the Democrats of cutting Medicare. Romney is trying the same trick again, but since he really does want to cut Medicare benefits, in fact that's a core plank in his platform, he ends up with this bizarre double talk.

It's difficult to believe the voters could fall for this but they already did once. Now they're running against contraception, the successful rescue of the auto industry (for which the treasury has already gotten its money back), higher taxes for the wealthy, and the withdrawal from Iraq, all of which are highly popular. And they're trying to walk this tightwire of being the defenders of Medicare and Social Security while simultaneously being against spending money on them. I don't how whether the Koch Brothers have enough money to make this work, but nothing can surprise me any more.

1935?

In case you don't remember, that was the year Hitler repudiated the Treaty of Versailles and ordered German rearmament; and passed the Neurenberg Laws depriving Jews of German citizenship. There is no equivalent of Nazi Germany today. The purported "threat" from Iran is utterly specious. So no, despite the economic parallels I don't see 1935 as a good analogy for the present critical moment. However, I do worry about a parallel to 1914, when WWI began, as a result of various minor disputes and posturing, mostly over central Europe, spiraled out of control.

This time, it's instability in the Middle East. No, not Iran's nuclear program, although the hype about it, the Israeli threat to bomb Iran, and the ongoing covert war between Israel and Iran make the mix all the more volatile. What worries me is the likely collapse of the Syrian regime, which threatens a sectarian civil war that will draw in Syria's neighbors and quite possibly blow Iraq apart in the process is the most worrisome prospect. Lebanon, Bahrain, and other countries in the region with sectarian and ethnic fault lines could also be destabilized. Of course Egypt and Libya are already very shaky and even Jordan is starting to look wobbly.

As the U.S., Russia and China maneuver to protect their interests and pick up the pieces -- with the U.S. very much in thrall to whatever the Israeli government claims is in its interest -- unpredictable complications will ensue. The likelihood of the great powers coming into direct military conflict is very small, but the consequences for the world economy as the most important oil producing region blows up and the the rest of the world falls to squabbling could be dire. What happens after that is unforeseeable.

I write this not to ruin anyone's day, but to proclaim that no, more than ever, is a time for statesmanship and international cooperation. Instead we're hearing a lot of bellicose nonsense from people who are only interested in partisan advantage, and who have no understanding of the people and politics of the Middle East.

News of the Weird

"An Illinois man was sentenced Friday to more than three years in federal prison for shipping unwanted penis enlargers to diabetes patients in a scheme to bilk Medicare out of more than $2.2 million."

It turns out he would just mail the devices to people and then bill Medicare for $284. And they paid.

George W. Bush apparently thought Medicare fraud was jes' fine, but the Obama administration has been cracking down. As you may recall, they made a $295 million bust in September. What is astonishing about this is a) how easy it was and b) that most of the perpetrators are physicians. When my own father was in a nursing home, with dementia, all sorts of services kept showing up on his statement that he definitely hadn't received and did not need. My mother tried complaining to the administration, but they didn't do anything -- quite possibly because they were getting a cut. We can hope that Eric Holder will continue to make progress on this front. Medicare is in enough financial trouble without all this blatant theft.

Dr. Pinocchio?

Some of what's in this survey in the new Health Affairs (you only get to read the abstract but that's probably good enough) isn't quite straightforward to interpret, but on the whole it gives one pause. It seems that about 1/3 of physicians who responded do not entirely agree that they are obliged to disclose significant errors that they make to their patients. More than 11% think they don't have to fully inform patients of the benefits and risks of treatments, and 17% think it's okay to tell patients "something that is not true." More than 1/3 also think they don't have to disclose financial relationships with drug and device companies.

As for fessing up to actually doing stuff like this, yep, 11% say they have in fact told a patient or child's guardian something that is not true in the past year. Now, that could be ethically justified, if, for example, a pediatrician concealed something a child said in confidence. (In fact, under the laws of most states, children of varying ages less than 18 can seek reproductive care or substance abuse treatment without parental knowledge or consent.) The authors don't go into this possibility. But it isn't just pediatricians who reported doing this.

More strikingly, more than half said they had described a patient's prognosis in inaccurately positive terms. Some said they did this often. Now this does constitute telling them something that is not true, but I guess they don't necessarily see it that way. And 20% fessed up to not disclosing a medical error because they didn't want to be sued. And watch out for this one -- 28.4% said they had violated a patient's confidentiality.

This is just what they admit to, and even though it's confidential, we social scientists know that "social desirability response bias" is to be expected. That is why, for example, hardly anyone will tell an interviewer that they don't like black people or stuff like that. You have to figure it out by trickeration.

I'm not sure what to make of this. Res ipsa loquitur, I suppose, but I will make a couple of comments. It's human nature not to want to give people bad news, and it used to be the norm to conceal dire prognoses from patients. But it's no longer considered ethical, nor in the patient's interest emotionally or otherwise. As for concealing conflicts of interest, that's just one more evidence of the corruption that is deeply embedded in the professional culture. It's sad, really. As for not confessing to mistakes, what evidence there is suggests that makes you more, not less, likely to be sued. And I suppose many of those violations of confidentiality were inadvertent or thoughtless and immediately regretted (elevator talk). But still . . .

