Sunday, August 20, 2006

Innumeracy in Medicine


Overheard in the physicians' lounge:

Doc #1: I think I make just above the median for my specialty.

Doc #2: Very few people make more than the median in [my specialty].

Me: (butting in incredulously) But by definition, 50% make more than the median.

Doc#2: Well, yeah, but the median is skewed by a very few people at the top who make an inordinate amount.

Me: No, that's the average.

Doc #2: Oh, yeah. Well, I meant the average.

I'm sure he did, but then he's misinterpreting the data when he reads reports of median income in his specialty, or median anything. Sheeez!

Sunday, April 02, 2006

CPT Update 2007: (new codes)
100121 Intraoperative Intercession, first 90 minutes
100122 Intraoperative Intercession, each additional 60 minutes

picture credit: ronhudgins.com

[author's note: apologies for the gargantuan length of this thing. It's taken on a life of its own. And yes, I know this is not what the prayer study showed. That's the point. Enjoy!]


Dr. DeFACCto's friend was getting steamed.

"I'm sorry, Dr. Herzmesser, but your first pump case will have to wait till 10:30." The OR scheduling secretary looked apprehensive.

"Barb?" He turned to the senior OR nurse, who had been a fixture at Fictional Medical Center about as long as he. "What in the blue blazes is this about?" (He had been asked to 'tone down his language,' and goddammit, he was gonna try.)

"Well, Sammy, our backup PI, you know, the professional intercessor, called in sick." Barb alone among the nurses enjoyed first-name privilege with Herzmesser, a testament to her longevity or possibly to her knowing where the bodies were buried. So to speak. "Yeah, I know. Maybe he'll stay home and pray for himself. Anyway, the other one won't be freed up until the first case is done in room 5."

"The hell with prayer, Barb! This is crazy; I'm going ahead anyway." Now even the head nurse looked concerned. "If we don't start soon, we'll be here till effen midnight." So much for toning down his language.

"Uh, actually, Dr. Herzstenker -- by the way, I'm Phil Pinchpenny, the new cardiovascular product line administrator." An impossibly young-appearing guy in a suit, sporting a fine head of executive hair worn over a very earnest face had stepped forward. "It was decided in the cardiac prayer meeting last Thursday that, what with the big PR campaign by Downtown General and all, we would only do open heart cases without realtime intercession in life-threatening emergencies. I'm sure you remember their tagline: 'If you go to the wrong heart center, then you don't have a prayer.' Our CEO is determined that we'll outpray them and the sisters at St. Superior by next quarter, or else."

"Well, I'll be sure and order my wimple, but really..."

"I'm quite serious, Dr. Herzsenker, and that's why you should really start coming to the weekly prayer meetings. It's hard to demonstrate to the staff our committment to this new, evidence-based, therapeutic modality without the support of physicians such as yourself." He emphasized "evidence-based" as though to chide the physician: This isn't some touchy-feely BS; it's actual Science.

"Well, who's paying for these pray-ers, anyway? There's no third-party coverage."

"Actually, the Blues have promised to look into it in their next updates. That reminds me, would you be willing to accompany me, as our senior CV surgeon, to present our institutional data at the statewide Medicare Coverage Review meetings next week?"

Now Sammy really did feel like a Heart-sinker, picturing himself in a semi-darkened room saying, 'As you can see, this graph shows Reoperation Rates pre- and post-Intercession, with a p-value of...' or, better yet, 'As you can see, at least at our center, prayer has no effect on postop atrial fibrillation, but renal failure is a whole different story.' He shook his head.

It had all started with the publication of that study a year or so ago. Although many skeptics had challenged it, its methodology seemed to be ironclad. After investigators at a variety of international research centers had replicated its findings, the medical community had grudgingly come to accept its central conclusion: anonymous intercessory prayer reduced major postoperative complications following open-heart surgery by about 15%. That doesn't sound like such a big deal, but considering that the average major complication was estimated to cost hospitals and insurers $25,000, it didn't take a big decrease to make administrators sit up and take notice. First the faith-based hospitals, with their prayer infrastructure already in place, and then the university centers, pretty soon all the heart centers jumped on the bandwagon. There was a bit of a hitch at the government hospitals, but the ACLU publicly professed neutrality, so long as patients had the ability to 'opt out' from being prayed for.

