Hoisted from my comment . . .

On Charlie Pierce's blog  (which I heartily commend):

Some people here may view what I'm about to say as a bit contrarian, but believe me Paul Krugman agrees with me. Long-term, the cost of Medicare -- and Medicaid, and health care in general, but let's talk about medicare specifically -- is indeed a big problem, and it would be a good idea to start to get handle on it soon. (Conflating this with Social Security is indeed a scam.) Unfortunately, no politician, including BHO, is talking about the true nature of the problem and the needed solutions. No, we don't have to cut benefits, make beneficiaries pay more out of pocket, or even means test it (which would produce trivial revenues/savings). But we do need to a) pay less for drugs and overpaid medical specialists; b) stop doing unnecessary, useless and even harmless procedures (which is what Republicans call "death panels"), which requires basically changing the way we pay for health care; and c) invest more (not less as we are now discussing) in public health, social welfare and environmental protection programs that promote health, prevent disease, and will more than pay for themselves in avoided medical costs. And we need to do more comparative effectiveness and cost effectiveness research so we can figure out how to do all of the above right. That's the discussion we need to be having, but we aren't going near it.

My (unpublished) letter to the NYT

Much to my surprise, they sent me an e-mail saying they were considering publishing this, would I confirm I am the author? But of course they did not.

I am baffled as to why every journalist, including your own headline writer and reporter, are compelled to append the absurd phrase "the God particle" every time they mention the Higgs boson. The Higgs mechanism, Higgs field and Higgs boson have nothing whatever to do with God, an imaginary entity with no relevance to physics. Please stop it.

Reporters seem prone to these ridiculous verbal tics. I have written previously about "James 'Whitey" Bulger" and "Steven 'the Rifleman" Flemmi." Apparently it was illegal simply to print the men's names. Reporters also don't seem to know that they can stop using the word "alleged" after the person is convicted. Actually I don't think they know what it means or why they're supposed to say it in the first place.

Actually I'm being grumpy because I'm so disgusted with them on more substantive grounds. But you already knew that.

The real problem with health care in the U.S.

Here's a systematic analysis and a plausible tale told by Buz Cooper. In a pistachio shell:

Problem: U.S. spends more than 2X as much on health care as other affluent countries, gets worse health in return.

Buz says: :

1) Well, kinda, but U.S. is more affluent than most, so as a pct. of GDP we only spend 60% more.

My comment: Why does it follow that we should spend more on health care just because we're wealthier, if we aren't getting more for it? We don't eat six meals a day, or go to school for 30 years. If there's a "right" amount of health care we should just buy that much and spend more of our money on something else. But please go on.

 2)  The price of health care inputs is higher in the U.S. than elsewhere. Further correcting for that, we're only buying 31% more.

My comment: This is a good point, up to a point. On the other hand, given your point 1, incomes in the U.S. are higher than elsewhere so we would expect to pay higher salaries to doctors and nurses and EMTs and so on. But, on the other other hand, there's no reason why we should be paying higher prices for drugs and devices; and even in terms of our own general affluence, some medical specialties are definitely overcompensated. But either way yes, it's true that the higher spending doesn't entirely consist of higher consumption.

3)  The remaining 31% can be explained by general inequality. Poor people, of whom we have a lot compared to Europe and Canada, are less healthy and therefore need more health care.

My comment: Now you're talking. We need to spend much more, not less, on social welfare -- making sure that kids are well fed and educated; creating safe urban environments; providing affordable mass transit to connect people with jobs, and educational and cultural opportunities; providing affordable child care so parents can work safe in the knowledge that their children are well cared for; making sure decent housing is affordable for working people. And all that jazz. If we do that, we can get a huge return on our investment -- we'll save money on health care, have a stronger economy, and have healthier happier more fulfilled people. 

So why are we talking about doing the exact opposite? How did this moronic discourse come to rule our politics?

From Habermas to Cervantes

Habermas says that metaphysics is dead, epistemology is on life support, what really matters is epistemology. The philosophy of knowledge can only be pursued as the philosophy of communication. If I convince myself of a truth, and most do not agree with me, of what use is such a truth? Human reality has ineluctable elements, but it also has a huge socially constructed portion. How can we sort out the variety of claims -- of truth per se, or other kinds of validity -- and once have put them in appropriate buckets, how can we evaluate them? And how do we talk with each other about all of this?

