The silent epidemic

Methamphetamine is in the news a lot, what with meth labs exploding left and right -- recently in a nursing home, for crying out loud, and multiple ton busts in Mexico (most of which I'm sure was back on the market after payment of suitable bribes). We're spending a billion dollars a year to incarcerate tens of thousands of people for marijuana offenses, and we've so far spent half a trillion dollars in Afghanistan accomplishing exactly nothing to reduce heroin production. (Basically 100% of heroin comes from Afghan opium.)

However foolishly we are dealing with those issues, they are not any of them our biggest drug problem. (It's unclear that marijuana is much of a problem at all, except to the extent we make it one by prohibiting it. But that's for another day.) Anyway, the truth is that overdose deaths from prescription opioids are more common than deaths from heroin and cocaine combined. And for every OD, there are 461 abusers and 161 addicts, according to a SAMHSA survey -- and that's people who tell a survey taker they are addicts, presumably an underestimate.

As the CDC report linked above tell us, this represents an astonishingly explosive problem. Physicians in the U.S. are now prescribing the equivalent of 700 mg of morphine per capita in the U.S., which is enough to give every single living person a standard dose of hydrocodone every 4 hours for 3 weeks. A lot of these are diverted -- sold to people to whom they are not prescribed. Some of the problem is from prescription mills -- unscrupulous physicians who hand out prescriptions indiscriminately. Much of it is from physicians who are legitimately trying to meet the needs of people in pain but are either scammed by patients or don't have adequate training in pain management.

It used to be, in my view, that doctors were too reluctant to prescribe opioid analgesics, and many people with disabling pain were not adequately treated. A lot of people shared that view and medical culture changed to be more accommodating of opioid prescription but we've gone too far, it seems. These drugs are a great boon to humanity when used properly but they are obviously very dangerous as well. It's a wicked hard problem, as they say in my former hometown of Boston. There should be a very high threshold for prosecuting physicians -- there are clear cut cases where they aren't evaluating patients and are simply in business to hand out scrips all day. But there have also been cases of egregious prosecutorial overreach where DAs just had a different view of what constituted appropriate prescribing. And addicts can be very resourceful about conning people, including doctors.

Who will rid us of this disgusting political party?

As physician Mary Tinetti reminds us in the new JAMA, the whole "death panels" lie campaign is one of the worst acts of political malpractice since the Iraq war. (I believe you will just be able to read the first 100 words, because you aren't a member of our secret society.) As you may recall, the idea that Medicare would pay for you and your doctor to discuss your wishes for end of life care, called Advanced Care Planning, was popular on both sides of the aisle in the Capitol until Sarah Palin started blathering about "death panels."

Dr. Tinetti tells us that she has had 2 patients' families accuse her of being part of a government conspiracy to murder their parents because she asked them if they wanted to talk about their goals for care and how she could make decisions in accordance with those goals. That's what you get for listening to the Alaskan airhead and vulgar pigboy. Since 2 1/2 million people die in the U.S. every year pretty common and something we probably ought to plan for, but people have been lied and terrorized into not doing it.

Dr. Tinetti criticizes the president for giving in to this evil, and not speaking out to correct the lies and fear mongering. Granted, he has a lot of lies to deal with all at once, but I have a feeling he could actually win with the public.

The weird ways of our political culture

Sure, it's a lot of fun to see the vulgar pigboy finally suffering some consequences for his endless spewing of filth but I have to ask, why now? It's not as though his latest outrage is anything special. Racist abuse of the president and other public figures, gross and repulsive sexism, blatant lies, mocking people with disabilities, mocking the poor, despising the unfortunate, hatred and threats of violence -- these are his standard, everyday stock in trade. That hasn't bothered his advertisers or any of the stations that willingly turn themselves into sewers to carry the swill into the nation's automobiles and living rooms.

So what's different all of a sudden? Just that the latest victim is not a public figure, I suppose. That's basically what got Don Imus into trouble. The Rutgers women's basketball team were not wealthy or individually famous or looking ahead to a life as wealthy big time athletes. So you aren't supposed to go there. Pigboy can do whatever he wants to the president or Michael J. Fox, and oh by the way turn politics into a war against the truth, and lie the country into wars and ecological catastrophe. Not a problem. But his latest victim is just a humble law student so apparently that's a step over the line.

No, it doesn't really make any sense.

Mad Magazine has a blog!

Who knew?

Why must I point out the obvious?

If a woman is having sex and using contraception, then a man is also doing so. Only one of them, it seems, is a slut.

