When working in Africa in the 1980s with my good friend Victor Pretorius, I heard a legend about an important tribe in Central Africa, the Masai. The legend claimed that a genius member of the tribe in the nineteenth century or earlier had the idea that cow’s urine was the safest fluid for washing cooking utensils. Compared with the previous practice of using far from clean river water, it avoided the dangers of dysentery and probably saved many lives. This simple and effective public heath practice was cast out by medical missionaries who had quite different ideas, more religious than medical, about what was clean and what was dirty. Neither the original genius, nor the missionaries, knew anything about the epidemiology of water-borne disease. Whether or not there is any substance to this legend, it has stayed in my mind as a metaphor appropriate for many of our problems today. Inventions such as Newcomen’s steam engine, Faraday’s electrical machines, and the idea that fresh urine is a sterile fluid, all came long before their scientific understanding.
James Lovelock, A Rough Ride to the Future. This is like so much of real discovery in clinical medicine, although the academy gets to write the history of how it is supposed to work.
If a doctor expressed concern about a patient showing signs of addiction, Ms Panara was trained to counter those fears by educating them on so-called pseudo-addiction, she says. For example, an addict might turn up at the surgery requesting a fresh batch of pills before their 30-day supply should have run out, claiming they had lost the tablets or accidentally dropped them down the toilet. The advice that she was told to give the doctor was that the patient’s dosing was too low and should be increased, she says.
“The theory of pseudo-addiction was that a patient might exhibit these drug-seeking behaviours, but if their pain were adequately managed by giving a higher dose, then that drug-seeking behaviour would cease,” she says. “Thereby we were building their tolerance, building their physical dependence, and making them an addict.”
I still fail to see why we need drug representatives, nor why they are allowed.
For a baseline life expectancy of 80 years:
Well these are all taken from John Ioannadis’ article in JAMA. He asks : “Could these results possibly be true?”
The great financial crash led to some (but not enough) soul-searching about the state of academic economics and, in turn, the academy. Whole swathes of the modern research university are geared to the production of unreliable knowledge. There is money in it. Without wishing to understate in any way Ioannadis’ major contributions, we have known that there are fundamental methodological flaws in much of observational epidemiology for a long time (for instance see the late Alvan Feinstein’s article in Science). A must read.
(The Challenge of Reforming Nutritional Epidemiologic Research John P. A. Ioannidis, AMA. Published online August 23, 2018. doi:10.1001/jama.2018.11025)
It is not only taxi drivers that are being “uberised” but radiologists, lawyers, contractors and accountants. All these services can now be accessed at cut rates via platforms.
The NHS became such a platform, for good and bad. That is the real lesson here. The tech is an amplifier, but the fundamentals were always about power.
Those who rent seek on biomedical knowledge wish to seek to define the norms of what is foundational. What is foundational for the practice of medicine should be contested more. Anatomy for surgeons is an easy case to make. But for most non-surgeons, the case for much anatomy is far from simple.
In any historical account of the ascent of modern medicine, Versalius looms large. But this Nature article (Sex, religion and a towering treatise on anatomy) intrigues me for a not so obvious reason: the counterpoint between how such knowledge was represented and understood.
Even Vesalius realized that his images could be confusing, and devised an ingenious method to explain them. A letter or number was printed onto the image of each body part, with a separate key. Unfortunately, the characters were often too small to pick out against the swirling background….
Faced by such challenges, many medics might have given up on the images. Indeed, when we reconstructed what early modern readers and scholars found fascinating about the Fabrica, it was evidently the text. The clear majority of sixteenth- and seventeenth-century readers who annotated the book focused on that and left no traces of having engaged with the illustrations. Sixteenth-century reviews of the Fabrica confirm this impression, because they tended to discuss only the text.
This is no surprise. The Fabrica’s scholarly readership was trained in the traditions of Renaissance humanism, which put a strong emphasis on textual analysis. Even if they found it difficult to interpret visual information, medical practitioners were expert at making sense of long Latin texts.
Davidson had had enough. “I wasn’t even making 6 figures, and I was killing myself,” she recalled.