I think these are indeed the pressing questions right now. With powerful people inhabiting inconsistent realities, we need to do better than just dismiss those wackos, or murder them, or whatever. We must figure out how to talk with each other. You go, Jurgen!

While Rome burns . . .

Of course, the wingnuts don't believe in the fire even as it scorches their own asses. BMJ today reminds us that antibiotics will stop working for us unless we stop feeding them to livestock. The Brits actually have pretty good policies about this but it doesn't matter because lots of other countries don't and antibiotic resistant pathogens cross international borders as freely as the wind. We might want to do something about this before our kids start dying of staph infections. We might.

Of course, that might actually be merciful if we don't urgently start to deal with climate change. But you know, it's a hoax. Thanks, I feel better now.

This is getting scary

I like to think that I've had a productive research career so far, that the methods I've developed are promising, and that I have a chance in the years I have left to help people take better care of themselves, work more effectively with their physicians, prevent some bad outcomes, and even save us all money in the process. But I've only been able to do this because the American people have valued medical and health services research, and been willing to pay for it. If that isn't true any more, my work is over. I'm not sure what other kind of  job I can get right now, but I need to start thinking about it. That's kind of sad.

Anyway, in case you didn't know it, the work we do is essential if we're going to provide a decent level of Medicare benefits to the growing elderly population in the coming decades. That is a legitimate concern. No, not the spending on food stamps and environmental protection and food safety and veterans benefits and Headstart and diplomacy and highways and bridges and all that stuff that the Republicans have already cut and are demanding to cut further. But the long-term fate of Medicare is a real problem.

But here's the fact: we don't have to limit benefits or make seniors pay more out of pocket or even means test Medicare. (Which maybe sounds like social justice but is a very bad idea politically and would save scarcely any money.) We can get most of the way there by getting more bang for our bucks. Figuring out how to do that is what we do. And we actually understand the problems, unlike the interchangeably ignorant Rand Paul and Paul Ryan.

Here are a couple of examples from the new JAMA. They're very wonky, and I think you'll be stopped at the abstract anyway, which is probably a blessing. Lewis Lipsitz discusses the so-called 3-Night rule, and Steven Landers discusses the future of Medicare home health benefits.

The 3-Night rule is that in order to qualify for care in a Skilled Nursing Facility (SNF), you first have to spend 3 nights in the hospital. Back when the rule was created, it usually took that long for proper assessment and stabilization of whatever acute episode the person had suffered. The rule was intended to make sure people didn't receive skilled nursing care, which is quite expensive, unnecessarily. But, nowadays, it's often the case that somebody come into the ED and they can quickly receive whatever acute services they need and could be immediately sent on to a SNF without even being admitted. However, if that happens, Medicare won't cover the bills in the SNF, which few families can afford. What often happens is that doctors end up keeping people for three nights, just so they'll qualify, but hospital care is even more expensive than SNF care. Also, being in the hospital is bad for you, especially if you're old and frail.

So why not just bag the rule? Well, a funny thing can happen. If people who are in a nursing home but not receiving skilled nursing care, the nursing home gets a relatively low reimbursement. If the person has some sort of a setback, the facility can decide to start charging the SNF rate even if the person doesn't really need skilled nursing care. If they have to send them to the hospital instead, and get a doctor's authorization, they can't get away with that. The result is that waiving the 3-Night rule so far has not consistently demonstrated cost savings. But, if you structure payment and regulation correctly, you could indeed get both cost savings and better experiences and outcomes for patients. It takes policy wonks to figure out how to do this correctly, and well-designed trials and data analysis to prove what works and what doesn't.

There are similar issues with home care: how to get people the services they need, that can keep them at home and out of the hospital or nursing home, without overpaying or inviting fraud. If we can figure out how to do these things correctly, along with many other challenges, we can make Medicare much more sustainable while taking better care of people. But that takes a) investment up front and b) honesty and wisdom from politicians who prefer to exploit fears about Medicare to scare people into voting against their own interests. I'm talking to you Paul Ryan.

Remember Reality?

Most people seem to have forgotten all about that concept but I haven't, and I happen to know that reality bites. Here's Michael Tomasky discussing the debt limit, including a warning that has already come true: that Republicans will start claiming that hitting the debt limit will be harmless, or even, in the case of the yoyo interviewed at the link, beneficial.