This and that

We have entered a chronosynclastic infundibulum, Kurt Vonnegut's imagined cosmic phenomenon consisting of a region where all possible opinions are true. At least that's the corporate media view of the world, and as we know all too well it has allowed sociopathic billionaires to convince much of the public that science is a conspiracy against human freedom, by which they mean their own wealth. The Union of Concerned Scientists has taken a look at the current state of the deceivers' art in Heads They Win, Tails We Lose: How corporations corrupt science at the public's expense. From the publicity material:

Unfortunately, censorship of scientists and the manipulation, distortion, and suppression of scientific information have threatened federal science in recent years.

This problem has sparked much debate, but few have identified the key driver of political interference in federal science: the inappropriate influence of companies with a financial stake in the outcome.

I'm not sure it's true that few have identified the key driver, but whatever.

And along the same lines, Nader's Raiders have something to say about medical device regulation:

Regulation of medical devices—a $350 billion industry that includes such products as heart and brain stents, artificial hips and implantable defibrillators—is at a crossroads. With a major reauthorization bill up for debate, members of Congress already have introduced 14 bills1 that aim to accelerate devices’ path to the market, often by weakening measures intended to ensure patient safety.

The bills reflect industry’s concerted lobbying campaign. In 2011, the medical device industry spent $33.3 million on lobbying, raising its total to $158.7 million since 2007. In just the third and fourth quarters of 2011, at least 225 industry lobbyists—including 107 who previously worked for the federal government—lobbied members of Congress or executive branch officials on issues relating to medical device regulation.

Damn I miss George Carlin.

Drive-by anti-quackery

I don't spend a lot of time here debunking quackery -- I leave that to the crew at Science Based Medicine, which I recommend you visit, and bookmark if you're into it. One of the contributors has his own blog here, which tends toward the ultra-long-winded (where he finds time to do research and patient care I know not), but offers many a righteous rant.

A major frosting of the pumpkin for all these folks, and YT, is the invasion of so-called "Integrative Medicine," which is a propaganda name for irrational BS, into academia. Plenty of medical schools now have centers for "Integrative Medicine" and make room for all sorts of preposterous frauds, which the SBM folks call "quackademic medicine." No, there is no "vital energy," no qi, no meridians, and homeopathy is water. Diet and exercise are not "alternative," they are part of scientific medicine and yes, doctors do talk to their patients about them.

Anyhow . . . I think you can only read the first 150 words of this but I'll give you the 4-1-1. Paul Offit, a Philadelphia pediatrician and a well-known advocate for truth and reason (yeah, it's out of fashion) has tells conference-goers to the American Society for Microbiology that his own hospital has had no luck getting all of its workers to agree to an annual flu vaccine. It's required now - they lose their jobs if they refuse. We can argue about whether that's right or wrong, but 15% of them, it seems, make that choice. Says Offit, on the back of the form they could state why they declined to do so and "it was always things that were not biologically supportable." Meaning, I suppose, that vaccines cause autism or mad cow disease.

The reason the hospital has the policy is because they have many frail and immunocompromised patients whose lives they want to protect. In 2002, says Offit, two little girls got the flu while they were hospitalized, and they died. So Jenny McCarthy kills children. Got that?

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.

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.

News of the (Instructively) Weird

I caught this little item from the AP today in the Paper of Record. I'd like to just paste the whole thing but in fear of the copyright police I'll just give the lede:

Disability groups in Greece expressed anger on Monday at a government decision to expand a list of state-recognized disability categories to include pedophiles, exhibitionists and kleptomaniacs.

No, it's not The Onion, this is evidently real. It seems that in Greece, pyromaniacs, compulsive gamblers, fetishists and sadomasochists are already eligible for disability. The main advocacy organization for people with disabilities is outraged because this will dilute the pool of money available for them.

I was a student of the late Irving Kenneth Zola, a founder of the sociological study of disability and of the Self Help Movement; and I consulted for and worked with the Massachusetts Coalition of People with Disabilities, among other relevant experiences. I strongly support the basic philosophy that there is much to be gained in both productivity and justice if society can adapt -- architecturally, culturally, economically -- to be more inclusive and empowering of everyone, rather than creating a physical and social environment that many people cannot navigate and that fails to value the abilities that everyone has. After all, in one way or another we are all disabled, and will grow more so -- it's a matter of degree and of kind. (For example, watching an NBA game, I know I'm disabled.)