At the medical school where I used to teach, we had a first year course called Patient, Doctor and Society, where we tried to instill some professional values right up front. Then they canceled it because students were complaining it took up time they needed to cram for the anatomy final. I don't particularly care if my doctor remembers the names of all the bones in the ankle. I do care if he lies to me.

Hellas in a Handbasket

Greece has long been one of the least affluent countries in Europe. Nevertheless, we certainly think of it as a developed nation with a well educated population and a First World standard of living. To be sure, the country has been badly governed, resting on a dysfunctional political culture, and there was no way to avoid a day of reckoning.

But . . . As Keith Miller reports for NBC, the catastrophe is just horrific, and little noted or truly appreciated in the U.S. Economic catastrophes are always public health catastrophes as well. Greece is no exception. Miller reports that hospital admissions are up 25% (even as hospital budgets have been cut by 40%) and suicides have increased by 40%. Hungry and homeless people are flooding the streets, and money is running out for soup kitchens and food pantries. We've grown tolerant of famine in Africa, but how will the wealthy world react to famine in Europe?

All of this, of course, is caused by the power of what is essentially a fictitious device, money. The Greeks are being forced to starve themselves in order to ship whatever they have to their creditors. The resulting collapse of economic activity gives them even less with which to pay, and into the malestrom they descend. As Atrios has grown tired of pointing out, they could simply refuse to pay. True, they wouldn't be able to borrow any longer, but they can't borrow now. In addition to profligacy, they are in this trap because they don't have their own currency and they can't expand their money supply.

All this is, as MacLeish wrote in Panic, something like (I'm remembering from a long-ago reading) "Blight: Not on the grain. Drought: Not of the rain." Nothing objectively has happened to stop the Greek economy from functioning except that the money is being bled out of it. The factories, farms, fishing boats, stores and trucks are still there and they still could work just fine. Money isn't real, it's just symbolic. Yet there you are, sacrificed on its altar.

'Tis a puzzle

This may seem a bit off topic for Stayin' Alive, but it's my blog and I can do what I want. Frankly, I never understood what the point was of the $750 million U.S. embassy building in Iraq and the 2,000 diplomats and 14,000 other staff who are supposed to be stationed there. The Iraqis never understood it either -- as one is quoted saying, "Perhaps they want to run the Middle East from Iraq, and their embassy will be a base for them here."

If so, it didn't work out. The State Department has suddenly figured out that the whole thing is utterly pointless and they're planning to scale it back. That's great! We'll save a few billion dollars a year. (BTW that also means we can maybe get by without the 10,000 member mercenary army. Thought we'd withdrawn all our troops? Not exactly. We hired civilian mercenaries to do the same job for three or four times as much money.)

It appears that it took even Barack and Hillary until right now to realize that invading and occupying Iraq and trying to run the country for a few years didn't actually get us anything. In fact they hate us. Iraq has recently signed a trade agreement with Syria intended to help Syria evade sanctions -- it allows free transit of goods intended for Syria through Iraq. They're making all their oil development agreements with European and Chinese companies. Iraq is best buddies with Iran. U.S. personnel in Iraq are still routinely attacked. But since nobody has the slightest idea why the U.S. invaded Iraq in the first place or what exactly the hell President Cheney was trying to accomplish, I suppose it doesn't really matter.

Now, on the other hand

Having celebrated the wonderfulness of the modern age in my last post, I am now compelled to ponder the converse: we progress by traveling up the edge of a knife. The great advances in public health and lifespan touted by Dr. Fauci, and Stephen Pinker's recent widely noted assertion that we have entered an age of comparative peacefulness and non-violence, the recent gains in prosperity in the vast populations of Asia, the emergence of relative stability and democracy in Latin America and the particularly notable improvements in Brazilian economic and civic life -- these and other developments have given renewed credence to the thesis that human history is inherently progressive.

My master's thesis was title "Which Way is Up? Social Welfare and the Ideology of Progress." Back then (1978 to be exact) I questioned that claim. It was of course a central tenet of Marxism and continued to be essential to later Soviet Communist though, derived from German philosophical strands that also informed Nazism. (Non-identical cousins if ever there were.) And, perhaps a bit ironically, it is strongly associated with modern conservatism (viz. Robert Nisbet) and neo-liberalism alike (which emerged after 1978 but still).

The environmentalist and countercultural movements that shaped my thinking at the time, of course, were deeply skeptical of the essentiality of progress. I had no doubt but that the Enlightenment was a big step forward but I feared that it had given us command of great forces that we lacked the wisdom to wield responsibly. History is obviously progressive in the sense that over generations we accumulate knowledge, understanding of the universe, and technological prowess, although a surprisingly large percentage of people militantly reject one or more of these blessings. But whether that adds up to a better world for humans to live in is a question worthy of debate.

I will have more to say on this question of progress. It is a useful frame, I think, for pondering our current predicament.

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.