Next came the first wave of outsourcing. Certain monasteries set up up Intercession Centers, which could serve dozens of clients at once and offer a truly professional level of service. All you had to do was fax the patient's billing information at least thirty minutes prior to surgery and they handled the rest, gradually weaning down the frequency and intensity of intercession over the next 48 hours or until the patient left ICU, whichever came first. Of course, here in the Southeast there was widespread distrust of any Catholic-affiliated prayer centers, but several multi-denominational, predominantly Baptist, centers had sprung up to fill the need.

Dr. Herzmesser still shook his head as he reminisced. He had always been a laborare est orare kind of guy, but he wanted to heed the message being delivered by his trusty tools, the randomized clinical trial and his own -- God-given, he presumed -- common sense. Here they seemed to be in conflict. He realized that Barb and Phil were still there, looking at him.

"Sorry, Phil, got a root-canal scheduled that day. Maybe another time, OK?" He turned to Barb, "Guess I'll see you guys back around 10:30 then." And he headed off to the doctors' lounge.

[to be continued]

Wednesday, November 30, 2005

The Subjunctive: Not Quite Dead. Yet.

Earlier today, the NYT posted a story entitled, "When the Doctor Is in, but You Wish He Wasn't." Now I know that headline was likely not written by Gina Kolata*, but by an editor. That's right, an EDITOR. Sheeesh.

The headline has now been correctly moodified.

*For my money, the very best newspaper health writer out there.

Tuesday, July 12, 2005

Ethnopharmacology I

A hypothetical spot on BET:

Voiceover: [smooth African-American female voice, straight from Lite Jazz 10X] Heart failure is a major problem and a leading cause of death among African-Americans. In fact, heart failure disproportionately affects African-Americans.

Dr.DeFACCto: No argument here.

V/O: Now there's a new treatment for heart failure made especially for African-Americans, that's clinically proven to decrease complications and death from heart failure.

Dr. D: Weeelll, I don't know about new. After all, VHEFT-I was published in what, 1986? Aside from that, though, does the drug really know your nationality, too?

V/O: All-new BiDil® is now approved for treatment of heart failure in African-Americans. BiDil® is not for everyone; possible side effects include, but are not limited to: rash, headache, constipation, diarrhea, depression, mania, hair loss, excessive hair growth, painful genital ulcers, lupus, dizziness, headache, insomnia, hypersomnia, polysomnia, and others too horrible to mention...*

Dr. D: Yadda yadda ya.

V/O: So if you or a loved one, who happens to be African-American, has heart failure, ask your doctor about BiDil®. Specifically, ask Dr. DeFACCto. Do it today.

Dr.D: Huhh? Whazza?
[stirs self, wipes cigar ash from tweed shooting jacket] Must've been in a revery there. Well, certainly, the release of this 'new' drug raises a host of questions. Let's see if I can tackle a few of them here.

A-HeFT survival curve
  • Is this really a new drug?
    It's a new, fixed-dose combination drug, but the two component drugs, hydralazine and isosorbide dinitrate, have been around for decades.

  • Does it work?
    Actually, the data from the A-HeFT trial, which is the basis for its approval, are impressive (click graph for humanly readable version). This benefit in survival is in addition to standard heart failure therapy, although one could quibble as to how aggressively 'standard heart failure therapy' was pursued in the two groups.

  • How does the drug know if you're African, or American?
    Clearly, people of African descent have different frequency distributions than Europeans for many genes besides those involved in expression of obvious external traits. The authors of the trial posit that there are ethnic differences in the body's physiological reponses to weakening of the heart muscle. This is based on 'hindsight' review of previous studies which seemed to show black patients responding to this therapy and not whites. In all people, these response mechanisms tend to be beneficial in the short term, but maladaptive over the long term, contributing to the progression of heart failure and ultimately death. And as for nationality, the drug is indicated for use in "self-identified black patients" without regard to nationality.