They're already claiming that the government shutdown is harmless, except when they're complaining about the specific government services that have been suspended, for some mysterious reason having nothing to do with their refusing to fund them. But listen up folks: when we hit the debt limit, one of two things will happen. Either the U.S. stops paying interest on debt, in which case financial markets will devolve into chaos; or it stops mailing out Social Security checks and Medicare reimbursements, in which case we will plunge into an economic depression and people will starve and stuff like that.

Third possibility: Obama takes advantage of one of the options he has for ignoring the debt limit (platinum coin, constitution requires payment of government obligations), whereupon the House impeaches him and sues in federal court and the government remains in total chaos until January of 2015; meanwhile the shutdown continues and we go into a second Great Depression anyway.

This will happen. Their denying it in advance won't change anything. Do they really not understand that?

Doctor Doofus

There's nothing I can do, and nothing original I can say about the collapse of our republic, I'll just outsource to Timothy Egan then move on to my regular blogging agenda. Or rather, I will say this. It is really depressing to think that there are horrid communities in this country, full of racist, ignorant, cruel and repulsive people who would actually vote for the malignant clowns who run the Republican party. I will make sure never to visit such places.

Now, on to Stayin' Alive. In spite of 20 years or more of serious efforts to improve the quality of medical care and to rein in overdiagnosis, overtreatment and just plain wrong treatment, all sorts of news today that shows we are failing. First, I believe I have written before about low back pain. Most of the time it resolves on its own after a while; there is no benefit to commonly performed surgical procedures, nor to ordering MRI or other imaging procedures on routine presentation, and definitely more harm than benefit to prescribing narcotics. Ordinary over-the-counter pain relievers, maybe physical therapy, and just waiting are the right course unless there are other symptoms indicating a possible serious problem.

Well, Mafi et al in JAMA Internal Medicine (I think you'll get stopped at the abstract, but I have the magic cookie) find that from 1999 to 2010, mistreatment of low back pain increased in the U.S.

Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9%in 1999-2000 to 24.5%in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3%to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8%to 14.0%(P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2%to 11.3%during the study period (P < .001).

Meanwhile, futile treatment of critically ill patients continues more or less unabated; doctors continue to prescribe antibiotics for upper respiratory tract infections which is a) generally useless and b) actually harmful to patients and c) harmful to all of society; and, in BMJ, we learn that most trials of cancer screening don't even bother to assess harms, which says a lot about the underlying psychology of physicians and clinical researchers. Obviously, if you only study potential benefits and ignore potential harms, you'll end up doing a lot of stuff you shouldn't do.

I almost despair, at times. Patients also think that more is necessarily better, and of course this fundamental misunderstanding contaminates our politics as well. No, efforts to reduce overdiagnosis and overtreatment are not "death panels." They are life panels. Reducing waste and harm in medical care is the only way to make the whole enterprise sustainable, affordable, and available to everybody and at the same time, it means better outcomes and healthier people.

And to hell with Republicans.

Pahhhhhtttyyy!

In case you didn't know, it's NHL opening night and the Canadiens are at home. You can't even imagine what's going on here. There's a huge plaza in the middle of Rue Ste. Catherine with an open air concert space, which is featuring a free Kings of Leon Concert and 150 booths selling beer and booze. I mean it is absolutely bugfucking insane. I hung out with it for a while then it was just too much.

Believe me, Boston would never try this for opening night of baseball or football. You'd have a guaranteed riot with overturned and torched cars, serial sexual assaults, and mass tazerings and rubber bullets. Here, it's loud for sure, but non-violent. They can do it. We can't.

American Exceptionalism

What I could say of the conference is multiple and various, but one important theme is that the Europeans and Canadians here think we're completely nucking futz. To whit . . .

I attended a talk yesterday in which the investigator reported on surveying cancer patients about out of pocket costs. How much could they pay, how much did they pay, how was it affecting them financially and emotionally, yadda yadda yadda. As you might expect, the answers are not so much, more than they had, and disastrously. (Average cost: $600/mo. Top cost: tens of thousands of dollars a month. Average education: grade 12.)

A guy from Germany or the Netherlands or someplace -- you know, one of those totalitarian dungeons -- said basically WTF? In my country, in all of Europe, nobody who has cancer pays a penny. The speaker was nonplussed. What, you don't even have a copay? No no, the guy said. We might have a conversation over whether it's still worth it if the person is going to die anyway, but of course they don't have to pay. Why should they? They have cancer for heaven's sake!