But, as a fairly simple matter, I fail to see how pedophilia or kleptomania or pyromania are economically disabling conditions meriting a pension. Yes, if you've been convicted of a crime you will have difficulty getting a job, but that just raises the broader question of our policy toward ex-offenders. The diagnostic label seems irrelevant. All of these are behavioral proclivities, in other words, which our modern fashion is to categorize as "diseases," which is a matter of some philosophical contention but there you are.

However, if the Greek policy strikes you as bizarre, what about schizophrenia or severe bipolar disorder? These can qualify you for disability in the U.S., as could substance abuse disorders at one time (although that has been greatly restricted). That seems to make sense, to most people. And the vast majority certainly support accommodation and assistance for people who are blind, who cannot walk, who have cognitive limitations, and other more classic categories of disability. So where is the line, exactly?

I actually am not sure. This is a bit of puzzle.

Mitt Romney Endorses Obamacare!

Actually, what the headlines are actually saying is Mitt Romney Likes to Fire People! Yes, he did say that, and people are taking it totally out of context in order to completely change the meaning, but that's fun to do! And Romney himself already said it was okay when he did it to Barack Obama! And it fits with a pre-existing narrative! So it's the thing to do.

Okay. But I'm going to put his remark in context for a really radical new approach to journalism, and take a look at what he actually said and its relationship to public policy! Now I know that's strange and unethical and would ruin my career if I were a real journalist, but just for kicks. . .

What Romney actually said is that he wants to be able to choose his health insurance plan and pick another one if he doesn't like the one he already has. What a coincidence. If he waits until 2014, when the Patient Protection and Affordable Care Act takes full effect -- unless, of course, he becomes president and gets it repealed, as he has promised to do -- he'll be able to go to his state insurance exchange. There he will easily see all the health insurance plans available to him, and their various features, and pick the one he likes! Then, if he isn't happy with his experience, he'll be free to change it! That's Obamacare! He's for it!

So, what a reporter might ask him, if the reporter was interested in public policy instead of the horse race and gotchas and gaffes, is why, since he actually likes the key feature of the bill, does he want to repeal it? But that would require the reporter to know something, and be able to think one move ahead. That's unreasonable.


BTW: When a person publishes in medical journals, a person often gets strange e-mails, like this one:

I can use telepathy, you can easy find me online, my telepathic brain scan is on [URL redacted] What I find most fascinating my telepathy is nearly identical what Schizophrenics experiences or it manifest itself exact like "Schneider's first-rank symptoms". I can exchange voice, video, smell, people can read my mind, stalk on me, people can move small move muscles on my body from distance up to few kilometer and much more and all messages from me are transmitted to big number of people so I am a Mental Radio. One of the most advanced things I can do is to talk brain to brain and it is very fascinating, works 100% all the time and it is really talk direct to brain.

And it goes on. Why am I not surprised that his telepathy is nearly identical to what schizophrenics experience? Anyway, I mention this because of the anniversary of the shootings in Tucson. The perpetrator is, from all publicly available information, as deranged as it is possible for someone to be and was very clearly inhabiting an alternate universe when he did his awful deed. So my question is, why is the DoJ so intent on prosecuting him? That just seems pointless.

Does anybody remember public policy?

I am finding the TV news shows completely unwatchable because all they ever talk about is the ridiculous crap the Republican candidates for president are saying to and about each other.

And the way in which they are talking about said ridiculous crap is not to analyze why it is ridiculous (or not, if any of it happens to qualify as non-ridiculous), but rather simply to repeat it and speculate about how it will all resonate with Republican primary voters. Will Gingrich going negative on Romney backfire because people will think he isn't being nice? Will Ron Paul's failure to support bombing Iran make him seem soft? Is Romney parsing his support for the Massachusetts health care reform act and his abhorrence of the nearly identical federal act finely enough to convince people that there's no contradiction?

Which brings me to the real point of this post. Republicans know they're supposed to hate the Patient Protection and Affordable Care Act, but they don't know why they're supposed to hate it. Something to do with socialism and death panels, but exactly what it has to do with those things, no-one can say.

The stenographers recently reported that Rick Perry said he met a woman with cancer who implored him desperately that if the Affordable Care Act wasn't repealed soon, she'd be doomed. These news stories were correct -- Rick Perry did say that. And I'll even give the benefit of the doubt that the woman exists and said to Rick Perry what he says she said. However, this is not journalism, because what they did not bother to point out that there is no conceivable set of circumstances under which said woman could possibly be worse off with the Act than she would be without it. Yet there is no point in even asking what she might have been thinking and what the point was of Perry's anecdote.