  • Will it work in white folks, too?
    Aye, there's the rub. Nobody knows. And if Nitro-Med (the manufacturer) has any say about it , we'll likely never find out. Their patent is based on this drug's usefulness in black populations only, and it's an open question (to me, anyway) as to whether the patent would hold up if the drug were proven to be beneficial in a more general population. But it's all moot, anyway. These two medications are already available generically, for about $24 a month retail, when BiDil will sell for $180 a month, wholesale. But this is based on a fiction, as they say they'll sell to patients without pharmacy coverage for $25 a month.

  • Economic shenanigans aside, is this a good thing or bad?
    As an applied scientist, I'm always looking for the mechanism. Give me a blood test I can check which will predict whether Mrs. Jones is going to respond to this drug, irrespective of her skin color, and I'm reasonably happy. In a way, the advent of this drug is a step in that direction, toward individually tailored therapy, so I'm saying it's a good thing, mostly.

  • Why the Roman numeral "I" in the title?
    Hey, you never know when inspiration will strike again. [settles back down to deep contemplation]
*
BTW, the lupus thing is real , but real uncommon. The others I made up. Except headache; nitrates make your head feel like it's gonna blow.

Saturday, July 02, 2005

Bravo, Dr. Lee!

Hoping that human rights and medical ethics are nonpartisan values, I'd like to point out this Op-Ed from the Washington Post by the physician to President George H. W. Bush, Burton J. Lee III: The Stain of Torture. Dr. Lee is on the board of directors of Physicians for Human Rights. Ripping off some of his very fine prose,

As I have studied reports of torture throughout our troubled world since then [1963], I have always found comfort in knowing that at least it did not occur here, not among Americans.

Now that comfort is shattered. Reports of torture by U.S. forces have been ccompanied by evidence that military medical personnel have played a role in this abuse and by new military ethical guidelines that in effect authorize complicity by health professionals in ill-treatment of detainees. These new guidelines distort traditional ethical rules beyond recognition to serve the interests of interrogators, not doctors and detainees.

I urge my fellow health professionals to join me and many others in reaffirming our ethical commitment to prevent torture; to clearly state that systematic torture, sanctioned by the government and aided and abetted by our own profession, is not acceptable. As health professionals, we should support the growing calls for an independent, bipartisan commission to investigate torture in Iraq, Afghanistan, Guantanamo Bay and elsewhere, and demand restoration of ethical standards that protect physicians, nurses, medics and psychologists from becoming facilitators of abuse.


Amen. Check out the article to see his powerful final paragraph. The biggest tragedy is that these things even have to be said in today's America.

Friday, July 01, 2005

My patient went to Vietnam...


...and all I got was this -- uh -- uh -- what is it, exactly? Well, to describe it, it's about a 7-inch disk that rotates looks like a lazy susan [Edit: it looks like it'll rotate and it has a little play in it, but if you really rotate it, it feels like it's gonna have a comeapart], with ten highly varnished -- um -- guitars, my patient said. Never mind that most of them look more like sitars, at least to me. They have monofilament strings, floral decorations, and each has one or more bright red tassels. There's actually a heartwarming story here. Mr. Jones, we'll call him, is Vietnamese, but had not been back since the unpleasantness a few years back. This year he had the opportunity to return and visit family he hadn't seen in over twenty years. It clearly meant a great deal to him, and understandably so. I believe he was very greatful to have had the chance to go, and he was quite disproportionately appreciative of my small part in his being well enough to make the trip. I don't know if he had his gift for me shipped back, but I find it hard to picture him toting this rather delicate item through customs and a 20+-hour plane flight. Anyway, it's got a place of honor atop my CPU for the time being.

Thursday, June 30, 2005

Welcome!

Thanks for taking a look. I have an idea here to comment on goings on in the world of cardiology from the point of view of one in the trenches, looking at the world through jaded-colored glassses (but not lead specs -- too deep an indentation on my schnozz!). I'm an interventional cardiologist practicing here in Sweet Home Alabama, where even the wheelchairs are super-sized. I'm thinking I might need some new frames for my jaded lenses. Whaddya think? And why is it the doc is always the creepiest character?