Makes sense to me. Back in the U -- S-- S-- A one thing the confluence of government shutdown and opening of health insurance exchanges has accomplished is that it has forced the corporate media, against their will, to explain what's going on. Err, okay, the idea is that if you don't have health insurance and you haven't been able to get it because you couldn't afford it or you are disqualified by your diagnosis of pinky spasm, now you can get online and find good, cheap health insurance. Therefore you and your children and grandchildren are no longer free. Or something. Meanwhile people are having their regular doctor appointments and the doctor is telling Granny, no, there isn't any death panel and your Medicare is just the same as ever, except now your prescription drug coverage is better. Even if the doctor is a teabagger, what else is he gonna say? There isn't anything else.

So as far as I can tell this can't end well for Ted Cruz. But I don't prognosticate. We'll see.

The Great Sunny and Warm North

That's Montreal today and prognosticated to be so all week. I'll be here through Wednesday for the International Conference on Communication in Healthcare. I'll let y'all know whatever great stuff happens here (I'm speaking twice so it can't be all bad), but meanwhile I just have my superficial impressions of the city to share.

As you may have heard, they are all kinds of uppity about their effete effeminate language. It's illegal to have signs in English. You're allowed to put English under the French, in smaller print, but for the most part they don't even bother to do that. You'll mostly hear French on the street, but everybody is able to speak English. Of course I'm in the hotel and the staff is so perfectly bilingual its painful.

Rue Ste. Catherine is a major commercial boulevard. You can get any kind of cuisine you want here -- pizza is very popular, the usual burgers, there's an arepa place, Middle Eastern, Greek, pan-Asian, sushi, you name it. Well, one kind of food that I have not seen on offer is French. You can't get that here. The sidewalks are wide and the vehicle traffic on the light side, but the restaurants are 100% indoors. Sidewalk cafes is not a happening thing.

Rather like Basel, the high end and low end businesses are all mixed up here. Fancy watches, high priced clothing, right next to lap dances. There are also a lot of slackers, idle young adults, in some cases openly panhandling for beer and drugs. Lots of tobacco smoking. An ethnic potpourri. Quite stimulating. Now I'm off to the opening session.

Obsolescence

Tom Lehrer claimed that he gave up his public career and went back to laboring in anonymity as a math teacher because satire became obsolete when Henry Kissinger won the Nobel Peace Prize. I don't know if he meant it, but blogging about public health and health care seems kind of obsolete these days when the field is completely dominated by insane liars. I don't know what I can possibly contribute to this "discussion."

Kurt Eichenwald takes on the psychopathic Republican party in Vanity Fair, but I mean really, what's the use? A few tens of thousands of people will read it, most of whom are already pretty much tethered to reality, while 100 million will either get The Crazy mainlined by Faux News or, at best, be told by Chuck Todd that there is a dispute between people who are trying to stop Obamacare from destroying the economy and putting a government bureaucrat in every doctor's examining room; and people who are determined to have it take effect anyway just because.

The Republicans in congress are apparently determined to smash the U.S. economy and political system to rubble, half the people are cheering them on, and the corporate media are just transmitting the pictures. What is really weird is that the Camber of Commerce and most of the business establishment, which face disaster at the hands of the very monster they created, aren't trying to stop it. The vast majority of capitalists have everything to lose and nothing to gain from these nutjobs, but they still seem to think of them as their own tools and they can't stand to lose them. They will live to regret this very, very deeply.

For myself, I'm not sure what the future holds. I won't have a career, or even a job, if there isn't any federal funding for health services research. That's kind of sad since I've worked so long and hard to get to this point and I like to think that I'm starting to make a contribution in the public interest. But if the people don't want to pay for it, because government and knowledge are both equally evil, I guess I'll just have to figure out something else. It's on you, Chuck.

Jeopardy!

I keep sending these in to Alex Trebek, but for some reason they never use them. Remember, your answer must be in the form of a question.


Category: National Monuments
       Clue:  Nobody, it's an above-ground mausoleum

Answer: Who's buried in Grant's tomb?

Category: National origins
       Clue: Obviously!

Answer: Is the Pope Argentinian?

Category: Prominent Journalists
       Clue: Chuck Todd

Answer: Who?

Category: Metaphysics
       Clue: Metabolizing and reproducing entity

Answer: What is the meaning of life?

Category: Clerical Vestments
       Clue: Skirt for an Archbishop

Answer: What is Tutu?

Category: Existentialism
       Clue: Shit

Answer: What happens?