“Frustrated, she googled “ideal practice” one sleepless night and came across Atlas MD in Wichita, Kansas. That practice does not accept insurance, although patients still need to have insurance to cover health care beyond the scope of primary care. Instead of co-payments and deductibles, Atlas MD patients pay a monthly “membership fee” that covers all of the primary care their physician provides. But more importantly, this retainer guarantees unhurried, same-day appointments and round-the-clock accessibility to their physician, who would get to know their story “inside and out,” thanks to having to care for only around 500 patients.”
The most interesting thing in this article is the lengths the opponents go to to oppose such a change:
“For now, said Weisbart, chair of the Missouri chapter of Physicians for a National Health Program, there’s no evidence to support the argument that DPC [the model describe here], by allowing physicians to spend more time with patients, can prevent expensive downstream medical problems. “If they could prove it, I’d be one of their advocates,” he said, adding that he understands the attraction of DPC for physicians. “They can see a third or a quarter of the number of patients (as fee-for-service practices) and preserve their income.”
“Weisbart remains skeptical, though. Direct primary care practices might attract a different population of patients. The only way to compare how well the 2 models improve health and cut costs would be to conduct a trial that randomly assigned patients to DPC or fee-for-service practices. But, Weisbart added, such a trial would be difficult if not impossible to conduct. For one, it’s unlikely that a representative sample of US patients would agree to enroll in a study in which they were randomly assigned to a primary care physician. “And,” he added, “it would have to be large to show meaningful impact, which means the study would be expensive.”
Polling undertaken for the NHS recruitment campaign found that many people had an outdated view of nursing. It suggested most saw nurses primarily as “caring”, with far fewer regarding them as “leaders” or “innovators”.
Apparently this is not approved of. My mother would be turning over in her grave.
Did the NHS save your life, or did Doctors and Nurses save your life?
It’s an earnest question. A comment on an excellent FT piece: “Is Britain loving the NHS to death?”
I posted this awhile back, but it still makes me smile. I wrote:
Well my knowledge of Neanderthals is rather limited to the work showing that some of them would likely had red hair. But now a reviewer (Clive Gamble) in Nature of a book on Neanderthals states that
Wynn and Coolidge conclude that today, Neanderthals would be commercial fishermen or mechanics, based on their enormous strength and ability to learn the motor procedures needed. Their capacity for empathy might even have made them competent physicians, the authors say, although a lack of mathematical ability means that they would never have been able to graduate from medical school. Neanderthals would also make excellent army grunts, with their high levels of pain tolerance, and would be good tacticians in small combat units. They would never rewrite the tactical manual — although tearing it up, however thick, would not be a problem.
“It’s quite obvious that we should stop training radiologists,” said Geoffrey Hinton, an AI luminary, in 2016. In November Andrew Ng, another superstar researcher, when discussing AI’s ability to diagnose pneumonia from chest X-rays, wondered whether “radiologists should be worried about their jobs”. Given how widely applicable machine learning seems to be, such pronouncements are bound to alarm white-collar workers, from engineers to lawyers.
The Economist’s view is (rightly) more nuanced than Hinton’s statement on this topic might suggest, but this is real. For my own branch of clinical medicine, too. The interesting thing for those concerned with medical education is whether we will see the equivalent of the Osborne effect (and I don’t mean that Osborne effect).
In Britain, an Epipen — a simple device that saves lives in the case of severe allergic reactions — costs $70. In France and Germany, roughly the same. In America, it costs $600. But in 2007, it cost in America what it did in Britain, France, and Germany. What happened? A drug company called Mylan bought the rights to it — and then it didn’t just send prices soaring, it uses all kinds of shady tactics to maximize profits from insurance companies and healthcare systems both. How?
Well, what does it cost to “make” an Epipen? Not a whole lot. It’s just a device for delivering a dose of epinephrine. The dose used in it “costs” maybe $1. I put “cost” in quotes because even those numbers are mostly fictional — the marginal cost of producing a basic chemical like this is pennies. In fact, the real problem is that epinpehrine became too cheap to manufacture — so cheap that many producers stopped making it altogether. And so a company like Mylan swooped in, put two and two together: corner the supply, gain a monopoly on the demand side, and hey presto — mega profits.
That’s predatory capitalism — a drug that should cost pennies, if the economy were run a little more sanely, costs hundreds, without any regard for the human possibility that is destroyed. Mylan didn’t create any real value whatsoever, only extracted it, siphoned it off.