If she doesn't already have insurance, and she does already have cancer, she will not be able to get insurance until 2014, when the Affordable Care Act takes effect. Then she will be able to buy affordable health insurance and she'll be taken care of! If she does have insurance, she will simply keep it, exactly as it is now. In fact, she might even be able to get a subsidy and pay less. Yet she's doomed, doomed! To what? Being forced to buy health insurance even though she'd prefer to die?

What is lacking so far is any clear explanation and defense of the Act by its chief exponent. I presume that as he shifts into re-election mode we'll hear more, but meanwhile the Democrats in congress need to be doing much more to tell people what's really in the Act and why it's not the work of Satan after all. No-one, it seems, is bothering to do that, ceding the floor to Rick Perry's deranged (imaginary?) interlocutor. Surely we can do better.

The un-winter

After a very rough year -- from last winter's relentless, roof crushing snow, through two consecutive tropical storms that left Connecticut in the 19th Century for a week and went on to destroy the road network in Vermont, to a bizarre October snowstorm that wiped out the electric grid for the second time in two months, we figured we were headed for climate apocalypse. Then came the winter of 2011-2012. Or rather, it didn't.

Yeah, it gets below freezing at night but, except for a two day cold spell where we had basically normal January temperatures, it's been downright balmy in the afternoons. There has been no snow since October (sic), there is no snow on the ground, and there is rain in the forecast for next week. If you'll take a look at the snow cover map you'll see that there is basically none in the lower 48 except for the lake effect region of upper New York and northern New England. (Why would anyone choose to live in Buffalo?)

This may be convenient for homeowners and municipal budgets, but it is actually bad for agriculture. Snow insulates the soil and keeps it warm. It hides the voles from the hawks, and when it melts, it saturates the soil to get spring off to a good start. I'm sure the deer and turkeys are happy, but I'd like to slow down their depredations. (Yesterday, heading to work, I discovered the biggest flock of turkeys I have ever seen in my field. There may well have been 100 of them -- dozens, anyway.)

I'm sure winter will come eventually, but at this point, it will already be short. Does this have to do with global climate change? As with all weather, sorta kinda. This year, in sharp contrast to the past two, we've had a polar oscillation that has kept the arctic air bottled up. But it is fair to say that given this pattern, we're averaging a couple of degrees warmer than we otherwise would have. And when that's the difference between snow and rain, it means bare ground and that, in turn, means warmer temperatures on sunny afternoons.

The reason I go off on all this is that as you may recall, when we had all that snow in previous years, Rush Limbaugh and James Inhofe were chortling about how ridiculous the whole anthropogenic climate change thing was. Of course that was nonsense then -- the planet as a whole went right on warming, the arctic was very unusually warm,and the temperatures in the continental U.S. were normal. It's just that there was a lot of snow. But this year, with unusually warm weather in D.C. and everywhere else from Montana to North Dakota, I hear nothing from them.

So what's it going to take to get our rotten to the core political system to function and begin to respond to the greatest crisis humanity has faced since our unexplained population bottleneck 400,000 years ago? You tell me.

Hey Indeedy

Lawyer Einer Elhauge, in NEJM, explains why the individual mandate in the Affordable Care Act is indeed constitutional. Go ahead and read it but in case you're too lazy, he throws the kitchen sink at this question.

Most broadly, once you engage in commerce, then Congress can regulate you. And it is not the case that Congress can only regulate commercial activity -- Congress can regulate any activity that affects commerce, as it did when it limit wheat growing for self-consumption back in the 30s. (Yep, it did that, and the Supreme Court said it had that power in 1942 and re-affirmed it in 2005.) In 1790, Congress required ship owners to provide medical insurance to sailors; and in 1798, it required sailors to buy it for themselves. (Really!) In 1792, Congress required every able bodied citizen to buy a firearm. Furthermore, the distinction between the mandate -- buy insurance or pay a tax penalty -- and an actual tax -- e.g. the Medicare payroll tax -- is purely semantic. It amounts to the same thing. And he goes on and on.

This is pretty much what every dispassionate observer says -- there is no constitutional problem with the Affordable Care Act. But as we have already seen, lower courts have been divided on the question and guess what? It's Republican judges, exclusively, who have ruled against the Act. So what do you think the highly partisan, highly politicized Supreme Court majority will do? Uphold the Constitution and more than two centuries of precedent, or make an indefensible and deeply harmful decision in order to serve its political objectives?