Category: Grammar
       Clue: Objective Case

Answer: Are you talking to me?

As you can tell, I didn't sleep much last night. I'm gradually getting back to normal, but it's taking a while.

Still sick . . .

though getting better. I'll outsource to Jonathan Chait. It's long -- and I know the Intertubes has made it impossible for anyone to concentrate on a single essay for more than 35 seconds -- but it's a good explanation of what's going on with the Republican Doomsday Machine over the Affordable Care Act.

Said lengthiness is also the problem that has been a burr under my saddle for as long as I've been in this racket. It is just impossible to explain to people -- by which I mean not only your local parking lot attendant, steamfitter or divorce lawyer but also those people who style themselves journalists -- how the market for health care and health insurance works and what exactly we need to do to fix it. I just can't make it short and simple and also true. Especially with the entire population irretrievably lost in delusional faith in a non-existent entity called the "Free Market."

Anyway, we're at a hinge of history now folks. Chait may be a bit less optimistic than I, but I'm not in the prediction game.

Something you really, really don't want . . .

. . . is norovirus. At least I think that's what happened to me yesterday. Anyway, whatever it was, same basic idea. The diarrhea started at 3:00 am, and obviously, as I got out of bed and hit the light switch, there was a power outage. It was raining and darker than a black hole, so I spent the night groping my way back and forth from bed to toilet. By morning I managed to get downstairs to continue the performance from the sofa, but I was so weak and tired I could barely get off it to meet the recurrent necessity.

The good news about this is that it doesn't last long. The diarrhea subsided by evening and I even made it in to work today, because I had to, even though I still feel like crap. I'll have to eat something but the very idea of food is still repulsive. The other good news -- and as far as I'm concerned it is good news -- is that there is absolutely no medical treatment that can do the slightest good.* You just have to live through it, then it's over.

The reason that's good news is a) there's no way on earth I could have gotten to a doctor even if somebody would have seen me on a Sunday, and I wouldn't want to be thinking "Damn, if only." Second, it didn't cost anybody anything. If it's over in a day anyway, then okay sure if I had a $10 pill in the cabinet I could have popped that would have stopped it, that would have been worth it. Beyond that, not really.

Lesson: Wash you hands! Wash your vegetables! Keep you kitchen clean! I probably got it from restaurant food or just touching something that was contaminated -- norovirus is very contagious and there are plenty of ways to catch it without eating tainted food. But anything you can do to improve your chances I will strongly endorse.

*Frail elderly, very young and immunocompromised people can be seriously injured or killed, by dehydration Parents of young children should keep Pedialite or similar rehydration fluid in the house, just in case. Sugary drinks, however, are not a good idea.

It's going to happen, might as well hunker down

The Shrill One, here embracing the appellation, figures the Republicans have gone so far around the bend that yes, they will shut down the government and might just refuse to raise the debt limit. I'm holding off on investing my 2013 IRA contribution, because they might just knock us back into 1932.

There's more than enough blame to go around for the collapse of our hallowed republic, but let me single out the the worst offender and no, it's not the Koch brothers or the Club for Growth or Rush Limbaugh or even Fox News. It's CBS, ABC, NBC, CNN, NPR and the rest of the corporate media gang of idiots. Fox News and the Vulgar Pigboy know what they're doing, they do it on purpose, and they're just evil. They know they're lying all the time and they know how they're pushing the buttons and pulling the strings of their deluded followers. The others, however, pretend to be journalists and pretend to be providing some sort of a public service.

No and no. The coverage I see and hear consists of one or another Republican member of Congress declaring that "Obamacare" is the worst legislation of the past 50 years, that it will destroy the economy and our liberty and cost billions of jobs and raise the cost of health care." Then they have Harry Reid saying "no, we aren't going to defund it." That's the debate the people hear, in its entirety. And as Chuck Todd said yesterday, it's not his job to tell people the truth.

Polls show that the majority of people oppose the Affordable Care Act, and an even larger majority don't know what it does. I know damn well that isn't my fault, but I can't get 100 million people to read this blog.

I'll tell you what though. Roger Ailes and Rupert Murdoch and even the Koch brothers don't actually want economic collapse. I'm counting on them to make Rand Paul an offer he can't refuse.

Ripoff!