Yep. Wealth creators, and wealth aggregators. Profit harvesting mode.
Well, this was the modest description of a ‘new’ way to test blood. Except it wasn’t. The reality distortion field in hyperspace. If you don’t know the Theranos story — or doubt the importance of real journalism — have a look.
Science 21 June 2013: 1394-1399.
For most alumni, university fundraising may seem to be uncoordinated and lacking in focus—an assortment of phone calls, solicitous letters, and invitations to a class reunion. But for Steven Rum, it’s a science. And the goal is to carry out more research.
Rum is senior vice president for development and chief fundraiser for Johns Hopkins Medicine in Baltimore, Maryland. Last year, his team had a banner year, raising $318 million. Their approach places the physician scientists at Hopkins on the donor front lines. The goal is to turn the positive feelings of “grateful patients” into support for new research, faculty chairs, academic scholarships, bricks and mortar, or simply defraying the cost of running a multibillion-dollar medical center.
Rum has 65 full-time fundraisers on a staff of 165. Each one is responsible for meeting weekly with physicians—their “caseloads” range from a dozen to more than 30 docs—to discuss which of their patients might be potential donors. The conversation is designed to help them identify what Rum calls a donor’s “qualifying interest” and connect it to their “capacity,” that is, the ability to make a donation.
More often than not, Rum’s team finds that sweet spot…..
”Ideally, I’d like to have one gift officer manage no more than six doctors,” he says.
A beautifully written vignette in the NEJM by Abigail Luger
Now I’m the one contemplating a permanent departure. My health is fine, but my stamina is pretty much gone. Our health care system is not kind to the chronically ill and marginally insured, and it is not particularly kind to their doctors, either. Our patients are condemned to an unending swim against a hostile tide. Doctors can head for shore.
My third issue is more nuanced. The biggest reason for cataract blindness is the dearth of ophthalmologists. Orthopaedic surgeons in Leicester faced with a backlog of carpal tunnel surgery decided to train intensively one theatre nurse. As a result, our carpal tunnel surgery service is probably the best and most cost effective in the country. Having a person who is not a “fully qualified doctor and surgeon” operating on cataracts could be the best solution.
Quote from, John Sandford-Smith, retired ophthalmologist, Leicester. BMJ 2018;360:k640
This sort of argument is old, and largely correct. But you can only scale such a process with the help of some form of certification, because without it, there is no durable career structure. And without this, there is no investment.
Article in Nature. I largely agree, although my views are as much based on the hype-upon-hype that characterises so much of medical research, especially cancer. I do not have a reference, but whatever one’s views about the late David Horrobin, his Lancet article about cancer trials — written when he was dying from lymphoma — is worth a read. What a mess!
Key quotes from this article:
In 2017, my colleagues and I completed a study of all 48 cancer drugs approved by the European Medicines Agency between 2009 and 2013 (C. Davis et al. Br. Med. J. 359, j4530; 2017). Of the 68 clinical indications for these drugs (reasons to use a particular drug on a patient), only 24 (35%) demonstrated evidence of a survival benefit at the time of approval. Even fewer provided evidence of an improved quality of life for symptoms such as pain, tiredness and loss of appetite (7 trials; 10%). Most indications (36 of 68) still lacked such evidence three or more years after approval. Other groups in other regions have observed similar trends. For example, a 2015 study demonstrated that only a small proportion of cancer drugs approved by the FDA improved survival or quality of life (C. Kim and V. Prasad JAMA Intern. Med. 175, 1992–1994; 2015).
But the key point he makes is:
I believe that the low bar also undermines innovation and wastes money.
When assessments — whether in medicine or education — are flawed the loss in value is not in short term financial costs, but in what might have happened 10 years down the road.
“Why do doctors feel the need to do this? A study in The BMJ in 2015 suggested that there is an association between increased defensive practice and a reduced likelihood of being involved in litigation.2 One might conclude that defensive practice is a logical behaviour in the face of a culture that leads to doctors being fearful of the consequences of making an error or even of a known adverse outcome.
“No doctor sets out to practise defensively, but a system has been created where this is inevitable. The GMC acknowledges that medicine has become more defensive.3 Doctors often lack confidence in the fairness and competence of investigations and continue to see the GMC as threatening.”