I'm not real hopeful about this. By the way, I don't like the kludgy individual mandate, as you well know. It is not the best public policy, but we know why it happened -- to get the insurance companies on board with the legislation, because it's corporate lobbyists who run Congress. However, Congress has the constitutional power to make bad law.

There would be no constitutional problem whatsoever with universal, comprehensive single payer national health care. We know that because Medicare has already been upheld. Just extend it to everyone. We're done.

More on the mythical center

Continuing my recent musings, suppose I were to tell you that the midpoint between Honolulu and Nairobi is in Philippines Bay. (I believe it is, approximately.) Would that suggest a way to resolve the "controversy" over Barack Obama's birthplace?

Tom Englehardt, as usual, does a good job explicating the utter pointlessness of the recent adventures in Iraq and Afghanistan. (He's written the same essay about 97 times but you can never get too much of a good thing.) Now think about it. Who is the only prominent U.S. politician -- someone whose words are actually noticed by the hairhats on teevee, not a non-serious person such as Bernie Sanders -- who says this?

That would be the otherwise completely wacko Ron Paul. (And no, there are no other exceptions to Paul's wackoness. He says he wants to end the War on Drugs but he doesn't really mean it, he just wants to transfer it to state control. Ditto for all of his other libertarian pretensions. He's actually inimical to individual rights because he rejects the 14th amendment, which means that he does not believe that any of the rights enumerated in the Constitution need be respected by the states. So all of you Cheetoh-dusted Pepsi swillers can scrape the Ron Paul sticker off your parents' basement door.)

And this is the real problem with our politics. The Constitution, with its winner-take-all presidency and similarly modeled state governments, creates barren ground for third parties; while dissent on any one issue cannot bring down a government as in parliamentary systems. The result is that we perpetually have only two competing coalitions, and voters have only a choice between two complete menus, each of which is likely to contain 49% inedible swill.

I can't vote for Ron Paul's foreign policy, and the specific limitations he wants on the federal government, without getting abolishing the federal reserve and repealing the Civil Rights Act. And, now that I'm a citizen of Connecticut, I can't vote for Sen. Blumenthal's support for renewable energy investment without getting his gluttonous appetite for high tech military hardware. And you can no doubt think of your own conundrums.

There are many other big flaws in our Constitution -- not least the grossly unrepresentative Senate. The requirement that we treat it with religious reverence is preposterous. It really doesn't work very well. And we're seeing that right now, with a vengeance.

Parallel Universes

Of late there has been no point, for me at least, in watching TV news or any of the political chat shows such Ed or Rachel that I might ordinarily use to dispose of an hour so of unwanted consciousness. All they ever talk about is how the Republican candidates are likely to fare in the Iowa precinct caucuses, about which I give not a FFOARD.

This would be a pointless waste of airtime in any case, because when it's over, it will be what it will be, and 50,000 hours of speculation about it ahead of time will be completely meaningless and forgotten. But in the specific case of January 3, 2012, it's also bizarre, because there is one absolute guarantee: whoever wins will be either delusional, a cynical psychopath, or a little bit of both. The candidates are competing ruthlessly to prove that they are the most radically wrong they can possibly be about everything. The prize goes to the most profound, consistent, and unabashed ignoramus or liar.

I am quite sure, however, that Republican primary voters have a similar opinion of me and the godlesshippiecommiefaggotfreaks I hang out with. That I am a professor at an Ivy League university is an even graver insult. That this situation bodes ill for the future of our country and our planet is obvious.

What does not follow, however, is the fetishized conclusion of many a pundit that the way forward lies somewhere in the "middle" between what in my view is insanity and reason. There is no middle. There is no planet in which anthropogenic global warming is simultaneously a scientific fact and a massive conspiracy to defraud the National Science Foundation and destroy capitalism. There is no universe in which drowning the federal government in the bathtub causes economic collapse by ending necessary investment in public goods such as economically essential infrastructure, education, public health and scientific research; and simultaneously unleashes the heretofore enchained forces of the Job Creators, forced to leave us wallowing in underemployment by regulatory uncertainty and a 15% marginal tax rate. There is no universe in which allowing gay people to marry simultaneously respects individual rights and promotes social harmony; and calls down the wrath of God upon us.

There is no "center." There is no way to split the baby, even if baby splitting were a good idea in principle. We have nothing to talk about when we don't exist in the same world of facts.