I think you can only read the abstract (I have a magic cookie on my 'puter that dissolves paywalls), but the new JAMA has a brief review of the evidence about anti-oxidant vitamin supplements. These are the main ingredients in your typical multi-vitamin -- beta carotene/vitamin A, Vitamin C, Vitamin E -- you know, the classics. These have long been touted as promoting health and longevity, on the theory that oxidizing free radicals in the body cause cell damage. If you enter the term "antioxidant supplement" or similar into your favorite search engine, you'll get pages of ads.

Here's the bottom line, folks. The higher the study quality, the worse these look. In fact, taking Vitamin E, beta carotene and Vitamin A supplements is associated with higher all-cause mortality. Vitamin C and selenium (a mineral not a vitamin but also touted as an antioxidant) don't do anything, except cost you money. In other words, the people who are selling these, including big corporations that advertise heavily on TV, major retail chains including CVS and Walmart, and many more, are lying, stealing, and murdering people. And it's perfectly legal.

It is true that eating foods that are high in these substances is generally good for you. That would be your fruits and veggies. So do that instead. Don't buy any of this garbage.

Not exactly fraud

Obviously the cause of science, and therefore the cause of humanity, is harmed when scientists make up results or misrepresent their findings in a scientific paper. I get outraged about it, but it probably isn't all that common.

Even so, false beliefs often persist for a long time. Steven A. Greenberg, in BMJ, tells us how this can happen. This is an excellent and important piece of work which gores some very powerful, oxen, so I recommend it even though it may be somewhat heavy going.

To translate it into English, what Greenberg did was to study all the papers addressing a claim or hypothesis that an uncommon muscle disease called inclusion body myositis is caused by or at least includes in its pathogensis abnormal accumulation of beta amyloid protein, which is famous for being associated with Alzheimer's disease. (It really is found in the brains of people with Alzheimer's, but any causal relationship is unknown.)

He found a small number of original research papers that support the hypothesis, and at least as many that do not. However, in a nutshell, the negative papers were almost never cited in subsequent published research, whereas the positive papers received many citations. Furthermore, the positive papers were discussed in review articles that got even more citations, whereas the negative papers were not, further amplifying the strength of the belief.

It gets worse. Papers that either did not contain data supporting the hypothesis -- perhaps presenting it only as a hypothesis, or offering a data-free discussion -- are frequently cited attached to text claiming the hypothesis has been supported. And worse than that, papers which are not relevant to the hypothesis at all, or which even tend to undermine it, are frequently cited as supporting it. Abstracts -- which receive very limited peer review and contain only very limited presentation of methods -- are often cited as if they are peer reviewed articles. And titles of papers that do not contain original experimental data imply that they do.

Furthermore, proposals to the National Institutes of Health reflect all of these biases and falsehoods, and many of them have been funded. Yet it is not at all clear that this line of inquiry has any prospect of explaining the disease or benefiting patients.

This probably happens partly because of actually dishonesty, and partly because of carelessness. There is also a well-known bias on the part of journal editors against publishing negative findings. But the citation network also tends to grow with a powerful bias toward confirmation for reasons inherent to the research enterprise. When a finding is negative, there is nothing more to say about the subject. The investigators will not continue down that road, and they are unlikely to cite their own paper in the future because they won't be working on the problem any longer. But positive findings generate further funding, further research, self-citation, and citation by others seeking funding for related work. They make fodder for interesting review articles that tell a coherent story, whereas nobody is going to write a review article asserting merely that X does not cause Y.

Yes, these false pathways have to come to an end sooner or later, but it can take much too long.

Most outrageous scientific fraud evahh?

Probably not but it's right up there. Introducing Bruce Murdoch, professor at the University of Queensland, founding head of the Centre for Neurogenic Communication Disorders, and for nearly a decade dean of the UQ School of Health and Rehabilitation Sciences, author of nearly 400 peer reviewed journal articles and 13 books. Murdoch caused a sensation back in 2012 when he presented findings that transcranial magnetic stimulation -- basically applying powerful magnetic fields to the brain -- caused people with advanced Parkinson's disease to regain the ability to speak.

This  historic, miraculous breakthrough was then published in the European Journal of Neurology. Here's the funny part though, you'll really find this amusing. He never did the study. He made the whole thing up.

You've probably heard, and it's generally true, that most cases of research fraud are all about the intense, cutthroat competition for faculty appointments and promotions. We're turning out many more PhDs then will ever have a decent academic job (yes, I count myself lucky), and the competition for research funding also grows ever more brutal, so young people sometimes get desperate. Clearly, this explanation does not apply hear, as it also did not apply to Marc Hauser.