Tom Bourne quoted in the BMJ
A “world renowned” consultant radiologist has been suspended from the medical register for six months after being convicted of failing to pay more than £400,000 in tax on his private practice earnings. XXX a professor of cardiovascular imaging, was given a 15 month suspended prison sentence and fined £200,000 in 2015. The GMC argued that he should be erased from the register. But the medical practitioners tribunal concluded that he made a unique contribution to the care of critically ill patients and the development of cutting edge techniques.
Bmj September 30 , 464, 2017
Modern medicine is full of doctors who are already robotic. But good medicine is like any other subject that requires one to make judgements based on prior cases. You can follow rules, or you can think. The first kidney doctor (who I saw multiple times) never bothered to actually think.
This article is about truck drivers in the US, where getting a license requires a big investment. The article states that there is now a shortage of truck drivers and argues that this may be a result of the ‘inevitable’ rise of automated drivers.
Many young people are reluctant to pay $5,000-$10,000 to learn to drive an 18-wheeler at a time when experts are predicting that it is a dead end career.
This is akin to what I wrote about before. When people know that a line of work is ‘unlikely’ to continue, they are prone not to want to invest in it. It is not too fanciful to see this happening in medicine. Start with imaging specialties first; and then look at the use of paramedical staff in restricted clinical domains.
Restaurants have also lagged behind retailers in offering “experiences”, as the trade jargon has it, rather than the usual broccoli. This is how the more innovative retailers now try to differentiate themselves in a crowded market. It also lets them do something with their underused floor space. ….John Lewis, for instance, opened its 49th store in October with 20% of the space dedicated to eye tests, children’s car-seat fittings and free styling services for men. Selfridges, another big department store, marked the 400th anniversary of Shakespeare’s death in 2016 by performing “Much Ado about Nothing” in store, and last year it staged concerts. Waitrose hosts yoga classes, and Marks & Spencer mental-health drop-ins called Frazzled Cafés.
People say we spend too much on health, but business does not view it this way. As things approach the margin, there is even more to sell.
Most, if not all, of us, if asked to be cared for by a television doctor if we had a serious medical problem, would select Dr. Gregory House of the TV series House. He would fail most of the core competencies except for knowledge and skill.
Sidney Herman Weissman in Academic Medicine.
There is a parallel argument used in business: about rounding out the edges leading to less hard thinking. I might agree.
So, where it this from?
At the peak of the crisis, the hospital had the equivalent of eight full-time pharmacy employees battling the shortage. Technicians worked through the night to mix saline by hand, while nurses injected the solution of salt in water into patients using syringes — a task normally done by the metal stands and plastic bags used for intravenous drips. “Sometimes we’ve had over 20 nurses at a time doing that,” ..
Yes, in the US, at the Cleveland Clinic. FT
I love statistics, but I am just not very good at it, and find much of it extremely counter intuitive (which is why it is ‘fun’). The Monty Hall problem floored me, but then Paul Erdos got it wrong too (I am told), so I am in good — and numerate — company. During my intercalated degree in addition to a research methods tutorials (class size, n=2), we had one three hour stats practical each week (class size, n=10). We each used a Texas calculator, and working out a SD demanded concentration. Never mind, that during the rest of the week we were learning how to use FORTRAN and SPSS on a mainframe, ‘slowing’ down the process was useful.
Medicine has big problems with statistics although it is often not so much to do with ‘mathematical’ statistics but evidence in a broader sense. IMHO the biggest abusers are the epidemiologists and the EBM merchants with their clickbait NNT and the like. But I do think this whole field deserves much greater attention in undergraduate education, and cannot help but feel that you need much more small group teaching over a considerable period of time. Otherwise, it just degenerates into ‘What is this test for?’ exam fodder style of learning.
The problems we have within both medicine and medical research have been talked about for a long while. Perhaps things are improving, but it is only more recently that this topic has been acknowledged as a problem amongst practising scientists (rather than medics). This topic certainly resurfaces with increased frequency, and there have been letters on it in Nature recently. I like this one:
Too many practitioners who discuss the misuse of statistics in science propose technical remedies to a problem that is essentially social, cultural and ethical (see J. Leek et al. Nature 551, 557–559; 2017). In our view, technical fixes are doomed. As Steven Goodman writes in the article, there is nothing technically wrong with P values. But even when they are correct and appropriate, they can be misunderstood, misrepresented and misused — often in the haste to serve publication and career. P values should instead serve as a check on the quality of evidence.
