Ed’s corner of the web

This is great news.  It’s a little late in coming – well, actually a lot.  But truth and the self-correcting nature of scientific inquiry have finally won a little victory.  There has still been irreparable harm done to autism research and treatment as a whole, not to mention the fight against vaccine-preventable illness, but hopefully this is a reflection of the turning tide.

The NEJM had an interesting study this month on managing health care expenditures.  The prevailing wisdom has been that cost-sharing (making people more reponsible for the cost of their care) reduces expenditures while not harming health in the general population.  This study looked at a population of Medicare recipients and found otherwise.

When you raise the copays for Medicare enrollees, you end up making a little more money off of copays, and you reduce the total number outpatient visits.  This saves Medicare money.  This is good.  Unfortunately, you also increase the number of hospital admissions and the length of those admissions, with the end result being that you spend much more money than you save or bring in.  This is bad.

This is a prime example of why studies like this are crucial when deciding how to spend healthcare dollars.  The interplay of economics, health, and human behavior are so complex that there’s no predicting which way an intervention will take you.  Great study.

Great gutsy opinion piece from Barbara Ehrenreich of the LA Times.

Choice quote:

What we really need is a new women’s health movement, one that’s sharp and skeptical enough to ask all the hard questions: What are the environmental (or possibly lifestyle) causes of the breast cancer epidemic? Why are existing treatments such as chemotherapy so toxic and heavy-handed? And, if the old narrative of cancer’s progression from “early” to “late” stages no longer holds, what is the course of this disease (or diseases)?

What we don’t need, no matter how pretty and pink, is a ladies’ auxiliary to the cancer-industrial complex.

Regardless of how you feel about Bart Stupak’s amendment to the health care bill, I think Ehrenreich makes a very valid point about the need for skepticism and reason.

Some people go crazy with Christmas decorations, a rare few do both Thanksgiving and Christmas, but it’s only the very elite hard core decorator who goes for the end-of-year trifecta of Halloween, Thanksgiving, and Christmas.  Our across-the-street neighbor is one of these people.  Behold:

The picture can’t really do it justice.  The skeleton inside the glowing coffin on the first floor moves around.  The dude on the organ at the far right plays scary music.  And there are speakers that play all manner of screams, cat yowls, and other scary sounds.

My favorite costume of the night: a family of three little girls, the middle one dressed up as Dorothy, ruby slippers and all.  The little one was the cowardly lion, which was very practical since it looked very fleecy and warm.  The eldest (maybe about 4 years old) was dressed as the wicked witch, and she had ruby slippers, too.  Clearly she was the Wicked Witch of the East, pre-house-crushing.

Carisa’s favorite costume of the night: three little girls, maybe about 6 years old, dressed up in ripped up cheerleader costumes covered in blood.  Yeah.

Ah – a topic near and dear to my heart.  Like many of you who have traveled around with world with electronic equipment, I’ve been flabbergasted by the panoply of power plugs I have to navigate to get some juice back into my gadgets.  110V?  240V?  Two prong?  Three poles?  It’s enough to drive a man batty, I tell ya.  And it forces me to lug around a heavy voltage convertor, which stinks doubly for someone who prefers to travel light.  If, like me, you’ve always scratched your head and wondered how the world ended up this way, now you can finally learn why here.

Before this theme gets too old, I want to reserve a special shout-out for Wired Magazine.  Thank you, Wired, for having the bravery and integrity to do what the rest of mainstream media was unwilling to do: put “Vaccines don’t cause autism” on your cover, highlighted in fluorescent green, for the whole world to see.  And not only that, you backed that statement with a well-crafted, reasoned, non-hysterical article inside.  It makes me want to go out, buy extra copies, and put them in my hospital waiting rooms.  Bravo.  The rationality is very, very refreshing.

We’re going to continue today’s theme of thanks by sending some gratitude towards Minnesota.  Just like every other state in the nation, Minnesota is faced with a shortage of primary care physicians.  It doesn’t take a rocket scientist to figure out one of the big reasons: a graduating medical student has little reason to become a family physician if he or she can make two, three, or even more times as much money by choosing a more lucrative specialty, like dermatology or radiology.  This financial disincentive comes even more into play when considering the staggering six-figure debt that most medical school graduates are faced with today.  Part of the solution, Senator Franken realizes, is to provide loan forgiveness to those graduates who choose to enter primary care or work in underserved areas.  It’s a no-brainer that unfortunately hasn’t caught on very well in the power circles.  Here’s some hope that it gains some traction.

So there I was, drowning in comment spam, my poor little blog neglected out of an ill-informed, futile attempt to reduce the tide of spam coming from all the pharmacies of ill-repute out on the interwebs.  Desperate, I turned to my colleague Eliot Gelwan for help.  A prolific blogger himself, I knew I could turn to him for advice.  I was not disappointed, for Dr. Gelwan pointed me in the direction of Wordpress’s own anti-spam plugin, a feature I had not noticed in my helplessness and n00bishness.  Now girded in the armor of Akismet, I feel rejuvenated.  I no longer have to login to my blog in fear.

My little corner of the pediatric world seems to be rather occupied of late with a recent study published in the BMJ.  The study looked at a group of 240 kids in the Netherlands who were given either amoxicillin (an antibiotic) or placebo for treatment of otitis media (ear infection).  Looking back 3.5 years later, the researchers discovered that those kids who were randomized to receive amoxicillin had a 2.5 times higher risk of recurrent ear infection.

The trend in recent years has been for less and less antibiotic treatment of ear infection, opting instead for a “wait and see” approach for uncomplicated cases.  This has been a reflection of data that shows that most ear infections are caused by viruses (not helped by antibiotics), and that it doesn’t seem to make much difference whether one treats simple ear infections with antibiotics or not.

So you would think that docs would be receptive to this additional data further reinforcing the lack of need for antibiotics in many, if not most, ear infections.  You would think that, but you would be wrong.  Pediatricians and family medicine physicians have spent a lot of time on the intertubes resisting reduction of their antibiotic usage in ear infections, citing personal experience and anecdotal evidence (“back in my day…”) while giving wild exhortations in CAPITAL LETTERS.

The one thing that these docs don’t use to make their point is data – real data.  By that I mean large, randomized, well-controlled studies that seek to eliminate confounding variables and answer a specific clinical question.  At what point does personal experience become real data?  Never.  How long does one have to practice before their anecdotes become a valid basis for policy?  Let’s just say longer than anyone is willing to wait.

I pause here to realize that even doctors, for all their education, for all the trust placed in them by their patients, are just as prone as anyone to having “blind spots” – areas of thought that refuse to accept evidence contrary to their beliefs.  For some doctors, it’s vaccines and autism.  For others it’s herbal medicine.  For these docs, it just happens to be antibiotics and ear infections.

So what will it take to shed enough light on the issue to get these docs to change?  A large part of it, I think, is getting people to take their blinders off.  But this, unfortunately, is something you can’t do for them.  It’s not easy to self-criticize, but I firmly believe that opening your own practice and knowledge to critique can only help you become  more knowledgeable, more humble, and a better doctor.  Failing to do so might preserve a frail ego, but it does disservice to everyone else.

This is just too cool for words…