What is going on here? I'm not entirely sure but my guess is that the egotism and ambition that help drive people to the top ranks of academia are ultimately not satisfied by the very narrow circle of fame that pertains. That all the investigators in the field of neurogenic communication disorders have heard of you only slakes your hunger for admiration. When you go to those conferences, you still have to fly economy class, carry your own luggage, and make a 15 minute presentation on the same stage with assistant professors and post-docs. Your students only pretend to worship you because they want a recommendation or a toehold appointment as a lecturer. But if you can do something really astonishing, that will get your name on the television or even an appearance on a talk show, now you'll really be a celebrity, everybody will know you're the really big deal you already know you are.

In discussing other cases, I've pointed out the immense swath of destruction cut by this behavior. His students and post-docs will have trouble finding employment. The university may not be able to find alternative placement for some of them. His collaborators are disgraced. Funding that could have gone to productive research has been squandered. The very limited space in a top journal has been stolen from a legitimate study, and scientists the world over deceived. Some may have initiated work of their own which turns out to be a total waste. Thousands of people around the world have been given false hope.

Just sick.

The Gray Tsunami

You may recall recent findings that the rate of dementia among people 65 and older has been falling in England and Wales, and this is likely true here as well. It's basically because people are generally healthier. But . . .

It's very strange how the general reaction seems to have been, "Oh well then, what have we been so worried about?" News that isn't quite as bad as you thought it was going to be is still bad news. And the fact is that the prevalence of dementia still rises with age, and we're still going to have a lot more people living with dementia in coming years. The estimate here of tripling by 2050 might be too high, but 2 1/2 times as many is still a whole lot.

Now the IOM raises the alarm about cancer, another disease that is strongly associated with increasing age and which costs a whole hell of a lot of money to treat. Here's a good example of why medical advances can drive medical costs: there aren't any effective treatments for dementia, so it's actually relatively cheap. Many people do ultimately need custodial care and that can bankrupt families and strains Medicaid budgets, but Medicare is going to have to pay for all this cancer care and new therapies can cost $100,000 and up. Even though the benefit is generally small, our laws and our cultural consensus say that we still have to pay for them.

IOM also argues that advances in the field are so rapid that many physicians and treatment centers aren't keeping up; and that we'll have a growing shortage of relevant experts. It's hard to predict how this will play out. Advances in what are called medical informatics may make it easier for providers to select the right treatment protocols and deliver the latest, proven technologies. Basically, they won't have to know everything, the computer will tell them. (They will have to ask it the right questions.) Treatments that are really curative may end up saving some money in the long run, or cheaper treatments may emerge, but I'm not going to bet on that.

We can save money by all the means I talk about here -- not overdiagnosing and overtreating, not using useless treatments and tests, not overpaying for specialty care. At least we can in principle, it's proving to be very difficult politically because all that waste is somebody's income. But even if we manage to do that, medical costs will continue to increase. We're a wealthy society, we can afford it, but it means young and healthy people will have to pay for the care of old and sick people. That's a granite hard fact of life. Are we prepared to do it?

Update: And right on cue, This lands in my in-box. (I swear, it was after I put up this post.)

PLAINSBORO, N.J. – Promising targeted therapies and immunotherapies for melanoma, used in combinations so advanced they have outpaced the nation’s regulators, offer hope of survival to patients suffering from a cancer once seen as a “hopeless” malignancy, according to experts convened by The American Journal of Managed Care. A. Mark Fendrick, MD, co-editor-in-chief of AJMC, led the discussion with the following experts:

• Jeffrey Weber, MD, PhD, senior member, H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center.
• Antoni Ribas, MD, PhD, Jonsson Comprehensive Cancer Center, UCLA.  
• Jennifer Malin, MD, PhD, manager and medical director of oncology, WellPoint.

 “Melanoma has gone from being regarded by many oncologists in the community as an impossible-to-treat and hopeless malignancy to a disease that one might argue is the poster child for new targeted and immunologic therapies,” Dr. Weber said.
However, these drug combinations are not cheap, and the panelists warned that there is only so much that cancer patients, their employers and those who fund government health plans will be willing to pay. Already, Dr. Ribas warned, some melanoma patients lack access to cutting edge drugs like ipilimumab, depending on where they seek treatment and whether they have appropriate insurance coverage.