I think you could argue with the final sentence of this (selected) quote, but they are right about the big picture: narrow technical solutions are not the problem here. Instead, we are looking at a predictable outcome of the corruption of what being a scientist means.
The Osborne effect is described in Wikipedia as follows:
The Osborne effect is a term referring to the unintended consequences of a company announcing a future product, unaware of the risks involved or when the timing is misjudged, which ends up having a negative impact on the sales of the current product. This is often the case when a product is announced too long before its actual availability. This has the immediate effect of customers canceling or deferring orders for the current product, knowing that it will soon be obsolete, and any unexpected delays often means the new product comes to be perceived as vaporware, damaging the company’s credibility and profitability.
AI and associated technologies will have major effects in some areas of medicine. Think skin cancer diagnosis, for certain; or this weekend story in the FT on eye disease; and radiology and pathology. This then begs the question, whether these skills are so central to expertise within a clinical domain, that students should think hard about these areas as a career. Of course, diagnosis of skin lesions is not all a clinical expert in this domain does. Ditto, ophthalmologists do more than look at retinas. Automated ECG readers have not put cardiologists out of work, after all. And many technical advances increase — not reduce — workloads.
But at some stage, people might want to start wondering if some areas of medicine are (not) going to be secure as long term careers. The Osborne metaphor should be a warning about how messy all this could be. Hype, has costs.
After earning his medical degree in 1951 he trained in hospitals in Montreal. “To my surprise I also found I enjoyed clinical medicine,” he wrote in his Nobel prize biography. Then he quipped, “It took three years of hospital training after graduation, a year of internship and two of residency in neurology, before that interest finally wore off.”
This article in the NEJM gets to the kernel of one of the major problems in medicine: the increasing dysfunction of doctor-patient interaction fuelled — in part — by awful IT, and a systematic ability to admit that it is no longer possible to actually do what is required within the ‘allocated’ time. In many industries the goal is to match task with skill and, wherever possible, to reduce costs by allocating low skill tasks to those who cost less: ‘right person at the right time’. There is a variation of this in medicine: those charged with ‘support’ or undertaking ‘low skill tasks’ have just been removed, meaning all tasks — both high and low — are done by the same practitioner, but without any change in time allocated. This is akin to asking the pilot of a plane to serve you snacks and check you in, but keep the schedules the same.
In terms of medicine, that this happens is not so much a manifestation of a managerial view that places little value on ‘care’ (true), nor where business innovation (sic) is viewed as synonymous with sacking people (true), but a complete failure to understand their own business and what their own product is. In an ideal world businesses like this should go bust. The problems are when: they are run by the government; there are third party payers; or there is actively created informational asymmetry. Sometimes all three apply.
‘On December 16, 2017, the staff of the Centers for Disease Control and Prevention (CDC) were instructed not to use 7 words in its 2019 budget appropriation request: diversity, transgender, vulnerable, fetus, entitlement, evidence-based, and science-based. These basic phrases are intrinsic to public health. The US Department of Health and Human Services (HHS) offered alternative word choices, such as by modifying “evidence-based” with “community standards and wishes” and using “unborn child” instead of “fetus.”’
Yan Lecun of Facebook wrote:
In the history of science and technology, the engineering artefacts have almost always preceded the theoretical understanding: the lens and the telescope preceded optics theory, the steam engine preceded thermodynamics, the airplane preceded flight aerodynamics, radio and data communication preceded information theory, the computer preceded computer science.
This is so true for (much) medicine, too. The journal comes after the discovery.
Recent years have seen a major drive by government, the NHS, and mental health charities to change attitudes towards mental health and to raise its profile in line with physical health. In a crescendo of media coverage, royals and celebrities have opened up about their own struggles.
Despite having welcomed Prince Harry’s interview about his mental health in April, Wessely believes we can have too much of a good thing: too much awareness. He particularly questions surveys in which most students report mental health problems. “We should stop the awareness now. In fact, if anything we might be getting too aware. One wonders what’s happening when you have 78% of students telling their union they have mental health problems-you have to think, ‘Well, this seems unlikely.'”
Simon Wessely quoted in the BMJ 23 September 2017 p433